Volume 1 PDF
Volume 1 PDF
Volume 1 PDF
PRINCIPLES OF
ORAL AND
MAXILLOFACIAL
SURGERY Second Edition
Michael Miloro
Editor
G. E. Ghali Peter E. Larsen Peter D. Waite
Associate Editors
2004
BC Decker Inc
Hamilton London
BC Decker Inc
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2004 BC Decker Inc
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
04 05 06 07 / FP / 9 8 7 6 5 4 3 2 1
ISBN 1-55009-234-0
Printed in Canada
Illustrations by Paulette Dennis, Andre Jenks, and Kevin Millar.
Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord
with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to
check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly
important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-
by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not
intended as, and should not be employed as, a substitute for individual diagnosis and treatment.
DEDICATIONS
To Beth and Macy, my two reasons for being, for your love and support. To Pete, my teacher, for
making me a better surgeon and person.
Michael Miloro
To my wife, Hope, for being my best friend and the love of my life. To my parents, Elias and Linda,
and my brother Fred, for their support, inspiration, devotion, and love.
G. E. Ghali
To my wife, Patty, and my sons, Michael, Matthew, and Mark. You are the most important people in
my life, yet always understand and are patient with my absence. To my father who inspired me to
enter medicine. Lastly, to my former and current residents who teach me every day.
Peter Larsen
To my wife, Sallie, and my children, Allison, Eric, and Jon. To my father who inspired my interest in
oral and maxillofacial surgery and to my residents who have continued to teach me.
Peter Waite
CONTENTS
Deceased
v
vi Contents
54. Database Acquisition and Treatment Planning 63. Surgical and Nonsurgical Management of
Marc B. Ackerman, DMD; David M. Sarver, DMD, MS. . . . . 1087 Obstructive Sleep Apnea
B. D. Tiner, DDS, MD; Peter D. Waite, MPH, DDS, MD . . . . 1297
55. Orthodontics for Orthognathic Surgery
Larry M. Wolford, DMD; Eber L. L. Stevao, DDS, PhD; PART 9: FACIAL ESTHETIC SURGERY
C. Moody Alexander, DDS, MS;
Section Editor: Peter D. Waite, MPH, DDS, MD
Joao Roberto Goncalves, DDS, PhD. . . . . . . . . . . . . . . . . . . . . 1111
64. Blepharoplasty
56. Principles of Mandibular Orthognathic Surgery
Heidi L. Jarecki, MD; Mark J. Lucarelli, MD,
Dale S. Bloomquist, DDS, MS; Jessica J. Lee, DDS . . . . . . . . . 1135
Bradley N. Lemke, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1317
57. Maxillary Orthognathic Surgery
65. Basic Principles of Rhinoplasty
Vincent J. Perciaccante, DDS; Robert A. Bays, DDS . . . . . . . . 1179
James Koehler, DDS, MD; Peter D. Waite, MPH, DDS, MD. . . . 1345
58. Management of Facial Asymmetry
66. Rhytidectomy
Peter D. Waite, MPH, DDS, MD;
G. E. Ghali, DDS, MD; T. William Evans, DDS, MD . . . . . . . 1365
Scott D. Urban, DMD, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . 1205
67. Forehead and Brow Procedures
59. Soft Tissue Changes Associated with Orthognathic Surgery
Angelo Cuzalina, MD, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
Norman J. Betts, DDS, MS;
Sean P. Edwards, DDS, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . 1221 68. Liposculpting Procedures
Milan J. Jugan, DMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1407
60. Prevention and Management of Complications in
Orthognathic Surgery 69. Skin Rejuvenation Procedures
Joseph E. Van Sickels, DDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247 Gary D. Monheit, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1419
61. Orthognathic Surgery in the Patient with Cleft Palate 70. Alloplastic Esthetic Facial Augmentation
Timothy A. Turvey, DDS; Ramon L. Ruiz, DMD, MD; Bruce N. Epker, DDS, MSD, PhD . . . . . . . . . . . . . . . . . . . . . . 1435
Katherine W. L. Vig, BDS, MS, D. Orth.;
71. Otoplastic Surgery for the Protruding Ear
Bernard J. Costello, DMD, MD . . . . . . . . . . . . . . . . . . . . . . . . 1267
Todd G. Owsley, DDS, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . 1449
62. Distraction Osteogenesis
Suzanne U. Stucki-McCormick, MS, DDS. . . . . . . . . . . . . . . . 1277 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1461
PREFACE
ix
ENCOMIUM
Dr. Larry J. (Pete) Peterson is easily the smartest person I have ever known, and I do not mean with regard to medicine
and surgery alone. Pete certainly forgot more information in his life than most people ever know. He made everyone around
him want to be better than they were, and he helped them to reach their potential. Petersons Principles of Oral and Maxillo-
facial Surgery, Second Edition, is dedicated to this man. Unfortunately, the majority of readers will never have had the
opportunity to meet him and to experience his imposing presence. The fact that this book will continue to educate many
surgeons for years to come would have pleased him very much since his greatest passion in life was, perhaps, teaching.
Pete obtained his doctor of dental surgery degree at the University of Missouri, Kansas City, in 1968. He completed his
training in oral and maxillofacial surgery at Georgetown University, where he also received his masters of science degree.
Pete served on the faculty at the Medical College of Georgia and, subsequently, at the University of Connecticut as the direc-
tor of Oral and Maxillofacial Surgery Residency Training. However, he is best known for his academic accomplishments at
Ohio State University, where he served as chairman of Oral and Maxillofacial Surgery, Pathology, and Anesthesiology from
1982 through 1999. To experience the full range of our specialty, Pete entered private practice in 1999 and continued in that
area until his death on August 7, 2002.
Petes professional and personal accomplishments and his contributions to our specialty are innumerable. In 1993 Pete
assumed the role of editor-in-chief of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, upon
the retirement of Dr. Robert Shira. Pete demanded excellence in the manuscript submissions and maintained high standards
for this journal during his tenure. Pete also edited Contemporary Oral and Maxillofacial Surgery, which, like its predecessor
from his mentor Dr. Gustav O. Kruger, defined dental undergraduate education in oral and maxillofacial surgery nation-
wide. Petes dedication to education was further demonstrated in his role as chair of the American Association of Oral and
Maxillofacial Surgeons Committee on Residency Education and Training. He lectured and published extensively both
nationally and internationally, with a particular emphasis on the topics of odontogenic infections and dental implantology,
and his contributions to the literature are many and varied.
Pete was a loving husband and father and enjoyed life to the fullest at each and every opportunity. To Pete, life was a
journey. The answer to any problem was inconsequential; the long arduous path from question to answer was the only pur-
pose for the question in the first place. Dr. Peter Larsen and I had the privilege of working closely with Pete and experienc-
ing his talents and benefiting from his wisdom and guidance at Ohio State University for several years. We had the unique
opportunity to observe Pete in and out of the hospitalthe phrase work hard, play hard epitomizes the Peterson philos-
ophy. Peter Larsen remembered Pete at his funeral; here is a portion of that eulogy:
x
Encomium xi
When I tried to decide what to say about this amazing man, I started by making a list. What I discovered was a man of what I like to call
wonderful contradiction.
Pete was perhaps one of the most successful men I have known, yet he would have listed his Eagle Scout Award as being more important than
many of the prestigious professional honors he received.
He was our most vigorous critic and yet our strongest advocate.
He was the teacher of teachers but also the perpetual student.
He was not an OSU alumnus but bled scarlet and gray.
He demanded hard work but taught me that it isnt really work if you love what you do.
He was a teacher who, when honored, thanked his students for teaching him.
Although surrounded by personal success, he found the greatest satisfaction in the success of others.
He was our boss but was more comfortable as our partner in a raft on the New River.
He would argue with you, not to get you to agree, but to get you to disagree and defend.
He trained many to reach great financial success but placed the reward gained by teaching higher than any financial reward.
He had much of which to boast and be proud, but instead practiced humility.
He was perhaps the smartest man I have ever known but was always first to admit when you had a good idea, and was gracious enough not
to point out that he had thought of it himself, perhaps even years prior.
I never heard him speak on a topic when I was not totally impressed with the insight and knowledge he seemed to have, but he was often
more content listening to what others had to say.
He was more interested in finding the truth than about being right himself.
He was 15 years older than me but looked younger.
He would often tell residents, much to their dismay, I might add, that it is not the answer that is important, but the question.
Many of his accomplishments could easily be ranked on a 1-to-10 scale as a 10. Yet, I can still hear him say, There is no such thing as a 10.
He had the same enthusiasm for a giant rope swing as he did for a new operation.
He knew more than many of the speakers at the lectures he attended, but he always took notes.
He built what is perhaps the best Oral and Maxillofacial Surgery Department in the country, but, for me, his finest hour as our leader was
when he tenderly took care of Vicki, Arden Hegtvedts wife, when Arden died.
He was a man most deserving of a long and wonderful life, yet we are here today because this wonderful life has been tragically cut short.
If, as said by William James, the greatest use of life is to spend it for something that will outlast it, then Pete spent his life well. For, as I look
around, I see scores of us who owe so much of what we are to this one life well spent.
Pete died too young, and he will be missed, but through this textbook his teachings will continue.
Ronald M. Achong, DMD, MD Norman J. Betts, DDS, MS Larry L. Cunningham Jr, DDS, MD
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery Department of Oral Health Science
Louisiana State University School of Dentistry University of Michigan School of Dentistry University of Kentucky, College of Dentistry
New Orleans, Louisiana Ann Arbor, Michigan Lexington, Kentucky
Marc B. Ackerman, DMD Remy H. Blanchaert Jr, MD, DDS Angelo Cuzalina, MD, DDS
Private Practice Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Orthodontics Kansas City Schools of Dentistry and Medicine University of Oklahoma Health Science Center
Bryn Mawr, Pennsylvania University of Missouri Oklahoma City, Oklahoma
Kansas City, Missouri
C. Moody Alexander, DDS, MS Jeffrey B. Dembo, DDS, MS
Department of Orthodontics Michael S. Block, DMD Department of Oral Health Science
Baylor College of Dentistry, Texas A&M Department of Oral and Maxillofacial Surgery University of Kentucky College of Dentistry
University System Louisiana State University School of Dentistry Lexington, Kentucky
Dallas, Texas New Orleans, Louisiana
Eric J. Dierks, DMD, MD
Carl M. Allen, DDS, MSD Dale S. Bloomquist, DDS, MS Department of Oral and Maxillofacial Surgery
Section of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery Oregon Health Sciences University
Pathology, and Dental Anesthesiology University of Washington School of Dentistry Portland, Oregon
The Ohio State University, College of Dentistry Seattle, Washington
Columbus, Ohio David N. Duddleston, MD
Kevin J. Butterfield, DDS, MD Department of Medicine
Brian Alpert, DDS, FACD Department of Oral and Maxillofacial Surgery University of Mississippi Medical Center
Department of Surgical and Hospital Dentistry University of Connecticut Jackson, Mississippi
University of Louisville School of Dentistry Farmington, Connecticut
Louisville, Kentucky Sean P. Edwards, DDS, MD
Eric R. Carlson, DMD, MD Department of Oral and Maxillofacial Surgery
Meredith August, DMD, MD Department of Oral and Maxillofacial Surgery University of Michigan School of Dentistry
Department of Oral and Maxillofacial Surgery University of Tennessee Graduate School of Ann Arbor, Michigan
Harvard University Medicine
Boston, Massachusetts Knoxville, Tennessee Edward Ellis III, DDS, MS
Department of Surgery
Jonathan S. Bailey, DMD, MD Guillermo E. Chacon, DDS University of Texas Southwestern Medical
Department of Surgery Department of Oral and Maxillofacial Surgery Center
University of Illinois College of Medicine at The Ohio State University Medical Center Dallas, Texas
Urbana-Champaign Columbus, Ohio
Urbana, Illinois Bruce N. Epker, DDS, MSD, PhD
Rakesh K. Chandra, MD Aesthetic Facial Surgery Center
Robert A. Bays, DDS Department of Otolaryngology-Head and Weatherford, Texas
Department of Surgery Neck Surgery
Emory University School of Medicine University of Tennessee Health Science Center T. William Evans, DDS, MD, FACS
Atlanta, Georgia Memphis, Tennessee Department of Oral and Maxillofacial Surgery
The Ohio State University
Jeffrey D. Bennett, DMD M. Scott Connor, DDS, MD Columbus, Ohio;
Department of Oral Surgery and Hospital Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Dentistry Louisiana State University Health Sciences University of Michigan
Indiana University School of Dentistry Center Ann Arbor, Michigan
Indianapolis, Indiana Shreveport, Louisiana
Michael W. Finkelstein, DDS, MS
Charles N. Bertolami, DDS, D.Med.Sc. Bernard J. Costello, DMD, MD Department of Oral Pathology, Radiology, and
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery Medicine
University of California University of Pittsburgh University of Iowa, College of Dentistry
San Francisco, California Pittsburgh, Pennsylvania Iowa City, Iowa
xiii
xiv Contributors
Stephen B. Milam, DDS, PhD, FACD Vincent J. Perciaccante, DDS Michael S. Scherer, DDS, MD
Department of Oral and Maxillofacial Surgery Department of Surgery Department of Oral and Maxillofacial Surgery
University of Texas Health Science Center Emory University School of Medicine Case Western Reserve University School of
San Antonio, Texas Atlanta, Georgia Dental Medicine
Cleveland, Ohio
Michael Miloro, DMD, MD Larry J. Peterson, DDS, MS
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery Sterling R. Schow, DMD
The Nebraska Medical Center The Ohio State University, College of Dentistry Department of Oral and Maxillofacial Surgery
Omaha, Nebraska Columbus, Ohio Baylor College of Dentistry, Texas A&M
University System
Dale J. Misiek, DMD Joseph F. Piecuch, DMD, MD Dallas, Texas
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Louisiana State University Health Sciences University of Connecticut School of Dental Anthony G. Sclar, DMD
Center Medicine Department of Surgery
New Orleans, Louisiana Farmington, Connecticut University of Miami School of Medicine
Miami, Florida
Gary D. Monheit, MD Michael A. Pikos, DDS
Departments of Dermatology and Ophthalmology Department of Oral and Maxillofacial Surgery Vivek Shetty, DDS, Dr.Med.Dent.
University of Alabama University of Miami School of Medicine Department of Oral and Maxillofacial Surgery
Birmingham, Alabama Miami, Florida University of California
Los Angeles, California
Jeffrey J. Moses, DDS, FACD, FICD, FAACS M. Anthony Pogrel, DDS, MD, FRCS, FACS
Department of Dentistry Department of Oral and Maxillofacial Surgery James W. Sikes Jr, DMD, MD
University of California University of California Department of Oral and Maxillofacial Surgery
Los Angeles, California San Francisco, California Louisiana State University Health Sciences
Center
Gregory M. Ness, DDS Jeffrey C. Posnick, DMD, MD, FRCS(C), FACS Shreveport, Louisiana
Department of Oral and Maxillofacial Surgery Departments of Surgery and Pediatrics
The Ohio State University, College of Dentistry Georgetown University Medical Center Massimo Simion, DDS
Columbus, Ohio Washington, District of Columbia Department of Periodontology
University of Milan
Mark W. Ochs, DMD, MD Michael P. Powers, DDS, MS Milan, Italy
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
University of Pittsburgh School of Dental Case Western Reserve University School of Douglas P. Sinn, DDS
Medicine Dental Medicine Department of Surgery
Pittsburgh, Pennsylvania Cleveland, Ohio University of Texas Southwestern Medical
Center
Robert. A. Ord, MD, DDS, MS, FRCS, FACS Ramon L. Ruiz, DMD, MD Dallas, Texas
Department of Oral and Maxillofacial Surgery Departments of Oral and Maxillofacial Surgery
University of Maryland and Pediatrics Daniel B. Spagnoli, DDS, PhD
Baltimore, Maryland University of North Carolina Department of Oral and Maxillofacial Surgery
Chapel Hill, North Carolina Louisiana State University Health Sciences
Todd G. Owsley, DDS, MD Center
Carolina Surgical Arts, PA Thomas J. Salinas, DDS New Orleans, Louisiana
Greensboro, North Carolina Department of Otolaryngology
University of Nebraska Medical Center Peter M. Spalding, DDS, MS, MS
Stephen M. Parel, DDS, FACD, FICD Omaha, Nebraska Department of Growth and Development
Department of Oral and Maxillofacial Surgery University of Nebraska Medical Center College
Baylor College of Dentistry, Texas A&M Noah A. Sandler, DMD, MD of Dentistry
University System Department of Diagnostic and Surgical Sciences Lincoln, Nebraska
Dallas, Texas University of Minnesota
Minneapolis, Minnesota Eber L. L. Stevao, DDS, PhD
Alex E. Pazoki, MD, DDS Department of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery David M. Sarver, DMD, MS Baylor College of Dentistry, Texas A&M Univer-
University of Maryland Department of Orthodontics sity System
Baltimore, Maryland University of North Carolina Dallas, Texas
Chapel Hill, North Carolina
Deceased
xvi Contributors
Suzanne U. Stucki-McCormick, MS, DDS Scott D. Urban, DMD, MD Joel M. Weaver, DDS, PhD, FACD, FICD
Pacific Center for Jaw and Facial Surgery Department of Oral and Maxillofacial Surgery Department of Anesthesiology
Encinitas, California University of Alabama College of Medicine and Public Health
Birmingham, Alabama The Ohio State University
B. D. Tiner, DDS, MD Columbus, Ohio
Department of Oral and Maxillofacial Surgery Joseph E. Van Sickels, DDS
University of Texas Health Science Center Department of Oral Health Science Randall M. Wilk, DDS, PhD, MD
San Antonio, Texas University of Kentucky Department of Oral and Maxillofacial Surgery
Lexington, Kentucky Louisiana State University Health Sciences Center
Paul S. Tiwana, DDS, MD, MS New Orleans, Louisiana
Department of Oral and Maxillofacial Surgery Tomaso Vercellotti, MD, DDS
University of North Carolina Department of Ear, Nose, and Throat Larry M. Wolford, DMD
Chapel Hill, North Carolina University of Studies of Genova (Italy) Department of Oral and Maxillofacial Surgery
Genova, Italy Baylor College of Dentistry, Texas A&M
Yan Trokel, MD, DDS University System
Department of Oral and Maxillofacial Surgery Katherine W. L. Vig, BDS, MS, D. Orth, FDS(RCS) Dallas, Texas
University of Texas Southwestern Medical Center Department of Orthodontics
Dallas, Texas The Ohio State University, College of Dentistry Deborah L. Zeitler, DDS, MS
Columbus, Ohio Department of Oral and Maxillofacial Surgery
Maria J. Troulis, DDS, MSc University of Iowa College of Dentistry
Department of Oral and Maxillofacial Surgery Steven D. Vincent, DDS, MS Iowa City, Iowa
Harvard University Department of Oral Pathology, Radiology, and
Boston, Massachusetts Medicine Michael F. Zide, DMD
University of Iowa, College of Dentistry Department of Oral and Maxillofacial Surgery
Timothy A. Turvey, DDS Iowa City, Iowa University of Texas Southwestern Medical
Department of Oral and Maxillofacial Surgery School
University of North Carolina Peter D. Waite, MPH, DDS, MD, FACD Dallas, Texas
Chapel Hill, North Carolina Department of Oral and Maxillofacial Surgery
University of Alabama School of Dentistry
Birmingham, Alabama
Part 1
PRINCIPLES OF MEDICINE,
SURGERY, AND ANESTHESIA
CHAPTER 1
Wound Healing
Vivek Shetty, DDS, Dr.Med.Dent.
Charles N. Bertolami, DDS, D.Med.Sc.
The healing wound is an overt expression sue, then repair has occurred. Repair by closed primarily with sutures or other
of an intricate and tightly choreographed scarring is the bodys version of a spot means and healing proceeds rapidly with
sequence of cellular and biochemical weld and the replacement tissue is coarse no dehiscence and minimal scar forma-
responses directed toward restoring tissue and has a lower cellular content than tion. If conditions are less favorable,
integrity and functional capacity following native tissue. With the exception of bone wound healing is more complicated and
injury. Although healing culminates and liver, tissue disruption invariably occurs through a protracted filling of the
uneventfully in most instances, a variety of results in repair rather than regeneration. tissue defect with granulation and connec-
intrinsic and extrinsic factors can impede At the cellular level the rate and quali- tive tissue. This process is called healing by
or facilitate the process. Understanding ty of tissue healing depends on whether second intention and is commonly associ-
wound healing at multiple levelsbio- the constitutive cells are labile, stable, or ated with avulsive injury, local infection,
chemical, physiologic, cellular, and molec- permanent. Labile cells, including the ker- or inadequate closure of the wound. For
ularprovides the surgeon with a frame- atinocytes of the epidermis and epithelial more complex wounds, the surgeon may
work for basing clinical decisions aimed at cells of the oral mucosa, divide throughout attempt healing by third intention
optimizing the healing response. Equally their life span. Stable cells such as fi- through a staged procedure that combines
important it allows the surgeon to critical- broblasts exhibit a low rate of duplication secondary healing with delayed primary
ly appraise and selectively use the growing but can undergo rapid proliferation in closure. The avulsive or contaminated
array of biologic approaches that seek to response to injury. For example, bone wound is dbrided and allowed to granu-
assist healing by favorably modulating the injury causes pluripotential mesenchymal late and heal by second intention for 5 to
wound microenvironment. cells to speedily differentiate into 7 days. Once adequate granulation tissue
osteoblasts and osteoclasts. On the other has formed and the risk of infection
The Healing Process hand permanent cells such as specialized appears minimal, the wound is sutured
The restoration of tissue integrity, whether nerve and cardiac muscle cells do not close to heal by first intention.
initiated by trauma or surgery, is a phylo- divide in postnatal life. The surgeons
genetically primitive but essential defense expectation of normal healing should be Wound Healing Response
response. Injured organisms survive only correspondingly realistic and based on the Injury of any kind sets into motion a com-
if they can repair themselves quickly and inherent capabilities of the injured tissue. plex series of closely orchestrated and tem-
effectively. The healing response depends Whereas a fibrous scar is normal for skin porally overlapping processes directed
primarily on the type of tissue involved wounds, it is suboptimal in the context of toward restoring the integrity of the
and the nature of the tissue disruption. bone healing. involved tissue. The reparative processes
When restitution occurs by means of tis- At a more macro level the quality of are most commonly modeled in skin1;
sue that is structurally and functionally the healing response is influenced by the however, similar patterns of biochemical
indistinguishable from native tissue, nature of the tissue disruption and the cir- and cellular events occur in virtually every
regeneration has taken place. However, if cumstances surrounding wound closure. other tissue.2 To facilitate description, the
tissue integrity is reestablished primarily Healing by first intention occurs when a healing continuum of coagulation, inflam-
through the formation of fibrotic scar tis- clean laceration or surgical incision is mation, reepithelialization, granulation
4 Part 1: Principles of Medicine, Surgery, and Anesthesia
tissue, and matrix and tissue remodeling is begin arriving at the wound site within continue with the wound microdbride-
typically broken down into three distinct minutes of injury and rapidly establish ment initiated by the neutrophils. They
overlapping phases: inflammatory, prolif- themselves as the predominant cells. secrete collagenases and elastases to break
erative, and remodeling.3,4 Migrating through the scaffolding provid- down injured tissue and phagocytose bac-
ed by the fibrin-enriched clot, the short- teria and cell debris. Beyond their scaveng-
Inflammatory Phase lived leukocytes flood the site with pro- ing role the macrophages also serve as the
The inflammatory phase presages the teases and cytokines to help cleanse the primary source of healing mediators.
bodys reparative response and usually wound of contaminating bacteria, devital- Once activated, macrophages release a bat-
lasts for 3 to 5 days. Vasoconstriction of ized tissue, and degraded matrix compo- tery of growth factors and cytokines
the injured vasculature is the spontaneous nents. Neutrophil activity is accentuated (TGF-, TGF-1, PDGF, insulin-like
tissue reaction to staunch bleeding. Tissue by opsonic antibodies leaking into the growth factor [IGF]-I and -II, TNF-, and
trauma and local bleeding activate factor wound from the altered vasculature. IL-1) at the wound site, further amplifying
XII (Hageman factor), which initiates the Unless a wound is grossly infected, neu- and perpetuating the action of the chemi-
various effectors of the healing cascade trophil infiltration ceases after a few days. cal and cellular mediators released previ-
including the complement, plasminogen, However, the proinflammatory cytokines ously by degranulating platelets and neu-
kinin, and clotting systems. Circulating released by perishing neutrophils, includ- trophils.6 Macrophages influence all
platelets (thrombocytes) rapidly aggregate ing tumor necrosis factor (TNF-) and phases of early wound healing by regulat-
at the injury site and adhere to each other interleukins (IL-1a, IL-1b), continue to ing local tissue remodeling by proteolytic
and the exposed vascular subendothelial stimulate the inflammatory response for enzymes (eg, matrix metalloproteases and
collagen to form a primary platelet plug extended periods.5 collagenases), inducing formation of new
organized within a fibrin matrix. The clot Deployment of bloodborne mono- extracellular matrix, and modulating
secures hemostasis and provides a provi- cytes to the site of injury starts peaking as angiogenesis and fibroplasia through local
sional matrix through which cells can the levels of neutrophils decline. Activated production of cytokines such as throm-
migrate during the repair process. Addi- monocytes, now termed macrophages, bospondin-1 and IL-1b. The centrality of
tionally the clot serves as a reservoir of the
cytokines and growth factors that are
released as activated platelets degranulate
Fibrin clot
(Figure 1-1). The bolus of secreted pro-
teins, including interleukins, transforming Epidermis
Macrophage
growth factor (TGF-), platelet-derived
growth factor (PDGF), and vascular Platelet plug Epidermis
endothelial growth factor (VEGF), main- Growth Blood vessel
tain the wound milieu and regulate subse- TGF- 1 factors
PDGF MMP TGF- 1
quent healing.1 PDGF TGF- 2
Blood vessel
TGF- 3
Once hemostasis is secured the reac-
tive vasoconstriction is replaced by a more Dermis FGF-2 Fibroblast
persistent period of vasodilation that is Fibroblast TGF- 1
mediated by histamine, prostaglandins, Dermis
tion tissue) containing inflammatory cells, guished by the establishment of local microcirculation and formation of extracellular matrix and
immature collagen. Epidermal cells migrate laterally below the fibrin clot, and granulation tissue
fibroblasts, and budding vasculature begins to organize below the epithelium. MMPs = matrix metalloproteinases; t-PA = tissue plas-
enclosed in a loose matrix. An essential minogen activator; u-PA = urinary plasminogen activator. Adapted from Bissell MJ and Radisky D.70
first step is the establishment of a local
microcirculation to supply the oxygen and
nutrients necessary for the elevated meta- matrix synthesis dissipates, evidencing the depends on the depth of the wound and
bolic needs of regenerating tissues. The highly precise spatial and temporal regula- its location. In some instances the forces
generation of new capillary blood vessels tion of normal healing. of wound contracture are capable of
(angiogenesis) from the interrupted vas- At the surface of the dermal wound deforming osseous structures.
culature is driven by wound hypoxia as new epithelium forms to seal off the
well as with native growth factors, particu- denuded wound surface. Epidermal cells Remodeling Phase
larly VEGF, fibroblast growth factor 2 originating from the wound margins The proliferative phase is progressively
(FGF-2), and TNF- (see Figure 1-2). undergo a proliferative burst and begin to replaced by an extended period of pro-
Around the same time, matrix-generating resurface the wound above the basement gressive remodeling and strengthening of
fibroblasts migrate into the wound in membrane. The process of reepithelializa- the immature scar tissue. The remodel-
response to the cytokines and growth fac- tion progresses more rapidly in oral ing/maturation phase can last for several
tors released by inflammatory cells and mucosal wounds in contrast to the skin. years and involves a finely choreographed
wounded tissue. The fibroblasts start syn- In a mucosal wound the epithelial cells balance between matrix degradation and
thesizing new extracellular matrix (ECM) migrate directly onto the moist exposed formation. As the metabolic demands of
and immature collagen (Type III). The surface of the fibrin clot instead of under the healing wound decrease, the rich net-
scaffold of collagen fibers serves to sup- the dry exudate (scab) of the dermis. work of capillaries begins to regress.
port the newly formed blood vessels sup- Once the epithelial edges meet, contact Under the general direction of the
plying the wound. Stimulated fibroblasts inhibition halts further lateral prolifera- cytokines and growth factors, the collage-
also secrete a range of growth factors, tion. Reepithelialization is facilitated by nous matrix is continually degraded,
thereby producing a feedback loop and underlying contractile connective tissue, resynthesized, reorganized, and stabilized
sustaining the repair process. Collagen which shrinks in size to draw the wound by molecular crosslinking into a scar. The
deposition rapidly increases the tensile margins toward one another. Wound con- fibroblasts start to disappear and the colla-
strength of the wound and decreases the traction is driven by a proportion of the gen Type III deposited during the granula-
reliance on closure material to hold the fibroblasts that transform into myofi- tion phase is gradually replaced by
wound edges together. Once adequate col- broblasts and generate strong contractile stronger Type I collagen. Correspondingly
lagen and ECM have been generated, forces. The extent of wound contraction the tensile strength of the scar tissue
6 Part 1: Principles of Medicine, Surgery, and Anesthesia
gradually increases and eventually injury is rare. Histologically, changes of tion of the connective tissue matrix. Bone is
approaches about 80% of the original degeneration are evident in all axons adja- a biologically privileged tissue in that it
strength. Homeostasis of scar collagen and cent to the site of injury.11 Shortly after heals by regeneration rather than repair.
ECM is regulated to a large extent by ser- nerve severance, the investing Schwann Left alone, fractured bone is capable of
ine proteases and matrix metallopro- cells begin to undergo a series of cellular restoring itself spontaneously through
teinases (MMPs) under the control of the changes called wallerian degeneration. sequential tissue formation and differentia-
regulatory cytokines. Tissue inhibitors of The degeneration is evident in all axons of tion, a process also referred to as indirect
the MMPS afford a natural counterbal- the distal nerve segment and in a few healing. As in skin the interfragmentary
ance to the MMPs and provide tight con- nodes of the proximal segment. Within thrombus that forms shortly after injury
trol of proteolytic activity within the scar. 78 hours injured axons start breaking staunches bleeding from ruptured vessels in
Any disruption of this orderly balance can up and are phagocytosed by adjacent the haversian canals, marrow, and perios-
lead to excess or inadequate matrix degra- Schwann cells and by macrophages that teum. Necrotic material at the fracture site
dation and result in either an exuberant migrate into the zone of injury. Once the elicits an immediate and intense acute
scar or wound dehiscence. axonal debris has been cleared, Schwann inflammatory response which attracts the
cell outgrowths attempt to connect the polymorphonuclear leukocytes and subse-
Specialized Healing proximal stump with the distal nerve quently macrophages to the fracture site.
stump. Surviving Schwann cells prolifer- The organizing hematoma serves as a fibrin
Nerve ate to form a band (Bngners band) that scaffold over which reparative cells can
Injury to the nerves innervating the orofa- will accept regenerating axonal sprouts migrate and perform their function. Invad-
cial region may range from simple contu- from the proximal stump. The proliferat- ing inflammatory cells and the succeeding
sion to complete interruption of the nerve. ing Schwann cells also promote nerve pluripotential mesenchymal cells begin to
The healing response depends on injury regeneration by secreting numerous neu- rapidly produce a soft fracture callus that
severity and extent of the injury.810 Neu- rotrophic factors that coordinate cellular fills up interfragmentary gaps. Comprised
ropraxia represents the mildest form of repair as well as cell adhesion molecules of fibrous tissue, cartilage, and young
nerve injury and is a transient interrup- that direct axonal growth. In the absence immature fiber bone, the soft compliant
tion of nerve conduction without loss of of surgical realignment or approximation callus acts as a biologic splint by binding
axonal continuity. The continuity of the of the nerve stumps, proliferating the severed bone segments and damping
epineural sheath and the axons is main- Schwann cells and outgrowing axonal interfragmentary motion. An orderly pro-
tained and morphologic alterations are sprouts may align within the randomly gression of tissue differentiation and matu-
minor. Recovery of the functional deficit is organized fibrin clot to form a disorga- ration eventually leads to fracture consoli-
spontaneous and usually complete within nized mass termed neuroma. dation and restoration of bone continuity.
3 to 4 weeks. If there is a physical disrup- The rate and extent of nerve regener- More commonly the surgeon chooses
tion of one or more axons without injury ation depend on several factors including to facilitate an abbreviated callus-free
to stromal tissue, the injury is described as type of injury, age, state of tissue nutri- bone healing termed direct healing (Figure
axonotmesis. Whereas individual axons tion, and the nerves involved. Although 1-3). The displaced bone segments are sur-
are severed, the investing Schwann cells the regeneration rate for peripheral nerves gically manipulated into an acceptable
and connective tissue elements remain varies considerably, it is generally consid- alignment and rigidly stabilized through
intact. The nature and extent of the ensu- ered to approximate 1 mm/d. The regen- the use of internal fixation devices. The
ing sensory or motor deficit relates to the eration phase lasts up to 3 months and resulting anatomic reduction is usually a
number and type of injured axons. Mor- ends on contact with the end-organ by a combination of small interfragmentary
phologic changes are manifest as degener- thin myelinated axon. In the concluding gaps separated by contact areas. Ingrowth
ation of the axoplasm and associated maturation phase both the diameter and of mesenchymal cells and blood vessels
structures distal to the site of injury and performance of the regenerating nerve starts shortly thereafter, and activated
partly proximal to the injury. Recovery of fiber increase. osteoblasts start depositing osteoid on the
the functional deficit depends on the surface of the fragment ends. In contact
degree of the damage. Bone zones where the fracture ends are closely
Complete transection of the nerve The process of bone healing after a fracture apposed, the fracture line is filled concen-
trunk is referred to as neurotmesis and has many features similar to that of skin trically by lamellar bone. Larger gaps are
spontaneous recovery from this type of healing except that it also involves calcifica- filled through a succession of fibrous
Wound Healing 7
Gap healing
Basic multicellular unit
Osteoblast
Osteoclast
Blood vessel
Osteocyte
Contact healing
FIGURE 1-3 Direct bone healing facilitated by a lag screw. The fracture site shows both gap healing and contact healing. The internal archi-
tecture of bone is restored eventually by the action of basic multicellular units.
tissue, fibrocartilage, and woven bone. In and the remainder are entombed inside the tors determining the mechanical milieu of
the absence of any microinstability at the mineralized matrix as osteocytes. a healing fracture include the fracture con-
fracture site, direct healing takes place While the primitive bone mineralizes, figuration, the accuracy of fracture reduc-
without any callus formation. remodeling BMUs cut their way through tion, the stability afforded by the selected
Subsequent bone remodeling eventual- the reparative tissue and replace it with fixation device, and the degree and nature
ly restores the original shape and internal mature bone. The grain of the new bone of microstrains provoked by function. If a
architecture of the fractured bone. Func- tissue starts paralleling local compression fracture fixation device is incapable of sta-
tional sculpting and remodeling of the and tension strains. Consequently the bilizing the fracture, the interfragmentary
primitive bone tissue is carried out by a shape and strength of the reparative bone microinstability provokes osteoclastic
temporary team of juxtaposed osteoclasts tissue changes to accommodate greater resorption of the fracture surfaces and
and osteoblasts called the basic multicellu- functional loading. Tissue-level strains results in a widening of the fracture gap.
lar unit (BMU). The osteoblasts develop produced by functional loading play an Although bone union may be ultimately
from pluripotent mesenchymal stem cells important role in the remodeling of the achieved through secondary healing by
whereas multicellular osteoclasts arise from regenerate bone. Whereas low levels of tis- callus production and endochondral ossi-
a monocyte/macrophage lineage.12 The sue strain (~2,000 microstrains) are con- fication, the healing is protracted. Fibrous
development and differentiation of the sidered physiologic and necessary for cell healing and nonunions are clinical mani-
BMUs are controlled by locally secreted differentiation and callus remodeling, festations of excessive microstrains inter-
growth factors, cytokines, and mechanical high strain levels (> 2,000 microstrains) fering with the cellular healing process.
signals. As osteoclasts at the leading edge of begin to adversely affect osteoblastic dif-
the BMUs excavate bone through prote- ferentiation and bone matrix forma- Extraction Wounds
olytic digestion, active osteoblasts move in, tion.13,14 If there is excess interfragmentary The healing of an extraction socket is a spe-
secreting layers of osteoid and slowly refill- motion, bone regenerates primarily cialized example of healing by second
ing the cavity. The osteoid begins to miner- through endochondral ossification or the intention.15 Immediately after the removal
alize when it is about 6 m thick. Osteo- formation of a cartilaginous callus that is of the tooth from the socket, blood fills the
clasts reaching the end of their lifespan of gradually replaced by new bone. In con- extraction site. Both intrinsic and extrinsic
2 weeks die and are removed by phagocytes. trast osseous healing across stabilized frac- pathways of the clotting cascade are activat-
The majority (up to 65%) of the remodel- ture segments occurs primarily through ed. The resultant fibrin meshwork contain-
ing osteoblasts also die within 3 months intramembranous ossification. Major fac- ing entrapped red blood cells seals off the
8 Part 1: Principles of Medicine, Surgery, and Anesthesia
torn blood vessels and reduces the size of Skin Grafts tion. Grafts rarely attain the sensory
the extraction wound. Organization of the qualities of normal skin, because the
Skin grafts may be either full thickness or
clot begins within the first 24 to 48 hours extent of re-innervation depends on how
split thickness.16 A full-thickness graft is
with engorgement and dilation of blood accessible the neurilemmal sheaths are to
composed of epidermis and the entire der-
vessels within the periodontal ligament the entering nerve fibers. The clinical
mis; a split-thickness graft is composed of
remnants, followed by leukocytic migration performance of the grafts depends on
the epidermis and varying amounts of der-
and formation of a fibrin layer. In the first their relative thickness. As split-thickness
mis. Depending on the amount of underly-
week the clot forms a temporary scaffold grafts are thinner than full-thickness
ing dermis included, split-thickness grafts
upon which inflammatory cells migrate. grafts, they are susceptible to trauma and
are described as thin, intermediate, or
Epithelium at the wound periphery grows undergo considerable contraction; how-
thick.17 Following grafting, nutritional sup-
over the surface of the organizing clot. ever, they have greater survival rates clin-
port for a free skin graft is initially provided
Osteoclasts accumulate along the alveolar ically. Full-thickness skin grafts do not
by plasma that exudes from the dilated cap-
bone crest setting the stage for active crestal take as well and are slow to revascular-
illaries of the host bed. A fibrin clot forms at
resorption. Angiogenesis proceeds in the ize. Nevertheless full-thickness grafts are
the graft-host interface, fixing the graft to
remnants of the periodontal ligaments. In less susceptible to trauma and undergo
the host bed. Host leukocytes infiltrate into
the second week the clot continues to get minimal shrinkage.
organized through fibroplasia and new the graft through the lower layers of the
blood vessels that begin to penetrate graft. Graft survival depends on the Wound Healing Complications
towards the center of the clot. Trabeculae of ingrowth of blood vessels from the host into Healing in the orofacial region is often
osteoid slowly extend into the clot from the the graft (neovascularization) and direct considered a natural and uneventful
alveolus, and osteoclastic resorption of the anastomoses between the graft and the host process and seldom intrudes into the sur-
cortical margin of the alveolar socket is vasculature (inosculation). Endothelial cap- geons consciousness. However, this
more distinct. By the third week the extrac- illary buds from the host site invade the changes when complications arise and
tion socket is filled with granulation tissue graft, reaching the dermoepidermal junc- encumber the wound healing continuum.
and poorly calcified bone forms at the tion by 48 hours. Concomitantly vascular Most wound healing complications mani-
wound perimeter. The surface of the connections are established between host fest in the early postsurgical period
wound is completely reepithelialized with and graft vessels. However, only a few of the although some may manifest much later.
minimal or no scar formation. Active bone ingrowing capillaries succeed in developing The two problems most commonly
remodeling by deposition and resorption a functional anastomosis. Formation of vas- encountered by the surgeon are wound
continues for several more weeks. Radi- cular connections between the recipient bed infection and dehiscence; proliferative
ographic evidence of bone formation does and transplant is signaled by the pink healing is less typical.
not become apparent until the sixth to appearance of the graft, which appears
eighth weeks following tooth extraction. between the third and fifth day postgraft- Wound Infection
Due to the ongoing process of bone remod- ing. Fibroblasts from the recipient bed Infections complicating surgical outcomes
eling the final healing product of the begin to invade the layer of fibrin and usually result from gross bacterial contam-
extraction site may not be discernible on leukocytes by the fourth day after trans- ination of susceptible wounds. All wounds
radiographs after 4 to 6 months. plantation. The fibrin clot is slowly are intrinsically contaminated by bacteria;
Occasionally the blood clot fails to resorbed and organized as fibroblastic however, this must be distinguished from
form or may disintegrate, causing a local- infiltration continues. By the ninth day the true wound infection where the bacterial
ized alveolar osteitis. In such instances new blood vessels and fibroblasts have burden of replicating microorganisms
healing is delayed considerably and the achieved a firm union, anchoring the deep actually impairs healing.18 Experimental
socket fills gradually. In the absence of a layers of the graft to the host bed. studies have demonstrated that regardless
healthy granulation tissue matrix, the Reinnervation of the skin graft occurs of the type of infecting microorganism,
apposition of regenerate bone to remain- by nerve fibers entering the graft through wound infection occurs when there are
ing alveolar bone takes place at a much its base and sides. The fibers follow the more than 1 105 organisms per gram of
slower rate. Compared to a normal socket vacated neurilemmal cell sheaths to re- tissue.19,20 Beyond relative numbers, the
the infected socket remains open or par- construct the innervation pattern of the pathogenicity of the infecting microorgan-
tially covered with hyperplastic epithelium donor skin. Recovery of sensation usually isms as well as host response factors deter-
for extended periods. begins within 2 months after transplanta- mine whether wound healing is impaired.
Wound Healing 9
The continual presence of a bacterial ure rather than improper suturing tech- sive production of collagen and extracellu-
infection stimulates the host immune niques. The dehisced wound may be lar matrix. Additionally, proliferative scar
defenses leading to the production of closed again or left to heal by secondary tissue exhibits increased numbers of
inflammatory mediators, such as intention, depending upon the extent of neoangiogenesis-promoting vasoactive
prostaglandins and thromboxane. Neu- the disruption and the surgeons assess- mediators as well as histamine-secreting
trophils migrating into the wound release ment of the clinical situation. mast cells capable of stimulating fibrous
cytotoxic enzymes and free oxygen radi- tissue growth. Although there is no effec-
cals. Thrombosis and vasoconstrictive Proliferative Scarring tive therapy for keloids, the more common
metabolites cause wound hypoxia, leading Some patients may go on to develop aber- methods for preventing or treating these
to enhanced bacterial proliferation and rant scar tissue at the site of their skin lesions focus on inhibiting protein synthe-
continued tissue damage. Bacteria injury. The two common forms of hyper- sis. These agents, primarily corticosteroids,
destroyed by host defense mechanisms proliferative healing, hypertrophic scars are injected into the scar to decrease
provoke varying degrees of inflammation and keloids, are characterized by hyper- fibroblast proliferation, decrease angiogen-
by releasing neutrophil proteases and vascularity and hypercellularity. Distinc- esis, and inhibit collagen synthesis and
endotoxins. Newly formed cells and their tive features include excessive scarring, extracellular matrix protein synthesis.
collagen matrix are vulnerable to these persistent inflammation, and an overpro-
breakdown products of wound infection, duction of extracellular matrix compo- Optimizing Wound Healing
and the resulting cell and collagen lysis nents, including glycosaminoglycans and At its very essence the wound represents
contribute to impaired healing. Clinical collagen Type I.21 Despite their overt an extreme disruption of the cellular
manifestations of wound infection include resemblance, hypertrophic scars and microenvironment. Restoration of con-
the classic signs and symptoms of local keloids do have some clinical dissimilari- stant internal conditions or homeostasis at
infection: erythema, warmth, swelling, ties. In general, hypertrophic scars arise the cellular level is a constant undertow of
pain, and accompanying odor and pus. shortly after the injury, tend to be circum- the healing response. A variety of local and
Inadequate tissue perfusion and oxy- scribed within the boundaries of the systemic factors can impede healing, and
genation of the wound further compro- wound, and eventually recede. Keloids, on the informed surgeon can anticipate and,
mise healing by allowing bacteria to prolif- the other hand, manifest months after the where possible, proactively address these
erate and establish infection. Failure to injury, grow beyond the wound bound- barriers to healing so that wound repair
follow aseptic technique is a frequent rea- aries, and rarely subside. There is a clear can progress normally.23
son for the introduction of virulent familial and racial predilection for keloid
microorganisms into the wound. Trans- formation, and susceptible individuals Tissue Trauma
formation of contaminated wounds into usually develop keloids on their face, ear Minimizing surgical trauma to the tissues
infected wounds is also facilitated by lobes, and anterior chest. helps promote faster healing and should
excessive tissue trauma, remnant necrotic Although processes leading to hyper- be a central consideration at every stage of
tissue, foreign bodies, or compromised trophic scar and keloid formation are not the surgical procedure, from placement of
host defenses. The most important factor yet clarified, altered apoptotic behavior is the incision to suturing of the wound.
in minimizing the risk of infection is believed to be a significant factor. Ordinar- Properly planned, the surgical incision is
meticulous surgical technique, including ily, apoptosis or programmed cell death is just long enough to allow optimum expo-
thorough dbridement, adequate hemo- responsible for the removal of inflammato- sure and adequate operating space. The
stasis, and elimination of dead space. ry cells as healing proceeds and for the evo- incision should be made with one clean
Careful technique must be augmented by lution of granulation tissue into scar. Dys- consistent stroke of evenly applied pres-
proper postoperative care, with an empha- regulation in apoptosis results in excessive sure. Sharp tissue dissection and carefully
sis on keeping the wound site clean and scarring, inflammation, and an overpro- placed retractors further minimize tissue
protecting it from trauma. duction of extracellular matrix compo- injury. Sutures are useful for holding the
nents. Both keloids and hypertrophic scars severed tissues in apposition until the
Wound Dehiscence demonstrate sustained elevation of growth wound has healed enough. However,
Partial or total separation of the wound factors including TGF- , platelet-derived sutures should be used judiciously as they
margins may manifest within the first growth factor, IL-1, and IGF-I.22 The have the ability to add to the risk of infec-
week after surgery. Most instances of growth factors, in turn, increase the num- tion and are capable of strangulating the
wound dehiscence result from tissue fail- bers of local fibroblasts and prompt exces- tissues if applied too tightly.
10 Part 1: Principles of Medicine, Surgery, and Anesthesia
Hemostasis and Wound oxygen tension drives the healing cigarette the peripheral vasoconstriction
Dbridement response.24,25 Oxygen is necessary for can last up to an hour; thus, a pack-a-day
hydroxylation of proline and lysine, the smoker remains tissue hypoxic for most
Bleeding from a transected vessel or dif-
polymerization and cross-linking of pro- part of each day. Smoking also increases
fuse oozing from the denuded surfaces
collagen strands, collagen transport, carboxyhemoglobin, increases platelet
interfere with the surgeons view of under-
fibroblast and endothelial cell replication, aggregation, increases blood viscosity,
lying structures. Achieving complete
effective leukocyte killing, angiogenesis, decreases collagen deposition, and decreas-
hemostasis before wound closure helps
and many other processes. Relative hypox- es prostacyclin formation, all of which neg-
prevent the formation of a hematoma
ia in the region of injury stimulates a atively affect wound healing. Patient opti-
postoperatively. The collection of blood or
fibroblastic response and helps mobilize mization, in the case of smokers, may
serum at the wound site provides an ideal
other cellular elements of repair.26 Howev- require that the patient abstain from smok-
medium for the growth of microorgan-
er, very low oxygen levels act together with ing for a minimum of 1 week before and
isms that cause infection. Additionally,
the lactic acid produced by infecting bac- after surgical procedures. Another way of
hematomas can result in necrosis of over-
teria to lower tissue pH and contribute to improving tissue oxygenation is the use of
lying flaps. However, hemostatic tech-
tissue breakdown. Cell lysis follows, with systemic hyperbaric oxygen (HBO) therapy
niques must not be used too aggressively releases of proteases and glycosidases and to induce the growth of new blood vessels
during surgery as the resulting tissue dam- subsequent digestion of extracellular and facilitate increased flow of oxygenated
age can prolong healing time. Postopera- matrix.27 Impaired local circulation also blood to the wound.
tively the surgeon may insert a drain or hinders delivery of nutrients, oxygen, and
apply a pressure dressing to help eliminate antibodies to the wound. Neutrophils are Diabetes
dead space in the wound. affected because they require a minimal Numerous studies have demonstrated that
Devitalized tissue and foreign bodies level of oxygen tension to exert their bac- the higher incidence of wound infection
in a healing wound act as a haven for bac- tericidal effect. Delayed movement of neu- associated with diabetes has less to do with
teria and shield them from the bodys trophils, opsonins, and the other media- the patient having diabetes and more to do
defenses.23 The dead cells and cellular tors of inflammation to the wound site with hyperglycemia. Simply put, a patient
debris of necrotic tissue have been shown further diminishes the effectiveness of the with well-controlled diabetes may not be
to reduce host immune defenses and phagocytic defense system and allows col- at a greater risk for wound healing prob-
encourage active infection. A necrotic bur- onizing bacteria to proliferate. Collagen lems than a nondiabetic patient. Tissue
den allowed to persist in the wound can synthesis is dependent on oxygen delivery hyperglycemia impacts every aspect of
prolong the inflammatory response, to the site, which in turn affects wound wound healing by adversely affecting the
mechanically obstruct the process of tensile strength. Most healing problems immune system including neutrophil and
wound healing, and impede reepithelial- associated with diabetes mellitus, irradia- lymphocyte function, chemotaxis, and
ization. Dirt and tar located in traumatic tion, small vessel atherosclerosis, chronic phagocytosis.30 Uncontrolled blood glu-
wounds not only jeopardize healing but infection, and altered cardiopulmonary cose hinders red blood cell permeability
may result in a tattoo deformity. By status can be attributed to local tissue and impairs blood flow through the criti-
removing dead and devitalized tissue, and ischemia. cal small vessels at the wound surface. The
any foreign material from a wound, Wound microcirculation after surgery hemoglobin release of oxygen is impaired,
dbridement helps to reduce the number determines the wounds ability to resist the resulting in oxygen and nutrient deficien-
of microbes, toxins, and other substances inevitable bacterial contamination.28 Tissue cy in the healing wound. The wound
that inhibit healing. The surgeon should rendered ischemic by rough handling, or ischemia and impaired recruitment of
also keep in mind that prosthetic grafts desiccated by cautery or prolonged air dry- cells resulting from the small vessel occlu-
and implants, despite refinements in bio- ing, tends to be poorly perfused and sus- sive disease renders the wound vulnerable
compatibility, can incite varying degrees of ceptible to infection. Similarly, tissue to bacterial and fungal infections.
foreign body reaction and adversely ischemia produced by tight or improperly
impact the healing process. placed sutures, poorly designed flaps, hypo- Immunocompromise
volemia, anemia, and peripheral vascular The immune response directs the healing
Tissue Perfusion disease, all adversely affect wound healing. response and protects the wound from
Poor tissue perfusion is one of the main Smoking is a common contributor to infection. In the absence of an adequate
barriers to healing inasmuch as tissue decreased tissue oxygenation.29 After every immune response, surgical outcomes are
Wound Healing 11
often compromised. An important assess- Radiation Injury ingly fibrotic and hypoxic due to oblitera-
ment parameter is total lymphocyte count. tive vasculitis, and the tissue susceptibility
Therapeutic radiation for head and neck
A mild deficit is a lymphocytic level to infection increases correspondingly.
tumors inevitably produces collateral
between 1,200 and 1,800, and levels below Once these changes occur they are irre-
damage in adjacent tissue and reduces its
800 are considered severe total lymphocyte versible and do not change with time.
capacity for regeneration and repair. The
deficits. Patients with debilitated immune Hence, the surgeon must always anticipate
pathologic processes of radiation injury
response include human immunodefi- the possibility of a complicated healing
start right away; however, the clinical and
ciency virus (HIV)-infected patients in following surgery or traumatic injury in
histologic features may not become appar-
advanced stages of the disease, patients on irradiated tissue. Wound dehiscence is
ent for weeks, months, or even years after
immunosuppressive therapy, and those common and the wound heals slowly or
treatment.34 The cellular and molecular
taking high-dose steroids for extended incompletely. Even minor trauma may
responses to tissue irradiation are imme-
periods.31 Studies indicate that HIV- result in ulceration and colonization by
diate, dose dependent, and can cause both
infected patients with CD4 counts of less opportunistic bacteria. If the patient can-
early and late consequences.35 DNA dam-
than 50 cells/mm3 are at significant risk of not mount an effective inflammatory
age from ionizing radiation leads to mitot-
poor wound outcome.32 Although newer response, progressive necrosis of the tis-
ic cell death in the first cell division after
immunosuppressive drugs, such as sues may follow. Healing can be achieved
cyclosporine, have no apparent effect on irradiation or within the first few divi- only by excising all nonvital tissue and
wound healing, other medications can sions. Early acute changes are observed covering the bed with a well-vascularized
retard the healing process both in rate and within a few weeks of treatment and pri- graft. Due to the relative hypoxia at the
quality by altering both the inflammatory marily involve cells with a high turnover irradiated site, tissue with intact blood
reaction and the cell metabolism. rate. The common symptoms of oral supply needs to be brought in to provide
The use of steroids, such as prednisone, mucositis and dermatitis result from loss both oxygen and the cells necessary for
is a typical example of how suppression of of functional cells and temporary lack of inflammation and healing. The progres-
the innate inflammatory process also replacement from the pools of rapidly sive obliteration of blood vessels makes
increases wound healing complications. proliferating cells. The inflammatory bone particularly vulnerable. Following
Exogenous corticosteroids diminish prolyl response is largely mediated by cytokines trauma or disintegration of the soft tissue
hydroxylase and lysyl oxidase activity, activated by the radiation injury. Overall cover due to inflammatory reaction, heal-
depressing fibroplasias, collagen formation, the response has the features of wound ing does not occur because irradiated
and neovascularity.33 Fibroblasts reach the healing; waves of cytokines are produced marrow cannot form granulation tissue.
site in a delayed fashion and wound strength in an attempt to heal the radiation injury. In such instances the avascular bone needs
is decreased by as much as 30%. Epithelial- The cytokines lead to an adaptive response to be removed down to the healthy por-
ization and wound contraction are also in the surrounding tissue, cause cellular tion to allow healing to proceed.
impaired. The inhibitory effects of gluco- infiltration, and promote collagen deposi-
corticosteriods can be attenuated to some tion. Damage to local vasculature is exac- Hyperbaric Oxygen Therapy
extent by vitamin A given concurrently. erbated by leukocyte adhesion to endothe- HBO therapy is based on the concept that
Most antineoplastic agents exert their lial cells and the formation of thrombi that low tissue oxygen tension, typically a par-
cytotoxic effect by interfering with DNA block the vascular lumen, further depriv- tial pressure of oxygen (PO2) of 5 to
or RNA production. The reduction in pro- ing the cells that depend on the vessels. 20 mm Hg, leads to anaerobic cellular
tein synthesis or cell division reveals itself The acute symptoms eventually start metabolism, increase in tissue lactate, and
as impaired proliferation of fibroblasts to subside as the constitutive cells gradual- a decrease in pH, all of which inhibit
and collagen formation. Attendant neu- ly recover their proliferative abilities. wound healing.64 HBO therapy entails the
tropenia also predisposes to wound infec- However, these early symptoms may not patient lying in a hyperbaric chamber
tion by prolonging the inflammatory be apparent in some tissues such as bone, and breathing 100% oxygen at 2.0 to
phase of wound healing. Because of their where cumulative progressive effects of 2.4 atmospheres for 1 to 2 hours. The
deleterious effect on wound healing, radiation can precipitate acute breakdown HBO therapy is repeated daily for 3 to
administration of antineoplastic drugs of tissue many years after therapy. The late 10 weeks. HBO increases the quantity of
should be restricted, when possible, until effects of radiation are permanent and dissolved oxygen and the driving pressure
such time that the potential for healing directly related to higher doses.36 Collagen for oxygen diffusion into the tissue. Corre-
complications has passed. hyalinizes and the tissues become increas- spondingly the oxygen diffusion distance
12 Part 1: Principles of Medicine, Surgery, and Anesthesia
is increased threefold to fourfold, and received special emphasis with respect to the hydroxylation process of proline and
wound PO2 ultimately reaches 800 to healing. Amino acids are critical for wound lysine. Healing wounds appear to be more
1,100 mm Hg. The therapy stimulates the healing with methionine, histidine, and sensitive to ascorbate deficiency than unin-
growth of fibroblasts and vascular arginine playing important roles. Nutri- jured tissue. Increased rates of collagen
endothelial cells, increases tissue vascular- tional deficiencies severe enough to lower turnover persist for a long time, and healed
ization, enhances the killing ability of serum albumin to < 2 g/dL are associated wounds may rupture when the individual
leukocytes, and is lethal for anaerobic bac- with a prolonged inflammatory phase, becomes scorbutic. Local antibacterial
teria. Clinical studies suggest that HBO decreased fibroplasia, and impaired neo- defenses are also impaired because ascorbic
therapy can be an effective adjunct in the vascularization, collagen synthesis, and acid is also necessary for neutrophil super-
management of diabetic wounds.65 Animal wound remodeling. As long as a state of oxide production. The B-complex vitamins
studies indicate that HBO therapy could be protein catabolism exists, the wound will and cobalt are essential cofactors in anti-
beneficial in the treatment of osteomyelitis be very slow to heal. Methionine appears to body formation, white blood cell function,
and soft tissue infections.66,67 Adverse be the key amino acid in wound healing. It and bacterial resistance. Depleted serum
effects of HBO therapy are barotraumas of is metabolized to cysteine, which plays a levels of micronutrients, including magne-
the ear, seizure, and pulmonary oxygen vital role in the inflammatory, proliferative, sium, copper, calcium, iron, and zinc, affect
toxicity. However, in the absence of con- and remodeling phases of wound healing. collagen synthesis.43 Copper is essential for
trolled scientific studies with well-defined Serum prealbumin is commonly covalent cross-linking of collagen whereas
end points, HBO therapy remains a con- used as an assessment parameter for pro- calcium is required for the normal function
troversial aspect of surgical practice.68,69 tein.40,41 Contrary to serum albumin, of granulocyte collagenase and other colla-
which has a very long half-life of about genases at the wound milieu. Zinc deficien-
Age 20 days, prealbumin has a shorter half- cy retards both fibroplasia and reepithelial-
In general wound healing is faster in the life of only 2 days. As such it provides a ization; cells migrate normally but do not
young and protracted in the elderly. The more rapid assessment ability. Normal undergo mitosis.44 Numerous enzymes are
decline in healing response results from serum prealbumin is about 22.5 mg/dL, a zinc dependent, particularly DNA poly-
the gradual reduction of tissue metabo- level below 17 mg/dL is considered a merase and reverse transcriptase. On the
lism as one ages, which may itself be a mild deficit, and a severe deficit would be other hand, exceeding the zinc levels can
manifestation of decreased circulatory below 11 mg/dL. As part of the perioper- exert a distinctly harmful effect on healing
efficiency. The major components of the ative optimization process, malnour- by inhibiting macrophage migration and
healing response in aging skin or mucosa ished patients may be provided with interfering with collagen cross-linking.
are deficient or damaged with progressive solutions that have been supplemented
injuries.37 As a result, free oxidative radi- with amino acids such as glutamine to Advances in Wound Care
cals continue to accumulate and are harm- promote improved mucosal structure An increased understanding of the wound
ful to the dermal enzymes responsible for and function and to enhance whole-body healing processes has generated height-
the integrity of the dermal or mucosal nitrogen kinetics. An absence of essential ened interest in manipulating the wound
composition. In addition the regional vas- building blocks obviously thwarts nor- microenvironment to facilitate healing.
cular support may be subjected to extrin- mal repair, but the reverse is not neces- Traditional passive ways of treating surgi-
sic deterioration and systemic disease sarily true. Whereas a minimum protein cal wounds are rapidly giving way to
decompensation, resulting in poor perfu- intake is important for healing, a high approaches that actively modulate wound
sion capability.38 However, in the absence protein diet does not shorten the time healing. Therapeutic interventions range
of compromising systemic conditions, dif- required for healing. from treatments that selectively jump-
ferences in healing as a function of age Several vitamins and trace minerals start the wound into the healing cascade,
seem to be small. play a significant role in wound healing.42 to methods that mechanically protect the
Vitamin A stimulates fibroplasia, collagen wound or increase oxygenation and perfu-
Nutrition cross-linking, and epithelialization, and will sion of the local tissues.45,46
Adequate nutrition is important for nor- restimulate these processes in the steroid-
mal repair.39 In malnourished patients retarded wound. Vitamin C deficiency Growth Factors
fibroplasia is delayed, angiogenesis impairs collagen synthesis by fibroblasts, Through their central ability to orches-
decreased, and wound healing and remod- because it is an important cofactor, along trate the various cellular activities that
eling prolonged. Dietary protein has with -ketoglutarate and ferrous iron, in underscore inflammation and healing,
Wound Healing 13
cytokines have profound effects on cell well as ciliary neurotrophic factor appear to bolus of exogenously applied growth fac-
proliferation, migration, and extracellular support the growth of sensory, sympathet- tor, gene transfer permits targeted, consis-
matrix synthesis.47 Accordingly newer ic, and motor neurons in vitro.5355 Insulin- tent, local delivery of peptides in high con-
interventions seek to control or modulate like growth factors have demonstrated sim- centrations to the wound environment.
the wound healing process by selectively ilar neurotrophic properties.56 Although Genes encoding for select growth factors
inhibiting or enhancing the tissue levels of most of the investigations hitherto have are delivered to the site of injury using a
the appropriate cytokines. been experimental, increasing sophistica- variety of viral, chemical, electrical, or
The more common clinical approach tion in the dosing, combinations, and deliv- mechanical methods.60 Cellular expression
has been to apply exogenous growth fac- ery of neurotropic growth factors will lead of the proteins encoded by the nucleic
tors, such as PGDF, angiogenesis factor, epi- to greater clinical application. acids help modulate healing by regulating
dermal growth factor (EGF), TGF, bFGF, Osteoinductive growth factors hold local events such as cell proliferation, cell
and IL-1, directly to the wound. However, special appeal to surgeons for their ability migration, and the formation of extracel-
the potential of these extrinsic agents has to promote the formation of new bone. Of lular matrix. The more popular methods
not yet been realized clinically and may the multiple osteoinductive cytokines, the for transfecting wounds involve the in vivo
relate to figuring out which growth factors bone morphogenetic proteins (BMPs) use of adenoviral vectors. Existing gene
to put into the wound, and when and at belonging to the TGF- superfamily have therapy technology is capable of express-
what dose. To date only a single growth fac- received the greatest attention. Advances in ing a number of modulatory proteins at
tor, recombinant human platelet-derived recombinant DNA techniques now allow the physiologic or supraphysiologic range
growth factor-BB (PDGF-BB), has been the production of these biomolecules in for up to 2 weeks.
approved by the United States Food and quantities large enough for routine clinical Numerous experimental studies have
Drug Administration for the treatment of applications. In particular, recombinant demonstrated the use of gene therapy in
cutaneous ulcers, specifically diabetic foot human bone morphogenetic protein-2 stimulating bone formation and regenera-
ulcers. Results from several controlled clin- (rhBMP-2) and rhBMP-7 have been stud- tion. Mesenchymal cells transfected with
ical trials show that PDGF-BB gel was effec- ied extensively for their ability to induce adenovirus-hBMP-2 cDNA have been
tive in healing diabetic ulcers in lower undifferentiated mesenchymal cells to dif- shown to be capable of forming bone when
extremities and significantly decreased ferentiate into osteoblasts (osteoinduc- injected intramuscularly in the thighs of
healing time when compared to the placebo tion). Yasko and colleagues used a rat seg- rodents.61,62 Similarly bone marrow cells
group.48,49 More recently, recombinant mental femoral defect model to show that transfected ex vivo with hBMP-2 cDNA
human keratinocyte growth factor 2 (KGF- rhBMP-2 can produce 100% union rates have been shown to heal femoral defects.63
2) has been shown to accelerate wound when combined with bone marrow.57 The Using osteoprogenitor cells for the expres-
healing in experimental animal models. It union rate achieved with the combination sion of bone-promoting osteogenic factors
enhanced both the formation of granula- approach was three times higher than that enables the cells to not only express bone
tion tissue in rabbits and wound closure of achieved with autologous cancellous bone growth promoting factors, but also to
the human meshed skin graft explanted on graft alone. Similarly, Toriumi and col- respond, differentiate, and participate in
athymic nude rats.50,51Experimental studies leagues showed that rhBMP-2 could heal the bone formation process. These early
suggest potential for the use of growth fac- mandibular defects with bone formed by studies suggest that advances in gene ther-
tors in facilitating peripheral nerve healing. the intramembranous pathway.58 The apy technology can be used to facilitate
Several growth factors belonging to the widespread application of osteoinductive healing of bone and other tissues and may
neurotrophin family have been implicated cytokines depends in large part on a better lead to better and less invasive reconstruc-
in the maintenance and repair of nerves. understanding of the complex interaction tive procedures in the near future.
Nerve growth factor (NGF), synthesized by of growth factors and the concentrations
Schwann cells distal to the site of injury, necessary to achieve specific effects. Dermal and Mucosal Substitutes
aids in the survival and development of Immediate wound coverage is critical for
sensory nerves. This finding has led some Gene Therapy accelerated wound healing. The coverage
investigators to suggest that exogenous The application of gene therapy to wound protects the wound from water loss, drying,
NGF application may assist in peripheral healing has been driven by the desire to and mechanical injury. Although autolo-
nerve regeneration following injury.52 selectively express a growth factor for con- gous grafts remain the standard for replac-
Newer neurotrophins such as brain-derived trolled periods of time at the site of tissue ing dermal mucosal surfaces, a number of
neurotrophic factor and neurotrophin-3 as injury.59 Unlike the diffuse effects of a bioengineered substitutes are finding their
14 Part 1: Principles of Medicine, Surgery, and Anesthesia
way into mainstream surgical practice. The 10. Sunderland S. Factors influencing the course of relation to wound healing in surgical
human skin substitutes available are regeneration and the quality of the recovery patients. Ann Surg 1991;214:60513.
after nerve suture. Brain 1952;75:1925. 28. Gottrup F. Oxygen, wound healing and the
grouped into three major types and serve as 11. Fu SY, Gordon T. The cellular and molecular development of infection. Present status.
excellent alternatives to autografts. The first basis of peripheral nerve regeneration. Mol Eur J Surg 2002;168:2603.
type consists of grafts of cultured epider- Neurobiol 1997;14(12):67116. 29. Krueger JK, Rohrich RJ. Clearing the smoke:
mal cells with no dermal components. The 12. Jilka RL. Biology of the basic multicellular unit the scientific rationale for tobacco absten-
second type has only dermal components. and the pathophysiology of osteoporosis. tion with plastic surgery. Plast Reconstr
Med Pediatr Oncol 2003;41:1825. Surg 2001;108:106373; discussion 10747.
The third type consists of a bilayer of both 13. Frost HM. A brief review for orthopedic sur- 30. Goodson WH III, Hunt TK. Wound healing in
dermal and epidermal elements. The chief geons: fatigue damage (microdamage) in well-controlled diabetic men. Surg Forum
effect of most skin replacements is to pro- bone (its determinants and clinical implica- 1984;35:6146.
mote wound healing by stimulating the tions). J Orthop Sci 1998;3:27281. 31. Burns J, Pieper B. HIV/AIDS: impact on healing.
14. Frost HM. From Wolff s law to the Utah para- Ostomy Wound Manage 2000;46(3):3040.
recipient host to produce a variety of
digm: insights about bone physiology and 32. Davis PA, Corless DJ, Gazzard BG, Wastell C.
wound healing cytokines. The use of cul- its clinical applications. Anat Rec Increased risk of wound complications and
tured skin to cover wounds is particularly 2001;262:398419. poor healing following laparotomy in HIV-
attractive inasmuch as the living cells 15. Huebsch RF, Hansen LS. A histopathologic seropositive and AIDS patients. Dig Surg
already know how to produce growth fac- study of extraction wounds in dogs. Oral 1999;16:607.
Surg Oral Med Oral Pathol 1969;28:18796. 33. Anstead GM. Steroids, retinoids, and wound
tors at the right time and in the right
16. Muller W. Split skin and full-thickness skin healing. Adv Wound Care 1998;11:27785.
amounts. The ultimate goal of bioengineers grafts. Mund Kiefer Gesichtschir 2000;4 34. Stone HB, Coleman CN, Anscher MS, McBride
is to develop engineered skin that contains Suppl 1:S31421. WH. Effects of radiation on normal tissue:
all of the components necessary to modu- 17. Branham GH, Thomas JR. Skin grafts. Oto- consequences and mechanisms. Lancet
late healing and allow for wound healing laryngol Clin North Am 1990;23:88997. Oncol 2003;4:52936.
18. Kingsley A. The wound infection continuum 35. Denham JW, Hauer-Jensen M. The radiothera-
with a surrogate that replicates native tissue
and its application to clinical practice. peutic injurya complex wound. Radio-
and limits scar formation. Ostomy Wound Manage 2003;49 Suppl ther Oncol 2002; 63:12945.
7A:17. 36. Tibbs MK. Wound healing following radiation
References 19. Robson MC, Krizek TK, Heggers JP. Biology of therapy: a review. Radiother Oncol
1. Singer AJ, Clark RA. Cutaneous wound heal- surgical infection. In: Ravitch MM, editor. 1997;42:99106.
ing. N Engl J Med. 1999;341:73846. Current problems in surgery. Chicago (IL): 37. Reed MJ, Koike T, Puolakkainen P. Wound
2. Hackam DJ, Ford HR. Cellular, biochemical, Yearbook Medical Publishers; 1973. p. 162. repair in aging. A review. Methods Mol
and clinical aspects of wound healing. Surg 20. Bowler PG. The 105 bacterial growth guideline: Med 2003;78:21737.
Infect (Larchmt) 2002;3 Suppl 1:S2335. reassessing its clinical relevance in wound 38. Fenske NA, Lober CW. Structural and func-
3. Clark RAF. Biology of dermal wound repair. healing. Ostomy Wound Manage 2003; tional changes of normal aging skin. J Am
Dermatol Clin 1993;11:64766. 49(1):4453. Acad Dermatol 1986;15(4 Pt 1):57185.
4. Steed DL. Wound-healing trajectories. Surg 21. Rahban SR, Garner WL. Fibroproliferative 39. Badwal RS, Bennett J. Nutritional considera-
Clin North Am 2003;83:54755. scars. Clin Plast Surg 2003;30(1):7789. tions in the surgical patient. Dent Clin
5. Werner S, Grose R. Regulation of wound heal- 22. Urioste SS, Arndt KA, Dover JS. Keloids and North Am 2003;47:37393.
ing by growth factors and cytokines. Physi- hypertrophic scars: review and treatment 40. Cartwright A. Nutritional assessment as part of
ol Rev 2003;83:83570. strategies. Semin Cutan Med Surg wound management. Nurs Times 2002;
6. McCartney-Francis NL, Wahl SM. TGF-beta 1999;18:15971. 98(44):623.
and macrophages in the rise and fall of 23. Burns JL, Mancoll JS, Phillips LG. Impairments 41. Collins N. The difference between albumin and
inflammation. In: Breit SN, Wahl SM, edi- to wound healing. Clin Plast Surg prealbumin. Adv Skin Wound Care
tors. TGF-beta and related cytokines in 2003;30:4756. 2001;14:2356.
inflammation. Basel: Birkhauser; 2001. p. 24. Bowler PG. Wound pathophysiology, infection 42. Ayello EA, Thomas DR, Litchford MA. Nutri-
6590. and therapeutic options. Ann Med 2002; tional aspects of wound healing. Home
7. Niesler CU, Ferguson MWJ. TGF-beta super- 34:41927. Healthc Nurse Manag 1999;17:71929.
family cytokines in wound healing. In: Breit 25. Hunt TK, Hopf H, Hussain Z. Physiology of 43. Scholl D, Langkamp-Henken B. Nutrient rec-
SN, Wahl SM, editors. TGF-beta and related wound healing. Adv Skin Wound Care ommendations for wound healing. J Intra-
cytokines in inflammation. Basel: 2000;13 Suppl 2:611. ven Nurs 2001; 24(2):12432.
Birkhauser; 2001. p. 17398. 26. Hunt TK, Conolly WB, Aronson SB, et al. 44. Tengrup I, Ahonen J, Zederfeldt B. Granulation
8. Thanos PK, Okajima S, Terzis JK. Ultrastruc- Anaerobic metabolism and wound healing: tissue formation in zinc-treated rats. Acta
ture and cellular biology of nerve regenera- a hypothesis for the initiation and cessation Chir Scand 1980;146:14.
tion. J Reconstr Microsurg 1998;14:42336. of collagen synthesis in wounds. Am J Surg 45. Krishnamoorthy L, Morris HL, Harding KG. A
9. Sunderland S. A classification of peripheral 1978;135:32832. dynamic regulator: the role of growth fac-
nerve injuries producing loss of function. 27. Jonsson K, Jensen JA, Goodson WH, et al. Tis- tors in tissue repair. J Wound Care
Brain 1951;74:4917. sue oxygenation, anemia, and perfusion in 2001;10(4):99101.
Wound Healing 15
46. Sefton MV, Woodhouse KA. Tissue engineer- rotrophins NT-3 and BDNF. Nature genetic protein-2 gene transfer induces
ing. J Cutan Med Surg 1998;3 Suppl 1993;363:3502. mesenchymal progenitor cell proliferation
1:S123. 55. Lewin S, Utley D, Cheng E, et al. Simultaneous and differentiation in vitro and bone forma-
47. Rumalla VK, Borah GL. Cytokines, growth fac- treatment with BDNF and CNTF after tion in vivo. J Orthop Res 1999;17:4350.
tors, and plastic surgery. Plast Reconstr peripheral nerve transection and repair 63. Lieberman JR, Daluiski A, Stevenson S, et al.
Surg 2001;108:71933. enhances rate of functional recovery com- The effect of regional gene therapy with
48. Wieman TJ, Smiell JM, Su Y. Efficacy and safe- pared with BDNF treatment alone. Laryn- bone morphogenetic protein-2-producing
ty of a topical gel formulation of recombi- goscope 1997;107:9929. bone-marrow cells on the repair of segmen-
nant human platelet-derived growth factor- 56. Glazner G, Lupien S, Miller J, Ishii D. Insulin- tal femoral defects in rats. J Bone Joint Surg
BB (Becaplermin) in patients with non like growth factor II correlates the rate of 1999;81A:90517.
healing diabetic ulcers: a phase III, random- sciatic nerve regeneration in rats. Neuro- 64. Broussard CL. Hyperbaric oxygenation and
ized, placebo-controlled, double-blind science 1993;54:7917. wound healing. J Wound Ostomy Conti-
study. Diabetes Care 1998;21:8227. 57. Yasko AW, Lane JM, Fellinger EJ, et al. The nence Nurs 2003;30:2106.
49. Steed DL. Clinical evaluation of recombinant healing of segmental bone defects, induced 65. Faglia E, Favales F, Aldeghi A, et al. Adjunctive
human platelet-derived growth factor for by recombinant human bone morpho- systemic hyperbaric oxygen therapy in
the treatment of lower extremity diabetic genetic protein (rhBMP-2): a radiographic, treatment of severe prevalently ischemic
ulcers. Diabetic Ulcer Study Group. J Vasc histological, and biomechanical study in diabetic foot ulcer. A randomized study.
Surg 1995;21:7181. rats. J Bone Joint Surg 1992;74A:65970. Diabetes Care 1996;19:133843.
50. Xia YP, Shao Y, Marcus J, et al. Effects of ker- 58. Toriumi DM, Kotler HS, Luxenberg DP, et al. 66. Bakker DJ. Hyperbaric oxygen therapy and the
atinocyte growth factor-2 (KGF-2) on Mandibular reconstruction with a recombi- diabetic foot. Diabetes Metab Res Rev
wound healing in an ischemia-impaired nant bone-inducing factor: functional, his- 2000;16 Suppl 1:S558.
rabbit ear model and on scar formation. J tologic, and biomechanical evaluation. 67. Mader JT, Guckian JC, Glass DL, Reinarz JA.
Pathol 1999;188:4318. Arch Otolaryngol Head Neck Surg 1991; Therapy with hyperbaric oxygen for exper-
51. Soler PM, Wright TE, Smith PD, et al. In vivo 117:110112. imental osteomyelitis due to Staphylococcus
characterization of keratinocyte growth 59. Braun-Falco M. Gene therapy concepts for aureus in rabbits. J Infect Dis 1978;
factor-2 as a potential wound healing agent. promoting wound healing. Hautarzt 138:3128.
Wound Repair Regen 1999;7:1728. 2002;53(4):23843. 68. Guo S, Counte MA, Romeis JC. Hyperbaric
52. He C, Chen Z, Chen Z. Enhancement of motor 60. Hoeller D, Petrie N, Yao F, Eriksson E. Gene oxygen technology: an overview of its appli-
neuron regeneration by nerve growth fac- therapy in soft tissue reconstruction. Cells cations, efficacy, and cost-effectiveness. Int J
tor. Microsurgery 1992;13:1514. Tissues Organs 2002; 172(2):11825. Technol Assess Health Care 2003;19:33946.
53. Utley D, Lewin S, Cheng E, et al. Brain derived 61. Lieberman JR, Le LQ, Wu L, et al. Regional 69. Coulthard P, Esposito M, Worthington HV,
neurotrophic factor and collagen tubuliza- gene therapy with a BMP-2-producing Jokstad A. Therapeutic use of hyperbaric
tion enhance functional recovery after murine stromal cell line induces hetero- oxygen for irradiated dental implant
peripheral nerve transection and repair. Arch topic and orthotopic bone formation in patients: a systematic review. J Dent Educ
Head Neck Surg 1996;122:40713. rodents. J Orthop Res 1998;16:3309. 2003;67(1):648.
54. Lohof A, Ip N, Poo M. Potentiation of develop- 62. Lou J, Xu F, Merkel K, et al. Gene therapy: ade- 70. Bissell MJ, Radisky D. Putting tumors in con-
ing neuromuscular synapses by the neu- novirus-mediated human bone morpho- text. Nature Rev Canc 2001;1:4654.
CHAPTER 2
Medical Management
of the Surgical Patient
James R. Hupp, DMD, MD, JD, MBA
David N. Duddleston, MD
Oral-maxillofacial surgery frequently the healthy patient. A preoperative patient should be questioned regarding their exer-
causes temporary but clinically significant questionnaire has been used in determin- cise tolerance with a question such as, If I
alteration of the anatomy and physiology ing whether any further risk should be asked you to walk as far as you could, how
of the upper aerodigestive tract, but has ascertained.1 The questions in Table 2-1 far would that be? This may be answered
minor direct impact on vital organ sys- have been valuable in preoperative patient as a function of time or distance. It is help-
tems. Therefore, the surgery itself is gener- evaluation. ful to ask, When was the last time you
ally safe to perform even on relatively In addition to this group of questions, walked that far? If there is a limitation of
unhealthy individuals. However, the phys- other questionnaire-type screening tools exercise, then ask, What is the reason for
iologic stresses produced by surgery and can be valuable. Exercise capacity, such as the limitation? It may be due to orthopedic
the anesthetic techniques necessary for the 6-minute walk test, use of medications or other musculoskeletal problems that
these procedures can lead to serious mor- and herbal supplements, and age can be limit exercise, or cardiac or pulmonary
bidity and mortality. This is especially true important determinants of perioperative insufficiency.
in patients with various organs on the risks.2 Exercise tolerance has been shown to Medication use is important, and with
brink of decompensation due to disease or predict long-term mortality as well as the use of a plethora of over-the-counter
comorbid conditions. short-term perioperative risks.3 All patients medications and dietary supplements,
This chapter presents the common
medical situations that can compromise
the successful outcome of oral or maxillo- Table 2-1 Preoperative Patient Questionnaire
facial surgery. Emphasis is given to the 1. Do you feel unwell?
means of detecting health problems pre- 2. Have you ever had any serious illnesses in the past?
operatively and preparing patients with 3. Do you get any more short of breath on exertion than other people of your age?
various medical disorders so that compli- 4. Do you have any coughing?
cations in the perioperative period are 5. Do you have any wheezing?
avoided or minimized. The liberal use of 6. Do you have any chest discomfort on exertion?
medical consultations is highly recom- 7. Do you have any ankle swelling?
mended for all situations in which a sur- 8. Have you taken any medicine or pills in the past 3 months (including excess alchol)?
geon has concerns for the medical well- 9. Do you have any allergies?
being of a surgical patient. 10. Have you had an anesthetic in the past 2 months?
11. Have you or your relatives had any problems with a previous anesthetic?
Most commonly oral-maxillofacial
12. What is the date of your last menstrual period?
surgery is performed on healthy patients.
13. Do you observe any serious abnormality from end of bed that might affect
A quick screen of health conditions may anesthetic? (Clinicians observation)
give additional data in the evaluation of
18 Part 1: Principles of Medicine, Surgery, and Anesthesia
specific questioning is in order. Aspirin 5. Pregnancy test for women who may be compromise the hearts ability to maintain
or other nonsteroidal anti-inflammatory pregnant adequate blood pressure intra- or postop-
drug use may exacerbate bleeding during 6. Hematocrit for surgery with expected eratively. These conditions include coro-
major surgery. Some herbal supplements major blood loss nary artery disease, valvular disease, vari-
are known to increase the risk of bleeding 7. Serum creatinine concentration if ous processes predisposing the heart to
as well.4 undergoing major surgery, hypoten- congestive failure, and abnormalities of
Finally age can be used as a surrogate sion is expected, nephrotoxic drugs electrical impulse generation or conduc-
for underlying disease or decreased reserve. will be used, or the patient is over age tion. In the discussion of the four condi-
There are no absolute cutoffs for age in esti- 50 years tions that follows, emphasis is on the
mation of risk; age of 70 years is used as a 8. Electrocardiogram (ECG) recommen- means of assessing the degree of cardiac
benchmark for a separate risk factor in sur- dations as above, unless obtained compromise and reserve, of improving the
gical mortality. Laboratory testing may be within the previous month situation preoperatively, and of managing
helpful in a small subset of patients. Rou- 9. Chest radiograph for patients over the condition perioperatively.
tine testing requirements may vary from 60 years, or for those with suspected
operative center, office, or hospital, but in cardiac or pulmonary disease, if such Coronary Artery Disease
general there is often overtesting and imaging has not been performed The two principal processes that cause an
under-review of the results. If guidelines at within the past 6 months insufficient blood supply to the myocardi-
a particular center have been established, it 10. Other tests only if the clinical evalua- um are coronary artery obstruction and
is important to use a checklist of the tests, tion suggests a likelihood of disease spasm. Myocardial ischemia will occur
including their results. Many of these tests when the supply of oxygen is inadequate
are arbitrary and not supported by evi- to meet the demand for oxygen. Myocar-
dence-based research. However, it is not Cardiac Disease dial oxygen need is increased when the
unreasonable to establish a schedule of rou- Cardiac disease is common in the North heart has increased rate or mass, or is
tine testing in unselected patients. While American and other populations, and the forced to work against an increased after-
most young and apparently healthy patients patient is usually well aware of any existing load that increases end-diastolic wall ten-
do not need any preoperative laboratory cardiac problem. Thus, it is essential to sion. In these situations symptoms of
testing, unselected adults over the age of screen for cardiovascular disease, and recent ischemia will occur if oxygen supply to the
40 years may benefit from a preoperative interventions have shown the ability to myocardium cannot be increased because
hematocrit and tests of renal function and greatly reduce perioperative risks in patients the coronary arteries are critically nar-
blood glucose. A blood count may reveal with known or suspected cardiac disease. rowed by fixed atheromatous lesions
anemia or serve as a benchmark when Preservation of cardiac health is an and/or spasm; clinically this is manifested
excessive blood loss or anemia is found essential element of any perioperative pro- by exercise-induced angina pectoris.
after surgery. Glucose determination is tocol. The proper match of oxygen supply to Coronary artery disease is one of the
helpful in those patients with diabetes or oxygen use in myocardial tissue is the key to most studied diseases in humans. Over the
obesity, and serves as a useful screening tool maintaining normal contractility and elec- past several years new paradigms regard-
for diabetes in the general population.5 trical activity. In the patient with a healthy ing coronary artery disease have emerged
The preoperative evaluation of healthy heart and lungs, the myocardium is protect- and have been validated. The idea of a
patients should include the following6,7: ed in the perioperative period by avoiding hard plaque slowly encircling the lumen of
hypovolemia, ensuring adequate oxygen- a coronary artery until occlusion has
1. A screening questionnaire for all carrying capacity of the blood, keeping occurred has been replaced by the concept
patients (see Table 2-1) serum electrolytes within physiologic limits, of plaque rupture. Many plaques in the
2. A history of exercise tolerance for all and supplying the lungs with adequate oxy- lumen of the coronary vessels are consid-
patients gen. Cardiac output also depends on prop- ered to be soft, with a membrane or thin
3. Blood pressure and pulse for all erly functioning valves. Finally the load cell layer covering a highly thrombogenic
patients against which the ventricles must work lipid core. This membrane may rupture
4. History and physical examination if should stay within reasonable limits to pre- even in small lesions, exposing thrombo-
one of the above is abnormal, in serve optimal myocardial function. genic materials into the blood. This sets up
patients over 60 years, or in those Several cardiac conditions can exist an immediate clotting cascade resulting in
undergoing major surgery preoperatively that have the potential to thrombus formation, occluding the vessel
Medical Management of the Surgical Patient 19
and precipitating myocardial infarction or Typically these symptoms are reproducible. 35 years and older, all females age 45 years
unstable angina.8,9 Patients who have angina symptoms that and older, and all other patients with a his-
Coronary artery disease includes the are progressive with less precipitating forces, tory suggestive of cardiac disease.13 More
progression of an endothelial lesion from angina with increasing frequency, or angina elaborate routine cardiac testing is unwar-
a fatty streak to an occlusive lesion or at rest are considered to have unstable angi- ranted. Although it is unlikely to see rest-
plaque rupture as noted above. Several risk na and require evaluation by a qualified car- ing ECG changes suggestive of acute
factors for coronary artery disease have diovascular specialist. ischemia, old silent infarcts (representing
been identified, including family history of There are no standard physical signs 20 to 60% of all infarctions) or conduction
early coronary disease (under age 65 yr), of coronary artery insufficiency so preop- blocks due to coronary disease may be
male gender, diabetes mellitus, and elevat- erative screening relies on historic infor- detected.14 It should be noted that 30% of
ed cholesterol, including total cholesterol mation and electrocardiography. A cardio- patients with a history of myocardial
and/or low-density lipoprotein (LDL) vascular examination may show evidence infarction have a normal resting ECG.15
cholesterol. High levels of LDL cholesterol, of vascular or valvular disease, or some ECG after controlled treadmill exercise is a
low levels of high-density lipoprotein cho- degree of cardiac decompensation. Symp- more sensitive means of detecting
lesterol, hypertension, and cigarette smok- toms of compromised coronary or carotid ischemic tendencies as evidenced by ST
ing are the most predictive risk factors of arteries should be sought preoperatively in depression or T-wave inversion. Patients
coronary artery disease. Additional risk all adult males, as well as in menopausal with a past history of cardiac disease
factors such as elevated levels of homocys- and postmenopausal females. should have preoperative posteroanterior
teine, C-reactive protein, myeloperoxidase and lateral chest radiographs to detect
and others are being evaluated.10 Interest- Physical Examination The physical early signs of congestive heart failure.
ingly a large percentage of patients with examination in patients with coronary Finally a thallium stress test can be used,
first-time myocardial infarction do not artery disease is frequently unrevealing. but only in the case of an equivocal tread-
have known risk factors for coronary The history is the most important deter- mill test, or coronary angiography can be
artery disease.11,12 minant of risk. However, a cardiovascular performed to identify areas of narrowing,
As noted above, a plaque may progress examination may show evidence of vascu- which predispose the patient to periopera-
to cause a limitation of flow of blood lar disease, valvular disease, or evidence of tive myocardial ischemia if clinical indica-
through the coronary artery to the cardiac decompensation. tions for angiography are present.
myocardial tissue. Myocardial ischemia Patients with findings of peripheral All patients with a documented history
produces decreased myocardial contractil- vascular disease should be considered at of angina may have an increased risk of
ity rapidly leading to systemic hypoten- high risk for underlying coronary artery perioperative infarction. This risk varies
sion and pulmonary vascular congestion. disease. On heart examination an S4 may with the severity of the coronary disease
The limitation of flow leads to the symp- be present, reflecting reduced compliance and the degree of physiologic stress in the
tom of angina. Patients may complain of a in an ischemic myocardium. Auscultation perioperative period. Patients with stable
squeezing, choking, or tight feeling in the of the neck, periumbilical area of the angina have only a slightly raised risk dur-
substernal region radiating to the throat, abdomen, and inguinal areas should be ing anesthesia and surgery compared to the
jaw, shoulders, or arms. The patient may used to detect bruits. In addition, pedal normal population. Angina that is worsen-
also experience dyspnea, diaphoresis, and pulses and inguinal pulses should be ing with respect to frequency, duration,
nausea. Anginal symptoms will dissipate checked. Diminished or absent pulses, response to medication, or ease of produc-
soon after the provoking activity ceases or cool feet, and skin changes such as hair tion is, by definition, unstable angina.
after transmucosal nitroglycerin is admin- loss in the ankles and feet may indicate Surgery in such a situation should only pro-
istered. Infarction symptoms will usually peripheral vascular disease. Specific ques- ceed if required emergently. Patients with
persist despite nitroglycerin use or rest. tioning about problems occurring during stable but poorly controlled angina need
It is important to ask patients suspected physical activity or postprandially should medical intervention to improve their car-
of having coronary artery disease if they be included. It must be remembered that diac status before most elective surgery.
have discomfort with exertion, rather than many patients with first time myocardial The American College of Cardiology
focusing on pain. A patient may give a his- infarction have no known risk factors. has produced a listing of major, intermedi-
tory of dyspnea and chest tightness, among A resting ECG should be done within ate and minor cardiovascular risk factors
other symptoms, after exertion, eating a a month of a planned elective general and matched these with a listing of higher-
heavy meal, or entering a cold environment. anesthetic and surgery in all males age risk operations. These risks are then entered
20 Part 1: Principles of Medicine, Surgery, and Anesthesia
into a straightforward algorithm directed to hypotension is avoided. Although some antagonism, blood pressure control, and
decisions on invasive testing, noninvasive studies indicate the risk of infarction prompt dysrhythmia recognition and man-
testing, intervention or progression to increases with the duration of surgery, this agement. To assist with these goals consider-
surgery (Table 2-2 and Figure 2-1).16 Risk has only been well documented in the case ation should be given to radial artery
reduction strategies have also evolved, with of major thoracic or upper abdominal pro- cannulation for blood gas and pH measure-
reduced emphasis on preoperative testing. cedures.18,19 In general, nonurgent surgery ment and precise blood pressure monitor-
The newest risk reduction strategy includes should be postponed for at least 6 weeks ing. The presence of signs of chronic con-
the use of -blockade in patients with after myocardial infarction. Patients who gestive failure following a myocardial
known coronary artery disease or with risk need nonurgent surgery in this 6-week win- infarction increases operative risk, as is dis-
factors for coronary artery disease.17 dow should be co-managed by a cardiolo- cussed later in this chapter.
Patients with stable, well-controlled gist. Modern day general anesthesia may The risk of general anesthesia after a
angina, or who have delayed surgery after an actually be protective of the myocardium, recent myocardial infarction is due to pos-
uncomplicated myocardial infarction for a because supraphysiologic levels of oxygen sible extension of the earlier myocardial
period dictated by their cardiologist, can are administered and cardiac work is mini- infarction and the development of cardiac
usually undergo elective maxillofacial pro- mized through maintenance of muscle dysrhythmias. A target-like zone is
cedures safely if intraoperative hyper- or relaxation, sympathetic nervous system described in myocardial infarction, with
the center being infarcted tissue. It is a
zone surrounding this infarcted tissue that
Table 2-2 Clinical Predictors of Increased Perioperative Cardiovascular Risk is considered to be stunned or vulnerable.
(Myocardial Infarction, Heart Failure, Death) This zone is the area into which the
Major myocardial infarction may extend and
Unstable coronary syndromes
from which dysrhythmias can be generat-
Acute or recent myocardial infarction* with evidence of important ischemic risk by ed. After the 6-week window has passed,
clinical symptoms or noninvasive study the patient can be evaluated as any other
Unstable or severe angina (Canadian Class III or IV)133 coronary artery disease patient.20
Decompensated heart failure Patients with coronary artery disease
Significant dysrhythmias have their greatest risk of cardiac problems
High-grade atrioventricular block in the early postoperative period. The car-
Symptomatic ventricular dysrhythmias in the presence of underlying heart disease diorespiratory system is no longer con-
Supraventricular arrhythmias with uncontrolled ventricular rate trolled by general anesthesia, and the nor-
Severe valvular disease mal stresses that occur in the early
Intermediate recovery period exist. There is usually a
need for increased cardiac output, which
Mild angina pectoris (Canadian Class I or II)
Previous myocardial infarction by history or pathological Q waves
the diseased heart may not be able to
Compensated or prior heart failure deliver or tolerate, and ischemia can result.
Diabetes mellitus (particularly insulin-dependent) Therefore, these patients need frequent
Renal insufficiency cardiopulmonary physical examinations
and close monitoring of vital signs, urine
Minor
output, jugular venous pressure, and elec-
Advanced age trolytes. An immediate postoperative ECG
Abnormal electrocardiogram (left ventricular hypertrophy, left bundle-branch block, should be obtained in patients with a his-
ST-T abnormalities) tory of coronary artery disease, particular-
Rhythm other than sinus (eg, atrial fibrillation) ly if they have any of the following:
Low functional capacity (eg, inability to climb one flight of stairs with a bag of groceries)
History of stroke
Unexplained hypotensive or syncopal
Uncontrolled systemic hypertension
episode
*The American College of Cardiology National Database Library defines recent myocardial infarction as greater than 7 days
but less than or equal to 1 month (30 days); acute myocardial infarction is within 7 days. Signs of heart failure
May include stable angina in patients who are unusually sedentary. Dysrhythmias
Adapted from Eagle KA et al.16
Angina
Medical Management of the Surgical Patient 21
Urgent or
elective surgery No
Coronary
Recurrent
STEP 2 revascularization Yes symptoms or signs?
within 5 years?
No Yes
Undesirable result or
No change in symptoms
Clinical
predictors
Consider delay
Consider coronary Go to step 6 Go to step 7
or cancel noncardiac
surgery angiography
Intermediate Minor or no
STEP 6 Clinical predictors clinical predictors STEP 7 Clinical predictors clinical predictors
Moderate or Moderate or
Functional capacity Poor Functional capacity Poor
excellent excellent
(< 4 METs) (< 4 METs)
(> 4 METs) (> 4 METs)
Consider Consider
Invasive testing coronary Invasive testing coronary
angiography angiography
FIGURE 2-1 Stepwise approach to preoperative cardiac assessment. Steps are discussed in the text. Note that subsequent care may include cancellation or delay of
surgery, coronary revascularization followed by noncardiac surgery, or intensified care. MET = metabolic equivalent. *Major clinical predictors include unstable
coronary syndromes, decompensated congestive heart failure, significant dysrhythmias, and severe valvular disease. Intermediate clinical predictors include mild
angina pectoris, prior myocardial infarction, compensated or prior congestive heart failure, diabetes mellitus, and renal insufficiency. Minor clinical predictors
include advanced age, abnormal electrocardiogram, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled systemic hypertension.
Adapted from from Eagle KA et al.16
22 Part 1: Principles of Medicine, Surgery, and Anesthesia
Care in the postoperative period using vasodilators, especially angiotensin- Diagnostic testing for patients with
should be taken to maintain normal converting enzyme (ACE) inhibitors, is an heart failure includes an ECG, which may
intravascular volume, avoid hyper- or important treatment in heart failure, cer- show Q waves of a previous myocardial
hypotension, keep serum electrolytes in tain valvular abnormalities, and hyperten- infarction, elevated QRS amplitude of left
their physiologically normal ranges, man- sion. For instance, afterload reduction in ventricular hypertrophy, or low QRS ampli-
age patient anxiety and pain, give supple- systolic dysfunction reduces the work of tude in some patients with severe myocar-
mental oxygen when needed, and resume the left ventricle against the normal arter- dial dysfunction. An echocardiogram may
preoperative cardiac medications. Signs of ial pressure. This reduces demand on the show evidence of diastolic dysfunction
infections or pulmonary problems should heart. Compliance refers to the ability of through measurements of compliance, or
be pursued aggressively. the heart to distend. Reduced compliance may show wall motion abnormalities and
in the left ventricle is described as a stiff- reduced ejection fraction.
Left Ventricular Dysfunction Left ventric- ness or alteration in the diastolic filling of Management of congestive heart fail-
ular dysfunction can result from myocardial the left ventricle. If the left ventricle does ure is indicated when evidence of decom-
infarction or primary cardiomyopathy. Left not fill properly during the cardiac cycle, pensation is present. Decompensation is
ventricular dysfunction can be separated pulmonary congestion can occur, even manifested by increased symptoms of dys-
into systolic or diastolic dysfunction. Sys- though the apparent forward flow of pnea on exertion or PND, the presence of
tolic dysfunction occurs after myocardial blood is not impaired. an S3 gallop rhythm, distended neck veins,
infarction or other direct muscle injury, Left ventricular systolic dysfunction or an increase in peripheral edema.22 The
causing either wall motion abnormalities or can be tolerated within the reserve capaci- decision is then made whether or not to
decreased cardiac output. Diastolic dysfunc- ty of the individual, or may manifest itself admit the patient to the hospital for treat-
tion results from stiffness or reduced com- as congestive heart failure. As noted above ment or to advanced treatment as an out-
pliance of the left ventricle.21 it can be due to insults, such as myocardial patient. This is determined more by the
Concepts of preload, afterload, and infarction, viral myocarditis, or direct severity of the heart failure than the
compliance are useful to know when dis- trauma to the heart. In addition there may urgency of the surgery. In either case the
cussing left ventricular dysfunction. Pre- be global dysfunction due to more wide- management includes starting or increas-
load is thought of as volume being pre- spread ischemia, idiopathic cardiomyopa- ing diuretic therapy, reducing afterload,
sented to the right heart. The right heart is thy, or valvular abnormalities. and in some cases, increasing contractility
a low-pressure chamber, handling the Symptoms suggesting congestive heart of the heart. If a diuretic has not been pre-
influx of blood via the right atrium. Excess failure include dyspnea on exertion, scribed, furosemide 20 mg daily for 3 to 4
volume may be presented to the pul- paroxysmal nocturnal dyspnea (PND), days should suffice in reducing total body
monary vasculature, resulting in pul- nighttime cough, and ankle swelling. salt and water. If a diuretic has already
monary congestion or pulmonary edema. Patients with PND may sit up on the side been prescribed, doubling of the dose is
Preload problems can occur from left of the bed for a moment and then get up indicated. Rarely a second diuretic such as
heart failure causing fluid to back up into to drink a glass of water. Patients with metolazone would be added to boost the
the pulmonary arterial tree, or may also be severe heart failure may sleep in a sitting loop diuretic.
due to reduced compliance in the left ven- position or slumped against a countertop. Afterload reduction is a key tenet in the
tricle. Rarely isolated right-sided ventricu- On physical examination of the heart treatment of congestive heart failure.23 An
lar failure occurs, such as from pulmonary there may be an S3 gallop rhythm and the ACE inhibitor is first-line treatment for
hypertension or right ventricular infarc- point of maximal impulse (PMI) may be congestive heart failure and would be
tion. Excess preload is usually managed shifted laterally and inferiorly. In addition added or increased in dose during an
with diuretic therapy or fluid restriction. a diffuse PMI may be present. A murmur episode of decompensated congestive heart
Afterload refers to the pressure in the of mitral insufficiency may be present due failure. Typically the systolic blood pressure
aorta against which the left ventricle must to dilated annulus of the heart. The neck is lowered to between 90 and 110 mm Hg
pump. This arterial resistance or afterload veins, which should be flat with the unless significant hypertension was in-
may be increased in hypertension and aor- patients chest being elevated 30, may be volved in the decompensation. After appro-
tic stenosis. Afterload may also be relative distended. On lung examination rales may priate diuretic therapy and ACE inhibition,
to the pumping capacity of the left ventri- be present from pulmonary congestion attention may be turned to systolic contrac-
cle; hence normal blood pressures may and there may be dullness to percussion tility. In cases of dilated cardiomyopathy
impair a failing heart. Afterload reduction from pleural effusions. the addition of digoxin can be helpful. Its
Medical Management of the Surgical Patient 23
applicability in other types of heart failure Fortunately the incidence of new cases of to the appearance of atrial fibrillation (AF)
is questionable. Digoxin therapy should be this problem has decreased substantially with possible atrial thrombus formation
guided by serum digoxin levels. In addition, since the use of antibiotics to manage and systemic arterial embolization.25,26
treatment of decompensated congestive streptococcal infections became common Examination of the patient with clini-
heart failure should include monitoring of practice. The rheumatic disease process cally significant mitral stenosis may reveal
electrolytes. If a patients known congestive causes valve fibrosis, fusion, and calcifica- an early diastolic opening snap followed
heart failure is compensated, the patients tion. These changes limit valve motion, by a low-pitched murmur and a loud first
surgical risk is greatly reduced toward nor- thus restricting the flow of blood into the heart sound. Patients in AF will character-
mal.24 If the patient has reasonable func- left ventricle. The latency period is usually istically have an irregularly irregular pulse.
tional capacity, for instance is able to walk 15 to 20 years. Once valve obstruction A chest radiograph will reveal an enlarged
two blocks or more without shortness of occurs the patient will begin to suffer left atrium, pulmonary vascular enlarge-
breath, the risk factor of heart failure can be gradually worsening exertional dyspnea ment, and in more severe cases right ven-
discounted, and the patient can come to and fatigue due to pulmonary vascular tricular hypertrophy. An ECG may reveal
surgery. In summary a patient with decom- congestion and progressive right heart AF, left atrial enlargement, and right ven-
pensated heart failure is at high risk for failure. Left arterial enlargement may lead tricular hypertrophy. Echocardiography is
major cardiac events, but this risk can be
greatly reduced with appropriate manage-
Table 2-3 Cardiac Conditions Associated with Infectious Endocarditis
ment, including diuretic therapy, afterload
reduction, and digoxin therapy when need- High-Risk Category: Prophylaxis Recommended
ed. Diastolic decompensation is usually Prosthetic cardiac valves
treated acutely with diuretic therapy alone, Previous infectious endocarditis
using afterload reduction and the use of - Complex cyanotic congenital heart disease
blockers if hypertension is present or fur- Moderate-Risk Category: Prophylaxis Recommended
ther treatment is needed. While -blockers
Most other congenital malformations
are often used in dilated cardiomyopathy,
Acquired valvular dysfunction
acute use in the treatment of decompensa-
Hypertropic cardiomyopathy
tion is not recommended. Mitral valve prolapse with valvular regurgitation
Valvular Heart Disease Negligible-Risk Category: Prophylaxis NOT Recommended
Most patients with valvular heart disease Coronary artery bypass graft
who have few symptoms or limitations of Mitral valve prolapse without regurgitation
activity can safely undergo most elective Physiologic, functional, or innocent heart murmur
maxillofacial surgery. Diseased cardiac Isolated secundum atrial septal defect
valves pose two general risks: precipitation Surgical repair of atrial septal defect; patent ductus arteriosus
Previous rheumatic fever without valvular dysfunction
of cardiac failure and susceptibility to
infective endocarditis. The likelihood of Oral Procedures in which Prophylaxis is Recommended
causing failure or worsening preexisting Dental extractions and biopsies
cardiac failure is dependent on the loca- Periodontal procedures
tion and severity of valve pathology. Pro- Dental implant placement
phylactic antibiotics should be used for all Periapical endodontic procedures
patients with a cardiac value abnormality Intraligamentary local anesthetic injections
with a resultant murmur who undergo Dental prophylaxis when bleeding is expected
maxillofacial procedures in which bleed- Other procedures causing intraoral bleeding
ing occurs (Tables 2-3 and 2-4 ). Oral Procedures in which Prophylaxis is NOT Recommended
Routine local anesthetic injection
Mitral Stenosis Mitral stenosis is almost Intracanal endodontic therapy
always a sequela of childhood rheumatic Suture removal
heart disease, although a definite history Taking impressions
can be obtained in only half of such cases.
24 Part 1: Principles of Medicine, Surgery, and Anesthesia
Table 2-4 Antibiotic Regimen for Prophylaxis of Infectious Endocarditis dimension of more than 55 mm indicates
left ventricular dysfunction). Doppler stud-
Situation Antibiotic Regimen
ies or cardiac angiography can be used to
Standard Amoxicillin Adults: 2 g orally 1 h before procedure determine the severity of dysfunction.
prophylaxis Children: 50 mg/kg orally 1 h before procedure* Patients with failure secondary to initial
Penicillin allergic Clindamycin Adults: 600 mg orally 1 h before procedure regurgitation are medically managed with
or Children: 20 mg/kg orally 1 h before procedure* sodium restriction, digoxin, diuretics, and
azithromycin Adults: 500 mg orally 1 h before procedure preload- and afterload-reducing vasodila-
or Children: 15 mg/kg orally 1 h before procedure* tors. Eventually surgical valve repair or
clarithromycin Adults: 500 mg orally 1 h before procedure replacement may be necessary.
Children: 15 mg/kg orally 1 h before procedure* There is little increased risk during
Unable to take Ampicillin Adults: 2 g IM or IV within 30 min before maxillofacial surgery for patients with
oral medication procedure well-controlled mitral regurgitation. The
Children: 20 mg/kg IV within 30 min before surgeon and anesthesiologist must guard
procedure* against the pulmonary edema to which
Unable to take oral Clindamycin Adults: 600 mg IV within 30 min before procedure these patients are prone. Monitoring of
medication and or Children: 20 mg/kg IV within 30 min before pulmonary capillary wedge pressure will
pencillin allergic cefazolin procedure* help guide therapy.
Adults: 1 g IM or IV within 30 min before
procedure Mitral Valve Prolapse
Children: 25 mg/kg IM or IV within 30 min before Mitral valve prolapse is a common form of
procedure* mitral regurgitation, most frequently seen
IM = intramuscularly; IV = intravenously. in young women, in which one or both of
*Total childrens dose should not exceed adult dose.
the mitral valve leaflets prolapse into the
left atrium during systole, allowing varying
degrees of regurgitation to occur. It is char-
usually the definitive test used to detect Mitral Regurgitation Mitral regurgita- acterized by a midsystolic click followed by
and characterize mitral stenosis. tion or insufficiency is most commonly a late systolic murmur. Symptoms include
Patients with severe mitral stenosis who the result of damage or dysfunction due to palpitations and chronic fatigue, but it can
require elective surgery may need preopera- coronary artery disease or from prior be asymptomatic; echocardiography is
tive mitral valve commissurotomy or valve rheumatic heart disease. The incompetent diagnostic. The prevalence of mitral valve
replacement. AF may be managed by preop- valve prompts left ventricular enlarge- prolapse in women and the general popula-
erative digitalization or -sympathetic block- ments as the heart works and expands to tion has been overestimated, with more
ade; pulmonary congestion is treated with maintain cardiac output. Symptoms of recent study showing a prevalence of about
diuretic therapy. Patients with a known or congestive failure appear as regurgitation 3%, equally distributed among men and
suspected atrial thrombus are usually on worsens and the enlarging heart transi- women; symptoms have been overestimat-
chronic anticoagulant therapy, which may tions to the decompensation (right) side ed as well.27 Mitral valve prolapse is usually
need temporary alteration. Surgeons should of the Frank-Starling curve. managed symptomatically, using -sympa-
note the compromised cardiac output of Physical examination of the patient thetic antagonists to control palpitations.28
patients with mitral stenosis. with significant mitral regurgitation will As with other causes of mitral regurgi-
Acute pulmonary edema is not reveal an apical point of maximal impact tation, with medical management there is
uncommon following noncardiac surgery displaced inferolaterally, an apical, high- little increased risk for anesthesia and
on patients with significant mitral steno- pitched, holosystolic murmur, and a third surgery. Patients should have ECG monitor-
sis, particularly if excess fluid replacement heart sound (gallop rhythm). Left ventricu- ing to detect intraoperative dysrhythmias,
was given. An additional problem facing lar hypertrophy and AF may appear on an and those with a murmur should be given
these patients is diminished pulmonary ECG. Echocardiography will help define the antibiotics to prevent infective endocarditis.
compliance that may require postopera- extent of valve disease and, with a measure-
tive mechanical ventilation longer than is ment of end-systolic left ventricular dimen- Aortic Regurgitation Aortic regurgita-
usually necessary. sion, the prognosis can be determined (a tion or insufficiency occurs when the
Medical Management of the Surgical Patient 25
aortic valve becomes partially incompe- tion, increasing stroke volume, and decreas- gical or anesthetic management. The aor-
tent, resulting in a backflow of aortic ing left ventricular end-diastolic volume tic valve opening must be narrowed to
blood into the left ventricle during dias- and pressure. Care must be taken when 75% of its normal size before obstructive
tole. This causes left ventricular volume using afterload reducers to not allow aortic signs occur. If aortic and mitral stenoses
overload resulting in hypertrophy and diastolic pressure to drop so low as to com- coexist, the problems due to mitral steno-
increased wall thickness, both of which promise coronary perfusion. sis will predominate. Perioperative risks in
increase myocardial oxygen requirements. patients with isolated aortic stenosis are
Patients with clinically significant aor- Aortic Stenosis Aortic stenosis can involve highest if the history includes exertional
tic regurgitation will report unusual the valve itself or be supra- or infravalvular. dizziness, syncope, or angina and the pres-
awareness of their heartbeat, prominent Valve stenosis is most often due to either a ence of coronary artery disease.
neck pulsations, and symptoms of pul- congenitally bicuspid valve (which occurs in The preservation of sinus rhythm is
monary congestion at rest that resolve about 2% of the population) or an aging- important in these patients. Tachydysrhyth-
during exercise. Examination reveals a related degeneration of a normal trileaflet mias must be avoided since the atrial kick
widened pulse pressure, a bisferious valve. In either situation valve fibrosis and supplies needed left ventricular filling.
(bifid) carotid pulse, an inferolaterally dis- calcification occur and cause varying degrees Supraventricular tachycardias should be
placed and prolonged apical PMI, and of left ventricular outflow obstruction. treated immediately with direct current car-
diastolic decrescendo murmur at the base. Symptoms classically include exer- dioversion. Sinus tachycardia may require
In severe cases there may be a third heart tional angina, syncope, or dyspnea. How- administration of a -sympathetic antago-
sound and apical low-pitched diastolic ever, many patients can be asymptomatic nist. Bradycardia is also harmful, and rates
(Austin Flint) murmur. until surgical stress unmasks problems. below 45 bpm should be increased with
The ECG will reveal left ventricular Physical examination of the patient with atropine. Anesthetics that cause myocardial
hypertrophy, and a chest radiograph will significant aortic stenosis will typically depression should be used cautiously, if at
show left ventricular and aortic root reveal a weak pulse, narrow pulse pressure, all, and systemic vascular resistance should
enlargement. Echocardiography with or and a nondisplaced but accentuated and be maintained. The ECG lead V5 should be
without a Doppler is used to diagnose and prolonged PMI. A diamond-shaped sys- monitored for signs of ischemia; if detected,
characterize aortic regurgitation. Patients tolic murmur is heard at the base while a coronary obstruction must be differentiated
with significant aortic regurgitation will be fourth heart sound is heard at the apex. from insufficient coronary filling pressure
treated with vasodilators such as calcium Patients typically have little pulmonary due to aortic stenosis.
channel blockers or ACE inhibitors. - hypertension so that many of the classic
Blockers should be avoided since they can noncardiac symptoms and signs of heart Prosthetic Heart Valves Patients with
prolong diastole, increasing the regurgitant failure are not present. But because the left prosthetic heart valves represent a special
flow. Eventually aortic valve replacement ventricle depends on the end-diastolic situation in which properly functioning
may be necessary. Low-risk patients have a boost from the left atrium, the develop- valves have essentially normal cardiac
near-normal sized left ventricular cavity, ment of AF can be catastrophic and should function but may have new problems
while high-risk patients nearing the time for be suspected in a patient with aortic steno- directly related to the artificial valve itself.
aortic valve replacement show enlargement sis who suddenly deteriorates. These patients are susceptible to endo-
of end-systolic left ventricular dimensions, An ECG shows left ventricular hyper- carditis (particularly staphylococcal), red
corrected for body surface area.29,30 trophy, while the chest radiograph reveals cell destruction by the valve, prosthetic
Typically bradycardia or vasodilation left ventricular and ascending aortic valve obstruction by thrombosis or pan-
cannot be tolerated; thus measures to pre- enlargement and calcification. Echocar- nus formation, and paravalvular regurgi-
vent these changes should be used. The diography can be used to define the valvu- tation. Serum bilirubin, lactate dehydroge-
ECG lead V5 should be monitored periop- lar pathology, and cardiac angiography is nase, and reticulocytes should be
eratively for signs of subendocardial used to determine the pressure gradient measured to detect occult hemolysis.
ischemia. Pulmonary artery catheterization across the valve and to check the status of Patients with mechanical (not biopros-
is useful in the perioperative period for the coronary arteries. Severely stenotic thetic) valves are on chronic anticoagulant
measuring left-sided pressure and cardiac valves may require surgical replacement. therapy that needs perioperative manage-
output. Afterload reduction may be helpful Patients with mild-to-moderate dys- ment. Patients with prosthetic valves
in patients with normal left ventricular function requiring maxillofacial surgery should be given antibiotics to prevent
function by reducing the regurgitant frac- typically require little modification in sur- infective endocarditis.
26 Part 1: Principles of Medicine, Surgery, and Anesthesia
Congestive Heart Failure as dyspnea at rest or on exertion, paroxys- operative central venous pressure or for
mal nocturnal dyspnea, and orthopnea placing a Swan-Ganz catheter. An
The normal myocardium responds to
commonly occur. Failure of the heart to indwelling arterial line can also be useful
increased physiologic demands by increas-
propel blood out of the systemic venous for monitoring mean arterial pressure and
ing the frequency of contractions and by
dilating through the Frank-Starling mecha- system can produce increased interstitial for obtaining samples for blood gas analy-
nism, which increases contractility (the end- fluid in the lower legs which is revealed as sis. After intubation the patients lung com-
diastolic wall tension). Heart failure occurs pitting edema of the feet, ankles, and even pliance should be monitored closely,
when the hearts compensatory mecha- shins, increased central venous pressure because decreased compliance is an early
nisms fail to handle the hemodynamic load, giving jugular venous distention, and por- sign of pulmonary edema. Mini-dose
causing blood to back up into the pul- tal hypertension causing hepatomegaly. heparin and elastic stockings can be used
monary vasculature, right heart, and major When surgery is contemplated for a postoperatively to decrease the likelihood
venous beds such as the portal system. patient with a history of congestive heart of deep vein thrombosis and pulmonary
Failure can be produced in two basic failure, preoperative steps should be taken embolization. Passive leg exercises and
ways. First, the heart can be overwhelmed to optimize the patients physical status. early ambulation postoperatively also help
by excessive loads, such as elevated preload The patient should be questioned about the prevent these problems. An early postoper-
(venous return; eg, by hypervolemia) or amount of exertion necessary to produce ative chest radiograph can reveal early
increased afterload (resistance to ejection; dyspnea and about how many pillows are signs of pulmonary edema, as does an ele-
eg, by elevated total peripheral resistance necessary while sleeping to prevent orthop- vation of pulmonary capillary wedge pres-
or aortic stenosis). Second, the hearts abil- nea, in order to quantitate the severity of sures. During recovery the patients physi-
ity to compensate for increased demands the cardiac disability. Nocturnal cough and cal activity and emotional stress should be
can be compromised, such as by myocar- restlessness and easy fatigability can be kept low to reduce unnecessary demands
dial infarction or cardiomyopathy. early symptoms of problems. Signs of con- on the heart.
Long-term management requires that gestive failure include jugular venous dis-
both excessive preload and afterload be tention, presence of a third heart sound Cardiac Dysrhythmias
modulated. Preload is lessened by limiting (gallop rhythm), pulsus alternans, basilar Patients with diagnosed or occult cardiac
intravascular volume through the use of rales, and pitting edema. A chest radi- rhythm disturbances present a manage-
dietary sodium restriction and diuretics, ograph and ECG should be used to mea- ment challenge to the surgeon and anes-
and by venodilation with drugs such as sure heart size, to visualize the lung fields, thesiologist in the perioperative period.
nitrates. Afterload is reduced through the and to help detect AF. If poorly compensat- Dysrhythmias can compromise cardiac
administration of vasodilators. Cardiac ed failure is detected, the risk of postopera- output leading to myocardial ischemia,
contractility is augmented by digoxin. tive pulmonary edema is raised by 25%.31 cerebral ischemia, congestive failure, or
Angiotensin-converting enzyme inhibitors Patients prone to failure can be shock. In addition, dysrhythmias can pre-
are another common therapeutic drug for improved by increased attention to sodium dispose towards the formation of intracar-
failure. Finally, physiologic demands on and water restriction and to their compli- diac thrombi and subsequent systemic
the heart are controlled by advising the ance with medications such as diuretics, embolization.
patient to get adequate rest and avoid digoxin, and preload and afterload reduc- Patients with significant dysrhythmias
strenuous exercise. ers. Potassium levels should be normalized. may or may not have symptoms. The ten-
A failing heart produces many signs Mild preoperative hypokalemia can be dency of dysrhythmias to compromise
and symptoms that vary according to the managed by oral replacement therapy or cardiac function frequently depends on
severity of the decompensation. Dilation intravenous administration at a rate of up overall cardiac health. For example, an
of the heart as it tries to compensate can to 10 mEq/h in concentrations up to otherwise healthy individual can easily tol-
be detected on a posteroanterior chest 30 mEq/L. Patients taking digoxin should erate heart rates at the extremes of the
radiograph. The chest film will also show have serum levels measured. Signs and range of 40 to 180, whereas someone with
increased pulmonary vascular markings symptoms of digoxin toxicity such as nau- a diseased heart would be less tolerant.
that occur as pressure forces fluid into sea, diarrhea, anorexia, and new dysrhyth- Anesthesia and surgery are capable of
interstitial spaces and alveoli, producing mias should prompt postponement of unmasking a tendency toward dysrhythmias
pulmonary edema. The signs of rales and surgery until levels are normalized. Con- through vagal stimulation, stress-related
decreased breath sounds in dependent sideration should be given to placement of release of catecholamines, drug-induced his-
portions of the lungs, and symptoms such a central venous line for monitoring peri- tamine release, dysrhythmogenic drugs such
Medical Management of the Surgical Patient 27
as inhalational anesthetics, and hypoxia due Atrial Flutter Atrial flutter (rate 250300) 200 watt-seconds. Patients with chronic
to inadequate ventilation. Statistically, peri- commonly appears with a 2:1 block produc- AF should be on anticoagulants, which
operative dysrhythmias, particularly during ing a ventricular rate of 125 to 150. Patients must be adjusted perioperatively.
intubation, are most common in patients in atrial flutter who undergo surgery have a
with preexisting dysrhythmias or heart dis- 50% mortality rate. It is therefore incum- Premature Ventricular Contractions Pre-
ease, or who are on digoxin medication or bent on the surgeon to identify and seek mature ventricular contractions (PVCs) can
undergo surgery and anesthesia for longer correction of this dysrhythmia preopera- be due to many causes including fever,
than 3 hours. In addition, surgery near the tively, with direct-current low-energy (25 to hypoxia, drugs (including digoxin, amino-
carotid sinus can cause atrioventricular con- 50 watt-seconds) cardioversion. phylline, and inhalational anesthetics), pul-
duction disturbances due to the stimulation monary artery catheters, electrolyte distur-
of intercostal nerves. Atrial Fibrillation Atrial fibrillation is bances, and myocardial ischemia, or they
The presence of significant cardiac dys- the second most common cardiac dys- may be idiopathic. The significance of PVC
rhythmias can often be detected based on rhythmia. It is commonly asymptomatic activity, including more complex ectopic
symptoms reported during a medical histo- but characteristically produces an irregu- ventricular disturbances such as nonsus-
ry, such as intermittent palpitations, unex- larly irregular pulse rhythm and a fibrilla- tained ventricular tachycardia, is controver-
plained syncopal episodes, and transient tion pattern on ECG. The atrial rate is sial. Long-term mortality is not reduced in
ischemic attacks. Determination of pulse greater than 350, whereas the ventricular PVC patients without apparent heart disease,
rate and rhythm should be obtained during rate varies from 140 to 180 bpm. Etiologies but PVCs postmyocardial infarction or with
the physical examination. An ECG should include any cause of left atrial hypertro- cardiomyopathy do carry increased risk. This
be obtained in all patients with either sus- phy, thyrotoxicosis, and coronary artery is more a function of underlying cardiomy-
pected or diagnosed dysrhythmias. disease, and may result from the excessive opathy rather than the dysrhythmia itself.
use of caffeine, cocaine, ethanol, diet pills, The discovery of significant PVC
Atrial Dysrhythmias The most common or nicotine, even in healthy hearts. activity on a preoperative ECG warrants a
dysrhythmia is sinus tachycardia with a heart The physiologic compromise pro- complete cardiac evaluation, and identi-
rate of 100 to 180. Such an elevated rate duced by AF depends on the ventricular fied causes of PVCs should be corrected
compromises cardiac ouput by lessening response, myocardial health, and duration preoperatively. Development of PVCs or
diastolic filling time and increasing myocar- of the dysrhythmia. A rapid ventricular runs of ventricular tachycardia during
dial oxygen consumption. Sinus tachycardia response increases perioperative mortality surgery may signal cardiac ischemia or
can have many etiologies including fever, by about 15%. Congestive heart failure or electrolyte abnormalities, which should be
hypovolemia, anemia, hypoxia, drug use, myocardial ischemia can appear abruptly investigated and corrected.35,36 The cause
and hyperthyroidism. Therapy is directed at in susceptible patients going into AF. of PVCs should be sought and corrected,
the underlying cause.32 Long-standing AF can allow the formation but note that lidocaine is no longer used to
of an atrial thrombus and subsequent suppress ectopic activity.
Paroxysmal Atrial Tachycardia Paroxys- thromboembolic complications.
mal atrial tachycardia (PAT) is a frequent Preoperative management of patients Ventricular Tachycardia The appearance
dysrhythmia with an atrial rate of 140 to 240 with a history of AF should include con- of three or more PVCs in a row is defined
and a lower ventricular response rate. PAT sideration of digitalization that by itself as ventricular tachycardia. It has a variety
can be due to digoxin toxicity or myocardial may convert AF to a normal sinus rhythm. of etiologies including hypoxia, acidosis,
ischemia, but is usually due to reentrant Intravenous verapamil can also be used myocardial ischemia, digoxin toxicity,
pathways between the atria and ventricles. but is less successful in converting AF. hyper- or hypokalemia, and hypercal-
The rhythm is unstable, reverting back Both digoxin and calcium channel antago- cemia. Prompt therapy consists of intra-
to sinus in almost all cases. Risk of surgical nists decrease chronotropy, thus helping to venous lidocaine or low-energy direct-
procedures is not elevated with a history of slow the ventricular response rate to more current cardioversion.37,38
PAT; however, if there have been frequent physiologic levels. Amiodarone has been
or recent episodes of PAT, a -blocker may shown to have prophylactic value.34 Care Heart Blocks Atrioventricular blocks
help prevent tachycardia. Ablation of reen- should be taken to not allow the ventricu- take several forms. A PR interval greater
trant pathways via electrophysiology pro- lar rate to fall below 70. Acute onset of AF than 20 ms constitutes a first degree atri-
cedures is the treatment of choice and is is most effectively managed with direct oventricular block and is of little signifi-
usually curative.33 current cardioversion starting at about cance perioperatively in the absence of
28 Part 1: Principles of Medicine, Surgery, and Anesthesia
other cardiac abnormalities. In second region. However, maxillofacial surgery does reserve and measure the potential
degree block, some atrial impulses are not sometimes involve prolonged general anes- response to measures taken to improve
conducted into the ventricles. The Mobitz thesia, and procedures can compromise the lung function.42,43
type I (Wenckebach) second degree block upper airways. Therefore, it is important to Measurement of arterial blood gases
has a PR interval that progressively discover and treat airway and lung abnor- (ABGs) is frequently a part of pulmonary
lengthens until a nonconducted P wave malities preoperatively or, when not possi- function testing. ABG determination
occurs and the cycle begins again. Mobitz ble, make necessary compensations in sur- serves both as a baseline for intra- and
type I rhythms are usually due to digoxin gical and anesthetic plans. postoperative measurements, and helps
excess, myocardial ischemia, or degenera- The medical history should ascertain assess the status of pulmonary gas
tion of cardiac conduction tissue. Treat- the following about the status of the venti- exchange. A low partial pressure of oxygen
ment with atropine is necessary only for latory system: the presence of symptoms (PaO2) may be due to hypoventilation, diffu-
excessively slow ventricular rates. Mobitz such as wheezing, productive cough, and sion impairment, shunting, or a ventilation-
type II second degree blocks have a con- low exercise tolerance; the use of pul- perfusion inequality, the last being the most
stant PR interval but frequent P waves monary medications; cigarette smoking; common cause. An elevated partial pressure
without a ventricular response. This is a prior thoracic surgery or trauma; and pre- of carbon dioxide (PaCO2) is a sign of
worrisome dysrhythmia and perioperative viously diagnosed pulmonary diseases hypoventilation either due to an inadequate
ventricular pacing should be considered.39 including asthma, pneumonia, chronic respiratory rate or depth, or to a ventilation-
Third degree atrioventricular blocks obstructive pulmonary disease (COPD), perfusion inequality. Intraoperative capnog-
imply a complete block of atrial impulses or tuberculosis. In physical examination, raphy and intra- and postoperative oximetry
into the ventricle. The ventricles therefore points of significance to the assessment of have reduced the need for frequent ABG
beat at their low intrinsic rate of about 45. the respiratory system include a careful sampling. Oximetry is also beneficial during
Therapy usually requires the use of a inspection of the nasal airways, ausculta- the first few hours after maxillofacial surgery,
pacemaker. tion of lung fields for abnormal sounds, when respiratory insufficiency is most likely
Bundle branch blocks present no direct inspection of mucosa and nail beds for to occur.44
contraindication to anesthesia and surgery signs of cyanosis or clubbing, and mea-
but usually signal some underlying cardiac surement of the respiratory rate.40,41 Asthma
disease. Pacing for bundle branch blocks is A plain chest radiograph is useful for Asthma is characterized by episodes of
necessary only if symptomatic bradycardia detecting diffuse or localized parenchymal wheezing, cough, and production of
or complete heart block occurs. disease, pulmonary edema, hyperinflation, mucous plugs. It is more common in chil-
Patients who have permanent cardiac and consolidations such as pneumonia or dren, although some adults will have new
pacemakers pose little increased risk dur- neoplasms. However, the yield from rou- or relapsed asthma later in life. Chronic
ing surgery over and above the underlying tine preoperative chest radiographs is low uncontrolled asthma can lead to COPD,
cardiac problem. If electrocautery is neces- in patients without a history or examina- and asthma complicated by cigarette
sary special care should be taken to ensure tion suggestive of pulmonary disease. smoking can lead to COPD as well. Ques-
that it is properly grounded. A magnet to Some pulmonary function testing can tions regarding history of asthma, fre-
convert a demand pacemaker to the fixed be performed at bedside, such as the quent or nocturnal coughing, shortness of
rate mode should be available in the oper- breath-holding test. The breath-holding breath, dyspnea on exertion, and produc-
ating suite. test involves having a patient make a max- tion of mucous plugs are helpful in diag-
imum inspiration and then hold the nosing asthma. Physical examination may
Surgery in the Patient with breath for as long as possible. Inability to show wheezing, particularly with forced
Respiratory Problems hold ones breath for at least 15 seconds is expiration.45,46
indicative of significant pulmonary prob- Well-controlled asthma does not pose a
General Assessment of lems. Spirometry is another useful bedside significant perioperative risk. Patients with
Airway and Lungs test for assessing pulmonary function well-controlled asthma should have a dose
Maxillofacial surgery itself has minimal although a delay in surgery is usually of albuterol by inhaler or nebulization prior
effect on pulmonary function compared unwarranted. Surgeons should request to general anesthesia to prevent intraopera-
with general thoracic or abdominal formal pulmonary function testing (PFT) tive bronchospasm or larynogospasm.47,48
surgery, except when tissue is being trans- for all patients in whom lung disease is The patient with a recent history of
ferred from the thorax to the maxillofacial suspected. PFTs help gauge respiratory problematic asthma is at significant risk
Medical Management of the Surgical Patient 29
when having general anesthesia and chance of anesthesia-induced laryn- dle- and large-sized bronchi have lost their
surgery. The bronchospasm that charac- gospasm and bronchospasm. Steroids are cilia and muscle tone, and exude excess
terizes asthma can develop precipitously then rapidly tapered and discontinued mucus, causing pooling of secretions and
and compromise ventilation, even with over 3 to 7 days postoperatively.49 reduced clearance of dust, smoke, and bac-
positive pressure, and may be difficult to Maintenance therapy in asthma has teria. Symptoms and signs of COPD
reverse in time to prevent complications. also broadened to include inhaled steroids, include chronic cough, sputum produc-
As with most conditions of this nature, long-acting -agonists, antileukotriene tion, shortness of breath, decreased exercise
recognition and prevention are the best drugs, and theophylline.5052 Inhaled tolerance, wheezing, and increased antero-
management strategies. steroids using metered-dose inhalers or posterior thoracic diameter. Patients with
The airway narrowing in asthma is dry-powder inhalation devices are given advanced disease may purse their lips to
due to smooth muscle contraction, edema on a regular dosing schedule and are not increase intrathoracic pressure during
in airway walls, or mucous plugging of air- absorbed, preventing systemic complica- exhalation, thus holding open airways that
ways. Whereas bronchospasm is rapidly tions of steroid use. would otherwise close prematurely.53
reversible with muscle relaxants, edema Prolonged corticosteroid use carries A chest radiograph may show hyperlu-
and plugging are not. its own risks as is discussed later in this cency, kyphosis, and depressed and flat-
The likelihood of an asthmatic episode chapter. The surgeon should confer with tened diaphragms. Pulmonary function
occurring during surgery can be judged by the physician managing a patients asthma tests show a reduced forced expiratory vol-
a few pieces of historic information. The to ensure that the patient has recently been ume in the first second of exhalation
frequency, severity, duration, and response evaluated and that the steroid regimen (FEV1) and a reduced forced vital capaci-
to therapy of recent asthma attacks will provides the least amount of drug that is ty/FEV1 ratio. FEV1 is compared to age,
help gauge how well an individuals asthma still effective. If possible the patient may gender, and racial norms, and an FEV1 of
is controlled and therefore the safety of benefit from a switch to inhaled cortico- less than 80% of predicted normal is abnor-
proceeding with surgical plans. steroid use through metered-dose inhalers mal, with readings of less than 60 indicating
When questioning a patient with asth- that may help minimize systemic effects. severe obstructive disease. Arterial blood
ma, key factors are the frequency and Intra- and postoperatively asthmatic gases may show a loss of oxygenation and
nature of attacks, current medication use, patients should be monitored for the elevated carbon dioxide, due to reduced gas
last use of steroids, and an indication of appearance of increased airway resistance, exchange and an alteration in the usual res-
the severity of asthma. A history of multi- wheezing, pulsus paradoxus, tachycardia, piratory drive. As the term implies, bron-
ple emergency room visits for asthma, fever, hypoxemia, hypercapnia, and acido- chospasm in COPD may be less responsive
hospitalization for asthma, history of sis. Atelectasis is common in asthmatics to bronchodilators than in asthma.
mechanical ventilation for asthma, and and causes an increased risk of bacterial Surgery and anesthesia for patients
steroid dependency are indicators of pneumonia, which is why thorough pul- with significant COPD usually brings few
severe asthma (Table 2-5). monary examinations must be given at intraoperative risks due to the lung disease
For many years aminophylline-like frequent intervals during recovery.49 itself. However, the likelihood of postoper-
treatment was the mainstay of asthma and ative pulmonary complications is high in
COPD treatment. Several medications Chronic Obstructive COPD patients. Therefore, proper preop-
have replaced aminophylline and theo- Pulmonary Disease erative identification and preparation are
phylline treatment. For acute treatment Chronic obstructive pulmonary disease important.
albuterol by inhaler or nebulized adminis- (COPD) is an all-encompassing term for Preparing COPD patients for surgery
tration is used. The usual dose is 1 to 2 lung diseases characterized by loss of lung usually involves reversing pathology able
actuations of a metered-dose inhaler or a tissue and its surface area. It includes to be altered medically. Hydration to
nebulization treatment every 4 to 6 hours chronic bronchitis, emphysema, and other
as needed, although hospitalized patients conditions, but these distinctions are rather Table 2-5 Questions for Asthma Patients
may receive dosing more frequently. In vague and do not result in differing man-
addition, oral or parenteral steroid treat- agement. Alveolar loss from destruction in Frequency and nature of attacks
ment is used more liberally than in past COPD results in less surface area to Use of oral steroids
years. Patients who are wheezing and are exchange gases and in lower smooth muscle Emergency room visits
Hospitalization
to undergo surgical treatment are usually tone of the bronchioles. Emphysematous
Mechanical ventilation
given steroids to reduce wheezing and the blebs may replace normal lung tissue. Mid-
30 Part 1: Principles of Medicine, Surgery, and Anesthesia
mobilize mucus secretions, inhaled - ating rupture and production of pneu- tioning glomeruli, a number that gradually
agonists by metered-dose inhaler or nebu- mothorax. The respiratory depressive decreases with age. Also, SC varies inversely
lization, and inhaled ipratropium are used effects of narcotics makes their use in with creatinine clearance (CCR). Thus, an
to optimize preoperative therapy. Oral or COPD patients hazardous, especially if it estimation of the CCR in males involves
parenteral steroids are used if wheezing is is likely that their effects will outlast the obtaining the level of SC and then multi-
detected prior to surgery. duration of needed anesthesia. plying its reciprocal by factors that are cor-
Production of mucopurulent sputum The techniques of controlled ventila- rect for muscle mass and age.
may indicate the need for preoperative tion must be altered in patients with
(140 Age in yr) (Weight in kg)
antibiotics to help improve COPD symp- obstructive airway disease. Ventilatory rates CCR =
toms. Ampicillin, trimethoprim/sulfa need to be slow enough (typically 6 to 10 (SC) (72 kg)
combinations, or erythromycin are used per minute) to allow sufficient exhalation
For females, the above result is multiplied
most commonly and are given in 7- to time and to compensate for slower diffu-
by 0.85. Although much less accurate,
10-day courses.54 sion of gases across membranes. Care
measurement of SC (normal is < 1.5
Cigarette smoking is the most common should be taken to avoid high pressures to
mg/dL) can be used to help gauge renal
cause of COPD and further exacerbates lessen the potential of ruptured bullae.
function. Although measurement of blood
symptoms if continued after irreversible Generally COPD patients do best with large
urea nitrogen is used commonly to test
lung pathology occurs. Reversible problems tidal volumes at slow rates and do not need
renal health, it is a crude measure and may
that smoking causes include the release of positive end-expiratory pressure.56
be misleading, especially in patients with
nicotine, production of carbon monoxide,
Surgery in the Patient with poor nutrition or who have been bleeding
mucus hypersecretion, impaired ciliary
Renal and Urinary Tract Disease into the intestinal tract.
function, and impaired local lung immuni-
Serum electrolyte abnormalities can
ty. Preoperative cessation of smoking for The kidneys play several roles in helping
signal significant renal disease. Poor renal
24 hours allows a significant decline in plas- maintain physiologic normalcy; they are
function will often result in decreased secre-
ma carboxyhemoglobin and nicotine levels, therefore important for continuing or
tion of potassium causing hyperkalemia or
but the rate of pulmonary complications regaining homeostasis during and after a concentrating defect leading to urinary
due to smoking takes weeks to fall after surgery and anesthesia. The renal system is sodium wasting and hydrogen ion retention
smoking is stopped. In the case of coronary necessary to support the processes of fluid, with resultant hyperchloremic metabolic
artery bypass grafting, the percentage of electrolyte, and acid-base balance, drug acidosis. Other indications of renal prob-
postoperative pulmonary complications in metabolism and elimination, blood pres- lems include proteinuria, pyuria, and hema-
former smokers does not begin to approach sure control through the renin-angiotensin turia, all detectable on routine urinalysis.
the rate seen in nonsmokers until after at system, red blood cell production through
least 8 weeks of abstinence from smoking.55 erythropoietin production, and vitamin D Chronic Renal Insufficiency
Other preoperative measures that can hydroxylation. The risks of anesthesia and surgery in the
prevent postoperative problems in patients There are several diseases that can patient with known renal insufficiency
with COPD include good nutrition and cor- affect one or more aspects of kidney func- vary according to the severity of renal
rection of hypokalemia to improve respira- tion. However, for the maxillofacial surgeon compromise. Patients with mild to moder-
tory muscle strength and familiarization of a better gauge of the degree to which the ate renal insufficiency (GFR of 25
the patient with incentive spirometry. Pre- patients ability to tolerate anesthesia and 50 mL/min) usually tolerate the perioper-
operative teaching in the use of incentive surgery is compromised is the adequacy of ative period well if properly managed.
spirometry, cough/deep breathing exercises, renal function. The glomerular filtration When renal function is severely impaired
and early ambulation help the patient pre- rate (GFR), normally 100 to 125 mL/min (GFR of 1025 mL/min) or frank failure is
pare for recovery before the pain and recov- per 1.73 m2 of body surface area in an adult, present (GFR < 10 mL/min), complica-
ery period from anesthesia occur. is the single most useful measure of renal tions of renal origin are much more likely.
There are several anesthetic considera- health. The GFR is measured clinically by Patients with severe renal insufficiency
tions for patients with COPD. Volatile determining the clearance of endogenous have a 60% increase in perioperative mor-
anesthetics provide bronchodilatory creatinine. The bodys serum creatinine bidity and a 2 to 4% increased mortality
effects and thus are useful. Nitrous oxide, (SC) load is highly dependent on muscle compared to healthy patients.57
on the other hand, may cause problems mass, and the clearance of creatinine from Extrarenal problems can be produced
due to its accumulation in bullae potenti- the serum depends on the number of func- by renal insufficiency. Normochromic or
Medical Management of the Surgical Patient 31
normocytic anemia frequently occurs due the residual anticoagulation problems of and enflurane. Many references are avail-
to several factors, including decreased ery- the past. However, surgeons should able that list drugs and dosing modifica-
thropoietin, decreased red cell survival remember the capability of heparin to tions needed in renal failure patients.
time, and bone marrow depression. In induce thrombocytopenia. Preoperative
addition, uremia can also cause decreased chest radiographs and an ECG can be used Hypertension
platelet aggregating ability and depressed to detect myocardial dysfunction or peri- Essential hypertension is one of the most
platelet factor 3 release.58 cardial problems due to uremia or chronic common disorders of adults, so it is not
Pericardial inflammation or effusion fluid overload. Plans should include the surprising that a large percentage of adult
is commonly associated with chronic ure- use of prophylactic antibiotics even for patients who require surgery have hyper-
mia or hemodialysis, as is myocardial dys- minimally invasive procedures.6163 tension. With more people aware of the
function. End-stage renal disease is almost Intraoperative management of the hazards of untreated hypertension, many
always complicated by systemic hyperten- patient with severe renal insufficiency patients seeking the type of care offered by
sion. Patients with renal insufficiency have should include careful cardiac monitoring specialty surgeons have had their hyper-
impairment of their immune systems with for dysrhythmias and fluid overload. tensive status evaluated and a manage-
heightened susceptibility to bacterial, Intravenous fluids should be administered ment regimen prescribed.
viral, and fungal infections. The cause in quantities only sufficient to replace Two basic problems can arise in the
seems to be faulty neutrophil and lympho- insensible fluid and blood losses, and be hypertensive patient requiring anesthesia
cyte production and function. Many of the free of potassium. If a hemodialysis vascu- and surgery. The first is that untreated
other problems caused by renal dysfunc- lar access (shunt) is in place, it should be chronic hypertension can damage many
tion affect the gastrointestinal tract. Symp- protected from trauma. Intraoperative organ systems, particularly the heart, kid-
toms of nausea, vomiting, diarrhea, and hemostasis should be especially meticu- neys, and brain. The damaged organs may
anorexia frequently accompany uremia. lous if the patient will be dialyzed imme- be less able to tolerate demands placed on
Acute stomatitis and salivary adenitis can diately after surgery.64,65 them during the perioperative period. The
occur, as can pancreatitis. The stomach After surgery, steps should be taken to second problem is that for many hyperten-
and intestine linings may undergo inflam- maintain proper fluid and electrolyte bal- sive patients, the medications prescribed
matory changes. Hepatitis C is present in ance, particularly until dialysis can be for controlling hypertension may dull
about 19% of dialysis patients.59 done. Most surgeons delay postoperative some of the natural responses the body
Excessive water retention is most easi- hemodialysis for at least 2 to 3 days to uses to counteract anesthetic and surgical
ly managed by fluid restriction, which lessen the chance of wound bleeding dur- challenges.66
usually helps improve the hypo-osmolar ing heparinization. However, patients with Statistically there is no increase in the
state, and sodium and hydrogen ion bal- oral or nasal procedures commonly swal- incidence of adverse effects from untreat-
ance. Hyperkalemia before elective surgery low a significant amount of blood, which ed hypertension as long as the diastolic
can be managed with dietary potassium increases the bloods nitrogen load and pressure is less than 110 mm Hg and no
restriction and potassium-wasting diuret- may prompt earlier dialysis than would concurrent medical problems exist. When
ics. More acute potassium control may otherwise be necessary. Extended nasogas- conferring with a patient the surgeon can
necessitate the use of cation-exchange tric suctioning may help prevent blood usually gain an idea of the likelihood of
resins, strategies to drive potassium intra- swallowing when the likelihood of swal- hypertensive organ damage by attempting
cellularly, or dialysis. Hypertension and lowing large amounts is high. to learn of the patients compliance with
fluid retention may necessitate diuretic use A significant problem that the anesthe- antihypertensive regimens. The patients
preoperatively. In cases of renal failure, siologist and surgeon face when managing physician can often supply this informa-
hemodialysis is recommended to reverse a patient with renal insufficiency is drug tion. Target organ damage can also be
fluid, electrolyte, and acid-base problems, elimination and the toxic effects of some detected by various physical and laborato-
as well as extrarenal disorders such as ure- drugs on the kidney. Drugs commonly ry examinations. Cardiac damage usually
mic immunodepression. Dialysis should used during maxillofacial surgery that manifests initially with left ventricular
be performed no more than 24 hours pre- need to be avoided or used with care in the hypertrophy (LVH). This causes a pro-
operatively. Platelet counts are helpful to patient with renal compromise include longed and displaced point of maximal
identify heparin-induced thrombocytope- cephalosporins, penicillin, and sulfa antibi- impact of the heart apex on palpation. In
nia.60 The lower heparin requirements in otics, nonsteroidal anti-inflammatory addition LVH shows on ECG, chest radi-
newer dialysis techniques prevent many of drugs, nondepolarizing muscle relaxants, ographs, and echocardiograms. With time,
32 Part 1: Principles of Medicine, Surgery, and Anesthesia
signs and symptoms of congestive heart um channel blockers may cause bradycar- The usual daily production of insulin
failure arise predisposing the heart to dys- dia but are usually well tolerated. Selective by a lean adult is 33 U; approximately 3 to
rhythmias, ischemia, and the appearance -blockers may cause first-dose hypoten- 5 U are needed for each meal while the basal
of pulmonary edema.67,68 sion, but are also usually well tolerated. insulin requirement is about 1 U/h. The
The renal damage caused by chronic Central -blockers may cause drowsiness, ketosis-prone diabetic patient produces less
high blood pressure usually consists of depression, and dry mouth.73,74 than 10% of the average daily insulin
nephrosclerosis. This may be detectable For the patient with poorly controlled requirement, but the typical type 2 diabetic
by routine urinalysis, on which protein- hypertension (systolic pressure over 200 mm patient produces an average of 15 U/24 h.
uria, hematuria, or pyuria is seen. Renal Hg, diastolic pressure over 110 mm Hg), the Type 1 diabetes presents the more sig-
damage may also cause serum creatinine surgeon should defer elective surgery until nificant challenge to the well-being of a
levels to rise. better control is obtained and any end-organ surgical patient. Patients are usually lean
Cerebral damage due to hyperten- damage is detected; appropriate compensa- and have had this disease since their youth.
sion usually manifests later in life with an tions should be made in the treatment plan. Those with long-standing type 1 diabetes
increased incidence of stroke. In addition Acute treatment of hypertension can include cannot go without their insulin for more
the cerebral vascular systems ability to clonidine given in 0.1 mg increments, or than 48 hours without diabetic ketoacido-
autoregulate is impaired so that a greater intravenous antihypertensives such as enala- sis (DKA) occurring. Hormones that
perfusion pressure must be maintained prilat, labetalol, or nicardipine infusion. Sub- increase during periods of physiologic
than would otherwise be necessary. Some lingual nifedipine should not be used. stress, including cortisol, catecholamines,
clinicians also believe chronic hyperten- Patients whose blood pressure is well and glucagon, act to counter the effects of
sion promotes the progress of carotid controlled preoperatively usually exhibit insulin, producing a stress-induced glu-
atherosclerosis and therefore recom- large swings in their blood pressure during cose intolerance, even in many healthy
mend that the surgeon auscultate for and after surgery. Hypotension usually nondiabetic patients. This is why type 1
carotid bruits. responds to fluid administration. Hyper- patients who depend on exogenous
Many of the vascular changes that tension can usually be tolerated if it does administration of their insulin commonly
occur because of chronic hypertension can not reach severe levels. Excessive increases have increased insulin requirements from
easily be seen in the one site where the in blood pressure can be managed with preoperative emotional stress, intraopera-
small vessels are visible; that is, the fundus short courses of additional antihyperten- tive anesthetic stress, and postoperative
of the eye. Hemorrhages and exudates sive medications until anesthetic drugs or wound, physiologic, and emotional stress.
seen on fundoscopic examination typical- surgery-related stresses have stopped, Studies have shown that elevated blood
ly indicate similar changes in other vascu- allowing patients to return to their preop- glucose not only impairs wound healing,
lar beds.69 erative status.75 but can also depress leukocyte and pancre-
There is a variety of treatment options atic -cell function. These are reasons, in
available for hypertensive patients, includ- Surgery in the Patient with addition to prevention of DKA, for appro-
ing diuretics, ACE inhibitors, angiotensin Endocrine Disorders priate insulin supplementation during and
receptor blockers (ARBs), -blockers, calci- after surgery.43,77
um channel blockers, selective 1-blockers, Diabetes Mellitus Type 1 patients, in contrast to type 2
and central -blockers. The surgeon should The impact of diabetes mellitus on the diabetics, have a high rate of systemic
be familiar with these drugs and their side anesthetic and surgical management of a problems. Peripheral neuropathies are
effects and risks in surgery.7072 patient is highly dependent on the type, common, predisposing these individuals
Diuretics can cause hypokalemia and severity, and degree of control of the dia- to chronic lower leg and foot lesions,
hyponatremia, necessitating screening of betes. Type 1 (insulin-dependent) dia- which should be detected and noted pre-
electrolytes prior to surgery. ACE betes mellitus is due to impaired produc- operatively and prevented perioperatively.
inhibitors and, less likely, ARBs can cause tion by or an insufficient mass of Long-standing diabetics are also at
hyperkalemia and decreased renal perfu- pancreatic islet -cells. Type 2 (non increased risk for coronary artery disease
sion. -Blockers reduce heart rate and insulin-dependent) diabetes mellitus and may suffer silent (painless) ischemic
contractility, although beneficial effects of occurs due to an altered number and episodes due to myocardial neuropathy.78
decreased myocardial demand and preser- affinity of peripheral insulin receptors. Insulin-dependent diabetics, particularly
vation of normal sinus rhythm generally Total insulin production may also be those with poor control, handle infections
outweigh perioperative risks of use. Calci- depressed but might be elevated.76 poorly. Therefore, vigilance should be
Medical Management of the Surgical Patient 33
especially high for breaks in aseptic tech- When patients are unlikely to enteral- T4, but only the unbound form of either
niques and consideration given to the use ly receive their usual caloric supply post- hormone is active, and in the case of T3 an
of prophylactic antibiotics. Type 1 patients operatively, their insulin should be given inactive form called reverse T3 (rT3) can
also have enhanced platelet stickiness that based on periodic (every 6 h) plasma glu- be formed. In normal states 35% of T4 is
may promote unwanted clotting in surgi- cose sampling. Insulin doses should be converted to T3 and 40% to rT3. However,
cal flaps. The formation of glycosylated gauged to keep the plasma glucose at in times of physical illness or emotional
hemoglobin A1C interferes with oxygen 150 to 250 mg/dL until normal dietary stress, or if certain drugs (such as cortico-
release into tissues.79 habits and activity levels return. The steroids) are used, a higher percentage of
A rational approach to management patients primary care physician can help T3 conversion to rT3 can occur.
of diabetes assists in maintaining glycemic guide dietary decisions. The most common laboratory tests
control perioperatively. Care should be Type 2 patients usually have fewer sys- of thyroid function are (1) measure-
given to avoid hypoglycemia at any time temic abnormalities due to diabetes and ments of total thyroid hormone (T) lev-
during surgery, and to prevent severe are less likely to suffer perioperative com- els by radioimmunoassay (normal is
hyperglycemia as well. The general range plications. But when major surgery and 5,012 pg/dL), in which high values indi-
of adequate control is between 120 and general anesthesia are performed, these cate hyperthyroidism and low values indi-
200 mg/dL. This would involve decreasing patients usually become hyperglycemic. cate hypothyroidism; and (2) T3 resin
the usual morning insulin by one-half to Not uncommonly patients who are well uptake, in which unoccupied thyroid hor-
allow plasma glucose to rise during the managed on diet and oral hypoglycemics mone binding sites on thyroid-binding
surgery, but providing enough basal will need temporary insulin supplementa- globulin are measured. High values of T3
insulin to prevent DKA.80,81 tion in the intra- and postoperative peri- resin uptake are associated with hypothy-
If a patient is to have relatively short- ods. As in type 1 patients, blood glucose roidism, whereas low values are consistent
duration ambulatory surgery and is should be kept at 150 to 250 mg/dL, with with hyperthyroidism.86
required to consume nothing by mouth insulin supplementation based on period-
the morning of surgery, only half the usual ic sampling.85 Hyperthyroidism Symptoms of hyper-
morning dose of insulin should be given at thyroidism include weight loss, palpita-
the time when intravenous access is Thyroid Disorders tions, and restlessness. Exophthalmos
gained. Surgery should be early in the The need for normal levels of thyroid hor- occurs in more severe cases owing to
morning and intravenous glucose should mones to maintain the function of many increased amounts of retro-orbital fat.
be given intraoperatively. During surgery of the bodys physiologic functions makes Once diagnosed, therapy usually begins
the clinician should watch for signs of proper thyroid gland function important with antithyroid drugs such as propylth-
hypoglycemia such as tachycardia and to the surgeon. The gland is composed of iouracil or methimazole. -adrenergic
diaphoresis. The patient should then be follicles, each of which is a lumen filled antagonists can be used to control symp-
encouraged to consume some calorie with thyroglobulin, which is produced by toms until thyroid hormone levels
source by mouth within 3 hours after a single layer of epithelial cells lining the decrease. Autoimmune thyrotoxicosis can
surgery is completed. Portable glucose follicle. Thyroid hormones, thyroxine (T3) be allowed time to resolve spontaneously,
monitoring is useful for intra- and postop- and triiodothyronine (T4), are produced or treatment with radioactive iodine can
erative serum glucose monitoring.82 and stored in the gland in a ratio of 10 to ablate the gland. Total thyroidectomy is
Patients requiring more major surgery 15:1 (T3:T4) and are released on stimula- seldom indicated, except for adenomas or
and longer duration general anesthesia are tion by thyroid-stimulating hormone, an malignancy.87,88
usually best managed in a setting in which anterior pituitary hormone. Between the Surgery in the face of hyperthyroidism
an anesthesiologist can monitor blood follicles parafollicular cells exist which carries high risks of cardiac dysrhythmias
glucose levels in the operating room and secrete calcitonin, whose function is to or failure, and the potential for causing a
administer insulin on an as-needed basis. help lower serum calcium by blocking its thyroid crisis. Therefore, elective surgery
The morning insulin should be withheld release from bone. should be deferred until thyroid hormone
until intravenous glucose is available; The majority of T3 and T4 released levels are properly managed. If emergency
then one-half to three-quarters of the from the gland are bound to various carri- surgery is necessary on a patient with
usual dose can be administered and sup- er proteins. Most circulating T3 is pro- poorly controlled hyperthyroidism,
plemented intraoperatively by the anes- duced by conversion from T4 in the liver -sympathetic antagonists can be used
thesiologist.83,84 and kidney. T3 is much more potent than to help control the effects of thyroid
34 Part 1: Principles of Medicine, Surgery, and Anesthesia
hormones on the heart while intravenous low levels at about 8:00 or 9:00 pm. Release vomiting, fever, restlessness, delirium,
sodium iodide (1 g) can be administered of cortisol is regulated by adrenocorti- hypotension, or coma. Because mineralo-
to help block hormone release from the cotropic hormone (ACTH) secreted by the corticoid production is not controlled by
thyroid gland. The -antagonist should be pituitary, with ACTH release normally ACTH, its levels remain normal.
continued postoperatively until the increased in time of physiologic stress. It is Prevention of problems remains the
administered antithyroid drugs have taken not unusual for plasma cortisol levels to focus of management of patients prone to
effect. Palpation of the thyroid gland remain elevated for up to 19 days after adrenal insufficiency. For those patients
should be gentle in patients with known major surgery. requiring higher doses of steroids, it is pru-
hyperthyroidism to avoid increasing hor- Excessive release of cortisol from the dent to use stress-dose steroids periopera-
mone release, and infections should be adrenal cortex (Cushings disease) is rare. tively. A typical dose is hydrocortisone
aggressively managed because they too These patients show truncal obesity, 100 mg intravenously on call to the operat-
may precipitate a thyroid crisis.8991 hypertension, thin skin that heals poorly, ing room, followed by 50 mg every 8 hours
and glucose intolerance. These problems for 48 hours postoperatively. The usual
Hypothyroidism The hypothyroid patient can also be seen in patients on long-term dose of oral steroids or its equivalent intra-
presents a lesser surgical and anesthetic risk therapeutic corticosteroids for problems venous dose can then be resumed. Note
when compared with the hyperthyroid such as inflammatory joint or bowel dis- that more minor procedures usually do not
patient. The insufficiency of thyroid hor- ease. Increased surgical risks faced by require steroid supplementation.94,95
mones causes cardiac depression, respiratory patients with hypercortisolism include
depression with weakening of the muscles of delayed wound healing and a tendency for Surgery in the Patient with
respiration, hyponatremia, constipation, infections. Delay of elective surgery is war- Hepatogastrointestinal
neurologic problems with memory loss and ranted until excessive cortisol levels are Disorders
depression, and several other metabolic under control. If surgery cannot wait,
problems. Signs of hypothyroidism include techniques designed to compensate for Liver Disease
weight gain, periorbital edema, bradycardia, poor wound healing such as better vascu- Surgeons are well aware of the livers vital
slowed deep tendon reflexes, generalized larized flaps and the use of prophylactic roles in processing nutrients, synthesizing
muscle weakness, and hair loss. antibiotics will be helpful. protein, and metabolizing drugs. Fortu-
The potential surgical problems in a Adrenal insufficiency is more com- nately the liver has a tremendous reserve
patient with untreated hypothyroidism monly seen due to exogenous therapeutic capacity for maintaining function in the
include intra- or postoperative heart fail- steroid administration than to primary face of even severe hepatic pathology.
ure, hypotension, ileus, mental confusion, adrenal glandular disease. Exogenous cor- Protein synthesis is one of the princi-
and delayed wound healing. Therefore, ticosteroids will inhibit ACTH release. pal liver activities. Of proteins produced,
thyroid replacement therapy is advisable Current concepts of steroid supplementa- the ones of particular concern to surgeons
prior to elective surgery. In an emergency tion for surgery hold that brief periods of and anesthesiologists are albumin and sev-
the surgeon must remain alert to potential steroid use, low-dose steroid use, and eral of the clotting factors. Hepatic pro-
problems due to the hypothyroidism and alternate-day steroid use do not suppress duction of albumin is in the range of 10 to
compensate for them if they occur.92 the hypothalamic-pituitary axis. Thus, if 15 g daily. Albumin helps maintain the
steroids have been used for less than 3 con- oncotic force necessary to restrict excessive
Adrenal Gland Disorders secutive weeks within the past year, the loss of intravascular fluid into the intersti-
The adrenal gland, responsible for the pro- dose of chronic steroids is 5 mg of pred- tium. Albumin also has a large number of
duction of a variety of hormones including nisone or less, or if alternate-day steroid reactive sites and can therefore reversibly
cortisol, aldosterone, and androgens, plays administration is used, no supplemental bind to most drugs. If albumin production
a central role in regulating many metabol- (stress-dose) steroids are needed.93 Once slows sufficiently that serum levels fall
ic processes. The gland usually comes to adrenal suppression has occurred, a below 2.5 g/dL, then edema, ascites, and an
the attention of surgeons because of patient is at great risk for problems during elevation in the free-to-bound ratio of
abnormalities in cortisol production. The major surgery due to their inability to administered drugs can result.
average daily secretion of cortisol in the mount a significant cortisol response to The vitamin Kdependent coagulation
adult is 15 to 17 mg (range 828 mg). the stress. This may precipitate an adrenal factors II, VII, IX, and X are made in the
Secretion follows a diurnal pattern, peak- crisis, signaled by the onset of lethargy, liver. A significant fall in their levels can be
ing at about 3:00 or 4:00 am, and falling to tachycardia, flank or abdominal pain, seen with either severe hepatocellular dis-
Medical Management of the Surgical Patient 35
ease or with impaired vitamin K absorp- damage. Elevations in serum alkaline monitor serum glucose levels. Patients
tion due to biliary problems. phosphatase indicate obstructed bile likely to handle nitrogen poorly, particu-
The liver is responsible for the proper ducts. Measurement of serum albumin larly those with a history of hepatic
function of several enzyme systems that helps gauge the severity of liver disease, encephalopathy, should be placed on
help to limit drug actions. Plasma with levels of less than 2.5 g/dL being sig- dietary protein restriction. If it is likely
cholinesterase is produced by the liver; by nificant; however, malnutrition can also that blood will be swallowed, the patient
breaking ester linkages it inactivates drugs cause hypoalbuminemia. Severe liver dis- may need measures to reduce nitrogen
such as succinylcholine and ester-type ease is indicated by a prolonged pro- absorption in the intestines, such as
local anesthetics. The hepatic microsomal thrombin time (PT) and a decreased administration of nonabsorbable antibi-
enzyme system converts lipid soluble platelet count. Suspicion of an infectious otics or the use of a cathartic such as lac-
drugs into more water soluble ones that cause of hepatic disease mandates the use tulose; consciousness should be closely
can be excreted by the kidney. Agents such of immunologic tests for signals of viral monitored.
as some benzodiazepines, lidocaine, disease. Hepatitis A, typically due to fecal Drugs used for anesthesia and analge-
meperidine, morphine, and alfentanil contamination of food and water, is evi- sia may need to be modified in the patient
depend on this system for elimination. denced by hepatitis A antibodies. Acute with hepatic disease. Drugs to avoid in
The most common insults to the liver hepatitis B, transmitted parenterally or patients with severe liver disease include all
that affect the performance of maxillofacial venereally, will stimulate production of nonsteroidal anti-inflammatory drugs,
surgery are ethanol and infectious hepatitis. surface and core antigen antibodies; the tetracyclines, pentazocine, and atenolol.
In the first case many liver functions can be chronic form is revealed by the presence of Drugs for which dosages need to be
compromised, whereas in the second case, only surface antigen antibodies. Non-A, reduced include diazepam, chlordiazepox-
not only is proper liver function jeopar- non-B hepatitis, caused by several differ- ide, meperidine, morphine, propoxyphene,
dized, the surgeon must also help prevent ent viruses and usually transmitted by theophylline, lidocaine, verapamil, and
the spread of the infection to others.96 infected blood products, causes elevated most -sympathetic antagonists. Most
Other important consequences of ALAT but no hepatitis A or B antibodies. anesthetics are generally safe to use in
liver disease include impaired glycogen Finally, hepatitis C (-agent), seen most patients with hepatic disease, although
storage and gluconeogenesis; hyper- commonly in illicit drug users and multi- some feel halothane, fentanyl, and nitrous
splenism due to obstructed portal blood ply transfused patients, causes the appear- oxide should be avoided because of their
flow, causing thrombocytopenia; and poor ance of -agent antibodies and in its acute potential for causing liver toxicity.
handling of large gastrointestinal nitrogen form coexists with hepatitis B.9799
loads such as swallowed blood, which Maxillofacial surgery in the patient Peptic Ulcer Disease
alters the level of consciousness in patients with mild to moderate liver disease usual- Peptic ulcers and gastritis are two of the
with severe liver dysfunction. ly presents few problems because of hepat- most common afflictions of adults, but
Significant liver problems cause a ic reserve. Borderline severe cases require they are usually easily controlled with H2
large number of signs and symptoms so special perioperative attention to prevent receptor antagonists, which reduce acid
that detection is usually straightforward. complications or a deterioration of liver secretion, or sucralfate that forms a pro-
Laboratory tests of liver function tend to function. Liver function tests, especially tective coat over lesions shielding them
be nonspecific indicators of tissue damage serum ALAT measurement, are useful. A from the effects of pepsin and acid.
but are commonly used to evaluate PT and platelet count are necessary to Although many patients still use antacids,
patients with suspected liver disease. detect a potential coagulopathy. Intra- side effects such as diarrhea (in magne-
Serum aspartate transaminase levels rise venous vitamin K (5 to 10 mg over 3 to sium-based antacids), constipation (in
because of damage to either liver, heart, 5 min) can be administered if a deficiency aluminum-based antacids), and sodium
kidney, or skeletal muscles. Changes in is suspected and will shorten an abnormal overload make them less desirable.
serum alanine aminotransferase (ALAT) PT in 4 to 12 hours. Fresh frozen plasma Signs of active gastrointestinal bleed-
levels, on the other hand, are more specif- can be used temporarily to make up for a ing include unexplained anemia and a
ic for hepatocellular disease. Lactate dehy- vitamin K deficiency until the parenterally guaiac-positive stools, but the process is
drogenase is commonly measured but is administered vitamin is effective. usually diagnosed based on the presence of
another nonspecific indicator of tissue Because patients with severe liver dis- epigastric pain temporarily relieved by
damage, although its isoenzyme-5 fraction ease have problems with improper gluco- food or antacids. Endoscopy is used to
is believed to be more specific for liver neogenesis, the surgeon should closely confirm clinical suspicions.
36 Part 1: Principles of Medicine, Surgery, and Anesthesia
Before maxillofacial surgery can be Nonarticular problems seen with RA intraoperatively. Patients with Sjgrens
performed in patients with a history of include pericarditis, pleuritis, pneumoni- syndrome will require special care to pre-
gastritis or peptic ulcer disease or predis- tis, myopathies, vasculitis, bone marrow vent eye desiccation. The skin of RA
posed to these problems due to prolonged depression, and skin ulcers. patients is commonly thin and easily dam-
physiologic stress, the surgeon must Rheumatoid arthritis patients are aged, so additional padding of pressure
ensure that the patients gastrointestinal treated with five classes of drugs: analgesics points is indicated. Preoperative PT and
problem is being addressed properly. The (NSAIDs), glucocorticoids, slow-acting partial thromboplastin time (PTT) mea-
clinician should verify that the patient is antirheumatic drugs (SAARDs), or dis- surement will help detect circulating anti-
compliant with either their H2 receptor ease-modifying antirheumatic drugs coagulants due to the RA. Early postoper-
antagonist regimen (cimetidine, 800 mg (DMARDs), and anticytokines. Analgesics ative ambulation, heat treatments, and
hs; ranitidine, 150 mg bid; or famotidine, include acetaminophen, tramadol, and possibly physical therapy of affected joints
40 mg hs) or with sucralfate (1 g qid). narcotics. NSAIDs range from over-the- will help prevent prolonged stiffness.
When the patient is unable to take oral counter ibuprofen to newer selective
medication, cimetidine (300 mg q8h), ran- cyclooxygenase-2 (COX-2) inhibitors such Other Connective Tissue
itidine (50 mg q8h), or famotidine (20 mg as celecoxib, rofecoxib, and valdecoxib. Disorders
q12h) can be given intravenously or intra- NSAIDs relieve pain and reduce inflamma- The patient coming to surgery may have
muscularly. tion but do not alter the course of rheuma- other connective tissue disorders such as
Patients with a predisposition to gas- toid arthritis. COX-2 inhibitors do not systemic lupus erythematosus (SLE), pso-
tritis or peptic ulcer disease should not be have any inherent benefit over older riatic arthritis, ankylosing spondylitis, der-
given non-steroidal anti-inflammatory NSAIDs other than less gastrointestinal matomyositis, and scleroderma, which
drugs (NSAIDs). The use of corticos- toxicity. Glucocorticoids effectively sup- have similar perioperative concerns.
teroids in these patients is controversial. press inflammation, often at low doses, but Preoperative assessment of patients
There is no strong scientific evidence that carry their own substantial risks. SAARDs with SLE and other connective tissue disor-
corticosteroids can cause peptic ulcers in and DMARDs include hydroxychloro- ders should include a thorough history and
most patients, but many clinicians avoid quine, sulfasalazine, methotrexate, and physical examination, a urinalysis, elec-
their use in these patients. leflunomide. Methotrexate is now consid- trolyte panel including blood urea nitrogen
ered to be first-line treatment for active and creatinine, a complete blood count,
Surgery in the Patient with rheumatoid arthritis. Penicillamine, aza- and a PT and PTT. Blood typing or screen-
Disorders of Connective thiaprine, cyclosporine, and gold salts are ing should be done in advance of surgery to
Tissue and Joints seldom used. Anticytokines include etaner- evaluate for blood compatibility. A chest
cept, infliximab, adalimumab, and anakin- radiograph and ECG are indicated for evi-
Rheumatoid Arthritis ra. These drug classes are often used in dence of pleural or pericardial disease.105
Rheumatoid arthritis (RA) is a chronic combination to control inflammation and Patients who have taken glucocorti-
disease causing not only polyarthritis but slow the progression of the disease.100103 coid therapy should be screened for use
also problems in serosal surfaces, blood Patients with RA who require endo- of stress-dose steroids, as noted above.
vessels, muscle, skin, and bone marrow. tracheal intubation should be evaluated Consider stopping NSAID therapy, if
Maxillofacial surgery in patients with RA preoperatively for their ability to extend at possible, to allow return of platelet func-
requires careful evaluation to discover the neck, open their mandible, and move tion. The time needed for this varies from
the extent of the patients abnormalities their cricoarytenoid joints. 7 to 10 days for aspirin to 1 day for
and to attempt to have those problems An early symptom of neck involve- ibuprofen. Generally NSAIDs other than
under reasonable control. Classic signs ment in RA is neck pain with radiation to aspirin should be stopped 3 to 4 days pre-
and symptoms of RA include morning the occiput. Preoperative cervical spine operatively, and acetaminophen or nar-
stiffness of involved joints, symmetric films should be considered to evaluate for cotics can be used to control pain during
involvement of proximal hand joints, subluxation of the cervical spine.104 The this time. There is no evidence that stop-
subcutaneous (rheumatoid) nodules surgeon needs to remain more vigilant ping SAARDs or DMARDs prior to
over bony prominences or extensor sur- than usual to prevent long periods of surgery conveys any benefit. Anticytokines
faces, elevated serum rheumatoid factor, overextension or flexion of involved joints. can limit immune response in severe
and marked bony erosions visible on Patients with Raynauds phenomenon infections, and in maxillofacial surgery
radiographs. need their fingers and toes kept warm these drugs should be discontinued
Medical Management of the Surgical Patient 37
1 week before surgery and resumed (Chronic recurrent seizures occur in 30% cases little can be done preoperatively to
2 weeks postoperatively. of patients with cerebral hematomas, 15% diminish the risk of a stroke during
Sjgrens syndrome patients should of those with depressed skull fractures, surgery. A careful neurologic examination
have artificial tears or lubricating gel placed and 5% of patients hospitalized with should be performed preoperatively to
in the eyes during anesthesia. Pilocarpine, if closed head injuries). Chronic posthead document residual damage, and again
used, should be held to avoid confusion trauma seizures usually do not occur until postoperatively to detect evidence of
over anesthetic complications of bron- 6 to 12 months from the time of injury. intraoperative problems.108
chospasm, bradycardia, and tremor. Patients providing a past history of Two situations in which preoperative
Patients with ankylosing spondylitis any form of seizure disorder (except per- improvement may be possible are in the
have similar spine concerns as RA patients. haps febrile seizures in childhood) should patient with either poorly controlled hyper-
Scleroderma patients may have limited be under the care of or evaluated by a neu- tension or severe carotid stenosis. Essential
mandibular movement as a consequence rologist before undergoing major elective hypertension is a known risk factor for the
of their disease, causing difficulty with surgery.107 Patients with well-documented development of a stroke; therefore, institu-
endotracheal intubation. SLE patients may seizures and who are under good control tion of successful antihypertensive therapy
have low platelets, which is generally well can safely have general anesthesia and before elective surgery is recommended.
tolerated without excessive bleeding. For surgery. Control is usually obtained by the The preoperative management of patients
counts less than 50,000, intravenous use of antiseizure medications such as with carotid lesions is controversial. Part of
immunoglobulin may be used to improve dilantin, phenobarbital, valproic acid, car- the problem is that the finding of a carotid
the platelet count. SLE patients may also bamazepine, ethosuximide, and clo- bruit by itself does not correlate with the
have evidence of the lupus anticoagulant, razepate. Most of these drugs can cause degree or even presence of carotid stenosis.
manifest by an elevated PTT. The lupus sedation, which can be additive with anes- Thus, angiography is necessary if stenosis is
anticoagulant, also referred to as antiphos- thetic drugs. Side effects of carbamazepine suspected, to document the severity of the
pholipid antibodies, can produce throm- and dilantin include nausea, dizziness, process. The question is whether to per-
boembolism. Patients may be treated with diplopia, and rarely bone marrow depres- form a carotid endarterectomy only if a TIA
aspirin if antibodies are present and there sion. Valproic acid can inhibit liver occurs or if carotid artery occlusion is
have been no previous thromboembolic enzymes, potentially causing oversedation greater than 70%.109
events, or may be fully anticoagulated, with barbiturates. Patients with a history of stroke or
requiring adjustment perioperatively.106 Newer drugs include lamotrigine, TIA frequently harbor coronary artery dis-
gabapentin, tiagibine, and topiramate. Most ease as well. A thorough assessment of the
Surgery in the Patient with of these drugs can cause sedation, which can risk for coronary disease is indicated, as
Neurologic and Neuromuscular be additive with anesthetic drugs. Other side noted in the above section.
Disorders effects vary with each drug. Patients with a history of cerebrovas-
When evaluating a patient with a cular disease are often placed on inhibitors
Seizure Disorders seizure disorder for surgery, the clinician of platelet aggregation such as aspirin or
Seizures are typically recurrent transient should learn of the frequency, type, dura- dipyridamole. Most physicians will permit
paroxysms of hyperactive brain function, tion, and sequelae of seizures to gauge the these drugs to be stopped at least 1 week
which can appear as impaired conscious- degree to which control of the seizures has preoperatively to prevent bleeding prob-
ness, involuntary movement, autonomic been obtained. Serum drug levels of these lems perioperatively. Stroke patients may
disturbance, or psychic experiences. They agents can be obtained to help check com- also have trouble clearing secretions or
can result from known causes such as pliance and predict the appearance of controlling saliva.
fever, ethanol withdrawal, hypoglycemia, seizures, if subtherapeutic, or possible
hypoxia, or brain damage, or be idiopath- toxic reactions. Malignant Hyperthermia
ic. Most investigators feel the fundamental Malignant hyperthermia is the leading
site of pathology is in the cerebral cortex, Cerebrovascular Disease cause of unexpected anesthetic deaths in
which can be detected on an electroen- Patients with a history of cerebrovascular North America. It is a rare genetic disorder
cephalogram (EEG). accidents, such as transient ischemic that manifests following treatment with
The reconstructive maxillofacial sur- attacks (TIAs) or strokes, requiring max- anesthetic agents, most commonly suc-
geon is likely to encounter patients who illofacial surgery need evaluation by their cinylcholine and halothane. The onset of
suffer seizures secondary to head trauma primary physician before surgery. In most malignant hyperthermia is usually within
38 Part 1: Principles of Medicine, Surgery, and Anesthesia
an hour of the administration of general Pectus deformities or kyphoscoliosis good patient preparation. Preoperative
anesthesia but rarely may be delayed as Limb girdle weakness checks of pulmonary and renal function
long as 11 hours. Hip dislocation, dislocated patella, will reveal patients at high risk for periop-
Approximately one-half of cases malaligned feet erative complications. The sputum and
appear to be inherited in an autosomal- Known central core myopathy urine should be checked for evidence of
dominant fashion; the remainder of cases Young males with previously described infection and blood count obtained to dis-
are inherited in different patterns. appearance cover if anemia is present. Special care
Susceptible patients with autosomal- Any history of myopathy of unknown needs to be taken to properly position and
dominant disease have any one of eight etiology pad vulnerable parts of the body during
distinct mutations in the ryanodine recep- and after surgery. Minidose heparin will
tor. This receptor is a homotetrameric cal- Patients with a known or suspected help prevent pulmonary embolism, as will
cium channel found in the sarcoplasmic tendency should be considered for local or keeping the legs elevated during surgery
reticulum of skeletal muscle. regional anesthetic techniques. If general and providing proper physical therapy
In the presence of anesthetic agents, anesthesia is necessary a technique that after surgery. Physical therapy is also nec-
alterations in the hydrophilic, amino- uses nitrous oxide, barbiturates, benzodi- essary to the upper extremities to prevent
terminal portion of the ryanodine recep- azepines, narcotics, or neuroleptic drugs is contractures. Continuous urinary
tor result in uncontrolled efflux of calcium advisable. Nondepolarizing muscle relax- catheterization is needed during surgery,
from the sarcoplasmic reticulum with sub- ants should be used if necessary. Drugs returning to the intermittent bladder
sequent tetany, increased skeletal muscle such as succinylcholine, amide local anes- catheterization regimen (in place preoper-
metabolism, and heat production. For thetics, ketamine, and volatile anesthetics atively) as soon as possible after surgery.
unclear reasons, overexpression of the should be avoided. Premedication with
wild-type ryanodine receptor does not dantrolene (1 mg/kg) orally the day before Surgery in the Patient with a
ablate abnormal myocyte responses to surgery or as an intravenous bolus the day Psychiatric Disorder
halothane, although overexpression of a of surgery is appropriate when malignant
mutated ryanodine receptor can induce hyperthermia is a high probability. In Affective Disorders
the malignant hyperthermia phenotype in addition a set protocol for its manage- Affective disorders such as depression are
myocytes from normal individuals. ment, should it occur, should be in place common problems in modern society.
Typically malignant hyperthermia before starting anesthesia for patients at Patients with this disorder need special
presents soon after induction of anesthesia risk for malignant hyperthermia.111,112 care during any surgical treatment.
with a rapid rise in body temperature and Major depression is characterized by a
muscle rigidity. Difficulty in ventilating Spinal Cord Disorders depressed mood and an inability to enjoy
the patient or opening the mandible for Paraplegia due to spinal cord damage can life. Symptoms include sleep disturbance
intubation are common early manifesta- cause a number of problems of which the such as early morning wakening, appetite
tions. Other signs include diaphoresis, surgeon needs to be cognizant. Abnormal disturbance, fatigue, decreased libido, low
tachypnea, tachycardia, hyperkalemia, bladder emptying predisposes these self-esteem, and a feeling of hopelessness.
hypocalcemia, elevated temperature and patients to urinary tract infections and Many patients are able to mask or deny their
carbon dioxide content of expired air, and chronic pyelonephritis. Paraplegia affect- symptoms when under no undue stress, but
cardiac dysrhythmias. Renal failure can ing the diaphragm can lead to pneumonia, facing a surgical procedure will usually
occur due to rhabdomyolysis and myoglo- and inability to exercise the lower extrem- uncover hidden symptoms of depression.
binuria.110 Consumptive coagulopathy can ities and pelvic region setting up a situa- In addition to the emotional problems
also be triggered. Mortality in patients in tion in which thromboembolism to the that patients with depression incur in the
which the disorder was not suspected lungs is common. Inability to move can perioperative period, problematic drug
before anesthesia ranges from 63 to 73%. also cause the development of decubitus interactions can occur between anesthetic
A predisposition to malignant hyper- ulcers. Renal and adrenal functions are agents and many of the agents used to
thermia should be suspected in patients often impaired due to amyloidosis, and control depression. Selective serotonin
with the following characteristics: anemia of chronic disease is frequent in reuptake inhibitors are in widespread use
paraplegics. for depression, anxiety, and panic disorder,
Unusual muscle hypertrophy Maxillofacial surgery for these indi- and are well tolerated perioperatively. Tri-
Ptosis, ophthalmoplegia, strabismus viduals can be accomplished safely with cyclic antidepressants are in common use
Medical Management of the Surgical Patient 39
for depression, chronic pain, and sleep dis- olanzapine, quetiapine, ziprasidone, and Previous history of DT and drinking a
orders. They can carry unwanted anti- aripiprazole. These medications have morning eye opener denote a high risk
cholinergic and hypotensive side effects, many drug-drug interactions, and consul- of alcohol withdrawal.
which should be remembered when anes- tation with a drug reference manual or Two strategies are available for the
thesia is given. An additional problem with pharmacist would be prudent to avoid alcoholic patient coming to surgery: con-
tricyclic antidepressants is their tendency such complications. tinuation of alcohol perioperatively, or
to cause increased conduction delays in Surgery in psychotic patients carries avoidance of alcohol with vigilance for
patients with preexisting heart blocks. no increased risk of complications as long withdrawal syndromes. While it seems
Monoamine oxidase inhibitors (MAOIs) as the disorder is well controlled. counterintuitive to continue alcohol use in
are also used to manage depressive symp- Acute psychosis, combativeness, and a hospital or postoperative setting, this
toms. They also have anticholinergic and agitation can be disruptive as well as strategy can prevent withdrawal; most
orthostatic hypotensive effects. Drugs with unsafe for the patient and medical staff. patients will resume drinking as soon as
sympathomimetic action should be avoided After ruling out serious medical complica- they can anyway. For patients newly
in patients on MAOIs. tions such as hypoxia, drug or alcohol abstaining, those with a prior history of
Lithium carbonate is used for patients withdrawal, serious infection, and DT may be given scheduled benzodi-
with bipolar (manic-depressive) disorders. myocardial infarction, administration of azepines, such as lorazepam 1 to 2 mg
It induces the characteristic ECG changes of loraze-pam 1 to 2 mg PO or IV, or every 8 hours, but most patients should be
inverted and flattened T waves. It can also haloperidol 1 to 2 mg PO, IM, or IV, can be observed for evidence of DT and treated
produce sinus node dysfunction and ven- used for control of symptoms acutely. based on symptoms. Early symptoms
tricular irritability. Serum levels should be Haloperidol also comes in a flavorless liq- include restlessness and tremulousness,
checked preoperatively in these patients. uid formula. followed by agitation, combativeness,
Benzodiazepines used for depression fever, and seizures. Symptoms should be
pose little risk for safe anesthesia as long as Substance Abuse treated as soon as they emerge, with
the anesthesiologist is aware of their use. oxazepam 15 to 30 mg PO every 6 to
Abrupt discontinuation should be avoided Alcoholism Patients who regularly con- 8 hours as needed, or lorazepam 1 to 2 mg
to prevent the appearance of a withdrawal sume large amounts of ethanol must be PO, IV, or IM every 6 to 8 hours as needed.
phenomenon. allowed to withdraw from the effects of the Most of the anesthetic hazards in the
Conditions such as anorexia nervosa alcohol before they undergo elective sober alcoholic patient are due to ethanol-
and bulimia should be addressed prior to surgery and anesthesia. Failure to follow induced hepatic changes (see Liver Dis-
major surgical procedures due to the this strategy risks the appearance of minor ease). Chronic ethanol use increases anes-
impairment to nutritional health and elec- alcohol withdrawal syndrome, with its thetic requirements for halothane and
trolyte balance they produce.113 compensatory neuronal excitability and isoflurane. Clearance of benzodiazepines
catecholamine release, or the severe syn- is also increased, so that larger doses may
Psychotic Disorders drome delirium tremens (DT) with hallu- be necessary in alcoholic patients. Patients
Psychotic disorders are characterized by cinosis, hyperpyrexia, hypertension, and with ethanol-induced liver disease are
delusions and hallucinations. Psychotic life-threatening cardiac dysrhythmias and prone to hypoglycemia and need frequent
patients are usually easily recognized by seizures.114,115 serum glucose determinations during and
the results of a comprehensive mental sta- The following four questions have a after surgery.
tus examination. Antipsychotic drugs such high sensitivity and specificity for detect-
as phenothiazines, thioxanthenes, buty- ing alcoholism.116 Opioid and Illicit Drug Abusers If
rophenones, and indalones control many surgery is urgently necessary in opioid-
of the symptoms of psychosis and cause Have you ever felt the need to cut dependent patients, it is usually prudent
little increased risk of problems with anes- down on drinking? for the surgeon to avoid precipitating the
thesia. They do have the tendency to cause Have you ever felt annoyed by criti- withdrawal syndrome by substituting
sedation and extrapyramidal symptoms in cism of your drinking? methadone (2.5 mg equals 10 mg of mor-
many patients. Introduction of atypical Have you ever had guilty feelings phine) for the abused opioid. Usually 20 to
antipsychotic medications has resulted in about your drinking? 40 mg of methadone is needed daily,
a large number of patients being convert- Have you ever taken a morning eye administered orally or intramuscularly in
ed to these drugs, including respiradone, opener? 4 to 6 divided doses. Clonidine has also
40 Part 1: Principles of Medicine, Surgery, and Anesthesia
been found useful for helping prevent Chase method is another means of gauging tion in incentive spirometry techniques.
symptoms of opioid withdrawal.117 risk in obese individuals in which surgical The increased risk of thrombophlebitis in
Hypotension is a common problem in risk is determined by the ratio of weight these patients can be lessened by the use of
opioid abusers during the perioperative versus height. a minidose heparin or enoxaparin regi-
period. They also are likely to have difficult Pulmonary problems are the most fre- men. Finally, a lowered threshold is appro-
veins in which to gain access, necessitating quent complications in the perioperative priate for placement of invasive monitors
placement of central lines. Intravenous period in obese patients. These include such as a central venous pressure line or a
illicit drug abusers also have a high inci- pulmonary embolism, bronchospasm, Swan-Ganz catheter.
dence of hepatitis B and C and human atelectasis, and pneumonia. Obesity cre- Obese patients are difficult anesthetic
immunodeficiency virus positivity. ates a form of restrictive lung disease, cases. They are typically more of a problem
Cocaine use potentiates problems especially when these patients are supine, to mask ventilate during the induction of
such as coronary vasospasm, myocardial due to excessive weight on the thorax and anesthesia. This should be anticipated by
ischemia/infarction, and dysrhythmias. abdomen that restricts full inspiration. being ready to quickly intubate the patient
The rapid metabolism of cocaine in a Before elective surgery in obese if necessary even though intubation itself
patients system prior to presenting for patients a careful history and physical can be challenging.120 The excess weight
surgery makes it unlikely that acutely examination are necessary to determine usually decreases pulmonary compliance
intoxicated patients will be placed under how the obesity may affect anesthesia and and the functional residual and vital capac-
sedation or general anesthesia.118,119 to detect a concurrent disease. Specific ities. It should be kept in mind that squeez-
questions about a history of daytime ing the bag connected to the endotracheal
Surgery in the Special Patient somnolence and snoring are needed to tube will not give an accurate feel of pul-
find if a patients airway is easily compro- monary compliance due to the weight of
Obese Patients mised. Past history of lung disease, heart the chest wall. Furthermore, the lowered
Obesity is a common affliction in modern problems, thrombophlebitis, or pul- lung capacities will cause an increased
society due to a combination of poor monary embolism should also be elicited. shunt fraction, which should be monitored
dietary habits and general lack of physical Obese patients should also be asked by frequent measurements of arterial blood
activity. The excessive weight in an obese about any previous problems in the gases. Chest weight effects on the lungs can
individual is due to an overabundance of establishment of venous access. The use- be lessened by elevating the upper body 15
adipose tissue. Morbid obesity is defined fulness of physical examination of the to 20 from the horizontal.
as when a patient is 100% over ideal body chest and abdomen is commonly limited The pharmacokinetics of drugs differ
weight due to fat accumulation. Calcula- in obese patients. Therefore, ancillary in obese versus lean individuals. The
tion of the body mass index (BMI) assists examination techniques such as PFTs, washout of fat-soluble anesthetic agents
in the diagnosis of obesity, with a BMI of ECG, and plain chest radiography are needs to begin earlier in the surgery to
30 kg/m2 and above defining obesity. usually warranted. allow the patient to be awakened when
Because obese patients have height- desired. When calculating the dose of
Body weight in kg ened risks of pulmonary problems, those water-soluble drugs, the estimated lean
BMI =
Square of stature who smoke should be helped to quit, body mass of the obese individual should
(height in m) hopefully for as long as possible before be used.
surgery. A reasonable program of weight Postoperative management of obese
Obesity by itself does not increase sur- reduction should also be recommended. patients should include elevation of the
gical mortality until it becomes severe, but Many patients may benefit from a consul- head of the bed, early ambulation, incen-
then the risk rises exponentially. The pon- tation about potential gastrointestinal tive spirometry, deep venous thrombosis
deral index has been used to quantitate the surgery for weight control. prophylaxis, and frequent physical exami-
increased risk faced by obese individuals. When planning surgery the possibility nation for signs of pulmonary problems or
The index is calculated by dividing an of regional anesthesia should be consid- deep vein thrombophlebitis.
individuals height in inches by the cube ered. Deep sedation should be avoided if
root of their weight in pounds. A result the airway is likely to be difficult to main- Geriatric Patients
greater than 12.5 correlates highly with a tain. If general anesthesia is selected as the Although many clinicians are concerned
significantly heightened risk of complica- method of pain and anxiety control, the that there will be medical complications
tions in the perioperative period. The patient can be given preoperative instruc- when treating elderly patients, studies sub-
Medical Management of the Surgical Patient 41
stantiate the fact that most elective surgery increased stiffness of the chest wall predis- extra care should be taken when transport-
is safe in healthy geriatric patients. Howev- pose lungs to atelectasis and ventilation- ing these patients to and from the operating
er, geriatric patients with chronic diseases perfusion imbalances, as does the table. Thinning of skin in older patients
such as COPD, diabetes, and coronary increased residual volume in older lungs. also makes them more susceptible to pres-
artery disease are certainly susceptible to Whereas the PaO2 on room air at age sure damage, heightening the need for
the same problems as younger individuals 30 years averages about 94 mm Hg, it nor- proper intraoperative padding.
with these same processes. Therefore, mally falls to about 74 mm Hg above age Geriatric patients tend to mount poor
when older patients have chronic diseases, 60 years. Vital capacity and expiratory flow fever responses to pyrogens. Therefore,
preoperative preparation should include rate begin to fall when individuals reach other signs of problems such as malaise or
efforts to minimize the detrimental effect age 30. Muscle weakness prevents forceful altered states of consciousness may need to
of the disease process on the patients coughing, and degeneration of bronchial be used to detect infections. The hearing
physiology.121 epithelium leads to less efficient lung and visual problems of older patients pre-
Even though elderly patients can cleansing. All of these changes help to dispose them to states of confusion own-
appear frail and sick, a large percentage are account for the relatively high incidence of ing to sensory deprivation; providing
actually well. Conversely the appearance of pulmonary complications following appropriate sensory stimulation helps pre-
health can be deceiving, because all older surgery in older patients. vent this problem. A decrease in gastroin-
individuals experience various changes in Renal function decreases 20 to 30% testinal motility leads to frequent consti-
physiologic function that can affect their between the ages of 30 and 80 years pation, and aging often causes impaired
response to the stress of an operation. because of natural loss of glomeruli and glucose tolerance.
Statistically the most common compli- fibrosis of interstitial tissue. Creatinine Evaluation of elderly patients before
cations that follow major surgery in the clearance falls, but because lean body mass elective maxillofacial surgery should begin
elderly are pulmonary embolism, myocar- also decreases there is usually no change in with a careful medical history. Old records
dial infarction, pneumonia, and congestive measured serum creatinine. An approxi- and consultation with the patients prima-
heart failure. The surgeon should be espe- mation of expected age-related changes in ry care provider are usually excellent
cially vigilant for a past history or perioper- renal function can be gained by the fol- sources of needed information. During the
ative signs of these problems. Furthermore, lowing equation: physical examination specific note should
although geriatric patients usually are able be made of the patients state of hydration,
Creatinine clearance
to withstand the initial physiologic stresses = 133 (0.84 Age) signs of age-related problems such as
(mL/min)
of surgery, if a complication occurs, they carotid or aortic stenosis, and any pul-
have less reserve to aid with recovery. This formula can be used to judge dosages monary and mental status problems. An
The heart undergoes age-related of drugs dependent on renal clearance. ECG and chest radiograph are useful for
changes that decrease the maximal heart Geriatric patients also suffer a loss of renal detecting occult problems and provide a
rate (220 age in yr). Cardiac output falls concentrating and diluting abilities as baseline for later comparisons.124,125
(about 1% each year after age 20 yr) tubules become less responsive to antidi- Intraoperatively the patient should be
because of increased afterload and uretic hormone. For that reason they can kept from excessive loss of heat and over-
decreased elasticity of arteries secondary easily have intravascular volume distur- or underhydration. Postoperatively, the
to atherosclerosis. This decreased elasticity bances and electrolyte abnormalities. clinician should be alert to possible respi-
also causes any small increase in blood Thirst perception also becomes a problem ratory depression due to narcotics and
volume to result in sharp increases in and thirst cannot be relied on to help signs of myocardial damage such as sud-
blood pressure. Total circulation time at gauge fluid requirements in these patients. den dyspnea or worsening of congestive
age 20 years is 48 seconds; this rises to Prostatic hypertrophy occurs in 80% of heart failure.
65 seconds at age 70 years. The cardiovas- men with age, causing urinary problems Drug modifications in the elderly
cular system also loses much of its respon- that are commonly worsened by general include reducing benzodiazepine dosages
siveness to catecholamines with age, so anesthesia.122,123 by at least 50%, recognizing the dysrhyth-
that postural hypotension is common. The loss of muscle mass and plasma mogenic potential of atropine, and being
Maximum coronary flow capacity in the volume with age may affect drug actions aware that narcotics such as morphine and
elderly is about 65% of that in teenagers. and necessitate changes in drug doses. meperidine have prolonged duration of
Pulmonary function also falls as peo- Older white females are also predisposed to action, and that water-soluble drugs will
ple get older. Loss of lung elasticity and loss of bone strength owing to osteoporosis; have a heightened pharmacologic effect
42 Part 1: Principles of Medicine, Surgery, and Anesthesia
while lipid-soluble drugs such as barbitu- Table 2-8 Medication to Avoid during Table 2-9 Medications for Breast-
rates will have a long elimination time.123 Pregnancy* Feeding Mothers
stable angina treated with coronary artery matic left ventribular dysfunctions. Am J with ventricular tachyarrhythmias. Cardiol
stenting. Am J Med 2003; 114:71522. Med 2003;114:4317. Clin 1993;11: 6583.
11. Greenland MD, Knoll MD, Stomler T, et al. 23. Ranjan A, Tarigopula L, Srivastara RK, et al. 39. Belocci F, Sontarelli P, Di Gennaro M, et al. The
Major risk factors as antecedents of fatal Effectiveness of the clinical pathway in the risk of cardiac complications in surgical
and nonfatal coronary heart disease events. management of congestive heart failure. patients with bifascicular block. Chest
JAMA 2003;290:8917. South Med J 2003;96:6613. 1980;77:3438.
12. Khot UN, Khot MB, Bajyer CT, et al. Preva- 24. Schiff GD, Fung S, Speroff T, et al. Decompen- 40. Hodgkin JD. Preoperative assessment of respira-
lence of conventional risk factors in sated heart failure: symptoms, patterns of tory function. Respir Care 1984;29:496505.
patients with coronary heart disease. JAMA onset, and contributing factors. Am J Med 41. Tisi GM. Preoperative identification and evalu-
2003;290:898904. 2003;114:62530. ation of the patient with lung disease. Med
13. Felner JM, Arensberg D. Perioperative manage- 25. Cohn JN. The management of chronic heart Clin North Am 1987;71:399412.
ment of the cardiac patient. In: Lubin MF, failure. N Engl J Med 1996;335:4908. 42. Ford GT, Guenter CA. Toward prevention of
Walker HK, Smith RB, editors. Medical man- 26. Rackley CE, Edwards JE, Karp RB. Mitral valve postoperative pulmonary complications.
agement of the surgical patient. 2nd Ed. disease. In: Hurst JW, editor. The heart. 7th Am Rev Respir Dis 1984;130:45.
Boston (MA): Butterworths; 1988. p. 91. Ed. New York (NY): McGraw-Hill; 1990. p. 43. Gass GD, Olsen GN. Preoperative pulmonary
14. Miller R, Silvoy G, Lumb PD. Anesthesia, surgery 820. function testing to predict postoperative
and myocardial infarction: a review. Anesth 27. Freed LA, Levy D, Levine RA, et al. Prevalence morbidity and mortality. Chest 1986;89:127.
Rev 1979;6:14. and clinical outcome of mitral valve pro- 44. Crapo RO. Pulmonary-function testing. N
15. Mauney FM, Ebert PA, Salistan DC. Postoper- lapse. N Engl J Med 1999;341:17. Engl J Med 1994;331:25.
ative myocardial infarction. A study of pre- 28. Cheitlin MD, Byrd RC. Prolapsed mitral valve. 45. McFadden ER Jr. Asthma. In: Braunwald E,
disposing factors, diagnosis and mortality Curr Probl Cardiol Dis 1984;8:151. Fauci AS, Kasper DL, et al, editors. Harri-
in a high-risk group of surgical patients. 29. Dujardin KS, Enriquez-Sarano M, Schaff HV, sons principles of internal medicine. 15th
Ann Surg 1970;172:497503. et al. Mortality and morbidity of aortic Ed. New York (NY): McGraw-Hill; 2001.
16. Eagle KA, Berger PB, Calkins H, et al. regurgitation in clinical practice. Circula- 46. Star RA. Treatment of acute renal failure. Kid-
ACC/AHA guideline update for periopera- tion 1999;99:18517. ney Int 1998;54:181731.
tive cardiovascular evaluation for noncar- 30. Iung B, Gohlke-Barwolf C, Tornos P, et al. Rec- 47. Van den Toorn LM, Overbeek SE, Prins J, et al.
diac surgery update: a report of the Ameri- ommendations on the management of the Asthma remission: does it exist? Curr Opin
can College of Cardiology/American Heart asymptomatic patient with valvular heart Pulm Med 2003;9:1520.
Association Task Force on Practice Guide- disease. Eur Heart J 2002;23:125366. 48. Bishop MJ, Cheney FW. Anesthesia for patients
lines. Committee to Update the 1996 31. Felner JM. Congestive heart failure. In: Lubin with asthma: low risk but not no risk. Anes-
Guidelines on Perioperative Cardiovascular MF, Walker HK, Smith RB, editors. Medical thesiology 1996;85:4556.
Evaluation for Noncardiac Surgery 2002; management of the surgical patient. 2nd 49. Warner DO, Warner MA, Barnes RD, et al.
American College of Cardiology Web site. Ed. Boston (MA): Butterworths; 1988. Perioperative respiratory complications in
Available at: http://www.acc.org/clinical/ p. 133. patients with asthma. Anesthesiology
guidelines/perio/update/pdf/perio_update. 32. Kaufman L. Unforeseen complications encoun- 1996;85:4607.
pdf (accessed November 18, 2003). tered during dental anesthesia. Proc R Soc 50. Chervinsky P, Bronsky EA, Dockhorn R, et al.
17. Auerbach A, Goldman L. Beta-blockers and Med 1966;59:73140. Fluticasone propionate aerosol for the treat-
reduction of cardiac events in noncardiac 33. Calkins H, Sousa J, el-Atassi R, et al. Diagnosis ment of adults with mild to moderate asth-
surgery: scientific review. JAMA 2002; and cure of the Wolff-Parkinson-White syn- ma. J Allerg Clin Immunol 1994;94:67683.
287:143544. drome or paroxysmal supraventricular 51. Kavuru M, Melomed J, Gross G, et al. Salme-
18. Goldman L, Caldera DL, Southwick FS, et al. tachycardias during a single electrophysio- terol and fluticasone propionate combined
Multi-factorial index of cardiac risk in non- logic test. N Engl J Med 1991;324:16128. in a new powder inhalation device for the
cardiac surgical procedures. N Engl J Med 34. Roy D. Amiodarone to prevent recurrence of treatment of asthma. Allerg Clin Immunol
1977;297:84550. full atrial fibrillation. N Engl J Med 2000;105:110816.
19. Hupp JR. Myocardial infarction: current man- 2000;342:91320. 52. Suissa S, Dennis R, Ernst P, et al. Effectiveness
agement strategies. J Oral Maxillofac Surg 35. Kennedy HL, Whitlock JA, Sprague MK, et al. of the leukotriene receptor antagonist zafir-
1989;47:10703. Long-term follow-up of asymptomatic lukast for mild-to-moderate asthma. Ann
20. Tschopp MD, Sorin J, Brener MD. Complica- healthy subjects with frequent and complex Intern Med 1977;126: 17783.
tions of acute myocardial infarction. Cleve ventricular ectopy. N Engl J Med 1985; 53. Celli B. Standards for the diagnosis and care of
Clin Dis Manage Proj. Available at: 312:1937. patients with chronic obstructive pul-
www.clevelandclinicmed.com (accessed 36. Bigger JT Jr, Fleiss JL, Kleiger R, et al. The rela- monary disease. Am J Respir Crit Care Med
June 23, 2003). tionships among ventricular arrhythmias, 1995;152:S7783.
21. Hochman JS. Cardiogenic shock complicating left ventricular dysfunction, and mortality 54. Soto FJ, Varkey B. Evidence-based approach to
acute myocardial infarction. Circulation in the 2 years after myocardial infarction. acute exacerbations of COPD. Curr Opin
2003;107: 29983002. Circulation 1984;69(2):2508. Pulm Med 2003;9:11724.
22. Drazner MH, Rome JE, Dries DL. Third heart 37. Lown B, Grayboys TB. Management of patients 55. Sethi JM, Rochester CL. Smoking and chronic
sound and elected jugular venous pressure with malignant ventricular dysrhythmias. obstructive pulmonary disease. Clin Chest
as markers of the subsequent development Am J Cardiol 1977;39:9108. Med 2000;21:6786.
of heart failure in patients with asympto- 38. Wyse DG. Pharmacologic therapy in patients 56. Rehder K, Sessler AD, Marsh HM. General
44 Part 1: Principles of Medicine, Surgery, and Anesthesia
anesthesia and the lung. Am Rev Respir Dis surgical patient. Surg Clin North Am ative glucocorticoid coverage: a reassess-
1975;112:54163. 1983;63:101733. ment 42 years after emergence of a problem.
57. Kellerman PS. Perioperative care of the renal 76. Alberti KG, Zimmet PZ. Definition, diagnosis Ann Surg 1994;219:41625.
patient. Arch Intern Med 1994;154:167488. and classification of diabetes mellitus and 95. Weatherill D, Spence AA. Anaesthesia and dis-
58. Anagnostou A, Kurtzman NA. The anemia of its complications. Diabet Med 1997; orders of the adrenal cortex. Br J Anaesth
chronic renal failure. Semin Nephrol 15:53953. 1984;56:7419.
1985;5:11527. 77. Fletcher J, Langman MS, Kellock TD. Effect of 96. Arteel G, Marsano L, Mendez C, et al. Advances
59. de Medina M, Ashby M, Schluter V, et al. Preva- surgery on blood sugar levels in diabetes in alcoholic liver disease. Clin Gastroenterol
lence of hepatitis C and G virus infection in mellitus. Lancet 1965;2:524. 2003;17:62547.
chronic hemodialysis patients. Am J Kidney 78. OSullivan JJ, Conroy RM, Macdonald K, et al. 97. Keefe EB. Cirrhosis of the liver. Sci Am Med
Dis 1998;31:2246. Silent ischaemia in diabetic men with auto- 1998;113.
60. Alberio L, Kimmerle S, Baumann A, et al. nomic neuropathy. Br Heart J 1991;66:3135. 98. Barrera JM, Bruguera M, Ercilla MG, et al. Per-
Rapid determination of anti-heparin/ 79. Rayfield EJ, Ault MJ, Keusch GT, et al. Infection sistent hepatitis C viremia after acute self-
platelet factor 4 antibody titers in the diag- and diabetes. Am J Med 1982;72:43950. limiting posttransfusion hepatitis C. Hepa-
nosis of heparin-induced thrombocytope- 80. Jacober SJ, Sowers JR. An update on perioperative tology 1995;21:63944.
nia. Am J Med 2003;114:52836. management of diabetes. Arch Intern Med 99. Liang TJ, Rehermann B, Seeff LB, et al. Patho-
61. Brenowitz JB, Williams CD, Edwards WS. 1999;159:240511. genesis, natural history, treatment, and pre-
Major surgery in patients with chronic 81. McAnulty GR, Robertshaw HJ, Hall GM. Anes- vention of hepatitis C. Ann Intern Med
renal failure. Am J Surg 1977;134:7659. thetic management of patients with dia- 2000;132:296305.
62. Burke GR, Gulyassy PF. Surgery in the patient betes mellitus. Br J Anaesth 2000;85:8090. 100. Adalimumab (Humira) for rheumatoid arthri-
with renal disease and related electrolyte 82. Clark CM, Lee DA. Prevention and treatment tis. Med Lett 2003;45:25.
disorders. Med Clin North Am 1979; of the complications of diabetes mellitus. N 101. Bombardier C, Laikne L, Reicin A, et al. Com-
63:119162. Engl J Med 1995;332:12107. parison of upper gastrointestinal toxicity of
63. Ifudu O. Care of patients undergoing hemodial- 83. Thomas DJ, Platt HS, Alberti KG. Insulin- rofecoxib and naproxen in patients with
rheumatoid arthritis. N Engl J Med 2000;
ysis. N Engl J Med 1998;339:105462. dependent diabetes: an assessment of con-
343;15208.
64. Thodhani R. Acute renal failure. N Engl J Med tinuous glucose-insulin potassium infusion,
102. Lee DM, Weinblatt ME. Rheumatoid arthritis.
1996;334:144860. and traditional treatment. Anesthesiology
Lancet 2001;358:90311.
65. Deutsch S. Anesthetic management of patients 1984;39:62937.
103. ODell JR. Combination DMARD therapy for
with chronic renal disease. South Med J 84. Jacober SJ, Sowers JR. An update on periopera-
rheumatoid arthritis. Ann Rheum Dis
1975;68:659. tive management of diabetes. Arch Intern
1996;55:7813.
66. Oparil S, Calhoun DA. High blood pressure. Med 1999;159: 240511.
104. Kwek TK, Lew TW, Thoo FL. The role of pre-
Sci Am Med 2000;16. 85. DeFronzo RA. Pharmacologic therapy for type
operative cervical spine X-rays in rheuma-
67. Edwards WJ. Preanesthetic management of the 2 diabetes mellitus. Ann Intern Med
toid arthritis. Anesth Intern Care 1998;
hypertensive patient. N Engl J Med 1979; 1999;131:281303.
26:63641.
301:1589. 86. Roizen MT, Hensel P, Lichtor JL, et al. Patients
105. Mills JA. Systemic lupus erythematosus. N Engl
68. Goldman L, Caldera DL. Risks of general anes- with disorders of thyroid function. Anesth
J Med 1994;330:18719.
thesia and elective operation in the hyperten- Clin North Am 1987;5:27786. 106. Preoperative evaluation and perioperative man-
sive patient. Anesthesiology 1979;50:28592. 87. Streetman DD, Khanderia V. Diagnosis and agement of patients with rheumatic diseases.
69. Ropper AH, Wechsler LR, Wilson LS. Carotid treatment of Graves disease. Ann Pharma- Up-to-Date; 2003. Available at: http//www.
bruit and the risk of stroke in elective cother 2003;37:11009. uptodateonline.com/application/topic.asp?fi
surgery. N Engl J Med 1982;307:138890. 88. Franklyn JA. The management of hyperthy- le=rheumati/46608 (accessed Jan 1, 2004).
70. Puschett JB. Diuretics and the therapy of roidism. N Engl J Med 1994;330:17318. 107. Shneker BF, Fountain NB. Epilepsy. Dis Month
hypertension. Am J Med Sci 2000;319:19. 89. Goldman DR. Surgery in patients with 2003;49:426-78.
71. Conlin PH, Williams GH. Use of calcium endocrine dysfunction. Med Clin North 108. Morgenstern LB, Kasner SE. Cerebrovascular
blockers in hypertension. Adv Intern Med Am 1987;71:499509. disorders. Sci Am Med 2000;115.
1998;43:53362. 90. Leech NJ, Dayan CM. Controversies in the 109. Kistler JP, Furie KL. Carotid endarterectomy
72. Thurman JM, Schrier RW. Comparative effects management of Graves disease. Clin revisited. N Engl J Med 2000;342:17435.
of angiotensin-converting enzyme Endocrinol 1998;49:2780. 110. Peters KR, Nance P, Wingard DW. Malignant
inhibitors and angiotensin blockers on 91. Singer PA, et al. Treatment guidelines for hyperthyroidism or malignant hyperther-
blood pressure and the kidney. Am J Med patients with hyperthyroidism and mia? Anesth Analg 1981;60:6135.
2003;114:58898. hypothyroidism. JAMA 1995;273:80812. 111. Wackym PA, Dubrow TJ, Abdul-Rasool IH, et al.
73. Colson P, Ryckwaert F, Coriat P. Renin 92. Lindsay RS, Toft AD. Hypothyroidism. Lancet Malignant hyperthermia in plastic surgery.
angiotensin system antagonists and anesthe- 1997; 349:4137. Plast Reconstr Surg 1988;82:87882.
sia. Anesth Analg 1999;89: 114355. 93. Schlaghecke R, Korneby E, Santen RT, et al. The 112. Hopkins PM. Malignant hyperthermia:
74. Bertrand M, Godet G, Meersschaert K, et al. effect of long-term glucocorticoid therapy advances in clinical management and diag-
Should the angiotensin II antagonists be on pituitary-adrenal responses to exoge- nosis. Br J Anaesth 2000;85:11828.
discontinued before surgery? Anesth Analg nous corticotropin-releasing hormone. N 113. Seller CA, Ravalia A. Anesthetic implications of
2001;92:2630. Engl J Med 1992;326:22630. anorexia nervosa. Anaesthesia 2003;58:
75. Martin DE, Kommerer WS. The hypertensive 94. Salem M, Tinsh RE, Bromberg J, et al. Perioper- 43743.
Medical Management of the Surgical Patient 45
114. Rimm Ed, Giovannucci EL, Willett WC, et al. 120. Juvin P, Lavaut E, Dupont H, et al. Difficult tra- 127. Bremme KA. Haemostatic changes in pregnan-
Prospective study of alcohol consumption cheal intubation is more common in obese cy. Clin Haematol 2003;16:15368.
and risk of coronary disease in men. Lancet than in lean patients. Anesth Analg 2003; 128. Santos AC, Pededrsen H. Current controversies
1991;338:46468. 97:595600. in obstetric anesthesia. Anesth Analg
115. Spies CD, Rommelspacher H. Alcohol withdraw- 121. Ershler WB, Longo DL. The biology of aging. 1994;78:75360.
al in the surgical patient: prevention and Cancer 1997;80:128493. 129. Koren G, Pastuszak A, Ito S. Drugs in pregnan-
treatment. Anesth Analg 1999;88:94654. 122. Greenblatt DJ, Sellers EM, Shader RI. Drug dis- cy. N Engl J Med 1998;338:112837.
116. Bush B, Shaw S, Cleary P, et al. Screening for
position in old age. N Engl J Med 1982; 130. Bamber JH, Dresner M. Aortocaval compres-
alcohol abuse using the CAGE question-
306:10818. sion in pregnancy: the effect of changing
naire. Am J Med 1987;82:2315.
123. Vestal R. Aging and pharmacology. Cancer the degree and directions of lateral tilt on
117. Jenkins LC. Anaesthetic problems due to drug
abuse and dependence. Can Anaesth Soc J 1997;80: 130210. maternal cardiac output. Anesth Analg
1972;19:46177. 124. Parikh SS, Chung F. Postoperative delirium in 2003;97:2568.
118. Cregler L, Mark H. Medical complications of the elderly. Anesth Analg 1995;80:122332. 131. Lipstein H, Lee CC, Crupi RS. A current con-
cocaine abuse. N Engl J Med 1986;315: 125. Peibe H-J. The aged cardiovascular risk patient. cept of eclampsia. Am J Emerg Med 2003;
14951500. Br J Anaesth 2000;85:76378. 21:2236.
119. Bernards CM, Teijeiro A. Illicit cocaine inges- 126. Campbell RL, Weiner M, Stewart LM. General 132. Cunningham FG, Lindheimer MD. Hyperten-
tion during anesthesia. Anesthesiology anesthesia for the pediatric patient. J Oral sion in pregnancy. N Engl J Med 1992;
1996;84:21820. Maxillofac Surg 1982;40:497506. 326:92732.
CHAPTER 3
Perioperative Considerations
Noah A. Sandler, DMD, MD
Many factors need to be considered when These were assigned a point system based patient daily function and surgical risk
evaluating a patient prior to oral and max- on their relative contribution to cardiac were also considered.
illofacial procedures. Whether a surgery is risk. The more points, the higher the risk Recent evidence based on 4,315
being performed in an office or operating of significant morbidity or mortality, pri- patients over the age of 50 years undergoing
room, the practitioner must acknowledge marily in the immediate postoperative elective noncardiac procedures suggests six
the impact of the surgery and the stress the period (Table 3-2). major risk factors exist. These are included
perioperative period potentially entails. In Since 1980 the American College of in a revised cardiac risk index: high-risk
addition, the pathophysiology of con- Cardiology in association with the Ameri- type of surgery, history of ischemic heart
comitant medical ailments that may mod- can Heart Association (ACC/AHA) has disease, congestive heart failure, cerebrovas-
ify therapy needs to be considered. Preop- produced guidelines for the management cular disease, preoperative treatment with
erative assessment, intraoperative of cardiovascular disease. In 1996 a com- insulin, and preoperative serum creatinine
monitoring, and postoperative care need mittee was developed to assess guidelines > 2.0 mg/dL.2 Based on these findings as
to be modified based on individual patient in the perioperative evaluation for noncar- well as support from similar studies and
requirements. The following discussion diac surgery. Expanding on the factors recent technologic advances in coronary
does not attempt to answer all questions identified by Goldman and colleagues, testing and therapies, the ACC/AHA
regarding perioperative patient care. Com-
mon clinical scenarios and disease
processes are presented. Despite our best Table 3-1 Risk Factors Commonly Associated with Perioperative Morbidity and Their
efforts to prevent problems through Point Value*
assessment and monitoring, problems or Risk Factor Point Value
emergencies can arise; therefore, this
Third heart sound or jugular venous distention 11
chapter also addresses patient monitoring Recent myocardial infarction 10
and emergency management of common Rhythm other than sinus or premature atrial contractions on last echocardiogram 7
clinical situations. > 5 premature ventricular contractions per minute at any time 7
Intraperitoneal, intrathoracic, or aortic operation 3
Cardiac Assessment Age > 70 yr 5
Since the 1970s risk assessment has been Important aortic stenosis 3
performed in an attempt to identify indi- Emergent operation 4
viduals who may encounter a significant Poor general medical condition 3
cardiac event (ie, myocardial infarction Partial pressure of oxygen < 60 or of carbon dioxide > 50 mm Hg
[MI] or death) in the perioperative period. K < 30 mEq/L
Creatinine > 3 mg/dL or blood urea nitrogen > 50 mg/dL
In their often-referenced article, Goldman
Chronic liver disease
and colleagues identified nine indepen-
Bedridden from noncardiac causes
dent factors associated with increased
*As determined in Goldman L et al.1 Adapted with permission from Goldman L et al.1
perioperative cardiac risk (Table 3-1).1
48 Part 1: Principles of Medicine, Surgery, and Anesthesia
Table 3-2 Assessment of Morbidity and Mortality Based on Cardiac Risk Factors* invasive testing (eg, stress test, echocardio-
graphy). This approach has been demon-
No or Minor Life-Threatening
Complications Complications Cardiac Deaths
strated in recent studies to be efficacious
Class Point Total (n = 943)(%) (n = 39)(%) (n = 19)(%) and cost-effective.47
Since most oral and maxillofacial sur-
I (n = 537) 05 532 (99) 4 (0.7) 1 (0)
gical procedures are considered to be
II (n = 316) 612 295 (93) 16 (5) 5 (2)
III (n = 130) 1325 112 (86) 15 (11) 3 (2)
intermediate risk, the primary cardiac risk
IV (n = 18) > 26 4 (22) 4 (22) 10 (56) factor is the existence of one or more of
*As determined in Goldman L et al.1
the major clinical predictors of risk (ie,
Documented intraoperative or postoperative myocardial infarction, pulmonary edema, or ventricular tachycardia. recent MI, unstable or severe angina,
Adapted with permission from Goldman L et al.1
decompensated heart failure, significant
dysrhythmias, and severe valve disease).
The primary method of initial identifica-
practice guidelines were updated in 2002.3 toris, prior MI as indicated by history tion of these factors is a history taking and
As part of these guidelines, consideration is or electrocardiography, compensated physical examination. Patients with identi-
given to cardiac testing for individuals or prior heart failure, preoperative fiable risks warrant deferment of surgery
determined to be at risk for a perioperative creatinine > 2 mg/dL (ie, renal insuffi- with a referral for consideration for a thor-
event. The following factors are assessed: ciency), and diabetes mellitus (DM), ough cardiac evaluation.
particularly insulin-dependent DM.
Is the surgery urgent? If delay of the In addition to these risks, the func- Myocardial Ischemia/Angina
surgery may be detrimental, cardiac tional capacity of the individual is The stress of elective surgery begins well
assessment may need to be performed determined. This is recorded in meta- before the incision is made. Activation of
at a later time. bolic equivalents (METs), where the hypothalamic-pituitary-adrenal axis is
Has the patient undergone coronary 1 MET is the oxygen consumption of a initiated by just scheduling the procedure
revascularization in the past 5 years or 70 kg 40-year-old man at rest. Func- and persists through the surgical period
percutaneous coronary intervention tional capacity is classified as excellent until at least a week after the surgery. Con-
from 6 months to 5 years previously? (> 10 METs), good (710 METs), mod- comitant with the release of cortisol is
If the patient has remained free from erate (47 METs), poor (< 4 METs) stimulation of the adrenal medulla and the
symptoms of ischemia, the risk of (Table 3-3). activation of the sympathetic nervous sys-
perioperative cardiac death or MI is What are the specific risks of the tem with catecholamine release. These
extremely low. surgery? Considerations include the responses may have served an evolutionary
Has the patient undergone a coronary type of surgery (eg, vascular surgery is purpose and/or aid in aspects of healing;
evaluation in the past 2 years? If inva- high risk) and hemodynamic changes however, they can be detrimental in a
sive or noninvasive testing was nega- that occur with certain surgeries (eg, debilitated patient with poor reserve.
tive and the person has remained significant bleeding or hypotension). Surgery, itself, necessitates myocardial
symptom free, no further periopera- Most oral and maxillofacial surgery work. Patients with atherosclerosis and
tive testing is indicated. procedures are considered to be of coronary artery disease with narrowing of
Does the individual have an unstable intermediate risk.
cardiac condition or major clinical Table 3-3 Metabolic Equivalents for
predictor of risk? These include acute In general, patients with no major and Common Activities
(within 7 d) or recent (730 d) MI, few intermediate predictors of clinical risk
Functional Metabolic
unstable or severe angina, decompen- and moderate or excellent functional Capacity Equivalents
sated heart failure, significant arrhyth- capacity can undergo oral and maxillofa-
Take care of yourself 1
mias, and severe valve disease. These cial surgery procedures with little risk of
Walk a block or two
conditions warrant delay of the proce- perioperative death or MI. On the other
Climb a flight of stairs 4
dure when possible, and usually coro- hand, individuals with poor functional
Heavy work
nary angiography is performed. capacity who are to undergo higher-risk
surgery (eg, head and neck cancer resec- Moderate recreation >10
Are there intermediate clinical predic-
Strenuous sports
tors of risk? These include angina pec- tion) are often considered for further non-
Perioperative Considerations 49
the coronary vessels may be unable to meet Patients with coronary artery disease crisis should be performed with intra-
this increased demand. Myocardial often have a history of hypertension. arterial blood pressure monitoring.
ischemia within 48 hours of surgery results Blood pressure is measured using the The term hypertensive urgency is char-
in a ninefold increase in the risk of unsta- proper cuff size with patients quiet and acterized by severely elevated blood pres-
ble angina (defined as angina at rest or comfortable (with back support, if seat- sure without acute end-organ damage.
increasing angina symptoms) and/or MI. ed) for at least 5 minutes prior to mea- Postoperative hypertension has been
Myocardial work is primarily deter- surement. Hypertension is defined as two defined arbitrarily as systolic blood pres-
mined by four factors related to myocar- elevated blood pressure readings separat- sure > 190 mm Hg and/or diastolic blood
dial oxygen demand: heart rate, preload, ed by at least 2 minutes of 140/90 mm pressure 100 mm Hg. It should be
afterload, and contractility. Preload repre- Hg on two or more separate visits. appreciated that most patients with
sents all factors that contribute to passive Healthy patients with persistent elevated severely elevated blood pressure (diastolic
ventricular wall stress (tension) at the end pressures 160/100 mm Hg and those > 110 mm Hg) have no acute end-organ
of diastole. It is approximately equal to considered to be at high risk (diabetics or damage. The elevated blood pressure
end-diastolic volume or pressure (ie, the patients with clinical cardiovascular dis- should be treated in a controlled fashion
volume of blood left in the heart after ease) should be considered for antihyper- in an intensive care unit. The use of sub-
diastole). Preload is generally a reflection tensive therapy.10 lingual nifedipine is strongly discouraged
of the volume status of a patient. It is Preoperatively, elevated blood pres- as this may result in a precipitous fall in
measured via the central venous pressure sure should be managed by deferring blood pressure. Similarly, intravenous
or the pulmonary capillary wedge pres- treatment for elective procedures. Intraop- hydralazine may result in severe uncon-
sure. Additionally, the left ventricular erative or postoperative hypertension trolled hypotension. Rapid and uncon-
end-diastolic volume determines the car- rarely requires treatment. Hypertensive trolled reduction of blood pressure may
diac output according to Starlings law. crisis or emergency is a sudden increase in result in cerebral, myocardial, and renal
Clinically, this means increasing precon- systolic and diastolic blood pressure asso- ischemia or infarction. Table 3-4 describes
traction muscle fiber length by increasing ciated with end-organ damage of the cen- commonly recommended medications
left ventricular end-diastolic volume tral nervous system, heart, or kidneys. and dosages should it be determined that
through volume administration leads to Headache, altered level of consciousness, reduction of blood pressure is necessary.11
an increase in the force of contraction. and less severe manifestations of central
Afterload, in turn, represents all of the fac- nervous system dysfunction are classic Recent Myocardial Infarction
tors that contribute to total ventricular findings in hypertensive encephalopathy. It is important to attempt to avoid the
wall stress (tension) during systole. The Advanced retinopathy with arteriolar stress of surgery if the patient is experienc-
primary determinants of afterload are the changes, hemorrhages, and exudates as ing acute ischemia or has a history of
total peripheral resistance against which well as papilledema are seen on fundus- recent infarction. Traditionally a 6-month
the heart muscle must pump and changes copic examination. Angina, acute MI, or interval between the initial incidence of
in intrathoracic pressure. Afterload is signs of heart failure can be present in MI and elective noncardiac surgery has
indirectly measured through blood pres- hypertensive crisis. Renal failure with olig- been advocated to avoid stress and the risk
sure and mean arterial pressure. Contrac- uria and/or hematuria is present with of re-infarction. However, recently the
tility is the ability of the heart muscle to damage to the kidneys. Less than 1% of importance of this time interval has been
shorten itself in the face of appropriate patients with a diagnosis of hypertension called into question. The use of throm-
stimuli.8 Of these factors, heart rate and experience a crisis. In the United States the bolytics, angioplasty, and risk stratifica-
afterload are the major contributors to incidence is higher among African Ameri- tion after an acute MI has been the impe-
cardiac work and myocardial oxygen con- cans and the elderly. The majority have tus for this change. Although some
sumption. Elevated heart rate is also previously been diagnosed with hyperten- patients may continue to have myocardi-
potentially harmful in that it decreases the sion and many have been prescribed anti- um at risk with subsequent ischemic
time that oxygen and nutrients can be hypertensive therapy but with poor con- episodes, others may have critical stenosis
delivered to the myocardial cells (diastolic trol. The incidence of postoperative converted to widely patent vessels. The
perfusion time). This is the basis for the hypertensive crisis varies depending on AHA/ACC Task Force on Perioperative
goal of maintaining the blood pressure the population studied and has been Evaluation of the Noncardiac Surgery has
and pulse within 10% of the preoperative reported in 4 to 35% of patients. Reduc- advocated that the group at highest risk is
value during anesthesia.9 tion of blood pressure in a hypertensive those who have had an MI within 6 weeks;
50 Part 1: Principles of Medicine, Surgery, and Anesthesia
Table 3-4 Common Antihypertensive Agents Used to Actively Lower Blood Pressure in Hypertensive Crisis
Drug Mechanism Dosage Comments
Clonidine Central 2-agonist 0.1 mg PO q20min Useful in hypertensive urgency; gradually
decreases BP
Diazoxide Smooth muscle relaxant 13 mg/kg IV, maximum single dose Causes rapid BP decrease
of 150 mg
Enalaprilat Angiotensin converting 1.25 mg over 5 min q6h Blocks angiotensin II
enzyme inhibitor
Esmolol 1-selective blocker 0.5 mg/kg followed by infusion of Rapid onset (60 s), short duration
25300 g/kg/min (1020 min)
Fenoldopam Dopamine agonist Initial dose 0.1 g/kg/min titrate; Short acting, increases renal perfusion
maximum 1.6 g/kg/min
Labetalol - and -blocker Loading dose of 20 mg followed Avoid larger bolus doses; can cause
(: = 1:7) by 2080 mg dose at 10 min hypotension
intervals or 12 mg/min infusion
Nicardipine Ca channel blocker 5 mg/h increasing 2.5 mg/h q5min Useful for cardiac and cerebral ischemia;
(maximum 15 mg/h) dose independent of weight
Nitroprusside Arterial/venous Infusion; usually < 2 g/kg/min Rapidly decreases BP; risk of cyanide
dilatation toxicity
Phentolamine -blocker IV 15 mg boluses Can cause tachyarrhythmias, angina
Trimethaphan Nondepolarizing IV infusion 0.51 mg/min; maximum Adrenergic block is therapeutic effect;
camsylate ganglionic block 15 mg/min cholinergic block of side effects
BP = blood pressure.
after this period risk stratification is based Acute Episode of Chest Pain Decompensated Congestive
on the presentation of the disease (ie, Suggestive of Myocardial Heart Failure
those with persistent symptoms consistent Ischemia/Infarction A history of worsening shortness of
with active ischemia remain at the highest
Immediate intervention includes the assess- breath (dyspnea), difficult ventilation
risk level).12
ment of vital signs and the administration of when assuming the supine position
During severe ischemic episodes the
oxygen and nitroglycerin tablets or spray at (orthopnea), or gasping for oxygen when
release of intracellular potassium from
injured cells may result in partial repolar- 0.4 mg/dose (to be repeated in 5 min inter- assuming the supine position when asleep
ization of the surviving cardiac cells, partic- vals for three doses or until the pain is elim- (paroxysmal nocturnal dyspnea) should
ularly along the infarct border. These cells inated). If the pain is persistent, intravenous alert the practitioner to the possibility of
may then initiate areas of ectopia, poten- morphine (25 mg q5min or until pain relief acute congestive heart failure. Signs of
tially leading to arrhythmias, especially is achieved) and aspirin 325 mg should be cardiac failure include raised jugular
with concurrent sympathetic stimulation, given. The local Emergency Medical Service venous pressure, added heart sounds (S3
electrolyte abnormalities, and ventricular should be contacted early as the protocol [the presence of a third heart sound], in
hypertrophy. -Blockers, nitroglycerin, and calls for the performance of an early 12-lead particular), pulmonary crackles (indicat-
amiodarone as well as high vagal tone can echocardiography (preferably by Emergency ing pulmonary edema), hepatomegaly,
be protective in this circumstance. In addi- Medical Service personnel) and screening of and peripheral edema. The presence of
tion, intra-aortic balloon pumps, ventricu- the patient for an antifibrinolytic or reperfu- any of these signs or symptoms warrants a
lar assist devices, coronary angioplasty, and sion (ie, an angioplasty with stent placement complete cardiac evaluation prior to initi-
revascularization may be indicated. or coronary artery bypass graft) procedure.13 ating any elective procedure.1,3
Perioperative Considerations 51
Arrhythmias peripheral vessels. Inhalation agents in gener- bility. If uncontrolled ventricular rates
al are not otherwise arrhythmogenic, but occur acutely in the perioperative period,
The normal pattern of electric transmis-
arrhythmias can be produced in the presence prompt treatment is necessary. Rate con-
sion of the heart starts with the initiation
of triggering agents and clinical situations trol is achieved with verapamil (a calcium
of the impulse in the sinoatrial (SA) node,
that generate a high catecholamine state. This channel blocker noted for decreasing con-
spreading through the atria with a conver-
includes light anesthesia levels (with hyper- duction at the AV node), digoxin, or
gence of the impulse at the atrioventricu-
tension and tachycardia), hypoxemia, hyper- esmolol (a 1-selective blocker). If patients
lar (AV) node. There is a delay of conduc-
carbia, and the use of exogenous epinephrine do not convert to sinus rhythm with these
tion through the AV node, accounting for
or aminophylline (the latter of which indi- agents, electrocardioversion with prior
the PR interval on the echocardiogram
rectly causes the release of endogenous cate- anticoagulation is attempted.
(ECG; 100 ms). This interval is prolonged
cholamines). The arrhythmogenic dose in It is interesting to note that a recently
by parasympathetic (vagal) stimulation
micrograms per kilogram of epinephrine performed meta-analysis has demonstrat-
and shortened by sympathetic activity.
administered by infiltration with various ed that -blockers reduce the incidence of
Activation of the ventricles starts on the
inhaled agents are 2.1 with halothane, 3.7 postoperative atrial fibrillation, whereas
left side of the interventricular septum, with halothane and lidocaine, 6.7 with isoflu- digoxin and verapamil have no effect. If a
crossing over to the right at the midpoint rane, and 10.9 with enflurane.16 PSVT is detected upon routine monitor-
of the septum. The impulse spreads Paroxysmal supraventricular tachy- ing, patients should be referred for further
through the Purkinje system to the apex. cardias (PSVTs) arise from the SA or AV evaluation. Acute evaluation is required if
The wave of depolarization then moves node, atrium, or an accessory AV connec- the individual is symptomatic and/or the
along the walls of the ventricles from the tion. They are common arrhythmias that rate is poorly controlled. A complete dis-
endocardium to the epicardium to reach are usually seen in cardiac surgical cussion of the causes and treatment proto-
the AV groove. patients (2040%) but can develop in cols of PSVTs is beyond the scope of this
Perioperative cardiac arrhythmias are patients undergoing noncardiac surgery chapter. The reader is hereby referred to
caused by abnormalities of cardiac (usually major vascular, cancer, or ortho- the most recent advanced cardiac life sup-
impulse formation, impulse conduction, pedic procedures). The onset and termi- port protocols released by the American
or a combination of both. There is a high- nation of these rhythms are usually Heart Association.13
er incidence of arrhythmias in the periop- abrupt, with rates between 120 and Abnormal conduction pathways can
erative setting, and anesthetic agents are 300 beats per minute (bpm). The ECG present as an irregular rhythm. Wolff-
known to alter cardiac impulse generation typically identifies the area of origin of Parkinson-White syndrome is a condi-
and conduction. Perioperative cate- the ectopic conduction with a positive P tion in which such a pathway connects
cholamines owing to exogenous adminis- wave being present in SA-node reentry the atria to the ventricles, bypassing the
tration or endogenous release in the pres- PSVTs, absent or inverted P waves in AV- AV junction through the bundles of Kent.
ence of ischemia set the stage for new node origin PSVTs, and altered P wave As a result of impulses traveling through
arrhythmia during this period.14,15 morphology in intra-atrial reentry PSVTs. this accessory pathway, the electrocardio-
Volatile agents directly decrease SA and The most common PSVT is atrial fibril- gram demonstrates a shortened PR
AV node automaticity, but increasing extra- lation (> 90% of SVTs in the postoperative interval (< 0.12 s), a wide QRS complex
cellular calcium can antagonize this phe- period). It can occur as the result of cardiac (> 0.10 s), and a characteristic slurring of
nomenon. A common occurrence with the disease, such as mitral valve disease, conges- the upstroke of the R wave (called a delta
use of volatile agents is isorhythmic AV disso- tive heart failure, coronary artery disease, or wave) (Figure 3-1). This extra or accesso-
ciation, in which the AV node generates the pericarditis. It can also be the result of sys- ry electric pathway is present in approxi-
pacemaker at a modestly higher rate than the temic processes such as thyrotoxicosis, pul- mately 1.5 per 1,000 people. It runs in
SA node. This is a result of direct depression monary embolus, chronic obstructive pul- families in < 1% of cases. In the majority
of the SA node by the volatile agent and some monary disease (COPD), alcohol or caffeine of individuals, it is completely silent and
stimulation of the AV node by sympathetic excess, or electrolyte disturbances. Changes is only detected on a routine ECG. In a
activity. Serious hemodynamic consequences seen on the ECG are most evident in lead II small proportion of patients, the extra
are not usually seen in healthy individuals as an irregular rhythm. electric pathway generates an electric cir-
but are a concern with ventricular noncom- Untreated PSVT can result in ventricu- cuit that produces a very rapid heart rate.
pliance such as ventricular hypertrophy as a lar rates that exceed 120 to 200 bpm, which Most patients tolerate this well, but some
result of atherosclerosis of the aorta or can cause significant hemodynamic insta- experience very troublesome palpitations,
52 Part 1: Principles of Medicine, Surgery, and Anesthesia
mature ventricular beats, but only 0.62% and became commercially available in
suffered severe adverse outcomes, which, 1986. In recent years the use of AICDs has
1
2 according to the author, may have been become widespread and has significantly
3 related more to the aggressive treatment reduced cardiac death in this susceptible
employed in these cases. More than six population from 40 to 60% to < 2 to 3%
premature ventricular contractions per over a 3-year postimplantation period.
minute, especially if they are multifocal, They are primarily used in cases of ventric-
are considered to be ventricular tachycar- ular ectopy or spontaneous/recurrent
Fusion
Delta wave
P wave
pacemaker (usually located in the subpec- sent is to calculate an anion gap (if infor- a resultant decreased pH. Metabolic
toral region or beltline of the anterior mation on electrolytes is available): acidosis is caused by the addition of an
abdominal wall). Avoidance of the use of acid source to the normal acid-base
Anion gap = Na+ ([C1] + [HCO3])
MRI is advisable as well. A discussion with buffering system. This acid source
the patients cardiologist prior to surgery is lowers the pH. One of the methods of
A normal range is 10 to 14 mEq/L.
prudent.17 buffering this acid is the carbonic acid
Metabolic alkalosis is caused by a rel-
system in the lung. Respiration rate
Electrolytes and ative increase in bicarbonate. Only rarely
and depth increase in an attempt to
Acid-Base Disturbances is this caused by the exogenous adminis-
eliminate the additional CO2 pro-
tration of bicarbonate since the kidney
With any arrhythmia, coexisting acid base duced, lowering the CO2. Ultimately,
normally excretes excess bicarbonate in
and electrolyte disturbances should be however, this system cannot eliminate
an individual who is well hydrated and
identified and corrected. Part of the periop- all of the additional acid and maintain
has good kidney function. More com-
erative assessment of hypoxia is the mainte- the normal acid-base ratio.18
monly this condition occurs owing to
nance of acid-base balance. Normal pH of The cause of alkalosis can be
electrolyte disturbances such as occur as a
arterial blood is 7.4 and is maintained to determined in a similar manner: pH
result of vomiting, nasogastric suctioning,
within 0.05 (ie, the normal pH range of the > 7.45 and PaCO2 > 40 mm Hg indi-
or diuretic use. Primarily this can occur
blood is 7.35 to 7.45). The main buffering cate a metabolic condition; pH > 7.45
through shifts in intracellular potassium.
of acids occurs through the lungs (through and PaCO2 < 40 mm Hg signify respi-
Hypokalemia increases the excitability
the conversion of carbonic acid [H2CO3] to ratory alkalosis.
and automaticity of cardiac muscle,
CO2 and H2O) and the kidney (through the 3. Confirm the acid-base relationship
increasing the possibility of arrhythmias.
base bicarbonate [NaHCO3]). through analysis of the bicarbonate
Hypomagnesmia can potentiate this effect
Respiratory acidosis occurs when the level (assuming normal kidney com-
by decreasing the extrusion of intracellular
lungs are not exhaling CO2 adequately. pensations are present).
calcium, which is also arrhythmogenic in
This can occur with emphysema or respi- In respiratory acidosis the kidney
cardiac conduction cells. Assessment of
ratory depressive states such as overseda- should retain bicarbonate and reestab-
electrolytes and their correction is there-
tion, respiratory insufficiency, and arrest. lish the normal 1:20 acid-to-base ratio
fore warranted in acid-base perturbations.
Conversely, respiratory alkalosis occurs (ie, the bicarbonate level should remain
when too much CO2 is expelled as in Examples of Acid-Base Analysis at its normal value of 24 mEq/L). In
hyperventilation, neurogenic disorders, metabolic acidosis there is usually a
and salicylate toxicity (which, interesting- bicarbonate deficit (ie, bicarbonate
1. Note the pH value: pH < 7.35 = acido-
ly, is accompanied by metabolic acidosis). level < 24 mEq/L).
sis; pH > 7.45 = alkalosis.
Metabolic acidosis is caused by a 2. Note the value of partial pressure of
deficit of the base bicarbonate. Normally carbon dioxide in arterial blood Case Example 1 A 54-year-old man is
there is an H2CO3-to-NaHCO3 ratio of (PaCO2 value). referred for lethargy. A review of systems
1:20. H+ is excreted in the urine, and bicar- If it is the same sign as the pH, the reveals polydypsia, polyphagia, and polyuria.
bonate is reabsorbed into the renal tubules condition is metabolic in nature. If it His laboratory results are as follows: arterial
to maintain this ratio. With the presence of is the opposite in sign, the condition is blood gases reveal a pH of 7.22, PaCO2 of
excess acid, the bicarbonate combines with respiratory. Therefore, pH < 7.35 and 24 mm Hg, and HCO3 of 12 mEq/L. Serum
this source of H+, is excreted, and is there- PaCO2 < 40 mm Hg indicate metabol- chemistries reveal Na =130 mEq/L, Cl =
fore no longer available for its usual ic acidosis; pH < 7.35 and PaCO2 94 mEq/L, K = 4.5 mEq/L, and glucose =
buffering role. This results in an upset of > 40 mm Hg signify respiratory acidosis. 600 mg/dL.
the 1:20 ratio and acidosis. Lactic acid This represents a method of In this example, the pH is < 7.35;
from muscle activity or anaerobic condi- analysis that is easy to remember. The therefore, it is a case of acidosis. The PaCO2
tions, diabetic ketoacidosis, renal failure, basis involves the underlying cause of is < 40 mm Hg; therefore, the process is
or exogenous sources such as methanol, each condition. Respiratory acidosis is metabolic acidosis. The bicarbonate level
ethanol, or paraldehyde can all serve as the primarily caused by an elevation of (12 mEq/L) confirms a relative bicarbonate
alternative acid source. A method to deter- CO2, causing a compensatory eleva- deficiency consistent with metabolic acido-
mine whether metabolic acidosis is pre- tion of carbonic acid in the lung with sis. An anion gap analysis is as follows:
54 Part 1: Principles of Medicine, Surgery, and Anesthesia
Na+ ([C1] + [HCO3]) rhage or exposure to radiocontrast agents. tory of renal insufficiency or a disease
130 (12 + 94)= 31.5 Many other conditions can predispose the mechanism (eg, diabetes mellitus) in which
kidneys to ischemic injury, including sep- kidney damage may be present and signifi-
This reveals the presence of an anion gap sis, cirrhosis, jaundice, hepatorenal syn- cant volume loss or hypotension may occur.
metabolic acidosis, consistent with dia- drome, congestive heart failure, shock, In addition, the use of intraoperative inva-
betic ketoacidosis based on the clinical malignant hypertension, preeclampsia, sive monitoring (ie, central venous pressure
presentation and elevated glucose level sickle cell anemia, collagen vascular dis- or pulmonary capillary wedge pressure)
(600 mg/dL). eases, and multiple myeloma. Many drugs may be warranted in these cases.19
also potentiate the risk of ischemic renal
Case Example 2 A 75-year-old woman injury through alterations in intrarenal Pulmonary Assessment
was recently started on furosemide to treat hemodynamics, including angiotensin-
pedal edema. She describes a loss of ener- converting enzyme inhibitors, nonsteroidal Asthma
gy and a light-headed sensation when aris- anti-inflammatory drugs, cyclosporine, Asthma is a disease characterized by an
ing from a seated position. Her arterial tacrolimus, and amphotericin B.19,22 episodic variable airflow obstruction with
blood gases indicate a pH of 7.53, PaCO2 The most susceptible area to ischemic increased airway reactivity. Recently the
of 52 mm Hg, and HCO3 of 32 mEq/L. injury is the tubular cells of the thick importance of submucosal inflammation
Serum chemistries show the following lev- ascending loop of Henle and a portion of and its control in managing asthma has
els: Na = 129 mEq/L, Cl = 90 mEq/L, the proximal convoluted tubules located in been stressed. Bronchoconstriction in asth-
K = 3.0 mEq/L, and glucose = 120 mg/dL. the renal medulla (Figure 3-2). The cells in matics is triggered by a stimulus such as an
In this case, the pH (7.53) and PaCO2 this region are rich in mitochondria and antigen, exercise, or exposure to cold. The
(52 mm Hg) reveal the presence of an are responsible primarily for chloride ion trigger elicits an acute inflammatory cas-
alkalotic state. This is confirmed by the absorption. A combination of low blood cade, characterized by degranulation of
bicarbonate level (32 mEq/L). Metabolic flow (compared with that in the renal cor- mast cells and activation of eosinophils and
alkalosis is often caused by secondary vol- tex) and high metabolic demand accounts macrophages in the airway. Released
ume depletion with resultant electrolyte for this susceptibility. Initially there is a leukotrienes, histamines, and bradykinins
shifts. The loss of intracellular potassium loss of urine-concentrating ability as the increase vascular permeability and resul-
can cause the shift of protons (H+) into the normal medullary gradient dissipates, fol- tant edema. The airways fill with mucus
cell to maintain neutrality. lowed by a decline in urine output as and inflammatory cells, and smooth mus-
tubules become obstructed and denuded. cles contract as a response to released medi-
Renal Insufficiency Traditionally, the management of ators and an increased cholinergic tone.24,25
It is interesting to note that an elevated cre- acute renal failure has been the mainte- Heightened airway responsiveness can
atinine is presently included as a factor in nance of urine output through the use of increase the likelihood or severity of bron-
risk assessment for surgery.2 Acute renal intravenous hydration and diuretics such chospasm under anesthesia. Aspects of the
failure is primarily a result of intraopera- as furosemide and mannitol in addition to patients history that may indicate the poten-
tive renal hypoperfusion. It is usually seen low-dose dopamine to maintain renal per- tial for problems to arise include frequent
in cardiopulmonary bypass procedures fusion. Recently this practice has come into nocturnal awakenings from bronchospasm,
and thoracoabdominal and abdominal question since increasing renal blood flow increased necessity for inhaler use, recent
aortic aneurysm repairs, where its inci- elevates the oxygen demand at the medulla hospitalizations or emergency department
dence is reported to be as high as 15%, and may lead to further injury.19 Present visits, a change in the amount or quality of
25%, and 5.4%, respectively.1921 In addi- research is directed at regulating renal secretions, or a recent viral illness or cold
tion to surgical type, preoperative renal vasoactive substances discovered in animal symptoms. Spirometry is helpful in the ini-
insufficiency is the single consistent pre- models including prostaglandins (especial- tial diagnosis and chronic management of
dictor of postoperative renal failure.19 ly prostaglandin E2), angiotensin II, nitric reactive airway disease. Its routine use adds
Additional insults that may further predis- oxide, endothelin, and adenosine.23 little information to the preoperative assess-
pose a patient to perioperative kidney fail- Since volume depletion and hypoten- ment that cannot be ascertained by the
ure are the presence of an already ischemic sion are risk factors for the development of recent history and physical examination.
state caused by renal artery stenosis, vol- acute renal failure, preoperative testing of Repeat assessments over time can be helpful,
ume depletion, and diabetes, or a recent blood urea nitrogen and creatinine should however, as subtle changes in flow rates can
acute ischemic event caused by hemor- be conducted in patients with a known his- be detected by spirometry before they
Perioperative Considerations 55
Renal
Descending Ascending
cortex
thin limb thick limb
of Henle's of Henle's
Renal loop loop
medulla
Ascending
thin limb
of Henle's Medullary
loop duct
become symptomatic; this allows preventive exchange. Under anesthesia wheezing and patients. The risks are highest in those
treatment to be initiated. bronchospasm can occur with or without patients undergoing endotracheal intuba-
The most common parameters that a prior history of reactive airway disease. tion (in whom there is an 11-fold increase
are assessed over time are the forced expi- Most wheezing is self-limited and requires in perioperative respiratory complica-
ratory volume generated in the first sec- no intervention, but it can indicate the ini- tions). Definitive criteria for canceling a
ond of exhalation and the peak expiratory tiation of a more severe bronchospasm. surgery to be performed under sedation or
flow rate (Figure 3-3).26 These parameters Patients with symptoms of bronchospasm general anesthesia have not been estab-
can be measured with inexpensive hand- preoperatively should have elective proce- lished, and the decision is often subjective.
held devices. A 20% variation in peak dures postponed.26 Suggested criteria for cancellation include
expiratory flow rates is normal. Rates that Whereas asthmatics have chronic the necessity of endotracheal intubation,
fall to 50 to 80% below normal are consid- hyperactivity of the airways, patients with parental observation that the child is acute-
ered a moderate exacerbation. Flow rates upper respiratory tract infections (URIs) ly ill the day of surgery, the presence of
< 50% of baseline are considered severe have acute airway reactivity that can last up nasal congestion and cough, concomitant
and require prompt medical attention. to 6 weeks after recovery from the initial exposure to passive smoke, and active spu-
The term reactive airway disease is infection. Airway hyperactivity in URIs is tum production. Most surgeons agree that
considered by some individuals to be syn- neurally mediated with an increase in the planned surgery, if elective, should be
onymous with asthma. However, airway vagal-mediated bronchoconstriction. Chil- postponed until after the acute symptoms
reactivity is also increased owing to aller- dren with a concomitant URI are especial- have resolved and have not recurred for a
gic rhinitis, bronchitis, emphysema, and ly susceptible to bronchospasm. These chil- 3-week period after the initial evaluation.27
respiratory viral infections. Bronchospasm dren are two to seven times more likely to
is a physical sign of acute increased airway have adverse events in the perioperative Treatment of a Reactive Airway
resistance. It is associated with tachypnea, period, and there is an increased risk of Inhaled short-acting 2-adrenergic agonists
wheezing, air trapping, and worsened gas postoperative desaturation in these are the drug of first choice for the treatment
56 Part 1: Principles of Medicine, Surgery, and Anesthesia
80
normal metabolism
ing SpO2 occurs secondary to changes in ic nervous system and the release of cate-
60 O2 reserve that can
the strength of the arterial pulse or patient cholamines from the adrenal medulla. be unloaded from
hemoglobin to
movement, resulting in either no signal or This effect persists for 30 minutes after 40 tissues with high
artificially low readings. Causes of these smoking a cigarette. Coronary artery vas- metabolism
20
errors include hypothermia, hypotension, cular resistance is similarly affected,
potentially leading to further limited Shift to right:
the use of vasopressors, electrocautery, 0
H+
0 20 40 60 80 100
artificial or opaque nail finishes, and addi- blood flow in areas predisposed to CO2
ischemia. Nicotine can also lower the Temperature
tional monitors such as an automatic Tissues Tissues Lungs
2,3 DPG
during at rest
blood pressure cuff or arterial line on the threshold for ventricular fibrillation. Car- exercise
same arm. The effects of other potential bon monoxide and nicotine have a rela-
Partial Pressure of Oxygen (mm Hg)
sources of error in SpO2 measurement are tively short half-life (carbon monoxide t1/2
given in Table 3-5.32 = 4 h; nicotine t1/2 = 3060 min). With FIGURE 3-5 Oxygen dissociation curve. DPG = 2,3-
Table 3-5 Some Sources of Error in Pulse Oximetry which is characterized by episodes of
apnea or hypopnea during sleep. Obstruc-
Source Effect on SpO2 Action
tive apnea is characterized by apnea
Carboxyhemoglobinemia Falsely high SpO2 Increase ventilation, despite a continuous respiratory effort
eliminate rebreathing against a closed airway. Central apnea is
Methemoglobinemia Falsely low readings, Administer methylene blue characterized by the loss of ventilatory
approaching 85% effort. Many patients diagnosed with OSA
Hyperbilirubinemia, Overestimation of SpO2 Eliminate causative agent can have periods of central apnea during
hyperalimentation, owing to interference sleep as well. Apnea is typically defined as
hyperlipidemia of light transmission 10 seconds or more of total cessation of
Venous pulsations Falsely low SpO2 Change site airflow. Hypopnea is defined as a reduc-
SpO2 = percent saturation of oxygen. tion in airflow (typically 3050%) or a
1992. Reproduced with permission of Alliance Communication Group, a division of Allen Press, Inc., from Mardirossan G reduction sufficient to lead to a 4%
and Schneider RE.32
decrease in arterial oxygen saturation. The
number of apneic or hypopneic episodes
Unfortunately, detrimental effects on levels in the workplace have been estimat- believed to be significant is five or more
ciliary function and mucus overproduc- ed to be higher than at home, and the time per hour. The exact number is arbitrary,
tion by respiratory mucosa as a response spent at work is usually longer. It is pru- as are the definitions of apnea and hypop-
to tobacco can last for months after smok- dent to determine secondhand smoke nea used by various sleep laboratories.
ing cessation. Additional detrimental exposure in the perioperative manage- Often individuals with OSA are noted to
effects include increased bronchial reactiv- ment of the surgical patient.34 have nocturnal snoring and daytime
ity, macrophage dysfunction, and changes hypersomnolence. OSA can lead to hyper-
in pulmonary surfactant. Assuming a Obesity capnia, systemic and pulmonary hyper-
smoker has not had long-term deleterious The difference between normality and obesi- tension, and cardiac arrhythmias.
effects related to COPD, these changes ty is arbitrary, but an individual with In the perioperative period, episodes
require 6 to 8 weeks for complete reversal. increased fat tissue to such an extent that of OSA are most frequent during rapid eye
Postoperative pulmonary complications physical and mental health are affected and movement sleep, the extent of which is rel-
including atelectasis, pneumonia, and life expectancy is reduced should be consid- atively low in the initial postoperative
bronchospasm are much more likely to ered obese. Body mass index (BMI) is wide- period but in excess on the third to fifth
occur in individuals who smoke. ly used in clinical and epidemiologic studies. postoperative nights. Caution should
Interestingly, increased pulmonary It is the ratio of body weight (in kilograms) therefore be exercised any time anesthetic
complications have been demonstrated to height (in meters squared). A patient with agents are used in a patient with a history
when a patient ceases smoking < 8 weeks a BMI of < 25 kg/m2 is considered normal. A or signs and symptoms consistent with
prior to a planned surgery. Therefore, rec- patient with a BMI of 25 to 30 kg/m2 is over- OSA. In addition, the continued use of
ommendations to the smoking patient weight but at relatively low risk for serious medical therapies including continuous
should include at least a 12- to 24-hour medical complications; one with a BMI of positive airway pressure should be stressed
smoking fast or, more desirably, a cessa- > 30 kg/m2 is obese with a higher risk of in the perioperative period.37
tion of smoking for 8 weeks or more. morbidity and mortality. Morbidly obese Morbid obesity is characterized by
Patients should be counseled that cessa- individuals have an increased risk of death reductions in functional residual capacity
tion for periods < 8 weeks may actually from cardiorespiratory and cerebrovascular (the volume remaining in the lungs after a
predispose the individual to increased pul- disorders, diabetes mellitus, and certain normal quiet expiration), expiratory
monary complications.33 forms of cancer in addition to many other reserve volume (the volume of air that can
In recent studies the effects of second- diseases. These risks are proportional to the forcefully be expired after a normal resting
hand or passive smoke have been ana- duration of obesity. Weight loss reduces the expiration), and total lung capacity. These
lyzed. The risks of chronic bronchitis, risks but only over time; weight reduction changes have been attributed to mass
asthma, and wheezing were all higher in immediately prior to surgery has not been loading and splinting of the diaphragm
patients exposed to involuntary tobacco shown to reduce perioperative risk.35,36 (Figure 3-6). Anesthesia compounds these
exposure, especially in the workplace with Approximately 5% of obese individu- problems and impairs the ability of the
a daily exposure of > 8 h/d. The exposure als have obstructive sleep apnea (OSA), obese to tolerate periods of apnea.30,31
Perioperative Considerations 59
Ventilation and Capnography Opponents to the use of capnography for reflect the adequacy of glucose control
nonintubated sedation cite sampling during the previous 1 to 3 months. Levels
Capnography is defined as the measure-
errors, particularly in individuals who are in nondiabetics range from 5 to 7% of
ment and display of exhaled carbon diox-
mouth breathing when nasal sampling is hemoglobin. Levels in diabetics with poor
ide. Increases in end-tidal CO2 combined
being used.3840 long-term glucose control exceed 8%.41
with decreases in the respiratory rate of the
individual have been demonstrated to be With more procedures being per-
Endocrine Assessment formed on an outpatient basis and the
an effective way to detect hypoventilation
and respiratory depression. Pulse oximetry, length of hospital stays being shortened
Diabetes Mellitus dramatically, perioperative management
in contrast, indirectly measures oxygena-
tion (partial pressure of oxygen in arterial Perioperative care of the diabetic patient of the diabetic patient has become more
blood). Based on the oxygen-hemoglobin depends on identification and assessment complicated. Many factors are present
dissociation curve (see Figure 3-5), there of the current status of end-organ disease. that determine the glycemic response,
can be a significant decline in oxygen satu- Long-standing diabetics frequently have including insulin secretion, insulin sensi-
ration that can go initially undetected by compromise in one or more organ system. tivity, overall metabolism, and nutrition-
the pulse oximeter. Capnography, by Commonly associated diseases include al intake in addition to the stress and
detecting hypoventilation, may be used to atherosclerosis, coronary artery disease, length of the procedure. Surgical stress
prevent hypoxia; upon noting hypoventila- hypertension, cardiomyopathy, cerebrovas- and some general anesthetic agents,
tion, the practitioner can take measures to cular disease, peripheral vascular disease, themselves, are associated with increases
improve patient ventilation. Proponents of peripheral and autonomic neuropathy, in the counter-regulatory hormones epi-
capnography for non intubated sedation and/or renal insufficiency. Preoperative nephrine, norepinephrine, glucagon,
advocate its use over other forms of venti- evaluation should focus on these concerns, growth hormone, and cortisol. The effect
latory monitors that can experience inter- and events of prior surgeries should be of these hormones is to elevate insulin
ference from operatory noise, clothing, or reviewed. For more complex procedures, resistance, which increases hepatic glu-
surgical drapes. These methods include laboratory values that may be reviewed cose production and decreases peripheral
observation of chest wall movements, include blood glucose, blood urea nitro- glucose use. Patients receiving pharmaco-
plethysmography, auscultation of breath gen, creatinine, urinalysis (for glucose, logic therapy to control their diabetes
sounds (precordial stethoscope), or palpa- ketones, and proteins), and glycosylated may also be susceptible to hypoglycemia,
tion or movement of the reservoir bag. hemoglobin (Hb A1c) levels. Hb A1c levels especially when fasting preoperatively.
Although hypoglycemia can cause signif-
icant morbidity, marked hyperglycemia
Maximal inspiratory level should also be avoided since it can lead to
dehydration and electrolyte disturbances
and impaired wound healing and predis-
pose to infection or diabetic ketoacidosis
IRV
IC
in the patient with type 1 DM. This is not
to say that patients with historically poor
VC
control of their disease should be rapidly
TLC normalized presurgically; little evidence
TV supports this approach. In general, the
Resting expiratory level goal for glucose control during surgery
ERV should be between 150 and 200 mg/dL.
The more unstable the diabetes, the more
FRC
Maximal expiratory level frequently this level should be assessed in
the perioperative period.
RV RV
As in all patients, underlying cardiac,
pulmonary, renal, and electrolyte distur-
bances and anemia should be evaluated.
FIGURE 3-6 Summary of lung volumes and capacities. ERV = expiratory reserve volume; FRC =
functional residual capacity; IC = inspiratory capacity; IRV = inspiratory reserve volume; RV = resid- Assessment should include a focus on the
ual volume; TLC = total lung capacity; TV = tidal volume; VC = vital capacity. microvascular (ie, renal insufficiency,
60 Part 1: Principles of Medicine, Surgery, and Anesthesia
retinopathy), macrovascular (including Types 1 and 2 DM Treated with Insulin procedures may require intravenous insulin
atherosclerosis, coronary artery disease, For individuals who take long-acting insulin regimens. Table 3-7 reviews the common
hypertension), and neuropathic signs relat- (ie, extended zinc suspension or glargine; types of insulin and their onset, peak activ-
ed to poor diabetes control. Medication Table 3-7), a switch to an intermediate-acting ity, and duration.
use and insulin regimen should be record- type is initiated a day or two prior to surgery.
ed. Management of the patient should be The regulation of intermediate insulin is then Hypoglycemia and Hyper-
coordinated with the individual who man- adjusted based on the likelihood of the glycemia: Identification and
ages the patients daily protocol. The fol- patient eating lunch. If the likelihood of oral Management
lowing are recommended guidelines in the intake at lunch time is high, two-thirds of the Direct neurologic symptoms and an
management of patients with diabetes who normal intermediate dose is given on the adrenergic response characterize the
require a period of nothing by mouth prior morning of the procedure. If the patient is manifestations of hypoglycemia. Neuro-
to their planned procedure. treated with a twice-daily dose of insulin, glycopenia generally begins with confu-
then one-half of the total morning dose of sion, irritability, fatigue, headache, and
Type 2 DM Controlled by Diet Only insulin (including short-acting) should be somnolence. Prolonged severe hypo-
Measurement of blood glucose should be administered in the morning as intermediate glycemia can cause seizures and even focal
considered prior to the procedure, after insulin. If the likelihood of consuming lunch neurologic deficits, coma, and death.
the procedure, and intraoperatively for is low, one-half of the total morning dose of Therefore, any new neurologic symptom
longer surgeries. Hyperglycemia is treated insulin (including short-acting) should be in the postoperative period should be
with short-acting insulin (regular or administered as intermediate-acting insulin investigated for hypoglycemia because
lispro), usually administered subcuta- for the patient treated with a single insulin prolonged deficit of glucose can result in
neously. It is prudent to remind patients dose and one-third for those on a twice-daily irreversible neurologic deficits. The
prior to discharge of the signs and symp- regimen. For the patient taking multiple adrenergic symptoms include anxiety,
toms of hyperglycemia (discussed below) doses of short-acting insulin, one-third of the restlessness, diaphoresis, tachycardia,
and to reinforce guidelines for contacting pre-meal dose of short-acting insulin is hypertension, arrhythmias, and angina
their physician. administered. Patients treated with continu- owing to catecholamine release in
ous insulin infusion therapy (with an insulin response to hypoglycemia. Recognition of
Type 2 DM Treated with Oral Hypo- pump) are treated with their usual basal infu- perioperative hypoglycemia can be diffi-
glycemic Agents Oral hypoglycemic sion rate. cult initially because presenting symp-
agents are generally administered the day Individual modifications of insulin toms can be altered or absent as a result of
prior to surgery and withheld the day of therapy may be required, and it is advisable the effects of anesthetic agents, analgesics,
surgery. If patients manifest marked to discuss the management with the and sympatholytic agents. In addition,
hyperglycemia, supplemental insulin may patients physician. Procedures scheduled diabetics with autonomic neuropathy
be indicated; the surgery may be per- later in the day can be more complex to have blunting of the adrenergic response
formed if electrolyte levels are acceptable. manage, and intravenous glucose infusion associated with hypoglycemia.
Table 3-6 provides information on com- and/or supplemental short-acting insulin Hypoglycemia is defined as glucose
mon oral hypoglycemic agents. may be necessary. Long complex operative < 50 mg/dL in adults and < 40 mg/dL in
Table 3-7 Onset, Peak, and Duration of Common Insulin Preparations cortisol helps maintain hemodynamic sta-
bility in the face of stress. Patients with
Type of Insulin Example Onset Peak Duration
long-term exogenous steroid use have a
Rapid-acting Lispro 515 min 3075 min 24 h blunted response to surgical stress com-
Aspart 515 min 12 h 36 h pared to that of normal controls, with
Short-acting Regular 3045 min 23 h 48 h resultant lower cortisol levels.
Adrenal crisis is usually seen in patients
Intermediate-acting NPH 24 h 48 h 1016 h
with adrenal suppression and is precipitat-
Zinc suspension 24 h 48 h 1016 h
ed by a stressor, typically surgery, trauma,
Prolonged intermediate- Extended zinc 35 h 812 h 1820 h or sepsis. Patients may experience
acting suspension intractable nausea and vomiting, abdomi-
Long-acting Glargine 48 h No peak 24 h nal pain, fever, lethargy, and coma.
Hypotension and a narrow pulse pressure
Premixed combination 70/30 or 50/50 3060 min Earlylate About 18 h
(the difference between systolic and dias-
insulin (NPH/regular) peak: 212 h
tolic pressure) are evident as shock ensues.
Based on these potential risks and anecdo-
tal reports published, supraphysiologic cor-
children. Its treatment is a glucose source glands themselves, or secondary, owing to ticosteroid regimens have been recom-
if oral intake is possible; however, to avoid decreased adrenocorticotropic hormone mended for patients on exogenous steroids.
the risk of aspiration and delay in absorp- (ACTH) because of pituitary or hypothala- Recent evidence suggests that patients
tion, 50 mL of 50% (25 g) of glucose mus disorders. Primary adrenal insufficien- on long-term steroids who receive no peri-
should be administered intravenously. cy is also known as Addisons disease and is operative coverage suffer a 1 to 2% risk of
Each milliliter of D50 raises the blood glu- thought to be the result of an autoimmune incurring a hypotensive crisis. Studies sup-
cose approximately 2 mg/dL. Glucagon process. Other causes of primary adrenal port maintaining patients on their daily
(12 mg), diazoxide, and octreotide have insufficiency include chronic granuloma- steroid dosage throughout the periopera-
been used but are typically reserved for tous disease including tuberculosis. tive period or providing smaller steroid
sulfonyl ureainduced hypoglycemia. Secondary adrenal insufficiency is most dosages rather than the supraphysiologic
Perioperatively many regulatory hor- commonly seen in patients on chronic glu- dosages once routinely recommended. An
mones that oppose insulin action are cocorticoid therapy. Patients on steroid exception to this practice is the critically ill
released. Catecholamines, glucocorticoids, therapy may have ACTH suppression a full patient, in whom supraphysiologic dosages
growth hormone, and glucagons can cause year after steroid therapy. Symptoms are often administered. An example of a
plasma glucose levels of > 180 mg/dL, include fatigue, weakness, anorexia, nausea suggested steroid regimen based on the
exceeding the capacity of the kidney and and vomiting, and weight loss. Only in pri- degree of stress is provided in Table 3-8.43,44
resulting in glycosuria. Glucose-induced mary adrenal insufficiency is ACTH elevat-
diuresis can occur, resulting in dehydra- ed, indirectly resulting in increased skin Thyroid Assessment
tion or the formation of ketone bodies, pigmentation, especially in skinfolds. In Hyperthyroidism primarily affects
which, in turn, results in diabetic ketoaci- primary adrenal insufficiency, aldosterone women, with a female-to-male ratio of
dosis. Treatment includes the use of intra- levels are low, resulting in dehydration with approximately 8:1. Common causes of
venous insulin and appropriate rehydra- hyponatremia and hyperkalemia since the hyperthyroidism include Graves disease (a
tion. One unit of regular insulin typically role of aldosterone in the kidney is resorp- toxic diffuse goiter secondary to an
lowers the glucose 25 to 30 mg/dL in a tion of sodium (and water) and excretion autoimmune reaction caused by stimula-
70 kg individual. Subcuticular injection of potassium. In secondary adrenal insuffi- tory antibodies to the thyroid-stimulating
should be avoided in the perioperative ciency, there are often other endocrine hormone receptor), toxic nodular goiter,
period owing to unpredictable cutaneous abnormalities present. exogenous thyroid hormone (iatrogenic),
blood flow.42 In individuals with an intact hypo- and iodine administration. The effects of
thalamic-pituitary-adrenal axis undergo- excess thyroid hormone include tachycar-
Adrenal Assessment ing a stressful event such as a surgical pro- dia, atrial fibrillation, premature ventricu-
Adrenal insufficiency is classified as either cedure, the adrenal glands increase their lar contractions, worsening of angina pec-
primary, owing to disease of the adrenal baseline secretion of cortisol. Increasing toris, and high-output cardiac failure
62 Part 1: Principles of Medicine, Surgery, and Anesthesia
owing to increased -receptor sensitivity. Failure to recognize that a patient has and mortality, most experts agree that mild
Respiratory complications include impair- uncontrolled hyperthyroidism can result to moderate hypothyroidism poses no
ment and weakness of respiratory muscles in a thyroid storm, which can manifest increased surgical risk. Elective surgery
with associated tachypnea, and hypercar- either during the procedure or in the should be postponed in hypothyroid
bia owing to the associated hypermetabol- postoperative period. It is characterized patients until adequate replacement thera-
ic state. Patients may be hypovolemic sec- by marked tachycardia, hyperthermia, py is administered. Usually this can be
ondary to diarrhea and hyperthermia. weakness, and an altered level of con- accomplished by oral thyroxine supple-
Exophthalmos secondary to fatty infiltrate sciousness. Untreated, the result can be mentation. Two weeks are required before
and edema can occur (ie, Graves congestive heart failure and/or cardio- the patient has symptomatic improvement.
orbitopathy) and, if severe, can lead to vascular collapse. Treatment includes air- Triiodothyronine, which is the active hor-
blindness. Bone resorption with secondary way and ventilatory support with mone, can be administered for a more
hypercalcemia may occur as well. increased minute ventilation to control acute response, but it usually takes more
It is important to assess the degree of excessive CO2 production. Body temper- than 2 weeks until the thyroid-stimulating
thyroid control through a history taking ature should be aggressively managed hormone, the marker for adequate thyroid
and physical examination (and confirma- with cool intravenous fluids, cooling function, normalizes.42
tory laboratory examination, if needed). blankets, and decreased ambient temper-
There is a direct correlation between the ature. -Blocker administration should Malignant Hyperthermia
severity of hyperthyroidism and intraop- be started immediately to interrupt the MH is a rare autosomal dominant trait in
erative risk. Patients scheduled for elec- adrenergic response. Traditionally, a which individuals inherit hypersensitivity
tive surgery should be made euthyroid nonselective -blocker, propranolol, has to specific trigger agents that cause the
before surgery (this usually requires been used. More recently the use of rapid accumulation of calcium into the
weeks), and cardiovascular control, as esmolol, a shorter-acting 1-selective sarcoplasmic reticulum of skeletal muscle.
demonstrated by stable vital signs, should blocker has been advocated. Patients This causes sudden hypermetabolic reac-
be confirmed. If the surgery cannot be with COPD, asthma, and congestive tions, leading to hyperthermia and mas-
delayed and the patient is hyperthyroid, heart failure are more likely to tolerate sive rhabdomyolysis. Trigger agents
-blockers are used to slow the heart rate therapy with a 1-selective agent. Hemo- include potent volatile anesthetic agents
and decrease the potential for arrhyth- dynamic monitoring and the correction and succinylcholine (a depolarizing mus-
mia. -Blockers also inhibit the deiodina- of fluid and electrolyte imbalances cle relaxant). Halothane has traditionally
tion of thyroxine to the more active tri- should be performed. The differential been described as a causative agent and
iodothyronine. This latter effect also diagnosis of a thyroid storm includes forms the basis of the diagnostic test to
occurs with the use of propylthiouracil, malignant hyperthermia (MH; see confirm MH. However, all volatile agents,
which additionally inhibits the synthesis below), neuroleptic malignant syn- including sevoflurane according to recent
of thyroid hormones. Iodine inhibits the drome, and pheochromocytoma. reports, can induce MH.45
release of thyroid hormones but is only Women are ten times more likely to The reaction that typically occurs is
given after antithyroid drugs to avoid a develop hypothyroidism than are men. The abrupt and severe, requiring immediate
thyroid hormone surge. most common cause is iatrogenic, sec- attention. Elevation of end-tidal CO2 is an
ondary to surgical resection or radioactive early sign, prior to temperature elevation.
Table 3-8 Suggested Preoperative
ablation of the thyroid gland. Hashimotos The main treatment is dantrolene, a non-
Surgical Steroid Coverage in Patients on thyroiditis, an autoimmune disorder char- specific muscle relaxant. Its mechanism is
Chronic Corticosteroid Regimens acterized by the presence of antimicrobial likely the blockade of the release of calci-
Surgical Steroid antibodies, is the most common noniatro- um from the sarcoplasmic reticulum. In
Stress (Hydrocortisone) Dose genic cause of hypothyroidism. an acute episode of MH, a supply of at
Low 25 mg on day of surgery
Hypothyroidism is usually insidious in least 36 vials of dantrolene should be avail-
onset and often goes unrecognized despite able for immediate use; this corresponds
Moderate 5075 mg on day of
multisystem effects. The most common to a maximum dose of 10 mg/kg in a 70 kg
surgery, 1 or 2 d taper
signs and symptoms include lethargy, con- adult. In an acute attack dantrolene is
Major 100150 mg on day of
stipation, cold intolerance, weight gain, administered repeatedly in 2 to 3 mg/kg
surgery, 1 or 2 d taper
and anorexia. Although severe hypothy- doses every 5 to 10 minutes. Each vial
Adapted from Salem M et al.44
roidism can result in increased morbidity needs to be reconstituted with 60 mL of
Perioperative Considerations 63
sterile water. Although the use of dantro- References 14. Forrest J, Cahalan M, Rehder K, et al. Multi-
lene has reduced the mortality risk from center study of general anesthesia II.
1. Goldman L, Caldera DL, Nussbaum SR, et al. Results. Anesthesiology 1990;72:2628.
50% prior to its use, there still is approxi- Multifactorial index of cardiac risk in non- 15. Forrest J, Rehder K, Cahalan M, Goldsmith C.
mately a 10% mortality rate. cardiac surgical procedures. N Engl J Med
Multicenter of general anesthesia III. Pre-
There is an estimated occurrence of 1977;297:84550.
dictors of severe perioperative adverse out-
2. Lee TH, Marcantonio ER, Mangione CM, et al.
MH in 1 of 15,000 children and 1 of comes. Anesthesiology 1992;76:315.
Derivation and prospective validation of a
50,000 adults. Those at risk for an attack 16. Elamana V. Anesthetic considerations in
simple index for prediction of cardiac risk
patients with cardiac arrhythmias, pace-
include survivors of an MH reaction and of major noncardiac surgery. Circulation
makers and AICDs. Int Anesthesiol Clin
individuals with muscular dystrophy. The 1999;100:10439.
2001;39(4):2142.
3. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA
clinical sign of masseter muscle spasm 17. Al-Khatib SM, Pritchett EL. Clinical features of
guideline update for perioperative cardio-
during anesthesia with halothane or suc- Wolff-Parkinson-White syndrome. Am
vascular evaluation for noncardiac
cinylcholine may also indicate a suscepti- Heart J 1999;138(3 Pt 1):40313.
surgeryexecutive summary a report of the
18. Horne C, Derrico D. Mastering ABGs. Am J
bility to MH. The in vitro caffeine American College of Cardiology/American
Nurs 1999;99(8):2632.
halothane contracture test is used to eval- Heart Association Task Force on Practice
19. Sadovnikoff N. Perioperative acute renal fail-
Guidelines (committee to update the 1996
uate individuals susceptible to developing ure. Int Anesthesiol Clin 2001;39(1):95109.
guidelines on perioperative cardiovascular
MH when exposed to triggering agents. 20. Godet G, Fleron MH, Vicaut E, et al. Risk fac-
evaluation for noncardiac surgery). Circula-
Diagnostic tests based on deoxyribonucle- tors for acute postoperative renal failure in
tion 2002;105:125767.
thoracic or thoracoabdominal aortic
ic acid are currently available for MH-sus- 4. Bartels C, Bechtel JF, Hossman V, Horsch S.
surgery: a prospective study. Anesth Analg
ceptible individuals. In addition to trigger Cardiac risk stratification for high-risk vas-
1997;85:122732.
cular surgery. Circulation 1997;95:24735.
agents, phenothiazines (such as prochlor- 5. Glance LG. Selective preoperative cardiac 21. Johnston KW. Multicenter prospective study of
perazine) should be avoided since there is screening improves five-year survival in nonruptured abdominal aortic aneurysm:
a possible association between MH and patients undergoing major vascular part II. Variables predicting morbidity and
surgery: a cost-effective analysis. J Cardio- mortality. J Vasc Surg 1989;9:43747.
neuroleptic malignant syndrome (NMS). 22. Thadvani R, Pascual M, Bonventre JV. Acute
thorac Vasc Anesth 1999;13:26571.
NMS is a rare, occasionally lethal, idiosyn- renal failure. N Engl J Med 1996;334:
6. Rubin DN, Ballal RS, Marwick TH. Outcomes
cratic complication associated with neu- and cost implications of a clinical-based 144960.
roleptic antipsychotic drugs. NMS is char- algorithm to guide the discriminate use of 23. Solomon R. Radiocontrast-induced nephropa-
thy. Semin Nephrol 1998;18:50518.
acterized by high temperature and muscle stress imaging before noncardiac surgery.
Am Heart J 1997;134:8392. 24. Moudgil G. The patient with reactive airways
rigidity. Anxiety and agents with sympath- disease. Can J Anaesth 1997;44(5):R7783.
7. Shaw LJ, Hachamovitch R, Cohen M, et al. Cost
omimetic activity, especially -agonists, implications of selective preoperative risk 25. Kersjens H, Groen HJ, van der Bij W. Respira-
have been demonstrated to aggravate MH screening in the care of candidates for tory medicine. BMJ 2001;323:134953.
experimentally. Agents that some authors peripheral vascular operations. Am J 26. Hurford WE. The bronchospastic patient. Int
Manag Care 1997;3:181727. Anesthesiol Clin 2000;38(1):7790.
have recommended to be avoided owing
8. Norton JM. Toward consistent definitions of 27. Ferrari L. Do children need a preoperative
to sympathomimetic effects include keta- assessment that is different from adults? Int
preload and afterload. Adv Physiol Educ
mine and atropine. The use of dantrolene 2001;25:5361. Anesthesiol Clin 1992;40(2):16786.
prophylaxis in MH patients is uncommon 9. Selzman CH, Miller SA, Zimmerman MA, 28. Tobias JD, Kubos KL, Hirshman CA. Amino-
in view of the low likelihood (00.62%) of Harken AH. The case for [beta]-adrenergic phylline does not attenuate histamine-
blockade as prophylaxis against periopera- induced airway constriction during
an MH reaction when a trigger-free anes-
tive cardiovascular morbidity and mortali- halothane anesthesia. Anesthesiology 1989;
thetic regimen is used. Dantrolene is asso- 1:7239.
ty. Arch Surg 2001;136:28690.
ciated with a high frequency of muscle 10. Garg J, Messerli A, Bakris G. Evaluation and 29. American Association of Oral and Maxillofa-
weakness and postoperative nausea. In the treatment of patients with systemic hyper- cial Surgeons. Office anesthesia evaluation
past, outpatient surgery was discouraged. tension. Circulation 2002;105(1):245861. manual. 6th ed. Rosemont (IL): American
11. Varon J, Marik P. The diagnosis and manage- Association of Oral and Maxillofacial Sur-
It is now recommended that careful post-
ment of hypertensive crisis. Chest 2000; geons; 2000.
operative monitoring be continued for at 118(1):21427. 30. American Heart Association. Guidelines 2000
least 4 hours. However, most oral and 12. Fleisher L. Evaluation of the patient with cardiac for cardiopulmonary resuscitation and
maxillofacial surgeons likely avoid per- disease undergoing noncardiac surgery: an emergency cardiovascular care. Circulation
forming outpatient sedation for someone update on the original AHA/ACC guidelines. 2000;102 Suppl 1:143308.
Int Anesthesiol Clin 2002;40(2):109120. 31. Woehlck HJ, Connoly LA, Cinquegrani MP, et
with a personal or family history of malig-
13. Cummins RO, editor. Advanced cardiac life al. Acute smoking increases ST depression
nant hyperthermia owing to the factors support. Dallas (TX): American Heart in humans during general anesthesia.
described.45,46 Association; 1997. Anesth Analg 1999;89:85663.
64 Part 1: Principles of Medicine, Surgery, and Anesthesia
32. Mardirossan G, Schneider RE. Limitations of 37. Benumof JL. Obstructive sleep apnea in the ative management of selected endocrine
pulse oximetry. Anesth Prog 1992;39:1946. adult obese patient. J Clin Anesth 2001; disorders. Int Anesthesiol Clin 2000;
33. Kotani N, Kushikata T, Hashimoto H, et al. 13:14456. 38(4):3167.
Recovery of intraoperative microbicidal 38. Bennett J, Petersen T, Burleson JA. Capnogra- 43. Brown CJ, Buie WD. Perioperative stress dose
and inflammatory functions of alveolar phy and ventilatory assessment during steroids: do they make a difference? J Am
immune cells after a tobacco smoke-free ambulatory dentoalveolar surgery. J Oral Coll Surg 2001;193:67886.
period. Anesthesiology 2001;94: 9991006. Maxillofac Surg 1997;55:9215. 44. Salem M, Tainish RE, Bromberg J, et al. Periop-
34. Radon K, Busching K, Heinrich J, et al. Passive 39. Vascello LA. A case for capnographic monitor- erative glucocorticoid coverage: a reassess-
smoking exposure: a risk factor for chronic ing as a standard of care. J Oral Maxillofac ment 42 years after emergence of a prob-
bronchitis and asthma in adults? Chest Surg 1999;57: 13427. lem. Ann Surg 1994;219:41625.
2002;122:108690. 40. Bennett J. A case against capnographic moni- 45. Ducart A, Adnet P, Renaud B, et al. Malignant
35. Shenkman Z, Shir Y, Brodsky JB. Perioperative toring as a standard of care. J Oral Maxillo- hyperthermia during sevoflurane adminis-
management of the obese patient. Br J fac Surg 1999;57: 134852. tration. Anesth Analg 1995;80:60911.
Anaesth 1993;70: 34959. 41. Jacober SJ, Sowers J. An update on periopera- 46. Abraham RB, Cahana A, Krivosic-Horber RM,
36. Adams JP, Murphy PG. Obesity in anesthesia tive management of diabetes. Arch Intern Perel A. Malignant hyperthermia suscepti-
and intensive care. Br J Anaesth 2000; Med 1999;159:240511. bility: anesthetic implications and risk
85:91108. 42. Graham GW, Unger BP, Coursin DB. Perioper- stratification. QJM 1997; 90(1):138.
CHAPTER 4
The primary purpose of preoperative tive risk; and (6) a thorough explanation of eries and medical problems. Unfortunate-
patient assessment is to provide sufficient the various treatment options in discus- ly, timely access to previous medical
information to the surgical and anesthetic sion with the patient or guardian to assist records may be difficult or impossible.
team members to permit them to formu- with their treatment decisions and to Usually, information concerning the
late the most appropriate surgical and obtain their informed consent. patients past medical, surgical, and anes-
anesthetic plans. The same process should Information such as current medica- thetic history can be gathered by a per-
be used for both office and hospitalized tions, drug allergies, the likelihood of preg- sonal or telephone interview. Although
patients, including trauma victims; med- nancy, family history of malignant hyper- completion of a health questionnaire or
ically, mentally, or physically compro- thermia, a significant medical or surgical medical history form by the patient may
mised patients; and healthy patients hav- history, and, if the procedure is scheduled be a starting point for the interview, it
ing elective surgery with either local at the time of evaluation, an assessment of alone does not meet the important goal of
anesthesia alone, conscious sedation, deep fluid or food ingestion may influence the establishing a personal dialogue with the
sedation, or general anesthesia. Depending surgeons choice on how to proceed. patient to ensure that this information is
on the variables discovered in the assess- A review of the previous medical as complete and accurate as possible. The
ment, modifications to the usual surgical records can provide a wealth of informa- true value of the medical history form is
and anesthetic regimens may be necessary tion that the patient may not know or be to alert the interviewer as to which areas
to improve the chances of attaining a satis- able to relate during their interview. For need further explanation. For example, a
factory outcome. example, if there is previous documenta- positive indication of asthma by the
The components of the preoperative tion of a difficult airway whereby an patient on a health screening question-
assessment are (1) a review of the previous anesthesiologist had significant difficulty naire is relatively worthless information
medical records if available, including all with mask ventilation and needed multi- by itself; it must be followed up with fur-
medical, surgical, and medication informa- ple attempts to intubate a severely retrog- ther questioning concerning the frequen-
tion; (2) a personal interview with the nathic patient, an oral surgeon might not cy of attacks, its precipitating factors, suc-
patient or knowledgeable guardian to choose to administer deep sedation or cessful measures for treatment, the most
obtain additional past medical and surgical light general anesthesia to that patient in recent attack, and the degree of severity of
histories; (3) a focused physical and psy- the office. Better alternatives might symptoms, including previous emergency
chological examination of the patient, with include light conscious sedation in the room treatments for severe asthmatic
emphasis on the cardiovascular and respi- office with only those drugs for which episodes, hospital admissions, or even
ratory systems and the adequacy of the air- pharmacologic antagonists exist, or possi- endotracheal intubation in the intensive
way in regard to the potential for difficulty bly an awake fiberoptic intubation in the care unit for status asthmaticus. Only
in attaining and maintaining its patency office, surgicenter, or hospital prior to the after appropriate questioning has been
during deep sedation or general anesthesia; induction of general anesthesia. For completed for each positive item on the
(4) a review of results of the medical tests patients who are poor historians, previous past medical history form can the
and referral for consultation if needed; (5) medical records may be the sole source of patients past medical, surgical, and anes-
a determination of the patients periopera- information concerning previous surg- thetic history be considered adequate.
66 Part 1: Principles of Medicine, Surgery, and Anesthesia
Obviously, the additional information vascular (polyarteritis nodosa), congenital as additional risk factors for perioperative
gleaned from the patient must be written (tetralogy of Fallot), infectious (bacterial cardiac complications in vascular surgery
on the form for review at the time of the endocarditis), inflammatory/autoimmune patients.2 They simplified the scoring sys-
procedure as well as for proper medicole- (scleroderma), traumatic (cardiac contu- tem of Goldman and colleagues into three
gal documentation. sion), toxic (alcoholic cardiomyopathy), classes, improving predictive accuracy.
Once the information is gathered, the pulmonary (cor pulmonale), metabolic Table 4-2 represents Goldman and col-
surgeon should categorize the surgical (obesity), neoplastic (carcinoid), and leagues and Detsky and colleagues factors
patient according to the American Society endocrine (hyperthyroidism). for perioperative cardiac risk.
of Anesthesiologists (ASA) Classification In a landmark article, Goldman and Although anesthetic and surgical care
of Physical Status (Table 4-1), even if only colleagues developed a multifactorial have markedly improved in the last
local anesthesia is to be used. ASA PS-1 index to assess cardiac risk associated with 25 years and risks may be less in some
patients would be expected to have a lower a variety of noncardiac procedures such as areas, Kenchaiah and colleagues recently
risk of perioperative complications than orthopedic and general surgery.1 This reported that in both men and women
ASA PS-4 patients. Despite a lack of prospective study followed 1,001 patients who are obese, the risk of heart failure was
absolute precision in accurately classifying older than 40 years at Massachusetts Gen- doubled.3 With the increasingly high
the perioperative risk for all patients, this eral Hospital until discharge and recorded prevalence of obesity in the United States,
index is, nevertheless, commonly used to all complications. Various potential risk this risk factor, among others, will prove
help identify certain risk factors so that factors for cardiac complications were cor- more important in determining the risk of
modifications in the treatment plan can be related with actual complications, and a poor outcomes in the future.
accomplished. For instance, ambulatory risk index based on a points system was
general anesthesia in a dental office for subsequently formed. Of the 537 Class I Ischemic Heart Disease Angina Pectoris
ASA PS-1 and many ASA PS-2 patients is patients, with 0 to 5 points, only 0.7% had and Coronary Artery Disease Angina
considered safe and cost effective, whereas life-threatening complications and 0.2% pectoris is typically a substernal chest pain
ASA PS-4 patients would only receive local experienced cardiac death. Patients with or pressure that may radiate to either arm,
anesthesia and perhaps light levels of anx- 6 to 12 points were placed into Class II, the neck, or the mandible that is initiated
iolysis in an office setting. whereas those with 13 to 25 points com- by exercise, mental stress, pain, or other
prised Class III. Class IV patients, with 26 factors that produce increased myocardial
Assessment of Cardiovascular or more points, had a 22% incidence of oxygen demand in the presence of reduced
Disease life-threatening complications and 56% oxygen delivery to the myocardium. It is
experienced cardiac death. Of all these fac- most often caused by coronary artery dis-
Cardiac Disease tors, a previous history of congestive heart ease, although other precipitating factors
Cardiac disease can be subdivided into disease was the most predictive of compli- include severe anemia, hypotension, vaso-
ischemic and nonischemic disease. cations, followed by a myocardial infarc- constrictor overdose, and coronary artery
Ischemic disease includes atherosclerotic tion within the previous 6 months. spasm. Angina pectoris may be classified
heart disease, angina pectoris, and previous Detsky and colleagues modified the as stable, unstable, or variant.
myocardial infarction. Nonischemic disease Goldman Index by including unstable Unfortunately, the symptoms of angina
includes a wide variety of etiologies, such as angina and remote myocardial infarction pectoris may be confused with mitral valve
prolapse, esophageal reflux, esophageal
spasm, peptic ulcer disease, biliary disease,
Table 4-1 American Society of Anesthesiologists Physical Status Classification
hyperventilation, musculoskeletal disease,
Classification Description and pulmonary disease. The diagnosis of
PS-1 Normal healthy patient angina pectoris is therefore not necessarily
PS-2 Patient with mild systemic disease easy for the clinician to establish.
PS-3 Patient with severe systemic disease Stable angina pectoris is diagnosed
PS-4 Patient with severe systemic disease and a constant life threat when there is minimal change over
PS-5 Moribund patient who is not expected to survive without the operation 2 months regarding precipitating factors,
PS-6 Declared brain-dead donor patient for organ harvest frequency, intensity, duration, and treat-
Adapted from American Society of Anesthesiologists. Relative value guide, 2003. Park Ridge (IL): American Society of ments for successful termination of the
Anesthesiologists; 2003.
attacks. Unstable angina pectoris relates to
Preoperative Patient Assessment 67
Table 4-2 Index of Cardiac Risk Common risk factors for coronary
artery disease include advanced age, dia-
Condition Goldman et al1 Detsky et al2
betes mellitus, hypertension, peripheral
Myocardial infarction vascular disease, hypercholesterolemia,
< 6 mo 10 10 obesity, cigarette smoking, sedentary
> 6 mo 5 lifestyle, and family history of coronary
Angina pectoris artery disease. According to Tarhan and col-
Unstable angina < 3 mo 10 leagues, the perioperative risk of an acute
Class III angina 10 myocardial infarction in patients without a
Class IV 20 history of myocardial infarction is 0.13%.5
Symptoms of congestive heart failure 11 Numerous retrospective studies
< 1 wk prior 10 involving large groups of patients indicate
> 1 wk prior 5 that the risk of a second myocardial infarc-
tion in the perioperative period seems to
Dysrhythmia
stabilize at approximately 6% after
Preventricular contractions > 5/min 7 5
Rhythm other than sinus rhythm 7 5
6 months from the initial infarction.58
However, the 6% re-infarction rate is con-
Valvular disease: significant/critical aortic stenosis 3 20 siderably higher than the 0.13% incidence
Miscellaneous of perioperative infarction for the same
Age > 70 yr 5 5 procedures in patients without previous
Emergency operation 4 10 myocardial infarction.
Major invasive surgery 3
Poor general health: obstructive pulmonary 3 5 Congestive Heart Disease Multiple stud-
disease, major electrolyte disturbance, renal ies indicate that the presence of congestive
failure, liver disease, nonambulatory failure is the single most important risk
Adapted from Goldman L et al1; Detsky A et al.2
factor for perioperative cardiac morbidity
independent of the presence of dysrhyth-
mias, cardiomyopathy, valvular disease, or
recent changes in some or all the above fac- place them into the appropriate category. coronary artery disease.1,9,10 Appropriate
tors. Thus, unstable angina is defined by Patients who are judged to have reasonable strategies for perioperative management
chest pain encountered during less than cardiac reserve and are considered stable include optimization with careful atten-
the usual exercise, or that lasts longer, is are certainly good candidates for relatively tion to fluid management and maximizing
more intense, more frequent, or requires simple office procedures while being care- therapies such as inotropes, diuretics,
more than normal measures to terminate fully monitored. Light to moderate levels vasodilators, and antidysrhythmics.
it. Unstable angina is also termed prein- of conscious sedation may prove beneficial The New York Heart Association
farction angina since it may be the harbin- in preventing an angina attack, particular- (NYHA) functional classification of
ger of an impending myocardial infarction. ly in the anxious patient, by reducing the patients with heart disease (Table 4-3) is
Variant angina, also known as Prinzmetals stress of the procedure and decreasing useful in categorizing patients who have
angina, may occur in patients who have no myocardial oxygen demand. Using pro-
detectable coronary artery disease but in found local anesthesia with no more than Table 4-3 New York Heart Association
whom coronary vasospasm occurs period- 40 g of epinephrine has been recom- Classification of Cardiac Patients
ically, even at rest or with ordinary exercise. mended by Malamed for medically com-
Class Symptoms
Cardiac dysrhythmias are frequently pre- promised dental patients.4 These patients
sent during such spasms. These patients should be told to take their usual prophy- I Asymptomatic cardiac disease
are frequently prescribed calcium channel lactic medications such as 1-adrenergic II Symptomatic with ordinary
activity, comfortable at rest
antagonists prophylactically. antagonists perioperatively, and to bring
III Symptomatic with minimal
Patients who elicit a history of angina their nitroglycerin sublingual tablets or
activity, comfortable at rest
pectoris must be thoroughly interviewed spray on the day of surgery to abort an
IV Symptomatic at rest
to permit the practitioner to properly attack if it were to occur.
68 Part 1: Principles of Medicine, Surgery, and Anesthesia
heart failure. It has been shown to be pre- syncopal episodes. Although syncope can echocardiography. Although an invasive
dictive of cardiac morbidity and mortality be caused by central nervous system procedure, cardiac catheterization is more
in the perioperative period. In Goldman pathology (epilepsy, stroke, or transient accurate in assessing aortic stenosis and has
and colleagues study, NYHA Class I ischemic attack), metabolic pathology a dual advantage of assessing coexisting
patients (asymptomatic cardiac disease) (hyperventilation or hypoglycemia), or coronary artery disease. Therefore, it is most
had a 3% risk of deeloping perioperative autonomic pathology (orthostatic important to carefully assess the significance
pulmonary edema, whereas the risk hypotension, carotid sinus hypersensitivi- of aortic stenosis for a patient who presents
increased to 25% in NYHA Class IV ty, or micturition syncope), episodes of with this diagnosis or in whom the practi-
patients (symptomatic at rest).10 Similarly, syncope in the presence of cardiac pathol- tioner suspects it may exist.
patients with signs of congestive heart fail- ogy such as heart block, ventricular tachy-
ure by examination or radiograph were cardia, and aortic stenosis are an ominous Aortic Regurgitation Aortic regurgita-
more likely to develop pulmonary edema sign. The incidence of sudden death is tion produces a diastolic murmur heard
than those without such signs. increased with aortic stenosis. best in the right second intercostal space
Identification of swollen ankles, Of all the valvular conditions encoun- and is associated with a widened pulse
ascites, and distended neck veins during tered in practice, aortic stenosis appears to pressure, decreased diastolic pressure, and
physical examination may help identify be the most significant. Goldman and col- bounding peripheral pulses. It is often
right-sided heart failure, whereas a persis- leagues recognized critical aortic stenosis seen in combination with left ventricular
tent cough, three-pillow orthopnea, and as an independent risk factor for poor out- hypertrophy on a chest radiograph and
rales on auscultation of the chest may be come. It increased the risk of perioperative electrocardiogram. Aortic regurgitation
significant signs and symptoms of left- cardiac death by a factor of 14.1,10 Critical associated with chronic aortic insufficien-
sided failure. aortic stenosis is generally defined as an cy is not associated with increased periop-
orifice of < 0.75 cm2 and/or > 50 mm Hg erative cardiac death according to Gold-
Nonischemic Heart Disease Valvular gradient across the valve during normal man and colleagues.1 However, aortic
Disease When valvular heart disease is cardiac output. This markedly increases insufficiency increases the perioperative
recognized through history or physical the resistance to normal aortic flow, and risk of congestive heart failure, which may
examination, the surgeon must judge the the increased load on the left ventricle result from factors that decrease the for-
potential impact that this condition might causes a concentric left ventricular hyper- ward flow of blood. The use of vasocon-
have in relation to the proposed procedure trophy and decreased compliance. strictors and the presence of anxiety, pain,
and the need for antibiotic prophylaxis to Myocardial oxygen demand is therefore and poorly controlled hypertension may
help prevent endocarditis. The extent to markedly increased, and ischemia-related increase peripheral vascular resistance and
which the patients physical activity is lim- chest pain can occur even without coro- contribute to pulmonary congestion.
ited by the cardiac condition usually serves nary artery disease. These patients do not Reduced inotropy and bradycardia
as a useful guide to determine whether tolerate increases in heart rate because of increase diastolic filling from aortic regur-
further consultation or testing is needed. decreased ejection time, filling time, and gitation, whereas tachycardia and vasodi-
The surgeon must understand the poten- diastolic coronary artery perfusion time of lation help maintain forward flow.
tial cardiac risks associated with the specif- the left ventricle. Thus, -adrenergic ago-
ic problem and know the physiologic con- nists, anticholinergics, vasodilators, hypo- Mitral Stenosis Mitral stenosis is usually
sequences associated with changes in volemia, pain, and anxiety are poorly tol- the result of fusion of the valve leaflets at
cardiac rate, rhythm, blood pressure, pre- erated, particularly for patients whose the commissures during the healing
load, afterload, and inotropy that anesthe- end-stage disease involves angina, syn- process from rheumatic fever. A normal-
sia and surgery may produce. cope, and congestive heart failure. sized orifice is 4 to 6 cm2, but the patient
The consulting cardiologist should becomes symptomatic when the area
Aortic Stenosis Aortic stenosis is recog- define the disease and the degree of hemo- decreases by 50%. The condition produces
nized by its characteristic systolic murmur dynamic significance and optimize the an opening snap early in diastole and a
in the second intercostal space. A chest patient prior to surgery. Echocardiography rumbling diastolic murmur heard best at
radiograph may demonstrate a prominent can be a useful tool to demonstrate abnor- the cardiac apex. It may be associated with
ascending aorta owing to poststenotic mal valve leaflets and a constricted orifice. left atrial enlargement on a chest radi-
dilatation. Symptoms include angina pec- The amount of flow reduction and the ograph and notched P waves on the elec-
toris, dyspnea on exertion, and a history of valvular area can be calculated with Doppler trocardiogram.
Preoperative Patient Assessment 69
Mitral stenosis without regurgitation with significant regurgitation and endo- cardiovascular parameters is essential to
causes left atrial enlargement and ulti- carditis. Appropriate care includes mea- facilitate rapid recognition, diagnosis, and
mately congestive heart failure. Critical sures to prevent significant positive treatment of life-threatening dysrhythmias
mitral stenosis is usually defined as an area inotropic and chronotropic responses to during any surgical procedure.
< 1 cm2. Because the atrial outflow is stress by adequate control of anxiety and Hypertrophic cardiomyopathy, also
reduced, tachycardia reduces the flow into pain, judicious use of -adrenergic ago- known as idiopathic hypertrophic subaor-
the left ventricle, which increases pul- nists such as epinephrine, and careful tic stenosis (IHSS), is usually an inherited
monary congestion and decreases cardiac monitoring of cardiovascular parameters autosomal dominant characteristic,
output. Thus, heart rate must remain rea- during surgery. although it can also be a result of long-
sonably normal, and the atrial kick asso- standing hypertension. The intraventricu-
ciated with sinus rhythm may be necessary Cardiomyopathy Cardiomyopathy may lar septum may be greatly thickened in
for maintaining cardiovascular stability. result from a variety of causes not related asymmetric septal hypertrophy, or the
to valvular or coronary disease, such as hypertrophy may be concentric. Depend-
Mitral Insufficiency Mitral insufficiency systemic disease, infection, or drug and ing on the area of hypertrophy, left ven-
is frequently associated with mitral steno- alcohol abuse. The degree of cardiac tricular outflow obstruction may occur
sis as the result of rheumatic heart disease. impairment can be estimated by invasive during systole. Furthermore, the septal
It produces a holosystolic blowing mur- or noninvasive measurement of the car- leaflet of the mitral valve may not function
mur heard best at the apex. It is often tol- diac ejection fraction (percent EF); this is properly owing to the hypertrophy of the
erated until the patient begins to develop the percentage of left ventricular blood septum, and mitral regurgitation may
signs and symptoms of congestive heart volume ejected into the aorta during each result. Fatal ventricular dysrhythmias may
failure. Mitral insufficiency is associated contraction. The normal value is approxi- result in sudden death even in apparently
with an increased mortality rate if present mately 70% and should increase with exer- healthy teenagers with undiagnosed
with other risk factors such as congestive cise or stress, whereas an EF of 30% is usu- hypertrophic cardiomyopathy. Ischemia
heart failure or recent myocardial infarc- ally associated with decreased exercise within the hypertrophic segment may also
tion.1,10 As in aortic insufficiency, atten- tolerance. Patients with an EF of 15% or result in myocardial infarction. Prepara-
tion must be given to preventing excessive less have significant physiologic impair- tion for surgery would include careful
fluid administration and to maintaining ment and may be candidates for cardiac monitoring of vital signs and minimiza-
forward blood flow with moderate transplantation. tion of those factors associated with
increases in heart rate and vasodilation. There are three classes of cardiomy- increases in cardiac inotropy and rate,
opathy: dilated, nondilated, and hyper- such as hypotension, vasodilation, -
Mitral Valve Prolapse Mitral valve pro- trophic. The typical findings associated adrenergic drugs, pain, and anxiety. Pre-
lapse, or Barlows syndrome, is associated with dilated cardiomyopathy include a operative 1-blockade, adequate hydra-
with a bulging or prolapse of the mitral marked increase in left ventricular end- tion, and local anesthetics without
valve leaflets into the left atrium during diastolic volume. The perioperative impli- epinephrine, unless absolutely necessary,
systole. Typically, it produces a nonejec- cations of dilated cardiomyopathy include are the usual components of good opera-
tion click cardiac murmur, often called optimization of function including careful tive planning.
click-murmur syndrome, heard best at fluid management and maximizing thera-
the cardiac apex and may be associated pies such as inotropes, diuretics, vasodila- Hypertension
with a regurgitant murmur. The diagnosis tors, and antidysrhythmics, as in the man- Hypertension is a very common disease.
is normally confirmed with echocardiog- agement of congestive heart failure. Although it can occur secondarily as a
raphy. Although not a benign condition, it Patients with nondilated cardiomyopa- result of a definable cause such as hyper-
is less likely to be problematic than many thy, also known as restrictive cardiomyopa- thyroidism or pheochromocytoma, it is
of the above valvular diseases. It is often thy, present with rigid ventricles that impair most often a multifactorial primary dis-
associated with a history of chest pain, diastolic filling, although the contractile ease of poorly understood origin, termed
anxiety attacks, dizziness, supraventricular function may remain somewhat intact. essential hypertension.11 In their seventh
tachycardia, and palpitations. These Right ventricular failure and elevated report, the Joint National Committee on
patients are at risk of paroxysmal tachy- venous pressures are common. Dysrhyth- Prevention, Detection, Evaluation and
dysrhythmias and sudden death. Occa- mias are a common cause of death in these Treatment of High Blood Pressure recent-
sionally, mitral valve prolapse is associated patients; therefore, careful monitoring of ly revised their definition of hypertension
70 Part 1: Principles of Medicine, Surgery, and Anesthesia
from previous reports, recognizing that Because the increased peripheral vas- of drugs such as clonidine or propranolol
early detection and treatment of prehy- cular resistance produces a contracted may develop severe rebound hyperten-
pertension and hypertension is impor- intravascular volume, hypertensive patients sion, tachycardia, and angina pectoris.
tant and ultimately reduces risk. Impor- are highly susceptible to the vasodilator Maintaining pharmacologic homeostasis,
tant key messages in the joint committees effects of sedative and anesthetic agents that with only a few exceptions, such as holding
latest report are as follows: (1) for may result in a relative or absolute severe or halving the usual dose of insulin if the
patients < 50 years of age, systolic blood hypotensive episode. patient is fasting preoperatively, is just as
pressure > 140 mm Hg is a much more Prolonged excessive hypotension in a important on the day of surgery as for any
important risk factor for cardiovascular patient with significant peripheral vascular other day.
disease than is diastolic pressure eleva- disease who needs a relatively high pressure
tion; (2) beginning with a pressure of to perfuse vital organs may be more detri- Assessment of Exercise
115/75 mm Hg, the risk of cardiovascular mental during surgery than permitting a Tolerance
disease doubles with every incremental modest degree of hypertension to continue. The Duke University Activity Status Index
increase of 20/10 mm Hg; and (3) a For patients planning for elective surgery (Table 4-5) uses the rate of oxygen con-
systolic pressure of between 120 and who are found to be significantly hyperten- sumption necessary to accomplish vari-
139 mm Hg or a diastolic pressure of sive at the preoperative assessment, it is best ous physical tasks to quantify the degree
between 80 and 89 mm Hg is prehyper- to postpone the procedure until their physi- of physical activity performed.14 One
tension, and lifestyle modifications are cian can optimize their pressure and vol- metabolic equivalent (MET) consumes
recommended to prevent cardiovascular ume status. It is recommended that surgery 3.5 mL/kg/min of oxygen. Hollenberg
disease (Table 4-4).11 be delayed, if possible, for poorly controlled indicated that patients who could undergo
Major risk factors for hypertension hypertensive patients with blood pres- > 7 METs had excellent functional capaci-
include smoking, dyslipidemia, diabetes sure above the mild to moderate range ty, whereas those able to perform only 4 to
mellitus, age > 60 years, gender (men and (> 180/110 mm Hg).11,13 7 METs had only moderate capacity.
postmenopausal women), and family Acute treatment of hypertension at Patients who could do < 4 METs had poor
history of cardiovascular disease in the time of elective surgery may produce functional capacity.15
women > 65 and men > 55 years. If blood pressure numbers that initially Experienced clinicians usually relate
untreated, it commonly causes coronary make the practitioner more comfortable that they have confidence in judging a
artery disease, cardiomegaly, congestive before starting anesthesia and the proce- patients overall capacity to safely undergo
heart failure, and end-organ damage to dure, but the less-than-optimized patient anesthesia and surgery by inquiring about
vital tissues such as the heart, kidneys, is much more likely to have significant the degree of exercise that the patient is
retina, and brain. Elevated systolic blood labile hypertensive and/or hypotensive able to accomplish. Those who can walk
pressure in the elderly appears to be a episodes during the course, and this may up several flights of steps without stopping
better predictor than elevated diastolic increase their risk of morbidity or mortal- to rest are much less worrisome than are
blood pressure of terminal end-organ ity. As a general rule, patients with hyper- those who can manage only a few steps
damage, such as coronary artery/cardio- tension should take all of their normal without developing severe dyspnea or
vascular disease, stroke, renal failure, antihypertensive medications at their nor- chest pain.
postoperative myocardial ischemia, and mal times with a sip of water prior to
overall death.11,12 surgery. Indeed, patients who skip a dose Perioperative Cardiovascular
Evaluation Algorithm
The most recent update of perioperative
Table 4-4 Classification of Hypertension cardiovascular evaluation guidelines by
Systolic BP Diastolic BP Category the American College of Cardiology and
the American Heart Association provides
< 120 and < 80 Normal
120139 or 8089 Prehypertension
a framework for determining the need for
140159 or 9099 Stage 1 hypertension (mild) additional cardiac consultation for
> 160 or > 100 Stage 2 hypertension (moderate) patients with cardiovascular disease,
Adapted from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of
depending on the presence of various
High Blood Pressure.11 predictors of risk for perioperative car-
BP = blood pressure.
diac death and nonfatal myocardial
Preoperative Patient Assessment 71
Table 4-5 Duke Activity Status Index nately, many patients, particularly smok-
ers, are not aware that they have signifi-
Activity METs Functional Capacity
cant pulmonary compromise until it is
Walk in house 1.75 Poor very advanced.
Personal care (dress, bath, toilet) 2.75 Poor As first reported by Morton in 1944,
Walk 12 blocks 2.75 Poor smoking is a risk factor for postoperative
Light work: dusting, washing dishes 2.7 Poor pulmonary complications, even among
Moderate work: vacuuming 3.5 Poor smokers without signs or symptoms of
Yard work: raking, mowing 4.5 Moderate
chronic obstructive pulmonary disease.16,17
Sexual relations 5.25 Moderate
The risk declines from 33 to 14.5% after
Climb stairs 5.5 Moderate
Golf, bowling 6 Moderate
only 8 weeks following cessation of smok-
Swim, basketball, ski 7.5 Excellent ing, whereas those who stop smoking for
Run 8 Excellent < 8 weeks have a higher risk of complica-
Adapted from Hlatky MA et al14; Hollenberg SM.15
tions than do current smokers.18
MET = metabolic equivalent; 1 MET = 3.5 mL/kg/min oxygen use. The assessment should start with
questions regarding dyspnea on exertion
and functional level of physical activity
infarction and the risk stratification for Although the guidelines in Figure 4-1 that can be accomplished, such as how
various noncardiac surgical procedures.13 do not specifically define the surgical risk many flights of stairs can be managed
Using these guidelines, the oral and max- category of the most common oral surgi- without rest. Patients with mild or only
illofacial surgeon can estimate the cardiac cal procedures, the surgeon should occasional symptoms usually need no
risks associated with the surgical proce- attempt to compare the severity of their further investigation, whereas those with
dure and decide whether the patients proposed surgery with that of the exam- frequent or severe symptoms may need
medical condition warrants further car- ples provided. Perhaps a Le Fort III frac- further evaluation and management
diac consultation. For instance, according ture would be similar in risk to an inter- prior to surgery. Although physical limi-
to the algorithm in Figure 4-1, a cardiac mediate-risk acetabular fracture, whereas tations may also be indicative of cardio-
patient with intermediate predictors of a dental implant would be considered a vascular disease or pulmonary disease,
cardiac risk (mild angina or controlled low-risk superficial procedure. they often present simultaneously
congestive heart failure) with good exer- because smoking is a major risk factor for
cise tolerance (equal to or greater than Assessment of Pulmonary cardiovascular disease.
4 METs) who is scheduled for a low-risk Disease Physical examination of the patient
surgery (tooth extraction or tori Patients with pulmonary disease must be with obstructive pulmonary disease may
removal) should not need an extensive carefully assessed preoperatively because reveal an increased anteroposterior
cardiac work-up. However, that same even healthy patients may develop pul- diameter of the chest, a depressed
patient scheduled for hemimandibulecto- monary complications as a direct result diaphragm, a hyperresonant thorax on
my, partial pharyngectomy, laryngecto- of surgery and anesthesia. Pulmonary percussion, and wheezing, particularly
my, or radical neck dissection with flap disease can be classified as either restric- during expiration. The chest radiograph
reconstruction that would entail large tive or obstructive. Restrictive disease may demonstrate hyperinflated lungs.
fluid shifts while under anesthesia for may be the result of, for instance, severe The forced expiratory volume in 1 sec-
many hours (high surgical risk) and who scoliosis or morbid obesity and results in ond (FEV1) is usually < 80% of the vital
has poor exercise tolerance (< 4 METs) a decrease in all measured lung volumes. capacity. Obstructive disease may be
should receive cardiac testing prior to Obstructive disease is usually the result of reversible, as in bronchial asthma, or it
surgery. Likewise, a patient with minor smoking or asthma and may be charac- might have a reversible component.
predictors of cardiac risk (advanced age terized by marked increases in residual Common irreversible diseases include
or previous stroke) scheduled for the volume and functional residual capacity. emphysema, chronic bronchitis, and
above high-risk surgery would not need A thorough past medical history and bronchiectasis. However, antibiotics and
cardiac consultation if his or her exercise physical examination related to the pul- bronchodilator therapy may reverse at
tolerance was good but should be referred monary system prior to sedation or gen- least some of the components of acute
if the exercise tolerance was poor. eral anesthesia is mandatory. Unfortu- symptoms of chronic bronchitis.
72 Part 1: Principles of Medicine, Surgery, and Anesthesia
No
No
No
No
Step 5: Intermediate predictor of risk Yes Step 6: Assess METs for intermediate-high-risk surgery
No
To OR
Step 8: Cardiac
Intermediate- High-risk testing High-risk To OR
To OR low-risk surgery surgery
surgery
Negative Positive
Cardiac catheterfix
FIGURE 4-1 Preoperative cardiac assessment algorithm for surgical risk of cardiac death/nonfatal myocardial
infarction. Major predictors of risk: unstable angina, decompensated heart failure, significant dysrhythmias, and
severe valvular disease; intermediate predictors of risk: mild angina, prior myocardial infarction, controlled heart
failure, diabetes, and renal insufficiency; minor predictors of risk: advanced age, abnormal electrocardiogram,
nonsinus rhythm, poor functional capacity, prior stroke, and uncontrolled hypertension. High-risk surgeries:
emergent major surgery, major vascular surgery, and prolonged cases/major blood loss/fluid shifts; intermediate-
risk surgeries: carotid endarterectomy, head and neck, intraperitoneal, intrathoracic, orthopedic, and prostate;
low-risk surgeries: endoscopic, superficial, cataract, and breast. METs = metabolic equivalents; OR = operating
room. Adapted from Eagle K et al.13
Asthma thesia. In addition to taking a careful his- the number of different asthma medica-
Bronchial asthma is a common pul- tory with regard to asthmatic triggers, fre- tions required to control symptoms and
monary condition that must be respected quency, severity, emergency room visits, the frequency and efficacy of their use.
for its potential to cause life-threatening and hospitalizations, one can also assess Wheezing from asthma immediately prior
complications during surgery and anes- the potential for an acute event by noting to the induction of anesthesia and surgery
Preoperative Patient Assessment 73
is an ominous sign and is reason to post- that reduce the luminal diameter of the patients. Should the respiratory rate of a
pone all but the most urgent procedures. airways and increase resistance to airflow. patient who is a chronic carbon dioxide
Chronic bacterial infections are common retainer decrease because of loss of respi-
Emphysema and produce inflammation and fibrosis ratory drive caused by the additional oxy-
Emphysema is characterized by irre- that further contribute to increased resis- gen, the practitioner may simply need to
versible enlargement of the alveolar air tance. Patients with chronic bronchitis remind the conscious patient to breathe,
ducts and by destruction of the walls of develop hypoxemia and carbon dioxide or manually ventilate the unconscious
these air spaces. The loss of elasticity of retention relatively early in the course of patient with positive pressure oxygen.
these structures permits collapse of the the disease compared with emphysema Only if a severely compromised pul-
airways during exhalation, resulting in patients. Cor pulmonale, manifested by monary patient is left unmonitored while
increased airway resistance. To keep their hepatojugular reflux and peripheral breathing 100% oxygen by face mask
airways from collapsing, patients with edema, also develops comparatively early would there be danger of oxygen causing
severe emphysema can be observed to and results in the patient being termed a hypoventilation in the dental office that is
purse their lips during exhalation to attain blue bloater. The preoperative evalua- properly equipped with airway adjuncts
positive end-expiratory pressure in their tion and management of chronic bronchi- needed for artificial ventilation.
airways. The chest radiograph typically tis is similar to that for emphysema.
demonstrates low flat diaphragms and Assessment of the Airway
extremely hyperlucent lung fields, consis- Bronchiectasis Assessment of the airway is one of the
tent with gas trapping and loss of lung Bronchiectasis occurs when there is an most important facets of the preanesthesia
parenchyma. abnormal enlargement of the bronchi that evaluation process because the inability to
Preoperative management may decrease are frequently filled with purulent sputum maintain a patent airway and provide ade-
the incidence of postoperative pulmonary and highly vascularized granulation tissue. quate ventilation and oxygenation is fre-
complications.19 Those with suspected sig- There is risk of significant hemoptysis and quently responsible for anesthesia-related
nificant obstructive disease may be candi- an increased risk of pulmonary edema, morbidity and mortality. In a closed
dates for preoperative pulmonary function pulmonary hypertension, and cor pul- claims study by the American Society of
testing and analysis of arterial blood gases. monale. Anesthesiologists, Caplan and colleagues
Many emphysema patients, commonly reported that 34% of 1,541 liability claims
known as pink puffers, have reasonably Summary were for adverse respiratory events.21 This
normal arterial blood gases as they are able The surgeon must complete a careful and was the largest source of adverse outcomes
to increase their minute ventilation and thorough past medical history and physi- in their study. Of these cases approximate-
cardiac output to compensate for increased cal examination to assess the risk of pul- ly 75% were related to either inadequate
airway resistance. With increasing pul- monary disease. Recognition of poor exer- ventilation (38%), esophageal intubation
monary artery pressures above a mean of cise tolerance, clubbing of the fingertips, (18%), and difficult intubation (17%).
20 mm Hg, cor pulmonale develops as the chronic cough and dyspnea with minimal Although the current universal use of the
right ventricle begins to fail, resulting in exertion, decreased breath sounds, pulse oximeter and end-tidal carbon diox-
hypoxemia, venous congestion, and sys- wheezes, rhonchi, and excessive expiratory ide monitoring have undoubtedly
temic edema. effort are ominous signs of significant pul- decreased some of these events, at least
Measurement of the ratio of FEV1 to monary disease that may warrant further some of the difficult intubations could
forced vital capacity (FVC) may help to evaluation and treatment prior to surgery have been situations in which the anesthe-
discern the severity of the disease and pre- and anesthesia. siologist could neither intubate nor mask
dict the chance for respiratory failure if the Many patients with severe pulmonary ventilate an apneic patient. Thus, the oral
ratio is < 50%.20 Carbon dioxide retention disease require continual administration and maxillofacial surgeon must carefully
typically occurs when the FEV1:FVC ratio of supplemental oxygen via a nasal can- assess the potential for this type of cata-
is < 35%. nula at home. This should be continued strophic failure to maintain the airway
during dental treatment. In the event of a during any sedation or anesthesia admin-
Chronic Bronchitis medical emergency such as chest pain, istered in the office or other surgical venue
Chronic bronchitis, characterized by a giving of 100% oxygen by face mask and and be prepared to properly manage that
chronic excess of mucus in the bronchi- monitoring of the respiratory rate are circumstance should it occur despite care-
oles, is due to enlarged mucous glands highly recommended for all such ful assessment and planning to avoid it.
74 Part 1: Principles of Medicine, Surgery, and Anesthesia
The American Society of Anesthesiol- is widely used.23 The hypothesis of Mal- airway compromise and tracheal deviation
ogists has developed and updated an algo- lampati and colleagues is that the base of associated with severe dentofacial and
rithm for management of the difficult air- the tongue in certain individuals is dispro- neck infections. Patients with a severe
way.22 As seen in Figure 4-2, these portionately large, which makes direct infection and significant trismus, orthop-
guidelines enable anesthesiologists, nurse laryngoscopy difficult. The tongue base is nea, dysphagia, drooling, and dyspnea may
anesthetists, dentist anesthesiologists, and therefore compared with other anatomic easily lose the patency of their tenuous air-
oral and maxillofacial surgeons to have a features that it may obscure. To perform way with even modest doses of sedative,
detailed series of plans and alternatives to this test correctly, the patient should be sit- anxiolytic, or opioid analgesic medications
facilitate the management of the difficult ting or standing upright and asked to given prior to attempted fiberoptic intuba-
airway. This reduces the likelihood of open their mouth as widely as possible tion. Preparations for an immediate surgi-
adverse outcomes such as death, brain without phonating. In Class I patients the cal airway must be made well in advance.
death, myocardial injury, and airway trau- uvula, faucial pillars, and soft palate are
ma. These guidelines recommend that a visible. In Class II patients only the faucial Assessment of Endocrine
careful airway history and examination be pillars and soft palate are visible, whereas Disease
conducted prior to the induction of anes- in the Class III patients, only the soft Any of the major endocrine disorders can
thesia to detect medical, surgical, and palate is observed. Class I patients are impact the course of anesthesia and
anesthetic factors including previous anes- expected to have normal airways, whereas surgery and should be considered in the
thetic records, if available, that may identi- patients in Class II are somewhat more preoperative assessment.
fy the difficult airway. likely to be difficult to intubate. Intubation
Congenital and acquired diseases or in Class III patients is even more likely to Adrenal Gland
conditions, for instance, may alter the air- be difficult. A lack of adrenal cortical activity, as in
way anatomy to such an extent that attain- Samsoon and Young later added a Addisons disease, may decrease the pro-
ing and maintaining a patent airway dur- fourth category to the original Mallampati duction of cortisol and aldosterone and
ing anesthesia may be difficult or classification.24 Their fourth class included alter cardiovascular stability. Patients who
impossible. Congenital conditions such as visualization of the hard palate but not the take supplemental glucocorticosteroids
Pierre Robin, Treacher Collins, Golden- soft palate or other structures. Class IV may have a suppression of adrenocorti-
hars, Klippel-Feil, and Down syndromes patients have the highest risk for a difficult cotropic hormone from their pituitary
are associated with abnormalities such as intubation (Figure 4-3). gland and may need preoperative supple-
restricted movement of the neck and Although difficult intubation does not mentation of cortisol. An overproduction
mandible, micrognathia, maxillary and always coincide with difficult mask venti- of epinephrine and norepinephrine in the
mandibular hypoplasia, and macroglossia. lation, one must recognize that patients in adrenal medulla from a pheochromocy-
Examples of acquired conditions include modified Mallampati Classes III and IV toma may create a hypertensive-tachycardiac
obesity, oropharyngeal space infections, pose an increased risk of loss of a patent crisis intraoperatively.
epiglottitis, tonsillitis, rheumatoid arthri- airway during nonintubated deep sedation
tis, tumors, temporomandibular joint dis- or general anesthesia. When compounded Thyroid Gland
orders, head and neck cancer surgery, and with other risk factors such as mandibular
oropharyngeal radiation therapy. retrognathia, obesity, or postradiation Hypothyroidism Hypothyroidism has
A careful physical examination of the therapy, the practitioner may elect to many potential causes and is usually deter-
airway must be accomplished. Anatomic administer only light conscious sedation mined by an assessment of levels of thyroid
characteristics associated with difficult with drugs that are pharmacologically stimulating hormone (TSH), triiodothyro-
intubation include a short large-diameter reversible or to secure the airway via awake nine (T3), and thyroxin (T4). Patients who
neck, retrognathia with obtuse mandibular fiberoptic intubation prior to induction of complain of fatigue and intolerance to cold
angles, protruding maxillary incisors, general anesthesia. and who are hypotensive may suffer from
decreased mobility of the temporo- In certain instances additional evalua- myxedema. Theoretically, myxedematous
mandibular joint, and a high-arched palate. tion of the airway may be prudent. For patients may be more susceptible to the
Although there is no airway rating sys- example, fiberoptic pharyngoscopy, soft depressant effects of anesthetics and less
tem that can accurately predict a difficult tissue radiography, computerized tomog- responsive to adrenergic vasopressors and
airway with high sensitivity and specifici- raphy, and magnetic resonance imaging cardiac inotropes. However, a retrospective
ty, the modified Mallampati classification may be helpful in identifying the extent of study demonstrated no significant difference
Preoperative Patient Assessment 75
FIGURE 4-2 Algorithm for management of a difficult airway. LMA = laryngeal mask airway. Reproduced with per-
mission from the American Society of Anesthesiologists.22
76 Part 1: Principles of Medicine, Surgery, and Anesthesia
their usual manner, as if surgery never hap- When the practitioner suspects liver dis- failure is an independent risk factor for
pened. An individualized approach to dia- ease during the perioperative assessment, mortality, regardless of other risk factors.32
betic management is essential. several screening tests are available. Acute He also noted that because the mortality
End-organ damage from diabetes may or chronic hepatocellular damage is indi- of contrast mediumassociated acute
result in problems that directly affect cated with elevations of aspartate amino- renal failure is above 30%, elective surgery
surgery and anesthesia. Renal failure may transferase (AST) and alanine amino- should be postponed if possible until renal
be the result of diabetic nephropathy, transferase (ALT). Acute damage can function returns to baseline in these
which may alter fluid and electrolyte bal- produce very high enzyme elevations, patients. Although newer less toxic con-
ance and drug elimination. The lack of whereas chronic damage may produce trast agents are now available, acute renal
erythropoietin production by the kidney only mildly elevated levels. ALT is more failure can still occur.
may result in significant anemia. Diabetic specific to hepatocytes. As previously discussed, renal failure
sensory neuropathy may permit myocar- Unconjugated bilirubin from normal is often a consequence of diabetes and
dial ischemia and silent myocardial infarc- red cell destruction may increase in the pres- long-standing hypertension. It can be
tion to go unrecognized by the patient and ence of severe liver disease if the hepatocytes responsible for congestive heart failure,
is an independent predictor of periopera- cannot conjugate it with glucuronide. Ele- fluid and electrolyte imbalance, anemia,
tive cardiac morbidity.30 Diabetic auto- vated serum bilirubin is responsible for the hypertension, and azotemia. When renal
nomic neuropathy may also increase the yellow jaundiced appearance. disease is suspected from the history and
risk of aspiration of gastric contents dur- Serum albumin and nearly all of the physical examination, several tests can be
ing deep sedation or general anesthesia by clotting factors such as prothrombin are completed to assess its presence and the
delaying gastric emptying. In addition, it produced in the liver. Severe liver disease degree of impairment. Because urea and
may cause unpredictable cardiovascular can decrease the synthesis of many impor- creatinine are excreted by glomerular fil-
responses to anesthetic drugs and to other tant proteins, as reflected in decreased tration and their blood levels are therefore
cardiovascular-active drugs. serum albumin levels. Additionally, inversely proportional to the glomerular
Metabolic acidosis with hyperglycemia because many anesthetic drugs are nor- filtration rate, blood urea nitrogen and
> 300 mg/dL in the diabetic defines mally highly bound to albumin, reduced serum creatinine levels are commonly
ketoacidosis. Insulin-resistance owing to serum albumin levels over a period of obtained to initially assess renal function.
trauma, surgery, or infection may be a con- many weeks may permit unusually high Creatinine serum levels are normally in
tributing factor. The conversion of fatty levels of free drug to exist in the plasma, the range of 0.6 to 1.5 mg/dL. Approxi-
acids to acetoacetic acid, -hydroxybu- which could produce a markedly mately a 50% loss in kidney function is
tyrate, and acetone in the absence of enhanced effect from a relatively small indicated by a creatinine level > 2.0,
insulin produces metabolic acidosis and dose. Reduced prothrombin levels would whereas a 75% loss of function would be
the fruity smell on the breath that may be be reflected in an increased prothrombin indicated by a creatinine level > 4.8. Crea-
recognized during the preoperative assess- time (PT) and International Normalized tinine levels > 10.0 are consistent with
ment. Extracellular potassium increases as Ratio (INR) and serve as additional mark- end-stage renal disease (ESRD).
it leaves the cells, and this results in intra- ers for the severity of hepatic disease. Patients with ESRD who depend on
cellular depletion of potassium in the pres- Because significant liver disease influences hemodialysis often present for periopera-
ence of hyperkalemia. Significant hypo- so many bodily functions, only necessary tive assessment in either a hypervolemic
volemia results from the osmotic diuretic simple procedures under local anesthesia or hypovolemic state, depending on
effect of glucose in the urine. All of these and perhaps nitrous oxideoxygen con- whether they need dialysis soon or have
deviations must be corrected with insulin, scious sedation should be attempted in an just completed it. Chronic hyperkalemia
fluid, and electrolytes before proceeding office setting for those patients with signif- and anemia are commonly seen. Patients
with all but the most urgent surgery. icant hepatic compromise. on hemodialysis are usually treated on the
day after dialysis, when they have some-
Assessment of Liver Disease Assessment of Renal Disease what stabilized their physiology and when
Preoperative assessment for liver disease is Renal disease has a great impact on peri- the effects of their dialysis-associated
particularly important for those individu- operative morbidity and mortality. The heparin are no longer present. Many of
als with cirrhosis or acute hepatitis mortality rate associated with acute renal these patients are quite sensitive to small
because morbidity and mortality rates failure ranges from 42 to 88%.31 Levy and doses of sedatives and anxiolytics; there-
with these diseases are markedly increased. colleagues demonstrated that acute renal fore, slow careful intravenous titration of
78 Part 1: Principles of Medicine, Surgery, and Anesthesia
these drugs prior to dental procedures is ommends that most dental surgery with a history of seizure should maintain
highly recommended. patients should remain at therapeutic lev- their antiseizure therapy during the peri-
els of their anticoagulant during the peri- operative period. The practitioner should
Assessment of Bleeding Disorders operative period. be aware of the frequency and duration of
A careful history regarding bleeding prob- When a bleeding disorder is suspect- the seizures, including the most recent
lems is essential prior to surgery. Excessive ed, the usual screening tests include the PT one, and what to expect should a seizure
bleeding may result from a variety of or INR to test the activity of the extrinsic occur. Despite maximal doses of multiple
causes. For instance, drugs such as acetyl- and final common pathways and the acti- medications, some patients remain poorly
salicylic acid and other nonselective non- vated partial thromboplastin time to test controlled, and the surgeon must then
steroidal anti-inflammatory analgesics the intrinsic and final common pathways. determine the most appropriate venue for
may inhibit platelet function. Liver dis- Platelet counts may be important when surgical treatment, while considering that
ease may decrease the production of clot- thrombocytopenia is suspected and bleed- the risks of pulmonary aspiration and res-
ting factors. A family history of bleeding ing time is prolonged. piratory insufficiency during seizure
may be the result of autosomal dominant episodes are increased.
transmission of von Willebrands disease Assessment of Neurologic and
to males and females, whereas hemophilia Neuromuscular Disorders Transient Ischemic Attack
A and B are both inherited as sex-linked The oral and maxillofacial surgeon may and Stroke
recessive traits. These patients may be tak- encounter a variety of patients with neu- Patients with a history of transient
ing various factors to bring their levels to rologic disorders. Neurologic examina- ischemic attacks (TIAs) or stroke should be
the normal range or may have had a his- tion may reveal important findings that evaluated in the same manner as those
tory of intravenous desmopressin admin- may alter treatment planning. For with angina pectoris and myocardial
istration to acutely elevate levels of factor instance, head-injured trauma patients infarction. Those who are deemed to have
VIII and von Willebrands factor prior to are classified according to the Glasgow unstable TIAs or who have had a stroke
surgery. A decreased ristocetin cofactor Coma Scale (Table 4-6).41 within the previous 6 months are managed
activity is the most sensitive and specific Protection of the airway without
screening test for von Willebrands disease increasing the chances of worsening any
Table 4-6 Glasgow Coma Scale
because large multimers of von Wille- existing neurologic impairment is of
brands factor are important in ristocetin- prime importance in severely trauma- Action Score
induced platelet aggregation. tized patients. The preoperative assess- Eye opening
To help uncover previously unrecog- ment of some of these patients may be, by Spontaneously 4
nized bleeding disorders prior to major necessity, quite limited during resuscita- To speech 3
dental surgery, Holtzman and colleagues tive procedures. Nevertheless, it is To pain 2
recommend preoperative laboratory absolutely necessary to accomplish to None 1
assessment of hemostasis prior to orthog- whatever degree is possible. Motor response
nathic surgery.33 However, there are a large Neuromuscular disorders such as Obeys 6
number of studies that generally concur Parkinsons disease or multiple sclerosis Localizes pain 5
that routine hemostatic testing of asymp- may increase the risks of ventilatory insuf- Withdraws from pain 4
tomatic patients does not significantly ficiency during spontaneous breathing Flexion to pain 3
alter treatment and is not cost-effective for and aspiration during sedation or anesthe- Extension to pain 2
None 1
the low yield.3439 sia when the airway is relatively unprotect-
Wahl reviewed more than 950 patients ed. Duchennes muscular dystrophy may Verbal response
continuously receiving anticoagulants be a risk factor for development of malig- Oriented 5
Confused 4
who underwent more than 2,400 dental nant hyperthermia or neuroleptic malig-
Inappropriate 3
surgical procedures, and only 12 (< 1.3%) nant syndrome in response to various
Incomprehensible 2
required more than local measures to con- anesthetic drugs.
None 1
trol bleeding.40 Conversely, of the 526
patients who stopped their anticoagulant Epilepsy Adapted from Teasdale G, Jennett B.41
Patients score determines category of neurologic impair-
therapy, 5 suffered serious embolic com- Epilepsy is a common neurologic disorder ment: 15 = normal; 13 or 14 = mild injury; 912 =
moderate injury; 38 = severe injury.
plications and 4 of the 5 died. Wahl rec- that requires careful assessment. Patients
Preoperative Patient Assessment 79
similarly to those with unstable angina and Most abnormalities were minimally outside comes is generally not cost-effective for
recent myocardial infarction, respectively. normal ranges, and only 0.1% of the the resulting low yield.4750 Although
The hypercoagulable state associated with patients had a resulting change in treat- many patients with significant diseases
the stress of surgery is more likely to man- ment. Most importantly, no patient received such as diabetes and coronary artery dis-
ifest itself in patients with preexisting dis- an important benefit from the tests. Like- ease, as well as women of child-bearing age
ease in coronary and cerebral arteries. wise, Dzankic found that the prevalence of who are not sure of their pregnancy status,
abnormal preoperative electrolyte values need certain laboratory testing preopera-
Preoperative Screening Tests for and thrombocytopenia was small and had a tively, routine testing of healthy asympto-
Asymptomatic Patients low predictive value in elderly surgical matic patients with no complicating fac-
With the advent of high-tech automated patients.44 Although more prevalent, abnor- tors is unwarranted.5153
equipment in the past several decades that mal hemoglobin, creatinine, and glucose A carefully taken medical history and a
can quickly complete a large number of values were also not predictive of postoper- thorough physical examination remain the
preoperative screening tests, practitioners ative adverse outcomes. Thus, the routine most important aspects of optimal patient
who wished to gather as much informa- preoperative testing in geriatric patients for care when supplemented by specific tests
tion as possible about their patient to opti- hemoglobin, creatinine, glucose, and elec- that are indicated by this information.
mize care and reduce poor outcomes trolytes on the basis of age alone may not be
began to order universal testing, even for indicated. Selective laboratory testing, as Summary
apparently healthy asymptomatic patients, indicated by history and physical examina- Having obtained and evaluated all of the
in a futile attempt to leave no stone tion, determines a patients comorbidities appropriate information from the above
unturned. Unfortunately, the indiscrimi- and surgical risk. sources, the oral and maxillofacial surgeon
nate ordering of multiple laboratory tests Narr and colleagues studied 3,000 must, in the end, judge whether the bene-
has many drawbacks and usually does not ASA PS-1 and PS-2 patients who received fit-to-risk ratio of completing a procedure
uncover diseases that normally should be elective surgery and found no benefit from for a particular patient, using a particular
discovered by other means such as a thor- the tests.45 Archer and colleagues complet- sedative/anesthesia technique in a specific
ough history and physical examination. ed a meta-analysis of over 14,000 patients venue (office, ambulatory surgical center,
For instance, Rabkin and Horne identified and concluded that the practice of obtain- or hospital), is acceptable. For some med-
165 patients who had been diagnosed ing routine preoperative chest radiographs ically, physically, or mentally complex
as having new electrocardiographic should be abandoned.46 patients, an alternative surgical procedure,
changes.42 However, of that number, 163 It is important to understand that the surgeon, anesthesia provider, anesthesia
were identified as having changes consis- normal values of various tests are often technique, and/or venue may be deemed
tent with their history and physical exam- set around a normal distribution that more appropriate than for those same
ination, so these changes were not unex- would include values of perhaps 95% of a variables with the healthy patient. Sound
pected. Of the 2 patients whose new healthy population. However, some professional judgment of the surgeon is
electrocardiographic changes were not healthy individuals may fall above or the hallmark of successful oral surgical
consistent with the basic information below the normal range yet still be without practice, and a complete preoperative
recorded in their chart, 1 patient was disease. When one considers the variable assessment of each patient provides an
found to be in atrial fibrillation, which selectivity of individual tests, it is not opportunity to influence that judgment
should most likely have been discovered by unreasonable to expect that from a large for a safe and successful operation. The
palpation of an irregular pulse during the battery of tests, at least one may reveal a oft-mentioned statement never treat a
examination process. The other patient falsely positive result. Such a result may stranger is indeed profound.
had no physical examination performed. prompt the clinician to seek additional
Thus, this study indicated that a thorough information from more invasive tests, References
history and physical examination should which may result in a severe complication. 1. Goldman L, Caldera D, Nussbaum SR, et al.
be the key to determining whether the Therefore, indiscriminate testing can actu- Multifactorial index of cardiac risk in non-
practitioner should look for new electro- ally do more damage than the potential cardiac surgical procedures. N Engl J Med
1977;297:84550.
cardiographic changes. harm of some unrecognized disease that it
2. Detsky A, Abrams H, McLaughlin J, et al. Pre-
Domoto and colleagues performed is designed to discover. Additionally, in an dicting cardiac complications in patients
19 screening tests in 70 asymptomatic elder- era of cost containment, testing asympto- undergoing non-cardiac surgery. J Gen
ly patients whose mean age was > 80 years.43 matic patients in hopes of improving out- Intern Med 1986;1:2119.
80 Part 1: Principles of Medicine, Surgery, and Anesthesia
3. Kenchaiah S, Evans J, Levy D, et al. Obesity and 17. Wightman JA. A prospective survey of the inci- 32. Levy E, Viscoli C, Horwitz R. The effect of
the risk of heart failure. N Engl J Med dence of postoperative pulmonary compli- acute renal failure on mortality: a cohort
2002;347:30513. cations. Br J Surg 1968;55:8591. analysis. JAMA 1996;275:148994.
4. Malamed S. Handbook of local anesthesia. 4th 18. Warner MA, Offord KP, Warner ME, et al. Role 33. Holtzman L, Burns E, Kraut R. Preoperative
ed. St Louis (Mo): Mosby-Year Book Inc; of preoperative cessation of smoking and laboratory assessment of hemostasis for
1997. other factors in postoperative pulmonary orthognathic surgery. Oral Surg Oral Med
5. Tarhan S, Moffitt E, Taylor W, Giuliani E. complications: a blinded prospective study Oral Pathol 1992;73:4036.
Myocardial infarction after general anesthe- of coronary artery bypass patients. Mayo 34. Eisenberg J, Clarke J, Sussman S. Prothrombin
sia. Anesth Analg 1977;56:45561. Clin Proc 1989;64:60916. and partial thromboplastin times as preop-
6. Steen P, Tinker J, Tarhan S. Myocardial rein- 19. Tarhan S, Moffitt E, Sessler A, et al. Risk of erative coagulation tests. Arch Surg
farction after anesthesia and surgery. JAMA anesthesia and surgery in patients with 1982;117:4851.
1978;239:256670. chronic bronchitis and chronic obstructive 35. Roher M, Michelotti M, Nahrweald D. A
7. Rao T, Jacobs K, El-Etr A. Reinfarction following pulmonary disease. Surgery 1973;74:7206. prospective evaluation of the efficacy of
anesthesia in patients with myocardial 20. Stein M, Cassara E. Preoperative pulmonary preoperative coagulation testing. Ann Surg
infarction. Anesthesiology 1983;59:499505. evaluation and therapy for surgery patients. 1988;208:5547.
8. Shah K, Kleinman B, Sami H, et al. Reevalua- JAMA 1970;211:78790. 36. Barber A, Green D, GalluzoT, Tsao C. The
tion of perioperative myocardial infarction 21. Caplan RA, Posner KL, Ward RJ, et al. Adverse bleeding time as a preoperative test. Am J
in patients with prior myocardial infarction respiratory events in anesthesia: a closed Med 1985;78:7614.
undergoing noncardiac operations. Anesth claims analysis. Anesthesiology 1990; 37. Myers E, Clarke-Pearson D, Olt G, et al. Preop-
Analg 1990;71:2315. 72:82833. erative coagulation testing on a gynecologic
9. Goldman L, Hashimoto B, Cook E, et al. Com- 22. American Society of Anesthesiologists. Practice oncology service. Obstet Gynecol 1994;
parative reproducibility and validity of sys- guidelines for management of the difficult 83:43844.
tems for assessing cardiovascular function- airway: an updated report by the American 38. MacPherson C, Jacobs P, Dent D. Abnormal
al class: advantages of a specific activity Society of Anesthesiologists Task Force on perioperative hemorrhage in asymptomatic
scale. Circulation 1981;64:122734. Management of the Difficult Airway. Anes- patients is not predicted by laboratory test-
10. Goldman L, Caldera D, Southwick F, et al. Car- thesiology 2003;98:126977. ing. S Afr Med J 1993; 83:1068.
diac risk factors and complications in non- 23. Mallampati SR, Gatt SP, Gugino LD, et al. A 39. Close H, Kryzer T, Nowlin J, Alving B. Hemo-
cardiac surgery. Medicine 1978;57:35970. clinical sign to predict difficult tracheal static assessment of patients before tonsil-
11. The seventh report of the Joint National Com- intubation. A prospective study. Can lectomy: prospective study. Otolaryngol
mittee on Prevention, Detection, Evaluation Anaesth Soc J 1985;32:42934. Head Neck Surg 1994;111:7338.
and Treatment of High Blood Pressure. 24. Samsoon GLT, Young JRB. Difficult tracheal 40. Wahl M. Myths of dental surgery in patients
Bethesda (MD): National Institute of Health; intubation: a retrospective study. Anaesthe- receiving anticoagulant therapy. J Am Dent
National Heart, Lung and Blood Institute; sia 1987;42:48790. Assoc 2000; 131:7781.
2003. NIH Publication No.: 03-5233. 25. Weinberg A, Brennan M, Gorman C, et al. Out- 41. Teasdale G, Jennett B. Assessment of coma and
12. Howell S, Hemming A, Allman K, et al. Predic- come of anesthesia and surgery in hypothy- impaired consciousness: a practical scale.
tors of postoperative myocardial ischemia. roid patients. Arch Intern Med 1983; Lancet 1974;2:814.
The role of intercurrent arterial hyperten- 143:8937. 42. Rabkin S, Horne J. Preoperative electrocardio-
sion and other cardiovascular risk factors. 26. Weinberg A, Ehrenwerth J. Anesthetic consid- graphy: effect of new abnormalities on clin-
Anaesthesia 1997;52:10711. erations and perioperative management of ical decisions. Can Med Assoc J 1983:
13. Eagle K, Berger P, Calkins H, et al. ACC/AHA patients with hypothyroidism. Adv Anes- 128:1467.
guideline for the perioperative cardiovascu- thesiol 1987;4:185212. 43. Domoto K, Ben R, Wei JY, et al. Yield of routine
lar evaluation for noncardiac surgery 27. Rossi L, Thiene G, Caragara L, et al. Dysrhyth- annual laboratory screening in the institu-
executive summary. A report of the Ameri- mias and sudden death in acromegalic tionalized elderly. Am J Public Health
can College of Cardiology/American Heart heart disease: a clinicopathologic study. 1985;75:2435.
Association Task Force on Practice Guide- Chest 1977;72:4958. 44. Dzankic S, Pastor D, Gonzalez C, et al. The
lines (committee to update the 1996 guide- 28. Martins J, Kerber R, Sherman M, et al. Cardiac prevalence and predictive value of abnormal
lines on perioperative cardiovascular evalu- size and function in acromegaly. Circula- preoperative laboratory tests in elderly sur-
ation for non-cardiac surgery). Anesth tion 1977;56:8639. gical patients. Anesth Analg 2001;93:3018.
Analg 2002;94:105264. 29. Hirsch I, McGill J, Cryer P, et al. Perioperative 45. Narr BJ, Hansen TR, Warner MA. Preoperative
14. Hlatky MA, Boineau RE, Higginbotham MB, et management of surgical patients with dia- laboratory screening in healthy Mayo
al. A brief self-administered questionnaire betes mellitus. Anesthesiology 1991; patients: cost-effective elimination of tests
to determine the functional capacity (the 74:34659. and unchanged outcomes. Mayo Clin Proc
Duke Activity Status Index). Am J Cardiol 30. Eagle K, Coley C, Newell J, et al. Combining 1991;66:1559.
1989;64:6514. clinical and thallium data optimizes preop- 46. Archer C, Levy AR, McGregor M. Value of rou-
15. Hollenberg SM. Preoperative cardiac risk erative assessment of cardiac risk before tine preoperative chest x-rays: meta analy-
assessment. Chest 1999;115:51s7s. major vascular surgery. Ann Intern Med sis. Can J Anaesth 1993;40:10227.
16. Morton HJV. Tobacco smoking and pul- 1989;110:85966. 47. Roizen MF, Kaplan EB, Schreider BD, et al.
monary complications after surgery. Lancet 31. Gelman S. Preserving renal function during The relative roles of the history and physi-
1944;1:36870. surgery. Anesth Analg 1992;74:8892. cal examination, and laboratory testing in
Preoperative Patient Assessment 81
preoperative evaluation for outpatient 49. Turnbull JM, Buck C. The value of preopera- 51. Lind LJ. Anesthetic management. Oral Max-
surgery: the Starling curve of preopera- tive screening investigations in otherwise illofac Surg Clin North Am 1996;8:23544.
tive laboratory testing. Anesthesiol Clin healthy individuals. Arch Intern Med 52. Roizen MF. Routine preoperative testing. In:
North Am 1987;5:1534. 1987;147:11015. Miller RD, editor. Anesthesia. 2nd ed. New
48. Johnson H, Knee-Ioli S, Butler TA, et al. Are 50. Perez A, Planell J, Bacardaz C, et al. Value of York: Churchill Livingstone; 1986. p. 22553.
routine preoperative laboratory screening routine preoperative tests: a multicenter 53. Kaplan EB, Sheier LB, Boeckmann MS, et al.
tests necessary to evaluate ambulatory study in four general hospitals. Br J Anaesth The usefulness of preoperative laboratory
surgery patients? Surgery 1988;104:63945. 1995;74:2506. screening. JAMA 1985;253:357681.
CHAPTER 5
Pharmacology of Outpatient
Anesthesia Medications
M. Cynthia Fukami, DMD, MS
Steven I. Ganzberg, DMD, MS
Intravenous sedation has a long history of medications derives from their actions in macodynamic effect. When a specific ligand
use in oral surgery practice. Oral sur- the central nervous system (CNS). binds to the extracellular portion of these
geons have been the historical leaders in At a cellular level the most frequent transmembrane receptors, a conformation-
the development of office-based ambula- mechanism by which drugs exert their al change in the domain of the receptor
tory anesthesia practice. The develop- pharmacologic effects is through interac- exposed towards the cytoplasm activates
ment of newer intravenous agents and tions with specific protein receptors either a specific enzyme or a second mes-
techniques have led to the increased embedded in cell membranes, which then senger system. Second messenger systems,
acceptance of these practices as being safe initiate a specific set of intracellular such as G proteins and cyclic adenosine
and cost effective. Currently, the vast actions. These protein receptors can be monophosphate, are complex cascades of
majority (> 70%) of surgical procedures characterized as ion channels or trans- signaling proteins that, once triggered, will
are performed on an ambulatory basis, membrane receptors. Ion channels allow produce the intended effect. An example of
and at least 20% of surgical procedures the passage of specific ions into or out of an enzyme-activated system is insulin,
are performed with office-based sedation the cell, including chloride, potassium, which binds to its specific receptor, activat-
or general anesthesia. sodium, and calcium. Alterations in the ing an intracellular enzyme called tyrosine
While it is neither possible nor the intracellular concentration of these ions kinase, resulting in increased glucose
intention of the authors to present the full initiate characteristic cellular effects such uptake. Muscarinic acetylcholine (ACh)
scope of anesthetic medications including as depolarization of a cell membrane or receptors also use a second messenger cas-
emergency medications in this chapter, movement of storage vesicles. Opening of cade involving intracellular calcium.
we will review the pharmacology of many ion channels may be triggered by either Some lipid-soluble drugs do not
agents used in office-based sedation and changes in membrane voltage or binding engage membrane receptors, but instead
general anesthesia practice. Where applic- by a specific ligand. Voltage-sensitive ion exert their pharmacodynamic effect intra-
able the use of these agents in oral surgical channels open and close depending on cell cellularly via receptors found in the cyto-
practice is highlighted. membrane voltage, whereas a ligand-gated plasm. Hormones and steroid medications
ion channel undergoes conformational cross the cell membrane and bind to cyto-
Pharmacodynamics changes when a drug or natural ligand plasmic receptors, which then alter cellular
and Pharmacokinetics binds to it, altering ion channel opening functions such as gene transcription. A
and closing. The -aminobutyric acid small number of medications may also
Pharmacodynamics (GABA) receptor is an example of a alter enzyme activity outside of cells, such
Pharmacodynamics is the study of the ligand-gated chloride ion receptor. as anticholinesterase drugs that block the
pharmacologic actions and clinical effects Transmembrane receptors are also lig- activity of acetylcholinesterase.
of a drug in the body.1 The clinical and regulated and typically rely on second Drugs are commonly classified as
response of most anesthetic and sedative messenger systems to carry out the phar- either agonists or antagonists for a specific
84 Part 1: Principles of Medicine, Surgery, and Anesthesia
receptor. Agonist drugs function to exert undergo partial metabolism prior to the plasma concentration falls by contin-
the normal property associated with entrance into the central circulation. This ued redistribution to other vessel-rich
receptor activation. GABA A agonists like process potentially reduces the plasma organs, and later to less vessel-rich organs
benzodiazepines activate GABA receptors, concentration of drug that reaches the such as skeletal muscle (approximately
allowing an influx of chloride, hyperpolar- effector site, such as the CNS. Since the 20% of cardiac output), anesthetic drug
izing the cell, and reducing neuronal activ- degree of gastrointestinal absorption and not bound to receptors in the brain will
ity, thus promoting the normal activity first-pass metabolism is unpredictable, PO transfer back into the central circulation
associated with GABA activation. Antago- sedative drugs can have less reliable clini- for further redistribution to other tissue
nist drugs exert the opposite effect of the cal effects. Most anesthetic agents used in sites. As the brain concentration of seda-
natural ligand or agonist drug activity. oral surgical practice are delivered intra- tive agent falls, the clinical effects of seda-
Competitive antagonists bind at the normal venously, intramuscularly, or by inhala- tion also decrease.
ligand-binding site but exert no pharma- tion. In contrast to oral agents these routes Characteristics of the drug itself affect
cologic effect. Instead the antagonist takes of administration do not undergo first- its distribution throughout the body.
up space at the binding site, thus blocking pass metabolism. Both intravenous and Lipophilic drugs readily cross the blood-
agonist drug activity. The higher the con- inhalation administration provide direct brain barrier and cellular membranes, and
centration of antagonist, the greater the entry into the central circulation, reaching generally exert their effects rapidly. Like-
blocking effect. Agonist activity returns peak plasma concentration very quickly wise lipophilic drugs can quickly exit the
once the antagonist concentration following drug administration. Inhalation CNS, shortening the duration of their
decreases or if additional agonist is admin- pharmacokinetics will be discussed in the effects. Hydrophilic medications either
istered to overcome the antagonist con- following section Inhalation Anesthetics. cross very slowly or must be transported
centration. Nondepolarizing neuromus- Distribution describes the movement by specific mechanisms. The size or mole-
cular blockers are competitive antagonists of the drug between body compartments. cular weight of the drug molecules influ-
for the acetylcholine receptor. Noncompet- The main factors influencing distribution ences movement across capillary walls;
itive antagonists do not bind at the ligand include the allocation of blood flow to a smaller molecules will cross more readily.
site but instead attach to a different loca- specific compartment, the concentration The degree to which the drug binds to
tion on the receptor, altering the configu- gradient of the drug between compart- plasma proteins such as albumin and 1-
ration of the binding site and preventing ments, the chemical structure of the drug, acid glycoprotein will affect the amount of
normal ligand binding. Administration of and plasma protein binding of the drug. free drug available to cross into the brain.
an additional agonist does not affect non- Following administration the majority of Most sedative agents are highly plasma-
competitive antagonist activity, as they do the drug initially redistributes to the protein bound. For example, initial doses
not compete for the same binding site. vessel-rich compartments. This vessel-rich of diazepam are 98% bound to plasma
Many pesticides are an example of non- group includes the brain, heart, kidney, protein and unavailable to cross into the
competitive antagonist agents. and liver, representing 10% of total body CNS. As the free drug plasma concentra-
mass but 75% of cardiac output. Since the tion decreases through further redistribu-
Pharmacokinetics major site of anesthetic agent activity is tion, and later metabolism and elimina-
Pharmacokinetics is the study of the fac- the brain, early distribution to the CNS tion, plasmaprotein-bound drug is
tors that affect the plasma concentration results in early anesthetic effects. released back into the plasma as free drug
of a drug in the body, encompassing the The transfer of the drug from the cen- and is able to cross the blood-brain barri-
processes of absorption, distribution, tral circulation to the brain is also deter- er. In this way drug bound to plasma pro-
metabolism, and elimination.1 Commonly mined by the concentration gradient tein may be thought of as a reservoir of
identified by the route of administration, between the two compartments. A lower drug that may contribute to prolonged
such as per oral (PO), intravenous (IV), concentration in one compartment favors sedative effects. Once plasma-protein
intramuscular (IM), or inhalation, the transfer from a region of higher con- binding sites have been filled, an addition-
absorption describes the point of entry of centration. Following initial intravenous al consequence is that further administra-
the drug into the body. Orally adminis- administration the initial drug concentra- tion of small quantities of drug can have
tered agents undergo first-pass metabolism; tion in the brain is low relative to the plas- profound effects as the majority of the
PO medications are absorbed by the ma concentration; thus, the drug will additional administered agent will be free
intestinal mucosa and carried via the por- rapidly transfer into the brain based on drug that is able to cross the blood-brain
tal circulation to the liver where they this differential concentration gradient. As barrier. Careful titration of intravenous
Pharmacology of Outpatient Anesthesia Medications 85
agents, especially after initial administra- hepatic enzyme activity. However, if the alpha half-life than the beta half-life. In
tion and filling of protein binding sites, is patients daily medications induce hepatic some cases residual CNS effects can be
important to avoid oversedation due to enzymes, then increased metabolism of predicted by a long elimination half-life.
this mechanism. Hypoproteinemia sec- additional medications is possible. Induc- The beta half-life has more use for orally
ondary to advanced age or severe liver fail- tion is isoform specific; a coadministered administered agents and particularly
ure can also dramatically increase the con- drug will only be affected by enzyme describes central compartment concentra-
centration of free drug, and dose induction if both drugs are metabolized by tion in a one-compartment model.
reduction may be required. the same enzyme system. Hepatic micro- The pharmacokinetics of a continu-
As redistribution continues, a fraction somal enzymes can also be inhibited by ous infusion of intravenous anesthetic
of the plasma concentration is delivered to certain drugs, thus reducing metabolism agents may be better described by the
the liver, the primary organ of drug metab- of drugs by a specific enzyme system. For context-sensitive half-time. This value
olism, undergoing transformation from a example, patients taking cimetidine for represents the time necessary for the
lipid-soluble entity to a water-soluble treatment of gastric ulcers may experience plasma drug concentration to decrease
form. There are four main pathways of prolonged residual CNS effects from by 50% after discontinuing a continuous
hepatic metabolism: oxidation, reduction, diazepam, as cimetidine inhibits the infusion, depending on how long the
hydrolysis, and conjugation. Phase I reac- hepatic enzymes that normally metabolize anesthetic agent has been administered.2
tions include the first three pathways, con- diazepam. Various tables have been pub- Figure 5-1 describes the context-sensitive
verting the drug into a water-soluble lished which list drugs that are substrates, half-time for a number of common anes-
metabolite or intermediate form. Phase II inducers, and inhibitors of the various thetic agents. Currently computer-
reactions involve most forms of conjuga- cytochrome enzyme systems. controlled pumps administer continuous
tion, in which an additional group is added Nonhepatic forms of metabolism are infusions based on a specific amount of
onto the metabolite in order to increase its important for certain anesthetic medica- drug per time, but the newest infusion
polarity. Subsequent elimination via the tions, and are useful in patients with signif- pumps can be programmed to calculate
kidney, the main excretory organ, requires icant liver or kidney disease. Drugs suscepti- and provide target plasma concentra-
hydrophilicity to avoid reabsorption of the ble to Hofmann elimination spontaneously tions of an agent to a specified anesthet-
excreted drug. Water-soluble drugs and degrade at body pH and temperature. Ester ic or analgesic level. In the future these
metabolites are eliminated chiefly by the hydrolysis by nonspecific and specific (eg, pumps will likely be integrated with con-
kidney, but also via the bile, lungs, skin, pseudocholinesterase) esterases is also less current electroencephalogram con-
and other organs. dependent on renal and hepatic functions. sciousness monitoring to individualize
Phase I hepatic reactions, including Redistribution, metabolism, and elim- anesthetic drug delivery.
the cytochrome P-450 (CYP-450) group of ination reduce the plasma concentration
enzymes which carry out the oxidation of the drug, increasing the transfer of drug Benzodiazepines
and reduction reactions, occur in the from tissue sites (eg, brain) back into the Benzodiazepines are the most commonly
hepatic smooth endoplasmic reticulum central circulation for further redistribu- used sedative and anxiolytic medications
(hepatic microsomal enzymes). The CYP- tion, metabolism, and elimination. Differ- in oral surgery. Their relatively high mar-
450 group of enzymes has been character- ent mathematical models involving these gin of safety as compared to other sedative-
ized into several isoforms, including CYP- processes have been developed that hypnotic medications, in addition to the avail-
3A4, CYP-2D6, and CYP-1A2. The describe the offset of activity of anesthetic ability of an effective reversal agent, makes
conjugation reaction of glucuronidation is agents. The fall of 50% of the plasma con- their use attractive during operator-anesthetist
also conducted by the hepatic microsomal centration of the drug secondary to redis- procedures in an outpatient setting.
enzymes. The hepatic microsomal tribution is termed the alpha half-life. The Benzodiazepines are composed of a
enzymes are unique in that certain chemi- removal of 50% of the drug from the body benzene and diazepine ring fused together.3
cals and drugs, including those used in due to metabolism and/or elimination is Agonist agents contain a 5-aryl substitution
anesthesia, can stimulate their activity. termed the beta half-life, or elimination which is not present on the antagonist
This is termed enzyme induction and gen- half-life. Offset of clinical effects and reversal agent (Figure 5-2). This structure
erally requires chronic exposure of the awakening from a bolus of an IV anesthet- binds to inhibitory GABA receptors found
drug to the enzyme system for at least sev- ic agent is more dependent on redistribu- throughout the brain, particularly in the
eral days or weeks. An isolated exposure to tion of the drug away from the brain and cerebral cortex. Binding to the GABA A
anesthetic agents is unlikely to induce is therefore better approximated by the subunit increases the frequency of pore
86 Part 1: Principles of Medicine, Surgery, and Anesthesia
reemergence of sedation several hours tration will be seen after 15 to 20 minutes sedation or euphoria. It is important to
after completion of the procedure, due to in the pediatric patient. note that narcotic medications do not pro-
enterohepatic metabolism. Upon inges- duce amnesia or classic sedation, nor do
tion of a fat-rich meal, bile is released Lorazepam they induce loss of consciousness or sensa-
into the gut, and active drug components Lorazepam is a long-acting benzodi- tion of touch at clinically relevant doses.
in the bile are reabsorbed by the intesti- azepine with a slow onset. Its use for PO Patients given opioid medications alone
nal mucosa and undergo first-pass and IV sedation is therefore limited but is will retain awareness and memory.
metabolism. These still active drugs are an option for oral preoperative anxioly- Instead, opioids are often used in combi-
then re-introduced into the central cir- sis, particularly the night before surgery nation with sedative-hypnotic medica-
culation and into the CNS, resulting in or for long operative appointments. tions such as benzodiazepines and barbi-
possible resedation. Dosage for an adult is 0.05 mg/kg, not to turates to provide analgesia and augment
exceed 4 mg total. the desired level of anesthesia.
Midazolam While the term opiate refers to any
Midazolam has an imidazole ring attached Triazolam drug derived from opium, opioid medica-
to its diazepine ring. The imidazole ring is Triazolam is only available in an oral for- tions include all substances, natural and
open, rendering the compound water solu- mulation as 0.125 mg and 0.25 mg tablets. synthetic, which bind to the opioid recep-
ble at pH less than 4, but the ring closes at This sleep adjunct can be used off-label for tors.7 Common opioid medications are
physiologic pH producing the lipid-soluble anxiolysis and sedation at a dose of 0.25 to shown in Figure 5-3. Endogenous opioids
benzodiazepine. Midazolam can therefore 0.5 mg for an adult. It is a very short-acting such as endorphins and enkephalins, and
be delivered in an aqueous solution, rather benzodiazepine and its effects are observed administered opioid medications like
than propylene glycol, resulting in less pain in 30 to 45 minutes with clinically effective morphine, bind to opioid receptors locat-
on intravenous and intramuscular injec- sedation lasting from 30 to 90 minutes. ed in presynaptic and postsynaptic neu-
tion.4 It is 2 to 3 times as potent at rons throughout the CNS as well as in
diazepam, with a faster onset, much faster Flumazenil peripheral afferent nerves. Agonist activity
elimination, and shorter duration of lin- Flumazenil is a highly specific competitive at these receptors either modifies or
gering effects. Its active metabolites are not antagonist for the benzodiazepine receptor decreases neuronal transmission of pain
thought to produce significant sedative and is used as a reversal agent for benzodi- signals. Several subtypes of opioid recep-
effects. Respiratory depression is more of a azepine agonists.6 It will reverse benzodi- tors (eg, , , ) with differential effects
concern with midazolam than diazepam azepine sedation, excessive disinhibition, have been identified. The and recep-
after bolus intravenous administration. and the additive ventilatory depression tors are predominantly responsible for
Midazolam is currently more popular related to benzodiazepines when combined analgesia, and most clinically used opioids
than diazepam for intravenous sedation for with opioids. Flumazenil is given 0.2 mg IV are agonists for the receptor. A subset of
short oral surgical procedures. For con- initially, followed by 0.1 mg at 1-minute opioids, termed agonist-antagonist opioids,
scious sedation 0.05 to 0.15 mg/kg IV in intervals as necessary, to a total of 1 mg. In are agonists at receptors and antagonists
divided doses is titrated to effect, typically emergency situations, 0.5 to 1 mg or more at receptors. Thus agonist-antagonist
given in 1 or 2 mg boluses every few min- may be administered in a bolus dose. opioids are contraindicated for patients on
utes. Peak effect is seen in approximately 5 Reversal effects may take several minutes to long-term opioids, such as those using
minutes. Dosage should be adjusted down- manifest. The effect of flumazenil will last these agents for chronic pain or those on
ward when given concurrently with other 30 to 60 minutes and may require redosing methadone maintenance for treatment of
medications such as opioids or propofol. since agonist drug activity may outlast the opioid substance abuse.
An intramuscular injection of 0.5 mg/kg to reversal effects. Flumazenil should not be Respiratory depression is the most
a maximum of 10 to 15 mg depending on administered to epileptic patients using common and pronounced side effect of
patient age is also possible. As an alterna- benzodiazepines for seizure control and receptor agonists as used in anesthetic
tive midazolam may be given orally at 0.5 should be used cautiously with other practice. This effect can be significantly
to 1 mg/kg (maximum 15 mg), usually epileptic patients. exacerbated with concurrent administra-
mixed into a flavored syrup or in a com- tion of other medications such as benzodi-
mercially available premixed product; this Opioids azepines, barbiturates, propofol, and other
route may be better accepted by pediatric Opioid medications are used in oral opioids. Respiratory depression is dose
patients.5 Clinical effect from PO adminis- surgery primarily for analgesia and mild dependent, resulting from a decrease in
88 Part 1: Principles of Medicine, Surgery, and Anesthesia
such characteristics fentanyl is a frequent lived, postoperative pain will not be Unlike all the other agents noted
choice for intravenous conscious seda- addressed by intraoperative remifentanil, above which are US Drug Enforcement
tion for short office-based procedures. It and alternative pain control with another Agency Schedule II controlled substances,
is typically given in 25 to 50 g incre- narcotic such as a nonsteroidal anti- nalbuphine is not currently a scheduled
ments towards a total dose of approxi- inflammatory drug (NSAID) or local controlled substance and does not require
mately 1 to 2 g/kg. It is also given during anesthesia should be considered towards state and federal documentation of use.
induction of general anesthesia, both the end of the procedure.
for analgesia and attenuation of airway Remifentanil is used in a total intra- Naloxone
reflexes during intubation. venous infusion anesthetic technique to Naloxone is a pure opioid antagonist that
Fentanyl does not induce histamine maintain anesthesia during dental surgery, is active at all opioid receptor subtypes. It
release and is therefore not associated with often in combination with propofol. For will reverse both the ventilatory depressive
vasodilatory or bronchospastic effects. analgesia during general anesthesia it is used and analgesic effects of opioids. It can also
However, at higher doses, it can cause more at 0.25 to 1 g/kg or 0.5 to 2 g/kg/min. Dur- be used to reverse chest wall or glottic
pronounced bradycardia than morphine. ing sedation the dose ranges from 0.05 to rigidity from fentanyl and its derivatives.
Fentanyl is a potent respiratory depressant. 0.10 g/kg/min. In patients taking opioids chronically (eg,
At high doses and with rapid bolus admin- Remifentanil, like fentanyl, can cause chronic pain management, illicit opioid
istration, fentanyl and other synthetic deriv- chest wall rigidity and caution should be users, methadone therapy for opioid
atives have been associated with chest wall used during bolus administration. It is abuse), naloxone must be used with cau-
and glottic rigidity, making ventilation also a highly potent respiratory depres- tion as the antagonist effect may precipi-
impossible; there are reports that even lower sant, and even at lower doses, apnea may tate acute opioid withdrawal and acute
doses (eg, 100 g) can trigger this centrally be pronounced. If spontaneous ventilation congestive heart failure may result.
mediated effect. Fentanyl-associated chest is desired the remifentanil infusion is usu- The initial dose is 0.4 to 2 mg IV for
wall rigidity is treated with either naloxone ally titrated to maintain an adequate respi- acute reversal. Naloxone can also be titrat-
or succinylcholine (SCh), and positive pres- ratory rate. None of these synthetic deriv- ed in 0.04 mg increments when gradual
sure O2 and other resuscitation equipment atives cause the release of histamine. adjustment of mild respiratory depression
should be immediately available. The inci- Sufentanil and alfentanil are shorter- is required. Because the duration of nalox-
dence of fentanyl rigidity is reduced by a acting agents than fentanyl but not as one activity is 30 to 45 minutes, reemer-
preceding dose of a benzodiazepine or other rapid in offset as remifentanil. These gence of respiratory depression may occur
hypnotic drug. agents are commonly used as a continuous and additional dosing may be needed.
infusion adjunct for intubated general
Remifentanil, Sufentanil, and anesthesia during cardiac or prolonged Barbiturates
Alfentanil surgery, particularly when residual opioid Barbiturates are sedative-hypnotic med-
Remifentanil, sufentanil, and alfentanil are effects are desirable postoperatively. They ications that have long been employed as
synthetic fentanyl derivatives used primar- are not as commonly used for office-based induction agents of general anesthesia.
ily for analgesia during general anesthesia. oral surgical anesthesia. Barbiturates produce sedation, loss of
Remifentanil in particular is associated consciousness, and amnesia. These drugs
with a rapid onset and extremely short Nalbuphine do not provide analgesia and may actually
duration of action, resulting in a signifi- Nalbuphine is the most frequently used reduce pain threshold at lower doses. Sev-
cantly shorter recovery time. Metabolized intravenous agonist-antagonist opioid. It eral barbiturates such as IV pentobarbital
by nonspecific plasma esterases, its clear- has a relatively short onset and duration of and oral phenobarbital are commonly
ance is very rapid and independent of both action of 2 to 4 hours at sedation doses of used as anticonvulsants for both preven-
hepatic and renal functions. It has a very 5 to 10 mg for the adult patient. Although tion and treatment of seizures. High doses
short context-sensitive half-time of 4 min- nalbuphine and other agonist-antagonist of any intravenous barbiturate can also
utes with virtually no cumulative effect, opioids do possess a ceiling effect for res- suppress acute seizure activity.
even following hours of continuous infu- piratory depression at higher doses, at Barbiturates are derivatives of barbi-
sion. These features make remifentanil equianalgesic and clinically relevant seda- turic acid (Figure 5-4). The characteristics
ideal for use in a titratable continuous tion doses, the respiratory depressant of the individual barbiturate are deter-
infusion. Of note is the fact that because effects are similar to agonist opioids. mined by the side chains attached to the
the actions of this medication are so short- Nalbuphine does not release histamine. barbiturate ring (Figure 5-5). For example,
90 Part 1: Principles of Medicine, Surgery, and Anesthesia
O zodiazepines), causing the chloride chan- sure, particularly when a full induction
H nel to remain open for a longer duration. dose is administered. This is partially
N C
1 6 The increased negative inward flow hyper- attenuated by a compensatory increase in
polarizes the membrane, decreasing neu- heart rate as baroreceptor reflexes remain
ronal transmission. intact. Hypotension is more evident in the
O C 2 5 CH2 + 2H2O Awakening from intravenous barbitu- elderly or medically compromised, hypo-
rates is dependent on redistribution from volemic patients. Thiopental can cause
3 4 the brain. These medications are metabo- histamine release, which is clinically
N C lized by hepatic enzymes without the for- insignificant with methohexital.
H
O mation of active metabolites and are then Intra-arterial injection of barbiturates
FIGURE 5-4 Chemical structure of barbituric cleared renally. Because these drugs are causes painful spasm of the vessel from
acid. highly protein-bound, hypoproteinemia precipitation of barbiturate crystals, which
secondary to liver failure or malnutrition damage the endothelium and may result
sulfur substitution on the no. 2 carbon in increases the plasma concentration of free in occlusion of the artery. At worst,
thiobarbiturates increases the lipid solu- drug. Chronic use of barbiturates can decreased distal perfusion may result in
bility of these drugs and hence decreases cause induction of liver enzymes. Barbitu- tissue necrosis of a limb or nerve damage
onset of action and duration of activity. rates are also contraindicated in patients and must be addressed immediately. The
The methyl group attached to the nitrogen with acute intermittent porphyria as they intravenous catheter should be left in
atom of the ring in methohexital results in may precipitate an attack. place, IV cardiac lidocaine or procaine
a more rapid onset for this oxybarbiturate Barbiturates are associated with a (without epinephrine) administered, and
and increased susceptibility to cleavage, dose-dependent decrease in respiratory the patient should be transported to an
producing a shorter duration than other rate and tidal volume with apnea observed emergency department where medications
oxybarbiturates. at higher doses. Centrally mediated or regional blockade may be given to
Barbiturates act on GABA receptors at peripheral vasodilation leads to a transient relieve the spasm and reduce the occlu-
a specific binding site (different from ben- drop of 10 to 30% in systemic blood pres- sion. Although also uncommon, venous
irritation and thrombosis secondary to
crystal formation is also possible with con-
centrations of barbiturates above 1%
O O O
H H H methohexital and 2.5% thiopental.
N N CH2CH2 N CH2CH=CH2 These medications are stored in pow-
O O O
der form and reconstituted in saline prior
to use as sodium salts. The alkalinity of the
N CH3CH2 N CHCH2CH2CH3 CHCH2CH2CH3 solutions prevents bacterial growth and
N
H H H
O O CH3 O CH3 ensures a longer refrigerated shelf life of
up to 2 weeks for thiopental and 6 weeks
Phenobarbital Pentobarbital Secobarbital
for methohexital.
Thiopental
Thiopental is an ultrashort-acting barbi-
O O O
turate that is commonly used at 3 to
H H H
N CH2CH=CH2 N CH2CH3 CH2CH=CH2
5 mg/kg IV to induce loss of conscious-
N
ness for general anesthesia prior to endo-
O S S tracheal intubation. It is associated with a
longer recovery than methohexital due to
N CHC=CCH2CH3 N CHCH2CH2CH3 CHCH2CH2CH3
N its decreased plasma clearance and is gen-
CH3 O CH3 O CH3 O
CH3 erally not used as a continuous infusion
to maintain anesthesia due to significant
Methohexital Thiopental Thiamylal storage in multiple drug compartments.
FIGURE 5-5 Chemical structure of barbiturates. A 2.5% solution of thiopental is less
Pharmacology of Outpatient Anesthesia Medications 91
normally be associated with such a drop in sist of a reaction to egg albumin. The N
O
blood pressure. Hypotension may there- original proprietary agent, Diprivan, uses
fore be very significant following bolus ethylenediaminetetraacetic acid as an CH3CH2OC
N
administration of propofol, particularly in antibacterial agent, whereas the generic
the elderly, medically compromised, and version contains a sulfite. Although this
CH3CH
hypovolemic patients. generic agent should not be used in
Propofol also leads to dose-dependent patients with known sulfite sensitivity, it
respiratory depression and can produce appears that allergic reactions and bron-
apnea at higher doses. It is not associated chospasm are very unlikely, although not
with histamine release and has bron- completely unheard of, in other patients
chodilatory properties. including asthmatics. Both drug suspen- FIGURE 5-7 Chemical structure of etomidate.
Recovery from anesthesia with propo- sions are pH neutral and can support bac-
fol has several unique characteristics. Com- terial growth; therefore, the observation Myoclonus is common in over 50% of
pared to other induction agents propofol is of sterile technique and discarding of an patients and may be partially prevented
associated with a more rapid awakening opened vial or filled syringe after 6 hours with pre-administration of a benzodi-
and recovery, with less residual CNS effects. are recommended. Cracked glass contain- azepine or opioid. Many patients experi-
Many patients also experience mild eupho- ers or discolored contents should be dis- ence pain on injection secondary to the
ria on awakening, which enhances reported carded, as sepsis is a possibility. propylene glycol. Etomidate has been asso-
satisfaction with the anesthesia postopera- ciated with adrenocortical suppression but
tively. Even at subhypnotic doses propofol Etomidate this is less profound when only a single
is associated with decreased postoperative Like midazolam, etomidate contains an induction dose is administered.
nausea and vomiting.9 All these features imidazole structure (Figure 5-7). It is
make propofol an attractive choice for out- water soluble but available in a 0.2% solu- Ketamine
patient procedures where decreased time to tion in propylene glycol. In the same way Ketamine is a phencyclidine derivative
discharge is desirable. as the other induction medications, etomi- (Figure 5-8) that induces a state of disso-
Even with an available generic formu- date interacts at the GABA receptor. ciative anesthesia. This is characterized as
lation the higher cost compared to barbi- Etomidate is used primarily as an a dissociation between the thalamocorti-
turates is still apparent. The increased cost induction agent for general anesthesia at cal and limbic systems, producing a
can overshadow the advantages of using 0.2 to 0.4 mg/kg IV. Its main advantage cataleptic state during which the patient
propofol infusions, especially if the surgi- over barbiturates and propofol is cardio- may appear awake but does not respond to
cal time is long (> 2 h), or if quick dis- vascular stability. Although systemic blood commands.11 The eyes may be open and
charge is not required. pressure can decrease by up to 15% with nystagmic. Ketamine does produce antero-
Several considerations should be etomidate, changes in heart rate are mini- grade amnesia, and unlike other induction
taken when using propofol. The solution mal. It also does not depress myocardial agents, it can produce intense analgesia.
can cause significant pain on injection, contractility. Etomidate is usually reserved Unlike other hypnotic agents keta-
especially in smaller vessels. This may be for patients with unstable cardiac disease mine does not interact with GABA recep-
attenuated with pre-administration of because it is more expensive than other tors. The exact mechanism of action is
opioids or 1% cardiac lidocaine. Unlike induction agents. unclear but ketamine is a nonselective
barbiturates, however, it does not cause Spontaneous respiration may be antagonist of supraspinal N-methyl-D-
vasospasm when inadvertently injected maintained. Respiratory depression is less aspartate receptors, which involve the exci-
into an artery. pronounced with etomidate compared to tatory neurotransmitter glutamate. Inhibi-
Anaphylaxis is rare but has been barbiturates, although apnea is still possi- tion of these receptors decreases neuronal
reported in patients with a history of ble with higher doses. signaling and is likely responsible for some
allergic reactions to other medications, Etomidate is metabolized by both analgesic effects. Ketamine may also inter-
especially neuromuscular blocking drugs. hepatic enzymes and plasma esterases. act with pain receptors in the spinal cord
A history of egg allergy does not necessar- This rapid clearance leads to awakening as well as opioid receptors, which may also
ily preclude the use of propofol, as the egg and recovery that is faster than with account for analgesia.12
protein contained in the suspension is thiopental but slower than with metho- Ketamine is highly lipid soluble and
lecithin, whereas most egg allergies con- hexital or propofol. redistributes quickly, which accounts for
Pharmacology of Outpatient Anesthesia Medications 93
ventilation (respiratory rate, tidal volume) Unlike intravenous medications these The exact mechanism of action of
will affect how quickly the concentration inhaled drugs are not administered in inhaled anesthetic agents at the CNS is still
of gas within the alveoli changes. doses of mg/kg. The equivalent of the controversial. Earlier theories have sug-
Each agent varies in its solubility in effective dose (ED50) of inhaled anesthetic gested that anesthetic molecules insert
blood and other tissues such as the brain agent is the minimum alveolar concentra- into and disrupt the lipid bilayer of neu-
and fat, and these characteristics determine tion (MAC). The MAC value of any given ronal cell membranes, thus interfering
the ease with which the gas crosses into the agent is the inhaled concentration (vol- with the cellular function. More current
different tissues. Of these, the blood:gas sol- ume %) of that agent required to prevent theories suggest that anesthetic molecules
ubility coefficient (Table 5-1) is the most movement in 50% of patients to a surgical may instead directly interact with cellular
useful in describing the onset and offset of stimulus. MAC values for different agents proteins, possibly with membrane ion
action of an anesthetic gas. The blood:gas are given in Table 5-1. MAC values provide channels or even specific receptors.
solubility coefficient expresses the extent to a useful dosage guide for anesthetic gases. Whereas N2O has mild or minimal
which the anesthetic gas molecules from In adults a level of 1.3 MAC will prevent sympathomimetic effects, all of the halo-
the alveolar spaces will dissolve into plasma movement in 95% of patients, whereas genated agents produce generalized car-
before the plasma solution becomes satu- 1.5 MAC (MAC-BAR) will block an diovascular depressant effects. The potent
rated. Conceptually, a lower coefficient adrenergic response in 95% of patients. volatile agents block peripheral vasocon-
means that the gas is less soluble in blood Below 0.3 MAC (MAC-Awake), patient striction thus lowering mean arterial
and will saturate the plasma compartment awareness is more likely. MAC values are blood pressure. At lower doses below
quickly. Additional overflow molecules additive; for example, if 0.5 MAC of N2O 1 MAC the baroreceptor sympathetic reflex
will then be free to move into other highly and 1.0 MAC of isoflurane are given is activated, which leads to a compensatory
vascular tissues such as the brain, where the simultaneously, the total MAC of anes- increase in heart rate. The exception is
CNS anesthetic effect takes place. A lower thetic agent administered to the patient is halothane, which in addition to directly
blood:gas coefficient therefore translates 1.5 MAC. It should be noted that MAC depressing myocardial contractility, blocks
into faster onset of action at the brain. Once values are general guidelines, and individ- the baroreceptor reflex. This resulting
the gas is discontinued and the alveolar and ual anesthetic requirements can be influ- decrease in cardiac output can lead to a
plasma concentrations decrease, the gas enced by a variety of factors such as age or precipitous drop in systemic blood pres-
molecules move down their concentration medical status. Neonates have the lowest sure with higher doses of halothane.
gradient from the tissues back into the MAC requirement, whereas children have Halothane also has the highest associa-
blood stream and then into the alveoli. the highest requirement. MAC require- tion with cardiac dysrhythmias. Halothane
Gases with lower blood:gas coefficients will ments subsequently decrease in the elderly induction commonly suppresses sinoatrial
likewise offload from the blood stream patient. MAC values are typically listed for node activity, leading to the development
into alveoli more quickly and can translate adult (30- to 35-year-old) patients at 1 atm of junctional rhythms. It also sensitizes the
into a faster offset of action. pressure and 20C. myocardium to catecholamine-related
Table 5-1 Different Properties of Nitrous Oxide and Potent Volatile Agents
General Properties of Inhalation Anesthetics Adults
Nitrous Oxide Isoflurane Enflurane Halothane Desflurane Sevoflurane
Molecular weight 44 184.5 184.5 197.4 168 218
Vapor pressure 20C Gas 238 172 243 664 160
MAC in O2 105 1.2 1.6 0.77 6.0 2.0
% recovered metabolites 0 0.2 2.4 20 0.02 3
Partition Coefficients at 37C
Blood:gas 0.47 1.46 1.91 2.5 0.42 0.69
Brain:blood 1.1 1.6 1.4 1.9 1.3 1.7
Muscle:blood 1.2 2.9 1.7 3.4 2 3.1
Fat:blood 2.3 45 36 51 27 48
MAC = minimum alveolar concentration.
Pharmacology of Outpatient Anesthesia Medications 95
ventricular dysrhythmias (Figure 5-9), par- halogenated agents produce a character- halogenated agent must be discontinued at
ticularly under conditions of hypercar- istic rapid and shallow spontaneous once and 100% O2 given, preferably
bia.15 Isoflurane, sevoflurane, and desflu- breathing pattern. A decrease in tidal vol- through a different circuit and machine.
rane are not significantly associated with ume is accompanied by an increase in the Dantrolene at 2.5 to 10 mg/kg IV must be
an increased incidence of epinephrine- frequency of breaths, but the faster respi- given as soon as possible. Cooling mea-
associated dysrhythmias. Epinephrine con- ratory rate does not fully compensate for sures including cooled IV fluids should be
tained in local anesthetic solutions should the smaller tidal volumes. Therefore, instituted. Emergency help must be
be limited to a maximum dose of 1 to minute ventilation is reduced and arterial obtained immediately and the patient will
2 g/kg during halothane anesthesia CO2 levels will be elevated in patients require medical management and moni-
whereas up to 3 to 4.5 g/kg is considered spontaneously breathing while under toring for at least 24 hours following the
safe with the other three agents. Under general anesthesia with these agents. The episode. Reemergence of the reaction is
halothane anesthesia, administration of 1.0 halogenated agents also cause a dose- common, requiring re-administration of
to 1.5 mg/kg cardiac lidocaine IV immedi- dependent decrease in airway resistance dantrolene, and acute renal failure is the
ately prior to intubation reduces the inci- and produce bronchodilation. Hypoxic most common morbidity secondary to
dence of ventricular dysrhythmias during pulmonary vasoconstriction is attenuated myoglobinemia. A mortality rate of 10% is
this stimulating period when endogenous at 0.1 MAC for all volatile agents. associated with an acute MH episode, even
epinephrine release may occur. Hypoxia Although hepatic blood flow decreases with immediate proper management.
and hypercarbia also lower the threshold with these agents, hepatic damage, if any,
for dysrhythmias and should be especially resulting from hypoxia is usually subclini- Nitrous Oxide
avoided with halothane anesthesia. Treat- cal and transient. Hepatotoxicity is more of N2O is commonly administered in dental
ment of the presenting dysrhythmia a concern with halothane administration. offices for anxiolysis and mild sedation. It
should be managed as required, including Renal blood flow and urine output are is a colorless and odorless gas, available in
hyperventilation, deepening of anesthetic reduced secondary to the decreased mean blue cylinders. In the dental setting it is
level and, if indicated, discontinuation of arterial pressure. The release of fluoride commonly administered with a nasal hood
halothane with administration of an alter- from the halogenated gases does not and appropriate scavenger system. Con-
native anesthetic agent. appear to cause clinically significant dam- centration ratios of N2O:O2 range up to
At usual doses N2O does not appre- age to renal tissues. With sevoflurane, fresh 70:30 on most N2O and anesthesia
ciably affect respiration. However, the gas flows should be at least 2 L/min to min- machines. High levels of N2O:O2 alone can
imize compound A accumulation in the produce sedation and significant analge-
CO2 absorber which can lead to very rare sia. Unexpected respiratory depression or
Patients Exhibiting Ventricular Extrasystoles (%)
100
hepatic or renal damage. airway obstruction can occur when N2O is
Halothane
(saline) Malignant hyperthermia (MH) is added to other sedative agents.
80
Halothane another rare but very dangerous reaction N2O in O2 is likely the most commonly
(lidocaine) triggered by the halogenated agents as well used sedative agent in dental offices and
60 Isoflurane as SCh. N2O, nondepolarizing neuromus- enjoys the unique advantage of not requir-
cular blockers, opioids, benzodiazepines, ing an escort after completion of the proce-
40 and other intravenous anesthetic agents dure provided adequate recovery time has
Enflurane do not trigger MH. Exposure to these elapsed. The drug can be titrated, usually
20 medications causes an abnormal receptor starting at 20% N2O and gradually increas-
in skeletal muscle cells to release excessive ing to 50% as needed. Doses above that
intracellular calcium, leading to uncon- level are associated with increased nausea
0
1 2 3 4 5 7 10 trolled muscle contractions. As a result and dysphoria, although the brief applica-
Epinephrine per Body Weight (g/kg) CO2 production increases quickly and tion of doses higher than 50% is useful dur-
FIGURE 5-9 Halothane sensitizes the myocardi- exhaled CO2 rises sharply. Initial signs ing local anesthetic administration and
um to dysrhythmias following administration of include tachycardia and tachypnea, along other short stimulating surgical episodes.
epinephrine in saline. Addition of 0.5% lido- with muscle stiffness. Metabolic acidosis At the conclusion of N2O sedation, 3 to
caine to the epinephrine solution decreases the
incidence of dysrhythmias, but the incidence is
and hyperkalemia develop next and car- 5 minutes of 100% O2 is administered to
still higher than during isoflurane use. Adapted diac arrest is a possibility. Increasing body prevent diffusion hypoxia; if room air O2 is
from Johnston RR et al.15 temperature is a relatively late sign. The given instead, the rapidly exiting N2O can
96 Part 1: Principles of Medicine, Surgery, and Anesthesia
dilute the O2 concentration in the alveoli to use and should be alert to potential misuse be slower than with other agents with
hypoxic levels during recovery. by other providers of these drugs. lower solubility coefficients.
With a low blood:gas solubility coeffi- Halothane is the oldest and most inex-
cient of 0.47, N2O has a very quick onset Potent Inhalation Agents pensive of currently available potent gases
and recovery. While N2O lacks the potency The halogenated inhalation agents com- but presents with the most deleterious side
of the halogenated agents at a MAC value monly in use today in the United States effects. As noted above, halothane is asso-
of 105, it also lacks the respiratory and car- include halothane, isoflurane, sevoflurane, ciated with significant cardiovascular
diovascular side effects. During general and desflurane. As seen in Figure 5-10, all changes and dysrhythmias. These should
anesthesia it is often administered to an are derivatives of ether except for be monitored closely during induction
intubated patient in combination with halothane. Unlike the original anesthetic and epinephrine administration, such as
other medications such as halogenated gas, diethyl ether, these agents are halo- with local anesthesia, when dysrythmias
gases and opioids. Using this combination genated and nonflammable. The newer are more commonly encountered. Unlike
can reduce the dose required of each drug halogenated agents, sevoflurane and desflu- the other agents, at least 15% of the
if given singly and will lessen the incidence rane, are unique in that all of the side chain halothane molecules are metabolized by
of potential side effects. N2O is also inex- halogen atoms are fluorine. The gases are the liver, and hepatotoxicity is more signif-
pensive and can reduce the total cost of stored and released by gas-specific vaporiz- icant with halothane, especially after
administered drugs. ers that control the concentration (volume repeated and prolonged administration.
There are a few contraindications for %) allowed into the anesthesia circuits and Halothane hepatitis is very rare but can
the use of N2O. It can enter closed spaces into the patient. They must also be scav- result in hepatic necrosis and death. Of all
faster than nitrogen can exit, leading to enged effectively so that room air levels do the halogenated agents it also appears to
distention of the closed space.13 In oral not affect health care personnel. be the most potent trigger for MH.
surgical practice the implication of this
property is to avoid N2O use in patients Halothane Halothane has a sweet non- Isoflurane Isoflurane is more pungent
with current otitis media and sinus infec- pungent odor that does not irritate the than halothane and is not a good choice
tions and with emphysema (blebs). Other airway mucosa to the extent of isoflurane for inhalation induction. It has an inter-
contraindications of N2O use include cur- and desflurane, and is therefore useful mediate potency (MAC 1.2) and blood:gas
rent respiratory disease and a history of for inhalation induction of general anes- partition coefficient (1.46). This agent is a
severe postoperative nausea. thesia. Halothane is very potent, with a common choice for maintenance of anes-
Several precautions should be exer- MAC value at 0.75 but a relatively high thesia, as recovery time is in the interme-
cised when using N2O. It has been impli- blood:gas solubility of 2.54. Therefore, diate range and shorter than halothane.
cated in producing sexual hallucinations halothane will have a slow onset of Isoflurane is also much more cost-effective
in some patients, predominantly young inhalation induction unless high doses for longer periods of anesthesia compared
women. An additional person such as an are used. Recovery from anesthesia will to two other popular agents, sevoflurane
assistant should always be present when
this gas is being administered. Patients
F Br CI F F
with preexisting psychiatric disorders may
experience exacerbated symptoms while F C C H H C C O C H
N N O
undergoing N2O sedation. Because low F CI F F F
levels of N2O in room air have been
demonstrated to increase spontaneous Nitrous oxide Halothane Enflurane
and desflurane; its cost per bottle is signif- thetized airways that it may precipitate with an analgesic duration of approximate-
icantly lower and the total amount used is coughing and laryngospasm. It is to be ly 6 hours. Ketorolac 30 mg IM is the anal-
less due to the lower MAC. avoided for inhalation inductions. During gesic equivalent of 10 mg of parenteral mor-
Isoflurane may be associated with an initial administration of desflurane, tachy- phine and does not produce opioid-related
increase in coronary steal phenomena, lead- cardia can also occur until deeper levels of respiratory depression, nausea, or sedation.3
ing some practitioners to avoid using this anesthesia are realized. NSAID use does have several cautions, how-
anesthetic in patients with significant ather- Desflurane is delivered from specially ever. Because of possible NSAID-induced
osclerotic cardiac disease. Otherwise, con- heated vaporizers as its vapor pressure is inhibition of platelet aggregation, the drug
traindications for using isoflurane are few. close to atmospheric pressure. It also pos- is normally administered after bleeding has
sesses only fluorine substitutions which, been controlled, and should be avoided for
Sevoflurane Sevoflurane is nonpungent like sevoflurane, confer a low blood:gas surgeries associated with postoperative
and a common choice for inhalation solubility. In fact, desflurane has the lowest hemorrhage. Patients with bleeding-related
induction. It has an intermediate potency blood:gas solubility coefficient (0.43) of disorders (gastrointestinal ulcers, inflam-
(MAC 2.0), and at higher doses, induction any inhalation agent, lower than even N2O. matory bowel disease, blood dyscrasias, liver
will be rapid. Recovery from sevoflurane This confers a quick onset and offset, and failure, etc) should not be given ketorolac.
following a short anesthetic (< 1 h) is more recovery can be very rapid following a Life-threatening bronchospasm can also
rapid than either isoflurane or halothane short anesthetic with desflurane. Like occur with NSAIDs, particularly in those
due to the lower blood:gas solubility coef- sevoflurane, desflurane is more expensive with a history of asthma or aspirin allergy.
ficient (0.69). For longer procedures, how- than the other gases, and considering its Because NSAIDs block prostaglandin pro-
ever, the advantage of faster recovery is off- higher MAC value (6.0), much more of the duction, patients who depend on renal
set by the much greater cost of sevoflurane gas will be used per minute, resulting in a prostaglandins for adequate renal function
compared to isoflurane. The recovery time significantly higher cost if desflurane is should be administered ketorolac cautious-
is also not significantly improved com- used for a longer procedure. ly. Patients with congestive heart failure,
pared to isoflurane, as both gases similarly hypovolemia, or cirrhosis, and those taking
redistribute into fat during longer anesthe- Perioperative Analgesic angiotensin-converting enzyme inhibitors
sia periods, and offset of these gases from Medications or angiotensin II receptor antagonists, may
fat storage is not different. Opioid medications, which have been dis- require renal perfusion to maintain ade-
All of the side chain halogen atoms in cussed previously, are the classic intraoper- quate renal perfusion, and NSAID adminis-
sevoflurane are fluorine, contributing to its ative and postoperative analgesic medica- tration can result in acute fluid retention.
low blood:gas solubility and recovery pro- tions. In the operating room opioids are This drug is also associated with a higher
file. Unlike earlier inhaled agents the small often given concurrently with other anes- cost than other analgesic medications.
amount of inorganic fluorine released dur- thetic agents in a balanced technique to The most commonly used agents for
ing sevoflurane use has not been associated supplement intraoperative analgesia. An postoperative pain control in oral surgery
with renal damage.16 Sevoflurane and CO2 opioid with a long duration of action like are likely the local anesthetics. Long-acting
absorbers (soda lime, barium lime) pro- morphine or hydromorphone is common- local anesthetics, like bupivacaine and etido-
duce a degradation product called com- ly administered by the practitioner prior to caine, provide several hours of analgesia for
pound A, an olefin, which is nephrotoxic in the end of the procedure, in anticipation of inferior alveolar nerve block anesthesia as
rats but has not been associated with signif- postoperative pain. During the initial phase well as soft tissue anesthesia in the maxilla.
icant permanent renal damage in humans. of postoperative care these medications Lidocaine with epinephrine given intraoper-
Regardless, sevoflurane is not usually the may be given either by the nursing staff or atively can also provide adequate analgesic
agent of choice for patients with renal dis- patient, administered via computer-aided duration until postoperative oral NSAIDs or
ease. Even in healthy patients many practi- patient-controlled analgesia pumps. opioid/acetaminophen combinations can
tioners recommend limiting sevoflurane Another option is ketorolac trometh- achieve reliable plasma levels for generally
use to less than 2 hours and maintaining a amine, currently the only available intra- predictable postoperative pain control.
total gas flow of at least 2 L/min, to reduce venous NSAID medication in the United
the production of compound A. States. This agent can provide effective anal- Neuromuscular-Blocking
gesia for many dentoalveolar procedures at Medications
Desflurane Desflurane is extremely pun- IV and IM doses of 30 to 60 mg or 0.5 to Skeletal muscle relaxation is often required
gent and can be so irritating to nonanes- 1.0 mg/kg. Onset time is 10 to 15 minutes, during surgery when patient movement
98 Part 1: Principles of Medicine, Surgery, and Anesthesia
interferes with procedures involving anes- emergent tracheal intubation is required to Pancuronium has the longest duration,
thesia or surgery. For example, paralysis treat laryngospasm. It is no longer used to whereas mivacurium has the shortest.
may be required to facilitate tracheal intu- maintain intraoperative paralysis. With any of these agents paralysis will last
bation, relax abdominal wall muscles for SCh has several notable side effects. longer than that produced with SCh and
access during gastrointestinal surgery, or Tachycardia can result upon initial admin- controlled ventilation must be provided.
completely inhibit patient movement dur- istration but sinus bradycardia may devel- Return of skeletal muscle function is usu-
ing ocular surgery. Whereas relaxation can op, especially with repeated administra- ally monitored by a nerve stimulator, and
be achieved with deeper anesthetic levels or tion. Widespread muscle contractions can the degree of paralysis is gauged by the
appropriate peripheral neural blockade, result in postoperative myalgia, which can number of twitches produced by stimula-
neuromuscular-blocking agents are com- at times be prevented by prior administra- tion of specific muscles, such as adductor
monly used to provide the necessary tion of a small dose of a nondepolarizing pollicis and orbicularis orbis. Paralysis
amount and duration of relaxation. muscle blocker. The contractions may may need to be reversed by an anti-
The potential of these drugs during increase intraocular and intragastric pres- cholinesterase to ensure adequate recovery
anesthesia and surgery was not recognized sure and can also cause a transient ele- of airway and respiratory muscle function
until the middle of the twentieth century. vation in plasma potassium levels by prior to extubation.
Many of the current neuromuscular- 0.5 mEq/L. Plasma potassium levels may Adverse effects may also affect the
blocking agents used are derivatives of rise even higher than 0.5 mEq/L in patients choice of neuromuscular-blocking agent
curare, one of the oldest paralyzing with certain neuromuscular disorders, and can be categorized by structure. The
agents, used by ancient hunters to para- stroke, spinal cord injury, or significant benzylisoquinoline compounds may trig-
lyze prey. All are competitive antagonists burn injury. SCh is therefore contraindi- ger histamine release thus causing flush-
that bind to the nicotinic ACh receptors cated in these patients, along with patients ing and peripheral vasodilation. Amino-
located at the postsynaptic membrane of in renal failure. SCh is a trigger for MH (see steroid structures may block vagal
the neuromuscular junction of skeletal section on malignant hyperthermia). Its activity, causing a noticeable increase in
muscle, thus interfering with proper con- use should also be avoided in patients with heart rate. Histamine release may be
traction of the muscle. pseudocholinesterase abnormalities, as the undesirable in asthmatic patients.
Neuromuscular-blocking agents can recovery from this drug will be prolonged. Increased heart rate can be problematic in
be classified as either depolarizing or non- patients with cardiovascular disease.
depolarizing, and within the latter group Nondepolarizing Agents Most of the nondepolarizing agents
can be divided based on structure, speed of All of the remaining neuromuscular are metabolized by the liver and excreted
onset, duration of action, and metabolism. blocking agents are nondepolarizing and by the kidney. Three of these are less
do not initiate muscle contraction upon dependent on hepatic or renal function.
Succinylcholine administration. The chemical structures of Mivacurium, like SCh, is metabolized by
SCh, two joined ACh molecules, was intro- these drugs fall into two classes: benzyliso- pseudocholinesterase and is affected by its
duced for surgical muscle relaxation in the quinolines and aminosteroids.13 Charac- deficiency. Atracurium and cisatracurium
1950s and is the only depolarizing agent teristics of currently available nondepolar- are removed by Hofmann elimination,
used today. Once SCh binds to the ACh izing muscle relaxants are outlined in whereby the drug spontaneously degrades
receptor, the postsynaptic membrane Table 5-2. at body pH and temperature.
depolarizes, an action potential is generat- Although it is not as rapid in onset as
ed, and the muscle contracts. Subsequent SCh, rocuronium has the fastest onset of Anticholinesterases
muscle contractions are delayed until SCh the nondepolarizing agents, with paralysis Anticholinesterases, or anti-acetyl-
dissociates from the receptor and is occurring at approximately 1 minute with cholinesterases, block the action of acetyl-
metabolized by pseudocholinesterase. higher doses. It is often chosen for facili- cholinesterase, the enzyme that breaks
SCh has the fastest onset (3060 s) and tating intubation when SCh cannot be down ACh. In anesthesia, anticholinesteras-
shortest duration (510 min) of the neuro- used, particularly in an emergent situa- es such as neostigmine, edrophonium, and
muscular-blocking agents and is typically tion. Onset time for most other agents is pyridostigmine are used to reverse the
used to treat laryngospasm not relieved with approximately 3 minutes. effects of nondepolarizing muscle relaxants
positive pressure (20 to 40 mg, or 0.1 to Drug selection for maintenance of once partial muscle function has returned
0.2 mg/kg). It is also given to facilitate tra- muscle relaxation is often based upon the and paralysis is no longer necessary, usually
cheal intubation (1 to 1.5 mg/kg IV) or when anticipated need for continued paralysis. at the conclusion of surgery. By increasing
Pharmacology of Outpatient Anesthesia Medications 99
the amount of ACh available at the neuro- and anticholinergic medications are paired gic medications specifically block mus-
muscular junction, more of the neurotrans- according to similar time of onset and carinic receptors but do not affect nico-
mitter can bind to nicotinic ACh receptors, duration. Glycopyrrolate is generally tinic receptors.
overcoming the competitive inhibition of administered with neostigmine, whereas Clinical uses in anesthesia of atropine,
the neuromuscular blocker and aiding in atropine is more commonly used with glycopyrrolate, and scopolamine are defined
the return of muscle function. edrophonium. Doses of these agents are by their varied effect at the muscarinic
Increased ACh will also bind to mus- listed in Table 5-3. receptor sites of different organs (Table 5-4).
carinic ACh receptors at the heart, lungs, Atropine has the fastest onset of increasing
salivary glands, and smooth muscle. This Anticholinergic Medications heart rate by blocking vagal nerve receptors
can lead to undesirable side effects includ- ACh is a neurotransmitter that binds to at the heart and is used to treat emergent
ing bradycardia, bronchospasm, abdomi- two types of receptors. Nicotinic receptors bradycardia. Both atropine and glycopyrro-
nal cramping, and excessive salivation.17 To are located at autonomic ganglia and the late are used to counteract bradycardia sec-
prevent these effects anticholinergic med- neuromuscular junctions of skeletal mus- ondary to anticholinesterase use during
ications such as atropine or glycopyrrolate, cle. Muscarinic receptors are found at reversal of muscle relaxation. All three anti-
which block muscarinic but not nicotinic postganglionic sites of the parasympathet- cholinergic medications decrease salivary
ACh receptors, are given together with ic nervous system at the heart, salivary secretions. Glycopyrrolate is a quaternary
anticholinesterases. The anticholinesterase glands, and smooth muscle. Anticholiner- ammonium compound, which cannot cross
the blood-brain barrier. Atropine and
Table 5-3 Reversal Doses of Acetylcholinesterase and Anticholinergic Medications
scopolamine, both tertiary amines, can
cross the blood-brain barrier and cause
Cholinesterase Dose Anticholinergic Dose sedation. Scopolamine is also used for man-
Cholinesterase (mg/kg) Anticholinergic (mg/mg of cholinesterase)
agement of nausea and prevention of
Neostigmine 0.40.8 Glycopyrrolate 0.2 motion sickness.
Edrophonium 0.51.0 Atropine 0.014 Central anticholinergic syndrome is a
The two most commonly used acetylcholinesterase medications are listed. Acetylcholinesterase and anticholinergic concern with higher doses of centrally
medications are given in recommended combinations according to similar onset time and duration of action of the
two types of drugs. The maximum dose of cholinesterase is not always necessary, but should be given based on the acting anticholinergic medications, mani-
degree of recovery from muscle relaxation. The dose of the anticholinergic drug is determined by the amount of festing as restlessness and confusion. It
cholinesterase given.
may be reversed by physostigmine, an
100 Part 1: Principles of Medicine, Surgery, and Anesthesia
Table 5-4 Varied Effects of Anticholinergic Medications although the antihistamines promethazine
and diphenhydramine also possess anti-
Anticholinergic Medication Characteristics
cholinergic effects.
Tachycardia Bronchodilation Sedation Antisialagogue Recently, dexamethasone has been
Atropine shown to decrease the incidence of PONV
Glycopyrrolate 0 when given shortly after induction of gen-
Scopolamine eral anesthesia. A minimum adult dose of
= mild effect; = moderate effect; = strong effect. 8 mg IV appears to be required for this
effect to be realized.19
Selection of anesthetic agents may
anticholinesterase that can cross the are associated with adverse effects such as help prevent PONV. Propofol appears to
blood-brain barrier. sedation and extrapyramidal reactions. have antiemetic effects as well, particu-
5-HT3 antagonists including ondansetron larly when administered for maintenance
Antiemetic Medications and dolasetron are expensive, but produce of anesthesia. Additional antiemetic
Postoperative nausea and vomiting less sedation and other adverse effects than treatment may be unnecessary following
(PONV) is one of the most common the dopamine antagonists. Antihistamines the use of propofol infusions, even in
complaints following surgery. Certain such as promethazine (which also possess- patients with a previous history of
groups of patients (female, obese, previ- es a phenothiazine structure) and diphen- PONV. Avoidance of known nausea trig-
ous history of nausea and vomiting) hydramine can cause significant sedation. gering agents such as N2O, ketamine, and
appear to be more susceptible. Certain Anticholinergic medications (eg, scopo- longer-acting opioid medications may
surgeries (ear, ocular, tonsillar, gyneco- lamine) are rarely used for PONV, also reduce PONV.
logic) are likewise associated with
increased PONV. Nausea and vomiting
after oral surgery is not uncommon. Antagonist
Swallowed blood and secretions stimu-
Ondansetron Promethazine Atropine Droperidol
late the gag reflex and are potent gastric
irritants. Drugs used during sedation and Agonist
anesthesia, such as N2O, opioids, and ket-
5-HT3 Histamine Muscarinic ACh Dopamine (D2)
amine, may trigger nausea postoperative-
ly. Other nonchemical triggers of nau- Nitrogen mustard
Receptor
sea include smell, gastric distention, site Cisplatin
motion, and even stress. Chemoreceptor Digoxin glycoside
Chemical triggers in the bloodstream Area trigger
postrema zone Opioid, analgesics
come into contact with an area in the (CTZ)
medulla lacking an intact blood-brain bar- Vestibular portion
rier called the chemoreceptor trigger zone of nerve VIII
(CTZ).18 The CTZ (Figure 5-11) contains
receptors for serotonin, histamine, mus-
carinic ACh, and dopamine. Opioids, tox- Parvicellular Emetic
reticular center Mediastinum
ins, and chemotherapy agents, as well as formation N2O
input from the middle ear, also stimulate
this area. Stimulation of the CTZ will acti-
vate vomiting.
Va
gu
References 7. Cherny NI. Opioid analgesics: comparative 14. Eger EI. New inhaled anesthetics. Anesthesiol-
features and prescribing guidelines. Drugs ogy 1994;80:90622.
1. Katzung BG. Basic and clinical pharmacology. 1996;51:71337. 15. Johnston RR, Eger EI, Wilson C. A comparative
8th Ed. New York: McGraw-Hill; 2000. 8. Hudson RJ, Stanski DR, Burch PG. Pharmacoki- interaction of epinephrine with enflurane,
2. Hughes MA, Glass PSA, Jacobs JR. Context- netics of methohexital and thiopental in sur- isoflurane, halothane in man. Anesth Analg
sensitive half-time in multicompartment gical patients. Anesthesiology 1983;59:2159. 1976;55:70912.
pharmacokinetic models for intravenous anes- 9. Borgeat A, Wilder-Smith OHG, Suter PM. The 16. Eger EI, Koblin DD, Bowland T, et al. Nephro-
thetic drugs. Anesthesiology 1992;76:33441. nonhypnotic therapeutic applications of toxicity of sevoflurane versus desflurane
3. Stoelting RK. Pharmacology and physiology in propofol. Anesthesiology 1994;80:64256.
anesthetic practice. 3rd ed. Philadephia anesthesia in volunteers. Anesth Analg
10. Smith I, White PF, Nathanson M, Gouldson R.
(PA): Lippincott; 1999. 1997;84:1608.
Propofol: an update on its clinical use.
4. Reves JG, Fragen RJ, Vinik R, Greenblatt DJ. 17. Morgan GE, Mikhail MS, Murray MJ. Clinical
Anesthesiology 1994;81:100543.
Midazolam: pharmacology and uses. Anes- anesthesiology. 3rd ed. New York: McGraw-
11. Reich DL, Silvay G. Ketamine: an update on the
thesiology 1985; 62:31024. first twenty-five years of clinical experience. Hill; 2002.
5. McMillan CO, Spahr-Schopfer LA, Sikich N, et Can J Anaesth 1989;36:18697. 18. Watcha MF, White PF. Postoperative nausea
al. Premedication of children with oral 12. Hirota K, Lambert DG. Ketamine: its mecha- and vomiting. Anesthesiology 1992;77:
midazolam. Can J Anaesth 1992;39:54550. nism(s) of action and unusual clinical uses. 16284.
6. Brogden RN, Goa KL. Flumazenil: a reappraisal Br J Anaesth 1996; 77:4414. 19. Henzi I, Walder B, Tramer MR. Dexamethasone
of its pharmacological properties and thera- 13. Faust RJ, Cucchiara RF, Wass CT . Anesthesiol- for the prevention of postoperative nausea
peutic efficacy as a benzodiazepine antago- ogy review. 3rd Ed. New York: Churchill and vomiting: a quantitative systematic
nist. Drugs 1991;42:106189. Livingstone; 2002. review. Anesth Analg 2002;90:18694.
CHAPTER 6
Pediatric Sedation
Jeffrey D. Bennett, DMD
Jeffrey B. Dembo, DDS, MS
Kevin J. Butterfield, DDS, MD
The anesthetic management of the pedi- ity to the pharynx, thereby rendering the exchange. The pediatric trachea is also
atric patient presents the oral and max- patient susceptible to airway obstruction more compliant. The increased complian-
illofacial surgeon with unique and differ- and irritation. These factors can result in cy makes the airway susceptible to col-
ent challenges from those with an adult a significant degree of hypoxia.1,2 Such lapse secondary to increased negative
patient. The surgeon must be aware of effects can be exacerbated by a decreased inspiratory pressure. This is significant
anatomic and physiologic differences, minute ventilation and airway tone sec- because of the potential for airway
different pharmacokinetics and pharma- ondary to sedative medication used dur- obstruction in the nonintubated patient.
codynamics of most medications, and ing the anesthetic administration. When patients become obstructed they
the unique psychological development of There are anatomic differences attempt to overcome the obstruction by
the child and his or her corresponding unique to the pediatric upper airway that increasing the respiratory effort. In the
ability to cope with the stress of the sur- increase the risk of airway obstruction. In child an attempt to compensate for upper
gical experience. As the child matures, the young child the tongue is large rela- airway obstruction with increasing respi-
changes in these parameters occur; there- tive to the size of the oral cavity. It is posi- ratory effort can cause collapse of the tra-
fore, an understanding of the growth and tioned higher in the oral cavity impinging chea and bronchial passages, which may
maturation of the pediatric patient dic- on the soft palate secondary to the ros- paradoxically worsen the obstruction. The
tates the selection of the anesthetic tech- trally positioned larynx. Lymphoid frightened child may already be at risk for
nique and medications used in the hypertrophy with enlargement of the airway collapse since crying tends to
patients management. tonsils and adenoids between the ages of increase negative inspiratory pressure.
4 and 10 years can also contribute to Anatomic differences between pedi-
Anatomic and Physiologic upper airway obstruction. atric and adult patients diminish the effica-
Considerations The lower airway, consisting of the cy of ventilation. In the child each rib is
trachea, bronchi, and alveoli, also differs angled more horizontally relative to the
Respiratory System between pediatric and adult patients. The vertebral column; adults ribs have a caudal
Much of the uniqueness regarding anes- trachea and bronchi are conduits in which slant.3 Additionally, the accessory muscles
thetic management of children in oral gas is transported from the environment are less developed in the child. This results
and maxillofacial surgery is focused on to the alveoli. The pediatric airway diam- in a less effective thoracic expansion and a
anesthesia delivered during intraoral pro- eter is relatively smaller than that of the greater dependence on diaphragmatic
cedures in which the patient is not intu- adult. Since resistance is inversely propor- breathing. Upper airway obstruction in the
bated. Intraoral surgery in the anes- tional to the radius of the lumen to the young child occurring with sedation can
thetized nonintubated patient presents a fourth power, there is an increased resis- result in a paradoxic chest wall movement,
formidable and unique challenge. The tance. Narrowing of the airway secondary characterized by an inward movement of
foremost concern is that the surgical to secretions or edema will have a more the chest opposing the expansile down-
sitethe oral cavityis in close proxim- profound adverse effect on airway ward movement of the diaphragm. Greater
104 Part 1: Principles of Medicine, Surgery, and Anesthesia
energy is required, which can lead to goscopy and visualization of the glottic The trachea is also shorter in the pedi-
fatigue and subsequent hypoxia. opening more difficult in the pediatric atric patient. It is not uncommon that
Exchange of gas takes place within the patient. Adenoidal hypertrophy can also head position is frequently changed dur-
alveoli. Closing volume, which is the vol- result in hemorrhage or obstruction of an ing an oral and maxillofacial surgery pro-
ume of the lung at which dependent air- endotracheal tube, particularly during cedure; this can cause the tube to become
ways begin to close, is greater in the pedi- nasal intubation. displaced out of the trachea or pass further
atric patient. The increased closing volume The narrowest part of the trachea in into the trachea and impinge on the
in the pediatric patient results in increased the pediatric patient is the cricoid carti- mucosa overlying the cricoid cartilage.
dead space ventilation. Thus, more energy lage, in contrast with the glottis in the Change in head position, use of an endo-
must be expended to adequately ventilate adult. It is not until the age of approxi- tracheal tube that is too large, and patient
the alveoli. The alveoli are also both small- mately 10 to 12 years that the pediatric age between 1 and 4 years are three factors
er and fewer in number in the pediatric airway matures to that of the adult. In contributing to the reported 1% incidence
patient than in the adult. The alveoli the pediatric patient care must be taken of postintubation croup.16
increase in number until around 8 years of when placing and securing an endotra- Certain congenital anomalies are well
life and continue to increase in size until cheal tube to prevent impingement of the recognized for their altered anatomy. Some
full adult growth is reached. The number tip of the tube on the narrow subglottic of the most commonly encountered disor-
of alveoli may increase more than 10-fold region. Such impingement of the endo- ders are Crouzon syndrome (hypoplastic
from infancy to adulthood, with a resul- tracheal tube on the tracheal mucosa can maxillaobligate mouth breather), Gold-
tant increase in surface area that can be as result in edema and tracheal narrowing enhars syndrome (micrognathia, vertebral
great as 60-fold.46 causing increased airway resistance post anomalies), hemifacial microsomia (hypo-
Functional residual capacity (FRC) is extubation. Uncuffed tubes are used by plasia of mandibular condyle and ramus),
the volume of gas in the lung after a nor- most anesthesiologists for patients less Mbius sequence (micrognathia and limit-
mal expiration and is related to the sur- than 8 to 10 years of age.13 The argu- ed mandibular movement), Pierre Robins
face area of the lung. The pediatric ments against cuffed tubes are that they anomalad (micrognathia, glossoptosis),
patient has a diminished FRC expressed increase the risk of airway mucosal and Treacher Collins syndrome (mandibu-
on a basis of weight.7 This is illustrated by injury and that an appropriately sized lar hypoplasia). These craniofacial anom-
a minute ventilation to FRC ratio of uncuffed endotracheal tube can provide alies may complicate ventilation and/or
approximately 5:1 in a 3 year old and 8:1 an adequate seal at the level of the cricoid endotracheal intubation. For example,
in a 5 year old compared to approximate- cartilage. Formulas exist for calculating maxillary or mandibular hypoplasia may
ly 2:1 in an adult.7 FRC decreases further the appropriate size of endotracheal tube increase the difficulty in achieving a satis-
in the sedated patient. The FRC provides ([age (yr) +16]/4) and the appropriate factory mask fit. Anatomic differences in
a pulmonary oxygen reserve.8 Because length of endotracheal insertion ([age the nasal cavity may impair nasal ventila-
children have a higher metabolic demand (yr)/2 + 12]).14 However, 28% of the tion. This can potentiate respiratory
and greater oxygen consumption, the time the initially selected uncuffed endo- obstruction during an intraoral procedure
decreased FRC results in a more rapid tracheal tube does not provide an ade- in which a pharyngeal curtain is placed and
desaturation of hemoglobin during peri- quate seal, and re-intubation may be nec- the patient is dependent on nasal respira-
ods of respiratory depression.911 One essary.15 An additional benefit in using tion. The tongue may be displaced posteri-
model comparing the child to the adult the uncuffed tube is that a larger tube orly by either maxillary or mandibular
concluded that an apneic period of 41 may be inserted, which causes less airway hypoplasia, increasing the potential for
seconds in the pediatric patient would resistance and less breathing work. The obstruction.
result in an arterial oxyhemoglobin satu- argument for a cuffed endotracheal tube
ration of 85%, compared with an apneic is that the fit can be adjusted and it can Cardiovascular System
period of 84 seconds in the adult.12 protect against aspiration. Ensuring that The pediatric cardiovascular system has
the cuff pressure does not exceed 25 cm some significant differences compared
Endotracheal Intubation There are also H2O, which is believed to be the mucosal with that of the adult. Each relevant phys-
anatomic differences between the pedi- capillary pressure, can minimize injury iologic difference is outlined below.
atric and adult airways that influence intu- to the mucosa. When using an uncuffed
bation. A large tongue, rostral larynx, and tube, an air leak of 25 cm H2O should Cardiac Output Perfusion is dependent
long and narrow epiglottis make laryn- be allowed. on cardiac output and peripheral resis-
Pediatric Sedation 105
tance. Cardiac output is dependent on The pediatric patient has increased comprehend the need for or benefits of the
heart rate and stroke volume. The pedi- parasympathetic innervation, result- surgical procedure. Children > 6 years old
atric heart has less compliance than that of ing in a more rapid onset of bradycar- or those who have better-developed social
the adult, with minimal ability to alter dia (which may be influenced indi- skills (eg, acquired from daycare programs)
stroke volume. Thus, pediatric cardiac rectly by respiratory impairment or may be more capable of understanding the
output is largely dependent on heart rate directly by the sedative drugs). situation and expressing their concerns.18
(Table 6-1). There is less cardiovascular compen- If possible, an older child should be
satory ability, which results in hemo- allowed to participate in determining the
Neural Innervation The myocardium is dynamic instability. anesthetic treatment and should be
innervated by both the sympathetic and exposed to the various induction tech-
parasympathetic nervous systems, with the Preoperative Evaluation of the niques: intravenous, intramuscular, oral,
parasympathetic nervous system having a Patient and inhalation.
greater influence in the pediatric patient Adolescents may be more capable of
The purpose of a preoperative evaluation
than in the adult. In one retrospective comprehending the planned surgery and
is to compile information about the
study the incidence of bradycardia during anesthetic management. However, they
patient to establish the most optimal treat-
anesthesia was reported to be age related. are not adults. They have the ability to
ment plan. One needs to assess the psy-
The incidence of bradycardia was approxi- demonstrate myriad behaviors and rapid
chological and behavioral development of
mately threefold less in the 3- to 4-year-old mood changes. A paradoxic reaction to
the patient, obtain a medical history that
compared with the 2- to 3-year-old.17 sedation in which the adolescent appears
identifies both acute and chronic disease
to become agitated after the administra-
processes, and determine the patients
Blood Pressure Blood pressure is the tion of anxiolytic medication may neces-
preparation for surgery (eg, cardiovascular
product of cardiac output and peripheral sitate a deeper level of anesthesia than
status), while performing an appropriate
vascular resistance. The pediatric patient what may have originally been planned.
physical examination dictated largely by
has less ability to alter peripheral vascular Another concern in the adolescent
the patients medical history.
resistance; therefore, blood pressure is large- patient is the use of illicit substances. This
ly dependent on cardiac output. A brady- Psychological Assessment has reached epidemic proportions with
cardia with resultant decreased cardiac out- an estimated 10.8% of 12- to 17-year-old
The perioperative period can be very
put thus results in a decrease in blood youths reported to be current illicit drug
stressful for a child. The child is confront-
pressure since the child cannot compensate users in 2001.19
ed with an unfamiliar environment, unfa-
by increasing peripheral vascular resistance. The presence of parents during the
miliar people, apprehension about the
administration of the sedative agent may
Summary unknown, and loss of control. The child
reduce the stress of the procedure and
fears separation from the parents, the
These fundamental concepts clearly illus- improve the childs cooperation. Con-
threat of needles, the perception of
trate the increased potential risks associat- versely, a parents anxiety may be sensed
impending pain, and the fear of mutila-
ed with sedating the pediatric patient: by the child, further exacerbating the
tion. Younger children frequently cannot
childs own level of anxiety.20 Clear, sim-
The airway is more susceptible to verbalize these concerns. Behavioral mani-
ple, and succinct explanations appropriate
obstruction, and the patient has less festations of perioperative anxiety may
for the age of the child may minimize
ventilatory reserve; these result in a include hyperventilation, trembling, cry-
adverse behavior.
more rapid oxygen desaturation (and ing, agitation, and/or physical resistance.
hypoxia causes bradycardia). Children < 6 years of age frequently cannot Preoperative Fasting
The risk of pulmonary aspiration of gas-
Table 6-1 Means and Ranges of Normal Cardiovascular Function tric contents in the pediatric patient dur-
Age (yr) ing anesthesia is reported to be up to
Function 26 713 1418 10 incidents per 10,000 cases.2123 Mor-
bidity secondary to aspiration includes
Heart rate (beats/min) 100 (80120) 90 (70110) 80 (5595)
obstruction from particulate material as
Systemic arterial pressure (mm Hg) 75115/5075 95125/6080 105140/6585
well as aspiration pneumonitis that is
Cardiac output (mL/kg/min) 150170 100140 90115
dependent on both the quantity and
106 Part 1: Principles of Medicine, Surgery, and Anesthesia
acidity of the aspirate. Establishing para- between the last food ingestion and the chospasm, severe coughing, airway hyper-
meters that minimize the risk of particu- injury is the critical time period that is activity, breath holding, diminished diffu-
late gastric contents as well as decrease important in assessing a patients risk of sion capacity, increased closing volumes,
the quantity and acidity of residual gas- gastric aspiration. Each patient and situa- atelectasis, and postintubation croup.3134
tric fluids can decrease the incidence of tion must be assessed individually. If The elevated hyperactivity with associated
this morbidity. sedation or general anesthesia is required, bronchoconstriction and the increased
Gastric emptying of solids is variable. patient management may necessitate the closing volume compounded by a greater
A 6- to 8-hour fast from solids is recom- placement of an endotracheal tube to oxygen uptake (secondary to the inflam-
mended to allow gastric emptying and minimize the risk of gastric aspiration. matory response of the infection) and a
minimize the risk of particulate aspira- The following interventions may min- decreased FRC (which normally occurs
tion. Alternatively, gastric emptying time imize the risk of aspiration and/or the with general anesthesia) increases the risk
for clear liquids is approximately 10 to ensuing injury that may result from gastric of hypoxemia.3542 Oxygen desaturation
15 minutes. After a 1-hour fast of clear aspiration: an H2-antagonist such as cime- can occur both intraoperatively and post-
liquids, approximately 80% of the con- tidine to decrease gastric acidity, a clear operatively; the latter indicates the need
sumed liquid is usually absorbed from antacid such as sodium citrate to decrease for continued postoperative monitoring.
the stomach. Numerous studies have gastric acidity, and metoclopramide to URIs have also been demonstrated to
shown that consumption of unlimited promote gastric emptying and increase the cause respiratory muscle weakness that
volumes of clear liquids by pediatric tone of the lower esophageal sphincter. can persist for up to 12 days.43 The patho-
patients up to 2 hours prior to surgery Glycopyrrolate also reduces the acidity physiologic changes that contribute to
does not significantly increase the quanti- and volume of gastric contents.29 these adverse respiratory events can persist
ty of gastric volume or gastric acidity.2428 Atropine, alternatively, decreases the tone for 4 to 6 weeks after the URI.
Guidelines have thus been established for of the lower esophageal sphincter and pre- Traditional office-based ambulatory
healthy pediatric patients that allow disposes to gastroesophageal reflux of anesthesia in oral and maxillofacial
unlimited amounts of clear liquids to be stomach contents. surgery is dependent on spontaneous ven-
consumed up to 2 to 3 hours prior to tilation in the nonintubated patient. This
surgery. This recommendation avoids the Upper Respiratory Infection is significant since the incidence of adverse
need for an extended fast, which has the It is not uncommon for children to present respiratory events is less in a patient anes-
potential to make the patient irritable for surgery with a runny nose. Reports of thetized with a face mask or laryngeal
and uncomfortable and to increase the children presenting to surgery with or hav- mask airway than in those with an endo-
incidence of hypotension secondary to ing recently had such symptoms state inci- tracheal tube. However, surgery involving
dehydration. However, in most cases it dences as high as 22.3% and 45.8%, respec- the airway has been shown to increase the
still may be simplest to state that the child tively.30 Rhinitis is not a contraindication risk of adverse respiratory events.
should have nothing by mouth (NPO) to general anesthesia. Alternatively, a child Although intraoral surgery is not truly air-
after midnight and to schedule the proce- with a severe upper respiratory infection way surgery, it encroaches on the airway
dure as the first case in the morning. (URI; symptoms include a productive and can cause airway irritability. The non-
Children who are scheduled in the after- cough, fever, and mucopurulent discharge) intubated patient undergoing oral or
noon may have a light breakfast at least should not be anesthetized. However, it is maxillofacial surgery is also susceptible to
6 hours prior to the surgery. unclear whether a child with a mild URI or periods of hypoventilation and apnea,
a child recovering from a URI should be which cannot be corrected without inter-
Emergency Treatment: anesthetized; therefore, it is important to rupting the surgery. Kinouchi and col-
Full Stomach differentiate between the diagnosis of leagues demonstrated that a patient with
Patients may present to the office or rhinitis and an infective process. an active or recent URI requires approxi-
emergency room requiring urgent care. Pathophysiologic changes in the pul- mately 30% less apneic time to desaturate
The injury or the patients ability to monary system secondary to a URI than does a healthy patient.44
cooperate may be such that the necessary include increased nasal and lower airway In conclusion, the patient who pre-
treatment cannot be completed on the secretions, increased airway edema and sents for elective surgery with allergic
patient while he or she is awake and non- inflammation, and increased airway rhinitis or a mild URI that is not of acute
medicated, despite the fact that the tachykinins. These pathophysiologic onset may be anesthetized in the office
patient is not NPO. The duration changes can result in laryngospasm, bron- without an endotracheal tube. If the
Pediatric Sedation 107
patient has a significant URI, the proce- of age has been reported to be approxi- medical/dental staff, (3) the medical his-
dure should be rescheduled. Traditional mately 0.5%.46 Because of the severity of tory of the patient, (4) the patients prior
guidelines suggest that the procedure the potential consequences of anesthetizing surgical or anesthetic experience, (5) the
should be rescheduled for 4 to 6 weeks a pregnant patient, it is important to reli- infringement of the procedure on the air-
later if the patient is to be intubated, but ably detect a pregnancy. An accurate and way, and (6) the duration of procedure.
because many children have several URIs reliable history in the educated patient can The selected technique should ideally be
per year, trying to reschedule the surgery be effective.47 However, many patients in painless, be accepted by the patient and
for a date when the child is without symp- this age group may not provide an accurate parents, be rapid in onset, be appropriate
toms may be difficult.45 Considering the history, especially in the presence of their in duration with rapid recovery, and have
above, a delay of 2 weeks is probably family. This is not an acceptable rationale minimal side effects and a broad margin
acceptable before performing a short for routine testing. If routine testing is of safety. If drug administration is associ-
office-based minor dentoalveolar proce- implemented, there is the potential for a ated with pain or adverse memories, the
dure in which the patient is not intubated. false-positive test result, which may have benefit of the sedation may be decreased.
significant emotional consequences. The The anesthetic must also provide an envi-
Cardiovascular Evaluation issue remains controversial. ronment in which the procedure can be
The child who presents for surgery with a completed. In certain clinical situations a
previously undiagnosed cardiac murmur Sedative Techniques moderate degree of movement may be
poses a diagnostic challenge. Innocent It is generally agreed that managing the acceptable, whereas in other situations no
murmurs are heard in up to 50% of nor- anxious, uncomfortable, and uncoopera- movement is acceptable. Also, the induc-
mal pediatric patients at some point dur- tive pediatric patient is one of the more tion agent may establish a depth such that
ing childhood. The cause of these mur- difficult anesthetic tasks. The primary the treatment may be completed, but in
murs is usually turbulent blood flow goals in the management of the pediatric other cases the goal of the induction
through any of the great vessels. Features patient include reducing anxiety, establish- agent may be to establish sufficient seda-
that commonly identify innocent mur- ing cooperation, ensuring comfort, estab- tion to allow intravenous access and
murs include those that are crescendo- lishing amnesia and analgesia, and ensur- maintenance of anesthesia with intra-
decrescendo and of short duration and ing hemodynamic stability. Although the venous agents. Lastly, and of extreme
low intensity, and those that occur early goals of sedation are similar for both the importance, one is cautioned not to
in systole. All diastolic murmurs are child and the adult, reducing anxiety in the sedate a young child who will be trans-
pathologic. The patients history may also adult may enhance cooperation, whereas in ported in a car seat prior to arrival in the
suggest signs and symptoms of cardiac the child it may not. To achieve a satisfac- office. The respiratory depressant effect
pathology. These may include limited tory result and facilitate completion of the of the medication combined with the
exercise tolerance, pale color, frequent planned surgical procedure, the child may positioning of the unattended child in the
respiratory problems, hypoxemia, palpi- require a greater depth of sedation. car can result in unrecognized upper air-
tations, or dysrhythmias. A murmur in an Sedation should be accomplished in way obstruction or respiratory impair-
asymptomatic child is frequently not as nonthreatening a manner as possible. ment, with resultant death or significant
pathologic, and no special anesthetic Because some children may be intensely neurologic impairment.48
considerations are required. However, if afraid of needles, establishing intra-
there is uncertainty regarding the signifi- venous access may not be possible. The Routes of Administration
cance of a murmur, a consultation with a surgeon must be familiar with alternative Sedative medication may be administered
cardiologist is recommended. For techniques that allow for a safe satisfacto- by many routes, including oral, intranasal,
patients with congenital heart disease, ry induction and recovery from anesthe- transmucosal, rectal, intramuscular,
prophylaxis against bacterial endocarditis sia. Each case must be considered indi- inhalational, and intravenous.49 The
is necessary. vidually to select both the most advantage of the intravenous route is that
appropriate drug and the route of admin- it results in the most rapid onset, rapid off-
Pregnancy Testing istration. The surgeon must take into set, and predictable effect. The disadvan-
in the Adolescent Patient consideration the following factors in tage is that it entails establishing intra-
The incidence of pregnancy detected by developing the anesthetic plan: (1) the venous access. A percentage of children do
routine universal testing in the ambulatory age of the patient, (2) the level of anxiety not cooperate and allow an intravenous
surgical adolescent between 12 and 21 years and ability to cooperate with catheter to be inserted. Many children
108 Part 1: Principles of Medicine, Surgery, and Anesthesia
tinuing the administration of the potent istration. Its primary disadvantage is the administration can be inadvertently aspi-
vapor agent via a traditional nasal hood. discomfort associated with the injection. rated by the crying child. Bronchial
This can result in the delivery of a diluted However, for the uncooperative child, it absorption can result in an excessive plas-
concentration of anesthetic agent to the may be the least traumatic method of ma level of drug.
alveoli, resulting in a lightening of the inducing anesthesia. Four anatomic The intranasal route was initially pro-
patients anesthetic depth. Such an occur- regions are used for intramuscular admin- posed for pediatric sedation because it was
rence would necessitate the interruption of istration of drugs: the deltoid muscle, the felt to avoid first-pass degradation, be
the procedure to replace the full face mask vastus lateralis muscle, the ventrogluteal rapid in onset, and be less traumatic than
to increase the alveolar concentration of area, and the superior lateral aspect of the the other routes that possessed these same
the inhalational agent. Although the con- gluteus maximus muscle. These sites have benefits.52 Medications administered
tinued administration of the vapor agent been identified because they have minimal intranasally do result in a rapid rise in the
via a nasal hood is not contraindicated, it numbers of nerves and large blood vessels, plasma level of a drug. This occurs because
may result in excessive environmental pol- as well as adequate bulk to accommodate the nasal cavity, which functions to warm
lution, even with a scavenger device that is the volume of the injected medication. and cleanse nasal respirations, has a rela-
a component of the nasal hood. A circuit The rapidity of onset of the drug is depen- tively extensive surface area with a thin
that scavenges the vapor agent must also be dent upon the perfusion of the muscle. nasal mucosa and an abundance of capil-
used with the face mask. To avoid these Absorption and onset are also affected by laries that facilitate the absorption of drug.
potential problems, especially for longer the ionization of the drug and the vehicle The nasal mucosa also provides a direct
procedures, the establishment of intra- in which it is dissolved. connection to the central nervous system
venous access is recommended. The Oral administration is considered by (CNS) through the cribriform plate. Med-
vasodilatory effects of the potent agent many to be the least-threatening induction ication may be absorbed through the crib-
may optimize conditions for establishing technique. Children are generally familiar riform plate directly into the CNS through
intravenous access. Once access is set, anes- with and readily accept oral medications. the capillary beds or the olfactory neu-
thetic depth can be maintained with intra- Oral administration also is generally well rons, or directly into the cerebrospinal
venous anesthetic agents. accepted by the mentally impaired or autis- fluid.53 Rhinitis or a URI may impair the
There are a few disadvantages to tic patient. However, oral techniques have absorption of a drug via this route.54
inhalation induction. The vapor agent has a limitations. In one study of children The intranasal route, although initially
scent that may be objectionable to some. between the age of 20 and 48 months, one- felt to be less traumatic than alternative
Applying a scent (eg, scented lip gloss) third of the children required that the med- routes, is frequently not well accepted by
selected by the child to the face mask may ication be administered into the back of children.55,56 The volume of medication
alter the odor of the agent. The odor may their throat with a needle-free syringe.50 used frequently results in a portion passing
also be minimized if the child breathes Although frequently used as a sole sedative into the pharynx and being swallowed.
through the nose as opposed to the agent by many surgeons, an oral sedative Therefore, the unpleasant taste of the med-
mouth.18 In addition, inhalation induction agent can be used as a premedicant prior to ication is not avoided, and the drug is sub-
is also dependent on the child accepting the establishing intravenous access or inducing ject to first-pass hepatic degradation. Mida-
face mask. Techniques such as asking the general anesthesia by a different route (eg, zolam is the most commonly intranasally
child to inflate a balloon may be employed inhalation or intramuscular). The limited administered medication, but the acidic pH
to distract the child. Any need for mild volume of fluid administered with the oral is irritating to the nasal mucosa.
restraint should be explained to the parent medication is not associated with an Transmucosal absorption has also
and may be used to facilitate induction in increased risk for aspiration pneumonitis.51 been considered. The oral epithelium is
the younger child. However, in older chil- The primary disadvantages of oral thin with a rich vascular supply. The min-
dren or extremely uncooperative children, sedation are the slow onset, variable imum epidermal barrier and the vascular
the technique is dependent on the childs response, and prolonged recovery. Inject- supply provide an environment that pro-
acceptance of the face mask. If excessive ing a sedative agent into the back of the motes relatively rapid absorption of drugs.
physical restraint is necessary, an alternative throat with a needle-free syringe (when Oral transmucosal administration of a
technique should be considered. the child does not otherwise accept the drug also has the advantage of avoiding
The intramuscular route of adminis- medication) has also been associated with hepatic first-pass degradation. Transmu-
tration approximates the rapidity and pre- adverse consequences. It has been theo- cosal administration requires cooperation
dictability of onset of intravenous admin- rized that the drug intended for orogastric of the patient to keep the drug in contact
110 Part 1: Principles of Medicine, Surgery, and Anesthesia
with the oral mucosa. The medication may drug within the rectum. However, there are thalamoneocortical and limbic systems,
be administered as a solution placed sub- significant anastomoses between the three which disrupts the brain from interpreting
lingually or as a lozenge. At the present rectal veins, and peak drug blood level has visual, auditory, and painful stimuli.61 The
time the only available lozenge that has an not clearly been shown to be dependent on analgesic effect, which occurs at subanes-
acceptable flavor and is commercially the location of agent deposition within the thesia plasma levels, is partially mediated
available is fentanyl citrate. Other sedative rectum. Solutions are absorbed more rapid- by ketamine binding to the -opioid and
medications are bitter. Palatability can be ly than are suppositories. A more dilute NMDA receptors. This is significant
improved by mixing these medications solution with greater volume provides more because the effect persists into the postop-
with a flavored solution that increases rapid onset and prolonged duration.59 Stool erative period and may decrease the need
their volume; thus, the solution will be bit- within the rectal vault as well as expulsion of for postoperative analgesia.62
ter or the volume will be excessive, neither an unmeasurable quantity of drug results in Ketamine is also unique in its effects
of which is advantageous for the transmu- delayed or decreased absorption. Alteration on the respiratory system. In clinical doses
cosal administration of a liquid/solution. in the integrity of the mucosa or the pres- commonly used in oral and maxillofacial
Many, if not most, pediatric patients ence of hemorrhoids results in greater surgery, ketamine usually preserves upper
expectorate the medication or premature- absorption. If a child is uncooperative, he or airway musculature tone, spontaneous res-
ly swallow the liquid medication that is she may tightly close the anal sphincter dur- pirations, and FRC. This minimizes the
placed within the oral cavity as opposed to ing any aspect of the administration incidence of upper airway obstruction and
keeping it there. process. Excessive force both in placing or hypopneas/apneas, and maintains the pul-
Rectal drug administration has been removing the catheter may result in a lacer- monary oxygen reserve.63,64 In contrast,
used for the administration of antiemet- ation of the mucosa and cause a greater most other anesthetics contribute to a
ics, antipyretics, and analgesics to both absorption of drug. decrease in muscular tone, respirations,
adults and pediatric patients. Many seda- and FRC. In addition to maintaining upper
tive drugs that are usually administered Pharmacologic Agents airway muscular tone, ketamine tends to
IV, IM, or orally can be administered rec- The objective in selecting a pharmacologic better maintain the pharyngeal and laryn-
tally. Rectal administration may also be agent is to choose an agent that establishes geal airway reflexes. This allows the patient
used in the management of emergencies. an appropriate environment to complete to maintain the ability to swallow and
For example, rectal administration of the surgical procedure. The effects sought cough, which minimizes the risk of pul-
diazepam is an acceptable route for the in the pediatric patient include anxiolysis, monary aspiration. Ketamine has also been
treatment of seizures.57,58 amnesia, analgesia, immobilization, seda- shown to relax bronchial smooth muscle
The rectum is a flat organ that is usu- tion, and hypnosis. There are numerous and cause bronchial dilatation. It has been
ally empty. Its blood supply is derived agents that are currently used by oral and used in the management of wheezing dur-
from the inferior rectal arteries and is maxillofacial surgeons and other practi- ing anesthesia.65
drained via the superior, middle, and infe- tioners. In this section we discuss what we Despite these benefits the practitioner
rior rectal veins. The superior rectal vein feel to be the most appropriate anesthetic must respect the inherent dangers associ-
drains into the hepatic portal circulation agents and the routes by which they ated with the anesthetic management of a
via the inferior mesenteric vein. The mid- should be delivered. patient. Respiratory depression character-
dle and inferior rectal veins drain into the ized by a decrease in respiratory rate and
internal iliac vein. The internal iliac vein Ketamine Ketamine is a pharmacologic tidal volume can occur with ketamine.
drains into the vena cava, thus bypassing agent that induces a distinct anesthetic Respiratory arrest has been reported in a
the hepatic-portal circulation and avoid- state that resembles catalepsy. The patient 4-year-old child following the intra-
ing first-pass metabolism by the liver. appears awake but is noncommunicative. muscular administration of ketamine
The absorption of a drug that is admin- Nonpurposeful movements may occur but 4 mg/kg.66 However, respiratory depres-
istered per rectum is affected by several fac- are not disruptive. The eyes are commonly sion is not common, and the occurrence of
tors. The variable absorption of the drug open with a blank stare and intact corneal apnea is more likely to occur in infants or
may be partially influenced by the venous and light reflexes.60 A lateral nystagmus is with the rapid intravenous infusion of an
drainage of the rectum. Therefore, some also very characteristic. Ketamine also induction dose greater than 2 mg/kg. Slow
individuals feel that absorption and subse- produces amnesia and analgesia. intravenous infusion over 30 to 60 seconds
quent peak plasma level of medication is The clinical effect created by ketamine of doses between 0.5 mg/kg and 1 mg/kg
dependent on the location of deposition of results from a dissociation between the should minimize the incidence of signifi-
Pediatric Sedation 111
cant respiratory depression. Aspiration of The advantage of intramuscular tration of a benzodiazepine with ketamine
gastric contents can also occur despite the administration is that it does not require may prolong recovery.75 Midazolam pro-
fact that ketamine better preserves the patient cooperation. The mild distress duces a better reduction in unpleasant
protective airway reflexes allowing a associated with the injection is brief as the dreams than does diazepam.76 The favor-
patient the ability to swallow and drug has a rapid onset, within 3 to 5 min- able pharmacokinetics of midazolam com-
cough.67,68 The protective reflexes, utes. Dosing recommendations up to pared with diazepam also provide a more
although less impaired than with other 10 mg/kg IM have been described in vari- rapid recovery. In a prospective investiga-
drugs, are diminished. We feel that a ous papers and texts. The larger dose clear- tion, ketamine 3 mg/kg with midazolam
patient who is considered not to have an ly produces a general anesthetic state. For 0.5 mg/kg was administered to pediatric
empty stomach should not be sedated, and office-based or emergency-department patients requiring sedation for minor sur-
disagree with those who feel that preserva- procedures performed by oral and maxillo- gical procedures in the emergency depart-
tion of the airway reflexes justifies sedating facial surgeons, however, a dose of 4 to ment.77 Although 30% of the patients who
such patients.69 The preservation of the 5 mg/kg IM should provide effective disso- received this regimen manifested inter-
laryngeal reflexes is a protective mecha- ciation. One investigation prospectively mittent crying, only 14% required addi-
nism; this may also contribute to airway assessed pediatric patients requiring seda- tional medication to establish a satisfactory
complications. Ketamine produces an tion for minor procedures in an emergency anesthetic state to allow completion of the
increase in salivary and tracheobronchial department and found that a 4 mg/kg dose planned treatment. Recovery for this regi-
secretions, and the preservation of the provided effective sedation and immobi- men was at times prolonged.
laryngeal reflexes may predispose the lization for 86.1% of the children. A satis- The level of sedation and immobiliza-
patient to laryngospasm. factory quality of sedation was achieved tion is dependent on the planned proce-
Ketamine has both direct and indirect with adjunctive local anesthesia for 97.2% dure. Although the intent is to provide an
effects on the cardiovasculature. The direct of these patients, although 3.7% required atraumatic experience for the child, a
myocardial depressant effects are generally mild restraint despite adequate sedation mildly dissociative sedative and analgesic
not seen in the healthy patient anesthetized and an absent withdrawal response to pain. state compared with a deeper dissociative
in the office. The indirect effects, which are Only 2.8% of the patients required a repeat anesthetic state may be acceptable for a
a result of a sympathetic stimulation, pro- dose secondary to inadequate sedation.73 brief dentoalveolar procedure. The intent
duce an increase in heart rate and blood Local anesthesia is an important compo- is to modify the patients perception of the
pressure. The former may be more com- nent of any sedative technique used by oral procedure. In this situation the patient is
mon in the pediatric patient. These effects and maxillofacial surgeons. Although this not profoundly sedated and the practi-
are well tolerated in the healthy pediatric study demonstrated that it is not always tioner has to tolerate some movement and
patient. These hemodynamic changes may required, incorporation of local anesthesia possibly some vocalization. Ketamine 2
be reduced when ketamine is combined into the anesthetic plan minimizes the mg/kg to 3 mg/kg IM should provide this
with an anesthetic agent that tends to blunt amount of other anesthetic agents desirable sedative depth. The lower dose of
sympathetic stimulation (eg, benzodi- required. The working time achieved from 2 mg/kg is advantageous in that recovery
azepines, propofol). a 4 mg/kg dose of ketamine was 15 to from injection to discharge approximates
A disadvantage of ketamine is its stimu- 30 minutes. A disadvantage of intramuscu- 60 minutes. For many children the low
lation of dreams and hallucinations lar ketamine is that recovery is variable and intramuscular dose of ketamine provides a
described as out of body experiences, sen- can be quite long. Although the mean depth of sedation that allows the place-
sations of floating, and delirium.70 Although recovery time in the above study was ment of an intravenous line. If necessary,
the incidence is less in children < 16 years of 82 minutes, recovery from injection to dis- the depth of sedation can then be modi-
age, the incidence may be as high as charge at times took up to 3 hours. fied using intravenous medications. Incre-
10%.71,72 Ketamine is also contraindicated Benzodiazepines can be administered mental doses of ketamine 5 to 10 mg IV
in patients who may have a globe or concomitantly with ketamine. The purpose can be administered to the sedated patient,
intracranial injury as ketamine increases for coadministering a benzodiazepine is to with onset occurring within 30 to 60 sec-
both intraocular and intracranial pressure. reduce the amount of ketamine adminis- onds. The duration of sedation is 10 to
Ketamine can be administered IV, IM, tered, reduce the incidence of ketamine- 15 minutes. Although we have found that
orally, intranasally, and rectally. We discuss induced hallucinations, attenuate the car- ketamine 2 mg/kg generally facilitates
only the intravenous, intramuscular, and diovascular effects of ketamine, and intravenous placement, one study report-
oral administrations of ketamine. provide additional amnesia.74 Coadminis- ed that 31% of the children resisted intra-
112 Part 1: Principles of Medicine, Surgery, and Anesthesia
venous placement with a dose of 3 3 to 10 mg/kg, a more consistent effect is of strategies to ensure that the full oral
mg/kg.78 For the patient who remains achieved with doses > 6 mg/kg. In one dose is taken. Atropine or glycopyrrolate
combative and for whom intravenous investigation oral ketamine 6 mg/kg was can be orally administered with ketamine;
access cannot be established, an additional administered for sedating anxious pediatric however, the time to peak decrease in sali-
dose of ketamine 1 to 2 mg/kg IM can be dental patients with a mean duration of vation is 2 hours.91
administered. If the child allows placement sedation of 36 minutes.84 The quality of Regardless of the route of administra-
of an intravenous catheter (without any sedation was reported as good for 65% of tion, ketamine can establish a clinical
premedicant), a dose of ketamine 0.5 to the patients, and 100% of the treatment was effect described as a chemical straight-
1 mg/kg IV administered over 30 to 60 sec- completed. Mean recovery time was jacket. The catatonic state created by ket-
onds will establish dissociation. 56 minutes with one child sleeping for amine is different from that with other
An anticholinergic agent (eg, glyco- 3 hours. Creating a state of deep sedation is general anesthetic agents; ketamine, when
pyrrolate or atropine) is frequently coad- dependent on using larger doses of medica- used at the doses discussed above, may not
ministered with ketamine to decrease tions. Ketamine 10 mg/kg PO was used as a be considered to be a true general anes-
hypersalivation. Tachycardia and postop- premedicant in the management of pedi- thetic. However, the anesthetic depth cre-
erative psychomimetic effects are prob- atric patients undergoing invasive oncolog- ated by ketamine is not consistent with
lems associated with ketamine. Atropine, ic procedures. Approximately 50% of the conscious sedation, and airway problems
when combined with ketamine, produces patients were unresponsive at 60 minutes. can occur. Therefore, appropriate anes-
a significantly higher heart rate compared This dose was ineffective in < 10% of the thetic standards for deep sedation or gen-
with the effect of glycopyrrolate. As a ter- patients.85 Recovery, however, generally eral anesthesia must be followed.
tiary amine, atropine crosses the blood- took 2 to 4 hours, with 20% of the patients
brain barrier and can, itself, produce being deeply sedated at 120 minutes post Midazolam Midazolam is a water-soluble
postoperative delirium. A higher inci- administration. Several authors have shown short-acting benzodiazepine. As a class of
dence of adverse emergence phenome- that the anxiolytic and sedative properties agents, the benzodiazepines provide anxiol-
non, however, was not identified in stud- of midazolam 0.5 mg/kg result in a more ysis, sedation, and amnesia. Midazolam can
ies comparing glycopyrrolate with clinically effective sedation than does keta- be administered IV, IM, orally, sublingually,
atropine.79,80 Both drugs can be mixed in mine 5 or 6 mg/kg.86,87 intranasally, or rectally. Because of its water
the same syringe with ketamine for an The combination of oral midazolam solubility, intramuscular injection of mida-
intramuscular injection. The peak effect and ketamine has also been described. This zolam is pain free, and absorption is pre-
of intramuscular glycopyrrolate occurs drug combination may provide effective dictable. Unlike ketamine, however, as a
within 30 minutes, at which time the pro- sedation when oral midazolam has been single agent there is no unique anesthetic
cedure is frequently completed and the ineffective. One study that demonstrated a benefit to the intramuscular administration
patient is in the recovery phase of treat- greater efficacy with this combination used of midazolam.
ment. If an intravenous line is to be estab- ketamine 4 mg/kg with midazolam Intranasal administration of midazo-
lished after the onset of sedation, glyco- 0.4 mg/kg.88 The reported dosing regimens lam was popular in the past. It was once
pyrrolate can be administered IV with a have varied from ketamine 4 to 10 mg/kg the most common intranasally adminis-
peak effect in approximately 1 minute. with midazolam 0.25 to 0.5 mg/kg. tered medication. However, because of an
The dose of atropine is 0.1 to 0.2 mg/kg, Situations may occur in the manage- acidic pH, it produces irritation to the
with a minimum dose of 0.1 mg and a ment of a mentally impaired, autistic, or nasal mucosa. The medication if adminis-
maximum dose of 0.6 mg. Glycopyrrolate older child in whom an intravenous line or tered slowly is discomforting and if
is twice as potent as atropine. The dose is an intramuscular injection cannot be administered rapidly passes through the
the same for both drugs, regardless of the administered without harm to the patient nose into the nasal pharynx and is swal-
route of administration. or the healthcare provider, and who will lowed. In a study that compared oral to
Ketamine can also be administered not accept a face mask. Oral ketamine intranasal administration of midazolam,
orally.81 Bioavailability is approximately alone or combined with oral midazolam children were found to be less tolerant of
17% following oral administration com- can be used to establish a cataleptic state, the intranasal administration.92
pared with 93% after intramuscular facilitating treatment of the combative Oral midazolam is probably the most
administration.82,83 Onset of sedation patient.89,90 It may be helpful to solicit widely used premedicant in children. The
occurs in approximately 20 minutes. assistance from the patients caregiver or recommended dose of midazolam is 0.5 to
Although doses reported have ranged from parent, as these individuals may be aware 1.0 mg/kg to a maximum of 20 mg. Mida-
Pediatric Sedation 113
zolam 0.5 mg/kg achieves anxiolysis in 70 Induction Agents Methohexital and Clinical trials and case series have demon-
to 80% of patients. The anesthetic depth propofol are rapid-onset short-acting strated propofols efficacy in pediatric
may be potentiated by the administration agents that are effective for induction and patients.101107 The proprietary formula-
of nitrous oxide. The combined adminis- maintenance of anesthesia. These are the tion of propofol (Diprivan) is licensed by
tration of 40% nitrous oxide with midazo- primary anesthetic agents for general the US Food and Drug Administration
lam 0.5 mg/kg has produced deep sedation anesthesia in oral and maxillofacial (FDA) for use in children > 3 years of age
in 12% of patients.93 surgery performed in an office. The phar- in the surgical setting.
Unlike ketamine, midazolam causes macology of these agents is discussed in Transient pain at the site of injection is
loss of airway muscle tone. Although air- Chapter 5, Pharmacology of Outpatient reported in approximately 10 to 20% of
way obstruction is not common with Anesthesia Medications. There are some patients given propofol. In the pediatric
doses of 0.5 to 1.0 mg/kg, airway obstruc- important points to make relative to their patient this discomfort may result in gra-
tion has been reported after 0.5 mg/kg oral use in the pediatric patient. dations of movement, which may require
midazolam.94 The incidence of airway Methohexital is an ultrashort-acting restraint of the patient until induction is
obstruction may increase with the admin- oxybarbiturate. It can be administered rec- fully achieved. Propofol may also cause
istration of nitrous oxide. In one study the tally, IM, and IV. The advantage to the rec- hypotension and bradycardia. The inci-
combined administration of 50% nitrous tal administration of methohexital is that dence is reported to be higher in the pedi-
oxide and 0.5 mg/kg oral midazolam the drug is administered in the presence of atric patient (17%) compared with that in
resulted in a 56% incidence of upper air- the parents, and, thus, the child is asleep the adult patient (310%). This usually is
way obstruction in children with enlarged prior to parental separation. Rectal admin- not detected in the adult oral and maxillo-
tonsils.95 With maintenance of airway istration, however, can be distressing, as facial surgery patient when a relatively low
patency, however, oral midazolam doses of discussed above. Methohexital can also be initial dose (< 1 mg/kg) is typically used to
0.5 to 0.75 mg/kg generally do not result in administered intramuscularly. Administra- achieve deep sedation or general anesthe-
a change in oxygen saturation, heart rate, tion is quite painful, and there is no advan- sia. Pediatric patients frequently need to
or blood pressure.96 tage to its use in office-based anesthesia be more profoundly anesthetized. This
The onset of effect of oral midazolam compared with other available intramus- requires the administration of a greater
is within 20 minutes, and the duration of cular agents. Neither rectal nor intramus- dose of propofol, which may result in a
sedation is 20 to 40 minutes. Patients can cular administration is generally employed higher occurrence of hypotension or
generally be discharged within 60 to in ambulatory oral and maxillofacial bradycardia in pediatric oral and maxillo-
90 minutes from the time at which the surgery offices. Most frequently methohex- facial surgery patients. Propofol may also
medication is administered. ital is administered IV. Interestingly, cause excitatory movement or myoclonus,
Midazolam is metabolized by the despite years of safe administration in this the incidence of which is greater in the
cytochrome oxidase system. Oral mida- environment, the manufacturers package pediatric patient (17% vs 310%).
zolam is subject to hepatic first-pass insert states that the use of methohexital in The greatest potential concern with
metabolism. Erythromycin, clarithro- the pediatric patient is not adequately the use of propofol in the pediatric
mycin, protease inhibitors, azole antifun- studied and thus not recommended. patient is that cases of fatal metabolic aci-
gal medications, fluvoxamine maleate, Propofol is an alkylphenol. Its charac- dosis and cardiac failure, termed propofol-
and grapefruit juice alter this cytochrome teristics include rapid onset and short infusion syndrome, have been reported in
oxidase system and result in a higher and duration of clinical effect, similar to over a dozen children.108112 These inci-
a more sustained midazolam plasma methohexital. Its high clearance rate and dents have all been associated with pro-
level.97,98 minimal tendency for drug accumulation longed intubation and propofol infusions.
Higher doses of oral midazolam (0.75 to make it a more ideal anesthetic agent for A review by the FDA concluded that
1.0 mg/kg) are associated with a greater ambulatory surgery in both adult and propofol had not been shown to have a
incidence of side effects. These include pediatric patients. In one study comparing direct link to any pediatric deaths.113
loss of head control, blurred vision, propofol to methohexital for anesthesia in Although the causal relationship between
and/or dysphoria. A paradoxic reaction pediatric patients undergoing procedures propofol and metabolic acidosis remains
may also occur in which the patient in a dental chair, propofol was associated unproven, clinicians should be aware of
becomes more excited as opposed to with a 9% incidence of ventricular the risk for this reaction in children and
sedated. This is more common in chil- arrhythmias compared with a 32% inci- limit the dose and duration of propofol
dren and adolescents.99 dence associated with methohexital.100 therapy accordingly.
114 Part 1: Principles of Medicine, Surgery, and Anesthesia
Inhalational Agents The origin of anes- ing, laryngospasm), whereas desflurane chospastic disease. All potent inhalational
thesia is rooted within dentistry. The first and isoflurane tend to irritate the airway if agents have myocardial depressant effects.
anesthetic was nitrous oxide. Nitrous oxide used for mask induction.119121 The cardiovascular depressant effects are
has anxiolytic, analgesic, amnestic, and The blood and tissue solubility of an greatest with halothane use, which can
sedative effects.114,115 Although not a inhalational agent is also important. These result in hypotension and bradycardia.
potent anesthetic agent, nitrous oxide pos- properties influence the speed of induc- However, of greater significance is the abil-
sesses a wide margin of safety and has few tion and emergence from anesthesia. ity of halothane to sensitize the heart to
(if any) residual side effects. Another Agents that have a low solubility in blood catecholamines with resultant dysrhyth-
advantage of nitrous oxide is its low solu- have a more rapid induction and shorter mias. One study reported that 48% of
bility. An anesthetic agent that has low sol- emergence time. The blood gas solubility pediatric patients anesthetized with
ubility has rapid equilibration between the coefficients of desflurane, nitrous oxide, halothane had arrhythmias compared with
alveoli and the blood, and the blood and sevoflurane, isoflurane, and halothane are 16% of those induced with 8% sevoflu-
the brain. This results in both rapid onset 0.42, 0.47, 0.6, 1.4, and 2.3, respectively. rane. Patients who had an incremental
and anesthetic emergence. Also, nitrous These figures imply a more rapid onset induction of sevoflurane had even fewer
oxide may be combined with other anes- and emergence for desflurane, sevoflu- arrhythmias. Furthermore, of the arrhyth-
thetic agents. A deep sedative or general rane, and nitrous oxide. mias associated with halothane, 40% were
anesthetic state may be established with the Since all anesthetic agents affect the ventricular arrhythmias (consisting of ven-
coadministration of nitrous oxide and an pulmonary and cardiovascular systems, it tricular tachycardia, bigeminy, and cou-
oral or parenteral agent. This may result in is important to understand these effects. plets); with sevoflurane, only 1% were ven-
respiratory impairment. Although nitrous All potent inhalational agents depress tricular arrhythmias (consisting of single
oxide may potentiate the effect of another minute ventilation in a dose-dependent ventricular ectopic beats).123 The occur-
agent, the discontinuance of it can, like- manner, with a resulting increase in partial rence of these arrhythmias may also be
wise, reverse the anesthetic depth and pro- pressure of carbon dioxide in arterial associated with the administration of local
mote a more rapid emergence.116118 blood (PaCO2). Clinically the practitioner anesthetics containing epinephrine.
Although nitrous oxide lacks sufficient will observe a decrease in tidal volume and Halothane is the only inhalational agent
potency to solely induce general anesthe- a slight increase in respiratory rate. that is associated with arrhythmias with
sia, halothane, sevoflurane, desflurane, and Although acceptable respiratory parame- clinical doses of epinephrine. A limit of
isoflurane have sufficient potency to ters can be maintained during sponta- 1 g/kg of epinephrine in patients receiv-
induce and maintain general anesthesia neous ventilations, of the two agents used ing halothane is recommended.124126
(Table 6-2). The primary benefit of an for mask induction, halothane produces Use of inhalational agents is advanta-
inhalational agent is for mask induction, less respiratory depression than does geous in the oral and maxillofacial sur-
and of the potent inhalational agents, only sevoflurane.122 Not all respiratory effects geons office because they provide a gener-
halothane and sevoflurane are nonpun- are detrimental. All inhalational agents are al anesthetic state without intravenous
gent. These agents can be administered to beneficial in that they produce bronchial access. Therefore, only agents that are
an awake patient with minimal respiratory dilatation and are advantageous in the pleasant and nonirritating to the airway
complications (eg, coughing, breath hold- management of the patient with bron- can be used. Halothane has traditionally
been the agent used by both anesthesiolo-
gists in the operating room and oral and
Table 6-2 Inhalational Anesthetic Agents maxillofacial surgeons in their offices.
Maximum Acceptable Concentration (%) Sevoflurane appears to have the character-
Blood
Agent Gas Solubility 112 yr Adult istics that most approximate the ideal
inhalational agent, in that it is of sufficient
Nitrous oxide 0.47 105.00
potency, is nonpungent, has a low blood
Halothane 2.40 0.87 0.76
and tissue solubility, and has limited car-
Sevoflurane 0.69 2.5 1.70
Desflurane 0.42 7.988.72 7.30
diorespiratory effects. Sevoflurane has
Isoflurane 1.40 1.60 1.20 replaced halothane in the operating rooms.
Adapted from Cauldwell CB. Induction, maintenance and emergence. In: Gregory GA, editor. Pediatric anesthesia. 2nd ed.
There are several variations in mask-
New York: Churchill Livingston; 1989. induction techniques. First, the inhala-
tional agent may be administered with a
Pediatric Sedation 115
combination of nitrous oxide and oxygen dental extractions lasting between 4 and is that it is a gastric irritant and is associ-
or 100% oxygen. The combination of 6 minutes have not demonstrated a more ated with nausea and vomiting.
nitrous oxide with the potent vapor agent rapid recovery with sevoflurane.133 In one Antihistamines are commonly used in
decreases the percentage of vapor agent study, in which children were subject to a medicine and dentistry for their anti-
required to achieve an anesthetic depth. 4-minute anesthesia, time to eye opening pruritic and antiemetic effects. When used
The decrease in minimum alveolar con- was 102 seconds with halothane and for these conditions, sedation is frequently
centration (MAC) for halothane is signif- 167 seconds with sevoflurane.134 an unwanted side effect. However, the
icantly clinically greater for halothane The last factor that needs to be consid- sedative effects can be used to advantage,
than for sevoflurane. This most likely is ered both in comparing sevoflurane and and antihistamines such as promethazine
related to the difference in solubility of halothane and in selecting an anesthetic and hydroxyzine are frequently combined
the two potent inhalational agents. agent for the office is the toxicity of each with other drugs such as chloral hydrate
Another variation in mask induction per- drug. Halothane is metabolized in the liver and meperidine to potentiate the sedative
tains to the concentration of inhalational to a trifluoroacetylated product, which effect of the primary anesthetic agent and
agent administered. The practitioner may binds liver proteins promoting an to provide antiemetic effects. The sedative
administer an incrementally increasing immunologic response that can result in effects of antihistamines may last between
concentration of an agent (eg, increasing hepatic injury. 135,136 The incidence, which 3 and 6 hours, and when used alone do not
an agent by 0.51% after a few breaths) or may be as high as 1 in 6,000 cases of anes- provide anxiolysis.
a high initial concentration of an agent thesia in adults, is significantly lower in the The oral transmucosal administration
(eg, sevoflurane 8%). Although one pediatric population. Sevoflurane, of a sedative medication is appealing. Fen-
would expect that sevoflurane would although not associated with liver toxicity, tanyl citrate is available as a lozenge on a
have a more rapid speed of induction, the has been associated with the potential for stick. The recommended dose is between
differences between sevoflurane and renal toxicity.137,138 The drug undergoes 10 and 20 g/kg. Bioavailability is between
halothane have not been consistently hepatic metabolism, which produces inor- 33% in children and 50% in adults.139
demonstrated.121,127 The difference in ganic fluoride. However, the rapid elimi- The difference in bioavailability
speed of induction appears to be less dis- nation of sevoflurane minimizes the renal results from the amount of drug that is
tinguishable when a high concentration fluoride exposure, which probably swallowed and the amount of drug that is
of halothane is used. accounts for the lack of clinical renal dys- absorbed through the oral mucosa. The
Similar to speed of induction, anes- function, despite some reports of serum drug provides both analgesia and sedation.
thetic emergence is dependent on several fluoride levels > 50 mol. Renal injury has Onset of analgesia precedes the onset of
variables. Agents that have a low blood also been associated with the formation of sedation. Analgesia also lasts for 2 to
solubility coefficient should have a short- compound A, which is a product of the 3 hours, providing some postoperative
er emergence time. Several studies have reaction between sevoflurane and CO2 pain control. Adverse side effects associat-
shown that desflurane, which has the low- absorbents. Most of the data, however, ed with the fentanyl lozenge include a high
est blood solubility coefficient, has a very suggest that compound A does not induce incidence of nausea and vomiting, and
rapid anesthetic emergence (57 min), renal toxicity in humans. pruritus. The major adverse effect associ-
and halothane, which has the highest ated with the use of fentanyl citrate is a
blood solubility coefficient, has a more Other Medications Chloral hydrate is higher incidence of respiratory depression
prolonged recovery (1021 min).128132 an alcohol-based sedative. It produces a than that seen with other sedative medica-
Sevoflurane has been shown, although not sleep from which one is easily roused, in tions. The respiratory depression associated
consistently, to have a more rapid anes- which the cardiorespiratory effects are with the fentanyl lozenge may last beyond
thetic emergence for intermediate- and consistent with those that occur with nat- the sedative effect.140
long-duration anesthetics compared with ural sleep. The onset of chloral hydrate is
halothane. However, typically the slow (3060 min), its duration is variable Perioperative Complications
required state of anesthesia for a pediatric (25 h), and it lacks the anxiolytic effects
dental procedure in the office is brief, last- of benzodiazepines. The sedative effect of Laryngospasm
ing < 10 minutes. Recovery from anesthe- chloral hydrate does not produce as Intraoral surgery in the anesthetized non-
sia is also dependent on the duration of favorable a work environment as the anx- intubated patient renders the patient sus-
the anesthesia. Clinical studies comparing iolytic effect of a benzodiazepine. 50 ceptible to airway obstruction and airway
sevoflurane and halothane for pediatric Another disadvantage of chloral hydrate irritation. Such irritation can result in a
116 Part 1: Principles of Medicine, Surgery, and Anesthesia
laryngospasm, which is the apposition of itive airway pressure cannot break whereas end-tidal CO2 is the most sensitive
the supraglottic folds, the false vocal cords, laryngospasm in the presence of com- sign of malignant hyperthermia.142,143
and the true vocal cords. The laryn- plete airway obstruction and may, in fact, Another potential life-threatening
gospasm may be sustained and may worsen laryngospasm by forcing supra- complication following the administration
become progressively worse as the supra- glottic tissues downward to occlude the of succinylcholine is hyperkalemic cardiac
glottic tissues fold over the vocal cords glottic opening. arrest. Hyperkalemic cardiac arrest follows
during forceful inspiratory efforts. The For the laryngospasm that is refracto- the administration of succinylcholine in
incidence of laryngospasm is 8.7 per ry to continuous positive airway pressure, patients with undiagnosed myopathies;
1,000 patients in the total population and a neuromuscular blocking agent should be succinylcholine induces rhabdomyolysis,
17.4 per 1,000 in patients < 9 years of age.39 administered. The ideal agent should have which causes hyperkalemia leading to
The treatment of laryngospasm rapid onset. For the nonintubated patient, bradycardia/asystolic rhythm. Several case
depends on whether the airway obstruc- rapid recovery is also desirable. Succinyl- reports have appeared in the literature
tion is complete or incomplete. The single choline is the only neuromuscular block- emphasizing this potential risk in the
diagnostic feature that distinguishes com- ing agent that provides these effects. pediatric patient, which exists because
plete from incomplete airway obstruction Duchennes and Beckers muscular dystro-
is simply the absence or presence of sound. Succinylcholine phies may go undiagnosed until the ages
If there are inspiratory or expiratory If intravenous access is available, suc- of 6 and 12 years, respectively.144,145
squeaks, sounds, grunts, or whistles, then cinylcholine 0.5 to 1.0 mg/kg is adminis- Alternative neuromuscular agents
chances are the child has incomplete air- tered. If the child is hypoxemic, atropine have been developed that can provide
way obstruction. Airway obstruction of 0.02 mg/kg should preceed the adminis- rapid onset and should be used for elective
either type requires initial treatment with tration of the succinylcholine to prevent a situations. Rocuronium may be used when
a patency-preserving maneuver such as bradycardia secondary to the muscarinic succinylcholine is contraindicated. Its
the jaw-thrust/chin-lift maneuver. effect of succinylcholine. If intravenous onset is rapid, however, with a consider-
Because incomplete airway obstruc- access is not available, succinylcholine ably longer duration. The administration
tion may rapidly become complete, signs may be administered intralingually or IM of lidocaine topically to the vocal cords
and symptoms of obstruction (eg, tra- (succinylcholine 4 mg/kg).141 may also be effective. Succinylcholine
cheal tug, paradoxic respiration) should There are several potential complica- remains the most ideal drug for the man-
be treated aggressively. The first maneu- tions associated with the use of succinyl- agement of laryngospasm and emergent
ver is to apply gentle continuous positive choline. These include myalgias, malignant tracheal intubation and is the essential
airway pressure with 100% O2 by face hyperthermia, masseter muscle rigidity, drug for managing laryngospasm in the
mask. An effective technique to deliver and hyperkalemic cardiac arrest in patients oral and maxillofacial surgery office.
gentle positive pressure is to flutter the with undiagnosed myopathies. In some
bag. In this technique the reservoir bag is children the administration of succinyl- Cricothyrotomy
very rapidly squeezed and released in a choline can result in masseter muscle Three approaches to emergency surgical
staccato rhythm, similar to what one spasm. Masseter muscle spasm may indi- opening of the airway are mentioned in
would see with an atrial flutter of the cate a susceptibility to malignant hyper- the literature: emergency tracheotomy,
heart. In essence, one performs a manual thermia, but it can also be isolated and not emergency cricothyrotomy, and emer-
high-frequency oscillatory ventilation progress to malignant hyperthermia. The gency transtracheal ventilation.146 In the
with this technique. If the patient anesthetic team needs to differentiate experience of most, emergency tracheoto-
improves, anesthesia and normal ventila- between an isolated spasm and a prodromal my cannot be performed rapidly enough
tion may be resumed. Overuse of the sign of an impending emergency to make a in dire situations. Likewise, transtracheal
high-pressure flush valve to fill the decision regarding the continuation of the jet ventilation is extremely hazardous in
breathing circuit and anesthetic bag may anesthetic and surgical course. In a tertiary children because barotrauma may occur
dilute potent anesthetic gases (if being environment with appropriate monitoring, owing to the restricted egress of ventilato-
used) and lead to a lighter plane of anes- the anesthesia may be continued with ry gas. Therefore, when endotracheal
thesia in the child. In addition, high pres- observation for the development of other intubation cannot be accomplished, the
sure applied to the airway may force gas systemic signs reflective of the hypermeta- most rapid method for oxygenating the
down the esophagus and into the stom- bolic state of malignant hyperthermia. patient in an emergency situation is
ach, reducing ventilation even more. Pos- Tachycardia is usually the earliest sign, cricothyrotomy.147
Pediatric Sedation 117
Nausea and Vomiting brainstem centers, and solitary tract nucle- pramide are well tolerated by adults, but
us. These structures are rich in dopamin- children are prone to dystonic reactions.
Postoperative nausea and vomiting
ergic, muscarinic, serotoninergic, hista- For this reason, metoclopramide is com-
(PONV) is a cause of morbidity in pediatric
minic, and opioid receptors. Blockade of bined frequently with diphenhydramine to
patients. Even mild PONV is associated
these receptors is the mechanism of the decrease this incidence. Although metoclo-
with delayed discharge, decreased parental
antiemetic action of drugs. At the present pramide has been used successfully to
satisfaction, and increased use of resources.
time there are no drugs known that act reduce the incidence of PONV in high-risk
More severe complications associated with
directly on the emetic center. children, it is not as effective as droperidol
PONV include dehydration and electrolyte
Routine administration of antiemetic or the newer serotonin antagonists.151,152
disturbances, or hypoxemia secondary to
agents to all children undergoing surgery
airway obstruction or aspiration. PONV
is not justifiable as the majority do not Histamine Antagonists The histamine
occurs in 6 to 42% of all pediatric surgical
experience PONV or have, at most, one or receptor antagonists are weakly antiemetic
patients. The incidence is variable depend-
two episodes. The agents used are the same drugs with profound sedative effects,
ing on age of the patient, the sex of the
as those used to manage PONV in the which make them less suitable for use in
patient (there is a greater incidence in
adult. The following discussion identifies postoperative patients. They are frequent-
females > 13 yr), the anesthetic agents used,
points significant to the management of ly combined with other anesthetic agents
and the surgical procedure. Fortunately, PONV in the pediatric patient. in an oral cocktail for their sedative and
severe or intractable PONV is less common, antiemetic effects. These drugs may be
occurring in 1 to 3% of pediatric patients.148 Phenothiazines The phenothiazines are useful for controlling emesis resulting
Anesthetic drug selection can have an believed to exert their antiemetic effects from vestibular stimulation, as occurs in
effect on the incidence of PONV. Pre- primarily by antagonism of central patients with motion sickness or after
operative midazolam has been associated dopaminergic receptors in the chemore- middle ear surgery. They also counteract
with reduced PONV in children.149 Sub- ceptor trigger zone. Low doses of chlor- the extrapyramidal effects of the more effi-
sedative doses of propofol also provide promazine, promethazine, and per- cacious dopamine receptor antagonists.
antiemetic effects. This contrasts with phenazine are effective in preventing and
methohexital, which is associated with a controlling PONV. These drugs are fre- Muscarinic Receptor Antagonists The
higher incidence of PONV than is propo- quently combined with opioids (when vestibular apparatus and the nucleus of
fol in adults. Studies are lacking compar- administered orally by pediatric dentists) the tractus solitarius are rich in mus-
ing the incidence of PONV of these two to decrease the emetic effect of the opioid. carinic and histaminic receptors. Mus-
agents in a pediatric population. Pre- All phenothiazines are capable of produ- carinic receptor antagonism is effective in
medication with opioid analgesics cing extrapyramidal symptoms and seda- preventing emesis related to vestibular
increases the risk of PONV. Oral trans- tion, which may complicate postoperative stimulation, which may be the mecha-
mucosal fentanyl citrate in doses of 5 to care. The degree of sedation varies nism of morphine-induced PONV. In
20 g/kg is associated with PONV in between phenothiazines, with little seda- adults the use of glycopyrrolate, a drug
almost all patients.140 As discussed above, tion produced by perphenazine compared that does not cross the blood-brain barri-
ketamine is an excellent agent for pedi- with the other phenothiazines.150 er, has been associated with three times
atric sedation. An unfortunate adverse the need for rescue antiemetic therapy
effect associated with ketamine is a Benzamides The benzamide derivative compared with atropine.153 Transdermal
reported incidence of PONV that is as metoclopramide has antiemetic and pro- scopolamine has been used successfully to
high as 50%. Nitrous oxide also has emet- kinetic effects and is the most effective reduce PONV in children receiving mor-
ic effects. However, concentrations < 40% antiemetic of this class. Its antiemetic phine but is associated with a significant
are less likely to cause PONV. effects are mediated by antagonism of cen- increase in sedation and dry mouth.154
Vomiting is a complicated response tral dopaminergic receptors, and at high Other potential side effects include dys-
mediated by the emetic center located in doses it also antagonizes serotonin-3 phoria, confusion, disorientation, halluci-
the lateral reticular formation of the receptors. In the gastrointestinal tract nations, and visual disturbances.
medulla. This center receives input from metoclopramide has significant dopamin-
several areas within the CNS, including the ergic and cholinergic actions and increases Serotonin Receptor Antagonists Sero-
chemoreceptor trigger zone, vestibular motility from the distal esophagus to the tonin antagonists were discovered
apparatus, cerebellum, higher cortical and ileocecal valve. High doses of metoclo- serendipitously when compounds struc-
118 Part 1: Principles of Medicine, Surgery, and Anesthesia
turally related to metoclopramide were patient anatomically, physiologically, and phenidate, dextroamphetamine, or pemo-
found to have significant antiemetic effects behaviorally. Beyond these differences the line. Methylphenidate is the most com-
but lacked dopamine receptor affinity. pediatric population is a diverse group monly prescribed drug for ADHD. In
These drugs produce pure antagonism of within itself. Oral and maxillofacial sur- addition to its use in the management of
the serotonin-3 receptor. Ondansetron was geons are involved with the management ADHD, 1 to 2% of the US high-school
the first drug of this class to become avail- of patients with craniofacial syndromes as population without a diagnosed medical
able for clinical use in 1991. Since that time well as other physical or mental impair- condition is reported to abuse this
granisetron, and dolasetron have been ments. The craniofacial syndromes may drug.160 These drugs increase the bioavail-
introduced. This class of pure serotonin-3 result in anatomic and physiologic alter- ability of neurotransmitters. The drugs
receptor antagonists is not associated with ations as well as mental disabilities. Poten- tend to cause an increase in blood pres-
the side effects of dopamine, muscarinic, or tial airway abnormalities include macro- sure and heart rate. Adverse effects are
histamine receptor antagonists. The most glossia, micrognathia, choanal atresia, similar to that of other sympathomimetic
serious side effects of ondansetron are rare limited mouth opening, kyphoscoliosis, or agents. CNS effects include restlessness,
hypersensitivity reactions.155 Gastric emp- cervical spine abnormalities. These abnor- dizziness, tremor, hyperactive reflexes,
tying and small bowel transit time were not malities may make the patient more sus- weakness, insomnia, delirium, and psy-
affected by ondansetron. Asymptomatic ceptible to upper airway obstruction and chosis. Cardiovascular effects may include
brief prolongation of the PR interval and compromise spontaneous ventilation, headaches, palpitations, arrhythmias,
the QRS complex of the electrocardiogram oxygenation, mask ventilation, or laryn- hypertension followed by hypotension,
have been reported in adults, but rapid goscopy and intubation. Many of these and circulatory collapse.161
intravenous infusion of ondansetron in patients may have significant cardiovascu- Perioperative management of a patient
children was not associated with changes in lar disease associated with their syndrome. on a psychostimulant (such as methyl-
heart rate, arterial pressure, or oxyhemo- Mental impairment may also be associated phenidate) includes recognizing signs and
globin saturation.156 Psychomotor and res- with several congenital syndromes. Alter- symptoms suggestive of inappropriate use.
piratory function were unaffected by natively, physical disabilities are not always If there is a suggestion regarding overdose of
ondansetron. Prophylactic ondansetron associated with mental impairments. The the medication, the surgery should be post-
0.05 to 0.15 mg/kg IV or orally reduced the health care provider must avoid treating poned. However, when the medication is
incidence of PONV in children after a vari- these patients as if they were mentally used appropriately, it is generally well toler-
ety of surgical procedures.157 impaired because of their inability to com- ated. If there are no indications of adverse
Glucocorticoids (dexamethasone, municate normally. Lastly, substance events, the medication should be continued
methylprednisolone) exert antiemetic abuse among children and teens has throughout the perioperative period.
properties by a mechanism as yet un- reached epidemic proportions. Chronic use of the medication may decrease
known. These drugs have been used suc- This section reviews the clinical pre- anesthetic requirements.
cessfully in the postoperative setting to pre- sentation and anesthetic management of The anesthetic management of these
vent PONV. Dexamethasone in doses up to some patients with special considerations. patients is dependent on the level of co-
1 mg/kg IV (maximum dose 25 mg) was operation of the patient. Preoperative
effective in reducing postoperative vomit- Attention Deficit Hyperactivity sedatives may be used. Many of these indi-
ing in children after tonsillectomy.158 How- Disorder viduals allow the placement of an intra-
ever, low-dose dexamethasone 0.15 mg/kg Attention deficit hyperactivity disorder venous catheter. However, for the patient
IV was not as effective as perphenazine (ADHD) is defined as a persistent severe in whom intravenous access cannot be
70 g/kg IV in preventing emesis after ton- pattern of inattention or hyperactivity- established, ketamine (with or without
sillectomy in children.159 This class of impulsivity symptoms compared with midazolam) administered orally or IM is
drugs is better used in combination with other children at a comparable develop- effective and not contraindicated owing to
another antiemetic than as the sole agent to mental level. Three subtypes of ADHD are the chronic use of a psychostimulant.
prevent PONV. identified: a predominantly hyperactive-
impulsive type, a predominantly inatten- Autism
Special Considerations tive type, and a combined type. It is esti- Autism is a complex developmental dis-
Oral and maxillofacial surgeons treat a mated to affect up to 5% of children. ability that typically appears during the
diverse group of patients. Simplistically, Medical therapy frequently includes first 3 years of life. The result of a neuro-
the pediatric patient differs from the adult psychostimulants such as methyl- logic disorder that affects the functioning
Pediatric Sedation 119
of the brain, autism is the third most com- with a potent vapor agent or intramuscular that > 50% of patients with cerebral palsy
mon developmental disability in the Unit- ketamine may be considered; however, the do not demonstrate mental impairment.
ed States and occurs in approximately 2 to individual may be too physically strong Dysarthria or speech abnormalities sec-
4 per 10,000 live births.162 Autism is four and combative for these techniques. An ondary to a lack of coordination in muscle
times more prevalent in boys than in girls alternative that should be considered (even movement of the mouth can be seen in
and knows no racial, ethnic, or social in the noncombative individual) is oral athetoid cerebral palsy. This muscle
boundaries. Family income, lifestyle, and administration of a premedicant of keta- abnormality should not be confused with
educational levels do not affect the chance mine or ketamine and midazolam.89 Alter- mental impairment. Seizures are seen in
of autisms occurrence. ations in management must be carried up to 35% of patients with spastic cerebral
Autism impacts the normal develop- over into the postoperative period, in palsy. The lack of muscle coordination
ment of the brain in the areas of social which many patients with behavioral or contributes to drooling and dysphagia.
interaction and communication skills. mental impairments are more agitated. The inability to handle the secretions and
Children and adults with autism typically Restraint may be necessary to prevent pre- the incompetent pharyngeal swallow
have difficulties in verbal and nonverbal mature removal of the intravenous line, reflex increase the risk of laryngospasm.
communication, social interactions, and wound disturbance, or self-injury. Individuals with impaired neurologic
leisure or play activities. The disorder function may also have an increased inci-
makes it difficult for them to communi- Cerebral Palsy dence of gastroesophageal reflux.
cate with others and relate to the outside Cerebral palsy is a group of neurologic Several factors must be taken into con-
world.163,164 In some cases aggressive and/or disorders that are characterized by sideration in treating these patients. The
self-injurious behavior may be present. impaired control of movement. The clini- spasticity and lack of coordination can
Persons with autism may exhibit repeated cal manifestations are variable and are contribute to a hyperactive gag reflex. Anx-
body movements (hand flapping, rock- dependent on the site and extent of injury. iety can aggravate the involuntary move-
ing), unusual responses to people, or There are four classifications: spastic, ments. Nitrous oxide sedation may be
attachments to objects and resistance to athetoid, ataxic, and mixed. Spastic cere- effective in reducing these responses.167
changes in routines. Children with autistic bral palsy is the most common form and Severe contractures may make positioning
disorders may include a subgroup of indi- affects up to 80% of the patients. Patients the patient difficult. Contractures, which
viduals with associated psychiatric symp- with spastic cerebral palsy present with may result in scoliosis, can result in a
toms, including aggression, self-abusive muscle hypertonicity, hyperreflexia, muscle restrictive lung disorder. The patients
behavior, and violent tantrums, and often- contractures, muscle rigidity, and muscle hypotonia may necessitate stabilization of
times necessitate the use of psychiatric weakness. The pattern of dysfunction can the head (even for the nonsedated patient).
medications; antipsychotics are the most be further classified into monoplegia (one If the patient is to be sedated, muscle weak-
prevalently prescribed medications in this limb), diplegia (both arms or both legs), ness may predispose the patient to
group.165 The autistic patient may also be hemiplegia (unilateral), triplegia (three impaired respirations. This may be com-
prescribed medications similar to those limbs), and quadriplegia (all limbs). The pounded by medications prescribed to
prescribed for ADHD. severity of the contractures may result in control the spasticity or seizure disorder.
Management of these patients in the spinal deformities such as scoliosis. Conscious sedation may be contraindicated
oral and maxillofacial surgery setting Athetoid or dyskinetic cerebral palsy is because of the inability to handle oral
requires respect for the autistic childs need characterized by choreiform, tremor, dys- secretions and the risk of gastroesophageal
for ritualistic behavior, which may result in tonia, and hypotonia. The involuntary reflux. It may be necessary to protect the
tantrum-like rages with any disruptions of movements seen with athetoid cerebral airway with the placement of an endo-
routine. Providing a calm environment palsy often increase with emotional stress. tracheal tube. In the event that the airway
with minimal stimulation and considera- Ataxic cerebral palsy is characterized by requires emergent intubation, the use of
tion of all associated pharmacologic influ- poor coordination and jerky movements. succinylcholine is not contraindicated.168
ences aids in the management of these Associated medical conditions include
patients. Premedication with a benzo- mental retardation, speech abnormalities, Down Syndrome
diazepine may be beneficial. However, seizures, drooling, dysphagia, and gastro- Down syndrome, or trisomy 21, is a com-
establishing an intravenous access still may esophageal reflux.166 Mental impairment is mon chromosomal disorder occurring at a
not be possible, and an alternative tech- most common in patients with spastic rate of 1.5 per 1,000 live births and is usu-
nique may be required. A mask induction cerebral palsy. It is important to recognize ally characterized by mild to moderate
120 Part 1: Principles of Medicine, Surgery, and Anesthesia
mental retardation, cardiovascular abnor- gressive loss of skeletal muscle function. choline is contraindicated because it can
malities, and craniofacial abnormalities. There are nine types of muscular dystro- cause rhabdomyolysis with a resultant
Craniofacial abnormalities that have an phies, the most common and dramatic hyperkalemia. Although all patients may
impact on the anesthetic management of being Duchennes disease (pseudohyper- have a slight increase in extracellular potas-
these patients include macroglossia, trophic muscular dystrophy). Symptoms sium after the administration of succinyl-
micrognathia, and a short neck, putting typically begin between the ages of 2 to choline, the increase in a patient with mus-
these patients at increased risk for airway 5 years, often with the patient becoming cular dystrophy can cause hyperkalemic
obstruction during sedation. Enlargement wheelchair-bound by age 12 years. Death cardiac arrest. The avoidance of succinyl-
of the lymphoid tissue may also place usually occurs between ages 15 and choline and volatile inhalational agents is
these patients at risk for upper airway 25 years, usually secondary to pneumonia also recommended because of the associa-
obstruction. In addition, these patients or congestive heart failure. Beckers mus- tion of Duchennes disease with increased
have generalized joint laxity that may be cular dystrophy is the next most common malignant hyperthermia. Nondepolarizing
associated with subluxation of the tem- form of muscular dystrophy. Its manifes- muscle relaxants may be used; however, a
poromandibular joint during airway tations are similar, although milder, to prolonged recovery time is seen in patients
manipulation. Intubation is usually not those of Duchennes disease. Its onset is with muscular dystrophy. The response to
difficult, but subglottic stenosis, which is later, and the progression of the disease is reversal agents is also variable. Additional-
present in up to 25% of Down syndrome slower. Time to onset of disease, being ly, patients are susceptible to an un-
individuals, may necessitate a smaller- wheelchair-bound, and death are 12, 30, explained late respiratory depression.
diameter endotracheal tube. and 42 years, respectively.169 Ambulatory surgery may be unadvisable
Atlantoaxial instability occurs in The anesthetic management of these but at a minimum requires prolonged
approximately 20% of patients with Down patients is complicated by muscle weak- observation prior to discharge.170
syndrome, and airway maneuvers, such as ness contributing to poor respiratory
neck positioning during anesthesia for air- function. Atrophy of the paraspinal mus- Substance Abuse
way opening or intubation, may induce a cles also leads to kyphoscoliosis (restric- Substance abuse amongst children and
serious cervical injury (C1-2 subluxation). tive lung disease), which further restricts teens has reached epidemic proportions,
This cervical spine instability is a con- respiratory function. Pulmonary function regardless of socioeconomic status. In
traindication for routine treatment until tests should be considered as part of the 2001 an estimated 15.9 million Americans
both the patient and the treatment risks are preoperative assessment. Patients with ages 12 or older were current illicit drug
fully evaluated. Sequelae to neurologic functional vital capacities < 35% of nor- users, meaning they had used an illicit
injury are usually characterized by signifi- mal are at increased risk. Muscle weakness drug during the month prior to the survey
cant symptoms or declining neurologic also contributes to obtunded laryngeal interview. This estimate represents 7.1% of
function without other neurologic dis- reflexes and an inability to clear tracheo- the population ages 12 years old or older.
order. Specific symptoms may include a bronchial secretions. Patients are at Among youths ages 12 to 17 years, approx-
positive Babinski sign, hyperactive deep increased risk for aspiration secondary to imately 10% were current illicit drug
tendon reflexes, ankle clonus, neck discom- the obtunded laryngeal reflexes and users. Data from 1999 to 2001 identify
fort, and gait abnormalities. delayed gastric emptying. marijuana as the most popular abused
Down syndrome is associated with Patients with muscular dystrophy may drug, with a use approximating 7% of this
congenital heart disease in approximately also have cardiovascular disorders. These population. Other abused substances
40% of its patients, and consideration of include degenerative cardiomyopathy, car- included psychotherapeutic agents
these abnormalities (endocardial cushion diac arrhythmias, and mitral valve pro- (approximately 3%), cocaine (approxi-
defect, ventricular septal defect, tetralogy of lapse. It is frequently difficult to assess car- mately 0.5%), hallucinogens (approxi-
Fallot, patent ductus arteriosus, and atrial diovascular function in these patients mately 1%), and inhalants (approximately
septal defect) in conjunction with their pri- because they are usually wheelchair-bound 1%). An adequate history taking prior to
mary care physician is mandatory prior to and not sufficiently stressed. However, car- anesthesia regarding substance use and
proceeding with a surgical procedure. diac compromise must be considered, espe- abuse is therefore mandatory with all
cially in an older individual. Anesthetic patients. This history allows for a safer
Muscular Dystrophy considerations must take into considera- selection of anesthetic agents and
Muscular dystrophy is a group of diseases tion the potential for underlying respira- improved management of any periopera-
of genetic origin, characterized by the pro- tory and cardiovascular disease. Succinyl- tive complications.
Pediatric Sedation 121
Alcohol Alcohol is the most commonly Amphetamine Amphetamine, a racemic associated with ventricular hypertrophy,
used and abused substance among mixture of -phenylisopropylamine, is an myocardial depression, and cardiomyopa-
teenagers. Most alcohol use by US indirect sympathomimetic drug. It is a thy. Long-term use may also lead to con-
teenagers is in the form of binge drinking. powerful CNS stimulant with peripheral traction band necrosis. This phenomenon
Most long-term systemic effects of chron- and actions. The CNS mechanism of is associated with hypermetabolic condi-
ic alcohol abuse, including hepatic injury, amphetamine appears dependent on the tions, such as cocaine abuse, hyper-
pancytopenia, and the neurotoxic effects local release of biogenic amines such as thyroidism, and pheochromocytoma
(seizures, Wernicke-Korsakoff syndrome) norepinephrine from storage sites in nerve resulting from continuous catecholamine
are not present in the pre-adult abuser. terminals. Acute amphetamine use dramat- concentration elevation. This condition
Nonetheless, laboratory examinations ically increases anesthetic requirement and predisposes the patient to dysrhythmias.175
may reveal elevation of -glutamyltrans- has been implicated in a case of severe intra- Patients may also manifest neurologic
ferase, which is usually the first liver operative intracranial hypertension.171,172 effects. A decrease in seizure threshold has
enzyme to increase as a result of heavy Chronic amphetamine use is associated been demonstrated in young adults.
ethanol ingestion. Hepatic damage owing with a markedly diminished anesthetic Ischemic cerebral vascular accidents may
to alcohol frequently results in an aspar- requirement.173 This results from chronic result from the hypertensive crisis potenti-
tate transaminasetoalanine amino- stimulation of adrenergic nerve terminals ated by the cerebral vasoconstriction result-
transferase ratio > 1. A mean corpuscular in the peripheral nervous system and ing from the increased serotonin levels.
volume > 100 is strong confirmatory evi- CNS that depletes CNS catecholamines. Respiratory complications associated
dence of alcoholism. Refractory hypotension can result both with intranasal administration include
Aspiration risk is significantly intra- and postoperatively, requiring sneezing, sniffing, and acute rhinitis. Pul-
increased in the chronic alcoholic as alco- prompt pharmacologic intervention. monary complications associated with
hol stimulates gastric acid secretion and There can be a diminished pressor inhalational administration include
delays gastric emptying time. In addition, response to ephedrine after chronic cocaine-induced asthma, chronic cough,
the alcoholic patient may consume alcohol amphetamine use. This is due to cate- pulmonary edema, and pneumoperi-
the morning of the procedure to quell the cholamine depletion in central and cardium. Acute intoxication may result in
signs of withdrawal, thus negating the peripheral adrenergic neurons. hypoxia owing to pulmonary vasculature
NPO status. Cardiovascular changes asso- vasoconstriction.
ciated with chronic alcohol abuse result in Cocaine Cocaine is an alkaloid derived High levels of cocaine may persist for
alcoholic cardiomyopathy, with resultant from the leaves of a South American 6 hours after nasal administration. Elective
tachycardia and unexplained atrial or ven- shrub. The drug is snorted (intranasal), anesthetic management should be
tricular ectopy. injected (intravenous), or smoked deferred for at least 24 hours after the
Alcohol abuse influences the choice (inhaled). Its administration provides an patient has last used cocaine. Electro-
of anesthetic agents used in an outpatient intense euphoria. Cocaine use amongst cardiographic monitoring is recommend-
setting. Tolerance to anesthetic agents 12- to 17-year-olds in the United States is ed in all patients owing to the potential for
appears to develop in the chronic alco- approximately 0.8%.174 silent ischemia and arrhythmias. Anes-
holic. Altered liver function results in an The medical effects from cocaine thetic management may include control of
increased toxicity with anesthetic agents result from both acute intoxication as well preoperative anxiety with benzo-
that undergo hepatic metabolism. Pro- as chronic use. CNS stimulation, hyper- diazepines. Consideration should be given
longed activity and increased serum vigilance, anxiety, and agitation are com- to avoiding adrenergic stimulants such as
levels of both succinylcholine and mon in the acutely intoxicated individual. ketamine and epinephrine-containing
local anesthetic agents are the result Cardiovascular effects may include tachy- local anesthetics.
of decreased activity of plasma cardia, arrhythmias, hypertension, and
cholinesterase. Nondepolarizing para- ischemia. Ischemic myocardial injury may Ecstasy 3,4-Methylenedioxymeth-
lytics are also prolonged in chronic alco- occur, even in the young patient. These amphetamine (MDMA) is a stimulant that
hol abuse secondary to an increased level effects result from the inhibition of neural has psychedelic effects that can last for 4 to
of acetylcholine. Intravenous agents reuptake of dopamine, serotonin, and 6 hours and is usually taken orally in pill
should also include a benzodiazepine that tryptophan; increased adrenergic activity; form. The psychological effects of MDMA
compensates for the lack of -aminobu- and blockade of the sodium conduction include confusion, depression, anxiety,
tyric acid (GABA)-ergic stimulation. channels. Chronic cocaine abuse has been sleeplessness, drug craving, and paranoia.
122 Part 1: Principles of Medicine, Surgery, and Anesthesia
Adverse physical effects include muscle Inhalational Substances Inhalation sub- nia, severe depression). It is difficult to
tension, involuntary teeth clenching, nau- stance abuse is a problem usually associated determine the extent and mechanism of the
sea, blurred vision, feeling faint, tremors, with young patients including preteens. The LSD involvement in these illnesses. Periop-
rapid eye movement, and sweating or 1997 Monitoring the Future nationwide erative anesthetic practice involves recogni-
chills. There is also an added risk involved survey reported that inhalant use is most tion of the potential psychiatric effects of
with MDMA ingestion by people with cir- common in the eighth grade, in which 5.6% LSD on patients and avoidance of poten-
culatory problems or heart disease because of students used inhalants on a past-month tially aggravating agents.
of MDMAs ability to increase heart rate basis and 11.8% on a past-year basis.179
and blood pressure. They may present with photophobia, eye Marijuana Marijuana is the most com-
In 2001 an estimated 8.1 million irritation, diplopia, tinnitus, sneezing, monly used nonalcohol illicit drug for
(3.6%) of Americans ages 12 or older had anorexia, chest pain, and dysrhythmia. people < 18 years old. In 2001 it was used
tried ecstasy at least once in their lifetime. Before administering anesthesia one must by 76% of current illicit drug users.
The principle constituent of ecstasy take into consideration hepatic, renal, bone Approximately 56% of current illicit drug
(MDMA) can produce robust deleterious marrow, and other organ pathology caused users consumed only marijuana, 20% used
effects on serotonergic functioning in ani- by halogenated and impure chemicals. marijuana and another illicit drug, and the
mals, including serotonin depletion and remaining 24% used an illicit drug but not
the degeneration of serotonergic nerve ter- Lysergic Acid Diethylamide Approxi- marijuana in the past month. Patients who
minals.176 Although MDMA has been mately 1% of 16-year-olds in the United use marijuana may present with anxiety,
characterized as a hallucinogenic amphet- States used lysergic acid diethylamide panic attacks, and sympathetic discharge.
amine because of its structural similarity (LSD) in 2001. LSD, also known as acid, is Adverse effects of marijuana include
to mescaline and amphetamine, it rarely odorless and colorless, has a slightly bitter immunodeficiency and upper airway
induces hallucinatory experiences, nor is it taste, and is usually taken by mouth. Often hyperreactivity. Cases of laryngospasms
as potent a psychostimulant as ampheta- LSD is added to absorbent paper such as within 36 hours of its use have been
mine. Whether neurotoxicity also occurs blotter paper and divided into small deco- reported.180 A 2-adrenergic agonist such
in humans is unknown, but emerging evi- rated squares, with each square represent- as albuterol may be considered to treat this
dence indicates that repeated ecstasy expo- ing one dose. The effects of LSD are unpre- increased airway reactivity. Other periop-
sure results in performance decrements in dictable. They depend on the amount erative considerations include that mari-
neurocognitive function, which may be a taken; the users personality, mood, and juana potentiates opioid-induced respira-
manifestation of neurotoxicity.177,178 expectations; and the surroundings in tory depression, and barbiturate and
Most ecstasy tablets contain MDMA; which the drug is used. Usually the user ketamine recovery time may be prolonged.
other commonly identified ingredients feels the first effects of the drug 30 to 90 Myocardial depression can occur, and the
include ketamine, methylenedioxy- minutes after taking it. Physical manifesta- threshold for sympathomimetic-induced
amphetamine, amphetamine, dextrometh- tions include mydriasis, hyperthermia, dysrhythmias is lowered.
orphan, and combinations of these drugs. tachycardia, hypertension, diaphoresis,
Some tablets contain inert ingredients, anorexia, and tremors. Extreme emotional PCP PCP is a dissociative anesthetic that
whereas others contain phencyclidine variability may occur, with extreme delu- originally was synthesized for intravenous
hydrochloride (PCP). sions and visual hallucinations. LSD effects use. Because of its postoperative emer-
Perioperative management may are prolonged, typically lasting for gence reactions (ie, hallucinations, pro-
involve addressing several complications, > 12 hours. Flashbacks with auditory and longed abnormal level of consciousness,
the most common being syndrome of visual hallucinations may recur suddenly agitation), it fell out of favor, and its use as
inappropriate antidiuretic hormone, and without reuse of the drug and may occur an anesthetic in humans was discontinued
hyperthermia. Other less common but within a few days or more than a year after in 1963. PCP subsequently emerged as an
well-known potential complications LSD use. Flashbacks usually occur in people oral drug of abuse. PCP is a commonly
include tachycardia, agitation, and nausea who have used hallucinogens chronically or abused street drug that is sold under many
and vomiting. Monitoring for the stigma- who have an underlying personality prob- different names and in various forms. It
ta of hyponatremia and hyperthermia lem. However, otherwise healthy people may be sold on the street in tablet or cap-
supplements a well-performed preopera- who use LSD may also experience flash- sule form, as a powder, or as a solution.
tive history to determine which patients backs. Long-term effects of chronic LSD The PCP content in each form differs
are at risk. include psychiatric disorders (schizophre- widely, commonly from 10 to 30%. Angel
Pediatric Sedation 123
dust, the powdered form of PCP, general- 8. Todres ID, Cronin JH. Growth and develop- 22. Olsson GL, Hallen B, Hambraeus-Jonzon K.
ly has a higher PCP content, occasionally ment. In: Cote, Todres, Goudsouzian, Ryan, Aspiration during anesthesia: a computer
editors. A practice of anesthesia for infants aided study of 185,358 anesthetics. Acta
reaching 100%. Angel dust may be sniffed, and children. 3rd ed. Philadelphia: W.B. Anaesthesiol Scand 1986; 30:8492.
smoked, ingested, or injected IV. Percuta- Saunders; 2001. p. 12. 23. Tiret L, Nivoche Y, Hatton F, et al. Complica-
neous absorption also has been reported 9. Benumof JL, Dagg R, Benumof R. Critical tions related to anaesthesia in infants and
to occur in individuals handling PCP (eg, hemoglobin desaturation will occur before children: a prospective survey of 40,240
return to an unparalyzed state following 1 anaesthetics. Br J Anaesth 1988;61:2639.
law enforcement officers). Smoking
mg/kg intravenous succinylcholine. Anes- 24. Maekawa N, Mikawa K, Yaku H, et al. Effects of
remains the desired method of use; the thesiology 1997;87:97982. two-, four-, and twelve-hour fasting inter-
substance commonly is sprinkled onto 10. Kinouchi K, Fukumitsu K, Tashiro C, et al. vals on preoperative gastric fluid pH and
dried leaf material (eg, marijuana, tobac- Duration of apnoea in anaesthetized chil- volume, and plasma glucose and lipid
co, oregano, mint) and then smoked. dren required for desaturation of haemo- homeostasis in children. Acta Anaesthesiol
globin to 95%: comparison of three differ- Scand 1993;37:7837.
Perioperative anesthetic considera- ent breathing gases. Pediatr Anaesth 25. Splinter WM, Stewart JA, Muir JG. The effect
tions include its sympathomimetic effects, 1995;5:1159. of preoperative apple juice on gastric con-
similar to its congener, ketamine, with the 11. Xue FS, Luo LK, Tong Sy, et al. Study of the safe tents, thirst, and hunger in children. Can J
potential for tachycardia, tachyarrhyth- threshold of apneic period in children dur- Anaesth 1989;36:558.
ing anesthesia induction. J Clin Anesth 26. Splinter WM, Stewart JA, Muir JG. Large vol-
mias, and a true hypertensive emergency. 1996;8:56874. umes of apple juice preoperatively do not
Maintaining normotension and avoiding 12. Farmery AD, Roe PG. A model to describe the affect gastric pH and volume in children.
sympathomimetics, which may exacerbate rate of oxyhaemoglobin desaturation dur- Can J Anaesth 1990;37:369.
PCPs effects, are the standard for anes- ing apnoea. Br J Anaesth 1996;76:28491. 27. Splinter WM, Schaefer JD, Zunder IH. Clear
13. Veyckemans F. New developments in the man-
thetic management. fluids three hours before surgery do not
agement of the paediatric airway: cuffed or
affect the gastric fluid contents of children.
uncuffed tracheal tubes, laryngeal mask air-
Summary way, cuffed oropharyngeal airway, tra-
Can J Anaesth 1990;37:498501.
28. Splinter WM, Schaefer JD. Ingestion of clear
Ambulatory anesthesia in the pediatric cheostomy and one-lung ventilation devices.
fluids is safe for adolescents up to three
patient can be safely achieved in the oral Curr Opin Anaesthesiol 1999;12:315.
hours before anesthesia. Br J Anaesth
14. King BR, Baker MD, Braitman LE, et al. Endo-
and maxillofacial surgery office. The sur- tracheal tube selection in children: a com-
1991;66:4852.
geon has an array of techniques that are 29. Salem MR, Wong AY, Mani M, et al. Premed-
parison of four methods. Ann Emerg Med
icant drugs and gastric juice pH and vol-
available. A technique has to be selected 1993;22:5304.
ume in pediatric patients. Anesthesiology
that is appropriate for the patient, the 15. Mostafa SM. Variation in subglottic size in
1976;44:2169.
children. Proc R Soc Med 1976;69:7935.
planned procedure, and the specific office. 30. Parnis SJ, Barker DS, Van Der Walt JH. Clinical
16. Litman RS, Keon TP. Postintubation croup in
predictors of anaesthetic complications in
children. Anesthesiology 1991;75:11223.
References 17. Keenan RL, Shapiro JH, Kane FR, et al. Brady- children with respiratory tract infections.
1. Allen NA, Rowbotham DJ, Nimmo WS. cardia during anesthesia in infants: an epi- Paediatr Anaesth 2001;11:2940.
Hypoxemia during outpatient anaesthesia. demiologic study. Anesthesiology 1994; 31. Bailey AG, Badgwell JM. Common and
Anaesthesia 1989;44:50911. 80:97682. uncommon co-existing diseases that com-
2. Bone ME, Galler D, Flynn PJ. Arterial oxygen 18. Pang LM, Liu LMP, Cote CJ. Premedication plicate pediatric anesthesia. In: Badgwell
saturation during general anaesthesia for and induction of anesthesia. In: Cote, JM, editor. Clinical pediatric anesthesia. 1st
paediatric dental extractions. Anaesthesia Todres, Goudsouzian, Ryan, editors. A ed. Philadelphia: Lippincott-Raven; 1997.
1987;42:87982. practice of anesthesia for infants and chil- 32. Cate TR, Roberts TS, Russ MA, et al. Effect of
3. Takahashi E, Atsumi H. Age differences in tho- dren. 3rd ed. Philadelphia: W.B. Saunders; common cold on pulmonary function. Am
racic form as indicated by thoracic index. 2001. p. 173. Rev Respir Dis 1973;108:85865.
Hum Biol 1955;27:65. 19. US Department of Health and Human Ser- 33. Fridy WW Jr, Ingram RH Jr, Hierholzer JC, et
4. Davies G, Reid L. Growth of the alveoli and vices. 2001 national household survey on al. Airway function during mild viral respi-
pulmonary arteries in childhood. Thorax drug abuse. Available at: http://www.samh- ratory illnesses. Ann Intern Med 1974;
1970;25:66981. sa.gov/oas/nhsda/2k1nhsda/vol1/chap- 80:1505.
5. Dunnil MS. Postnatal growth of the lung. Tho- ter2.htm#2.age (accessed Sept 25, 2003). 34. Horner GJ, Gray FD Jr. Effect of uncomplicat-
rax 1962;17:329. 20. Kain ZN, Mayes LC, OConnor TZ, et al. Pre- ed, presumptive influenza on the diffusion
6. Thurlbeck WM. Postnatal human lung growth. operative anxiety in children: predictors capacity of the lung. Am Rev Respir Dis
Thorax 1982;37:56471. and outcomes. Arch Pediatr Adolesc Med 1973;108:8669.
7. Gerhardt T, Reifenberg L, Hehre D, et al. Func- 1996;150:123845. 35. Cohen MM, Cameron CB. Should you cancel
tional residual capacity in normal neonates 21. Borland LM, Sereika SM, Woelfel SK, et al. the operation when a child has an upper
and children up to 5 years of age deter- Aspiration in pediatric patients during gen- respiratory tract infection? Anesth Analg
mined by a N2 washout method. Pediatr Res eral anesthesia: incidence and outcome. J 1991;72:2828.
1986;20:66871. Clin Anesth 1998;10:95102. 36. Dueck R, Prutow R, Richman D. Effect of
124 Part 1: Principles of Medicine, Surgery, and Anesthesia
parainfluenza infection on gas exchange al. A comparison of chloral hydrate and 66. Smith JA, Santer LJ. Respiratory arrest follow-
and FRC response to anesthesia in sheep. diazepam sedation in young children. Pedi- ing intramuscular ketamine injection in a 4
Anesthesiology 1991;74:104451. atr Dent 1990;12:337. year-old child. Ann Emerg Med 1993;
37. DeSoto H, Patel RI, Soliman IE, et al. Changes 51. Brzustowicz RM, Nelson DA, Betts EK, et al. 22:6135.
in oxygen saturation following general Efficacy of oral premedication for pediatric 67. Carson IW, Moore J, Balmer JP, et al. Laryngeal
anesthesia in children with upper respirato- outpatient surgery. Anesthesiology 1984; competence with ketamine and other
ry infection signs and symptoms undergo- 60:4757. drugs. Anesthesiology 1973;38:12833.
ing otolaryngological procedures. Anesthe- 52. Malinovsky J-M, Populaire C, Cozian A, et al. 68. Penrose BH. Aspiration pneumonitis following
siology 1988;68:2769. Premedication with midazolam in children. ketamine induction for general anesthesia.
38. Levy L, Pandit UA, Randel GI, et al. Upper res- Effect of intranasal, rectal, and oral routes Anesth Analg 1972;51:413.
piratory tract infections and general anaes- on plasma midazolam concentrations. 69. Green SM, Johnson NE. Ketamine sedation for
thesia in children: peri-operative complica- Anaesthesia 1995;50:3514. pediatric procedures: part 2, review and
tions and oxygen saturation. Anaesthesia 53. Hilger PA. Fundamentals of otolaryngology: a implications. Ann Emerg Med 1990;
1992;47:67882. textbook of ear, nose, and throat disease. 6th 19:103346.
39. Olsson GL, Hallen B. Laryngospasm during ed. Philadelphia: WB Saunders Co; 1989. 70. White PF, Ham J, Way WL. Pharmacology of
anesthesia: a computer-aided incidence 54. Walbergh EJ, Wills RJ, Eckhert J. Plasma con- ketamine isomers in surgical patients.
study in 136,929 patients. Acta Anaesthesi- centrations of midazolam in children fol- Anesthesiology 1980;52:2319.
ol Scand 1984;28:56775. lowing intranasal administration. Anesthe- 71. Hollister GR, Burn JMB. Side effects of keta-
40. Olsson GL. Bronchospasm during anesthesia: a siology 1991;74:2335. mine in pediatric-anesthesia. Anesth Analg
computer aided incidence study of 136,929 55. Fishbein M, Lugo RA, Woodland J, et al. Evalu- 1974;53:2647.
patients. Acta Anaesthesiol Scand 1987; ation of intranasal midazolam in children 72. Meyers EF, Charles P. Prolonged adverse reac-
31:24452. undergoing esophagogastroduodenoscopy. J tions to ketamine in children. Anesthesiolo-
41. Tait AR, Reynolds PI, Gutstein HB. Factors that Pediatr Gastroenterol Nutr 1997;25:2616. gy 1978;49: 3940.
influence an anesthesiologists decision to 56. Lejus C, Renaudin M, Testa S, et al. Midazolam 73. Green SM, Nakamura R, Johnson NE. Keta-
cancel elective surgery for the child with an for premedication in children: nasal vs. rec- mine sedation for pediatric procedures:
upper respiratory tract infection. J Clin tal administration. Eur J Anaesthesiol part 1, a prospective study. Ann Emerg Med
Anesth 1995;7:4919. 1997;14:2449. 1990;19:102432.
42. Tait AR, Malviya S, Voepel-Lewis T, et al. Risk fac- 57. Graves NM, Kreil RL. Rectal administration of 74. Jackson APF, Dhadphale PR, Callaghan ML.
tors for perioperative adverse respiratory antiepileptic drugs in children. Pediatr Haemodynamic studies during induction
events in children with upper respiratory tract of anaesthesia for open-heart surgery using
Neurol 1987;3:3216.
infections. Anesthesiology 2001;95:299306. diazepam and ketamine. Br J Anaesth
58. Knudsen FU. Rectal administration of
43. Mier-Jedrzejowicz A, Brophy C, Green M. Res- 1978;50:3758.
diazepam in solution in the acute treatment
piratory muscle weakness during upper res- 75. Reich DL, Silvay G. Ketamine: an update on the
of convulsions in infants and children. Arch
piratory tract infections. Am Rev Respir Dis first twenty-five years of clinical experience.
Dis Child 1979;54:8557.
1988;138:57. Can J Anaesth 1989;35:18697.
59. Forbes RB, Vanderwalker GE. Comparison of
44. Kinouchi K, Tanigami H, Tashiro C, et al. 76. Cartwright PD, Pingel SM. Midazolam and
two and ten per cent rectal methoxitone for
Duration of apnea in anesthetized infants diazepam in ketamine anaesthesia. Anaes-
induction of anaesthesia in children. Can J
and children required for desaturation of thesia1984;39:43942.
Anaesth 1988;35:3459.
hemoglobin to 95%. Anesthesiology 1992; 77. Pruitt JW, Goldwasser MS, Sabol SR, et al.
60. White PF, Way WL, Trevor AJ. Ketamineits
77:11057. Intramuscular ketamine, midazolam, and
pharmacology and therapeutic uses. Anes-
45. Martin LD. Anesthetic implications of an glycopyrrolate for pediatric sedation in the
upper respiratory infection in children. thesiology 1982;56:11636. emergency department. J Oral Maxillofac
Pediatr Clin North Am 1994;41:12130. 61. Kitahata LM, Taub A, Kosaka Y. Lamina specif- Surg 1995;53:137.
46. Pierre N, Moy L, Redd S, et al. Evaluation of a ic suppression of dorsal-horn unit activity 78. Ryhanen P, Kangas T, Rantakla S. Premedica-
pregnancy-testing protocol in adolescents by ketamine hydrochloride. Anesthesiology tion for outpatient adenoidectomy: com-
undergoing surgery. J Pediatr Adolesc 1973;38:411. parison between ketamine and pethidine.
Gynecol 1998;11:13941. 62. Smith DJ, Bouchal RL, deSanctic CA, et al. Prop- Laryngoscope 1980;90:494500.
47. Malviya S, DErrico C, Reynolds P, et al. Should erties of the interaction between ketamine 79. Mogensen F, Muller D, Valentin N. Glycopyrro-
pregnancy testing be routine in adolescent and opiate binding sites in vivo and in vitro. late during ketamine/diazepam anaesthesia:
patients prior to surgery? Anesth Analg Neuropharmacology 1987;26:125360. a double-blind comparison with atropine.
1996;83:8548. 63. Drummond GB. Comparison of sedation with Acta Anaesthesiol Scand 1986;30:3326.
48. Cote CJ, Notterman DA, Karl HW, et al. midazolam and ketamine: effects on airway 80. Toft P, Romer UD. Glycopyrrolate compared
Adverse sedation events in pediatrics: a crit- muscle activity. Br J Anaesth 1996;76:6637. with atropine in association with ketamine
ical incidence analysis of contributing fac- 64. Shulman D, Beardsmore CS, Aronson HB, et al. anaesthesia. Acta Anaesthesiol Scand
tors. Pediatrics 2000;105:1494. The effect of ketamine on the functional 1987;31:43840.
49. Committee on Drugs, American Academy of residual capacity in young children. Anes- 81. Qureshi FA, Mellis PT, McFadden MA. Efficacy
Pediatrics. Alternate routes of drug admin- thesiology 1985;62:5516. of oral ketamine for providing sedation and
istration: advantages and disadvantages. 65. Corssen G, Gutierrez J, Reves JG, et al. Ketamine analgesia to children requiring laceration
Pediatrics 1997;100:14352. in the anesthetic management of asthmatic repair. Pediatr Emerg Care 1995;11:937.
50. Badalaty MM, Houpt MI, Koenigsberg SR, et patients. Anesth Analg 1972;51:58896. 82. Grant IS, Nimmo WS, McNichol LR, et al. Ket-
Pediatric Sedation 125
amine disposition in children and adults. Br 99. van der Bijl P, Roelofse JA. Disinhibitory reac- Staircase assessment of the magnitude and
J Anaesth 1983;55:110711. tions to benzodiazepines: a review. J Oral time course of 50% nitrous oxide analgesia.
83. Grant IS, Nimmo WS, Clements JA. Pharmaco- Maxillofac Surg 1991;49:51923. J Dent Res 1992;71: 1598603.
kinetics and analgesic effect of IM and oral 100. Ewah B, Carr C. A comparison of propofol and 116. Litman RS, Berkowitz RJ, Ward DS. Levels of
ketamine. Br J Anaesth 1981;53:80510. methohexitone for dental chair anaesthesia consciousness and ventilatory parameters
84. Alfonzo-Echeverri EC, Berg JH, Wild TW, et al. in children. Anaesthesia 1993;48:2602. in young children during sedation with oral
Oral ketamine for pediatric dental surgery 101. Borgeat A, Popovic V, Meier D, et al. Compari- midazolam and nitrous oxide. Arch Pediatr
sedation. Pediatr Dent 1993;15:1825. son of propofol and thiopental/halothane Adolesc Med 1996;150;6715.
85. Tobias JD, Phipps S, Smith B, et al. Oral keta- for short-duration ENT surgical procedures 117. Litman RS, Kottra JA, Berkowitz RJ, et al.
mine premedication to alleviate the distress in children. Anesth Analg 1990;71:5115. Breathing patterns and levels of conscious-
of invasive procedures in pediatric oncolo- 102. Havel CJ Jr, Strait RT, Hennes H. A clinical trial ness in children during administration of
gy patients. Pediatrics 1992;90:53741. of propofol vs midazolam for procedural nitrous oxide after oral midazolam pre-
86. Alderson PJ, Lerman J. Oral premedication for sedation in a pediatric emergency depart- medication. J Oral Maxillofac Surg 1997;55:
paediatric ambulatory anaesthesia: a com- ment. Acad Emerg Med 1999;6:98997. 13727.
parison of midazolam and ketamine. Can J 103. Hertzog JH, Campbell JK, Dalton HJ, et al. 118. Litman RS, Kottra JA, Verga KA, et al. Chloral
Anaesth 1994;41:2216. Propofol anesthesia for invasive procedures hydrate sedation: the additive sedative and
87. Funk W, Jakob W, Riedl T, et al. Oral preanes- in ambulatory and hospitalized children: respiratory depressant effects of nitrous
thetic medication for children: double-blind experience in the pediatric intensive care oxide. Anesth Analg 1998;86:7248.
randomized study of a combination of mida- unit. Pediatrics 1999;103(3):E30. 119. Epstein RH, Stein AL, Marr AT, et al. High con-
zolam and ketamine vs. midazolam or keta- 104. Lebovic S, Reich DL, Steinberg LG, et al. Com- centration versus incremental induction of
mine alone. Br J Anaesth 2000;84:33540. parison of propofol versus ketamine for anesthesia with sevoflurane in children: a
88. Warner DL, Cabaret J, Velling D. Ketamine plus anesthesia in pediatric patients undergoing comparison of induction times, vital signs,
midazolam, a most effective paediatric oral cardiac catheterization. Anesth Analg and complications. J Clin Anesth 1998
premedicant. Paediatr Anaesth 1995;2:2935. 1992;74:4904. ;10:415.
89. Rosenberg M. Oral ketamine for deep sedation 105. Martin TM, Nicolson SC, Bargas MS. Propofol 120. Kern C, Erb T, Frei FJ. Haemodynamic
of difficult-to-manage children who are anesthesia reduces emesis and airway responses to sevoflurane compared with
mentally handicapped: case report. Pediatr obstruction in pediatric outpatients. halothane during inhalational induction in
Dent 1991;13:2213. Anesth Analg 1993;76:1448. children. Paediatr Anaesth 1997;7:43944.
90. Rainey L, van der Walt JH. The anaesthetic 106. Norreslet J, Wahlgreen C. Propofol infusion for 121. Sigston PE, Jenkins AM, Jackson EC, et al.
management of autistic children. Anaesth sedation of children. Crit Care Med Rapid inhalation induction in children: 8%
Intensive Care 1998;26:6826. 1990;18:8902. sevoflurane compared to 5% halothane. Br
91. Mirakhur RK. Comparative study of the effects 107. Reed MD, Yamashita TS, Marx CM, et al. A J Anaesth 1997;78:3625.
of oral and I.M. atropine and hyoscine in pharmacokinetically based propofol dosing 122. Doi M, Ikeda K. Respiratory effects of sevoflu-
volunteers. Br J Anaesth 1978;50:5918. strategy for sedation of the critically ill, rane used in conjunction with nitrous oxide
92. Connors K, Terndrup TE. Nasal versus oral mechanically ventilated pediatric patient. & surgical stimulation. J Clin Anesth
midazolam for sedation of anxious children Crit Care Med 1996;24:147381. 1994;6:14.
undergoing laceration repair. Ann Emerg 108. Macrae D, James I. Propofol infusion in chil- 123. Blayney MR, Malins AF, Cooper GM. Cardiac
Med 1994;24:10749. dren. BMJ 1992;305:9534. arrhythmias in children during outpatient
93. Litman RS, Kottra JA, Berkowitz RJ, et al. Breath- 109. Bray RJ. Fatal myocardial failure associated general anaesthesia: a prospective random-
ing patterns and levels of consciousness in with a propofol infusion in a child. Anaes- ized trial. Lancet 1999;354:18646.
children during administration of nitrous thesia 1995;50(1):94. 124. Johnston RR, Eger EI Jr, Wilson C. A compara-
oxide after oral midazolam premedication. J 110. Cray SH, Robinson BH, Cox PN. Lactic tive interaction of epinephrine with enflu-
Oral Maxillofac Surg 1997;55: 13727. acidemia and bradyarrhythmia in a child rane, isoflurane, and halothane in man.
94. Litman RS. Airway obstruction after oral mida- sedated with propofol. Crit Care Med Anesth Analg 1976;55:70912.
zolam. Anesthesiology 1996;85:12178. 1998;26:208792. 125. Moore MA, Weiskopf RB, Eger EI Jr, et al.
95. Litman RS, Kottra JA, Berkowitz RJ, et al. 111. Parke TJ, Stevens JE, Rice AS, et al. Metabolic Arrhythmogenic doses of epinephrine are
Upper airway obstruction during midazo- acidosis and fatal myocardial failure after similar during desflurane or isoflurane
lam/nitrous oxide sedation in children with propofol infusion in children: five case anesthesia in humans. Anesthesiology
enlarged tonsils. Pediatr Dent 1998; reports. BMJ 1992;305:6136. 1993;79:9437.
20:31820. 112. Strickland RA, Murray MJ. Fatal metabolic aci- 126. Navarro R, Weiskopf RB, Morre MA, et al.
96. McMillan CO, Spahr SI, Sikich N, et al. Pre- dosis in a pediatric patient receiving an Humans anesthetized with sevoflurane or
medication of children with oral midazo- infusion of propofol in the intensive care isoflurane have similar arrhythmogenic
lam. Can J Anaesth 1992;39:54550. unit: is there a relationship? Crit Care Med response to epinephrine. Anesthesiology
97. Hiller A, Olkkola KT, Isohanni P, et al. Uncon- 1995;23:4059. 1994;80:5459.
sciousness associated with midazolam and 113. FDC Reports. US Food and Drug Administra- 127. Simmons M, Miller CD, Cummings GC, et al.
erythromycin. Br J Anaesth 1994;65:8268. tion; 1992 Sep 7;54:14. Outpatient pediatric dental anesthesia: a
98. Bailey DG, Malcolm J, Arnold O, et al. Grape- 114. Jastak JT, Donaldson D. Nitrous oxide. Anesth comparison of halothane, enflurane, and
fruit juice-drug interactions. Br J Clin Phar- Prog 1991;38:14253. isoflurane. Anaesthesia 1989;44:7358.
macol 1998;46: 10110. 115. Kaufman E, Chastain DC, Gaughan AM, et al. 128. Campbell C, Nahrwold ML, Miller DD. Clini-
126 Part 1: Principles of Medicine, Surgery, and Anesthesia
cal comparison of sevoflurane and isoflu- 141. Liu LM, DeCook TH, Goudsouzian NG, et al. lar compromise in children. Paediatr
rane when administered with nitrous oxide Dose response to intramuscular succinyl- Anaesth 1995;5:1214.
for surgical procedures of intermediate choline in children. Anesthesiology 1981; 157. Furst SR, Sullivan LJ, Soriano SG, et al. Effects
duration. Can J Anaesth 1995;42:88490. 55:599602. of ondansetron on emesis in the first 24
129. Davis PJ, Cohen IT, McGowan FX, et al. Recov- 142. Lazzell VA, Carr AS, Lerman J, et al. The inci- hours after craniotomy in children. Anesth
ery characteristics of desflurane versus dence of masseter muscle rigidity after suc- Analg 1996;83:3258.
halothane for maintenance of anesthesia in cinylcholine in infants and children. Can J 158. Morton NS, Camu F, Dorman T, et al.
pediatric ambulatory patients. Anesthesiol- Anaesth 1994;41:4759. Ondansetron reduces nausea and vomiting
ogy 1994;80:298302. 143. Littleford JA, Patel LR, Bose D, et al. Masseter after paediatric adenotonsillectomy. Paedi-
130. Epstein RH, Mendel HG, Guarnieri KM, et al. muscle spasm in children: implications of atr Anaesth 1997;7:3745.
Sevoflurane versus halothane for general continuing the triggering anesthetic. 159. Pappas ALS, Sukhani R, Hotaling AJ, et al. The
anesthesia in pediatric patients: a compara- Anesth Analg 1991;72:15160. effect of preoperative dexamethasone on
tive study of vital signs, induction and 144. Sullivan M, Thompson WK, Hill GD. Succinyl- the immediate and delayed postoperative
emergence. J Clin Anesth 1995;7:23744. choline induced cardiac arrest in children morbidity in children undergoing adeno-
131. Nathanson MH, Fredman B, Smith I, et al. with undiagnosed myopathy. Can J Anaesth tonsillectomy. Anesth Analg 1998;87:5761.
Sevoflurane versus desflurane for outpa- 1994;41:497501. 160. US Department of Health and Human Ser-
tient anesthesia: a comparison of mainte- 145. Kerr TP, Durward A, Hodgson SV, et al. Hyper- vices. 19992000 National household sur-
nance and recovery profiles. Anesth Analg kalaemic cardiac arrest in a manifesting vey on drug abuse. Available at:
1995;81:118690. carrier of Duchenne muscular dystrophy http://www.samhsa.gov/oas/ nhsda/2kde-
132. Welborn LG, Hannallah RS, Norden JM, et al. following general anaesthesia. Eur J Paedia- tailedtabs/Vol_1_Part_1/sect1v1.htm#1.10
Comparison of emergence and recovery tr 2001;160:57980. 9b (accessed Sept 25, 2003).
characteristics of sevoflurane, desflurane, 146. deLisser EA, Muravchick S. Emergency 161. Huss M, Lehmkuhl U. Methylphenidate and
and halothane in pediatric ambulatory transtracheal ventilation. Anesthesiology substance abuse: a review of pharmacology,
patients. Anesth Analg 1996;83:91720. 1981;55:6067. animal, and clinical studies. J Atten Disord
133. Ariffin SA, Whyte JA, Malins AF, et al. Com- 147. Peak DA, Roy S. Needle cricothyroidotomy 2002;6 Suppl 1:S6571.
parison of induction and recovery between revisited. Pediatr Emerg Care 1999;15:2246. 162. Frith U. Autism. Sci Am 1993;268:10814.
sevoflurane and halothane supplementa- 148. Cohen MM, Cameron CB, Duncan PG. Pedi- 163. Bauer S. Autism and the pervasive develop-
tion of anaesthesia in children undergoing atric anesthesia morbidity and mortality in mental disorders: part 1. Pediatr Rev 1995;
outpatient dental extractions. Br J Anaesth the perioperative period. Anesth Analg 16(4):13060.
1997;78:1579. 1990;70:1607. 164. Bauer S. Autism and the pervasive develop-
134. Paris ST, Cafferkey M, Tarling M, et al. Com- 149. Splinter WM, MacNeill HB, Menard EA, et al. mental disorders: part 2. Pediatr Rev
parison of sevoflurane and halothane for Midazolam reduces vomiting after tonsil- 1995;16(5):16876.
outpatient dental anaesthesia in children. lectomy in children. Can J Anaesth 165. Behrman RE, Kliegman RM, Arvin AM, edi-
Br J Anaesth 1997;79:2804. 1995;42:2013. tors. Nelson textbook of pediatrics. 16th ed.
135. Kenna JG, Jones RM. The organ toxicity of 150. Splinter WM, Roberts DJ. Perphenazine Philadelphia: WB Saunders; 2000. p. 878.
inhaled anesthetics. Anesth Analg 1995; decreases vomiting by children after tonsil- 166. Stoelting RK, Dierdorf SF. Diseases common to
81:S5166. lectomy. Can J Anaesth 1997;44:130810. the pediatric patient. In: Stoelting RK, Dier-
136. Njoku D, Laster MJ, Gong DH, et al. Biotrans- 151. Ferrari LR, Donlon JV. Metoclopramide dorf SF, editors. Anesthesia and co-existing
diseases. 3rd ed. Edinburgh: Churchill Liv-
formation of halothane, enflurane, isoflu- reduces the incidence of vomiting after ton-
ingston; 1993. p. 579.
rane, and desflurane to trifluoroacetylated sillectomy in children. Anesth Analg
167. Kaufman E, Meyer S, Wolnerman JS, et al.
liver proteins: association between protein 1992;75:3514.
Transient suppression of involuntary
acylation and hepatic injury. Anesth Analg 152. Fujii Y, Toyooka H, Tanak H. Antiemetic effica-
movements in cerebral palsy patients dur-
1997;84:1738. cy of granisetron and metoclopramide in
ing dental treatment. Anesth Progr
137. Malan TP Jr. Sevoflurane and renal function. children undergoing ophthalmic or ENT
1991;38:2005.
Anesth Analg 1995;81:S3945. surgery. Can J Anaesth 1996;43:10959.
168. Theroux MC, Brandom BW, Zagnoev M, et al.
138. Ebert TJ, Messana LD, Uhrich TD, et al. 153. Salmenpera M, Kuoppamaki R, Salmenpera A.
Dose response of succinylcholine at the
Absence of renal and hepatic toxicity after Do anticholinergic agents affect the occur-
adductor pollicis of children with cerebral
1.25 minimum alveolar anesthetic concen- rence of postanaesthetic nausea? Acta
palsy during propofol and nitrous oxide
tration sevoflurane anesthesia in volun- Anaesthesiol Scand 1992;36:4458. anesthesia. Anesth Analg 1994;79:7615.
teers. Anesth Analg 1998;86:6627. 154. Doyle E, Byers G, McNicol LR, Morton NS. 169. Engel AG. Diseases of muscles (myopathies)
139. Dsida RM, Wheeler M, Birmingham PK, et al. Prevention of postoperative nausea and and neuromuscular junction. In: Bennett
Premedication of pediatric tonsillectomy vomiting with transdermal hyoscine in JC, Plum F, editors. Cecil textbook of med-
patients with oral transmucosal fentanyl children using patient-controlled analgesia. icine. 20th ed. Philadelphia: WB Saunders;
citrate. Anesth Analg 1998;86:6670. Br J Anaesth 1994;72:726. 1996. p. 2161.
140. Epstein RH, Mendel HG, Witkowski TA, et al. 155. Smith RN. Safety of ondansetron. Eur J Cancer 170. Tonkovic-Capin M, Cheng EY. Perioperative
The safety and efficacy of oral transmucos- Clin Oncol 1989;25 Suppl 1:S4750. management of the patient with muscular
al fentanyl citrate for preoperative sedation 156. Rose JB, McCloskey JJ. Rapid intravenous dystrophy. In: Altee JL, editor. Complica-
in young children. Anesth Analg administration of ondansetron or metoclo- tions in anesthesia. Philadephia: WB Saun-
1996;83:12005. pramide is not associated with cardiovascu- ders; 1999. p. 486.
Pediatric Sedation 127
171. Foex P, Prys-Robert D. Anesthesia and the household survey on drug abuse. Available at: 177. Morgan JF. Ecstasy use and neuropathology. Br
hypertensive patient. Br J Anaesth 1974; http://www.samhsa.gov/oas/nhsda/98Summ J Psychiatry 1999;175:589.
46;57588. Html/NHSDA98Summ-05.htm#P369_29947 178. Rodgers J. Cognitive performance amongst
172. Michel R, Adams AP. Acute amphetamine abuse. (accessed Sept 25, 2003). recreational users of ecstasy. Psychophar-
Problems during general anaesthesia for neu- 175. Laposata EA. Cocaine-induced heart disease: macology (Berl) 2000;151:1924.
rosurgery. Anaesthesia 1979;34:10169. mechanisms and pathology. J Thorac Imag- 179. US Department of Health and Human Services.
173. Johnston RR, Way WL, Millard RD. Alteration ing 1991;6:6875. 1998 national drug control strategy. Available
of anesthetic requirement by amphetamine. 176. Ricaurte GA, Yuan J, McCann UD. (+/-)3,4-Meth- at: http://www.health.org.ndcs98/ii.html,
Anesthesiology 1972;36:35763. ylenedioxymethamphetamine (Ecstasy)- 1999.
174. US Department of Health and Human Services. induced serotonin neurotoxicity: studies in 180. White SM. Cannabis abuse and laryngospasm.
Summary of findings from the 1998 national animals. Neuropsychobiology 2001;42:510. Anaesthesia 2002;57:6223.
Part 2
DENTOALVEOLAR SURGERY
CHAPTER 7
Management of Impacted
Teeth Other than Third Molars
Deborah L. Zeitler, DDS, MS
The management of impacted teeth is a Myrberg examined more than 6,000 Although impaction of permanent
basic component of most oral and max- Swedish school children and found a 5.4% teeth is a relatively common finding, the
illofacial surgery practices. Although the prevalence of impacted teeth excluding lack of eruption of a primary tooth is
majority of impacted teeth are third third molars.2 In an evaluation of 3,874 apparently quite rare. When it occurs it is
molars, any other tooth may be impacted. full-mouth radiographs, Dachi and How- almost always a mandibular molar. Sub-
The usual care for impacted third molars ell found the incidence of impacted merged teeth are common in the primary
is removal; however, the care for impact- canines in the maxilla to be 0.92% and of dentition but generally reflect teeth that
ed teeth other than third molars may other nonthird molar teeth to be 0.38%.3 erupted into a normal position and later
include exposure (with or without This study also identified maxillary became ankylosed and secondarily sub-
attachment of an orthodontic bracket), canines as the most commonly impacted merged. Bianchi and Roccuzzo have iden-
uprighting, transplantation, or removal. teeth after maxillary and mandibular tified 10 cases in the literature of the past
These teeth often pose challenges in treat- third molars. In a study of middle-aged 20 years that appear to illustrate primary
ment planning and surgical care. This and older Swedish women, Grondahl impaction of deciduous teeth.6 A recent
chapter includes information on inci- found approximately 25 nonthird molar review suggests that primary tooth
dence, etiology, evaluation, and surgical impacted teeth in 1,418 women evaluat- impaction is usually associated with
treatment options. ed.4 Again, the canine tooth was the most defects in the development and eruption
frequent nonthird molar impaction of the permanent successor, suggesting the
Incidence identified, followed by premolars and sec- need for long-term follow-up.7
The incidence of impacted permanent ond molars. This study examined an older
teeth has been addressed in several stud- population than did most of the other
ies. Grover and Lorton examined 5,000 studies and had a lower incidence of
army recruits and found a high frequency nonthird molar impacted teeth. Presum-
of impacted teeth (Figure 7-1).1 Although ably symptomatic teeth and those with
maxillary and mandibular third molars pathologic findings were removed at ear-
were the teeth most commonly impacted, lier ages in this population.4 These studies
212 teeth excluding third and fourth are all similar in identifying the maxillary
molars were impacted. This study identi- canine as the tooth most likely to be
fied the maxillary canine as the tooth impacted following third molars. The
most likely to be impacted following max- next most likely teeth to be impacted are
illary and mandibular third molars. mandibular bicuspids, followed by maxil-
Impactions of every permanent tooth lary bicuspids and second molars.
were identified except the mandibular Impactions of first molars and incisors are
incisors and first molars. Thilander and relatively uncommon (Figure 7-2).5 FIGURE 7-1 Multiple impacted teeth.
132 Part 2: Dentoalveolar Surgery
tooth, dentigerous cysts or odontogenic ized on the lingual or palatal side. A facial consequences of treatment.4 Methods of
tumors, and pericoronitis.5,9 or buccally located tooth moves in the treatment of impacted permanent teeth
opposite direction to the tube shift.17 The include orthodontic assistance through
Evaluation buccal object rule uses two radiographs surgical exposure with or without attach-
Clinical diagnosis of impacted permanent taken with different vertical angulations of ment of the tooth, surgical uprighting,
teeth is straightforward, involving clinical the x-ray beam. An object located on the transplantation, and surgical removal.
inspection that discloses the absence of the buccal side moves inferiorly with the beam
tooth in its normal position combined directed inferiorly, whereas an object Exposure
with the radiographic assessment showing located in a lingual or palatal position Surgical exposure is a procedure that
the unerupted position of the tooth. moves superiorly. The periapical occlusal allows natural eruption of impacted
Radiographic assessment of the method uses the periapical radiograph teeth.9,20 hman and hman studied 542
impacted teeth is important in the prepa- taken with a standard technique and an impacted teeth in 389 patients.20 In this
ration for surgical or orthodontic treat- occlusal radiograph to give two different study the crowns of the teeth were surgi-
ment. Most techniques for localization of views of the impacted tooth.17 cally exposed with removal of tissues in
an impacted tooth have been studied pri- Panoramic films can be used to assess the direction most appropriate for crown
marily with maxillary canines. These tech- maxillary canine position (Figure 7-5).18 movement. The wounds were packed until
niques, however, can be generalized to This technique uses the property that an they were totally epithelialized. The teeth
other teeth in the oral cavity. Ericson and object closer to the tube (palatal) is rela- were allowed to erupt for up to 24 months
Kurol have studied the radiographic tively magnified, and is most accurate or until the greatest diameter of the crown
appearance of ectopically erupting maxil- when the tooth is close to the alveolar reached the level of the mucosal surface.
lary canines and have found that a palpa- crest. A study comparing magnification Of 542 teeth only 16 were failures (failure
ble canine generally erupts in a relatively from a panoramic radiograph with a verti- to erupt after 24 mo or with other compli-
normal position.14 Most canines can be cal parallax from occlusal and panoramic cations). This study found that the teeth
evaluated with accuracy from convention- films showed a slight superiority for the tended to show a change of inclination of
al periapical films. Axial or panoramic vertical parallax method. Both methods the longitudinal access by rotation along
films were less useful.14 When polytomo- were better at localizing palatal cuspids the root. Age did not appear to be a factor
grams were used, root resorption was than labial cuspids.19 in success, although most patients were
diagnosed with greater accuracy. This < age 19 years.20
study indicated that the optimal age for Surgical Treatment In a study of impacted premolars, Thi-
evaluating an ectopically positioned Treatment of impacted permanent teeth lander and Thilander showed that surgical
canine was 10 to 13 years, depending on must be based on clinical and radiograph- exposure alone resulted in eruption, pro-
individual development.15 A study com- ic evaluation as well as a determination of vided that space was present in the arch.21
paring plain film radiography with com- future risks. Clearly, teeth that are sympto- However, mesially tipped premolars had a
puted tomography (CT) showed CT to be matic, have caused infection in the sur- poor prognosis and required orthodontic
superior in showing tooth and root shape, rounding tissues, or have radiographic evi-
crown-root relationship, and tooth incli- dence of development of changes (cyst
nation.16 However, the higher cost and formation, resorption of adjacent teeth, or
radiation dose of CT limits its use to root resorption of the impacted teeth)
impacted teeth in unusual positions or in require surgical treatment. Treatment of
proximity to vital structures. the asymptomatic tooth must take into
Standard radiographic techniques account many factors, including age, spe-
may be used to localize the unerupted cific prevalence of pathologic conditions,
teeth. These include the tube shift method, severity of potential pathology associated
buccal object rule, and periapical occlusal with impacted teeth, progression of
method.17 The tube shift method uses two untreated conditions, frequency and
periapical radiographs, shifting the tube severity of potential complications of
horizontally between exposures. If the treatment, potential patient discomfort
unerupted tooth moves in the same direc- and inconvenience associated with either FIGURE 7-5 Panoramic films can be used to
tion in which the tube is shifted, it is local- treatment or nontreatment, and economic localize maxillary canines.
134 Part 2: Dentoalveolar Surgery
guidance. Laskin and Peskin believe that if done with a conservative exposure of the
exposure of teeth is to result in successful tooth, removing only enough soft tissue
spontaneous eruption, it should be done and bone to place the bonded bracket, and
as soon as it is determined that the tooth is avoiding exposure of the CEJ.9
not going to erupt spontaneously.22 Studies have compared simple expo-
More commonly, the technique of sure with packing to maintain a gingival
surgical exposure is combined with attach- path for eruption, with exposure and
ment of an orthodontic appliance to the bonding of a bracket. Iramaneerat and
tooth, allowing active guidance of the colleagues found that there was no differ-
A
impacted tooth into an ideal position. ence in total orthodontic treatment time
Important factors in this technique are for the two techniques.26 Pearson and col-
prior orthodontic treatment to provide leagues found that bracketing was more
adequate space within the dental arch for costly and more likely to require reopera-
the impacted tooth, and anchorage. Many tion.27 Nonetheless, placing a bracket is
appliances have been advocated, including the more popular technique, perhaps
polycarbonate crowns and pins inserted owing to orthodontist preference and
into the structure of the tooth. Both of patient comfort.
these techniques are used rarely because of For the most common type of
the problems of availability of bonded nonthird molar impaction, the maxillary
orthodontic brackets/buttons. palatal cuspid, the typical surgical exposure
B
Wires placed around the cervical line involves reflection of the full-thickness
of the tooth have been a common method palatal flap, conservative exposure of the
of orthodontic guidance; however, this tooth, and bonding of a bracket to its
technique has been regarded as relatively palatal surface (Figure 7-6). If the tooth is
invasive. A clinical report in 1981 identi- near the free edge of the flap, soft tissue
fied external resorption as a possible may be removed to leave the crown
sequela of the wide exposure at the cemen- exposed; the wound is then packed gently
toenamel junction (CEJ) that is necessary during the initial healing period. If the
for placement of a cervical wire.23 This tooth is deeply impacted, it may be more
complication was studied by Kohavi and appropriate to replace the soft tissue flap,
colleagues in 1984 in 23 patients who had bringing a wire attached to the bonded
surgical exposure and attachment of a cer- bracket through the soft tissues near the
vical wire to the tooth.24 The teeth were crest of the ridge. The technique of replac- C
separated into two groups; one had light ing the flap has been examined for its peri-
FIGURE 7-6 A, Right maxillary canine is
exposure for placement of a band not odontal consequences. The clinical out- unerupted. B, Radiograph showing impacted
exposing the CEJ, and the second had comes show minimal effects of the closed canine. C, Bracket placed. Reproduced with per-
heavy exposure involving the removal of eruption technique on the periodontium.28 mission from Zeitler D. Management of impact-
ed teeth other than third molars. Oral Maxillo-
bone, complete removal of the follicular Management of the cuspid that is fac Surg Clin North Am 1993;5:95103.
sac, and full exposure of the CEJ. This impacted on the labial side follows the
study showed significantly more damaging same general principles as for the palatally
effects of the heavy exposure technique, impacted cuspid. A position in the arch tify the position of the impacted tooth.
and the authors recommended avoiding must be established by preliminary ortho- The crown of the tooth is conservatively
exposure of the neck of the tooth for dontic treatment prior to cuspid exposure. uncovered, and a bonded bracket is
placement of a cervical wire.24 An additional important factor for the attached; then vertical releasing incisions
Although the use of attachments such labially impacted cuspid is preservation of are made to provide a broadly based flap
as rare earth magnets has been advised for attached mucosa adjacent to the cervical that is superiorly repositioned to cover the
the movement of teeth, the most common line of this tooth. Generally the most CEJ of the tooth. The bonded bracket
method is the placement of a bonded appropriate technique is to begin with a helps to support the attached gingiva in
orthodontic bracket.25 This can usually be full-thickness mucoperiosteal flap to iden- this apical relationship (Figure 7-7). As the
Management of Impacted Teeth Other than Third Molars 135
Uprighting
Surgical uprighting of teeth has been
applied most commonly to impacted
molars. Reynolds identifies several reasons
for uprighting lower molar teeth, includ-
ing providing occlusion with opposing
teeth and proximal contacts with adjacent C
teeth, minimizing the risk of caries and
FIGURE 7-9 A, Impacted second molar. B, Sec-
periodontal disease, and assisting in FIGURE 7-8 Third molar in path of second molar ond molar lifted into position. C, Six-month fol-
orthodontic treatment.29 Paleczny adds eruption. low-up radiograph of repositioned second molar.
136 Part 2: Dentoalveolar Surgery
is ensuring that there are no occlusal and Thilander studied 47 patients with 56 surgical principles of radiographic assess-
forces on the repositioned second molar. canines that were surgically transplanted.33 ment and careful surgical technique must
This generally does not require equilibra- The advocated technique is a careful wide be followed. Conservation of bone
tion on the opposing tooth, but an exposure of the impacted tooth. The tooth through conservative exposure and
occlusal adjustment can be performed if is then moved into its position within the removal with sectioning of the tooth
necessary. Antibiotics are prescribed fol- dental arch and stabilized with a segmental should be considered. Impacted canines
lowing this procedure. orthodontic appliance. Endodontic treat- should be approached from the surface of
An endodontic evaluation should be ment begins with calcium hydroxide paste the maxilla with which they are most
performed 3 weeks following the upright- 6 to 8 weeks after the surgical procedure. closely associated. Labially impacted
ing of the tooth. When a tooth with fully Conventional root canal filling is per- canines are frequently removed with an
developed roots is repositioned, endodon- formed at 1 year following surgery. This elevator technique, but palatal canines
tic treatment, if indicated, should be study showed a successful outcome in 54 of generally require removal of the crown
undertaken approximately 6 to 8 weeks 56 transplanted canines. Their concluding followed by sectioning of the root. Longi-
following the surgery. Radiographs recommendation is to perform conven- tudinal sectioning of the root of the palatal
should be taken at 6-month intervals for 2 tional orthodontic treatment for impacted canine often is useful and may conserve
years to evaluate the postoperative course canines in children and young individuals. bone. When a large palatal flap has been
(see Figure 7-9C).31 However, when extraction would other- reflected, maintaining a palatal splint to
wise be performed, they recommend support the soft tissues for several days
Transplantation transalveolar transplantation as a sound prevents hematoma formation.
Transplantation of teeth has been advocat- alternative (Figure 7-10).33 Impacted maxillary bicuspids may be
ed as an alternative to other methods of removed much like canines. Mandibular
treatment of impacted teeth. It may be Removal bicuspids are generally approached from
appropriate for the adult patient who can- Surgical removal of impacted permanent the labial surface of the mandible. Care
not undergo conventional orthodontic teeth may be performed when other meth- must be taken to preserve the integrity of
movement of a canine or premolar. Sagne ods of treatment are unavailable. Basic the mental nerve when the impacted tooth
is nearby. When the impacted lower bicus-
pid is lingually positioned, it is sometimes
useful to identify the tooth through a lin-
gual exposure; a labial flap then may be
raised and a small hole placed in the labial
surface of the bone to allow the bicuspid
to be pushed through to the lingual.
Removal of impacted molars is similar to
removal of impacted third molars.
Summary
A B
Impacted teeth other than third molars are
FIGURE 7-10 A, Geminated tooth no. 8. relatively common findings. Much can be
B, After removal of abnormal tooth no. 8 done to preserve these teeth and allow
and transplantation of erupted tooth no. 9,
the unerupted tooth no. 9 is expected to their functional positioning within the
erupt. C, Radiograph of geminated tooth no. dental arch. Surgical exposure with or
8. D, Radiograph of duplicated tooth no. 9. without orthodontic guidance, surgical
uprighting, and transplantation of teeth
are valuable techniques that can be mas-
tered by oral and maxillofacial surgeons.
Although some studies have indicated that
routine removal of impacted teeth is not
necessary, removal is indicated in many
C D
different situations.
Management of Impacted Teeth Other than Third Molars 137
References 12. Moyres RE. Handbook of orthodontics. 4th ed. 23. Shapiro Y, Katine MM. Treatment of impacted
Chicago: Year Book Medical Publishers; cuspids: the hazard lasso. Angle Orthod
1. Grover PS, Lorton L. The incidence of 1988. p. 387. 1981;51:2037.
unerupted permanent teeth and related 13. Ranta R. Impacted maxillary second perma- 24. Kohavi D, Becker A, Silverman Y. Surgical
clinical cases. Oral Surg Oral Med Oral nent molars. J Dent Child 1985;52:4851. exposure, orthodontic movement, and final
Pathol 1985;59:4205. 14. Ericson S, Kurol J. Radiographic assessment of tooth position as factors in periodontal
2. Thilander B, Myrberg N. The prevalence of maxillary canine eruption in children with breakdown of treated palatally impacted
malocclusion in Swedish schoolchildren. clinical signs of eruption disturbance. Eur J canines. Am J Orthod 1984;85:727.
Scand J Dent Res 1973;81:1220. Orthod 1986;8:13340. 25. Vardimon AD, Graber TM, Drescher D,
3. Dachi SF, Howell FV. A survey of 3,874 routine 15. Ericson S, Kurol J. Radiographic examination of Bourauel C. Rare earth magnets and
full-mouth radiographs: II. A study of ectopically erupting maxillary canines. Am J impaction. Am J Orthod Dentofacial
impacted teeth. Oral Surg Oral Med Oral Orthod Dentofacial Orthop 1987;91:48392. Orthop 1991;100:494512.
Pathol 1961;14:11659. 16. Bodner L, Bar-Ziv J, Becker A. Image accuracy of 26. Iramaneerat S, Cunningham S, Horrocks E.
4. Grondahl AM. Prevalence of impacted teeth plain film radiography and computerized The effect of two alternative methods of
and associated pathology in middle-aged tomography in assessing morphological canine exposure upon subsequent duration
and older Swedish women. Community abnormality of impacted teeth. Am J Orthod of orthodontic treatment. Int J Paediatr
Dent Oral Epidemiol 1991;19:1169. Dentofacial Orthop 2001;120:6238. Dent 1998;8:1239.
5. Raghoebar GM, Boering G, Vissink A, Stegen- 17. Langland OE, Sippy FH, Langlais RP. Textbook 27. Pearson MH, Robinson SN, Reed R, et al. Man-
ga B. Eruption disturbances of permanent of dental radiology. 2nd ed. Springfield agement of palatally impacted canines: the
molars: a review. J Oral Pathol Med 1991; (IL): Charles C Thomas; 1973. findings of a collaborative study. Eur J
20:15966. 18. Chaushu S, Chaushu G, Becker A. The use of Orthod 1997;19:5115.
6. Bianchi SD, Roccuzzo M. Primary impaction of panoramic radiographs to localize dis- 28. Becker A, Brim I, Ben-Basset Y, et al. Closed
primary teeth: a review and report of three placed maxillary canines. Oral Surg Oral eruption surgical technique for impacted
cases. J Clin Pediatr Dent 1991;15:1658. Med Oral Pathol Oral Radiol Endod maxillary incisors: a post-orthodontic peri-
7. Ostuka Y, Mitomi T, Tomizawa M, Noda T. A 1999;88:5116. odontal evaluation. Am J Orthod Dentofa-
review of clinical features in 13 cases of cial Orthop 2002;122:914.
19. Mason C, Papadakou P, Roberts GJ. The radi-
impacted primary teeth. Int J Paediatr Dent 29. Reynolds LM. Uprighting lower molar teeth.
ographic localization of impacted maxillary
2001;11:5763. Br J Orthod 1976;3:4551.
canines: a comparison of methods. Eur J
30. Paleczny G. Treatment of the ankylosed
8. American Association of Oral and Maxillofa- Orthod 2001;23:2534.
mandibular permanent first molar: a case
cial Surgery. Impacted teeth. Oral Health 20. hman I, hman A. The eruption tendency study. J Can Dent Assoc 1991;57:7179.
1998;88:312. and changes of direction of impacted teeth 31. Johnson JV, Quirk GP. Surgical repositioning
9. Bishara SE. Impacted maxillary canines: a following surgical exposure. Oral Surg Oral of impacted mandibular second molar
review. Am J Orthod Dentofacial Orthop Med Oral Pathol 1980;49:3839. teeth: case report. Am J Orthod Dentofacial
1992;101:15971. 21. Thilander B, Thilander H. Impacted premolars. Orthop 1987;91:24251.
10. Levy I, Regan D. Impaction of maxillary per- In: Transactions of the European Ortho- 32. Vig KW. Some methods of uprighting lower sec-
manent second molars by the third molars. dontic Society. Gothenburg, Sweden: Euro- ond molarsII. Br J Orthod 1976;3:3944.
J Paediatr Dent 1989;5:314. pean Orthodontic Society; 1976. p. 16775. 33. Sagne S, Thilander B. Transalveolar transplan-
11. Jacoby H. The etiology of maxillary canine 22. Laskin DM, Peskin S. Surgical aids in orthodon- tation of maxillary canines. A follow-up
impaction. Am J Orthod 1983;84:12532. tics. Dent Clin North Am 1968; July:50924. study. Eur J Orthod 1990;12:1407.
CHAPTER 8
Impacted Teeth
Gregory M. Ness, DDS
Larry J. Peterson, DDS, MS
Removal of impacted teeth is one of the Development of the Mandibular molar assuming a position at approxi-
most common surgical procedures per- Third Molar mately the root level of the adjacent sec-
formed by oral and maxillofacial sur- ond molar. The angulation of the crown
The mandibular third molar is the most
geons, and most surgeons cite third becomes more horizontal also. Usually the
commonly impacted tooth. It also presents
molar removal as the operation most roots are completely formed with an open
the greatest surgical challenge and invites
likely to humble them. Extensive training, apex by age 18 years. By age 24 years 95%
the greatest controversy when indications
skill, and experience are necessary to per- of all third molars that will erupt have
for removal are considered. When the sur-
form this procedure with minimal trau- completed their eruption.
geon is determining whether a specific
ma. When the surgeon is untrained The change in orientation of the
third molar will become impacted and
and/or inexperienced, the incidence of occlusal surface from a straight anterior
whether it should be removed, he or she
complications rises significantly.13 inclination to a straight vertical inclina-
Determining the need for removal of needs to have a clear understanding of the tion occurs primarily during root forma-
asymptomatic teeth is no less problemat- development and movement of the third tion. During this time the tooth rotates
ic. In many situations this decision is molar between the ages of 7 and 25 years. from horizontal to mesioangular to verti-
made based on clinical experience and A number of longitudinal studies cal. Therefore, the normal development
professional judgment; in others the have clearly defined the development and and eruption pattern, assuming the tooth
decision is clear cut based on available eruption pattern of the third molar.47 has sufficient room to erupt, brings the
scientific data. Contemporary medical The mandibular third molar tooth germ is tooth into its final position by age 20 years.
and dental practices demand evidence- usually visible radiographically by age Most third molars do not follow this
based decision-making, and the surgeon 9 years, and cusp mineralization is com- typical eruption sequence and, instead,
is called on more and more frequently to pleted approximately 2 years later. At age become impacted teeth. Approximately half
justify surgical procedures, including the 11 years, the tooth is located within the do not assume the vertical position and
removal of third molars. anterior border of the ramus with its remain as mesioangular impactions. There
This chapter reviews and discusses occlusal surface facing almost directly are several possible explanations for this.
the indications and contraindications for anteriorly. The level of the tooth germ is The Belfast Study Group claims that there
the removal of impacted teeth, the classi- approximately at the occlusal plane of the may be differential root growth between the
fication of impacted teeth and the deter- erupted dentition. Crown formation is mesial and distal roots, which causes the
mination of the degree of difficulty of usually complete by age 14 years, and the tooth to either remain mesially inclined or
surgery, the parameters of perioperative roots are approximately 50% formed by rotate to a vertical position depending on
patient care, and the likely complications age 16 years. During this time the body of the amount of root development.7,8 In their
and their management following third the mandible grows in length at the studies they have found that underdevelop-
molar surgery. expense of resorption of the anterior bor- ment of the mesial root results in a
der of the ramus. As this process occurs mesioangular impaction. Overdevelopment
the position of the third molar relative to of the same root results in over-rotation
Deceased. the adjacent teeth changes, with the third of the third molar into a distoangular
140 Part 2: Dentoalveolar Surgery
impaction. Overdevelopment of the distal Impacted versus nearly vertical and have adequate horizon-
root, commonly with a mesial curve, is Unerupted Teeth tal space are more likely to erupt than to
responsible for severe mesioangular or hor- remain impacted. However, if the crown-
Not all unerupted teeth are impacted. A
izontal impaction. The Belfast Group has to-space ratio is > 1 or if the tooth orien-
tooth is considered impacted when it has
noted that, whereas the expected normal tation diverges substantially from vertical,
failed to fully erupt into the oral cavity
rotation is from horizontal to mesioangular within its expected developmental time the tooth is unlikely ever to erupt fully.
to vertical, failure of rotation from the period and can no longer reasonably be
mesioangular to the vertical position is also Indications for Removal of an
expected to do so. Consequently, diagnos- Impacted Tooth
common. To a lesser extent, they docu- ing an impaction demands a clear under-
mented worsening of the angulation from standing of the usual chronology of erup- An impacted tooth can cause the patient
mesioangular to horizontal impaction and tion, as well the factors that influence mild to serious problems if it remains in
over-rotation from mesioangular to dis- eruption potential. the unerupted state. Not every impacted
toangular. These over-rotations from It is important to remember that tooth causes a problem of clinical signif-
mesioangular to horizontal and from eruption of lower third molars is complete icance, but each does have that potential.
mesioangular to distoangular occur during at the average age of 20 years but that it A body of information has been collect-
the terminal portion of root development. can occur up to age 24 years. A tooth that ed based on extensive clinical experience
A second major reason for the failure appears impacted at age 18 years may have and clinical studies from which indica-
of the third molar to rotate into a vertical as much as a 30 to 50% chance of erupting tions for removal of impacted teeth have
position and erupt involves the relation of fully by age 25 years, according to several been developed. For some indications,
the bony arch length to the sum of the longitudinal studies.1113 It is fairly well there is lack of evidence-based data
mesiodistal widths of the teeth in the arch. established that the position of retained gained from long-term prospective lon-
Several studies have demonstrated that third molars does not change substantially gitudinal studies.
when there is inadequate bony length, after age 25 years,14 although there is some
there is a higher proportion of impacted evidence of continued movement as late as
Pericoronitis Prevention or
teeth.6,9,10 In general, patients with impact- the fourth decade.11 Many patients are
Treatment
ed teeth almost invariably have larger- evaluated for third molar removal in their When a third molar, usually the mandibu-
sized teeth than do those without late teens, and the surgeon must therefore lar third molar, partially erupts through
impactions.10 Even when the tooth-bone attempt to discern the probable outcome the oral mucosa, the potential for the
relationship is favorable, a lower third of the eruption process based on more establishment of a mild to moderate
molar that is positioned lateral to the nor- than tooth position alone. inflammatory response similar to gingivi-
mal position almost always fails to erupt.6 Numerous studies have evaluated the tis and periodontitis exists. In certain situ-
This may also be the result of the dense influence of various factors on the erup- ations the patient may actually experience
bone present in the external oblique ridge. tion potential of a lower third molar. Two a severe infection, which may require vig-
A final factor that seems to be associ- factors consistently emerge as most prog- orous medical and surgical treatment. The
ated with an increased incidence of tooth nostic: angulation of the third molar and bacteria that are most commonly associat-
impaction is retarded maturation of the space available for its emergence.1519 By ed with pericoronitis are Peptostreptococ-
third molar. When dental development of age 18 to 20 years, lower third molars that cus, Fusobacterium, and Bacteroides (Por-
the tooth lags behind the skeletal growth are horizontal or strongly mesioangular phyromonas).2022 Initial treatment of
and maturation of the jaws, there is an have much less eruption potential than do pericoronitis is usually aimed at dbride-
increased incidence of impaction. This is those that are oriented more vertically. ment of the periodontal pocket by irriga-
most likely a result of a decreased influ- Distoangular teeth are intermediate in tion or by mechanical means, disinfection
ence of the tooth on the growth pattern their likelihood to erupt fully. However, of the pocket with an irrigation solution
and resorption of the mandible. This phe- the strongest hope of future eruption lies such as hydrogen peroxide or chlorhexi-
nomenon results in the rather counterin- with those third molars that can be seen dine, and surgical management by extrac-
tuitive observation that in a 20-year-old, radiographically to have space at least as tion of the opposing maxillary third molar
an impacted third molar with partially wide as their crown between the distal of and, occasionally, of the offending
developed roots is less likely to erupt than the second molar and the ascending mandibular third molar. Severe cases of
a similarly positioned tooth with fully mandibular ramus. At age 20 years, pericoronitis with systemic symptoms
developed roots. unerupted lower third molars that are may warrant antibiotic therapy.
Impacted Teeth 141
Prevention of recurrent pericoronitis tory markers at the distal of the second are planned, presurgical removal of the
is usually achieved by removal of the molar and around the third molar.2830 In impacted teeth may facilitate the orthog-
involved mandibular third molar. patients whose dental health is poor and nathic procedure. Delaying removal of third
Although operculectomy has been recom- who have partially erupted third molars, the molars until mandibular osteotomy, espe-
mended for management of this problem, periodontal condition around the second cially in mandibular advancement surgery,
the soft tissue redundancy usually recurs molar and partially erupted third molar can substantially reduces the thickness and
owing to the relationship between the become extremely severe at an early age. quality of lingual bone at the proximal
anterior border of the ramus and the fully aspect of the distal segment, where fixation
or partially erupted mandibular third Orthodontic Considerations screws are usually applied. If third molars
molar. Pericoronitis can occur whenever The presence of the impacted third molar, are to be removed in advance, sufficient
the involved tooth is partially exposed especially in the mandible, may be respon- time must be allowed for the extraction site
through the mucosa, but it occurs most sible for several orthodontic problems. to fill with mature bone. On the other hand,
commonly around mandibular third These problems fall into three general following maxillary down-fracture a deeply
molars that have soft or hard tissue lying areas, which are outlined below. impacted upper third molar is often easily
over the posterior aspect of the crown.23 approached superiorly through the maxil-
Approximately 25 to 30% of impacted Crowding of Mandibular Incisors Per- lary sinus and may be safely removed in this
mandibular third molars are extracted haps one of the most controversial issues manner without compromising the soft tis-
because of pericoronitis or recurrent peri- regarding mandibular third molars has sue vascular pedicle of the maxilla.
coronitis.14,2427 Pericoronitis is the most been the issue of their influence on anteri- Although these circumstances involve a
common reason for removal of impacted or crowding of mandibular incisor teeth, small percentage of all impacted third
third molars after age 20 years. With especially after orthodontic therapy. A molars, the surgeon must plan well in
increasing age, the incidence of pericoro- variety of studies have been reported that advance (612 mo) for patients undergoing
nitis as an indication for removal of support both sides of the controversy. these procedures.
impacted teeth also increases. Many of these studies have been reviews of
small numbers of patients or of anecdotal Prevention of Odontogenic
Prevention of Dental Disease information.31,32 More recent literature Cysts and Tumors
Dental caries can occur in the mandibular includes longitudinal reviews of ortho- In the impacted third molar that is left
third molar or in the adjacent second dontically treated patients in larger num- intact in the jaw, the follicular sac that was
molar, most commonly at the cervical line. bers,33,34 and the preponderance of evi- responsible for the formation of the crown
Owing to the patients inability to effec- dence now suggests that impacted third may undergo cystic degeneration and
tively clean this area and because the third molars are not a significant cause of post- form a dentigerous cyst. The follicular sac
molar is inaccessible to the restorative orthodontic anterior crowding. In fact, may also develop an odontogenic tumor
dentist, caries in the second and third anterior incisor crowding is associated or, in quite rare cases, a malignancy. These
molars are responsible for extraction of with deficient arch length rather than the possibilities have frequently been cited as a
impacted third molars in approximately mere presence of impacted teeth. reason for removal of asymptomatic teeth;
15% of patients.14,2427 As with pericoroni- although rare, when pathology occurs, it
tis, the presence of caries and eventual pul- Obstruction of Orthodontic Treatment may pose a serious health threat.35 The
pal necrosis are responsible for an increas- In some situations the orthodontist general incidence of neoplastic change
ing percentage of extractions with age. attempts to move the molar teeth distally, around impacted molars has been estimat-
The presence of the partially impacted but the presence of an impacted third ed to be about 3%.36,37 In retrospective
third molar and the patients inability to molar may inhibit or even prevent this surveys of large numbers of patients,
clean the area thoroughly may result in early procedure. Therefore, if the orthodontist between 1 and 2% of all third molars that
advanced periodontal disease. This is the is attempting to move the buccal segments are extracted are removed because of the
primary reason for removal of approxi- posteriorly, removal of the impacted third presence of odontogenic cysts and
mately 5% of impacted third molars.14,2427 molar may facilitate treatment and allow tumors.14,2427 These pathologic entities
Even young patients in otherwise good gen- predictable outcomes. are usually seen in patients under age
eral periodontal health have a significant 40 years, suggesting that the risk of neo-
increase in periodontal pocketing, attach- Interference with Orthognathic Surgery plastic change around impacted third
ment loss, pathogen activity, and inflamma- When maxillary or mandibular osteotomies molars may decrease with age.
142 Part 2: Dentoalveolar Surgery
Root Resorption of ful consideration. In older patients with cians agree that if a patient presents with
Adjacent Teeth tooth- or implant-borne fixed prostheses, one or more of the above pathologic prob-
asymptomatic deeply impacted teeth can be lems or symptoms, the involved teeth
Third molars in the process of eruption
may cause root resorption of adjacent safely left in place. However, if a removable should be removed. It is much less clear
teeth. The general view is that misaligned prosthesis is to be made and the bone over- what should be done prophylactically with
erupting teeth may resorb the roots of adja- lying the impacted tooth is thin, the tooth teeth that are impacted before they cause
cent teeth, just as succedaneous teeth resorb should probably be removed before the these problems. Most of the symptomatic
the roots of primary teeth during their nor- final prosthesis is constructed. pathologic problems that result from third
mal eruption sequence. The actual occur- molars occur as a result of a partially
Prevention of Jaw Fracture erupted tooth. There is a lower incidence
rence of significant root resorption of adja-
cent teeth is not clear, although it may be as Patients who engage in contact sports, of problems associated with a complete
high as 7%.38 If root resorption is noted on such as football, rugby, martial arts, and bony impaction.
adjacent teeth, the surgeon should consider some so-called noncontact sports such as
removing the third molar as soon as it is basketball, should consider having their Contradictions for Removal of
convenient. In most cases the adjacent impacted third molars removed to prevent Impacted Teeth
tooth repairs itself with the deposition of a jaw fracture during competition. An The decision to remove a given impacted
layer of cementum over the resorbed area impacted third molar presents an area of tooth must be based on a careful evalua-
and the formation of secondary dentin. lowered resistance to fracture in the tion of the potential benefits versus risks.
However, if resorption is severe and the mandible and is therefore a common site In situations in which pathology exists, the
mandibular third molar displaces signifi- for fracture.3941 Additionally, the presence decision to remove the tooth is uncompli-
cantly into the roots of the second molar, of an impacted third molar in the line of cated because it is necessary to treat the
both teeth may require removal. fracture may cause increased complica- disease process. Likewise, there are situa-
tions in the treatment of the fracture. tions in which removal of impacted teeth
Teeth under Dental Prostheses is contraindicated because the surgical
Before construction of a removable or Management of complications and sequelae outweigh the
fixed prosthesis, the dentist should make Unexplained Pain potential benefits. The general contraindi-
sure that there are no impacted teeth in Occasionally patients complain of jaw cations for removal of impacted teeth can
the edentulous area that is being restored. pain in the area of an impacted third be grouped into three primary areas:
If such teeth are present, the general rec- molar that has neither clinical nor radi- advanced patient age, poor health, and
ommendation is that they be removed ographic signs of pathology. In these situ- surgical damage to adjacent structures.42
before the final placement of the prosthe- ations removal of the impacted third
sis. Teeth that are completely covered with molar frequently results in resolution of Extremes of Age
bone, that show no pathologic changes, this pain. At this time there is no plausible Healing generally occurs more rapidly and
and that are in patients more than 40 years explanation as to why this relief of pain more completely in younger patients;
old are unlikely to develop problems on occurs. Approximately 1 to 2% of however, surgical removal of unerupted
their own. However, if a removable tissue- mandibular third molars that are extracted third molars in the very young is con-
borne prosthesis is to be constructed on a are removed for this reason.14,2427 traindicated. Although some clinicians
ridge where an impacted tooth is covered When a patient presents with this type report that removal of the tooth bud of the
by only soft tissue or 1 or 2 mm of bone, it of complaint, the surgeon must make sure developing third molar at age 8 or 9 years
is highly likely that in time the overlying that all other sources of pain are ruled out can be accomplished with minimal surgi-
bone will be resorbed, the mucosa will before suggesting surgical removal of the cal morbidity,43 the general consensus is
perforate, and the area will become painful third molar. In addition, the patient must that this is not a prudent approach. The
and often inflamed. If this occurs, the be informed that removal of the third original view was based on the belief that
impacted tooth will often need to be molar may not relieve the pain completely. accurate growth predictions could be
removed and the dental prosthesis either made and, therefore, that an accurate
altered or refabricated. Summary determination could be established
Each situation must be viewed individ- The preceding discussion has dealt with regarding whether a given tooth would be
ually, and the risks and benefits of remov- the indications for removal of sympto- impacted. If such a determination were the
ing the impacted tooth must be given care- matic impacted third molars. Most clini- case, then the tooth bud could be removed
Impacted Teeth 143
relatively atraumatically in the very young monary disease, and other health prob- as a contraindication to removal of the
patient. The evidence at this time, howev- lems. Thus, the combination of advanced impacted tooth.
er, is contradictory to that opinion, and age and compromised health status may
the general consensus is that removal of contraindicate the removal of impacted Surgery and Perioperative Care
the tooth bud at this stage may, in fact, be teeth that have no pathologic processes.
unnecessary because the involved third Other factors may compromise the Determining Surgical Difficulty
molar may erupt into proper position. health status of younger people, such as Preoperative evaluation of the third molar,
As a patient becomes older there is congenital coagulopathies, asthma, and both clinically and radiographically, is a
decreased healing response,44 which may epilepsy. In this group of patients, it may critical step in the surgical procedure for
result in a greater bony defect postopera- be necessary to remove impacted teeth removal of impacted teeth. The surgeon
tively than was present because of the before the incipient pathologic process pays particular attention to the variety of
impacted tooth. Additionally, the surgical becomes fulminant. Thus, not only in the factors known to make the impaction
procedure grows more and more difficult older compromised patient but also the surgery more or less difficult. A variety of
as the patient ages owing to more densely younger compromised patient, the sur- classification systems have been developed
calcified bone, which is less flexible and geon occasionally needs to remove symp- to aid in the determination of difficulty.
more likely to fracture. As a patient ages, tomatic as well as asymptomatic third The three most widely used are angulation
the response to surgical insult is tolerated molars. The compromised medical status of the impacted tooth, the relationship of
less easily and the recuperation period becomes a relative contraindication and the impacted tooth to the anterior border
grows longer. There is overwhelming clin- may require the surgeon to work closely of the ramus and the second molar, and
ical evidence to support the fact that the with the patients physician to manage the the depth of the impaction and the type of
number of days missed from work and patients medical problems. tissue overlying the impacted tooth.
other normal activity following third It is generally acknowledged that the
molar extraction is much higher in the Surgical Damage to mesioangular impaction, which accounts
patient over age 40 years compared with Adjacent Structures for approximately 45% of all impacted
patients under age 18 years. Occasionally an impacted tooth is posi- mandibular third molars, is the least diffi-
As a general rule, if a patient has a fully tioned such that its removal may seriously cult to remove. The vertical impaction
impacted third molar that is completely compromise adjacent nerves, teeth, and (40% of all impactions) and the horizon-
covered with bone, has no obvious potential other vital structures (eg, sinus), making it tal impaction (10%) are intermediate in
source of communication with the oral cav- prudent to leave the impacted tooth in difficulty, whereas the distoangular
ity, and has no signs of pathology such as an situ. The potential complications must be impaction (5%) is the most difficult.
enlarged follicular sac, and if the patient is weighed against the potential benefits of The relationship of the impacted
over age 40, the tooth probably should not surgical removal of the tooth. When fully tooth to the anterior border of the ramus
be removed. Long-term follow-up by the developed, totally bone-impacted third is a reflection of the amount of room
patients dentist should be performed peri- molars are present around the inferior available for the tooth eruption as well as
odically, with radiography performed every alveolar nerve; it may be best to leave that the planned extraction. If the length of the
several years to ensure that no adverse impacted tooth in place and not risk per- alveolar process anterior to the anterior
sequelae are occurring. If signs of pathology manent anesthesia of the inferior alveolar border of the ramus is sufficient to allow
develop, the tooth should be removed. If the nerve. In such situations the potential risk tooth eruption, the tooth is generally less
overlying bone is very thin and a removable of development of pathologic problems difficult to remove. Conversely, teeth that
denture is to be placed over that tooth, the would be relatively small, and, therefore, are essentially buried in the ramus of the
tooth should probably be removed before the advantage of removal of such a tooth mandible are more difficult to remove.
the final prosthesis is constructed. would not outweigh the potential risks. The depth of the impaction under the
Surgical extraction of impacted third hard and soft tissues is likewise an important
Compromised Medical Status molars can result in significant bony consideration in determining the degree of
Patients who have impacted teeth may defects that may not heal adequately in difficulty. The most commonly used scheme
have some compromise in their health sta- older patients and, in fact, may result in for determining difficulty involves consider-
tus, especially if they are elderly. As age the loss of adjacent teeth rather than the ation of the soft tissues and partial or com-
increases, so does the incidence of moder- improvement or preservation of peri- plete bony impaction. It is widely employed
ate to severe cardiovascular disease, pul- odontal health. This also would be viewed in part because it may be the most useful
144 Part 2: Dentoalveolar Surgery
indicator of the time required for surgery necessitating greater bone removal to the best possible healing environment in
and, perhaps even more importantly, deliver the tooth from its socket. the postoperative period.
because it is the system required to classify In summary, the degree of difficulty of The initial step in removing impacted
and code impaction procedures to all com- the surgery to remove an impacted tooth is teeth is to reflect a mucoperiosteal flap,
mercial insurance carriers. Surprisingly, fac- determined primarily by two major fac- which is adequate in size to permit access.
tors such as the angulation of impaction, the tors: (1) the depth of impaction and type The most commonly used flap is the enve-
relationship of the tooth to the anterior bor- of overlying tissue and (2) the age of the lope flap, which extends from just posteri-
der of the ramus, and the root morphology patient. Full bony impactions are always or to the position of the impacted tooth
may have little influence on the time that more difficult to remove than are soft tis- anteriorly to approximately the level of the
surgery requires.45 sue impactions and, given two impactions first molar (Figure 8-1A and B). If the sur-
Other factors have been implicated in of the same depth, the impaction in the geon requires greater access to remove a
making the extraction process more diffi- older patient is always more difficult than deeply impacted tooth, the envelope flap
cult. Roots can be either conical and fused the one in the younger patient. may not be sufficient. In that case, a release
roots or separate and divergent, with the A corollary of surgical difficulty is dif- incision is done on the anterior aspect of
latter being more difficult to manage. A ficulty of recovery from the surgery. As a the incision, creating a three-cornered flap
large follicular sac around the crown of the general rule, a more challenging and time- (Figure 8-1C and D). The envelope inci-
tooth provides more room for access to consuming surgical procedure results in a sion is usually associated with fewer com-
the tooth, making it less difficult to extract more troublesome and prolonged postop- plications and tends to heal more rapidly
than one with essentially no space around erative recovery. It is more difficult to per- and with less pain than the three-cornered
the crown of the tooth. form surgery in the older individual, and it flap. The buccal artery is sometimes
Another important determinant of is harder for these patients to recover from encountered when creating the releasing
difficulty of extraction is the age of the the surgical procedure. incision, and this may be bothersome dur-
patient. When impacted teeth are ing the early portion of the surgery.
removed before age 20 years, the surgery Technique The posterior extension of the inci-
is almost always less difficult to perform. The technique for removal of impacted sion must extend to the lateral aspect of
The roots are usually incompletely third molars is one that must be learned the anterior border of the mandibular
formed and thus less bone removal is on a theoretic basis and then performed ramus. The incision should not continue
required for tooth extraction. There is repeatedly to gain adequate experience. posteriorly in a straight line because the
usually a broader pericoronal space There is more variety in presentation of mandibular ramus diverges laterally. If the
formed by the follicle of the tooth, which the surgical situation of impacted third incision were to be extended straight, the
provides additional access for tooth molars than in any other dental surgical blade might damage the lingual nerve.
extraction without bone removal. Because procedure. Therefore, extensive experience High-resolution magnetic resonance
the roots of the impacted teeth are incom- is required to master their removal. A vari- imaging has demonstrated that the lingual
pletely formed, they are usually separated ety of textbooks are available that describe nerve may be intimately associated with
from the inferior alveolar nerve. in detail the technique for removal of the the lingual cortical plate in the third molar
In contradistinction, removal of different types of impactions.46,47 region in 25% of cases and be above the
impacted teeth in patients of older age In general, the surgeons approach lingual crest in 10%.48 The mucoperiosteal
groups is almost always more difficult. The must gain adequate access to the underly- flap is reflected laterally to the external
roots are usually completely formed and ing bone and tooth through a properly oblique ridge with a periosteal elevator
are thus longer, which requires more bone designed and reflected soft tissue flap. and held in this position with a retractor
removal, and closer to the inferior alveolar Bone must be removed in an atraumatic, such as an Austin or Minnesota.
canal, which increases the risk of postsur- aseptic, and nonheat-producing tech- The most commonly used incision
gical anesthesia and paresthesia. The fol- nique, with as little bone removed and used for the maxillary third molar is also
licular sac almost always degenerates with damaged as possible. The tooth is then an envelope incision (Figure 8-2A and B).
age, which makes the pericoronal space divided into sections and delivered with It extends posteriorly from the distobuccal
thinner; as a result, more bone must be elevators, using judicious amounts of force line angle of the second molar and anteri-
removed for access to the crown of the to prevent complications. Finally, the orly to the first molar. A releasing incision
tooth. Finally, there is increasing density wound must be thoroughly dbrided is rarely necessary for the maxillary third
and decreasing elasticity in the bone, mechanically and by irrigation to provide molar (Figure 8-2C and D), although it
Impacted Teeth 145
A B C
FIGURE 8-4 A, When removing a mesioangular impaction, buccal and distal bone are removed to expose crown of tooth to its cervical line. B, The distal
aspect of the crown is then sectioned from tooth. Occasionally it is necessary to section the entire tooth into two portions rather than to section the distal
portion of crown only. C, After the distal portion of crown has been delivered, a small straight elevator is inserted into the purchase point on mesial aspect
of third molar, and the tooth is delivered with a rotational and level motion of elevator. Adapted from Peterson LJ, Ellis E III, Hupp JR, Tucker MR, edi-
tors. Contemporary oral and maxillofacial surgery. 4th ed. St Louis: CV Mosby; 2003.
Use of Perioperative
Systemic Antibiotics
One of the primary goals of the surgeon in
performing any surgical procedure is to pre-
vent postoperative infection as a result of
surgery. To achieve this goal, prophylactic
antibiotics are necessary in some surgical
procedures. Most of these procedures fall
into the clean-contaminated or contaminat- C D
ed categories of surgery. The incidence of
FIGURE 8-5 A, During the removal of a horizontal impaction, the bone overlying the tooththat
postoperative infections in a clean surgery is is, the bone on the distal and buccal aspects of toothis removed with a bur. B, The crown is sec-
related more to operator technique than to tioned from the roots of the tooth and is delivered from socket. C, The roots are delivered together
the use of prophylactic antibiotics. or independently with a Cryer elevator used with a rotational motion. The roots may need to be
separated into two parts: occasionally the purchase point is made in the root to allow the Cryer ele-
Surgery for the removal of impacted vator to engage it. D, The mesial root of the tooth is elevated in similar fashion. Adapted from Peter-
third molars clearly fits into the category of son LJ, Ellis E III, Hupp JR, Tucker MR, editors. Contemporary oral and maxillofacial surgery. 4th
clean-contaminated surgery; however, the ed. St Louis: CV Mosby; 2003.
148 Part 2: Dentoalveolar Surgery
A B C
FIGURE 8-6 A, When removing a vertical impaction, the bone on the occlusal, buccal, and distal aspects of the crown is removed, and the tooth is sectioned into
mesial and distal portions. If the tooth has a fused single root, the distal portion of the crown is sectioned off in a manner similar to that depicted for a mesio-
angular impaction. B, The posterior aspect of the crown is elevated first with a Cryer elevator inserted into a small purchase point in the distal portion of the tooth.
C, A small straight no. 301 elevator is then used to lift the mesial aspect of the tooth with a rotary and levering motion. Adapted from Peterson LJ, Ellis E III, Hupp
JR, Tucker MR, editors. Contemporary oral and maxillofacial surgery. 4th ed. St Louis: CV Mosby; 2003.
exact incidence of postoperative infection experienced surgeon would expect to have patient. Although the literature contains
is unknown. In the usual sense of the word, an infection rate in the range of 1 to 5% for many articles that discuss the use of pro-
infection probably is a rare occurrence fol- all third molar procedures.50 It is difficult, phylactic perioperative antibiotics, there is
lowing third molar surgery. This means and probably impossible, to reduce infec- essentially no report of their usefulness in
that it is unusual to see pain, swelling, and tion rates below 5% with the use of pro- the prevention of infection following third
a production of purulence that requires phylactic antibiotics. Therefore, it is molar surgery.51,52
incision and drainage or antibiotic therapy. unnecessary to use prophylactic antibiotics A more subtle type of wound healing
The incidence of such infections is very low in third molar surgery to prevent postoper- problem that occurs after the surgical
for most surgeons. In general, a competent ative infection in the normal healthy removal of the impacted mandibular third
A B C
FIGURE 8-7 A, For a distoangular impaction, the occlusal, buccal, and distal bone is removed with a bur. It is important to remember that more distal
bone must be taken off than for a vertical or mesioangular impaction. B, The crown of the tooth is sectioned off with a bur and is delivered with straight
elevator. C, The purchase point is put into the remaining root portion of the tooth, and the roots are delivered by a Cryer elevator with a wheel-and-axle
motion. If the roots diverge, it may be necessary in some cases to split them into independent portions. Adapted from Peterson LJ, Ellis E III, Hupp JR,
Tucker MR, editors. Contemporary oral and maxillofacial surgery. 4th ed. St Louis: CV Mosby; 2003.
Impacted Teeth 149
versus benefits becomes important. given 125 mg IV at the time of surgery fol-
Although systemic antibiotics are effective lowed by significantly lower doses, usually
in the reduction of postoperative dry sock- 40 mg PO tid or qid, later on the day of
et, they are no more effective than are local surgery and for two days after surgery.
measures. The increase of antibiotic-relat- High-dose short-term steroid use is
ed complications, such as allergy, resistant associated with minimal side effects. It is
bacteria, gastrointestinal side effects, and contraindicated in the patient with gastric
secondary infections, is not outweighed by ulcer disease, active infection, and certain
the benefits. Therefore, the use of perioper- types of psychosis. The administration of
ative systemic antibiotic administration perioperative steroids may increase the
does not seem to be valid. incidence of alveolar osteitis after third
A
molar surgery, but the data are lacking as
Use of Perioperative Steroids to the precise degree of increase.6165
Just as the oral and maxillofacial surgeon
desires to minimize the incidence of infec- Expected Postoperative Course
tion following third molar surgery, he or Surgical removal of impacted third molars
she also has a major interest in reducing is associated with a moderate incidence of
the perioperative morbidity. The use of complications, around 10%.66,67 These
corticosteroids to help minimize swelling, complications range from the expected
trismus, and pain has gained wide accep- and predictable outcomes, such as
tance in the oral and maxillofacial surgery swelling, pain, stiffness, and mild bleeding,
community. The method of usage, howev- to more severe and permanent complica-
er, is extremely variable, and the most tions, such as inferior alveolar nerve anes-
effective therapeutic regimen has yet to be thesia and fracture of the mandible. The
clearly delineated. overall incidence of complication and the
B There is little doubt that an initial severity of these complications are associ-
intravenous dose of steroid at the time of ated most directly with the depth of
FIGURE 8-8 Delivery of an impacted maxillary
third molar. A, Once the soft tissue has been surgery has a major clinical impact on impaction, that is, whether it is a complete
reflected, a small amount of buccal bone is swelling and trismus in the early postoper- bony impaction, and to the age of the
removed with a bur or a hand chisel. B, The ative period. However, if the initial intra- patient.6870 Because of factors already dis-
tooth is then delivered by a small straight eleva- venous dose is not followed up with addi- cussed, removal of impacted teeth in the
tor with rotational and lever types of motion.
The tooth is delivered in the distobuccal and tional doses of steroids, this early older patient is associated with a higher
occlusal direction. Adapted from Peterson LJ, advantage disappears by the second or incidence of postoperative complications,
Ellis E III, Hupp JR, Tucker MR, editors. Con- third postoperative day. Maximum control especially alveolar osteitis, infections,
temporary oral and maxillofacial surgery. 4th ed.
St Louis: CV Mosby; 2003.
of swelling requires that additional mandible fracture, and inferior alveolar
steroids be given for 1 or 2 days following nerve anesthesia. The removal of complete
surgery. The two most widely used steroids bony impactions is likewise associated
molar is so-called alveolar osteitis or dry are dexamethasone and methylpred- with increased postoperative pain and
socket. This disturbance in wound healing nisolone. Both of these are almost pure morbidity and an increase in the incidence
is most likely caused by the combination of glucocorticoids, with little mineralocorti- of inferior alveolar nerve anesthesia.
saliva and anaerobic bacteria. The use of coid effect. Additionally, these two appear Another determinant of the incidence
prophylactic antibiotics in third molar to have the least depressing effect on of complications of third molar surgery is
surgery does, in fact, reduce the incidence leukocyte chemotaxis. Common dosages the relative experience and training of the
of dry socket. Other techniques that reduce of dexamethasone are 4 to 12 mg IV at the surgeon. The less experienced surgeon will
bacterial contamination of the socket, such time of surgery. Additional oral dosages of have a significantly higher incidence of
as copious irrigation, preoperative rinses 4 to 8 mg bid on the day of surgery and for complications than the trained experienced
with chlorhexidine, and placement of two days afterward result in the maximum surgeon.1,2 After the surgical removal of an
antibiotics in the extraction socket, are also relief of swelling, trismus, and pain. impacted third molar, certain normal
effective.5360 Once again, the issue of risks Methylprednisolone is most commonly physiologic responses occur. These include
150 Part 2: Dentoalveolar Surgery
such things as mild bleeding, swelling, The socket can also be packed with oxi- more sensitive to postoperative pain than
stiffness, and pain. All of these are inter- dized cellulose. Unlike the gelatin sponge, men76; thus, they require more analgesics.
preted by the patient as being unpleasant oxidized cellulose can be packed into the Analgesics should be given before the
and should therefore be minimized as socket under pressure. In some situations effect of the local anesthesia subsides. In
much as possible. microfibrillar collagen can be used to pro- this manner, the pain is usually easier to
With experience, most oral and max- mote platelet plug formation. Patients who control, requires less drug, and may
illofacial surgeons develop a clear under- have known acquired or congenital coagu- require a less potent analgesic. The admin-
standing of third molar surgerys impact lopathies require extensive preparation and istration of nonsteroidal analgesics before
on their patients lives. However, despite its preoperative planning (eg, determination surgery may be beneficial in aiding in the
extreme importance, this topic has of International Normalized Ratio, factor control of postoperative pain.
received little significant study. Several replacement, hematology consultation) The most important determinant of
authorities have published data on the before third molars are removed surgically. the amount of postoperative pain that
short-term impact of third molar removal occurs is the length of the operation. Nei-
on quality of life.71,72 As expected, third Swelling ther swelling nor trismus correlate with
molar removal often has a profoundly Postsurgical edema or swelling is an the length of time of the surgery. There is,
negative impact for the first 4 to 7 days expected sequela of third molar surgery. however, a strong correlation between
after surgery, but longer follow-up reveals As discussed earlier, the parenteral admin- postoperative pain and trismus, indicating
improved quality of life, mostly resulting istration of corticosteroids is frequently that pain may be one of the principal rea-
from the elimination of chronic pain and employed to help minimize the swelling sons for the limitation of opening after the
inflammation (usually pericoronitis). A that occurs. The application of ice packs to removal of impacted third molars.77
large multicenter prospective study, the the face may make the patient feel more
Third Molar Project, has recently pro- comfortable but has no effect on the mag- Complications of Impaction
duced detailed data on the postoperative nitude of edema.74 The swelling usually Surgery
quality of life in patients who undergo reaches its peak by the end of the second
third molar removal.73 The performing postoperative day and is usually resolved Infection
surgeon must be intimately familiar with by the fifth to seventh day. An uncommon postsurgical complication
this information if he or she is to provide related to the removal of impacted third
proper preoperative counseling. Stiffness molars is infection. The incidence of
Trismus is a normal and expected out- infection following the removal of third
Bleeding come following third molar surgery. molars is very low, ranging from 1.7 to
Bleeding can be minimized by using a good Patients who are administered steroids for 2.7%.78 Infection after removal of
surgical technique and by avoiding the the control of edema also tend to have less mandibular third molars is almost always
tearing of flaps or excessive trauma to the trismus. Like edema, jaw stiffness usually a minor complication. About 50% of
overlying soft tissue. When a vessel is cut, reaches its peak on the second day and infections are localized subperiosteal
the bleeding should be stopped to prevent resolves by the end of the first week. abscess-type infections, which occur 2 to
secondary hemorrhage following surgery. 4 weeks after a previously uneventful
The most effective way to achieve hemosta- Pain postoperative course. These are usually
sis following surgery is to apply a moist Another postsurgical morbidity expected attributed to debris that is left under the
gauze pack directly over the site of the after third molar surgery is pain. The post- mucoperiosteal flap and are easily treated
surgery with adequate pressure. This is surgical pain begins when the effects of the by surgical dbridement and drainage. Of
usually done by having the patient bite local anesthesia subside and reaches its the remaining 50%, few postoperative
down on a moist gauze pad. In some maximum intensity during the first infections are significant enough to war-
patients, immediate postoperative hemo- 12 hours postoperatively.75 A large variety rant surgery, antibiotics, and hospitaliza-
stasis is difficult. In such situations a vari- of analgesics are available for management tion. Infections occur in the first postop-
ety of techniques can be employed to help of postsurgical pain. The most common erative week after third molar surgery
secure local hemostasis, including oversu- ones are combinations of acetylsalicylic approximately 0.5 to 1% of the time. This
turing and the application of topical acid or acetaminophen with codeine and is an acceptable infection rate and would
thrombin on a small piece of absorbable its congeners, and the nonsteroidal anti- not be decreased with the administration
gelatin sponge into the extraction socket. inflammatory analgesics. Women may be of prophylactic antibiotics.
Impacted Teeth 151
Fracture female patients who take oral contracep- clusion of surgery, place a small square of
tives.81, 82 Its occurrence can be reduced by gelatin sponge saturated with tetracycline
One of the most frequent problems
several techniques, most of which are in the socket, and continue chlorhexidine
encountered in removing third molars is
the fracture of a portion of the root, which aimed at reducing the bacterial contami- rinses for 1 additional week. This combina-
may be difficult to retrieve. In these situa- nation of the surgical site. Presurgical irri- tion approach should substantially reduce
tions the root fragment may be displaced gation with antimicrobial agents such as the incidence of dry socket.
into the submandibular space, the inferior chlorhexidine reduces the incidence of dry
socket by up to 50%.2 Copious irrigation Nerve Disturbances
alveolar canal, or the maxillary sinus.
Uninfected roots left within the alveolar of the surgical site with large volumes of Surgical removal of mandibular third
bone have been shown to remain in place saline is also effective in reducing dry molars places both the lingual and inferior
without postoperative complications.79 socket.49 Topical placement of small alveolar branches of the third division of
The pulpal tissues undergo fibrosis, and amounts of antibiotics such as tetracycline the trigeminal nerve at risk for injury. The
the root becomes totally incorporated or lincomycin may also decrease the inci- lingual nerve is most often injured during
within the alveolar bone. Aggressive and dence of alveolar osteitis.8386 soft tissue flap reflection, whereas the infe-
destructive attempts to remove portions The goal of treatment of dry socket is rior alveolar nerve is injured when the
of roots that are in precarious positions to relieve the patients pain during the roots of the teeth are manipulated and ele-
seem to be unwarranted and may cause delayed healing process. This is usually vated from the socket. The generally
more damage than benefit. Radiographic accomplished by irrigation of the involved accepted incidence of injury to the inferi-
follow-up may be all that is required. socket, gentle mechanical dbridement, or alveolar and lingual nerves following
and placement of an obtundent dressing, third molar surgery is about 3%.6669,8890
Alveolar Osteitis which usually contains eugenol. The dress- Only a small proportion of these anesthe-
The incidence of alveolar osteitis or dry ing may need to be changed on a daily sia and paresthesia problems remain per-
socket following the removal of impacted basis for several days and then less fre- manent. However, there is a significant
mandibular third molars varies between 3 quently after that. The pain syndrome incidence of some minor alterations of
and 25%. Most of the variation is most usually resolves within 3 to 5 days, sensation after injury caused by third
likely a result of the definition of the syn- although it may take as long as 10 to molar surgery. As many as 45% of nerve
drome. When dry socket is defined in terms 14 days in some patients. There is some compression injuries, which are typical in
of pain that requires the patient to return evidence that topical antibiotics such as third molar surgery, result in a permanent
to the surgeons office, the incidence is metronidazole may hasten resolution of neurosensory abnormality.91
probably in the range of 20 to 25%.2,8087 the dry socket.87 Inferior alveolar nerve injury is most
The pathogenesis of alveolar osteitis In summary, alveolar osteitis is a dis- likely to occur in specific situations. The
has not been clearly defined, but the condi- turbance in healing that occurs after the first and most commonly reported predis-
tion is most likely the result of lysis of a formation of a mature blood clot but posing factor is complete bony impaction
fully formed blood clot before the clot is before the blood clot is replaced with gran- of mandibular third molars. The angula-
replaced with granulation tissue. This fibri- ulation tissue. The primary etiology tion classifications most commonly
nolysis occurs during the third and fourth appears to be one of excess fibrinolysis, involved are usually mesioangular and ver-
days and results in symptoms of pain and with bacteria playing an important but yet tical impaction. In some cases, nerve prox-
malodor after the third day or so following ill-defined role. Antimicrobial agents deliv- imity to the root is indicated by an appar-
extraction. The source of the fibrinolytic ered by perioperative mouthrinses, topical- ent narrowing of the inferior alveolar
agents may be tissue, saliva, or bacteria.80 ly placed in the socket, or administered sys- canal as it crosses the root or severe root
The role of bacteria in this process can be temically all help to reduce the incidence of dilaceration adjacent to the canal. Other
confirmed empirically based on the fact dry socket. Mechanical dbridement and well-documented radiographic signs are
that systemic and topical antibiotic prophy- copious saline irrigation of the surgical diversion of the path of the canal by the
laxis reduces the incidence of dry socket by wound also are effective in reducing the tooth, darkening of the apical end of the
approximately 50 to 75%. The periodontal incidence of dry socket. A rational root indicating that it is included within
ligament may also play a role in the devel- approach may be to provide preoperative the canal, and interruption of the
opment of alveolar osteitis. chlorhexidine rinses for approximately radiopaque white line of the canal.92 In
The incidence of dry socket seems to 1 week before surgery, irrigate the wound surgically verified inferior alveolar nerve
be higher in patients who smoke and in thoroughly with normal saline at the con- injuries, the presence of more than one of
152 Part 2: Dentoalveolar Surgery
these signs was highly sensitive but not asymptomatic, is not causing any restriction ed because the healing response in older
highly specific for the risk of injury, in jaw movement, and is not causing pain, patients would likely result in a large per-
whereas the absence of all of these signs the surgeon should consider leaving the sistent postsurgical defect.
had a strong negative predictive value.93 tooth in place. If the decision is made to After third molar surgery, the bone
When they are noted on a preoperative remove the tooth, three-dimensional local- height distal to the second molar usually
evaluation of the radiograph, the surgeon ization of the tooth should be made before remains at the preoperative level,9597
should take extraordinary precautions to surgery is initiated. although some studies have indicated a net
avoid injury to the nerve, such as addition- If the tooth is displaced into the max- gain in bone level after surgery.98 If the
al bone removal or sectioning of the tooth illary sinus, retrieval is usually done by a bone level on the distal aspect of the
into extra pieces, and the patient should be Caldwell-Luc procedure at the same mandibular second molar is compromised
counseled in advance regarding his or her appointment. The surgeon should localize by the presence of the third molar, it usual-
increased risk of nerve injury. the tooth with at least a one-dimensional ly remains at that level following the heal-
When an injury to the lingual or infe- radiographic view and preferably a three- ing of the bone. There is universal agree-
rior alveolar nerve is diagnosed in the dimensional study before performing the ment that bone healing is better if surgery
postoperative period, the surgeon should retrieval surgery.94 is done before the third molar resorbs the
begin long-term planning for its manage- Fracture of the mandible during the bone on the distal aspect of the second
ment including consideration of referral removal of impacted mandibular third molar and while the patient is young.99101
to a neurologist and/or microneurosur- molars is a rare occurrence. The typical The greatest bony defect occurs in situa-
geon. These issues are dealt with elsewhere situation is a deeply impacted third molar, tions in which the third molar has resorbed
in this textbook. most commonly in an older individual extensive amounts of bone from the sec-
with dense bone. The surgeon places ond molar in an older patient, which com-
Rare Complications excessive pressure on the tooth with an promises bony repair and bone healing.
The complications already discussed are the elevator in an attempt to deliver the tooth The other periodontal parameter of
more common occurrences, accounting for or tooth section into the mouth; the frac- importance is attachment level or, less
the great majority of complications in ture occurs, and the remaining portion of accurately, sulcus or pocket depth. As with
surgery to remove impacted third molars. the tooth is easily retrieved. The surgeon bone levels, if the preoperative pocket
Several additional complications occur should then perform an immediate reduc- depth is great, the postoperative pocket
only rarely and are mentioned briefly. tion and fixation of the fracture. If the sur- depth is likely to be similar. In most studies
Maxillary third molars that are deeply geon has the experience and the arma- the attachment level has been found to be at
impacted may have only thin layers of bone mentarium available, rigid internal essentially the same level as it is preopera-
posteriorly separating them from the fixation with miniplates is an excellent tively.95,102,103 In older patients with com-
infratemporal fossa, or anteriorly separating choice in this unfortunate situation. Wire plete bony impactions, pocket depth and
them from the maxillary sinus. Small fixation and application of intermaxillary attachment levels may be significantly
amounts of pressure in an errant direction fixation is an acceptable alternative. Late lower than preoperative levels. However, in
can result in displacement of the maxillary mandible fractures usually occur 4 to patients younger than age 19 years, removal
third molar into these adjacent spaces. When 6 weeks following extraction in patients of complete bony impactions results in no
a maxillary third molar is displaced posteri- over age 40 years. compromise in attachment level or pocket
orly into the infratemporal fossa, the sur- depth. Initial healing after third molar
geon should try to manipulate the tooth Periodontal Healing after Third surgery usually results in a reduction in
back into the socket with finger pressure Molar Surgery pocket depth in young patients.97 The long-
placed high in the buccal vestibule near the Two of the important reasons for remov- term healing in this group continues for up
pterygoid plates. If this is unsuccessful, the ing impacted third molars is to preserve to 4 years after surgery, with continuing
surgeon can attempt to recover the tooth by periodontal health or, in some situations, reduction in probable pocket depths.100
placing the suction tip into the socket and to treat a periodontitis that already However, long-term follow-up of older
aiming it posteriorly. If both of these maneu- exists.23 A relative contraindication to the patients clearly demonstrates that this long-
vers are unsuccessful in recovering the tooth, removal of impacted third molars is a sit- term healing does not occur.98,100 Usually,
the most effective technique is to allow the uation in which there is good periodontal the surgeon makes an attempt to mechani-
tooth to undergo fibrosis and to return 2 to health and a complete bony impaction in cally dbride the distal aspect of the second
4 weeks later to remove it. If the tooth is an older patient. Removal is contraindicat- molar root area with a curette to encourage
Impacted Teeth 153
15. Hattab FN, Abu Alhaija ESJ. Radiographic in patients with asymptomatic third molars. 46. Waite DE, editor. Textbook of practical oral
evaluation of third molar eruption space. J Oral Maxillofac Surg 2002;60:12415. and maxillofacial surgery, 3rd ed. Philadel-
Oral Surg Oral Med Oral Pathol Oral Radi- 31. Ades AG, Joondeph DR, Little RM, Chapko phia: Lea & Febinger; 1987.
ol Endod 1999;88:28591. MK. A long-term study of the relationship 47. Andreasen JO, Petersen JK, Laskin D. Textbook
16. Venta I, Murtomaa H, Ylipaavalniemi P. A of third molars to changes in the mandibu- and color atlas of tooth impactions: diag-
device to predict lower third molar erup- lar dental arch. Am J Orthod Dentofacial nosis, treatment, and prevention. Oxford:
tion. Oral Surg Oral Med Oral Pathol Oral Orthop 1990;97:32335. Munksgaard; 1998.
Radiol Endod 1997;84:598603. 32. Bishara SE, Andreasen G. Third molars: a 48. Miloro M, Halkias LE, Slone HW, Chakeres
17. Venta I. Predictive model for impaction of review. Am J Orthod 1983;83:131. DW. Assessment of the lingual nerve in the
lower third molars. Oral Surg Oral Med 33. Richardson ME. The etiology of late lower arch third molar region using magnetic reso-
Oral Pathol 1993; 76:699703. crowding alternative to mesially directed nance imaging. J Oral Maxillofac Surg
18. Mollaoglu N, Cetiner S, Gungor K. Patterns of forces: a review. Am J Orthod Dentofacial 1997;52:1347.
third molar impaction in a group of volun- Orthop 1994;105:5927. 49. Sweet JB, Butler DP, Drager JL. Effects of lavage
teers in Turkey. Clin Oral Investig 34. Kahl B, Gerlach L, Hilgers RD. A long-term, techniques with third molar surgery. Oral
2002;6:10913. follow-up, radiographic evaluation of Surg 1976;42:15268.
19. Venta I, Schou S. Accuracy of the third molar asymptomatic impacted third molars in 50. Loukota RA. The incidence of infection after
eruption predictor in predicting eruption. orthodontically treated patients. Int J Oral third molar removal. Br J Oral Maxillofac
Oral Surg Oral Med Oral Pathol Oral Radi- Maxillofac Surg 1994;23:27985. Surg 1991; 29:3367.
ol Endod 2001;91:63842. 35. Curran AE, Damm DD, Drummond JF. Patho- 51. Happonen RP, Backstrom AC, Ylipaavalniemi
20. Heimdahl A, Nord CE. Treatment of orofacial logically significant pericoronal lesions in P. Prophylactic use of phenoxymethylpeni-
infections of odontogenic origin. Scand J adults: histopathologic evaluation. J Oral cillin and tinidazole in mandibular third
Infect Dis 1985;46 Suppl:1015. Maxillofac Surg 2002;60: 6137. molar surgery, a comparative placebo con-
21. Van Winkelhoff AJ, Carlee AW, deGraaff J. 36. Guven O, Keskin A, Akal UK. The incidence of trolled clinical trial. Br J Oral Maxillofac
Bacteroides endodontalis and other black- cysts and tumors around impacted third Surg 1990;28:125.
pigmented Bacteroides species in odonto- molars. Int J Oral Maxillofac Surg 2000; 52. Bystedt H, Nord CE. Effect of antibiotic treat-
genic abscesses. Infect Immun 1985;49:4947. 29:1315. ment on postoperative infections after sur-
22. Mombelli A, Buser D, Lang NP, Berthold H. 37. Berge TI. Incidence of large third-molar- gical removal of mandibular third molars.
Suspected periodontopathogens in erupt- associated cystic lesions requiring hospital- Swed Dent J 1980;4:2738.
ing third molar sites of periodontally ization. Acta Odontol Scand 1996;54:32731. 53. Bystedt H, yon Konow L, Nord CE. Effect of
healthy individuals. J Clin Periodontol 38. Nitzan D, Keren T, Marmary Y. Does an tinidazole on postoperative complications
1990;17:4854. impacted tooth cause root resorption of the after surgical removal of impacted
23. Leone SA, Edenfield MJ, Cohen ME. Correla- adjacent one? Oral Surg 1981;51:2214. mandibular third molars. Scand J Infect Dis
tion of acute pericoronitis and the position 39. Yamada T, Sawaki Y, Tohnai I, et al. A study of 1981;26 Suppl:1359.
of the mandibular third molar. Oral Surg sports-related mandibular angle fracture: 54. Hellem S, Nordenra A. Prevention of postoper-
1986;62:24550. relation to the position of the third molars. ative symptoms by general antibiotic treat-
24. Nordenram A, Hultin M, Kjellman O, Ram- Scand J Med Sci Sports 1998;8:1169. ment and local bandage in removal of
strom G. Indications for surgical removal of 40. Safdar N, Meechan JG. Relationship between mandibular third molars. Int J Oral Surg
the mandibular third molar. Swed Dent J fractures of the mandibular angle and the 1973;2:2738.
1987;2:239. presence and state of eruption of the lower 55. Kariro GSN. Metronidazole (Flagyl) and Arnica
25. Stanley HR, Alattar M, Collett WE, et al. Patho- 3rd molar. Oral Surg Oral Med Oral Pathol montana in the prevention of post-surgical
logical sequelae of neglected impacted Oral Radiol Endod 1995;79:6804. complications; a comparative placebo con-
third molars. J Oral Pathol 1988;17:1137. 41. Tevepaugh DB, Dodson TB. Are mandibular trolled clinical trial. Br J Oral Maxillofac
26. von Wowern N, Nielsen HO. The fate of impact- third molars a risk factor for angle frac- Surg 1984;22:429.
ed lower third molars after the age of 20. Int tures? A retrospective cohort study. J Oral 56. Krekmanov L, Nordenram A. Postoperative
J Oral Maxillofac Surg 1989;18:27780. Maxillofac Surg 1995;53:6469. complications after surgical removal of
27. Schroeder DC, Cecil JC III, Cohen ME. Reten- 42. Peterson LJ. Principles of management of mandibular third molars. Int J Oral Max-
tion and extraction of third molars in naval impacted teeth. In: Peterson LJ, Ellis E III, illofac Surg 1986;15:259.
personnel. Mil Med 1983;148:503. Hupp JR, Tucker MR, editors. Contempo- 57. Krekmanov L, Hallander HO. Relationship
28. Blakey GH, Marciani RD, Haug RH, et al. Peri- rary oral and maxillofacial surgery. 4th ed. between bacterial contamination and alve-
odontal pathology associated with asymp- St Louis: CV Mosby; 2003. p. 184213. olitis after third molar surgery. Int J Oral
tomatic third molars. J Oral Maxillofac 43. Ricketts RM. Studies leading to the practice of Surg 1950;9:27480.
Surg 2002;60:122733. abortion of lower third molars. Dent Clin 58. Krekmanov L. Alveolitis after operative
29. White RP, Madianos PN, Offenbacher S, et al. North Am 1979; 23:393411. removal of third molars in the mandible.
Microbial complexes detected in the sec- 44. Amler MH. The age factor in human extraction Int J Oral Surg 1981;10:1739.
ond/third molar region in patients with wound healing. J Oral Surg 1977;35:1937. 59. Macgregor AJ, Addy A. Value of penicillin in
asymptomatic third molars. J Oral Maxillo- 45. LarsenPE, Mesieha ZS, Peterson LJ, Beck FM. the prevention of pain, swelling and tris-
fac Surg 2002;60:123440. Impacted third molars: radiographic fea- mus following the removal of ectopic
30. White, RP, Offenbacher S, Phillips C, et al. tures used to predict extraction difficulty. J mandibular third molars. Int J Oral Surg
Inflammatory mediators and periodontitis Dent Res 1991;70:5517. 1980;9:16672.
Impacted Teeth 155
60. Rood JP, Murgatroyd JM. Metronidazole in the 75. Seymour RA, Blair GS, Wyatt FAR. Post- 91. Robinson PP. Observations on the recovery of
prevention of dry socket. Br J Oral Surg operative dental pain and analgesic effica- sensation following inferior alveolar nerve
1979;17:6270. cy. Br J Oral Surg 1983;23:298303. injuries. Br J Oral Maxillofac Surg 1988;
61. Hooley JR, Francis FH. Betamethasone in traumat- 76. Seymour RA, Meechan JG, Blair GS. An inves- 26:17789.
ic oral surgery. J Oral Surg 1969;27:398403. tigation into post-operative pain after third 92. Rood JP. The radiological prediction of infe-
62. Huffman GG. Use of methylprednisolone sodi- molar surgery under local analgesia. Br J rior alveolar nerve injury during third
um succinate to reduce postoperative Oral Maxillofac Surg 1985;23:4108. molar surgery. Br J Oral Maxillofac Surg
edema after removal of impacted third 77. Pedersen A. Interrelation of complaints after 1990;28:205.
molars. J Oral Surg 1977;35:1989. removal of impacted mandibular third 93. Blaeser BF, August MA, Donoff RB, et al.
63. Pedersen A. Decadron phosphate in the relief molars. Int J Oral Surg 1985;14:2414. Panoramic radiographic risk factors for
of complaints after third molar surgery. Int 78. Nordenram A, Grave S. Alveolitis sicca dolorosa inferior alveolar nerve injury after third
J Oral Surg 1985;14:23540. after removal of impacted mandibular third molar extraction. J Oral Maxillofac Surg
64. Beirne OH, Hollander B. The effect of methyl- molars. Int J Oral Surg 1983;12:22631. 2003;61:41721.
prednisolone on pain, trismus, and swelling 79. Knutsson K, Lysell L, Rohlin M. Postoperative 94. Oberman M, Horowitz I, Ramon Y. Acciden-
after removal of third molars. Oral Surg status after partial removal of the mandibu- tal displacement of impacted maxillary
1986;61:1348. lar third molar. Swed Dent J 1989;13:1522. third molars. Int J Oral Maxillofac Surg
65. Bustedt H, Nordenram A. Effect of methylpred- 80. Nitzan DNW. On the genesis of dry socket. J 1986;15:7568.
nisolone on complications after removal of Oral Maxillofac Surg 1983;41:70610. 95. Osborne WH, Snyder AJ, Tempel TR. Attach-
impacted mandibular third molars. Swed 81. Sweet JB, Butler DP. The relationship of smok- ment levels and crevicular depths at the
Dent J 1985;9:659. ing to localized osteitis. J Oral Surg distal of mandibular second molars fol-
66. Nordenram A. Postoperative complications in 1979;37:7325. lowing removal of adjacent third molars. J
oral surgery. Swed Dent J 1983;7:10914. 82. Meechan JG, MacGregor IDM, Rogers SN, et al. Periodontol 1982;53:935.
67. Goldberg MH, Nemarich AN, Marco WP. The effect of smoking on immediate post- 96. Meister F Jr, Nery EB, Angell DM, Meister
Complications after mandibular third extraction socket filling with blood and the RC. Periodontal assessment following sur-
molar surgery: a statistical analysis of 500 incidence of painful socket. Br J Oral Max- gical removal of mandibular third molars.
consecutive procedures in private practice. illofac Surg 1988;26:4029. Gen Dent 1986; 34Apr:1203.
J Am Dent Assoc 1985;111:2779. 83. Swanson AE. A double-blind study on the 97. Kugelberg CF, Ahlstrom U, Ericson S, Hugo-
68. Bruce RA, Frederickson GC, Small CS. Age of effectiveness of tetracycline in reducing the son A. Periodontal healing after impacted
patients and morbidity associated with incidence of fibrinolytic alveolitis. J Oral lower third molar surgery. Int J Oral Surg
mandibular third molar surgery. J Am Maxillofac Surg 1989;47:1657. 1985;14:2940.
Dent Assoc 1980;101:2405. 84. Nordenram A, Sydens G, Odegaard J. Neomycin- 98. Marmary Y, Brayer L, Tzukert A, Feller L.
69. Osborn TP, Frederickson C, Small IA, Torger- bacitracin cones in impacted third molar Alveolar bone repair following extraction
son TS. A prospective study of complica- sockets. Int J Oral Surg 1973;2:27983. of impacted mandibular third molars.
tions related to mandibular third molar 85. Goldman DR, Kilgore DS, Panzer JD, Atkinson Oral Surg 1985;60:324.
surgery. J Oral Maxillofac Surg 1985; WH. Prevention of dry socket by local 99. Ash MM Jr, Costich ER, Hayward JR. A study
43:7679. application of lincomycin in Gelfoam. Oral of periodontal hazards of third molars.
70. Hinds EC, Frey KF. Hazards of retained third Surg 1973;35:4724. J Periodontol 1962;33:20919.
molars in older persons: report of 15 cases. 86. Hall HD, Bildman BS, Hand CD. Prevention of 100. Kugelberg CF. Periodontal healing two and
J Am Dent Assoc 1980;101:24650. dry socket with local application of tetra- four years after impacted lower third
71. McGrath C, Comfort MB, Lo ECM, Luo Y. cycline. J Oral Surg 1971;29:357. molar surgery. Int J Oral Maxillofac Surg
Changes in life quality following third 87. Mitchell L. Topical metronidazole in the treat- 1990;19:3415.
molar surgerythe immediate postopera- ment of dry socket. Br Dent J 1984; 101. Kugelberg CF, Ahlstrom U, Ericson S, et al.
tive period. Br Dent J 2003;194:2658. 156:1324. The influence of anatomical, pathophysi-
72. Shafer DM, Frank ME, Gent JF, Fischer ME. 88. Kipp DP, Goldstein BH, Weiss WW Jr. Dyses- ological and other factors on periodontal
Gustatory function after third molar thesia after mandibular third molar healing after impacted lower 3rd molar
extraction. Oral Surg Oral Med Oral Pathol surgery: a retrospective study and analysis surgery a multiple-regression analysis.
Oral Radiol Endod 1999;87:41928. of 1,377 surgical procedures. J Am Dent J Clin Periodontol 1991;18:3743.
73. White RP, Shugars DA, Shafer DM, et al. Assoc 1980;100:18592. 102. Grondahl HG, Lekholm U. Influence of
Recovery after third molar surgery: clinical 89. Wofford DT, Miller RI. Prospective study of mandibular third molars on related sup-
and health-related quality of life outcomes. dysesthesia following odontectomy of porting tissues. Int J Oral Surg 1973;
J Oral Maxillofac Surg 2003;61:53544. impacted mandibular third molars. J Oral 2:13742.
74. Forsgren H, Heimdahl AN, Johansson B, Krek- Maxillofac Surg 1987;45:159. 103. Chin Quee TA, Gosselin D, Miller EP, Stamm
manov L. Effect of application of cold 90. Mason DA. Lingual nerve damage following JW. Surgical removal of the fully impacted
dressings on the postoperative course in lower third molar surgery. Int J Oral Max- mandibular third molar. J Periodontol
oral surgery. Int J Oral Surg 1985;14:2238. illofac Surg 1988; 17:2904. 1985;56:62530.
CHAPTER 9
Preprosthetic and
Reconstructive Surgery
Daniel B. Spagnoli, DDS, PhD
Steven G. Gollehon, DDS, MD
Dale J. Misiek, DMD
Preprosthetic surgery in the 1970s and In spite of the fact that routine dental ic platform for supportive or retentive
early 1980s involved methods to prepare or care has improved over the past century, mechanisms that will maintain or support
improve a patients ability to wear com- approximately 10% of the population is prosthetic rehabilitation without con-
plete or partial dentures. Most procedures either partially or completely edentulous tributing to further bone or tissue loss.
were centered around soft tissue correc- and > 30% of patients older than 65 years This environment will allow for a prosthe-
tions that allowed prosthetic devices to fit are completely edentulous.2 Although sis that restores function, is stable and
more securely and function more comfort- these figures are predicted to decrease over retentive, preserves the associated struc-
ably. In severe cases bony augmentation the next several decades, the treatment of tures, and satisfies esthetics.3
was incorporated and included such proce- partial and total edentulism will never be
dures as cartilage grafts, rib grafts, alloplas- completely eliminated from the oral and Characteristics of Alveolar Bone
tic augmentation, visor osteotomies, and maxillofacial surgeons armamentarium. in the Edentulous Patient
sandwich grafts. Patients who were poor Since the primary goal in preprosthet- Native alveolar bone responds to the func-
candidates for surgery were often left with ic reconstructive surgery is to eliminate tional effects (or lack thereof) caused by
less-than-satisfactory results both func- the condition of edentulism, one must edentulism. Increased resorption owing to
tionally and esthetically. consider the etiology of the edentulous traditional methods of oral rehabilitation
In the late 1970s Brnemark and col- state when evaluating patients and plan- with complete and partial dentures often
leagues demonstrated the safety and effica- ning treatment. In many cases the etiology results in an overall acceleration of the
cy of the implant-borne prosthesis.1 In the of a patients edentulism has a major bear- resorptive process. The mandible is affect-
1990s implantology, distraction osteogene- ing on the reconstructive and restorative ed to a greater degree than the maxilla
sis, and guided tissue regeneration signifi- plan. Edentulism arising from neglect of owing to muscle attachments and func-
cantly expanded the capabilities of todays the dentition and/or periodontal disease tional surface area.4 As a result, there is
reconstructive and preprosthetic surgeon. often poses different reconstructive chal- proportionally a qualitative and quantita-
Genetically engineered growth factors will lenges than does that resulting from trau- tive loss of tissue, resulting in adverse
soon revolutionize our thoughts about ma, ablative surgery, or congenital defects. skeletal relationships in essentially all spa-
reconstructive procedures. As a result, Although restoration of a functional den- tial dimensions (Figure 9-1).
more patients are able to tolerate proce- tition is the common goal, each specific General systemic factors, such as
dures because they are given increased etiology poses its own unique set of chal- osteoporosis, endocrine abnormalities,
freedom and satisfaction with regard to lenges. The goal of preprosthetic and renal dysfunction, and nutritional defi-
their prosthetic devices and, in many cases, reconstructive surgery in the twenty-first ciencies, play a role in the overall rate of
undergo less-invasive techniques. century is to establish a functional biolog- alveolar atrophy. Local factors, including
158 Part 2: Dentoalveolar Surgery
soft tissue relationship including histologic maintains bone osteons, the functional tional, cognitive, and physical ability to
type and condition, bone and/or soft tissue unit of bone, and consequently the via- participate with the reconstructive plan is
grafting/repositioning, options regarding bility of bone shape and form. Bone crucial to the success of future restora-
implant-supported or -stabilized prosthetic requires stimulation often referred to as tions and overall patient satisfaction. The
treatment, immediate versus delayed the minimum essential strain to main- evaluation process should include a com-
implant placement, preservation of existing tain itself. Both insufficient strain and prehensive work-up of the patients
alveolar bone with implants, and correction excessive loads can lead to regressive predilection for metabolic disease,
or minimization of the effects of combina- remodeling of bone, with the classic including serum calcium, phosphate,
tion syndrome in cases involving partially example being denture compression albumin, alkaline phosphatase, and calci-
edentulous patients. leading to an anterior-posterior and tonin levels.5 Decreased renal function
Prior to developing a plan one must transverse deficient maxilla opposing a and the presence of a vitamin D deficien-
consider the amount and source of bone wide mandible that is excessive in its cy should also be ruled out. The mainte-
loss. Common causes of primary bone anterior-posterior dimension. nance of bone mass requires a balanced
loss include trauma, pathology such as Residual ridge form has been calcium metabolism, a functional
periodontal disease, destructive cysts or described and classified by Cawood and endocrine system, and physiologic load-
tumors, and bone loss associated with Howell7 (Figures 9-2 and 9-3) as follows: ing of bone tissue. Secondary medical
extraction and alveoloplasty. Secondary complications affecting edentulous
Class Identate
bone loss, if not prevented, can follow all patients include candidiasis, hyperkerato-
Class IIpostextraction
of the primary types listed above. Sec- sis, fibrous inflammatory hyperplasia,
Class IIIconvex ridge form, with
ondary maxillary/mandibular bone loss dysplasia, papillomatosis, breathing
adequate height and width of alveolar
is an insidious regressive remodeling of changes, and diet compromise away from
process
alveolar and even basal bone that is a natural foods high in fiber and toward an
Class IVknife-edge form with ade-
sequela of tooth loss. This secondary increase in processed foods.
quate height but inadequate width of
process is referred to as edentulous bone
alveolar process Hard and Soft Tissue
loss and varies in degree based on a
Class Vflat-ridge form with loss of Examination
number of factors. The pathophysiology
alveolar process
of edentulous bone loss relates to an A problem-oriented physical examination
Class VIloss of basal bone that may
individuals characteristic anatomy, should include evaluation of the maxillo-
be extensive but follows no predictable
metabolic state, jaw function, and prior mandibular relationship; existing alveolar
pattern
use of and type of prosthesis. Anatomi- contour, height, and width; soft tissue
cally, individuals with long dolicho- Modifications to this classification that attachments; pathology; tissue health;
cephalic faces typically have greater ver- may be relevant to contemporary recon- palatal vault dimension; hamular notch-
tical ridge dimensions than do those with structive methods include subclassifica- ing; and vestibular depth. Identification of
short brachycephalic faces. In addition, tions in II and VI: Class IIno defect, both soft tissue and underlying bone char-
those with shorter faces are capable of a buccal wall defect, or multiwall defect or acteristics and/or deficiencies is essential
higher bite force. Metabolic disorders deficiency; and Class VImarginal resec- to formulate a successful reconstructive
can have a significant impact on a tion defect or continuity defect. plan. This plan should be defined and pre-
patients potential to benefit from sented to the patient both to educate the
osseous reconstructive surgery. Nutri- Medical Considerations patient and to allow him or her to play a
tional or endocrine disorders and any During the patient evaluation process, role in the overall decision-making process
associated osteopenia, osteoporosis, and particular attention to the patients chief with all members of the dental team.
especially osteomalacia must be complaint and concerns is imperative; a The soft tissue evaluation should
addressed prior beginning bone recon- thorough understanding of the past med- involve careful visualization, palpation,
struction.5 Mechanical influences on the ical history is mandatory in the treatment and functional examination of the overly-
maxilla and mandible have a variable and evaluation of any patient. A current ing soft tissue and associated muscle
effect on the preservation of bone. The or previous history regarding the attachments (Figure 9-4). Retraction of
normal nonregressive remodeling of patients success or failure at maintaining the upper and lower lips help one identify
bone essentially represents a balance previous prosthetic devices is also neces- muscle and frenum attachments buccally.
between breakdown and repair that sary. Careful attention to patients func- A mouth mirror can be used lingually to
160 Part 2: Dentoalveolar Surgery
0
Radiographic Evaluation
10 To date, the panoramic radiograph pro-
vides the best screening source for the
20 overall evaluation and survey of bony
structures and pathology in the maxillofa-
B 10 mm 0 mm II III IV V VI cial skeleton. From examination radi-
ographs, one can identify and evaluate
Greater palatine foramen pathology, estimate anatomic variations
Resorption (mm)
Resorption (mm)
rehabilitation. Cephalometric analysis in
25
combination with mounted dental models
helps one establish the planned path of 15
insertion of future prosthetic devices as 5
well as identify discrepancies in interarch
5 mm 15 mm
relationships that affect the restorative plan
(Figure 9-6).9 Molar
In recent years computed tomography 35
(CT) has played an increased role in the
25
treatment planning of complex cases.
Detailed evaluation of alveolar contour, 15
neurovascular position, and sinus anato- 5
my is available for the subsequent plan-
5 mm 15 mm
ning of advanced implant applications. I II III IV V VI VII VIII
Zygomatic implants that obviate the need FIGURE 9-3 Modified Cawood and Howell classification of resorption. The thicker line illustrates the amount
for sinus lifting can be used in cases of attached mucosa, which decreases with progressive resorption. Adapted from Cawood JI, Howell RA.7
involving edentulous atrophic maxillary
sinuses (Figure 9-7). Careful evaluation of
the path of insertion is easily accom- results (Figure 9-9). In addition, accuracy where available until the final bony aug-
plished using coronal CT examination of of the surgical procedure can be greatly mentation is complete. Complications
the maxillary sinuses. CT can also provide increased with an overall decrease in the such as dehiscence, loss of keratinized
the clinician with information regarding duration of the procedure. mucosa, and obliteration of vestibular
bone quantity and volume as well as den- depth can be avoided if respect is given to
sity (Figure 9-8). Treatment Planning overlying soft tissue. Once bony healing is
In many cases the combination of Considerations complete, if the overlying tissue is clearly
imaging modalities and mounted models The conventional tissue-borne prosthesis excessive, removal of the excess soft tissue
with diagnostic wax-ups can be helpful in has given way to implant-borne devices can proceed without complication. Using
determining the reconstructive plan. These that have proven superior in providing the classification of edentulous jaws
elements are also useful in the fabrication of increased patient function, confidence, according to Cawood and Howell,7 the
surgical stents guiding implant placement and esthetics. Preprosthetic surgical reconstructive surgeon can plan treatment
or grafting procedures. Surgical stents fab- preparation of areas directly involved with for his or her patients accordingly.
ricated from CT-based models combine device support and stability are of prima- Many excellent reconstructive plans
esthetic and surgical considerations; bridge ry importance and should be addressed achieve less-than-satisfactory results
the gap between the model surgery and the early in the treatment plan. because of inadequate anesthetic manage-
operation; and allow cooperation between Overlying soft tissue procedures need ment of the patient during the procedure.
the surgeon, laboratory technician, peri- not be attempted until satisfactory posi- Although many procedures can be accom-
odontist, prosthodontist, and orthodontist, tioning of underlying bony tissues is com- plished under local anesthesia or sedation,
which results in a cost-effective prosthetic plete. As a general rule, one should always the clinician must have a low threshold to
reconstruction with improved esthetic maintain excessive soft tissue coverage provide general anesthesia in a controlled
162 Part 2: Dentoalveolar Surgery
A
B
Another aspect of facial bone growth matized sinus. This finding suggests that
and development relevant to reconstruc- the capacity for remodeling by the
tion that needs to be clearly understood is periosteal membrane exists even after the
the regional differences in periosteum face is mature, and that viable bone estab-
activity that exist in association with facial lished by autogenous grafts or rhBMP-2-
bones. It is a misconception that the cor- mediated induction responds to this
tices of growing facial bones are produced process.11
only by periosteum. In fact, at least half of Another concept of facial growth that
A the facial bone tissue is formed by endos- bears relevance to contemporary methods
teum, the inner membrane lining the of reconstruction is the functional matrix
medullary cavity. Of great significance to concept that has largely been described by
the placement of alveolar ridge or alveolar Moss.12 This concept states that bone,
defect bone grafts are the findings that itself, does not regulate the rate of bone
about half of the periosteal surfaces of facial growth. Instead, it is the functional soft
bones are resorptive in nature and half are tissue matrix related to bone that actually
depository. These properties exist because directs and determines the skeletal growth
facial growth is a complex balance between process. The vector and extent of bone
deposition and resorption that adds to the growth are secondarily dependent on the
size and shape of a bone while it is being growth of associated soft tissue. Bone, by
B displaced to achieve its final position and virtue of its matrix maturity, gives feed-
FIGURE 9-9 A, Computer-generated surgical relationships to the bones of the facial cra- back to this process by either inhibiting it
stent for implant placement. B, Clinical photo- nial skeleton. One can study the works and or allowing it to accelerate. Thus, the vol-
graph of implants placed with the use of a com- diagrams of Enlow and colleagues to gain a ume of bone generated is based on genetic
puter-generated surgical stent.
better understanding of these concepts and properties of the soft tissue and a mechan-
the regional variations of naturally resorp- ical equilibration between bone and its
tive and depository surfaces of the facial soft tissue matrix. These principles are vis-
addition, calcification of the matrix pre- skeleton.10 This understanding should help ited when distraction forces are applied to
cludes interstitial growth, so bone can only one better determine the most efficacious osteotomized bone.
grow by the appositional activity of its location for graft placement. For example, In 1989 Ilizarov forwarded the theory
membranes. Periosteum has a dense con- the anterior surface of the maxillary and of tension-stress applied to bone as a
nective tissue component and is struc- mandibular alveolar ridges are resorptive mechanism of lengthening bone.13,14 He
turally adapted to transfer tensile forces and thus are best treated by the placement stated that controlled mechanically
that are generated by muscles, tendons, of interpositional grafts in association with applied tension-stress allows bone and soft
and ligaments to bone. the endosteal aspects of these bones, as seen tissue to regenerate in a controlled, reli-
The majority of the facial skeleton is in Figure 9-10. Interestingly, the periosteal able, and reproducible manner. During the
not under load during development; thus lining of the maxillary sinus is also mostly latency phase of distraction, there is a
it does not require an endochondral phase, resorptive. Successful bone grafting via the periosteal and medullary revascularization
so it develops by an intramembranous sinus lift technique has been demonstrated and recovery. Simultaneously a relatively
process. In the natural state, alveolar bone by numerous authors using a variety of hypovascular fibrous interzone develops
is protected from load by the dentition graft techniques. It has been our experience that is rich in osteoprogenitor cells and
and is actually stimulated by strain forces that sinus lift grafts of autogenous cancel- serves as a pseudogrowth plate. Adjacent
transferred to the alveolus via the peri- lous bone, and bone induced to grow by and connected to the interzone are areas of
odontal ligament. Although technology to rhBMP-2, secondarily treated with osseo- hypervascular trabeculae aligned in the
date has not been able to exactly replicate integrated implants remodel over time. A direction of the distraction. Osteoprogen-
this interface, osseointegrated implants follow-up of > 5 years of some of our itor cells in the interzone differentiate into
have a similar protective effect on underly- patients has shown that the grafts become osteoblasts and line the trabeculae. As dis-
ing bone, native or reconstructed, and thus scalloped over the surfaces of the implants, traction progresses, appositional bone
should be a component of all alveolar similar to the relationship seen when natur- growth enlarges the trabeculae. This
bone reconstructive plans. al roots extend above the floor of a pneu- underscores the idea that mechanical
Preprosthetic and Reconstructive Surgery 165
the graft. Osteoclasts remove mineral, and verified by culture prior to release. ferred from one species to another. Implants
forming Howships lacunae along the tra- Processing of allogeneic bone is designed of this type contain an organic component
beculae. This resorptive process exposes to achieve sterility and reduce immuno- that would elicit a strong immune
the extracellular matrix of bone, which is genicity. Bone cell membranes have both response; thus, they are not used in con-
the natural location of the bone-inductive class I and II major histocompatibility temporary practice. Bovine implants that
glycoprotein BMP. Exposure of BMP initi- complexes on their surfaces. These are the have undergone complete deproteinization
ates an inductive process characterized by main sources of immunogenicity within to remove the organic component have
chemotaxis of mesenchymal stem cells, allogeneic bone grafts. Allogeneic bone been shown to be nonimmunogenic. These
proliferation of cells in response to mito- implants are processed to remove the implants remain as an inorganic mineral
genic signals, and differentiation of cells organic matrix and only retain the miner- scaffold that can be used for their osteocon-
into osteoblasts.17 Inducible cell popula- al components; architecture is generally ductive properties as graft extenders or for
tions may be local or distant from the graft considered to be nonimmunogenic. extraction-site preservation.
site. Examples of local cell populations that Implants retaining both mineral and The above discussion has identified
may contribute to the graft include osteo- organic components or demineralized two reconstructive methods that can reli-
progenitor cells in the graft endosteum, implants with only the organic compo- ably restore bone with the characteristics
stem cells of the transplanted marrow, or nent are washed and then lyophilized to necessary for maintaining osseointegrated
cells in the cambium layer of adjacent reduce immunogenicity. In most cases implants. These methods include autoge-
periosteum. Additional inducible pluripo- this process reduces the immune response nous cancellous bone grafts and distrac-
tent cells may arrive at the graft site with to clinically insignificant levels. In addi- tion histogenesis alone or with graft sup-
budding blood vessels. During phase two tion to this treatment, allogeneic bank plementation. A third approach alluded to
there is progressive osteoclastic resorption bone is irradiated with -rays, a process above is the use of rhBMP-2.20 rhBMP-2
of phase one osteoid and nonviable graft that assures sterility and further reduces has been studied extensively in animal
trabeculae; this continues to expose BMP, antigenicity. Unfortunately, this requires models, and human clinical trials in the
which perpetuates the differentiation of 2 to 3 Mrad per radiation dose, which areas of orthopedic surgery, spine surgery,
osteoblasts, leading to the formation of destroys BMP and thus the ability of these and maxillofacial surgery have been ongo-
mature vascular osteocyte-rich bone. implants to be osteoinductive.18 ing during the past decade. rhBMP-2/ACS,
This two-phase bone graft healing Common applications of allogeneic which is the clinical combination of BMP
process is the one that most reliably and bone implants for preprosthetic surgery with an absorbable collagen sponge carrier
quickly can regenerate bone with charac- include mandibles, iliac crest segments, and placed with a metal cage, received US Food
teristics suitable for implant placement. calcified or decalcified ribs that can be pre- and Drug Administration (FDA) approval
When choosing a bone graft, one must pared and used as biologic trays for the place- for spine fusion surgery in 2002. To date,
consider its ultimate purpose; since most ment and retention of cancellous bone grafts. US human clinical trials related to maxillo-
grafts associated with preprosthetic Additional uses include mineral matrix or facial reconstruction include complete fea-
surgery are designed to support implants, demineralized particulate implants used as sibility studies, safety and efficacy studies,
these grafts must provide the biologic osteoconductive graft extenders or for and dose-response studies involving either
environment necessary for osseointegra- extraction-site shape and form preservation. alveolar ridge buccal wall defects or poste-
tion. Osseointegration is a biologic Research on particle size suggests that parti- rior maxillary alveolar bone deficiency at
process, and its long-term success requires cles in the range of 250 to 850 m are the sinus lift bone sites. Safety has been estab-
vascular osteocyte-rich bone. most useful. Although the current carrier sys- lished, and a dose of 1.5 mg/mL, the same
Another adjunct to preprosthetic tem used for rhBMP-2 bone induction is a dose used for spine fusion, was chosen for
bone reconstruction is the use of allo- collagen membrane, Becker and colleagues maxillofacial applications after completion
geneic bone. Since these grafts are nonvi- showed that BMP extracted from the bone of a sinus lift dose-response study. A
able, they are technically implants. Allo- can be added to particulate 200 to 500 m 20-center study of pivotal sinus lifts is near
geneic bone is procured in a fresh sterile demineralized freeze-dried bone allografts completion; its dual end points include the
manner from cadavers of genetically obtained from four American tissue banks; evaluation of bone regeneration at end
unrelated individuals. American Associa- this resulted in the transformation of non- point one and the evaluation of 2-year
tion of Tissue Bank standards require that inductive particles to particles with osteoin- loaded implant data at end point two. To
all donors be screened, serologic tests be ductive properties.19 Heterogeneous bone date, a time frame for submitting this data
performed, and all specimens be sterilized grafts, or xenografts, are specimens trans- for FDA approval has not been established.
Preprosthetic and Reconstructive Surgery 167
At our center 9 patients were enrolled in bone formation. Bone regenerated by this extraction, conservative extraction tech-
the pivotal study, with 21 evaluated sinus process has characteristics of bone desir- niques using periosteotomes to maintain
lifts sites. All study sites were confirmed able for implant placement (Figure 9-11). alveolar continuity, immediate grafting of
before treatment by CT scan to have 5 mm Hopefully, the discussion of host extraction sites, relief of undercuts using
or less of natural bone. Six months after properties and regenerative or graft tech- bone grafts or hydroxylapatite (HA) aug-
graft placement, comparative CT scans niques in this section will aid one in deter- mentation, and guided tissue regeneration.
were obtained from all study sites and the mining the best graft for sites to be recon- In cases where bony abnormalities or
presence of graft and graft dimensions structed as part of a preprosthetic surgical undercuts require attention, selective alveo-
were assessed. All sites had enough bone treatment plan. lar recontouring is indicated.
for placement of implants at least 4 mm in Advances in implant technology have
diameter and 12 mm high. Trephine- Hard Tissue Recontouring placed a greater emphasis on planning for
procured biopsy specimens obtained at the alveolar ridge preservation. Beginning at
time of implant placement were used to Current Trends in the initial consultation, all extraction sites
verify the presence of homogeneous vascu- Alveolar Preservation should be considered for implant recon-
lar osteocyte-rich bone with a normal tra- As dental implants continue to grow in struction. Regardless of the reason for
becular and marrow-space architecture. At popularity and play a major role in pros- extraction (ie, pulpal disease, periodontal
our center all 21 implants have remained thetic reconstruction, the need for tradi- disease, or trauma), every effort should be
functionally loaded for at least 36 months. tional bony recontouring at the time of made to maintain alveolar bone, particu-
These results are preliminary and may not extraction has been de-emphasized. Cur- larly buccal (labial) and lingual (palatal)
reflect the findings of all centers. Similar to rent trends tend to lean toward preserva- walls. However, even with alveolar bone
natural BMP, rhBMP-2/ACS has been tion of alveolar bone and overlying maintenance, there can be unpredictable
shown to stimulate the cascade of bone- periosteal blood supply, which enhances resorption in a short period of time.21
regeneration events, including chemotaxis, and preserves future bone volume. Alterna- Multiple adjacent extractions may also
induction of pluripotent cells, and prolifer- tives to traditional alveoloplasty have contribute to extensive alveolar bone loss
ation. Our results to date show that this emerged in an effort to maintain bone precluding implant reconstruction.
technique has the potential to significantly height and volume for the placement of Historically, techniques for alveolar
enhance patient care by providing an implants to provide a stable platform for ridge preservation were developed to
unlimited supply of nonimmunogenic prosthetic reconstruction. Such alternatives facilitate conventional denture prostheses.
sterile protein that can induce de novo include orthodontic guided tooth/root HA materials were the first materials not
A B C
FIGURE 9-11 Stages of bone maturation are evident in these photomicrographs of autogenous bone grafts, autogenous grafts with bone morphogenetic protein
(BMP), and distraction-regenerate. A, Autogenous tibial plateau with no filler was placed in this sinus lift site with < 5 mm of native bone, procured by trephine,
and sampled at 6 months after the graft. Viable osteocyte-rich bone trabeculae are evident with normal marrow spaces with a few residual foci of nonviable graft
(100 original magnification; hematoxylin and eosin stain). B, BMP was placed in an identical site to that shown in Figure A (75 original magnification:
hematoxylin and eosin stain). This specimen reveals viable trabeculae with normal haversian canals, de novo bone growth, and no nonviable components.
C, Regenerate was procured at the time of the distractor removal at this mandibular distraction site. The regenerated growth represents woven bone with some
mature haversian systems (128 original magnification: hematoxylin and eosin stain).
168 Part 2: Dentoalveolar Surgery
plagued by host rejection and fibrous longer in the grafted site.25 A second prod- Alveoloplasty
encapsulation. Previously, the use of poly- uct, derived from human bone, is processed Often hard and soft tissues of the oral
methyl methacrylate, vitreous carbon, by solvent extraction and dehydration. Ani- region need to undergo recontouring to
and aluminum oxide had led to poor mal studies have shown that there is near- provide a healthy and stable environment
results. Root form and particulate HA complete remodeling with little or no rem- for future prosthetic restorations. Simple
both were adapted and successful in pre- nant of the human anorganic bone left in alveolar recontouring after extractions
serving alveolar ridge form.22 The obvious the specimen.26 consists of compression and in-fracture of
limitation with nonresorbable materials is Both the deproteinized bovine bone the socket; however, one must avoid over-
that they preclude later implant recon- and the solvent dehydrated mineralized compression and over-reduction of irreg-
struction. Tricalcium phosphate is a human bone appear to have great potential ularities. Current trends endorse a selec-
resorbable ceramic that was originally in alveolar ridge preservation. These materi- tive stent-guided approach to site-specific
thought would solve this problem, but it als take a long time to resorb, so a ridge form bony recontouring, eliminating bony
proved not to be truly osteoconductive as is maintained over an extended period of abnormalities that interfere with prosthet-
it promoted giant cell rather than osteo- time, and are resorbed and remodeled via ic reconstruction or insertion. Multiple
clastic resorption.23 This resulted in limit- an osteoclastic process that results in bone irregularities produce undercuts that are
ed osteogenic potential. Another alloplast ideally suited for implant placement. obstructions to the path of insertion for
that has been used for this purpose is The technique for alveolar ridge preser- conventional prosthetic appliances. These
bioactive glass, which consists of calcium, vation at the time of extraction has been obstructions need a more complex alve-
phosphorus, silicone, and sodium, but, described by Sclar.27 Atraumatic extraction oloplasty to achieve desired results. In
again, the biologic behavior of the is essential. Preservation of buccal or labial many cases the elevation of mucoperi-
replacement bone was never felt to be sat- bone may be facilitated by the use of micro- osteal flaps using a crestal incision with
isfactory for implant reconstruction.24 osteotomes, and, whenever possible, buccal vertical releases is necessary to prevent
The gold standard for use for bony or labial mucoperiosteal elevation is to be tears and to produce the best access to the
reconstruction anywhere has always been avoided or limited. The socket should be alveolar ridge. During mucoperiosteal flap
autogenous grafts. The dilemma with auto- gently curetted and irrigated, and in the resection, periosteal and Woodson eleva-
genous grafts involves donor site morbidi- presence of periodontal infection, topical tors are the most appropriate tools to pre-
ty: whether from an intraoral or extraoral antibiotics may be helpful. Tetracycline vent excess flap reflection, devitalization,
source, the additional surgery and inconve- powder mixed with the deproteinized and sequestrum formation. These condi-
nience to the patient has precluded its gen- bovine bone or the solvent dehydrated min- tions increase pain and discomfort for the
eral use. To avoid the use of a donor site, eralized human bone may allow for the use patient and increase the duration needed
various allogeneic bone preparations have of either of these types of bone in almost before prosthetic restoration can proceed.
been advocated. Stringent tissue bank regu- any clinical situation. It is not essential that The use of a rongeur or file for advanced
lations have provided the public with the graft have complete watertight mucosal recontouring is preferred to rotary instru-
greater confidence in the use of these mate- coverage. Collagen membrane is used to ments to prevent over-reduction. For large
rials. Anorganic bone has most recently prevent spillage of the material from the bony defects, rotary instrument recon-
been adapted for use in alveolar ridge socket, particularly in maxillary extractions. touring is preferred. Normal saline irriga-
preparation. Two products are currently When temporary restorations are employed tion is used to keep bony temperatures
available commercially. The first is a at the time of surgery, an ovate pontic pro- < 47C to maintain bone viability.
xenograft derived from a bovine source. visional restoration helps to support the Owing to the physiology of bone and
The main advantage of this type of materi- adjacent mucosa during soft tissue matura- current restorative options available,
al is that it is available in an almost unlim- tion. In selected instances immediate place- interseptal alveoloplasty is rarely indicat-
ited supply and is chemically and biologi- ment of implants in the extraction site can ed. The main disadvantage of this proce-
cally almost identical to human bone. be done in conjunction with the use of these dure is the overall decrease in ridge thick-
Minimal immune response is elicited deproteinized bone preparations. Because ness, which results in a ridge that may be
because of the absence of protein; however, of the slow resorptive nature of both of too thin to accommodate future implant
the resorption rate of bovine cortical bone these bone preparations, they may be ideal- placement.9 Removal of interseptal bone
is slow. In both animal and human studies, ly suited for buccal or labial defects that eliminates endosteal growth potential,
remnants of nonvital cortical bone have would otherwise be grafted with autoge- which is necessary for ridge preservation.
been shown to be present 18 months or nous cortical bone. Therefore, if this technique is to be used,
Preprosthetic and Reconstructive Surgery 169
one must be cognizant of ridge thickness area should be done at the conclusion of preferably a penicillinase-resistant penicillin
and reduce the labial dimension only the procedure to verify the relief of the such as an amoxicillin/clavulanate potassi-
enough to lessen or eliminate undercuts in defect. The incision can be closed with um preparation or a second-generation
areas where implants are not anticipated. resorbable sutures. In areas that require a cephalosporin. The patient is instructed to
After hard tissue recontouring, exces- large amount of graft material, scoring of take sinus medications including antihista-
sive soft tissue is removed to relieve mobile the periosteum can assist in closure of soft mines and decongestants for approximately
tissue that decreases the fit and functional tissue defects. In addition, the use of a 10 to 14 days and not to create excessive
characteristics of the final prosthesis. Clo- resorbable collagen membrane can be transmural pressure across the incision site
sure with a resorbable running/lock-stitch used to prevent tissue ingrowth into the by blowing his or her nose or sucking
suture is preferred because fewer knots are surgical site. through straws.
less irritating for the patient.
Tuberosity Reduction Genial Tubercle Reduction
Treatment of Exostoses Excesses in the maxillary tuberosity may The genioglossus muscle attaches to the
Undercuts and exostoses are more common consist of soft tissue, bone, or both. Sound- lingual aspect of the anterior mandible. As
in the maxilla than in the mandible. In areas ing, which is performed with a needle, can the edentulous mandible resorbs, this
requiring bony reduction, local anesthetic differentiate between the causes with a local tubercle may become significantly pro-
should be infiltrated. This produces ade- anesthetic needle or by panoramic radi- nounced. In cases in which anterior
quate anesthesia for the patient as well as an ograph. Bony irregularities may be identi- mandibular augmentation is indicated,
aid in hydrodissection of the overlying tis- fied, and variations in anatomy as well as the leaving this bony projection as a base for
sues, which facilitates flap elevation. In the level of the maxillary sinuses can be ascer- subsequent grafting facilitates augmenta-
mandible an inferior alveolar neurovascular tained. Excesses in the area of the maxillary tion of mandibular height. During conven-
block may also be necessary. A crestal inci- tuberosity may encroach on the interarch tional mandibular denture fabrication, this
sion extending approximately 1.5 cm space and decrease the overall freeway space bony tuberosity as well as its associated
beyond each end of the area requiring con- needed for proper prosthetic function. muscle attachments may create displace-
tour should be completed. A full mucoperi- Access to the tuberosity area can be obtained ment issues with the overlying prostheses.
osteal flap is reflected to expose all the areas easily using a crestal incision beginning in In these cases it should be relieved. Floor-
of bony protuberance. Vertical releasing the area of the posterior tuberosity and pro- of-mouth lowering procedures should also
incisions may be necessary if adequate gressing forward to the edge of the defect be considered in cases in which genioglos-
exposure cannot be obtained since trauma using a no. 12 scalpel blade. Periosteal dis- sus and mylohyoid muscle attachments
of the soft tissue flap may occur. Recontour- section then ensues exposing the underlying interfere with stability and function of
ing of exostoses may require the use of a bony anatomy. Excesses in bony anatomy are conventional mandibular prostheses.
rotary instrument in large areas or a hand removed using a side-cutting rongeur. Care- Bilateral lingual nerve blocks in the
rasp or file in minor areas. Once removal of ful evaluation of the level of the maxillary floor of the mouth are necessary to achieve
the bony protuberance is complete and sinus must be done before bony recontour- adequate anesthesia in this area. A crestal
visualization confirms that no irregularities ing is attempted in the area of the tuberosity. incision from the midbody of the mandible
or undercuts exist, suturing may be per- Sharp undermining of the overlying soft tis- to the midline bilaterally is necessary for
formed to close the soft tissue incision. If sue may be performed in a wedge-shaped proper exposure. A subperiosteal dissection
nonresorbable sutures are used, they should fashion beginning at the edge of a crestal exposes the tubercle and its adjacent muscle
be removed in approximately 7 days. incision to thin the overall soft tissue bulk attachment. Sharp excision of the muscle
In areas likely to be restored with overlying the bony tuberosity. Excess overly- from its bony attachment may be per-
implants or implant-supported prosthe- ing soft tissue may be trimmed in an elliptic formed with electrocautery, with careful
ses, irregularities and undercuts are best fashion from edges of the crestal incision to attention to hemostasis. A subsequent
treated using corticocancellous grafts from allow a tension-free passive closure (Figure hematoma in the floor of the mouth may
an autogenous or alloplastic source. This 9-12). Closure is performed using a nonre- lead to airway embarrassment and life-
can be done using a vertical incision only sorbable suture in a running fashion. Small threatening consequences if left unchecked.
adjacent to the proposed area of grafting. sinus perforations require no treatment as Once the muscle is detached, the bony
A subperiosteal dissection is used to create long as the membrane remains intact. Large tubercle may then be relieved using rotary
a pocket for placement of the graft mater- perforations must be treated with a tension- instrumentation or a rongeur. Closure is
ial. Visual inspection and palpation of the free tight closure as well as antibiotics, performed using a resorbable suture in a
170 Part 2: Dentoalveolar Surgery
running fashion. The genioglossus muscle In the maxilla, bilateral greater palatine cedure. Closure is performed with a
is left to reattach independently. and incisive blocks are performed to resorbable suture. Presurgical fabrication
achieve adequate anesthesia. Local infiltra- of a thermoplastic stent, made from dental
Tori Removal tion of the overlying mucosa helps with models with the defect removed, in combi-
The etiology of maxillary and mandibular hemostasis and hydrodissection that facili- nation with a tissue conditioner helps to
tori is unknown; however, they have an tates flap elevation. A linear midline inci- eliminate resulting dead space, increase
incidence of 40% in males and 20% in sion with posterior and anterior vertical patient comfort, and facilitate healing in
females.28 Tori may appear as a single or releases or a U-shaped incision in the cases in which communication occurs with
multiloculated bony mass in the palate or palate followed by a subperiosteal dissec- the nasal floor. Soft tissue breakdown is not
on the lingual aspect of the anterior tion is used to expose the defect. Rotary uncommon over a midline incision; how-
mandible either unilaterally or bilaterally. instrumentation with a round acrylic bur ever, meticulous hygiene, irrigation, and
In the dentate patient they are rarely indi- may be used for small areas; however, for tissue conditioners help to minimize these
cated for removal. Nevertheless, repeated large tori, the treatment of choice is sec- complications.
overlying mucosal trauma and interfer- tioning with a cross-cut fissure bur. Once Mandibular tori are accessed using
ence with normal speech and masticatory sectioned into several pieces, the torus is bilateral inferior alveolar and lingual
patterns may necessitate treatment. In the easily removed with an osteotome. Care nerve blocks as well as local infiltration to
patient requiring complete or partial con- must be taken not to over-reduce the palate facilitate dissection. A generous crestal
ventional prosthetic restoration, they may and expose the floor of the nose. Final con- incision with subsequent mucoperiosteal
be a significant obstruction to insertion or touring may be done with an egg-shaped flap elevation is performed. Maintenance
interfere with the overall comfort, fit, and recontouring bur (Figure 9-13). Copious of the periosteal attachment in the mid-
function of the planned prosthesis. irrigation is necessary throughout the pro- line reduces hematoma formation and
maintains vestibular depth. Nevertheless,
when large tori encroach on the midline,
maintenance of this midline periosteal
attachment is impossible. Careful flap
elevation with attention to the thin fri-
able overlying mucosa is necessary as this
tissue is easily damaged. Small protuber-
ances can be sheared away with a mallet
and osteotome. Large tori are divided
superiorly from the adjacent bone with a
fissure bur parallel to the medial axis of
the mandible and are out-fractured away
from the mandible by an osteotome,
which provides leverage (Figure 9-14).
A B The residual bony fragment inferiorly
may then be relieved with a hand rasp or
bone file. It is not imperative that the
entire protuberance be removed as long
as the goals of the procedure are
achieved. Copious irrigation during this
procedure is imperative, and closure is
completed using a resorbable suture in a
running fashion. Temporary denture
delivery or gauze packing lingually may
be used to prevent hematoma formation
FIGURE 9-12 A, Area of soft tissue to be excised and should be maintained for approxi-
in an elliptic fashion over the tuberosity. B,
Removal of tissue and undermining of buccal and mately 1 day postoperatively. Wound
C
palatal flaps completed. C, Final tissue closure. dehiscence and breakdown with exposure
Preprosthetic and Reconstructive Surgery 171
Inflammatory Papillary
Hyperplasia
Once thought to be a neoplastic process,
inflammatory papillary hyperplasia occurs
mainly in patients with existing prosthetic
appliances.29 An underlying fungal etiolo-
gy most often is the source of the inflam-
matory process and appears to coincide
with mechanical irritation and poor
hygiene practices. The lesion appears as
A B multiple proliferative nodules underlying
FIGURE 9-14 A, Rotary trough exposes a mandibular torus and creates a cleavage plane between the a mandibular prosthesis likely colonized
torus and mandible. B, Osteotome shears the remaining attachment of the torus from mandible. with Candida. Early stages are easily treat-
ed by an improvement of hygiene practices
and by the use of antifungal therapy such
valuable after grafting or augmentation it maintains the vestibule and increases the as nystatin tid alternating with clotrima-
procedures are performed to increase the width of the attached keratinized mucosa. zole troches intermittently. Nocturnal
overall bony volume. soaking of the prosthesis in an antifungal
Fibrous Inflammatory solution or in an extremely dilute solution
Hypermobile Tissue Hyperplasia of sodium hypochlorite helps decrease the
When excess mobile unsupported tissue Fibrous inflammatory hyperplasia is often overall colonization of the prosthesis.
remains after successful alveolar ridge the result of an ill-fitting denture that pro- In proliferative cases necessitating sur-
restoration, or when mobile tissue exists in duces underlying inflammation of the gical treatment, excision in a supraperi-
the presence of a preserved alveolar ridge, mucosa and eventual fibrous proliferation osteal plane is the method of choice.
removal of this tissue is the treatment of resulting in patient discomfort and a Many methods are acceptable, including
choice. Usually infiltrative local anesthesia decreased fit of the overlying prosthesis. sharp excision with a scalpel, rotary
can be performed in selected areas. Sharp Early management consists mainly of dbridement, loop electrocautery as
excision parallel to the defect in a adjustment of the offending denture described by Guernsey, and laser ablation
supraperiosteal fashion allows for removal flange with an associated soft reline of the with a carbon dioxide laser.3032 Because
of mobile tissue to an acceptable level. prosthesis. When there is little chance of of the awkward access needed to remove
Beveled incisions may be needed to blend eliminating the fibrous component, surgi- the lesions, laser ablation is the method
the excision with surrounding adjacent tis- cal excision is necessary. In most cases we employ. Treatment proceeds suprape-
sues and maintain continuity to the sur- laser ablation with a carbon dioxide laser riosteally to prevent exposure of under-
rounding soft tissue. Closure with is the method of choice. When the treat- lying palatal bone. Subsequently, place-
resorbable suture then approximates resid- ment of large lesions would result in sig- ment of a tissue conditioner and a
ual tissues. Impressions for prosthesis fabri- nificant scarring and obliteration of the denture reline is helpful to minimize
cation should proceed after a 3- to 4-week vestibule, sharp excision with undermin- patient discomfort.
period to allow for adequate soft tissue ing of the adjacent mucosa and reapproxi-
remodeling. In cases in which denture mation of the tissues is preferred. Again, Treatment of the Labial and
flange extension is anticipated, the clinician maintenance of a supraperiosteal plane Lingual Frenum
must be careful to preserve the vestibule with repositioning of mucosal edges
when undermining for soft tissue closure. allowing for subsequent granulation is Labial Frenectomy
Granulation is a better alternative if resid- preferred over approximation of wound Labial frenum attachments consist of thin
ual tissues cannot be approximated because edges that results in the alteration of bands of fibrous tissue covered with
Preprosthetic and Reconstructive Surgery 173
Wide-based frenum attachments may hemostat can be used to minimize blood illary vestibule without distortion or
best be treated with a localized vestibulo- loss and improve visibility. After removal inversion of the upper lip, adequate
plasty technique. A supraperiosteal dissec- of the hemostat, an incision is created labiovestibular depth is present (Figure
tion is used to expose the underlying perios- through the area previously closed within 9-18).9 If distortion occurs then maxil-
teum. Superior repositioning of the mucosa the hemostat. Careful attention must be lary vestibuloplasty using split-thickness
is completed, and the wound margin is given to Whartons ducts and superficial skin grafts or laser vestibuloplasty is the
sutured to the underlying periosteum at the blood vessels in the floor of the mouth and appropriate procedure.
depth of the vestibule. Healing proceeds by ventral tongue. The edges of the incision Submucous vestibuloplasty can be per-
secondary intention. A preexisting denture are undermined, and the wound edges are formed in the office setting under outpa-
or stent may be used for patient comfort in approximated and closed with a running tient general anesthesia or deep sedation. A
the initial postoperative period. resorbable suture, burying the knots to midline incision is placed through the
minimize patient discomfort. mucosa in the maxilla, followed by mucosal
Lingual Frenectomy undermining bilaterally. A supraperiosteal
High lingual frenum attachments may Ridge Extension Procedures in separation of the intermediate muscle and
consist of different tissue types including the Maxilla and Mandible soft tissue attachments is completed. Sharp
mucosa, connective tissue, and superficial incision of this intermediate tissue plane is
genioglossus muscle fibers. This attach- Submucous Vestibuloplasty made at its attachment near the crest of the
ment can interfere with denture stability, In 1959 Obwegeser described the submu- maxillary alveolus. This tissue layer may
speech, and the tongues range of motion. cous vestibuloplasty to extend fixed alve- then be excised or superiorly repositioned
Bilateral lingual blocks and local infiltra- olar ridge tissue in the maxilla.33 This (Figure 9-19). Closure of the incision and
tion in the anterior mandible provide ade- procedure is particularly useful in placement of a postsurgical stent or den-
quate anesthesia for the lingual frenum patients who have undergone alveolar ture rigidly screwed to the palate is neces-
excision. To provide adequate traction, a ridge resorption with an encroachment sary to maintain the new position of the
suture is placed through the tip of the of attachments to the crest of the ridge. soft tissue attachments. Removal of the
tongue. Surgical release of the lingual Submucous vestibuloplasty is ideal when denture or stent is performed 2 weeks
frenum requires dividing the attachment the remainder of the maxilla is anatomi- postoperatively. During the healing peri-
of the fibrous connective tissue at the base cally conducive to prosthetic reconstruc- od, mucosal tissue adheres to the underly-
of the tongue in a transverse fashion, fol- tion. Adequate mucosal length must be ing periosteum, creating an extension of
lowed by closure in a linear direction, available for this procedure to be success- fixed tissue covering the maxillary alveo-
which completely releases the ventral ful without disproportionate alteration of lus. A final reline of the patients denture
aspect of the tongue from the alveolar the upper lip. If a tongue blade or mouth may proceed at approximately 1 month
ridge (Figure 9-17). Electrocautery or a mirror is placed to the height of the max- postoperatively.
A B C
FIGURE 9-17 A, Lingual frenum attachment encroaching on an atrophic mandibular alveolus. B, Excision of the frenum with undermining
of mucosal edges. Note: Care must be taken to avoid causing damage to Whartons ducts. C, Final closure of mucosal edges.
Preprosthetic and Reconstructive Surgery 175
and submucosa undermining to the alveolus fixed tissue attachments. As a result, these
is followed by a supraperiosteal dissection to procedures are rarely used today.
the depth of the vestibule (Figure 9-21).
The mucosal flap is then sutured to the Hard Tissue Augmentation
depth of the vestibule and stabilized with a As stated previously, the overall goals of
stent or denture. The labial denuded tissue reconstructive preprosthetic surgery are to
is allowed to epithelialize secondarily. provide an environment for the prosthesis
In the transpositional vestibuloplasty, that will restore function, create stability
the periosteum is incised at the crest of the and retention, and service associated
alveolus and transposed and sutured to the structures as well as satisfy esthetics and
denuded labial submucosa. The elevated prevent minor sensory loss. There are
mucosal flap is then positioned over the many classification systems of rigid defi-
FIGURE 9-18 A mirror presses the vestibular exposed bone and sutured to the depth of ciencies associated with many treatment
mucosa to the desired height to evaluate the ade-
quacy of lip mucosa. In this example, extension of the vestibule (Figure 9-22). options; nevertheless, each patient must be
the vestibular mucosa superiorly on the alveolar These procedures provide satisfactory evaluated individually. When atrophy of
ridge does not result in thinning or intrusion of the results provided that adequate mandibular the alveolus necessitates bony augmenta-
lip. Reproduced with permission from Tucker MR. height exists preoperatively. A minimum tion, undercuts, exostoses, and inappro-
Ambulatory preprosthetic reconstructive surgery.
In: Peterson LJ, Indresano AT, Marciani RD, Roser of 15 mm is acceptable for the above pro- priate tissue attachments should be identi-
SM. Principles of oral and maxillofacial surgery. cedures. Disadvantages include unpre- fied and included in the overall surgical
Vol 2. Philadelphia (PA): JB Lippincott Company; dictable results, scarring, and relapse. plan prior to prosthetic fabrication.
1992. p. 1126.
Mandibular Vestibuloplasty Maxillary Augmentation
and Floor-of-Mouth Lowering In the past, vestibuloplasties were the
Maxillary Vestibuloplasty Procedures procedure of choice to accentuate the
When a submucous vestibuloplasty is con- As with labial muscle attachments and soft alveolus in the atrophic maxilla. Unfortu-
traindicated, mucosa pedicled from the tissue in the buccal vestibule, the mylohyoid nately, poor quality and quantity of bone
upper lip may be repositioned at the depth and genioglossus attachments can preclude combined with excessive occlusal loading
of the vestibule in a supraperiosteal fashion. denture flange placement lingually. In a com- by conventional prostheses continued to
The exposed periosteum can then be left to bination of the procedures described by accelerate the resorptive process. Either
epithelialize secondarily. Split-thickness Trauner as well as Obwegeser and MacIn- augmentation or transantral implant
skin grafts may be used to help shorten the tosh, both labial and lingual extension proce- cross-arch stabilization must be consid-
healing period. In addition, placement of a dures can be performed to effectively lower ered when anatomic encroachment of the
relined denture may minimize patient dis- the floor of the mouth (Figure 9-23).3638 palatal vault or zygomatic buttress and
comfort and help to mold and adapt under- This procedure eliminates the components loss of tuberosity height affect overall fit
lying soft tissues and/or skin grafts. involved in the displacement of conven- and function of a conventional prosthe-
Another option in this situation is tional dentures and provides a broad base sis. This section discusses conventional
laser vestibuloplasty. A carbon dioxide of fixed tissue for prosthetic support. Again, augmentation procedures of the maxilla
laser is used to resect tissue in a supraperi- adequate mandibular height of at least to restore acceptable alveolar form and
osteal plane to the depth of the proposed 15 mm is required. Split-thickness skin dimensions.
vestibule. A denture with a soft reline is grafting is used to cover the denuded There is a fourfold increase in resorp-
then placed to maintain vestibular depth. periosteum and facilitate healing. tion in the mandible compared with that
Removal of the denture in 2 to 3 weeks Today, with the incorporation of in the maxilla, combination syndromes
reveals a nicely epithelialized vestibule that endosteal implants and the fabrication of not withstanding. When severe resorption
extends to the desired depth (Figure 9-20). implant-borne prostheses, lingual and buc- results in severely atrophic ridges
colabial flange extensions to stabilize (Cawood and Howell Classes IVVI),
Lip-Switch Vestibuloplasty mandibular prostheses are not necessary. some form of augmentation is indicated.
Both lingually based and labially based Consequently, attention is directed toward Onlay, interpositional, or inlay grafting are
vestibuloplasties have been described.34,35 preservation or preparation of the alveolus the procedures of choice to reestablish
In the former an incision in the lower lip for implants rather than extension of the acceptable maxillary dimensions.
176 Part 2: Dentoalveolar Surgery
Mucosa
Shallow submucosal tissue
A B
and muscle attachments
C
Submucosal
incision
Submucosal
incisions Mucosa
Splint
D E F
FIGURE 9-19 Maxillary submucosal vestibuloplasty. A, Following the creation of a vertical midline inci-
sion, scissors are used to bluntly dissect a thin mucosal layer. B, A second supraperiosteal dissection is
created using blunt dissection. C, Interposing submucosal tissue layer created by submucosal and
supraperiosteal dissections. D, Interposing tissue layer is divided with scissors. The mucosal attachment
to the periosteum may be increased by removal of this tissue layer. E, Connected submucosal and
supraperiosteal dissections. F, Splint extended in to the maximum height of the vestibule, placing the
mucosa and periosteum in direct contact. G, Preoperative appearance of the maxilla with muscular
attachments on the lateral aspects of the maxilla. H, Postoperative view. A,B,E,F adapted from Tucker
MR. Ambulatory preprosthetic reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser
G SM. Principles of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company;
1992. p. 11267. C,D,G,H reproduced with permission from Tucker MR. Ambulatory preprosthetic
reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and
maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1127.
B C D
FIGURE 9-20 Open submucosal vestibuloplasty. A, Submucosal dissection between two anterior vertical incisions followed by an incision on the crest of the alve-
olar ridge. B, Preoperative appearance of the maxilla; hydroxylapatite augmentation had been performed but resulted in inadequate vestibular depth. C, Intra-
operative photograph after elevation of the mucosal flap and removal of submucosal tissue. D, Appearance at the time of splint removal. A adapted from and BD
reproduced with permission from Tucker MR. Ambulatory preprosthetic reconstructive surgery. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles
of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company; 1992. p. 1128.
and possibly stimulate future bone with careful manipulation with an Onlay Grafts When clinical loss of the
growth. Adequate dimensions, however, osteotome, taking care to maintain the alveolar ridge and palatal vault occur
should exist that allow for a midcrestal labial periosteal attachment. An interposi- (Cawood and Howell Class V), vertical
osteotomy to separate the buccal and lin- tional cancellous graft can then be placed onlay augmentation of the maxilla is indi-
gual cortices (Figures 9-24 and 9-25). A in the resulting defect, replacing the lost cated. Initial attempts at alveolar restora-
labial incision originates just lateral to the bony mass. Closure of the incision is away tion involved the use of autogenous rib
vestibule and continues supraperiosteally from the graft site and usually requires grafts; however, currently corticocancellous
to a few millimeters below the crest of the suturing of the flap edge to the periosteum blocks of iliac crest are the source of
alveolus. A subperiosteal flap then origi- with subsequent granulation of the choice.39,40 In a similar approach to that
nates exposing the underlying crest. Copi- remainder of the exposed tissue bed. described above, the crest of the alveolus is
ous irrigation accompanies an osteotomy Endosteal implants can be placed approxi- exposed and grafts are secured with 1.5 to
circumferentially anterior to the maxillary mately 3 to 4 months later; waiting this 2.0 mm screws. Studies show increased suc-
sinus from one side to the other. Mobiliza- length of time has been shown to increase cess with implant placement in a second-
tion of the labial segment can be achieved overall long-term implant success. stage procedure rather than using them as
178 Part 2: Dentoalveolar Surgery
A B
D E
Preprosthetic and Reconstructive Surgery 179
Mandibular Augmentation
models, model surgery to reposition the ure 9-28).46 During the evaluation and One of the most challenging procedures in
segment, and diagnostic wax-ups of the treatment planning stage, the restorative reconstructive surgery remains the recon-
proposed opposing dentition help one to dentist should play a major role in deter- struction of the severely atrophic mandible
verify the feasibility and success of the mining the final position of the maxillary (Cawood and Howell Classes V and VI).
future prosthetic reconstruction. Surgical and mandibular arches. Clinical examina- Patients exhibiting these deficits are charac-
splint fabrication is necessary to support tion, radiographic and cephalometric teristically overclosed, which creates an
and stabilize the segment postoperatively. examinations, and articulated models aged appearance, are usually severely debil-
Increased stability is obtained if as many should be attained to determine appropri- itated from a functional perspective, and
teeth as possible are included in the splint
to help stabilize the teeth in the reposi-
tioned segment. The splint can be thick-
ened to the opposing edentulous alveolar
ridge to prevent relapse and to maintain the A B
new vertical alignment of the repositioned
segment. Techniques for segmental surgery
are discussed Chapter 57, Maxillary
Orthognathic Surgery, and in other texts.
An adequate healing period of approxi-
mately 6 to 8 weeks should precede pros-
thetic rehabilitation.
In totally edentulous patients with
skeletal abnormalities that prevent suc-
cessful prosthetic reconstruction owing to
an incompatibility of the alveolar arches,
orthognathic surgical procedures may cre-
ate a more compatible skeletal and alveolar FIGURE 9-27 A, Sinus lift procedure with an inward trapdoor fracture of lateral sinus wall. B, Graft materi-
al is placed on the floor of the sinus. The sinus lining should not be perforated during the elevation of the bone.
ridge relationship. This can aid the
Adapted from Beirne OR. Osseointegrated implant systems. In: Peterson LJ, Indresano AT, Marciani RD,
restorative dentist in the fabrication of Roser SM. Principles of oral and maxillofacial surgery. Vol 2. Philadelphia (PA): JB Lippincott Company;
functional and esthetic restorations (Fig- 1992. p. 1146.
182 Part 2: Dentoalveolar Surgery
A B C D
FIGURE 9-28 A and B, Preoperative views of a 52-year-old patient show severely collapsed circumoral tissues. C and D, The same patient 6 months postopera-
tively. Note the improvement of the sagging chin and support for circumoral muscles. Better support for the lower lip also favorably affects the position of the upper
lip. The patient is not wearing dentures in any of the photographs. Reproduced with permission from Stoelinga PJW. 61
often present with significant risk for cadaveric mandibles combined with auto- 3 to 4 mm below the inferior border of the
pathologic fracture of the mandible. genous cancellous bone (Figure 9-29).5860 mandible and anteriorly to the contralat-
Because the ideal graft should be vascular- The following describes our technique for eral side. The superficial layer of the deep
ized and eventually incorporated into the inferior augmentation of the atrophic cervical fascia is sharply dissected. The fas-
host bone through a combination of osteo- mandible using the latter method. cia is then incorporated in the reflection; a
conduction and induction, autogenous Incisions are placed as inconspicuous- nerve tester is used to perform a careful
bone grafts consistently meet these require- ly as possible from one mandibular angle evaluation for the marginal mandibular
ments and offer the most advantages to the to the other and proceed circumferentially branch of the facial nerve. Reflection
reconstructive plan. Unfortunately, graft
resorption and unpredictable remodeling
have complicated grafting procedures;
however, rigid fixation and later incorpora-
tion of dental implants have allowed for
the needed stability postoperatively with
regard to resorption and have promoted
beneficial stimulation to preserve existing
graft volume. Initially, mandibular aug-
mentation with autogenous rib and ileum B
enjoyed little long-term success. However,
recent incorporation of rigid fixation,
delayed implant placement 6 months after
grafting (allowing for the initial stage of
graft resorption), guided tissue regenera- A
tion, and BMP have all contributed to
FIGURE 9-29 A, Cadaveric mandible tray rigid-
increased success rates in onlay augmenta- ly fixed to an atrophic mandible with autoge-
tion of the mandible.5357 nous cancellous bone sandwiched between native
and cadaveric bone. Note that bur holes have
Inferior Border Augmentation Inferior been created to facilitate the revascularization of
the graft. B, Cadaveric tray filled with autoge-
border augmentation has been demon- nous bone before insetting. C, Graft and cadav- C
strated using autogenous rib or composite eric tray inset for inferior border augmentation.
Preprosthetic and Reconstructive Surgery 183
superficial to the capsule of the sub- The lingual periosteum maintains ridge shown to be a viable solution to defects of
mandibular gland allows dissection to the form and its presence results in minimal the long bone, mandible, and midface.
inferior border. Facial blood vessels are resorption of the transpositioned basalar Application to alveolar bone has been limit-
located and managed with surgical ties bone, as described by Stoelinga.61 Peterson ed only by technologic advancement in
accordingly. The inferior border is exposed and Slade as well as Harle described the appliancesthe principles are still the
in a subperiosteal dissection with great visor osteotomy in the late 1970s (Figure same. Alveolar distraction offers some dis-
care to avoid intraoral exposure. Cadaver- 9-30).62,63 Unfortunately, labial bone graft- tinct advantages over traditional bone-
ic mandibular adjustment involves reliev- ing of the superiorly repositioned lingual grafting techniques. No donor site morbidi-
ing the condyles and superior rami, thin- segment was necessary to reproduce alveo- ty is involved, and the actual distraction
ning the bone to a uniform thickness of lar dimensions that were compatible with process from the latency period through
approximately 2 to 3 mm, and creating a prosthesis use. Schettler and Holtermann active distraction and consolidation is actu-
scalloped tray to incorporate the autoge- and then Stoelinga and Tideman described ally shorter than Phase I and Phase II bone
nous bone. Repeated try-ins are necessary a horizontal osteotomy with interposi- remodeling and maturation. The quality of
to evaluate the overall adaptation to the tional grafts to augment mandibular the bone grown in response to this ten-
native mandible. Osseous interfaces as well height, with repositioning of the inferior sion/stress application is ideal for implant
as form and symmetry as they relate to the alveolar neurovascular bundle (Figures placement. The vascularity and cellularity of
overall maxillomandibular relationship 9-31 and 9-32).64,65 Unfortunately, neu- the bone promote osseointegration of den-
are evaluated. Once appropriate dimen- rosensory complications and collapse of tal implants. The greatest successes are relat-
sions have been reached, the atrophic the lingual segment became significant ed to the achievement of vertical graft sta-
mandible fits securely inside the cadaveric disadvantages to this technique. With the bility. One of the biggest problems in
specimen without creating a Class III incorporation of mandibular implants alveolar bone grafting historically has been
appearance, and flap closure is attainable, and the success of full mandibular pros- maintaining vertical augmentation of bone
bur holes are drilled throughout the spec- theses that are supported by four or five graft sites. When distraction is used, the
imen to facilitate vascularization. Autoge- anterior implants between mental forami- transported alveolar segment does not
nous bone is then obtained from the na, many of these pedicled and interposi- undergo any significant resorptive process
ileum, morselized, and placed in the tional procedures are in decline today. because it maintains its own viability
cadaveric specimen. BMP soaked in colla- through an intact periosteal blood supply.
gen is placed in the recipient bed as well as Alveolar Distraction The intermediate regenerate quickly trans-
in a layered fashion over the autogenous Osteogenesis forms into immature woven bone and
graft. The entire specimen is fixed rigidly As alluded to previously, growing bone via matures through the normal processes of
to the native mandible using screw fixa- the application of tension or stress has been active bone remodeling. The sequencing of
tion posterior to the area of future
implant placement and in the mandibular
midline, where implants are usually not
placed. Postoperatively patients can func-
tion with their preexisting prosthesis and
enjoy increased stabilization of the
mandible. When combined with implant
placement at 4 to 6 months, this proce-
dure results in an overall resorption rate
of < 5% and is associated with low rates of
infection and dehiscence intraorally
owing to the maintenance of mucosal bar-
riers during reconstruction.
and the bone plate device manufactured waiting for full mineralization of the ideal environment for implant-supported
by Walter Lorenz Surgical are two devices regenerate, one can place the implants, and -stabilized prosthetic reconstruction.
that adhere to the principles of distraction which then provide further rigidity to the
and rigid fixation (Figure 9-33). transport segment and allow for healing of References
After placement of a distraction both the implant and the immature regen-
1. Brnemark PI, Hansson B, Adell R, et al.
device, a latency period must be observed, erate simultaneously. The total treatment Osseointegrated implants in the treatment
the duration of which is 4 to 7 days, time is thus much shorter than with con- of the edentulous jaw. Experience from a
depending on the age of the patient and ventional bone grafting with either auto- 10-year period. Scand J Plast Reconstr Surg
the quality of tissue at the transport site. genous or allogeneic bone, and in most Suppl 1977;16:1132.
2. Weintraub JA, Burt BA. Oral health status in
The latter is significant in patients who cases the appliance does not interfere with
the United States: tooth loss and eden-
have previously undergone irradiation, day-to-day function. Other than the tulism. J Dent Educ 1985;49:36878.
multiple surgical procedures, or trauma, inability to wear a transitional prosthesis, 3. Cawood JI, Stoelinga JPW, et al. International
resulting in scar tissue and compromised there is minimal disruption of the normal research group on reconstructive prepros-
blood supply. The active distraction peri- activity and diet. Morbidity is generally thetic surgeryconsensus report. Int J Oral
od varies depending on the distance the minimal and is related strictly to manage- Maxillofac Surg 2000;29:13962.
4. Tallgren A. The continuing reduction of resid-
segment is transported. Standard princi- ment of soft tissue flaps, maintenance of
ual alveolar ridges in complete denture
ples must be followed. The rate and adequate transport segment blood supply, wearers: mixed longitudinal study covering
rhythm of transport is 1 mm/d in divided and proper positioning of osteotomies. 25 years. J Prosthet Dent 1972;27:12032.
segments0.25 mm four times a day is 5. Bays RA. The pathophysiology and anatomy of
the most practical for appliances as well as Conclusion edentulous bone loss. In: Fonseka R, Davis
W, editors. Reconstructive preprosthetic
the patient. The consolidation phase com- With the evolution and success of dental
oral and maxillofacial surgery. Philadel-
mences when the distraction is complete. implant technology, guided tissue regener- phia: W.B. Saunders; 1985. p 1941.
Generally the consolidation period should ation, and genetically engineered growth 6. Starshak TJ. Oral anatomy and physiology. In:
be three times the length of the distraction factors such as BMP, current indications Starshak TJ, Saunders B, editors. Prepros-
period. The extraosseous appliances pro- for grafting and augmentation are usually thetic oral and maxillofacial surgery. St.
Louis: Mosby; 1980.
vide rigid fixation to promote faster matu- related to facilitation of implant place-
7. Cawood JI, Howell RA. A classification of the
ration of the regenerated bone. At the con- ment. Time-honored reconstructive pro- edentulous jaws. Int J Oral Maxillofac Surg
clusion of the consolidation phase, the cedures including bone grafting and aug- 1988;17:2326.
appliance can be removed. Rather than mentation are also evolving to create the 8. Crandal CE, Trueblood SN. Roentgenographic
186 Part 2: Dentoalveolar Surgery
findings in edentulous areas. Oral Surg osteoclast resorption of bone substitute fixed with screw implants for the treatment
1960;13:1342. biomaterials used for implant site augmen- of severely resorbed maxillae. Radiographic
9. Ochs MW, Tucker MR. Preprosthetic surgery. tation: a pilot study. Int J Oral Maxillofac evaluation of preoperative bone dimen-
In: Peterson LJ, Ellis E, Hupp J, Tucker M, Implants 2002;17:32130. sions, postoperative bone loss, and changes
editors. Contemporary oral and maxillofa- 26. Alexopoulou M, Semergidis T, Sereti M. Allo- in soft tissue profile. Int J Oral Maxillofac
cial surgery. 4th ed. St Louis: Mosby; 2003. genic bone grafting of small and medium Surg 1996;25:3519.
p. 248304. defects of the jaws. Presented at the XIV 42. Vermeeren JI, Wismeijer D, van Wass MA.
10. Enlow DH, Kuroda T, Lewis AB. The morpho- congress of the European Association for One-step reconstruction of the severely
logical and morphogenetic basis for cranio- Cranio-Maxillofacial Surgery. 1998 Sep- resorbed mandible with onlay bone grafts
facial form and pattern. Angle Orthod tember 15; Helsinki, Finland. and endosteal implants. A 5-year follow-up.
1971;41:16188. 27. Sclar AG. Preserving alveolar ridge anatomy Int J Oral Maxillofac Surg 1996;25:1125.
11. Wozney JM. The bone morphogenetic protein following tooth removal in conjunction 43. Nystrom E, Lundgren S, Gonne J, Nilson H.
family and osteogenesis. Mol Reprod Dev with immediate implant placement. The Interpositional bone grafting in LeFort I
1992;31:1607. Bio-Col technique. Atlas Oral Maxillofac osteotomy for reconstruction of the
12. Moss ML. The primary role of functional Surg Clin North Am 1999;7(2):3959. atrophic edentulous maxilla. A two stage
matrices in facial growth. Am J Orthod 28. Kalas S. The occurrence of torus palatinus and technique. Int J Oral Maxillofac Surg
1969;55:56677. torus mandibularis in 2,478 dental patients. 1997;26:4237.
13. Ilizarov GA. The tension-stress effect on the Oral Surg 1953;6:113443. 44. Keller EE, Eckerd SE, Tolman DE. Maxillary
genesis and growth of tissues. Clin Orthop 29. Bhaskar SN. Synopsis of oral pathology. 7th ed. antral and nasal one stage inlay composite
1989;238:24981. St. Louis: Mosby; 1986. bone graft. A preliminary report on 30
14. Ilizarov GA, editor. Transosseous osteosynthe- 30. Guernsey LH. Reactive inflammatory papillary recipient sites. J Oral Maxillofac Surg
sis. Germany: Springer-Verlag; 1992. hyperplasia of the palate. Oral Surg 1994;52:43848.
15. Sullivan WG, Szwajkun PR. Revascularization 1965;20:81427. 45. Astrand P, Nord PG, Brnemark PI. Titanium
of cranial versus iliac crest bone grafts in 31. Starshak TJ. Corrective soft tissue surgery. In: implants and onlay bone grafts to the
the rat. Plast Reconstr Surg 1991;87:11058. Sharshak TJ, Saunders, B, editors. Prepros- atrophic edentulous maxilla. A three year
16. Burchardt H. The biology of bone graft repair. thetic oral and maxillofacial surgery. St. longitudinal study. Int J Oral Maxillofac
Clin Orthop 1983;174:2842. Louis: Mosby; 1980. Surg 1996;25:259.
17. Reddi AH, Weintroub S, Muthukumaran N. 32. Hartwell CN Jr. Syllabus of complete dentures. 46. Bell WH, Profit WR, White RP Jr. Surgical cor-
Biologic principles of bone induction. Philadelphia: Lea & Febiger; 1968. rection of dentofacial deformities. Philadel-
Orthop Clin North Am 1987;18:20712. 33. Obwegeser H. Die Submukose Vestibulumplaspik. phia: W.B. Saunders; 1980.
18. Hosney M. Recent concepts in bone grafting Dtsch Zahnarztl Z 1959;14:62938. 47. Piecuch J, Segal D, Grasso J. Augmentation of
and banking. J Craniomandib Pract 1987; 34. Kazanjian VH. Surgical operations as related to the atrophic maxilla with interpositional
5:17082. satisfactory dentures. Dent Cosmos autogenous bone grafts. J Maxillofac Surg
19. Becker WM, Urist M, Tucker L . Human deminer- 1924;66:38791. 1984;12:1336.
alized freeze-dried bone: inadequate induced 35. Keithley JL, Gamble JW. The lip-switch: a 48. Cawood JI, Stoelinga PJW, Brouns, JJ. A recon-
bone formation in athymic mice. A prelimi- modification of Kazanjians labial vestibu- struction of the severely resorbed, Class VI
nary report. J Periodontol 1995;66:8228. loplasty. J Oral Surg 1978;36:70107. in maxilla. A two step procedure. Int J Oral
20. Wozney JM, Rosen V, Celeste A, et al. Novel reg- 36. Trauner R. Alveoloplasty with ridge extensions Maxillofac Surg 1994;23:21925.
ulators of bone formation: molecular clones on the lingual side of the lower jaw to solve 49. Piecuch JF, Silverstein K, Quinn PD. Bone
and activities. Science 1998;42:152834. the problem of a lower dental prosthesis. grafts in preprosthetic surgery. Oral Max-
21. Dean OT. Surgery for the denture patient. J Am Oral Surg 1952;5:3408. illofacial Surgery Knowledge Update, Vol II.
Dent Assoc 1936;23:12432. 37. MacIntosh RB, Obwegeser HL. Preprosthetic Chicago (IL): American Association of Oral
22. Kent JN, Jarcho M. Reconstruction of the alveo- surgery: a scheme for its effective employ- and Maxillofacial Surgeons; 1998. p. 1131
lar ridge with hydroxyapatite. In: Fonseca R, ment J Oral Surg 1967;25:397415. 50. Locher MC, Sailer HF. Results after a LeFort I
Davis W, editors. Reconstructive preprosthet- 38. Richardson D, Cawood JI. Anterior maxillary osteotomy in combination with titanium
ic oral and maxillofacial surgery. Philadel- osteoplasty to broaden the narrow maxil- implants: sinus inlay method. Oral Maxillo-
phia: WB Saunders; 1985. p. 853936. lary ridge. Int J Oral Maxillofac Surg fac Surg Clin North Am 1994;6:67988.
23. Wiltfang J, Schlegel K, Schultze-Mosgau S, et 1991;20:3438. 51. Block MS, Kent JN. Sinus augmentation for den-
al. Sinus floor augmentation with beta- 39. Terry BC, Albright JE, Baker RD. Alveolar ridge tal implants: the use of autogenous bone.
tricalciumphosphate (beta-TCP): does augmentation in the edentulous maxilla J Oral Maxillofac Surg 1997;55:12816.
platelet-rich plasma promote its osseous with the use of autogenous ribs. J Oral Surg 52. Thoma KH, Holland DJ. Atrophy of the
integration and degradation? Clin Oral 1974;32:42934. mandible. Oral Surg 1951;4:147781.
Implants Res 2003;14:2138. 40. Terry BC. Subperiosteal onlay grafts. In: 53. Curtis T, Ware W. Autogenous bone graft pro-
24. Stvrtecky R, Gorustovich A, Perio C, Gugliel- Stoelinga PJW, editor. Proceedings Consen- cedures for atrophic edentulous mandibles.
motti MB. A histologic study of bone sus Conference: 8th International Congress J Prosthet Dent 1977;38:36679.
response to bioactive glass particles used Conference in Oral Surgery. Chicago: 54. Saunders B, Cox R. Inferior border rib grafting
before implant placement: a clinical report. Quintessence International; 1984. for augmentation of the atrophic edentulous
J Prosthet Dent 2003;90:4248. 41. Nystrom E, Ahlqvist J, Kahnberg KE, Ronsen- mandible. J Oral Surg 1976;34:897900.
25. Taylor JC, Cuff SE, Leger JP, et al. In vitro quist JB. Autogenous onlay bone grafts 55. Davis WH, Delo RI, Ward WB. et al. Long term
Preprosthetic and Reconstructive Surgery 187
ridge augmentation with rib graft. J Max- border grafting and implants: a preliminary 63. Harle F. A follow up investigation of surgical
illofac Surg 1975; 3:1036. report. Int J Oral Maxillofac Implants correction of the atrophied alveolar ridge
56. Bell WH, Buche W, Kennedy J III, et al. Surgi- 1992;7:8793. with visor osteotomy. J Maxillofac Surg
cal correction of the atrophic alveolar ridge: 60. Miloro M, Quinn PD. Prevention of recurrent 1979;7:28393.
a preliminary report on a new concept of pathologic fracture of the atrophic 64. Schettler D, Holtermann W. Clinical and exper-
treatment. Oral Surg 1977;43:48598. mandible using inferior border grafting: imental results of a sandwich-technique for
57. Baker RD, Connole PW. Preprosthetic aug- report of two cases. J Oral Maxillofac Surg mandibular alveolar ridge augmentation. J
mentation grafting: autogenous bone. J 1994;52:41420. Maxillofac Surg 1977;5:199202.
Oral Surg 1977;35:54151. 61. Stoelinga PJW. Preprosthetic reconstructive 65. Stoelinga PJW, Tideman H. Interpositional
58. Quinn PD. The atrophic mandible: an alterna- surgery. In: Peterson LJ, Indresano AT, Mar- bone graft augmentation of the atrophic
tive to superior border grafting. In: Wor- ciani RD, Roser SM, editors. Principles of mandible: a preliminary report. J Oral Surg
thington P, Evans J, editors. Controversies oral and maxillofacial surgery. Philadel- 1978;36:302.
in oral and maxillofacial surgery. Philadel- phia: JB Lippincott Co; 1992. p. 1169207. 66. Chin M. Alveolar distraction osteogenesis. In:
phia: W.B. Saunders; 1994. p. 4606. 62. Peterson LJ, Slade E. Mandibular ridge augmenta- Samchucov ML, Cope JB, Cherkashin AM,
59. Quinn PD, Kent JN, MacAfee KA. Reconstruct- tion by a modified visor osteotomy: a prelim- editors. Craniofacial distraction osteogene-
ing the atrophic mandible with inferior inary report. J Oral Surg 1977;35:9991004. sis. St. Louis: Mosby; 2001. p. 38792.
CHAPTER 10
Osseointegration
Michael S. Block, DMD
Ronald M. Achong, DMD, MD
History of Dental Implants chrome-molybdenum screw with a cone- were first placed in patients in 1965 and
shaped head for the cementation of a jacket studies showed prolonged survival, free-
Replacement of lost dentition has been
crown. The implant remained stable and standing function, bone maintenance, and
traced to ancient Egyptian and South Amer-
asymptomatic until 1955, at which time the significant improvement in benefit-to-risk
ican civilizations.1 In ancient Egyptian writ-
ings implanted animal and carved ivory patient died in a car accident. Strock wrote, ratio over all previous implants.13 This
teeth were the oldest examples of primitive The histological sections of implants in the breakthrough has revolutionalized max-
implantology. In eighteenth and nineteenth dog study showed remarkable complete tol- illofacial reconstruction. Subsequently,
century England and colonial America, erance of the dental implant and the pathol- various implant designs have been manu-
poor individuals sold their teeth for extrac- ogist report so indicated to our gratifica- factured and research in implantology has
tion and transplantation to wealthy recipi- tion. Strock demonstrated for the first time grown exponentially. The frontiers of
ents.2 The clinical outcomes of these trans- that metallic endosteal dental implants were implantology are rapidly being advanced
planted dentitions were either ankylosis or tolerated in humans, with a survival rate of and esthetics continue to be an integral
root resorption. Continued research pro- up to 17 years.8
part of this progress.
longed allotransplant survival but did not Due to inadequate alveolar bone height
appreciably improve predictability. in certain sites of the jaws, subperiosteal Implant Materials and Surface
In 1809 Maggiolo placed an immedi- implants were developed. In 1943 Dahl
Implant materials have undergone a num-
ate single-stage gold implant in a fresh placed a metal structure on the maxillary
ber of different modifications and devel-
extraction site with the coronal aspect of alveolar crest with four projecting posts.9
opments over the past 40 years. Commer-
the fixture protruding just above the gin- Multiple variations to this initial design
cially pure titanium has excellent
giva.3 Postoperative complications includ- were fabricated but these devices often
biocompatibility and mechanical proper-
ed severe pain and gingival inflammation. resulted in wound dehiscence. Blade
ties. When titanium is exposed to air, a
Since then various implant materials were implants were introduced by Linkow and
by Roberts and Roberts.10,11 There were 2 to 10 nm thick oxide layer is formed
used ranging from roughened lead roots
numerous configurations with broad appli- immediately on its surface.14 This layer is
holding a platinum post to tubes of gold
cations, and the implants became the most bioinert. However, strength issues with
and iridium.36 Adams in 1937 patented a
submergible threaded cylindrical implant widely used device in implantology in the pure titanium have led manufacturers to
with a ball head screwed to the root for United States and abroad (Figure 10-1). use a titanium alloy to enhance strength
retention for an overdenture in a fashion A two-staged threaded titanium root- of the implant. Most abutments are made
similar to that done today.7 form implant was first presented in North of titanium alloy. The use of alloy signifi-
Up to this point implant success was America by Brnemark in 1978.12 He cantly increases strength, which can be an
marginal with a maximum longevity of only showed that titanium oculars, placed in issue with small-diameter and internal
a few years. Strock placed the first long-term the femurs of rabbits, osseointegrated in connections. Titanium alloy (Ti-6Al-4V)
endosseous implant at Harvard in 1938.8 the femurs of rabbits after a period of is becoming the metal of choice for
This implant was a threaded cobalt- healing. Two-staged titanium implants endosseous dental implants.
190 Part 2: Dentoalveolar Surgery
high-speed drilling causes physiologic heat was generated. When cortical bone was a follow-up period of 3 years.26 The over-
damage to bone. In 1983 Eriksson and prepared using the spiral drill, irrigation all cumulative implant survival rate after
Albrektsson demonstrated the occurrence decreased the maximum temperature by functional loading was 97.7% in the
of irreversible histologic damage in the 10C or more. It is recommended by all mandible and 98.4% in the maxilla. Coop-
rabbit tibia when heat exposure at a tem- manufacturers that the bur be moved up er and colleagues investigated the early
perature of 47C was longer than and down while preparing the implant site, loaded implants in clinical function with-
1 minute.21 An even greater injury to allow accessibility of irrigation to the out risking the result of osseointegration.27
occurred after heating the bone to 53C for cutting edges of the bur, neutralizing heat They demonstrated a 96.2% implant sur-
1 minute, and heating to temperatures of generation and removing bone debris. vival rate with loaded unsplinted maxil-
60C or more resulted in permanent cessa- lary anterior single-tooth implants
tion of blood flow and obvious necrosis Time for Integration 3 weeks after one-stage surgical place-
that showed no sign of repair over follow- Historically a nonloading healing period ment.27 The majority of the tapered
up period of 100 days.21 of machined-surfaced dental implants has threaded implants were placed in type
Minimal heat during implant site been 4 to 6 months for the mandible and 3 bone with a minimal length of 11 mm.
preparation has been recommended to 6 months for the maxilla.24 The 4- to The mean change in marginal bone level
achieve optimal healing conditions. 6-month recommendations were made to was 0.4 mm with a mean gain in papilla
Although the relationship between speed prevent the development of a fibrous length of 0.61 mm at 12 months. In a
and heat generation is still under debate, encapsulation of the implant fixtures that recent report unsplinted implants placed
the consensus has been to recommend occurs with premature loading. These by a single-stage procedure were successful
speeds of less than 2,000 rpm with copious early recommendations for implant surgi- when loaded by a mandibular overdenture
irrigation for preparation of implant sites.21 cal protocol were developed based on clin- prosthesis.28 Further developments in
In 1986 Eriksson and Adell showed that the ical observations and not necessarily based implant surfaces will greatly reduce inte-
Brnemark drilling system had a mean on an understanding of the biologic prin- gration time (Figure 10-3).
maximum temperature of 30.3C during ciples of implant integration. The original
drilling, with a maximum temperature of Brnemark protocol has been greatly Key Reasons for Failure
33.8C.22 The duration of maximum tem- modified due to the advances in implant Endosseous dental implants have been
perature never exceeded 5 seconds. microtopographic surfaces and design. In used successfully throughout the past few
Watanabe and colleagues measured recent years histologic and experimental decades. Unfortunately implants are not
heat distribution to the surrounding bone studies have shown that specifically always successful. Improper implant
with three different implant drill systems, designed microtopographic implant sur- placement can result in a framework
in 1992.23 Generation of heat in the pres- faces can result in increased bone-to- design that compromises esthetics and
ence or absence of irrigation when drilling implant contact at earlier healing times distribution of force on implants.
with spiral or spade-type drills was than obtained with machined-surface Endosseous implants distribute occlusal
observed in the pig rib via thermography. implants. Over the years histologic and load best in an axial direction, but if the
The maximum temperature generated clinical studies investigating early and occlusal load is in a lateral direction, many
without irrigation was significantly greater immediate implant loading revealed that damaging stresses, including shear stress-
than with irrigation for each drill. The heat implants can be placed into function earli- es, are generated directly at the crest of
generated continuously spread to the sur- er than previously recommended. In 1998 bone. Lazzara proposed that off-angle
rounding bone even after the bur or drill Lazzara and colleagues evaluated the effi- implant positioning requiring over 25 of
was removed from the bone, and the origi- cacy of loading Osseotite dental implants angle correction will cause an implant
nal temperature returned in about 60 sec- at 2 months to determine the effect of to fail.29 Overheating bone during place-
onds. The spiral drill required the longest early loading on implant performance and ment will result in a fibrous tissue against
time to generate heat, with gradual increase survival.25 The cumulative implant sur- the implant surface rather than the bone.
of temperature. The round bur and cannon vival rate was 98.5% at 12.6 months. The Placing implants into bone of poor quali-
or spade drill could finish cutting in a short cumulative postloading implant survival ty without consideration to the mechani-
time, with rapid generation of heat. Maxi- rate was 99.8% at 10.5 months. Testori and cal forces of loading can result in early
mum temperature without irrigation was colleagues investigated the clinical out- or late failure. Lack of bone contact at
higher than with irrigation for any drill. come of 2 months of loaded Osseotite the time of placement is also a factor lead-
With irrigation at proper speed, minimal implants placed in the posterior jaws, with ing to lack of integration or marginal
192 Part 2: Dentoalveolar Surgery
between ordered, living bone and the sur- the bone marrow via monoblast differenti- Phase Three: Maturation Phase
face of a load carrying implant.24 ation. Macrophages can be activated by
After the establishment of a well-
Wound healing consists of three fun- products of activated lymphocytes and the
vascularized immature connective tissue,
damental phases: inflammation, prolifera- complement system. Macrophages have
osteogenesis continues by the recruit-
tion, and maturation. The induction of the ability to ingest inflammatory debris
ment, proliferation, and differentiation of
bone formation at surgical interfaces by phagocytosis and to digest such parti-
osteoblastic cells.32 Differentiated
reflects a major alteration in cellular envi- cles by releasing hydrolytic enzymes.32
osteoblasts secrete a collagenous matrix
ronment. These crucial events involve an
Phase Two: Proliferative Phase and contribute to its mineralization.
inflammatory phase, a proliferative phase,
Osteoid-type bone within a vascularized
and a maturation phase. Microvascular ingrowth from the adja-
connective tissue matrix becomes
cent bony tissues during this phase is
Phase One: Inflammatory Phase deposited at dental implant surgical
called neovascularization.35 Cellular dif-
interfaces.16 Eventually this matrix
Bone healing around implants results in a ferentiation, proliferation, and activation
envelops the osteoblastic cells and is sub-
well-defined progression of tissue result in the production of an immature
sequently mineralized. This cell-rich and
responses that are designed to remove tis- connective tissue matrix that is later
sue debris, to reestablish vascular supply remodeled. The local inflammatory cells unorganized bone is called woven bone.
and produce a new skeletal matrix. Platelet (fibroblasts, osteoblasts, and progenitor Loading of the dental implant stimulates
contact with implant surfaces causes liber- cells) proliferate within the wound and the transformation of woven bone to
ation of intracellular granules that, when begin to lay down collagen.36 This combi- lamellar bone.16 Lamellar bone is an
released, are involved in the early events nation of collagen and a rich capillary organized bone displaying a haversian
associated with tissue injury.33 Release of network forms granulation tissue with a architecture. Bone remodeling occurs
adenosine diphosphate, serotonin, prosta- low oxygen tension. This hypoxic state, around an implant in response to loading
glandins, and thromboxane A2 promotes combined with certain cytokines such as forces transmitted through the implant to
platelet aggregation, resulting in a hemo- basic fibroblast growth factor (bFGF) and the surrounding bone. The lamellae
static plug. Platelets continue to degranu- platelet-derived growth factor, is respon- around the implant are remodeled
late during the formation of the hemosta- sible for stimulating angiogenesis. bFGF according to the exposed load, which
tic plug and release constituents that seems to activate hydrolytic enzymes, with passage of time, shows a characteris-
increase vascular permeability (serotonin, such as stromelysin, collagenase, and plas- tic pattern of well-organized concentric
kinins, and prostaglandins) and con- minogen, which help to dissolve the base- lamellae with formation of osteons in the
tribute to the inflammatory response ment membranes of local blood vessels.32 traditional manner.16
accompanying tissue injury.33 Reestablishment of local microcirculation Under normal circumstances healing
Acute wound healing consists of a cel- improves tissue oxygen tension and pro- of implants is usually associated with a
lular inflammatory response dominated vides essential nutrients necessary for reduction in the height of alveolar margin-
mainly by neutrophils. Migration of the connective tissue regeneration. al bone. Approximately 0.5 to 1.5 mm of
neutrophils to the site of injury generally Local mesenchymal cells begin to dif- vertical bone loss occurs during the first
peaks during the first 3 to 4 days following ferentiate into fibroblasts, osteoblasts, and year after implant insertion.35 The rapid
surgery.34 These cells are attracted to the chondroblasts in response to local hypoxia initial bone loss is attributed to the gener-
local area by chemotactic stimuli and then and cytokines released from platelets, alized healing response resulting from the
migrate from the intravascular space to macrophages, and other cellular elements.32 inevitable surgical trauma, such as
the interstitial space by diapedesis. The These cells begin to lay down an extracellu- periosteal elevation, removal of marginal
role of these cells is primarily phagocytosis lar matrix composed of collagen, gly- bone, and bone damage caused by drilling.
and digestion of debris and damaged tis- cosaminoglycans, glycoproteins, and glyco-
sue. Digestion of tissue is feasible via the lipids. The initial fibrous tissue and ground Options for the Edentulous
release of digestive enzymes such as colla- substance that are laid down eventually Mandible
genase, elastase, and cathepsin.34 By the form into a fibrocartilaginous callus. The Options for patients with an edentulous
fifth day macrophages predominate and initial bone laid down is randomly arranged mandible include a conventional denture,
remain until the reparative sequence is (woven type) bone.36 Woven bone forma- a tissue-borne implant-supported pros-
completed.32 These cells are derived from tion clearly dominates wound healing at this thesis, or an implant-supported prosthesis
circulating monocytes that originate from point for the first 4 to 6 weeks after surgery. (Figure 10-4).
194 Part 2: Dentoalveolar Surgery
Two Implants marrow space, or it may have very mini- tions are marked in a similar manner ante-
mal marrow with an abundance of corti- rior to the two distal locations. If a fifth
In general, when placing two implants for
cal bone. The smaller the mandible, the implant is to be used, then a mark is made
an overdenture, one should take into con-
more cortical bone and less cancellous in the midline of the mandible. By using
sideration the potential need for addition-
bone is available. When encountering the caliper, the implant bodies are placed a
al implants at a later time. Some patients
very dense bone it is important to period- sufficient distance apart to ensure ade-
enjoy the overdenture prosthesis but may
ically clean the drill bits to keep the cut- quate space for restoration and hygiene.
complain of food getting caught under the
ting surfaces clean of debris during the The use of CT-generated models of the
denture, mobility of the prosthesis when
preparation of the implant site. For coat- mandible can result in surgical templates
speaking, swallowing, or chewing, and a
ed implants a threadformer type of bur is that can be secured to the jaws with pins or
desire to eliminate changing clips, O rings,
used to create threads in the bone. For the implants themselves, resulting in pre-
or locator-type attachments. These
self-tapping implants the surgeon may cise implant location by preoperative
patients may then desire the retention of a
need to use a slightly larger bur than is planning. As the planning process matures
fixed or fixed-removable prosthesis. For
customarily used in other areas of the with CT-generated applications and tem-
these patients three additional implants
mouth. For example, rather than using a plates, incisions will be needed less often.
may be placed to result in a total of five
3.0 mm bur prior to self tapping a After the implant locations are identi-
implants in the anterior mandible, which 3.75 mm implant, a 3.25 mm diameter fied, the first drill in the implant drilling
is sufficient to support an implant-borne drill may be necessary to allow for ease of sequence is used. If available a surgical
prosthesis. Taking this into consideration implant insertion into very dense bone. stent is placed in order to correctly locate
when placing two implants into the anteri- the implants in relation to the teeth. For
or mandible, locating the implants 20 mm Four or More Implants Class III mandibles the implants can be
apart, each 10 mm from the midline of the Four or more implants are placed when angled slightly lingually, for Class II
mandible, allows for later implant place- considering an implant-borne prosthesis. mandibles the implants can be angled
ment if needed. Implant-borne prostheses include hybrid slightly anteriorly, and for Class I
Implant placement at the correct screwed-retained, crown-and-bridge type, mandibles the implants are placed verti-
height in relation to the alveolar crest is or fixed/removable with milled bars and cally in relation to the inferior border of
crucial. If the implant is placed such that retentive devices (see Figure 10-4). The the mandible. Regardless of the angulation
the cover screw is superficial to the adja- incision design is similar for placement of of the implants, the crestal location of the
cent bone, a chance of incisional dehis- four or more implants into the anterior implants is the same, with the implants
cence or mucosal breakdown may occur. It mandible. The subperiosteal reflection exiting the crest midcrestally without
is advantageous to countersink implants should be sufficient to expose the lingual excessive labial or lingual location.
in the anterior mandible sufficiently (1 to and labial cortices and the mental foramen
2 mm depending on the type of external bilaterally. After the periosteal reflection is Augmentation of the
or internal connection of the specific completed, the surgeon has an excellent Atrophic Mandible
implant used) to allow the height of the view of the operative site, the contours of If the patient is in satisfactory health for a
cover screw to be in a flush relationship the bone, and the location of the mental bone graft harvest procedure, the indica-
with the adjacent alveolar bone. The sur- foramen. A caliper is used to mark the tion for bone augmentation of the anteri-
geon should follow the guidelines for the alveolar ridge at no less than 5 mm anteri- or mandible is a patient with less than
specific implant system being used. For or to the mental foramen. This distance is 6 mm of bone height. Patients with greater
one-stage implants temporary healing usually the anterior extent of the nerve, as than 6 mm of bone height can do well
abutments are placed as recommended by it loops forward in the bone prior to exit- with implants without bone augmenta-
the manufacturer. Accidental loading from ing the bone at the mental foramen. A tion.37 Most clinicians will use iliac crest
poorly relined dentures can lead to trauma small round bur is used to place a depres- corticocancellous blocks to augment the
to the implants and eventual loss. Thus it sion in the bone to locate the implant site height in an atrophic mandible. The pro-
is prudent to excessively relieve and use on one side of the mandible. A similar cedure can be performed through either
appropriate soft liners for the transitional mark is placed on the opposite side of the an intraoral or an extraoral incision,
denture during the healing period. mandible, no less than fivemm anterior to depending on clinician preference (Figure
The anterior mandible may have a the mental foramen. The caliper is then set 10-5). The placement of implants at
dense cortical plate with an abundant to 7 or 8 mm and the next implant loca- the time of bone graft placement is also
196 Part 2: Dentoalveolar Surgery
ly or within the vestibule. The crestal inci- ral approach to graft the atrophic
sion places the incision over the bone mandible include avoidance of intraoral
graft, but it also allows the surgeon to have incision breakdown, avoidance of an
the best chance to avoid incisional dehis- intraoral communication with the bone
cence secondary to vascular insufficiency. graft and potential infection, maintenance
A vestibular incision places the incision of the vestibular attachments, which may
away from the bone graft; however, blood eliminate the need for vestibuloplasty, and
supply to the edge of the vestibular inci- ease of reflection of the inferior alveolar
A sion travels through the dense fibrous tis- nerve from the alveolar crest without
sue over the crest and thus may be prone incising over the nerve (Figure 10-6).
to breakdown secondary to vascular insuf- These advantages often are significant and
ficiency. Both of the intraoral incisions offer the patient the least chance of inci-
and their subsequent release will result in sional dehiscence; hence, this approach is
obliteration of the vestibule, which will the method of choice for these authors.
require secondary soft tissue grafting. One From this approach bone grafts can be
should note that the mental foramen is placed in either block or particulate form,
often palpable on the alveolar crest, with with implants used as tent poles to
some portion of the inferior alveolar nerve maintain space over the graft.38
B
dehisced from the mandible secondary to Most clinicians will allow at least
FIGURE 10-5 A, Iliac crest corticocancellous resorption of the alveolar crest bone. 4 months to healing of the iliac crest cor-
block graft augmentation of the atrophic The bone grafts are harvested and ticocancellous bone graft prior to placing
mandible, through an extraoral approach with
simultaneous placement of two implants. B, trimmed as necessary. The goal of the graft implants. Iliac crest corticocancellous
Panoramic radiograph of final prosthesis retained should be to restore the mandible to
by two overdenture attachments. Reproduced approximately 15 mm of vertical height;
with permission from Block MS. Color atlas of however, for a 3 mm mandible, gaining
dental implant surgery. Philadelphia (PA): W.B.
Saunders Company, 2001. p. 28. this amount of bone may be excessive. For
the extremely small 1 to 5 mm tall
mandible, restoring the mandible to 10 to
clinician dependent. If implants are placed 13 mm is considered a great success. Two
at the time of bone graft placement, then or three pieces of corticocancellous bone
the patients time to restoration is blocks are trimmed and placed over the
decreased, the graft can be secured to the superior aspect of the mandible. The edges
mandible with threaded implants, and the are smoothed and the grafts are stabilized A
shorter time to functional loading may pre- in position with screws placed through the
vent graft resorption. The disadvantages of grafts, engaging the inferior border of the
placing implants at the time of bone graft mandible. If implants are placed at the
placement include possible partial resorp- time of graft placement, the clinician must
tion of the graft and exposed portions of weigh the possibility of partial graft
the implants, which is difficult to treat, mal- resorption and subsequent implant fail-
position of the implants due to lack of ure. Implants can be placed 4 months after
proper angulation at placement, which can the graft was performed, and combined
be technically challenging from an extrao- with a simultaneous vestibuloplasty.
The disadvantage of using an extraoral B
ral approach, and potential lack of integra-
tion secondary to poor graft remodeling. approach is the scar that results and diffi- FIGURE 10-6 A, Atrophic mandible in a
Technically the graft procedures are similar, culty placing implants at the time of graft 75-year-old female. B, A 5-year follow-up radi-
with the exception of the surgical prepara- placement. Most implants, when placed ograph of 10 mm long implants placed without
bone graft. Reproduced with permission from
tion of the sites for the implants. into a bone graft performed through an
Block MS. Color atlas of dental implant surgery.
Intraoral incisions for placement of extraoral incision, are flared to the labial Philadelphia (PA): W.B. Saunders Company,
blocks of bone can be made either crestal- aspect. The advantages of using an extrao- 2001. p. 2930.
Osseointegration 197
grafts heal well but start resorbing after A panoramic radiograph and a physi- Parels classification of the edentulous
3 to 4 months, so the surgeon may need to cal examination are often all that are maxilla is useful for conceptualization of
place the implants at 3 months, depending required to delineate satisfactory bone the prosthetic plan (personal communica-
on consolidation and remodeling of the bulk for the placement of implants into tion, 1991). The Class I maxilla involves the
bone graft, which is determined radi- the maxilla. From the panoramic radi- patient who seems to be missing only the
ographically. If necessary a split- thickness ograph one can estimate the amount of maxillary teeth, but has retained the alveo-
dissection can be made intraorally and a vertical bone available throughout the lar bone almost to its original level (Figure
palatal or split-thickness dermis or skin entire maxilla. Occasionally a reformatted 10-7). The Class II maxilla has lost the
graft can be placed to restore some sem- CT scan is obtained to confirm the pres- teeth and some of the alveolar bone, and
blance of vestibule. At the time of vestibu- ence of bone prior to implant placement. the Class III maxilla has lost the teeth and
loplasty, rigid fixation screws can be If cross-sectional radiography is planned, most of the alveolar bone to the basal level.
removed and implants placed, engaging using a radiopaque stent at the time of the For the Class I patient a fixed restora-
the inferior border of the mandible. When radiography significantly increases the tion, borne by implants, can be fabricated
simultaneously performing a vestibulo- amount of information gathered. The because the patient has adequate alveolar
plasty with implant placement, one should teeth in the patients prosthesis are made bone for support of the soft tissues and is
countersink the implants below the level radiopaque by using a radiopaque mater- missing only the teeth. There is usually
of the periosteum so that the graft can lay ial, typically 20 to 30% barium sulfate greater than 10 mm of bone height in
flush and not be tented up off the host tis- combined with clear acrylic so that the both the anterior and posterior maxilla.
sue bed by the dome-like prominence of teeth are included in the cross-sectional For a fixed crown-and-bridge restoration,
the cover screws of implants. image. This provides information con- implants need to be placed within the
cerning the relationship of the bone to the confines of the teeth of the planned
Placement of Implants into desired teeth. restoration. The implants should be
Atrophic Mandibles without
Grafting
The majority of patients with atrophic
mandible with less than 10 mm of bone
height and at least 5 to 6 mm of height are
not good candidates for bone grafting sec-
ondary to health-related issues. For these
patients four implants can be placed, with
1 to 2 mm of the implant through the infe-
rior border of the mandible, and 1 to 2 mm
supracrestal as necessary. It is important to A B
gently prepare the bone with new sharp
drills and pretap these bones since they can
be brittle and have minimal blood supply.
The implants should be placed to avoid
labial protrusion (see Figure 10-6).37
placed to avoid the embrasure regions in exception is the use of the Zygomaticus to chew all textured foods without the pros-
order to promote esthetics and oral implant fixtures. These prostheses require thesis depending on the tissues for support,
hygiene. For a fixed crown-and-bridge posterior maxillary vertical height of bone then a sufficient number of implants is
restoration, the implants should be placed for implants placed in the first molar required to resist the forces of mastication.
3 mm apical to the gingival margin of the region. The removable prosthesis requires For these patients it is recommended to use
planned restoration in order to allow the two to four implants placed into the anteri- six to eight implants for an implant-
restorative dentist to develop a natural or maxilla to support a bar that has reten- supported fixed or fixed/removable prosthe-
emergence of the crowns from the gingi- tive vertical stress-breaking attachments. sis, with an adequate number of implants
va. If the Class I patient desires a tissue- Edentulous maxillary prostheses are usual- located posteriorly to support the molars.
borne overdenture on four implants ly fabricated with cross-arch stabilization of Eight implants in the anterior and
because of financial constraints, then the the left and right implants. Cross-arch sta- posterior maxilla are used to support a
design of the overdenture bar must be bilization significantly increases implant suprastructure for a totally implant-
such as to avoid excessive space-occupy- survival long term. borne restoration with tissue contact only
ing designs, since the patient is missing for speech. If a bar-type structure is
only their teeth, not the alveolus. Placement of Four Implants planned, the implants should be placed
The Class II patients rarely can be into the Anterior Maxilla within the confines of the borders of the
esthetically managed with a fixed crown- For the patient with adequate anterior ver- planned prosthesis, and not labial or out-
and-bridge prosthesis since they require tical bone height, and for whom a treat- side the borders of the teeth. The
the labial flange of the maxillary prosthe- ment plan has been made for anterior implants should be placed to avoid
sis to support the nasal-labial soft tissues. implants for overdenture support, four impingement of the teeth in the overden-
In order to distinguish the need for implants can be placed. It is recommended ture and to allow space for the fabrication
acrylic to support the soft tissues, it is to place at least four implants for a tissue- of the bar. For many of these implant-
useful to duplicate their maxillary den- supported overdenture in the maxilla. Four borne cases, implants are placed from the
tures and remove the labial flange, leaving implants in the anterior maxilla are used to canine region extending posteriorly, with
only the teeth. The resultant soft tissue support a rigid bar, often combined with a minimal number of implants placed
profile with the modified duplicated vertical stress-broken attachments placed into the incisal region. This pattern of
maxillary denture will easily help the at the distal aspects. Implants for overden- placement makes the design of the anteri-
implant team and patient decide on a tures are typically placed with their centers or portion of the prosthesis easier.
treatment plan. If the patients look good slightly palatal to the crest to avoid dehis- The implants for fixed/removable
without the flange of their denture, indi- cence and thin bone over the facial aspect overdentures are typically placed with
cating sufficient nasal-labial support, a of the implants. The incisive canal should their centers slightly palatal to the crest in
fixed crown-and-bridge restoration can be avoided as a site for implant placement. order to avoid dehiscence and thin bone
be fabricated using pink porcelain or Specifically, implants for overdentures are over the facial aspect of the implants. The
acrylic to decrease apical gaps from lost place in the canine and premolar locations, implants can be positioned from second
alveolar bone. In addition the deficiency dependent on the availability of bone. An molar to central incisor; however, most
of alveolar bone necessitates placing the implant can be placed in the lateral incisor restorative dentists prefer to avoid of the
implants more apical than is ideal, result- position if necessary. However, implants central incisor and second molar sites. The
ing in excessively long teeth, teeth with placed in the central incisor locations com- second molar site can be used in select
pink acrylic, a removable lip plumper, plicate the prosthetic rehabilitation since cases, but it does make the placement of
or a hybrid-type prosthesis with space the presence of the abutments and a bar screws, abutments, and transfer copings
between the prosthesis and the implants. near the midline may result in excessive difficult. In addition the bars may need the
A fixed crown-and-bridge, fixed/ palatal bulk in the denture, which may be space of the second molar site for attach-
removable (spark erosion or milled pros- bothersome to the patient. ments, depending on the prosthetic design
thesis), or removable overdenture-type of the retentive bar.
prosthesis may be prescribed. The implant- Placement of Eight Implants
borne fixed and fixed-removable prostheses without a Graft Placement of Eight Implants
require at least six, or preferably eight, If the goals of the patients are to have a den- with Sinus Grafts
endosseous implants to adequately support ture or prosthesis that will enable them to Patients who have received a treatment plan
a maxillary implant-borne prosthesis. The have a palateless prosthesis and allow them or an implant-borne restoration but who
Osseointegration 199
have insufficient vertical bone for the place- ical loading that the restoration and The surgical incision is made slightly
ment of implants in the maxilla posterior to hence implants will feel. Canine guid- palatal to the crest, with vertical releasing
the canines are considered for a combina- ance or group function is usually present incisions flaring into the vestibule in order
tion of sinus grafting and implant place- and can affect the position of the to keep the base of the flap wider than the
ment. The sinus grafts can be performed as implants. Canine discursion is recom- crestal incision width. Full-thickness sub-
one surgery, followed 6 to 12 months later mended when placing posterior implants periosteal labial and palatal flaps are reflect-
with implant placement, or the sinus graft for fixed restorations. The ideal single ed to expose the crest and to provide visu-
can be performed and the implants placed premolar or molar restoration has a bal- alization of the vertical cortices of bone.
at the time of the sinus graft. If the sinus anced occlusion that will result in atrau- The implant should be placed with its axis
graft is performed prior to implant place- matic forces upon the implant. Single- parallel to the occlusal forces, with the
ment, the surgeon should verify that bone tooth implants should be placed such emergence of the implant angling to meet
has formed within the graft. that the implant is under the working the buccal cusps of the mandibular teeth.
We and our colleagues perform sinus cusp of the tooth, to avoid excessive can-
grafting with immediate placement of tilever forces. Maximal length implants Multiple ImplantBorne
implants. Currently, the recommended should be used whenever possible. Short Restorations for the Posterior
sinus graft material is autogenous bone, implants in the posterior jaws tend to Maxilla
harvested from the jaws, tibia, or iliac have less long-term survival than longer Since these restorations commonly
crest. If necessary the autogenous bone implants. The crown-to-root ratio needs involve the distal teeth, assessment of the
volume can be augmented with deminer- to be addressed. Complete treatment availability of bone in relation to the
alized bone in a ratio not to exceed 1:1. planning, which includes knowledge of sinus is critical. If 10 mm of bone is not
Hydroxylapatite-coated implants are used the final restoration, will increase success available, then a sinus augmentation is
for immediate placement into sinus grafts. and limit complications. indicated. If two long implants can be
placed without the need for a sinus graft, effects on the proposed implant site. It is detail of gaining access to the underlying
along with sinus elevation of a third site common to find a deficiency in labial bone bone is critical for obtaining a perfect
by the use of osteotomes, then 8 mm of with loss of the previous root eminence result, without ablation of the papilla or
bone for the third implant is acceptable. form of the ridge. In addition, the overly- vertical scars from poor incision design
However, the use of osteotomes to elevate ing soft tissue at the level of the alveolar and technique. If there is 5 mm from the
the sinus floor by 2 mm is not a proce- crest may be thin, resulting in a lack of contact point of the teeth to the crestal
dure that has abundant scientific valida- stippling, variations in gingival color, and bone of the adjacent tooth, then the use of
tion. Therefore the patient must be increased translucency resulting in parts of sulcular incisions is indicated. If there are
apprised of the risks and potential failure. the implant and abutment showing papillae present but the teeth are long,
When in doubt a sinus elevation is per- through the gingiva. with an excess of 5 mm between the con-
formed. The mechanics of the final The majority of anterior maxillary tact point to the crestal bone of the adja-
restoration need to be taken into consid- single-tooth sites present with inadequate cent tooth, then the patient needs to be
eration when placing multiple implants bone and soft tissue, requiring both bone warned that papillae may not be present
for a full quadrant restoration. and soft tissue augmentation. The height after implant placement. When necessary,
There are patients who have suffi- of the papilla reflects the underlying cre- vertical incisions should be beveled to
cient vertical bone but are deficient in stal bone height on the adjacent teeth.37 allow for esthetic scar healing. When the
the width projection of the bone. After Careful assessment of the bone levels on bone anatomy permits, the use of a tissue
maxillary teeth are extracted for a variety the adjacent teeth enables the surgeon and punch and avoidance of incisions will
of reasons, facial bone resorption can restorative dentist to inform patients of allow for no scars and no loss of papilla.
occur, leaving the palatal bone intact, the realistic expectations of retaining or Angulation of the implant should
with the alveolus thin and deficient. Plac- creating papilla for an esthetic single- result in the axis of the implant being ori-
ing the implant in the ideal position may tooth restoration. ented to emerge slightly palatal to the inci-
result in facial bone dehiscence. For the The presurgical assessment, using the sive edge of the planned restoration. If
thin ridge in the posterior maxilla, with esthetic tooth wax-up, results in the ability placed at or anterior to the incisive edge of
sufficient bone height, several surgical of the surgeon to estimate the height and the tooth, there may be difficulty in devel-
options are available. These include the width of a bone graft, if one is indicated. oping the emergence profile of the restora-
use of particulate bone grafting with For severe bone deficiency, which prevents tion. If the implant is placed too far labial,
membrane coverage, the use of onlay implant stabilization, a bone graft should with the anterior edge of the implant at the
bone grafts harvested from the symph- be placed at least 4 months prior to edge of the gingival margin of the planned
ysis or ramus, and ridge expansion using implant placement, allowing future tooth, then with addition of the abutment
osteotomes or osteotomies. implant placement in the ideal location and porcelain, the gingival contour will be
horizontally and vertically. When the excessive and gingival recession results. As
Restorative Options for deficit of the bone is such that the implant the platform (ie, diameter of the implant)
Single-Unit Restorations in the can be placed and is mechanically stable, increases, the clinician must be cautious to
Anterior Maxilla with a portion of its surface exposed ensure that the labial edge of the implant is
Esthetic implant restorations represent a through the bone, then a hard tissue par- not excessively labial, or emergence of the
challenge to reproduce normal-appearing ticulate graft is placed at the same time as crown will be compromised and will result
restorations with normal-appearing soft the placement of the implant. The materi- in an obese crown form. Most restorations
tissue profile and integrity. Most implant al used for grafting depends on the extent require more than 1 mm of clearance from
sites that require esthetics have deficien- of the implant bone fenestration. Autoge- the labial surface of the implant to the
cies in the ideal bone and overlying soft nous bone is used for larger fenestrations, eventual clinical crown, secondary to
tissue, and must be enhanced with a vari- with a gradual increase in hydroxylapatite development of the emergence profile of
ety of surgical techniques. A tooth may be used as the implant bone dehiscence the restoration from the subgingival por-
missing because of lack of tooth develop- decreases in size. tion of the implant restoration.
ment, caries, external or internal resorp- The depth of the implant in relation to
tion of teeth following trauma, root canal Incision Considerations for the planned gingival margin is also critical.
complications, bone loss from periodontal Esthetic Sites If the implant is placed too shallow, with
disease, or recent dentoalveolar trauma. When placing an implant in the central 2 mm or less from the top of the implant to
Each of these etiologies has secondary incisor location, careful attention to the the gingival margin, then several adverse
Osseointegration 201
events can occur. The metal from the endosseous implant therapy has gained graft is placed. The decision to avoid a graft
implant may be visible through the gingival credibility. The Strauman system has long- is based on the thickness of the labial bone
margin. Because the distance from the top term data indicating that a one-stage and the prior healing patterns of the
of the implant to the gingival margin is unloaded implant system can work in all patient, if known. However, in our institu-
minimal, metal showing through the gingi- areas of the mouth, in distinction to the tion, an anterior extraction site without a
va is difficult to camouflage. A minimal dis- Swiss screw and the Brnemark proto- socket graft is more prone to labial bone
tance between the gingival margin and the cols.14 Recently, more interest has arisen resorption and hence less-than-ideal bone
top of the implant may also result in diffi- for placement of implants into the esthet- is available at the time of implant place-
culty in adjusting the margins of the abut- ic zone of the maxilla, with either immedi- ment. If a graft is placed into the socket,
ment, with porcelain extending to the ate loading or the use of a healing abut- then after 3 to 6 months, depending on the
implant itself. It is then difficult to develop a ment that mimics the natural shape of the material placed, the implant can usually be
natural appearance since the gingival mar- tooth. The hypothesis is that by placing a placed in an ideal location.
gin region of the restoration is excessively healing abutment with natural contours, If there is ideal bone and soft tissue
bulked or round in shape. The use of ceram- the soft tissue response will be enhanced, present at the time of extraction, an
ic abutments may help in these adverse situ- potentially resulting in a more esthetic implant can be placed at the time of extrac-
ations. However, proper implant placement final restoration. tion. The clinician should decide prior to
is a simple means to avoid these problems. Treatment planning for a one-stage or extraction if a provisional restoration is to
immediately temporized anterior maxil- be placed at the time of implant placement,
Immediate Loading and lary restoration begins with a list of con- or if the implant is to have a healing abut-
One-Stage Protocol traindications. If a tooth is present and ment placed for a one-stage protocol, or
The evolution of implant-related therapies needs to be extracted, a one-stage exposed submerged for a two-stage protocol.
in the modern era was based on the work implant placement at the time of extrac- Preoperative planning for immediate
of Brnemark and colleagues, who scien- tion will require the following: temporization after implant placement
tifically validated the process of placing an involves fabrication of a surgical guide
No purulent drainage or exudate from
implant into bone, waiting a period of that precisely locates the implant in one
the site
time for bone to heal to the implant, fol- position. The surgeon must work closely
Excellent gingival tissue quality with-
lowed by long-term functional loading.13 with the restorative dentist to ensure that
out excessive granulation tissue
During the 1970s and early 1980s a one- the planned placement of the implant will
Lack of periapical, uncontrolled radi-
stage threaded titanium plasma-coated indeed be able to be performed. The
olucency
implant was used for overdenture reten- restorative dentist should be available dur-
Adequate bone levels circumferential-
tion with immediate loading. The Swiss ing surgery to guide the surgical place-
ly without the need for additional soft
screw was placed into the anterior ment and be able to adapt the temporary
or hard tissue grafting
mandible and had excellent long-term restoration after implant placement.
success. Other one-stage implant systems The clinician has several options (Table After the implant is placed and the ori-
were slow to develop, but as they have 10-1). At the time of tooth extraction, if entation approved by the restorative den-
emerged with data to support a one-stage there are any of the contraindications pre- tist, the abutment is placed, and removed
process (ie, with no need for exposure sent as described above, either a graft can be as necessary so that changes in its height
surgery), the concept of a one-stage placed into the extraction socket, or no and contours can be accomplished outside
of the mouth. The abutment and tempo- 2. Shulman LB. Transplantation and replantation implants: current status and future devel-
rary crown may be prepared on a model of teeth. Laskin: Oral and maxillofacial opments. Int J Oral Maxillofac Implants.
surgery. Vol 2. St. Louis (MO): C.V. Mosby 2000;15:1546.
prior to surgery in selected cases. The abut- Co.; 1985. p. 1326. 19. Cordioli G, Zajzoub Z, Piatelli A, ScaranoA.
ment is placed and tightened to the 3. Driskell TD. History of implants. J Calif Dent Removal torque and histomorphometric
implant and the temporary crown com- Assoc 1987;15:1625. study of four different titanium surfaces. Int
pleted. The occlusion should be relieved to 4. Bonwell, AC. First District Dental Society. In: J Oral Maxillofac Implants 2000;15:66874.
Greenfield EG, editor. Implantation of arti- 20. Cochran DL, Buser D, ten Bruggenkate C, et al
avoid loading the implant during the heal-
ficial bridge abutments. Dent Cosmos The use of reduced healing times on ITI
ing period. In some patients who may be 1913;55:364. implants with a sandblasted and acid-
prone to loading the implant because of 5. Greenfield EJ. Implantation of artificial crown etched (SLA) surface: early results from
athletics, weight lifting, or their occlusion, and bridge abutments. Dent Cosmos clinical trials on ITI SLA implants. Clin
an anatomic healing abutment or a custom 1913;55:364. Oral Implants Res 2002;13:14453.
6. Harris SM. An artificial tooth. Dent Cosmos 21. Eriksson RA, Albrektsson T. Temperature
healing abutment can be placed in order to 1887;55:433. threshold levels for heat-induced bone tis-
preserve the morphology of the gingiva, 7. Adams PB, inventor. Anchoring means for false sue injury: a vital-microscopic study in the
without the presence of a tooth form. teeth. US patent 2,112,007. 1938 March 22. rabbit. J Prosthet Dent 1983;50:101.
Procedures performed during the inte- 8. Strock EA. Experimental work on a method for 22. Eriksson RA, Adell R. Temperatures during
the replacement of missing teeth by direct drilling for placement of implants using the
gration or healing period are delayed until
implantation of a metal support into the osseointegration technique. J Oral Maxillo-
implant integration has occurred, in order alveolus. Am J Orthodont Oral Surg fac Surg 1986;44:47.
to avoid disturbance of this critical aspect 1939;25:45772. 23. Watanabe F, Tawanda Y, Komatsu S, Hata Y.
of implant success. Approximately 9. Dahl GSA. Om impijlighenten for implanta- Heat distribution in bone during prepara-
2 months after the implants have been tion i Keken au metaliskelett som has eller tion of implant sites: heat analysis by real-
rention for fastoc eller avatagbara prostesor. time thermography. Int J Oral Maxillofac
placed, the patients are seen by the restora-
J Odontol Tidskr 1943;51:440. Implants 1992;7:2129.
tive dentist and surgeon to decide, based 10. Linkow LI. The blade-vent: a new dimension in 24. Adell R, Lekholm U, Brnemark PI. Surgical
on the esthetic set-up, whether the implant endosseous implants. Dent Concepts procedures. In: Brnemark PI, Zarb GA,
site requires additional augmentation of 1968;11:312. Albrektsson T, editors. Tissue integrated
11. Roberts HD, Roberts RA. The ramus prostheses: osseointegration in clinical den-
the ridge. The goal is to achieve a convex
endosseous implants. J South Calif Dent tistry. Chicago (IL): Quintessence Publish-
ridge profile and develop the sites shape to Assoc 1970;38:5717. ing Co. Inc.; 1985. p. 21132.
allow for the restoration to emerge from 12. Proceedings of the Toronto Consensus Devel- 25. Lazzara R, Porter S, Testori T, et al. A prospec-
the gingiva, similar to a natural tooth. Our opment Conference on Dental Implants. J tive multicenter evaluation loading of
experience indicates that 70% of the Prosthet Dent 1983;49:50. Osseotite implants two months after place-
13. Brnemark PI. Introduction to osseointegra- ment: one-year results. J Esthet Dent
implant sites that required hard tissue
tion. In: Brnemark PI, et al, editors. Tissue 1998;10(6):2809.
grafts also benefited from subepithelial integrated prostheses. Chicago (IL): Quin- 26. Testori T, DelFabbroCH, Feldman S, et al. A
connective tissue grafts placed 312 months tessence Publishing Co. Inc.; 1985. p. 29. multicenter prospective evaluation of 2-
after implant placement. 14. Schenk RK, Buser D. Osseointegration: a reali- months loaded Osseotite implants placed
ty. Periodontology. 2000;17:2235. in the posterior jaws: 3 year follow-up
Summary 15. Sykaras N, Iacopino A, Marker V, et al. Implant results. Clin Oral Implants Res 2001;12:17.
materials, design and surface topographies: 27. Cooper L, Felton D, Kugelberg C, et al. A mul-
The successful restoration of the patient their effect on osseointegration [review]. ticenter 12 month evaluation of single-
with dental implants can result in a change Int J Oral Maxillofac Implants 2000; tooth implants restored 3 weeks after 1
in dental function and health, with a happy 15:67590. stage surgery. Int J Oral Maxillofac
16. Buser D, Schenk RK, Steinemann S, et al. Influ- Implants 2001;16:18292.
patient. The basis for the use of dental
ence of surface characteristics on bone inte- 28. Cooper LF, Scurria MS, Lang LA, et al. Treat-
implants is initiated by the normal gration of titanium implants. A histometric ment of edentulism using Astra Tech
sequence of wound healing, the translation study in miniature pigs. J Biomed Mater implants and ball abutments to retain
of surface engineering to implant design, Res 1991;25:889902. mandibular overdentures. Int J Oral Max-
and evidence-based trials that verify and 17. Thomas KA, Kay JF, Cook SD, Jarcho M. The illofac Implants 1999;14:64653.
effect of surface macrotexture and 29. Lazzara RJ. Esthetic and restorative benefits of
confirm efficacy of treatment methods. hydroxylapatite coating on the mechanical non-axillary loaded implants. Implant
strengths and histologic profiles of titanium Dent 1995;4:2823.
References implant materials. J Biomed Mater Res 30. Krekeler G, Schilli W, Diemer J. Should the exit
1. Lemons J, Natiella J. Biomaterials, biocompati- 1987;21:1395414. of the artificial abutment tooth be posi-
bility and peri-implant considerations. 18. Brunski JB, Puleo DA, Nanci A. Biomaterials tioned in the region on attached gingival?
Dent Clin North Am 1986;30:323. and biomechanics of oral and maxillofacial Int J Oral Surg 1985; 14:5048.
Osseointegration 203
31. Block MS, Kent JN. Factors associated with soft AT, Marciani RD, Roser SM, editors. Prin- 36. Cooper LF. Biologic determinants of bone for-
and hard tissue compromise of endosseous ciples of oral and maxillofacial surgery. mation for osseointegration: clues for
implants. J Oral Maxillofac Surg 1990; Philadelphia (PA): JB Lippincott; 1992. future clinical improvements. J Prosthet
48:115360. p. 318. Dent 1998;80:43949.
32. Feinberg SE, Steinberg B, Helman J. Healing of 34. Black J. Reaction of biological molecules with 37. Higuchi KW, Block MS. Current trends in
traumatic injuries. In: Fonseca RJ, Walker biomechanical surfaces. In: Black J, editor. implant reconstruction. J Oral Maxillofac
RV, Betts NJ, Barber HD, editors. Oral and Biologic performance of materials. Funda- Surg 1995;Suppl 1:719.
maxillofacial trauma. Vol 1. 2nd Ed. mentals of biocompatibility. New York 38. Marx RE, Shellenberger T, Winsatt J, Correra P.
Philadelphia (PA): WB Saunders Co.; 1997. (NY): Marcel Dekker; 1981. p. 45. Severely resorbed mandible: predictable
p. 1359. 35. Adell R. A 15 year study of osseointegrated reconstruction with soft tissue matrix
33. Shetty V, Bertolami CN. The physiology of implants in the treatment of the edentulous expansion (Tent Pole) grafts. J Oral Max-
wound healing. In: Peterson LJ, Indresano jaw. Int J Oral Surg 1981;10:387416. illofac Surg 2002;60:87888.
CHAPTER 11
Soft Tissue Integration Flap Management surgeon visualize whether adequate tissue
The term soft tissue integration describes Considerations quality and volume are available in the area
critical for prosthetic emergence. The sur-
the biologic processes that occur during The primary goal of implant soft tissue
geon can then decide where the incisions
the formation and maturation of the struc- management is to establish a healthy peri-
tural relationship between the soft tissues implant soft tissue environment. This goal is will have to be made or how the existing
(connective tissue and epithelium) and the accomplished by obtaining circumferential soft tissues must be manipulated with spe-
transmucosal portion of an implant. adaptation of attached tissues around the cific surgical maneuvers to establish a sta-
Although experimental and clinical transmucosal implant structures, thereby ble periimplant soft tissue environment in
research have only recently begun to focus providing the connective tissue and epithe- each individual case.
on improving our understanding of the lium needed for the formation of a protec-
Design for Submerged
factors that can affect this soft tissue envi- tive soft tissue seal.1 In addition, when
Implant Placement
ronment, our current knowledge indicates implant therapy is performed in esthetic
that the maintenance of a healthy soft tis- areas, re-creating natural-appearing soft tis- When placing a submerged implant, the
sue barrier is as important as osseointegra- sue architecture and topography at the buccal flap must be designed to preserve
tion itself for the long-term success of an prosthetic recipient site is often necessary. both the blood supply to the implant site
implant-supported prosthesis. As such, the To achieve these goals, the surgeon must and the topography of the alveolar ridge
implant surgeon must be well acquainted carefully preserve and manipulate existing and mucobuccal fold. The access flap is
with various surgical techniques and soft tissues at the implant site and perform outlined by a pericrestal incision and one
approaches for successfully managing peri- soft tissue augmentation, when indicated. or more linear or curvilinear vertical
implant soft tissues in commonly encoun- The quantity, quality, and positioning of releasing incisions that extend onto the
tered clinical situations. Furthermore, the existing attached tissues relative to the buccal aspect of the alveolar ridge. The
when an inadequate quantity or quality of planned implant emergence should be pericrestal incision is beveled to the lin-
soft tissue is available to secure a stable evaluated prior to implant surgery. The gual or palatal aspects (Figure 11-1). The
periimplant environment, the implant sur- flap should be designed to ensure that an incision is initiated over the lingual or
geon must know the principles and tech- adequate band of attached, good-quality palatal aspects of the ridge crest, and the
niques to successfully reconstruct these tissue is always available lingual or palatal scalpel blade is angled to make contact
components. This chapter focuses on basic to the planned implant emergence. Design- with the underlying bone. Typically, linear
principles and surgical techniques to man- ing the flap in this fashion is practical vertical releasing incisions are used in
age and, when indicated, reconstruct peri- because subsequent correction of soft tis- edentulous situations and curvilinear
implant soft tissues to enhance the long- sue problems occurring in lingual and beveled incisions are used in partially
term predictability and esthetic outcomes palatal areas is difficult. Preoperative eval- edentulous situations. In either case,
achieved in implant therapy. uation using a surgical template helps the reflection of the buccal flap exposes the
206 Part 2: Dentoalveolar Surgery
45 mm
56 mm 34 mm
FIGURE 11-7 Resective contouring maneuver. FIGURE 11-8 Papilla regeneration maneuver. FIGURE 11-9 Lateral flap advancement maneu-
When the apicocoronal dimension of the attached When the apicocoronal dimension of the ver. When the apicocoronal dimension of the
tissue remaining on the buccal flap used for the attached tissue remaining on the buccal flap used attached tissue remaining on the buccal flap used
abutment connection or a nonsubmerged implant for an abutment connection or a nonsubmerged for an abutment connection or a nonsubmerged
placement is between 5 and 6 mm, resective con- implant placement is between 4 and 5 mm, the implant placement is between 3 and 4 mm, lateral
touring is used to facilitate circumferential adap- papilla regeneration maneuver is used to facili- flap advancement is used to facilitate circumferen-
tation of the soft tissues around the emerging tate circumferential adaptation of the soft tissues tial adaptation of the soft tissues around the emerg-
implant structures. Adapted from Sclar A.3 around the emerging implant structures. Adapt- ing implant structures. Adapted from Sclar A.3
ed from Sclar A.3
passively advances the pedicle into the implant placement to include the cementation of provisional and perma-
interimplant space is effective in many sit- attached tissues present in adjacent eden- nent restorations, removal of implant
uations. Care must be taken to avoid tulous areas. As the closure progresses, healing abutments, replacement of healing
placement of the suture through the pedi- the flap advances, resulting in primary abutments with permanent abutments,
cle as this would reduce circulation to the closure around the implants and the cre- taking of implant-level impressions, and
pedicle. Another variation of this tech- ation of a denuded area that will heal by placement of provisional and permanent
nique uses pedicles created in the palatal secondary intention at the distal extent of implant restorations.
flap, which can also be rotated to fill the the dissection. This surgical maneuver is After the final restoration the intra-
interimplant spaces, and is especially use- useful in edentulous situations and in crevicular esthetic restorative margins may
ful in maxillary situations where thick Kennedy Class I and II partially edentu- continue to present a permanent inflamma-
palatal tissues exist.3 lous situations. tory challenge to the surrounding soft tissue
attachment apparatus. Some implant prac-
Lateral Flap Advancement When the Rationale for Soft Tissue titioners believe that the microgap at the site
width of the gingival tissues remaining on Grafting with Implants of the abutment connection to two-piece
the buccal flap is 3 to 4 mm, the use of the The rationale for soft tissue augmentation implants may present a similar challenge.
lateral flap advancement maneuver facili- around dental implants is related to the Whether these challenges result in an initial
tates primary closure and circumferential need for soft tissue around natural denti- apical displacement of the marginal tissues
adaptation of attached tissues around the tion. In general, experienced clinicians or possibly even progressive loss of attach-
emerging implant structures (Figure 11-9).3 agree that an adequate zone of attached ment depends on multiple factors, includ-
This maneuver is especially suited for tissue around a natural tooth or implant ing the following3:
completely edentulous or posterior par- prosthesis is desirable to better withstand
tially edentulous implant case types, where the functional stresses resulting from mas- Age of the patient
an adequate band of attached tissue exists tication and oral hygiene. Moreover, a cer- General health of the patient
adjacent to the implant site. Attached tis- tain amount of attached tissue is needed to Host resistance factors
sues available from adjacent areas are sim- withstand the potential mechanical and Effects of systemic medications
ply repositioned to obtain primary closure bacterial challenges presented by esthetic Periodontal phenotype
with attached tissues around the emerging restorations that extend below the free Technique and effectiveness of oral
implant structures. gingival margin. Potential mechanical hygiene
This maneuver requires that the flap challenges include tooth preparation, soft Frequency and technique of profes-
be designed to extend beyond the area of tissue retraction, impression procedures, sional oral hygiene care
Soft Tissue Management in Implant Therapy 209
Operative technique esthetic area, soft tissue augmentation is vide a means for rigid immobilization of
Choice of restorative materials indicated prior to implant placement. In the graft tissue. Initial graft survival
Initial location of restorative margin most instances this can be accomplished requires that the graft be immobilized and
vis--vis circumferential biologic with an epithelialized palatal mucosal intimately adapted to the recipient site.
width requirements graft, which quickly provides an improve- Mobility of the graft during initial healing
Prominence of the implant position in ment in the quality of the soft tissues. can interfere with its early nourishment
the alveolus Similarly, in esthetic areas, small- through plasmatic diffusion or can disrupt
Pre-existing bony dehiscence volume soft tissue esthetic ridge defects the newly forming circulatory supply to
Design and surface characteristics of can be corrected simultaneously with sub- the graft, resulting in excessive shrinkage
the implant merged or nonsubmerged implant place- or sloughing of the graft.
Depth of implant placement ment with subepithelial connective tissue The third principle is that adequate
Thickness and apicocoronal dimen- grafting, whereas large-volume soft tissue hemostasis must be obtained at the recipi-
sion of the attached tissue esthetic ridge defects are most predictably ent site. Active hemorrhage at the site pre-
reconstructed prior to implant placement vents the intimate adaptation of the graft to
Because multiple factors influence the with a series of subepithelial connective the recipient site. Hemorrhage also inter-
health of the marginal tissues, prospective tissue grafts. Large-volume soft tissue feres with the maintenance of the thin layer
or retrospective experimental or clinical defects can also be corrected with the use of fibrin between the graft and recipient
studies are difficult to design and conduct, of a vascularized interpositional periosteal site, which serves to physically attach the
much less interpret. Certainly, studies that connective tissue (VIP-CT) flap, which, in graft to the recipient site and provides for
primarily consider the apicocoronal ideal circumstances, allows for predictable the plasmatic diffusion that initially nour-
dimension of attached tissue and its effect reconstruction synchronous with implant ishes the graft before its vascularization.
on marginal soft tissue health, without placement. Preparation of a recipient site with a uni-
considering the other factors, are incon- form surface enhances the intimate adapta-
clusive at best. Therefore, the rationale for Principles of Oral Soft tion with the graft. The periosteum is gen-
soft tissue augmentation around natural Tissue Grafting erally considered to be an excellent
dentition or a dental implant prosthesis The first principle of oral soft tissue graft- recipient site for oral soft tissue grafts
should be based on clinical experience ing is that the recipient site must provide because it fulfills all of the requirements
rather than on results from experimental for graft vascularization. It is understood discussed above. In addition, decorticated
or clinical studies.3 that free grafts initially survive by plasmat- alveolar bone can support and nourish a
ic diffusion and are subsequently vascular- free soft tissue graft, although immobilizing
Clinical Guidelines for Soft ized as capillaries and arterioles form a vas- the graft at the site is more troublesome.
Tissue Augmentation cular network providing the permanent The fourth principle of oral soft tissue
When the apicocoronal dimension of circulation for the graft. When a recipient grafting involves the size and thickness of
attached tissue remaining on the buccal site is partially avascular (eg, a denuded the donor tissue. The donor tissue must be
flap will be < 3 mm, the surgeon should root surface, an exposed implant abutment, large enough to facilitate immobilization
consider soft tissue augmentation. Other or an area recently reconstructed with a at the recipient site and to take advantage
factors to consider include tissue thick- block bone graft), the dissection should be of peripheral circulation when root or
ness, tissue quality, the presence of soft tis- extended to provide a peripheral source of abutment coverage is the goal. The graft
sue inflammation or pathology, the type of circulation to support the free graft over the also must be large enough and thick
implant restoration planned, and the avascular or poorly vascularized areas. enough to achieve the desired volume aug-
esthetic importance of the site. In a nones- Although pedicle grafts and flaps maintain mentation after secondary contraction has
thetic area the surgeon can use the various their blood supply, it is also good surgical occurred. In addition, the donor tissue
surgical maneuvers described above to practice to prepare a recipient site that can should be harvested to ensure a uniform
obtain primary closure and then reevalu- contribute circulation to ensure optimal graft surface that facilitates intimate adap-
ate the need for soft tissue grafting based results in the event of a reduction of circu- tation to the recipient site. Thicker grafts
on the health and volume of periimplant lation to a portion (most commonly, the (> 1.25 mm) are especially useful for root
attached tissues obtained after initial heal- margin) of the pedicle graft or flap. and abutment coverage when graft healing
ing. In contrast, when the total width of The second principle of oral soft tissue over the central portion of the avascular
attached tissue present is < 3 mm in an grafting is that the recipient site must pro- surface is characterized by necrosis. The
210 Part 2: Dentoalveolar Surgery
necrotic graft is gradually overtaken by zontal incision is made through the inter- repositioned to the lingual or palatal aspect
granulation tissue from the periphery and implant papilla coronal to the desired final of the implants (Figure 11-10A). This step
ultimately forms a scar. Thicker grafts are tissue position. This facilitates abutment is extremely important when implants are
better able to maintain their physical coverage with the gingival graft. When gin- placed in the mandible because subsequent
integrity during this process, which can gival grafting is performed at second-stage lingual soft tissue defects in this area are dif-
take as long as 4 to 6 weeks. In summary, surgery or simultaneously with nonsub- ficult to correct. A split-thickness dissection
harvesting a graft that is too small or too merged implant placement, the horizontal is then carried apically to create a uniform
thin should be avoided by evaluating the incision is made at the mucogingival junc- periosteal site. In the edentulous mandible,
donor site prior to surgery and by apply- tion, and any existing gingival tissues are care must be taken to avoid damage to the
ing the foregoing principles during
recipient- and donor-site surgery.
Although failure to adhere to these
surgical principles may not result in the
loss of the soft tissue graft, increased com-
plications such as inadequate volume
yield, graft sloughing, wound breakdown,
infection, and patient discomfort can be
expected.
General Considerations
The use of an epithelialized palatal graft
for the treatment of a mucogingival defect
has enjoyed a long history of predictable
success.46 This versatile technique can be
used not only to increase the dimensions
of attached tissue around the natural den-
tition and dental implants but also as a B
predictable method for covering denuded
root or abutment surfaces. Although the
term free gingival graft is a misnomer, it is
commonly used to describe the transfer of
epithelialized tissue harvested from the
palate. When the contemporary surgical
technique is used as described below, thick
split-thickness grafts (> 1.25 mm) or full-
thickness grafts are preferred around both
natural dentition and dental implants.
C
Contemporary Surgical
Technique FIGURE 11-10 Surgical technique for gingival grafting simultaneous with abutment connection or
nonsubmerged implant placement. A, A full-thickness horizontal incision is made at the mucogingi-
The surgical technique for gingival grafting val junction, and a partial-thickness vertical releasing incision is made at the midline. B, Full-
around dental implants is essentially the thickness elevation of the flap lingually exposes the ridge crest and allows repositioning of the kera-
same as the technique used around natural tinized tissues lingually for abutment connection or nonsubmerged implant placement. C, Split-
thickness dissection on the buccal aspect of the alveolar ridge provides a recipient site for rigid immo-
dentition.37 When gingival grafting is per- bilization of the donor graft, which is adapted around the emerging implant structures and secured to
formed after implant abutment connection the lingual tissues and to the periosteum peripherally. The dissection is limited distally to avoid
or delivery of the final restoration, a hori- unwanted injury to the mental nerve. Adapted from Sclar A.3
Soft Tissue Management in Implant Therapy 211
mental nerve with the vertical releasing and then to the periosteum peripherally to essary trauma and hematoma formation at
incisions that typically outline the mesial rigidly immobilize the graft at the recipient the periphery. During subsequent implant
and distal extents of the recipient site in the site (Figures 11-10C, 11-11, and 11-12). surgery, a 3 mm or greater portion of the
dentate patient. Instead, in these instances a The following graft immobilization pres- mature grafted tissue is repositioned lin-
midline vertical releasing incision and sure is applied with a moistened saline gually, providing good-quality gingival tis-
sharp dissection are used to create an ade- gauze for 10 minutes. Although a periodon- sue for wound closure over submerged
quate recipient site (> 5 mm apicocoronal tal dressing is not necessary for the recipi- implants and circumferential adaptation of
dimension) with a half-moon shape, as ent site, a protective dressing for the donor attached tissue around emerging implant
shown in Figure 11-10B. Subsequently, the site is recommended. abutments or nonsubmerged implants.
mucosal flaps are excised and residual elas- Gingival grafting is indicated prior to
tic or muscular tissue are removed with tis- implant placement in the severely atrophic Subepithelial Connective Tissue
sue scissors or nippers. When working in a maxilla or mandible that is < 10 mm in Grafting for Dental Implants
severely atrophic mandible, the mucosal height and has < 3 mm of attached tissue.
flaps are preserved and sutured to the In this clinical situation the surgeon should General Considerations
periosteum at the base of the dissection. avoid significant dissection of the palatal or
The technique for graft immobilization is lingual tissues. Instead, a large recipient The subepithelial connective tissue graft is
the same regardless of whether gingival bed is created on the buccal aspect of the an extremely versatile procedure that can
grafting is performed around natural denti- site, extending far enough apically from the be used to enhance soft tissue contours
tion, at second-stage surgery for submerged midcrest to re-create the buccal vestibular around the natural dentition and dental
implants, or at the time of nonsubmerged fold. The graft is then harvested and rigid- implants (Figures 11-1311-15). The pro-
implant placement. The graft is sutured to ly immobilized with sutures placed cedure combines the use of a free soft tis-
each papilla or interimplant area coronally approximately 5 mm apart to avoid unnec- sue autograft harvested from the palate
A B C
D E F
FIGURE 11-11 A, Preoperative view of four submerged implants ready for abutment connection. The amount of attached tissue is inadequate to ensure a
stable periimplant soft tissue environment. B, Split-thickness dissection is performed to create a uniform periosteal recipient site. C, Full-thickness elevation
of the attached tissues exposes the implants for abutment connection; the existing keratinized tissue has been repositioned to the lingual aspect of the emerg-
ing abutments. D, A palatal mucosal graft (gingival graft) is harvested from each side of the palate. E, The grafts have been contoured for precise adaptation
around the abutments and secured to the lingual tissues and periosteum peripherally. F, This 2-month postoperative view demonstrates a tremendous vol-
ume yield from the gingival grafting procedure. A stable periimplant soft tissue environment has been obtained. Reproduced with permission from Sclar A.3
212 Part 2: Dentoalveolar Surgery
Surgical Technique:
Donor-Site Surgery
The technique for harvesting subepithelial
A B
connective tissue grafts from the premolar
FIGURE 11-14 A, The progressive soft tissue recession around this lateral incisor implant restoration region of the palate has two variations: the
jeopardized its long-term success. B, A subepithelial connective tissue graft was performed via a closed single-incision approach and the dual-
pouch recipient site, resulting in the restoration of soft tissue esthetics and stability for this patient with
incision approach.7,8 In either case, the
a thin scalloped periodontium. Prophylactic soft tissue grafting would have prevented the recession
from occurring and is indicated when intracrevicular restorations are planned for patients who pre- donor-site surgery begins with a full-
sent with thin periodontal tissues. Reproduced with permission from Sclar A.3 thickness curvilinear incision made
Soft Tissue Management in Implant Therapy 213
A B C
FIGURE 11-15 A, Preoperative view of central incisor implant site with a small-volume soft tissue esthetic ridge defect. B, An open flap approach involv-
ing full thickness dissection at the ridge crest and partial thickness dissection on the buccal aspect of the alveolar ridge was used for the implant placement
and synchronous subepithelial connective tissue grafting. Coronal advancement of the cover flap enabled further soft tissue volume enhancement via sub-
mersion of the one-piece nonsubmerged implant, thus expanding the soft tissue envelope. C, Following conservative exposure and insertion of a custom
abutment and provisional restoration, the soft tissues were allowed to stabilize prior to the delivery of the final restoration, which demonstrates pleasing
soft tissue esthetics. Reproduced with permission from Sclar A.3
and a horizontal incision is made through uniform thickness is technically more chal-
the apical aspect of the donor tissue from lenging when the single-incision approach
within the pouch. The harvested tissue, is used, primary closure of the palatal
which contains epithelium, connective tis- wound results in greater patient comfort.
sue, and periosteum, is then transferred with As a result, most experienced surgeons pre-
tissue forceps to the recipient site or tem- fer this approach.
porarily placed on sterile gauze moistened
with saline. If the graft is submerged under Surgical Technique:
the recipients site flap, curved Iris tissue scis- Recipient-Site Surgery
sors should be used to remove the epithelial Preparation of the recipient site involves
tissue. Hemostasis is then obtained at the either the elevation of a split-thickness flap
donor site by placing an absorbable collagen through supraperiosteal dissection (open
dressing, such as CollaPlug, and applying technique) or a supraperiosteal dissection,
pressure with saline-moistened gauze. The which avoids vertical releasing incisions to
donor site is closed using interrupted 4-0 create an envelope or pouch (closed tech-
chromic gut sutures on a P3 needle passed nique). The decision of which technique to FIGURE 11-17 Subepithelial connective tissue
through the interproximal areas. use when grafting around a natural tooth grafting donor-site surgery via the single-incision
The single-incision technique differs in or an implant restoration depends on sev- approach. The cross-sectional view demonstrates
that only one incision is used to establish eral factors. The open technique allows the pathways of the incision and the dissection
for the donor-site harvest. The shaded area rep-
access to both the subperiosteal and subep- direct visualization during dissection, resents the resultant donor graft consisting of
ithelial planes of dissection. This approach which ensures the preparation of a uniform both connective tissue and periosteum. Adapted
begins with a full-thickness curvilinear recipient site. This approach also allows for from Sclar A.3
incision, as described above. Next, the significant coronal advancement when ver-
scalpel is reoriented within the incision tical soft tissue augmentation is needed ment or root exposure is < 4 mm apico-
until it is parallel to the surface of the over an exposed root or abutment surface. coronally or when there is a significant risk
palatal tissue. Subepithelial dissection that The vertical releasing incisions used in the of sloughing of the cover flap because of
parallels the external surface of the palatal open technique sacrifice some circulation. poor vascularity at the site.
tissue is accomplished to create a rectangu- However, the use of a curvilinear beveled
lar pouch. After making the first incision, flap with tension-releasing cutback inci- Closed Technique The technique for
the surgeon may find it useful to perform sions avoids embarrassment of circulation closed recipient-site preparation is the same
subperiosteal elevation coronally. This to the flap margin and allows for greater whether it is performed around a natural
improves visualization of available soft tis- coronal flap advancement than do tradi- tooth or an implant restoration. A horizon-
sue thickness (Figure 11-17), thereby aiding tional trapezoidal flaps that require tal incision is extended to the mesial and
the surgeon to establish the appropriate periosteal releasing incisions to allow even distal aspects of the soft tissue defect just
subepithelial plane of dissection. The limited coronal advancement. coronal to the level of the root or abutment
remainder of the surgical procedure is In contrast, the closed technique avoids coverage desired (Figure 11-18). Using a
identical to the procedure described above the need for vertical incisions, thus preserv- no. 15C scalpel, the surgeon makes this
for the dual-incision technique. ing the blood supply to the site and opti- incision at a right angle to the epithelium at
The advantage of the dual-incision mizing esthetic results. However, as a a depth of approximately 1 mm. The hori-
approach is that it is easier to perform. blind technique, it can be technically zontal incisions not only mark the grafts
Since the thickness of the donor tissue is more demanding. Also, because it does not final coronal position but also facilitate the
defined by the second incision, the result is allow for significant coronal advancement pouch dissection and subsequent immobi-
the harvesting of a graft of uniform thick- of the cover flap, this technique is of limit- lization of the graft.
ness. The disadvantage of this approach is ed use when significant vertical soft tissue Next, the scalpel is oriented parallel to
that primary closure is seldom possible, augmentation is needed, and it is con- the tissue surface, and the horizontal inci-
and, therefore, the palatal wound can be traindicated whenever vestibular depth sions are extended into the sulcus to create
uncomfortable. Nevertheless, this approach limits the preparation of an adequately the entrance to the recipient site. The split-
is usually recommended for the novice sur- sized recipient site. In general, the closed thickness dissection is extended apically
geon. Although harvesting a donor graft of recipient site is preferred when the abut- beyond the mucogingival junction at the
Soft Tissue Management in Implant Therapy 215
procedures and for improving soft tissue flap. The dissection is initiated coronally an epithelial surface, which would prevent
contours during implant-site development with a no. 15C scalpel blade. Flap elevation initial wound healing and could result in
or when performed over a submerged is continued apically under direct vision dehiscence along the incision. The dimen-
implant (Figure 11-19). The dissection with sharp dissection under tension, which sions of the recipient site are then measured
begins by outlining the recipient site with is carefully maintained with the use of with a periodontal probe, and hemostasis is
partial-thickness horizontal and vertical micro-Adson tissue forceps. The goal is to obtained by applying gentle pressure with
incisions using a no. 15C scalpel blade on a maximize the thickness of the overlying tis- saline-moistened gauze.
round handle. The horizontal incision, sue flap, leaving only a thin layer of immo- Once the donor graft has been har-
which is performed first, extends mesial and bile periosteum. When coronal advance- vested, it is usually trimmed to be slightly
distal to the soft tissue defect at a level just ment of the cover flap is performed, the smaller than the open recipient site. This
coronal to the final soft tissue position adjacent papillary areas are de-epithelialized facilitates immobilization of the graft and
desired after augmentation. Exaggerated with a fresh no. 15C scalpel. This further suturing of the cover flap into position
curvilinear beveled incisions with tension- extends the wound margin, thereby reduc- without unwanted engagement of the
releasing cutback incisions are then initiated ing flap retraction and greatly enhancing underlying graft, which can cause graft
apically well beyond the mucogingival junc- incision line esthetics. It also eliminates the dislodgment secondary to swelling or
tion to outline the cover flap. Next, sharp possibility that the undersurface of the retraction of the cover flap. Whether graft-
dissection is used to elevate a split-thickness coronally advanced flap will be coapted over ing around natural dentition or an
implant restoration(s), the graft is first
secured coronally with sutures passed
through the adjacent papillary areas using
a 4-0 chromic gut suture on a P3 needle.
Alternatively, sling sutures can be used for
this purpose. Next, the graft is secured lat-
erally and apically to the periosteum with
additional sutures. The goal is to gently
stretch the tissue, thus improving its adap-
tation to the recipient site.
Next, the cover flap is secured coronally
with interrupted sutures passing through the
papillae. These sutures should pass through
the facial flap and the de-epithelialized pap-
A B illary tissue and then return under the con-
tact points, where they are tied facially. Alter-
natively, a sling suture can be used. In this
case, the suture passes through the flap and
the papillary tissue on the first pass; it then
passes under the contact points as it returns
to the facial aspect, where it is tied. Depend-
ing on the thickness of the cover flap tissue,
4-0 or 5-0 chromic gut suture on a P3 needle
is used. Next, the cover flap is secured later-
ally. The use of exaggerated curvilinear
beveled incisions to outline the cover flap
not only extends the recipient site, providing
additional circulation to sustain the graft, it
C D also facilitates immobilization of the graft
FIGURE 11-19 Open flap technique for the preparation of a recipient site for a subepithelial connec-
and closure of the cover flap.
tive tissue graft to improve soft tissue contours at an implant site. This approach is useful at the time The suture needle should be perpen-
of abutment connection (A and B) and over a submerged implant (C and D). Adapted from Sclar A.3 dicular to the beveled incision as it passes
Soft Tissue Management in Implant Therapy 217
through the tissue. It also should be orient- ply derived from the connective tissue and severely scarred, rendering them inad-
ed in an apicocoronal direction as it is periosteal plexus within the flap provides equate to support required hard tissue
passed through the flap and adjacent tissue. the biologic basis for predictable simulta- implant-site development (Figure 11-20).
A single pass is recommended to ensure neous hard and soft tissue grafting proce- It is a predictable means of resubmerging
precise positioning of the cover flap. The dures during esthetic implant-site devel- an implant in the anterior area when an
attached tissue contained in the flap is first opment, even at compromised sites. unexpected soft tissue dehiscence compro-
precisely repositioned and secured with Additional advantages of the technique mises the final esthetic result.
sutures placed laterally. The sutures then include negligible postoperative soft tissue The volume of tissue transfer routine-
are placed apical to the mucogingival junc- shrinkage; enhanced results realized from ly obtained with the VIP-CT flap has also
tion. When performed as part of implant- hard tissue grafting procedures owing to allowed the camouflaging of small-volume
site development or when grafting over a the supplemental source of circulation and combination hard and soft tissue ridge
submerged implant, the recipient site is the contribution to phase-two bone graft defects, as well as the correction of large-
extended further onto the palatal or lingual healing provided by the mesenchymal cells volume soft tissue defects simultaneously
surface of the alveolar ridge via split- transferred with the flap; and, when hard with implant placement (Figures 11-21
thickness dissection, and the graft is and soft tissue site-development proce- and 11-22), as previously discussed.
secured in a similar fashion before closing dures are necessary, a reduction in treat- Of greatest significance, this technique
the cover flaps, as described above. Moist- ment time and patient inconvenience. provides the implant surgeon with a
ened saline gauze is used to apply gentle Although the amount of horizontal proven technique for predictable simulta-
pressure at the site for 10 minutes; a peri- soft tissue augmentation obtained with the neous hard and soft tissue esthetic
odontal dressing is not usually needed. VIP-CT flap is consistently greater than implant-site development at compro-
that obtained with free soft tissue grafting mised anterior sites with large-volume
Vascularized Interpositional techniques, the amount of vertical soft tis- combination esthetic ridge defects (Figure
Periosteal Connective sue augmentation typically obtained 11-23). These enhanced results are direct-
Tissue Flap exceeds that obtainable even when several ly related to maintenance of intact circula-
free soft tissue grafts are performed, which tion to the flap and decreased postsurgical
General Considerations has allowed the re-creation of positive gin- contraction.
The vascularized interpositional periosteal gival architecture, even in situations where
connective tissue flap (VIP-CT) flap is an previous hard and soft tissue site develop- Surgical Technique
innovative technique that provides for ment techniques have fallen short. This As in the previously described techniques,
reconstruction of large-volume soft tissue technique has also proven useful in the the surgeon begins by outlining and prepar-
esthetic ridge defects with a single proce- treatment of compromised sites in which ing the recipient site and then proceeds to
dure.3 In addition, the pedicled blood sup- existing soft tissues were poor in quality donor-site preparation. An exaggerated
A B C
FIGURE 11-20 Use of the vascularized interpositional periosteal connective tissue (VIP-CT) flap to restore soft tissue volume and health at a severely
compromised site. A, Preoperative view of a severely compromised lateral incisor site following a failed bone graft that resulted in the loss of col and papil-
la on the adjacent central incisor and severely scarred and inelastic soft tissue cover at the site. B, A VIP-CT flap was performed to provide sufficient vol-
ume of good-quality tissue to support the subsequent bone graft. C, The final result after subsequent bone grafting demonstrates the complete recon-
struction of natural ridge contours and the successful restoration of the adjacent col and papilla, a remarkable result that is not always obtainable even
with the VIP-CT flap. Reproduced with permission from Sclar A.3
218 Part 2: Dentoalveolar Surgery
hard tissue grafting or implant placement. the distal aspect of the canine. The outline
The palatal incision at the distal aspect of of the periostealconnective tissue pedicle
the recipient site parallels the gingival mar- is now complete. Limiting the incisions to
gin on the oral aspect of the adjacent tooth the anatomic landmarks given ensures
(Figure 11-24A). that the margin of the pedicle is safely har-
After recipient-site preparation, donor- vested from the palatal area, where the
site preparation begins by extending this thickest amount of connective tissue is
incision horizontally to the distal aspect of available, without risk of damage to adja-
A the second premolar. To facilitate subse- cent neurovascular structures. Next, a
quent closure of the donor site, the orienta- Buser periosteal elevator is used to careful-
tion of this incision should be slightly ly elevate the periostealconnective tissue
beveled and follow a path approximately 2 pedicle and undermine the full thickness
mm apical to the free gingival margins of of the palatal mucosa and periosteum at
the canine and premolar teeth (see Figure the base of the pedicle, just beyond the
11-24A). Sharp dissection is then used midline of the palate (Figure 11-24B). This
internally to create a split-thickness palatal subperiosteal elevation or undermining
flap in the premolar area. The subepithe-
lial dissection is carried mesially toward
B the distal aspect of the canine. The sur-
geon should be careful to maintain an ade-
quate thickness of the palatal cover flap to
avoid sloughing. In most cases the dissec-
tion has to be deeper in the area of the
palatal rugae to avoid perforating the
cover flap. Next, a vertical incision is made
internally through the connective tissue A
and periosteum at the distal extent of the
subepithelial dissection, as far apically as is
C possible without damaging the greater
palatine neurovascular structures. This
FIGURE 11-21 Use of the vascularized interpo- incision defines the margin of the flap.
sitional periosteal connective tissue (VIP-CT)
flap for the correction of a small-volume combi- Using a Buser periosteal elevator and a
nation hard and soft tissue esthetic ridge defect. membrane-placement instrument, the
A, Preoperative view of a maxillary canine site surgeon then carefully elevates the resul-
with a ridge lap pontic attempting to disguise an tant periostealconnective tissue layer,
obvious ridge contour defect. B, After implant
beginning in the second premolar area and B
placement, a VIP-CT flap is rotated and inter-
posed underneath the donor- and recipient-site working toward the anterior extent of the
FIGURE 11-22 Use of the vascularized interpo-
flaps, which are closed primarily. C, The final dissection. Usually, this careful subpe- sitional periosteal connective tissue (VIP-CT)
restoration demonstrates a natural esthetic riosteal dissection yields intact periosteum flap for the correction of a large-volume soft tis-
emergence and successful camouflaging of the on the undersurface of the pedicle, which sue esthetic ridge defect simultaneous with a sub-
small-volume combination esthetic ridge defect. merged implant placement. A, Preoperative view
Reproduced with permission from Sclar A.3
aids in subsequent rigid immobilization of
the graft. Furthermore, intact periosteum of a lateral incisor implant site with removable
partial denture with a tissue-colored flange used
potentially provides osteoblastic activity if to disguise the large-volume soft tissue defect at
curvilinear beveled flap design is used at the applied over a bone graft when simultane- the site. B, The final restoration demonstrates a
recipient site. Abbreviated vertical releasing ous hard and soft tissue site development natural emergence and soft tissue esthetics fol-
incisions are extended over the alveolar crest is performed. A second incision is then lowing the implant placement and synchronous
use of the VIP-CT flap. Typically, several free soft
onto the palatal surface at both the mesial initiated under tension internally at the
tissue grafts are necessary to restore a large-
and distal aspects of the recipient site. This apical extent of the previous vertical inci- volume soft tissue defect. Reproduced with per-
allows full exposure of the ridge crest for sion and extended horizontally anterior to mission from Sclar A.3
Soft Tissue Management in Implant Therapy 219
A B
C D
FIGURE 11-23 Simultaneous reconstruction of a large-volume combination hard and soft tissue esthetic ridge defect for the
replacement of four maxillary incisors. A, Preoperative view of the compromised site secondary to multiple interventions
leading to tooth loss and a previously failed attempt at bone graft reconstruction. B, Intraoperative view following rigid fix-
ation of corticocancellous block bone grafts and condensation of particulate bone graft material. The vascularized interpo-
sitional periosteal connective tissue (VIP-CT) flaps have been prepared and are ready for rotation over the block bone graft,
thereby improving the volume of the soft tissue in the areas critical for prosthetic emergence and supplementing the circula-
tion of the soft tissue cover for enhanced bone graft healing. C, Nonsubmerged central and lateral incisor implants were
placed after 4 months of healing with customized tooth-form healing abutments. The final restorative abutments, pictured
in this clinical photograph, were delivered after an additional 4 months. Note that use of the VIP-CT flap simultaneous with
the block bone grafting procedure resulted in a significant vertical soft tissue augmentation and the restoration of the nat-
ural soft tissue architecture at the site. D, The final restorations are harmonious in appearance, and pleasing gingival esthet-
ics are evident. Reproduced with permission from Sclar A.3
begins at the distal aspect of the dissection culation. The subepithelial plane is super- ated at the pivot point of flap rotation
in the area of the second premolar and is ficial to the greater palatine vessels but along the line of greatest tension. Although
carried anteriorly toward but short of the deep enough to avoid sloughing of the the line of greatest tension is the radius of
incisive foramen so as to avoid compro- palatal cover flap. The subperiosteal plane the rotation arc created by the apical hori-
mise to the neurovascular structures in is deep to the greater palatine vessels and is zontal incision, the pivot point may not
this area. Doing so provides additional limited anteriorly and posteriorly to avoid coincide with the termination of that inci-
elasticity at the base of the pedicle to allow damage to the neurovascular structures as sion. This is because the periosteal under-
passive rotation to the recipient site with- they course through the palate. mining causes a favorable displacement of
out the need for a tension-releasing cut- Tension-releasing cutback incisions the flaps pivot point and in most cases
back incision. Essentially, the two distinct extended into the base of the pedicle flap allows for tension-free rotation of the flap
planes of dissection performed define the are rarely necessary when subperiosteal into the maxillary anterior area without
interpositional periostealconnective tis- undermining is performed. When un- the need for a tension-releasing cutback
sue pedicle flap without disrupting its cir- avoidable, these relaxing incisions are initi- incision. Nevertheless, when a tension-
220 Part 2: Dentoalveolar Surgery
A B C
FIGURE 11-24 Surgical technique for the vascularized interpositional periosteal connective tissue (VIP-CT) flap. A, Occlusal view of incisions that out-
line the donor and recipient sites. Note that the preparation of the recipient site involves de-epithelialization of the adjacent col and papillary areas.
B, After split-thickness recipient-site preparation, de-epithelialization of the attached tissue on the buccal aspect of the ridge as well as the adjacent col and
papillary areas is performed, and implant placement is completed. Subsequently, the VIP-CT flap is developed via subepithelial and subperiosteal dissec-
tions performed within the bicuspid region of the palate. C, Subperiosteal undermining is extended to the midline, allowing the flap to passively rotate to
the midline, where it is secured to the de-epithelialized areas and periosteum at a split-thickness recipient site, or over a block bone graft when simultane-
ous reconstruction is performed. Adapted from Sclar A.3
releasing cutback incision is necessary subepithelial connective tissue grafts in above for the gingival and subepithelial
despite undermining, the surgeon must be periodontal surgery since 1996. AlloDerm connective tissue grafts. The AlloDerm
careful to limit the length of the incision to grafts are composed of freeze-dried allo- graft must be rehydrated for 10 minutes
avoid embarrassing the circulation. An graft skin processed to remove all immuno- before use. Two distinct sides of the Allo-
intraoperative assessment of the area of genic cellular components (epidermis and Derm graft are identified by applying the
greatest tension will guide the placement of dermal cells), leaving a useful acellular der- patients blood to each surface and rinsing
releasing incisions. Next, the flap is rotated mal matrix for soft tissue augmentation. with sterile saline. The connective tissue
into the recipient site and rigidly immobi- AlloDerm can be used to increase the width side will retain the red coloration, whereas
lized with sutures placed apically and/or of attached tissue around the natural denti- the basement membrane side will appear
laterally (Figure 11-24C). Alternatively, the tion and implants, obtain root or abutment white. The connective tissue side contains
flap can be secured directly to a block bone coverage, and correct small-volume soft tis- preexisting vascular channels that allow for
graft using sutures passed through tran- sue ridge defects. The advantages of using cellular infiltration and revascularization.
sosseous perforations in the bone graft. An AlloDerm include the elimination of When used as an onlay graft to increase the
absorbable collagen dressing, such as Col- donor-site surgery for greater patient com- width of attached tissues, the connective tis-
laPlug, is used as an aid to hemostasis and fort, unlimited tissue supply, excellent han- sue side should be oriented toward and inti-
to eliminate dead space in the donor har- dling characteristics, and decreased surgical mately adapted to the recipient site (Figure
vest area. Finally, the donor and recipient time. Disadvantages include greater sec- 11-25). When used for root or abutment
sites are closed primarily with absorbable ondary shrinkage and slower healing at the coverage, the basement membrane side of
sutures, and gentle pressure is applied with recipient sites when used as an onlay graft the graft should be oriented toward the
saline-moistened gauze for 10 minutes. or when complete coverage of an interposi- exposed root or abutment (Figure 11-26).
tional AlloDerm graft is not obtainable. The basement membrane side of the Allo-
Oral Soft Tissue Grafting Predictable root or abutment coverage Derm graft facilitates epithelial cell migra-
with Acellular Dermal Matrix requires coverage of the AlloDerm graft tion and attachment. Wherever possible,
with good-quality cover flap tissue. the author recommends preparing a larger
General Considerations recipient site (68 mm apicocoronal
Acellular dermal matrix (AlloDerm) has Surgical Technique dimension) and immobilizing a larger Allo-
been used as an alternative to harvesting The surgical technique for using AlloDerm Derm graft compared to what is used when
autogenous epithelialized palatal grafts and is essentially the same as that described an autogenous gingival graft is performed.
Soft Tissue Management in Implant Therapy 221
Conclusion
This chapter provides the implant surgeon
with the basic information necessary for
successful management of periimplant soft
tissues in the most common clinical sce-
narios. In addition, it presents principles of
oral soft tissue grafting and surgical details
of the most commonly used oral soft tissue
A B grafting techniques. However, as limited
FIGURE 11-25 Use of AlloDerm (a freeze-dried allograft skin processed to remove all immunogenic
information concerning the indications,
cellular components [epidermis and dermal cells]) to increase the width of attached tissue around an advantages, and expected outcomes of the
implant restoration. A, Intraoperative view of the use of an AlloDerm graft simultaneous with the individual surgical approaches and tech-
placement of four nonsubmerged implants in an edentulous mandible to improve the periimplant soft niques has been presented, further study by
tissue environment and to eliminate mobile mucosal tissues in the area, while increasing vestibular the reader is encouraged.
depth. B, The 2-month postoperative view demonstrates a sufficient area of attached nonmobile peri-
implant soft tissues to ensure a healthy soft tissue environment and ample access for oral hygiene References
maintenance. Reproduced with permission from Sclar A.3 1. Schroeder A, van der Zypen E, Stich H, Sutter
F. The reaction to bone, connective tissue,
and epithelium to endosteal implants with
titanium-sprayed surfaces. J Maxillofac
Surg 1981;9:1525.
2. Palacci P, Ericsson I, Engstrand P, Rangert B.
Optimal implant positioning and soft tissue
management for the Brnemark System.
Chicago: Quintessence Publishing Co.;
1995. p. 5970.
3. Sclar A. Soft tissue and esthetic considerations
in implant therapy. Chicago: Quintessence;
2003. p. 5254.
A B 4. Sullivan HC, Atkins JH. Free autogenous gingi-
val grafts, I. Principles of successful graft-
FIGURE 11-26 Use of AlloDerm (a freeze-dried allograft skin processed to remove all immunogenic ing. Periodontics 1968;6:1219.
cellular components [epidermis and dermal cells]) for root- or abutment-coverage procedures. A, Pre- 5. Gordon HP, Sullivan HC, Atkins JH. Free auto-
operative view of generalized progressive periodontal soft tissue recession treated with AlloDerm grafts. genous gingival grafts, II. Supplemental
B, The postoperative view demonstrates successful root coverage at sites amenable to such a result and findingshistology of the graft site. Peri-
an increased width of attached tissue at those sites not amenable to complete root coverage. odontics 1968;6:1303.
6. Sullivan HC, Atkins JH. Free autogenous gingi-
val grafts, III. Utilization of grafts in the
treatment of gingival recession. Periodon-
This offsets the additional shrinkage prior to its immobilization at the recipient tics 1968;6:15260.
7. Langer B, Calagna L. The subepithelial connec-
observed with AlloDerm onlay grafts. site. Subsequently, activated PRP is used
tive tissue graft: a new approach to the
Improvement has been observed in the topically at the recipient site as a growth enhancement of anterior cosmetics. Int J
rate of incorporation of AlloDerm onlay factorenriched wound dressing. Whenev- Periodontics Restorative Dent 1982;
and interpositional grafts when platelet- er PRP is used with AlloDerm or autoge- 2(2):2334.
rich plasma (PRP) is incorporated into the nous soft tissue grafts, care must be taken 8. Reiser C, Bruno JF, Mahan PE, Larkin LH. The
subepithelial connective tissue graft palatal
surgical protocol.3 In these instances the to avoid the formation of a PRP blood clot donor site: anatomic considerations for
AlloDerm graft is first rehydrated in non- between the soft tissue graft and the surgeons. Int J Periodontics Restorative
activated anticoagulated PRP solution periosteal recipient site or the cover flap.3 Dent 1996;16:1317.
CHAPTER 12
Strategies to increase alveolar vertical well for moderate-sized defects, whereas Figure 12-1 illustrates a posterior
dimension fall into six general categories: distraction osteogenesis is reserved for mandible atrophy in which 7 mm of verti-
(1) guided bone graft augmentation, (2) more extensive alveolar defects. Large bone cal bone height is required. After full
onlay block grafting, (3) interposition mass deficiencies, where there is not thickness flap elevation, a couple of
alveolar bone graft, (4) alveolar distraction enough bone to distract, require iliac bone 10 mm long tenting screws have been
osteogenesis, (5) iliac corticocancellous graft reconstruction, though a vertical gain placed in order to avoid the membrane
augmentation bone graft, and (6) the of 10 mm is difficult to achieve in these set- collapse toward the bone ridge. The corti-
sinus bone graft. tings. Finally, there is the sinus bone graft, cal bone has been perforated with a round
The difficulty in gaining and main- which functions as an endosteal expan- bur (see Figure 12-1A). Autogenous bone
taining alveolar vertical augmentation is sion of alveolar vertical bone mass. chips have been placed and covered with a
well established in the literature, but the titanium-reinforced expanded polytetra-
various procedures that have been used Guided Bone Graft fluoroethylene (ePTFE) membrane (see
have been complicated by relapse and Augmentation Figure 12-1B). After 6 months of unevent-
resorption.13 Augmentations without the Vertical bone augmentation of deficient ful healing, a mucoperiosteal flap has been
placement of implants generally resorb alveolar ridges can be obtained with guid- elevated (see Figure 12-1C), and the mem-
unless a nonresorbable grafting material ed bone regeneration techniques. These brane has been removed to expose the
such as hydroxylapatite is used.46 techniques allow vertical augmentation of regenerated bone (see Figure 12-1D). Two
This chapter reviews the indications up to 10 mm both in the posterior and Brnemark implants have been placed (see
and contraindications for the above proce- anterior maxilla and mandible. A barrier Figure 12-1E). Figure 12-1F and 12-1G
dures, all of which have found their niche membrane is placed and stabilized with show the final porcelain-fused-to-metal
in oral and maxillofacial surgery recon- tacks or screws in order to protect an auto- prosthesis and the periapical x-ray after
struction using osseointegrated implants. genous bone graft usually harvested from 3 years of occlusal loading.
Alveolar vertical defects have been the retromolar area in the mandible. The
classified according to the size of the membrane is maintained in the site com- Mandibular Block Autografts
defect.7 Deficiencies can range from 1 or pletely covered by the soft tissues for a for Localized Vertical Ridge
2 mm to more than 20 mm in height. In period of at least 6 months. Augmentation
general monocortical grafts or guided bone The implants can be placed either at Mandibular block autografts have been
graft augmentations are useful for smaller the time of bone regeneration or at the used extensively for alveolar ridge aug-
augmentations. Interpositional grafts work membrane removal surgery. mentation with great success and include
224 Part 2: Dentoalveolar Surgery
damaged blood vessels produces platelet- border of the mandible. This allows for tinues in the buccal sulcus opposite the
derived growth factor and transforming good visualization of the entire symph- first bicuspid where an oblique release is
growth factor (TGF-), which accelerate ysis, including both mental neurovascular made to the depth of the vestibule. A full
wound healing. Site preparation facilitates bundles. It also provides easy retraction thickness mucoperiosteal flap is then
intimate adaptation of the graft to its at the inferior border and results in a rel- reflected to the inferior border allowing
underlying bony bed. Second, two-point atively dry field. Contrast this with the for visualization of the external oblique
fixation of each block is important to pre- vestibular approach, which results in ridge, buccal shelf, lateral ramus and body,
vent microrotation of the graft resulting in more limited access, incomplete visual- and mental neurovascular bundle. The
incomplete bone incorporation. Low-pro- ization of the mental neurovascular bun- flap is further elevated superiorly from the
file self-tapping screws are recommended. dles, and more difficulty in superior and ascending ramus and includes stripping of
Third, primary closure without tension of inferior retraction of the flap margins. the temporalis muscle attachment.
the wound site is critical to prevent dehis- Also, there is typically bleeding secondary There are three complete osteotomies
cence, which is the primary complication to the mentalis muscle incision resulting and one bone groove that need to be pre-
of monocortical block grafts. Careful in the need for hemostasis. Finally, pared prior to graft harvest. A superior
attention to undermining the flap will wound dehiscence from the sulcular osteotomy is created with a 702L fissure
allow for complete relaxation prior to clo- approach is rare. The vestibular incision bur in a straight handpiece. It begins
sure. Prosthesis contact with the ridge is can result in wound dehiscence and scar opposite the mandibular second molar
not allowed for the entire duration of band formation. and continues posteriorly to the ascend-
healing. Finally, implant placement must A 702L tapered fissure bur in a ing ramus approximately 4 to 5 mm
follow graft incorporation and should straight handpiece is used to penetrate the medial to the external oblique ridge. The
never be done simultaneously. This stag- symphysis cortex via a series of holes that length of this osteotomy depends on the
ing provides predictable bone volume and outline the graft. It is important to not graft size. The anterior extent of this
optimal bone density to be created prior to encroach within 5 mm of the apices of the bone cut can approach the distal aspect
stage 1 surgery. incisor and canine teeth as well as the of the first molar, depending on the ante-
The symphysis can provide a range of mental neurovascular bundles. Also, the rior location of the buccal shelf. A modi-
dense cortical cancellous bone ranging inferior osteotomy is made no closer than fied channel retractor is used for ideal
from 4 to 11 mm, in contrast to a typical 4 mm from the inferior border. All holes access to the lateral ramus body area to
ramus buccal shelf block graft that is 3 to are then connected to a depth of at least allow for two vertical bone cuts. The
4 mm. These grafts can be used for pre- the full extent of the bur flutes (7 mm). osteotomies begin at each end of the
dictable horizontal augmentation of 5 to The graft is then harvested using straight superior bone cut and continue inferior-
7 mm and vertical augmentation of up to and curved osteotomes or modified bone ly approximately 12 mm. All osteotomies
and including 6 mm. spreaders. The donor site is packed with just barely penetrate cortical bone.
gauze soaked in either saline or platelet- Finally, a no. 8 round bur is used to cre-
Symphysis Block Graft Harvest poor plasma. Closure of the site is done ate a groove connecting the inferior
A sulcular incision design is preferred for after graft fixation and includes a particu- aspect of each vertical osteotomy. The
the symphysis block graft harvest as late graft. This graft is not critical to the graft is then harvested using modified
opposed to the more conventional esthetic outcome; however, grafting of the bone spreaders that are malleted along
vestibular design. This approach can be donor site to allow for a secondary block the superior osteotomy. The graft will
safely used if the periodontium is healthy harvest can be done. fracture along the inferior groove and
and no crowns are present in the anterior should be carefully harvested so as to
dentition. Also, a highly scalloped thin Ramus Buccal Shelf Block avoid injury to the inferior alveolar neu-
gingival biotype is contraindicated. Graft Harvest rovascular bundle. The sharp ledge that
The incision begins in the sulcus A full thickness mucoperiosteal incision is is created at the superior extent of the
from second bicuspid to second bicuspid. made distal to the most posterior tooth in ascending ramus is then smoothed with
An oblique releasing incision is made at the mandible and continues to the retro- a large round fissure bur. Gauze moist-
the mesial buccal line angle of these teeth molar pad and ascending ramus. An ened with either saline or platelet-poor
and continues into the depth of the buc- oblique release incision can be made into plasma is then packed into the wound
cal vestibule. A full thickness mucope- the buccinator muscle at the posterior site. Closure of the donor site can be
riosteal flap is reflected to the inferior extent of this incision. The incision con- done after graft fixation.
226 Part 2: Dentoalveolar Surgery
Case 1 The recipient site was exposed via a additional platelet-rich plasma was
full thickness buccal flap reflection (Fig- placed over the graft complex (Figure 12-
A healthy 59-year-old white female was
referred for implant evaluation. Clinical ure 12-2D). Site preparation included 2N). Primary closure without tension
and radiographic examination revealed a slight decortication and perforation was accomplished prior to particulate
missing right maxillary second bicuspid prior to block grafting (Figure 12-2E). A grafting and administration of platelet-
and all molars (Figure 12-2A). The edentu- right ramus buccal shelf graft was har- rich plasma. A posterior vertical release
lous space exhibited a deficiency in alveolar vested in the conventional manner (Fig- incision was also made to allow for
height of approximately 4 mm, along with ure 12-2FH) and contoured to size (Fig- advancement of the full thickness flap
minimal sinus pneumatization precluding ure 12-2I and 12-2J). Platelet-rich (Figure 12-2O and P). Five months later
the need for sinus grafting (Figure 12-2B plasma was then placed on the recipient the site was reentered revealing excellent
and C). The treatment plan included verti- site prior to block graft fixation (Figure block incorporation (Figure 12-2Q).
cal bone augmentation using a right ramus 12-2K and L). Particulate demineralized Implants were placed in a nonsubmerged
buccal shelf block graft prior to implant freeze-dried bone allograft was mortised mode because of the excellent type 1
placement for a three-unit fixed bridge. superior to the graft (Figure 12-2M), and quality bone (Figure 12-2R and S).
A B C
D E F
G H I
FIGURE 12-2 A, Clinical photograph indicating edentulous right posterior maxilla. B, Radiograph depicting vertical deficiency and minimal sinus pneumatiza-
tion. C, Model depicting vertical alveolar deficiency. D, Full thickness buccal flap reflection. E, Site preparation including decortication and perforation. F, Right
ramus buccal shelf block graft harvest. G, Ramus buccal shelf graftcortical surface. H, Ramus buccal shelf graftmarrow surface. I, Contouring of block graft.
(CONTINUED ON NEXT PAGE)
Bone Grafting Strategies for Vertical Alveolar Augmentation 227
J K L
M N O
P Q R
FIGURE 12-2 (CONTINUED) J, Block graft contoured within confines of surgical stent. K, Platelet-rich plas-
ma applied to recipient site. L, Screw fixation completed. M, Particulate demineralized freeze-dried bone
allograft mortised. N, Platelet-rich plasma impregnated collagen covering entire wound site. O, Buccal flap
release. P, Tension-free primary closure. Q, Excellent block graft incorporation at 5 months. R, Stage 1
surgery. S, Stage 1 nonsubmerged implant placement completed.
Case 2 B). Clinical and radiographic examina- plan included vertical ridge augmenta-
A healthy 62-year-old white female was tion revealed missing mandibular tion of the right side with a symphysis
referred for implant evaluation. This molars bilaterally (Figure 12-3AC). graft and of the left side with a right
patient was unhappy with her existing Also noted was a vertical deficiency of ramus buccal shelf block graft.
bilateral distal extension partial denture more than 5 mm in the right posterior The right edentulous site was exposed,
and desired fixed prosthetic work in mandible and 4 mm in the left posterior appropriate crestal decortication and per-
both edentulous areas (Figure 12-3A and edentulous mandible. The treatment foration was done, and a symphysis block
228 Part 2: Dentoalveolar Surgery
A B C
D E F
FIGURE 12-3 A, Right posterior edentulous mandible. B, Left posterior edentulous mandible. C, Radiograph indicating bilateral posterior mandibular vertical
deficiency. D, Block graft fixation with platelet-rich plasma application. E, Block graft fixation. Note butt joint at anterior recipient donor interface. F, Excellent
block graft incorporation at 5 months. (CONTINUED ON NEXT PAGE)
graft was fixated to the crest (Figure 12-3D incorporate exceptionally well with recipi- bundle is avoidable with proper surgical
and E). Platelet-rich plasma was applied to ent bone in a relatively short time. They technique, especially in the use of the sul-
the recipient site prior to graft fixation. also maintain post-implant placement cular approach for bone harvest. Block
Five months later both sites were reentered bone volume and retain their radiograph- fracture and bicortical block harvest can
and revealed no evidence of bone resorp- ic density to the augmented site. Despite also be prevented by following good surgi-
tion (Figure 12-3F and G). The right side the many advantages block grafts offer for cal technique. Pain, swelling, and bruising
revealed vertical augmentation of 5 mm. alveolar ridge augmentation, there are occur as normal postoperative sequellae
Three threaded Spline implants were complications with posterior mandibular and are not excessive in nature. Use of
placed in a nonsubmerged mode because autografts when used for horizontal and platelet-rich plasma has decreased overall
of the excellent type 1 quality bone (Figure vertical augmentation. Morbidity with this soft tissue morbidity. Infection rate is min-
12-3H and I). The left edentulous space grafting protocol is associated with both imal (< 1%). Neurosensory deficits
was augmented 4 mm with a right ramus donor and recipient sites. This includes include altered sensation of the lower lip,
buccal shelf block graft in the same fash- experience with 434 grafts harvested chin (temporary 19%; permanent < 1%),
ion and three threaded implants were also between August 1991 and December 2002: and dysesthesia of the anterior mandibu-
placed nonsubmerged (Figure 12-3JL). 208 symphysis grafts and 226 ramus buc- lar dentition (transient 53%; permanent
Both sites were ultimately grafted with cal shelf grafts. < 1%). No evidence of dehiscence was
epithelial palatal tissue for enhanced kera- Symphysis donor site morbidity seen using the sulcular approach.
tinized gingiva (Figure 12-3M and N), and includes intraoperative complications The ramus buccal shelf harvest can
three-unit fixed bridgework was fabricated such as bleeding; mental nerve injury; soft also result in intraoperative complications
for each site (Figure 12-3O). tissue injury of cheeks, lips, and tongue; including bleeding, nerve injury, soft tis-
Mandibular block autografts for verti- block graft fracture; and potential bicorti- sue injury, block fracture, and mandible
cal alveolar ridge augmentation are pre- cal harvest. Bleeding episodes are intra- fracture. Intrabony bleeding and soft tis-
dictable and offer many advantages. These bony and can be taken care of with sue bleeding can be handled with cautery.
grafts are primarily cortical in nature, cautery, local anesthesia, and collagen Injury to the inferior alveolar neurovascu-
exhibit minimal resorption, and tend to plugs. Injury to the mental neurovascular lar bundle and the lingual neurovascular
Bone Grafting Strategies for Vertical Alveolar Augmentation 229
G H I
J K L
M N O
FIGURE 12-3 (CONTINUED) G, Excellent block graft incorporation at 5 months. H, Stage 1 implant surgery. I, Nonsubmerged implant placement. J, Ramus buccal
shelf block graft with fixation. K, Radiograph indicating block graft in fixation. L, Completed stage 1 nonsubmerged implant placement. M, N, Completed epithelial
palatal graft. O, Completed restorations.
bundle can be avoided with proper soft tis- only. No incidence of altered sensation of ondary to both intrabony and soft tissue
sue manipulation and meticulous osteoto- mandibular dentition has been found. vessel transection. Pain, swelling, and
my preparation. Block fracture is also an Infection rate is less than 1%. bruising are mild to moderate and are
avoidable problem with proper surgical Recipient site morbidity includes tris- minimized with platelet-rich plasma.
technique. Postoperative morbidity mus, bleeding, pain, swelling, bruising, Infection rate is less than 1% and is usual-
includes trismus (approximately 34%) but infection, neurosensory deficits, bone ly secondary to graft exposure. Nerve neu-
is certainly transient and can take up to resorption, dehiscence, and graft failure. rosensory deficits can occur secondary to
2 weeks to resolve. Pain, swelling, and Trismus can be expected, as the surgical site preparation and block fixation because
bruising are typically mild to moderate protocol for reconstruction of the posteri- normal anatomy is violated. Dehiscence
and, again, are minimal with use of or mandible includes manipulation of the and graft failure (approximately 2.5%) are
platelet-rich plasma. Infection rate is less posterior mandibular musculature. Inci- seen secondary to soft tissue closure with
than 1%. Altered sensation of the lower lip dence is less than 40% and is transient. tension or prosthesis contact with the graft
or chin occurs approximately 8% of the Bleeding of the recipient bed is intentional site. (Strong recommendation: avoid the
time, with less than 1% being permanent. secondary to meticulous site preparation use of any type of prosthesis secondary to
Altered sensation of the lingual nerve has (decortication and perforation), but exces- posterior mandibular block graft recon-
also been reported but has been transient sive bleeding, although rare, can occur sec- struction.) Finally, block graft resorption at
230 Part 2: Dentoalveolar Surgery
stage 1 surgery is minimal (0 to 1.5 mm) of implants such as in the anterior maxilla establish both the final vertical height and
but can be excessive if dehiscence of the or in the posterior mandible when a stable the crestal axis of the osteotomized segment
graft occurs. In summary, overall morbidi- vertical augmentation is required, usually (Figures 12-4G and H).
ty of mandibular block autografts for over a three- or four-tooth segment.
atrophic posterior mandibular reconstruc- Figure 12-4A to C illustrates an anteri- Alveolar Distraction
tion is minimal. Most complications are or maxillary defect treated with interposi- Osteogenesis
preventable. Those that occur can be han- tional grafting. Figure 12-4D shows a poste- A deficient alveolus can be distracted to
dled predictably with minimal adverse rior mandibular deficiency with 6 mm of improve vertical dimension for implant
effects to the patient. bone available above the inferior alveolar placement. Sufficient width (5 mm) and
nerve. An osteotomy was done (Figure vertical height (8 to 10 mm) of a distrac-
Interpositional Bone Graft 12-4E) through a vestibular incision to tion site are needed in order to ensure suf-
The interpositional bone graft is placed maintain both lingual and crestal blood ficient (5 5 mm) bone mass of the seg-
between a mobilized segmental osteotomy supply. An interpositional cortical bone ment to be translated.
and the basal bone. A typical vertical gain graft harvested from the ramus was placed Figure 12-5A to G illustrates a case
is 4 or 5 mm in the maxilla but 5 to 10 mm at the osteotomy site, raising the alveolus where severe atrophy of both soft and hard
in the mandible. The indication for the about 7 mm (Figure 12-4F). The raised seg- tissues left a significant alveolar retrog-
procedure is an alveolar defect where there ment rotated slightly lingually, but this was nathia and a vertical defect of at least
is insufficient vertical height for placement compensated for by using a bone plate to 10 mm (see Figure 12-5A and B). Using a
A B C
D E F
A B C
D E F
G H
vestibular approach, a flared osteotomy was Figure 12-5G to J, indicating a stable bone which iliac bone graft was combined with
made (see Figure 12-5C). Then a biphase pattern and reasonable esthetic restoration. sinus augmentation and Le Fort I
distractor plate was placed in order to gain advancement. Figure 12-6A shows the pre-
vertical and horizontal displacement (see Iliac Corticocancellous Grafting operative finding of severe bone loss
Figure 12-5D). Following a vertical distrac- When the jaw is too deficient to do mono- including maxillary retrognathia. A 5 mm
tion of 12 mm (see Figure 12-5E), horizon- cortical grafting or osteotomies, bone graft maxillary advancement with a Le Fort I
tal movement was achieved by tightening augmentation with iliac corticocancellous osteotomy fixated with resorbable bone
the nut on the horizontally placed screws graft is needed. Major grafting is usually plates was done. The anterior reconstruc-
for a 5 mm horizontal movement. Four required when bone mass needs to be tion relied on onlay corticocancellous
months later,, implants were placed (see expanded in order to gain enough bone block graft supported by particulate mar-
Figure 12-5F). The final restoration was for osseointegration. row. Graft preservation strategies such as
placed an additional 4 months later. A Figure 12-6A to G shows a patient barrier membrane and titanium mesh
1-year postrestorative finding is shown in who had severe maxillary atrophy in may be helpful, but in this case a cortical
232 Part 2: Dentoalveolar Surgery
A B C
D E F
G H
graft was placed laterally, which minimizes ic loading (temporary dentures) degraded The sinus intrusion osteotomy can be
the need for a barrier membrane. Figure the final vertical augmentation dimension, done on the day of extraction if the wound
12-6B shows the down-fractured maxilla, but not significantly. Typically, 6 to 8 mm is clear of soft tissue and infection. In the
where both sinus and nasal membranes of vertical gain is judged a success in the case shown in Figure 12-7A, the intrusion
are elevated and preserved. The advanced severely atrophic case. was done with a bone graft and implant
maxilla augmented laterally and vertically placement 6 weeks after the dental extrac-
around the arch is shown in Figure 12-6C. Sinus Bone Graft tion. At this stage epithelial closure of the
Figure 12-6D shows the augmentation The sinus bone graft is well established as wound was present, and a residual infec-
6 months after grafting just prior to one of the most stable vertical augmenta- tion had resolved. A bone graft was taken
implant placement. Figure 12-6E shows tion procedures in the surgeons arma- from the mandible and intruded into the
exposure of the implants 6 months after mentarium. sinus floor using an osteotome. Bone graft
that for a total of 1 year of bone graft con- Three techniques are used, including: was also placed into defects within the
solidation. A final fixed-hybrid restoration extraction socket. Figure 12-7A to C show
is shown in Figure 12-6F and G. Two years 1. Sinus intrusion osteotomy the sinus grafting and implant procedure.
after dental restoration bone levels 2. Lateral approach sinus membrane ele- Figure 12-7D show the final bone graft
remained stable, but there is some varia- vation consolidation 1 year after final restoration.
tion in graft consolidation and resorption 3. Alveolar augmentation combined The lateral sinus graft is done through
within the graft (Figure 12-6H). Prosthet- with sinus elevation (shown above) a Caldwell-Luc approach by elevating the
Bone Grafting Strategies for Vertical Alveolar Augmentation 233
possible in a highly compromised site. This term bone ingrowth and residual micro- chin grafts as donor sites for maxillary bone
setting argues for the use of particulate hardness of porous block hydroxyaptite augmentation: part II. Dent Implantol
implants in humans. J Oral Maxillofac Surg Update 1996;7:14.
bone marrow harvested from the tibia or 1998;56:1297301. 14. Pikos MA. Alveolar ridge augmentation with
ilium and possibly adjuncts such as 5. Tinti C, Parma-Benefenati S. Vertical ridge aug- ramus buccal shelf autografts and impacted
platelet-rich plasma. mentation: surgical protocol and restrospec- third molar removal. Dent Implantol
tive evaluation of 48 consecutively inserted Update 1999;4:2731.
Summary implants. Int J Periodontics Restorative Dent 15. Pikos MA. Block autografts for localized ridge
1998;18:43443. augmentation: part I. The posterior maxil-
The difficulty of treating alveolar vertical 6. Nystrom E, Kahnberg K-E, Gunne J. Bone la. Implant Dent 1999;8:27984.
defects requires the surgeon to be skilled grafts and Branemark implants in the treat- 16. Pikos MA. Block autografts for localized ridge
in all of the above modalities. In skilled ment of the severely resorbed maxilla: a two augmentation: part II. The posterior
hands, various approaches can be used in year longitudinal study. Int J Oral Maxillo- mandible. Implant Dent 2000;9:6775.
fac Implants 1993;8:4553. 17. Bidez MW, Misch CE. Force transfer in implant
treating the same type of defect. 7. Jensen OT, Shulman L, Block M, Iacono V. dentistry: basic concepts and principles.
In most cases defect sites are not Report of the sinus consensus conference of Oral Implantol 1992;18:26474.
strictly vertically deficient. Skill in alveolar 1996. Int J Oral Maxillofac Implants 18. Kummer BKF. Biomechanics of bone: mechan-
width augmentation, or combined treat- 1998;13 Suppl:1145. ical properties, functional structure, func-
8. Misch CM, Misch CE, Resnik R, et al. Recon- tional adaptation. In: Fung YC, Perrone H,
ment, is needed as well. With all of these
struction of maxillary alveolar defects with Anliker M. Biomechanics: foundations and
measures, the ultimate restorative goal is mandibuar symphysis grafts for dental objectives. Englewood Cliffs (NJ): Prentice-
to obtain orthoalveolar form, a concept implants: a preliminary procedural report. Hall; 1972. p 273.
that now encompasses a broad array of Int J Oral Maxillofac Implants 1992;7:3606. 19. Jensen OT, Greer R. Immediate placement of
surgical innovation. 9. Misch CM. Comparison of intraoral donor osseointegrating implants into the maxil-
sites for onlay grafting prior to implant lary sinus augmented with mineralized
placement. Int J Oral Maxillofac Implants cancellous allograft and Gore-Tex: second-
References 1997;12:76776. stage surgical and histological findings. In:
1. Davis WH, Delo RI, Ward B, et al. Long term 10. Sindet-Pedersen S, Enemark H. Reconstruc- Laney WR, Tolman DE, editors. Tissue inte-
ridge augmentation with rib graft. J Max- tion of alveolar clefts with mandibular or gration in oral, orthopedic, and maxillofa-
illofac Surg 1975;3:1036. iliac crest bone grafts: a comparative study. cial reconstruction. Chicago: Quintessence;
2. Baker RD, Terry BC, Connole PW. Long term J Oral Maxillofac Surg 1990;48:5548. 1992. p 32133.
results of alveolar ridge augmentation. J 11. Pikos MA. Buccolingual expansion of the max- 20. Jensen OT, Ueda M, Laster Z, et al. Alveolar
Oral Surg 1979; 37:48691. illary ridge. Dent Implantol Update 1992; distraction osteogenesis. Select Readings
3. Keller EE. The maxillary interpositional compos- 3:857. Oral Maxillofac Surg 2002;10:140.
ite graft. In: Worthington P, Branemark P-I, 12. Pikos MA. Facilitating implant placement with 21. Jensen OT, Sennerby L. Histologic analysis of
editors. Advanced osseointegration surgery: chin grafts as donor sites for maxillary bone clinically retrieved titanium microimplants
application in the maxillofacial region. Chica- augmentation: part I. Dent Implantol placed in conjunction with maxillary sinus
go: Quintessence; 1992. p. 16274. Update 1995;6:8992. floor augmentation. Int J Oral Maxillofac
4. Ayers R, Simska S, Nunes C, Wolford L. Long- 13. Pikos MA. Facilitating implant placement with Implants 1998;13:51321.
CHAPTER 13
Severely resorbed edentulous maxillae inability to wear any prosthesis, and a preferably four anterior standard
present very complex problems for the higher failure rate for conventional implants are needed in combination
surgeon and restorative dentist.1 Lack of implants placed in large bone grafts. with bilateral zygoma implants.
internal osseous stimulation and nonphys- In partial or incomplete maxillectomy
iologic crestal bone loading results in con- Zygoma Implant patients when additional implants
tinued resorption of an already atrophic The zygoma implant is an extended-length can be placed in other sites such as the
edentulous maxilla. The end result is an (3052.5 mm) machined titanium fixture
inability to use a conventional full denture that is placed through the crestal (slightly
prosthesis. palatal) aspect of the resorbed posterior
In 1999 Dr. Per-Ingvar Brnemark and maxilla transantrally into the compact
colleagues introduced the zygoma implant bone of the zygoma. In addition to two to
(P-I Brnemark, personal communication, four conventional fixtures in the anterior
1999). In their initial study over a 10-year maxilla, initial stability of this elongated
period, 110 implants were placed. Each fixture is assured by its contact with four
patient had an additional two to four con- osseous cortices (Figure 13-1)35:
ventional implants placed in the anterior
1. At the ridge crest
maxilla, which was restored with cross
2. The sinus floor A
arch stabilization. Of the zygoma fixtures
3. The roof of the maxillary sinus
placed and restored in the initial study,
4. The superior border of the zygoma
only two were lost in the first year of
occlusal loading, and three failed in the The zygoma implant provides posteri-
subsequent 8 years for a long-term success or maxillary anchorage when the existing
rate of > 95%. osseous structures do not allow standard
The availability of the zygoma implant implant placement. The alternative in this
has provided a viable alternative for treat- situation includes bone graft augmenta-
ment of patients with extreme resorption tion (sinus lifts and onlay grafts) with their
of the edentulous maxilla or large pneu- attendant costs, discomfort, prolonged
matized maxillary sinuses.1,2 Before the treatment times, and higher complication
introduction of this fixture, implant- rates. The zygoma fixture is suggested in B
supported or -retained fixed or removable the following circumstances: FIGURE 13-1 A, Schematic representation of min-
prostheses in the atrophic maxilla could imal recommended zygoma and standard implant
only be considered after extensive ridge When full maxillary edentulism is fixtures for restoration with cross-arch stabilization
preparation. This preparation usually accompanied by advanced posterior and fixed restoration. B, Schematic representation
of ideal zygoma and standard implant fixtures for
included major autologous bone grafting, resorption that would otherwise restoration with cross-arch stabilization and fixed
prolonged treatment times, long-term require grafting. At least two and restoration.
236 Part 2: Dentoalveolar Surgery
Severe Atrophy
Although most of these patients will essen-
tially be graft candidates, there are some
who, because of history or physical circum-
stances, cannot or will not undergo these
procedures. A history of consistent graft
failure or a systemic compromise that con-
traindicates grafting are examples of miti-
gating factors that may require considering A
FIGURE 13-2 Most edentulous maxilla patients an alternative approach such as use of the
with a history of denture use will have some zygoma implant (Figure 13-5AD). Experi-
degree of moderate atrophy as depicted here. ence to date with these patients is not
Grafting procedures for augmenting existing
bone levels is a commonly recommended therapy extensive, but early indications of implant
for patients with this level of bone loss. survival are seen as encouraging, even with
the most severely compromised maxillae
(Figures 13-5E and 13-6).
piriform sinus, orbital rims, palatal
Prosthesis design for the severely
shelves, or pterygoid plates to support
atrophic maxilla with implant support
cross-arch stabilization. B
may be influenced by the relative size dis-
Indications parity between the two jaws. Most such FIGURE 13-4 A, The completed fixed partial den-
atrophy results in an undersized maxilla ture, facial view. B, Occlusal view illustrating the
While the zygoma implant is most often cantilever dimensions and screw retention sites.
relative to the corresponding mandible,
used in cases of moderate to severe atrophy,
even in cases where both arches are equal-
it can be considered a valuable procedure
ly resorbed. Cantilever considerations and
for any patient in need of posterior maxil- lary implants but have sinus extensions
implant stress distribution may mandate
lary implant support with or without sig- that eliminate the potential for posterior
the use of an overdenture prosthesis rather
nificant atrophy. The ability to avoid graft- implants without augmentation (Figure
than a fixed restoration in order to manage
ing in many patients, along with the 13-8). If such grafting is indicated but
occlusal alignment and lateral spacing
continuous use of an interim maxillary countermanded by patient request or
(Figure 13-7).
prosthesis also makes the zygoma implant health considerations, the zygoma
approach appealing as a treatment option. Inadequate Posterior Support approach can be equally effective.
A B C
D E
FIGURE 13-5 A, Severe maxillary atrophy is demonstrated on this survey film. The patient had a history of several failed onlay bone graft procedures.
B, At one point, these implants were placed in graft and native bone. All failed, with a resultant destruction of functional support bone. C, Maxillary
dimensions from continuous lateral atrophy resulted in a residual anatomy that did not require sinus invasion for implant placement. Even though this is
unusual, it did not affect the structural integrity of the implants. D, Implants were placed on either side of the two zygoma fixtures for stability. E, All
implants were successfully integrated and were positionally suitable for prosthesis construction.
A B C
FIGURE 13-7 A, An overdenture bar splint was constructed with lateral extensions to keep the retentive elements aligned with the occluding surfaces. B, The undersurface
of the overdenture illustrates the mechanical retention provided. C, Frontal view of the finished prosthesis.
238 Part 2: Dentoalveolar Surgery
Contraindications
Other than the most obvious contraindica-
tions, such as systemic compromise or
sinus disease, there are only two specific
situations that would complicate the use of
the zygoma implant or make it unneces-
FIGURE 13-9 This ectodermal dysplasia patient FIGURE 13-10 The effects of long-term overden-
presents with partial anodontia and associated ture use without adequate caries control are evi- sary. First, where adequate maxillary bone
findings typical of this syndrome. dent intraorally. exists for implant placement in numbers
The Zygoma Implant 239
Complications
The most significant complication to
zygoma implant therapy is the loss of the
implant (Figures 13-16AC). Our expe-
A B rience to date indicates this is a relatively
infrequent occurrence, but the impact on
FIGURE 13-12 Both constructions used porcelain-fused-to-metal technology. A, The completed max- the original treatment plan is significant.
illary fixed partial denture. B, Frontal view of both restorations in occlusion. Without this support element, posterior
anchorage may be severely compromised
and positions to support a prosthetic fact, often depends more on the volume and cantilever extensions to the first
appliance, the zygoma implant is not need- and condition of anterior bone than exist- molar region may overstress the remain-
ed. The second situation is where there is ing posterior anatomy to determine ing components. Correcting the resultant
not enough premaxillary support for at whether some edentulous patients may be imbalance using a zygoma approach will
least two stable implants with good poten- candidates for this procedure. In such require a healing period for bone regen-
tial longevity. Differential diagnosis, in instances, bone-grafting procedures should eration in the original site and eventual
A B C
D E F
G
240 Part 2: Dentoalveolar Surgery
Presurgical Assessment:
E Radiographic
Adequate radiographic examination is
F needed prior to surgery to identify or rule
out sinus or other pathology and to evalu-
FIGURE 13-14 A, These five anterior and two zygoma implants were loaded immediately with a rein-
forced resin bridge converted from the original denture. B, The cantilever extensions are limited at the ate the osseous anatomy of both the zygo-
provisional stage, but the reinforced bridge provides a rigid cross-arch effect. This prosthesis was deliv- ma and maxilla. The thickness of the
ered immediately following surgery. C, Radiographically, all implants appear integrated at remaining alveolar bone inferior to the
5.5 months. The provisional fixed partial denture has not been removed during that time period. sinus in the second premolarfirst molar
D, The soft tissue response viewed at removal of the provisional prosthesis shows relatively good epithe-
lial recovery. The deep tissue response in the zygoma regions results from the long-term resin connection region should be sufficient to provide
subgingivally. E, The definitive prosthesis was completed approximately 8 months after stage I surgery. some support for the long implant near
F, Radiographically all implants appear well integrated and functioning normally. the abutment connection. The apex of the
sinus just lateral to the orbital floor should
replacement of a second implant. Inter- plete function using both the original be identified and the quality and quantity
im therapy may include the use of a pro- and rescue zygoma fixtures for posterior of the bone that will support the apical
visional restoration on the remaining support (Figure 13-16EG). end of the zygoma implant evaluated. The
integrated implants but should not anterior maxillary alveolus should also be
include a cantilever extension on the Presurgical Assessment: Clinical evaluated to determine if enough residual
affected side (Figure 13-16D). To date, Current use of the zygoma implant dic- bone is available to place two to four ante-
this rescue approach has proven effective tates ultimate restoration with cross-arch rior implants. Panoramic, periapical,
in the two instances that we have experi- stabilization of the fixtures with addi- cephalometric, and plain tomography or
enced in zygomatic implant failure. Both tional implants. Adequate bone must be computerized exposures are all helpful in
have ultimately been restored to com- available to place and retain at least two this evaluation.
The Zygoma Implant 241
A B C
A B C
D E
FIGURE 13-16 A, An impression coping has been attached to the zygoma implant at the final impres-
sion appointment. B, It was noted that there was rotational instability of this fixture with movement
of the coping. C, The implant was removed without resistance. There was no sign of bone adherence
to any of the implant surface. D, A provisional restoration was created for interim use while the fail-
ure site healed and during the healing period for another zygoma implant. The cantilever extension
to the affected side has been reduced to only premolar occlusion. E, Occlusal view of the completed
restoration on healthy zygoma implants bilaterally. F, Frontal view of ceramometal restoration.
G, Radiographic view. The right side zygoma implant side shows an integrated replacement fixture.
G
242 Part 2: Dentoalveolar Surgery
Surgical Protocol the sinus. Preparation of the slot in the and a 3.5 mm twist drill. The preparation
sinus wall allows the surgeon to visualize is carried through the body of the zygoma,
Surgery for zygoma implant placement is
best performed using deep intravenous directly the passage of all drill prepara- through the cortical bone of the sinus
sedation or a general anesthetic. Local tions and implant insertion through the roof, and through the cortex at the superi-
anesthesia with vestibular infiltration, lateral sinus. When preparing the slot, the or border of the zygoma body at the notch.
second-division nerve blocks, and percu- schneiderian membrane in the sinus is The soft tissues at the superior portion of
taneous blocks or infiltration lateral and removed to allow good visualization and the preparation are protected by the zygo-
superior to the zygomatic notch just later- to prevent its interference with site prepa- ma retractor (Figure 13-22). Each fissure
al to the orbital rim should be adminis- ration and implant insertion. If portions bur has incremental markings from 30 to
tered. Bilateral inferior alveolar nerve of the membranes are picked up by the 52.5 mm, which help the surgeon deter-
blocks are also helpful if the procedure is implant and carried into the implant mine the needed implant length. When the
performed with sedation because signifi- preparation in the body of the zygoma,
cant retraction of the tongue, lower lip, they could interfere with osseointegration.
and mandible are needed to ensure ade- A series of long drills are used for
quate access for the procedure. incremental preparation of the implant
A crestal incision, placed slightly to site. The zygoma implant varies in length
the palatal aspect of the ridge in the first from 30 to 52.5 mm (Figures 13-17 and
molarsecond bicuspid region is made 13-18). The apical two-thirds of the
from the right- to left-tuberosity regions implant is 4 mm in diameter and the alve-
with bilateral releasing incisions at the olar one-third is 5 mm in diameter. The
incision ends. A releasing incision at the initial drill is a round bur, which is used to
maxillary midline is also helpful for flap start the implant preparation at the second
development and retraction. The lateral bicuspidfirst molar area as near the crest
maxilla is exposed by elevating full- of the residual alveolar ridge as possible
thickness mucoperiosteal flaps sufficient usually slightly to the palatal aspect. The
to visualize the zygomatic buttress from surgeon must preserve enough bone later- FIGURE 13-17 Zygoma implant armamentari-
ridge crest to the superior surface of the al to the site to fully surround the alveolar um. From left to right: zygomatic retractor,
zygoma at the zygomatic notch, just later- portion of the implant. The round bur is round bur, 2.0 mm fissure bur, depth gauge,
3.5 mm pilot drill, 3.5 mm twist drill, 50 mm
al to the orbit. The anterior maxilla is directed through the sinus floor and zygoma implant, mandrel and cover screw dri-
exposed to the piriform rims to avoid tear- through the lateral sinus superiorly fol- vers, manual implant driver, final depth gauge
ing the flap during retraction and to allow lowing the axis of the lateral wall slot chuck, chuck changer.
placement of conventional anterior maxil- preparation to the top of the sinus where it
lary implants. The entire lateral surface of indents the site of the preparation in the
the zygomatic buttress is exposed using a zygoma body. The slot preparation allows
palpating finger extraorally at the zygo- direct visualization of the passage of the
matic notch to ensure that the dissection is drill and the subsequent instrumentation
not directed into the orbital floor. During and implant insertion (Figures 13-19
the dissection, the infraorbital nerve 13-21). A custom-designed zygoma retrac-
should be identified and protected. tor with a toe-out tip is kept in position
A fissure bur, usually a 703 or 702, in a over the zygomatic notch throughout the
straight surgical handpiece is used to make site preparation to provide good visualiza-
a slot exposure vertically in the lateral tion and protect the surrounding anato-
wall of the sinus near the height of the my. The retractor also has a midline mark-
zygomatic buttress.3 The slot should paral- er that parallels the site preparation and
lel the planned course of the zygoma assists in orientation of the drills in the
implant just medial to the lateral sinus proper direction (see Figure 13-20). Sub-
FIGURE 13-18 Zygoma implant. Apical two-
wall. The slot should extend from near the sequent drills to complete the preparation
thirds of implant is 4 mm in diameter. Alveolar
sinus floor at the planned site of implant are, in sequence, long 2.9 mm diameter one-third is 5 mm in diameter. Note 45-angled
placement superiorly to near the roof of twist drills, a 2.9 mm to 3.5 mm pilot drill, abutment platform.
The Zygoma Implant 243
fixed bridge construction on implants. Jaw tory, and patient approval of the esthetic structure (Figures 13-45 and 13-46). Fol-
relation records are obtained using presentation is confirmed (Figures 13- lowing a second try-in appointment for
implant-stabilized record bases and wax 4213-44). Silicone putty indexes are made evaluation of passive fit and esthetics, the
rims (Figure 13-41). The try-in with teeth of the approved wax-up and are used to prosthesis is processed with heat polymer-
follows the trial set-up done in the labora- provide a matrix for creation of a metal bar izing resin (Figure 13-47). Delivery is
FIGURE 13-34 The surgical cast is poured in FIGURE 13-37 Soft tissue conditioning material FIGURE 13-40 The master cast should be an
dental stone, and appropriate gold cylinders are can then be used over the entire denture base absolute replica of the patients presentation
attached to the abutment and fixture level repli- area to create tissue contact and a peripheral seal intraorally. It is usually necessary to use a verifi-
cas. The gold bar is bent to a shape that contacts retention. cation jig to assure that the positions and orien-
each gold cylinder, and the connection is com- tation of the individual implant components are
pleted with a soldering procedure using a duplicated from the mouth.
microwelding torch.
FIGURE 13-39 The final impression is made using FIGURE 13-42 The mounted casts should be an
FIGURE 13-36 The previous denture conditioning a custom tray, to control material thickness, and articulated representation of the patients jaw
material is removed from the patients denture, an open top technique, which allows the individ- relationships.
and a disclosing material is used to identify any ual copings to be picked up rather than transferred
areas of excessive contact against the denture base. into the impression material.
The Zygoma Implant 247
accomplished using appropriate screws and milled from solid blocks of titanium with porcelain-fused-to-metal restoration. The
screw torques to provide even and complete excellent passive fit properties (Figures procedure for constructing these prosthe-
seating (Figures 13-48 and 13-49). 13-5013-54).11 In select situations, such as ses is essentially the same up to the point of
The bar structures are generally waxed minimal interocclusal distance or high the patient-approved wax-up. The metal
and cast in precious metals but can also be load forces, it may be beneficial to use a substructure will be designed to provide
5. Surgical access difficultdeep seda- treatment alternative for many patients the posterior maxilla. Ann R Australas Coll
tion or general anesthetic required with atrophic edentulous maxillae. Dent Surg 2000;15:2833.
6. Schnitman PA, Wohrle PS, Rubenstein JE, et al.
As with all properly planned and exe- Ten-year results for Brnemark implants
References immediately loaded with fixed prostheses at
cuted implant prosthetic procedures,
1. Bedrossian E, Stumpel L, Beckely M, Indersana implant placement. Int J Oral Maxillofac
extensive coordination between the sur- T. The zygomatic implant: preliminary data Implants 1997;12:495503.
geon and the prosthodontist is necessary on treatment of severely resorbed maxillae. 7. Jaffin RA, Kumar A, Bermann CL. Immediate
before initiating treatment. Ideally, the A clinical report. Int J Oral Maxillofac loading of implants in partially and fully
Implants 2002;17:8615. edentulous jaws: a series of 27 case reports.
prosthodontist should be available at J Periodontol 2000;71:8335.
2. Bedrossian E, Stumpel LJ. Immediate stabiliza-
surgery. Similarly, the surgeon should tion at stage II of zygomatic implants: ratio- 8. Salama H, Rose LF, Salama M, Betts NH.
become familiar with the prosthetic needs nale and technique. J Prosthet Dent Immediate of bilaterally splinted titanium
root-form implants in prosthodontics a
and techniques involved with fixture posi- 2001;86:104.
technique reexamined: two cases. Int J Peri-
tioning and restoration. Finally, patient 3. Stella JP, Warner MR. Sinus slot technique for
odontol Rest Dent 1995;15:34460.
simplification and improved orientation of
education, preparation, evaluation, and 9. Tarnow DP, Emtiaz S, Classi A. Immediate
zygomaticus dental implants: a technical loading of threaded implants at stage 1
informed consent are major parts of the note. Int J Oral Maxillofac Implants surgery in edentulous arches: ten consecu-
procedure and its ultimate success. Patient 2000;15:88993. tive case reports with 1- to 5-year data. Int
understanding, before treatment is initiat- 4. Parel SM, Brnemark PI, Ohrnell LO, Svensson J Oral Maxillofac Implants 1997;12:31924.
ed, should include the need for meticulous B. Remote implant anchorage for the reha- 10. Zhao R, Skalak R, Brnemark PI. An analysis of
bilitation of maxillary defects. J Prosthet a fixed prosthesis supported by the zygo-
hygiene and maintenance. Dent 2001;86:37781. matic fixture. (In press).
The zygoma implant, when under- 5. Higuchi KW. The zygomaticus fixture: an alter- 11. Parel SM. The single-piece milled titanium
stood and appropriately used, provides a native approach for implant anchorage in implant bridge. Dent Today 2003;21:1068.
CHAPTER 14
Implant Prosthodontics
Thomas J. Salinas, DDS
teeth is a good prognostic indicator of the factor to bone density, this disease seems to ease processes are well controlled, it may
likelihood of creating and preserving affect the hip and spine of those afflicted. be advisable to treat the patient to
interdental papilla. Generally, the distance No clear correlation can be demonstrated improve the overall quality of life.
from the residual alveolar bone to the con- that osteoporosis is a contraindication to Chemotherapy given to patients during
tact area of the restoration can be assessed the placement of dental implants.16 osseointegration has not been shown to
on a periapical film. The likelihood of hav- Periodontal disease is a local factor be subtractive in success.3234
ing a papilla is depicted in Table 14-1. that should be under control to avoid
Bone volume is best assessed by radi- adverse effects of a unique population of Radiographic Evaluation
ographic techniques, although a rudimen- microbiota affecting these diseased Periapical radiographs are an excellent
tary estimate can be made clinically by pal- sites.1719 way to evaluate single missing teeth since
pation and inspection. Assessing a patient Bruxism is another local factor that they depict a minimally magnified
for mandibular implant reconstruction can compromise long-term success. Gen- amount of bone and root topography.
may include intraoral/extraoral palpation erally, bruxism promotes micromovement Adjacent root angulation, pulp chamber
as well as panoramic, occlusal, and lateral of the implant bone interface. In bone size, periodontal defects, interproximal
cephalometric radiographs. Single-tooth types 3 and 4, bruxism may have a more bone, and residual pathology are some of
replacement in the esthetic zone also can pronounced effect on the long-term the factors critical to the treatment plan-
be assessed by comparison of the bony osseointegration. Off-axis and lateral ning of single-tooth implant restorations
topography of the adjacent teeth as well as loading of dental implants by bruxism or (Figure 14-3).
periapical/panoramic radiographs. Bone is other parafunctional forces can be delete- Occlusal radiographs for mandibular
a scaffold for soft tissue, and it is typical rious in the long term with respect to arch assessment also can give an apprecia-
for bone loss to occur on a scale of accelerated bone loss and prosthetic fail- tion of the size of the inner and outer cor-
0.2 mm/yr after implant placement. ure. Self-awareness and occlusal splint tices as well as the position of the mental
Therefore, it is not unusual that soft tissue therapy may provide appropriate protec- foramina (Figure 14-4). It may be also feasi-
recession occurs in this period of time. tion. If these factors cannot be controlled ble to incorporate a radiographic marker on
This recession should be anticipated, espe- preoperatively, alternative treatment the patients denture to give a perspective of
cially when considering placing implants should be considered. the relationship of the mental foramina to
in the esthetic zone and elsewhere. Radiation to the head and neck in the overlying prosthesis. This can be done
It is well documented that local and excess of 50 Gy is considered a contraindi- with either lead foil from a film packet taped
systemic factors such as cigarette smoking cation to dental implant placement in to the underside of the patients denture or
have a deleterious effect on the long-term most cases. There are instances in which a stainless steel wire attached with sticky
success of dental implants.1013 It is also the radiation has created a significant
well documented that smoking decreases degree of xerostomia, which is incompati-
bone density.14 In one study failure rates of ble with retaining natural teeth or stabiliz-
implants placed in type 4 bone approached ing prostheses. Given the risks of osteora-
35% in smokers; placement of implants dionecrosis, hyperbaric oxygen should be
into types 1, 2, and 3 bone of smokers considered if placement of implants would
resulted in a failure rate approaching 3%.15 significantly improve the oral health and
Although osteoporosis can be a negating quality of life in these individuals.2022
However, there are several studies that
refute the benefit of hyperbaric oxygen to
Table 14-1 Potential of Creating/
Preserving Papilla the long-term survival of dental
implants.23,24 Standard protocol suggested
Distance from Bone to Chance of
Contact Area (mm) Creating Papilla (%) by Marx and Ames is 20 preoperative dives
and 10 postoperative dives.25
4.0 100 Systemic factors such as diabetes, con-
5.0 100
nective tissue diseases, autoimmune dis-
6.0 56
eases, and HIV are considered relative
7.0 27 FIGURE 14-3 Presurgical planning for placement
contraindications to treatment with of an implant into site no. 10. Minimal magnifi-
Adapted from Tarnow DP et al.7
osseointegrated implants.2631 If these dis- cation is noted from the periapical radiograph.
Implant Prosthodontics 253
wax to the buccal or occlusal portion of the Linear tomography is a useful adjunct in the work-up for determining maxillo-
mandibular relationships and occlusal schemes.
mandibular denture. when considering a single-tooth implant or
Panoramic radiographs are excellent definitive positioning of the inferior alveo-
screening examinations that give a broad lar canal, concavity of the nasal fossa, and Computed tomography (CT) can be
perspective on the inferior alveolar canal, the maxillary sinus. This feature is an exten- helpful when considering maxillary reha-
maxillary sinus, mental foramina, and sion of most modern panoramic radi- bilitation with a full complement of
nasal floor; they are used for treatment ographic units. It gives a three-dimensional implants or when other craniofacial land-
planning of single and multiple missing perspective of the primary radiograph, marks are planned for use. CT may be
teeth. The panoramic film generally has a which can help one anticipate grafting pro- used in conjunction with computerized
magnification factor of about 25%, cedures or select an implant length and technology to aid implant placement.
which should be anticipated on the configuration (Figure 14-7). These images may be reformatted to con-
work-up to gain a better appreciation of struct a three-dimensional image of the
the actual position of vital structures and selected part of the craniofacial skeleton.
the size of implant to be selected. CT scans are useful in assessing the health
Methods of standardizing the magnifica- of the maxillary sinus prior to augmentive
tion factor include the use of known- procedures (Figure 14-8).
diameter stainless steel shots incorporat- A radiographic or imaging stent can be
ed in a vacuum-formed stent worn at the used when there is a need to join the pros-
time of radiography (Figure 14-5). This thetic information to the bony topograph-
varies from patient to patient, by loca- ic information. In creating these stents,
tion, and also with the machine used. acrylic resin can be mixed with 30% or less
Panoramic radiographs are also useful A barium sulfate as a radiographic marker to
for verifying complete seating of impres- create the contour of the intended restora-
sion and restorative components. Use of tion. Some denture teeth are true to
this film over a standard periapical radi- anatomic form and create a radiopaque
ograph is preferable since the incident appearance when included in the stent. As
beam of the tube is more likely to be per- an alternative, access channels can be filled
pendicular to the long axis of the with gutta-percha as a radiographic mark-
implant. Also, many edentulous patients er. If verified radiographically, this imaging
have a shallow floor of mouth and flat stent may double as a surgical stent.
palatal vault owing to resorption. It is far
easier to obtain a perpendicular view of B Surgical Stents
the implant platform in these circum- Fabrication of surgical stents for implant
FIGURE 14-5 A and B, Five-millimeter stainless
stances, which is critical to the accurate steel shots in vacuum-formed stent to calculate placement should be part of every case
performance in the treatment stages. the magnification factor. since the placement is permanent and
254 Part 2: Dentoalveolar Surgery
One additional consideration is that, that flexes and rebounds as it opens and
unlike natural teeth, implants have no pro- closes. Traditionally, mandibular full-arch
prioception. In fact, many patients reconstruction has involved placement of
restored with dental implants have a sig- four to six implants between the mental
nificantly increased bite force within the foramina with a minimal cantilever to the
Y first year.3941 In partially dentate cases, the posterior.45 The greater the anterior poste-
implant restoration should have equal or rior spread, the greater the amount of can-
slightly less occlusal loading than the nat- tilever possible. On average, a 16 mm dis-
ural tooth (Figure 14-12). Also, the tal cantilever is permitted (Figure 14-14).
occlusal contacts should preferably be To avoid using a cantilever, it may be nec-
X placed over the platform of the implant to essary to place implants distal to the men-
minimize the possibility of screw loosen- tal foramen. In such a case, division of the
ing. Although this often may not be possi- prosthesis into two components prevents
ble, it should be striven for to minimize unfavorable stress transfer. Another
FIGURE 14-11 Ideal crown-to-implant ratio complications. option is to use the distal fixtures for ver-
occurs when X Y. tical support and not engage the abut-
Full-Arch Restorations ment-implant junction with an abutment-
Full-arch reconstructions of the maxilla coping screw.46 This allows some flexure of
length frequently approaches this measure-
should be based on placement of 8 to the mandible without transferring stress
ment. Standard implant diameters with
10 implants splinted for cross-arch stabili- to the prosthesis and/or implants. Pros-
shorter lengths have been shown to have a
ty.42,43 Reasonable length implants thetic screw or implant failure may result
high failure rate.36,37 Often, replacement of
(> 12 mm) should be considered especial- if a solid prosthetic connection spans the
teeth in a compromised site gives rise to sin-
ly in the posterior maxilla as shorter splinted first molar regions.
gle or multiunit restorations that have poor
implants into this relatively soft bone have
or unfavorable crown-to-implant ratios. If Implant Selection
been shown to do poorly in the long
the restoration participates in anterior guid-
term.44 The maxillary sinuses may pre- Historically, osseointegrated dental
ance, it should be splinted to other implants.
clude placement of a full complement of implants were introduced in their original
If the restoration participates in posterior
implants, and sinus augmentation or per- configuration as a machined parallel walled
occlusion, it should be protected by natural
haps the use of extended-length implants screw. The implant possessed a platform
canine teeth to limit lateral loads in excur-
into the zygomatic bones bilaterally may with a 4.1 mm diameter, an external hex
sions. If it is placed in conjunction with
allow an optimum force distribution for implant platform (originally used to drive
other implants in the posterior, it may be
full-arch prostheses (Figure 14-13). the implant into position), and a 3.75 mm
splinted for mutual support.
Full-arch reconstruction of the diameter body; this has been the most com-
Occlusion mandible can involve different considera- mon implant type placed worldwide (Fig-
tions as the mandible is a dynamic bone ure 14-15). The original applications were
There are several axioms in implant den-
tistry relating to occlusion:
Avoid lateral component forces when-
ever possible.38
Establish occlusal forces along the
long axis of the implant.
For added stability, splint implants
when possible.
When restoring occlusion of an entire
arch, favor the weaker of the two arch-
es. (In other words, an implant-borne
restoration opposing a complete den-
FIGURE 14-12 Contact of the implant occlusion FIGURE 14-13 Full-arch reconstruction using
ture should be restored with bilateral should be over the platform of the implant and two zygomatic implants and three endosseous
balanced occlusion.) slightly less intense than that of natural teeth. implants.
256 Part 2: Dentoalveolar Surgery
surgical stability in trabecular bone became Morse tapers are anywhere from 0 to 7%,
more apparent. Significant mechanical and dentistry most commonly employs the
improvement in abutment and screw- 4 to 7% series. Use of specific implants
retained components occurred in the early resistant to the problems of abutment
1990s and markedly decreased complica- screw loosening and immediate stability is
tions.49 Current trends are toward the use of probably more critical in cases of single
tapered macroretentive implant configura- missing teeth or in which a cemented
tions, based on the fact that tapered screw- implant crown and bridge are planned. The
type implants have increased surgical sta- traditional parallel walled screw continues
bility in soft bone. An example of these to enjoy success in the general population
FIGURE 14-14 Cantilevering is about 16 mm. types of implants is shown in Figure 14-17. of edentulous patients restored with
With these trends it is apparent that inter- implants50,51; the vast majority of prospec-
piloted for the edentulous patient, and lim- nal connections are preferable for fixed tive and retrospective studies have conclud-
ited restorative options were available in the tooth replacement since abutment screw ed that this specific implant is highly suc-
first years of its introduction. In later years loosening appears significantly less with cessful for restorations in edentulous
the use of surface-textured press-fit type internal connections than with butt-joint patients.5254 Long-term development has
implants also became popular because their implants. The Morse taper, a cone within a resulted in an increased number of compo-
surgical installation was simplistic and cone attachment mechanism, is a feature of nents for edentulous applications. The
achieved earlier integration into softer some implant systems that allow the abut- development of an extensive armamentari-
types of bone (Figure 14-16). At this time ment-prosthetic connection to facilitate um of abutment connections and restora-
the connection of abutments or prostheses installation and to maintain stability (Fig- tive components currently exists for
to the surface of the implant was character- ure 14-18). This taper creates a seating effect restoration with esthetic fixed prostheses.
ized as a butt-joint connection. Abutment of the connection to the internal aspects of Many well-known systems have this versa-
stability with single- and multiple-tooth the implant; therefore, fewer lateral stresses tility available, which is especially impor-
replacement using standard externally are transferred to the abutment screw, tant when considering implant restorations
hexed implants has a history of cyclic resulting in a less frequent incidence of in the esthetic zone. It is advisable for the
fatigue with abutment screw loosening.47,48 screw loosening and fracture. Morse tapers surgeon to become familiar with the
As extended applications developed for the are measured in percentage units that reflect restorative components available when
use of replacements for single and multiple the shaft length relative to the radius of the treatment planning for implants cases.
teeth and with immediate loading, an shaft. Thus, if for every centimeter of shaft Consideration of the components makes it
increased need for secure abutment con- the radius increases 0.01 cm, this would by easier to select the appropriate system for
nections, esthetic versatility, and improved definition be a 1% Morse taper. Most both surgical installation and restoration.
FIGURE 14-15 Standard externally hexed implant. FIGURE 14-16 Press-fit cylinder-type implant. FIGURE 14-17 Tapered-wall screw implant.
Implant Prosthodontics 257
Single-Tooth Replacement
other implant restorations, the implant and implant-borne occlusion). It may be mandibular resorption. This is especially
single crown is the most successful. If suf- appropriate to recommend only an true when restoring the skeletal Class II
ficient bone, soft tissue, and restorative implant-retained overdenture for a favor- patient. The use of a flange may be neces-
dimension exist, replacement with an able mandibular arch. However, mandibu- sary to eliminate the labiomental fold
implant-supported single-tooth restora- lar arches with limited support, vestibular usually apparent in these cases. Likewise
tion is considered the standard of care and extension, and extensive bone resorption the use of a flange in the edentulous max-
should be offered to the patient.69,70 may require an implant-borne prosthesis. illary arch may be beneficial to restore
The success of removable prostheses upper lip support as well as the esthetic
relies on the combination of retention, The Esthetic Zone integrity so critical to this area. A func-
support, and stability, which can be defi- Esthetic considerations encompass addi- tional lingual maxillary alveolar seal is
cient. Implant dentistry today is rooted tional complex concerns such as gingival essential for correct labiodental conso-
historically from treatment of mandibular display, proportion of teeth in the esthetic nant production; in cases of advanced
edentulism,71,72 which is currently the most zone, and bone density support. The resorption of the maxilla, an overdenture
predictable form of dental implant thera- esthetic zone is generally considered to be may be the appropriate treatment.
py.7376 This success is primarily owing to the maxillary anterior area. When consid-
the high degree of success of osseointegra- ering replacement of a single tooth in the Cemented Single Units
tion in the anterior mandible.53 A conven- esthetic zone, the adjacent dentition Cemented prostheses may be preferable to
tional mandibular prosthesis should be should also be evaluated for proportional- screw-retained designs for single-unit
evaluated for retention, support, and sta- ity and position. From a frontal plane the crowns in the anterior areas. They tend to
bility. Difficulty with speech, swallowing, lateral incisor should be about two-thirds provide minimized bulk of the restoration.
and mastication should be considered the width of the central incisor. Likewise, Overcontoured bulky restorations are not
when evaluating prostheses. Patient accep- the width of the canine when viewed from hygienic and are detrimental to the main-
tance of conventional prostheses may be the same vantage point should be about tenance of periimplant tissues. The axis of
contingent on stability and comfort when two-thirds the width of the lateral incisor, implant placement should be aimed
masticating. A patients chief complaint and so on. The width-to-length ratio of through the incisal edge for standard-
should be closely scrutinized and correlat- esthetically pleasing central incisors diameter implants (Figure 14-23). This
ed with the clinical examination to help should be about 66 to 80%.77 The axioms results in predictable esthetics and man-
formulate the proper treatment; the com- are ranges found in nature and are consid- ageable soft tissues. If a comparably wider
plaint is the foundation for a wide array of ered pleasing to the human eye. If these implant is placed (4.3, 5.0, or 6.0 mm) in
considerations that determine avenues proportions are not present, they may be an esthetic site, the long axis should tra-
possible for a candidate considering treat- created by surgical periodontics, restora- verse just palatal through the incisal edge.
ment with osseointegrated implants. Many tive dentistry, orthodontics, and, if appro- Errors in placement to the facial of the
of these considerations help to determine priate, osseointegrated implants. incisal edge produce not only difficulties
which imaging studies, preparatory treat- Occasionally, replacement of maxil- with angulation correction, but also a soft
ment, and number of ancillary procedures lary or mandibular canines may present a
are needed; if the treatment goals are feasi- compromise in either occlusion or esthet-
ble; and what time and cost commitment is ics for the functional goal of eliminating
involved. Treatment should be targeted at lateral forces on the restoration/ implant.
specific goals to achieve a predictable out- Esthetic and/or functional correction may
come that addresses the patients function- dictate the need for pretreatment ortho-
al and/or esthetic problem. The treatment dontics, endodontics, periodontics, and
may encompass several different routes concurrent restorative dentistry. A com-
paying attention to time, cost, longevity, plete examination that includes diagnostic
and levels of invasiveness. models, radiographs, and clinical pho-
The amount of keratinized/fixed tis- tographs can be invaluable.
sue, vestibular depth, available bone, and Esthetic considerations for removable
FIGURE 14-23 Long axis of implant placement
opposing occlusion are all important fac- prosthodontics may be a concern for
through the incisal edge of the stent for cement-
tors to consider prior to implant treatment lower edentulous arches when restoring retained prostheses. (Surgery performed by
(ie, natural dentition, edentulous arch, the facial contours typically lost in Michael S. Block, DMD)
260 Part 2: Dentoalveolar Surgery
Cantilevered FPDs
Cantilevered fixed prostheses may be used
in implant dentistry provided there is ade-
quate length to the supporting implants
and limited distance to the cantilever. This
may be especially useful when there is an
insufficient amount of bone or when sig-
FIGURE 14-30 Alveolar bone loss resulting in nificant site morbidity may result. Posteri-
the need for an onlay bone graft prior to implant or cantilevering probably is a more com-
placement. mon scenario, typically owing to a greater
availability of bone in the anterior area of FIGURE 14-34 Anterior cantilever fixed partial
denture.
the jaws. Anterior cantilevering may be
used in areas where posterior anchorage is
superior to anterior anchorage (Figure 14- ly dentate in at least one arch.90 Many in
34). Cantilevering requires that a frame- this age group have difficulty wearing
work be connected at a maximum clamp mandibular complete dentures owing to
force; such stability is best achieved with poor support and retention precipitated
screw-retained frameworks. Occlusal con- by advanced bone resorption, xerostomia,
tact created on the pontic should be very loss of attached keratinized tissue, and
light to coincident. neuromuscular degeneration. The use of
implants for these edentulous patients has
FIGURE 14-31 Cranial onlay bone graft in the Restorations for the Edentulous been shown to actually preserve existing
posterior maxilla. (Image courtesy of Leon F. Patient bone as opposed to results with conven-
Davis, DMD, MD)
tional dentures.91 Increased support and
Implant-Retained Overdentures anchorage can be improved with the use of
implants of reasonable length impossible. Those over 65 years of age are said to rep- at least two osseointegrated implants in
In these cases lateral positioning of the resent a significant proportion of the US the anterior mandible. The use of stud
inferior alveolar nerve with implant place- population, and the average life expectan- attachments connected to the implants
ment may be the only option for treatment cy has risen by 30 years since 1900.89 This can be a cost-effective measure to improve
other than a removable partial denture. is due mostly to the increase in medical retention, stability, and support (Figure
Nerve repositioning is an effective adjunct advances and critical care. A sizable por- 14-35). If a stud-retained denture is
in implant placement, but the technique tion of this group is edentulous or partial- planned, the implants should be as parallel
FIGURE 14-32 Individual fixed units protect- FIGURE 14-33 Placement of two implants in the FIGURE 14-35 Stud-retained overdenture using
ed from canine rise in lateral excursions. posterior mandible after inferior alveolar nerve O-ring attachments.
transpositioning.
264 Part 2: Dentoalveolar Surgery
as possible to avoid premature wear of the seen in the anterior mandibular area, may
attachment mechanism. The vertical be better supported by the splinting effect 45 mm
height of the attachment should be con- of a bar attachment. Second, non-parallel 24 mm
sidered as some edentulous mandibular implants create different paths of inser- 12 mm
arches do not provide > 4 mm of restora- tion, which subsequently serve to wear and
tive dimension for the mandibular den- disable the stud attachment prematurely.
ture. Preoperative planning calls for the In these cases the bar attachment can cor-
evaluation of the patients present difficul- rect this problem by providing a single
ty. Reasonable esthetics, occlusion, and path of insertion. Third, implants placed
extension should be evaluated first. If in close proximity to each other may pro-
these factors seem to be appropriate, vide better anchorage to the overdenture if
panoramic radiographs and possibly an a bar attachment is incorporated that
occlusal radiograph are helpful in deter- places the attachment mechanism at a
mining the position of the mental forami- wider base than the interimplant distance. FIGURE 14-37 Minimum clearances needed for
na. A prime objective is to place at least There are some spatial considerations a bar-attached overdenture.
two implants as far apart as possible with- of using a bar attachment that should be
in this area. The anterior loop of the infe- evaluated prior to treatment planning. ever possible, cross-arch stabilization is
rior alveolar nerve can extend as far for- The vertical height needed for a bar preferred for maxillary implant-retained
ward as 7 mm prior to exiting the mental attachment can approach 11 mm. This or supported overdentures. In these cases
foramen; thus, consideration should be measurement is taken from the occlusal it may be prudent to also incorporate full
given to proper site selection.92 A radi- plane to the highest point of the alveolar palatal coverage to assist with some resid-
ographic marker such as a piece of foil process. This distance will provide for the ual load transfer to the hard palate. The
taken from a film packet or a standardized height of the bar (2 to 4 mm), 2 mm under prosthetic treatment of these implant
stainless steel shot can be secured to the the bar for maintenance of hygiene, and at cases is assimilated to the Kennedy Class I
patients denture and placed in the mouth least 7 to 8 mm of restorative material in partially edentulous arch in that stress-
prior to panoramic and/or occlusal radi- the overdenture (usually acrylic resin) breaking attachments and stress distribu-
ography. This will give an indication of the (Figure 14-37). tion to the soft tissue support posteriorly
correct site selection for implants in the Implant-retained overdentures for the are important considerations.
anterior mandible. After the site has been maxilla should always incorporate the use
selected, an open channel can be created in of bar attachments. The literature cites Implant-Supported
the stent to allow surgical latitude. Either poor long-term success for lone-standing Overdentures
duplication of the patients denture or a implants supporting overdentures in the Implant-supported overdentures may be
wax trial tooth subsequently processed in maxilla. A minimum of four implants in indicated when a patient has significant dif-
clear acrylic resin can be helpful in deter- the anterior maxilla splinted with a bar ficulty in all factors of support, retention,
mining the position. In general, tapered seems to be appropriate treatment. When- and stability. Anatomically there may be
arch forms with extensive resorption may cause to suspect that extensive resorption
direct placement of implants in close has taken place that has resulted in the loss
proximity to each other. In other words, of alveolar structure. Consequently, implant
implants placed < 20 mm apart may not anchorage can be used to aid in the support
be mechanically advantageous for use and retention of overdenture prostheses.
independently as stud attachments. In Historically, most of the literature
these cases, it may be desirable to connect available on implant-supported restora-
the implants with a bar attachment to cre- tions in the mandible has been planned for
ate a wider base of anchorage (Figure 14- four to six implants intraforaminally.93,94
36). There are several reasons to plan the More contemporary literature suggests the
implant-retained denture for a bar attach- use of four widely spaced implants in this
ment. First, short (10 mm or less) region opposing an edentulous arch with
implants or implants placed in cancellous FIGURE 14-36 Bar-retained denture using dis- equally successful rates.95,96 The strategy for
bone or types 3 and 4 bone, not typically tal attachments to widen the retentive base. using implants in the anterior mandibular
Implant Prosthodontics 265
one of available space. Generally, the more preserve what bone remains.105,106 The use
space available (13+ mm vertically), the of tapered implants in these sites has
more indication there is for an overden- become popular to obliterate the socket
ture prosthesis. Incipient resorption or defect while being firmly anchored in the
minimal space availability (912 mm ver- majority of the bony walls. A word of cau-
tically) may indicate the use of a ceramo- tion is advised for those teeth that have
metal design (Figure 14-41). Implant- drifted or are not in an ideal location as
supported maxillary overdentures are tooth position influences implant posi-
frequently used in cases of moderate to tion. Indications for placement into a
severe resorption as they replace not only recent extraction socket are freedom from
missing mastication and esthetics but also infection and reasonable orientation of
FIGURE 14-43 Orthodontic extrusion of a non-
phonetic physiology as well. Speech pro- the existing tooth. Ways of facilitating this restorable tooth to aid with migration of the
duction may rely heavily on adaptation of technique may incorporate orthodontic soft/hard tissue as well as atraumatic root
the prosthesis to the palatal gingiva. This extrusion to create a smaller socket in the removal.
is best accomplished with an overdenture bone, facilitating extraction, and overcor-
prosthesis to seal this linguoalveolar area recting bone apposition to recreate miss- For immediate placement after extraction,
phonetically. Attachment mechanisms for ing architecture (Figure 14-43).107 The the socket should be obliterated by the
the maxillary implant-supported over- extrusion should take place slowly, usually implant and/or grafting materials. Micro-
denture are the same for the mandibular over 3 to 6 months. movement in excess of 50 to 75m has
overdenture with the exception of plunger been shown to inhibit osseointegration to
or locking attachments placed palatally Surgical Installation Stability a fibrous tissue deposition instead of bone
(Figure 14-42). Installation of implants into bone usually apposition111; therefore, occlusion placed
is characterized by minimizing the inher- on a provisional restoration during the
Contemporary Techniques ent gap between the implant and bone critical period of osseointegration must be
surface. Although this can be accom- carefully controlled to eliminate this sce-
Immediate Placement plished with both screw-type and press-fit nario. Interproximal contact with adjacent
Immediate placement of implants into implants, parallel- and tapered-walled teeth should also be eliminated. If this
extraction sockets has been considered for screws are uniquely suited to providing modality is desired, a more controlled
some time. Although it has been per- firm stability at surgical placement.108110 technique of protecting the occlusion with
formed successfully, inflammation and This becomes an important consideration a centric relation splint orthotic may be
infection should be eradicated for pre- when achieving osseointegration under appropriate. Immediate loading for single
dictable osseointegration to occur. Con- placement either in an extraction site, teeth mandates more data before it can be
siderations for using immediate placement where a provisional restoration will also be recommended for routine use. However,
capitalize on the osteogenic potential of a inserted, or where other implants will be controlled immediate loading of multiple
recent extraction site and the chance to joined for an immediate-load prosthesis. connected implants in the anterior
mandible has been favorably surveyed and
can be cautiously recommended as long as
there are careful control of occlusion and
passive splinting frameworks.112
Immediate Restoration
Immediate restoration of a single-tooth
implant may be incorporated in the
esthetic zone (Figure 14-44). The indica-
tions are freedom from occlusal overload
and lateral forces. Sometimes, it is difficult
to control occlusion, and the creation of
FIGURE 14-41 Full-arch ceramometal fixed FIGURE 14-42 Swivel latches placed to the
prosthesis cemented on custom fixed abutments. palatal aspect for a maxillary spark erosion over- an occlusal splint may be a prudent way to
(Prostheses courtesy Steven LoCascio, DDS ) denture prosthesis. protect the implant while osseointegration
Implant Prosthodontics 267
include bone loss, mobility, and pain. Success Criteria of the interproximal dental papilla. J Peri-
Clinical examination should include light odontol 1992;63:9956.
Historically, the criteria of success have 8. Tarnow DP, Cho SC, Wallace SS. The effect of
percussion and gentle evaluation of soft
involved one of quantification of pain, inter-implant distance on the height of
tissue, which may include a standardized inter-implant bone crest. J Periodontol
mobility, and peri-implant radiolucency.
periimplant probing using nonmetallic 2000;71:5469.
These criteria were established by Albrek-
standardized force probes. Radiographic 9. Albrektsson T, Zarb GA, Worthington P, Erics-
tsson and colleagues and remain one of son RA. The long term efficacy of currently
evaluation includes both periapical and
the standards in long-term evaluation of used dental implants: a review and pro-
panoramic radiographs. If the restoration
dental implants.144 Recently additional cri- posed criteria of success. Int J Oral Maxillo-
is screw retained, it can be removed every fac Implants 1986;1:1125.
teria have been added for the assessment
2 years, cleaned, and resecured, or cleaned 10. Bain CA, Moy PK. The association between the
of hard and soft tissue responses. Margin- failure of dental implants and cigarette
in position. Cleaning of implant and tita-
al bone loss of < 4 mm or probing depth of smoking. Int J Oral Maxillofac Implants
nium abutment surfaces should be done
< 4 mm and a crevicular fluid flow rate of 1993;8:60915.
with either gold or polyethylene (Teflon) 11. Kan JY, Rungcharassaeng K, Lozada JL,
< 2.5 mm are considered indicators of suc-
instruments so as not to scratch these bio- Goodacre CJ. Effects of smoking on
cess.141 Mobility, if present, should be test-
logically critical surfaces and make them implant success in grafted maxillary sinus-
ed on an individual basis to best assess a es. J Prosthet Dent 1999;82:30711.
prone to plaque accumulation (Figure 14-
true measure. Therefore, removing the 12. De Bruyn H, Collaert B. The effect of smoking
54).142 Any scratches or crevices created by
prosthesis (especially if it is splinted with on early implant failure. Clin Oral Implants
this or other processes impose a nidus for Res 1994;5:2604.
other implants) and gently percussing
plaque and calculus accumulation. After 13. Lindquist LW, Carlsson GE, Jemt T. Association
with either a blunt instrument or a stan-
cleaning, polishing with either toothpaste between marginal bone loss around
dardized torque instrument will give an osseointegrated mandibular implants and
or a light prophylaxis paste is recommend-
indication of mobility. Other methods smoking habits: a 10 year follow-up study. J
ed. Since a perimucosal seal exists between
involved the use of Periotest instruments Dent Res 1997;76:166774.
the implant and abutment and tissue, it is 14. Kiel DP, Zhang Y, Hannan MT, et al. The effect
or nanodevices that promote radiofre-
not suggested that cemented restorations of smoking at different life stages on bone
quency response from the osseointegrated
be removed routinely as this may jeopar- mineral density in elderly men and women.
implant to give an indication of mobility. Osteoporos Int 1996;6:2408.
dize the integrity of the restoration and
15. Jaffin RA, Berman CL. The excessive loss of
surrounding tissues. However, if the References Branemark fixtures in type IV bone: a 5
restoration is retrievable, the prosthesis 1. Waerhaug J. Anatomy, physiology and patholo- year analysis. J Periodontol 1991;62:24.
and/or attachment should be removed gy of the gingival pocket. Rev Belge Med 16. Zarb GA, Lekholm U, Albrektsson T, Tenen-
every 18 to 24 months for dbridement, Dent 1966;21(1):915. baum H. Aging, osteoporosis, and dental
2. Gargiulo AW, Wentz FM, Orban B. Dimensions implants. Chicago: Quintessence Publish-
inspection, and polishing.143 If abutment
and relations of the dento-gingival junction ing; 2002.
or coping screws have been torqued previ- in humans. J Periodontol 1961;32:2617. 17. Mombelli A, van Oosten MAC, Schurch E,
ously, it is generally suggested that they be 3. Cochran DL, Hermann JS, Schenk RK, et al. Lang NP. The microbiota associated with
replaced to avoid future fatigue fracture. Biologic width around titanium implants. successful or failing osseointegrated titani-
A histometric analysis of the implanto- um implants. Oral Microbiol Immunol
gingival junction around unloaded and 1987;2:14551.
loaded nonsubmerged implants in the canine 18. Quirynen M, Naert I, van Steenberghe D, et al.
mandible. J Periodontol 1997;68:18698. Periodontal aspects of osseointegrated fix-
4. Bengazi F, Wennstrom JL, Lekholm U. Recession tures supporting an overdenture. A 4-year
of the soft tissue margin at oral implants. A 2 retrospective study. J Clin Periodontol
year longitudinal prospective study. Clin 1991;18:71928.
Oral Implants Res 1996;7:30310. 19. Rutar A, Lang NP, Buser D, et al. Retrospective
5. Olsson M, Lindhe J. Periodontal characteristics assessment of clinical and microbiological
in individuals with varying form of the factors affecting periimplant tissue condi-
upper central incisors. J Clin Periodontol tions. Clin Oral Implants Res 2001;
1991;18:7882. 12:18995.
6. Sanavi F, Weisgold A, Rose LF. Biologic width 20. Esser E, Wagner W. Dental implants following
and its relation to periodontal biotypes. J radical oral cancer surgery and adjuvant
Esthet Dent 1998;10:15763. radiotherapy. Int J Oral Maxillofac Implants
FIGURE 14-54 The use of polyethylene-tipped 7. Tarnow DP, Magner AW, Fletcher P. The effect 1997;12:5527.
instruments facilitates plaque removal from tita- of the distance from the contact point to 21. Jisander S, Grenthe B, Alberius P. Dental
nium implant surfaces. the crest of bone on the presence or absence implant survival in the irradiated jaw: a
272 Part 2: Dentoalveolar Surgery
preliminary report. Int J Oral Maxillofac with implant supported overdentures: a year report. Int J Oral Maxillofac Implants
Implants 1997;12:6438. review of the literature. Int J Prosthodont 1988;3:1916.
22. Taylor TD, Worthington P. Osseointegrated 1998;11:715. 51. Brnemark PI, Svensson B, van Steenberghe D.
implant rehabilitation of the previously 37. Sennerby L, Roos J. Surgical determinants of Ten-year survival rates of fixed prostheses
irradiated mandible: results of a limited trial clinical success of osseointegrated oral on four or six implants ad modum Brne-
at 3 to 7 years. J Prosthet Dent 1993;69:609. implants: a review of the literature. Int J mark in full edentulism. Clin Oral Implants
23. Keller EE, Tolman DE, Zuck SL, Eckert SE. Prosthodont 1998;11:40820. Res 1995;6:22731.
Mandibular endosseous implants and auto- 38. Misch CE. Contemporary implant dentistry. 52. Adell R, Eriksson B, Lekholm U, et al. Long-
genous bone grafting in irradiated tissue: a 2nd ed. St. Louis: Mosby; 1999. term follow-up study of osseointegrated
10-year retrospective study. Int J Oral Max- 39. Lindquist LW, Carlsson GE. Long term effects implants in the treatment of totally edentu-
illofac Implants 1997;12:80013. on chewing with mandibular fixed prosthe- lous jaws. Int J Oral Maxillofac Implants
24. Keller EE. Placement of dental implants in the ses on osseointegrated implants. Acta 1990;5:34759.
irradiated mandible: a protocol without Odontol Scand 1985;43(1):3945. 53. Adell R, Lekholm U, Rockier B, Brnemark PI.
adjunctive hyperbaric oxygen. J Oral Max- 40. Haraldson T, Carlsson GE. Bite force and oral A 15-year study of osseointegrated
illofac Surg 1997;55:97280. function in patients with osseointegrated implants in the treatment of the edentulous
25. Marx RE, Ames J. The use of hyperbaric oxy- oral implants. Scand J Dent Res 1977; jaw. Int J Oral Surg 1981;10:387416.
gen therapy in bony reconstruction of the 85:2008. 54. Thomason JM. The McGill consensus state-
irradiated and tissue deficient patient. J 41. Jemt T, Carlsson GE. Aspects of mastication ment on overdentures. Mandibular
Oral Maxillofac Surg 1982;40:41220. with bridges on osseointegrated implants. 2-implant overdentures as first choice stan-
26. Olson JW, Shernoff AF, Tarlow JL, et al. Dental Scand J Dent Res 1986;94:6671. dard of care for edentulous patients. Eur J
endosseous implant assessments in a type 2 42. Misch CE. Iliac crest grafts and endosteal Prosthodont Restor Dent 2002;10:956.
diabetic population: a prospective study. Int implants to restore 35 severely resorbed 55. Abrahamsson I, Berglundh T, Glantz PO, Lind-
J Oral Maxillofac Implants 2000;15:8118. total edentulous maxillae: a retrospective he J. The mucosal attachment at different
27. Balshi TJ, Wolfinger GJ. Dental implants in the study. Proceedings of the 2nd World Con- abutments. An experimental study in dogs.
diabetic patient: a retrospective study. gress of Osseointegration; 1996 Oct; Rome. J Clin Periodontol 1998;25:7217.
Implant Dent 1999;8:3559. 43. Li KK, Stephens WL, Gliklich R. Reconstruction 56. Sorenson JA, Martinoff JT. Clinically signifi-
28. Jensen J, Sindet-Pedersen S. Osseointegrated of the severely atrophic edentulous maxilla cant factors in dowel designs. J Prosthet
implants for prosthetic reconstruction in a using the LeFort I osteotomy with simulta- Dent 1984;52:2835.
patient with scleroderma: report of a case. J neous bone graft and implant placement. J 57. Assif D, Oren E, Marshak BL, Aviv I. Photoe-
Oral Maxillofac Surg 1990;48:73941. Oral Maxillofacial Surg 1996;54:5427. lastic analysis of stress transfer by endodon-
29. Isidor F, Brondum K, Hansen HJ, et al. Out- 44. Jaffin RA, Berman CL. The excessive loss of tically treated teeth to the supporting struc-
come of treatment with implant-retained Branemark fixtures in type IV bone: a 5- ture using different restorative techniques. J
dental prostheses in patients with Sjgren year analysis. J Periodontol 1991;62:24. Prosthet Dent 1989;61:53543.
syndrome. Int J Oral Maxillofac Implants 45. Albrektsson T, Zarb GA, Brnemark PI. Tissue- 58. Milot P, Stein RS. Root fracture in endodonti-
1999;14:73643. integrated prosthesis: osseointegration in cally treated teeth related to post selection
30. Rajnay ZW, Hochstetter RL. Immediate place- clinical dentistry. Chicago: Quintessence; and crown design. J Prosthet Dent
ment of an endosseous root-form implant 1983. 1992;68:42835.
in an HIV-positive patient: report of a case. 46. McCartney JW. Cantilever rests: an alternative 59. Palmqvist S, Swartz B. Artificial crowns and
J Periodontol 1998; 69:116771. to the unsupported distal cantilever of fixed partial dentures 18 to 23 years after
31. Rocher P, Veron C, Vert M, et al. Risks and reg- osseointegrated implant supported pros- placement. Int J Prosthodont 1993;6:27985.
ulations related to materials used in implan- theses for the edentulous mandible. J Pros- 60. Walton JN, Gardner FM, Agar JR. A survey of
tology and maxillofacial surgery. Rev Stom- thet Dent 1992;68:8179. crown and fixed partial denture failures:
atol Chir Maxillofac 1995;96:28192. 47. Jemt T, Linden B, Lekholm U. Failures and length of service and reasons for replace-
32. Kovacs AF. Influence of chemotherapy on complications in 127 consecutively placed ment. J Prosthet Dent 1986;56:41621.
endosteal implant survival and success in fixed partial prostheses supported by 61. Karlsson S. Failures and length of service in
oral cancer patients. Int J Oral Maxillofac Brnemark implants from prosthetic treat- fixed prosthodontics after long-term func-
Surg 2001;30:1447. ment to first annual checkup. Int J Oral tion. Swed Dent J 1989;13:18592.
33. Karr RA, Kramer DC, Toth BB. Dental Maxillofac Implant 1992;7(1):404. 62. Scurria MS, Bader JD, Shugars DA. A meta
implants and chemotherapy complications. 48. Binon PP. Evaluation of machining accuracy analysis of fixed partial denture survival:
J Prosthet Dent 1992;67:6837. and consistency of selected implants, stan- prostheses and abutments. J Prosthet Dent
34. Steiner M, Windchy A, Gould AR, et al. Effects dard abutments and laboratory analogs. Int 1998;79:45964.
of chemotherapy in patients with dental J Prosthodont 1995;8:16278. 63. Walton TR. An up to 15 year longitudinal study
implants. J Oral Implantol 1995;21:1427. 49. Eckert SE, Wollan PC. Retrospective review of of 515 metal-ceramic FPDs. Part 1. Out-
35. Sadan A, Raigrodski AJ, Salinas TJ. Prosthetic 1170 endosseous implants placed in partial- come. Int J Prosthodont 2002;15:43945.
considerations in the fabrication of surgical ly edentulous jaws. J Prosthet Dent 1998; 64. Haas R, Mensdorff-Pouilly N, Mailath G,
stents for implant placement. Pract Peri- 79:41521. Watzek G. Brnemark single tooth
odontics Aesthet Dent 1997;9:100311. 50. Naert I, De Clercq M, Theuniers G, Schepers F. implants: a preliminary report of 76
36. Chan MF, Narhi TO, de Baat C, Kalk W. Treat- Overdentures supported by osseointegrated implants. J Prosthet Dent 1995;73:2749.
ment of the atrophic edentulous maxilla fixtures for the edentulous mandible: a 2.5- 65. Schmitt A, Zarb GA. The longitudinal clinical
Implant Prosthodontics 273
effectiveness of osseointegrated dental 79. Rangert B, Gunne J, Glantz P-O, Svensson A. 93. Friberg B, Grondahl K, Lekholm U, Branemark
implants for single-tooth replacement. Int J Vertical load distribution on a three unit PI. Long-term follow-up of severely atroph-
Prosthodont 1993;6:197202. prosthesis supported by a natural tooth and ic edentulous mandibles reconstructed with
66. Laney WR, Jemt T, Harris D, et al. Osseointe- a single tooth implant. An in vivo study. short Brnemark implants. Clin Implant
grated implants for single-tooth replace- Clin Oral Implants Res 1995;6:406. Dent Relat Res 2000;2:1849.
ment: progress report from a multicenter 80. Solnit GS, Schneider RL. An alternative to 94. Triplett RG, Mason ME, Alfonso WF, McAnear
prospective study after 3 years. Int J Oral splinting multiple implants: use of the ITI JT. Endosseous cylinder implants in severe-
Maxillofac Implants 1994;9:4954. system. J Prosthodont 1998;7:1149. ly atrophic mandibles. Int J Oral Maxillofac
67. Andersson B, Odman P, Lindvall AM, Brne- 81. Ehrenkranz H, Langer B. The incorporation of Implants 1991; 6:2649.
mark PI. Cemented single crowns on teeth into the full arch implant reconstruc- 95. Batenburg RH, Meijer HJ, Raghoebar GM,
osseointegrated implants after 5 years: tion. Quintessence Dent Technol Yearbook Vissink A. Treatment concept for mandibu-
results from a prospective study on 2002; 25:21322. lar overdentures supported by endosseous
CeraOne. Int J Prosthodont 1998; 11:2128. 82. Lewis S. Treatment planning: teeth versus implants: a literature review. Int J Oral
68. Goodacre CJ, Kan JY, Rungcharassaeng K, et al. implants. Int J Periodontics Restorative Maxillofac Implants 1998;13:53945.
Clinical complications of osseointegrated Dent 1996;16:36777. 96. Balshi TJ, Wolfinger GJ. Immediate loading of
implants. J Prosthet Dent 1999;81:53752. 83. Block MS, Lirette D, Gardiner D, et al. Prospec- Branemark implants in edentulous
69. Bader HI. Treatment planning for implants tive evaluation of implants connected to mandibles: a preliminary report. Implant
versus root canal therapy: a contemporary teeth. Int J Oral Maxillofac Implants Dent 1997;6:838.
dilemma. Implant Dent 2002;11:21723. 2002;17:47387. 97. Misch CE. Contemporary implant dentistry.
70. Curley AW. Dental implant jurisprudence: 84. Zuhr O, Schenk G, Schoberer U, et al. Mainte- 2nd ed. St. Louis: Mosby; 1999.
avoiding the legal failure. J Calif Dent Assoc nance of the original emergence profile for 98. Beumer J, Lewis SG. The Branemark Implant
2001;29:84753. natural esthetics with implant supported System, clinical and laboratory procedures.
71. Branemark PI, Adell R, Breine U, et al. restorations. Quintessence Dent Technol St. Louis: Ishiyaku EuroAmerica; 1989.
Yearbook 2002;25:14454.
Intraosseous anchorage of dental prosthe- 99. Rubenstein JE. Implant rehabilitation of the
85. Rangert B, Sullivan RM, Jemt TM. Load factor
ses. I. Experimental studies. Scand J Plast mandible compromised by radiotherapy.
control for implants in the partially edentu-
Reconstr Surg Hand Surg 1969;3:81100. In: Taylor TD, editor. Clinical maxillofacial
lous segment. Int J Oral Maxillofac
72. Adell R, Hansson BO, Branemark PI, Breine U. prosthetics. Chicago: Quintessence; 2000. p.
Implants 1997;12:36070.
Intraosseous anchorage of dental prostheses. 189203.
86. Cliff SE, Fisher J, Watson CJ. Stress and strain
II. Review of clinical approaches. Scand J 100. Fredrickson EJ, Stevens PJ, Gress ML. Implant
distribution in the bone surrounding a new
Plast Reconstr Surg Hand Surg 1970;4:1008. prosthodontics: clinical and laboratory
design of dental implant: a comparison
73. Lindquist LW, Carlsson GE, Jemt T. A prospec- procedures. St. Louis: Mosby; 1995.
with a threaded Branemark type implant.
tive 15 year follow up study of mandibular 101. Goodkind RJ, Heringlake CB. Mandibular flex-
Proc Inst Mech Eng [H] 1993;207: 1338.
fixed prostheses supported by osseointe- ure in opening and closing movements. J
87. Piatelli A, Scarano A, Paolantonio M. Clinical
grated implants. Clinical results and mar- Prosthet Dent 1973;30:1348.
and histologic features of a non-axial load
ginal bone loss. Clin Oral Implants Res 102. Zarone F, Apicella A, Nicolais L, et al.
on the osseointegration of a posterior
1996;7:32936. Mandibular flexure and stress buildup in
mandibular implant: report of a case. Int J
74. Feine JS, Carlsson GE, Awad MA, et al. The Oral Maxillofac Implants 1998;13:2735. mandibular full-arch fixed prostheses sup-
McGill concensus statement on overden- 88. Kan JY, Lozada JL, Boyne PJ, et al. Mandibular ported by osseointegrated implants. Clin
tures. Mandibular two-implant overden- fracture after endosseous implant place- Oral Implants Res 2003;14:10314.
ture as first choice standard of care for ment in conjunction with inferior alveolar 103. Jimnez-Lpez V. Oral rehabilitation with
edentulous patients. Gerodontology 2002; nerve transposition: a patient treatment implant-supported prostheses. Chicago:
19(1):34. report. Int J Oral Maxillofac Implants Quintessence; 1999.
75. Ferrigno N, Laureti M, Fanali S, Grippaudo G. 1997;12:6559. 104. Taylor TD. Fixed implant rehabilitation for the
A long term follow up study of non- 89. Cooper MR, Stewart DC, Kahl FR, et al. Medi- edentulous maxilla. Int J Oral Maxillofac
submerged ITI implants in the treatment of cine at the medical center then and now: Implants 1991;6:32937.
totally edentulous jaws. Part I: ten-year life one hundred years of progress. South Med J 105. Rosenquist B, Grenthe B. Immediate place-
table analysis of a prospective multi-center 2002;95:111321. ment of implants into extraction sockets:
study with 1286 implants. Clin Oral 90. Douglass CW, Shih A, Ostry L. Will there be a implant survival. Int J Oral Maxillofac
Implants Res 2002;13:26073. need for complete dentures in the United Implants 1996;11:2059.
76. Laney WR, Tolman DE, Keller EE, et al. Dental States in 2020? J Prosthet Dent 2002;87:58. 106. Wilson TG Jr, Schenk R, Buser D, Cochran D.
implants: tissue integrated prosthesis utiliz- 91. Sennerby L, Carlsson GE, Bergman B, War- Implants placed in immediate extraction
ing the osseointegration concept. Mayo fvinge J. Mandibular bone resorption in sites: a report of histologic and histometric
Clin Proc 1986;61:917. patients treated with tissue integrated pros- analyses of human biopsies. Int J Oral Max-
77. Chiche G, Pinault A. Esthetics of anterior fixed theses and in complete denture wearers. illofac Implants 1998;13:33341.
prosthodontics. Chicago: Quintessence; Acta Odontol Scand 1988;46:13540. 107. Salama H, Garber DA, Salama MA, et al. Fifty
1990. 92. Arzouman MJ, Otis L, Kipnis V, Levine D. years of interdisciplinary site development:
78. Sheets CG, Earthman JC. Tooth intrusion in Observations of the anterior loop of the lessons and guidelines from periodontal
implant assisted prostheses. J Prosthet Dent inferior alveolar canal. Int J Oral Maxillofac prosthesis. J Esthet Dent 1998;10:14956.
1997;77:3945. Implants 1993:8:295300. 108. Adriaenssens P, Hermans M. Immediate
274 Part 2: Dentoalveolar Surgery
implant function in the anterior maxilla: a 119. Randow K, Ericsson I, Nilner K, et al. Immedi- 132. Tjellstrom A, Lindstrom J, Hallen O, et al.
surgical technique to enhance primary sta- ate functional loading of Brnemark dental Osseointegrated titanium implants in the
bility for Brnemark Mk III and Mk IV implants. An 18 month clinical follow up temporal bone. A clinical study on bone
implants. A randomized, prospective clini- study. Clin Oral Implants Res 1999;10:815. anchored hearing aids. Am J Otolaryngol
cal study at the 1 year follow up. Appl 120. Ganeles J, Rosenberg MM, Holt RL, Reichman 1981;2:30410.
Osseointegration Res 2001;2(1):1721. LH. Immediate loading of implants with 133. Parel SM, Tjellstrom A. The United States and
109. Glauser R, Portmann, Ruhstaller P, et al. Initial fixed restorations in the completely edentu- Swedish experience with osseointegration
implant stability using different implant lous mandible: report of 27 patients from a and facial prostheses. J Prosthet Dent
designs and surgical techniques. A compar- private practice. Int J Oral Maxillofac 1991;6:759.
ative clinical study using insertion torque Implants 2001;16:41826. 134. Wolfaardt JF, Wilkes GH, Parel SM, Tjellstrom
and resonance frequency analysis. Appl 121. Brnemark PI, Engstrand P, Ohrnell LO, et al. A. Craniofacial osseointegration: the Cana-
Osseointegration Res 2001;2(1):68. Branemark Novum: a new treatment con- dian experience. Int J Oral Maxillofac
110. Rompen E, DaSilva D, Hockers T, et al. Influ- cept for rehabilitation of the edentulous Implants 1993;8:197204.
ence of implant design on primary fit and mandible. Preliminary results from a 135. Nishimura RD, Roumanas E, Beumer J III, et
stability. A RFA and histological compari- prospective clinical follow-up study. Clin al. Restoration of irradiated patients using
son of MkIII and MkIV Brnemark Implant Dent Relat Res 1999;1:216. osseointegrated implants: current perspec-
implants in the dog mandible. Appl 122. Canto MT, Devesa SS. Oral cavity and pharynx tives. J Prosthet Dent 1998;79:6417.
Osseointegration Res 2001;2(1):911. cancers incidence rates in the United States, 136. Klein M, Menneking H, Neumann K, et al.
111. Pilliar RM, Deporter DA, Watson PA. Tissue- 19751998. Oral Oncol 2002;38:6107. Computed tomographic study of bone
implant interface: micromovement effect. 123. Hidalgo DA. Fibula free flap: a new method of availability for facial prosthesis-bearing
In: Vincenzini P, editor. Materials in clinical mandible reconstruction. Plast Reconstr endosteal implants. Int J Oral Maxillofac
applications. Proceeding of Topical Sympo- Surg Hand Surg 1989;84(1):719. Surg 1997;26:26871.
sium VII on Materials in Clinical Applica- 124. Zlotolow IM, Huryn JM, Piro JD, et al. 137. Visch LL, van Waas MA, Schmitz PI, Levendag
tions of the 8th CIMTEC-World Ceramics Osseointegrated implants and functional PC. A clinical evaluation of implants in
Congress and Forum on New Materials; prosthetic rehabilitation in microvascular irradiated oral cancer patients. J Dent Res
1994 June 28July 4; Florence, Italy. Faenza, fibula free flap reconstructed mandibles. 2002;81:8569.
Italy: Techna; 1995. p. 56979. Am J Surg 1992;164:67781. 138. Granstrom G, Tjellstrom A, Brnemark PI.
112. Schnitman P, Whorle P, Rubenstein JE. Imme- 125. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Osseointegrated implants in irradiated
diate fixed interim prostheses supported by Reconstruction of the mandible with bone: a case controlled study using adjunc-
2 stage threaded implants; methodology osseous free flaps: a 10-year experience with tive hyperbaric oxygen therapy. J Oral Max-
and results. J Oral Implants 1990;16:96105. 150 consecutive patients. Plast Reconstr illofac Surg 1999;57:4939.
113. Ericsson I, Nilson H, Nilner K. Immediate func- Surg Hand Surg 1999;104:131420. 139. Binon PP, McHugh MJ. The effect of eliminat-
tional loading of Brnemark single tooth 126. Aramany MA. Basic principles of obturator ing implant/abutment rotational misfit on
implants. A 5-year clinical follow-up study. design for partially edentulous patients. screw joint stability. Int J Prosthodont
Appl Osseointegration Res 2001;2:1215. Part I. Classification. J Prosthet Dent 1996;9:5119.
114. Buser D, Mericske-Stern R, Bernard JP, et al. 1978;40:5547. 140. Scholander S. A retrospective evaluation of 259
Long-term evaluation of non-submerged 127. Boyne PJ. Analysis of performance of root- single-tooth replacements by the use of
ITI implants. Part I: 8-year life table analy- form endosseous implants placed in the Branemark implants. Int J Prosthodont
sis of a prospective multi-center study with maxillary sinus. J Long Term Eff Med 1999;12:48391.
2359 implants. Clin Oral Implants Res Implants 1993;3:14359. 141. Behneke A, Beheneke N, dHoedt B. A 5 year
1997;8:16172. 128. Olson JW, Dent CD, Morris HF, Ochi S. Long- longitudinal study of the clinical effective-
115. Malo P, Rangert B, Dvrster L. Immediate term assessment (5 to 71 months) of ness of ITI solid-screw implants in the
function of Branemark implants in the endosseous dental implants placed in the treatment of mandibular edentulism. Int J
esthetic zone. A retrospective clinical study augmented maxillary sinus. Ann Periodon- Oral Maxillofac Implants 2002;17:799810.
with 6 months to 4 years of follow up. Clin tol 2000;5(1):1526. 142. Hallmon WW, Waldrop TC, Meffert RM, Wade
Implant Dent Relat Res 2000;2:13745. 129. Boyes-Varley JG, Howes DG, Lownie JF. The BW. A comparative study of the effects of
116. Brunski J. In vivo bone response to biome- zygomaticus implant protocol in the treat- metallic, nonmetallic, and sonic instrumen-
chanical loading at the bone/dental implant ment of the severely resorbed maxilla. SADJ tation on titanium abutment surfaces. Int J
interface. Adv Dent Res 1999;13:99119. 2003;58:1069, 1134. Oral Maxillofac Implants 1996;11(1):96100.
117. Schnitman PA, Whrle PS, Rubenstein JE, et al. 130. Bedrossian E, Stumpel L III, Beckely ML, 143. Meffert RM. Follow up and maintenance. In:
Ten year results for Branemark implants Indresano T. The zygomatic implant: pre- Babbush CA, editor. Dental implants. The
immediately loaded with fixed prostheses at liminary data on treatment of severely art and science. Philadelphia: Saunders;
implant placement. Int J Oral Maxillofac resorbed maxillae. A clinical report. Int J 2001. p. 397428.
Implants 1997;12:495503. Oral Maxillofac Implants 2002;17:8615. 144. Albrektsson T, Zarb GA, Worthington P, Erics-
118. Henry P, Rosenberg J. Single-stage surgery for 131. Parel SM, Branemark PI, Ohrnell LO, Svensson son RA. The long term efficacy of currently
rehabilitation of the edentulous mandible. B. Remote implant anchorage for the reha- used dental implants: a review and pro-
Preliminary results. Pract Periodontics Aes- bilitation of maxillary defects. J Prosthet posed criteria of success. Int J Oral Maxillo-
thet Dent 1994;6:18. Dent 2001;86:37781. fac Implants 1986;1:1125.
Part 3
MAXILLOFACIAL INFECTIONS
CHAPTER 15
Principles of Management of
Odontogenic Infections
Thomas R. Flynn, DMD
The incidence, severity, morbidity, and by remaining abreast of current develop- accomplished the first three steps listed
mortality of odontogenic infections have ments in the microbiology and antibiotic above. A careful history and a brief but
declined dramatically over the past 60 years. therapy of odontogenic infections. thorough physical examination should
In 1940 Ashbel Williams published a series The late Dr. Larry Peterson, who allow the treating surgeon to determine the
of 31 cases of Ludwigs angina in which brought the first edition of this text to anatomic location, rate of progression, and
54% of the subjects died.1 Only 3 years fruition, articulated the principles of man- the potential for airway compromise of a
later, he and Dr. Walter Guralnick pub- agement of odontogenic deep fascial space given infection. The host defenses, includ-
lished the first prospective case series in infections. These are eight sequential steps ing immune system competence and the
the field of head and neck infections, in that, if followed with thoroughness and level of systemic reserves that can be called
which the mortality rate of Ludwigs angi- good judgment, will ensure a high level of upon by the patient to maintain homeosta-
na was reduced to 10%.2 This dramatic care for these increasingly uncommon, yet sis, are largely determined by history. Given
reduction in mortality from 54 to 10% was occasionally life-threatening infections. this initial database the surgeon must then
not due to the first use of penicillin in the These principles outline the structure decide upon the setting of care, which will
treatment of these infections. Rather, Dr. of this chapter. The eight steps in the have a great influence on the outcome.
Guralnick applied the principles of the ini- management of odontogenic infections The clinical presentation and relevant
tial establishment of airway security, fol- are as follows: surgical anatomy of infections of the vari-
lowed by early and aggressive surgical ous deep fascial spaces of the head and neck
1. Determine the severity of infection.
drainage of all anatomic spaces affected by have been well described in other texts.4,5
2. Evaluate host defenses.
cellulitis or abscess. Since then, with the The borders, contents, and relations of the
3. Decide on the setting of care.
use of antibiotics and advanced medical various anatomic deep spaces that are like-
4. Treat surgically.
supportive care, the mortality of Ludwigs ly to be invaded by odontogenic infections
5. Support medically.
angina has been further reduced to 4%.3 are described in Tables 15-1 and 15-2.
6. Choose and prescribe antibiotic
Dentistry has made great progress in Three major factors must be consid-
therapy.
the prevention and early intervention of ered in determining the severity of an
7. Administer the antibiotic properly.
odontogenic infections. Oral and maxillo- infection of the head and neck: anatomic
8. Evaluate the patient frequently.
facial surgeons, as noted above, have made location, rate of progression, and airway
great strides in managing and preventing This chapter will examine each of compromise.
mortality in severe odontogenic infec- these principles in order and discuss and
tions. These accomplishments, however, relate current knowledge to them. Anatomic Location
impose upon the oral and maxillofacial The anatomic spaces of the head and neck
surgeon the obligation to remain intellec- Step 1: Determine the Severity can be graded in severity by the level to
tually prepared for the always unscheduled of Infection which they threaten the airway or vital
occurrence of severe odontogenic infec- Within the first few minutes of the presen- structures, such as the heart and medi-
tions by keeping ones knowledge of the tation of a patient with a significant odon- astinum or the cranial contents. The buccal,
relevant anatomy and surgery fresh, and togenic infection, the surgeon should have infraorbital vestibular, and subperiosteal
278 Part 3: Maxillofacial Infections
Table 15-1 Borders of the Deep Spaces of the Head and Neck
Borders
Space Anterior Posterior Superior Inferior Superficial or Medial* Deep or Lateral
Buccal Corner of mouth Masseter m., Maxilla, Mandible Subcutaneous Buccinator m.
pterygomandibular infraorbital space tissue and skin
space
Infraorbital Nasal cartilages Buccal space Quadratus labii Oral mucosa Quadratus labii Levator anguli oris m.,
superioris m. superioris m. maxilla
Submandibular Ant. belly Post. belly Inf. and med. Digastric tendon Platysma m., Mylohyoid,
digastric m. digastric, surfaces of investing fascia hyoglossus
stylohyoid, mandible sup. constrictor mm.
stylopharyngeus mm.
Submental Inf. border of Hyoid bone Mylohyoid m. Investing fascia Investing fascia Ant. bellies
mandible digastric m.
Sublingual Lingual surface of Submandibular Oral mucosa Mylohyoid m. Muscles of tongue* Lingual surface of
mandible space mandible
Pterygomandibular Buccal space Parotid gland Lateral Inf. border of Med. pterygoid Ascending ramus of
pterygoid m. mandible muscle* mandible
Submasseteric Buccal space Parotid gland Zygomatic arch Inf. border of Ascending ramus Masseter m.
mandible of mandible*
Lateral pharyngeal Sup. and mid. Carotid sheath Skull base Hyoid bone Pharyngeal Medial pterygoid m.
pharyngeal and scalene fascia constrictors and
constrictor mm. retropharyngeal
space*
Retropharyngeal Sup. and mid. Alar fascia Skull base Fusion of alar and Carotid sheath and
pharyngeal prevertebral fasciae lateral pharyngeal
constrictor mm. at C6-T4 space
Pretracheal Sternothyroid- Retropharyngeal Thyroid cartilage Superior Sternothyroid- Visceral fascia over
thyrohyoid fascia space mediastinum thyrohyoid fascia trachea and thyroid
gland
Adapted from Flynn TR.5
ant. = anterior; inf. = inferior; lat. = lateral; m. = muscle; mm. = muscles; med. = medial; mid. = middle; post. = posterior; sup. = superior.
*
Medial border; lateral border.
spaces can be categorized as having low sublingual). Infections that have high tively.6 Table 15-3 lists the severity score for
severity because infections in these spaces severity are those in which swelling can each of the various deep fascial spaces.
do not threaten the airway or vital struc- directly obstruct or deviate the airway or Thus, a patient with cellulitis or abscess of
tures. Infections of anatomic spaces that threaten vital structures. These anatomic the right buccal (SS = 1), right pterygo-
can hinder access to the airway due to spaces are the lateral pharyngeal and mandibular (SS = 2), and right lateral pha-
swelling or trismus can be classified as hav- retropharyngeal, the danger space, and the ryngeal (SS = 3) spaces would have a total
ing moderate severity. Such anatomic mediastinum. Cavernous sinus thrombosis severity score of 6, which is the sum of the
spaces include the masticatory space, and other intracranial infection also have values assigned to each of the three
whose components may be considered sep- high severity. In 1999 Flynn and colleagues anatomic spaces. Flynn and colleagues
arately as the submasseteric, pterygo- devised a severity score (SS) that assigned a were able to explain by correlation analysis
mandibular, and superficial and deep tem- numerical value of 1 to 4 for involvement 66% of the length of hospital stay with a
poral spaces, and the perimandibular of each of the low, moderate, severe, or model that used the initial SS and the white
spaces (submandibular, submental, and extreme severity anatomic spaces, respec- blood cell count on admission. 6
Principles of Management of Odontogenic Infections 279
Table 15-3 Severity Scores of Fascial Space Infections This is probably because patients with
more severe and rapidly progressive infec-
Severity Score Anatomic Space
tions were frightened enough to seek hos-
Severity score = 1 Vestibular pital care early on.
(low risk to airway or vital structures) Subperiosteal Odontogenic infections generally pass
Space of the body of the mandible through three stages before they resolve,
Infraorbital the characteristics of which are listed in
Buccal
Table 15-4. During the first 1 to 3 days the
Severity score = 2 Submandibular swelling is soft, mildly tender, and doughy
(moderate risk to airway or vital structures) Submental in consistency. Between days 2 and 5 the
Sublingual swelling becomes hard, red, and exquisitely
Pterygomandibular tender. Its borders are diffuse and spread-
Submasseteric ing. Between the fifth and seventh days the
Superficial temporal center of the cellulitis begins to soften and
Deep temporal (or infratemporal)
the underlying abscess undermines the
Severity score = 3 Lateral pharyngeal skin or mucosa, making it compressible
(high risk to airway or vital structures) Retropharyngeal and shiny. The yellow color of the underly-
Pretracheal ing pus may be seen through the thin
Severity score = 4 Danger space (space 4) epithelial layers. At this stage the term fluc-
(extreme risk to airway or vital structures) Mediastinum tuance is appropriately applied. Fluctuance
Intracranial infection implies the palpation of a fluid wave by one
The severity score for a given patient is the sum of the severity scores for all of the spaces involved by cellulitis or abscess, hand as the abscess is compressed by the
based on clinical and radiographic examination. other hand. The final stage of odontogenic
infection is resolution, which generally
occurs after spontaneous or surgical
Rate of Progression toms of swelling, pain, trismus, and airway
drainage of an abscess cavity. The swelling
Upon interviewing the patient with an compromise. In their study of hospitalized then begins to decrease in size, redness, and
infection, the surgeon can appraise the odontogenic infections, Flynn and col- tenderness. The resolving swelling may stay
rate of progression by inquiring about the leagues found that the number of days of firm for some time, however, as the inflam-
onset of swelling and pain and comparing swelling prior to admission correlated matory process is involved in removing
those times to the current signs and symp- negatively with the initial severity score.6 necrotic tissue and bacterial debris.
This disease also appears to decrease host with acquired immunodeficiency syn- temic diseases in conjunction with direct
resistance to more severe odontogenic drome (AIDS) and pre-AIDS. Although management of the infection.
infections such as necrotizing faciitis and patients with HIV seropositivity may
deep fascial space infections. suffer a more intense and/or prolonged Step 3: Decide on the
The iatrogenic use of steroids has hospital course than other patients, HIV Setting of Care
increased over recent years with the use of seropositivity does not seem to increase Table 15-6 lists the indications for hospi-
these medications to treat asthma, skin con- the incidence of severe odontogenic tal admission of the patient with a severe
ditions, autoimmune diseases, cancer, and infections.14 odontogenic infection. As previously
other inflammatory conditions. Cortico- stated, an elevated fever increases meta-
steroids appear to stabilize the cell mem- Systemic Reserve bolic needs and fluid losses, which can
branes of immunocompetent cells, thereby The host response to severe infection can lead to dehydration. In addition to the
decreasing the immune response. Patients place a severe physiologic load on the clinical signs of dry skin, chapped lips,
with organ transplants are often treated body. Fever can increase sensible and loss of skin turgor, and dry mucous
with corticosteroids, as well as other insensible fluid losses and caloric require- membranes, dehydration can be assessed
immunosuppressive medications such as ments. A prolonged fever may cause dehy- in the presence of normal serum creati-
cyclosporine and azathioprine, to suppress dration, which can therefore decrease car- nine by an elevated urine specific gravi-
organ rejection reactions. diovascular reserves and deplete glycogen ty (over 1.030) or an elevated blood urea
It has been postulated that every stores, shifting the body metabolism to a nitrogen (BUN), which indicates prere-
patient with malignant disease has some catabolic state. The surgeon should also nal azotemia.
defect of the immune system. The mecha- be aware that elderly individuals are not Infections in deep spaces that have a
nisms of immune compromise in malig- able to mount high fevers, as often seen severity score of 2 or greater (see Table 15-
nancy are variable and not well identified, in children. Therefore, an elevated tem- 3) can hinder access to the airway for intu-
but the surgeon treating the patient with perature at an advanced age is not only a bation by causing trismus, directly com-
ongoing cancer should assume that there sign of a particularly severe infection, but press the airway by swelling, or threaten
is some defect of the immune system. also an omen of decreased cardiovascular vital structures directly. Thus, an odonto-
Cancer chemotherapy directly suppresses and metabolic reserve, due to the genic infection involving the masticator
the immune system along with rapidly demands placed on the elderly patients space, the perimandibular spaces, or deep-
dividing cancer cells. Therefore, all physiology.15 er spaces indicates hospital admission.
patients who have received cancer In several studies, the white blood cell Occasionally general anesthesia is
chemotherapy within the past year should count at admission has been a significant required for patient management due to
be considered immunocompromised. predictor of the length of hospital stay.6,16 inability to achieve adequate local anesthe-
Other conditions that impair Therefore, evaluation of leukocytosis is sia, the need to secure the airway, or the
immune function include malnutrition, important in determining the severity of inability of the patient to cooperate, as in a
alcoholism, and chronic renal disease. infection as well as in estimating the young child. Sometimes concurrent sys-
The role of human immunodeficiency length of hospital stay. temic disease indicates hospital admission
virus (HIV) infection in diminishing The physiologic stress of a serious and may even delay surgery, as in the need
host resistance to odontogenic infections infection can disrupt previously well- to reverse warfarin anticoagulation.
is somewhat unclear and paradoxical. established control of systemic diseases
HIV infection first and primarily dam- such as diabetes, hypertension, and renal
ages the T cell. On the other hand, most disease. The increased cardiac and respira- Table 15-6 Indications for Hospital
Admission
odontogenic infections are due to extra- tory demands of a severe infection may
cellular bacteria, which are attacked by B deplete scarce physiologic reserves in the Temperature > 101F (38.3C)
cells, the white blood cells that elaborate patient with chronic obstructive pul- Dehydration
antibodies. Although HIV infection may monary disease or atherosclerotic heart Threat to the airway or vital structures
damage B cells early in the course of the disease, for example. Thus, an otherwise Infection in moderate or high severity
disease, its most devastating effects are mild or moderate infection may be a sig- anatomic spaces
seen on the T cells, which explains the nificant threat to the patient with systemic Need for general anesthesia
Need for inpatient control of systemic
increased rate of cancers and infections disease, and the surgeon should be careful
disease
by intracellular pathogens in patients to evaluate and manage concurrent sys-
284 Part 3: Maxillofacial Infections
In deciding whether to admit the tions that are not amenable to profound Surgical Drainage
patient with a serious odontogenic infec- local anesthesia. An infection that is rapid-
In general, surgery for management of
tion, it is generally safer to err on the side ly progressing through the anatomic fas-
severe odontogenic infections is not diffi-
of hospital admission. The inpatient set- cial planes, as in necrotizing fasciitis, indi-
cult. Given a thorough knowledge of the
ting affords the patient with continual cates the prompt establishment of a secure
anatomy of the deep fascial spaces of the
professional monitoring, supportive med- airway, even if for anticipatory reasons, as
head and neck, the surgeon should be able,
ical care, the availability of radiologic and well as the possible need to extend the
by using appropriate anatomic landmarks,
medical consultative services, and, most anatomic dissection into regions that had
to use small incisions and blunt dissection
importantly, a team that can rapidly not been contemplated preoperatively.
without direct exposure and visualization
secure the airway should it become com- Sometimes general anesthesia is required
of the entire infected anatomic space. Fig-
promised. for patient management reasons alone,
ure 15-6 illustrates the appropriate loca-
especially in the patient who is not able to
Step 4: Treat Surgically cooperate, such as a young child or men-
tions for extraoral incision placement for
drainage of the various anatomic deep
tally handicapped individual.
Airway Security Successful airway management in dif-
spaces. In addition a vertical incision over
The dramatic reduction in the mortality the pterygomandibular raphe can be used
ficult situations requires a team
of Ludwigs angina from 54 to 10% in approach. Preoperatively the surgeon to drain the pterygomandibular space as
only 3 years, afforded by Williams and should communicate with the anesthesi- well as the anterior compartment of the
Guralnick, was made possible by their ologist to establish the airway manage- lateral pharyngeal space, as illustrated in
changed surgical policy of immediate ment plan. The anesthesiologist should Figure 15-7. Lest the surgeon crush a vital
establishment of airway security by early be interested in understanding the structure within the beaks of a hemostat
intubation or tracheotomy, followed by anatomic location of the infection, as well during blunt dissection, it is crucial to
aggressive and early surgical inter- as its implications for airway manage- insert the instrument closed, then open it
vention.2 No antibiotics were used in their ment. The anesthesiologist will value the at the depth of penetration, and then with-
patients, except sulfa drugs in some cases. opportunity to see any effacement, dis- draw the instrument in the open position.
In the antibiotic era mortality has been placement, or deviation of the airway as A hemostat should never be blindly closed
further reduced to about 4%.3 It is there- demonstrated on clinical examination while it is inside a surgical wound. Anoth-
fore apparent that immediate establish- and CT. The airway management plan er important principle of surgical incision
ment of airway security and early aggres- should include the projected initial man- and drainage is the need to dissect a path-
sive surgical therapy are the most agement, as well as secondary procedures way for the drain that includes the loca-
important intervention steps in the man- should the initial approach fail. tions where pus is most likely to be found.
agement of severe odontogenic infections. An infrequently used surgical tech- This can be guided by the preoperative CT
Table 15-7 lists the indications for an nique that may aid in protecting the air- examination and by knowledge of the
operating room procedure. The para- way during intubation or tracheotomy is pathways that odontogenic infection is
mount indication is of course to establish needle decompression. In this technique, most likely to take. For example, in
airway security. The involvement of mod- under local anesthesia an abscess of the drainage of the submandibular space, if
erate or high severity anatomic spaces gen- pterygomandibular, lateral pharyngeal, incisions are placed over the anterior and
erally necessitates a more complicated air- submandibular, or sublingual space is posterior bellies of the digastric muscle at
way management procedure, as well as aspirated with a large-bore needle in order the submandibular, submental, and sub-
surgical intervention in anatomic loca- to decompress the surrounding tissues. lingual location and at the submandibular,
This maneuver may decrease the risk of sublingual location as shown in Figure 15-
abscess rupture through taut, distended 6, then the dissection must pass superiorly
Table 15-7 When to Go to the
Operating Room oropharyngeal tissues during instrumen- and medially until the medial (lingual)
tation of the airway. Additional benefits of plate of the mandible is contacted. The
To establish airway security this procedure are the redirection of pus most likely pathway for odontogenic
Moderate to high anatomic severity drainage into the oral cavity or onto the infections to enter the submandibular
Multiple space involvement
skin, where it can easily be removed, and space is through the thin lingual plate of
Rapidly progressing infection
obtaining an excellent specimen for cul- the mandible, which also approximates the
Need for general anesthesia
ture and sensitivity testing. root apices of the lower molar teeth. By
Principles of Management of Odontogenic Infections 285
sensitive to the natural and semisynthetic otics he or she uses. Metronidazole has a organisms involved, then maximum killing
penicillins, such as penicillin V and amoxi- disulfiram-like reaction with alcohol, and power will be achieved. These are examples
cillin. Therefore, it is reasonable to use should be used with caution in pregnancy. of concentration-dependent antibiotics.22
penicillin plus a -lactamase inhibitor such With time-dependent antibiotics,
as ampicillin-sulbactam or a penicillin plus Step 7: Administer the such as the -lactams and vancomycin,
metronidazole as alternative antibiotics for Antibiotic Properly antibiotic effectiveness is determined by
serious odontogenic infections. The peni- The tissue level of antibiotics determines the duration for which the serum concen-
cillins and metronidazole have the advan- their effectiveness. Those tissue levels are tration of the antibiotic remains above the
tage of crossing the blood-brain barrier of course dependent on the antibiotics MIC. With time-dependent antibiotics, it
when the meninges are inflamed. Clin- level in serum, through which the antibi- is necessary to know the serum elimina-
damycin, on the other hand, does not cross otic must pass in order to achieve thera- tion half-life (t1/2) of the antibiotic in
the blood-brain barrier. Therefore, it is peutic levels in soft tissues, bone, brain, order to determine its proper dosage inter-
appropriate to use penicillin plus metro- and abscess cavities. Administration of val. The dosage interval can then be
nidazole or ampicillin-sulbactam when antibiotics by the oral route requires that designed in order to maintain the serum
there is a risk of an odontogenic infection the drug successfully navigate the vagaries concentration above the MIC for at least
entering the cranial cavity.22 of the highly acidic stomach, the chemical 40% of the dosage interval.22
Few cephalosporins are able to cross qualities of ingested foods, and the basic Fortunately, the mathematics involved
the blood-brain barrier. Some third- intestinal tract. Once an antibiotic is in these calculations have already been
generation cephalosporins, such as cef- absorbed by the gastric or intestinal determined by the drug manufacturer.
tadizime, can do so. In addition, ceftadiz- mucosa, it may then be subject to first- Dosage intervals should not be changed
ime is effective against the oral strepto- pass metabolism in the liver and subse- from published guidelines by the surgeon.
cocci and most oral anaerobes. Among the quent excretion though the bile. Part of Nonetheless, the surgeon must be aware of
cephalosporins, therefore, ceftadizime is the excreted antibiotic may then be reab- the greater effectiveness of intravenous
the alternative antibiotic of choice. sorbed by the intestine, resulting in antibiotics over their oral counterparts.
A new fluoroquinolone antibiotic, enterohepatic recirculation. For these rea- For example, when penicillin G is given
moxifloxacin has great promise in the sons orally administered antibiotics every 4 hours intravenously, a peak serum
treatment of head and neck infections. Its achieve much lower serum levels at a slow- blood level of 20 g/mL is achieved. Since
spectrum against oral streptococci and er rate than when they are injected direct- the serum elimination half-life of peni-
anaerobes is excellent. Its absorption is ly into the vascular system intravenously. cillin G is 0.5 hours, after 3 hours (6 half-
virtually complete via either the oral or Some antibiotics, however, are equally lives) the serum concentration will be
intravenous routes, and it penetrates well absorbed intravenously and orally. The approximately 0.3 g/mL. Since the MIC90
bone readily. Therefore, this new antibi- fluoroquinolones, such as ciprofloxacin and of Streptococcus viridans is 0.2 g/mL, the
otic may become a significant addition to moxifloxacin, are the best examples of this. serum concentration of penicillin G after
the oral and maxillofacial surgeons For this reason the fluoroquinolones are an intravenous dose of 2 million units will
armamentarium. not given intravenously unless use of the remain above the MIC90 for approximate-
Even though metronidazole is active oral route is contraindicated. ly 75% of the dosage interval. Therefore,
only against obligate anaerobic bacteria, its The minimum inhibitory concentra- penicillin G, 2 million units given intra-
use alone in the treatment of odontogenic tion (MIC) is the concentration of an venously every 4 hours, should be highly
infections, when combined with appropri- antibiotic that is required to kill a given effective against the viridans group of
ate surgical therapy, may be effective. In one percentage of the strains of a particular streptococci, especially the abscess-
study, ornidazole, a member of the nitroim- species, reported as 50% or 90% of strains forming S. milleri group.
idazole family, was effective when used (MIC50 or MIC90, respectively). The effec- By the same method the peak serum
alone in the management of odontogenic tiveness of some antibiotics is determined level that can be achieved with an oral
infections.27 Thus, the use of metronidazole by the ratio of the serum concentration of dose of 500 mg of amoxicillin is
alone may be an appropriate stratagem the antibiotic to the MIC required to kill a 7.5 g/mL, and its t1/2 is only 1.2 hours.
when all of the other appropriate antibiotics particular organism. For example, with the Since amoxicillins MIC90 for viridans
are contraindicated. As with all antibiotics, fluoroquinolones and the aminoglyco- streptococci is 2 g/mL, the serum con-
the surgeon should be aware of the side sides, if the serum concentration achieved centration of amoxicillin will fall below
effects and drug interactions of the antibi- is three to four times the MIC for the the MIC90 at approximately 2 hours after
290 Part 3: Maxillofacial Infections
the peak serum level has been achieved, symptoms allowing the next treat- 15-11B, there is continued oropharyngeal
which is only 25% of the 8-hour dosage ment decisions to be made. swelling surrounding the endotracheal tube
interval. Therefore, oral amoxicillin, even at 5 postoperative days. On the other hand
though it is considered by many to be a For odontogenic deep fascial space the infection has progressed from the suc-
more effective antibiotic, is less likely to be infections that are serious enough for hos- cessfully drained left pterygomandibular
effective against the viridans streptococci pitalization, daily clinical evaluation and space to the left and right lateral pharyngeal
than intravenous penicillin G. wound care are required. By 2 to 3 postop- spaces, as well as the retropharyngeal space.
Another practical matter that must erative days the clinical signs of improve- This patient was taken back to the operating
always be considered in administering ment should be apparent, such as decreas- room for repeated drainage of all of the
antibiotics is their cost, especially their ing swelling, defervescence, cessation of infected spaces.
cost to the patient. When a patient does wound drainage, declining white blood It should be noted, however, that in
not have prescription drug insurance cov- cell count, decreased malaise, and a this authors experience the use of CT
erage, such as in the working poor and the decrease in airway swelling such that extu- scanning to determine whether a patient
elderly, the retail cost of the antibiotic can bation can be considered. Also at this time can be extubated gives a late positive sig-
be a significant factor in whether the pre- preliminary Grams stains and/or culture nal. The best available clinical test for the
scribed antibiotic is indeed followed. In reports should be available, which may ability to extubate in the case of upper air-
2003 the retail cost of 1 weeks supply of provide some guidance as to the appropri- way swelling is the air leak test (Figure 15-
penicillin V 500 mg taken 4 times per day ateness of the empiric antibiotic therapy. 12). The air leak test is performed in the
was US$12.09 at a large pharmacy chain in If the above signs of clinical improve- following manner in the spontaneously
the northeastern United States. The retail ment are not apparent, then it may be nec- ventilating patient:
cost of 1 weeks supply of clindamycin essary to begin an investigation for possi-
300 mg taken 4 times per day was US$58.59. ble treatment failure. The causes of 1. The endotracheal tube and trachea are
These prices reflect generic medications, treatment failure in odontogenic infec- suctioned.
not brand name antibiotics, which are sig- tions are listed in Table 15-9. One of the 2. The oxygen supply is reconnected and
nificantly more expensive. Thus, an indi- best methods of reevaluation is the post- any coughing that was stimulated by
gent patient may not be able to pay for a operative CT. A postoperative CT can the tracheal suctioning is allowed to
more expensive antibiotic, and therefore identify continued airway swelling that subside.
he or she may be forced to either take may preclude extubation, or further 3. The oropharynx and oral cavity are
reduced amounts of the antibiotic, to spread of the infection into previously suctioned free of debris, hemorrhage,
extend the dosage interval, or to forgo tak- undrained anatomic spaces, or it may con- and secretions.
ing the antibiotic entirely. Accordingly the firm adequate surgical drainage of all the 4. The cuff of the endotracheal tube is
astute clinician will take the cost factor involved anatomic spaces by the visualiza- deflated while the oxygen supply is
into account. When appropriate, a frank tion of radiopaque drains in all of the maintained.
discussion of the cost of the antibiotic as involved fascial spaces. 5. After waiting for any coughing to sub-
compared to the patients means appears Sometimes it is difficult to determine side, the oxygen supply is disconnected
to be the best policy. whether the inability to extubate a patient is
due to antibiotic resistance or inadequate
Step 8: Evaluate the Patient surgical drainage. Figure 15-11 illustrates
Frequently Table 15-9 Causes of Treatment Failure
two such cases in which a postoperative CT
In outpatient infections that have been treat- was able to identify the most likely cause for Inadequate surgery
ed by tooth extraction and intraoral incision the lack of clinical improvement. In Figure Depressed host defenses
and drainage, the most appropriate initial 15-11A, oropharyngeal swelling surrounds Foreign body
Antibiotic problems
follow-up appointment is usually at 2 days the endotracheal tube in spite of the pres-
Patient noncompliance
postoperatively for the following reasons: ence of surgical drains in all of the infected
Drug not reaching site
spaces. This lack of improvement at 4 post- Drug dosage too low
1. Usually the drainage has ceased and the operative days was due to therapeutic failure Wrong bacterial diagnosis
drain can be discontinued at this time. of penicillin, which was treated by changing Wrong antibiotic
2. There is usually a discernible improve- this patients antibiotic to clindamycin. Sub- Adapted from Peterson LJ.32
ment or deterioration in signs and sequently the patient improved. In Figure
Principles of Management of Odontogenic Infections 291
this mnemonic can be used to provide a occur by an alternate pathway, such as Table 15-10 Criteria for Changing
differential diagnosis for the chronic proximal fistulization of the sub- Antibiotics
drainage of pus. Foreign bodies may be mandibular salivary duct due to a salivary
Allergy, toxic reaction, or intolerance
represented by bone plates and screws, or stone blocking the natural opening of
dental or cosmetic facial implants. Whartons duct. Culture and/or sensitivity test indicating
resistance
Epithelium may cause chronic drainage If a thorough search for previously
simply because an epithelialized fistulous undetected pathogens turns up negative or Failure of clinical improvement, given
tract has not been completely excised or or if another cause for treatment failure Removal of odontogenic cause
Adequate surgical drainage (suggest
because an epithelium-lined cyst has cannot be found, then the surgeon should
postoperative imaging)
drained externally. Tumors (especially consider the possibility of antibiotic fail-
Other causes for treatment failure
malignant ones) that become infected do ure, such as microbial resistance to empir-
ruled out
not heal, which may result in chronic ic antibiotic therapy or the use of an incor- 4872 h of the same antibiotic therapy
drainage. Infection can of course drain rect dosage or route of administration for
chronically, which should alert the sur- the antibiotic. The criteria for changing
geon to suspect osteomyelitis or a chron- antibiotics are listed in Table 15-10.
nosis, antibiotic resistance, and previously
ic periapical abscess that is draining onto Because of the necessary time delay in
undiagnosed medically compromising
the skin, as in Figure 15-13. Distal obtaining culture and sensitivity reports, it
conditions. Although adherence to these
obstruction classically refers to intestinal is occasionally necessary to change from
principles cannot always guarantee a suc-
obstructions, but the concept can still be one empiric antibiotic to another. Ideally
cessful result, it can assure the oral and
applied to the salivary ducts and to the the surgeon should consider another of
maxillofacial surgeon that he or she is
natural sinus drainage pathways, such as the empiric antibiotics of choice listed in
practicing at the highest standard of care.
the ostium of the maxillary sinus. When Table 15-8. The input of an infectious dis-
these openings for natural drainage of ease consultant may also be valuable in Acknowledgment
saliva or mucus become obstructed, then this situation.
The author wishes to thank Lisa Lavargna for
infection may result and drainage may
Summary her expert assistance in the preparation of this
manuscript.
Severe odontogenic infections can be the
most challenging cases that an oral and References
maxillofacial surgeon will be called on to 1. Williams AC. Ludwigs angina. Surg Gynecol
treat. Often the patient with a severe odon- Obstet 1940;70:140.
togenic infection has significant systemic 2. Williams AC, Guralnick WC. The diagnosis
or immune compromise, and the constant and treatment of Ludwigs angina: a report
of twenty cases. N Engl J Med 1943;
threat of airway obstruction due to infec-
228:443.
tions in the maxillofacial region raises the 3. Hought RT, Fitzgerald BE, Latta JE, Zallen, RD.
risk of such cases incalculably. Further- Ludwigs angina: report of two cases and
more, the increasing rarity of these cases review of the literature from 1945 to January
and the ever-changing worlds of microbi- 1979. J Oral Surg 1980;38:84955.
4. Flynn TR. Anatomy and surgery of deep fascial
ology and antibiotic therapy make staying space infections. In: Kelly JJ, editor. Oral
abreast of this field difficult for the busy and maxillofacial surgery knowledge
surgeon. Therefore, the eight steps in the update 1994. Rosemont (IL): American
treatment of severe odontogenic infec- Association of Oral and Maxillofacial Sur-
geons; 1994. p. 79107.
tions, first outlined by Dr. Larry Peterson,
5. Flynn TR. Anatomy of oral and maxillofacial
remain the fundamental guiding principles infections. In: Topazian RG, Goldberg MH,
that oral and maxillofacial surgeons must Hupp JR, editors. Oral and maxillofacial
use in successful management of these infections. 4th Ed. Philadelphia (PA): WB
cases. The application of the eight steps Saunders Company; 2002. p. 188213.
FIGURE 15-13 A draining sinus tract onto the face 6. Flynn TR, Wiltz M, Adamo AK, et al. Predict-
must be thorough and the surgeons mind ing length of hospital stay and penicillin
resulting from an untreated periapical abscess.
Reproduced with permission from Flynn TR and must always remain open to the possibility failure in severe odontogenic infections. Int
Topazian RG.30 of treatment failure, an error in initial diag- J Oral Maxillofac Surg 1999;28 Suppl 1:48.
Principles of Management of Odontogenic Infections 293
7. Umeda M, Minamikawa T, Komatsubara H, et 16. Dodson TB, Barton JA, Kaban LB. Predictors of of acute dentoalveolar abscess. Br Dent J
al. Necrotizing fasciitis caused by dental outcome in children hospitalized with max- 1993;175:16974.
infection: a retrospective analysis of 9 cases illofacial infections: a linear logistic model. 26. Paterson SA, Curzon ME. The effect of amoxy-
and a review of the literature. Oral Surg J Oral Maxillofac Surg 1991;49:83842. cillin versus penicillin V in the treatment of
Oral Med Oral Pathol Oral Radiol Endod 17. Gidley PW, Ghorayeb BY, Stiernberg CM, et al. acutely abscessed primary teeth. Br Dent J
2003;95:28390. Contemporary management of deep neck 1993;174:4439.
8. Balcerak RJ, Sisto JM, Bosack RC. Cervicofacial space infections. Otolaryngol Head Neck 27. Von Konow L, Nord CE. Ornidazole compared
necrotizing fasciitis: report of three cases Surg 1997;116:1622. to phenoxymethylpenicillin in the treat-
and literature review. J Oral Maxillofac Surg 18. Marra S, Hotaling AJ. Deep neck infections. ment of orofacial infections. J Antimicrob
1988;46:4509. Am J Otol 1996;17:28798. Chemother 1983;11:20715.
9. Langford FPJ, Moon RE, Stolp BW, et al. Treat- 19. Shumrick KA. Deep neck infections. In: Papar- 28. Flynn TR. The timing of incision and drainage.
ment of cervical necrotizing fasciitis with ella MM, editor. Otolaryngology. Vol 3. 3rd In: Piecuch JF, editor. Oral and maxillofa-
hyperbaric oxygen therapy. Otolaryngol Ed. Philadelphia (PA): WB Saunders Com- cial surgery knowledge update 2001. Rose-
Head Neck Surg 1995;112:2748. pany; 1991. p. 255663. mont (IL): American Association of Oral
10. Mallampati SR, Gatt SP, Gugino SP, et al. A 20. Biederman GR, Dodson TB. Epidemiologic and Maxillofacial Surgeons; 2001. p. 7584.
clinical sign to predict difficult tracheal review of facial infections in hospitalized 29. Flynn TR, Piecuch JF, Topazian RG. Infections
of the oral cavity. In: Feigin RD, Cherry JD,
intubation: a prospective study. Can pediatric patients. J Oral Maxillofac Surg
editors. Textbook of pediatric infectious dis-
Anaesth Soc J 1985;32:42934. 1994;52:10425.
eases. Vol 1. 4th Ed. Philadelphia (PA): WB
11. Frerk CM. Predicting difficult intubation. 21. Telford G. Postoperative fever. In: Condon RE,
Saunders Co.; 1998. p. 13448.
Anaesthesia 1991;46:10058. Nyhus LM, editors. Manual of surgical
30. Flynn TR, Topazian RG. Infections of the oral
12. Flynn TR. Anesthetic and airway considera- therapeutics. 6th Ed. Boston (MA): Little,
cavity. In: Waite D, editor. Textbook of
tions in oral and maxillofacial infections. Brown; 1985. p. 179.
practical oral and maxillofacial surgery. 3rd
In: Topazian RG, Goldberg MH, editors. 22. Flynn TR, Halpern LR. Antibiotic selection in Ed. Philadelphia (PA): Lea & Febiger; 1987.
Oral and maxillofacial infections. 3rd Ed. head and neck infections. Oral Maxillofac p. 273310.
Philadelphia (PA): WB Saunders Company; Surg Clin North Am 2003;15:1738. 31. Flynn TR. Surgical management of orofacial
1993. p. 496517. 23. Fazakerley MW, McGowan P, Hardy P, et al. A infections. Atlas Oral Maxillofac Surg Clin
13. Miller WD, Furst IM, Sandor GKB, et al. A comparative study of cephradine, amoxy- North Am 2000; 8:77100.
prospective blinded comparison of clinical cillin and phenoxymethylpenicillin in the 32. Peterson LJ. Principles of management and pre-
examination and computed tomography in treatment of acute dentoalveolar infection. vention of odontogenic infections. In: Peter-
deep neck infections. Laryngoscope 1999; Br Dent J 1993;174:35963. son LJ, Ellis E, Hupp JR, Tucker MR, editors.
109:18739. 24. Gilmore WC, Jacobus NV, Gorbach SL, et al. A Contemporary oral and maxillofacial
14. Miller EJ Jr, Dodson TB. The risk of serious prospective double-blind evaluation of surgery. 4th Ed. St. Louis (MO): Mosby;
odontogenic infections in HIV-positive penicillin versus clindamycin in the treat- 2003. p. 34466.
patients: a pilot study. Oral Surg Oral Med ment of odontogenic infections. J Oral 33. Bennett JD, Flynn TR. Anesthetic considerations
Oral Pathol Oral Radiol Endod 1998; Maxillofac Surg 1988;46:106570. in orofacial infections. In: Topazian RG,
86:4069. 25. Lewis MA, Carmichael F, MacFarlane TW, et al. Goldberg MH, Hupp JR, editors. Oral and
15. Flynn TR. Odontogenic infections. Oral Max- A randomised trial of co-amoxiclav (Aug- maxillofacial infections. 4th Ed. Philadelphia
illofac Surg Clin North Am 1991;3:31129. mentin) versus penicillin V in the treatment (PA): WB Saunders Co.; 2002. p. 43955.
CHAPTER 16
Sinus Infections
Rakesh K. Chandra, MD
David W. Kennedy, MD
Chronic sinusitis is a disease with high computed tomography (CT) have demonstrated that even small anatomic
prevalence in the American population, enhanced diagnostic accuracy, treatment variations or inflammatory processes in
affecting up to 13.4% of the population planning, and surgical capabilities. Prior this location may impair ventilation and
and accounting for almost 2% of all to these developments, management pri- drainage of the adjacent sinuses, with sub-
ambulatory diagnoses rendered.1 This marily consisted of antibiotic therapy, sequent development of significant
condition is important not only because of with surgery (often performed via facial inflammatory disease in these regions.
its frequency but because complications of incisions) reserved for complications. This observation led him to employ endo-
sinusitis may carry severe neurologic, oph- Endoscopy and CT have permitted elective scopes for the surgical management of
thalmologic, and systemic consequences. management of sinusitis for symptomatic sinusitis such that disease processes affect-
Therefore it is incumbent on all practi- improvement and the prevention of com- ing the natural sinus drainage pathways
tioners, particularly those who manage plications. Advances in our understanding could be addressed. Particularly, he
structures of the maxillofacial complex, to of microbiology, allergy, and pharmacolo- showed that even limited surgical proce-
be familiar with the features of sinonasal gy have complemented these modalities. dures directed toward the OMC and ante-
disease. Technologic advances in diagnos- The first fiber-optic nasal examination rior ethmoid sinuses can result in
tic imaging, endoscopy, and surgical was performed by Hirshman using a mod- improvement of ventilation and drainage
instrumentation have revolutionized the ified cystoscope. Instrumentation was of the frontal and maxillary sinuses.
diagnosis and treatment of sinusitis. Fur- then refined after World War II, permit- During the 1980s Stammberger, also
thermore, both clinical experience and ting the development of smaller scopes of Graz, and Kennedy, in the United
basic science knowledge have modified with improved illumination. Hopkins States, further refined and popularized
our perspective of sinusitis such that we designed a series of rigid endoscopes in these techniques.3 Since that time nasal
now understand it as an inflammatory dis- the early 1950s. They were relatively small endoscopy has been employed in the sur-
order, rather than a purely infectious in diameter and had wide field high- gical management of sinonasal neoplasms
process. This chapter attempts to synthe- contrast optics and bright illumination. as well as a multitude of both skull base
size a framework for understanding the This technology was used by Professor W. and orbital pathologies. Although indica-
etiology, clinical presentation, diagnosis, Messerklinger of Graz, Austria, for system- tions do exist for external approaches to
medical treatment, and surgery for atic nasal airway evaluation. Importantly, the paranasal sinuses, endoscopic
sinonasal inflammatory disease. These ele- Messerklinger observed that primary approaches are typically first line in the
ments are discussed in the context of our inflammatory processes of the lateral nasal surgical management algorithm. Recent
current knowledge base and the latest wall, particularly the middle meatus, advances in surgical instrumentation have
technologic innovations. resulted in secondary disease of the maxil- included the development of angled for-
The diagnosis and management of lary and frontal sinuses.2 This led to the ceps, drills, and telescopes. Additionally,
sinusitis has traditionally been based on definition of the osteomeatal complex the availability of stereotactic navigation-
patient symptomatology and plain film (OMC; Figure 16-1) as the site of common al imaging has permitted more compre-
imaging. The advent of sinonasal drainage for the maxillary, frontal, and hensive surgery to be performed safely.
endoscopy and the wide availability of anterior ethmoid sinuses. Messerklinger The practices of optimal medical therapy,
296 Part 3: Maxillofacial Infections
Clinical Presentation
Sinusitis is a clinical diagnosis that is con-
Table 16-1 Factors Associated with a History of Rhinosinusitis*
firmed by physical examination, including
nasal endoscopy, and radiographic imag- Major Factors Minor Factors
ing. The Task Force on Rhinosinusitis Facial pain/pressure Headache
sponsored by the American Academy of Facial congestion/fullness Maxillary dental pain
OtolaryngologyHead and Neck Surgery Nasal drainage/discharge Cough
has established criteria to define a history Postnasal drip Halitosis (bad breath)
consistent with sinusitis.3 These are based Nasal obstruction/blockage Fatigue
on patient signs and symptoms and are Hyposmia/anosmia (decreased or absent sense of smell) Ear pain, pressure, or
grouped into major and minor criteria, as Fever (acute sinusitis only) fullness
Purulence on nasal endoscopy (diagnostic by itself) Fever
outlined in Table 16-1. The presence of
*Either two major factors, or one major and two minor, are required for a diagnosis of rhinosinusitis. Purulence on nasal
two or more major factors, or one major endoscopy is diagnostic. Fever is a major factor only in the acute stage.
plus at least two minor factors, is consid-
Sinus Infections 297
criteria have existed for 4 to 12 weeks, and bones in the superior portion of the poste- wall that hangs just superior to the
in chronic sinusitis the criteria are pre- rior nasal cavity (see Figure 16-2). infundibulum. The drainage tract from
sent for at least 12 weeks. In recurrent The remaining discussion details the the frontal sinus courses inferiorly from
acute sinusitis, episodes last < 4 weeks, anatomy of the middle meatus and the the sinus medial to the medial orbital wall,
but the patient is asymptomatic between OMC, for this is the critical region in the lateral to the middle turbinate, and anteri-
episodes. Rhinosinusitis may also have development of sinusitis. These structures or to the ethmoid bulla. This tract, known
significant fungal components and may are mainly derived from the ethmoid as the frontal recess, is highly variable and
be influenced by environmental, general bone, a T-shaped structure, of which the is often lined with variant anterior eth-
host, and local host factors (see below). vertical part contributes to the nasal sep- moid air cells. It is apparent that even min-
tum, middle (and superior) turbinate, eth- imal inflammatory disease in the OMC
Etiology moid air cell system, and the lateral nasal can impair sinus ventilation and drainage
wall (see Figure 16-1). The horizontal por- of the adjacent ethmoid, maxillary, and
Anatomy and Physiology of the tion forms the cribriform plate of the skull frontal sinuses.
Nose and Paranasal Sinuses base. The uncinate is a sickle-shaped The paranasal sinuses and the majori-
The pathophysiology of sinusitis must be process of ethmoid bone that lies along the ty of the nasal cavity itself are lined with
understood in the context of the normal lateral nasal wall. The cleft-like space later- pseudostratified columnar ciliated epithe-
anatomy and physiology of the nose and al to this structure is known as the lium (respiratory type). The cilia suspend
paranasal sinuses. The paranasal sinuses infundibulum, and this is the region into a mucous blanket, which is secreted by
are formed early in development as which the maxillary sinus drains. The goblet cells in the mucous membrane (Fig-
evaginations of respiratory mucosa from medial opening of the infundibulum, ure 16-3). The cilia propel this blanket in a
the nose into the facial bones. Cavity for- where it opens into the middle meatus, is predetermined direction (Figure 16-4), in
mation begins in utero, and pneumatiza- known as the hiatus semilunaris. The eth- a manner similar to the mucociliary esca-
tion continues into early adolescent life. moid bulla is a prominence of anterior lator of the tracheobronchial tree. This
The ethmoid sinus develops into a bony ethmoid air cell(s) along the lateral nasal phenomenon is important because in the
labyrinth of 3 to 15 small air cells on each
side. In contrast, the other sinus cavities
develop as a single bony cavity on each
side of the facial skeleton, although vari-
ations may exist. The ostium of each
sinus represents the point at which out-
pouching initiated.
The lateral nasal wall on each side is
lined by three turbinate bones designated
as inferior, middle, and superior (Figure
16-2). The space under each is known as Superior
turbinate
either the inferior, middle, or superior
meatus, respectively. The OMC is a space
within the middle meatus into which the Middle
maxillary, anterior ethmoid, and frontal turbinate
Over 100 chemicals have been found to including the immune or metabolic status troversial as these organisms are known to
cause nasal irritation, many of which are of the host, the duration of the disease colonize the anterior nose and are less fre-
found in cigarette smoke. Pollutants may process, whether the infection is commu- quently isolated when the anterior nose is
contribute to sinusitis through several nity or hospital acquired, and antibiotic disinfected.25 Most authors agree, howev-
mechanisms. Deposition of irritant parti- resistance patterns. In uncomplicated er, that S. aureus is a significant pathogen
cles in the mucous blanket during respira- acute sinusitis, Streptococcus pneumoniae and should be treated when identified.26,27
tion can increase the relative concentration and Haemophilus influenzae are the most Gram-negative organisms that may be iso-
to which the mucous membrane is commonly isolated pathogens; Moraxella lated include Pseudomonas, Klebsiella, and
exposed, resulting in direct chemical and catarrhalis may also be a significant Proteus. Viridans streptococci, organisms
physical irritation, which subsequently pro- organism, particularly in the pediatric commonly found among oral flora, are
motes the inflammatory process.15 The irri- population. Staphylococcus aureus, Strep- observed in up to one-third of cases.24
tant effects of these chemicals may also tococcus pyogenes, coagulase-negative Interestingly, one study identified anaer-
induce neurogenic inflammation through staphylococci, anaerobes, and gram- obes in 93% of specimens in children with
vasodilation, tissue edema, and leukocyte negative organisms are found in varying chronic sinusitis.28 However, because the
influx. Specifically, neuropeptides such as proportions. The pathogenic roles of upper aerodigestive tract is highly colo-
substance P from unmyelinated sensory staphylococcal species in acute sinusitis are nized with anaerobes,29 their role in the
fibers have been implicated.16 Pollutants unclear as these are found near the maxil- infectious process is unclear. Postsurgical-
may also impair mucociliary clearance lary ostium in 60% of healthy asympto- ly, the sinonasal mucosa is frequently colo-
through alterations in mucus viscosity, matic adults.21 Anaerobes, when isolated, nized or infected with Pseudomonas
inhibition of ciliary function, and increases are typically a component of a mixed bac- and/or S. aureus, and patients may still be
in epithelial permeability. The typical terial infection and may be the result of an susceptible to acute exacerbations by the
chemical components of outdoor pollution extension of a dental abscess.22 It should pathogens involved in acute sinusitis.
have been shown to increase neutrophil also be noted that up to 50% of patients
counts in nasal lavage specimens.17 A study diagnosed clinically with acute sinusitis Role of Fungi
in Finland also correlated the increase in have sterile sinus aspirates. The reason for Much has evolved in our understanding of
nasal polyposis and frontal sinusitis with air this is unclear, but it may reflect viral or the role of fungi in sinusitis, and different
pollution. These studies provide circum- allergic processes diagnosed as bacterial patterns of fungal sinusitis exist. Fungal
stantial but objective evidence that pollu- sinusitis. Nosocomial acute sinusitis may disease can be classified as noninvasive or
tants play a significant role in the increasing be caused by nasal intubation, nasal pack- invasive. Both fungal balls and allergic
prevalence of chronic sinusitis.18 ing, patient immobility, chronic debilita- fungal sinusitis are part of the noninvasive
Recently there has been investigation tion, and/or immunosuppression. The group, although recently it has been sug-
into a possible role for gastroesophageal most common species isolated in these gested that fungus has a wider role as an
reflux disease (GERD) in sinonasal cases is Pseudomonas, although S. aureus is active factor in the pathogenesis of
inflammation, particularly in the pediatric also frequently isolated, and the bacteriolo- eosinophilic chronic rhinosinusitis. Inva-
population.19,20 In fact, GERD has been gy may be unpredictable. sive fungal disease is typically a fulminant
associated with a multitude of inflamma- Patients with chronic sinusitis typical- disease in immunocompromised individ-
tory processes of the upper aerodigestive ly represent a population with several uals but can also occur occasionally as an
tract including esophagitis, pharyngitis, months to years of symptoms who have indolent disease in patients who are
and laryngitis. Evidence for its role in received multiple antibiotic courses. Thus immunocompetent. Fungal balls are typi-
sinusitis, however, is circumstantial, and the bacterial profile in these patients dif- cally seen in immunocompetent individu-
many feel that it is not a significant predis- fers from that of acute sinusitis. Polymi- als with chronic (or recurrent acute)
posing factor.20 Nonetheless, GERD crobial infections and antibiotic-resistant symptomatology that is often subtle and
should be suspected in children whose organisms are often found. In general, a restricted to a single sinus. Patients may
inflammation appears refractory to med- higher proportion of S. aureus, coagulase- complain about the perception of a foul
ical and surgical management. negative staphylococci, gram-negative odor and occasionally report expelling
bacilli, and streptococci are isolated in fungal debris with nose blowing. Most
Bacteriology of Sinusitis addition to the typical pathogens of acute commonly, a fungal ball consisting of
The type of bacteria involved in a sinus sinusitis.23,24 The roles of S. aureus and Aspergillus fumigatus is found in the max-
infection depends on multiple factors, coagulase-negative staphylococci are con- illary sinus with scant inflammatory cell
Sinus Infections 301
infiltration in the surrounding mucosa.30 course is unusually refractory to medical Aspergillus flavus is the most common
The condition is indolent, and cure is therapy. Additionally, advanced nasal organism encountered. Symptoms of
often achieved after surgical removal of polyposis with inspissated mucin and chronic sinusitis are initially present, but
the fungus ball and assurance of patency fungal debris may cause thinning of bone these progress to cause visual and neuro-
of the natural sinus ostium. of the adjacent orbit and skull base. The logic signs. Nasal endoscopy may reveal
Allergic fungal sinusitis (AFS) is a goals for treatment of AFS are to eliminate granulomatous inflammation.31 Bone
form of noninvasive fungal sinusitis seen the fungal antigenic load and to reestab- destruction ultimately occurs. Treatment
in immunocompetent patients, who lish sinus ventilation, drainage, and includes surgical removal of fungal debris
exhibit a hypersensitivity reaction to fun- mucociliary clearance. Surgery has a and affected tissues, as well as systemic and
gal organisms in the nose and sinuses. The prominent role in these regards but must local antifungal therapy.
disease typically presents with unilateral be complemented with medical therapies
nasal polyposis and thick tenacious secre- to both reduce inflammation and elimi- Genetic Disorders
tions.31 The most commonly implicated nate the fungal load. Little is known regarding genetic influ-
fungi are those of the Dematiaceae fami- Immunocompromised patients are at ences on the risk of developing sinusitis,
ly,32 but Aspergillus species are also seen. risk for developing fulminant invasive fun- and the exact contribution of hereditary
The exact pathophysiology is controversial gal sinusitis. This patient population is variables is difficult to quantify given the
but is thought to involve IgE-mediated composed of diabetics, transplant patients, multifactorial nature of the disease. How-
(type I) responses. IgE-sensitized mast those receiving cancer chemotherapy, burn ever, recently the ADAM33 gene has been
cells are activated by exposure to fungal victims, the elderly, and patients with con- identified as being associated with the
antigens resulting in degranulation, influx genital or acquired immunodeficiency. In closely related disease asthma. Many of the
of eosinophils, and exacerbation of addition to the typical symptoms of sinusi- predisposing inflammatory conditions
inflammation via the release of major tis, patients with invasive fungal disease discussed previously, particularly those
basic protein. Immune complex (type III) may present with severe pain, fever, prop- involving an atopic response, also tend to
reactions involving IgG have also been tosis, visual impairment, cranial neuropa- cluster in families, suggesting a genetic
identified. Patients have a severe inflam- thy, other focal neurologic findings, component. Additionally, several defined
matory reaction with nasal polyposis and seizures, and altered mental status. Invasive congenital syndromes are associated with
inspissated allergic mucin consisting of fungal sinusitis may begin as a noninvasive sinusitis. These include defects of metabo-
eosinophil breakdown products (Charcot- form with subsequent tissue invasion in a lism, ciliary structure/function, and the
Leyden crystals) and fungal forms. AFS- susceptible patient. Aspergillus and fungi of immune system. Some of the more com-
like conditions have also been described in the Mucoraceae family are often implicat- mon pathologies with a primary genetic
which mucin is observed, but fungal forms ed, with the latter being more common in basis are outlined below.
are not identified microscopically or by diabetics. Black necrotic eschars of the Cystic fibrosis (CF) is an autosomal
culture.33 Recent studies by Ponikau and nasal mucosa are noted during nasal recessive disorder affecting epithelial trans-
colleagues and Taylor and colleagues, how- endoscopy, with bone destruction on CT port of chloride and water via mutations in
ever, revealed that fungi can be demon- scans. Biopsy of the border of the eschar is the CFTR gene. This results in abnormally
strated with increased sensitivity using essential to confirm the diagnosis. Biopsy is viscous secretions, which become inspis-
novel culture and staining techniques.34,35 also necessary when pale insensate mucosa sated in the lung, pancreas, and sinonasal
In fact, this group showed that fungi are is discovered in a patient with a strong his- tract, ultimately leading to chronic inflam-
present in 93% of 101 patients with chron- tory and risk factors for invasive fungal mation and fibrosis. In the sinonasal tract,
ic sinusitis.34 This has led to the hypothesis sinusitis. Treatment requires aggressive patients exhibit florid polyposis and colo-
that the fungi, themselves, may induce an surgical dbridement of infected and devi- nization with Pseudomonas. A sweat test to
eosinophilic response, and that fungi may talized tissues, topical and systemic anti- detect elevated chloride levels is diagnostic
play a prominent role in chronic sinusitis, fungal medications, and management of and should be performed on any child pre-
even in the absence of frank AFS. This area predisposing conditions. senting with nasal polyposis. Recent data
of research is progressing rapidly. The chronic indolent form of invasive also suggest that heterozygous carriers may
Patients with AFS may present with fungal sinusitis is more commonly be at increased risk for developing chronic
the typical signs and symptoms of chron- observed in immunocompetent patients sinusitis.36 Aggressive medical manage-
ic sinusitis. Underlying AFS must be sus- and is endemic in Sudan, but it has also ment against Pseudomonas is necessary;
pected in a chronic sinusitis patient whose been observed in type II diabetics. treatment also includes surgery to remove
302 Part 3: Maxillofacial Infections
polyps and chronically infected tissue and tified.4244 The particular type of immun-
to provide sinus ventilation. Pulmonary odeficiency involved may dictate the
disease is typically the life-limiting mani- nature of the superinfecting organism.45
festation of CF, but in the era of lung trans- For example, complement defects are
plantation, patients may live well into the associated with gram-negative infections.
fourth or fifth decade. Difficult-to-manage sinus disease should
Inherited disorders of ciliary struc- inspire an investigation into this area,
ture or function also are associated with including the quantitative measurement of
chronic sinus disease. Kartageners triad immunoglobulins and possibly comple-
is a syndrome involving sinusitis, ment levels.
bronchiectasis, and situs inversus.37
Sinus, middle ear, and pulmonary dis- Diagnosis
eases are observed in nearly all cases, and
male patients are usually infertile sec- Roles of Endoscopy and CT
ondary to sperm immobility. These man- Sinus infections are typically diagnosed
ifestations are a consequence of structur- based on clinical criteria described previ- FIGURE 16-6 Purulent discharge from the
al defects in the dynein arms of cilia. middle meatus draining into the nasopharynx
ously (see Table 16-1). Symptom severity adjacent to the eustachian tube orifice. Repro-
Light microscopy reveals a reduction in and effect on quality of life can be scored duced with permission from Joe SA, Bolger WE,
ciliary beat frequency, and structural on multiple different scales.46,47 Acute Kennedy DW. Nasal endoscopy: diagnosis and
abnormalities can be observed under sinusitis is frequently diagnosed and man- staging of inflammatory sinus disease. In:
Kennedy DW, Bolger WE, Zinreich SJ, editors.
electron microscopy. Primary ciliary aged by the primary care practitioner Diseases of the sinuses: diagnosis and manage-
dyskinesia (or immotile cilia syndrome) largely based on history, but recurrent ment. Hamilton: BC Decker Inc; 2001. p. 120.
is twice as common as Kartageners syn- acute sinusitis, chronic sinusitis, or that
drome and has similar sinopulmonary which has failed medical management
manifestations without situs inversus.38 requires endoscopic evaluation and radi-
These patients often live a normal life ographic imaging. This is important
span with timely management of because over two-thirds of patients who
sinopulmonary infections and prophylac- meet the criteria for rhinosinusitis have
tic measures such as avoidance of envi- negative results on endoscopy, and over M
ronmental pollutants. 50% have negative results on CT scans.46
Youngs syndrome is also associated Sinusitis can be diagnosed regardless
with chronic sinusitis, lung disease, and of symptomatic criteria if pus is noted in
male infertility.39 The etiology of male the middle meatus during nasal
infertility, however, is secondary to endoscopy (Figure 16-6). In patients who I
obstruction of the epididymis, and sperm have had surgical antrostomy, pus may be S P
motility is normal. There is no association seen within the maxillary sinus. This can
with situs inversus. Sinus and lung disease be cultured during the examination, with
usually do not progress beyond childhood, the results being useful in antibiotic selec-
and few require sinus surgery.40 tion. In addition to purulence, nasal
Multiple inherited immunodeficiency endoscopy can detect mucosal inflamma-
disorders may be associated with sinusitis. tion, edema, polyposis (Figure 16-7), and
These typically involve defects of antibody- anatomic variations such as a deviated FIGURE 16-7 View into left nasal cavity demon-
mediated immunity, particularly IgG sub- septum. A recent study demonstrated that strates a polyp (P) extending from the middle
meatus. S = septum; M = middle turbinate; I =
class deficiency, for which the inheritance the findings of purulence, polyps, or inferior turbinate. Reproduced with permission
pattern is unknown.41 Common variable mucosal edema correlate with sinusitis by from Joe SA, Bolger WE, Kennedy DW. Nasal
immunodeficiency (dominant or reces- CT, but anatomic variation was not a sig- endoscopy: diagnosis and staging of inflammato-
sive), IgA deficiency (dominant), X-linked ry sinus disease. In: Kennedy DW, Bolger WE,
nificant predictor. Also, negative
Zinreich SJ, editors. Diseases of the sinuses: diag-
agammaglobulinemia, and complement endoscopy was a good predictor for CT nosis and management. Hamilton: BC Decker
deficiencies are among the disorders iden- scan results that were normal or indicated Inc; 2001. p. 123.
Sinus Infections 303
A B C D E
a
c c acc
FIGURE 16-13 Orbital complications of sinusitis: A, preseptal cellulitis (c); B, orbital cellulitis (c); C, orbital subperiosteal abscess (a); D, orbital abscess (a);
E, septic thrombosis of the cavernous sinus (t). Adapted from Lusk RP, Tychsen L, Park TS. Complications of sinusitis. In: Lusk RP, editor. Pediatric sinusitis. New
York: Raven Press; 1992. p. 12746.
This develops secondary to the spread of sure. This complication may be surpris-
infection through emissary veins into ingly indolent because there are no focal
the cranial bone marrow, and thus neurologic signs and examination of the
essentially represents osteomyelitis of cerebrospinal fluid (CSF) is often nor- f
the frontal bone. mal.59 In a manner analogous to the g
An epidural abscess develops from orbital abscess, subdural and brain
osteitis of the posterior table of the frontal abscesses can occur from the direct spread
sinus extending into the space between the of an epidural abscess or from retrograde
frontal bone and the dura. Patients present thrombophlebitis. Increased intracranial
with low-grade fever and worsening pressure is significant in these cases and e
headache from elevated intracranial pres- may lead to herniation and death. Subdur-
b a
al abscess may cause septic venous throm- d
bosis and venous infarction.60 Brain
abscess is associated with brain necrosis.
In contrast to the above intracranial Frontal
sinus c
conditions, which usually arise from the
frontal sinus, meningitis typically arises
from infection of the ethmoid or sphenoid b
sinus.61 The typical presenting symptoms
and signs are high fever, headaches,
seizures, and delirium. Lumbar puncture
is necessary to establish the diagnosis and
obtain culture results.
FIGURE 16-14 Axial computed tomography scan FIGURE 16-15 Intracranial complications of sinusitis.
demonstrating a subperiosteal abscess adjacent to Treatment These include osteomyelitis (a), periorbital abscess (b),
the right medial orbital wall secondary to acute epidural abscess (c), subdural abscess (d), brain abscess
infection in the ipsilateral ethmoid sinuses. (e), meningitis (f), and septic thrombosis of the superi-
Reproduced with permission from Choi SS, Medical Management or sagittal sinus (g). Adapted from Choi SS, Grundfast
Grundfast KM. Complications in sinus disease. KM. Complications in sinus disease. In: Kennedy DW,
The principle of therapy for sinusitis is
In: Kennedy DW, Bolger WE, ZinreichSJ, editors. Bolger WE, ZinreichSJ, editors. Diseases of the sinuses:
Diseases of the sinuses: diagnosis and manage- to break the cycle of impaired mucocil- diagnosis and management. Hamilton: BC Decker Inc;
ment. Hamilton: BC Decker Inc; 2001. p. 170. iary clearance, stasis, infection, and 2001. p. 172.
306 Part 3: Maxillofacial Infections
inflammation. Treatment for uncompli- ing factor, antihistamines may be indicat- be considered. Recent trends have included
cated acute sinusitis is primarily med- ed. Topical steroids, although useful in the use of antibiotic-containing irrigations
ical, with antibiotics representing the chronic rhinosinusitis, have no proven and nebulized aerosols, particularly in con-
mainstay of therapy. In most primary efficacy in the treatment of acute sinusitis junction with endoscopic sinus surgery.65
care settings, it is acceptable to initiate but may have a prophylactic effect in pre- Steroids are also a mainstay in the
antibiotic therapy when the criteria for venting recurrent acute episodes. Oral treatment of chronic sinusitis. Steroids
acute sinusitis are met. First-line drugs steroids (eg, prednisone or methylpred- decrease inflammation nonspecifically via
for acute rhinosinusitis recommended by nisolone) are not typically prescribed for a variety of mechanisms. Primarily they
the Agency for Health Care Policy and acute sinusitis when a significant bacterial inhibit cell-mediated immunity by block-
Research Institute include amoxicillin component is expected because the ing lymphocyte migration and prolifera-
(500 mg PO tid) and trimethoprim/ immunosuppressive effects may promote tion.66,67 Eosinophil and basophil counts
sulfamethoxazole (double strength tablets, the development of complications. How- are reduced,68 and the release of histamine
one PO bid). It has been further recom- ever, oral steroids are useful in the man- and leukotriene from basophils is inhibit-
mended that cephalosporins, macrolides, agement of acute exacerbations of chronic ed. Also, steroids decrease both vascular
penicillinase-resistant penicillins, and sinusitis to control the baseline inflamma- permeability and the secretory activity of
fluoroquinolones should be reserved for tory tendencies of the sinonasal mucosa. submucosal glands.69
failures of first-line therapy or for com- Nasal saline irrigations and mucolytics Topical nasal steroids are effective in
plications. However, some have ques- (eg, guaifenesin 600 mg PO bidqid) may reducing mucosal inflammatory changes
tioned whether, given the high incidence have a role in the treatment of both acute and are considered safe for long-term use.70
of pneumococcal and H. influenzae resis- and chronic sinusitis by assisting the With initiation of the medication, sympto-
tance in many areas, this graduated mobilization of secretions. matic improvement is not realized until
antibiotic response is really appropriate. Antibiotic therapy is also a major com- > 1 week of use.71 Patients must be coun-
Treatment duration should be at least 10 ponent in the treatment of chronic (and seled in this regard because most patients
to 14 days, and antibiotic doses must be subacute) sinusitis. The principles of treat- expect the immediate relief provided by
adjusted for patient weight (in children) ment, however, differ from those for acute topical decongestants, which cannot be
and for hepatorenal function, where sinusitis. First, the appropriate duration of used long-term without rebound vasocon-
appropriate. Recent trends have included therapy may be as long as 3 to 6 weeks.27,63 gestion. Potential risks associated with nasal
the use of culture-directed therapy, Additionally, empiric therapy requires reg- steroids include epistaxis and septal perfo-
which, at least theoretically, allows long- imens with coverage of Staphylococcus and ration. The complications of systemic
term cost effective management. This can anaerobes in addition to the common steroid use, although possible, are rare with
be performed safely and accurately using pathogens of acute sinusitis (S. pneumoni- topical nasal steroids. Studies have demon-
a middle meatal swab under endoscopic ae, H. influenzae, and M. catarrhalis).26 strated increased risk of acute open-angle
guidance.62 Culture-directed therapy is essential as glaucoma and ocular hypertension with
Oral decongestants such as pseu- antibiotic resistance is a significant prob- inhaled but not intranasal steroid use.72
doephedrine and topical decongestants lem in this patient population. Virtually all Suppression of the adrenocortical axis has
such as phenylephrine and oxymetazoline strains of M. catarrhalis and over 50% of been observed with higher-than-recom-
may be useful by decreasing tissue edema those of H. influenzae are penicillin resis- mended dosages,73 but other studies have
by -adrenergic vasoconstriction. This tant.64 Commonly employed regimens shown that routine daily use is not associat-
allows sinus ventilation and symptomatic include clindamycin (150 mg PO qid) plus ed with axis suppression.74
relief. Topical decongestants must be used either trimethoprim/sulfamethoxazole or a Oral steroid therapy can be used inter-
judiciously, however, as continuance of fluoroquinolone. Amoxicillin-clavulanate mittently in patients with chronic sinusitis
these medications beyond 3 to 5 days is and selected oral second- and third- to manage acute exacerbations. Several
associated with reduced duration of action generation cephalosporins may be useful different steroid compounds are available,
and rebound vasodilation, a condition as single-agent therapy. New-generation and each has its own relative potencies and
known as rhinitis medicamentosa. The macrolides (clarithromycin, azithromycin) side effects. Most often either prednisone
roles for antihistamines and topical nasal and other cephalosporins may be effective, or methylprednisolone is used. Doses usu-
steroids in the management of acute infec- depending on culture and sensitivity ally begin at 30 mg daily (or equivalent)
tions are controversial. If allergy is thought results.26 Each antibiotic has a unique pro- and are tapered over 2 to 3 weeks. Tapering
to be a significant predisposing or coexist- file of toxicities and side effects that must doses are required after 5 to 7 days of ther-
Sinus Infections 307
apy secondary to suppression of the Surgery sory ethmoid air cells, such as the infraor-
adrenocortical axis. Severe acute exacerba- bital cell or concha bullosa, and anatomic
Indications for surgery include (1) acute
tions may require higher dosages, and anomalies such as maxillary sinus hypopla-
sinusitis with a pending or evolving com-
some patients with recalcitrant chronic sia are noted. Triplanar reconstructions of
plication, (2) chronic sinusitis that has
rhinosinusitis may necessitate long-term thinly cut CT scans are used as part of a
failed maximum medical management
steroid regimens. Often, protracted steroid stereotactic imaging protocol (Figure 16-
including at least 3 weeks of broad-
courses are necessary for management of 16). This is useful to assess anatomy and
spectrum antibiotics, and (3) most forms
coexisting asthma in this patient popula- pathology in the axial, coronal, and sagittal
of fungal sinusitis. In cases of complicated
tion.12 Systemic steroid therapy is poten- planes both preoperatively and intraopera-
acute sinusitis and invasive fungal disease,
tially associated with serious side effects. tively, where the surgeon can correlate
surgery should be performed on an urgent
Long-term use may result in osteopenia or endoscopic and CT findings during dissec-
or emergent basis.
osteoporosis, which may be reversible in tion. Use of this technology is indicated
In uncomplicated chronic sinusitis the
early phases.75 Patients on long-term oral when normal anatomic landmarks have
goals of surgery are to eliminate mechani-
steroids should therefore undergo bone- been altered, as in patients who have had
cal obstruction of mucociliary flow,
density studies regularly. Steroid use is also previous surgery and in cases of massive
remove chronically inflamed mucosa and
associated with cataracts, hyperglycemia, polyposis. Patients with advanced chronic
glaucoma, sodium retention, fat accumu- bone, manage/prevent complications, and inflammatory disease, particularly those
lation, and psychosocial changes. rule out other disorders such as neoplasia. with nasal polyposis, are treated with oral
Patients with chronic sinusitis with sig- The determination that maximal medical steroids for up to 2 weeks before surgery.
nificant atopic components may be difficult management has failed must be individu- Courses of oral and occasionally intra-
to manage. The most important strategy in alized. It should be noted that the indica- venous antibiotics are required in selected
this population is avoidance. Antihistamine tions for surgery are more stringent in the cases preoperatively.
use should be limited to those with docu- pediatric population, for whom some Surgery is performed under the visu-
mented allergy by testing or clear allergic advocate 3 weeks of intravenous antibiotic alization of endoscopes (Figure 16-17),
stigmata such as frequent sneezing or itchy therapy prior to consideration of surgery.77 often with angled lenses, and with a vari-
watery eyes. Antihistamines may cause dry- Children with severe chronic sinusitis ety of forceps and punches (Figure 16-18).
ing and thickening of nasal secretions should first have thorough work-up and Powered tissue shavers similar to those
resulting in impaired mucociliary flow; appropriate treatment for conditions used in arthroscopic surgery are also used
therefore, they must be used judiciously. A such as allergy, GERD, CF, and immun- (Figure 16-19). The goals of surgery are to
full discussion of allergy management is odeficiency. Simple measures such as remove chronically inflamed tissue and to
beyond the scope of this chapter, but it may avoidance of pollutants (eg, secondhand restore sinus ventilation, drainage, and
include topical and oral steroids, antihista- cigarette smoke78) and environmental mucociliary clearance. Evidence exists that
mines, and mast cell stabilizers. There is allergens may avert the need for surgery. in chronic sinusitis the inflammatory
also mounting evidence supporting the use One study demonstrated allergies in 80% process involves the underlying bone.82,83
of immunotherapy, particularly in cases of children with sinusitis.79 Children in Thus, it is especially important to resect
with an allergic fungal component.76 day-care centers may be prone to upper the bony ethmoid partitions underlying
Antifungal agents may also have a role respiratory infections and consequently chronically inflamed mucosa. Diseased
in the treatment of sinusitis. Invasive forms chronic sinusitis.80 Other series have mucosa is resected, whereas normal
often require intravenous therapy with shown that medical treatment of GERD mucosa is preserved. It is critical to avoid
amphotericin B. Use of this medication is may eliminate the need for sinus surgery stripping of normal mucosa because
limited by renal toxicity. Chronic sinusitis in 90% of children otherwise considered denuded bone results in delayed healing,84
with an allergic fungal component may surgical candidates.81 and the regenerated mucosa does not
also be treated with antifungal agents Prior to surgery it is important to eval- regain normal ciliary density.
including itraconazole (200 mg PO bid). uate the CT scan to assess the extent of In performing maxillary antrostomy,
Topical nasal irrigation with solutions con- inflammatory disease and the patients the uncinate process is completely resected
taining amphotericin B or nystatin has also anatomy. A mental checklist is developed and the natural ostium (see Figure 16-19)
been employed in the treatment of fungal to assess the depth of the ethmoid skull is identified and subsequently enlarged.
sinusitis. The efficacy of these treatments is base and the position and integrity of the The opening must communicate with the
an area of active research. medial orbital walls. The presence of acces- natural ostium in a manner that permits
308 Part 3: Maxillofacial Infections
rior ethmoid. If blindness is encountered matic, they may also contribute to ostial
postoperatively, initial management is to stenosis and obstruction and, ultimately,
remove any nasal packing and perform the need for revision surgery. Postopera-
orbital massage to evacuate any bleeding. tively, the surgically opened sinus cavities
Emergent ophthalmologic consultation are dbrided under endoscopic visualiza-
should be obtained, and lateral canthoto- tion in the office setting. Patients are asked
my or endoscopic orbital decompression to use nasal saline sprays and/or irriga-
may be required. Another complication of tions to reduce crusting and facilitate the
sinus surgery affecting the eye is naso- dbridement process. Recalcitrant cases
lacrimal duct injury. Postoperatively, the may benefit from the addition of antibi-
patient presents with epiphora, or tearing. otics to these irrigation solutions.87
The nasolacrimal duct courses anterior to Postoperative medical management
the natural ostium of the maxillary sinus and long-term follow-up care is critically
and can be injured when the antrostomy is important. Patients are usually put on a
FIGURE 16-19 A powered tissue shaver is used to enlarged anteriorly. course of oral antibiotics to prevent bacte-
resect the inferior portion of the uncinate process,
The most common complication after rial proliferation in the blood and mucus
exposing the natural ostium of the maxillary
sinus. Reproduced with permission from Parsons endoscopic sinus surgery is the formation that may collect in the sinus cavities post-
DS, Nishioka G. Pediatric sinus surgery. In: of synechiae, observed in approximately operatively. Antibiotic selection and the
Kennedy DW, Bolger WE, Zinreich SJ, editors. 8%.86 Although these may be asympto- duration of treatment are individualized
Diseases of the sinuses: diagnosis and manage-
ment. Hamilton: BC Decker Inc. 2001. p. 275.
according to culture results and the degree ious risk factors develop sinusitis has not ment of patients with asthma and chronic
of inflammation observed. Antibiotics can been defined. Sinusitis can be managed sinusitis. Am J Rhinol 2001;15:4953.
13. Settipane GA. Epidemiology of nasal polyps.
be discontinued once the mucosa has effectively, however, with medical therapy Allergy Asthma Proc 1996;17:2316.
recovered and ciliary activity can offset the in most cases. There are clear roles for sur- 14. Lockey RF, Rucknagel DL, Vanselow NA.
stagnation of secretions. Topical and oral gical intervention in acute sinusitis with Familial occurrence of asthma, nasal
steroids are often prescribed postopera- complications (or pending complications), polyps, and aspirin intolerance. Ann Intern
tively to decrease inflammation and Med 1973;78:5763.
chronic sinusitis that has failed medical
15. Trevino RJ. Air pollution and its effect on the
reduce scar formation during the healing management, and the various forms of fun- upper respiratory tract and on allergic rhi-
process. Although some patients require gal disease. Combined with appropriate nosinusitis. Otolaryngol Head Neck Surg
long-term oral steroid therapy, it is prefer- medical management, surgical outcomes 1996;114:23941.
ably avoided, when possible, given the side can be maximized in these cases. 16. Nadel JA. Neutral endopeptidase modulates
effects. In contrast, patients almost univer- neurogenic inflammation. Eur Respir J
1991;4:74554.
sally require long-term treatment with References 17. Peden DB, Setzer RW, Devlin RB. Ozone expo-
topical nasal steroids. This is usually well 1. Murphy MP, Fishman P, Short SO, et al. Health sure has both a priming effect on allergen-
tolerated and is considered safe. care utilization and cost among adults with induced responses and an intrinsic inflam-
chronic rhinosinusitis enrolled in a health matory action in the nasal airways of
Overall endoscopic sinus surgery is
maintenance organization. Otolaryngol perennially allergic asthmatics. Am J Respir
considered successful in 80 to 90% of Head Neck Surg 2002;127:36776. Crit Care Med 1995;151:133645.
patients after at least 2 years follow-up.86,88 2. Messerklinger W. Uber die Drainage der men- 18. Suonpaa J, Antila J. Increase of acute frontal
The natural history for patients with nasal schichen Nebenhohlen unter normalen sinusitis in southwestern Finland. Scand J
polyps undergoing surgery alone is recur- und pathologischen Bedingungen. 1. Mit- Infect Dis 1990; 22:5638.
rence since polyposis is multifactorial and teilung. Monatsschr Ohrenheilkd Laryngol 19. Barbero GJ. Gastroesophageal reflux and upper
Rhinol 1966;101:5668. airway disease: a commentary. Otolaryngol
is associated with a tendency toward 3. Lanza DC, Kennedy DW. Adult rhinosinusitis Clin North Am 1996;29:2738.
mucosal inflammatory reactivity. One defined. Otolaryngol Head Neck Surg 20. Parsons DS. Chronic sinusitis: a medical or
study demonstrated recurrent polyp dis- 1997;117:S17. surgical disease? Otolaryngol Clin North
ease in 55% of patients after a mean 4. Lanza DC, Kennedy DW. Nose and sinus Am 1996;29:19.
follow-up of 3 years and 5 months. mucosal inflammation. Curr Opin Oto- 21. Chow JM, Hartman J, Stankiewicz JA. Endo-
laryngol Head Neck Surg 1994;2:2732. scopic directed cultures of the maxillary
Nonetheless, surgery has a clear role in 5. Aust R, Drettner B. Oxygenation in the human sinus ostium. Oper Tech Otolaryngol Head
these patients as is evidenced by the obser- maxillary sinus under normal and patho- Neck Surg 1993;4:869.
vation that over half were asymptomatic logical conditions. Acta Otolaryngol 1973; 22. Williams BL, McCann GF, Schoenknecht FD.
or significantly improved, and none were 78:2649. Bacteriology of dental abscesses of endodon-
worse.88 Diligent postoperative care 6. Aust R, Drettner B. The patency of the maxil- tic origin. J Clin Microbiol 1983;18:7704.
lary sinus ostium in relation to body pos- 23. Doyle PW, Woodham JD. Evaluation of the
including dbridement, medical manage- ture. Acta Otolaryngol 1975;80:4436. microbiology of chronic ethmoid sinusitis.
ment, and possibly allergy therapy is 7. Drettner B, Lindholm CE. The borderline J Clin Microbiol 1992;29:2396400.
essential to reduce or eliminate the ten- between acute rhinitis and sinusitis. Acta 24. Orobello PW, Park RI, Belcher LJ, et al. Micro-
dency toward recurrence, and long-term Otolaryngol 1967; 64:50813. biology of chronic sinusitis in children.
endoscopic follow-up is required to evalu- 8. Turner BW, Cail WS, Hendley JO, et al. Physio- Arch Otolaryngol Head Neck Surg
logic abnormalities in the paranasal sinuses 1991;117:9803.
ate for and treat even asymptomatic dis-
during experimental rhinovirus colds. J 25. Jiang RS, Hsu CY, Leu JF. Bacteriology of eth-
ease. Studies have also demonstrated that Allergy Clin Immunol 1992;90:4748. moid sinusitis in chronic sinusitis. Am J
sinus surgery in patients with both asthma 9. Russel DI, Ryan WJ, Towers JF. Complications Rhinol 1997;11:1337.
and nasal polyposis may decrease both of automated root canal treatment. Apical 26. Poole MD. Selecting an oral broad spectrum
pulmonary and nasal symptoms and perforation and overfilling. Br Dent J antibiotic. Ear Nose Throat J 1992;71:4445.
1982;153:3938. 27. Benninger MS, Anon J, Mabry RL. The medical
reduce the dependency on oral steroids.
10. Furukawa CT. The role of allergy in sinusitis in management of rhinosinusitis. Otolaryngol
children. J Allergy Clin Immunol 1992; Head Neck Surg 1997:117:S419.
Conclusions 90:5157. 28. Brook I. Microbiology and management of
Ultimately, additional advancements in our 11. Senior BA, Kennedy DW, Tanabodee J, et al. sinusitis. J Otolaryngol 1996;25:24956.
management of sinus disease will require Long-term impact of functional endoscop- 29. Busch DF. Anaerobes in infections of the head
ic sinus surgery on asthma. Otolaryngol and neck and ear, nose, and throat. Rev
advancements in our understanding of the
Head Neck Surg 1999;121:668. Infect Dis 1984;Suppl 6:11522.
pathophysiology. At this time, a common 12. Palmer JN, Conley DB, Dong DG, et al. Efficacy 30. Ferreiro JA, Carlson BA, Cody T. Paranasal sinus
pathway, through which patients with var- of endoscopic sinus surgery in the manage- fungal balls. Head Neck 1997;19:4816.
Sinus Infections 311
31. deShazo RD, OBrien M, Chapin K, et al. A new item Sino-Nasal Outcome Test (SNOT-20). 63. Druce HM. Diagnosis and management of
classification and diagnostic criteria for Otolaryngol Head Neck Surg 2002;126:417. recurrent and chronic sinusitis in adults. In:
invasive fungal sinusitis. Arch Otolaryngol 48. Havas TE, Motbey JA, Gullane PJ. Prevalence Gereshwin ME, Incaudo GA, editors. Dis-
Head Neck Surg 1997;123:11818. of incidental abnormalities on computer- eases of the sinuses. Totowa (NJ): Humana
32. Manning SC, Holman M. Further evidence for ized tomographic scans of the paranasal Press; 1996. p. 21533.
allergic pathophysiology in allergic fungal sinuses. Arch Otolaryngol Head Neck Surg 64. Kennedy DW, editor. Sinus disease, guide to
sinusitis. Laryngoscope 1998;108:148596. 1988;114:8569. first line management. Darien (CT): Health
33. Cody DT, Neel HB, Ferrerio JA, Roberts GD. 49. Kuhn JP. Imaging of the paranasal sinuses: cur- Communications; 1994.
Allergic fungal sinusitis: the Mayo Clinic rent status. J Allergy Clin Immunol 1986; 65. Desrosiers MY, Salas-Prato M. Treatment of
experience. Laryngoscope 1994;104:10749. 77:69. chronic rhinosinusitis refractory to other
34. Ponikau JU, Sherris DA, Kern EB, et al. The 50. Melhelm ER, Oliverio PJ, Benson ML, et al. treatments with topical antibiotic therapy
diagnosis and incidence of allergic fungal Optimal CT evaluation for functional delivered by means of a large-particle neb-
sinusitis. Mayo Clin Proc 1999;74:87784. endoscopic sinus surgery. Am J Neuroradi- ulizer: results of a controlled trial. Oto-
35. Taylor MJ, Ponikau JU, Sherris DA, et al. Detec- ol 1991;12:84954. laryngol Head Neck Surg 2001;125:2659.
tion of fungal organisms in eosinophilic 51. Zinreich SJ, Gottwald T. Radiographic anatomy 66. Rebuk JW, Mellinger RC. Interruption by topi-
mucin using a fluorescein-labeled chitin- of the sinuses. In: Kennedy DW, Bolger WE, cal cortisone of leukocytic cycles in acute
specific binding protein. Otolaryngol Head Zinreich SJ, editors. Diseases of the sinuses: inflammation in man. Ann N Y Acad Sci
Neck Surg 2002;127:37783. diagnosis and management. Hamilton: BC 1953;56:71523.
36. Wang XJ, Molan B, Leopold DA, et al. An Decker Inc; 2001. p. 1327. 67. Kelso A, Munck A. Glucocorticoid inhibition of
increased frequency of CF mutations in 52. Zinreich SJ, Kennedy DW, Malat J, et al. Fungal lymphokine secretion by alloreactive T lym-
patients with chronic sinusitis [abstract]. sinusitis: diagnosis with CT and MR imag- phocyte clones. J Immunol 1984;133:78491.
Am J Hum Genet 1998;63:55A. ing. Radiology 1988;169:43944. 68. Schleimer RP. Glucocorticoids: their mecha-
37. Kartagener M. Zur oathogenese dur brochiek- 53. Chandler JR, Langenbrunner DJ, Stevens ER. nism of action and use in allergic diseases.
tasien: brochiektasien bei situs viscerum In: Middleton E, Reed CE, Ellis EF, et al,
The pathogenesis of orbital complications
inversus. Beitr Klin Tuberk 1933;83:498501. editors. Allergy: principles and practice. 4th
in acute sinusitis. Laryngoscope 1970;80:
38. Cox DW, Talamo RC. Genetic aspects of pedi- ed. St Louis: CV Mosby; 1993. p. 893925.
141428.
atric lung disease. Pediatr Clin North Am 69. Shimura S, Sasaki T, Ikeda K, et al. Direct
54. Gamble RC. Acute inflammation of the orbit in
1979;26:46780. inhibitory action of glucocorticoids on glyco-
children. Arch Ophthalmol 1933;10:48397.
39. Young D. Surgical treatment of male infertility. conjugate secretion from airway submucosal
55. Gutowski WM, Mulbury PE, Hengerer AL, et
J Reprod Fertil 1970;23:5412. glands. Am Rev Respir Dis 1990;141:10449.
al. The role of CT scans in managing the
40. Handelsman DJ, Conway AJ, Boylan LM, Tur- 70. Nuutinen J, Ruoppi P, Suonpaa J. One dose
orbital complications of ethmoiditis. Int J
tle JR. Youngs syndrome. Obstructive beclomethasone dipropionate aerosol in the
Pediatr Otorhinolaryngol 1988;15:11728.
azoospermia and chronic sinopulmonary treatment of seasonal allergic rhinitis. A pre-
56. Southwick FS, Richardson EP, Schwartz MN.
infections. N Engl J Med 1984:310:39. liminary report. Rhinology 1987;25:1217.
Septic thrombosis of the dural venous
41. Umetsu DT, Ambrosino DM, Quinti I, et al. 71. Holmberg K, Juliusson S, Balder B, et al. Fluti-
sinuses. Medicine 1986;158:82106. casone propionate aqueous nasal spray in
Recurrent sinopulmonary infections and
impaired antibody response to bacterial 57. Sofferman RA. Cavernous sinus throm- the treatment of nasal polyposis. Ann Aller-
capsular polysaccharide antigens in chil- bophlebitis secondary to sphenoid sinusitis. gy Asthma Immunol 1997;78:2706.
dren with selective IgG subclass deficiency. Ann Otol Rhinol Laryngol 1964;73:2107. 72. Garbe E, Lelorier J, Boivin JF, Suissa S. Inhaled
N Engl J Med 1985;313:124751. 58. Clayman GL, Adams GL, Paugh DR, et al. and nasal glucocorticoids and the risks of
42. Cunningham-Rundles C. Clinical and Intracranial complications of paranasal ocular hypertension or open-angle glauco-
immunologic analyses of 103 patients with sinusitis: a combined institutional review. ma. JAMA 1997;227:7227.
common variable immunodeficiency. J Clin Laryngoscope 1991;101:2349. 73. Knuttson U, Stierna P, Marcus C, et al. Effects
Immunol 1989;9:335. 59. Blitzer A, Carmel P. Intracranial complications of intranasal glucocorticoids on endoge-
43. Plebani A, Ugazio AG, Monafo V, Burgio GR. of disease of the paranasal sinuses. In: nous glucocorticoid peripheral and central
Clinical heterogeneity and reversibility of Blitzer A, Lawson W, Friedman WH, edi- function. J Endocrinol 1995;144:30110.
selective immunoglobulin A deficiency in tors. Surgery of the paranasal sinuses. 74. Bryson HM, Faulds D. Intranasal fluticasone
80 children. Lancet 1986;1:82931. Philadelphia: WB Saunders Co; 1985. p. propionate: a review of its pharmacody-
44. Lederman HM, Winkelstein JA. X-lined agam- 32837. namic and pharmacokinetic properties and
maglobulinemia: an analysis of 96 patients. 60. Renaudin JW, Frazee J. Subdural empyema- therapeutic potential in allergic rhinitis.
Medicine 1985;64:14556. importance of early diagnosis. Neuro- Drugs 1992;43:76075.
45. Ferguson BJ, Mabry RL. Laboratory diagnosis. surgery 1980;7:4779. 75. Laan RFJM, van Riel PLCM, van de Putte LBE,
Otolaryngol Head Neck Surg 1997; 61. Courville CB. Subdural empyema secondary to et al. Low dose prednisone induces rapid
117:S1226. purulent frontal sinusitis. Arch Otolaryngol reversible axial bone loss in patients with
46. Stankiewicz JA, Chow JM. Nasal endoscopy 1944;39:21130. rheumatoid arthritis. Ann Intern Med
and the definition and diagnosis of chronic 62. Talbot GH, Kennedy DW, Scheld WM, Granito 1993;119:9638.
rhinosinusitis. Otolaryngol Head Neck K. Rigid nasal endoscopy versus sinus 76. Marple B, Newcomer M, Schwade N, Mabry R.
Surg 2002;126:6237. puncture and aspiration for microbiologic Natural history of allergic fungal sinusitis: a
47. Piccirillo JF, Merritt MG Jr, Richards ML. Psy- documentation of acute bacterial maxillary 4 to 10-year follow-up. Otolaryngol Head
chometric and clinimetric validity of the 20- sinusitis. Clin Infect Dis 2001;33:166875. Neck Surg 2002; 127:3616.
312 Part 3: Maxillofacial Infections
77. Buchman CA, Yellon RF, Bluestone CD. Alterna- 81. Bothwell M, Parsons DS, Talbot A, et al. Out- 85. Ramadan HH, Allen GC. Complications of
tive to endoscopic sinus surgery in manage- come of reflux therapy on pediatric chron- endoscopic sinus surgery in a residency
ment of pediatric chronic rhinosinusitis ic sinusitis. Otolaryngol Head Neck Surg training program. Laryngoscope 1995;
refractory to oral antimicrobial therapy. Oto- 1999;121:25562. 105:3769.
laryngol Head Neck Surg 1999;120:21924. 82. Kennedy DW, Senior BA, Gannon FH, et al. 86. Stammberger H, Posawetz W. Functional
78. Barr MB, Weiss ST, Segal MR, et al. The rela- Histology and histomorphometry of eth- endoscopic sinus surgery. Concept, indica-
tionship of nasal diseases to lower respira- moid bone in chronic rhinosinusitis. tions, and results of the Messerklinger tech-
tory tract symptoms and illness in a ran- Laryngoscope 1998;108:5027. nique. Eur Arch Otorhinolaryngol 1990;
dom sample of children. Pediatr Pulmonol 83. Perloff J, Gannon FH, Bolger WE, et al. Bone 247:6376.
1992;14:914. involvement in chronic sinusitis: an appar- 87. Leonard DW, Bolger WE. Topical antibiotic
79. Parsons DS, Phillips SE. Functional endoscopic ent pathway for the spread of infection. therapy for recalcitrant sinusitis. Laryngo-
surgery in children: a retrospective analysis Laryngoscope 2000;110:20959. scope 1999;109:66870.
of results. Laryngoscope 1993;103:899903. 84. Moriyama H, Yanagi K, Otori N, et al. Healing 88. Danielsen A, Olofsson J. Endoscopic endonasal
80. Wald ER. Sinusitis in children. Pediatr Infect process of sinus mucosa after endoscopic surgerya long-term follow-up study. Acta
Dis J 1988;7:S1508. sinus surgery. Am J Rhinol 1996;10:616. Otolaryngol 1996;116:6119.
CHAPTER 17
or cascade. In the normal healthy host, this ture. The clinician must begin empiric facial region will present with classic
process is self-limiting and is a component antibiotic treatment based on the most symptoms:
of healing. Occasionally, however, in the likely pathogens. This could include peni-
Pain
normal host, and certainly in the compro- cillin and metronidazole as dual-drug
Swelling and erythema of overlying
mised host, there is the potential for this therapy or clindamycin as a single-drug
tissues
process to progress to the point where it is treatment. Definitive antimicrobial ther-
Adenopathy
considered pathologic. With inflammation apy should be based on the final culture
Fever
there is hyperemia and increased blood and sensitivities for optimal medical
Paresthesia of the inferior alveolar
flow to the affected area. Additional leuko- management results.
nerve
cytes are recruited to this area to fight off
Classification Trismus
infection. Pus is formed when there is an
Malaise
overwhelming supply of bacteria and cellu- Over the years many ways of classifying
Fistulas
lar debris that cannot be eliminated by the osteomyelitis have been presented. A
bodys natural defense mechanisms. When rather complex classification system was The pain in osteomyelitis is often
the pus and subsequent inflammatory proposed by Cierny and colleagues. 7 described as a deep and boring pain,
response occur in the bone marrow, an ele- Osteomyelitis was classified as being which is often out of proportion to the
vated intramedullary pressure is created either suppurative or nonsuppurative by clinical picture. In acute osteomyelitis it is
which further decreases the blood supply to Lew and Waldvogel.8 This classification very common to see swelling and erythe-
this region. The pus can travel via haversian was modified by Topazian.9 Additional ma of the overlying tissues, which are
and Volkmanns canals to spread through- authors classified osteomyelitis as being indicative of the cellulitic phase of the
out the medullary and cortical bones. Once either hematogenous or secondary to a inflammatory process of the underlying
the pus has perforated the cortical bone and contiguous focus of infection.10 Another bone. Fever often accompanies acute
collects under the periosteum, the system proposed by Hudson essentially osteomyelitis, whereas it is relatively rare
periosteal blood supply is compromised divided the presentation of osteomyelitis in chronic osteomyelitis. Paresthesia of
and this further aggravates the local condi- into acute and chronic forms.11 With the the inferior alveolar nerve is a classic sign
tion. The end point occurs when the pus multitude of classification systems, the of a pressure on the inferior alveolar
exits the soft tissues either by intraoral or controversy involved in adequately clas- nerve from the inflammatory process
extraoral fistulas. sifying osteomyelitis is clearly evident. within the medullary bone of the
However, for simplicitys sake, the mandible. Trismus may be present if
Microbiology classification system offered by Hudson there is inflammatory response in the
More than 500 bacterial taxa have been is the most advantageous to the clinician. muscles of mastication of the maxillofa-
identified in the mouth.46 The mouth Osteomyelitis is divided into acute or cial region. The patient commonly has
and the anus are opposing ends of the chronic forms based on the presence of malaise or a feeling of overall illness and
same alimentary tube, and many clini- the disease for a 1-month duration.11 fatigue, which would accompany any sys-
cians consider them to be the most high- temic infection. Lastly both intraoral and
ly contaminated areas of the human 1. Acute osteomyelitis
extraoral fistulas are generally present
a. Contiguous focus (Figure 17-2)
body. In the past, staphylococcal species with the chronic phase of osteomyelitis of
b. Progressive
were considered the major pathogen in the maxillofacial region.
c. Hematogenous
osteomyelitis of the jaws. However, with Often these patients will have a labo-
2. Chronic osteomyelitis
refinements in the collection and pro- ratory work-up as part of their initial
a. Recurrent multifocal (Figure 17-3)
cessing of microbiologic specimens, we examination. In the acute phase of
b. Garrs (Figure 17-4)
are able to get a true picture of the osteomyelitis it is common to see a leuko-
c. Suppurative or nonsuppurative
disease-causing organisms. As with most cytosis with left shift, common in any
(Figure 17-5)
oral infections the prime pathogenic acute infection. Leukocytosis is relatively
d. Sclerosing (Figure 17-6)
species are streptococci and anaerobic uncommon in the chronic phases of
bacteria. The anaerobes responsible are osteomyelitis. The patient may also exhib-
generally bacteroides or peptostreptococ- Clinical Presentation it an elevated erythrocyte sedimentation
ci species. Often, the infections are mixed, Very often, as with any infection, the rate (ESR) and C-reactive protein (CRP).
growing several pathogens on final cul- patient with osteomyelitis of the maxillo- Both the ESR and CRP are very sensitive
Osteomyelitis and Osteoradionecrosis 315
A B C
D E F
G H I
FIGURE 17-3 A, Panoramic view taken of a 55-year-old female before extraction of symptomatic tooth no. 17. The patient had a history of unusual infections and
recurrent infections without a specific diagnosis. The patient began having pain and swelling in the left mandible after tooth no. 17 was extracted. B, Panoramic view
of no. 17 site postoperatively. C, Panoramic view after intraoral dbridements of the left mandible and extraction of teeth no. 18, 29, 20. Histopathology confirmed
diagnosis of osteomyelitis. The patient was treated with antibiotics based on culture and sensitivity reports. D, Panoramic view shows radiographic worsening of dis-
ease. Note the classic appearance of moth-eaten bone and impending pathologic fracture of the left mandible. Medical work-up revealed hypogamma globulinemia, a
chronic immunocompromised state. E, Bone specimen showing osteomyelitis resected. F, Panoramic view after left mandible resection of osteomyelitis with pathologic
fracture. Rigid internal fixation with a reconstruction plate allowed maintenance of space and facial form with continuous jaw function and mobility. G, The patient
was asymptomatic for 2 years before having pain and swelling in the anterior mandible. Dbridement revealed necrotic moth-eaten bone. H, The patient eventually
required removal of the remainder of the right mandible due to uncontrollable osteomyelitis. The patient was hospitalized and received intravenous antibiotics based
on multiple specific culture and sensitivity reports. She also received intravenous gamma globulin to correct hypogammaglobulinemia. Hyperbaric oxygen treatments
were also used to treat refractory osteomyelitis. The patient had a prolonged in-patient hospital course with multiple surgeries. I, Panoramic view with subtotal
mandibulectomy for osteomyelitis. Only the left ramus and condyle remain intact. The patient is currently on daily antibiotic immunosuppressive therapy for life, as
well as monthly infusions of gamma globulin. Despite aggressive medical management by infectious disease experts, she still has bouts of recurrent pneumonia.
Treatment Clearly the first step in the treatment of be sent for Gram stain, culture, sensitivity,
The management of osteomyelitis of the osteomyelitis is diagnosing the condition and histopathologic evaluations. The clini-
maxillofacial region requires both medical correctly. The tentative diagnosis is made cal response to the treatment of any patient
and surgical interventions. In rare cases of from clinical evaluation, radiographic eval- will be compromised unless altered host
infantile osteomyelitis, intravenous antibi- uation, and tissue diagnosis. The clinician factors can be optimized. Medical evalua-
otic therapy alone may eradicate the dis- must be aware that malignancies can mimic tion and management in defining and
ease. Antibiotic therapy is rarely curative the presentation of osteomyelitis and must treating any immunocompromised state is
in later-onset cases, and the overwhelming be kept in the differential diagnosis until indicated and often helpful. For example,
majority of osteomyelitis cases require ruled out by tissue histopathology (Figure glucose control in a diabetic patient should
surgical intervention. 17-7). Tissues from the affected site should be stabilized for best response to therapy.
Osteomyelitis and Osteoradionecrosis 317
Surgical Options
Classic treatment is sequestrectomy and
saucerization. The aim is to dbride the A
necrotic or poorly vascularized bony
sequestra in the infected area and improve
blood flow. Sequestrectomy involves
removing infected and avascular pieces of
bonegenerally the cortical plates in the
infected area. Saucerization involves the
removal of the adjacent bony cortices and
open packing to permit healing by sec-
ondary intention after the infected bone
has been removed. Decortication involves
removal of the dense, often chronically C D
infected and poorly vascularized bony cor- FIGURE 17-4 A, Facial view of a 13-year-old male, otherwise healthy. Note the swelling of the right mandible
tex and placement of the vascular perios- posterior body. B, Close-up of the panoramic view of the right mandible. Note the proliferative periostitis at the
teum adjacent to the medullary bone to inferior border that is characteristic of Garrs osteomyelitis. C, Close-up of the right mandible inferior border
allow increased blood flow and healing in with classic onion skin appearance. D, Occlusal view of the right mandible showing onion skin appearance.
(Courtesy of Dr. Mark Bernstein)
the affected area. The key element in the
above procedures is determined clinically
by cutting back to good bleeding bone. ture. Indeed, we have primarily grafted ment method works by increasing tissue
Clinical judgment is crucial in these steps such areas when the sequestrectomy and oxygenation levels that would help fight
but can be aided by preoperative imaging saucerization have been deemed adequate. off any anaerobic bacteria present in
that shows the bony extent of the patholo- Some authors have proposed adjunc- these wounds. The widespread use of
gy. It is often necessary to remove teeth tive treatment methods that deliver high HBO treatment of osteomyelitis still
adjacent to an area of osteomyelitis. In doses of antibiotic to the area using remains controversial.
removing adjacent teeth and bone the antibiotic impregnated beads or wound Resection of the jaw bone has tradi-
clinician must be aware that these surgical irrigation systems.1416 This therapy tionally been reserved as a last-ditch effort,
procedures may weaken the jaw bone and works on the premise that high local lev- generally after smaller dbridements have
make it susceptible to pathologic fracture els of antibiotics are made available and been performed or previous therapy has
(see Figure 17-6). the overall systemic load is very low, thus been unsuccessful or to remove areas
Supporting the weakened area with a reducing the possible side effect and involved with pathologic fracture. This
fixation device (external fixator or recon- complication rate. resection is generally performed via an
struction type plate) and/or placing the Hyperbaric oxygen (HBO) treatment extraoral route, and reconstruction can be
patient in maxillomandibular fixation is has also been advocated for the treatment either immediate or delayed based on the
frequently used to prevent pathologic frac- of refractory osteomyelitis. This treat- surgeons preference. Rigid internal fixation
318 Part 3: Maxillofacial Infections
D
Osteoradionecrosis
Radiation therapy is a valuable treatment
modality in treating cancer of the maxillo-
facial region. Radiation therapy can be
used alone or as adjunctive therapy in
C combination with surgery and chemother-
apy. Radiation therapy like any treatment
modality has deleterious side effects,
including mucositis and xerostomia. One
of the most dreaded side effects is osteora-
F dionecrosis (ORN). Historically, ORN was
felt to represent a radiation-induced
osteomyelitis. However, Marx has shown
that osteoradionecrosis represents a
chronic nonhealing wound that is hypox-
E ic, hypocellular, and hypovascular.17 In
years past, the radiation therapist used
H orthovoltage therapy and there was a high
incidence of ORN. However, the modern
FIGURE 17-5 A, Panoramic view taken of a radiation therapists use megavoltage,
42-year-old male with pain and swelling of the left which is felt to be kinder to the bone and
mandible. Problems started after failed root canal
soft tissues. In addition, collimation and
treatment on tooth no. 18. Teeth no. 18 and 17 were
extracted. The left mandible was dbrided and oral shielding of tissues in conjunction with
antibiotic treatment was prescribed. Note the gener- careful dental evaluation preoperatively
alized osteolysis of the left mandible with dissolution have greatly decreased the incidence of
of the inferior border. B, Technetium 99 bone scan
ORN. The effects of radiation last a life-
lighting up the left mandible. C, Patient with
extraoral fistula, paresthesia, and painful dysesthesia time and do not decrease over time.
of the left mandible that was scheduled for resection. ORN is generally caused by trauma to
D, Specimen showing bony destruction of the left the radiated area, usually by dental extrac-
mandible. Tissue was sent for culture and sensitivity
tion, but it can also occur spontaneously.
and histopathologic diagnoses. E, Surgical site show-
ing defect and normal bleeding bone margins. F, Left The clinical picture of ORN is most com-
hemimandible with reconstruction plate in place to monly seen with pain and exposed bone in
maintain space and facial form and provide imme- the maxillofacial region (Figures 17-9 and
diate function. The patients mandible was to be
17-10). ORN is more common in the
reconstructed in a second-stage procedure. G, Post-
operative anteroposterior view of the mandible. mandible than in the maxilla for reasons
G H, Postoperative panoramic view of the mandible. described earlier in this chapter. A dosage of
Osteomyelitis and Osteoradionecrosis 319
C
B
D F
G H I
FIGURE 17-6 A, Panoramic view taken of a 70-year-old male with pain and swelling in the right
mandible. Note the sclerotic lesion in the right mandible. B, Close-up of a panoramic view showing
sclerotic lesion in the right mandible. Incisional biopsy revealed osteomyelitis. C, Axial computed
tomography (CT) scan showing sclerotic lesion of the right mandible. D, Axial CT scan showing
lesion of the right mandible. E, Coronal CT scan showing sclerotic lesion of the right mandible with
areas of moth-eaten bone. F, Panoramic view of the right mandible after dbridement back to good
bleeding bone. G, Close-up of a panoramic view showing a weakened area of the right mandible. H,
Panoramic view of the mandible 3 months postoperatively. The patient had heard a pop while
J chewing. I, Close-up of a panoramic view showing pathologic fracture of the right mandible. J, Open
reduction and rigid internal fixation of pathologic fracture of the right mandible.
radiation above 5,000 to 6,000 rads is gen- The treatment of ORN is aimed at dbridements of exposed bone may work
erally felt to make the mandible susceptible removing the nonviable (necrotic) tissue in the most minor cases of ORN. Current
to ORN. Radiographically, the appearance and allowing the body to heal itself. The therapy calls for augmentation of tissue
on the orthopantomogram or CT scan clinician must always be aware that tissue healing response by the use of HBO. HBO
resembles conventional osteomyelitis with removed in a prior cancer patient should therapy consists of 100% oxygen delivered
areas of osteolysis and bony sequestrum. be sent to pathology to rule out occult or in a pressurized manner. Tissues treated
Often there is an appearance of moth-eaten recurrent malignant disease that is mas- with HBO have increased levels of oxygen,
bone present on these films. querading as a bony infection. Minor which has a negative effect on bacteria and
320 Part 3: Maxillofacial Infections
A B C
D E F
G H
FIGURE 17-8 A, Panoramic view taken of a 64-year-old female with symptomatic tooth no. 32 scheduled for extraction. B, Close-up of a panoramic view
showing decay in partially impacted tooth no. 32. C, Panoramic view of the mandible with pain, swelling, and paresthesia of the right mandible. D, Close-
up of a panoramic view showing pathologic fracture with bone sequestrum at the right mandibular angle region. E, Right angle dbrided via an extraoral
approach. F, Rigid fixation applied to a defect fracture. No bony contact is present after osteomyelitis is dbrided to normal bleeding time. G, The patient
receives an autogenous bone graft as part of primary surgery. H, Panoramic view of dbridements and reconstruction as a one-stage procedure.
A B C
FIGURE 17-9 A, Panoramic view of the mandible post-radiation in a patient with oral squamous cell carcinoma. Note the large bony sequestrum. B and
C, Intraoral views of the right and left mandible showing exposed bone. (CONTINUED ON NEXT PAGE)
322 Part 3: Maxillofacial Infections
F G
proven successful in the dental reconstruc- these conditions can be started with some- infections. Oral Maxillofac Clin North Am
tion of these patients.22 thing as innocuous and common as a den- 1991;3:24757.
7. Cierny G, Mader J, Pennick J. A clinical staging
tal extraction. system for osteomyelitis. Contemp Orthop
Conclusion Clinicians must always be vigilant for 1985;10:17.
Osteomyelitis and osteoradionecrosis pre- post-treatment complications, including 8. Lew DP, Waldvogel FA. Osteomyelitis. N Engl J
sent an ongoing and potentially difficult Med 1997;336:9991007.
osteomyelitis and osteoradionecrosis.
9. Topazian RG. Osteomyelitis of the jaws. In:
clinical scenario to manage. Many patients Despite advances in both medical manage- Topazian G, Goldberg H, Hupp JR, editors.
will receive a combination of surgery and ment and surgical therapy, the absolute Oral and maxillofacial infections. 4th ed.
medical management to adequately heal answer to the prevention and/or oral man- Philadelphia (PA): W.B. Saunders; 2002.
from these diseases. Some patients will be 10. Vighagool A, Calhoun J, Mader J, et al. Thera-
agement of osteomyelitis and osteora-
py of bone and joint infections. Hosp For-
required to undergo extensive and poten- dionecrosis has yet to be found. mul 1993;28:66.
tially disfiguring surgery to manage their 11. Hudson JW. Osteomyelitis and osteora-
disease. The medical management, includ- References dionecrosis. In: Fonseca RJ, editor. Oral and
ing antibiotic therapy and HBO treat- 1. Marx RE. Chronic osteomyelitis of the jaws. maxillofacial surgery. Vol 5. Philadelphia
Oral Maxillofac Surg Clin North Am (PA): W.B. Saunders; 2000.
ment, may be expensive, time consuming,
1991;3:36781. 12. Schuknecht B, Carls F, Vulavanis, et al.
and disruptive to the patients life. Both of Mandibular osteomyelitis: evaluation and
2. Marx RE. Pamidronate and zoledronate
staging in 18 patients using magnetic reso-
induced avascular necrosis of the jaws. J
nance imaging, computed tomography and
Oral Maxillofac Surg 2003;61:11158.
conventional radiographs. J Craniomaxillo-
3. Migliorati CA. Bisphosphonates and oral cavi-
fac Surg 1997;25:26.
ty avascular bone necrosis. J Clin Oncol
13. Peterson L, Thomson R. Use of the clinical lab-
2003;21:42534.
oratory for the diagnosis and management
4. Schuster GS. Microbiology of the orofacial of infectious diseases related to the oral cav-
region. In: Topazian G, Goldberg H, Hupp ity. Infect Dis Clin North Am 1999;13:775.
JR, editors. Oral and maxillofacial infec- 14. Alpert B, Colosi T, vonFraunhofer JA, et al.
tions. 4th ed. Philadelphia (PA): W.B. Saun- The in-vivo behavior of gentamicin
ders; 2002. PMMA beads in the maxillofacial region.
5. Flynn TR. Anatomy and surgery of deep space J Oral Maxillofac Surg 1989; 47:46.
infections of the head and neck knowl- 15. Chisholm B, Lew D, Sadasivan I. The use of
edge update. Rosemont (IL): American tobramycin impregnated polymethyl-
FIGURE 17-10 Rare case of maxillary osteora- Association of Oral and Maxillofacial Sur- methracrylate beads in the treatment of
dionecrosis. Clinical presentation is one of geons; 1993. p. 3042. osteomyelitis of the mandible. J Oral Max-
exposed bone and pain. 6. Peterson LJ. Microbiology of head and neck illofac Surg 1993;51:444.
Osteomyelitis and Osteoradionecrosis 323
16. Grime P, Bowerman J, Weller P. Gentamicin tion: a rational approach to donor site 21. Cordeiro PG, Disa JJ, Hidalgo DA, et al. Recon-
impregnated PMMA beds in the treat- selection. Ann Plast Surg 2001;47:3859. struction of the mandible with osseous free
ment of chronic osteomyelitis of the 19. Hidalgo DA, Disa JJ, Cordeiro PG, et al. A review flaps: a 10 year experience with 150 consec-
mandible. Br J Oral Maxillofac Surg of 716 consecutive free flaps for oncologic utive patients. Plast Reconstr Surg 1999;
1990;28:367. surgical defects: refinement in donor site 104:131420.
17. Marx RE. Osteoradionecrosis: a new concept of selection and technique. Plast Reconstr Surg 22. Disa JJ, Winters RM, Hidalgo DA. Long term
its pathophysiology. J Oral Maxillofac Surg 1998;102:72232. evaluation of bone mass in free fibula flap
1983;41:283. 20. Hidalgo DA, Pusic AL. Free flap mandibular mandibular reconstruction. Am J Surg
18. Disa JJ, Pusic Al, Hidalgo DA, et al. Simplifying reconstruction: a 10 year follow-up study. 1997;174:5036.
microvascular head and neck reconstruc- Plast Reconstruct Surg 2002;110: 4389.
Part 4
MAXILLOFACIAL TRAUMA
CHAPTER 18
The initial assessment and management of ma care.3 The third death peak occurs days threatening. This group of patients even-
a patients injuries must be completed in or weeks after the injury and is usually due tually requires surgical or medical man-
an accurate and systematic manner to to sepsis, multiple organ failure, or pul- agement, although the exact nature of the
quickly establish the extent of any injury monary embolism.4 injury may not become apparent until
to vital life-support systems. Nearly 25 to Patients are assessed and treatment after significant evaluation and observa-
33% of deaths caused by injury can be priorities are established based on tion. Laboratory studies, additional phys-
prevented when an organized and system- patients injuries and the stability of their ical findings, radiographic examinations,
atic approach is used.1 vital signs. In any emergency involving a and observations for several days or
Significant data exist to suggest that critical injury, logical and sequential weeks may be required.5 The goal of ini-
death from trauma has a trimodal distrib- treatment priorities must be established tial emergency care is to recognize life-
ution.2 The first peak on a linear distribu- on the basis of overall patient assessment. threatening injuries and to provide life-
tion of deaths is within seconds or minutes Injuries can be divided into three general saving and support measures until
of the injury. Invariably these deaths are categories: severe, urgent, and nonur- definitive care can be initiated.
due to lacerations of the brain, brainstem, gent.2 Severe injuries are immediately life
upper spinal cord, heart, aorta, or other threatening and interfere with vital phys- Assessment of the
large vessels. Few of these patients can be iologic functions; examples are compro- Severity of Injury
saved, although in areas with rapid trans- mised airway, inadequate breathing , The primary goal of triage is to prioritize
port, a few of these deaths have been hemorrhage, and circulatory system victims according to the severity and
avoided. The second death peak occurs damage or shock. These injuries consti- urgency of their injuries and the availabil-
within the first few hours after injury. The tute approximately 5% of patient injuries ity of the required care. With regional
period following injury has been called the but represent over 50% of injuries associ- trauma centers in modern trauma sys-
golden hour because these patients may ated with all trauma deaths. Urgent tems, the goal of triage is to rapidly and
be saved with rapid assessment and man- injuries make up approximately 10 to accurately identify patients with life-
agement of their injuries. Death is usually 15% of all injuries and offer no immedi- threatening injuries and to treat those
due to central nervous system (CNS) ate threat to life. These patients may have patients appropriately, while at the same
injury or hemorrhage. Recent analysis of injuries to the abdomen, orofacial struc- time avoiding unnecessary transport of
trauma system efficacy suggests that trau- tures, chest, or extremities that require less severely injured patients (Figure 18-
ma deaths could be reduced by at least surgical intervention or repair, but their 1).68 Over the past three decades many
10% through organized trauma systems. vital signs are stable. Nonurgent injuries scales and scoring systems have been
These patients, whose numbers are signif- account for approximately 80% of all developed as tools to predict outcomes
icant, benefit most from regionalized trau- injuries and are not immediately life based on several criteria.
328 Part 4: Maxillofacial Trauma
Table 18-1 Glasgow Coma Scale with lower scores representing an increas- Table 18-3 Predicting Mortality Using
ing severity of injury. Trauma scores of the Revised Trauma Score
Action Score
around 8 indicate an approximate 33% Trauma Score Mortality Rate (%)
Eye opening probability for mortality (Table 18-3).13,14
Spontaneously 4 In 1989 Champion and colleagues per- 12 <1
To speech 3 formed the Major Trauma Outcome 10 12
To pain 2 8 33
Study, consisting of an analysis of 33,308
None 1 6 37
trauma patients whose cases were submit-
Motor response 4 66
ted by 89 hospitals across the United States 2 70
Obeys 6 and Canada, with survival probabilities
Localizes pain 5 0 > 99
associated with admission trauma scores Adapted from Senkowski CK and McKenney MG.14
Withdraws from pain 4
determined for 25,327 patients. They con-
Flexion to pain 3
cluded that patients likely to benefit from
Extension to pain 2
None 1
prompt diagnosis and definitive care at In addition to the field scales that
level I trauma centers are those with an measure abnormal physiologic signs for
Verbal response
original trauma score of 12 or less.12 assessment of injury for triage decisions,
Oriented 5
Confused 4
mechanism-of-injury factors and anatom-
Injury Severity Score ic factors are also important considerations.
Inappropriate 3
Incomprehensible 2 The Injury Severity Score was developed Mechanism-of-injury factors can provide
None 1 to deal with multiple traumatic injuries. insight to a possible significant injury that
Adapted from Teasdale G and Jennett B.9 It compares death rates from blunt trau- has not yet resulted in significant changes
Patients score determines category of neurologic impair- ma using data that rate the severity of in vital signs. Those such factors that have a
ment: 15 = normal; 13 or 14 = mild injury; 912 =
moderate injury; 38 = severe injury. injury in each of the three most severely high correlation with life-threatening
injured organ systems. Each injury is injuries include the following16:
evaluated and categorized according to
Evidence of a collision involving high-
With the original trauma score, the total the injured organ system (respiratory,
energy dissipation or rapid deceleration
points added to give a trauma score of 1 to CNS, cardiovascular, abdominal, extrem-
A fall of 6 m or more
15, the higher the score, the better the prog- ities, and skin) and graded according to
Evidence that the patient was in a dan-
nosis. Thus, an injured patient who exhibits the severity of the injury: 1 is minor; 2
gerous environment when injured (eg,
eye opening to painful stimulus (score 2), a moderate; 3 severe nonlife threatening;
a burning building or icy water)
verbal response that is incomprehensible 4 life threatening, survival probable; 5
An automobile accident in which it
(score 2) and withdrawal from a painful survival not probable; 6 fatal cardiovas-
takes > 20 minutes to remove the
stimulus (score 4) would have a GCS of cular, CNS, or burn injuries. The three
patient, there is significant damage to
8 points and would contribute 3 points to highest scores for organ systems are then
the passenger compartment, rearward
the trauma score. squared and added; the highest injury
displacement of the front axle has
The Revised Trauma Score has a coded severity score possible is 108 (62 + 62 +
occurred, the patient is ejected from
value for each of three variables (Table 18- 62). Mortality rates have been found to
the vehicle, a rollover occurs, or other
2). A value of 0 to 4 is assigned for each increase with greater severity of injury
passengers have died
variable to give a total range of 0 to 12, and age (Table 18-4).15
Anatomic factors that correlate with
Table 18-2 Revised Trauma Score Variables mortality include penetrating trauma to the
Glasgow Coma Scale Systolic Blood Pressure (mm Hg) Respiratory Rate Coded Value
head, neck, torso, groin, or thigh; flail chest;
major burns; amputations; two or more
1315 > 89 1029 4 proximal long bone fractures; and paralysis.
912 7689 > 29 3 Concurrent disease or factors such as age of
68 5075 69 2
< 5 years or > 55 years and known cardiac
4 or 5 149 15 1
or respiratory disease may sharply worsen a
3 0 0 0
patients prognosis, even in the presence of
Adapted from Champion HR et al.12
only a moderately severe injury.17
330 Part 4: Maxillofacial Trauma
Table 18-4 Mortality Rates for Various Injury Severity Scores by Age Groups soft suction catheter or nasogastric tube,
be compromised as these tubes may inad-
Mortality Rates for Scores (%)
vertently be passed into the contents of
Age (yr) n 15 25 35 45 55 the cranial vault during attempts at a pha-
049 1,540 3 8 32 61 89 ryngeal suction.
5069 316 5 21 56 68 100 The jaw thrust procedure requires the
70+ 109 16 45 82 100 100 placement of both hands along the
Adapted from Powers M.15 ascending ramus of the mandible at the
mandibular angle. The fingers are placed
behind the inferior border of the angle,
The American College of Surgeons neurologic examination to establish degree and the thumbs are placed over the teeth
Committee on Trauma Subcommittee on of consciousness, and exposure of the or chin. The mandible is then gently
Advanced Trauma Life Support has devel- patient via complete undressing to avoid pulled forward with the fingers at the
oped a schematic orderly assessment of injuries being missed because they are cam- angle and rotated inferiorly with pressure
injured patients. The Advanced Trauma ouflaged by clothing. from the thumbs. The elbows may be
Life Support (ATLS) system consists of placed on the surface alongside the
rapid primary evaluation, resuscitation of Airway Maintenance with patient to assist with stability. The jaw-
vital functions, a detailed secondary Cervical Spine Control thrust procedure is the safest method of
assessment, and, finally, the initiation of The highest priority in the initial assess- jaw manipulation in a patient with a sus-
definitive care (see Figure 18-1).7 ment of the trauma patient is the estab- pected cervical injury. The jaw-thrust
lishment and maintenance of a patent air- procedure does require two hands, and
Other Scoring Systems way. In the trauma patient, upper airway assistance must be available to clear the
Many other scoring systems and tools have obstruction may be due to bleeding from debris and other obstructions. After the
been created in attempts to accurately aid oral or facial structures, aspiration of for- jaw is opened, it may be possible to place
triage and to predict outcomes, including eign materials, or regurgitation of stom- a bite lock or large suction device to
the Pediatric Trauma Score,18 the Trauma ach contents. Commonly, the upper air- wedge the teeth open. An oral or nasal
and Injury Severity Score,19 and A Severity way is obstructed by the position of the airway should be placed to elevate the
Characteristic of Trauma score20; recently tongue, especially in the unconscious base of the tongue and to maintain the
scales using the ninth edition of Interna- patient (Figure 18-3). Initially a chin-lift patent airway.
tional Classification of Diseases nomen- or jaw-thrust procedure may position the With any patient sustaining injuries
clature have been implemented including tongue and open the airway. The chin-lift above the clavicle, one should assume
an International Classification of Disease- procedure is performed by placing the there may be a cervical spine injury and
Based Injury Severity Score.21 thumb over the incisal edges of the avoid hyperextension or hyperflexion of
mandibular anterior teeth and wrapping the patients neck during attempts to
Primary Survey: ABCs the fingers tightly around the symphysis establish an airway. Excessive movement
An algorithm for the initial systemic evalu- or the mandible. The chin is then lifted of the cervical spine can turn a fracture
ation and stabilization of the multiply gently anteriorly and the mouth opened, without neurologic damage into a frac-
injured patient is presented in Figure 18-2. if possible. This method should not ture that causes paralysis. Maintenance
During the primary survey, life-threatening hyperextend the neck.8 The other hand of the cervical spine in the neutral posi-
conditions are identified and reversed can be used to assist with access to the oral tion is best achieved with the use of a
quickly. This period calls for quick and effi- cavity, using the fingers in a sweeping backboard, bindings, and purpose-built
cient evaluation of the patients injuries and motion to remove such things as debris, head immobilizers. The use of soft or
almost-simultaneous lifesaving interven- vomitus, blood, and dentures that may be semirigid collars allows, at best, only
tion. The primary survey progresses in a responsible for the obstruction. A tonsil- 50% stabilization of movement.22 Cervi-
logical manner based on the ABCs: airway lar suction tip is helpful to remove accu- cal spine injury should be assumed pre-
maintenance with cervical spine control, mulations from the pharynx. Patients sent and protected against until the
breathing and adequate ventilation, and cir- with facial injuries who may have basilar patient can be stabilized and cervical
culation with control of hemorrhage. Let- skull fractures or fractures of the cribri- injury can be ruled out during the sec-
ters D and E have also been added: a brief form plate may, with the routine use of a ondary survey.
Multiple trauma
Insert chest tube. 1. Confirm diagnosis Obtain CT scan or Obtain aortic arch Obtain head
with echocardiogram perform peritoneal arteriogram. CT scan.
or needle aspiration, lavage.
Yes
if time permits.
2.. Perform thoracotomy.
confirmed by feeling and listening for air suggestive of inadequate ventilation. Dis-
movement at the nostrils and mouth tant heart sounds and distended neck
supplemental oxygen may be delivered by veins are suggestive of cardiac tamponade.
face mask. The exchange of air does not Arterial oxygen tension (PaO2) should be
guarantee adequate ventilation. The chest maintained between 70 and 100 mm Hg.
wall of a patient with a pneumothorax, Aside from airway obstruction, the causes
flail chest, or hemothorax may move but of inadequate ventilation in the trauma
not ventilate effectively. Also, shallow victim result from altered chest wall
A breaths with minimal tidal volumes do not mechanics. Open pneumothorax, flail
ventilate the lungs effectively. Very slow or chest, tension pneumothorax, and mas-
rapid rates of respiration usually suggest sive hemothorax are immediate life-
poor ventilation. The patients status threatening conditions and should be
should be reevaluated constantly. If signs quickly identified and treated.
of adequate ventilation deteriorate, a
secure airway should be placed (ideally an Open Pneumothorax An open pneumo-
endotracheal tube) and assisted ventila- thorax is due to a defect in the chest wall,
tion should be started. If the patient is not allowing the air to be moved in and out of
breathing after establishment of an airway, the pleural cavity with each respiration
artificial ventilation should be provided (Figure 18-4). Because of the loss of
B with a bag-valve mask or a bag attached to chest wall integrity, equilibrium develops
an endotracheal tube. The patient who between intrathoracic pressure and
requires assisted positive pressure ventila- atmospheric pressure. The involved lung
tion from an Ambu bag or ventilator must collapses on inspiration and slightly
be carefully monitored if the chest status expands on expiration, causing air to be
has not been completely evaluated. sucked in and out of the wound; this is
Changes in intrathoracic pressure may referred to as a sucking chest wound. If
convert a simple pneumothorax into a the opening in the chest wall is approxi-
tension pneumothorax. The chest should mately two-thirds of the diameter of the
be exposed and inspected for obvious trachea, air will pass through the path of
injuries and open wounds. There should least resistancethe chest wall defect.
be equal expansion of the chest wall with- With the collapse of the involved lung and
out intercostal and supraclavicular muscle a loss of negative pleural pressure, the
C retractions during respiration. The rate of expired air from the normal lung passes to
breathing should be evaluated for tachyp- the involved lung instead of out of the tra-
FIGURE 18-3 A, Commonly in the unconscious
patient, the tongue drops posteriorly to occlude the nea or other abnormal breathing patterns. chea, and it returns to the normal lung on
airway. This may be especially true in the patient Signs of chest injury or impending hypox- inspiration. This eventually results in a
with mandibular fractures because the tongue ia are frequently subtle and include an large functional dead space in the normal
loses support. A patient with a suspected maxillo-
increased rate of breathing and a change in lung and, combined with loss of the
facial or head trauma must have the head stabi-
lized at all times to prevent hyperflexion of an breathing pattern, frequently toward shal- involved lung, may develop into a severe
injured cervical spine until the possibility of injury lower respirations.7 The chest wall should ventilation-perfusion problem.
has been ruled out. B, With the cervical spine sta- also be inspected for bruising, flail chest, An open pneumothorax should be
bilized, a jaw-thrust may be used. C, A Chin-lift
procedure also may be helpful to open the airway. and bleeding, and the neck should be eval- treated with coverage of the defect with a
Adapted from Powers M.15 uated for evidence of tracheal deviation, sterile occlusive dressing that is secured on
subcutaneous emphysema, and distended three sides of the dressing to the chest. The
jugular veins. The chest should be palpat- unsecured side of the dressing acts as a
Breathing ed for the presence of rib or sternal frac- one-way valve, allowing air to escape the
With establishment of an adequate airway, tures, subcutaneous emphysema, and pleural cavity on expiration. Secure taping
the pulmonary status must be evaluated. If wounds. Auscultation of the chest may of all edges of the dressing results in an
the patient is breathing spontaneously reveal a lack of breath sounds in an area, accumulation of air within the thoracic
Initial Management of the Trauma Patient 333
Chest wall
defect
Collapsed lung
A Air B C
FIGURE 18-4 A, A pneumothorax develops from damage to the chest wall or laceration of the lung pleura, with a resulting loss of negative intrapleural pres-
sure. A pneumothorax may be graded as small (1560%) or large (> 60%). B and C, An open or communicating chest wound occurs when there is an open
wound in the chest wall. Air can often be heard moving in and out of the wound during respirations; the condition may be referred to as a sucking chest wound.
An open pneumothorax may be converted to a simple pneumothorax with the use of an occlusive dressing over the chest wall wound. Care must be taken not to
create a trapdoor effect and cause a tension pneumothorax to develop. Adapted from Powers M.15
cavity and a subsequent tension pneu- affected lung is not oxygenated. With a illary line. The midaxillary line is general-
mothorax. Occlusive dressings such as pneumothorax, percussion of the chest ly preferred for cosmetic reasons, and if
petrolatum gauze may be used as a tempo- shows hyperresonance. Breath sounds are the tube is positioned properly superiorly
rary measure during initial examination usually distant or absent. Management of toward the apex of the lung, it can effec-
or over large defects. A chest tube must be the pneumothorax is confirmed and eval- tively remove both fluid and air.
placed in a distant site on the affected uated with upright chest radiographs. An A skin incision of approximately 3 cm
chest wall to avoid development of a ten- open pneumothorax that has a dressing in length is made one intercostal space
sion pneumothorax, and the wound must placed over the chest wound becomes a below the intended placement of the tube.
eventually be closed in the operating closed pneumothorax. If the tube is to be placed through the
room. If the lung does not expand after Pneumothoraces that are traumatically fourth intercostal space, an incision is made
closure of the defect or if signs of poor induced are usually treated with a tube through the skin along the fifth intercostal
ventilation persist, the patient should be thoracostomy to correct any respiratory space. A gloved finger is used to tunnel
placed on a ventilator with positive end- compromise. A small pneumothorax may transversely through the subcutaneous tis-
expiratory pressure (PEEP) to expand the be treated by hospitalization and careful sue to the inferior margin of the fourth rib.
lung. The patient should be carefully mon- observation if the patient is otherwise The intercostal muscles are separated with a
itored and have a chest tube in place to healthy, is symptom free, and does not large Kelly clamp, and the chest tube is
avoid the development of a tension pneu- need general anesthesia or positive pres- inserted superiorly and posteriorly into the
mothorax caused by a tear in one of the sure ventilation and if the size of the pneu- pleural cavity. The tube should be secured
bronchi or in the lung parenchyma. Signs mothorax is not increasing as measured on to the skin with sutures, and an occlusive
of a tension pneumothorax in patients on serial 24-hour chest radiographs.23,24 This dressing should be used to cover the defect
ventilators include increased airway resis- is rarely the case with the trauma victim, around the tube. The tube is then connect-
tance and diminished tidal volume. and a chest tube should be placed immedi- ed to an underwater sealed drainage to
A closed pneumothorax may develop ately in the multiply injured patient with a remove the air or fluid. Upright posteroan-
from blunt trauma to the chest or a lung pneumothorax (Figure 18-5). terior and lateral chest radiographs should
laceration, possibly from a fractured rib. A moderate-sized chest tube (3240F be taken to confirm the position of the
Air from the lung to the pleural space in adults or 2630F in children) is general- chest tube, the position of the last drainage
equalizes the pressures, and the lung col- ly placed either anteriorly in the second hole on the tube, and the position and
lapses. A ventilation-perfusion deficit intercostal space midclavicular line or in amount of air or fluid remaining in the
occurs because the blood circulated to the the fourth or fifth intercostal space midax- pleural cavity. Daily physical examination
334 Part 4: Maxillofacial Trauma
may be due to a head injury and disruption therefore, 100% oxygen delivery is accept- to allow for typing, cross-matching, and
of cerebellar reflex systems, airway distress able only until PaO2 levels can be ascer- baseline hematologic and chemical stud-
from maxillofacial or neck injuries, or pul- tained. Some concern exists about the sup- ies. If there is any doubt of adequate venti-
monary injuries such as pulmonary contu- pression of the respiratory drive with lation, arterial blood should be obtained
sion, flail chest, and a tension or open pneu- oxygen therapy, but the hypoxic drive can for blood gas analysis.
mothorax that mechanically does not be reestablished following stabilization of Tissue perfusion and oxygenation are
provide for proper delivery of oxygen to the the injured patient. dependent on cardiac output and are
cardiovascular system. Oxygen can be deliv- The most important mechanism of best initially evaluated by physical exam-
ered through a nasal cannula, face mask, or delivery of oxygen to the tissues is the ination of skin perfusion, pulse rate, uri-
endotracheal tube. A person breathing hemoglobin within the erythrocytes in the nary output characteristics, and the
100% oxygen can move five times more cardiovascular system. In a traumatized mental status of the patient. Blood pres-
oxygen into the alveoli with each breath as patient, hemorrhage may decrease the sure levels are commonly used to mea-
when breathing normal air. Oxygen therapy available hemoglobin to the point of sure cardiac output and to define hypov-
can increase available oxygen by as much as hypooxygenation of vital organ tissues and olemia, but in the emergency situation
400% above normal.27 cell death. A normal hemoglobin of time does not permit blood pressure
Administered oxygen can increase the 15 g/100 mL provides transport of 20% level measurement and the physical signs
inspired oxygen to 8 L/min and can volume of oxygen, whereas a hemoglobin of hypovolemia are more sensitive to
increase the fraction of inspired oxygen of 7 g/100 mL carries only a 10% volume developing shock. The response of the
(FiO2). A higher FiO2 can be delivered by a of oxygen, which is the critical reserve level blood pressure level to intravascular loss
Venturi mask, with the proper application of oxygen consumption for most tissues, is nonlinear because compensatory
of a bag and mask system. The greatest dif- especially the myocardium and brain.27 mechanisms of increased cardiac rate
ficulty with this system is maintaining an The treatment of shock in the patient with and contractility, along with venous and
adequate seal between the mask and face. multisystem injuries is directed toward arteriolar vasoconstriction, maintain the
The thumb and index finger are placed restoring cellular and organ perfusion blood pressure in the young healthy
over the mask to hold the mask securely with adequately oxygenated blood, rather adult during the first 15 to 20% of
over the mouth and nose, and the other than merely restoring the patients blood intravascular blood loss. After a blood
fingers are curled beneath the inferior bor- pressure and pulse rate.8 loss of 20%, the blood pressure level may
der of the mandible. The FiO2 can be drop significantly. (In the elderly patient
increased in a bag and mask system with a Circulation with less-efficient compensating mecha-
rebreathing mask and an oxygen accumu- Following establishment of an adequate nisms, the decline in blood pressure lev-
lator to deliver a high concentration of airway and breathing in the injured els may begin to develop after a 10 to
oxygen. Ventilation with the bag and mask patient, the cardiovascular system of the 15% blood loss.) The patient may arrest
system is difficult in patients with possible patient must be assessed and control of at an intravascular blood loss of 40%.29
maxillofacial, cervical spine, or thoracic baseline circulation to the tissues must be Blood pressure level may be insensitive
injuries, and the patient should be intu- quickly restored. The most common cause to the early signs of shock, and a patients
bated if oxygen resuscitation is required. of shock in the traumatized patient is blood pressure level may quickly drop
Endotracheal intubation helps to pro- hypovolemia caused by hemorrhage, following the initial assessment as the com-
tect the airway and facilitates adequate either externally or internally into body pensating mechanisms can no longer pro-
lung inflation with high FiO2 in the cavities. Assessment of the degree of shock vide for the intravascular volume loss. Also,
injured patient. Oxygen administered is important because inadequate tissue the usual baseline blood pressure level of
through the endotracheal tube should perfusion can cause irreversible damage to the patient is often unknown. A patient
increase the FiO2 by 100% (especially if the vital organs such as the brain or kidneys in who has a systolic pressure of 120 mm Hg
patient is comatose) until arterial blood a short time period. During the primary but is normally hypertensive may have a
gas measurements confirm hemoglobin assessment a minimum of two large-bore significant loss, whereas a healthy young
saturation (PaO2 > 6070 mm Hg), at (1416 gauge) intravenous catheters athlete may have a normal systolic pressure
which point FiO2 can be lowered to should be placed peripherally if fluid of 90 mm Hg and the blood loss might be
between 40 and 60%.28 Pulmonary oxygen resuscitation is required. At the time of assumed to be greater than it is.
toxicity may result if 100% oxygen is placement of an intravenous catheter, Skin perfusion is the most reliable
administered continuously for 24 hours; blood should be drawn from the catheter indicator of poor tissue perfusion during
338 Part 4: Maxillofacial Trauma
the initial evaluation of the patient. The abnormalities within the heart, hypo- pressure falls below 60 mm Hg. The men-
early physiologic compensation for vol- volemic status may not be represented by tal changes usually seen are agitation, con-
ume loss is vasoconstriction of the vessels increased pulse rates. fusion, uncooperativeness, anxiety, and
to the skin and muscles. The cutaneous The location of the pulse may give some irrationality. These alterations in mental
capillary beds are one of the first areas to indication of the cardiac output. Generally, status can also be seen in a patient with
shut down in response to hypovolemia if the radial pulse is palpable, the patients head trauma, spinal injury, drug or alcohol
because of stimulus from the sympathetic systolic blood pressure is > 80 mm Hg; if the intoxication, hypoxia, or hypoglycemia. In
nervous system and the adrenal gland femoral pulse is palpable, the patients sys- the emergency situation these other causes
through epinephrine and norepinephrine tolic blood pressure is 70 mm Hg or higher; of mental status changes should be inves-
release. The release of the catecholamines and if the carotid pulse is noted, the systolic tigated when hypovolemia is suspected in
causes sweating, and during palpation the blood pressure is > 60 mm Hg. Pulse the agitated patient who has or possibly
skin may feel cool and damp. The lower rhythm and regularity may also provide has suffered substantial blood loss.29
extremities are usually first to be affected, clues to increasing hypovolemia and car- Hypovolemia caused by hemorrhage
and the first indication of intravascular diac hypoxia. Cardiac dysrhythmias such as may commonly cause flat neck veins. Dis-
loss may be paleness and coolness of the premature ventricular contractions or arte- tended neck veins, however, suggest either
skin over the feet and kneecaps. A check of rial fibrillations produce an irregular rate tension pneumothorax or cardiac dys-
the capillary filling time by performing a and rhythm, signaling the loss of compen- function. As discussed earlier, with tension
blanch test gives an estimate of the sating mechanisms maintaining myocardial pneumothorax an examination of the
amount of blood flowing to the capillary oxygenation. chest may reveal absent breath sounds and
beds. In this test, pressure is placed on the Decreased intravascular volume is a hyperresonant chest. Cardiac dysfunc-
fingernail, toenail, or hypothenar emi- immediately reflected in decreased urinary tion results from cardiac tamponade,
nence of the hand (to evacuate blood from output because the compensatory mecha- myocardial contusion or infarction, or an
the capillary beds), followed by a quick nisms of the body decrease blood flow to the air embolus.
release of the pressure. The time required kidneys in favor of blood flow to the heart Cardiac tamponade presents a clinical
for the blood to return to the capillary and brain. Any patient with significant trau- picture that is similar to that of tension
beds, represented by the restoration of ma should always have an indwelling uri- pneumothoraxdistended neck veins,
normal tissue color, is usually < 2 seconds nary catheter inserted to monitor urine vol- decreased cardiac output, and hypoten-
in the normovolemic patient. This indi- ume every 15 minutes.29 A minimally sion. Blunt or penetrating trauma may
cates that the capillary beds are receiving adequate urine output is 0.5 mL/kg/h, and cause blood to accumulate in the pericar-
adequate circulation.30 fluid therapy should be initiated to main- dial sac. The blood in the pericardial sac
The rate and character of the pulse is a tain at least this level of urinary output. If results in inadequate cardiac filling during
good measure of the cardiac rate. The pulse the patients injuries include pelvic frac- diastole, diminished cardiac output, and
rate is a more sensitive measure of hypo- tures or blunt trauma to the groin, a uri- circulatory failure. Cardiac tamponade
volemia than is the blood pressure, but it is nary catheter should not be placed until a usually is associated with penetrating
affected by other factors commonly associ- urethrogram can be evaluated for urethral wounds to the chest that have injured the
ated with the trauma situation, such as the injury. If urethral injury is unlikely, the uri- tissues of the heart. The classic Becks triad
patients pain, excitement, and emotional nary catheter may be placed with minimal of decreased systolic blood pressure levels,
response, resulting in tachycardia without concern. Classic signs of urethral injury distended neck veins, and muffled heart
underlying hypovolemia. However, in include blood at the meatus, scrotal sounds may be observed. The expected dis-
adults with tachycardia > 120 beats/min, hematoma, or a high-ridding boggy tended neck veins caused by increased cen-
hypovolemia should be expected and inves- prostate on rectal examination. tral venous pressure may be absent because
tigated further. Older patients generally are Alterations in the mental status of the of hypovolemia. The neck veins, if distend-
unable to exceed rates of 140 beats/min in a trauma patient caused solely by hypo- ed, may become distended further during
hypovolemic state, whereas younger volemia are uncommon, except in the inspiration (Kussmauls sign), and the pul-
patients may present rates of 160 to most progressive preterminal stages of sus paradoxus (lowering of the systolic
180 beats/min with severe intravascular intravascular fluid loss. Compensatory pressure by > 10 mm Hg on normal inspi-
loss. In patients who have pacemakers, are mechanisms maintain blood flow to the ration) may be accentuated or absent. Ten-
taking heart-blocking medications such as brain, and hypoperfusion to the brain sion pneumothorax may mimic cardiac
propranolol or digoxin, or have conduction does not develop until the systolic blood tamponade or, because of the nature of the
Initial Management of the Trauma Patient 339
penetrating injury, may develop at the Bleeding may be external or internal into PASG/MAST garments are still used by
same time as cardiac tamponade, thus pre- body cavities. Most external hemorrhage some to stabilize pelvic fractures. Scalp or
senting a confusing clinical presentation. can be controlled with direct pressure to the skin wounds may best be managed with
Cardiac tamponade is initially man- wound. If an extremity is involved, it should immediate closure with large monofilament
aged by prompt pericardial aspiration be elevated. Firm pressure should be contin- sutures (without cosmetic closure consider-
through the subxiphoid route (Figure 18- uous, and if the dressings become soaked ations) and direct pressure until the hemor-
9). Because radiographs and physical they should not be removed but, rather, cov- rhage is controlled.
examination are not helpful, a positive ered with additional dressings. Removal of a Because of the rich blood supply to
pericardial aspiration along with a history dressing may disrupt clot formation and the face and neck, significant hemorrhage
of chest trauma is frequently the only promote further bleeding. Firm pressure on may be associated with large scalp
method of making a correct diagnosis. the major artery in the axilla, antecubital wounds, nasal or midface fractures, and
Because of the self-sealing qualities of the space, wrist, groin, popliteal space, or ankle penetrating neck wounds. In a short peri-
myocardium, aspiration of pericardial may assist in control of hemorrhage distal to od of time the scalp may lose a large
blood alone may temporarily relieve symp- the site. Pressure points should only be used amount of blood, which oozes from the
toms. All trauma patients with a positive if direct wound pressure is not effective galea and loose connective tissue layers.
pericardial aspiration require open thora- alone. Pressure bandages include the use of The wound can be approximated rapidly
cotomy and inspection of the heart. Peri- air-pillow splints and blood pressure cuffs. with 2-0 nonresorbable sutures without
cardial aspiration may not be diagnostic or Pneumatic antishock garments (PASGs) regard to cosmetic closure. Direct pressure
therapeutic if the blood in the pericardial and medical (military) antishock trousers should then be placed over the wound to
sac has clotted, as occurs in 10% of patients (MASTs) previously used to increase blood control the hemorrhage and minimize
with cardiac tamponade.29 If aspiration pressure in cases of hypotension have been hematoma formation. After the patient
does not lead to diagnosis or improvement found to be detrimental in some situations has been stabilized, the sutures may be
of the patients condition, only emergent such as instances of vascular injuries.31 The removed and a more cosmetic approach
thoracotomy can solve the problem.
Pericardial aspiration through the
subxiphoid route involves the insertion of
a needle, preferably covered by a plastic
catheter (angiocatheter), at 90 slightly to
the left of the xiphoid process. The needle Manubrium
is inserted until it clears the sternal border
and is then directed at 45 toward the left
scapula to directly enter the pericardium.
Suction is placed on the needle hub to Pericardium
Pericardium
identify by blood return when the needle Heart
Heart
has entered the pericardial sac. If the nee-
dle is properly placed, as little as 50 cc of
blood from the pericardial sac should Xiphoid
result in a marked improvement in the process
patients condition.
45
Control of Bleeding Hemorrhage is
defined as an acute loss of circulating blood. A B
Normally the blood volume is approximate-
FIGURE 18-9 Pericardiocentesis can be transiently lifesaving when a significant cardiac tamponade develops. A
ly 7% of the adult ideal body weight. A 70 kg and B, The patient is placed in a supine position, and a 16- or 18-gauge needle on a 60 cc syringe is introduced
male has approximately 5 L of circulating just to the left side of the xiphoid process. The needle should be introduced at a 45 angle to the chest wall, 45
blood. The blood volume does not increase off the midline and directed toward the posterior aspect of the left shoulder. A popping sensation may be felt as
significantly in obese patients, and in chil- the pericardium is entered. If the blood within the pericardial sac is slightly clotted, it may interfere with the
effectiveness of the procedure. Relief of a depressed systolic blood pressure level should be immediate, resulting
dren the blood volume is usually between 8 from an increased stroke volume. The procedure may be required several times until definitive treatment can be
and 9% of body weight (8090 mL/kg).7 initiated. Adapted from Powers M.15
340 Part 4: Maxillofacial Trauma
Nasal pack
(anterior)
Gauze pack
(posterior)
Forceps Suture
A B C
Gauze pack
FIGURE 18-11 A combined technique used for anterior and posterior packing of the nasal cavity involves the following: A, A small red rubber catheter is intro-
duced through the nostrils and carefully passed posteriorly along the floor of the nose until visualized in the oropharynx. Care must be taken with Le Fort II level,
nasoethmoid, or other fractures involving the cribriform plate that the catheter does not pass through the fracture site into the cranial vault. Once the catheter is
visualized, a forceps may be used to grasp the catheter and pull it into the oral cavity. B, The catheter is then sutured to a tape that is secured to a wad of gauze
packing material. The catheter is drawn from the nasal cavity through the nostril, pulling the gauze pack into position in the nasopharynx against the posterior
aspect of the nasal cavity. C, Once the posterior pack is in place, the anterior pack (consisting of 1 cm ribbon gauze) is packed in an orderly fashion along the nasal
floor, building superiorly; this allows for easy removal and efficient packing of the nasal cavity. Adapted from Leigh JM. Primary care. In: Rowe NC, Williams JC,
editors. Maxillofacial injuries. Edinburgh: Churchill-Livingston; 1985. p. 5474.
Initial Management of the Trauma Patient 341
Ligation of the external carotid artery may occlusion, refraction, and clot formation; or
be required only in extreme cases; usually by open exploratory surgery.
it is ineffective when used alone and with-
out direct control of hemorrhage because Hypovolemic Shock in the Patient with
of the collateral circulation of the face. Multisystem Injuries The most common
The potential internal sites of hemor- cause of shock seen in the patient with mul-
rhage are the thoracic cavity, abdomen, tisystem injuries is hypovolemia caused by
retroperitoneum, and extremities. A com- hemorrhage. Virtually all multisystemic
plete physical examination with radiogra- injuries are accompanied by a degree of
phy and computed tomography (CT) is hypovolemic shock that presents as a grad-
useful to identify hemorrhages into these ed physiologic response to hemorrhage.
areas (Figures 18-12 and 18-13). When This response can be classified based on the
there is no evidence of external or intratho- percentage of acute blood loss (Table 18-5).
racic bleeding, continued severe hypo-
volemia is usually the result of bleeding into Class I Hemorrhage: Blood Loss of Up
the abdomen or at fracture sites. Blood loss to 15% The clinical symptoms of blood
with fractures should be considered to be at loss of up to 750 mL in the 70 kg adult
least 1,000 to 2,000 mL for pelvic fractures, male are minimal. A mild tachycardia is
500 to 1,000 mL for femur fractures, 250 to noted, but the compensatory mechanisms FIGURE 18-13 Femur fracture. Fat embolism
500 mL for tibia or humerus fractures, and of the body retain normal blood pressure syndrome is usually associated with major frac-
125 to 250 mL for fractures of smaller levels, pulse pressure, respiratory rate, and tures of long bones, especially of the femur. The
patient typically does well for 24 to 48 hours and
bones. A hematoma the size of an apple tissue perfusion. then develops progressive respiratory and central
usually contains at least 500 mL of blood. nervous system deterioration. Concomitant lab-
Control of hemorrhage into internal spaces Class II Hemorrhage: Blood Loss of oratory value changes include hypoxemia,
thrombocytopenia, fat in the urine, and a slight
is not done in the primary survey unless the 15 to 30% Blood loss of 15 to 30% repre- drop in hemoglobin. Fat enters the venous sinu-
hemorrhage may have damaging effects on sents an 800 to 1,500 mL loss in the 70 kg soids at the fractured site and becomes lodged in
the cardiovascular or pulmonary system. A adult male. Clinical symptoms commonly the lung alveoli.
slow internal hemorrhage may be con- expected with this level of blood loss are
trolled by secondary fixation of fractures; tachycardia, tachypnea, and a decrease in signs of inadequate tissue perfusion,
by the defense mechanisms of vascular the difference between systolic and dias- including marked tachycardia (120 to
tolic blood pressure or pulse pressure. The 140 beats/min), tachypnea, marked vaso-
decrease in pulse pressure level is due to constriction, a decreased systolic pressure
the elevation of catecholamines and level, diaphoresis, anxiety, restlessness, and
increased peripheral vascular resistance in decreased urinary output.
response to the decreased intravascular
components. The increase in diastolic Class IV Hemorrhage: Blood Loss of > 40%
pressure suggests hypovolemia because Blood losses approaching half of the
there is no noticeable increase in the sys- intravascular volume produce an immedi-
tolic pressure in the early stages of blood ately life-threatening situation. Symptoms
loss. The peripheral vasoconstriction may include marked tachycardia, a significant
show an elongated capillary refill time, decrease in the systolic blood pressure
and the skin may feel cold and moist. level to < 60 mm Hg, marked vasocon-
striction with a very narrow pulse pres-
FIGURE 18-12 Pelvic fracture. Pelvic fractures,
fractures of the femur, and multiple fractures of Class III Hemorrhage: Blood Loss of sure, marked diaphoresis, obtunded men-
other long bones may cause hypovolemic shock 30 to 40% In the 70 kg adult male, a 30 tal state, and no urinary output.
and life-threatening blood loss, the primary site to 40% blood volume loss represents a
of which may be difficult to determine. Typical
1,500 to 2,000 mL loss, which is fairly Management In managing the trauma
closed fractures of the pelvis may lose 1 to 5 L of
blood, femur fractures 1 to 4 L, and arm frac- detrimental to the survival of vital organ patient in shock, the speed with which
tures 0.5 to 1 L from the vasculature. tissues. Patients present with the classic resuscitation is initiated and the time
342 Part 4: Maxillofacial Trauma
Table 18-5 Estimated Fluid and Blood Losses* cal observations of these parameters are
difficult to quantitate, as is measuring
Class I Class II Class III Class IV
improvement of stabilization of the circu-
Blood loss (mL) Up to 750 7501,500 1,5002,000 > 2,000 latory system.
Blood loss (% vol) Up to 15 1530 3040 > 40 Adequate urine production is a pre-
Pulse rate < 100 > 100 > 120 > 140 dictable sign of renal function, except in
Blood pressure Normal Normal Decreased Decreased
cases in which urine production may be
enhanced by the use of diuretics. For this
Pulse pressure Normal or Decreased Decreased Decreased
reason, urinary output is a prime indication
increased
of resuscitation and patient response. A
Respiratory rate 1420 2030 3040 > 35
Foley catheter should be placed in the blad-
Urine output (mL/h) > 30 2030 515 Negligible der as soon as possible to measure urinary
Mental status Slightly Mildly Anxious, Confused, flow. There are three contraindications for
anxious anxious confused lethargic the insertion of a Foley catheter, and the
Fluid replacement Crystalloid Crystalloid Crystalloid Crystalloid catheter should not be placed until all have
and blood and blood been ruled out. These contraindications in
Adapted from American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: student the traumatized patient are the presence of
course manual. 6th ed. Chicago: American College of Surgeons; 1997. p. 98. blood at the urethral meatus, of hemor-
*Based on the initial presentation of a 70 kg man.
The guidelines in the table are based on the 3-for-1 rule. This rule is derived from the empiric observation that most rhage into the scrotum, and of a high-
patients in hemorrhagic shock require as much as 300 mL of electrolyte solution for each 100 mL of blood loss. Applied
blindly, these guidelines can result in excessive or inadequate fluid administration. For example, a patient with a crush
riding prostate (Figure 18-14A).3335
injury to the extremity may have hypotension out of proportion with his or her blood loss and requires fluids in excess of Attempts to pass a catheter up an injured
the 3:1 guidelines. In contrast, a patient whose ongoing blood loss is being replaced by blood transfusion requires < 3:1.
The use of bolus therapy with careful monitoring of the patients response can moderate these extremes.
urethra can convert an incomplete lacera-
tion into a complete laceration and can
introduce infection into the perineal and
required to reverse shock are the factors catheters of the same length and diameter, retropubic hematoma. A rectal examination
crucial to the patients outcome.32 The whether inserted peripherally or centrally, should be performed in all trauma patients
focus should again always be on control- give the identical flow rate, but a longer with suspected pelvic trauma before place-
ling the hemorrhage, whether it be central catheter delivers a lower possible ment of a catheter. With posterior urethral
through basic measures such as pressure maximum flow rate than does a shorter disruption, the prostate may be forced supe-
and elevation or through rapid peripherally placed catheter. A central line riorly by a hematoma; if the prostate cannot
imaging/surgical intervention. Two large- through the subclavian or internal jugular be palpated, a urethral injury should be sus-
bore (16 gauge or larger) short angio- vein routes usually takes longer to place pected (Figure 18-14B).36
catheters are a minimum for beginning than does a peripheral line and may The initial intravenous resuscitation
fluid therapy. Initial attempts should be require disruption of other resuscitation fluid used in most hospitals is a balanced
made to place percutaneously the measures such as chest compressions dur- electrolyte solution such as lactated
catheters in the basilic or cephalic veins in ing placement. Furthermore, a central line Ringers solution or 0.9% normal saline.
the antecubital fossa of both arms. Percu- may complicate resuscitation of the trau- During prolonged shock, isotonic fluid is
taneous placement of femoral, jugular, or ma victim by causing or aggravating a lost from the intravascular and interstitial
subclavian vein catheters may also be used developing pneumothorax or hemotho- spaces to the extracellular space. Initially,
if there are no abdominal injuries or rax or other potential complications asso- the patient should be given 2 L of intra-
pelvic or femur fractures. When the ciated with its placement. Therefore, venous fluid (20 mL/kg for a pediatric
patient is in an extreme hypovolemic peripheral intravenous lines are the access patient) rapidly over 10 to 15 minutes and
state, placement of percutaneous of choice in the primary management of then observed. If this maneuver does not
catheters may be difficult; venous cut- the trauma patient. raise the systolic blood pressure to at least
down procedures to expose the saphenous Circulatory support and proper oxy- 80 to 100 mm Hg, the patient requires
vein provide venous access for fluid resus- genation of tissues require adequate sys- additional fluid, blood, and control of
citation. Flow is directly dependent on the tolic and diastolic blood pressure levels, blood loss. There is still controversy about
catheters internal diameter and is inverse- pulse pressure levels, pulse rate character- the use of colloids (albumin, plasma pro-
ly dependent on its length. Therefore, two istics, and capillary refill times. The clini- tein fractions) and artificial plasma
Initial Management of the Trauma Patient 343
circulation back to the heart. Frequently, damage or changes in ICP. Further pleted and management of life-threatening
the patient with multisystem trauma has changes in pupil reactivity or levels of con- conditions has begun. During the secondary
injuries to the abdomen or chest that may sciousness may be due to alterations in assessment the patients vital signs and
interfere with the respiratory capacity if ventilation or oxygenation status. The condition should be constantly monitored
the patient is in the Trendelenburgs posi- most common causes of coma or to evaluate the therapeutic interventions
tion. Alternatively, both of the patients depressed levels of consciousness are initiated during the primary assessment
legs can be elevated while the patients hypoxia, hypercarbia, and hypoperfusion and to further assess the patient for any
trunk is maintained in a supine position.43 of the brain.42 Depressed levels of con- other life-threatening problems not evi-
sciousness and narrow pinpoint pupils dent during the primary survey. Changes
Neurologic Examination may result after an opiate overdose. After in the patients vital signs, respiratory and
Upon completion of the assessment of the an overdose with meperidine hydrochlo- circulatory status, and neurologic func-
cardiovascular system and control of any ride, the pupils may appear normal or
external hemorrhage, a brief neurologic dilated. In both cases, treatment requires
evaluation is performed to establish the the narcotic antagonist naloxone
patients level of consciousness and pupil- hydrochloride, 0.4 mg initially. Care
lary size and reaction. This brief neuro- should be taken to avoid a quick violent Airway
logic examination quickly identifies any withdrawal phase in the opiate abuser; this Cervical collar
severe CNS problems that require imme- is accompanied by profound distress, nau-
Intravenous
diate intervention or additional diagnos- sea, agitation, and muscle cramps. lines
tic evaluation. A lack of consciousness Both hypoglycemia and hyper-
with altered pupil reaction to light glycemia can cause depressed levels of
requires an immediate CT scan of the consciousness. If a quick blood glucose Chest tube
head and management with mannitol or level cannot be obtained (and depending
fluid restrictions. Be aware of any medica- on other injuries), the patient can be
tions that the patient may have received or given and immediate bolus of 25 g of glu-
drugs he or she may have taken that may cose to manage critical hypoglycemia. A
affect the pupils. benefit of the glucose load is the hyperos-
The Committee on Trauma of the molar status that may, for a short time,
Foley catheter
American College of Surgeons recom- reduce cerebral edema.44
mends the use of the mnemonic AVPU.7,8
In this system, each letter describes a level Exposure of the Patient
of consciousness in relation to the The patient should be completely disrobed
patients response to external stimuli: so that all of the body can be visualized,
alert, responds to vocal stimuli, responds palpated, and examined for injuries or
to painful stimuli, and unresponsive. bleeding sites. The clothing must be com-
A more detailed quantitative neuro- pletely removed, even if the patient is
logic examination is part of the secondary secured to a spinal backboard. The easiest
survey of the trauma patient. The primary method is to cut the clothing down the
survey establishes a baseline; if the midline of the torso, arms, and legs to FIGURE 18-15 The primary assessment of the
patient with multiple injuries requires evalua-
patients neurologic condition varies from facilitate the examination and assessment.
tion and maintenance of an adequate airway
the primary to the secondary survey, a Frequent careful reevaluation of the with cervical protection, adequate breathing
change in intracranial status may be pre- injured patients vital signs is important to (including the placement of chest tubes to cor-
sent. A decrease in the level of conscious- monitor the patients ability to maintain rect alterations in normal lung and chest wall
physiologic conditions), and adequate circula-
ness may indicate decreased cerebral oxy- an adequate airway, breathing, and circu- tion and hemodynamics, with the placement of
genation or perfusion. lation (Figure 18-15). two large-bore intravenous lines peripherally
The reactivity of the pupils to light and the insertion of a Foley catheter after pos-
provides a quick assessment of cerebral Secondary Assessment sible urethral damage is ruled out. The patient
should be totally exposed so that the entire
function. The pupils should react equally. The secondary assessment does not begin body can be examined for injuries. Adapted
Changes represent cerebral or optic nerve until the primary assessment has been com- from Powers M.15
Initial Management of the Trauma Patient 345
tions are expected in the first 12 hours.7 caused by increased ICP that can be con- Dura
The secondary assessment includes a sub- trolled with aggressive management.
Subdural hematoma
jective and objective evaluation of the Failure to prevent increased ICP is the
injured patient. most frequent cause of death in hospital- Cranium
A subjective assessment should ized patients with a severe head injury.
Falx cerebri
include a brief interview with the patient, Hypertension with concomitant brady-
if possible. A brief health history can be cardia may indicate increasing ICP
useful, including medications; allergies; (Cushings phenomenon). Hypotension Dura
previous surgery; a history of the injury; with tachycardia usually indicates blood
and the location, duration, time frame, loss. Shock is rarely associated with the
and intensity of the chief complaint. Obvi- primary neurologic injury, and systemic
sources of blood loss should be investi- Intracerebral
ously, the comatose patient cannot pro-
hematoma
vide useful subjective information, but gated. The classic findings of Cushings
family members, bystanders, or other vic- phenomenon are usually present < 25% Dura
tims may provide some details. of the time, even when the ICP is found
Epidural
The objective assessment should to be > 30 mm Hg and a value > 15 mm hematoma
involve inspection, palpation, percussion, Hg is considered abnormal.
and auscultation of the patient from head Accurate continual neurologic assess-
to toe. Each segment of the body (head ment and examination for mass lesions
and skull, chest, maxillofacial area and with CT scans are rapid noninvasive tech- Middle meningeal
neck, spinal cord, abdomen, extremities, niques that are not life threatening for the artery
and neurologic condition) is evaluated to patient with a head injury and that estab-
provide a baseline of the patients present lish a baseline examination for future FIGURE 18-16 Mass lesions commonly associated with
head trauma include epidural hemorrhage, subdural
condition. Special procedures such as studies. When an intracranial injury is sus- hemorrhage, and intracerebral hemorrhage. A subdural
peritoneal lavage, radiographic studies, pected, CT scans can quickly and easily be hematoma is usually caused by venous bleeding with
and further blood studies may be done at used to diagnose localized intracranial progressive loss of neurologic function. The epidural
hemorrhage (Figure 18-17), contusion, hematoma is usually associated with skull fractures near
this time. the temporoparietal region, with tearing of the middle
foreign bodies, and skull fractures. In meningeal artery. Adapted from Powers M.15
Head and Skull addition, secondary effects of trauma such
Primary injuries to the head and skull as edema, ischemia, infarction, brain shift,
may involve lacerations, abrasions, avul- and hydrocephalus can be seen on CT gested that a CT of the head be obtained in
sions, and contusions of the scalp; frac- scans. In the acutely traumatized patient, all patients with blunt head trauma who
tures of the cranium and cerebral contu- CT scans can be used to diagnose intra- have experienced a loss of consciousness
sions; and intracranial bleeding to the cerebral and extracerebral blood collec- or mild amnesia, even those with normal
brain from lacerations or shearing tions with nearly 100% accuracy. A signif- neurologic findings.45
injuries. The brain may also suffer sec- icant mass lesion can cause cerebral Extreme care should always be taken
ondary insults from intracranial bleed- ischemia by elevating ICP or by compress- when moving a patient with a head trauma
ing, hypoxia, and ischemia. Hypoxia is ing vascular structures. A CT scan should to the CT machine because of the high
due to an impaired delivery of oxygen to be done immediately following stabiliza- incidence of associated cervical spine frac-
the brain, whereas ischemia can result tion of the injured patient, rather than tures in patients with head and facial trau-
from arterial hypotension, elevated ICP, waiting for signs of an expanding intracra- mas.46 If trauma to the spine is suspected,
or pressure on intracranial vessels from nial hematoma. Indications for a CT scan the cervical spine should be immobilized
expanding hematomas resulting in a her- include seizure activity, unconsciousness before the patient is moved and the CT
niation of the brain from the cranial lasting for more than a few minutes, examination should be extended to study
vault (Figure 18-16). The secondary abnormal mental status, abnormal neuro- the cervical spine as well. In addition, any
insults of hypoxia and various forms of logic evaluation, and evidence of a skull suspected facial injuries should be exam-
ischemia are usually preventable. About fracture found on physical examination. ined by extending the CT examination
one-half of patients with head injuries There is still controversy regarding when a inferiorlyas low as the inferior border of
have some degree of reversible injury head CT is appropriate. It has been sug- the mandible. Unfortunately, in many cases
346 Part 4: Maxillofacial Trauma
A B C
FIGURE 18-17 Computed tomography scans demonstrating anatomic variances associated with intracranial bleeding. A, Subarachnoid hemorrhage is
defined as blood within the cerebral spinal fluid and meningeal intima and probably results from tears of small subarachnoid vessels. Blood is spread
diffusely through the arachnoid matter and usually does not cause mass effect, but may predispose a patient to cerebral vasospasm. B, Intracerebral hem-
orrhage is formed deep within the brain tissue and is usually caused by shearing or tensile forces that mechanically stretch and tear deep small-caliber arte-
rioles as the brain is propelled against irregular surfaces in the cranial vault. Note the surrounding edema and mass effect. C, Subdural hematomas are
blood clots that form between the dura and the brain. They are usually caused by the movement of the brain relative to the skull, as is seen in acceleration-
deceleration injuries. Note the considerable shift of midline to the right.
evaluation and treatment of facial injuries The head should be examined for signs of a best verbal response, and best motor
must be delayed for a significant time, basilar skull fracture: hematoma over the response. Two regions of the brain, if
which means that the patient is needlessly mastoid process behind the ears (Battles injured, can produce unconsciousness;
transported back to the radiology depart- sign); hemotympanum; cerebrospinal fluid the cerebral cortices bilaterally and the
ment for further studies because of failure (CSF), rhinorrhea, or otorrhea; and subscler- brainstem reticular activation system
to initially extend the CT examination. al hemorrhage. Whenever a basilar skull frac- regardless of the cause of injury, can also
As ICP increases above normal, a fair- ture is suspected, a nasogastric tube should depress the level of consciousness.7
ly standard progression of neurologic not be used because the tube may inadver- Examination of the motor function is
abnormalities ensues, involving sections of tently pass into the cranial vault. part of the GCS, which gives information
the brain sequentially: the cerebral cortex, The neurologic examination should about any asymmetry of function. The con-
producing an altered state of conscious- be brief and should evaluate the level of scious patient should be asked to move the
ness; the midbrain, producing dilation and consciousness, motor and cranial nerve extremities in response to commands. An
then fixation of the pupils, initially on the function (suggestive of developing mass inability to do so may represent damage to
side of the lesion, with varying degrees of lesions), brainstem findings, and trends in the limb or spinal cord. In the unconscious
bilateral hemiparesis; the pons, resulting the neurologic status. Alcohol and drug patient, deep tendon reflex and plantar
in a loss of the corneal reflex and the intoxication are frequently associated with response testing can assess both sensory
occurrence of the dolls eye reflex (Figure injured patients in the trauma situation input and motor output. Of special concern
18-18); and the medulla, producing, in and may complicate the neurologic exam- is abnormal posturing and nonpurposeful
sequence, apnea, hypotension, and death. ination. A decreased level of consciousness movement to stimulus. Abnormal flexor
The physical examination of the head should not be attributed to alcohol or activity (decorticate) involves flexion of the
should include an examination of the scalp other drugs until intracranial pathologic forearms on the chest with flexion of the
for lacerations and foreign bodies. Because of conditions have been ruled out. wrists and fingers; in abnormal extensor
the rich vascular supply of the scalp, especial- The GCS (discussed above) provides a posturing, the arms, hands, and fingers are
ly in children, scalp injuries may result in sig- simple method of grading consciousness extended with the hands abducted. In both
nificant blood loss. Lacerations may overlie an and functional capacity of the cerebral cases the lower extremities are extended
injury to the cranium, or intracranial hemor- cortex (see Table 18-1). It can be used and no attempt is made to localize the point
rhage may be present. An untreated scalp both in the field and as a reassessment of stimulation. Although bilateral extensor
wound with a cranial injury may eventually tool to assess brain function, brain dam- plantar responses are nonspecific, a unilat-
act as a port for bacteria to enter the injured age, and patient progress, based on the eral Babinski sign points to corticospinal
area, causing meningitis or a brain abscess. three behavioral responses: eye opening, tract damage.
Initial Management of the Trauma Patient 347
Pupillary function, eye movements, autonomic innervation of the eyes. The dolls eye reflex, requires an intact vestibu-
and eye opening can provide information iris is supplied by both sympathetic and lar or acoustic (seventh) nerve to permit
about the level of consciousness, as well as parasympathetic fibers. Stimulation of the head rotation to evaluate reflexive move-
about brainstem function. The size, shape, sympathetic fibers causes the pupil to ment of the eyes (see Figure 18-18). Obvi-
and reactivity of the pupil to light provide dilate and upper eyelid to elevate. ously this maneuver is not to be used with
information about second and third nerve Thus, significant information about patients who have a suspected cervical
function and midbrain activity. A sluggish the trauma patient can be obtained by spine injury. The oculovestibular response
reactive or a dilated nonreactive (blown) looking into the eyes. If a light is shone test evaluates the third, fourth, sixth, and
pupil on one side indicates compression of into the right eye and the left eye does not eighth cranial nerves, as well as brainstem
the third cranial nerve by brain herniation respond, there may be a disruption of the activity. In this test the external auditory
in the unconscious patient. The pupillary right optic or left oculomotor nerves. If canal is irrigated with cold water; there
light reflex can be used to evaluate cranial the light is then shone into the left eye and should be full eye movement toward the
nerve function and possible elevated ICP it does not respond, a disruption of the ear canal lavaged with cold water. If not,
with brain herniation. In normal activity, third cranial nerve should be suspected. there may be a disruption along any of the
when light is shone in one eye, both pupils Pupillary dilatation of one eye may be due neural tracts or of the tympanic mem-
constrict equally. The optic or second cra- to a developing brain herniation on the brane (see Figure 18-18).
nial nerve carries both visual and pupillary ipsilateral side, with bilateral pupillary A lumbar puncture should not be
fibers. The optic nerves connect shortly dilatation suggestive of significant mid- performed in patients with acute head
after they leave the retina to form the optic brain injury or loss of parasympathetic injuries. The change in pressure associat-
chiasm. At the optic chiasm, the nasal function. Conversely, pinpoint pupils after ed with the removal of CSF from the lum-
fibers cross to join the temporal fibers head trauma may indicate drug overdose bar region may precipitate cerebral herni-
from the other eye, and the visual fibers or loss of sympathetic tone as seen in ation in the patient with an elevated ICP.
cross to the visual occipital cortex. The Horners syndrome. CSF emerging from the nose or ear is
pupillary fibers are relayed bilaterally to The function of the brainstem may commonly associated with a basilar skull
the Edinger-Westphal nucleus of the ocu- also be assessed with evaluation of the fracture. Clear or red-tinged fluid that
lomotor or third cranial nerve. The cranial corneal reflex, which involves sensory drains from the nose or ear should be
nerve supplies the sphincter muscle of the input from the trigeminal (fifth) nerve. considered to be CSF. There is no reliable
iris, allowing it to contract. There is also The oculocephalic maneuver, or test of the method available in the emergency
A B C
FIGURE 18-18 Responses that test the third, sixth, and eighth cranial nerves, as well as ascending brainstem pathways from the pontomedullary junction to the
mesencephalon. A, The caloric response (oculovestibular maneuver) involves the placement of cold water into the ear. In a comatose patient, the eyes should ton-
ically deviate toward the irrigated ear. B, Patient at rest. C, In the oculocephalic response (dolls eye reflex) in comatose patients, the head is turned from the mid-
line and there is a reflex movement of the eyes in the opposite direction of head rotation. Adapted from Powers M.15
348 Part 4: Maxillofacial Trauma
department for distinguishing CSF from of possible seizure activity. Ongoing hematocrit, and urinalysis should be
nasal mucosa. The use of glucose indicator seizures may be controlled with a benzodi- obtained. Six potentially lethal injuries to
sticks is associated with a high incidence of azepine. Neurosurgical consultation consider in the secondary assessment are
false-positive results. A useful aid may be a should be obtained early in the manage- pulmonary contusion, aortic disruption,
ring sign. A drop of the fluid from the ment of any obvious head trauma. Patients tracheobronchial disruption, esophageal
nose or ear is placed on a piece of filter with severe head injuries (GCS < 8) disruption, traumatic diaphragmatic her-
paper. If the fluid is CSF, the blood compo- should undergo rapid sequence intubation nia, and myocardial contusion.7
nents of the fluid remain in the center and technique for airway protection and better Pulmonary contusions are treated in
rings of clear fluid form around them.7 control of ICP. The patients ICP is con- the same manner regardless of whether
A CT scan should be performed to trolled using various techniques, including there is an accompanying flail chest injury.
determine whether there is a fracture reverse Trendelenburg position, osmotic Pulmonary contusions are common in
site. The head of the bed should be ele- diuresis (mannitol), hyperventilation of blunt chest trauma because the capillary
vated to 90. If indicated, the fracture the intubated patient (although there is damage within the lungs results in intersti-
should be reduced. The leakage should little or no documented benefit to this tial and intra-alveolar edema and shunting.
cease after 7 days; if it does not, neuro- procedure), sedation, pharmacologic Pulmonary contusions and adult respira-
surgical procedures may be indicated to paralysis, and phenobarbital coma (last tory distress syndrome (ARDS) are the
repair the dural tear. resort). Judicious use of resuscitative fluids most common potentially lethal chest
A rectal examination is an essential and control of systemic hypertension also injuries seen in the United States because
part of the examination of the patient with help to control ICP. the resulting respiratory failure does not
a head injury. Rectal sphincter tone is pre- occur instantaneously but develops in 24 to
sent if the injury is intracranial only; if Chest 72 hours.24 The patient may complain of
there is no rectal tone, a coexisting spinal Throughout the secondary assessment of pain and dyspnea, and blood gas levels
cord injury is present. Coexisting head and the multiply injured patient, the primary tend to deteriorate progressively over the
spine injuries should be suspected until evaluation of airway, breathing, and circu- initial 48 to 72 hours as increasing edema
proven otherwise. lation must be monitored for development develops in the alveoli. Chest radiographs
A head injury is initially classified as of difficulties or overlooked problems. reveal a developing opacification of the
mild (GCS 1315), moderate (GCS 912), Pneumothorax, open pneumothorax, involved areas. Treatment involves ade-
or severe (GCS 8). Patients with head hemothorax, flail chest, and cardiac tam- quate ventilation of the lungs, including
injuries who experience no loss of con- ponade may develop after the primary chest physiotherapy, supplemental oxygen,
sciousness, no amnesia, no palpable frac- assessment and must be treated according- coughing with deep breathing, and
tures, and a GCS score of 15 can be dis- ly. It is estimated that chest injuries are nasotracheal suction. If ventilatory assis-
charged home to a reliable caretaker; brain responsible for 20 to 25% of all trauma tance is required, spontaneous ventilation
imaging is unnecessary, although it is gen- deaths per year in the United States.26 with intermediate mechanical ventilation
erally recommended that CT imaging be The secondary assessment of chest
performed due to its low cost and its con- trauma involves the evaluation of an
venience. Patients who experience a loss of upright chest radiograph for the presence
consciousness or amnesia, or have a GCS of air in the mediastinum or under the
score of 13 or 14 must undergo an imme- diaphragm, widening of the mediastinum
diate head CT. If this noncontrast study with a shift toward the midline, thoracic
finding is negative, the patient can be dis- injuries and fractures that alter lung expan-
charged to a reliable caretaker. If there is a sion, and the presence of fluid. Figure 18-
focal neurologic finding on examination, a 19 shows a chest radiograph of a patient
GCS score of < 13, or an intracranial without chest trauma. In most instances
lesion seen on the head CT, the patient the trauma patient needs to be immobi-
should be admitted to an intensive care lized on a backboard (Figure 18-20), and a
unit or neurologic observation unit for supine film is substituted for an upright
continuing care. The administration of one. If a chest injury is suspected, a CT
prophylactic phenytoin at a loading dose scan should also be obtained. An electro-
of 18 mg/kg IV is used by some for control cardiogram, arterial blood gas analysis, FIGURE 18-19 Normal upright chest radiograph.
Initial Management of the Trauma Patient 349
motor vehicle accidents. Multiple studies should be obtained and read prior to the ments. Abdominal breathing and the use
have reported a 10 to 20% association of removal of stabilization. If a helmet is of the respiratory accessory muscles will
cervical spine injuries with maxillofacial worn by the victim, the helmet should be be evident.7
injuries in the multiply traumatized secured to the long spine board with 8 cm Bachulis and colleagues evaluated
patient although recent data suggest no cloth tape, and cervical spine radiographs 4,941 trauma victims between February
increase in cervical spine injury when facial should be taken and cleared for cervical 1981 and July 1985 and found that 1,923
trauma is present.48,49 Approximately 55% spine injury before the attempted removal (39%) had radiographs taken of their cer-
of spinal injuries occur in the cervical of the helmet. vical spines.51 Injuries to the cervical spine
region, 15% in the thoracic region, 15% in Physical examination of the patient were detected in 94 patients (5%). Ninety
the thoracolumbar junction, and 15% in with a suspected spinal injury should be of these patients had cervical spine frac-
the lumbosacral area.8 Identification of done carefully, with the patient in a neutral tures; four had a disruption of the cervical
cervical spine injury is essential in the position and with minimal movement of longitudinal ligaments without bony
management of blunt trauma because a the spine and head (see Figure 18-20). The injury and were quadriplegic. In the study
missed injury can result in catastrophic presence of an unstable cervical spine the overall incidence of cervical spine
spinal cord damage. Tetraplegia as a result injury must be considered in the evalua- injury in the trauma patient was 2%. Neu-
of cervical spine injury is not only a tion and resuscitation of every patient with rologic deficit did not develop in any
tragedy for the patient; it also represents a injuries associated with blunt trauma. The patient with a neurologically intact spinal
tremendous financial burden to society.50 catastrophic physical consequences of irre- cord at the time of admission. The
According to the National Spinal Cord versible quadriplegia, as well as the huge researchers found that, of the 94 patients,
Injury Center Databank, in July 1996, the economic costs required to care for this there were 65 alert patients with no neuro-
average medical cost of the first year of a lifelong disability, require that great care logic deficits who had unstable cervical
cord injury involving C1 through C4 was must be taken to rule out unstable cervical spine injuries. Without exception, these
$417,000 (US).50 Patients can be expected spine injury. The patient should be treated patients either complained of neck pain or
to have medical costs of $1,350,000 over as if there has been an unstable injury to of pain on palpation of the neck. Other
the course of their lifetime as well as lost the nerves, bone, muscles, and other struc- studies have reported that no alert patient
wages and productivity. Patients can then tures of the neck until there is positive clin- without neck pain was found to have any
expect a greatly shortened life span, which ical and radiographic evidence that there is cervical injury.51 Fischer concluded that a
varies according to the age of the patient at no injury. The neck and spine should be screening radiographic examination of the
the time of injury.48 carefully examined for deformity, edema, cervical spine is not indicated in the alert,
A description of the mechanism of ecchymosis, muscle spasm, and tenderness sober, and cooperative patient with no
injury, especially high-velocity accident, while being carefully supported to avoid complaints of neck pain and no tender-
may give clues to a possible injury of the further damage associated with an unsta- ness to palpation of the neck, even when
spine such as a whiplash injury. The ble cervical neck injury. significant injury is present; however, the
patient may experience little discomfort The neurologic examination of the author does recommend screening for all
from major injury to the chest, abdomen, patient with a spinal injury is similar to patients with decreased levels of con-
and extremities as a result of sensory loss that of the patient with closed head trau- sciousness and a history of an injury that
from a spinal injury. Because of the loss of ma. The mental status, motor function, could have conceivably injured the cervical
sympathetic tone with cervical injuries, sensation over dermatomes, brainstem spine, for all patients with neurologic
the patient may present with a systolic reflex, and spinal reflexes should all be deficits compatible with cervical origin,
blood pressure level of 70 to 80 mm Hg evaluated and charted. The patient should and for all patients with neck pain or ten-
without the tachycardia, cool extremities, be carefully examined for rectal tone and derness.51 Cervical spine injuries may
poor perfusion, and decreased urinary bladder control as evidence of autonomic result from axial loading, flexion, exten-
output noted in the patient with hypo- function. Hypoventilation caused by sion, rotation, lateral bending, and distrac-
volemic shock. The neurologic shock is paralysis of the intercostal muscles results tion or combinations of these mechanisms
due to dilatation of the arterial system, loss from injury to the lower cervical or upper of injury (Figure 18-21).
of muscle tone, and loss of reflexes. The thoracic spinal cord. If the upper or mid- In the study by Bachulis and col-
absence of neurologic deficit does not dle cervical spin is injured, the diaphragm leagues, lateral cross-table cervical spine
exclude injury to the cervical spine. A will also be paralyzed as a result of involve- radiographs were obtained in all injured
complete series of cervical radiographs ment of the C3 though C5 spinal cord seg- patients and demonstrated cervical spine
Initial Management of the Trauma Patient 351
injury in 70 patients but not in the other (anteroposterior, oblique cervical, and lat- bilization device such a cervical collar
24, for an unacceptable false-negative rate eral cervical) plus an open-mouth odon- allows significant movement of the cervical
of 26%. The authors recommended that toid view or a CT scan of the neck coupled spine.53 The recommended stabilization
all patients at risk for cervical spine injury with adequate cervical spine immobiliza- for patients with cervical fractures is a cer-
must have a complete initial radiographic tion during evaluation and resuscitation vical collar in combination with a long
examination, including lateral, anteropos- should allow the cervical spine to be spinal board. Appropriate head holders or
terior, odontoid, and right and left viewed safely. sandbags should be used bilaterally to sup-
oblique views of the cervical spine. CT On a lateral cervical spine radiograph, port the neck laterally, and the head should
scanning was found to be the most useful the soft tissue thickness between the phar- be secured with an 8 cm cloth tape across
modality to confirm a cervical spine ynx and osseous C3 should be < 5 mm. An the forehead and around the board (see
injury in those patients with a suspected increase in this area suggests a fracture. The Figure 18-20). Obviously, maintaining a
injury to the cervical spine not confirmed distance may vary with inspiration or expi- stable airway is critical in patients who
on plain film radiographs. They recom- ration.7 On the lateral view the features to have suffered significant head and neck
mend the use of CT scans of the neck for be examined are the general contour of the trauma. Cervical neck protection as well as
patients with a possible neck injury and spine, the vertical alignment of the anteri- a nasal trumpet or similar airway protec-
associated head injury that requires a CT or and posterior margins of the vertebral tion device may be indicated to maintain a
scan of the brain, for patients in whom bodies, the midlaminar line, the width of patent airway. If the airway becomes unsta-
radiographic visualization of C6 or C7 are the spinal column, and evidence of com- ble, nasotracheal intubation or cricothy-
difficult, and for patients with a suspected pression or fracture of individual verte- roidotomy should be performed, in that
cervical injury that is not detected in brae. On anteroposterior views the height order, always ensuring that the cervical
screening radiographs.46 A recent study by and alignment of the spinous processes spine continues to be stabilized.
Griffen and colleagues concluded that CT and the interspinous distances are exam- CT should be used for further evalua-
scanning of the cervical spine should ined. The discovery of any findings sug- tion of detected or suspected fractures,
replace plain film studies in blunt trauma gesting the presence of a cervical spinal evaluation of questionable plain films, and
patients completely.52 injury mandates the use of protective mea- to complete radiographic examination of
Visualization of all seven cervical ver- sures. It has been demonstrated that a sta- areas not well visualized by plain films.
tebrae is important (see Figure 18-21).
The shoulders must be distracted inferior-
ly by pulling down on the arms to provide
a clear view of the spinal anatomy from C6
through T1. It is important that a clear
view of the spine at the C6 and C7 level be
obtained without obstruction by the
shoulders to obtain a proper diagnostic
study. If visualization of C6 and T1 cannot
be obtained, the radiographic view may be
improved by placing the arms in a swim-
mers position, with downward traction
on one arm and upward traction on the
other and the radiograph beam aimed
through the axilla of the upward arm.
Radiographs should be examined for frac-
tures and fracture dislocations of the spine
by evaluation the anteroposterior diame-
ter of the spinal canal; the contour and
alignment of the vertebral bodies; dis- A B
placement of bony fractures of the lami-
FIGURE 18-21 Normal cervical radiographs: A, lateral; B, anteroposterior. Radiographs should be
nae, pedicles, or neural fascicles; and soft examined for prevertebral edema, subluxation, widening of the interspinous distance, widening of the
tissue swelling.18 Three-way cervical views atlantodental interval, bony fractures, malalignment, or jumped facets.
352 Part 4: Maxillofacial Trauma
The lower cervical spine often is not well ma. A DPL is usually performed with a ster- and, if used early enough, in determining
visualized on radiographs, even with use ile intravenous catheter inserted percuta- renal artery injury. Disadvantages include
of the swimmers position, and a CT scan neously through a small midline incision suboptimal sensitivity for injuries of the
is frequently required. about 2.5 to 4 cm below the umbilicus. The pancreas, diaphragm, small bowel, and
catheter is advanced into the pelvis after the mesentery. Injuries of the small bowel and
Abdomen bladder has been emptied. If no blood, bile, mesentery can have profound morbidity
With abdominal trauma, the physical or intestinal fluid is aspirated, the abdominal and even mortality if not diagnosed early.
examination is an informative portion of cavity is irrigated with 1 L of saline. The fluid In the absence of hepatic or splenic
the diagnostic evaluation. Penetrating is then drained from the abdomen through injuries, the presence of free fluid in the
wounds must be identified, and many sur- the intravenous tubing. It is generally felt abdominal cavity suggests an injury to the
geons believe that the safest management that the presence of 100,000 red blood cells gastrointestinal tract and/or its mesentery
of penetrating wounds is a laparotomy.7 or 500 white blood cells per cubic millimeter and mandates early surgical intervention.
The abdominal girth should be measured after blunt trauma is sufficient to make a Complications also can result from intra-
at the umbilicus soon after admission to laparotomy mandatory (Table 18-6). venous contrast administration. The cost
establish a baseline against which to evalu- CT scanning of the abdomen is also can also be significant, especially if estab-
ate possible intra-abdominal bleeding. acceptable if the patient is stable and lished indications are not followed.
Abdominal rigidity and tenderness are emergent laparotomy is not indicated. The Ultrasonography or focused assess-
important signs of peritoneal irritation by advantages to CT include that it is nonin- ment with sonography for trauma is rapid-
blood or internal contents, and they may vasive; it is capable of discerning the pres- ly becoming an integral diagnostic compo-
be the main indications for a laparotomy ence, source, and approximate quantity of nent in trauma centers. Ultrasonography
of a patient injured by blunt trauma. Rec- intraperitoneal hemorrhage; and it occa- has undergone a large number of clinical
tal and pelvic examinations are essential if sionally can demonstrate active bleeding. evaluations in Europe, Asia, and the United
there is a question of pelvic or perineal CT scanning coincidentally evaluates the States. Its primary role is detecting free
injury. A nasogastric tube should be retroperitoneuman area not sampled by intraperitoneal blood after blunt trauma.
passed, if possible, into the stomach to DPLas well as the vertebral column and This is accomplished by a focused exami-
remove gastric contents. can be readily extended above or below the nation of specific anatomic areas where
Plain films have limited value in abdomen to visualize the thorax or pelvis. blood or fluid is most likely to accumulate.
abdominal trauma. They can be useful in It is helpful in the evaluation of hematuria Ultrasonography can also evaluate the
localizing foreign bodies, bony structures,
and free air with the use of anteroposteri-
or and cross-table views.
Table 18-6 Parameters for Evaluation of Peritoneal Lavage Fluid
The use of diagnostic peritoneal lavage
(DPL), once a standard diagnostic test used Positive 20 mL gross blood on free aspiration (10 mL in children)
in blunt and occasionally penetrating 100,000 RBCs/mm3
abdominal traumas, has decreased signifi- 500 WBCs/mm3 (if obtained 1 h after the injury)
175 U amylase/100 mL
cantly with the advancement in CT and
Bacteria (determined with Grams stain)
ultrasonography. DPL is indicated in
Bile (by inspection of chemical determination of bilirubin content)
patients with a history of blunt abdominal
Food particles (microscopic analysis of strained or spun specimen)
trauma and increasing pain, patients with
unexplained hypovolemia following multi- Intermediate Pink fluid on free aspiration
ple trauma, patients who are candidates for 50,000100,000 RBCs/mm3
100500 WBCs/mm3
laparotomy but who have questionable find-
75175 U amylase/100 mL
ings, and patients who have experienced
severe trauma and who may require an Negative Clear aspirate
extended period under general anesthesia.7 50,000 RBCs/mm3
Absolute contraindications to DPL are a his- 100 WBCs/mm3
tory of multiple abdominal operations and < 75 U amylase/100 mL
obvious indications for an exploratory Adapted from Powers M.15
RBC = red blood cell; WBC = white blood cell.
laparotomyfree air and penetrating trau-
Initial Management of the Trauma Patient 353
pericardial space and intraperitoneal Indeterminate studies require follow-up. forced superiorly by a hematoma. If the
spaces. Ultrasonography carries a host of Ultrasonography is less sensitive and prostate is not palpable, a genitourinary
advantages: more operator dependent than is DPL injury should be suspected.33
in revealing hemoperitoneum and Absence of blood at the meatus and
It is a portable instrument that can be
cannot distinguish blood from ascites. palpability of the prostate on rectal exam-
brought to the bedside in the trauma
Ultrasonography (as well as DPL) ination are sufficient evidence to allow the
resuscitation area.
does not detect the presence of solid passage of a urethral catheter. If resistance
Studies of the pericardial and
parenchymal damage if free intraperi- is noted, the catheter should be removed.
intraperitoneal spaces can be accom-
toneal blood is absent, as in subcapsu- Retrograde urethrography is the best
plished in < 5 minutes.
lar splenic injury.56 method to establish continuity of or dam-
Sensitivity in detecting as little as 100
Finally, ultrasonography is poor for age to the urethra.33
mL to, more typically, 500 mL of
detecting a bowel injury in which Urine should be obtained and evaluat-
intraperitoneal fluid ranges from 60
hemorrhage tends to be inconsequen- ed for the presence of blood. A urinalysis
to 95% in most recent studies, and
tial, and failure to diagnose hollow vis- of 10 or more red blood cells on a high-
specificity for hemoperitoneum is
cus perforation in a timely manner power field is suggestive of a urinary sys-
excellent.54
can have catastrophic results. tem injury. Hematuria is the best indicator
Unlike DPL, ultrasonography can
of renal injury, and the degree of hema-
rapidly gauge the mediastinum, is
Table 18-7 presents indications, advan- turia may not correlate with the degree of
noninvasive, and can be performed
tages, and disadvantages of ultrasonogra- injury. If the patient with a blunt injury is
serially and by multiple technicians.
phy, DPL, and CT in blunt abdominal stable but has hematuria, a CT scan can be
Unlike CT scanning, ultrasonography
trauma. used to accurately visualize the genitouri-
does not pose a potential radiation
nary system and abdominal and retroperi-
hazard and does not require adminis- Genitourinary Tract toneal contents.
tration of contrast agents.
When an injury to the genitourinary tract
Performing focused ultrasonographic Extremities
is suspected, urologic consultation is
examinations with an abdominal
required to further evaluate and diagnose Pelvic fractures, fractures of the femur,
trauma patient does not require the
the extent of injury. The major cause of and multiple fractures of other long bones
skill of a board-certified radiologist,
urethral ruptures is blunt trauma. Over may cause hypovolemic shock and life-
which allows ultrasonography to be
95% of patients with a pelvic fracture have threatening blood loss, the primary site of
more readily accessible to injured
an associated posterior urethral rupture. which may be difficult to determine. Typi-
patients. Accuracy correlates with
The force of the injury causes a shearing cal closed fractures of the pelvis may lose
length of training and experience, but
effect between the urethra and the urogen- 1 to 5 L of blood, femur fractures 1 to 4 L,
expertise can be readily accomplished
ital diaphragm.34 Anterior urethral rup- and arm fractures 0.5 to 1 L from the vas-
in emergency medicine and surgical
tures are also commonly associated with culature.58 Certain extremity injuries are
training programs.55
blunt trauma. Most of these injuries occur considered life threatening because of
Overall, ultrasonography can serve as
in men.57 associated complicationsmassive open
an accurate and rapid test and is a less
Blood at the urethral meatus is the sin- fractures with ragged dirty wounds; bilat-
expensive diagnostic screening tool
gle best indicator of urethral trauma.35 The eral femoral shaft fractures (open or
than are DPL and CT.
meatus must be carefully inspected for closed); vascular injuries, with or without
However, there are disadvantages to the use even the slightest amount of blood before fractures, proximal to the knee or elbow;
of ultrasonography, including the following: inserting a urethral catheter. As is discussed crush injuries of the abdomen and pelvis;
above, attempts to introduce a Foley major pelvic fractures; and traumatic
It does not image solid parenchymal catheter up an injured urethra can convert amputations of the arm or leg.7
damage, the retroperitoneum, or an incomplete laceration into a complete Physical examinations should consist
diaphragmatic defects very well. laceration with a subsequent retropubic or of inspection and palpation of the chest,
It is technically compromised by the perineal hematoma.33 A rectal examination abdomen, pelvis, and all four extremities.
uncooperative agitated patient, as well must be performed on all patients with a Areas of tenderness, discoloration,
as by obesity, substantial bowel gas, suspected pelvic injury. With posterior ure- swelling, and deformity should be inspect-
and subcutaneous air. thral disruption, the prostate may be ed, and proper radiographs should be
354 Part 4: Maxillofacial Trauma
Table 18-7 Indications, Advantages, and Disadvantages of DPL, Ultrasonography, and CT in Blunt Abdominal Trauma
DPL Ultrasonography CT
Indication Document bleeding if BP Document fluid if BP Document organ injury if
BP normal
Advantages Early diagnosis and sensitive; Early diagnosis; noninvasive and Most specific for injury;
98% accurate repeatable; 8697% accurate 9298% accurate
Disadvantages Invasive; misses injury to Operator dependent; bowel gas and Cost and time; misses diaphragm,
diaphragm or retroperitoneum subcutaneous air distortion; misses bowel tract, and some pancreatic
diaphragm, bowel, and some pancreatic injuries
pancreatic injuries
Adapted from American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors: student course manual. 6th ed. Chicago: American College of Surgeons;
1997. p. 166.
BP = blood pressure; CT = computed tomography; DPL = diagnostic peritoneal lavage.
obtained. All peripheral pulses should be fracture treatment.56 The primary treat- Long-bone fractures are a common
examined for evidence of vascular injury. ment is ventilatory assistance. Therapy cause of fat embolisms and ARDS. Opera-
Pulse rates should be equal; any abnormal- with steroids and acetylsalicylic acid has tive fixation of long-bone fractures in
ity of distal pulse rates suggests a vascular been shown to be helpful, possibly because patients with multiple injuries within the
injury and must be explained. Doppler of a reduction of platelet aggregation. first few days of injury can minimize the
examination of the extremity is useful, but With a better understanding of fluid development of fat embolisms.56 Primary
angiography is the best test for definitively and electrolyte therapy, an early aggressive rigid fixation allows the patient to get out
evaluating a suspected vascular injury management of hemorrhagic shock and of bed and assume an upright position,
when the diagnosis is in doubt.7 prompt surgical treatment are now possi- thus improving pulmonary and muscu-
Direct pressure should be used to con- ble. However, in the interest of acute resus- loskeletal function. Early mobilization,
trol hemorrhage, and fractures should be citation, orthopedic injuries are often over- along with the use of mechanical ventila-
splinted as quickly as possible. Splints looked initially and are treated at a later tion with PEEP, lowers the incidences of
should generally include joints above and time. When these injuries involve the spine, ARDS and remote organ failure.60
below the site of injury. Prompt orthope- pelvis, or femur, immobilization of the
dic consultation should be obtained. patient is necessary for the purpose of trac- References
Fat embolism syndrome is usually tion. In immobilized patients with unstable 1. Cales RH, Trunkey DD. Preventable trauma
associated with major fractures of long fractures, there is an increased morbidity deaths: a review of trauma care systems
bones, especially of the femur. The patient caused by respiratory failure or sepsis with development. JAMA 1985;254:105963.
typically does well for 24 to 48 hours and related multiple organ failure. The severely 2. Committee on Trauma of the American Col-
then develops progressive respiratory and injured patient with orthopedic fractures lege of Surgeons. Hospital and prehospital
resources for optimal care of the injured
CNS deterioration. Concomitant labora- who survives the acute phase of treatment patient. Bull Am Coll Surg 1983;68:11.
tory value changes include hypoxemia, generally undergoes a prolonged course in 3. Mann NC, Mullins RJ, MacKenzie EJ, et al. Sys-
thrombocytopenia, fat in the urine, and a the intensive care unit. This leads to mor- tematic review of published evidence
slight drop in hemoglobin. Fat enters the bidity secondary to decreased muscu- regarding trauma system effectiveness. J
venous sinusoids at the fractured site and loskeletal function (eg, muscle wasting, stiff Trauma. 1999;47(3 Suppl):S2533.
4. Acosta JA, Yang JC, Winchell RJ, et al. Lethal
becomes lodged in the lung alveoli. Fat joints, loss of limb length) caused by delays injuries and time to death in a level I trau-
embolism syndrome has been reported to in fracture stabilization and subsequent ma center. J Am Coll Surg 1998;186:52833.
occur with 30 to 50% of major long-bone patient mobilization.60 Studies have shown 5. Shires GT. Principles of trauma care. 3rd ed.
and pelvis fractures.59 However, with the that early fracture stabilization can signifi- New York: McGraw-Hill; 1985.
current coordinated management of mul- cantly decrease mortality, musculoskeletal 6. Hoyt DB, Mikulaschek AW, Winchell RJ. Trau-
ma triage and interhospital transfer. In:
tiply injured patients, the incidence of morbidity, and cardiopulmonary and Mattox KL, Feliciano DV, Moore EE, edi-
both fat embolisms and ARDS is decreased metabolic consequences commonly associ- tors. Trauma. 4th ed. New York: McGraw-
by expeditious femoral shaft and pelvic ated with multiple trauma.58 Hill; 2000. p. 8198.
Initial Management of the Trauma Patient 355
7. Collicott PE. Advanced trauma life support ence with 1,199 patients. Chest 2000; resuscitation: a brief overview of the cur-
course for physicians. Chicago (IL): Ameri- 117(5):127985. rent debate. J Trauma 2003;54:S828.
can College of Surgeons Committee on 24. Eckstein M, Henderson S, Markouchick VJ. Tho- 40. Barnes A. Status of the use of universal donor
Trauma, Subcommittee on Advanced Life rax. In: Marx J, editor. Rosens emergency blood transfusions. Clin Lab Sci 1973;
Support; 1984. medicine: concepts and clinical practice. 5th 4:14760.
8. American College of Surgeons Committee on ed. St. Louis: Mosby Inc.; 2002. p. 3878. 41. Faringer PD, Mullins RJ, Johnson RL, Trunkey
Trauma. Advanced trauma life support for 25. Symbas PN. Autotransfusion from hemotho- DD. Blood component supplementation
doctors: student course manual. Chicago rax: experimental and clinical studies. J during massive transfusion of AS-1 red cells
(IL): American College of Surgeons; 1997. Trauma 1972;12:68995. in trauma patients. J Trauma 1993;34:4817.
9. Teasdale G, Jennett B. Assessment of coma and 26. Cogbill TH, Landercasper J. Injury to the chest 42. Garvin AS, Fisher RP. Resuscitation of trauma
impaired consciousness: a practical scale. wall. In: Mattox KL, Feliciano DV, Moore EE, patients with typespecific uncross-matched
Lancet 1974;2:814. editors. Trauma, 4th ed. New York: McGraw- blood. J Trauma 1984;24:32731.
10. Langfitt TW. Measuring the outcome from Hill; 2000. p. 483505. 43. Guntheroth WG, Abel FL, Mullins GC. The
head injuries. J Neurosurg 1978;48:6738. 27. Guyton AC. Textbook of medical physiology. effect of Trendelenburgs position on blood
11. Champion HR, Sacco WJ, Carnazzo AJ, et al. The 5th ed. Philadelphia: WB Saunders; 1976. pressure and carotid flow. Surg Gynecol
trauma score. Crit Care Med 1981;9:6726. 28. Pope PE, Hudson LD. Acute respiratory failure. Obstet 1964;119:3458.
12. Champion HR, Sacco WJ, Copes WS, et al. A In: Callaham ML, editor. Current therapy in 44. McSwain NE, Kerstein MD, editors. Evaluation
revision of the trauma score. J Trauma emergency medicine. Toronto: BC Decker and management of trauma. Norwalk
1989;29:6239. Inc; 1987. (CT): Appleton-Century-Crofts; 1987.
13. Van Natta TL, Morris JA Jr. Injury scoring and 29. Mullins RJ. Management of shock. In: Mattox 45. Nagy KK, Joseph KT, Krosner SM, et al. The util-
trauma outcomes. In: Mattox KL, Feliciano KL, Feliciano DV, Moore EE, editors. Trau- ity of head computed tomography after min-
DV, Moore EE, editors. Trauma. 4th ed. ma 4th ed. New York: McGraw-Hill; 2000. imal head injury. J Trauma 1999;46:26870.
New York: McGraw-Hill; 2000. p. 6980. p. 195232. 46. Bachulis BC, Long WB, Hynes GD, Johnson
14. Senkowski CK, McKenney MG. Trauma scor- 30. Luce JM. Respiratory monitoring in critical MC. Clinical indications for cervical spine
ing systems: a review. J Am Coll Surg care. In: Goldman L, Bennett JC, editors. radiographs in the traumatized patient. Am
1999;189:491503. Cecil textbook of medicine, 21st ed. New J Surg 1987;153:4737.
15. Powers M. Initial assessment and management York: WB Saunders Co; 2000. p. 48589. 47. Shuck JM, Snow NJ. Injury to the chest wall. In:
of the trauma patient. In: Peterson LJ, 31. Bikell WH, Pepe PE, Bailey ML, et al. Random- Mattox KC, Moore EE, Feliciano DV, edi-
Indresano AT, Marciani RD, Roser SM, edi- ized trial of pneumatic antishock garments tors. Trauma. Norwalk (CT): Appleton &
tors. Principles of oral and maxillofacial in the prehospital management of penetrat- Lange; 1988. p. 11523.
surgery. Vol 1. Philadelphia (PA): JB Lippin- ing abdominal injuries. Ann Emerg Med 48. Ivy ME, Cohn SM. Addressing the myths of
cott Company; 1992. p. 269310. 1987;16:6538. cervical spine injury management. Am J
16. Saletta JD, Geis WP. Initial assessment of trau- 32. Sohmer PR, Dawson RB. Transfusion therapy Emerg Med 1997;15:591602.
ma. In: Moylan JA, editor. Trauma surgery. in trauma: a review of the principles and 49. Hills MW, Deane SA. Head injury and facial
Philadelphia: JB Lippincott Company; techniques used in the MEIMSS program. injury: is there an increased risk of cervical
1988:125. Am Surg 1979;45:10925. spine injury? J Trauma 1993;34:54957.
17. American College of Surgeons Committee on 33. McAninch JW. Traumatic injuries to the ure- 50. National Spinal Cord Injury Statistical Center
Trauma. Field categorization of trauma thra. J Trauma 1981;21:2917. (NSCISC). Spinal cord injury: facts and fig-
patients. Bull Am Coll Surg 1986;71:10. 34. Pokorny M, Pontes JE, Pierce JM Jr. Urologic ures at a glance. Birmingham (AL):NSCISC:
18. Tepas JJ, Mollitt DL, Talbert JL, Bryant M. The injuries associated with pelvic trauma. J July 1996.
Pediatric Trauma Score as a predictor of Urol 1979;121:4557. 51. Fischer RP. Cervical radiographic evaluation of
injury severity in the injured child. J Pediatr 35. McAninch JW. Assessment and diagnosis of alert patient following blunt trauma. Ann
Surg 1987;22:148. urinary and genital injuries. In: McAninch Emerg Med 1984;13:9057.
19. Boyd CR, Tolson MA, Copes WS. Evaluating JW, editor. Trauma management; urogeni- 52. Griffen MM, Frykberg ER, Kerwin AJ, et al.
trauma care: the TRISS method. J Trauma tal trauma. New York: Theime Stratton; Radiographic clearance of blunt cervical
1987;27:3708. 1985. p. 285301. spine injury: plain radiograph or computed
20. Champion HR, Copes WS, Sacco WJ, et al. A 36. Devine PC, Devine CJ Jr. Posterior urethral tomography scan? J Trauma 2003;55:2227.
new characterization of injury severity. J injuries associated with pelvic fractures. 53. Frame SB. Prehospital care. In: Mattox KL, Feli-
Trauma 1990;30:53945. Urology 1982;20:46770. ciano DV, Moore EE, editors. Trauma, 4th
21. Osler T. ICISS: an International Classification 37. Bell RM, Krantz BE. Initial assessment. In: ed. New York: McGraw-Hill; 2000. p. 117.
of Disease-Based Injury Severity Score. J Mattox KL, Feliciano DV, Moore EE, edi- 54. Rozycki GS, Ballard RB, Feliciano DV, et al.
Trauma 1996; 41(3):3806. tors. Trauma 4th ed. New York: McGraw- Surgeon-performed ultrasound for the
22. Cline JR, Scheidel E, Bigsby EF. A comparison Hill; 2000. p. 15370. assessment of truncal injuries: lessons
of methods of cervical immobilization used 38. Velanovich V. Crystaloid versus colloid fluid learned from 1540 patients. Ann Surg
in patient extraction and transport. J Trau- resuscitation: a meta-analysis of mortality. 1998;228:55767.
ma 1985;25:64953. Surgery 1989;105:6571. 55. Smith RS, Kern SJ, Fry WR, Helmer SD. Insti-
23. Weissberg D, Refaely Y. Pneumothorax: experi- 39. Rizoli SB. Crystalloids and colloids in trauma tutional learning curve of surgeon-
356 Part 4: Maxillofacial Trauma
performed trauma ultrasound. Arch Surg 57. Condon RE, Nyhus CM, editors. Manual of Prevention of fat embolism by early inter-
1998; 133:5305. surgical therapeutics. 5th ed. Boston: Little nal fixation of fractures in patients with
56. Shanmuganathan K, Mirvis SE, Sherbourne Brown and Co; 1981. multiple injuries. Injury 1976;8:1105.
CD. Hemoperitoneum as the sole indica- 58. LaDuca JN, Bone LL, Seibel RW, Border JR. 60. Johnson KD, Cadambi A, Seiber GB. Incidence
tor of abdominal visceral injuries: a Primary open reduction and internal fixa- of adult respiratory distress syndrome in
potential limitation of screening abdomi- tion of open fractures. J Trauma 1980; patients with multiple musculoskeletal
nal US for trauma. Radiology 1999; 20:5806. injuries: effect of early operative stabiliza-
212:42330. 59. Riska EB, Von Bonsdorff H, Hakkinen S, et al. tion of fractures. J Trauma 1985;25:37584.
CHAPTER 19
In the United States over 11 million trau- parotid duct may result. It is unusual for Treatment of soft tissue injuries
matic wounds are treated in emergency bleeding from soft tissue injuries to the involves early reconstructive procedures
departments each year. Facial lacerations face to result in a shock state. Lacerations addressing both the soft tissue and the
comprise approximately 50% of these involving the scalp can occasionally be underlying bony injury in a minimum
wounds.1 Facial injuries impact both func- difficult to control with pressure and may number of stages.6,7 Occasionally it is bet-
tion and esthetics. There is often a psycho- require clamping, ligation, or electro- ter to delay soft tissue repair until the facial
logical aspect associated with the injury cautery. fractures have been addressed. In patients
secondary to patients concern regarding In soft tissue injuries not involving the with large avulsion of tissue, definitive
permanent scarring and subsequent facial face the length of time from initial injury early reconstruction of the tissue loss with
disfigurement. According to a recent sur- to treatment is important. Secondary risk regional or microvascular flaps may be
vey, cosmetic outcome is the single most of infection increases with the lapse of required.8,9
important aspect of care to the patient.2 time.3 Because of the rich vascularity of
the face there is no golden period for Anatomic Evaluation
Principles of Management suture repair of facial wounds. In fact heal- Following the initial evaluation and resus-
The initial examination involves evaluat- ing of facial wounds is unaffected by the citation, injuries to the soft tissues should
ing and stabilizing the trauma patient. Any interval between injury and repair.4 be evaluated during the secondary survey.
life-threatening conditions should be Patients who are immunized and have Patients sustaining trauma often have
identified and managed immediately. The received a booster injection within the last associated soft tissue injuries. Facial
conditions of the airway, breathing, and 10 years do not require tetanus prophylax- injuries can be superficial but may extend
circulation are examined, followed by a is if the wound is not tetanus prone. to involve adjacent structures including
general neurologic assessment with partic- Tetanus-prone wounds are those with bones, nerves, ducts, muscles, vessels,
ular attention to cervical spine and cranial heavy contamination from soil or manure, glands, and/or dentoalveolar structures.
injuries. devitalized tissue, or deep puncture Associated injuries, including vascular
It is important to achieve hemostasis wounds. If the wound is tetanus prone and injury, may develop acutely or days after
when stabilizing and evaluating the the patient has not received a booster the injury.10,11
patient who has sustained trauma. Most injection within 5 years prior to the injury, A thorough head and neck examina-
bleeding will respond to application of a a 0.5 mL tetanus toxoid boost injection tion determines the extent of associated
pressure dressing. Occasionally surgical should be given. If the patient has not facial wounds. Peripheral cranial nerves are
exploration and packing of the wound received a booster within 10 years prior, commonly involved with lacerations that
under general anesthesia may be indicat- they should receive a booster injection for involve the face. The facial nerve divides
ed. In rare instances vessels in the neck any wound. Patients who are not immu- the parotid gland into deep and superficial
may need to be ligated. Indiscriminate nized should receive both a booster injec- portions (Figure 19-1). Any injury to the
clamping inside the wound should be tion and 250 units of tetanus gland should raise suspicion for associated
avoided because damage to important immunoglobulin, followed by a full course facial nerve injury.12 The facial nerve exits
structures such as the facial nerve or of immunization.5 the stylomastoid foramen and divides into
358 Part 4: Maxillofacial Trauma
Geniculate ganglion
Temporal branches
Stylomastoid foramen
Buccal branch
Parotid duct
Buccal branch
Digastric branch
Parotid gland
Stylohyoid branch
Cervical branch
FIGURE 19-2 Anatomy of the facial nerve. FIGURE 19-3 Zone of arborization of the facial nerve.
Soft Tissue Injuries 359
A polymeric silicone (Silastic) catheter is Lidocaine is a popular local anesthetic ronment results and limits leukocyte
placed to bridge the defect. The severed ends and ranges in strength from 0.5 to 2%. It is function.15 Soft tissue wounds are often
are then sutured over the catheter, which is usually administered with epinephrine contaminated with bacteria and foreign
left in place for 10 to 14 days (Figure 19-4). 1:100,000. Lidocaine has a rapid onset of material. Treatment of these injuries
The parotid capsule should be closed to pre- action, a wide margin of safety, and a low involves copious irrigation and is aimed
vent formation of a parotid duct fistula or incidence of allergic sensitivity. A thor- at minimizing the bacterial wound flora
sialocele. Lacerations are closed primarily ough evaluation of the seventh cranial and removing any foreign bodies. With
and a pressure dressing is placed to prevent nerve should be undertaken prior to injec- respect to infection rates, studies have
fluid accumulation. tion of anesthetic or administration of a shown no statistical difference in wounds
There are several protocols for evalua- general anesthetic. Injecting local anes- irrigated with normal saline when com-
tion and treatment of penetrating injuries thetic prior to cleaning the wound will pared to other solutions. Pulsatile-type
to the neck, face, and temporal bone. If allow more effective preparation. Local irrigation devices may be helpful to
there is suspicion that deep critical struc- anesthetics containing epinephrine have remove debris, necrotic tissue, and loose
tures have been injured, the appropriate been used successfully in all areas of the material. Hydrogen peroxide impedes
protocol should be followed. face but may not be optimal in areas where wound healing and has poor bactericidal
tissue monitoring is critical or where activity. A good rule is to avoid irrigating
Sequence of Repair and extensive undermining of the soft tissue is the wound with any solution that would
Basic Technique necessary.13 One should avoid injecting not be suitable for irrigating the eye.
A decision is made to repair the wound in directly into the wound when important Careful and meticulous cleaning of the
the emergency department or to perform landmarks could be distorted. Regional wounds primarily will avoid unfavorable
the repair in the operating room under a nerve blocks are beneficial in minimizing results such as tattooing, infection,
general anesthetic. Large complicated lac- the amount of local anesthesia required hypertrophic scarring, and granulomas.
erations demand ideal lighting and and also prevent distortion of the tissues.14 A scrub brush and detergent soap may be
patient cooperation. In injuries where After adequate anesthesia has been necessary to remove deeply imbedded
there is a concern that deep structures obtained, the wound is thoroughly foreign material. However, soaps may
have been damaged, a general anesthetic dbrided. Nonvital tissue is conservative- cause cellular damage and necrosis. A
affords the best opportunity for explo- ly excised in an attempt to salvage most of surgical blade may be helpful to scrape
ration and repair. The patient may the tissue. Devitalized tissue potentiates foreign material that is deeply embedded.
require repair of other traumatic injuries infection, which inhibits phagocytosis. Polymyxin B sulfate can be used to
in the operating room, and on many Persistent infection at a wound site leads remove residual grease or tar in wounds.
occasions, definitive repair of associated to the release of inflammatory cytokines Proper cleaning and good surgical
facial soft tissue injuries can be per- from monocytes and macrophages, which technique are imperative in minimizing
formed at the same time. delays wound healing. An anaerobic envi- infection. Infections are rare when the
A B
FIGURE 19-4 A, This laceration shows the parotid duct severed and cannulated with a polyethylene tube. B, The duct is sutured
over the tubing.
360 Part 4: Maxillofacial Trauma
wound is closed so that no dead space, devi- heals it will contract along its length and soft tissue repair. If repair of the facial
talized tissue, or foreign bodies remain width and become inverted due to colla- bones is delayed, it is optimal to close the
beneath the sutured skin. Hydrogen perox- gen and fibroblast maturation. Initial lacerations initially. The wounds can be
ide is minimally bactericidal and toxic to management is aimed at producing a reentered and revised if needed to access
fibroblasts even when diluted to 1:100.16 slightly everted wound edge. The wound the fracture site.
Diluted hydrogen peroxide is useful in the continues to remodel up to a year follow-
postoperative period in cleaning crusts ing injury but never regains greater than Types of Injuries
away from incision lines in order to mini- 80% of the strength of intact skin.
mize scarring. Tissue adhesives are gaining in popu- Abrasions
Common methods for closing larity. Some studies have suggested similar Shear forces that remove a superficial layer
wounds include suturing, applying adhe- cosmetic outcomes in wounds treated with of skin cause abrasions. The wound should
sives, and stapling. It is preferable to suture octylcyanoacrylate when compared to be gently cleansed with a mild soap solu-
complex facial lacerations secondary to standard wound closure techniques for tion and irrigated with normal saline.
esthetic considerations. A layered closure noncrush-induced lacerations treated less These superficial injuries usually heal with
is almost always necessary and eliminates than 6 hours after injury.2022 Closure of local wound care. It is important to deter-
dead space beneath the wound. If the dead lacerations with octylcyanoacrylate is mine whether foreign bodies have been
space is not obliterated, accumulation of faster than standard wound closure meth- embedded in the wound. Failure to remove
inflammatory exudates may occur. This ods. However, its use should be avoided in all foreign material can lead to permanent
leads to infection, which in turn may cause complex lacerations involving the face, tattooing of the soft tissue. After the
tension across the epidermis. Tension can where there are esthetic concerns. wound is cleansed the abrasion is covered
cause necrosis of the skin edges due to Suture materials and different surgical with a thin layer of topical antibiotic oint-
impairment of the vascular supply and techniques do not show substantial differ- ment to minimize desiccation and sec-
may cause an increase in scarring.17 ences in relation to outcome. General ondary crusting of the wound.
Injuries involving anatomic borders characteristics of the patient (ie, sex and Reepithelialization without significant
such as the vermilion of the lip must be age) and of the wound (ie, length and site) scarring is complete in 7 to 10 days if the
reapproximated precisely. Examples of seem to be important predictors of adverse epidermal pegs have not been completely
these landmarks include eyebrows, lip tissue reaction.23,24 Suboptimal appear- removed. If the laceration significantly
margins, and eyelids. Lacerations should ance is associated with wounds that are extends into the reticular dermal layer, sig-
be closed by placing a suture in the center infected, wide, incompletely approximat- nificant scarring is likely.
of the laceration to avoid creating exces- ed, or have sustained a crush injury. The
sive tissue on the end of the laceration total number of bacteria is more impor- Contusions
(dog-ear). Deep layers should be reap- tant that the species of bacteria contami- Contusions are caused by blunt trauma
proximated with 3-0 or 4-0 buried nating a wound. Greater than 105 aerobic that causes edema and hematoma forma-
resorbable sutures. The superficial skin is organisms per gram of tissue are needed tion in the subcutaneous tissues. The asso-
closed with 5-0 or 6-0 suture. It is impor- for contamination, and crush-type ciated soft tissue swelling and ecchymosis
tant to avoid causing puncture marks wounds are 100 times more susceptible to can be extensive. Small hematomas usually
when grasping the wound edges. Margins infection.25 resolve without treatment; hypopigmenta-
should be undermined to allow slight Delayed primary closure may be neces- tion or hyperpigmentation of the involved
eversion of the wound margin. Skin sary in some instances. Patients who may tissue can occur, but is rarely permanent.
sutures should be removed 4 to 6 days benefit from a delayed procedure include Large hematomas should be drained to
after placement. By this time the wound those with extensive facial edema, a subcu- prevent permanent pigmentary changes
has regained only 3 to 7% of its tensile taneous hematoma, or those with wounds and secondary subcutaneous atrophy.
strength and adhesive strips help support that are severely contused and contain
the wound margins.18 devitalized tissue. Secondary revision pro- Lacerations
At 7 to 10 days following suture cedures are usually undertaken months Lacerations are caused by sharp injuries to
removal the collagen has begun to cross- later to allow for scar maturation. the soft tissue (Figure 19-6). Lacerations
link. The wound is now able to tolerate Clinical examination and radiographs can have sharp, contused, ragged, or stel-
early controlled motion with little risk of are used to diagnose fractures of the face. late margins. The depth of penetration
disruption (Figure 19-5).19 As the wound Facial fractures are ideally treated prior to should be carefully explored in the acute
Soft Tissue Injuries 361
Injury
Coagulation of
platelets
Collagen fiber
Dbridement
Resistance to
infection
Contraction
Granulocytes
Proteoglycan
synthesis
Neovascular growth
Procollagen
Collagen lysis
Healed wound
setting. Closure is performed using a lay- plasty at the time of primary wound Avulsive Injures
ered technique. If the margins are beveled repair. Flap-like lacerations occur when a Avulsive injures are characterized by the
or ragged they should be conservatively component of the soft tissue has been ele- loss of segments of soft tissue. Undermin-
excised to provide perpendicular skin vated secondary to trauma. Eliminating ing the adjacent tissue, followed by prima-
edges to prevent excessive scar formation. dead space by layered closure and pressure ry closure, can close small areas. When pri-
Rarely is there an indication for changing dressings is especially important in these mary closure is not possible, other options
the direction of the wound margins by Z- trapdoor injuries. are considered. These include local flaps or
362 Part 4: Maxillofacial Trauma
A B C D
FIGURE 19-7 A, Patient with avulsive injuries including the upper and lower eyelids. B, Elevation of multiple advancement and rotation flaps to gain coverage.
C, Securing the flaps into position. D, Closure of lacerations and flaps.
Soft Tissue Injuries 363
Gunshot Wounds to the Face duction of craniofacial approaches with Regional Considerations
Gunshot wounds require careful attention rigid fixation have led to an evolution of
Certain anatomic areas deserve special con-
and evaluation for associated facial frac- treating facial injuries. The esthetic and
sideration. Reestablishment of anatomic
tures. Both entry and exit wounds should be functional results of facial injury are
zones with proper orientation is critical in
evaluated. Exit wounds often produce improved dramatically by the combina-
achieving optimal esthetic results.
marked tissue destruction and require acute tion of a definitive open reduction of bone
dbridement. Regional flaps can be useful in with early replacement of soft tissue into Scalp and Forehead
treating facial soft tissue defects caused by its primary position. Immediate definitive
Scalp wounds can occasionally cause a
gunshot wounds (Figure 19-8).8 reconstructions with rigid fixation of the
large amount of blood loss due to the rich
Ballistic facial injuries are grouped by facial fractures and closure of the lacera- vascular supply in this region and the
etiology: gunshot, shotgun, and high- tions are recommended. Standard inci- inelasticity of the scalp preventing con-
energy avulsive injuries.36 Over the past 20 sions often need to be modified because of traction and closure of the vessels. The lay-
years advances in imaging and the intro- the soft tissue wounds. ers of the scalp (SCALP) include the skin,
subcutaneous tissue, aponeurosis layer,
loose subepicranial space, and pericranial
layer.
In patients sustaining scalp injuries it
is important to evaluate for associated
intracranial injuries. Careful inspection
should be performed to look for evidence
of skull fractures. Because the scalp has an
excellent blood supply in the subcuta-
neous tissues as well as the pericranial lay-
ers, avulsed tissue, skin grafts, and various
flaps have a high rate of survival. Hollan-
der and colleagues found no significant
difference in rate of infection in scalp lac-
erations that were irrigated compared to
those that were not.37
A B In avulsive defects in which the peri-
cranium is intact and primary closure is
not possible, a split-thickness skin graft
can be used. A secondary reconstructive
procedure involving various rotational
and advancement flaps or tissue expansion
can be undertaken after healing of the
defect.38 If the cranial bone is exposed
with large avulsive defects, then various
flap procedures are indicated primarily.
Reconstruction of the eyebrow is dif-
ficult secondarily, and efforts to repair
lacerations primarily without distortion
are important. Eyebrows should never be
shaved, as regrowth of the hair is unpre-
dictable. Closure of lacerations should
C D attempt to salvage as much tissue as pos-
sible. Care should be taken to avoid dam-
FIGURE 19-8 A, Patient who sustained a shotgun wound with avulsion of tissue. B, Preoperative
radiograph showing associated comminuted facial fractures. C, Reapproximation of the bone and soft age to the remaining hair follicles. Scars
tissue. D, Postoperative radiograph showing the reduction of multiple facial fractures. can be removed 6 to 12 months later with
364 Part 4: Maxillofacial Trauma
incisions made parallel to the hair folli- probe into the puncta and into the wound
cles to avoid injury. (Figure 19-12). The ends of the lacerated
duct are identified and approximated over
Eyelid and Nasolacrimal a polymeric silicone tube (Crawford tube).
Apparatus The tube is left in place for 8 to 12 weeks.
A thorough ophthalmologic examination If only one canaliculus is intact and func-
is important to assess for injuries to the tioning, the patient most likely will have
globe and to evaluate and document visu- adequate drainage.40 If the patient exhibits
al acuity. Closure of lacerations involving chronic epiphora postoperatively, then a
the eyelids is done in a layered fashion dacryocystorhinostomy is indicated.
(Figure 19-9). Care should be taken to pre- Avulsive injuries to the eyelids are
cisely reapproximate the eyelid margins treated with skin grafts and/or local flaps.
and the tarsus (Figure 19-10). The con- Defects of up to 25% of the eyelid length
A
junctiva and tarsus are closed with can be closed primarily. Skin grafts har-
resorbable sutures with the knot buried to vested from the opposite eyelid provide
avoid irritating the cornea. The orbicular excellent texture and color match.
muscle is then closed followed by closure
of the skin. Injuries involving the upper Nose
eyelid may include detachment of the lev- The nose occupies a prominent position
ator aponeurosis and Mllers muscle on the face and is often injured. Injuries of
from the tarsal plate. The muscles should the internal nose should be evaluated
be identified and reattached to the tarsal using a nasal speculum. The septum
plate in order to prevent ptosis and restore should be evaluated for the presence of a
levator function. hematoma, which appears as a bluish ele-
The lacrimal gland produces tears, vation of the mucosa. Hematomas involv-
which flow across the cornea and drain ing the nasal septum should be evacuated
into canaliculi via the puncta of the upper with a small incision or needle aspiration. B
and lower eyelid margins (Figure 19-11). Nasal packing or polymeric silicone nasal FIGURE 19-10 A, Pentagonal resection of the
From the canaliculi the tears enter the splints can be placed to prevent recurrence lower lid allows straight closure of the tarsal
nasolacrimal duct and drain into the infe- of the hematomas and are removed in 7 to plate. B, Closure is made with no suture materi-
al through the conjunctiva.
rior meatus of the nose. Any lacerations 10 days. A running 4-0 chromic gut mat-
that involve the medial third of the eyelid tress suture placed in and through the sep-
should be carefully inspected for damage tum can prevent recurrence. Untreated
to the canaliculus.39 Repair is accom- hematomas can lead to infection and collapse of the septum and a resultant
plished by introducing a lacrimal duct necrosis of the cartilage, which may cause saddle nose.
A B C
FIGURE 19-9 Surgical repair of the eyelid. A, Excision of outer lamina on one side and inner lamina on the other. B, After excision. C, Closure. Inner sutures are
buried to avoid suture material irritating the conjunctiva.
Soft Tissue Injuries 365
Ear
Injuries involving the external ear should
alert one to the possibility of other injuries.
Drainage beneath
interior turbinate An otoscopic examination of the external
auditory canal and tympanic membrane
combined with a hearing assessment
FIGURE 19-11 Nasolacrimal system anatomy. should be performed prior to treatment.
Injuries to the auricle include ecchymosis,
abrasion, laceration, hematoma, and par-
tial or total avulsion.
Hematomas involving the ear usually
occur when the ear sustains a glancing
blow. These should be drained with a
needle or incision. An incision is often
preferable to simple aspiration because
there is less of a chance of reaccumula-
tion of the hematoma.42 Evacuation of
the hematoma prevents fibrosis and
development of a cauliflower ear defor-
mity. A bolster dressing should be placed
A
to prevent recurrence of the hematoma. A
stent can also be fabricated from poly-
siloxane impression material and kept in
place for 7 days.43
The ear has a very good vascular sup-
ply and can maintain tissue on a small
pedicle. Injuries involving the cartilage
often do not require sutures. If sutures
are required a minimal amount are used
to avoid devitalizing the region of carti-
lage (Figure 19-14). Avulsive injuries of
the ear can involve a portion of the ear or
B
the entire ear (Figure 19-15). If the
FIGURE 19-12 A, Lacrimal probe identifies the disrupted canaliculi. avulsed segment is 1 cm or less, it can be
B, A polymeric silicone tube is cannulated through the canaliculi. reattached and allowed to revascularize.44
366 Part 4: Maxillofacial Trauma
Lip
C D
The lip anatomy involves a transition of
FIGURE 19-13 A, Nasal tip defect resulting from a bite. B, Elevation and advancement of local internal mucosal tissue to skin. Scars that affect
nasal flaps to provide mucosal coverage. C, Placement of cartilage and bone grafts to reconstruct the the orbicularis oris may result in func-
internal anatomy of the nose. D, The pedicled flap is sutured into place. The flap is divided 3 weeks later.
tional difficulties. Nerve blocks are help-
ful in wounds involving the lip to prevent
distortion caused from injecting directly
into the wound. A single suture should be
placed initially to reapproximate the ver-
milion border exactly. Deep tissues are
closed in layers, followed by closure of the
mucosa with 4-0 chromic and skin clo-
sure with 6-0 nylon suture.
Avulsive defects of the lips require
special attention. Up to one-fourth of the
lip can be closed primarily with accept-
able functional and esthetic results.
Injuries that involve a greater amount of
tissue loss can be reconstructed with a
variety of flaps such as Abbe-Estlander or
Karapandzic (Figure 19-18).
Neck
Successful management of penetrating
injuries of the neck depends on a clear
A B
understanding of the anatomy of the
FIGURE 19-14 A, Auricle injury with lacerations involving the cartilage. B, Postoperative appearance. region. Injuries can involve deep structures
Soft Tissue Injuries 367
Preauricular flap
Denuded area
Postauricular flap
A B C
FIGURE 19-15 A, Conversion of a defect to a wedge. B, The use of Burows triangles. C, Conversion of a defect to a star.
affecting the vascular, respiratory, diges- the cricoid cartilage. Zone II is from the ative diagnostic testing. Zone III extends
tive, neurologic, endocrine, and skeletal level of the cricoid cartilage to the angle of from the angle of the mandible to the base of
systems.46 The neck is divided into three the mandible. It is the most surgically the skull.
anatomic zones.47 Zone I extends from the accessible and is the easiest to evaluate There is controversy regarding which pen-
level of the clavicles and sternal notch to intraoperatively without the aid of preoper- etrating neck wounds require exploration.4650
368 Part 4: Maxillofacial Trauma
A B C
D E
A B C
FIGURE 19-18 A, Avulsive lip resulting from a dog bite. The lower lip flap is outlined. B, The pedicled Abbe flap is sutured into place and divided 3 weeks
later. C, After division of the flap.
adjunct in the management of specific References 13. Leach J. Proper handling of soft tissue in the acute
types of injuries. Facial scars continue to phase. Facial Plast Surg 2001; 17:22738.
1. Hollander JE, Singer AJ, Valentine S, et al. 14. Zide BM, Swift R. How to block and tackle the
mature over a period of 12 to 18 months. Wound registry: development and valida-
face. Plast Reconstr Surg 1998;101:84051.
A recent study found no difference in tion. Ann Emerg Med 1995;25:67585.
15. Hohn DC, MacKay RD, Halliday B, et al. Effect
outcome of surgical scars treated with 2. Singer AJ, Mach C, Thode HC Jr, et al. Patient
of oxygen tension on microbicidal function
priorities with traumatic lacerations. Am J
pulsed carbon dioxide laser when com- of leukocytes in wounds and in vitro. Surg
Emerg Med 2000;18:6836.
pared with dermabrasion.51 Forum 1976;27:18-20.
3. Pearson AS, Wolford RW. Management of skin
16. Lineweaver W, Howard R, Soucy D. Topical
Keeping a wound clean and scab free trauma. Prim Care 2000;27:47592.
antimicrobial toxicity. Arch Surg 1985;
allows for more rapid reepithelialization.52 4. Berk WA, Osbourne DD, Taylor DD. Evalua-
120:26770.
tion of the golden period for wound
Epithelial cells survive and migrate better 17. Chantarasak ND, Milner H. A comparison of
repair: 204 cases from a Third World emer-
in a moist environment. Antibiotic oint- scar quality in wounds closed under tension
gency department. Ann Emerg Med 1998;
with PGA (Dexon) and polydioxanne
ment can enhance this migration. It is not 17:496500.
(PDS). Br J Plast Surg 1989;68791
epithelialization that provides strength to 5. Hsu SS, Groleau G. Tetanus in the emergency
18. Thomas DW, ONeill ID, Harding KG, et al. Cuta-
department: a current review. J Emerg Med
the wound but rather the collagen fibers neous wound healing: a current perspective. J
2001; 20:35765.
supporting the surface. Rebuilding of 6. Moy LS. Management of acute wounds. Der- Oral Maxillofac Surg 1995;53:4427.
fibers takes time, and suturing a wound matol Clin 1993;11:75966. 19. Key SJ, Thomas DW, Shepherd JP. The man-
agement of soft tissue facial wounds. Br J
splints the skin together until new connec- 7. Hollier L, Grantcharova EP, Kattash M. Facial
gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 1995;33(2):7685.
tive tissue is built. 20. Singer AJ, Hollander JE, Valentine SM, et al.
Oral Maxillofac Surg 2001;59:27782.
Cleaning daily with dilute hydrogen 8. Motamedi MH, Behnia H. Experience with Prospective, randomized, controlled trial of
peroxide and dressing with antibiotic oint- regional flaps in the comprehensive treat- tissue adhesive (2-octylcyanoacrylate) vs
ment is standard. Patients should avoid ment of maxillofacial soft-tissue injuries in standard wound closure techniques for lac-
war victims. J Craniomaxillofac Surg 1999; eration repair. Stony Brook Octylcyano-
sun exposure for the first 6 months after
27:25665. acrylate Study Group. Acad Emerg Med
the injury to prevent hyperpigmentation 1998;5:949.
9. Zide MF. Pexing and presuturing for closure of
of the areas. traumatic soft tissue injuries. J Oral Max- 21. Singer AJ, Quinn JV, Clark RE, et al. Closure of
illofac Surg 1994;52:698703. lacerations and incisions with octylcyano-
Summary 10. Punjabi AP, Plaisier BR, Haug RH, et al. Diagno- acrylate: a multicenter randomized con-
sis and management of blunt carotid artery trolled trial. Surgery 2002;131:2706.
Soft tissue injuries involving the face can
injury in oral and maxillofacial surgery. J Oral 22. Singer AJ, Quinn JV, Thode HC Jr, et al. Deter-
be devastating to the patient. Primary Maxillofac Surg 1997;55:138895. minants of poor outcome after laceration
repair of these wounds is almost always 11. Morrissette MP, Chewning LC. Rapid airway and surgical incision repair. Plast Reconstr
advantageous over delayed secondary compromise following traumatic laceration Surg 2002;110:42935.
procedures. The primary goals of treat- of the facial artery. J Oral Maxillofac Surg 23. Gabrielli F, Potenza C, Puddu P, et al. Suture
1990;48:98990. materials and other factors associated with
ment are to restore patients to their pre- tissue reactivity, infection, and wound dehis-
12. Lewkowicz AA, Hasson O, Nahlieli O. Traumatic
operative state of function and to achieve injuries to the parotid gland and duct. J Oral cence among plastic surgery outpatients.
an esthetic result. Maxillofac Surg 2002;60:67680. Plast Reconstr Surg 2001;107:3845.
370 Part 4: Maxillofacial Trauma
24. Hollander JE, Singer AJ, Valentine SM, et al. closure of mammalian bites. Acad Emerg 44. Punjabi AP, Haug RH, Jordan RB. Manage-
Risk factors for infection in patients with Med 2000;7:15761. ment of injuries to the auricle. J Oral Max-
traumatic lacerations. Acad Emerg Med 35. Krebs JW, Strine TW, Childs JE. Rabies surveil- illofac Surg 1997;55:7329.
2001;8:71620. lance in the United States during 1992. J 45. Mladick RA, Horton CE, Adamson JE, et al.
25. Edlich RF, Rodeheaver GT, Morgan RF, et al. Am Vet Med Assoc 1993;203:1718-31. The pocket principle: a new technique for
Principles of emergency wound manage- 36. Clark N, Birely B, Manson PN, et al. High- the reattachment of a severed ear part. Plast
ment. Ann Emerg Med 1988;17:1284-302. energy ballistic and avulsive facial injuries: Reconstr Surg 1971;48:21923.
26. Wolff KD. Management of animal bite injuries classification, patterns, and an algorithm 46. Thompson EC, Porter JM, Fernandez LG. Pen-
of the face: experience with 94 patients. J for primary reconstruction. Plast Reconstr etrating neck trauma: an overview of man-
Oral Maxillofac Surg 1998;56:83843. Surg 1996;98(4):583601. agement. J Oral Maxillofac Surg 2002;
27. Kountakis SE, Chamblee SA, Maillard AAJ, et 37. Hollander JE, Richman PB, Werblud M, et al. Irri- 60:91823.
al. Animal bites to the head and neck. Ear gation in facial and scalp lacerations: does it 47. Roon AJ, Christensen N. Evaluation and treat-
Nose Throat J 1998;77:21620. alter outcome? Ann Emerg Med 1998;31:737. ment of penetrating cervical injuries. Trau-
ma 1979;19:3917.
28. Dire DJ. Emergency management of dog and 38. Welch TB, Boyne PJ. The management of trau-
48. Sriussadaporn S, Pak-Art R, Tharavej C, et al.
cat bite wounds. Emerg Med Clin North matic scalp injuries: report of cases. J Oral
Selective management of penetrating neck
Am 1992;10:71936. Maxillofac Surg 1991;49:100714.
injuries based on clinical presentations is
29. Morgan JP III, Haug RH, Murphy MT. Man- 39. Beadles KA, Lessner AM. Management of trau-
safe and practical. Int Surg 2001;86:903.
agement of facial dog bite injuries. J Oral matic eyelid lacerations. Semin Ophthal-
49. Hersman G, Barker P, Bowley DM, et al. The
Maxillofac Surg 1995;53:43541. mol 1994;9:14551.
management of penetrating neck injuries.
30. Garcia VF. Animal bites and Pasturella infec- 40. Smit TJ, Mourits MP. Monocanalicular lesions:
Int Surg 2001; 86:829.
tions. Pediatr Rev 1997;18:12730. to reconstruct or not. Ophthalmology 50. Mazolewski PJ, Curry JD, Browder T, et al. Com-
31. Gilbert DN, Moellering RC, Sande MA. The 1999; 106:13102. puted tomographic scan can be used for sur-
Sanford guide to antimicrobial therapy. Vol 41. Herford AS, Zide MF. Reconstruction of super- gical decision making in zone II penetrating
32. Hyde Park (VT): Antimicrobial Thera- ficial skin cancer defects of the nose. J Oral neck injuries. J Trauma 2001;51:3159.
py, Inc.; 2002. p. 36. Maxillofac Surg 2001;59:7607. 51. Nehal KS, Levine VJ, Ross B, et al. Comparison
32. Callaham M. Prophylactic antibiotics in com- 42. Starck WJ, Kaltman SI. Current concepts in the of high-energy pulsed carbon dioxide laser
mon dog bite wounds: a controlled study. surgical management of traumatic auricu- resurfacing and dermabrasion in the revi-
Ann Emerg Med 1980;9:4104. lar hematoma. J Oral Maxillofac Surg sion of surgical scars. Dermatol Surg
33. Donkor P, Bankas DO. A study of primary clo- 1992;50:800-2. 1998;24:64750.
sure of human bite injuries to the face. J 43. Starck WJ, McNeir DA. Semirigid stent for use 52. Brown CD, Zitelli JA. Choice of wound dress-
Oral Maxillofac Surg 1997;55:47981. after auricular cartilage graft harvest. J Oral ings and ointments. Otolaryngol Clin
34. Chen E, Hornig S, Shepherd SM, et al. Primary Maxillofac Surg 1992;50:95-8. North Am 1995;28:108191.
CHAPTER 20
Internal fixation simply implies the place- Inherent in these definitions is the prereq- Nonrigid Internal Fixation
ment of wires, screws, plates, rods, pins, uisite for surgical exposure to anatomical-
Any form of bone fixation that is not
and other hardware directly to the bones to ly align the fragments (open reduction)
strong (rigid) enough to prevent inter-
help stabilize a fracture. Internal fixation and secure the fixation hardware. To rigid-
fragmentary motion across the fracture
can be rigid or nonrigid depending on the ly stabilize fractures, an operative proce-
when actively using the skeletal structure
nature of the fracture, and the type, dure is necessary.
is considered nonrigid. The basic differ-
strength, size, and location of the hard- Examples of rigid fixation in the
ence between rigid and nonrigid fixation
ware placed. Since various degrees and mandible are the use of two lag screws or
centers on interfragmentary mobility. If
many types of nonrigid fixation exist, it is bone plates across a fracture, the use of a
there is mobility of the osseous frag-
useful to first define rigid internal fixa- reconstruction bone plate with at least
ments during active use of the skeletal
tion. By default any technique that does three screws on each side of the fracture,
structure following application of inter-
not satisfy this definition can then be con- and the use of a large compression plate
nal fixation devices, internal fixation is
sidered nonrigid. across a fracture (Figure 20-1). Properly
applied, these fixation schemes are of suf- nonrigid. An example of nonrigid fixa-
Rigid Internal Fixation ficient rigidity to prevent interfragmen- tion is a transosseous wire placed across
The term rigid internal fixation has many tary mobility during the healing period. a mandibular fracture. The wire can only
definitions. For instance, one definition is An inseparable corollary to the pre- provide stability by virtue of its (limited)
any form of bone fixation in which other- vention of interfragmentary mobility by ability to prevent spreading of the gap,
wise deforming biomechanical forces are rigid fixation is a peculiar type of bone but by itself, the wire cannot neutralize
either countered or used to advantage to healing where no callus forms. The bones torsion and/or shear forces. Additional
stabilize the fracture fragments and to per- instead go on to heal by a process of haver- fixation measures then become neces-
mit loading of the bone so far as to permit sian remodeling. Histologically, osteoclasts sary, such as the use of maxillomandibu-
active motion.1 This definition, although cross the fracture gap and are followed by lar fixation (MMF) (Figure 20-3).
admittedly long and perhaps confusing, blood vessels and osteoblasts (Figure 20- However, various forms of nonrigid
encompasses the essence of the technique 2). New bone is laid down by the fixation are recognized, and there is a
as practiced today and includes clues to osteoblasts, forming osteons which cross continuum between rigid fixation and
the methods of applying the appropriate the gap and impart microscopic points of no fixation at all. There are some forms
hardware. A more basic definition which bony union to the fracture.3 A remodeling of nonrigid fixation that are strong
includes the same objectives is any form phase then converts the entire area to mor- enough to allow active use of the skele-
of fixation applied directly to the bones phologically normal bone. This type of ton during the healing phase but not of
which is strong enough to prevent inter- bone healing is termed primary or direct sufficient strength to prevent interfrag-
fragmentary motion across the fracture bone union, and it requires absolute mentary mobility. These types of fixa-
when actively using the skeletal struc- immobilization between the osseous frag- tion have been called functionally stable
ture.2 Most of the differences in technique ments, that is, rigid fixation, and minimal fixation, indicating that there is adequate
are in the application of the fixation. distance (gap) between them. stability to allow function even though
372 Part 4: Maxillofacial Trauma
A B C
D E F
G
FIGURE 20-1 Examples of rigid fixation schemes for mandibular fracture. A, A large compression plate in
combination with an arch bar for a symphysis fracture (two-point fixation). B, Two lag screws inserted
across a symphysis fracture (two-point fixation). C, Two bone plates for a symphysis fracture (two-point
fixation). These may or may not be compression plates. Typically the larger one at the inferior border is a
compression plate and the one located more superiorly is not. D, Two bone plates for a mandibular body
fracture (two-point fixation). These may or may not be compression plates. Typically the larger one at the
inferior border is a compression plate and the one located more superiorly is not. E, A lag screw placed at
the inferior border combined with a smaller bone plate located more superiorly (may or may not be com-
pression plate; two-point fixation). The use of an arch bar offers a third point of fixation. F, A large com-
pression plate placed at the inferior border of a body fracture combined with an arch bar (two-point fixa-
tion). G, A compression plate at the inferior border of an angle fracture combined with a noncompression
plate at the superior border (two-point fixation). The upper plate could also be a compression plate. H, Two I
noncompression miniplates applied to an angle fracture (two-point fixation). I, Reconstruction bone plate
applied to the inferior border of an angle fracture (one-point fixation). Rigidity is provided by virtue of the
thickness (strength) of the plate and the use of at least three bone screws on each side of the fracture.
Rigid versus Nonrigid Fixation 373
form across a mobile gap. The formation callus on a radiograph indicates that Biomechanic Studies versus
of a callus can be thought of as natures there is mobility between the fragments, Clinical Outcomes
internal fixation, providing stability to requiring the deposition of the callus to When selecting a fixation scheme for a
the osseous fragments so that bone immobilize the fragments to allow given fracture, one has to consider many
union can proceed. The appearance of a ossification to proceed. things, such as the size and number of fix-
Rigid versus Nonrigid Fixation 375
tion. Comminuted or defect fractures, or superior border is more effective in pre- border (see Figure 20-4).4 Because metal-
those where a minimum of bone contact is venting this separation of fragments lic plates have high tensile strength, even
present, cannot be treated by load-sharing under function than applying them at thin plates work adequately at the angle
fixation because there is insufficient bone the inferior border (Figure 20-8C and to prevent the tendency for a gap to form
stock adjacent to the fracture to resist dis- D). There is little tendency for isolated at the superior border under function.13
placement by functional forces. fractures of the angle to have medial or Isolated fractures of the mandibular
lateral displacement during function, so body behave similarly under function, with
Regional Dynamic Forces the fixation requirement is mainly to a tendency for a gap to form at the superi-
Different regions of the mandible under- prevent separation of the superior bor- or surface, but the more anterior the frac-
go different magnitudes and direction of der. Relatively small plates can therefore ture, the more tendency for torquing of the
forces. In simplistic terms fractures of adequately control this fracture. The fragments to occur, causing mediolateral
the angle under most functional situa- Champy miniplate technique functions misalignment of the inferior border. While
tions tend to open at the superior bor- extremely well for this fracture and con- the arch bar may provide sufficient resis-
der (Figure 20-8A and B). Therefore, the sists of a 2.0 mm miniplate applied with tance to the tendency for a gap to form
application of fixation devices at the monocortical screws along the superior between the teeth under function, a plate
Elevator Tension
muscle forces Depressor muscles
-
- -- and occlusal forces
+ -
+ - -- - -- - - - -
+
+ + ++
+ +
A ++ +++
B
Compression
C D
FIGURE 20-8 Functional forces acting across the intact mandibular angle or body region (A) and after a fracture (B). Note that a gap
tends to form at the superior border of a fractured mandibular angle secondary to muscle and occlusal forces. The superior border is
therefore called the zone of tension (separation), whereas the inferior border is under compressive force during function (compression
zone). C, A small bone plate applied along the zone of tension (separation) is very effective in countering the forces of mastication, and
effectively neutralizes the forces, maintaining closure of the fracture gap. D, A small plate applied in the zone of compression (inferior
border) is very ineffective in neutralizing the muscle forces, and a gap will easily form superiorly in the zone of tension.
Rigid versus Nonrigid Fixation 377
Lag Screw Fixation sion. One should always place the lag
screw in a direction that is perpendicular
The lag screw fixation technique consists of
to the line of fracture to prevent overrid-
using screws to compress fracture frag-
ing and displacement during tightening of
ments without the use of bone plates. To
the screws (Figure 20-15).
apply the lag screw technique, two sound
bony cortices are required because this Plate Fatigue
technique shares the loads with the bone.
Bone plates may break under function,
The hole in the cortex under the head of the
resulting in possible loss of fixation, infec-
screw is called the gliding hole. It is the
tion, nonunion and/or malunion. Plates
same diameter as the external diameter of
break for a number of reasons, but most
the screw threads, so the threads will not
fracture in vivo because of fatigue. Plates
FIGURE 20-13 A locking platescrew system. engage this cortex. The screw threads on the
used in maxillofacial surgery today are
Note the second set of threads just under the head terminal end of the screw engage the oppo-
of the screw that will lock into receptacle threads usually made of titanium. Titanium is a
site cortex. By tightening the screw a tensile relatively biocompatible material and has
inside the hole of the bone plate.
force is created within the screw that com- material properties that are considered
presses the bony cortices together, tightly adequate for internal fixation when appro-
be very difficult to perfectly adapt to the reducing the fracture (Figure 20-14). priate plates are selected. One of the unde-
contours of the bone. Another theoretical As with using compression bone sirable properties of titanium is its brittle-
advantage to the use of locking bone plates, lag screw fixation is a technique ness (or lack of ductility) when compared
platescrew systems is that the screws are that should only be used to provide to bone. One only has to bend a miniplate
unlikely to loosen from the bone. This absolute rigid fixation. Micromotion back and forth a couple of times to see
means that even if a screw is inserted into across a fracture secured with lag screws how readily it will fracture. Placement of
a fracture gap, loosening of the screw will will likely result in dissolution of the bone bone plates on areas of the mandible that
not occur. The possible advantage to this around the screws, with loss of stability. are constantly and repeatedly deformed
property of a locking platescrew system is Therefore, lag screws should only be under function can result in fatigue frac-
a decreased incidence of inflammatory selected when there is sufficient bone ture of the plates. Examples are 2.0 mm
complications from loosening of the hard- available to place at least two screws into
ware. It is known that loose hardware sound bone that can, in all likelihood, cre-
propagates an inflammatory response and ate rigidity across the fracture.
promotes infection. For the hardware or a The use of lag screws has several
locking platescrew system to loosen, advantages over the use of bone plates. It A
loosening of a screw from the plate or uses less hardware when compared to the
loosening of all of the screws from their use of plates thus making it more cost
bony insertions would have to occur. Both effective. When properly applied, lag
of these are unlikely. A third advantage to screws are a very rigid method of internal
a locking screwplate system is that the fixation. Because there is no plate to be
amount of stability provided across the bent, the insertion of a lag screw is quick-
er and easier, and the reduction more B
fracture gap is greater than when standard
nonlocking screws are used.15,16 accurate than when bone plates are used.
While the possible advantages to a One must understand completely that the
locking platescrew fixation system are lag screw technique of fixation is one that
theoretical, whether clinical results can be relies on compression of bone fragments. FIGURE 20-14 Technique of lag screw place-
ment. A, The outer cortex is drilled to the exter-
improved is not clear from the literature. If the intervening bone is unstable due to nal diameter of the screw threads, and is coun-
However, given the potential advantages comminution or is missing, compressing tersunk to receive the head of the screw. The
that locking platescrew systems provide, across this area will cause displacement of inner cortex is drilled to the internal diameter of
such systems should be considered when- the bone fragments, overriding of seg- the screw. B, Screw tightening creates compres-
sion of the bony interfaces because the head of
ever noncompression plates are chosen ments, and/or shortening of the fracture the screw compresses the outer cortex against the
for a fracture. gap, resulting in problems with the occlu- inner cortex that is engaged by the screw threads.
380 Part 4: Maxillofacial Trauma
Perpendicular to
long axis of bone Perpendicular
to fracture
border of the mandible combined with an with either two 2.0 mm miniplates, or a mandible pulls the mandible posteriorly,
arch bar is usually adequate fixation for iso- stronger bone plate at the inferior border, as and because there is no posterior support
lated simple linear fractures of the symph- well as using the arch bar as another point via the temporomandibular joints, the lat-
ysis and body regions (two-point fixation). of fixation (Figure 20-19). The angle frac- eral mandibular fragments open like a
If an arch bar is not used or the teeth are not ture can then be treated with a single supe- book. Such fractures must be carefully
sound, one should use either a stronger rior border 2.0 mm miniplate. Similarly if managed to first restore the mandibular
plate at the inferior border or add another an angle fracture is combined with a con- width and then to maintain it. A short thin
2.0 mm miniplate more superiorly along tralateral condylar process fracture, one bone plate, like a 2.0 mm miniplate, or even
the lateral cortex. The application of a single should consider the application of more two 2.0 mm miniplates, may not offer suffi-
2.0 mm miniplate along the superior border stable fixation at the angle if the condylar cient resistance to the tendency to widen
is also adequate fixation for most isolated process is going to be treated closed using (Figure 20-21A). If one chooses to treat the
simple linear fractures of the angle region.4 no MMF and functional therapy (Figure condylar process fracture(s) closed, very
Lag screws can also be used instead of or in 20-20). In that case two 2.0 mm miniplates stable fixation must be applied across the
addition to plates, where appropriate. (or an alternative rigid treatment) should reduced mandibular symphysis to retain
When two fractures are present there is be considered. If the condylar process were the normal width of the mandible. This can
a greater tendency for the segments to dis- going to undergo open reduction and inter- be achieved by several techniques, but the
place because of the bilateral loss of support nal fixation, or if several weeks of MMF most stable is to either use a reconstruction
that occurs. Widening of the mandible were going to be used, then the angle frac- plate applied across the symphysis (Figure
must be prevented by applying adequate ture could be treated with a single superior 20-21B), or if the fracture is linear, two
internal fixation to resist that tendency. border 2.0 mm miniplate (functionally sta- well-placed lag screws (see Figure 20-1B).
With bilateral simple linear fractures one ble but not rigid fixation).4 The application of two thicker 2.0 mm
should always consider using a more rigid The fracture pattern that has the most bone plates (thicker than miniplates) would
form of fixation on at least one of the frac- tendency for widening is the midsymphysis also suffice (see Figure 20-1C). If one chose
tures. For instance, when an angle fracture fracture combined with condylar process to open the condylar process fractures, then
is combined with a contralateral body or fractures, especially when both condyles are the symphysis fracture can be treated as an
symphysis fracture, one should consider fractured. In such cases the musculature isolated symphysis fracture, with whatever
treating the body or symphysis fracture attached to the lingual surface of the technique the surgeon usually chooses.
Nonrigid
(functionally
stable) Gap
Rigid
FIGURE 20-19 Possible fixation scheme for right angle and left body frac- FIGURE 20-20 Demonstration of how widening of the mandible can occur
tures of the mandible. The more accessible body fracture is treated with a after an angle fracture treated without rigid fixation is combined with closed
more rigid form of fixation (eg, a thicker bone plate at the inferior border treatment of a contralateral condylar process fracture. The single 4-hole
or two miniplates). The angle fracture can then be treated with a function- 2.0 mm miniplate that works very well in this location for isolated fractures
ally stable form of fixation, which is easier to apply than would be a rigid of the mandibular angle may not be able to prevent the tendency for widen-
technique at the angle. The angle fracture is thus treated as if it were an iso- ing. With the loss of the articulation at the temporomandibular joint on the
lated fracture, with a single 4-hole 2.0 mm miniplate. right side, the entire right side of the mandible can also cause torquing at the
left angle fracture under function, leading to displacement and malocclusion.
382 Part 4: Maxillofacial Trauma
Gap
A B
FIGURE 20-21 A, Combination of a symphysis fracture treated with a single short bone plate and concomitant closed treatment of a
condylar process fracture can result in widening of the mandible. Because the bone plate is applied along the buccal cortex, it has a
mechanical disadvantage in preventing widening of the mandible. To prevent this, a longer, thicker, stronger plate should be applied
that yolks the mandible (B).
Summary screwed plates via a buccal approach. J of fractures of the facial skull. 1. Biome-
Maxillofac Surg 1978;6:149. chanics. In: Kruger E, Schilli W, editors.
While the number of plating sets and fixa- 5. Mller ME, Allgwer M, Willenegger H. Man- Oral and maxillofacial traumatology. Vol 1.
tion schemes are numerous, one can usually ual of internal fixation. New York: Springer- Chicago (IL): Quintessence Publishing Co.;
treat most fractures with very few instru- Verlag; 1970. 1982. p. 1258.
6. Choi BH, Kim KN, Kang HS. Clinical and in 15. Sderholm A-L, Lindqvist C, Skutnabb K,
ment sets. It is possible to treat the majority vitro evaluation of mandibular angle frac- Rahn B. Bridging of mandibular defects
of fractures of the mandible either with lag ture fixation with two-miniplate system. with two different reconstruction systems:
screws, 2.0 mm miniplates, or reconstruc- Oral Surg 1995;79:6925. an experimental study. J Oral Maxillofac
tion bone plates. There are, however, frac- 7. Kroon FH, Mathisson M, Cordey JR, Rahn BA. Surg 1991;49:1098105.
The use of miniplates in mandibular frac- 16. Gutwald R, Bscher P, Schramm A, et al. Bio-
tures where one may wish to use 2.0 mm
tures. An in vitro study. J Craniomaxillofac mechanical stability of an internal mini-
screws but thicker plates than miniplates, for Surg 1991;19:199204. fixation-system in maxillofacial osteosyn-
instance, condylar process fractures or frac- 8. Rudderman RH, Mullen RL. Biomechanics of thesis. Med Biol Eng Comp 1999;37 Suppl
tures of the atrophic mandible. In those the facial skeleton. Clin Plast Surg 2:280.
cases one can use thicker and stronger bone 1992;19:1129. 17. Hylander WL, Johnson KR. Jaw muscle func-
9. Ellis E, Karas N. Treatment of mandibular tion and wishboning of the mandible dur-
plates that accommodate 2.0 mm screws. For
angle fractures using two mini-dynamic ing mastication in macaques and baboons.
these situations a locking 2.0 mm bone plat- compression plates. J Oral Maxillofac Surg Am J Phys Anthrop 1994; 94:52347.
ing set that has plates of varying lengths and 1992;50:95863. 18. Ellis E, Dean J. Rigid fixation of mandibular
thicknesses allows one to choose the appro- 10. Ellis E, Sinn DP. Treatment of mandibular condyle fractures. Oral Surg 1993;76:615.
priate bone plate for almost any location. angle fractures using two 2.4 mm dynamic 19. Hammer B, Schier P, Prein J. Osteosynthesis of
compression plates. J Oral Maxillofac Surg condylar neck fractures: a review of 30
1993;51:96973. patients. Br J Oral Maxillofac Surg
References 11. Ellis E, Walker L. Treatment of mandibular angle 1997;35:28891.
1. Allgwer M, Spiegel PG. Internal fixation of fractures using two noncompression mini- 20. Choi B-H, Kim K-N, Kim H-J, Kim M-K. Eval-
fractures: evolution of concepts. Clin plates. J Oral Maxillofac Surg 1994;52:10326. uation of condylar neck fracture plating
Orthop 1979;138:269. 12. Ellis E, Walker LR. Treatment of mandibular angle techniques. J Craniomaxillofac Surg
2. Ellis E. Rigid skeletal fixation of fractures. J fractures using one noncompression mini- 1999;27:10912.
Oral Maxillofac Surg 1993;51:16373. plate. J Oral Maxillofac Surg 1996;54:86471. 21. Schilli W, Stoll P, Bhr W, Prein J. Mandibular
3. Schenk R, Willenegger H. Morphological find- 13. Potter J, Ellis E. Treatment of mandibular angle fractures. In: Prein J, editor. Manual of
ings in primary fracture healing. Symp Biol fractures with a malleable non-compres- internal fixation in the cranio-facial skele-
Hung 1967;7:75. sion miniplate. J Oral Maxillofac Surg ton. Chapt. 3. Techniques recommended by
4. Champy M, Lodd JP, Schmitt R, et al. 1999;57:28892. the AO/ASIF Maxillofacial Group. Berlin:
Mandibular osteosynthesis by miniature 14. Niederdellmann H. Fundamentals of healing Springer-Verlag; 1998. p. 87.
CHAPTER 21
History ken tooth should initially be treated with a bution cause the poor coordination that
medieval endodontic procedure by intra- leads to falls. In the larger surveys, the
Although there is speculation about whom
pulpal cautery with a hot iron instrument.3 pediatric population accounts for 5% of
the first dental surgeons were, dentoalveo-
Claudius Galen (~ AD 130200), a all facial fractures.4 Andreasen reported a
lar trauma has existed since humans began
Greek physician, also subscribed to the bimodal trend in the peak incidence of
to walk the earth. Altercations with
belief that reestablishing occlusion was dentoalveolar trauma in children aged 2 to
humans and animals, accidents, as well as
essential in treating dentoalveolar frac- 4 years and 8 to 10 years. Likewise, there
dental treatment misadventures each have
tures (see Figure 21-1).3 was an overall prevalence of 11 to 30% in
a part in the development of todays den-
the children with primary dentition.
toalveolar treatment protocols. Etiology and Incidence Those with permanent or mixed dentition
Arguably, Hippocrates of Cos, who
Dentoalveolar injuries commonly occur in ranged from 5 to 20%. The ratio of men to
lived during the Greco-Roman period
the pediatric, teenage, and adult popula- women was 2:1.5
(350 BCAD 750 ) was the first to document
tions. Each group has specific etiologies Children and adolescents overlap with
treatment regimens for dentoalveolar
that pertain to age, sex, and demographics. respect to the etiology of dentoalveolar
trauma in his writings. He discussed bind-
In the pediatric group, the primary injury. Contact sports and playground
ing teeth together in mandible fractures.
cause of these injuries is falls. Possibly dur- activities lead to most injuries. In fact,
Gold wire or linen thread was used as bri-
ing the first years of life, the early anatom- approximately one-third of all dental trau-
dle wire. He alluded to various splinting
ic development and skeletal weight distri- ma is secondary to sporting accidents.6
techniques that involved teeth that were
distant to the fractured or subluxed area
(Figure 21-1). In the same way, to expedite
the healing process, he stressed recaptur-
ing proper occlusion, a concept that is still
practiced today.
We could theoretically think of Hip-
pocrates as one of the first investigators to
see the value in evidenced-based treat-
ment protocols; he is credited with sepa-
rating the obscure religious beliefs from A B
true medical observation.1,2
FIGURE 21-1 Mandible found at the ancient site of Sidon in Lebanon (dated 500 BC). Gold wire was
Archigenes (~ 59 BC AD 17), a Roman used to splint periodontally involved anterior incisors. A, Frontal view. B, Lingual view. Reproduced
physician and dentist, believed that a bro- with permission from The Archaeological Museum, American University, Beirut, Lebanon.
384 Part 4: Maxillofacial Trauma
The use of mouthguards and appropriate goscopy technique and the unmonitored
head gear, however, has helped to decrease biting force of the comatose patient also
sport-related injuries.7 potentially caused dentoalveolar injury.15,16
Child abuse appears to be another signif- With direct trauma, maxillary incisors
icant cause of dentoalveolar and facial injury. are the most frequently traumatized teeth,
An alarming census of child abuse is docu- especially if they are associated with a Class II
mented in the literature. In the year 2000 an Division 1 malocclusion. Trauma to the pri-
estimated 879,000 children were abused. Of mary dentition usually results in various
these, 19.3% were physically abused.8 In the luxations (~ 75%), whereas in permanent
United States, over 50% of physical trauma in dentition, crown or crown-root fractures
child abuse occurs in the head and neck are the normal (39%).17 Indirect trauma to FIGURE 21-2 Blunt facial trauma resulting in
region. Internationally, about 7% of all phys- the dentition usually results from the force- soft tissue lacerations and dental and alveolar
ical injuries involve the oral cavity, with 9% ful impact of the mandible with the maxil- compromise.
between ages 0 and 19 years.9,10 la, following a blow to the chin region.
Generally, adult injuries are caused by These traumas will often result in injury to Unaccounted for avulsed teeth, free
motor vehicle collisions, contact sports, the posterior teeth (Figure 21-2).5 tooth fragments, or dislodged restorations
altercations or assaults, industrial acci- raise the suspicion of aspiration. For this
dents, and iatrogenic medical or dental History and Physical reason, auscultation of the chest to rule
misadventures. Examination out wheezing or labored breathing is
Demographic and behavioral research Obtain a thorough history of the patient essential. Owing to its anatomic position,
has increased the professions understand- and the traumatic incident. Preinjury data, the right mainstem bronchus is often the
ing of psychosocial issues that relate to such as biographic, demographic, past med- site of foreign body dislodgment. Support
facial trauma. ical history, time of incident, occlusion, any positive finding with proper neck,
Leathers and colleagues reported on location of incident, loss of consciousness, chest, and abdominal radiographs.22 If for-
orofacial injury profiles in an inner-city and nature of the incident could potentially eign bodies exist in the abdomen, arrange
hospital. They found that most orofacial expedite the treatment process.18,19 follow-up for the patient with radi-
injuries resulted from intentional violence, The potential for aspiration, airway ographs, and monitor for the risk of gas-
and the victims were primarily socially compromise, and neurosensory deficit trointestinal (GI) obstruction until the
and economically disadvantaged groups in dictates that the clinician should thor- foreign body is cleared.
the minority populations.11,12 oughly evaluate all dentoalveolar-injured
Black and colleagues related substance patients prior to managing dental injuries. Maxillofacial Examination
abusespecifically alcohol and street The initial examination should be system- For medicolegal purposes, consider preop-
drugswith orofacial injuries. They atic, methodic, and comprehensive (see erative photographs prior to invasive
found that a significantly greater propor- Figure 21-2). Equally, an injury that could treatment.
tion of patients who screened positive for involve tooth or alveolar fracture may be Include the following in the patient
drug and alcohol abuse at the time of injury substantial enough to cause a brief loss of examination23:
had a previous history of head injury consciousness. The clinical presentation of
Extraoral soft tissue
and/or orofacial injury. Further, we should closed head injuries, such as basal skull
Intraoral soft tissue
consider the high rate of recidivism in this fractures and epidural hematomas, may be
Jaws and alveolar bone
population as another behavioral factor.13 occult. Hence, if these are not recognized
Teeth (displacement and mobility)
Other groups that are at increased risk early, they may have devastating conse-
Percussion and pulp testing
of dentoaveolar trauma are those with quences. Davidoff and colleagues reported
seizure disorders, mental disorders, and that it was not uncommon for a closed Ensure that the patient is cleaned
congenital maxillofacial abnormalities. head injury to result when a loss of con- extraorally with a mild antiseptic soap,
Lockhart and colleagues reported find- sciousness of less than 1 hour occurred, while taking care not to further inoculate
ings, by the Risk Management Foundation, along with facial trauma.20 Signs of confu- injury sites with debris or foreign bodies.
indicated that damage to the teeth was the sion followed by lucid intervals may Consider tetanus prophylaxis, depending
most frequent anesthesia-related claim, require further radiographic and/or com- on previous immunization compliance
often resulting in litigation.14 Poor laryn- puted tomography (CT) scan studies.21 and wound presentation. (Table 21-1).24
Management of Alveolar and Dental Fractures 385
Table 21-1 Summary of Tetanus Prophylaxis Test percussion sensitivity and pulp
vitality to rule out periodontal ligament
Nontetanus-Prone Wounds Tetanus-Prone Wounds
injury or one of the many forms of frac-
History of Adsorbed Tetanus Td* TIG Td* TIG (250 U IM) tures. Gentle tapping of the injured and
Unknown or 3 doses Yes No Yes Yes noninjured control teeth is the technique
3 doses No No No No of choice. Use the handle of a mouth mir-
Td = tetanus and diphtheria toxoids adsorbedfor adult use; TIG = tetanus immune globulinhuman. ror or a specially designed calibrated per-
*For children < 7 yr old: DTP (DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For persons cussion instrument. Tactile, auditory, and
7 yr old, Td is preferred to tetanus toxoid alone.
If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed toxoid, should be given. visual senses are used. Dullness may alert
Yes, if > 10 yr since last dose.
Yes, if > 5 yr since last dose. (More frequent boosters are not needed and can accentuate side effects.)
the surgeon to the possibility of a luxa-
Adapted from Alexander RH and Proctor HJ.24 tion injury or alveolar fracture. The qual-
ity of this sound indicates that the teeth
are not in optimal contact with the adja-
Thoroughly inspect superficial and deep Stensens duct or orifice injuries. The lips, cent bony structure. If the enamel is frac-
lacerations, abrasions, or any soft tissue the floor of the mouth, and the tongue tured or infraction has occurred, the
compromise. The mechanism of injury regions are all areas at risk for penetrating sound is reminiscent of a cracked tea
elicited in the history and the soft tissue or secondary injury and thus should be cup.31 The typical sound of the unin-
defect alerts the surgeon to suspect under- inspected accordingly. Account for all frac- jured tooth is that of solid metallic reso-
lying hard-tissue damage, such as to the tured or missing teeth and restorations or nance. Percussion testing, in and of itself,
maxilla, the mandible, the temporo- assume they were swallowed, aspirated, or can add insult to injury; thus, control and
mandibular joint (TMJ), and alveolar frac- lodged within adjacent structures. Similar- caution are warranted.
tures. Success rates are time-dependent ly, arrange for radiographic evaluation of Evaluate tooth vitality via various pulp
with dentoalveolar trauma, and generally the maxillary and nasal sinuses prior to testing modalities. Mechanical, thermal,
perioral soft tissue lacerations (lips) further treatment.2830 and electrical noxious stimuli are used.
should be repaired after intraoral treat- While examining for jaw and alveolar These tests use various stimuli to check for
ment, except in cases of poor hemorrhage bone fractures, the presence of gross mobil- conduction disturbances at the sensory
control. In children, women, and the ity or pericoronal bleeding of the involved receptors of the pulp. The pulp comprises
elderly, if the injury observed fails to cor- teeth may be noted. Sublingual ecchymosis both nonmyelinated and myelinated nerve
relate well with the history given, suspect at the floor of the mouth is pathognomon- fibers, which regulate vascular changes and
and subsequently rule out abuse. Authori- ic for an underlying mandible fracture. Step respond to pain stimuli, respectively. As the
ties, such as social services representatives, defects, crepitation, malocclusion, and gin- tooth develops, the pain fibers (ie, myeli-
initiate proper legal protocols, if necessary. gival lacerations all raise suspicion of possi- nated) increase, while simultaneously low-
Prior to any intraoral manipulations, ble underlying bony defects. ering the electrometric pulp stimula-
obtain initial radiographic studies (eg, in the Assess all fractured teeth for enamel, tion.32,33 This concept sheds light on some
pediatric patient, knowledge of the errant dentin, and pulpal involvement. Complete of the treatment differences in open and
deciduous tooth root to the permanent mobility of the crown may indicate closed apices of the permanent dentition.
tooth bud position). The chance of further crown-root fracture. Superficial crazing or Pulp testing in the acute phase of den-
damage could be exponentially disastrous to infractions may be identified with a direct toalveolar fracture is controversial and
both the future eruption and the morphol- light source, transilluminating perpendic- heavily based on the cooperation and com-
ogy of the developing permanent tooth.2527 ular to the long axis of the tooth from the munication of the patient as well as the
Approach intraoral soft tissue exami- incisal edge. Inspect and consider each repair process of the injured pulp tissue.
nation with caution. Carefully manipulate tooth at risk, even at sites distal to the ini- The fear of possibly experiencing increased
and handle traumatized tissues to avoid tial traumatic impact. Indirect trauma of pain during testing, especially in children,
further compromise. Depending on the the chin may cause posterior dentition limits verbal objectivity and may render
mechanism of injury, bone or tooth frag- defects, such as vertical or cusp fractures. pulp testing too unreliable. Also, acutely
ments may have penetrated these delicate Check occlusion and note any displace- injured teeth may revascularize in approxi-
areas. Closely inspect hematoma forma- ments, intrusions, or luxations. The direc- mately 1 month, thus increasing the risk of
tion or ecchymotic areas. Buccal mucosal tion of force is most commonly in a false-negative results during pulp testing.
lacerations should raise the suspicion for buccal-lingual direction. The development stage of the involved
386 Part 4: Maxillofacial Trauma
teeth also plays a significant role in the and prognosis. Figure 21-3 provides the ographs. The periapical radiograph pro-
repair process. Incomplete apical develop- dentoalveolar trauma record, which should vides the most detailed information about
ment increases the chances of pulp repair include, but is not limited to, these entities. root fractures and the dislocation of teeth.
and revascularization. As the tooth Following treatment, periapical films can
matures and apical width constriction Radiographic Examination confirm the proper positioning of an
starts, the chances of pulp repair decrease. Radiographic examination is essential to avulsed or luxated tooth into the alveolus.
Bacterial invasion in the pulp injury zone determine whether any underlying struc- Occlusal radiographs, however, pro-
increases the risk of total pulp necrosis. tures are damaged and should include vide a larger field of view, and the detail is
Paradoxically, occasionally uninjured teeth periapical, occlusal, and panoramic radi- almost as sharp as a periapical radiograph.
may not respond as expected. Even with
this controversy in mind, pulp testing con-
tinues. Some of the testing paraphernalia Dentoalveolar Trauma Record
are listed as follows34:
Name: _____________________________________ Date: _____________________
Mechanical stimulation
Dental probe Age:
Cavity prepping with drills Sex:
Saline-laden cotton pledget Incident:
(fractured teeth) Cause
Thermal test Location
Time
Heated gutta-percha
Ice Neurologic status:
Locus of control
Ethyl chloride
Consciousness
Carbon dioxide snow Headache
Dichlorodifluoromethane Nausea, vomiting
Electrometric test Extraoral findings:
Electric pulp testers Intraoral findings:
A B C
D E F
FIGURE 21-5 Diagram of injuries to dental tissue and pulp. A, Crown infraction. B, Crown fracture confined to enam-
el and dentin (uncomplicated crown fracture). C, Crown fracture directly involving pulp (complicated). D, Uncompli-
cated root fracture. E, Complicated crown-root fracture. F, Horizontal root fracture. Adapted from Andreasen JO, editor.
Traumatic injuries of the teeth. 1st ed. Philadelphia (PA): W.B. Saunders; 1972.
Crown Fracture exposure, is the primary source of pulpal Although zinc oxideeugenol cement has
without Pulp Involvement complications following injury. Prognosis been one of the best agents for producing
Crown fractures are the most frequent is better if the enamel-dentin fracture a hermetic antibacterial seal, it is generally
injuries in the permanent dentition. involves a tooth that has not been luxated not recommended at the site where a com-
Crown fractures that expose dentinal because the blood supply to the pulp has posite resin restoration is placed because
tubules potentially may lead to contami- not been disturbed, and the immunologic the eugenol component may interfere with
nation and inflammation of the pulp, defense systems in the pulp will combat polymerization, at least with some com-
eventually resulting in pulpal necrosis if bacterial invasion (Figure 21-8). posites. A similar effect has been seen with
untreated. Luxation injury concomitant to Treatment is directed at protecting the a hard-setting calcium hydroxide paste,
crown fractures, with or without pulp pulp by sealing the dentinal tubules. resulting in bond strength reduction in
Management of Alveolar and Dental Fractures 389
Crown-Root Fracture
A fracture that is longitudinal and follows
the long axis of the tooth or if the coronal
D fragment constitutes more than one-third
of the clinical root, extraction is generally
FIGURE 21-6 Diagram of injuries to periodontal tis-
sues. A, Periodontal concussion. B, Subluxation. C, Lux- recommended. However, with a fracture
ation, dislocation, or partial avulsion. D, Exarticulation line that is above or slightly below the cer-
or avulsion. Adapted from Andreasen JO, editor. Trau- vical margin, appropriate forms of conser-
matic injuries of the teeth. 1st ed. Philadelphia (PA): vative therapy can usually be used to
C W.B. Saunders; 1972.
restore the tooth. Crown lengthening or
orthodontic elevation of the involved
certain dental-bonding agents. In fractures crown fractures by Andreasen and Class III tooth may be necessary.
with dentin exposure only, we recommend fractures by Ellis. Prognosis depends on
a dental bonding agent, followed by a the length of time that has elapsed since Root Fracture
composite restoration. With pulp expo- the injury occurred, the size of the pulp This type of fracture is limited to fractures
sure, the preferred treatment is calcium exposure, the condition of the pulp (vital involving the roots only (Ellis IV). Most
hydroxide placed directly over the expo- or nonvital), and the stage of root devel- root fractures occur in the apical and mid-
sure and sealed in place with a glass opment. Make every effort to preserve the dle one-third and rarely in the cervical
ionomer cement followed by a dentin pulp in immature teeth. Conversely, in one-third. Root fractures are not always
bonding agent and composite.37 mature teeth with extensive loss of tooth horizontal; in fact, they are often diagonal
structure, pulp extirpation and root canal in angulation. Radiographs taken immedi-
Crown Fracture with Pulp therapy are prudent before post, core and ately after an injury may not show a hori-
Involvement crown restoration. The prognosis is best zontal or diagonal root fracture. After 1 or
Crown fractures involving the enamel, for teeth with a vital pulp exposure if the 2 weeks when inflammation, hemorrhage,
dentin, and pulp are called complicated fracture is treated within the first 2 hours. and resorption have caused the fragments
390 Part 4: Maxillofacial Trauma
substance is being ultimately replaced by dentinal walls of the root canal, giving the and direction of traumatic impact. Fifteen
bone, and radiographically a loss of the chamber an enlarged appearance. The ces- to 61% of luxation injuries occur in the
periodontal space and progressive root sation of this process will require root permanent dentition and 62 to73% in the
resorption is seen. canal therapy (Figure 21-10). primary dentition. Multiple teeth are usu-
INFLAMMATORY RESORPTION Inflam- The potential devastating effects of the ally involved in luxation injuries.40
matory resorption appears as well- resorptive process require immediate and
circumscribed areas of cementum and proper treatment of periodontal injuries. Subluxation Subluxation injuries occur
dentin resorption. The localized adjacent when there is an injury to the tooth-
periodontal tissue is markedly inflamed. Classification of Periodontal Injuries supporting structures that causes abnor-
The onset of inflammation is a result of Periodontal injuries are classified as con- mal loosening; however, there is no clinical
the infected and necrotic pulp tissue with- cussions and displacements. Displace- or radiographic displacement of the
in the root canal. The radiograph shows an ments include subluxations, intrusive involved tooth. The tooth is sensitive to
appearance of root resorption with lines of luxations, extrusive luxations, and lateral percussion testing and occlusal forces.
adjacent bone radiolucency. luxations. Rupture of the periodontal tissues is usu-
ally evident by bleeding at the gingival
Root Canal Resorption Root canal Concussion Often this injury is over- margin crevice (Figure 21-11).
resorption, also known as internal root looked because no acute clinical or radi- Treatment is similar to that for concus-
resorption, presents less often than root ographic evidence of trauma is seen. No sion injuries with occlusal adjustments and
surface resorption. Studies found that it abnormal mobility, displacement, or bleed- vitality testing. Excessive mobility may
appears in both permanent and primary ing is apparent; only minimal injury to the necessitate nonrigid stabilization. Continue
teeth. Radiographic imaging may be tissues was acquired. Frequently, the history follow-up evaluation and vitality testing for
equivocal; labial or lingual presentations of the insult guides the surgeon to the sus- 6 to 8 weeks.
of surface resorption may be erroneously pected tooth or teeth. The hallmark to diag- Approximately 26% of injuries with
superimposed over the root canal. To nosis is a marked reaction to percussion in this classification result in pupal necrosis,
avoid a misdiagnosis supplemental radi- both the horizontal and vertical directions. and endodontic treatment is indicated.
ographic views are warranted. Root canal The discomfort is similar to that of a hot Studies show that external resorption will
resorption is classified as two types: (1) tooth, hyperemic quality. Because a con-
internal replacement resorption and (2) cussed tooth may take on a chronic course
internal inflammatory resorption. or exhibit progressive problematic seque-
INTERNAL REPLACEMENT RESORPTION lae, it warrants close monitoring.
Internal replacement resorption shows Treatment includes taking the sus-
metaplastic replacement of normal pulp pected tooth out of occlusion to avoid
tissue into cancellous bone, resulting in a function. If at all plausible, consider
widened pulp chamber. This is a character- occlusal adjustments on the opposing den-
istic process that is seen in root fractures tition, thereby limiting further trauma to
and, to a lesser extent, in luxation injuries. the involved tooth.
INTERNAL INFLAMMATORY RESORPTION
Internal inflammatory resorption often Displacements Displacement injuries, or
located at the cervical region of the pulp, luxations, principally involve the primary
presents radiographically as an irregular and permanent maxillary central incisors.
or oval-shaped radiolucent enlargement The mandibular teeth are less at risk,
within the pulp chamber. This condition unless a Class III malocclusion exists. Gen-
relates to the ingression of bacteria via erally, displacement injuries are more
dentinal tubules within a necrotic pulp prevalent in primary dentition owing to
delineated as the necrotic pulp zone. Pos- the increased elasticity and resilience of
sibly, this zone is responsible for the pro- the bony supporting structures. Converse-
FIGURE 21-10 Maxillary lateral incisor with a
gression of the process. Normal pulp tissue ly, permanent teeth will have an increased
history of periodontal injury (subluxation). Evi-
is altered and transformed into granula- risk of tooth fracture.38,39 The specific lux- dence of internal root resorption, specifically, inter-
tion tissue with giant cells that resorb the ation classification depends on the force nal inflammatory resorption (arrow), is seen.
392 Part 4: Maxillofacial Trauma
of the canal, will eradicate the bacterial of intrusion. B, Teeth extruded, aligned, and sta-
encountered. Intrusive injuries are the
bilized with nonrigid splint. Soft tissue gingival
most severe of the luxation injuries that contamination and allow for the repair of wound repaired.
involve the pediatric patient. The intruded the periodontal ligament.
primary tooth may be impinging on the Replace the CaOH filler if it resorbs
tooth bud of the permanent successors in during the healing process. Arrange for occlusion to ensure no rotation has
a buccal-occlusal position.2628 The inci- frequent radiographic follow-up at occurred. Then, stabilize the tooth with a
dence of pupal necrosis is relatively high 3-month intervals, and continue for 6 to nonrigid splint for approximately 2 to
(96%). Inflammatory resorption inci- 12 months. Perform conventional root 3 weeks. If signs of pulp necrosis occur,
dence may reach 52% as a result of the canal therapy with gutta-percha obtura- employ endodontic therapy.
necrotic pulp (Figure 21-12). tion when signs of resorption have ceased.
Lateral Luxations Lateral luxations may
Extrusive Luxation Extrusive luxations result from traumatic forces that displace the
are the partial displacement of the tooth tooth, or teeth, in many directions; however,
out of the socket in a coronal or incisal the lingual direction appears to be the most
direction with lingual deviation of the prevalent. These luxations often involve the
crown. This results in the rupture and sev- bony alveolar socket. The radiographic
erance of the neurovascular and periodon- appearance is similar to the extruded tooth
tal ligament (PDL) tissues, respectively. on occlusal views, with the PDL space
There is gross mobility and bleeding at the widening in the apical direction. Linear or
gingival margin. Further, radiographically, comminuted fractures are the norm. Lingual
the PDL space is widened. A dull sound is and buccal plate expansion may render the
heard on percussion testing. Pulp necrosis tooth mobile. Localized soft tissue compro-
occurs approximately 64% of the time, mise is often apparent. When bony defects
FIGURE 21-11 Patient with subluxed left max- and a relatively low frequency of external exist beneath the gingiva, it is common to see
illary central incisor. Bleeding and ecchymosis at resorption is seen at 7%.41 complex lacerations and step defects.
the gingival margin crevice denotes rupture of It is treated by delicately placing the Because the tooth is often locked in an errant
the periodontal tissues. Treatment involved sta-
bilization with a custom-fabricated nonrigid extruded tooth back into the proper posi- position, the percussion resonance and
splint for 2 weeks. tion in the socket. Check and re-check mobility resemble the intruded tooth.
Management of Alveolar and Dental Fractures 393
The key to treatment is to reestablish tion, these injuries involve tooth, or teeth, is a readily available medium for the lay per-
preinjury occlusion. Delay soft tissue repair that are completely dislodged from the son, and, because time is of the essence, it is
until this is completed. Manipulate the socket for a period of time. Owing to the the medium of choice in the absence of
tooth or teeth back into the socket. If an higher risk of aspiration, supporting Hanks solution or ViaSpan. Milk will only
alveolar segment is involved, reposition it. structure damage, or actual physical loss of prevent further cellular demise; thus, it is
Digitally apply buccal and lingual pressure the tooth, these injuries require special used specifically when teeth have been
in cases of traumatic bony expansion to attention. Old ideology and myths still extraoral for < 20 minutes. Any periodontal
ensure early PDL repair. Apply a nonrigid plague the use of newer proven protocols. ligament extraoral exposure > 15 minutes
splint that is extended to and is supported Avulsion injuries occur from 0.5 to will deplete most of the cell metabolites; for
by the presumably uninjured adjacent about 16% in the permanent dentition and this reason, a longer period of extraoral time
teeth. Leave the splint in place for 2 to occur less in the primary dentition (7 to limits milks effectiveness to maintain cellu-
8 weeks, depending on bony healing, which 13%), with children ages 7 to 9 years being lar viability. Unlike Hanks solution and
may require longer stabilization time. Avoid most associated with this injury. These ViaSpan, which can store avulsed teeth and
the use of disimpaction devices, such as for- injuries usually involve a single tooth, with replenish cellular metabolites for 24 hours
ceps or hemostats, while attempting to the maxillary central incisor most often at and 1 week, respectively, milk as a storage
reestablish proper alignment of teeth or risk, which is due to the relative instability medium becomes ineffective after approxi-
segments. Excessive fulcruming forces may of the periodontal ligament during the mately 6 hours.50,51
further compromise the tooth and/or sup- progressive eruption of these teeth.46
porting structure. The treatment of such injuries must Treatment Considering the root matura-
In persons who may have experienced be geared toward early reestablishment of tion, the extraoral time, and the general
delayed treatment in excess of 48 hours, periodontal ligament cellular physiology.
reestablishing occlusion may be difficult and The fate of the avulsed tooth depends on
traumatic. Consider spontaneous or ortho- the cellular viability of the periodontal
dontic realignment. Continue frequent radi- fibers that remain attached to the root sur-
ographic follow-up and vitality testing for face prior to reimplantation. Although
several months. Adjacent teeth that may extraoral time is a factor, newer physiolog-
have become devitalized warrant vitality ically compatible solutions are available
testing. Any signs of pulp necrosis should be that can maintain and/or replenish peri-
met with immediate endodontic therapy. odontal ligament cell metabolites. Two
Another complication to consider is such solutions are Hanks balanced salt
the loss of marginal bone support in both solution and ViaSpan (Figures 21-13 and FIGURE 21-13 Hanks balanced salt solution,
lateral and intrusive luxation injuries, 21-14).4749 commercially available as Save-A-Tooth
(Phoenix Lazarus, Inc.).
which can occur as a temporary or perma- Both Hanks solution and ViaSpan are
nent condition. It is seen clinically as an physiologic with compatible pH and
ingrowth of granulation tissue at the gin- osmolality (Table 21-2). ViaSpan is the
gival crevice, resulting in a loss of attach- solution of choice for organ storage dur-
ment. This is the normal process of peri- ing transport for transplantation. The rel-
odontium healing and takes up to 6 to ative availability and cost effectiveness of
8 weeks. When this process occurs, contin- Hanks solution makes it the medium of
ue maintenance of the splint and pay close choice in storage of avulsed teeth. Com-
attention to oral hygiene compliance to mercially available by Phoenix Lazarus
prevent further bone loss. Inc., Save-A-Tooth, an emergency tooth
The frequency of this bony loss reach- preserving system that contains Hanks
es 5% for lateral luxations and 31% in solution as its active ingredient, is a main-
intruded luxations.45 stay in many athletic first aid kits.
Other methods for temporarily storing
Exarticulations (Avulsions) an avulsed tooth are milk, saliva, and saline;
Seemingly, avulsion injuries are the worst however, their ability to replenish cellular FIGURE 21-14 ViaSpan, cold storage solution
of the dentoalveolar injuries. By defini- metabolites has not been documented. Milk currently available as an organ transport solution.
394 Part 4: Maxillofacial Trauma
Table 21-2 Solutions to Replenish the need for multiple CaOH replace- owing to a necrotic pulp or compromised
Periodontal Ligament Cell Metabolites mentsone of which is ProRoot MTA PDL, respectively.
Solution Characteristics (Mineral Trioxide Aggregate), marketed by In individuals who experience an extra-
Densply Tulsa Dental. Contrary to CaOH, oral period that exceeds 2 hours, apical root
Hanks balanced pH = 7.2
MTA provides a hard-setting nonre- morphology plays little role in the success
salt solution Osmolality = 320 mOsm
sorbable surface with cavity adaptation. It rate. Eliminate the necrotic periodontal lig-
ViaSpan pH = 7.4 provides excellent tissue biocompatibility ament strands manually or chemically in a
Osmolality = 320 mOsm
and allows for immediate apical seal.53,54 sodium hypochlorite wash for approxi-
Cows milk pH = 6.56.7 The increased potential for reestab- mately 30 minutes. Perform root canal ther-
Osmolality = 225 mOsm lishment of pulpal circulation in teeth apy extraorally with conventional cleansing
with open apices has been shown to and shaping of the canal. Withhold final
improve prognosis of survival of the pulp obturation until the canal, dentinal tubules,
health of the tooth preinjury determines the and PDL in the avulsed tooth (Figures and root surface have been treated with var-
route of treatment. The idea of early or 21-15 and 21-16). This revascularization ious chemicals in a stepwise fashion. First, a
immediate replantation should be adopted. process is optimized by the topical appli- citric acid bath for 3 minutes, followed by
Teeth that are in poor condition from cation of doxycycline. Individuals who rinsing with 0.9% NaCl, will open and
a hygiene standpoint are generally not have avulsed teeth with mature or closed debride the dentinal tubules, thus allowing
replanted. Those that present with moder- apices and who present within the 2-hour unimpeded ingrowth of connective tissue to
ate to severe periodontal disease, gross time frame are treated by placing the the root surface. Second, the tooth should
caries involving the pulp, apical abscess tooth in Hanks solution for about be moved to a 1% stannous fluoride solu-
formations, infection at the replanting site, 30 minutes, followed by replantation and tion for 5 minutes. This will decrease the
and bony defects and/or alveolar injuries, splinting for 7 to 10 days. Carry out risk of the resorption process.
in which supporting bone is lost are less endodontic cleansing and shaping of the Finally, set up a 5-minute bath of
likely to be considered for replantation. canal, and place a CaOH filling just prior 1 mg/20 mL doxycycline, which will rid
To optimize success of treatment, to splint removal. Final gutta-percha the root surface of residual bacterial rem-
replant and stabilize avulsed teeth within obturation is contingent on resolving nants and facilitate pulpal revasculariza-
2 hours (120 minutes); periodontal liga- canal and/or root pathology (6 to tion. Complete the final obturation with
ment cells become irreversibly necrotic 12 months). Late failure of the replanta- gutta-percha. The tooth is then replanted
after this time frame. Attempt to salvage tion process is manifested as either into preinjury alignment and splinted for
avulsed teeth, even if the critical 2-hour inflammatory or replacement resorption 7 to 10 days (Tables 21-3 and 21-4).50,52,55
period has passed, but the prognosis
becomes progressively worse.
Teeth with open apices > 1 mm diame-
100
ter have a prognosis that is much better 90
Pulp Survival (%)
100
recommendations (Figure 21-17). The
Healing/Survival (%)
Peridontal Ligament
90 arch bar, self-curing, Essig, intracoronal,
80 and circumferential splints may rarely pre-
70
60 sent with an indication but are not rou-
50 tinely recommended. Each has been
40
30
demonstrated to violate one or many of
20 the basic splint requirements. The arch
10 bar, in particular, produces an eruptive or
0
1 5 10 extrusive force because of the placement of
the wire beneath the height of contour of
Time (yr)
the tooth. Also the rigid nature of these
techniques will facilitate the external
Closed apex Open apex resorption process (Table 21-6).
FIGURE 21-16 Periodontal healing/survival after replantation relat-
Treatment of Fractures of the
ed to stage of root development (closed vs open). Adapted from
Andreasen JO and Andreasen FM.34 Alveolar Process
Owing to the exposed anatomy, alveolar
Splinting Protocol and Technique Splint- acid-etch/resin splint (or variants of this fractures usually occur at the incisor and
ing after avulsion and displacement injuries technique) is the treatment of choice.56,57 premolar regions. Treatment involves early
immobilizes the tooth or segment into prop- This technique fulfills the requirements of reduction and stabilization of the involved
er preinjury alignment and allows for the ini- acceptable splint utilization in a maxillofacial segments. Depending on the fractures
tial pulpal revasculature and periodontal lig- traumatic injury (Table 21-5).
ament healing course. Several techniques The acid-etch technique is the only
Table 21-4 Treatment Summary for
have been advocated in the past; however, the system that most closely adheres to these Teeth Avulsed > 2 Hours*
Table 21-5 Splint Requirements for dual treatment of the dental and/or
alveolar injury and the jaw injury (eg,
The splint should arch bars and maxillomandibular fixa-
1. Be able to be applied directly in the mouth without delay owing to laboratory procedures
tion). Perform the more invasive open
2. Stabilize the injured tooth in a normal position
reduction if indicated.
3. Provide adequate fixation throughout the entire period of immobilization
Avulsive injuries will often expose
4. Neither damage the gingiva nor predispose to caries and should allow for a basic oral
hygiene regimen bone and jeopardize tooth support. Aim
5. Not interfere with occlusion or articulation treatment at soft tissue coverage in the
6. Not interfere with any required endodontic therapy form of judicious mucosal advancement
7. Preferably fulfill esthetic demands flaps. Consider early removal for teeth
8. Allow a certain mobility (nonrigid) to aid periodontal ligament healing in cases of without bony support.
fixation after luxation injuries and replacement of avulsed teeth; however, after root
fracture, the splint should be rigid to permit optimal formation of a dentin callus to Treatment of Trauma to the
unite the root fragments Gingiva and Alveolar Mucosa
9. Be easily removed without re-injury to tooth Traumatic injury to the oral soft tissue
Adapted from Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Munksgaard; mainly consists of abrasion, contusion,
1994. p. 3478.
and laceration. If these injuries are not
addressed, they can place the underlying
severity, use either an open or closed tech- tion and inadequate bony envelopment bony tissue at risk for devitalization. Fre-
nique. Digital manipulation and pressure, indicate early removal. quently these injuries may alert the sur-
along with rigid splint stabilization, will Successful treatment of alveolar frac- geon to underlying trauma. The ultimate
usually be sufficient in the closed tech- tures is associated with the pupal healing goal of treatment is to reestablish vital soft
nique. Leave the splint in place for approx- after the injury. When the fracture level is tissue bony coverage.
imately 4 weeks. apical to the root tips, the vascular supply
A gross displacement and/or imped- to the pulp is less at risk; however, if the Abrasion An abrasion is a superficial
ance to reduction may necessitate the line of the fracture and root apices are in wound wherein the epithelial or gingival
open technique. Inability to freely reduce contact, the teeth in the alveolar segment tissue is rubbed, worn, or scratched. Treat-
fracture segments may be due to root or are at a higher risk for internal or external ment consists of local cleansing with a
bony interferences or impaction (apical resorption. mild disinfectant soap for the skin and
lock) (Figure 21-18). Access to the area In concomitant injuries, such as saline rinsing and/or irrigation of the gin-
involves an incision that provides ade- maxillary or mandibular fractures, early giva. Antibiotic coverage is seldom neces-
quate exposure and is located apical to the maxillomandibular fixation is accom- sary. Inspect the wound for possible for-
fracture lines. The segment is then disim- plished with a technique that will allow eign body (asphalt) accumulation, which
pacted or freed up. Proper alignment and
occlusion are then attained, and the seg-
ments are stabilized with suitable trans-
osseous wire or a small (2.0 mm) mono-
cortical plate. Ensure that the closure of
the wound is meticulous to prevent expo-
sure of bone and/or hardware to the
ingress of bacteria.
Stabilize teeth that may be mobile
in the fractured segment with an
appropriate secondary splint after bony
stabilization. Likewise, avoid removing A B
teeth that are considered nonsalvage-
FIGURE 21-17 Acid-etch splinting technique. A, Subluxed tooth and alveolar fracture associated with
able and that are within the bony seg- maxillary left central incisors. B, Nonrigid passive placement of splint. Traumatized teeth are placed
ment until the bony healing phase is into preinjury alignment, acid-etched, and stabilized with composite resin. Splint is free of occlusion
completed (~ 4 weeks). Obvious infec- and soft tissue trauma.
Management of Alveolar and Dental Fractures 397
A B C
FIGURE 21-19 Anatomic position of the prima-
ry dentition to the developing permanent tooth FIGURE 21-20 A, Normal position of primary tooth to permanent tooth bud. B, Apical intrusion of pri-
bud. Note the buccal-occlusal and buccal- mary root impinging on permanent tooth bud. Blue arrows denote permanent tooth bud. C, Hypoplasia
incisal position of the primary roots (arrow). of permanent tooth secondary to apical intrusion.
of force to the developing tooth is possi- Table 21-7 provides a summary of the applied by the primary dentition. They
ble in displacement injuries, which may treatment regimen. found that the individuals age at the time
cause interference with odontogenesis, Andreasen and Raven reported on the of injury and the type of luxation play a
ultimately resulting in enamel discol- general prognosis of the traumatized per- major role in the errant development of the
oration and/or hyploplasia (Figure 21-20). manent successors, secondary to forces permanent dentition (Figure 21-21).21,22,59
100
Permanent Dentition (%)
Malformed or Normal
75
50
25
FIGURE 21-21 Association of the type of luxation injury with respect to the malformation of the permanent dentition. Adapted from
Andreasen JO and Ravn JJ.59
References 5. Andreasen JO. Classification, etiology and epi- press/2002/abuse.html (accessed March 29,
demiology. In: Andreases JO, editor. Trau- 2004).
1. Fonseca RJ, Walker RV, Betts NJ, Barber HD. matic injuries of the teeth. 2nd ed. Copen- 9. Peng L, Kazzi, AA. Dental, fractured tooth.
Oral and maxillofacial trauma. 2nd ed. Vol
hagen: Munksgaard; 1981. p.19. eMedicine Journal 2001;2:6.
1. Philadelphia (PA):W.B. Saunders Co;
6. Lephart SM, Fu FH. Emergency treatment of 10. Laskin DM. The recognition of child abuse.
1997. p. 474.
athletic injuries. Dent Clin North Am J Oral Surg 1978;36:349.
2. Shaynes Dental Site. History of dentistry,
1991;35:707. 11. Leathers RD, Shetty V, Black EE, Atchison K. Oro-
Greco-Roman dentistry (AD 350750),
Available at: http://www.dental-site.itgo. 7. Heintz WD. Mouth protection for athletics facial injury and patterns of care in an inner-
com/grecoroman.htm (accessed March 17, today. In: Godwin WD, Long BR, city hospital. Int J Oral Biol 1998;23:538.
2003). Cartwright CB, editors. The relationship of 12. Leathers RD, Le AD, Black EE, McQuirter JL. Oro-
3. Shaynes Dental Site. History of dentistry, internal protection devices to athletic facial injury in underserved minority popula-
Islamic-Medieval Europe (AD 7501200), injuries and athletic performance. Ann tions. Dent Clin N Am 2003;47:12739.
Available at: http://www.dental-site.itgo. Arbor (MI): University of Michigan; 1982. 13. Black EE, Atchison K, Shetty V, et al. The rela-
com/Islamic. htm (accessed March 17, 2003). 8. U.S. Department of Health and Human Services. tionship of substance abuse to orofacial
4. James D. Maxillofacial injuries in children. In: Childrens Bureau. National child abuse and injuries in an inner-city population. Int J
Rowe NL, Williams JLL, editors. Maxillofa- neglect data system. Summary of key find- Oral Biol 1998:4752.
cial injuries. 1st ed. Edinburg: Churchill ings from calendar year 2000. April 2002. 14. Lockhard PB, Feldbau EV, Gabel RA, et al.
Livingstone; 1985. p. 538. Available at: http://www.acf.hhs.gov/news/ Dental complications during and after
400 Part 4: Maxillofacial Trauma
tracheal intubation. J Am Dent Assoc 1986; 29. Snawder KD, Bastawni AE, OToole TJ. Tooth alveolar root filling with calcium hydroxide
112:480. fragments lodged in unexpected areas. on periodontal healing after replantation of
15. Piercell MP, White DE, Nelson R. Prevention of JAMA 1976;233:13789. permanent incisors in monkeys. J Endod
self-inflicted trauma in semicomatose 30. Gilliland RF, Taylor CG, Wade WM Jr. Inhala- 1981;7:349.
patients. J Oral Surg 1974;32:903. tion of a tooth during maxillofacial injury: 45. Andreasen FM, Vestergaard Pedersen B. Prog-
16. Wright RB, Mansfield FF. Damage to teeth dur- report of a case. J Oral Surg 1972;30:83940. nosis of luxated permanent teeth the
ing the administration of general anesthe- 31. Rowe NL, Killey HC. The clinical examination development of pulp necrosis. Endod Dent
sia. Anesth Anal 1974:53:405. of fractures of the middle third of the facial Traumatol 1985;1:20720.
17. Andreasen JO. Etiology and pathogenesis of skeleton involving the dentoalveolar com- 46. Andreasen JO, Andreasen FM. Textbook and
traumatic dental injuries. Scand J Dent Res ponent. In: Rowe NL, Killey HC, editors. color atlas of traumatic injuries to the teeth.
1970;78:329. Fractures of the facial skeleton. 2nd ed. 3rd ed. Copenhagen: Munksgaard; 1994.
18. Fonseca RJ. Oral and maxillofacial surgery, Baltimore (ML): Williams & Wilkins; 1970. p. 383.
trauma. Vol 3. Philadelphia (PA):W.B. p. 345. 47. Krasner P, Rankow HJ. New philosophy for the
Saunders Co; 2000. p. 46. 32. Fulling H-J, Andreasen JO. Influence of matu- treatment of avulsed teeth. Oral Surg Oral
19. Assael LA, Ellis EE. Soft tissue and dentoalveo- ration status and tooth type of permanent Med Oral Path Oral Radiol Endod
lar injuries. In: Peterson LJ, Ellis E, Hupp teeth upon electrometric and thermal pulp 1995;79:616.
JR, Tucker MR, editors. Contemporary oral testing. Scand J Dent Res 1976;84:28690. 48. Krasner P, Persen P. Preserving avulsed teeth
and maxillofacial. 2nd ed. St. Louis (MO): 33. Johnsen DJ. Innervation of teeth: qualitative, for replantation. J Am Dent Assoc 1992;
C.V. Mosby Co.; 1988. p. 230. quantitative, and developmental assess- 123:80.
20. Davidoff G, Jakubowski M, Thomas D, Alpert ment. J Dent Res 1985;64:55563. 49. Thorp M, Friedman S. Periodontal healing of
M. The spectrum of closed-head injury in 34. Andreasen JO, Andreasen FM. Textbook and replanted teeth stored in Viaspan, milk, and
facial trauma victims: incidence and color atlas of traumatic injuries to the teeth. Hanks balanced salt solution. Endod Dent
impact. Ann Emerg Med 1988;17:27. 3rd ed. Copenhagen: Munksgaard; 1994. Traumatol 1992;8:183.
21. Bucci MN, Phillips TJ, McGillicuddy JE. p. 20210. 50. Fonseca RJ. Oral and maxillofacial surgery,
Delayed epidural hemorrhage in hypoten- 35. Wilder-Smith PEEB. A new method for the trauma. Vol 3. Philadelphia (PA):W.B.
sive multiple trauma patients. Neuro- non-invasive measurement of pupal blood Saunders Co.; 2000. p. 648.
surgery 1986;19:658. flow. Int Endod J 1988;21:30712. 51. Hiltz J, Trope M. Vitality of human lip fibro-
22. Alexander RH, Proctor HJ. Advance Trauma 36. Gazelius B, Olgart L, Edwall L. Non-invasive blast in milk, Hanks balanced salt solution
Life Support.(ATLS) Course for Physicians. recordings of blood flow in human dental and Viaspan storage media. Endod Dent
5th ed. Chicago (IL): American College of pulp. Endod Dent Traumatol 1986;2:21921. Traumatol 1991;7:6972.
Surgeons; 1993. p. 2137. 37. Andreasen JO, Andreasen FM. Essentials of 52. Cvek M, Cleaton-Jones P, Austin J, et al. Effect
23. Fonseca RJ, Marciani RD, Hendler BH. Oral traumatic injuries to the teeth. 2nd ed. St. of topical application of doxycycline on
and maxillofacial surgery, trauma. Vol 3. Louis (MO): C.V. Mosby Co.; 2000. p. 25. pulp revascularization and periodontal
Diagnosis and management of dentoalveo- 38. Andreasen JO, Ravn JJ. Epidemiology of trau- healing in reimplanted monkey incisors.
lar injuries. Philadelphia (PA):W.B. Saun- matic dental injuries to primary and per- Endod Dent Traumatol 1990;170.
ders Co; 2000. p. 4850. manent teeth in a Danish population sam- 53. Cohen S, Burns RC. Pathways of the pulp. 8th
24. Alexander RH, Proctor HJ. Advance Trauma ple. Int J Oral Surg 1972;1:2359. ed. St. Louis (MO): C.V. Mosby Co.; 2002.
Life Support.(ATLS) Course for Physicians. 39. Schreiber CK. The effect of trauma on the p. 56263.
5th ed. Chicago (IL): American College of anterior deciduous teeth. Br Dent J 1959; 54. Lieblich SE. Surgical aspects of apicoectomy with
Surgeons; 1993. p. 357. 106:340. hands on demonstration of microapical
25. Tsukiboshi T. Treatment planning for trauma- 40. Andreasen JO, Andreasen FM. Textbook and preparation. Surgical mini-lectures (M222). J
tized teeth. Carol Stream (IL): Quintessence color atlas of traumatic injuries to the teeth. Oral Maxillofac Surg 2003;100.
Publishing Co.; 2000. p.1058. 3rd ed. Copenhagen: Munksgaard. 1994. 55. Selvig KA, Bjorvatn K, Bogle GC, Wikesjo
26. Andreasen JO, Sundstrom B, Ravn JJ. The p. 31577. UME. Effect of stannous fluoride and tetra-
effect of traumatic injuries to primary 41. Andreasen JO. Luxation of permanent teeth cycline on periodontal repair after delayed
teeth on their permanent successors. I. A due to trauma: a clinical and radiographic tooth replantation in dogs. Scand J Dent
clinical, radiographic, microradiographic follow-up study of 189 injured teeth. Scand Res 1992;100:200.
and electron-microscopic study of 117 J Dent Res 1970;78:273. 56. Andreasen JO, Andreasen FM. Textbook and color
injured permanent teeth. Scand J Dent Res 42. Cvek M. Treatment of non-vital permanent atlas of traumatic injuries to the teeth. 3rd ed.
1970; 79:21983. incisors with calcium hydroxide. II. Effect Copenhagen: Munksgaard. 1994. p. 34750.
27. Andreasen JO, Ravn JJ. The effect of traumatic on external root resorption in luxated teeth 57. Kehoe JC. Splinting and replantation after
injuries to primary teeth on their perma- compared with effect of root filling with traumatic avulsion. J Am Dent Assoc 1986;
nent successors. II. A clinical and radi- gutta-percha: a follow-up. Odontol Rev 112:224.
ographic follow-up of 213 injured teeth. 1973;24:343. 58. Schultz RC. Facial injuries. 2nd ed. Year Book
Scand J Dent Res 1970;79:28494. 43. Coccia CT. A clinical investigation of root Medical Publishers Inc; 1977. p. 8791.
28. Booth NA. Complications associated with resorption rates in replanted young perma- 59. Andreasen JO, Ravn JJ. Enamel changes in
treatment of traumatic injuries of the oral nent incisors: a five year study. J Endod permanent teeth after trauma to their pri-
cavity-aspiration of teeth: report of a case. J 1980;6:413. mary predecessors. Scand J Dent Res
Oral Surg 1953;11:242342. 44. Andreasen JO, Kristerson L. The effect of extra- 1973;81:203.
CHAPTER 22
Principles of Management of
Mandibular Fractures
Guillermo E. Chacon, DDS
Peter E. Larsen, DDS
Management of trauma has always been masticate properly, to speak normally, and Fixation must be able to resist the dis-
one of the surgical subsets in which oral to allow for articular movements as ample placing forces acting on the mandible. It
and maxillofacial surgeons have excelled as before the trauma. In order to achieve can take one of two forms: direct or indi-
over the years. More particularly, our these goals, restoration of the normal rect. When direct fixation is used, the frac-
experience with dental anatomy, head and occlusion of the patient becomes para- ture site is opened, visualized, and reduced;
neck physiology, and occlusion provides mount for the treating surgeon. then stabilization is applied across the frac-
us with unparalleled skills for the manage- Basic principles of orthopedic surgery ture site. The rigidity of direct fixation can
ment of mandibular fractures. also apply to mandibular fractures includ- range from a simple osteosynthesis wire
The mandible is the second most ing reduction, fixation, immobilization, across the fracture (ie, nonrigid fixation) to
commonly fractured part of the maxillofa- and supportive therapies. It is well known a miniplate at the area of fracture tension
cial skeleton because of its position and that union of the fracture segments will (ie, semirigid fixation) or a compression
prominence.1,2 The location and pattern of only occur in the absence of excessive bone plate (ie, rigid fixation) to compres-
the fractures are determined by the mech- mobility. Stability of the fracture segments sion screws alone (lag screw technique).
anism of injury and the direction of the is key for proper hard and soft tissue heal- Indirect fixation is the stabilization of the
vector of the force. In addition to this, the ing in the injured area. Therefore, the frac- proximal and distal fragments of the bone
patients age, the presence of teeth, and the ture site must be stabilized by mechanical at a site distant from the fracture line. The
physical properties of the causing agent means in order to help guide the physio-
also have a direct effect on the characteris- logic process toward normal bony healing.
tics of the resulting injury.3 Reduction of the fracture can be
Bony instability of the involved achieved either with an open or closed
anatomic areas is usually easily recognized technique. In open reduction, as the name
during clinical examination. Dental mal- implies, the fracture site is exposed, allow-
occlusion, gingival lacerations, and ing direct visualization and confirmation
hematoma formation are some of the of the procedure. This is typically accom-
most common clinical manifestations. panied by the direct application of a fixa-
In the management of any bone frac- tion device at the fracture site (Figure 22-
ture, the goals of treatment are to restore 1). A closed reduction takes place when
proper function by ensuring union of the the fracture site is not surgically exposed
fractured segments and reestablishing but the reduction is deemed accurate by
preinjury strength; to restore any contour palpation of the bony fragments and by FIGURE 22-1 Open reduction with internal fix-
defect that might arise as a result of the restoration of the functioning segments, ation implies surgical exposure, visualization,
injury; and to prevent infection at the frac- for example, restoration of the dental and manipulation with the placement of a stabi-
lization device directly along the bone segments
ture site. Restoration of mandibular func- occlusion by wiring the teeth together,
involved in the fracture. A locking reconstruction
tion, in particular, as part of the stomatog- using splints, or employing external pins plate has been placed on this injury via a sub-
nathic system must include the ability to (Figure 22-2). mandibular approach.
402 Part 4: Maxillofacial Trauma
Biomechanical Considerations
Studies of the relationship between the
nature, severity, and direction of traumatic
force on the resultant mandibular injury
were made by Huelke and colleagues.1419
Before this, few experimental studies had
been done with regard to the mechanism of
mandibular fracture. Most literature regard-
ing the mechanism of fracture was based on
clinical impressions and opinions.
Early investigators showed that linear
A
fractures in long bones were initiated by
FIGURE 22-3 Superior (A) and lateral (B) views of bone failure resulting from tensile strain
a mandibular external fixator. In this particular sys- rather than compressive strain.20 Huelke
tem, biphasic pins are applied transcutaneously and
are secured to one another using a universal joint and Harger applied forces of varying mag-
system and rigid metal rods. nitudes and direction to dried mandibles
and observed the resultant production of
tension and compression.17 They found
that > 75% of all experimentally produced
fractures of the mandible were in primary
areas of tensile strain, which supported a
B similar observation made earlier in long
Principles of Management of Mandibular Fractures 403
bones. A notable exception was that com- This produces a fracture that begins in the tension develops along the lateral aspect of
minuted condylar head injury that was lingual region and spreads toward the buc- the condylar neck and mandibular body
produced by a load parallel to the cal aspect.17 The mobile contralateral regions, as well as along the lingual aspect
mandibular ramus was primarily the condylar process moves in a direction of the symphysis. This leads to bilateral
result of compressive force. away from the impact point until it is lim- condylar fractures and a symphysis frac-
In response to loading, the mandible is ited by the bony fossa and associated soft ture (Figure 22-5).
similar to an arch because it distributes the tissue. At this point, tension develops Variation from these standard fracture
force of impact throughout its length (Fig- along the lateral aspect of the contralater- patterns occurs for two general reasons.
ure 22-4). However, unlike the arch, the al condylar neck, and a fracture occurs. If First, there is a wide range in the possible
mandible is not a smooth curve of uni- greater force is applied to the parasymph- magnitude and direction of the impact
form bone, but rather it has discontinu- ysis-body region, not only will tension and in the shape of the object delivering
ities such as foramina, sharp bends, ridges, develop along the contralateral condylar the impact. Second, the condition of the
and regions of reduced cross-sectional neck leading to fracture in this area, but dentition, position of the mandible, and
dimension like the subcondylar area. As a continued medial movement of the small- influence of associated soft tissues could
result, parts of the mandible develop er ipsilateral mandibular segment will lead not be controlled in these studies.
greater force per unit area, and conse- to bending and tension forces along the Early observers felt that the presence of
quently, tensile strain is concentrated in lateral aspect and subsequent fracture of posterior dentition tended to reduce the
these locations. the condylar process on the ipsilateral side. incidence of condylar injury.2123 The
When a force is directed along the Force applied directly in the symphysis implication was that, as the mandible was
parasymphysis-body region of the region along an axial plane is distributed forced posteriorly and superiorly, the denti-
mandible, compressive strain develops along the arch of the mandible. Because tion would meet and absorb some of the
along the buccal aspect, whereas tensile the condylar heads are free to rotate with- force, thereby diminishing the force
strain develops along the lingual aspect. in the glenoid fossa to a certain degree, received at the condyle. This was supported
Force
Compression Compression
Compression
Tension
Compression Compression
Rotational movement
permitted
Tension Tension
FIGURE 22-4 The effect of a load on an arch where ends are free to rotate. Adapted from Larsen PE. Traumatic injuries
of the condyle. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM, editors. Principles of oral and maxillofacial
surgery. Vol 1. Philadelphia (PA): JB Lippincott Company; 1992. p. 444.
404 Part 4: Maxillofacial Trauma
Evaluation of Mandibular
Fractures
Traumatic craniofacial and skull base
Tension Compression Compression Tension
injuries require a multidisciplinary team
approach. Trauma physicians must evalu-
ate carefully, triage properly, and maintain
a high index of suspicion to improve sur-
vival and enhance functional recovery.
Frequently, craniofacial and skull base
injuries are overlooked while treating
more life-threatening injuries.27 Unno-
Tension ticed complex craniofacial and skull base
fractures, cerebrospinal fluid fistulas, and
cranial nerve injuries can result in blind-
ness, diplopia, deafness, facial paralysis, or
meningitis.
Following the principles of Advanced
Compression
Trauma Life Support, during the initial
assessment in the emergency department,
the first and most critical obligation is to
make sure that the airway is patent and
FIGURE 22-5 Force directed at the symphysis along an axial plane is distributed along the arch of the free of potential obstruction. The tongue,
mandible. Tension is dissipated along the mandible, and the fracture occurs bilaterally in the area of which may have a tendency to fall back,
least stability, the condylar neck. As in other fractures, a symphysis fracture may develop caused by
tension from the blow. Adapted from Larsen PE. Traumatic injuries of the condyle. In: Peterson LJ, must be controlled, and objects obstruct-
Indresano AT, Marciani RD, Roser SM, editors. Principles of oral and maxillofacial surgery. Vol 1. ing the airway must be removed. If an
Philadelphia (PA): JB Lippincott Company; 1992. p. 445. obstruction cannot be removed, a new air-
way must be established by endotracheal
intubation (remembering possible cervical
by the clinical observation that the posteri- molars are present, this area represented a spine injuries) or cricothyrotomy. After
or dentition was often fractured on the side region of inherent weakness and the inci- the airway has been secured and respira-
of the condylar fracture. However, more dence of condylar fractures decreases, tion is occurring, vital signs must be
recent findings do not support this theory whereas the incidence of mandibular angle assessed, including pulse rate and blood
and show that all types of fractures occur, fractures increases.25 pressure. Any significant blood loss is like-
irrespective of the occlusion, and that no Although unable to show that the ly to be coming from injuries apart from
correlation exists between the degree of dis- occlusion played any role in the type of those of the face. Other critical injuries
location, level of fracture, or type of frac- fracture produced, investigators have must be ruled out, including intracranial
ture with the presence of a distal occlu- found that the relative degree of mandibu- hemorrhages, cervical and other spinal
sion.24 Although the presence or absence of lar opening at the time of impact does play injuries, chest injuries, abdominal trauma,
a posterior dentition does not correlate an important role in the type of fracture and fractures of the long bones.
with the incidence of fracture, the presence that occurs.23,26 More recent studies have Local examination of the face and jaws
of specific teeth, particularly impacted third shown that not only is the incidence of should be conducted in a logical sequence.
molars, has been shown to markedly affect fracture higher when the mouth is open, The first objective is to obtain an accurate
the incidence of mandibular fractures. It but the level of fracture varies with degree history from the patient, or relative if the
was shown that, when impacted third of opening. When the mouth is opened, patient cannot cooperate. Pertinent to a
Principles of Management of Mandibular Fractures 405
occlusion, fracture of the dentition, and pain at a fracture site. In the case of sub-
decreased interincisal opening. condylar fractures, firm posterior pressure
Continuing with the systematic evalu- on the chin will cause pain in the pre-
ation of the patient, it is suggested that auricular region.
examination of the soft tissues be under-
taken next. The gingival tissue should be Radiographic Evaluation
inspected for tears or lacerations. With the To adequately screen for the presence of a
aid of a tongue blade, the floor of the mandibular fracture, at least two views at
mouth is examined; sublingual ecchymosis right angles to each other are necessary. A
is almost pathognomonic of a fracture of panoramic radiograph and a reverse
FIGURE 22-8 Significant midline deviation the mandible. Next the dentition is exam- Townes view (Figure 22-11) are adequate
toward the fracture side along with buccal cusp ined for evidence of broken teeth and for screening studies for this purpose. If only
tip fractures of both mandibular bicuspids and steps or irregularities in the dental arch. one view is used, fractures can easily be
first molar.
The patient is asked to lightly bite the teeth missed.28 In the multiple-trauma patient
together and to say whether the bite feels for whom panoramic radiographs are not
premature contact is present bilaterally on different from normal, following which the possible, lateral oblique views may be sub-
the posterior dentition with an anterior occlusion is inspected. Premature occlusal stituted. Other radiographic views that
open bite. The posterior dentition may be contacts are noted. The three causes of an may be useful depending on the circum-
fractured on both sides in these situations. altered occlusion in the trauma patient are stances are posteroanterior mandibular,
Often the patient with a fracture of the a displaced fracture, a dental injury such as mandibular occlusal, and periapical. Linear
condylar process also has a limited range a displaced tooth, and a temporomandibu- tomographies of the temporomandibular
of motion. This limitation, however, is pri- lar joint effusion or dislocation. joints can also be useful in the evaluation
marily caused by voluntary restriction as a If the patient is edentulous and has of fractures at the level of the condylar
result of pain. One has to keep in mind intact dentures with him, these can be process. However, intracapsular fractures
that any limitation of mandibular move- replaced in the mouth and the occlusion
ment may also be a result of reflex muscle inspected (Figure 22-9). The mandible
spasm, temporomandibular effusion, or should then be grasped on each side of any
mechanical obstruction to the coronoid suspected fracture and gently manipulated
process resulting from depression of the to assess mobility. If no fracture can be
zygomatic arch. Other less common find- found but clinical suspicion remains high,
ings include blood within the external the mandible may be compressed by
auditory canal and, in the case of fracture applying pressure over both angles (Figure
dislocation, development of a prominent 22-10). This nearly always gives rise to
preauricular depression. Careful otoscopic
evaluation of the external auditory canal is
of particular importance in patients sus-
pected to have suffered an injury at this
level. Occasionally a fracture of the condy-
lar process will produce a tear in the
epithelial lining of the anterior wall of the
canal, which produces bleeding from the
acoustic meatus. It is important to deter-
mine that this bleeding is not coming from
behind a ruptured tympanic membrane,
which may signify a basilar skull fracture.
A detailed intraoral examination FIGURE 22-9 The patients own dentures often
become very useful instruments in the assessment FIGURE 22-10 The application of gentle biman-
should be undertaken with good lighting
and management of mandibular fractures in the ual pressure over the angle regions can unmask a
and immediate availability of suction. The edentulous patient, if they are intact or can be minimally displaced fracture in the anterior
most common intraoral findings are mal- reasonably repaired. region of the mandible.
Principles of Management of Mandibular Fractures 407
characterize the nature and severity of and their counteracting forces also play a
the orofacial injury engenders variation primary role in the pattern and direction
in practice patterns.30 Probably the most of the fractures. It is the displacing forces
basic question one should ask at the ini- of the muscles of mastication that influ-
tial evaluation is whether the fractures ence favorableness (Figures 22-14 and
are displaced or nondisplaced. Depend- 22-15). The principle of favorableness is
ing on the amount of energy transmitted based on the direction of a fracture line
to the facial skeleton and the vector in as viewed on radiographs in the horizon-
FIGURE 22-14 Diagram of horizontally unfa-
which such force is directed, there will be tal or vertical plane. A horizontally favor-
vorable (left) and favorable (right) fracture
more or less disruption of the normal able fracture line resists the upward dis- lines. Arrows indicate displacing forces. Adapted
anatomic structures. Muscle attachment placing forces, such as the pull of the from Luyk NH.88 p. 410.
Principles of Management of Mandibular Fractures 409
skin communicating with the fracture may be localized to the fracture site, Nonfracture Injuries of the
site, edentulous portions of the such as the result of a cyst or metasta- Articular Apparatus
mandible may be involved. tic tumor, or as part of a generalized
The most commonly documented result of
Greenstick fracture: This type of frac- skeletal disorder, such as osteopetrosis.
trauma to the articular apparatus and
ture frequently occurs in children and Displaced fracture: Fractures may be
mandibular condyle is fracture. Other
involves incomplete loss of continuity nondisplaced, deviated, or displaced.
injuries occur as well and must be considered
of the bone. Usually one cortex is frac- A nondisplaced fracture is a linear
in the differential diagnosis (Table 22-1).
tured and the other is bent, leading to fracture with the proximal fragment
Anterior dislocation occurs when the
distortion without complete section. retaining its usual anatomic relation-
condyle moves anterior to the articular
There is no mobility between the ship with the distal fragment. In a
eminence. This is by far the most common
proximal and distal fragments. deviated fracture, a simple angulation
situation and represents a pathologic for-
Comminuted fractures: These are of the condylar process exists in rela-
ward extension of the normal translational
fractures that exhibit multiple frag- tion to the remaining mandibular
movement of the condylar head. Unlike
mentation of the bone at one fracture fragment, without development of a
subluxation, which is also a forward exten-
site. These are usually the result of gap or overlap between the two seg-
sion of the condyle, dislocation is not self-
greater forces than would normally be ments. Displacement is defined as
reducing. Dislocation may be caused by
encountered in simple fractures. movement of the condylar fragment
yawning, oral sex, phenothiazine use, and
Complex or complicated fracture: This in relation to the mandibular segment
trauma. Traumatically induced anterior
type of injury implies damage to struc- with movement at the fracture site.
dislocation is most commonly bilateral,
tures adjacent to the bone such as major The fragment can be displaced in a lat-
but it may occur unilaterally (particularly
vessels, nerves, or joint structures. This eral, medial, or anteroposterior direc-
if associated with a concomitant fracture
usually implies damage to the inferior tion. In displaced fractures the articu-
elsewhere in the mandible). The diagnosis
alveolar artery, vein, and nerve in lar surface of the condyle remains
of an anteriorly dislocated mandible is
mandibular fractures proximal to the within the glenoid fossa and does not
made by the following clinical features: an
mental foramen and distal to the herniate through the joint capsule.
anterior open bite with the inability to
mandibular foramen. On rare occasions Dislocated fracture: A dislocation
close the mouth; severe pain in the region
a peripheral branch of the facial nerve occurs when the head of the condyle
may be damaged or the inferior alveolar moves in such a way that it no longer
nerve injured in subcondylar fractures. articulates with the glenoid fossa.
Table 22-1 Injuries of the Articular
Telescoped or impacted fracture: This When this is associated with a fracture Apparatus
type of injury is rarely seen in the of the condyle, it is termed a fracture
mandible, but it implies that one bony dislocation. Fracture dislocations are Effusion
fragment is forcibly driven into the discussed more completely later in this Hemorrhagic or serous
other. This type of injury must be dis- chapter. The mandibular condyle may Soft tissue injury
impacted before clinical movement also be dislocated as a result of trauma Disk
between the fragments is detectable. without an associated condylar frac- Capsule
Indirect fracture: Direct fractures arise ture. Dislocations can occur anterior- Ligaments
immediately adjacent to the point of ly, posteriorly, laterally, and superiorly. Dislocation of the condyle from the fossa
contact of the trauma, whereas indi- Special situations: Other types of frac- Without fracture
rect fractures arise at a point distant tures that do not readily fit the above With fracture other than condyle
With associated condylar fracture
from the site of the fracturing force. classification include grossly commin-
An example of this is a subcondylar uted fractures or fractures involving Fracture
fracture occurring in combination adjacent bony structures, such as the Nondisplaced
Deviated
with a symphysis fracture. glenoid fossa or tympanic plate; open
Displaced
Pathologic fracture: A pathologic frac- or compound fractures; and fractures
Dislocated
ture is said to occur when a fracture in which a combination of several dif- Comminuted
results from normal function or mini- ferent types of fractures exist. Open Involving adjacent bony structures
mal trauma in a bone weakened by fractures of the condyle are usually
Combinations of the above
pathology. The pathology involved caused by missiles such as bullets.
Principles of Management of Mandibular Fractures 411
anterior to the ear; absence of the condyle these maneuvers. In refractory cases or in tion of the dislocation through manipula-
from the glenoid fossa with a visible and cases associated with mandibular body and tion of the dislocated segment by grasping
palpable preauricular depression; inability angle fractures in which the dislocated seg- it with a thumb on the dentition and with
to move the mandible except to open the ment is difficult to control by manipula- the fingers extraorally along the body of the
mouth slightly in a purely rotational man- tion, surgical intervention may be required. mandible. If the proximal segment size is
ner; difficulty in speaking; and a prognath- A percutaneous bone hook placed through inadequate for this maneuver, a percuta-
ic lower jaw. Finally, if unilateral disloca- the sigmoid notch or wires placed through neous towel clip through the angle or a
tion is present, the chin will be deviated to the angle of the mandible allow for addi- small incision with placement of a wire
the opposite side (Figure 22-17). Patients tional downward traction.38,39 Following through the angle (as described for anterior
with anterior dislocation of the mandibu- successful reduction, the patient should be dislocation) may be necessary. After reduc-
lar condyles without other mandibular instructed to refrain from opening his or tion of the dislocation, treatment of the
trauma should be approached using the her mouth widely and to support the jaw associated fracture is accomplished, prefer-
following treatment protocol: 2 cc of local with a hand under the chin when yawning ably with rigid internal fixation.
anesthetic solution should be deposited for a period of 3 weeks to allow for healing Superior dislocation into the middle
into the joint capsule followed by manual of the injured soft tissue in and around the cranial fossa without associated fracture of
reduction. If this is unsuccessful or the joint. IMF is not necessary for a first-time the mandibular condyle has been
patient is overly apprehensive, diazepam acute anterior dislocation of the jaw, described. The patient is predisposed to
should be carefully titrated intravenously unless it persistently dislocates after this type of dislocation when the condylar
followed by further attempts at manual reduction. In persistent, recurrent dislo- head is small and rounded.40 This injury is
reduction. If these measures fail, then gen- cation, contributing factors, such as phe- more common when the mouth is open at
eral anesthesia with the use of a muscle nothiazine use, should be identified. A the moment of impact.41 This type of
relaxant may be necessary.37 It is usually soft diet may also be recommended for injury usually occurs with concomitant
possible to reduce an acute dislocation with several days along with a nonsteroidal midface fractures that are telescoped,
anti-inflammatory analgesic. causing shortening of the vertical dimen-
When a blow to the mandible pro- sion of the face and allowing superior dis-
duces primarily a posterior vector of force location of the mandibular condyle. Supe-
and does not result in fracture of the rior dislocation of the mandibular condyle
condylar neck, the head of the condyle is associated with cerebral contusion and
may be forced into a posterior dislocation. basilar skull fracture with facial nerve
This injury is frequently associated with paralysis and deafness. These patients pre-
laceration and fracture of the external sent with severe restriction of interincisal
auditory canal leading to hemorrhage that opening, pain in the area of the temporo-
is visible at the external acoustic meatus.26 mandibular joint, bleeding from the exter-
In most cases maintenance of the patients nal auditory canal or hemotympanum,
occlusion and treatment of the associated and deviation of the jaw to the affected
ear injuries are the only management pro- side. A variety of treatment modalities are
cedures necessary. recommended, including observation,
Lateral dislocation of the condylar head condylotomy, elastic traction, condylecto-
is always associated with a concomitant my, and manual reduction.42 Neurosurgi-
fracture either of the condyle or elsewhere cal consultation is required.
within the mandible. The diagnosis of this Effusion and hemarthrosis of the
condition is straightforward. The condylar temporomandibular joint after trauma
head is palpable as a hard mass either in the occur similarly as in other joints.23 In
preauricular region or in the lower part of most cases this leads to a distention of
FIGURE 22-17 Prognathic appearance, chin the temporal space. This type of injury is the joint capsule with varying amounts
deviation, and a large amount of swelling on the associated with a marked crossbite, which is of discomfort. Frequently deviation of
right side of the face as a result of a right unilat- not attributable solely to the mandibular the mandible away from the affected side
eral condylar dislocation, which occurred as a
result of a blow to the chin during a motor ve- fracture but instead is secondary to the dis- occurs as a result of downward pressure
hicle crash. placed condyle. Treatment requires reduc- on the condyle from the production of
412 Part 4: Maxillofacial Trauma
fluid within the joint. This produces achieve a stable occlusion without manip- motor vehicle accident.2,48,5153 Males are
facial asymmetry and malocclusion (Fig- ulation of the jaw, Ivy loop wiring or arch overwhelmingly reported to be affected
ure 22-18). bars should be placed and guiding elastics more frequently than females in a ratio rang-
The treatment of traumatically used to produce a stable occlusion. ing from 3:1 to 7:1 depending on the survey
induced effusions of the temporo- Arthrocentesis, arthroscopy, or both are and especially the country involved.48,54,55
mandibular joint is aimed at the restora- common therapies for hemarthrosis in Predictably, such studies reveal the most sus-
tion of preinjury occlusion with return to other joints and may also be considered.43 ceptible age group for both sexes is between
function and relief of pain. If the patient Regardless of the therapy chosen, care 21 and 30 years of age.54,56,57
presents with the subjective symptoms of a should be taken to avoid excessive IMF In most cases, mandibular fractures
joint effusion but has a stable and repro- because this may result in a long-term lim- are encountered in isolation from any
ducible occlusion, the condition may be itation of function. It has been suggested other facial fractures. But different studies
managed with close daily observation, that this limitation in function is a result have revealed that almost 20% of these
nonsteroidal anti-inflammatorv medica- of organization of the blood within the patients have concomitant fractures in
tions, and a soft diet. Frequently the con- joint space with development of fibrosis other anatomic structures of the facial
dition will resolve in a matter of days. If, and subsequent ankylosis. Many authors skeleton,5860 with the most common one
however, the malocclusion is significant have emphasized the importance of this being the zygomaticomaxillary complex.61
enough that the patient is unable to proposed mechanism in the development Further injury away from the facial region
of ankylosis.44,45 Aspiration or arthroscop- may also be present, including multiple-
ic lavage may alleviate this. It is possible, system trauma. In the study by Ellis and
however, that the development of limited colleagues of 2,137 patients with mandibu-
function and ankylosis is more dependent lar fractures, 10.5% of subjects sustained
on the inability to maintain a full range of other injuries outside the maxillofacial
motion during the IMF period rather than region.48 Injury patterns are largely depen-
on the hemarthrosis. This theory is sup- dent on the mechanism of injury, with
ported by the failure of experimentally patients involved in motor vehicle acci-
induced hemarthroses to produce ankylo- dents sustaining a great percentage of other
sis,46 and by the absence of ankylosis and injuries. The distribution of principal frac-
limited function after iatrogenically ture sites has been reported as 33% involv-
induced hemarthroses during joint injec- ing the body, 29% in the condylar region,
tions or arthroscopy.47 Most likely, 23% the angle, and 8% in the symphysis
decreased range of motion after joint effu- region (Figure 22-19). It is not unusual to
sion is the result of intra-articular fibrosis sustain more than one fracture site in the
potentiated by prolonged IMF. mandible. Mandibular fractures are mul-
tiple in more than 50% of the cases.48,62,63
Treatment of Mandibular The left side is more commonly involved,
A
Fractures in particular the left angle, probably
Fractures of the mandible have been report- because most assailants are right-handed
ed to comprise between 40 and 62% of all and the left side of the jaw would be the
facial fractures,36, 48, 49 although these figures side most likely to be struck.57 Falls show a
may not represent the true incidence greater proportion of subcondylar frac-
because isolated nasal fractures are seldom tures, as high as 36.3% in one study.49
included in such surveys. If these injuries are When multiple fractures of the mandible
taken into account, the occurrence of are considered, the most common combi-
mandibular fractures decreases to anywhere nations are angle and opposite body, bilat-
between 10 and 25% of all facial fractures eral body, bilateral angle, and condyle and
B depending on the mechanism of injury.50 opposite body (Figure 22-20).36
The literature is consistent on the fact that The site of fracture is also determined
FIGURE 22-18 Significant facial asymmetry (A)
and malocclusion (B) resulting from a large left about one-half of all patients who suffer by the size, direction, and surface area of
temporomandibular joint hemarthrosis. mandibular fractures are involved in a the impacting blow. An impact to the chin
Principles of Management of Mandibular Fractures 413
and fracture outcomes from those of the choose the simplest and most effective
direct fracture; that is, the tensile strain surgical method available to reach them.
develops on the side opposite to the The goals to be achieved in treatment
29.3
4.8 impact. In the case of greenstick fractures, of fractures of the mandible are listed in
the fracture occurs on the tension side and Table 22-2. Maintenance of a stable occlu-
bending occurs on the compression side. sion is necessary for both functional and
esthetic reasons. Complete range of motion
23.1
1.4
General Approach and Goals of also allows normal mastication and pre-
Therapy vents the development of contralateral tem-
33.0
Deciding on the correct treatment is often poromandibular joint dysfunction. A nor-
8.4
more difficult than administering the mal range of motion is most dependent on
treatment itself. The dilemma concerning postoperative retraining of the muscles and
FIGURE 22-19 Percentage of mandibular fracture the appropriate management of fractures elimination of pain. Ideally, the disk-
site distribution. Adapted from Luyk NH.88 p. 411.
of the mandibular condyle is most exem- condylar relationship should remain intact
plary of this. Technically easy procedures without evidence of internal derangement.
with a line of force through the symphysis such as closed reduction have experienced Some clinical signs of internal derangement
and temporomandibular joints will pro- long-term successful results, whereas more such as joint noise can be tolerated if not
duce a single subcondylar fracture at complicated and technically demanding associated with pain or decreased range of
193 kg (425 lb.) and a bilateral subcondy- procedures of open reduction have con- motion. Growth disturbance can result
lar fracture at about 250 kg (550 lb.), tinually and cyclically been employed in from ankylosis or from injury to the carti-
whereas symphyseal fractures require an attempt to improve on the results laginous head of the condyle. A goal of
force between 250 and 408 kg (900 lb.).64 obtained with closed reduction. Although treatment should include early mobilization
An impact to the lateral aspect of the anatomic reduction with rigid internal to prevent ankylosis and close follow-up to
mandibular body using a 2.5 10 cm (1 stabilization of the fracture segments may identify growth changes early in their devel-
4 in.) impact surface will produce a be desirable, it is essential that the surgeon opment. Attainment of an anatomic bony
mandibular fracture at 136 to 317 kg clearly define the goals of therapy and union is not a primary goal in treatment of
(300700 lb.). When an impact force is
delivered to the mandible, the bone bends
inward, producing compressive forces on
the impacted (lateral) surface and tensile
forces on the lingual (medial) surfaces of
the bone opposite the impact site.18 Frac-
ture results when the tensile strain over-
comes the resistance of the bone, begin-
ning on the medial side of the mandible
and progressing through the bone toward
A B
the impact point.
Direct fracture may occur at the site of
impact, but additional indirect fractures
may result when higher forces are
involved. An example would be a blow to
the left angle, causing a direct fracture at
the left-angle region and an indirect frac-
ture in the right body. Occasionally, only
indirect fracture results, usually in the sub-
condylar area as, for example, when a blow C D
on the chin results in a fracture of either
FIGURE 22-20 Most common multiple mandibular fracture sites: A, angle and opposite body;
condylar neck. Indirect fractures demon- B, bilateral body; C, bilateral angle; and D, condyle and opposite angle. Adapted from Luyk NH.88
strate the opposite tensile strain patterns p. 413.
414 Part 4: Maxillofacial Trauma
Table 22-2 Goals of Therapy Therefore, the indications for closed strongly promote closed reduction for the
reduction may simply be stated as all cases management of fractures of the mandibu-
1. Obtain stable occlusion. in which an open reduction is either not lar condyle in both adults and chil-
2. Restore interincisal opening and
indicated or is contraindicated. Several dren.21,22,33,34,6770 These uniformly excel-
mandibular excursive movements.
conditions deserve specific mention. lent results were obtained in all ages of
3. Establish a full range of mandibular
excursive movements.
Grossly comminuted fractures are, as a patients treated.71 Conclusions drawn by
4. Minimize deviation of the mandible. general rule, best treated by closed reduc- various authors are the following: no cor-
5. Produce a pain-free articular apparatus tion, because using open reduction tech- relation exists between the degree of radi-
at rest and during function. niques would jeopardize the blood supply ographic displacement and the severity of
6. Avoid internal derangement of the to the small bone fragments and lead to an clinical symptoms; no correlation exists
temporomandibular joint on the increased likelihood of infection. This cat- between the radiographic alignment of the
injured or the contralateral side. egory also includes gunshot wounds, fracture segments and postoperative func-
7. Avoid the long-term complication of which are particularly prone to infection. tion; growth complications and ankylosis
growth disturbance. Fractures in the severely atrophic are exceedingly rare; open reduction with
edentulous mandible represent a difficult internal fixation is fraught with complica-
clinical situation. On the one hand, there is tions; and evidence supports the choice of
condylar fractures, particularly if it must be limited osteogenic potential; the majority closed reduction as the primary treatment
done at the expense of other more impor- of the blood supply comes from the modality for condylar fractures regardless
tant goals. A malunion or fibrous union periosteum, so an open reduction further of the degree of displacement.
that functions normally without pain is disrupts the blood supply. On the other Although the majority of the large stud-
preferable to a radiographically excellent hand, a stable, nonmobile reduction and ies reviewed patients in all age groups, some
reduction that does not eliminate pain or fixation of these fractures is difficult with authors specifically studied children and
limits motion. closed reduction techniques. Open reduc- their response to conservative management
tion with limited dissection of the soft tis- of condylar fractures.7278 All obtained
Treatment Options sue and rigid fixation may be the preferred
technique. Later in this chapter we review
Closed Reduction If the principle of in more detail the management of this
using the simplest method to achieve opti- group of patients.
mal results is to be followed, the use of In situations where there is a lack of
closed reduction for mandibular fractures soft tissue overlying the fracture site, soft
should be widely used. According to Bern- tissue flaps have to be transposed to cover
stein, It is safe to say that the vast majori- a fracture site (particularly if a through-
ty of fractures of the mandible may be and-through communication exists
treated satisfactorily by the method of between the skin and oral cavity). The
closed reduction.65 May and colleagues go presence of bone plates, screws, and wires
further66: Many fractures are probably may increase the likelihood of infection
overtreated by open reduction. It is impor- under these circumstances.
tant to realize that the majority of frac- Fractures in children involving the
tures can be successfully managed by con- developing dentition are difficult to man-
servative means (closed reduction). This age by open reduction because of the pos-
concept becomes critical when one con- sibility of damage to the tooth buds or
siders the economic significance of inflat- partially erupted teeth (Figure 22-21).
ed hospital, operating room material, and Closed reduction of fractures of the
personnel costs. Even more important, the mandible together with indirect fixation
need for general anesthesia is obviated. A can be achieved by either the application FIGURE 22-21 Posteroanterior mandibular
patient with a mandibular fracture man- of IMF or by applying a technique to the view of a 4-year-old child with a symphysis frac-
aged by closed technique can be success- mandible only. ture. Management of this injury through an
open reduction with internal fixation poses a sig-
fully treated as an outpatient with either The overwhelming majority of pub- nificant risk of damaging the developing perma-
local anesthesia or conscious sedation. lished clinical series over the past 50 years nent dentition.
Principles of Management of Mandibular Fractures 415
excellent results with minimal complica- 4 weeks, and in older patients in 6 to (Figure 22-23), continuous wire loop tech-
tions when fractures of the condyle in chil- 8 weeks. Several other factors should be nique (Stouts method, Obwegesers
dren were treated with closed methods. taken into account when deciding on the method), cast cap splints, and IMF screws
The superiority of closed reduction of appropriate regime for a particular patient. (Figure 22-24).
condylar fractures is also supported by The following situations generally require Methods for dentate patients usually
numerous animal studies. Experimentally longer periods of IMF: comminuted frac- include 0.5 mm (25-gauge) soft stainless
induced fracture dislocation in rhesus mon- tures; fractures in alcoholics, particularly steel wires around the teeth. In general, the
keys has resulted in a workable, usable those with nutritional problems; fractures wires should be handled in a similar fash-
mandibular articulation regardless of in patients with psychosocial handicaps; ion for all methods, following certain
whether the condyle was left remaining at fractures treated late; and fractures with principles:
right angle to the ramus, pushed medially or teeth removed in the line of the fracture.
1. Tighten the wires with a continuous
anteriorly, or reduced and maintained via
tension.
transosseous wire. There was little sacrifice Length of Fixation for Condylar Fractures
2. Direct the force apically when tighten-
of mandibular growth or symmetry.79 Fur- Ideally, the period of IMF should allow for
ing the wires.
ther studies compared three methods of reestablishment of the preinjury occlusion
3. Tighten all wires in a clockwise direc-
treatment for fracture dislocations in rhesus and should not be longer. Increased length
tion.
monkeys.80, 81 No difference existed between of the time of fixation may result in limita-
4. At the end of tightening, turn only half
those treated with internal fixation using tion in function or ankylosis of the joint. In
a turn at a time.
wire ligature, those treated with maxillo- practice, a wide variety of opinions exists
5. Turn the end of the wire into the inter-
mandibular fixation, or those who received over the length of time that constitutes an
proximal embrasure.
no treatment. No incidents of nonunion adequate period of fixation. Differences
were reported with any closed technique. depend on the age of the patient, the type of These additional rules apply when
fracture, and the presence of other fractures. arch bars are used:
Length of Fixation Traditionally the Most clinicians agree that a shorter period is
1. Adapt the arch bar closely.
length of IMF used for adult mandibular needed in children, but they are no closer in
2. Use a cuspid wrap wire where indicated.
fractures has been 6 to 8 weeks. However, agreement over what this time should be.
3. Avoid placing the wire across the
this length of IMF is not without penalty. Animal studies have shown excellent occlu-
intermaxillary stabilization lugs.
Often patients continue to lose weight sion and postoperative function even in
4. Use circumferential wires when single
during this period, they may not be able to fracture dislocations when no IMF is
teeth stand alone, and intraosseous
return to work, and there is some evidence used.7981 Some studies in humans also
suspension or circum-mandibular
of histologic changes in the temporo- agree with this. However, the inability to
wires in edentulous areas.
mandibular joint.82,83 Juniper and Awty occlude the teeth without pain is frequently
5. In the area of the fracture, reduction
were able to demonstrate that 80% of present in patients with condylar fractures
should be accomplished prior to stabi-
mandibular fractures treated by open or and does require some period of fixation.
lization of the arch bar on both sides
closed reduction and IMF were clinically Attempts to predetermine which fractures
of the fracture.
united in 4 weeks.84 They were also able to will need longer IMF than others have been
demonstrate a clear relationship between made.85 The length of time has been based
the age of the patient and the predictabili- on the presence or absence of teeth, the type
ty of early fracture union. These results of fracture, and the age of the patient. How-
were confirmed by Amaratunga.85 He ever, Walker has suggested that a relatively
found that 75% of mandibular fractures short period of intermaxillary fixation is
were clinically stable by 4 weeks, that required for all patients regardless of age,
almost all fractures in children healed in occlusion, and type of fracture.86,87
2 weeks, and that a significant number of
fractures in older patients took 8 weeks to Intermaxillary Techniques DENTATE
heal. It appears that each individual case PATIENTS Intermaxillary techniques in
must be judged on its merits but that most dentate patients include application of
uncomplicated fractures in children are arch bars (Figure 22-22), direct wiring, Ivy FIGURE22-22 Placement of Erich arch bars for
united in 2 to 3 weeks, in adults 3 to loop wiring (interdental eyelet wiring) noninvasive treatment of a mandibular fracture.
416 Part 4: Maxillofacial Trauma
A B
FIGURE 22-24 An option to obtain intermaxillary fixation in patients with a reliable occlusion is the FIGURE 22-25 For the fabrication of a lingual
use of intermaxillary fixation screws. In most cases two screws placed on each side is sufficient to splint, the cast must be carefully sectioned along
maintain the reduction. A, Right buccal view. B, Left buccal view. the areas where the fractures are located.
Principles of Management of Mandibular Fractures 417
Medically Compromised Patients Some essary, the maximal blood supply to the
patients with special medical conditions fracture site should be preserved.
are best treated without IMF. They may be If closed reduction is used for the
better treated with an open reduction. treatment of a condylar process fracture, it
This group of patients includes those with is best that intermaxillary fixation be dis-
decreased pulmonary function. Williams continued in all patients at approximately
and Cawood have demonstrated signifi- 10 to 14 days. If other mandibular frac-
cant decrease in pulmonary function asso- tures are associated with the fractured
ciated with IMF.90 Patients with gastroin- condyle, it is desirable to treat them with
testinal disorders who are on a liquid diet, some form of additional stabilization,
FIGURE 22-29 Intermaxillary fixation in an particularly one based on milk products, such as a lingual splint, external pins, or
edentulous patient using Gunnings splints with may have difficulties. Those with severe rigid internal fixation. This allows for the
arch bars imbedded into the acrylic.
seizure disorders in which airway difficul- early release of IMF without compromis-
ties may arise with IMF and patients with ing the healing of these other fractures.
follow.89 If, in addition to a fracture in this psychiatric or neurologic problems may be
area, the patient also has a concomitant candidates for open reduction. Open Reduction of Condylar Fractures
angle or condylar fracture, the risk of lat- A variety of useful techniques for open
eral flaring of the mandibular angles is a Concurrent Condylar Fracture Associated reduction have been described.73,9194 The
very real possibility. This negative result with Fractures Elsewhere in the Mandible reason for employing open reduction in
can be much worse in cases in which bilat- It is often advantageous to be able to mobi- each case was to avoid the complications
eral condylar fractures are present and in lize condylar fractures early to prevent pos- found in closed reduction. No data or
patients with associated midfacial frac- sible ankylosis. This is particularly true in follow-up of patients was presented to
tures, when the mandible is used as the cases of intracapsular fractures in which document this. Tanasen and Lamberg,
base for the reconstruction. immobilization is more likely to lead to Zide and Kent, and Raveh and colleagues
ankylosis. In this situation open reduction followed patients with open reduction for
Prolonged Delay in Treatment of the Frac- and fixation of angle, body, or symphyseal up to 37 months.9597 Complication rates
ture with Interpositional Soft Tissue fractures will allow early mobilization of of 85, 50, and 10% were seen, respectively,
Occasionally when there has been an an associated condylar fracture. including facial nerve dysfunction and
excessive delay in treating a fractured There are certain contraindications to keloid formation. No comparison was
mandible, interpositional tissue between the use of open reduction of mandibular made with patients treated with closed
the two bone ends can prevent a satisfac- fractures. As a general principle, when a reduction during the same time period.
tory closed reduction. In this situation an simpler means of treating a fracture can be Chuong and Piper attempted to compare
open reduction is necessary to remove the used, it should be. This is often more cost- closed reduction with open reduction,
soft tissue between the fragments. effective for the community at large and including concomitant disk repair in their
often results in fewer complications. How- study.98 Eight of nine open reduction
Complex Facial Fractures The satisfacto- ever, each individual case must be judged patients who were studied for an average
ry reduction of complex facial fractures on its merits. of 11 months experienced complications
requires two stable reference points to The periosteal blood supply of multi- (89%). Six of 12 patients receiving closed
which the maxillary complex can be ple small fragments of bone can be jeopar- reduction were found to have malocclu-
reduced. These include a stable supraorbital dized when an open reduction is attempt- sion at the end of treatment (50%). It is
bar of bone and also a stable mandible. This ed for comminuted fractures. This can possible that the high incidence of maloc-
often necessitates open reduction and fixa- lead to an increased likelihood of infection clusion in the closed reduction group
tion of the mandibular fractures. Open and delayed healing. Gunshot wounds are might be a result of prolonged fixation,
reduction and fixation of a subcondylar best managed by closed reduction when- inadequate follow-up, and lack of super-
fracture are indicated when there are bilat- ever possible, because often the bone is vised postoperative rehabilitation.87
eral subcondylar fractures in the presence comminuted and there is a greater risk of There is a lack of any controlled clinical
of complex middle third fractures, so that a infection in these fractures. Atrophic data to indicate the superiority of open
stable vertical platform is provided on edentulous mandibles must be treated reduction techniques as a primary mode of
which the face can be reconstructed. with care. When an open reduction is nec- management of condylar fractures in
Principles of Management of Mandibular Fractures 419
children or adults. Although it is apparent formed or in those situations in which a nale for open condylar reduction in
that, in some situations, an unacceptable closed reduction is not possible. Limitation these situations is that it allows for the
incidence of complications results when of function may be caused by fracture with establishment of a horizontal and verti-
closed reduction is employed, it is inappro- dislocation of the proximal segment into cal dimension of the midface when this
priate to assume that an open technique the middle cranial fossa, by invasion of the cannot be achieved by other means. If
can avoid these complications until this is joint by a foreign body, by lateral extracap- rigid internal fixation of the midface is
borne out in controlled clinical trials. sular dislocation of the condylar head, or by possible, then open reduction of the
Despite the evidence in favor of closed the presence of any fracture dislocation that condyle may no longer be indicated.
reduction as the treatment of choice for produces a mechanical stop, preventing 2. Situations in which IMF is not feasible.
the majority of fractured condyles in both mandibular movement. Inability to per- Certain medical conditions, such as
children and adults, there are indications form a closed reduction may result when poorly controlled seizures, psychiatric
for the performance of open reduction the fracture is displaced so that it is impos- disorders, or severe mental retarda-
(Table 22-3). sible to manipulate the teeth into an appro- tion, make maxillomandibular fixation
In the past the indication for open priate occlusion. difficult and possibly dangerous. Also,
reduction of a condylar fracture was pri- patients with multiple trauma, partic-
marily a radiographic one. Essentially, it Possible or Relative Indications Possible ularly head injury or chest injury, are
was thought that the condyle behaved like or relative indications for open reduction at increased risk for complications if
other areas of the mandible or other also exist and should be assessed on the
placed in maxillomandibular fixation
bones in the body and that it would basis of benefit as opposed to risk:
unless tracheostomy is planned. In
respond better and heal with more satis-
1. Bilateral condylar fractures with com- addition, maxillomandibular fixation
factory function if an ideal anatomic
minuted midfacial fractures. The ratio- is extremely difficult in those patients
reduction were obtained.93,95,99,100 It has
been shown that there is little if any cor-
relation between the degree of displace- Table 22-3 Indications for Open Reduction of Fractures of the Mandibular Condyle
ment or dislocation of the fracture and 1. Absolute indications
the ability to obtain satisfactory function A. Limitation of function secondary to the following:
with a closed reduction. A more func- 1. Fracture into middle cranial fossa
tional approach in assessing the need for 2. Foreign body within the joint capsule
open reduction was taken by Zide and 3. Lateral extracapsular dislocation of condylar head
Kent.96,101 According to these investiga- 4. Other fracture dislocations in which a mechanical stop is present on opening,
tors, indications for open reduction of which is confirmed radiographically
condylar fractures should rely on the B. Inability to bring the teeth into occlusion for closed reduction
identification of specific clinical entities
2. Relative indications
that, when treated with closed reduction,
A. Bilateral condylar fractures with comminuted midface fractures in which rigid
would result in a high degree of failure.
internal fixation of the midface is not possible
They also take into account an objective B. Situations when intermaxillary fixation is not feasible as a result of the following:
evaluation of function at the time of the 1. Medical restrictions
planned reduction, the presence and con- a. Poorly controlled seizure disorder
dition of the patients dentition, the like- b. Psychiatric disorders
lihood of successfully performing a c. Severe mental retardation
closed reduction, and the presence of d. Concomitant injuries such as head injury or chest injury (unless
other modifying factors such as the tracheostomy is planned)
patients medical condition or the exis- 2. Displaced fractures where dentures or splints are not feasible because of severe
tence of other facial fractures. mandibular atrophy
C. Bilateral fractures in which it is impossible to determine what the proper occlusion is
as a result of loss of posterior teeth or the presence of a preinjury skeletal
Absolute Indications Absolute indica-
malocclusion
tions for open reduction are present in those
D. In fracture dislocation in adults to restore the position and function of the
situations in which limitation in function is
meniscus (controversial)
highly probable if a closed reduction is per-
420 Part 4: Maxillofacial Trauma
with displaced condylar fractures in that, in fracture dislocations in which may be easily approached from an intra-
whom dentures are not present and open reduction is indicated, an oral incision.103 In severe anteromedial
splints are not feasible because of attempt should be made to reposition fracture dislocations in which the condylar
severe mandibular atrophy. the disk at the time of the reduction. head is not retrievable despite the choice
3. Bilateral fractures in which it is However, inadequate data exist to of approach, a vertical ramus osteotomy,
impossible to determine the proper suggest that open reduction per- followed by removal of the osteotomized
occlusion. Occasionally, a patient with formed solely for the purpose of disk segment, has been recommended.104106
bilateral fractures will have such an repositioning is valid. This allows for access to the proximal
ambiguous occlusion that, even with condylar head, which is located medially
the use of study models and careful Surgical Approach CONDYLAR FRACTURES and is also removed. Rigid fixation with
clinical examination, it is not possible A variety of surgical approaches to the frac- plates or screws is carried out between the
to determine the appropriate maxillo- tured condyle have been suggested, includ- ramus segment and condylar head. The
mandibular relation. This may lead to ing intraoral, submandibular, retro- unit is returned as a free autogenous bone
inappropriate placement of the mandibular, preauricular, and, more graft, and the osteotomy is plated. This
mandible into malocclusion or to recently, endoscopic. The most important technique is useful for high dislocated
placement of a preexisting malocclu- factor in determining the approach used is fractures and may be accomplished
sion into a normal relation, thereby the level at which the fracture has occurred. through a retromandibular approach.
predisposing the patient to nonunion Modifying factors such as the degree of dis- OTHER MANDIBULAR FRACTURES
or long-term functional disability. placement or dislocation and the planned Open reduction of mandibular fractures
4. Fracture dislocation in an adult method of fixation may also have a bearing prior to the advent of antibiotics was asso-
patient to restore position and func- on the approach selected. ciated with a high incidence of infection.
tion of the disk. Previous emphasis on Traditionally fractures in the condylar Following the introduction of antibiotics,
indications for open reduction have neck and above were best approached most clinicians used the extraoral
centered around the need for bony through a preauricular or endaural inci- approach to the fracture site. This tech-
reduction and fixation without con- sion.101 This approach also has the added nique, however, is time-consuming, results
sideration of disk position. The advantage of allowing for surgical manip- in a visible surgical scar, and can damage
unstated implication of most of the ulation of the soft tissues within the joint, adjacent structures, particularly the mar-
literature is that the position of the if desired. Subcondylar fractures and frac- ginal mandibular branch of the facial
dislocated disk is not critical for opti- tures extending into the upper ramus nerve. Transoral open reduction has been
mal functional results after condyle region are best approached using a retro- advocated as an excellent alternative.107110
fracture.98 However, this is contradic- mandibular or Hinds approach.102 The The technique is claimed to be quicker to
tory, given the present emphasis on incision begins approximately 1 cm below perform, results in no extraoral scar, and
the importance of correct condylar the lobe of the ear and 1 cm posterior to does not damage the facial nerve. Less
disk alignment for management of the ramus of the mandible. The dissection postoperative wound care is required, and
those patients with internal derange- is carried down to the parotid gland, it is simple to perform the techniques
ment of the temporomandibular which is retracted anteriorly, providing under local anesthesia. Transoral open
joint. The disk is important in the access to the vertical fibers of the masseter reduction of mandibular fractures is use-
prevention of post-traumatic ankylo- muscle overlying the ramus. These fibers ful in tooth-bearing portions of the jaw
sis.47 An interesting concept has been are not stripped but instead are separated (ie, in symphyseal, body, and angle frac-
raised about the possible necessity for bluntly along their vertical course, allow- tures). Complications rates and infection
disk repositioning, especially in frac- ing access to the underlying ramus. Access rates appear to be similar between the two
ture dislocations, to allow for optimal can easily be gained to relatively high sub- techniques when large numbers of cases
temporomandibular joint function. condylar fractures through this approach, are studied.111,112
Some clinicians have suggested that and a variety of fixation techniques are Occasionally, a combination of ap-
open reduction and internal fixation possible without additional percutaneous proaches is necessary, particularly in frac-
of condylar fractures in conjunction puncture, as may be needed if a sub- ture dislocations in which a preauricular
with disk repair is a biologically mandibular approach is used. Low sub- approach may be necessary to retrieve the
sound approach.98 Based on their condylar fractures, especially those with- proximal segment, while fixation is per-
experience, it might be recommended out a significant degree of displacement, formed through another approach.113
Principles of Management of Mandibular Fractures 421
Throughout the past decade, surgeons fixation devices may be employed (Figure
have become interested in the concept of 22-31). In a given situation, any one of
minimally invasive surgical approaches to these techniques may have certain advan-
avoid potential patient morbidity from tages over the other. With the development
more traditional open surgical techniques. of sophisticated rigid internal fixation sys-
With the development of these techniques, tems and instrumentation for their place-
management of these injuries via an endo- ment, miniplate fixation of these fractures
scopic approach has gained great popular- will be the technique most readily
ity among surgeons. In 1994 Ma and Fang employed in most cases. Miniature bone
were the first ones to describe the use of an plates can be applied using any of the pre-
endoscope to access the mandibular angle viously discussed approaches. These plates
region.114 Later Jacobovicz and colleagues have the advantage of being available in a
modified this technique for the manage- wide variety of shapes and sizes; they are A
ment of condylar fractures.115 Recently, now readily available in most operating
more authors have also described their rooms; and they provide a more stable
experience with this approach.116118 form of fixation than do wires or Kirschn-
The surgical approach, as described by er wires. Theoretically, bone plates have
Miloro,118 requires a 15 to 20 mm modified another advantagethey can be placed on
Risdon incision to gain access to the lateral a relatively small proximal fragment first,
ramus. A subperiosteal dissection is then allowing for the creation of a handle to
performed blindly to create an optical cav- more effectively manipulate the proximal
ity on the lateral aspect of the ramus on segment into an appropriate reduction.
the fracture side from the sigmoid notch to Should the incision selected not allow for
the inferior border and from the mandibu- total access to the fracture, currently avail-
lar notch anteriorly to the posterior border able bone-plating systems are equipped
of the ascending ramus posteriorly. A mod- with instrumentation for percutaneous B
ified Storz retractor with a curved end is placement of screws.
FIGURE 22-30 Endoscopic management of condylar
then placed through the incision and below WIRE Intraosteal wiring (wire fractures offers excellent reduction and fixation of the
the periosteum to engage the sigmoid osteosynthesis) can be placed either by an fracture segments, while reducing the morbidity of
notch. A 4 mm, 30 endoscope is used for intra- or extraoral route using one of three conventional open approaches to this site. A, Visual-
retraction and visualization of the surgical basic techniques: ization of the condylar neck fracture. B, Titanium
miniplate in place after reduction. (Photographs
site. Following irrigation and the use of a courtesy of Michael Miloro, DMD, MD)
suction elevator, the sigmoid notch, inferi- 1. A simple straight wire across the frac-
or border, mandibular notch, posterior ture site (Figure 22-32A). This should
border, and the fracture site can be clearly be placed so that the direction of pull of 3. Transosseous circum-mandibular
identified endoscopically. The fractured the wire is perpendicular to the fracture wiring (Obwegesers technique) (Fig-
segments are then repositioned and site. This technique can be either ure 22-32C). This is a useful wiring
reduced. Inferior traction on the angle of through both the buccal and lingual technique when the fracture runs
the mandible, although limited by IMF, can cortical plate or it may be used on the obliquely compared with the inferior
be helpful in the mobilization of the seg- buccal cortical plate only. This is useful border of the mandible. If the fracture
ments. Fixation is achieved with a 2.0 mm in the angle region, where a third molar line is too vertical the wire could
titanium miniplate and screws through a socket can be quickly and easily used become displaced into the fracture line.
preauricular stab incision and trocar (Fig- for a simple straight buccal cortex wire.
ure 22-30). Following reduction and stabi- 2. Figure-of-eight wire (Figure 22-32B). The wire used should be a pre-
lization, the IMF is released for evaluation This wiring technique has been stretched soft stainless steel, and the frac-
of the occlusion. shown to have increased strength ture should be held in a reduced position
compared with simple techniques at while the wire is being tightened so that
Methods of Fixation Once access to the both the inferior and superior borders the wire does not reduce the fracture and
fracture has been achieved, any number of in angle fractures.119 possibly lead to wire breakage.
422 Part 4: Maxillofacial Trauma
A B C
D E F
G H I
FIGURE 22-31 Previously reported techniques for direct stabilization of condyle fractures: A, Silverman (1925); B and C, Thoma (1945); D, Stephenson
(1952); E, Robinson (1960); F, Robinson (1962); G, Messer (1972); H, Kobert (1978); I, Petzel (1982). (CONITINUED ON NEXT PAGE)
Principles of Management of Mandibular Fractures 423
RIGID FIXATION Dissatisfaction with seek alternative methods of treatment, Edentulous Fractures The edentulous
the use of IMF as a means of treatment of including the use of rigid internal fixation. mandible in the trauma patient has several
mandibular fractures has resulted in the The principal disadvantages of the com- factors modifying its behavior that the den-
development of open reduction and fixa- pression plating systems for mandibular tate mandible does not. The loss of the teeth
tion techniques that do not require the teeth fractures are the use of an external approach, results in resorption of the alveolar bone,
to be wired together. Criticism of the disad- thus giving rise to facial scarring and the which weakens the mandible. The loss of
vantages of prolonged immobilization of potential for damage to the mandibular bone also means that there is less cross-
the jaws has included patient complaints of branch of the facial nerve, and the use of sectional area of bone in contact in fracture
panic, insomnia, social inconvenience, pho- very rigid plates, giving rise to stress shield- patients and less periosteum and endos-
netic disturbance, loss of effective work ing, although this has never been shown to teum to supply the osteogenic cells for frac-
time, physical discomfort, weight loss, histo- be a problem in mandibular fractures. Also, ture healing. Because of the aging process
logic changes in the condylar head, and dif- the position of the teeth and inferior alveolar the majority of the blood supply to the
ficulty recovering a normal range of jaw nerve and the use of bicortical screw fixation edentulous mandible is from the perios-
movement. This has led some clinicians to necessitate that the compression plates be teum rather than the inferior alveolar
424 Part 4: Maxillofacial Trauma
A B C
FIGURE 22-32 A, Simple wiring technique. B, Figure-of-eight wire. C, Transosseous circum-mandibular wire. Adapted from Luyk NH.88 p. 427.
artery.122 A larger percentage of fractures in therapy may be all that is necessary. More which may be mobile during the mixed den-
the edentulous patient are not compound definitive treatment will be necessary if the tition stage and whose shape has little in the
because of the lack of teeth. Minor displace- fragments are displaced or excessively way of undercut areas, which means that they
ment of the bones can be easily accommo- mobile. The bilateral body fracture do not retain wire as well as adult teeth. The
dated in the construction of new dentures. deserves special mention because the pull presence of tooth buds reduces the area avail-
The edentulous population also tends to of the suprahyoid muscles tends to displace able for interosteal fixation, and there exists a
have more health problems resulting from this fracture inferiorly. These usually occur greater potential for ankylosis and growth
conditions such as osteoporosis, diabetes in the pencil-thin atrophic mandible. A disturbances in the younger population.
mellitus, and steroid therapy, which may variety of treatment modalities have been Also, children do not tend to tolerate IMF as
directly affect bone healing. The site distrib- suggested to treat these difficult fractures well as adult patients. On the other hand,
ution of fractures tends to be different in the including open reduction with rigid inter- fractures tend to heal quicker in children and
edentulous patient, with a higher percent- nal fixation, closed reduction with and slight malocclusion problems can be com-
age of body fractures (43.5%) and lower without bone grafts, and external pin fixa- pensated for by growth of the patient.
percentages of angle (15.2%) and symphy- tion. When the edentulous mandible is Children make up about 5% of all
seal (4.3%) fractures (Figure 22-33).123 A comminuted again because of the poor mandibular fractures. These fractures are
20% incidence of nonunion has been blood supply to the bone fragments, those rare in children under 5 years of age because
reported in the treatment of edentulous fragments are best managed by closed of the greater elasticity of the bone and
fractures, particularly when nonrigid fixa- reduction. The use of semirigid fixation lighter weight of children, which lowers the
tion was applied in open reduction cases.111 systems without some form of IMF is not
Longer periods of immobilization have also indicated in this patient subset.
been shown to be necessary to achieve satis- External pin fixation by the biphasic
factory healing.124,125 technique is often used in edentulous frac-
The anatomic site influences treat- tures. It obviates the need for IMF, thus 37.0 0
ment. If the location of the fracture is pos- allowing early mobilization of the jaw and
terior to the denture-bearing area, then improving feeding in some patients. It can
either additional fixation (eg, external pin be used in comminuted fractures without
fixation) or open reduction and fixation jeopardizing blood supply to the fractures,
15.2
may be necessary to control the proximal and it can also bridge a bone loss gap
43.5
fragment. Muscle pull on the edentulous before bone grafting. 4.3
jaw is considerably weaker than in a den-
tate mandible and undisplaced fractures Fractures in Children As previously men-
are often closed injuries. Therefore, if the tioned, fractures in children are less common
FIGURE 22-33 Percentage of fracture sites in
fragments are undisplaced or minimally than in adults. Their management is compli- edentulous patients. Adapted from Luyk NH.88
displaced and not mobile, conservative cated by the presence of deciduous teeth, p. 429.
Principles of Management of Mandibular Fractures 425
forces of impact during falls. Condylar frac- communication with the mouth, no peri- tures whether closed reduction or open
tures appear to be common, affecting about coronitis exists, and reduction of the frac- reduction is contemplated. The antibiotic
46% of patients either alone or in combina- ture is achievable without removal. Shetty prophylaxis should begin preoperatively
tion with other fractures.126 and Freymiller reviewed the indications and be continued for not more than
Mandibular fractures in children can for removal of teeth in the line of the frac- 24 hours postreduction.
often be successfully managed by acrylic ture as follows137:
splint therapy of the mandible only or Complications
with eyelet wires and IMF.126,127 A short- 1. Teeth grossly loosened, showing evi-
ened period of IMF, 2 to 3 weeks, is all that dence of periapical pathology or sig- Delayed Union and Nonunion
is required. When an open reduction is nificant periodontal disease Nonunion is distinguished from delayed
required, it has been successfully accom- 2. Partially erupted third molars with union by the potential of the bone to heal.
plished by the extraoral route using inferi- pericoronitis or associated cyst Delayed union is a temporary condition in
or border wiring in order to avoid the 3. Teeth that prevent reduction of fractures which adequate reduction and immobiliza-
tooth buds.128,129 4. Teeth with fractured roots tion eventually produces bony union. On
If adequate bone height is available 5. Teeth with exposed root apices or the other hand, nonunion may persist
below the area where the tooth buds are entire root surface from the apex to indefinitely without evidence of bone heal-
located, the use of resorbable plates offers the gingival margin ing unless surgical treatment is undertaken
a great advantage to fixate these fractures 6. An excessive delay from the time of to repair the fracture. Nonunion is general-
(Figure 22-34). fracture to definite treatment ly characterized by pain and abnormal
Complications are rare in this group of mobility following treatment. Malocclusion
patients. Malunion, nonunion, and infec- Use of Antibiotics may be present in dentate cases and mobil-
tion tend to have a low incidence.67 Two Zallen and Curry demonstrated that with ity exists across the fracture line. Radi-
serious complications that can occur, how- compound mandibular fractures, an infec- ographs demonstrate no evidence of heal-
ever, are ankylosis and growth distur- tion rate of 50% can be expected in those ing and in later stages show rounding off of
bances. Both of these tend to be more com- patients who do not receive antibiotic ther- the bone ends. Delayed and nonunion
mon with intracapsular condylar fractures apy.138 A prospective trial was undertaken in occur in about 3% of fractures.140
and when the damage is of a crushing which only dentate compound mandibular There are several causes and contribut-
nature.130 The incidence and severity of fractures were evaluated. One-half of the ing factors. The most common reason is
these complications can be reduced by patients in this study received prophylactic poor reduction and immobilization.141
shorter periods of IMF and close follow-up. antibiotics, usually penicillin. It was not This is more likely in edentulous fractures.
stated for how long the antibiotic therapy Infection is often an underlying cause, and
Management of Teeth in the Line of Frac- was continued or when it started in relation any tooth in the line of the fracture must be
ture In the past, teeth in the line of the to the injury. One-half the patients who did carefully assessed for root fracture and
fracture were always removed.23,131,132 not receive antibiotics had infections at the vitality. A decreased blood supply can lead
Their removal was advocated because frac- fracture site as opposed to only 6% of those to delays in healing. Excessive stripping of
tures of the dentate portion of the jaws are who did receive antibiotics. It seemed to
compound via the periodontal ligament make little difference whether the fractures
and it was believed that this communica- were treated by open or closed reduction.
tion fostered infection, osteomyelitis, and All fractures in this study were treated within
nonunion. However, Neal and colleagues, 36 hours. Another study has confirmed these
Kahnberg and Ridell, Schneider and Stern, results in facial fractures and has suggested
and Amaratunga have all been able to that short-term prophylaxis as is used in elec-
show that the majority of teeth in the frac- tive surgery may be as effective as the more
ture line can be saved if appropriate usual 5-day course of antibiotics.139 This
antibiotic therapy and fixation techniques group also found little difference in the inci-
are used.133136 The impacted mandibular dence of infection whether there was a delay
third molar tooth deserves special men- in treatment of mandibular fractures or not.
tion. Most authors have advocated leaving Penicillin should remain the antibiotic FIGURE 22-34 Use of a resorbable plate for fixa-
the tooth in situ if the tooth is not in direct of choice for compound mandibular frac- tion of a symphysis fracture in a 4-year-old child.
426 Part 4: Maxillofacial Trauma
the periosteum, especially in comminuted commonly.58 Treatment has already been clusion.145,146 Malocclusion can be cor-
and edentulous fractures, can lead to outlined as for delayed and nonunion of rected by further or prolonged IMF in the
delayed healing. Metabolic deficiencies and fractures. early stages of healing, and selective tooth
alcoholism are also significant contributors grinding, orthodontics, or osteotomies
to delayed healing. Cannell and Boyd Malunion after complete bony union.
showed a high incidence of delayed union Malunions can be defined as a bone union Malocclusion that does not result
and nonunion in a group of alcoholic of the fracture in which some displace- from growth alterations but from a mal-
patients.142 These patients were probably ment of the bones still exists. Not all union of the condyle fracture occurs infre-
also at increased likelihood to sustain a malunions of fractured mandibles are quently if an adequate follow-up regimen
mandibular fracture. Although the exact clinically significant. Often malunions in is followed. If malocclusion does persist,
reasons for delayed healing in this group of edentulous patients or those involving the its management is similar to the manage-
patients is not known, they are known to ramus and condylar area of the mandible ment of malocclusion from other causes.
have metabolic and vitamin deficiencies, result in no clinically detectable alteration Judicious use of equilibration, orthodon-
poor compliance particularly with IMF, in appearance or function. When, the tics, and orthognathic surgery allows for
poor bony quality, and impaired local dentate portion of the jaw is involved, restoration of a functional occlusion.
blood supply, all of which could be con- however, a malocclusion can result. The Before reconstructing the occlusion to this
tributing factors. These patients should be rates of malocclusion in patients treated new articulation, it is necessary to allow a
treated whenever possible with closed with IMF tend to be very low. In one period of 6 to 12 months for complete
reductions, because this treatment has a prospective trial between rigid internal healing and for any remodeling of the
lower incidence of complications in this fixation and standard techniques the rate articular apparatus to occur.
group of patients.142 of malocclusion with the rigid fixation
Treatment of delayed union and was three times higher. However, as the Nerve Injury
nonunion is aimed at eliminating the authors concede, they were initially inex- Traumatic injury to the inferior alveolar
underlying cause of the problem. When perienced with the technique and others nerve is common in displaced fractures of
infection is present it must be managed have reported a low incidence of maloc- the body and angle of the mandible. There
with dbridement of sequestra, drainage,
and antibiotic therapy. Loose fixation such
as wires and plates must be removed, and
adequate fixation with IMF, extraoral pin
fixation, or even rigid plate fixation should
be applied across the fracture site.143 If
there is a gap between the bone ends, a
bone graft may be necessary.
Infection
Infection and osteomyelitis appear to be
the most common complications (Figure
22-35). In some studies, particularly with-
out antibiotics, it may occur in over 50%
of cases.144 Some of the underlying causes
have already been discussed. These can be
divided into systemic factors, such as alco-
holism and no antibiotic coverage, and
local factors, such as poor reduction and
fixation, fractured teeth in the line of frac-
ture, and comminuted fractures. A B
Most infections appear to be mixed in
FIGURE 22-35 A, Sinus tract from an infected anterior mandibular fracture after open reduction
nature, with -hemolytic Streptococcus with internal fixation. B, After hardware removal and bony dbridement, a large defect can be
and Bacteroides spp organisms found most observed in the left parasymphysis region.
Principles of Management of Mandibular Fractures 427
are few studies documenting recovery of theory. Frequently, complete regeneration Temporomandibular Joint
the nerve. Larsen and Nielsen reported a of the condyle occurs in young patients, Dysfunction
permanent disturbance in mental nerve with no residual deficit following frac-
A wide range of temporomandibular
function in 8% of 229 patients studied.147 ture, and better regeneration occurs in
joint problems may result from injuries
Return of nerve function depends on the actively growing patients, particularly
to the condylar apparatus. Internal
degree of initial trauma to the nerve and an those under the age of 12 years.148,149 This
derangement and ankylosis are perhaps
accurate reduction and adequate fixation clinical observation is supported by
the two most common.
of the mandibular fracture. Rarely other experimental studies,104 which found
branches of the mandibular division of the that, following surgically created fracture
Internal Derangement A correlation
trigeminal nerve can be affected. These dislocations in young monkeys, excellent
exists between previous condylar fracture
include the masseteric nerve, auriculotem- regeneration occurred with no growth
and the development of internal derange-
poral nerve (both with condylar fractures), disturbance in any of the animals. This
ment of the temporomandibular joint.
and the buccal and lingual nerves associat- ability for restitution of growth in chil-
There is a greater incidence of temporo-
ed with intraoral lacerations with body or dren under the age of 12 years appears to
mandibular joint pain, deviation on open-
angle fractures. Also rare is damage to the account for the lack of direct correlation
ing and joint noise in patients with previ-
marginal mandibular branch of the facial between the age of injury and the degree
ous condylar fractures.71 The resultant
nerve with fractures of the condyle, ramus, of growth disturbancea correlation
internal derangement primarily occurs in
and angle of the mandible. It is more com- that would be expected if the sole deter-
adults and is of two broad types. The first
mon to see this nerve damage caused by a minant were the amount of growth left at
is internal derangement that occurs on the
laceration along its course. the time of injury.
side of the fracture and results from soft
Most fractures of the mandible heal The concept that the condylar carti-
tissue injury within the joint. Open reduc-
with relatively simple management. All lage acts as a growth center has been
tion with direct repair of the injured soft
clinicians must be wary of overtreatment replaced by the theory that the cartilage
of simple cases that can lead to an increase acts as a remodeling center.150 The resti-
in cost of treatment for both the patient tution of growth seen after condylar
and society and also an increase in compli- injury (which at times may actually lead
cation rates. to overgrowth of the affected condyle) is
a direct result of this remodeling center
Growth Alteration within the condylar cartilage reacting to a
Growth alterations as the result of traumatic episode. It is not unusual for a
condylar injury may occur as the result new condylar apparatus to develop, with
of two mechanisms. Over- or understim- resorption of the displaced or dislocated
ulation of normal growth may result condylar head. This compensatory
from direct injury to the condyle, or a growth seems to depend on the potential
restriction of normal growth may occur space created by the displacement of the
secondary to fibrosis or scarring of the stump of the condylar process.150 For this
surrounding tissue. reason, it is important to maintain the
It was once thought that fracture of mandible in its original occlusion, not
the condyle produced a growth deficit in only for a few weeks during healing, but
proportion to the age of the patient at the also for the next several months while
time of injury: the younger the child, the bony regeneration and compensatory
greater potential growth problem. 120 growth occur. Even when occlusion is
However, although it is true that children maintained and the patient is of the ideal
undergo several periods of rapid growth age, 25% of subjects experience a growth
during their development and that an disturbance.148,149,151 Because of this, ade-
injury during one of these growth peri- quate patient education and long-term
FIGURE 22-36 Significant mandibular hypopla-
ods may be associated with a higher inci- follow-up for several years is necessary in
sia in a 12-year-old boy, resulting from bilateral
dence of growth alteration,78 other fac- children with fractures of the condyle intracapsular condylar fractures suffered shortly
tors are involved that alter this simplistic (Figure 22-36). after birth.
428 Part 4: Maxillofacial Trauma
tissues has been advocated by some as a op ankylosis. The postinjury relation of the area of temporomandibular joint ankylo-
possible means of preventing this prob- condylar stump with the glenoid fossa is sis.48 Experimentally, ankylosis has been
lem.98,99 No long-term data have estab- also a factor. With fractures of the condylar created in a baboon by a combination of
lished that this is effective. The other form head, a greater likelihood exists that there bilateral fractures of the condyloid
of internal derangement occurs contralat- will be intimate contact between the prox- process, diskectomy, and prolonged
eral to the condylar injury. This derange- imal portion of the distal segment and the immobilization, while the same procedure
ment was described by Gerry as the glenoid fossa, predisposing the patient to without diskectomy did not produce
condylar postfracture syndrome.32 ankylosis.48 Failure to produce ankylosis ankylosis.48 Thus far, this discussion has
Patients who develop a unilateral hinge after experimentally induced condylar been limited to the development of true
type of joint after a fracture can rapidly fractures,81 coupled with the clinical obser- ankylosis with the formation of a bony or
develop overfunction of the contralateral vation that the incidence of intracapsular fibrous union within the joint itself. There
joint with hypermobility and, ultimately, fracture is much higher than that of anky- is also the potential for the development
anterior dislocation of the disk. losis, leads one to believe that other factors of pseudo ankylosis if soft tissue trauma
besides the site of fracture must be opera- surrounding the joint leads to fibrosis and
Ankylosis Ankylosis is a rare complica- tive in the production of ankylosis. scarring or (in the case of zygomatic arch
tion of mandibular fractures. It is more like- The condyle of a young child is more and coronoid fractures) a bony union
ly to occur in children and is associated with easily crushed than fractured,153,154 possibly develops between other fractured areas
intracapsular fractures and immobilization because the cortical bone of the child is rel- and not within the joint itself.
of the mandible. The most commonly atively thin and the condylar neck broad.155 In summary, it is likely that the follow-
accepted etiology is of intra-articular The immediate subarticular layer is also ing groups of patients will be at high risk for
hemorrhage, leading to abnormal fibrosis extensively vascularized. An impact leading development of ankylosis: patients under
and ultimately ankylosis.141 In children, if to a crush injury is more common in a child the age of 10 years at the time of injury;
left untreated, it results in disturbed because of these anatomic differences, and patients with intracapsular fractures and
growth and underdevelopment of the the resulting fragments of highly vascular- fracture dislocations with gross telescoping;
affected side. Prevention is easier than cure, ized osteogenic material that are dispersed
and the use of only short periods of IMF in throughout the joint space may be the
children can help reduce the occurrence of cause of ankylosis.155 This theory helps to
this complication. Management once the explain the clinical observation that there is
condition is established is surgical with a a greater predisposition for post-traumatic
temporomandibular joint arthroplasty, ankylosis in patients sustaining such
wide resection of the ankylotic portion of injuries before the age of 10 years.156
bone, coronoidectomy, and reconstruction It is widely accepted that the length of
with a costochondral rib graft, with active the maxillomandibular fixation may play
early and prolonged mobilization and a role in the development of ankylosis.
exercises.152 Markey was unable to produce ankylosis
Although development of internal after experimentally induced fracture
derangement seems to occur solely in with prolonged maxillomandibular fixa-
adult patients, ankylosis is much more tion.157 In studies performed by Beekler
common in children (Figure 22-37). and Walker, ankylosis occurred with pro-
Factors contributing to the develop- longed fixation, while no ankylosis could
ment of ankylosis have been outlined.35 be created in a moving jaw.81 This con-
They include the site and type of fracture, firms the observation that the duration of
the age of the patient at the time of injury, immobilization is contributory to the
the duration of IMF, and the extent of development of ankylosis, although it is
damage to the disk. not the primary determinant. The loca-
The site and type of fracture may play tion and condition of the disk may be
an important role in whether or not anky- another determinant in the occurrence of
FIGURE 22-37 Coronal computed tomography
losis occurs. It is widely accepted that intra- temporomandibular joint ankylosis scan of the patient in Figure 22-36 showing true
capsular fractures are more likely to devel- because one never finds the disk in the bony ankylosis of both temporomandibular joints.
Principles of Management of Mandibular Fractures 429
and patients with compound comminuted condylar segments.159,160 If aberrant rein- sion. Children of less than 12 years of age
fractures, particularly if the coronoid nervation occurs from this injury, the late rarely require more fixation, but patients
process and zygoma are also involved.35 complication of auriculotemporal syn- over the age of 12 years show extreme
Prevention of temporomandibular drome may result.160,161 variability, regardless of fracture type. If
joint ankylosis is accomplished by recog- the occlusion is stable and reproducible at
nition of those patients at risk, brief Postoperative Management the time of IMF release, then jaw-opening
immobilization periods, and aggressive Regardless of the technique employed for exercises are begun. If aggressive physio-
postoperative physiotherapy and long- treatment of the mandibular fractures, the therapy is initiated after release of IMF for
term follow-up. postoperative management of the patient treatment of a condylar process fracture,
is critical for long-term successful rehabil- the patient should be evaluated in
Other Complications Associated itation and return to function. 24 hours to confirm the presence of a
with Condylar Fractures In cases in which open reduction inter- stable occlusion. The arch bars are left in
When the condylar head is forced posteri- nal fixation is employed without the use of place and training elastics are used. The
orly in the process of fracture, some force postoperative IMF, follow-up visits should purpose of these elastics is to permit func-
is directed against the posterior and supe- be used as reinforcement sessions to remind tion, while maintaining the occlusion. An
rior walls of the glenoid fossa. Fracture of the patient about proper diet and progres- effective way to accomplish this is to grad-
the tympanic plate may occur. In addition, sive increase in function. It has been our ually reduce the use of elastics over a peri-
partial obstruction of the external audito- experience that in many respects this group od of time. Initially, elastics should be used
ry canal may result, causing a conductive of patients should be monitored more 24 hours a day. They should be placed
hearing loss because of the close proximi- closely than those treated with IMF to pre- lightly during the daytime to assist in
ty of the middle ear. Patients with a histo- vent possible postoperative complications guiding the mandible into occlusion, par-
ry of a condyle fracture should undergo a secondary to their injudicious or untimely ticularly if significant deviation is present,
careful otoscopic examination to evaluate return to normal diet and function. and applied more tightly at night. After
the condition of the anterior wall of the The proper length of maxillo- 1 week, it may be possible to completely
external auditory canal, as well as to mandibular fixation (if used), the dura- abandon daytime elastic fixation and con-
observe for signs of potential middle ear tion and frequency of evaluation by the tinue with relatively tight elastic fixation at
injury. Appropriate consultation must be surgeon, the early detection of potential night. After another 1 to 2 weeks of this
obtained if injuries of this nature are indi- complications, the judicious use of physio- therapy, assuming that continued mainte-
cated by clinical examination or history. therapy, and proper patient education are nance of a normal occlusion is present, the
Basilar skull fracture along the floor of the all necessary. In most cases some form of patient should be allowed to function
middle cranial fossa may also occur from a IMF will have been employed. The length without any guiding elastic fixation for
similar mechanism, resulting in cerebral of the fixation period, as previously dis- approximately 1 week. If, at that time,
contusion. The fracture may also spread cussed, varies between 2 to 8 weeks there continues to be a stable occlusion,
through the petrous portion of the tempo- depending on many factors. At the end of further evaluation should continue for
ral bone, resulting in injury of cranial this period, a systematic approach for other problems, such as limited mouth
nerves VII and VIII and a neurosensory removal of the fixation is desirable. A opening or pain, and the arch bars may be
hearing deficit (as opposed to a conduc- follow-up regimen similar to that described removed. If, on the removal of the IMF or
tion deficit), facial nerve paralysis, and by Walker must then be instituted.87,88 This at any time during the training period, the
possibly Battles sign. allows for wound healing monitoring, oral occlusion becomes unstable and nonre-
If either of the fracture segments hygiene reinforcement, and observation of producible, an additional period of tight
encroaches on the infratemporal fossa, adequate dietary intake. It also gives the intermaxillary fixation with wires or elas-
trauma to the nerves or vessels in this area clinician the opportunity to control the tics is indicated for 1 or 2 weeks. Clinical
may occur. Damage of a large vessel can occlusion in those patients who need fur- experience seems to indicate that a longer
result in hematoma formation or develop- ther stabilization, while encouraging early period of controlled elastic traction is often
ment of a false aneurysm.158 This expand- movement in those patients who have sta- needed in adults with displaced or dislo-
ing hematoma or false aneurysm may also ble occlusions. It is impossible to predict cated fractures, particularly if these are
cause injury to the seventh cranial nerve. on the basis of the type of fracture which bilateral. Even with judicious use of guid-
The third division of the cranial nerve V patients will need continued aggressive ing elastic fixation, patient education, and
may also be injured by the displaced elastic guidance to maintain their occlu- careful continued evaluation, malocclusion
430 Part 4: Maxillofacial Trauma
persists in some patients. In these cases one compression plate (DCP). Acta Orthop 25. Petzel JR, Bulles G. Experimental studies of the
must consider equilibration, orthodontics, Scand 1969;125:4561. fracture behaviour of the mandibular condy-
9. Michelet F, Deymes J, Dessus B. Osteosynthesis lar process. J Maxillofac Surg 1981;9:2115.
osteotomies, or a combination of these to with miniaturized screwed plates in maxillo- 26. Cope MR, Lawlor MG. An unusual mandibular
correct the malocclusion. facial surgery. J Maxillofac Surg 1973; dislocation. Br J Oral Maxillofac Surg
Throughout the post-IMF period, 1:7984. 1985;23:1127.
aggressive maintenance of range of 10. Champy M, Lodde JP, Schmitt R, et al. 27. Katzen JT, Jarrahy R, Eby JB, et al. Craniofacial
Mandibular osteosynthesis by miniature and skull base trauma. J Trauma 2003;
motion is necessary. In some patients this
screwed plates via a buccal approach. 54:102634.
may be as simple as instructing them to J Maxillofac Surg 1978;6:1421. 28. Chacon GE, Dawson KH, Myall RW, Beirne
open their mouths as wide as possible in a 11. Rahn BA. Direct and indirect bone healing OR. A comparative study of 2 imaging tech-
symmetrical manner. Other patients may after operative fracture treatment. Oto- niques for the diagnosis of condylar frac-
initially require daily evaluations and laryngol Clin North Am 1987;20:42540. tures in children. J Oral Maxillofac Surg
12. Worthington P, Champy M. Monocortical 2003;61:66872.
forced opening by the surgeon. Manually 29. Chayra GA, Meador LR, Laskin DM. Compari-
miniplate osteosynthesis. Otolaryngol Clin
forcing the teeth apart, use of a ratchet, North Am 1987;20:60720. son of panoramic and standard radiographs
mouth props, progressive wedging of 13. Davies BW, Cerdena JP, Guyuron B. Noncom- for the diagnosis of mandibular fractures.
tongue blades between the teeth, or other pression unicortical miniplate osteosynthe- J Oral Maxillofac Surg 1986;44:6779.
sis of mandibular fractures. Ann Plast Surg 30. Shetty V, Atchison K, Belin TR, et al. Clinician
more sophisticated physiotherapy devices
1992;28:4149. variability in characterizing mandible frac-
are all effective means of regaining pre- tures. J Oral Maxillofac Surg 2001;59:254
14. Huelke DF. Mechanics in the production of
injury interincisal opening. mandibular fractures: a study with the 61; discussion 2612.
The success or failure of any pro- stresscoat technique. I. Symphyseal 31. Gilhuus-Moe O. Fracture of the mandibular
condyle in the growth period. Acta Odontol
posed treatment for the fractured impacts. J Dent Res 1964;43: 43746.
Scand 1971;29:5363.
mandible, whether by open or closed 15. Huelke DF, Burdi AR, Eymen C. Mandibular
32. Gerry RG. Condylar fractures. Br J Oral Surg
fractures as related to site of trauma and state
reduction, will necessarily hinge on the 1965;3:11422.
of dentition. J Dent Res 1961;40:12626.
careful adherence to sound physiologic 16. Huelke DF, Burdi AR, Eymen CE. Association
33. Blevins D, Gores RJ. Fractures of the mandibu-
and surgical principles and to close post- lar condyloid process: results of conserva-
between mandibular fractures and site of
tive treatment in 140 patients. J Oral Surg
operative follow-up. trauma, dentition and age. J Oral Surg
Anesth Hosp Dent 1961;19:32933.
Anesth Hosp Dent 1962;20:47881.
34. MacLennan WD. Consideration of 180 cases of
References 17. Huelke DF, Harger JH. Maxillofacial injuries:
typical fractures of the mandibular condy-
1. Ogundare BO, Bonnick A, Bayley N. Pattern of their nature and mechanisms of produc-
lar process. Br J Plast Surg 1952;5:1227.
mandibular fractures in an urban major tion. J Oral Surg 1969;27:45160.
35. Bradley P. Injuries of the condylar and coronoid
trauma center. J Oral Maxillofac Surg 2003; 18. Huelke DF, Harger JH. Mechanisms in the pro-
process. In: Rowe NL, Williams JL, editors.
61:7138. duction of mandibular fractures: an exper-
Maxillofacial injuries. Volume 1. Edinburgh:
2. Thaller SR. Management of mandibular frac- imental study. J Oral Surg 1968;26:869. Churchill-Livingstone; 1985. p. 33762.
tures. Arch Otolaryngol Head Neck Surg 19. Huelke DF, Patrick LM. Mechanics in the pro- 36. Kelly DE, Harrigan WF. A survey of facial frac-
1994;120:447. duction of mandibular fractures: strain- tures: Bellevue Hospital 1948-1974. J Oral
3. Fasola AO, Obiechina AE, Arotiba JT. Incidence gauge measurements of impacts to the chin. Surg 1975;33:1469.
and pattern of maxillofacial fractures in the J Dent Res 1964;43:43746. 37. Luyk NH, Larsen PE. The diagnosis and treat-
elderly. Int J Oral Maxillofac Surg 20. Evans FG, Pedersen HE, Lissner HR. The role ment of the dislocated mandible. Am J
2003;32:2068. of tensile stress in the mechanism of Emerg Med 1989;7:32935.
4. Hoffman WY, Barton RM, Price M, Mathes SJ. femoral fractures. J Bone Joint Surg 1951; 38. Lello GE. Treatment of long standing
Rigid internal fixation vs. traditional tech- 33:4858. mandibular dislocation of the mandible.
niques for the treatment of mandible frac- 21. Kromer H. Closed and open reduction of condy- J Oral Maxillofac Surg 1987;45:8936.
tures; J Trauma 1990;30:10326. lar fractures. Denl Rec 1953;73:56971. 39. Hayward JR. Prolonged dislocation of the
5. Kellman RM. Recent advances in facial plating 22. Chalmers J. Lyons Club. Fractures involving mandible. J Oral Surg 1965;23:58594.
techniques. Facial Plast Surg Clin North the mandibular condyle: a post-treatment 40. da Fonseca GD. Experimental study on frac-
Am 1995;3:22739. survey of 120 cases. J Oral Surg 1974;9:233. tures of the mandibular condylar process
6. Dawson KH, Chigurupati R. Fixation of 23. Rowe NL, Killey HC. Fractures of the facial (mandibular condylar process fractures).
mandibular fractures: a tincture of science. skeleton. 2nd ed. Edinburgh: Churchill- Int J Oral Surg 1974;3:89101.
Ann R Australas Coll Dent Surg Livingstone; 1968. 41. Ihalainen U, Tasanen A. Central dislocation of
2002;16:11822. 24. Lindahl L. Condylar fractures of the mandible. the mandibular condyle into the middle
7. Cawood JI. Small plate osteosynthesis of I. Classification and relation to age, occlu- cranial fossa: a case report and review of the
mandibular fractures. Br J Oral Maxillofac sion and concomitant injuries of teeth and literature. Int J Oral Surg 1983;12:3945.
Surg 1985;7791. teeth supporting structures, and fractures 42. Musgrove BT. Dislocation of the mandibular
8. Allgower M, Ehrsam R, Ganz R, Matter P, Per- of the mandibular body. Int J Oral Surg condyle into the middle cranial fossa. Br J
ren SM. Clinical experience with a new 1977;6:1221. Oral Maxillofac Surg 1986;24:227.
Principles of Management of Mandibular Fractures 431
43. Harilainen A, Myllynen P, Anhla H, Seitsalo S. 60. Luyk NH, Ferguson JW. The diagnosis and ini- 79. Walker RV. Traumatic mandibular condyle
The significance of arthroscopy and exami- tial management of the fractured mandible. fracture dislocations. Am J Surg 1960;
nation under anesthesia in the diagnosis of Am J Emerg Med 1991;9:3529. 100:85063.
fresh injury haemarthrosis of the knee 61. Motamedi MH. An assessment of maxillofacial 80. Beekler DM, Walker RV. Condyle fractures.
joint. Injury 1988;19:214. fractures: a 5-year study of 237 patients. J Oral Surg 1969;27:5634.
44. Fieldhouse J. Bilateral temporomandibular joint J Oral Maxillofac Surg 2003;61:614. 81. Boyne PJ. Osseous repair and mandibular
ankylosis with associated micrognathia: 62. Kreutziger KL, Kreutziger KL. Comprehensive growth after subcondylar fractures. J Oral
report of a case. Br J Oral Surg 1974;11:2136. surgical management of mandibular frac- Surg 1967;225:3009.
45. Guralnick WC, Kaban LB. Surgical treatment tures. Southern Med J 1992;85:50618. 82. Smets LM, Van Damme PA, Stoelinga. Non-
of mandibular hypomobility. J Oral Surg 63. Walker RV, Bertz JE. Facial and extracranial surgical treatment of condylar fractures in
1976;34:3438. head injuries. Care of the trauma patient. adults: a retrospective analysis. J Cran-
46. Hoaglund FT. Experimental hemarthrosis. Shires GT, editor. New York: McGraw-Hill iomaxillofac Surg 2003;31:1627.
83. Glineburg RW, Laskin DM, Blankstein DL. The
J Bone Joint Surg 1967;49:28598. Book Co; 1966. p 478.
effect of immobilization on the primate
47. Laskin DM. Role of the meniscus in the etiolo- 64. Huelke DF, Compton CP. Facial injuries in
temporomandibular joint: a histologic and
gy of posttraumatic temporomandibular automobile crashes. J Oral Maxillofac Surg
histochemical study. J Oral Maxillofac Surg
joint ankylosis. Int J Oral Surg 1978; 1983;41:2414.
1982;40:38.
7:3405. 65. Bernstein L. Practical points in the manage-
84. Juniper RP, Awty MD. The immobilization
48. Ellis E, Moos KF, EI-Attar A. Ten years of ment of mandibular fractures. Trans Am
period for fractures of the mandibular
mandibular fractures: An analysis of 2,137 Acad Opthalmol Otolaryngol 1970;74: body. J Oral Surg 1973;36:15763.
cases. Oral Surg 1985;59:1209. 106873. 85. Amaratunga NA. The relation of age to the
49. Leathers R, Le AD, Black E, McQuirter JL. Orofa- 66. May M, Tucker HM, Ogura IH. Closed man- immobilization period required for healing
cial injury in underserved minority popula- agement of mandibular fractures. Arch of mandibular fractures. J Oral Maxillofac
tions. Dent Clin North Am 2003;47:12739. Otolaryngol 1972;95:537. Surg 1987;45:1113.
50. Calloway DM, Anton MA, Jacobs JS Changing 67. Cook RM, MacFarlane WI. Subcondylar frac- 86. Walker RV. The consultant: condylar fractures.
concepts and controversies in the manage- ture of the mandible. Oral Surg Oral Med J Oral Surg 1966;24:3679.
ment of mandibular fractures. Clin Plast Oral Pathol 1969;27:297304. 87. Walker RV. Open reduction of condylar frac-
Surg 1992;19:5969. 68. MacGregor AB, Fordyce GL. The treatment of tures of the mandible in conjunction with
51. Edwards TJ, David DJ, Simpson DA, Abott AA. fracture of the neck of the mandibular repair of discal injury: discussion. J Oral
Patterns of mandibular fractures in Ade- condyle. Br Dent J 1957;106:351. Maxillofac Surg 1988;46:2623.
laide, South Australia. Aust N Z J Surg 69. Leake D, Doykos J, Habal M, et al. Long-term 88. Luyk NH. Principles of management of frac-
1994;64:30711. follow-up of fractures of the mandibular tures of the mandible. In:. Peterson LJ,
52. Fridrich KL, Pena-Velaso G, Olson AJ. Chang- condyle in children. Plast Reconstr Surg Indresano AT, Marciani RD, Roser SM edi-
ing trends with mandibular fractures: A 1971;47:12731. tors. Principles of oral and maxillofacial
review of 1067 cases. J Oral Maxillofac Surg 70. Lindahl L. Condylar fractures of the mandible. surgery. Philadelphia, PA: Lippincott-
1992;50:5869. IV. Function of the masticatory system. Int Raven; 1992. p. 381434.
53. Iizuka T, Lindqvist C. Rigid internal fixation of J Oral Surg 1977;6:195203. 89. Messer EJ, Keller JJ. A rational approach to the
mandibular fractures: an analysis of 270 71. De Riu G, Gamba U, Anghioni M, Sessena E. A mandibular parasymphyseal fracture.
fractures using the AO/ASIF method. Int J comparison of open and closed treatment of J Oral Surg 1976;34:80810.
Oral Maxillofac Surg 1992;21:659. condylar fractures: a change in philosophy. 90. Williams JG, Cawood JI. Effect of intermaxil-
54. Hagan EH, Huelke DR. An analysis of 319 case Int J Oral Maxillofac Surg 2001;30:3849. lary fixation on pulmonary function. Int J
reports of mandibular fractures. J Oral Surg 72. MacLennan WD, Simpson W. Treatment of the Oral Maxillofac Surg 1990;19:768.
91. Wood GD. Assessment of function following
1961;19:93104. fractured mandibular condylar process in
fracture of the mandible. Br Dent J
55. Van Hoof RF, Merkx CA, Stekenlenburg EC. children. Br J Plast Surg 1965;18:4237.
1980;149:13741.
The different pattern of fractures of the 73. Thomson HG, Farmer AW, Lindsay WK. Condy-
92. Brown AE, Obeid G. A simplified method for
facial skeleton in four European countries. lar neck fractures of the mandible in chil-
the internal fixation of fractures of the
Int J Oral Surg 1977;6:311. dren. Plast Reconstr Surg 1964;34:45263.
mandibular condyle. Br J Oral Maxillofac
56. El-Degwi A, Mathog RH: Mandible fractures 74. Russell D, Nosti JC, Reavis C. Treatment of
Surg 1984;22:14550.
medical and economic considerations. Oto- fractures of the mandibular condyle. 93. Wennogle CF, Delo RI. A pin-in-groove tech-
laryngol Head Neck Surg 1993;108:2139. J Trauma 1972;12:7047. nique for reduction of displaced subcondy-
57. Olson RA, Fonseca RJ, Zeitler DL, Osborn DB. 75. Hotz RP. Functional jaw orthopedics in the lar fractures of the mandible. J Oral Max-
Fractures of the mandible: a review of 580 treatment of condylar fractures. Am J illofac Surg 1985;43:65965.
cases. J Oral Surg 1982;40:238. Orthod 1978;73:36577. 94. Kitayama S. A new method of intraoral open
58. Salem JE, Lilly G, Cutcher JL, Steiner M. Analy- 76. Rowe NL. Fractures of the jaws in children. reduction using a screw applied through
sis of 523 mandibular fractures. Oral Surg J Oral Surg 1969;27:497507. the mandibular crest of condylar fractures.
1968;26:3905. 77. Waite DE. Pediatric fractures of the jaw and J Craniomaxillofac Surg 1989;17:1623.
59. Haug RH, Prather J, Indresano AT. An epi- facial bones. Pediatrics 1973;51:5519. 95. Tanasen A, Lamberg MA. Transosseous wiring
demiologic survey of facial fractures and 78. Rakower W, Protzell A, Rosencrans M. Treat- in the treatment of condylar fractures of the
concomitant injuries. J Oral Maxillofac ment of displaced condylar fractures in mandible. J Oral Maxillofac Surg 1976;
Surg 1990;48:92632. children. J Oral Surg 1961;19:51721. 4:2006.
432 Part 4: Maxillofacial Trauma
96. Zide MF, Kent JN. Indications for open reduc- 114. Ma S, Fang RH. Endoscopic mandibular angle 133. Neal DC, Wagner W, Alpert B. Morbidity asso-
tion of mandibular condyle fractures. J Oral surgery: a swine model. Ann Plast Surg ciated with teeth in the line of mandibular
Maxillofac Surg 1983;41:8998. 1994;33:4735. fractures. J Oral Surg 1978;36:85962.
97. Raveh J, Vuillemin T, Ladrach K. Open reduc- 115. Jacobovicz J, Lee C, Trabulsy PP. Endoscopic 134. Kahnberg KE, Ridell A. Prognosis of teeth
tion of the dislocated fractured condylar repair of mandibular subcondylar frac- involved in the line of mandibular frac-
process: indications and surgical procedures. tures. Plast Reconstr Surg 1998;101:43741. tures. Int J Oral Surg 1979;8:16372.
J Oral Maxillofac Surg 1989;47:1207. 116. Troulis MJ, Kaban LB. Endoscopic approach to 135. Schneider SS, Stern M. Teeth in the line of
98. Chuong R, Piper MA. Open reduction of the ramus/condyle unit: Clinical applica- mandibular fractures. J Oral Surg 1971;
condylar fractures of the mandible in con- tions. J Oral Maxillofac Surg 2001;59;5039. 29:1079.
junction with repair of discal injury: a pre- 117. Sandler NA. Endoscopic-assisted reduction 136. de Amaratunga NA. The effect of teeth in the
liminary report. J Oral Maxillofac Surg and fixation of a mandibular subcondylar line of mandibular fractures on healing. J
1988;46:25763. fracture: report of a case. J Oral Maxillofac Oral Maxillofac Surg 1987;45:3124.
99. Lund K. Unusual fracture dislocation of the Surg 2001;59:147982. 137. Shetty V, Freymiller E. Teeth in the line of frac-
mandibular condyle in a six year old girl. 118. Miloro M. Endoscopic-assisted repair of sub- ture: a review. J Oral Maxillofac Surg
Int J Oral Surg 1972;1:5360. condylar fractures. Oral Surg Oral Med 1989;47:13036.
100. Henny FA. A technique for open reduction of Oral Pathol Oral Radiol Endod 2003; 138. Zallen RD, Curry IT. A study of antibiotic
fractures of the mandibular condyle. J Oral 96:38791. usage in compound mandibular fractures. J
Surg 1951;9:2335. 119. Fisher IT, Cleaton-Jones PE, Lownie JF. Relative Oral Surg 1975;33:4314.
101. Zide MF. Open reduction of mandibular efficiencies of various wiring configurations 139. Chole RA, Yee J. Antibiotic prophylaxis for
condyle fractures: indications and tech- commonly used in open reductions of frac- facial fractures. Arch Otolaryngol Head
nique. Clin Plast Surg 1989;16:6976. tures of the angle of the mandible. Oral Surg Neck Surg 1987;113:10557.
102. Hinds EC, Girotti WJ. Vertical subcondylar Oral Med Oral Pathol 1990;70:107. 140. Chuong R, Donoff RB, Guralnick WC. A retro-
osteotomy: a reappraisal. J Oral Surg 120. Johansson B, Krekmanov L, Thomsson spective analysis of 327 mandibular frac-
1967;24:16470. M.0Miniplate osteosynthesis of infected tures. J Oral Maxillofac Surg 1983;41:3059.
mandibular fractures. J Craniomaxillofac
103. Jeter TS, Vansickels JE, Nishioka GJ. Intraoral 141. Mathog RH, Rosenberg Z. Complications in
Surg 1988;16:227.
open reduction with rigid internal fixation the treatment of facial fractures. Otolaryn-
121. Woo SL, Lothringer KS, Akeson WH, et al. Less
of mandibular subcondylar fractures. J Oral gol Clin North Am 1976;9:53352.
rigid internal fixation plates: historical per-
Maxillofac Surg 1988;11136. 142. Cannell H, Boyd R. The management of max-
spectives and new concepts. J Orthop Res
104. Ellis E, Reynolds ST, Park HS. A method to illofacial injuries in vagrant alcoholics. J
1984;1:43149.
rigidly fix high condylar fractures. Oral Maxillofac Surg 1985;13:1214.
122. Bradley JC. Age changes in the vascular supply
Surg Oral Med Oral Pathol 1989;68:36974. 143. Beckers HL. Treatment of initially infected
of the mandible. Br Dent J 1972;132:1424.
105. Boyne PJ. Free grafting of traumatically dis- mandibular fractures with bone plates. J
123. Marciani RD. Invasive management of the
placed or resected mandibular condyles. J Oral Surg 1979;37:3103.
fractured atrophic edentulous mandible.
Oral Maxillofac Surg 1989;47:22832. 144. Abiose BO. Maxillofacial skeleton injuries in
J Oral Maxillofac Surg 2001;59:7925.
106. Mikkonen P, Lindqvist C, Pihakari A, et al. the western states of Nigeria. Br J Oral Max-
124. Amaratunga NA. A comparative study of the
Osteotomy-osteosynthesis in displaced illofac Surg 1986;24:319.
clinical aspects of edentulous and dentu-
condylar fractures. Int J Oral Maxillofac lous mandibular fractures. J Oral Maxillo- 145. Dodson TB, Perrott DH, Kaban LB, Gordon
Surg 1989;18:26770. fac Surg 1988;46:35. NC. Fixation of mandibular fractures: a
107. Hooley JR. Reduction of mandibular fractures 125. Bruce RA, Strachan DS. Fractures of the eden- comparative analysis of rigid internal fixa-
by intraoral inferior border wiring. J Oral tulous mandible: the Chalmers J. Lyons tion and standard fixation technique. J Oral
Surg 1969;27:8791. Academy study. J Oral Surg 1976;34:9739. Maxillofac Surg 1990;48:3626.
108. Paul JK. Intraoral open reduction. J Oral Surg 126. Amaratunga NA. Mandibular fractures in chil- 146. Tu HK, Tenhulzen D. Compression osteosynthe-
1968;26:51622. dren-A study of clinical aspects, treatment sis of mandibular fractures: a retrospective
109. Rontal E, Meyerhoff W, Hohmann A. The needs and complications. J Oral Maxillofac study. J Oral Maxillofac Surg 1985;43:5859.
transoral reduction of mandibular frac- Surg 1988;46:63740. 147. Larsen OD, Nielsen A. Mandibular fractures. 1.
tures. Arch Otolaryngol 1973;97:27982. 127. MacLennan WD, Simpson W. Treatment of An analysis of their etiology and location in
110. Sazima HJ, Grafft ML, Fulcher CL. Transoral fractured mandibular condylar processes in 286 patients. Scand J Plast Reconstr Surg
reduction of mandibular fractures. J Oral children. Br J Plast Surg 1965;18:4237. 1976;10:2138.
Surg 1971;29:24754. 128. Krausen AS, Samuel M. Pediatric jaw fractures: 148. Proffit WR, Vig KW, Turvey TA. Early fracture
111. van Dijk L, Brons R, Bosker H. Treatment of indications for open reduction. Otolaryn- of the mandibular condyles: frequently an
mandibular fractures by means of stable gol Head Neck Surg 1979;87:31822. unsuspected cause of growth disturbances.
internal wire fixation. Int J Oral Surg 129. Khosla M, Boren W. Mandibular fractures in Am J Orthod 1980;78:124.
1977;6:1736. children and their management. J Oral Surg 149. Gilhuus-Moe O. Fractures of the mandibular
112. Freihofer HP Jr, Sailer HF. Experience with 1971;24:11621. condyle in the growth period. Histologic
intraoral trans-osseous wiring mandibular 130. Walker DG. Facial development. Ann R Coll and autoradiographic observations in the
fractures. J Maxillofac Surg 1973;1:24852. Surg Engl. 1957 Aug;21:90118. contralateral, nontraumatized condyle.
113. Takenoshita Y, Oka M, Tashiro H. Surgical 131. Kruger GO. Textbook of oral surgery. 3rd ed. St Acta Odontol Scand 1971; 29:5363
treatment of fractures of the mandibular Louis (MO): C.V. Mosby; 1968. 150. Durkin JF, Heeley J, Irving JT. The cartilage of
condylar neck. J Craniomaxillofac Surg 132. Clark HB. Practical oral surgery. 2nd ed. the mandibular condyle. Oral Sci Rev
1989;17:11924. Philadelphia (PA): Lea & Febiger; 1959. 1973;2:2999.
Principles of Management of Mandibular Fractures 433
151. Lund K. Mandibular growth and remodeling in relation to some deformities. Br Dent J tial facial paralysis secondary to mandibu-
process after condylar fracture. A longitudi- 1944;76:5763. lar fracture. J Oral Surg 1970;28:8546.
nal roentgencephalometric study. Acta 155. Rowe NL. Ankylosis of the temporo- 159. Schmidseder R, Scheunemann H. Nerve
Odontol Scand Suppl. 1974;32:113117. mandibular joint. J R Col Surg Edinb injuries in fractures of the condylar neck.
152. Munro IR, Chen YR, Park BY. Simultaneous 1982;27:6779. J Maxillofac Surg 1977;5:18690.
total correction of temporomandibular 156. Topazian RG. Etiology of ankylosis of the tem- 160. Laws IM. Two unusual complications of
ankylosis and facial asymmetry. Plast poromandibular joint: analysis of 44 cases. fractured condyles. Br J Oral Surg 1967;
Reconstr Surg 1986;77:51729. J Oral Surg 1964;22:22733. 5:519.
153. Dufuormental ML. Fractures of the mandible 157. Markey RG. Condylar trauma and facial asym- 161. Martis C, Athanassiades S. Auriculotemporal
in the region of the joint. Br Dent J 1929; metry: an experimental study [thesis]. syndrome (Freyes syndrome) secondary to
50:6202. Seattle: University of Washington; 1974. fracture of the mandibular condyle. Plast
154. Roushton MA. Growth of mandibular condyle 158. Kennedy JW, Kent JN. False aneurysm and par- Reconstr Surg 1969;44:6034.
CHAPTER 23.1
The results of epidemiologic surveys on describe treatments for maxillary frac- It was not until 1901 that Ren Le Fort
maxillary fractures differ with the politics tures or the iatrogenic fracture of the published his landmark works, a three-part
and population density of the geographic maxilla for therapeutic purposes. In 1822 experiment using 32 cadavers that were
region studied, the era in which the sur- Charles Fredrick William Reiche provid- either intact or decapitated.1012 The heads
veys were performed, the socioeconomic ed the first detailed treatise of maxillary of the cadavers were subjected to various
status of the population, and the institu- fractures, entitled De Maxillae Superiors types of trauma; the soft tissue was then
tion whose experience was reviewed.15 It Fractura.7 In 1823 Carl Ferdinand van removed and the bones were examined. Le
is difficult to make generalized statements Graefe described the use of a head frame Fort noted that, generally, if the face was
about the findings of these studies, but for treating a maxillary fracture.7 His fractured, the skull was not. He then stated
trends do exist, and these trends make it device was as technically complex as that fractures occurred through three weak
clear that maxillary fractures are more fre- those currently in use. In 1859 Bernhard lines in the facial bony structure: those that
quently associated with motor vehicle R. K. Von Langenbeck described a tech- protect the cranial cavity, those that cir-
accidents and motorcycle accidents than nique for the osteoplastic resection of the cumscribe the midface, and those that cut
with any other cause. Maxillary fractures maxilla.8 In 1867 David Cheever dis- across the face. From these three lines the
most often occur in conjunction with cussed complete mobilization of the Le Fort classification system was developed
other facial fractures and are most often maxilla with the use of chisels for the (Figure 23.1-1).
associated with injuries such as lacera- removal of a nasopharyngeal tumor.9 In
tions, other facial fractures, orthopedic 1893 Otto Lanz also described the cre- Le Fort Classification System
injury, and neurologic injury.1,2,5,6 Most ation of an iatrogenic maxillary fracture In his description of maxillary fractures Le
maxillary fractures occur in young men for access to a tumor. Fort considered several factors: the vector
aged 16 to 40 years; they are most com-
mon among patients between 21 and
25 years of age, and the risk of sustaining
facial bone fractures increases as the age of
the patient increases.6
of force overcoming the inertia of the face; suture along the medial wall of the orbit one-eighth-inch steel wire was
the thickness of the bone and buttresses through the superior orbital fissure. It imbedded in the sides on a line
counteracting the mass, velocity, and point then extends along the inferior orbital fis- with the ends of the teeth, then
of application; and the maxilla, which he sure and the lateral orbital wall to the bent backward upon itself oppo-
noticed was unaffected by muscle pull, zygomaticofrontal suture. The zygomati- site the cuspid teeth. . . . From
unlike the long bones. These considera- cotemporal suture is also separated. The this was constructed a hard-rub-
tions resulted in a classification of three fracture then extends along the sphenoid ber splint, with the wires
levels of fracture. bone, separating the pterygoid plates. The attached. . . . The splint is held in
septum becomes separated at the cribri- position by means of double
Le Fort I Level form plate of the ethmoid. Le Fort III frac- elastic straps attached to the wire
Maxillary fractures at the Le Fort I level tures are most often comminuted. With on each side and buckled to a
traverse the lateral antral wall, the lateral highly comminuted fractures, patients close-fitting leather or net cap,
nasal wall, and the lower third of the sep- may sustain fractures at more than one which is reinforced with leather
tum, and they separate at the pterygoid level. Virtually all combinations of Le Fort and laced firmly on the head. . . .
plates. Thus, the entire mobilized segment I, II, and III fractures are possible on either The object of [the splint] was to
consists of the maxillary alveolar bone, the side of the face. furnish a sure guide to the nor-
palatine bone, the lower third of the nasal In Garretsons 1898 treatise the pri- mal position of the superior
septum, and the lower third of the ptery- mary method of treating fractures of the maxillae. Without this the cor-
goid plates. The superior two-thirds of maxillae was to construct a bandage or rectness of the adjustment of the
these bones remain associated with the dressing that elevated the mandible into bones could not have been veri-
face. occlusion and secure it there.13 A number fied. Its importance therefore
of materials were used to add stability to cannot be overestimated.14
Le Fort II Level these bandages, including plaster of
Maxillary fractures at the Le Fort II level Paris, wood, gutta-percha, and vulcan- Similar treatment modalities were
involve most of the nasal bones, the max- ized rubber. In addition to splinting the presented by Brophy in 1918; he present-
illary bones, the palatine bones, the lower jaws Garretson advocated the use of ed illustrations of the splints as well as
two-thirds of the nasal septum, the den- interdental splints, stating As a means of preoperative and postoperative images of
toalveolus, and the pterygoid plates. dressing in any complicated jaw fracture, a patient.15
Unlike the horizontal separation noted in the interdental splint is as invaluable and
the Le Fort I fracture, the Le Fort II frac- reliable as it is simple of construction Anatomy
ture is pyramidal in shape. The fracture and easy of application.13 The two maxillae are paired structures
extends from below the nasofrontal suture Blair gave a very good description of connected by a midline suture; the bones
through the nasal bones along the maxilla the anatomy of maxillary fractures and of together compose a five-sided pyramid.
to the zygomaticomaxillary suture and the examination for diagnosing such frac- The anterior surface slopes downward
includes the medial inferior third of the tures.14 He noted that mandibular ban- from its superior contact with the frontal
orbit. The fracture then continues along dages were insufficient to stabilize maxil- and nasal bones at an angle of approxi-
the zygomaticomaxillary suture to and lary fractures and advocated a maxillary mately 15. The most prominent point at
through the pterygoid plates. The septum splint, quoting an authority of the day, Dr. the anterior surface is the anterior nasal
is also separated superiorly. The segments John L. Marshall: spine. A number of protuberances exist on
may be intact below this line of fracture, the maxilla, formed by the alveolar base
but they are most often comminuted. Impressions of the upper and and origins of the small facial muscles.
lower teeth were taken with the The lateral surface of the maxillae forms
Le Fort III Level modeling compound by first the infratemporal fossae and buccal
Fractures at the Le Fort III level involve the molding it upon the upper teeth vestibule and attaches to the zygoma. Most
nasal bones, the zygomas, the maxillae, the and while it was yet soft forcing of the superior surface forms the majority
palatine bones, and the pterygoid plates. the lower jaw upward until a cor- of the orbital floor.
These fractures essentially separate the rect occlusion of the teeth was The medial surface of each maxilla
face along the base of the skull. The frac- obtained. This impression was forms the midline suture and lateral nasal
ture line extends from the nasofrontal trimmed to the desired shape; a walls. This includes the nasal concha and
Management of Maxillary Fractures 437
sinus ostia. The ostium of the naso- riorly; therefore, fractures at the Le Fort II the ascending branches of the ptery-
lacrimal duct is beneath the inferior con- level may occur inferior to the nasofrontal gopalatine ganglion. The frontal process of
cha. The ostia of the maxillary sinus and suture. The nasal septum is a thin trape- the maxilla contains the lacrimal appara-
middle ethmoids, as well as the opening of zoidal bone lying perpendicular to and tus, which is housed between the medial
the nasofrontal duct, lie beneath the mid- joining the maxillae and palatine bones. canthal ligaments.
dle concha. The superior border is thick and articu- The blood supply to the maxillae and
The inferior border composes the lates with the ethmoid bone.16 palatine bones is through the periosteum,
palatal vault and alveolus, which contain The ethmoid bone is cuboidal and the incisive artery, and the greater and
the teeth. The posterior border abuts the extremely pneumatized; thus, it can be lesser palatine arteries. The internal maxil-
sphenoid bone and the pterygomaxillary easily fractured and comminuted. The lary artery, a source of potentially devas-
suture.16 Within the maxilla is the maxil- cribriform plate of the ethmoid composes tating hemorrhage, lies posterior to the
lary sinus. This 34 33 25 mm air cavi- the roof of the nasal cavity and communi- maxillae and palatine bones and anterior
ty is responsible for the weakness of the cates with the anterior cranial fossae to the pterygoid plates of the sphenoid.18
maxilla. The sinus is present at birth but through multiple foramina for the olfacto- The blood supply to the nasal septum and
does not pneumatize to its mature extent ry nerves. Lateral to the crista galli is a slit the lateral nasal walls is provided by the
until the patient reaches 14 to 15 years of through which dura mater is exposed. Pos- anterior and posterior ethmoidal arteries,
age. Minor changes in the sinus continue terior and superior movements of the the sphenopalatine artery, and the greater
throughout life.17 The strong buttresses of midface can easily comminute this bone, palatine and superior labial arteries.16
the maxilla are the lateral piriform but- thus disrupting the dura mater and result-
tress, the zygomatic buttress, the greater ing in a cerebrospinal fluid leak.16 Diagnosis
palatine buttress, and the floor of the nose. The zygoma abuts the frontal bone at
The palatine bone is L shaped and the frontozygomatic suture and the tem- Clinical Examination
abuts the posterior maxilla as a paired poral bone at the zygomaticotemporal Advanced trauma life-support protocols
structure. These bones assist the maxilla in suture. The maxilla and zygoma form two- should be followed for all patients who
forming the posterior sinus, the posterior thirds of the orbital rim and, along with have suffered trauma. Detailed examina-
lateral nasal wall, and the pterygomaxillary the palatine bone, one-third of the walls tion of maxillofacial fractures is complet-
suture. When joined to the maxilla the four and floor of the orbit. ed in the secondary survey, after the pri-
bones represent one unit (Figure 23.1-2).16 The infraorbital nerve traverses the mary survey and successful resuscitation
The nasal bones are paired structures orbital floor and exits through the infraor- have been completed. As has been done
that abut the frontal bone superiorly, the bital foramen. The maxillary bone, along historically the clinical examination
maxilla laterally, the septum posteriorly with the zygoma, forms the inferior orbital should begin with the initial observation
and medially, and each other anteriorly fissure. Through this fissure run the max- of the patient, followed by palpation of
and medially. The bones are thicker supe- illary nerve, the infraorbital vessels, and the fractures.14,19 As was written by Blair
in 1914, In all cases of injury of the
Nasal bone face the dental arches and the palate
should be inspected, and the facial bones
outlined digitally.14 Lacerations, abra-
Nasal septum
sions, and ecchymotic areas should be
recorded. Periorbital ecchymosis and
Zygomatic bone facial edema should be noted and are very
typical of these fractures. Epistaxis with
Palatine bone any evidence of cerebrospinal fluid leak-
age (clear fluid mixed with blood, tram
Maxilla lines) should be identified. Asymmetry
of the nose, traumatic telecanthus, a flat
nasal bridge, and a dish-shaped face should
all be noted. Intraorally the examiner may
FIGURE 23.1-2 Disarticulated midfacial skeleton demonstrates the anatomy of the maxilla, the zygo- see fractured teeth, vestibular ecchymosis
ma, the nasal bones, and the nasal septum. and edema, palatal ecchymosis, mucosal
438 Part 4: Maxillofacial Trauma
In areas such as the orbital rim or nasal case such as this, severe difficulty with dis- Surgical Splints
bone, 1.3 mm or 1.0 mm systems may be impaction of Le Fort level fractures can be In cases of gross comminution, periodon-
used. In cases in which bone contact easily overcome by completing the frac- tal disease, or inadequate partial dentition
is decreased because of comminution, ture with an osteotomy. This concept is (less than three occluding teeth per sex-
1.7 mm or 2.0 mm systems may be used. not as novel as it might sound; in 1914, tant), occlusal wafers or palatal splints are
If resistance is encountered during Blair wrote, if the impaction cannot be useful. These splints are fabricated after
mobilization of the maxilla, Rowe disim- broken up . . . resort may be had to a small, impressions have been taken and model
paction forceps may be used to help sharp chisel.14 After down-fracture the surgery has been completed. When an
reduce the fracture (Figure 23.1-9). The maxilla can easily be moved into appropri- occlusal wafer is fabricated it should cover
paired forceps are placed with the fat end ate occlusion and stabilized without fur- the occlusal surfaces and the heights of
in the nose and the bowed end on the ther difficulty (Figure 23.1-10). contour, but it should not encroach on the
palate. The surgeon stands over the Immediate bone grafting has been soft tissues. Holes should be placed
patients head and in an inferior-anterior advocated for the severely comminuted between occlusal surfaces in the splint so
movement disimpacts the maxilla. Further maxillary antrum.37 This treatment pre- that it may be ligated separately to the arch
assistance may be provided with Hayton- vents prolapse of the facial soft tissue into bar, as might be done with an orthognath-
Williams forceps used in conjunction with the maxillary sinus and the facial deforma- ic surgical splint.
the Rowe disimpaction forceps. tion that results. Titanium mesh works well The Gunnings splint has been used to
If the maxillary fracture is incomplete for this procedure; it is malleable, can be establish intermaxillary fixation for eden-
(eg, greenstick fracture), the surgeon may quickly fixated, resists pressure of the soft tulous patients; this splint is essentially a
have difficulty in mobilizing the maxilla. tissues of the face, becomes osseointegrated, denture baseplate fabricated to the existing
The fractured hemimaxilla may be and allows regrowth of the native tissue (ie, edentulous or partially edentulous ridge
impacted or telescoped, causing severe ciliated respiratory epithelium, goblet cells, with arch bars or suspension brackets.39
malocclusion with minimal mobility. In a squamous epithelium) (Figure 23.1-11).38 Dentures can also be secured to the jaws
A A B
C D
FIGURE 23.1-10 A, B, Clinical images showing an unfractured right maxillary antrum and a com-
minuted telescoped left maxillary fracture that was very difficult to reduce. C, D, After an osteotomy was
FIGURE 23.1-9 A, Rowe disimpaction forceps. performed at the Le Fort I level on the right side, the maxilla could be easily mobilized, and the fracture
B, Application of the forceps. was reduced and fixated without further difficulty.
Management of Maxillary Fractures 441
with bone screws before intermaxillary to the use of vascularized free flaps in that potential complications of transloca-
fixation is attempted. this situation.20 tion, extrusion, and growth restriction can
For cases of avulsion, whether free flaps be avoided.42,43 Triana and Shockley
Special Considerations are used or not, implant reconstruction reported the use of an L-lactic acid and
should be considered. Implants with obtu- glycolic acid resorbable plating system;
High-Force or Avulsive Injuries High- rators can be used, as is often seen in partial advantages of the system include ease of
caliber high-velocity gunshot wounds, maxillectomy after tumor resection. contouring the plates, appropriate rigidity
blast injuries, and high-speed motor vehi- Implant restorations can also be placed in of the systems, resorption within
cle accidents with unrestrained victims bone from composite flap reconstructions.41 12 months, no increased risk of postoper-
cause most avulsion injuries associated ative wound infection, and the apparent
with maxillary fractures. The priority in Injuries to Geriatric Patients Geriatric absence of growth restriction.42
treating these injuries is to preserve as patients who suffer a Le Fort injury pose a
much of the remaining tissue as possible. special concern. Additional medical ill- Complications
Consideration and administration of a nesses and disabilities may render general Complications associated with maxillary
narrow-spectrum antibiotic directed at anesthesia quite risky for these patients. fractures and their repair are listed in
oral and nasal contaminants, as well as The surgeon should exercise judgment Table 23.1-1. A number of these complica-
tetanus prophylaxis, are a priority in these when morbid medical conditions coexist tions may not be readily apparent until
injuries. As is true for all injuries these with minimally displaced fractures in weeks or months after injury, but the
wounds should be thoroughly evaluated edentulous patients. A new prosthesis may potential for their occurrence should be
for bleeding, foreign bodies, and extent of be more effective than reduction and fixa- borne in mind during evaluation and
damage. Extensive irrigation with pulsed tion of the fracture. treatment of the patient.
fluids should be used to remove debris. The geriatric maxilla is less vascular Perioperative and postoperative air-
Life-threatening hemorrhage should and has more pneumatized antra, less alve- way obstructions are unusual in cases of
be addressed early for homeostasis and olar bone, and less dense trabeculation. maxillary fracture alone. However, these
for airway management.40 Hemorrhage Should reduction and fixation be required, conditions may occur in association with
that cannot be controlled by local mea- existing dentures may be modified by
sures such as packing (anterior and pos- relining and affixing arch bars or intermax-
terior) and electrocautery is an indica- illary fixation buttons. A Gunnings splint
tion for angiography and embolization may also be fabricated. Such a splint may
of the injured artery or arteries. Because be fixed to the zygoma, the anterior nasal
of the collateral blood supply of the face, spine, the piriform rim, or the palate, either
most tissues remain viable with only a with wires or cortical bone screws.
small isthmus of blood supply. Fractures
should be repaired with rigid fixation. Pediatric Maxillary Fractures Pediatric
Voids in bone should be addressed with a maxillary fractures occur infrequently. A
secondary reconstruction. Multiple lac- Because the pediatric sinuses are not high-
erations with comminuted fractures will ly pneumatized, these fractures tend to be
be associated with edema and substantial less comminuted in children than in
venous congestion. This tissue may pro- adults. No long-term studies have been
vide satisfactory blood supply to existing undertaken with populations large enough
segments but not to large bone grafts. to determine what alterations in maxillary
Next the soft tissue lacerations should be growth will occur after pediatric maxillary
addressed. Advancement flaps should be fractures. When fixation is undertaken,
used only to cover exposed bone or to consideration should be given to the con- B
correct oronasal or oroantral fistulas. If tour and the root length of the primary
too little soft tissue exists, flaps should dentition. The use of occlusal splints and FIGURE 23.1-11 A, Titanium mesh is preformed
before it is sterilized and used in maxillary recon-
not be advanced; such repairs should be skeletal fixation should be entertained.
struction. Reproduced with permission from Haug
addressed during a secondary recon- Resorbable plating systems have been RH et al.51 B, Intraoperative view of the use of tita-
struction. Consideration should be given advocated for use in pediatric patients so nium mesh.
442 Part 4: Maxillofacial Trauma
Table 23.1-1 Complications Associated source cannot be identified, then arteriog- Malunion of maxillary fractures can
with Maxillary Fractures raphy and embolization are indicated. obstruct the nasolacrimal ducts. This
Aneurysms and pseudoaneurysms are obstruction causes epiphora and may lead
Infraorbital nerve paresthesia
complications of maxillofacial trauma but to episodes of dacryocystitis. Bone seg-
Enophthalmos
Infection
rarely occur as the result of isolated maxil- ments from fractured or improperly
Exposed hardware lary fractures. They can also result in post- reduced maxillary fractures can also
Deviated septum operative bleeding and are indications for impinge on the infraorbital nerve, causing
Nasal obstruction angiography and embolization.45 numbness of the distribution of the sec-
Altered vision Because of the proximity of the maxil- ond division of the trigeminal nerve.
Nonunion la to the orbits, complications associated Although the reduction and fixation
Malunion or malocclusion with vision can occur. Blindness is rarely of maxillary fractures may at times seem
Epiphora associated with midface fractures and is straightforward, the proximity of compli-
Foreign body reactions most often seen in fracture patterns cated anatomic structures and the conse-
Scarring involving the orbit, often with a more quences of inaccurate repair make it
Sinusitis severe mechanism of injury.46 Immediate incumbent on the surgeon to follow sound
Adapted from Haug RH et al.52
postoperative blindness can be a compli- surgical principles in the management of
cation of the reduction of high Le Fort these fractures.
fractures (Le Fort III or fractures involving
extubation while the patient is obtunded, the orbits) and occurs because of Acknowledgments
with a septal hematoma or nasal packing, increased intraorbital hemorrhage or The authors thank Flo Witte, MA, ELS, for
and with excessively edematous soft tissues pressure, a retinal artery spasm, retrobul- her expert editorial assistance.
that do not allow breathing through the bar hemorrhage, or the impingement of
nasal airways. Patients with intermaxillary bone fragments on the optic nerve.47 An References
fixation and complete dentition may have undiagnosed or inadequately treated 1. Haug RH, Prather J, Indresano AT. An epi-
difficulty breathing during this time. Rein- orbital floor fracture (alone or in combi- demiologic survey of facial fractures and
tubation, opening nasopharyngeal air- nation with a zygomatic component) can concomitant injuries. J Oral Maxillofac
ways, or merely removing the intermaxil- lead to enophthalmos and diplopia. Surg 1990;48:92632.
2. Turvey TA. Midfacial fractures: a retrospective
lary fixation may be effective. Uncorrected The most obvious postoperative com-
analysis of 593 cases. J Oral Surg 1977;
nasal septal fractures can lead to postoper- plications are misplaced bone segments or 35:88791.
ative airway obstruction that remains after fixation devices. These complications are 3. Kelly DE, Harrigan WF. A survey of facial frac-
all soft tissue swelling has resolved. Acute readily identified by clinical examination tures: Bellevue Hospital, 19481974. J Oral
sinusitis can result from prolonged naso- (eg, malocclusion) or postoperative radi- Surg 1975;33:1469.
4. Adekeye EO. The pattern of fractures of the
tracheal intubation.44 Acute or chronic ographic examinations. A second surgical facial skeleton in Kaduna, Nigeria. A survey
sinusitis may also occur in the ethmoid, procedure will correct such complications. of 1,447 cases. Oral Surg Oral Med Oral
sphenoid, frontal, and maxillary sinuses Other complications related to rigid inter- Pathol 1980;49:4915.
because fractures may obliterate or nal fixation include palpability, infection, 5. Iida S, Kogo M, Sugiura T, et al. Retrospective
analysis of 1502 patients with facial fractures.
obstruct the sinus ducts or ostia. extrusion or exposure, translocation,
Int J Oral Maxillofac Surg 2001;30:28690.
Postoperative hemorrhage occurs if stress shielding, cortical osteopenia, and 6. Gassner R, Tuli T, Hachl O, et al. Cranio-
arterioles and veins are not ligated when nonunion.48,49 Nonunion of the fractured maxillofacial trauma: a 10 year review of
lacerations are repaired, if inadequate segments can occur as the result of inade- 9,543 cases with 21,067 injuries. J Cran-
bone reduction allows continued oozing quate blood supply, inaccurate position, iomaxillofac Surg 2003;31:5161.
7. Dingman RO, Natvig P. The men of elder days.
of blood, if an aneurysm is present, or if an movement of segments, infection, or
In: Dingman RO, Natvig P, editors. Surgery
artery is partially transected. Lacerations nutritional deficiencies.50 Infections may of facial fractures. Philadelphia (PA): W.B.
should be reexplored so that hemorrhage be caused by contaminated soft tissue lac- Saunders; 1964. p. 2935.
can be controlled. Hematomas should be erations or foreign bodies, hematomas, or 8. Drommer RB. The history of the Le Fort I
odontogenic infections from previously osteotomy. J Maxillofac Surg 1986;
drained. Oozing of blood from bone
14:11922.
requires re-reduction or the use of bone diseased or fractured teeth. Infection 9. Moloney F, Worthington P. The origin of the Le
wax. Hemorrhage from a major artery around bone plates and screws can occur Fort I maxillary osteotomy: Cheevers oper-
requires emergency tamponade; if the years after their placement. ation. J Oral Surg 1981;39:7314.
Management of Maxillary Fractures 443
10. Le Fort R. Etude experimentale sur les fractures lar embolization of intractable epistaxis. face reconstruction. Plast Reconstr Surg
de la machoire superiore. Rev Chir 1901; Zhonghua Yi Xue Za Zhi (Taipei) 2002;110:102232.
23:20827. 2000;63:20512. 39. Chalian VA. Maxillofacial problems involving
11. Le Fort R. Etude experimentale sur les fractures 24. Borsa JJ, Fontaine AB, Eskridge JM, et al. Trans- the use of splints and stents. In: Laney WR,
de la machoire superiore. Rev Chir catheter arterial embolization for intractable editor. Maxillofacial prosthetics. Littleton
1901;23:36079. epistaxis secondary to gunshot wounds. J (MA): PSG Publishing Co.; 1979. p. 2169.
12. Le Fort R. Etude experimentale sur les fractures Vasc Interv Radiol 1999;10:297302. 40. Ng M, Saadat D, Sinha UK. Managing the
de la machoire superiore. Rev Chir 25. Ardekian L, Samet N, Shoshani Y, Taicher S. emergency airway in Le Fort fractures. J
1901;23:479507. Life-threatening bleeding following max- Craniomaxillofac Trauma 1998;4:3843.
13. Garretson JE. A system of oral surgery and illofacial trauma. J Craniomaxillofac Surg 41. Hayter JP, Cawood JI. Oral rehabilitation with
dentistry being a treatise on the diseases 1993;21:3368. endosteal implants and free flaps. Int J Oral
and surgery of the mouth, jaws, face, teeth 26. Dewhurst SN, Mason C, Roberts GJ. Emergency Maxillofac Surg 1996;25:312.
and associate parts. London: J.B. Lippincott treatment of orodental injuries: a review. Br 42. Triana RJ Jr, Shockley WW. Pediatric zygomati-
Co.; 1898. p. 1084. J Oral Maxillofac Surg 1998;36:16575. co-orbital complex fractures: the use of
14. Blair VP. Surgery and diseases of the mouth 27. Dale RA. Dentoalveolar trauma. Emerg Med resorbable plating systems. A case report. J
and jaws. St. Louis (MO): C.V. Mosby Co.; Clin North Am 2000;18:52138. Craniomaxillofac Trauma 1998;4:326.
1914. p. 603. 28. Ball DR, Clark M, Jefferson P, Stewart T. 43. Haug RH, Cunningham LL, Brandt MT. Plates,
15. Brophy TW. Oral surgery: a treatise on the dis- Improved submental intubation. Anaesthe- screws and children: their relationships in
eases, injuries and malformations of the sia 2003;58:189. craniomaxillofacial trauma. J Long Term
mouth and associated parts. Philadelphia 29. Johnson TR. Submental intubation versus tra- Eff Med Implants 2003;13:27187.
(PA): P. Blakistons Son & Co.; 1918. p. 1090. cheostomy. Br J Anaesth 2002;89:3445. 44. Bell RM, Page GV, Bynoe RP, et al. Post-traumatic
16. Williams PL, Bannister LH, Berry MM, et al. 30. Caron G, Paquin R, Lessard MR, et al. Sub- sinusitis. J Trauma 1988;28:92330.
Grays anatomy: the anatomical basis of mental endotracheal intubation: an alterna- 45. Cunningham LL Jr, Van Sickels J, Brandt MT.
medicine and surgery. New York (NY): tive to tracheotomy in patients with midfa- Angiographic evaluation of the head and
Churchill Livingstone; 1995. p. 2092. cial and panfacial fractures. J Trauma neck. Atlas Oral Maxillofac Surg Clin North
17. Salentijn L. Anatomy and embryology. In: 2000;48:23540. Am 2003;11:7386.
Blitzed A, Lawson W, Freidman W, editors. 31. Nwoku AL, Al Balawi SA, Al Zahrani SA. A 46. Ashar A, Kovacs A, Khan S, Hakim J. Blindness
Surgery of the paranasal sinuses. Vol 1. modified method of submental oroendo- associated with midfacial fractures. J Oral
Philadelphia (PA): W.B. Saunders; 1985. tracheal intubation. Saudi Med J Maxillofac Surg 1998;56:114651.
p. 135. 2002;23:736. 47. Girotto JA, Gamble WB, Robertson B, et al.
18. Turvey TA, Fonseca RJ. The anatomy of the 32. Chandu A, Smith AC, Gebert R. Submental Blindness after reduction of facial fractures.
internal maxillary artery in the ptery- intubation: an alternative to short-term tra- Plast Reconstr Surg 1998;102:182134.
gopalatine fossa: its relationship to maxil- cheostomy. Anaesth Intensive Care 48. Bhanot S, Alex JC, Lowlicht RA, et al. The efficacy
lary surgery. J Oral Surg 1980;38:925. 2000;28:1935. of resorbable plates in head and neck recon-
19. Rowe NL, Killey HC. Fractures of the facial 33. Haug RH, Indresano AT. Management of max- struction. Laryngoscope 2002;112:8908.
skeleton. Edinburgh and London: E. & S. illary fractures. In: Peterson LJ, editor. Prin- 49. Iizuka T, Lindqvist C. Rigid internal fixation of
Livingstone Ltd.; 1955. p. 923. ciples of oral and maxillofacial surgery. Vol mandibular fractures. An analysis of 270
20. Cunningham LL, Haug RH, Ford J. Firearm 1. Philadelphia (PA): J.B. Lippincott Co.; fractures treated using the AO/ASIF
injuries to the maxillofacial region: an 1992. p. 46988. method. Int J Oral Maxillofac Surg
overview of current thoughts regarding 34. Sherman MJ. Intraoral reduction of maxillary 1992;21:659.
demographics, pathophysiology, and man- fractures by malar suspension. J Oral Surg 50. Rowe NL. Nonunion of the mandible and
agement. J Oral Maxillofac Surg 2003; 1955;13:321. maxilla. J Oral Surg 1969;27:5209.
61:93242. 35. Thoma K. Methods of fixation of the jaws and 51. Haug RH, Jenkins WS, Brandt MT. Advances in
21. Hadfield PJ, Gane SB, Leighton SE. Epistaxis their indications. Oral Surg 1948;6:12534. plate and screw technology: thought on
due to traumatic internal carotid artery 36. Adams WM. Internal wiring fixation of facial design and clinical applications. Semin
aneurysm. Int J Pediatr Otorhinolaryngol fractures. Surgery 1942;12:52340. Plast Surg 2002;16:21927.
2002;66:1936. 37. Gruss JS, Phillips JH. Complex facial trauma: 52. Haug RH, Bradrick JP, Morgan JP. Complica-
22. Kerwin AJ, Bynoe RP, Murray J, et al. Liberal- the evolving role of rigid fixation and tions in the treatment of midface fractures.
ized screening for blunt carotid and verte- immediate bone graft reconstruction. Clin In: Kaban LB, Pogrel MA, Perrott DH, edi-
bral artery injuries is justified. J Trauma Plast Surg 1989;16:93104. tors. Complications in oral and maxillofa-
2001;51:30814. 38. Schubert W, Gear AJ, Lee C, et al. Incorpora- cial surgery. Philadelphia (PA): W.B. Saun-
23. Luo CB, Teng MM, Lirng JF, et al. Endovascu- tion of titanium mesh in orbital and mid- ders; 1997. p. 153.
CHAPTER 23.2
Management of Zygomatic
Complex Fractures
Jonathan S. Bailey, DMD, MD
Michael S. Goldwasser, DDS, MD
The zygoma articulates with the frontal, plications of zygomatic complex frac- small portion of the sphenoid body. The
sphenoid, temporal, and maxillary bones tures are discussed. lateral orbital wall is the thickest and is
and contributes significantly to the formed by the zygoma and the greater
strength and stability of the midface. The Surgical Anatomy wing of the sphenoid.
forward projection of the zygoma causes it The zygoma has four projections, which The orbital roof is composed of the
to be injured frequently.1 The zygoma may create a quadrangular shape: the frontal, frontal bone and lesser wing of the sphe-
be separated from its four articulations. temporal, maxillary, and the infraorbital noid (Figure 23.2-1C).
This is called a zygomatic complex frac- rim. The zygoma articulates with four The zygomatic arch includes the tem-
ture. The terms trimalar or tripod fracture bones: the frontal, temporal, maxilla, and poral process of the zygoma and the zygo-
are therefore inaccurate. These terms sphenoid. A zygomatic complex fracture matic process of the temporal bone. The
reflect an inability to easily identify the includes disruption of the four articulat- glenoid fossa and articular eminence are
orbital (zygomaticosphenoid) portion of ing sutures: zygomaticofrontal, zygomati- located at the posterior aspect of the zygo-
the injury before the advent of computed cotemporal, zygomaticomaxillary, and matic process of the temporal bone.
tomography (CT). The zygomatic arch the zygomaticosphenoid sutures (Figure The sensory nerve associated with
may be fractured independently or as part 23.2-1A and B). the zygoma is the second division of the
of a zygomatic complex fracture. All zygomatic complex fractures trigeminal nerve. The zygomatic, facial,
The cause of zygomatic injuries varies involve the orbital floor, and therefore an and temporal branches exit the foramina
with patient demographics and the location understanding of orbital anatomic features in the body of the zygoma and supply
of the reporting institution. Matsunaga and is essential for those treating these injuries. sensation to the cheek and anterior tem-
Simpson at Los Angeles County/University The orbit is a quadrilateral pyramid that is poral region. The infraorbital nerve pass-
of Southern California Medical Center based anteriorly. The orbital floor slopes es through the orbital floor and exits at
found that a majority of the 1,200 zygo- inferiorly and is the shortest of the orbital the infraorbital foramen (see Figure
matic fractures studied were the result of walls, averaging 47 mm.4 It is composed of 23.2-1C). It provides sensation to the
motor vehicle accidents (MVAs).2 In con- the orbital plate of the maxilla, the orbital anterior cheek, lateral nose, upper lip,
trast, Ellis and colleagues found that 80% of surface of the zygomatic bone, and the and maxillary anterior teeth. Muscles of
zygomatic fractures in Glasgow, Scotland, orbital process of the palatine bone. facial expression originating from the
resulted from assaults, falls, or sports The medial and lateral walls con- zygoma include the zygomaticus major
injuries. Only approximately 13% of frac- verge posteriorly at the orbital apex. The and labii superioris. They are innervated
tures in this series involved MVAs.3 medial wall consists of the frontal by cranial nerve VII. The masseter mus-
In this chapter, the anatomic fea- process of the maxilla, the lacrimal bone, cle inserts along the temporal surface of
tures, diagnosis, management, and com- the orbital plate of the ethmoid, and a the zygoma and arch and is innervated by
446 Part 4: Maxillofacial Trauma
a branch of the mandibular nerve (see The position of the globe in relation process of the zygoma). The shape and
Figure 23.2-1A). to the horizontal axis is maintained by location of the medial and lateral canthi
The temporalis fascia attaches to the Lockwoods suspensory ligament. This of the eyelid are maintained by the can-
frontal process of the zygoma and zygo- attaches medially to the posterior aspect thal tendons. The lateral canthal tendon
matic arch (Figure 23.2-1D). The fascia of the lacrimal bone and laterally to the is attached to Whitnalls tubercle. The
produces resistance to inferior displace- orbital (Whitnalls) tubercle (which is medial canthal tendon is attached to the
ment of a fractured fragment by the 1 cm below the zygomaticofrontal suture anterior and posterior lacrimal crests.
downward pull of the masseter muscle. on the medial aspect of the frontal Zygomatic complex fractures are often
Zygomatic arch
Frontozygomatic suture
Temporalis fascia
Zygomaticotemporal suture
Zygomaticomaxillary suture
Masseter muscle
A B
Skin
Frontomaxillary Medial canthal
suture ligament Subcutaneous
tissue
Optic foramen Lacrimal gland
Lateral skull
Superior orbital Lateral canthal Temporalis
fissure ligament muscle
Posterior Palpebral fissure Superficial
lacrimal crest
temporal fascia
Anterior Inferior tarsus
Deep
lacrimal crest temporal fascia
Infraorbital nerve
Lacrimal bone Potential space
and vessels
formed by
Infraorbital foramen
division of
temporal fascia
C
Zygomatic arch
FIGURE 23.2-1 A, Relation of muscles and cranial bones to the zygomatic complex as seen in frontal or lat-
Coronoid
eral view. B, Relation of the skull to the zygomatic complex as seen from a submental view. C, Relation of process
soft tissues, muscle, and nerves to the orbit as seen from a frontal view. D, Frontal view of fascia and muscle
attachment to the skull, zygomatic arch, and coronoid process. Adapted from Perrott DH, Kaban LB. Man-
agement of zygomatic complex fractures. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles
of oral and maxillofacial surgery. Vol. 1. Philadelphia (PA): J.B. Lippincott Company; 1992. p. 490491. D
Management of Zygomatic Complex Fractures 447
accompanied by an antimongoloid conjunctival hemorrhage is often noted. Evaluation of the eye includes docu-
(downward) cant of the lateral canthal Downward displacement of the zygoma mentation of visual acuity, pupillary
region caused by displacement of the produces an antimongoloid slant to the response to light, fundoscopic examination,
zygoma (see Figure 23.2-1C). lateral canthus, enophthalmos, and accen- ocular movement, and globe position. Lim-
tuation of the supratarsal fold of the upper itation of motion of the extraocular mus-
Diagnosis eyelid (Figure 23.2-2). Lacerations in the cles, diplopia, and enophthalmos may be
Zygomatic fractures are not life threaten- facial region should lead the surgeon to noted if significant fractures of the orbital
ing and are usually treated after more seri- suspect underlying fracture. floor or medial or lateral walls are present.
ous injuries are stabilized and swelling has Palpation of the zygomaticofrontal Lack of pupillary response and ptosis are
resolved 4 to 5 days after injuries. suture, the entire 360 of the orbital rim, present if cranial nerve III has been injured.
Initial evaluation of the patient with a and the zygomatic arch should be carried Injuries to the optic nerve, hyphema, injury
zygomatic fracture includes documenta- out in an orderly fashion. Tenderness, a to the globe, retro-orbital hemorrhage, reti-
tion of the bony injury and the status of step-off, or separation at the sutures are nal detachment, and disruption of the
surrounding soft tissue (eyelids, lacrimal indicative of a fracture. Intraorally, disrup- lacrimal ducts may also be present.
apparatus, canthal tendons, and globe) tion at the zygomaticomaxillary buttress Neurologic examination includes
and cranial nerves II to VI. Visual acuity area is palpable, and ecchymosis in the careful evaluation of all cranial nerves,
and the status of the globe and retina region of the canine fossa may be visible. with special attention directed toward cra-
should be established; an ophthalmologist The range of mandibular motion is evalu- nial nerves II, III, IV, V, and VI.
should be consulted for suspected or ques- ated to rule out impingement of the zygo-
tionable ophthalmic injury. matic arch on the coronoid process. Radiographic Evaluation
In isolated zygomatic arch fractures, a The diagnosis of zygomatic fractures is
History depression is observed and palpated ante- usually established by history and physical
The nature, force, and direction of the rior to the tragus (Figure 23.2-3). Pain and examination. CT scan of the facial bones,
injuring blow should be determined from decreased mandibular motion are com- in axial and coronal planes, is standard for
the patient and any witnesses. A direct lat- monly present with these injuries, whereas all patients with suspected zygomatic frac-
eral blow, as in an assault, often results in an orbital signs are usually absent. tures.810 Radiographs are helpful for
isolated zygomatic arch or an inferomedial-
ly displaced zygomatic complex fracture. A
frontal blow usually produces a posteriorly
and inferiorly displaced fracture.
The patient with a zygomatic complex
fracture complains of pain, periorbital
edema, and ecchymosis. There may be
paresthesia or anesthesia over the cheek,
lateral nose, upper lip, and maxillary ante-
rior teeth resulting from injury to the
zygomaticotemporal or infraorbital
nerves. This occurs in 18 to 83% of all
patients with zygomatic trauma.3,57 When
the arch is medially displaced, the patient
may complain of trismus. Epistaxis and
diplopia may be present.3
Physical Examination A B
Ecchymosis and edema are the most com-
FIGURE 23.2-2 A, A 22-year-old male who sustained a blow to the right cheek. Frontal
mon early clinical signs and are present in
photograph illustrates the typical signs of zygomatic complex fracture: periorbital ecchy-
61% of all zygomatic injuries.2 Depression mosis, edema, antimongoloid slant, and subconjunctival hemorrhage. B, A 38-year-old
of the malar eminence and infraorbital male who sustained a blow to the left cheek 2 weeks prior to presentation. Frontal pho-
rim produce flattening of the cheek. Sub- tograph demonstrates resolving periorbital ecchymosis and malar depression.
448 Part 4: Maxillofacial Trauma
A B C
FIGURE 23.2-3 A 36-year-old male who sustained a blow to the left cheek. A, Frontal photograph illustrates the typical findings of a zygomatic
arch fracture: preauricular depression. B, Worms-eye view. C, Axial CT scan demonstrating isolated depressed left zygomatic arch fracture.
confirmation and for medicolegal docu- read and interpret these films to diagnose Classification of Fractures
mentation and to establish the extent of and treat these patients is mandatory.
Historically, the classification of zygomatic
the bony injury.
fractures was used to predict which fractures
Waters View The single best radiograph
Computed Tomography would remain stable after reduction. Clini-
for evaluation of zygomatic complex frac-
cally, this would allow the surgeon to identi-
CT is the gold standard for radiographic tures is Waters view. It is a posteroanterior
fy those fractures that would require open
evaluation of zygomatic fractures. Axial projection with the head positioned at a
reduction and some method of fixation.
and coronal images are obtained to define 27 angle to the vertical and the chin rest-
In 1961 Knight and North classified
fracture patterns, degree of displacement, ing on the cassette. This projects the
and comminution and to evaluate the petrous pyramids off the maxillary sinus- zygomatic fractures by the direction of dis-
orbital soft tissues. Specifically, CT scans es, permitting visualization of the sinuses, placement on a Waters view radiograph.11
allow for visualization of the buttresses of lateral orbits, and infraorbital rims (Figure With the advent of CT scans and the
the midfacial skeleton: nasomaxillary, zygo- 23.2-4B). When this is combined with an increased use of rigid internal fixation,
maticomaxillary, infraorbital, zygomati- erect Waters view, a stereographic view of more modern classification schemes aim
cofrontal, zygomaticosphenoid, and zygo- the fracture can be obtained. In patients to identify those fractures that require
maticotemporal buttresses. Coronal views who are unable to assume a facedown aggressive surgical approaches.
are particularly helpful in the evaluation of position, a reverse Waters projection pro- In 1990, Manson and colleagues pro-
orbital floor fractures (Figure 23.2-4A).9 vides similar information. posed a method of classification based on
Soft tissue windows, in the coronal plane, the pattern of segmentation and displace-
are useful to evaluate the extraocular mus- Caldwells View Caldwells view is a pos- ment.8 Fractures that demonstrated little
cles and to evaluate for herniation of orbital teroanterior projection with the face at a or no displacement were classified as low-
tissues into the maxillary sinus. 15 angle to the cassette. This study is help- energy injuries. Incomplete fractures of
ful in the evaluation of rotation (around a one or more articulations may be present.
Plain Radiographs horizontal axis). Middle-energy fractures demonstrated
CT scans have replaced plain films for the complete fracture of all articulations with
diagnosis and management of zygomatic Submentovertex View The submen- mild to moderate displacement. Com-
complex fractures. However, a fundamental tovertex (jug-handle) view is directed minution may be present (Figure 23.2-5).
working knowledge of this technique is from the submandibular region to the ver- High-energy injuries were characterized
required. In many emergency rooms and tex of the skull. It is helpful in the evalua- by comminution in the lateral orbit and
hospitals, trauma patients will still have plain tion of the zygomatic arch and malar pro- lateral displacement with segmentation of
film radiographic evaluation. The ability to jection (Figure 23.2-4C). the zygomatic arch (Figure 23.2-6).
Management of Zygomatic Complex Fractures 449
Gruss and colleagues proposed a sys- tures were incomplete low-energy frac- method notes that as the amount of dis-
tem that stressed the importance of recog- tures with fracture of only one zygomatic placement and comminution increases,
nizing and treating zygomatic arch frac- pillar: the zygomatic arch, lateral orbital the role of open reduction and internal
tures in association with the zygomatic wall, or infraorbital rim. Type B fractures fixation increases.
body.12 Like Manson and colleagues, Gruss were designated complete monofrag-
stressed the importance of identifying and ment fractures with fracture and dis- Treatment
treating segmentation, comminution, and placement along all four articulations. Treatment of zygomatic fractures must be
lateral bowing of the zygomatic arch. Type C multifragment fractures includ- based on a complete preoperative evalua-
Zingg and colleagues, in a review of ed fragmentation of the zygomatic body. tion. This includes a CT scan with axial and
1,025 zygomatic fractures, classified these Although all three classification coronal images to fully appreciate the nature
injuries into three categories.7 Type A frac- schemes vary to some degree, each of the injury. Classification techniques,
A B C
FIGURE 23.2-5 Middle-energy fracture. A, Axial CT scan demonstrating displacement of the lateral orbital wall. B, Coronal CT scan demonstrating frac-
ture and minimal displacement of the infraorbital rim. C, Coronal CT scan demonstrating mild displacement of the zygomaticomaxillary buttress.
450 Part 4: Maxillofacial Trauma
Superficial fascia
and subcutaneous
tissue retracted
A B
FIGURE 23.2-7 Gilliess approach to reduce zygomatic arch fracture. A, Temporal incision through subcutaneous and superficial fascia down to
the deep temporal fascia. B, Reduction of fracture with elevator. Adapted from Perrott DH, Kaban LB. Management of zygomatic complex frac-
tures. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and maxillofacial surgery. Vol. 1. Philadelphia (PA): J.B.
Lippincott Company; 1992. p. 498.
Open reduction with internal fixation Middle-Energy Zygomatic Complex Frac- ceeding to open reduction and internal
is seldom necessary for treatment of iso- tures Middle-energy, displaced zygo- fixation. The zygomaticomaxillary but-
lated zygomatic arch fractures. Internal matic complex fractures require reduction tress is exposed first and stabilized with a
fixation with miniplates may be required and internal fixation. Over the past plate if necessary.
as part of the management of high-energy 20 years there has been an increase in the The zygomaticofrontal buttress is
comminuted zygomatic complex or panfa- use of open reduction and internal fixa- exposed next and also stabilized with a
cial fractures. tion. In 1984, Zachariadis and colleagues plate if required. This method requires
managed 45% of all zygoma fractures with proper patient selection, experience, and
Zygomatic Complex Fractures the Gillies technique. At the same institu- meticulous technique to ensure accurate
tion, in 1995, only 2.5% of these fractures reduction and stabilization.
Low-Energy Zygomatic Complex Frac- were treated by this same method.22 Other authors recommend routine
tures Low-energy, nondisplaced or In 1996, Ellis and Kittidumkerng pro- exposure of two or more of the three ante-
minimally displaced zygomatic complex posed an algorithm of treatment for isolat- rior buttresses for middle-energy injuries:
fractures may require no operative cor- ed middle-energy zygomatic complex frac- the zyomaticomaxillary buttress, zygo-
rection. The patient should be observed tures that did not require orbital maticofrontal buttress, and the infraorbital
longitudinally for signs of displacement, reconstruction (Figure 23.2-8).23 The initial rim (Figures 23.2-1023.2-12). In this man
extraocular muscle dysfunction, and step in this algorithm is reduction of the xner, multiple buttresses are visualized and
enophthalmos after swelling resolves. Sta- fracture. Ellis and others recommend the the three-dimensional accuracy of the
ble, minimally displaced zygomatic com- use of a Carroll-Girard screw, which is reduction can be confirmed.2427
plex fractures without significant clinical inserted transcutaneously into the malar
findings may require no treatment. The eminence (Figure 23.2-9). The Carroll- High-Energy Zygomatic Complex Frac-
patient should be made to appreciate the Girard screw provides excellent three- tures A more aggressive surgical approach
risk of residual asymmetry of the cheek, dimensional control to reduce the fracture. should be planned to treat high-energy frac-
orbit, and eyelid if the fracture is not If the reduction is unstable, or if there tures (Figure 23.2-13).12,23,24,28 There is often
reduced. Documentation, including pho- is question regarding the accuracy of the significant comminution of the anterior
tographs, is recommended.21 reduction, the author recommends pro- buttresses, making anatomic reduction
452 Part 4: Maxillofacial Trauma
Reduce fracture
(Carroll-Girard screw)
STOP
margin (see Figures 23.2-13 and 23.2-14A). orbital septum) is used to expose the
It should extend from lateral to the punc- infraorbital rim. Variations of this tech-
tum in a natural skinfold. The fibers of the nique include a retroseptal dissection. This
orbicularis muscle are separated horizon- approach maintains the integrity of the
tally at the same level as the skin incision, lower lid but requires retraction of the
and a composite skin-muscle flap is elevat- orbital fat during fracture reduction and
ed anterior to the orbital septum. A fixation (Figure 23.2-16).31
periosteal incision is made on the anterior A lateral canthotomy can be used to
surface of the infraorbital rim. Subpe- increase exposure. Meticulous repair of
riosteal dissection is then completed to the lateral canthotomy is required to pre-
FIGURE 23.2-10 Intraoral exposure and fixa-
expose the orbital rim and floor.31,33 Multi- vent asymmetry.31,38,40,41
tion of zygomaticomaxillary buttress fracture. ple variations of this technique have been Manson and colleagues described a
described including a skin-only flap, a method to expose the entire lateral orbit,
stepped skin-muscle flap, and a subtarsal infraorbital rim, and orbital floor through
the confines of the lateral eyebrow parallel approach. These have been compared to a single incision. This may be performed
to the superior lateral orbital rim (see Fig- each other and to the transconjunctival inci- with a subciliary or transconjunctival
ure 23.2-14A). Dissection is continued sion.3436 Regardless of technique, trans- approach and requires extended subpe-
through the orbicularis oris and the cutaneous approaches are associated with a riosteal dissection with mobilization of the
periosteum to the fracture site. higher incidence of ectropion, increased lateral canthal tendon.44
scleral show, and cutaneous scarring.3740
Surgical Approach to the Infraorbital Rim To avoid the problems associated with Pitfalls in Surgical Approach to the Infra-
and Orbit Access and exposure for open cutaneous incisions, many authors recom- orbital Rim and Orbit All approaches to
reduction of the infraorbital rim and orbital mend the transconjunctival approach.3742 the infraorbital rim may result in complica-
floor can be achieved through a transcuta- Tessier described this approach in 1973 tions. The subciliary and transconjunctival
neous subciliary or transconjunctival inci- (Figures 23.2-14C and 23.2-15).43 The incisions may result in ectropion, entropi-
sion. Protection of the globe with a scleral lower lid is retracted, and an incision is on, and increased scleral show. Advocates of
shield or tarsorrhaphy is recommended. made below the lower border of the tarsus. the transconjunctival approach cite
A subciliary incision is made 1 to 2 mm Dissection is extended inferiorly, and a increased rates of ectropion and scleral
below and parallel to the lower eyelash preseptal dissection (superficial to the show with transcutaneous incisions (see
Figure 23.2-13J).3740 In 1993, Appling
found a 12% rate of transient ectropion
and 28% rate of permanent scleral show
with a subciliary approach. In comparison,
the transconjunctival approach had no
transient ectropion and a 3% rate of per-
manent scleral show.39
Multiple factors have been cited as the
cause of increased scleral show and ectro-
pion. During the dissection to the orbital
rim, care should be taken to ensure that
the placement of the periosteal incision is
on the anterior surface of the maxilla. An
incision placed on the superior rim or
posterior to the orbital rim may violate the
orbital septum. Subsequent scarring and
contracture of the septum may result in
FIGURE 23.2-11 Exposure and fixation of zygo- FIGURE 23.2-12 Exposure and fixation of infra- increased scleral show or ectropion.44
maticofrontal buttress fracture via a supratarsal orbital rim fracture via a subciliary incision. Improper wound closure may also
fold incision. contribute to lower lid complications.
454 Part 4: Maxillofacial Trauma
A B C D
E F G
Temporal
(Gillies)
Subciliary
Conjunctival
Percutaneous
A B C
FIGURE 23.2-14 Frontal view illustrating periorbital incision sites. A, Four different incisions for repair of zygoma fractures. B, Upper eyelid incision within the lateral
supratarsal fold. C, Transconjuctival incision below the lower border of the tarsus. Adapted from Perrott DH, Kaban LB. Management of zygomatic complex fractures.
In: Peterson LJ, Indresano AT, Marciani RD, Roser SM. Principles of oral and maxillofacial surgery. Vol. 1. Philadelphia (PA): J.B. Lippincott Company; 1992. p. 500.
Following wide subperiosteal exposure, proposed as a technique to prevent ectro- and anteriorly to the lateral orbital rim. The
which is often required for complex frac- pion. This may encourage re-draping of facial nerve is protected within the flap.12,31
ture repair, the facial soft tissues may the lower eyelid tissues.23,44
descend caudally, resulting in loss of ante- Internal Fixation Historically, many
rior projection, accentuation of the Surgical Approach to the Zygomatic Arch methods have been used for stabilization of
nasolabial fold, increased scleral show, and In high-energy zygomatic complex frac- zygomatic complex fractures. These have
ectropion. Phillips and colleagues recom- tures or secondary correction of zygomat- included antral packing, percutaneous wire
mend resuspension of the periosteum, ic deformities, access is limited with con- fixation, and wire osteosynthesis. It is now
muscle, and subcutaneous tissue. Multiple ventional incisions. To obtain adequate accepted that miniplate or microplate fixa-
holes are drilled in the inferolateral orbital exposure, a coronal incision combined tion provides the best results and minimal
rim. The edge of the periosteum, muscle, with a lower eyelid approach is recom- complications.22,4547
and subcutaneous tissue is sutured to the mended (see Figure 23.2-13F).
orbital rim. This may minimize traction The initial incision is through the skin,
on the infraorbital tissue and subsequent subcutaneous tissue, and galea of the scalp.
ectropion or increased scleral show.33 Elevation of the coronal flap proceeds in the
Lastly, postoperative support for the subgaleal loose areolar connective tissue Conjunctiva
lower eyelid with a frost stitch has been superficial to the pericranium. The tempo- Tarsal plate
ral and preauricular plane of dissection is
Orbital septum
along the temporal fascia, which can be
identified by its characteristic glistening Orbital fat
Controversy exists regarding the best face, this buttress may not be as helpful in For middle-energy injuries with expo-
location for internal fixation and the num- evaluating reduction of a rotated frac- sure of all three anterior buttresses, the
ber and type of plates required. Multiple ture.12,54 The thickness of the soft tissue zygomaticofrontal fracture may be stabi-
studies have tried to characterize the forces overlying this region is variable. In some lized temporarily with an interosseous
placed on the zygomatic complex and the instances it may be quite thin and a large wire.26,28 This is followed by fixation of the
amount of fixation required to achieve plate may be palpable. If stable fixation can zygomaticomaxillary fracture and the
stability.23,24,29,4854 These forces include be achieved at other sites, a smaller plate infraorbital rim. The temporary wire at the
the masseter and temporalis muscles and may be used.55 zygomaticofrontal fracture is replaced with
fascia and soft tissue contracture, which a plate. The orbital floor is reconstructed
cause rotational movements in multiple Internal Fixation of the Infraorbital Rim after the zygoma has been restored to its
axes around the zygomatic buttresses. Unlike the zygomaticofrontal buttress, the correct three-dimensional position.26,53
Internal fixation must provide enough infraorbital rim has poor quality bone for In high-energy fractures, the zygomatic
strength to resist these forces. internal fixation.55 Additionally, the lower arch should be reconstructed first.12,24,28,45,53
For low- and middle-energy fractures, eyelid skin is quite thin, and large plates are
stable fixation can be achieved at one or easily palpable. Despite these concerns, fix- Management of the Orbital Floor
more of the anterior buttresses. The loca- ation of this site is required to define the Patients with middle-energy zygomatic
tion of fixation and number of sites of fix- orbital volume and facial width.5759 The complex injuries and no clinical or radi-
ation depends on the fracture pattern, infraorbital rim is typically displaced poste- ographic evidence of orbital disruption do
location, vector of displacement, and riorly and inferiorly.28 The fracture should not require exploration.23 Middle-energy
degree of instability. Occasionally one- be mobilized anteriorly and superiorly and injuries with displacement of the orbital
point fixation may be adequate.7,23,26,50,52 stabilized. Typically a 1.0 or 1.5 microplate rim or floor or herniation of soft tissue
More commonly two- or three-point sta- is used to stabilize the infraorbital into the sinus should be explored (see Fig-
bilization is required.7,23,24,26,27,45,50,55 rim.26,27,30,55 A potential pitfall in reduction ure 23.2-4A). Clinical indications for
For high-energy injuries, a fourth of this fracture is an unappreciated hemi- orbital exploration include enophthalmos,
point of fixation is required. The zygomat- nasoethmoid fracture (see Figure 23.2- limitation of extraocular muscle function
ic arch is typically comminuted and later- 13D). If the infraorbital rim is secured to with a positive forced duction test, and
ally displaced. Open reduction and inter- this undiagnosed displaced segment, post- persistent diplopia. High-energy fractures
nal fixation is required to restore proper operative facial widening may occur.23,54,60 require a more aggressive approach, and
facial width and projection.7,12,23,24,45,55 the orbital rim and floor should be
Internal Fixation of the Zygomatic Arch explored and reconstructed.23,24,26,45,53,61
Internal Fixation of the Zygomaticomax- Internal fixation of the zygomatic arch is Fujino and Makino classified orbital
illary Buttress The zygomaticomaxillary required for high-energy fractures that floor injuries as linear and pure blow-out
buttress provides an ideal location for demonstrate comminution and lateral dis- fractures (Figure 23.2-17). A linear frac-
internal fixation for middle- and high- placement.12,23,24,28,55 Restoration of this ture occurs when the infraorbital rim is
energy fractures.53,54 Anatomic reduction sagittal buttress assists in restoring facial struck, displacing the orbital contents and
of this fracture assists in restoring malar projection and facial width. When exposed, floor posteriorly.62 The orbital septum is
projection, but is difficult if the buttress is the zygomatic arch is often reduced and sta- torn, herniating soft tissue into the maxil-
comminuted. The overlying soft tissue is bilized first in the sequence of repair of lary sinus. When the force is removed, the
thick, and plate palpability is not a con- high-energy injuries. Caution must be used orbital floor returns to its original position
cern. Therefore, this fracture should be in restoring a straight arch and not a and the soft tissues are entrapped in the
stabilized with 1.5 or 2.0 plates.23,26,55,56 curved arch, which will decrease facial fracture site. Comminution of the orbital
projection. This fracture typically requires a floor is produced by a force ten times
Internal Fixation of the Zygomaticofrontal large plate to resist deformational forces.55,56 greater than that required for a linear frac-
Buttress The zygomaticofrontal buttress ture. Fragments are forced inferiorly into
contains excellent bone for fixation and can Sequence of Internal Fixation As in the the sinus, producing bony discontinuity.
accommodate a 2.0 plate.55 The reduction treatment of panfacial fractures, a system- Indications for exploration of isolated
and fixation of this fracture will reestablish atic approach is helpful to ensure accurate orbital floor fractures include CT scan evi-
the vertical height of the zygomatic com- restoration of facial height, width, and dence of a fracture and herniation of
plex. However, because of its narrow inter- projection.28,53 orbital tissue, enophthalmos, dystopia,
Management of Zygomatic Complex Fractures 457
fractures. An increase in orbital volume is zygomatic complex fractures and isolated response to injury. They hypothesize that
the most common etiology.5759 zygomatic arch fractures had the lowest this may impair contractility and decrease
Grant and colleagues described this incidence of diplopia, while pure blow-out excursions of the muscles.45,82,8587
clinical problem eloquently by comparing fractures had the highest incidence. Axial and coronal CT scans and oph-
the shape of the orbit to that of a cone. The The principal causes of diplopia thalmologic consultation are recommended
volume of a cone is 13 (r2) h. The orbital include edema and hematoma, entrap- to assist in evaluation.45,82 Diplopia related
rim position determines the radius of the ment of the extraocular muscles and to edema, hematoma, or neurogenic causes
cone and the anteroposterior orbital orbital tissue, and injury to cranial nerves may resolve without intervention. Diplopia
length is the height of the cone. In this III, IV, or VI. Histologic studies by Iliff and resulting from entrapment requires explo-
equation, the radius is squared and small colleagues have shown post-traumatic ration and reduction of herniated orbital
increases in the radius result in dramatic fibrosis of the extraocular muscles in tissue (Figure 23.2-19).45,60,61,6365,82
increases in volume. Clinically, poor align-
ment of the orbital rim may significantly
increase the orbital volume and result in
enophthalmos.58
Orbital floor blow-out fracture also
may result in enophthalmos by increasing
the orbital volume (Figure 23.2-18). With
improved CT technology, calculation of
orbital volume and its implication regard-
ing orbital floor fractures is possible.73,7780
Raskin and colleagues demonstrated that a
13% increase in orbital volume, at 4 weeks,
results in significant enophthalmos
(> 2 mm).79 The critical size of the orbital
defect and herniation of orbital tissues have
also been studied. In 2002, Ploder and col- A B
leagues reported that a mean fracture area
of 4.08 cm or a mean displaced tissue vol-
ume of 1.89 mL, was associated with greater
than 2 mm of enophthalmos.80 In general,
approximately 1 cm3 of displaced tissue
equals 1 mm of enophthalmos.81
Late repair of enophthalmos is techni-
cally challenging. Wide access with osteoto-
my of the zygoma, repositioning, and
grafting is usually required. Re-draping of
the periorbital soft tissue including a can-
thopexy may be required.5759
Diplopia
Diplopia is a common sequela of midfacial
fractures. The incidence varies between 17 C D
and 83% and depends on the time of pre-
FIGURE 23.2-18 A, A 27-year-old female presented with late enophthalmos and diplopia after
sentation following the injury and the pat-
an undiagnosed orbital floor fracture. Note vertical dystopia and prominent supratarsal fold.
tern and severity of the injury.3,68,8284 In a
B, Coronal CT scan demonstrating displacement of the orbital floor. C, One-year postopera-
review of 2,067 zygomatic complex frac- tive frontal photograph after transconjunctival reconstruction of the orbital floor with titani-
tures, Ellis and colleagues noted a 5.4 to um mesh. Note the symmetry of the vertical globe position and the supratarsal fold. D, Post-
74.5% incidence of diplopia.3 Nondisplaced operative coronal CT scan demonstrating titanium mesh reconstruction of the orbital floor.
Management of Zygomatic Complex Fractures 459
A B C
FIGURE 23.2-19 A, A 45-year-old male suffered a fall and presented with right orbital floor blow-out fracture and significant restric-
tion of the inferior rectus and diplopia. B, Coronal CT scan demonstrating large orbital floor blow-out fracture with herniation of the
orbital contents into the maxillary sinus. C, Postoperative view after transconjunctival reconstruction of the orbital floor with titani-
um mesh and return of normal extraocular muscle function. Note projection of the globes without evidence of enophthalmos.
Persistent bothersome diplopia that may include systemic steroids or surgery Trismus
does not resolve may require treatment by with orbital or optic nerve decompression.
Patients with zygomatic fractures com-
an ophthalmologist. The condition may Treatment of facial fractures may be
monly present acutely with a complaint of
respond to exercise or surgery.45,61 delayed.45,90
trismus. However, there are few cases of
Traumatic Hyphema Superior Orbital Fissure
Trauma to the eye may result in bleeding Syndrome
into the anterior chamberthe area Superior orbital fissure syndrome is an
between the clear cornea and the colored iris uncommon complication following facial
(Figure 23.2-20). Ophthalmology consulta- trauma. Presentation may include ptosis,
tion is recommended. Goals of treatment ophthalmoplegia, forehead anesthesia, and
include prevention of rebleeding, which may a fixed dilated pupil. Proptosis may be pre-
occur in 5 to 30% of patients, and mainte- sent. Treatment may include reduction of
nance of normal ocular tension.88.89 fractures, steroids, orbital apex explo-
Management of hyphema consists of ration, and aspiration of retrobulbar
supportive therapy including elevation of hematoma if present.91 A
the head of bed and patching of the injured
eye. Medical management includes topical Retrobulbar Hemorrhage
cycloplegics, corticosteroids, and -blockers. Retrobulbar hemorrhage is a rare but severe
Systemic antifibrinolytics, carbonic anhy- complication that may be the result of
drase inhibitors, and osmotic agents may either the initial injury or the operative cor-
also be required. Rarely, surgical interven- rection. Disruption of the retinal circula-
tion by the ophthalmologist is required. tion may lead to irreversible ischemia and
Repair of fractures may be delayed. permanent blindness. In a review of 1,405
orbitozygomatic fractures, Ord reported a
Traumatic Optic Neuropathy 0.03% incidence of postoperative retrobul- B
Traumatic optic neuropathy may manifest bar hemorrhage with visual loss.92 An
FIGURE 23.2-20 Retrobulbar hemorrhage. A,
as conditions ranging from mild visual emergent ophthalmologic consultation is
This patient presented with periorbital pain, fixed
deficit to complete visual loss. An ophthal- necessary; however, decompression with and dilated pupil, proptosis, and acute progressive
mologic consultation is mandatory. Treat- lateral canthotomy and cantholysis should loss of vision. Note hyphema. B, Immediate later-
ment varies depending on the cause but not be delayed (see Figure 23.2-20). al canthotomy and cantholysis were performed.
460 Part 4: Maxillofacial Trauma
long-term reduced mandibular range of Toward CT-based facial fracture manage- zygomaticomaxillary complex fractures.
motion following zygomatic complex ment. Plast Reconstr Surg 1990;85:202. Oral Surg Oral Med Oral Path 1995;80:624.
9. Tanrikulu R, Erol B. Comparison of computed 26. Hollier LH, Thornton J, Pazmino P, Stal S. The
fractures reported in the literature. The tomograph with conventional radiograph management of orbitozygomatic fractures.
most likely cause is impingement of the for midfacial fractures. Dentomaxillofac Plast Reconstr Surg 2003;111:2386.
zygomatic body on the coronoid process Radiol 2001;32:141. 27. Adamo AK, Pollick SA, Lauer SA, Sterman HR.
of the mandible. Trismus may also occur 10. Assael LA. Clinical aspects of imaging in max- Zygomatico-orbital fractures: historical per-
secondary to fibrous or fibro-osseous illofacial trauma. Radiol Clin North Am spective and current surgical management. J
1993;31:209. Craniomaxillofac Trauma 1995;1(2):26.
ankylosis of the coronoid to the zygomat- 11. Knight JS, North JF. The classification of malar 28. Manson PN, Clark N, Robertson B, et al. Sub-
ic arch. A CT scan should be obtained to fractures: an analysis of displacement as a unit principles in midface fractures: the
confirm the diagnosis. Coronoidectomy is guide to treatment. Br J Plast Surg 1961; importance of sagittal buttresses, soft-tissue
the most common treatment. If the zygo- 13:325. reductions, and sequencing treatment of
12. Gruss JS, Van Wyck L, Phillips JH, Antonyshyn segmental fractures. Plast Reconstr Surg
ma is improperly reduced, zygomatic
O. The importance of the zygomatic arch in 1999;103:1287.
osteotomy and repositioning may be nec- complex midfacial fracture repair and cor- 29. Rohner D, Tay A, Meng CS, et al. The sphe-
essary to restore unrestricted motion of rection of posttraumatic orbitozyogmatic nozygomatic suture as the key site for
the mandible.61,93 deformities. Plast Reconstr Surg 1990;85:878. osteosynthesis of the orbitozygomatic com-
13. Smith HW, Yanagisawa E. Fracture-dislocations plex in panfacial fractures: a biomechanical
Acknowledgment of zygoma and zygomatic arch. Arch Oto- study in human cadavers based on clinical
laryngol 1961;73:68. practice. Plast Reconstr Surg 2002;110:1463.
The authors gratefully acknowledge Drs. 14. Goldthwaite RH. Plastic repair of depressed 30. Swift JQ. Isolated zygoma fractures. Atlas Oral
Kaban and Perrott, the authors of the fracture of the lower orbital rim. J Am Med Maxillofac Clin North Am 1993;1:7183.
chapter on zygomatic complex fractures in Assoc 1924;82:628. 31. Ellis E, Zide M. Surgical approaches to the
the first edition of Principles of Oral and 15. Quinn JH. Lateral coronoid approach for facial skeleton. Baltimore (MD): William
intra-oral reduction of fractures of the and Wilkins; 1995.
Maxillofacial Surgery, whose work served
zygomatic arch. J Oral Surg 1977;35:321. 32. Kung DS, Kaban LB. Supratarsal fold incision
as the foundation of this chapter. 16. Gillies HD, Kilner TP, Stone D. Fractures of the for approach to the superior lateral orbit.
malarzygomatic compound, with a descrip- Oral Surg Oral Med Oral Path 1996;81:522.
References tion of a new x-ray position. Br J Surg 33. Phillips JH, Gruss JS, Wells MD, Chollett A.
1. Leech TR, Martin BC, Trabue JC. An analysis of 1927;14:651. Periosteal suspension of the lower eyelid
the etiology, treatment and complications 17. Dingman RO, Natvig P. Surgery of facial frac- and cheek following subciliary exposure of
of fractures of the malar compound and tures. Philadelphia: W.B. Saunders; 1964. facial fractures. Plast Reconstr Surg 1991;
zygoma. J Surg 1956;92:9204. p. 226. 88:145.
2. Matsunaga RS, Simpson W, Toffal PH. Simplified 18. Mathog R. Maxillofacial trauma. Baltimore 34. Rohrich RJ, Janis JE, Adams WP. Subciliary ver-
protocol for treatment of malar fractures. (MD): William & Wilkins; 1984. p. 3984. sus subtarsal approaches to orbitozygomat-
Based on a 1,220-case eight-year experience. 19. Uglesic V, Virag M. A method of zygomatic ic fractures. Plast Reconstr Surg 2003;
Arch Otolaryngol 1977;103:535. arch stabilization. Br J Oral Maxillofac Surg 111:1708.
3. Ellis E, El-Attar A, Moos KF. An analysis of 1994;32:396. 35. Werther JR. Cutaneous approaches to the
2,067 cases of zygomatico-orbital fracture. J 20. Thomson ERE. A simple zygomatic splint. Br lower lid and orbit. J Oral Maxillofac Surg
Oral Maxillofac Surg 1985;43:417. Dent J 1983;155:257. 1998;56:60.
4. Rontal E, Rontal M, Guilford FT. Surgical 21. Feinstein FR, Krizek TJ. Fractures of the zygo- 36. Bahr W, Bagambisa FB, Schlegel G, Schilli W.
anatomy of the orbit. Ann Otol Rhino ma and zygomatic arch. In: Foster CA, Comparison of transcutaneous incisions
Laryngol 1979;88:3826. Sherman JE, editors. Surgery of facial bone for exposure of the infraorbital rim and
5. Vriens JP, van der Glas HW, Moos KF, Koole R. fractures. New York: Churchill Livingstone; orbital floor: a retrospective study. Plast
Infraorbital nerve function following treat- 1987. p. 123. Reconstr Surg 1992;90:585.
ment of orbitozygomatic complex fractures 22. Zachariades N, Mezitis M, Anagnostopoulos D. 37. Wray RC, Holtmann B, Ribaudo M, et al. A
a multitest approach. Int J Oral Maxillofac Changing trends in the treatment of zygo- comparison of conjunctival and subciliary
Surg 1998;27:27. maticomaxillary complex fractures; a incisions for orbital fractures. Br J Plast
6. Taicher S, Ardekian L, Samet N, et al. Recovery 12-year evaluation of methods used. J Oral Surg 1977;30:142.
of infraorbital nerve after zygomatic com- Maxillofac Surg 1998;56(11):1152. 38. Holtzmann B, Wray RC, Little AG. A random-
plex fractures: a preliminary study of differ- 23. Ellis E, Kittidumkerng W. Analysis of treatment ized comparison of four incisions for
ent treatment methods. Int J Oral Maxillo- of isolated zygomaticomaxillary complex orbital fractures. Plast Reconstr Surg
fac Surg 1993;22:339. fractures. J Oral Maxillofac Surg 1996;54:386. 1981;67:731.
7. Zingg M, Laedrach K, Chen J, et al. Classifica- 24. Yaremchuk MJ. Orbital deformity after craniofa- 39. Appling WD, Patrinely JR, Salzer TA.
tion and treatment of zygomatic fractures: cial fracture repair: avoidance and treatment. Transconjunctival approach vs. subciliary
a review of 1,025 cases. J Oral Maxillofac J Craniomaxillofac Trauma 1999;5(2):7. skin-muscle flap approach for orbital frac-
Surg 1992;50:778. 25. Makowski GJ, Van Sickels JE. Evaluation of ture repair. Arch Otolaryngol Head Neck
8. Manson PN, Markowitz B, Mirvis S, et al. results with three-point visualization of Surg 1993;119:1000.
Management of Zygomatic Complex Fractures 461
40. Patel PC, Sobota BT, Patel NM, et al. Compar- 55. Prein J. Manual of internal fixation in the 72. Manson PN, Clifford CN, Su CT, et al. Mecha-
ison of transconjunctival versus subciliary cranio-facial skeleton. New York: Springer- nisms of global support and post-traumatic
approaches for orbital fractures: a review of Verlag; 1998. enophthalmos I. The anatomy of the liga-
60 cases. J Craniomaxillofac Trauma 56. Manson PN. Discussion: the spenozygomatic ment sling and its relations to intermuscu-
1998;4:17. suture as a key site for osteosynthesis of the lar cone orbital fat. Plast Reconstr Surg
41. Waite PD, Carr DD. The transconjunctival orbitozygomatic complex in panfacial frac- 1987;77:193.
approach for treating orbital trauma. J Oral tures; a biomechanical study in human 73. Manson PN, Grivas A, Rosenbaum A, et al.
Maxillofac Surg 1991;49:499. cadavers based on clinical practice. Plast Studies on enophthalmos II. The measure-
42. Baumann A, Ewers R. Use of the preseptal Reconstr Surg 2002;110:1472. ment of orbital injuries and their treatment
transconjunctival approach in orbit recon- 57. Longaker MT, Kawamoto HK. Enophthalmos by quantitative computed tomography.
struction surgery. J Oral Maxillofac Surg revisited. Clin Plast Surg 1997;24:531. Plast Reconstr Surg 1986;77:20314.
2001;59:287. 58. Grant MP, Iliff NT, Manson PN. Strategies for 74. Gruss JS, Mackinnon SE, Kassel EE, Cooper
43. Tessier P. The conjunctival approach to the the treatment of enophthalmos. Clin Plast PW. The role of primary bone grafting in
orbital floor and maxilla in congenital mal- Surg 1997;24:539. complex craniomaxillofacial trauma. Plast
formations and trauma. J Maxillofac Surg 59. Pearl RM. Enophthalmos correction: princi- Reconstr Surg 1985;75(1):17.
1973;1:3. ples guiding proper treatment. Op Tech 75. Manson PN, Crawley WA, Yaremchuk MJ, et al.
44. Manson PN, Ruas E, Iliff N, Yaremchuk M. Sin- Plast Reconstr Surg 1998;5(4):352. Midface fractures: advantages of immediate
gle eyelid incision for exposure of the zygo- 60. Smith ML, Williams JK, Gruss JS. Management extended open reduction and bone graft-
matic bone and orbit reconstruction. Plast of orbital fractures. Op Tech Plast Reconstr ing. Plast Reconstr Surg 1985;76(1):1.
Reconstr Surg 1987;79:120. Surg 1998;5(4):312. 76. Spinelli HM, Forman DL. Current treatment of
45. Hammer B. Orbital fractures diagnosis, opera- 61. Fonseca RJ, Walker RV, Betts NJ, Barber HD. post-traumatic deformities. Residual orbital,
tive treatment, secondary corrections. Seat- Oral and maxillofacial trauma. Philadel- adnexal, and soft-tissue abnormalities. Clin
tle (WA): Hogrefe and Huber; 2001. phia (PA): W.B. Saunders; 1997. Plast Surg 1997;24:519.
62. Fujino T, Makino K. Entrapment mechanism
46. Fonseca RJ. Discussion: changing trends in the 77. Dolynchuk KN, Tadjalli HE, Manson PN.
and ocular injury in orbital blow-out frac-
treatment of zygomaticomaxillary complex Orbital volumetric analysis: clinical applica-
ture. Plast Reconstr Surg 1980;65:571.
fractures: a 12 year evaluation of methods tions in orbitozygomatic complex injuries. J
63. Catone GA, Morrissette MP, Carlson ER. A ret-
used. J Oral Maxillofac Surg 1998;56:1156. Craniomaxillofac Trauma 1996;2:56.
rospective study of untreated orbital blow-
47. Shortinghuis J, Bos RR, Vissink A. Complica- 78. Yab K, Tajima S, Ohba S. Displacement of eye-
out fractures. J Oral Maxillofac Surg
tions of internal fixation of maxillofacial ball in orbital blow-out fractures. Plast
1988;46:1033.
fractures with microplates. J Oral Maxillo- Reconstr Surg 1997;100:1409.
64. Shumrick KA, Campbell AC. Management of
fac Surg 1999;50:130. 79. Raskin EM, Millman AL, Lubkin V, et al. Pre-
the orbital rim and floor in zygoma and
48. Rudderman RH, Mullen RL. Biomechanics of diction of late enophthalmos by volumetric
midface fractures: criteria for selective
the facial skeleton. Clin Plast Surg 1992; analysis of orbital fractures. Ophthal Plast
exploration. Facial Plast Surg 1998;14:77.
19(2):11. Reconstr Surg 1998;14:19.
65. Hartstein ME, Roper-Hall G. Update on orbital
49. Dal Santo F, Ellis E, Throckmorton GS. The 80. Ploder O, Klug C, Voracek M, et al. Evaluation
floor fractures: indications and timing for
effects of zygomatic complex fracture on of computer-based area and volume mea-
repair. Facial Plast Surg 2000;16:95.
masseteric muscle force. J Oral Maxillofac 66. Ellis E, Tan Y. Assessment of internal orbital surement from coronal computed tomog-
Surg 1992;50:791. reconstructions for pure blow-out frac- raphy scans in isolated blow-out fractures
50. Davidson J, Nickerson D, Nickerson B. Zygo- tures: cranial bone grafts versus titanium of the orbital floor. J Oral Maxillofac Surg
matic fractures; comparison of methods of mesh. J Oral Maxillofac Surg 2003;61:442. 2002;60:1267.
internal fixation. Plast Reconstr Surg 67. Li KK. Repair of traumatic orbital wall defects 81. Manson PN, Illif N, Robertson B. Discussion:
1990;86:25. with nasal septal cartilage: report of five evaluation of computer-based area and vol-
51. Kasrai L, Hearn T, Gur E, Forrest CR. A biome- cases. J Oral Maxillofac Surg 1997;55:1098. ume measurement from coronal computed
chanical analysis of the orbitozygomatic com- 68. Chen JM, Zingg M, Laedrach K, Raveh J. Early tomography scans in isolated blow-out
plex in human cadavers; examination of load surgical intervention for orbital floor frac- fractures of the orbital floor. J Oral Max-
sharing and failure patterns following fixation tures; a clinical evaluation of lyophilized illofac Surg 2002;60:1273.
with titanium and bioresorbable plating sys- dura and cartilage reconstruction. J Oral 82. Al-Qurainy IA, Stassen LF, Dutton GN, et al.
tems. J Craniofac Surg 1999;10:237. Maxillofac Surg 1992;50:935. Diplopia following midfacial fractures. Br J
52. Fujioki M, Yamanoto T, Miyazalo O, Nishimu- 69. Mackenzie DJ, Arora B, Hansen J. Orbital floor Oral Maxillofac Surg 1991;29:302.
ra G. Stability of one-plate fixation for repair with titanium mesh screen. J Cran- 83. Carr RM, Mathog RH. Early and delayed repair
zygomatic bone fracture. Plast Reconstr iomaxillofac Trauma 1999;5(3):9. of orbitozygomatic complex fractures.
Surg 2002;109:817. 70. Choi JC, Sims CD, Casanova R, et al. Porous J Oral Maxillofac Surg 1997;55:253.
53. Rohrich RJ, Hollier LH, Watumull D. Optimiz- polyethylene implant for orbital wall recon- 84. Hosal BM, Beatty RL. Diplopia and enophthal-
ing the management of orbitozygomatic struction. J Craniomaxillofac Trauma mos after surgical repair of blow-out frac-
fractures. Clin Plast Surg 1993;19:149. 1995;1(3):42. ture. Orbit 2002; 21(1):27.
54. Manson PN. Discussion: analysis of treatment 71. Baumann A, Burggasser G, Gauss N, Ewers R. 85. Putterman AM, Stevens T, Urist MN. Nonsurgi-
for isolated zygomaticomaxillary complex Orbital floor reconstruction with an allo- cal management of blow-out fractures of the
fractures. J Oral Maxillofac Surg 1996; plastic resorbable polydioxanone sheet. Int orbitalfloor. Am J Ophthalmol 1974;77:232.
54:400. J Oral Maxillofac Surg 2002;31:367. 86. Putterman AM. Late management of blow-out
462 Part 4: Maxillofacial Trauma
fractures of the orbital floor. In: Aston SJ, 88. Gossman MD, Roberts DM, Barr CC. Oph- 91. Rohrick RJ, Hackney FL, Parikh RS. Superior
Hornblass A, Meltzer MA, Rees TD, editors. thalmic aspects of orbital injury. Clin Plast orbital fissure syndrome: current manage-
Third international symposium of plastic Surg 1992;19(1):71. ment concepts. J Craniomaxillofac Trauma
and reconstructive surgery of the eye 89. Brandt MT, Haug RH. Traumatic hyphema: a 1995;1(2):44.
adnexa. Baltimore (MD): Williams & comprehensive review. J Oral Maxillofac 92. Ord RA. Postoperative retrobulbar hemor-
Wilkins; 1982. p 8695. Surg 2001;59:1462. rhage and blindness complicating trauma
87. Iliff N, Manson PN, Katz J, et al. Mechanisms 90. Spoor TC, McHenry JG. Management of trau- surgery. Br J Oral Surg 1981;19:202.
of extraocular muscle injury in orbital frac- matic optic neuropathy. J Craniomaxillofac 93. Ostrofsky MK, Lownie JF. Zygomatico-coronoid
tures. Plast Reconstr Surg 1999;103:787. Trauma 1996;2(1):14. ankylosis. J Oral Surg 1977;35:752.
CHAPTER 24
Orbital Fractures fortunate since inward or medial displace- tissue into the maxillary sinus and/or eth-
ment of midfacial or zygomatic bones can moid air cells adjacent to these walls. In
Anatomy reduce the orbital volume and be accom- essence, the paranasal sinuses and ethmoid
panied by orbital hemorrhage. The subse- air cells serve as air bags or shock absorbers
The orbit is the bony vault that houses the
quent increased intraorbital pressure is to the globe and orbital contents. This pro-
eyeball, or globe. It is a quadrangular-based
pyramid that has its peak at the orbital apex. most often relieved by traumatic expan- tective mechanism explains why globe per-
The average adult orbit has a volume of sion of the walls with herniation of orbital foration is relatively uncommon following
30 cc; the globe averages 7 cc (Figure 24-1).
Even a modest change in the position of one Orbital anatomy Sites of potential
of the bony walls can have a significant visual impairment
impact on the orbital volume and, thus,
m
globe position. The orbit serves to house 4c
Retrobulbar hematoma
cortical bone that generally protects the Blow-in fracture
orbital contents and globe from direct
blunt trauma. Seven bones form the orbit: 2 cm
m
3c
4.
Optic nerve
4.
5 6 cm
cm
Bleeding
forming a protective socket for the globe, Vasospasm
these bones also provide origins for the
extraocular muscles, and foramina and fis- 1 cm Optic canal
Shearing of nerve
sures for cranial nerves and blood vessels.3 Contusion
The orbital walls vary considerably in Bone-fragment injury
midfacial trauma. Orbital fractures that The orbital floor is formed primarily by the
involve the frontal sinuses more common- orbital process of the maxillaanterolater-
ly result in serious eye injuries.4,5 These ally by a portion of the zygomatic bone, and
fractures, following blunt trauma, and the posteriorly by a small portion of the pala-
associated blindness are probably not seen tine bone. The maxillary sinuses are present
as often owing to the severity of forces and at birth and reach the orbital floor and
concomitant neurologic, cervical spine, infraorbital canal by age 2 years.7 The inferi-
and multisystem trauma. In short, they or orbital fissure gives rise to the infraorbital
generally are not survivable events. groove from its midportion, which is about
The orbital roof consists mainly of 2.5 to 3 cm from the infraorbital rim. The
the frontal bone, with the anterior cranial infraorbital fissure converts to a canal FIGURE 24-2 Right bony orbit. The inferior
fossa superior to it. The lesser wing of the halfway forward, carrying the infraorbital orbital fissure can be seen converting to a canal
angling medially at the Y-shaped divide. The
sphenoid has a minor contribution poste- nerve and vessels and opening approximate- lacrimal fossa is characteristically thin. The lam-
riorly. The superior orbital rim is general- ly 5 mm below the rim of the maxilla as the ina papyracea occupies the majority of the medi-
ly rather thick and then rapidly becomes infraorbital foramen (Table 24-1).8 The al wall, with the frontoethmoidal suture at the
quite thin (< 1 mm) posterior from the infraorbital nerve provides sensory innerva- superior extent.
edge. In elderly patients the orbital roof tion to the upper lip, lateral nose, and ante-
may be resorbed in select areas, allowing rior maxillary teeth and mucosa. The orbital into the underlying maxillary sinus with
the dura to become confluent with the floor can be as thin as 0.5 mm, with its extension laterally to the infraorbital canal.
periorbita. This should be kept in mind weakest portion just medial to the infraor- The lateral wall of the orbit is formed
during orbital dissection and elevation in bital groove and canal. This explains the mainly by the greater wing of the sphenoid
this region for both trauma and tumor phenomenon that most blunt traumas and portions of the zygoma. Although this
work. Generally, the anterior portion of resulting in orbital floor blow-outs are man- tends to be the strongest wall, it is fairly
the orbital roof is occupied by the supra- ifested primarily with injury and sagging of commonly fractured along the front-
orbital extension of the frontal sinus. The the medial orbital floor and orbital contents ozygomatic junction, extending slightly
frontal sinus begins to form around the
age of 6 years and is unilateral in 5% of Table 24-1 Orbital Fissures/Canals and Their Contents
adults and lacking in another 5%. Location Contents
Anterolaterally there is a smooth broad
fossa that houses the lacrimal gland. At Superior orbital fissurelesser and Motor nerves: III (superior and inferior
greater wings of sphenoid divisions), IV (trochlear), V (abducens)
the most medial extent is the trochlea,
Sensory nerves: V1 (frontal, lacrimal, nasociliary),
approximately 4 mm behind the rim.
sympathetic fibers
There the cartilaginous pulley has a dual Vessels: superior ophthalmic vein, anastomosis of
insertion for the superior oblique muscle recurrent lacrimal and middle meningeal arteries
tendon. At the junction of the medial
one-third and lateral two-thirds of the Inferior orbital fissuregreater wing Sensory nerves: V2 (infraorbital and zygomatic),
of sphenoid; palatine, zygomatic, parasympathetic branches of pterygopalatine
superior rim is the supraorbital notch. In
and maxillary bones ganglion
one-fourth of adults, a supraorbital fora-
Vessel: inferior ophthalmic vein and branches to
men is found, secondary to the ossifica- pterygoid plexus
tion of the ligament crossing the inferior
extent.6 When reflecting bicoronal flaps, a Optic canallesser wing of sphenoid Optic nerve, meninges, ophthalmic artery,
small triangular wedge ostectomy should sympathetic fibers
be performed in these individuals to Anterior ethmoid canalfrontal and Nerve: anterior ethmoid becomes dorsal nasal
relieve the encased supraorbital nerve ethmoid bones Vessel: anterior ethmoid artery
and vessels and to allow for a relaxed Posterior ethmoid canalfrontal and Nerve: posterior ethmoid
reflection of tissues at the rim. ethmoid bones Vessel: posterior ethmoid artery
The orbital floor is bordered laterally by
Nasolacrimal fossalacrimal and Nasolacrimal sac and duct
the inferior orbital fissure. However, there is
maxillary bones
no distinct border medially (Figure 24-2).
Orbital and Ocular Trauma 465
posteriorly and then running vertically The majority of the medial wall is formed fissures, or muscle origins such as that of
along the thinnest portion of the suture by the extremely thin (0.20.4 mm) lami- the inferior oblique. When encountering
line, where the greater wing of the sphe- na papyracea of the ethmoid bone. resistance, surgeons should attempt to
noid and zygoma meet. This wall separates Housed along the frontoethmoidal junc- identify the exact anatomic reason for the
the orbit from the temporalis muscle. tion are the anterior and posterior eth- resistance, such as structures that may
Owing to the heavy nature of this muscle moidal foramina. The anterior ethmoidal need to be preserved or periorbital tissues
and the direction of blunt forces, generally foramen is 20 to 25 mm behind the medi- that have become entrapped in fracture
there is some mild degree of inward dis- al orbital rim, and 12 mm beyond this is lines. Knowledge of the limits of safe sub-
placement. The lateral orbital walls, if they the posterior ethmoidal foramen. The periosteal dissection is mandatory. Also
were to be extended posteriorly, would foramina can be found approximately important is knowing the distance from
form a 90 angle to each other. Each later- two-thirds of the way up the medial the intact orbital rim, where vital struc-
al orbital wall forms a 45 angle at the orbital wall, within the frontoethmoidal tures can be identified. Generally, a subpe-
orbital apex, with its medial wall counter- suture line, and serve as important surgi- riosteal dissection from the inferior lateral
part. This is important to bear in mind cal landmarks identifying the level of the rims can be safely extended for 25 mm. An
when attempting to realign or reconstruct corresponding cribriform plate. Orbital exploration distance of 30 mm from the
fractured walls. The superior orbital fis- surgeons use these arteries as the land- superior orbital rim or anterior lacrimal
sure separates the greater and lesser wings marks for the superior extent of orbital crest (found on the frontal process of the
of the sphenoid and serves as the delin- wall decompression. The anterior eth- maxilla) can be safe.5 A high medial wall
eation between the orbital roof and lateral moidal foramen transmits the anterior dissection places the orbital apex and optic
wall. At the orbital apex the lesser wing of ethmoidal artery and anterior ethmoidal canal at risk. One caveat to these safe sur-
the sphenoid forms the lateral portion of branches from the nasociliary nerve from gical exploration distances is that they are
the ring of the optic canal. One centimeter the orbit coursing into the nasal cavity. averages of known landmarks to intact
below the frontozygomatic suture, and just This is why otolaryngologists sometimes adult orbital rims. When traumatic forces
internal (34 mm) to the lateral orbital use a medio-orbital approach to ligate or displace a portion of a rim, it is generally
rim, is Whitnalls tubercle (lateral orbital cauterize the anterior ethmoidal artery to in a posterior or medial direction, which
tubercle). This gentle outcropping of bone control recalcitrant nasal bleeding. effectively reduces these distances. Knowl-
functions as the insertion point for the lat- Although the anterior ethmoidal vessel edge of the bony orbital anatomy, with its
eral retinacular structures. The lateral reti- can be cauterized with few ill effects, the foramina, fissures, and attachment areas,
naculum is composed of the lateral horn contents of the posterior ethmoidal fora- helps the surgeon to avoid injuries to vital
of the levator aponeurosis; the lateral can- men (posterior ethmoidal artery and, vari- structures contained within them.1 Aver-
thal tendon of the eyelids; and the inferior ably, a sphenoethmoidal nerve from the age distances for locating these critical
suspensory (Lockwoods) ligament and nasociliary nerve) are generally allowed to structures as they relate to identifiable
multiple fine check ligaments of the later- remain intact since they serve as a useful bony landmarks are contained in Table 24-2.
al rectus muscle. These soft tissue attach- delineation to the posterior extent of safe Surgeons should avoid disrupting the
ments are found anatomically in this order medial wall dissection. medial canthal tendon, lacrimal appara-
proceeding inferiorly and posteriorly from Once beyond the orbital rims, subpe- tus, pulley of the superior oblique muscle,
the rim. These multiple structures become riosteal dissection generally proceeds fair- supraorbital nerves and vessel, attach-
confluent to form the common lateral reti- ly easily, except for points of nerves or ves- ments to Whitnalls tubercle, and the ori-
naculum, which is the actual insertion to sels perforating through foramina, orbital gin of the inferior oblique muscle.
the tubercle.6 Clinically the point to
remember is that reattachment of the lat- Table 24-2 Distance of Vital Orbital Structures from Bony Landmarks
eral canthal tendon should be to the later- Structure Reference Landmark Mean Distance (mm)
al orbital tubercle.
The medial wall of the orbit is by far Midpoint of inferior orbital fissure Infraorbital foramen 24
the most complex and potentially prob- Anterior ethmoidal foramen Anterior lacrimal crest 24
Superior orbital fissure Zygomaticofrontal suture 35
lematic to manage in severe trauma. The
Superior orbital fissure Supraorbital notch 40
medial orbital wall is composed anterior-
Optic canal (medial aspect) Anterior lacrimal crest 42
to-posterior by a portion of the maxillary, Optic canal (superior aspect) Supraorbital notch 45
lacrimal, ethmoid, and sphenoid bones.
466 Part 4: Maxillofacial Trauma
The anterior boundary of the orbit is the anterior insertion offers considerable ligament of the lid. Mllers muscle arises
defined by the orbital septum. The upper resistance to dissection, which helps one beneath the levator muscle and inserts into
and lower eyelids are anatomically similar avoid inadvertent injury to the lacrimal the superior border of the tarsal plate.
in their composition, with corresponding sac. At the lateral edge of the orbicularis Mllers is a smooth muscle that receives
layers anteriorly to posteriorly. When one oculi, the superficial fibers form an indis- sympathetic input for its tone and helps
is looking downward, the lid retractors tinct raphe, and it is the deeper fibers that regulate the resting position of the upper
enable the lower eyelid to roll with the comprise the lateral canthal tendon, eyelids while the eyes are open. Increased
globe, thus avoiding a visual field cut. The inserting onto Whitnalls tubercle.9 The stimulation or sympathetic input causes a
lids have a very thin keratinized epitheli- upper and lower lids should form a 30 to wide-eyed look and a more alert appear-
um that is loosely attached to the underly- 40 angle at the lateral canthus, which is ance.10 The capsulopalpebral fascia and the
ing orbicularis oculi muscle (Table 24-3). situated 1 cm below the frontozygomatic inferior tarsal muscle in the lower eyelids
The orbicularis oculi muscle is innervated suture. Typically, the lateral canthus is sit- are also termed the lower lid retractors.
by cranial nerve VII and acts as a sphincter uated 2 to 4 mm above the medial canthus. The lid retractors are formed from the
and closing force for the eyelids. In the Just posterior to the orbicularis oculi fibrous attachments of the inferior rectus
relaxed state the orbicularis oculi is is the orbital septum. The orbital septum and inferior oblique muscles, and fuse with
opposed in the upper eyelid by the levator is continuous with the orbital periosteum Lockwoods inferior suspensory ligament.
palpebrae superioris, which is innervated and the periosteum of the facial bones The tarsal plate is formed by dense
by cranial nerve III. The resting tone and overlying the rims. One to two millimeters fibrous connective tissue and is primarily
level of the upper eyelid are partly deter- below the inferior rim, where these layers responsible for the convex form of each of
mined by the amount of sympathetic converge on the facial aspect, is a the lids. The tarsal border parallels the free
input to Mllers muscle. The orbicularis periosteal thickening called the arcus mar- margin of the eyelid. The horizontal
oculi has two distinct layers: the outer ginalis.5 This is a useful landmark when length of each tarsus is approximately
superficial fibers (orbital portion) and the performing an infraciliary or preseptal 30 mm. The height is greatest in the mid-
deeper fibers (palpebral portion). The transconjunctival approach to the inferior portion of the lid. The height of the upper
palpebral section medially has intricate rim. If one stays in front of the orbital sep- tarsus is 10 mm, whereas in the lower lid it
insertions and envelops the lacrimal sac by tum and incises below the arcus margin- is 4 mm. Embedded within the tarsal
dividing into intertwined deep and super- alis, then orbital contents and fat do not plates are a fine network of meibomian
ficial heads. The superficial portion inserts herniate into the field. The distal edges of (sebaceous) glands. When obstructed and
onto the anterior lacrimal crest. The inner the orbital septum insert into the superior chronically inflamed, these glands can
deep head inserts into the fascia of the edge of the tarsal plates. The orbital sep- form a cyst-like mass called a chalazion.
lacrimal sac and posterior lacrimal crest. tum and these insertions prevent the pre- The lacrimal system is responsible for
The medial canthal tendon is formed by aponeurotic orbital fat from herniating the lubrication and wetting of the globe.
the condensation of the orbicularis muscle out into the eyelids. Superiorly there is a Accessory lacrimal glands perform normal
fibers. It is the superficial head of the can- central and medial fat pad, and inferiorly wetting of the eye, and the lacrimal gland
thal tendon that has a tenacious insertion there are three distinct fat pads (medial, produces reflex tearing. The lacrimal
into the anterior lacrimal crest. This is central, and lateral). With aging, the gland, which is situated in the anterior
beneficial during orbital approaches since orbital septum can become lax and, partic- aspect of the superior lateral orbit, is
ularly in the lower lids, result in baggy divided into two lobes by the levator
lids. Severe sagging of the lower lids is aponeurosis. The larger orbital lobe lies
Table 24-3 Eyelid Layers: Cutaneous referred to as festooning. above the levator aponeurosis, and its tear
(Anterior) to Conjunctival (Posterior)
The primary elevator of the upper eye- ducts traverse the palpebral lobe, which
Skin lids is the levator palpebrae superioris has 6 to 12 tear ductules that empty into
Subcutaneous areolar tissue muscle. Inferiorly it forms an aponeurosis the superior lateral fornix. When drilling
Striated muscle (orbicularis oculi) below Whitnalls ligament that attaches in this region, such as during a repair of a
Submuscular areolar tissue (contains main broadly over the anterior tarsal plate. frontozygomatic fracture, one must take
sensory nerves to lids)
Approximately 15 to 20 mm above the care not to injure the palpebral lobe or to
Fibrous layer with tarsal plates
tarsal plate, the aponeurosis consists of a inadvertently remove it, thinking that it is
Nonstriated smooth muscle
thickened fascial band, which is termed herniated fat; this error often results in a
Mucous membrane or conjunctiva
Whitnalls ligament. This is a suspensory problematic dry eye. Lacrimal secretions,
Orbital and Ocular Trauma 467
or tears, traverse medially and inferiorly Fracture Configurations cally 29 to 32 mm; it is slightly more in
across the globe, wetting the cornea, and black and Asian individuals. Lacrimal
Isolated orbital wall fractures account for
accumulate at the medial inferior aspect of drainage problems can also arise from
4 to 16% of all facial fractures. If fractures
the eye. The fluid is then either drawn or severe NOE fractures owing to canalicular
that extend outside the orbit are included,
pumped into the lacrimal puncta of the or lacrimal sac disruption or scarring.
such as those of the zygomatic complex
upper and lower eyelids. These puncta are Internal orbital fractures occur in
(ZMC) and naso-orbitoethmoid (NOE),
only 0.2 to 0.3 mm in diameter. The upper numerous patterns. These fractures are
then this accounts for 30 to 55% of all
punctum is usually just slightly medial in typically described by their location and
facial fractures.11,12
relation to the lower punctum. When the the size of the defect. Three basic patterns
ZMC fractures are the most common-
lids close, the puncta come into contact. of internal orbital fractures have been
ly occurring facial fracture, second only to
The upper and lower canaliculi travel described: linear, blow-out, and com-
nasal fractures. By definition, ZMC frac-
within the lids, first vertically (2 mm), plex.14 Linear internal orbital fractures
tures are the most common fracture with
then horizontally for 8 to 10 mm, parallel- maintain periosteal attachments and typi-
orbital involvement.13 The ZMC, or tri-
ing the lid margin. They join to form a cally do not result in a defect with orbital
pod, often hinges about the frontozygo-
common canaliculus just before entering content herniation; however, they can
matic suture with a medial, inferior, and
the lateral aspect of the lacrimal sac, which result in a significant enlargement of the
is one-third of the way down from the posterior vector of rotational displace- orbital volume with a resulting late enoph-
upper portion of the sac. Typically, the ment. This is due to the direction and thalmos. Blow-out fractures are the most
lacrimal sac is 1 cm in length and 5 mm in force of blunt trauma and the variable common. By definition, these are limited
diameter. The palpebral portion of the thicknesses of the components of the to one wall and typically are 2 cm or less in
orbicularis oculi has dense intertwined ZMC. The frontozygomatic area offers the diameter. The most commonly involved
insertions that envelope the lacrimal sac. thickest pillar. When fractured there is wall with a blow-out fracture is the anteri-
Inferiorly, the sac drains into the naso- usually a slight vertical displacement with or medial orbital floor, followed by the
lacrimal duct, which has a 12 mm intra- a reasonable anteroposterior alignment. medial wall and, less frequently, the orbital
bony canal coursing inferiorly and posteri- The much thinner anterior maxillary and roof, which can present as a blow-in frac-
orly that opens into the inferior meatus of lateral orbital floor offers little resistance ture. Exploration, repair, or reconstruction
the nasal cavity below the inferior concha. to fracture and displacement. of an orbital roof fracture may be indicat-
This opening is 30 to 35 mm from the edge Fractures of the NOE are most often ed if a dural tear is suspected or to prevent
of the external nares. Reflux of tears and due to severe blunt midface trauma. These a pulsatile globe. This rhythmic inward
nasal mucus back up into the nasolacrimal fractures create cosmetic deformities with a and outward movement of the eye is due
duct is prevented by a mucosal fold called flattening of the nasal dorsum and a widen- to the cerebrovascular pulsation and the
Hasners valve. With persistent epiphora ing of the intercanthal distance; they can influence of respiration on the overlying
following trauma or surgical intervention, also be accompanied by a violation of the cerebral hemispheres. This phenomenon
it is important to establish the precise underlying dura with a cerebrospinal fluid is typically not present acutely but occurs
point of mechanical obstruction that (CSF) leak. Any persistent or copious clear after resolution of edema, with the recov-
exists within the lacrimal drainage system. nasal drainage should be tested to deter- ered patient complaining of persistent
Irrigation of the inferior canaliculus may mine a 2-transferrin level to rule out a CSF blurred or double vision. Complex inter-
relieve temporary obstruction owing to leak. It is uncommon for the canthal ten- nal orbital fractures consist of extensive
dry or thickened secretions. A dye disap- dons to become disinserted from the bones. fractures affecting two or more orbital
pearance test, Jones I or II, nasolacrimal This is particularly true of the lateral can- walls; they often extend to the posterior
irrigation, or dacryocystography can help thal tendon. Traumatic telecanthus with orbit and may involve the optic canal.
one determine the precise point of NOE fractures is a result of a flattening of These complex fractures are usually asso-
obstruction and guide surgical planning. the nasal bridge and a lateral splaying of the ciated with more severe trauma and sur-
Following trauma or operative interven- orbital rims and anterior lacrimal crest. rounding fractures such as Le Fort II, Le
tion, epiphora may be due to hypersecre- Reduction and fixation of these bony seg- Fort III, and frontal sinus fractures.
tion from a corneal abrasion, lash ptosis, ments and, less frequently, direct transnasal
foreign bodies, or entropion, all of which wiring are necessary for adequate restora- Clinical Examination
serve as persistent stimuli leading to reflex tion of medial intercanthal distance and Even in the most severely injured patient,
lacrimal gland secretion. alignment. In adult Caucasians this is typi- the mechanism of injury and surrounding
468 Part 4: Maxillofacial Trauma
history should be ascertained before per- Extraocular movements are evaluated vertical dystopia. This is often ascertained
forming a clinical examination of the orbit to rule out mechanical entrapment or pare- from above or by standing directly in front
and globe. A systematic approach assessing sis. Diplopia, and the field of gaze in which of the patient. Visual fields are tested for
both the globes and orbits further defines it occurs, should be noted (Figure 24-3). Of each eye, one at a time, by confrontation.
functional and cosmetic defects. The initial greatest concern is diplopia in the primary The examiner and patient faces should be
ophthalmologic evaluation should include (straight-ahead) and downward gazes. positioned directly toward each other,
periorbital examination, visual acuity, ocu- These are the two fields that are used most 0.6 m apart. The patient is asked to stare
lar motility, pupillary responses, visual often. Mild or equivocal restriction (< 5) directly into the examiners eyes, while the
fields, and a fundoscopic examination. in extreme fields of gaze is common in the examiners hand is held in their own
Visual acuity should be independent- setting of severe orbital trauma with hem- extreme field of gaze, midway between the
ly tested on each eye using a Snellen chart orrhage or edema. Computed tomography patient and the examiner. The patient is
at a standard 6 m (20 ft.) distance or with (CT) scan findings should be correlated then asked to detect numbers of fingers
reading of standard-type print at 40 cm with any clinically noted entrapment. If showing, motion, or the digit displayed. In
(16 in.). The patient should wear their mechanical entrapment is suspected, then essence, the examiners peripheral field of
corrective lenses during this examination. the eye should be topically anesthetized and gaze is serving as a control for the patient.
If over 40 years of age, the patient should a forced duction performed with a fine- Quadrant defects are indicative of
be wearing his or her reading glasses. The toothed forceps. Typically, an Adson forceps post-chiasm injury. A fundoscopic exami-
eyelids and periorbital region should be is used at the inferior fornix with the beaks nation should be performed in a dimly lit
inspected for edema, chemosis, ecchymo- open, pressing inward against the depth of room to help maximize pupillary dilata-
sis, lacerations, ptosis, asymmetric lid the fornix and toward the globe side, until tion and ease of the examination. Lens dis-
drape, canalicular injury, and canthal ten- the globe rolls downward slightly. The location, vitreous hemorrhage, retinal
don disruption. With significant acute beaks are then pressed together, grasping detachment, and foreign bodies may be
periorbital ecchymosis, there should be an the insertion of the inferior rectus. Upward, noted or may be the cause for not being
increased suspicion of a direct blunt globe downward, and lateral motions can be eval- able to view the fundus. If history and ini-
injury or an internal orbital wall fracture. uated. The point of doing a forced duction tial clinical findings warrant a dilated fun-
A lid retractor (Desmarres) is useful for test is to determine whether the diplopia is doscopic examination, then neurologic
separating swollen tight lids so that the due to a restriction of a muscle or paresis of status should be reevaluated and con-
globe and pupil can be adequately exam- a muscle. firmed, and clearance from the primary
ined. Also, this retractor may serve to lift Pupillary light reactivity, size, shape, treating physician or neurosurgeon first
the edge of the lid to examine its inner and symmetry should all be assessed and obtained. A dilated fundoscopic examina-
aspect. With an upper eyelid laceration, noted. If unequal pupils (anisocoria) or an tion with indirect ophthalmoscopy is gen-
any fat that is herniating below the level of irregularly pointing pupil is found, then erally performed by an ophthalmologist to
the brow through the wound should cause the patient should be queried regarding rule out more occult injuries or examine a
concern that an underlying injury has previous ocular trauma or eye surgery greater portion of the globe toward the
occurred to the levator muscle. Likewise, (cataracts). An irregular pupil often points equator. The ophthalmologist may elect to
if the palpebral conjunctiva has been vio- toward the site of a globe penetration or perform tonometry or a slit-lamp exami-
lated, it is prudent to consult an ophthal- injury. This is often teardrop shaped, with nation. Tonometry indirectly measures
mologist to rule out a globe perforation. the narrow portion pointing toward the intraocular pressure by placing the instru-
With a medial vertical laceration of the perforated side of the globe, which is usu- ment on the surface of the eye. Normal
lids, particularly the lower, gentle lateral ally concealed beneath the lid (Figure 24- (1020 mm Hg) or symmetric bilateral
retraction may reveal a cut canaliculus or 4). An ophthalmologist should be consult- readings are reassuring. However, this does
medial canthal tendon disinsertion. ed immediately and precautionary not rule out a penetrating injury. With ele-
Canalicular disruption warrants an measures instituted, including protective vated pressures but an otherwise unre-
urgent ophthalmology consult and usual- Fox shield over the eye, head-of-bed eleva- markable examination, a history of glau-
ly requires surgical reanastomosis and sil- tion, bed rest, analgesics, and antiemetics coma should be elicited. An acute
icone tube placement into the naso- to avoid sudden increases in intraocular abnormally high intraocular pressure with
lacrimal system and surrounding pressure owing to Valsalva forces. exophthalmos, limited globe movement,
supportive repair to prevent outflow Both globes should be evaluated for and resistance to retropulsion is indicative
obstruction and epiphora. any acute enophthalmos, exophthalmos, or of a retrobulbar hematoma, which may
Orbital and Ocular Trauma 469
120 105 90 75 60
70 Name: ____________________________________________
45
135
60 Date: ________________________________________
Diagnosis: ______________________________
50
30
150
40
30
165 15
20
10
A
60 50 40 30 20 10 10 20 30 40 50 60 70 80 90 0
180 90 80 70
10
20 345
195
30
Object
B No mm2
1/16
___________ mm Diameter pupil
0 40
W R G B Color
I 1/4 330
210
II 1
50 Correction
III 4
Relat. Intens.
IV 16
V 64 60 No 4 3 2 1
315
No Relat. 225 0
Intens.
1 0,0315 I
70
2 0,100 e, e II
240 255 270 285 300 sid lin
he his III
0,315 et gt
C 3
ng alon
Object
a IV
4 1,00 ch x
To inde V
ing
ITEM #708300 FORM #6100-2 sw
OS. OD. Vision: __________ sph O __________ cyl ________ = ________
120 105 90 75 60
70 Name: ____________________________________________
135 45
60
Date: ________________________________________
D 50 Diagnosis: ______________________________
150 30
40
30
165 15
20
10
60 50 40 30 20 10 10 20 30 40 50 60 70 80 90 0
180 90 80 70
10
20 345
195
30
Object
___________ mm Diameter pupil
No mm2
0 1/16 40
W R G B Color
I 1/4 330
210
II 1 Correction
50 Relat. Intens.
III 4
IV 16 No 4 3 2 1
64
60 0
V 315
Relat.
225 I
No Intens.
II
1 0,0315 70 e, e
sid s lin III
2 0,100 240 255 270 285 300 the thi
Object
n ge long IV
3 0,315 a
ch x a V
4 1,00 To inde
ing
sw
E F ITEM #708300 FORM #6100-2 OS. OD. Vision: __________ sph O __________ cyl ________ = ________
FIGURE 24-3 This 9-year-old child presented with complaint of double vision and cheek numbness after being struck in the left orbital region with a hardball.
A, Note the lateral subconjunctival hemorrhage and that there was no difficulty in the upgaze. B, In downgaze he had severe firm fixed restriction of the left eye
that was positive to a forced duction test. C, The right lateral gaze had trace restriction. D, The left lateral gaze was unremarkable. E, Direct coronal computed
tomography (CT) scan of the bony window revealed a trapdoor fracture of the left orbital floor with herniation and a probable impingement of the inferior oblique
muscle and fascial framework. F, Diploic visual fields (Goldman visual field test). With binocular testing, patients are asked to look at the grid and track a point-
ed light that is shown from behind the chart. When patients experience double vision, they respond to the examiner who charts the abnormality. In this case, the
upper grid was recorded at the initial presentation. Diplopia was experienced in all areas below the line (1012). This childs severely limited downgaze, corre-
lated with the CT findings, prompted surgical exploration and orbital floor repair within 12 hours. The lower grid was recorded at 10 days postoperatively and
showed marked improvement in the downgaze, with diplopia occurring at 40 inferiorly.
470 Part 4: Maxillofacial Trauma
Finally, the bony orbital rim should be alone. Waters projection allows visualiza-
palpated for steps, crepitus, and mobility. tion of the orbital roof and floor and is
The patient should be queried about particularly useful for evaluating orbital
altered or lack of sensation, and neurosen- floor blow-out fractures (Figure 24-6).
sory testing should be performed to evalu- With this 23 (preferably posteroanterior)
ate the supraorbital, supratrochlear, and view, the petrous portion of the temporal
infraorbital nerves. bones is projected below the maxillary
sinuses and indirect signs of fracture can
Imaging be noted, such as a teardrop formation or
Once a complete ophthalmologic and oral air-fluid levels. This is also an excellent
FIGURE 24-4 Laceration of the right lower
medial eyelid that extends through the margin. examination has been performed, selected view to assess a ZMC fracture.
At first the examiner thought there was simply studies such as CT or magnetic resonance If plain films reveal an internal orbital
a strand of clotted blood on the medial globe. imaging (MRI) can be ordered with fracture that possibly warrants surgical
Recognition of the irregular-pointing pupil led defined parameters to provide meaningful intervention, then CT scans should be
to the suspicion of a globe perforation, which
was confirmed with a dilated ophthalmologic results. Imaging is essential for proper obtained. The fracture can then be fully eval-
examination. diagnosis and treatment of orbital trauma. uated for surgical treatment planning. CT
Noncontrasted CT is the primary imaging allows excellent visualization of orbital soft
require acute evacuation via a lateral can- modality currently used for evaluating tissues and permits one to simultaneously
thotomy. A soft eye with a relatively low injuries from blunt or penetrating trauma, assess the cranial vault and brain during a
pressure or deep anterior chamber is sug- as well as for localizing most orbital foreign trauma scan. A trauma CT scan series gen-
gestive of a posterior scleral rupture. bodies.15 Other imaging modalities, such as erally involves 10 mm axial cuts of the crani-
A slit-lamp examination is generally plain radiography, reconstructed three- um and 5 mm cuts through the facial region.
performed with the patient in an upright dimensional CT, MRI, ophthalmic ultra- If finer detail or three-dimensional recon-
position; if the patient is confined to a sonography, color Doppler imaging, and structed images are desirable, then 1 mm
bed, a modified examination can be per- angiography, may provide necessary addi- fine cuts can be ordered. Internal orbital
formed with a penlight. A handheld tional information in select instances. CT fractures are best evaluated when the imag-
portable slit lamp can be used in the trau- scans have become the standard of care in ing plane is perpendicular to the fracture
ma setting. The purpose of this examina- evaluating acute orbital injuries. Standard line. Thus, images are usually obtained in
tion is to evaluate the surface contour of radiography is a readily available and inex-
the globe and cornea to rule out conjunc- pensive method for primary evaluations of
tival chemosis (swelling), hemorrhage, orbital fractures. Plain radiography, how-
emphysema, and foreign bodies. The ever, is inadequate when used in evaluating
anterior chamber should be evaluated for internal orbital fractures, and it is difficult
depth, clarity, and hyphema (blood in the to localize foreign bodies with plain films
anterior chamber). Hyphema, if found,
should be evaluated by an ophthalmolo-
gist so that surgical evacuation or medical
management may be instituted in an
effort to avoid occlusion of the trabecular
meshwork, which may lead to glaucoma
or a fixed iris. The iriss shape and reactiv-
ity should also be noted. If a corneal abra-
sion or laceration is suspected, this may be
more thoroughly evaluated with fluores-
cein dye and a Woods lamp (cobalt blue
light). The fluorescein dye pools in the
laceration or abrasion and fluoresces with
FIGURE 24-5 A broad corneal abrasion of the FIGURE 24-6 Waters view demonstrating opaci-
a bright lime-green hue under the lamp- right eye illustrated with the pooled fluorescein fication of the left maxillary sinus and a medially
light (Figure 24-5). dye under a cobalt blue (Woods) lamp. displaced left zygomatic buttress and arch.
Orbital and Ocular Trauma 471
both the axial and coronal planes to fully severe displacement, or for secondary Ophthalmic ultrasonography is sel-
evaluate the fracture lines, patterns, and reconstruction, three-dimensional CT dom used but is a readily available, safe,
volume changes. This is particularly useful scanning is invaluable for surgical treat- inexpensive, and noninvasive imaging
for comparison to the contralateral or ment planning.19 Generally, 1 to 1.5 mm modality.24 Foreign bodies located in the
uninjured side. The standard imaging fine axial cuts are obtained; the patient orbit can be identified with ultrasonog-
approach for facial trauma is to obtain must remain motionless for the entire scan, raphy but are much more difficult to
direct (non-reformatted) 3 to 5 mm sec- which may include more than 100 slices. detect when located in the orbital apex
tions in the axial and coronal planes. Intra- CT imaging has some drawbacks. As owing to signal reflection. Wood and
venous contrast offers no advantages to the previously mentioned, patients may be other radiolucent materials can be
evaluation of acute bony facial injuries. unable to position themselves comfortably detected with ultrasonography.25 Color
Direct coronal views with 3 mm sections for direct coronal imaging. Sedation may Doppler imaging is an ultrasound tech-
are preferred for evaluating orbital roof or be warranted in pediatric or uncoopera- nique that provides simultaneous two-
floor fractures; however, they may be unob- tive trauma patients. However, with facial dimensional images and visualization of
tainable owing to cervical spine precautions bleeding, possible concomitant mandible blood flow.26 It can be useful in evaluat-
or the patients inability to extend the neck fractures, or obtundation from alcohol or ing a post-traumatic high-flow carotid
and adequately position him- or herself for street-drug use, a secure airway must be cavernous fistula. However, angiography
the coronal CT. In these patients, reformat- maintained throughout the radiology pro- remains the study of choice for defini-
ted coronal images can be obtained based cedure. This may require endotracheal tively establishing this diagnosis.
on the axial image data set. However, with intubation. CT scans may fail to reveal
this technique, there can be a loss of spatial radiolucent foreign bodies such as wood Ocular Injuries and
resolution on the reformatted images. The or vegetative matter.20 In these instances Disturbances
axial images with fine detail (1 mm slices) ultrasonography and MRI are most useful Patients who sustain midfacial trauma,
must be obtained to allow for meaningful in detecting the radiolucent foreign body particularly in motor vehicle accidents,
reformatted image quality. If an optic canal and localizing it. These studies should be often have concomitant neurologic and
fracture is suspected, then 1 to 1.5 mm axial obtained when the CT scans are equivocal multisystem injuries. A neurologically
cuts should be obtained.16,17 This allows a or when physical examination suggests the impaired or uncooperative patient pre-
better determination and correlation of any presence of foreign bodies. sents additional challenges in performing
afferent visual defect owing to possible MRI can be useful in the setting of an adequate orbital and ophthalmologic
bony impingement. orbital trauma to assess soft tissue injury examination. It is paramount that the pri-
Although MRI is generally accepted as or entrapment of extraocular muscles in mary tenets of advanced trauma life sup-
a superior soft tissue imaging modality, CT the area of the orbital suspensory frame- port be adhered to in securing the airway
scans adequately assess lens dislocation, vit- work. Standard radiographs or CT scans and protecting the cervical spine. When
reous hemorrhage, ruptured globe, retrob- should be obtained before MRI is per- orbital fractures caused by severe blunt
ulbar hemorrhage, or avulsion of the optic formed on patients with suspected force trauma are detected, additional asso-
nerve. CT is the imaging of choice in local- intraocular or intraorbital ferromagnetic ciated injuries should be sought, such as
izing metallic and most nonmetallic foreign bodies because of the potential for dis- orbital canal or apex involvement, retro-
bodies in relation to the globe, muscular placement of the metallic fragments, bulbar hematoma, or globe perforation.
cone (area inside the extraocular muscles), resulting in further significant ocular or When there are multiple midface frac-
and the optic nerve.15,18 The location and brain injury.21,22 With CT imaging, wood tures, such as those of the ZMC, NOE, and
extent of any subperiosteal hematoma for- can appear isodense with fat or mimic frontal sinus, and Le Fort II or Le Fort III
mation, with possible mass effects, can also intraorbital air. If the history or clinical fractures, then more severe intraorbital
be adequately assessed with CT imaging. examination indicates that fragments of injury, bleeding, and globe perforation are
Computer-generated three-dimensional wood may have penetrated the orbit or likely. Basilar skull fractures, as evidenced
CT imaging can provide superior views and globe, then an MRI should be ordered. An by clinical signs such as CSF otorrhea or
spatial orientation of fragments for com- MRI should also be performed when an rhinorrhea, Battles sign, or CT evidence
plex orbital and facial fractures. In the apparent orbital emphysema (focal air col- such as fracture lines or intracranial air,
majority of acute facial fractures, three- lection) fails to resorb rapidly (within sev- are generally caused by high-velocity
dimensional CT scanning is unnecessary. eral days); this may suggest a space- impact and are often associated with
However, with complex facial trauma with occupying foreign body.23 severe neurologic injury.
472 Part 4: Maxillofacial Trauma
Superior orbital fissure syndrome is and the lack of a potential drainage path-
characterized by impairment of cranial way through paranasal sinuses, such as the
nerves III, IV, V, and VI secondary to com- ethmoids or maxillary sinus. In essence,
pression by a fractured bony segment or there is a compartment syndrome result-
hematoma formation in the region. Orbital ing from elevation of intraorbital pressure,
apex syndrome has all the hallmarks of which leads to central retinal artery com-
superior orbital fissure syndrome, with the pression, or ischemia of the optic nerve.
addition of optic nerve (cranial nerve II) The increased intraorbital pressures can
injury. Between 0.6 and 4% of patients suf- secondarily raise the intraocular pressure,
fering orbital fractures have a globe injury which, in turn, compromises the ocular
FIGURE 24-8 A full-thickness corneal laceration
or optic nerve impairment, resulting in a blood supply.2931 In most instances
and an irregular pupil of the right eye is seen
significant or total loss of vision in one requiring emergent treatment, there is a during a slit-lamp examination.
eye.27,28 This fact highlights the need for a degree of exophthalmos and excessive ten-
thorough initial ophthalmologic and visu- sion of the lids. Although CT scanning to
al acuity assessment, with follow-up serial confirm the diagnosis is desirable, there scleral rupture is at the site of previous
examinations as indicated. should not be unnecessary delay in the cataract surgery, at the limbus, or just pos-
surgical management. The immediate or terior to the insertion of the rectus mus-
Visual Impairment urgent surgical management for retrobul- cles onto the globe, which is 5 to 7 mm
Visual impairment or total vision loss can bar hematoma evacuation consists of a lat- from the edge of the limbus. The area
occur at various levels along the optic eral canthotomy, with or without inferior under the muscle insertion is anatomically
pathway. Direct injury or forces transmit- cantholysis, and disinsertion of the sep- the weakest and thinnest portion of the
ted to the globe by displaced fracture seg- tum along the lower eyelid in a medial sclera. With suspected globe perforation,
ments can result in retrobulbar direction. A small Penrose drain is left in pupillary dilatation and inspection by an
hematoma, globe rupture, hyphema, lens place for 24 to 48 hours to ensure adequate ophthalmologist is mandatory. The
displacement, vitreous hemorrhage, reti- drainage and to prevent reaccumulation. inspection may be difficultthe injury
nal detachment, and optic nerve injury. Additional maneuvers to lower the may not be visible on fundoscopic exami-
Patients with orbital fractures and any intraocular pressure include administra- nation since it is anterior to the equator of
degree of visual impairment who com- tion of intravenous mannitol or acetazo- the globe and externally may be hidden
plain of severe ocular pain should be eval- lamide or application of various glaucoma underneath the rectus muscle insertion.
uated for retrobulbar hematoma. It is medications. Typically, blow-in fractures Detection and surgical access for repair
often the less impressive orbital fracture or inward rotation of the ZMC does not may require dissection of the bulbar con-
that leads to retrobulbar hematoma for- result in increased intraorbital or intraoc- junctiva with retraction of the extraocular
mation (Figure 24-7). This is due to bleed- ular pressures with visual impairment. muscles and external globe inspection.
ing within a relatively closed compartment This is most likely due to pressure relief The penetrating injuries should be treated
and volume expansion provided by addi- emergently, or within 12 hours, to decrease
tional orbital wall fractures such as the the risk of infection or ocular content her-
medial wall into the ethmoid or the floor niation. The ultimate visual outcome
sagging into the maxillary sinus. directly correlates with the presenting
A penetrating globe injury can result visual acuity. Few eyes that cannot detect
from what appears to be an innocuous hand motions or have no light perception
small laceration or from horrific blunt- (NLP) regain useful vision. Globe injuries
force trauma. When an eyelid laceration is should be addressed before any facial lac-
accompanied by an asymmetric pupil, erations are repaired. The exception is sig-
without a prior history of surgery, then a nificant active blood loss from a severed
globe perforation likely exists (Figure 24- vessel.
8). Blunt trauma can lead to globe perfo- Hyphema is blood in the anterior
FIGURE 24-7 Axial computed tomography scan
ration owing to a scleral rupture from the chamber of the eye. It can be as severe as
of a right retrobulbar hematoma. This diffuse
infiltrative pattern is characteristic, whereas the sudden instantaneous increased intraocu- complete obliteration of the anterior
discreet clot mass is less common. lar pressure. The most common site for chamber, termed eight-ball hyphema, or
Orbital and Ocular Trauma 473
more commonly a thin 1 to 2 mm layering limits aqueous humor production) or instituted. Maneuvers involve bedrest in a
at the inferior margin in the upright posi- hyperosmotics (mannitol). With severe head-up position and assurance that there
tion (Figure 24-9). Some hyphemas are hyphema, intraocular surgery to irrigate, is no Valsalva-type exertion; these prevent
termed microhyphemas, with red blood aspirate, and evacuate the clot may be nec- further extension of the detachment.
cells floating in the anterior chamber and essary to prevent optic atrophy owing to Operative management may include any
not layering out. The level and severity of elevated pressures, or to avoid permanent or all of the following: a scleral buckle,
the hyphema should be noted and record- corneal blood staining.32 The anterior cryotherapy a vitrectomy, or endolaser. In-
ed. The bleeding is from the rupture of an chamber washout is the most commonly office pneumatic retinopexy works well
iris or ciliary body vessel and usually is the performed procedure for this purpose. with superior detachments: an inert
result of blunt trauma. Patients often com- Vitreous hemorrhage can result from expandable gas is injected into the vitreous
plain of eye pain and, occasionally, visual blunt trauma with the rupture of ciliary, and indirect laser treatment is applied.
loss if the amount of bleeding is severe. retinal, or choroidal vessels. If, during fun- Optic nerve injury or compromise can
Medical management of hyphema is doscopic examination, the retina cannot result from orbital fractures in the posteri-
aimed at preventing rebleeding and be visualized despite a normal-appearing or region or optic canal. Optic nerve
venous congestion and promoting clear- anterior chamber and lens, vitreous hem- injury or vascular compromise is charac-
ance of the existing blood. This may orrhage is most likely present. As with terized by decreased visual acuity, dimin-
include hospitalization, bed rest, head-of- hyphema, initial management typically ished color vision, and a relative afferent
bed elevation, and longer-acting cyclo- involves hospitalization, bedrest with pupillary defect. It is possible to retain
plegics (topical agents such as scopo- head-of-bed elevation, and serial clinical very good vision and yet still have an optic
lamine or atropine). Cycloplegics examinations. Vitreous hemorrhage is nerve injury manifested by color deficits,
maintain a dilated pupil and thus immobi- slow to resolve, and it may take months for afferent papillary defect, and visual field
lization of the iris, which discourages fur- this to clear, with symptomatic visual loss. Detection of early subtle changes
ther rebleeding. Topical steroids may be improvement.33 A vitrectomy may be require that a cooperative patient under-
administered to decrease further rebleed- required after 6 months if satisfactory goes visual acuity testing, consisting of
ing and reduce intraocular inflammation. resorption has not occurred. testing with a Snellen chart, finger count-
Oral aminocaproic acid is an antifibri- Lens dislocation may be detected by ing, detection of motion, or light percep-
nolytic recommended to reduce the inci- fundoscopic or slit-lamp examination. The tion. Patients may present with NLP,
dence of rebleeding into the anterior lens, in its normal anatomic position, phys- which mandates an emergency consulta-
chamber. In moderate to severe cases there ically separates the anterior and posterior tion with an ophthalmologist and a fine
should be daily monitoring of intraocular chambers, but it can be dislocated either axial CT imaging of the orbital apex. If
pressures and control of any high pressure partially or totally into either one. Symp- NLP persists > 48 hours, then rarely does
increases with intravenous carbonic anhy- toms include monocular diplopia and any meaningful vision return to the affect-
drase inhibitors (acetazolamide, which blurred vision; thus, it is important to check ed eye. Patients with NLP or severely
each eyes visual acuity independently. Pos- decreased visual acuity may be suffering
terior dislocation may be well tolerated; from traumatic optic neuropathy and
however, complete anterior dislocation can should be given high-dose systemic
result in glaucoma and usually requires methylprednisolone therapy for at least
emergency extraction of the lens. 48 to 72 hours (initial loading dose of
Rhegmatogenous retinal detachment 30 mg/kg IV methylprednisolone sodium
and peripheral tears result from blunt succinate, followed by 15 mg/kg IV 2 h
force trauma. Characteristic symptoms later and q6h thereafter).3436 If the patient
include flashing lights and a field loss best is uncooperative, heavily sedated, or
described as a curtain or window shade unconscious, pupillary reaction can be
coming over the eye. On fundoscopic monitored and followed as a sensitive test
FIGURE 24-9 This partial hyphema of the right examination, the retina may not be clearly of optic nerve (cranial nerve II) function.
eye resulted from a punch to the face; a comput- visualized, or undulations may be present. This is best achieved in a dimly lit room; a
ed tomography scan showed a minimally dis- Retinal detachments require surgery.33 An penlight is moved alternating from one
placed orbital floor fracture. The slit-lamp
examination shows early layering. This patient emergency consultation with an ophthal- eye to the other every 2 to 3 seconds, and
received nonoperative management. mologist and initial maneuvers should be the pupillary response is observed. With
474 Part 4: Maxillofacial Trauma
the light shining into the normal eye, both persists, an ophthalmologic consultation 1 cm can be accommodated by the brain
pupils should exhibit a brisk constriction. should be sought. Systemic corticosteroids and should not result in diplopia in the
If the light is then directed from the unin- hasten the resolution of orbital edema and primary fields of gaze. Therefore, any bony
jured to the injured eye the pupil on the the resulting diplopia, which is fairly com- wall revision or reconstruction should be
injured eye will dilate. This is indicative of mon following blunt trauma to the orbit. performed to correct a cosmetic or other
an optic nerve injury (relative afferent Persistent post-traumatic diplopia is functional defect without promise of cor-
pupillary defect). A unilateral, fixed, dilat- best evaluated by an ophthalmologist. It is rection or improvement in any coexisting
ed pupil is usually due to an efferent path- important to establish an accurate diagno- diplopia. These reconstruction procedures
way injury (cranial nerve III), or some sis and precise etiology. The basic evalua- should be performed and allowed to heal,
form of intracranial injury or bleed, which tion should include assessing symmetry of and the diplopia allowed to stabilize for
is usually accompanied by other neurolog- the corneal light reflexes and testing of 6 months prior to the strabismus surgery,
ic lateralizing signs. ductions (following a finger in all eight which would address the diplopia.
fields of gaze) including a selective forced In the trauma setting, diplopia may be
Diplopia duction. The forced duction helps distin- due to restricted ocular motility from a
When a patient complains of seeing a dou- guish between restricted motion from prolapse of the periorbital contents into
ble image of the same object, the examin- entrapment, scarring, or fibrotic contrac- the medially fractured ethmoid air cells or
er should first test each eye independently tures versus a neurogenic motility disorder underlying maxillary sinus. Such diplopia
by covering the opposite eye to determine (cranial nerves III, IV, or VI). Ophthalmol- may also be due to entrapment or direct
whether the diplopia is monocular or ogists use diploic visual fields (see Figure impingement on the fine suspensory liga-
binocular. Monocular diplopia is usually 24-3F) to quantify and categorize the mentous system of the orbit or, less fre-
due to lens dislocation or opacification, or diplopia; serial examinations allow accu- quently, of the extraocular muscles.
another disturbance in the clear media rate tracking of spontaneous recovery or Restricted motility or entrapment is com-
along the visual axis. Acute binocular postsurgical progress. In the acute setting, monly found with orbital floor and medi-
diplopia, secondary to trauma, derives restrictive disorders are managed with al wall fractures, less frequently with roof
from one of three basic mechanisms: early bony orbital surgery and reconstruc- fractures, and rarely with lateral wall frac-
edema or hematoma, restricted motility, tion, whereas neurogenic disorders are tures. Significant medial wall fractures are
or neurogenic injury. The most common managed with the injection of botulinum manifested primarily by enophthalmos
cause of binocular diplopia following toxin into select extraocular muscles owing to volume expansion.
trauma is orbital edema and hematoma. whose forces are unopposed by the injured When testing range of motion, if there
This is usually found in peripheral fields of or restricted muscles. Following bony is repeatedly a firm fixed limited stop of
gaze, and, if other findings are absent, orbital reconstruction or selective botu- unilateral eye motion, the eye should be
diplopia in the primary and downward linum toxin injections, there should be a anesthetized topically and a forced duction
gazes usually resolves along with the 6- to 12-month waiting period for the test performed. Occasionally the entrap-
edema in 7 to 10 days. Slight diplopia in diplopia to stabilize. Then, any residual ment or incarceration of the supporting
extreme peripheral fields of gaze may per- and stable diplopia can be addressed with structures or muscles is mild, and during
sist for months but is rarely problematic strabismus (extraocular muscle) surgery. the forced duction, initial resistance may
since individuals seldom require these Strabismus surgery has two basic maneu- be encountered and then relieved. In such
extreme views for everyday function. Also vers: a repositioning of muscle insertions an instance, the positive forced duction test
the patient may complain that the phe- onto the sclera or a weakening of the was both diagnostic and therapeutic. How-
nomenon is transitory and that sudden opposing muscles. After a period of heal- ever, if the forced duction test is positive
looking upward and outward (superior- ing, selective botulinum toxin injections and mimics the voluntary active point of
ly and laterally, such as when looking in a or more minor revision strabismus restricted motion, this should be correlated
rearview mirror) may cause instantaneous surgery may be required to fine-tune the with CT scan findings (see Figure 24-3).37
but brief diplopia. Binocular vision with- result. The important point to stress is that A repeatable fixed point of limitation is
out diplopia is most important in the pri- a healed abnormal bony wall position or usually due to direct entrapment of the
mary (straight-ahead) and downward orbital volume changes, resulting in extraocular muscles or the capsulopalpe-
fields of gaze. The majority of our daily enophthalmos or vertical dystopia, typi- bral fascia (fascia of Tenon). This is more
activities, such as conversing, reading, and cally do not cause stable significant common in linear floor fractures than in
walking, use these visual fields. If diplopia diplopia. In fact, vertical dystopia of up to comminuted multiple wall fractures.
Orbital and Ocular Trauma 475
Patients with muscle or Tenon capsule lacrimal drainage system injury, canthal defatted skin graft for primary recon-
incarceration confirmed by CT are candi- tendon disruption, or injury to the tarsal struction (Figure 24-10).
dates for urgent exploration and repair plate and levator aponeurosis. After
(within 12 h). Prolonged muscle entrap- antibiotics and tetanus prophylaxis have Lacrimal Injuries
ment with ischemia can lead to fibrosis been administered as necessary, the wound Injuries to the lacrimal drainage system
(Volkmanns contracture) with permanent should be cleansed and dbrided, taking most often result from direct eyelid lacera-
diplopia, despite surgical release of the care to protect the globe, possibly with a tions at the medial edge of the lid, which
entrapped tissues. When exploring these contact lens. The eyelid laceration should traverse the lid margin and disrupt the infe-
fractures, the entrapped fascia or muscle be repaired in a layered fashion, starting rior canaliculus. Canalicular lacerations
can be difficult to release. This classically with the tarsal plate repair (with 6-0 also occur indirectly when strong forces are
occurs in the pediatric patient with an polyglycolic acid), lid margin (two to three applied to the lateral aspect of the lids. This
anteroposterior linear fracture of the interrupted sutures with 6-0 silk, which is tension directed laterally causes the eyelid
orbital floor with no accompanying rim nonirritating to the cornea), orbicularis to split at the weakest point, which is just
fracture. When an area of resistance is muscle re-apposition (multiple 6-0 plain medial to the punctum (Figure 24-11).
encountered initially and correlates to this gut sutures), and finally skin (with 6-0 Damage to the lacrimal drainage system
same anatomic location on CT, then con- nylon or 6-0 fast-absorbing gut). Topical can also be seen with severe medial rim and
sideration should be given to inserting an ophthalmic ointment should be pre- orbital wall fractures. A disruption in the
instrument within the anterior fracture scribed since these agents come in contact lacrimal system can be detected by passing
line and gently twisting or prying to open with the globe frequently, and sutures a lacrimal probe through the punctum and
up the fracture, or taking a fine osteotome should be removed in 5 or 6 days. Patients visualizing the blunt-tipped probe within
or instrument to fracture away a small should be followed up and monitored for the laceration or wound. It is especially
adjacent strip of orbital floor so that a thin potential complications such as scar con- important to detect this with the inferior
blunt malleable retractor on either side of tracture or lid notching. Several weeks canaliculus since this system is dominant in
the entrapped area can gently lift and post repair, if significant lid contracture or the vast majority of patients.
reduce the entrapped soft tissues back into focal thickening is noted, then selective Repair involves reanastomosis of the
the orbit. Direct grasping of the tissues and judicious steroid injections (triamci- canaliculus and either mono- or bicanalic-
tugging to reduce them back into the orbit nolone acetonide, 40 mg/mL) can be ular intubation. With bicanalicular intu-
may result in further contusion and injury. administered with accompanying daily bation, repair is performed by passing a
Diplopia can be due to a central oph- massage by the patient. silicone intubation tube through the
thalmoplegia owing to impairment of cra- In my experience, avulsion or loss of puncta into the laceration and then locat-
nial nerves III, IV, or VI. The fourth nerve eyelid soft tissue is rare. When this ing the distal cut end of the drainage sys-
is the most commonly injured at the point occurs, it is usually from an abrasive tem for passing the tube into the nose,
where it passes over the petrous ridge of crushing macerated-type laceration sus- which is retrieved with a hook beneath the
the temporal bone. This results in vertical tained in such accidents as a rollover in inferior turbinate. Typically both the supe-
diplopia and a compensatory head tilt to an all-terrain vehicle or ejection from a rior and inferior canaliculi are intubated
the opposite shoulder. These nerves have motor vehicle. In evaluating these (usually one is uninjured); both silicone
fairly long intracranial tracts and can be injuries, the examiner should moisten the tubes are passed into the nose and are tied
injured by direct skull fractures or be com- rolled edges of the laceration and attempt to each other. This allows for retention of
pressed by intracranial bleeds or diffuse to gently realign them. One should not the looped tube for 6 to 12 weeks. Intraop-
cerebral edema after blunt head trauma. abnormally align the tissues, borrowing eratively, the silicone tubes are stretched
Cranial nerve palsies often spontaneously them from the periphery and shortening toward the external nares, tied together,
recover within 6 to 9 months. Recovery is them in the vertical dimension. This can and typically oversewn or tied with a fine
quite variable and is dependent on severi- result in lid retraction or lagophthalmos, silk suture to allow for long-term reten-
ty and the type of injury. with risks of corneal exposure and ulcer- tion. If no tension is applied to the cut
ation. It is best either to leave a small ends of the silicone tubing while tying,
Eyelid Lacerations amount of denuded underlying tissues, then, postoperatively, the loop formed at
Eyelid lacerations, particularly those which will reepithelialize secondarily, and the canaliculi puncta will migrate laterally
extending to the lid margin and gray line, possibly perform a temporary tarsorrha- toward the cornea, causing irritation or an
should be thoroughly evaluated for phy, or, for larger defects, to harvest a thin annoying visual field disturbance.
476 Part 4: Maxillofacial Trauma
A B
Telecanthus ment of the more normal narrow intercan- transnasally from the contralateral medial
thal distance. Preoperatively, one should orbital wall and then suturing the medial
Traumatic telecanthus typically results from
determine whether the increased intercan- canthus to the wire loop. The wire is then
severe midfacial trauma (NOE) with dis-
thal distance is due to either a unilateral or a drawn to the opposite side by gradually
placement and splaying of the bones that
bilateral injury. Treatment typically includes twisting the two ends around a short sec-
serve as attachments for the medial canthal
an approach via a coronal incision, a Lynch tion of titanium microplate situated in the
tendons. It is less frequently due to lacera- (lateral nasal) approach, or a combination, opposite medial orbital wall (Figure 24-12).
tion and actual physical disruption and with reduction and fixation of the displaced
disinsertion of the canthal tendons from the bones or direct transnasal wiring. External Nonoperative Management of
underlying bone. Therefore, traumatic tele- splinting rarely yields satisfactory results. Orbital Fractures
canthus from these injuries is best treated I have found that direct canthal tendon Indications for nonoperative or, as it has
early (within 710 d) following injury to reattachment with transnasal wire fixation previously been termed, conservative man-
prevent scarring and secondary maladaptive is best performed by passing a doubled-end agement of orbital fractures has been con-
changes that compromise the reestablish- loop of 30-gauge stainless steel wire troversial for many years. Some historic
Orbital and Ocular Trauma 477
of Ophthalmic, Plastic and Reconstructive within a 30 range of the primary visual ographic finding because it exists is not
Surgery revealed that two-thirds of oculo- (straight-ahead) gaze.49 They based this on satisfactory. The surgeon, with the assis-
plastic surgeons were operating within their findings that there were poor results tance of his ophthalmology colleagues,
2 weeks of injury with few serious compli- when late repairs were performed in this should determine what, if any, functional
cations or sequelae.46 Although this was patient group. deficits and cosmetic deformities exist. A
reassuring that current surgical approach- Clearly the advent and ready availabil- specific anatomic reason for these should
es and techniques were safe, there was no ity of CT for use in diagnosing trapdoor be sought. Then, if the magnitude of the
inquiry into what the criteria or determi- fractures with mechanical impingement of functional deficit or cosmetic deformity
nates were for undertaking surgical repair. the orbital structures helped to refine warrants surgery, the type of surgical
What was helpful was that several ensu- diagnostic capabilities and to aid treat- approach, repair, and materials should
ing studies began to delineate which patients ment planning. Several groups of authors specifically address the structural causes.
exhibiting functional deficits might benefit emphasized the need for correlating a pos- In a patient with the clinical findings of
from surgical exploration as opposed to itive forced duction test with CT evidence only soft indications for surgery, a
observation. Koorneef, in an anatomic study, of incarceration or impingement.50,51 2-week observational period seems pru-
showed that fine connective tissue septa sur- Without specific evidence of a trapdoor dent. Several studies have addressed cos-
rounded the extraocular muscles.47 He advo- phenomenon or direct impingement, metic deformities as they relate to orbital
cated eye movement exercises in patients orbital floor fractures with limited motili- floor fractures, offering indications for
with mild or moderate restrictive motility as ty were observed for 2 weeks. Persistent surgery versus observation. Hawes and
long as there was demonstrated serial symptoms or findings then prompted sur- Dortzbach used tomography and felt that
improvement in motility. He purported that gical intervention. Trapdoor fractures or orbital floor fractures involving > 50% of
edema, hemorrhage, and connective tissue fine linear breaks without rim fractures are the surface area should be reconstructed
entrapment were responsible for the majori- much more common in pediatric patients. within the first 2 weeks to avoid the pre-
ty of limited motility in patients with orbital When severe limitation of movement is dictable development of enophthalmos.49
floor injuries. encountered (typically upward or down- They also stated that patients with smaller
In 1984 Smith and colleagues intro- ward gaze, or both) and is correlated with orbital floor fractures but with > 2 mm of
duced the concept that Volkmanns con- CT findings, this is a true emergency that enophthalmos present at 2 weeks postin-
tracture might occur as a result of elevated should be treated surgically to relieve the jury should undergo orbital floor recon-
intraorbital compartment pressures.48 entrapment as soon as possible. struction. This recommendation is based
Although this phenomenon was well- Since his initial controversial 1974 on the fact that later repair is technically
known, documented, and proven in the article, Putterman has revised his indica- more difficult with less optimal outcomes
orthopedic literature to occur with extrem- tions for surgical intervention.52 Putter- owing to scar contracture and muscle
ities, it was unproven to occur in the orbit. man and his colleagues indications are shortening. Parsons and Mathog were able
Volkmanns contracture is a paresis from now comparable to those of other sur- to demonstrate, using a laboratory model,
muscle shortening and fibrosis that results geons. They advocate 7 days of systemic that orbital floor fracture and displace-
in limited mobility. Applying this concept corticosteroids to speed the resolution of ment of equal magnitude with the medial
to the orbit, Smith and colleagues recom- diplopia within the first 3 weeks. This may wall fracture and displacement had a
mended surgical intervention in the elderly, aid in resolving edema and helping deter- much greater effect on globe position.53
in individuals who are hypotensive, and for mine who might benefit from surgery. This study supports the practice of most
small or linear orbital floor fractures with Although persistent functional limitations surgeons, which is nonsurgical and obser-
coexisting diplopia. They felt that these sit- are usually clear indications for surgery, vational management of isolated displaced
uations left patients at an increased risk for controversy remains in treating those medial wall fractures.
orbital compartment syndrome, thus patients who demonstrate a steady but When orbital fractures are associated
developing permanent limited mobility slow resolution of their diplopia that per- with other facial fractures such as Le Fort or
owing to Volkmann-like contractures. Con- sists beyond 3 weeks. ZMC fractures, several authors have advo-
current with these theories and recommen- When the surgeon is confronted with cated orbital floor exploration and repair
dations was the report by Hawes and any orbital fracture, it is helpful to catego- with any evidence of prolapse of the orbital
Dortzbach that emphasized the need for rize the clinical deficits and goals of surgi- contents into the sinus.54,55 In 1991 Putter-
surgical repair within 2 weeks following cal treatment as being either functional or man and colleagues advocated following
injury in patients with persistent diplopia cosmetic. Simply operating on a radi- patients closely for the development of
Orbital and Ocular Trauma 479
enophthalmos, using objective measure- function, diplopia and decreased visual ures or who have NLPthe fine-cut axial
ment with a Hertel exophthalmometer, or acuity are the two main areas of concern. CT scans of the orbital apex and canal
serial measurements for vertical dystopia by The majority of surgeons and articles in should be reviewed with the radiologist to
aligning the top of a clear ruler to both published literature support early surgical determine whether there is bony mechan-
undisturbed medial canthi and noting intervention in a patient with an orbital ical impingement, hematoma, and/or
where the ruler bisects each eye.52 Despite floor fracture that has mechanical restric- edema compressing the optic nerve or vas-
numerous reports, clinical series, and tion of gaze and a positive forced duction cular supply. With the increasing popular-
author suggestions, controversy still test with a CT scan that has a trapdoor ity of endoscopic approaches to the cranial
remains regarding the management appearance or suggestions of inferior rec- base (typically for tumor removal), most
of those patients who develop only tus muscle incarceration.56,57 This phe- major medical centers have neurosurgeons
mild enophthalmos or hypo-opthalmos nomenon occurs more in children with and/or otolaryngology head and neck spe-
(12 mm) without any functional deficits linear fractures owing to the elasticity of cialists that are competent in performing
during the acute observational period. their bones.58 Pediatric or adult patients transnasal endoscopic optic canal decom-
with these findings warrant early interven- pression. If at all possible, this should per-
Operative Management of tion to free up the tissues and hopefully formed within 12 to 24 hours of the con-
Orbital Fractures prevent any permanent restriction owing firmed diagnosis of external optic nerve
to ischemic necrosis or scar contracture. In compression within the canal proper.
Indications patients with less impressive restrictive Cosmetic deformities such as enoph-
It is imperative that the surgeon has a com- motility (1015), a positive forced duc- thalmos or hypo-ophthalmos result from a
plete understanding of the mechanism of tion test, and no CT evidence of muscle bony orbital volume increase, extrusion of
injury and potential complications to make entrapment, an observational period of intraconal fat into extraconal spaces, or
a full diagnosis and an appropriate treat- several weeks is reasonable. These patients prolapse of orbital contents into the maxil-
ment plan in each type of orbital fracture. may only have entrapment of some of the lary sinus or ethmoid air cells. Contrary to
Patients with a suspected or known orbital fine connective tissue septa supporting the long-standing dogma, post-traumatic fat
fracture should undergo thorough clinical globe, and with routine daily function atrophy does not play a significant role in
examination, including fundoscopic exam- and/or eye exercises, this restriction typi- the development of these deformities.59
ination; visual acuity; pupillary reactivity; cally steadily improves. Clinical follow-up Most surgeons currently undertake surgi-
detection of diplopia, extraocular move- with a series of examinations (two or cal intervention in orbital floor reconstruc-
ment with any limitations noted, enoph- three) within the first 14 days, steroid ther- tion if there is 2 to 3 mm or greater of
thalmos, and vertical dystopia; forced duc- apy, and eye movement exercises should enophthalmos or hypo-ophthalmos in the
tion testing; and recording of paresthesias. optimize the outcome. In any patient with presence of orbital edema or hematoma.
Radiographic studies should determine the an orbital fracture that has persistent The rationale is that early repair offers the
full extent of the orbital fracture and any mechanical restriction or diplopia within most favorable outcome and that the cos-
surrounding and associated facial fractures. 30 of their primary gaze, especially the metic deformity only worsens as the edema
CT scans, especially in the direct coronal downgaze (used during reading), surgical and hematoma resolve. Orbital floor
plane, are the gold standard for use in exploration is warranted. Prior to under- defects of greater than half of the surface
orbital surgery treatment planning. Con- taking surgery, however, any neurogenic or area with concomitant CT evidence of the
traindications for surgery are hyphema, central component should be ruled out. disruption or prolapse into the underlining
retinal tears, globe perforation, the patient Although infrequently employed, elec- antrum generally should be repaired.
sees only with the eye on the injured side, tromyography can be used to distinguish Again, the rationale for this is that as the
and life-threatening instability. neurogenic diplopia from mechanical edema resolves, eventually there is some
Indications for surgery can be divided restriction in problematic or brain-injured degree of enophthalmos or vertical
into functional and cosmetic categories. A patients. Neurogenic or neuromuscular dystopia that creates a cosmetically unac-
logical systematic approach is prudent in injuries are more suitably treated by stra- ceptable or, less frequently, functional prob-
selecting patients who are suitable for bismus surgery. With regard to decreased lem requiring surgery. With minimal floor
acute or early surgical repair versus those visual acuity, an ophthalmologist should disruption (< 50%) and no entrapment or
who deserve an observational period with assess the patient serially for resolution or significant herniation, observation for 2
intervention when signs or symptoms improvement. In more severe cases weeks is prudent. If the patient develops
warrant it (Figure 24-13). With regard to patients who can only see shadows or fig- any functional problems or enophthalmos
480 Part 4: Maxillofacial Trauma
() Forced duction test (+) Forced duction test Enophthalmos or Normal globe position
inferior dystopia
Younger Follow
Emergent Surgical > 50% floor < 50% floor
normotensive clinically
exploration exploration defect or soft defect
patient with serial tissue prolapse
examinations
Serial examinations,
eye exercises, and Steroids and follow-up
steroids for 710 d clinically for 14 d
Evidence of No evidence of
neuromuscular neuromuscular No surgery Orbital floor reconstruction No surgery
injury (by forced injury
generation and
retraction test)
Strabismus Surgical
surgery exploration
FIGURE 24-13 Orbital floor fracture evaluation and treatment decision diagram. CT = computed tomography; () = negative; (+) = positive.
> 2 mm, then surgery can be undertaken to of the anatomic areas need to be accessed Inferior and Lateral Orbital Approaches
treat the functional or cosmetic defect. with direct visualization and which intact There are three basic incisions used for
Unnecessary delays approaching 6 weeks bony edges or landmarks need to be found accessing the orbital floor: the infraorbital,
and beyond make the surgical repair more or fixated to accomplish the repair. This subciliary, and transconjunctival (Figure 24-
difficult and the ultimate outcome less helps the surgeon determine which soft 14). Although there are three basic
desirable owing to scarring and muscle tissue incision should be employed. In approaches, there are numerous technical
shortening. general, most surgeons prefer to first variations based on surgical training and
grossly reduce and usually fixate all perior- individual preference. Clearly the subciliary
Surgical Approaches bital and facial fractures prior to accom- and transconjunctival incisions are the most
Once it has been determined a patient plishing internal orbital repairs. The most popular owing to their superior esthetics
requires surgical intervention, a well- commonly used surgical approaches and and generous access, and the fact that sur-
thought-out plan and sequential approach methods of reconstruction are presented geons are familiar with their use. It is my
should be developed. Of paramount here so that the surgeon can make an indi- opinion that the infraorbital or rim incision
importance is the determination of which vidualized and informed decision. results in the worst esthetics and offers no
Orbital and Ocular Trauma 481
Subciliary incision
Tarsal plate
Subtarsal incision
Orbital septum
Fornix incision
Capsulopalpebral
fascial extension
(inferior lid retractors)
Rim incision
Whitnall's inferior
suspensory ligament
FIGURE 24-14 Cross-sectional view of the inferior lid and various floor approach incisions. Adapted from
Ochs MW, Johns FR. Orbital trauma. In: Fonseca RJ, Marciani RD, Hendler BH, editors. Oral and max-
illofacial surgery: trauma. Vol 3. Philadelphia (PA): W.B. Saunders; 2000. p. 208.
advantages over the two former approaches; marginalis. The periosteum of the orbital the same level as the periosteal incision.
therefore, it should not be employed. rim is then reflected upward and inward, This approach is used less often owing to
The subciliary incision was popular- and dissection is carried out over the the amount of stretching on the unsup-
ized by Converse in 1944.60 Typically a orbital rim. One must bear in mind that ported large skin flap and the resultant
gently curved linear skin incision is made the orbital floor drops off several millime- high rate of ectropion (permanent in 8%)
several millimeters below the lid edge or ters toward the inferior direction prior to and potential skin necrosis, particularly in
eyelash margin, preferably in a skin crease. heading straight posteriorly. The orbital the elderly patient who has a history of
The skin flap is then undermined in an floor dissection can then be extended pos- heavy smoking.61 These complications
inferior direction for several millimeters teriorly for a safe distance of 30 mm. With prompted the development of an alterna-
before traversing deeper inward directly an intact adult rim, the optic canal is only tive technique called the skin-muscle
through the orbicularis oculi muscle fibers 40 mm from the anterior lacrimal crest, flap. With this procedure a similar inci-
and stopping when the orbital septum is and with any rim displacement inward, sion is accomplished 1 to 2 mm below the
encountered. The rationale for the divi- this margin of safety is further decreased. lid margin but is carried through both the
sion of the skin and muscle at different A modification of the subciliary approach skin and muscle at the same level down to
levels (stepping the incision lines) is that it is the skin only incision. This technique the tarsal plate. Again, the plane of dissec-
helps to prevent direct or full-thickness is comparable to the technique just tion is carried out anterior or superficial to
scarring and tethering of the eyelid. Once described, except that after dividing the the orbital septum (preseptal) until the
the orbital septum has been encountered, skin, the inferior dissection is carried out orbital rim is encountered. This approach
the preseptal approach is then carried out superficially to the orbicularis oculi mus- results in excellent esthetics, a simplified
inferiorly to the orbital rim, and the cle fibers until the inferior orbital rim is dissection, and a decreased incidence of
periosteum is incised just below the arcus reached, and then the muscle is divided at hematoma formation or skin necrosis.
482 Part 4: Maxillofacial Trauma
This skin-muscle flap still carries a 6% rate performed rather than an inappropriate common approaches used for the lateral
of early ectropion62; however, it is general- tethering of more superficial or superior orbital rim or ZF suture area. The other
ly temporary and resolves within several eyelid layers and structures to the underly- incisions described are used more often
weeks with gentle massage. This was con- ing rim. Many instances of early ectropi- when extensive facial fractures are present
firmed by several investigators who corre- on or a shortened lid are the result of that require extensive skeletal exposure of
lated preoperative periorbital edema and improper suturing. The transconjunctival the superior rim, cranial vault, or zygo-
increased age positively with the develop- preseptal approach enjoys a low incidence matic arch.
ment of this temporary ectropion with the of unfavorable scarring with ectropion or The lateral brow incision is placed on
subciliary approach.63 A revision of this entropion (1.2%).55 However, one draw- the extreme outer aspect of the eyebrow,
approach or technique is to use a relaxed back to this approach remains a some- usually just superior to the ZF suture. The
skin tension line incision. what-limited view during the preseptal ZF suture line is usually approximately
The transconjunctival approach for dissection and limited exposure once the 1 cm above the lateral canthus. Generally,
orbital floor fractures was first popular- orbital floor has been accessed. For this the skin of the lateral brow is tented over
ized by Tessier and Converse and col- reason, the lateral canthotomy and com- the superior lateral orbital rim, and a
leagues in 1973 for orbital floor frac- plete severance of the lower limb of the 1.5 cm curvilinear incision is made in a
tures.64,65 The two basic variations of this lateral canthal tendon (inferior cantholy- beveled fashion paralleling the hair folli-
approach to the orbital rim are retroseptal sis) was introduced by McCord and Moses cles. Double-pronged skin hooks are then
or preseptal approaches. Although the ret- in 1979.68 This procedure allows for a gen- placed on the skin margins, and traction is
roseptal approach is a more direct erous tension-free exposure to the orbital maintained with digital palpation of the
approach to the rim, it exposes the orbital floor, lateral orbital wall, and medial area. internal edge of the orbital rim. The skin
fat, which herniates into the surgical field The surgical exposure obtained with the incision opening is then gently retracted
and may interfere with the surgery and transconjunctival approach with the infe- inferolaterally more directly over the ZF
result in more fat atrophy, especially with rior cantholysis is superior to that of a suture, and a needle-tipped Bovie cautery
cautery, and hence enophthalmos. For this subciliary incision. Also, the much smaller is used to divide the orbicularis oculi mus-
reason, the preseptal approach is generally cutaneous incision is placed in a more cle fibers overlying the rim and ZF suture.
favored.66 The preseptal approach (see Fig- favorable area of the crows-feet. Additional undermining and dissection is
ure 24-14) as described by Tessier involves The majority of surgeons currently carried out in an inferolateral direction to
an incision through the palpebral con- use the transconjunctival incision with or provide full and adequate access to the
junctiva just 2 to 3 mm below the inferior without canthotomy or the subciliary inci- fracture and enough adjacent bone to
edge of the tarsus that is extended through sion (preseptal approach) for orbital rim allow for rigid fixation. The advantages of
the inferior lid retractors and orbital sep- and floor access.69 Both of these basic inci- not extending the skin incision beyond the
tum.64 Next, a preseptal vertical dissection sions provide good exposure with excel- brow obviously involve esthetics (placing
is carried out down several millimeters lent esthetics and an extremely low rate of it in the well-camouflaged and hidden area
below the orbital rim, and the periosteum complications. Each surgeons own train- of the hair follicles) but also include that
is incised. The dissection of the facial ing, familiarity, and personal preference the skin is stepped and muscle incisions
aspect of the rim and the floor is then car- should guide which rim approach is used. are made in distinct layers, which provide
ried out. This obviates orbital fat hernia- for more favorable healing. This incision
tion in a fairly bloodless field. The necessi- Superior and Medial Orbital Approaches also allows access for placing a blunt
ty for a periosteal closure is controversial Access to the superior orbital rim and curved instrument deep to the zygomatic
owing to the possibility of entropion or zygomaticofrontal (ZF) suture can be arch for the reduction of the ZMC or arch
ectropion with inadvertent suturing of the accomplished via a lateral eyebrow inci- fractures. Closure should be accomplished
periosteum to the orbital septum or other sion, upper blepharoplasty incision, coro- in three distinct layers of periosteum, sub-
layers.64,67 Some surgeons advocate a Frost nal incision, or lateral canthotomy inci- cutaneous tissue, and skin. The periosteal,
suture for a period of 24 to 48 hours to sion that is an extension of a subciliary or muscle, and deep subcutaneous closures
allow for proper lower lid redraping dur- transconjunctival incision with a superior are particularly important in that they
ing early healing. Most surgeons find this cantholysis. The eyebrow incision, if per- provide the bulk of soft tissue over any
unnecessary. If there is any difficulty in formed properly, results in excellent plates and screws in the region.
identifying opposing edges of the cut esthetics and is quickly and easily per- The upper blepharoplasty incision can
periosteum, then no suturing should be formed; therefore, it is one of the more also be used for access to the ZF suture.
Orbital and Ocular Trauma 483
The incision is placed in one of the upper removal. Local anesthesia with vasocon- rotica, subcutaneous buried suturing, and
eyelid skin creases, preferably the deepest strictors is helpful for hemostasis and closure of the skin. It is important to
crease (which can be marked preopera- often obviates the need for compression remember that when a hemicoronal inci-
tively, with the patient awake). The skin (Raney) clips. The incision is carried out sion is employed, the medial extent of the
incision is then carried down through sub- through the skin, subcutaneous connec- incision should be carried beyond the
cutaneous tissue, retracted somewhat lat- tive tissue, and galea aponeurotica into the midsagittal plane and extended complete-
erally, and extended through the orbicu- loose areolar tissue in the midline. The ly to the hairline. This allows for adequate
laris oculi and periosteum by sharp subgaleal plane of dissection is contiguous reflection and retraction over the entire
dissection. Generally a 1 cm length of the with a plane deep to the parietotemporal zygoma and orbital rim structures.
lateral blepharoplasty incision is all that is fascia in the area of the temporalis muscle. When a transconjunctival incision is
required for complete access to the lateral The incision is then extended laterally in used with a lateral canthotomy, an exten-
orbital rim. This is due to the suppleness the supraperiosteal plane; it is helpful to sion of the dissection superiorly can be
and mobility of the thin eyelid skin. Care insert a Metzenbaum or curved Mayo scis- used for access to the ZF suture by severing
should be taken to not over-retract the tis- sors in this plane prior to extending the the superior limb of the canthal tendon.67
sue, and the skin incision should be incision laterally. This prevents inadver- This approach provides good access to the
extended slightly laterally if excessive tent incising or nicking of the temporalis lateral and infraorbital skeleton; however, it
retraction forces are apparent. Separate in an otherwise dry field. The dissection is is less frequently used because it requires a
suturing of the periosteum and skin are all carried out laterally to the superior tem- more complex closure and re-anchoring of
that is required. poral line bilaterally. Dissection is then the lateral canthal tendon complex. Any
The coronal incision allows for excel- carried anteriorly to the frontal bone, and misalignment results in canthal dystopia,
lent access to the entire supraorbital rim, a horizontal incision is made through the usually in an inferior direction, and a
roof, frontal sinus, superior aspects of the periosteum approximately 2 cm above the rounded-out almond-shaped eye appear-
nasal bone, lateral orbital rim and wall, superior orbital rim. The incision is car- ance. If the superior canthal tendon and its
medial orbital rim and wall, and zygomat- ried laterally to the superior temporal line origin to the internal rim are allowed to
ic arch.70 This approach is generally neces- and joined with the preauricular area infe- remain intact, it provides a highly reliable
sary for extensive facial fractures involving riorly through the superficial layer of the landmark to which the inferior canthal
the zygoma, frontal sinus, and NOE com- deep temporal fascia to protect the tempo- limb can be sewn, resulting in excellent
plex and for Le Fort III fractures. Numer- ral and frontal branches of the facial sharp-angled (3040) esthetics.
ous variations of the incision design exist, nerve.71 The facial nerve courses in a plane The entire lateral wall and rim is easi-
but generally a curvilinear incision is superficial to the deep temporal fascia ly accessed through a standard blepharo-
placed at least 2 cm posterior to the hair- approximately 1 to 3 cm from the tragus plasty incision that extends only to the lat-
line (in the midline) and then extended along the zygomatic arch.72 This approach eral orbital rim. This approach is
posteriorly, paralleling the hairline, and provides complete access to the medial, commonly used for lateral orbital decom-
finally inferiorly into the preauricular lateral, and superior orbital rims. When a pressions in cases of severe thyroid
region. It is generally helpful to carry the more extensive view of the medial orbital orbitopathy and it affords excellent expo-
vertical component of the coronal incision wall is required, subperiosteal dissection sure also to portions of the orbital roof
overlying the temporalis muscle just pos- and release of the superior trochlea can be and to the apex of the orbit laterally.
terior to the junction of the superior helix performedthe flap is retracted more
and the scalp. It is then sharply angled for- inferiorly over the nasal dorsum, with a Medial Orbital Approaches Access to
ward, hugging the anterior helix and direct view of the medial wall. No attempts the medial orbital rim and superior aspect
preauricular skin crease down to the pre- should be made to re-attach the trochlea of the medial orbital wall can be accom-
tragal area. By doing so, the superficial since, when the soft tissues are re-draped, plished through a coronal incision, as pre-
temporal vessels are generally not encoun- the trochlea re-adheres on its own. Sutur- viously described. However, a separate lat-
tered or violated and retracted forward ing may actually pierce or violate the eral nasal incision can be used for isolated
with the flap, allowing for a much drier trochlear tendon and result in ocular medial wall exploration or to access the
field. It is not necessary to shave the scalp, motility disturbances. Closure of the coro- inferior aspect of the medial orbital floor.
but a 1 cm area of hair can be trimmed at nal flap should include suspending the This can be a transconjunctival or subcil-
the incision to allow for ease of closure, deep temporal fascia over the temporalis iary approach to the inferior rim and floor.
postoperative hygiene, and suture muscle, deep closure of the galea aponeu- The entire medial wall can be visualized by
484 Part 4: Maxillofacial Trauma
extending the transconjunctival incision need to step these layers. The periosteum Linear fractures are generally caused
through the caruncle. The medial orbital can then be reflected posteriorly and supe- by blunt forces directly to the globe or par-
wall and rim, by definition, are involved in riorly to the medial orbital rim and wall. tially to the rim and most often result in an
fractures of the NOE complex, Le Fort II The medial canthal tendon and lacrimal esthetic deformity such as enophthalmos
and III fractures, extensive frontal sinus sac lie posterior and just inferior to the or hypo-ophthalmos. Functional deformi-
fractures, and, occasionally, large blow-out incision. The anterior ethmoidal vessels lie ties with entrapment are less common with
fractures. The lateral nasal incision is most posteriorly and superiorly approximately linear orbital fractures. However, isolated
often used for access to the medial orbital 24 mm from the anterior lacrimal crest. linear fractures can have an instantaneous
rim to reconstruct a detached medial can- These vessels can be gently divided with trapdoor effect owing to momentary
thal tendon with direct transnasal wiring. bipolar cautery, providing excellent hemo- expansion and entrap the edge of soft tis-
This type of injury often occurs with NOE stasis and improved access for identifying sues including the inferior rectus. Once
fractures and Le Fort III fractures. As stat- an intact bony ledge. However, one should tightly pinched between these bony seg-
ed earlier, medial orbital wall fractures bear in mind that any bony violation or ments, this manifests itself as severe ocular
generally do not result in any entrapment entry superior to this line carries the motility restriction that is reproducible on
or ocular mobility problems. Generally the potential risk for entry into the anterior serial examinations at the same point of
upper one-third of the medial orbital wall cranial fossa. When an orbital implant is limitation. There is also a positive result to
is uninvolved or nondisplaced, simply required along the medial wall, anterior the forced duction test. This type of frac-
because it is the very thick extension of the fixation of the implant is recommended. ture necessitates immediate surgical inter-
cranial base. The lower two-thirds of the vention to prevent the ischemic necrosis of
medial orbital wall overlie the ethmoid air Acute Repair the extraocular muscles. The majority of
cells and can be displaced inward, result- Internal orbital fractures have varied pat- linear fractures in the orbit do not result in
ing in volume expansion. Unless there is terns and degrees of severity. It is helpful esthetic deformities such as enophthalmos
extensive involvement, generally the to attempt to classify them either as linear, or hypo-ophthalmos unless there is an
resulting increase in orbital volume does blow-out, or complex fractures. Linear associated facial fracture such as a frac-
not result in the development of enoph- fractures are those in which the bone frag- tured ZMC with a medial and downward
thalmos. If the inferior two-thirds of the ments and walls remain intact. However, rotation. It is the volume changes that
medial wall or orbital floor are involved owing to angulation or overlap, they may account for the abnormal globe position.
and require surgical repair, then the previ- result in either a bony orbital volume The goal of reconstruction is to restore the
ously described approaches to the orbital increase or decrease. Overlap fractures anatomic position of the bony rim and
floor should suffice. However, fractures general result in a bony defect of one associated facial bones and to reapproxi-
that extend farther superiorly (above the orbital wall (typically the medial orbital mate, to the best of ones ability, the nor-
frontoethmoidal suture/anterior eth- floor) and are the most common orbital mal bony orbital volume with a recon-
moidal foramen) may require a lateral fracture. Blow-in fractures can occur in structive material. Numerous materials
nasal approach or coronal incision. The any orbital wall but most commonly occur have been described in the literature for
lateral nasal approach involves a vertical in the roof and are associated with frontal these purposes, such as porous polyethyl-
gentle curvilinear 1 cm incision approxi- sinus fractures. Blow-in and blow-out ene, bioresorbable polydioxanone, nylon,
mately 5 to 10 mm medial to the insertion fractures of the orbital roof occur with gelatin film, titanium mesh, and autoge-
of the medial canthus. Care should be equal frequency. Complex fractures are nous bone grafts (split-thickness calvarium
taken not to place this incision too close to those that involve two or more walls, are and, less frequently, iliac crest).7379 Each
the medial canthus as this can result in a > 2 cm in diameter, or are comminuted material has advantages and disadvantages
scar contracture with webbing and an with displaced and unretrievable segments. related to the strength, application, reactiv-
abnormal epicanthal fold postoperatively. Often these complex fractures are associat- ity, infection rate, biointegration, and com-
The incision should be placed over the lat- ed with fractures that extend beyond the plication rate associated with its use.
eral nasal structures properly, and after the orbital frame such as Le Fort II or III and For linear and blow-out fractures, I
skin incision is made, the dissection frontal sinus fractures. These are termed prefer to use thin (0.85 mm) porous poly-
should be carried straight medially combined fractures. The goals of acute or ethylene sheeting. This alloplastic material
through skin, subcutaneous tissue, and a primary reconstruction of primary orbital is extremely biocompatible and nonresorp-
rudimentary portion of the orbicularis fractures are to alleviate any functional tive. It has more than adequate tensile
oculi muscle and periosteum. There is no deficit and to restore the facial esthetics. strength and does not cause any capsule
Orbital and Ocular Trauma 485
formation such as that seen with polymeric because intact internal medial or posterior ones awareness of the potential for serious
silicone sheeting. It has considerable flexi- bony margins have not been identified or globe injury when dealing with isolated or
bility (which can be improved with place- accessed. However, the possibility of unac- pure blow-out fractures.
ment in an autoclaved saline) and little ceptable postoperative scarring to the The goal of primary reconstruction of
memory properties. The pore size allows mesh may occur, resulting in limited ocu- blow-out fractures is to restore the config-
tissue ingrowth, which reduces the risk of lar motility. Therefore, when titanium uration of the orbital walls, return pro-
migration.80 However, I still recommend mesh is employed, I still prefer to overlay it lapsed orbital contents to the orbit proper,
anchoring the porous polyethylene sheet- with either a split-thickness calvarial graft and eliminate any impingement or entrap-
ing to the anterior lateral orbital floor with or a sheet of porous polyethylene sheeting. ment of orbital soft tissues. In contrast to
a single titanium screw (Figure 24-15). The These materials are secured to the under- the orbital floor blow-out fractures, isolat-
greatest advantages of this material are its lying mesh with either 30-gauge stainless ed blow-out fractures to the roof or medi-
ease of contouring, in situ carving, burring, steel wire or suturing. al walls usually do not contribute signifi-
and that it can be layered posteriorly Blow-out fractures typically involve cantly to the development of cosmetic
behind the orbital equator to achieve prop- one orbital wall (usually the anterior or deformities or result in entrapment or
er orbital volume and contour.52 medial portion of the orbital floor) and limited ocular motility. As a result, medial
Titanium mesh, with fixation to sur- are < 2 cm in diameter. Enophthalmos and roof defects are managed by observa-
rounding intact orbital rims, is quite use- associated with orbital blow-out fractures tion, serial examinations, and intervention
ful when there are severe or comminuted is due to an enlargement of the orbital when symptoms warrant. The most diffi-
injuries and a cantilevering is required bony volume that allows the orbital fat to cult area of the orbital floor blow-out frac-
be distributed within a larger compart- ture to repair is the posterior medial
ment.39 Fat atrophy contributes little, if extent, which is beyond the globe axis.
anything, to the development of early or Often, an intact bony ledge cannot be
late enophthalmos.81 The reverse mecha- identified or the graft material is not
nism, often referred to as blow-in fracture, extended posteriorly enough to support
may result in a decreased orbital volume. the orbital contents in this region. This
Exophthalmos and ocular motility distur- area is often responsible for a failed
bances are uncommon unless there are enophthalmos repair in orbital blow-out
surrounding severe associated fractures fractures. It is the reconstruction of this
such as ZMC or frontal sinus fractures. posterior medial floor to its normal con-
In 1960 Converse and Smith intro- tour that is the key to restoring normal
A
duced the concept of pure (isolated globe position both anteroposteriorly and
floor) and impure (floor and rim) blow- vertically. It is this scenario that is prob-
out fractures.39 Pure fractures are thought lematic in delayed reconstructions since
to be caused by a sudden instantaneous attempts to create a normal anteroposteri-
increase in intraorbital pressures from or position of the globe may result in inap-
direct blunt-force trauma to the globe propriate overpositioning of the globe in a
itself. Impure fractures are purported to be superior direction. I prefer to use gelatin
caused by direct trauma and compression film as a temporary barrier for small or
of the bony rim and collapse of the sur- linear defects, simply to prevent entrap-
rounding facial bones, and result in the dis- ment during normal active ocular motion.
B
ruption of the internal orbital walls. What This film is resorbed rather rapidly and
FIGURE 24-15 A, Right inferior orbital rim and is most disconcerting is the finding of asso- does not provide much structural support;
floor fracture reduced and fixated with a 1.7 mm ciated globe trauma such as hyphema, iri- therefore, it is not used for larger defects in
microplate. A portion of the mid-rim was suc-
tioned away from the antrum and was missing. doplegia (ciliary body paralysis), and reti- which herniation of contents into the
B, The floor defect was reconstructed with 0.85 mm nal hemorrhage in 90% of patients with underlying sinus is a possibility. Generally,
thick porous polyethylene sheeting secured with a pure blow-out fractures. This supports the the orbital blow-out fracture is explored in
single 4 mm long 1.7 mm screw at the anterior notion that pure blow-out fractures are all of the intact bony walls identified. Once
lateral intact floor. A tab extension of the sheeting
was fashioned at the rim defect, curved, and created by substantial instantaneous direct the malleable ribbon or globe retractors
secured with a 5-0 nylon mattress suture. globe trauma. This fact should heighten have supported the globe and orbital
486 Part 4: Maxillofacial Trauma
contents superiorly, then the reconstruc- Complex orbital fractures are general- also completely dissect and expose all
tive material can be slid underneath them ly associated with additional surrounding internal orbital fractures prior to fixation
and overlap the intact bony margins midfacial and frontal sinus fractures. Pri- of the surrounding periorbital or midfa-
slightly at the majority of areas to provide mary reconstruction of these defects is cial fractures. Generally the orbital rim is
adequate support. I prefer to use porous challenging owing to the extent of these plated with 1.7 mm or finer plating sys-
polyethylene for moderate to large blow- injuries, the lack of any normal identifi- tems. Care should be taken at the inferior
out fractures. The porous polyethylene able anatomy, and poor surrounding bony orbital rim and especially the lateral
sheeting can be secured with a single posi- support for rigid fixation and anchoring orbital rim to keep the plates several mil-
tional screw (usually 1.7 mm external of reconstructive materials. However, it is limeters from the edge of the rim; other-
thread diameter) or an extended tab of in this group of individuals that primary wise, they will be annoyingly palpable
this material can be sutured to the orbital repair with normal anatomic realignment once the soft tissue edema has subsided.
rim orbital plate (see Figure 24-15). Care is critical for acceptable esthetic and func- Once the orbital rims and midfacial bones
should be taken to not extend the grafts up tional outcomes. Delaying the primary have been fixated, the moderate to large
to the orbital rim or over the edge since repair beyond 7 to 10 days usually results orbital floor defects are generally repaired
these will be palpable and would improp- in some secondary soft tissue changes, the with porous polyethylene and anchored to
erly reconstruct the normal anatomic con- inability to completely retrieve small bony the anterior inferior floor with a single
tour to the floor, which should dip down segments, and a less-than-desirable out- screw. Sometimes layering of this material
behind the rim for several millimeters come. The initial step in the reconstruc- with an additional sheet posteriorly is
before proceeding posteriorly. Also, the tion of complex facial fractures is adequate required to achieve correct anteroposteri-
extension of semirigid grafts onto the exposure of all midfacial structures with or globe positioning. More extensive
orbital rim has an undesirable ramping adequate alignment and reduction prior to defects may require titanium mesh or
effect, which tends to position the globe in rigid fixation of any components with orbital floor plates with screw fixation to
an abnormal posterior direction, resulting plates and screws (Figure 24-16). This the rims and autogenous bone grafts. Sev-
in enophthalmos. After the floor graft is helps one avoid misalignment, over- eral bone grafts can be secured to the
placed and secured, trimming or smooth- reduction, or improper angulation of metallic mesh framework to independent-
ing should be accomplished and a forced these segments. Achieving adequate expo- ly reconstruct the floor, medial wall, and,
duction test performed prior to any sure requires more extensive subperiosteal less frequently, the lateral orbital walls.
wound closure to ensure that no impinge- dissection than is done for most other The advantage of having bone overlie the
ment of the soft tissues has occurred. orbital fractures. It may be desirable to metallic mesh is that remodeling can
A B C
FIGURE 24-16 A, An elderly female sustained a severely displaced left zygomatic complex (ZMC) fracture with > 75% orbital floor disruption. She was on
warfarin sodium and had moderately decreased left visual acuity with increased ocular pressures. B, Axial CT scan revealed a ZMC fracture with a severe pos-
terior, medial, and moderate inferior displacement. C, The patient was taken urgently (within 12 h) for surgical treatment to reduce the fracture and re-expand
the orbital volume. Serial examination and ocular pressure checks were performed every 2 hours pre- and postoperatively. Owing to cardiac risk factors, the
anticoagulation was not reversed, nor was the patient treated with fresh frozen plasma. The zygomaticofrontal (ZF) suture area was first approached through
a lateral brow incision. After the intraoral vestibular and then transconjunctival approaches were accomplished, the ZF fracture was plated. (CONTINUED)
Orbital and Ocular Trauma 487
D E F
occursecondary revision surgery is large defects with comminution, overcor- by several millimeters is often necessary to
enhanced when dissecting along a healed rection of the enophthalmos component take into account the orbital edema that
bony surface versus bare mesh. In severe or (but not a hyper-ophthalmic deformity) exists. In addition, with bone grafts, some
488 Part 4: Maxillofacial Trauma
mild resorption can take place with subtle rounding anatomy is obscured. This pro- the bony segments. Therefore, proper
settling. However, it is the resolution of the phylactic intubation of the superior and reduction and fixation of the bony skeleton
edema that accounts for the majority of inferior canaliculi and the lacrimal system to the surrounding stable bone (maxilla,
postoperative globe position changes. helps to avoid iatrogenic injury during the orbital, and frontal) often corrects the tele-
ZMC fractures are second only to extensive dissection required to treat this canthus deformity. This should be accom-
nasal fractures in incidence. These frac- type of injury. The tubes can be allowed to plished and the medial canthal position
tures are described in greater detail in remain in place several weeks postopera- reassessed. If the canthal position is still
Chapter 23.2, Management of Zygomat- tively during the resolution of edema. unacceptable, then a fine stainless steel wire
ic Complex Fractures and Chapter 25, Repair of NOE injuries is recommended (30-gauge) can be secured directly to the
Management of Frontal Sinus and Naso- within the first 7 to 10 days after injury, canthal tendon or preferably, sutured to the
orbitoethmoid Complex Fractures. before the soft tissues have had the chance wire that has been passed transnasally.
Some discussion is warranted here, as to re-adapt with significant scarring con- The double-armed wire is inserted
ZMC fractures relate to orbital involve- tracture and generally a flattened and from the contralateral orbit to the side that
ment and appropriate intraoperative splayed appearance to the orbits and mid- will be anchored, with the entry point on
sequencing. Nonfragmented or single- face. NOE injuries generally do not cause the medial wall being just posterior and
piece ZMC fractures are generally dis- entrapment simply because of the orbital superior to lacrimal fossa. This can be
placed in an inferior, medial, and posteri- walls involved and the degree of comminu- accomplished by prethreading the double-
or direction, with a pivot-point rotation tion. However, entrapment of the medial armed wire into a gently curved 16-gauge
about the ZF suture. As a result, the orbital rectus can occur during reconstruction, fix- needle, passing it transnasally through
floor suffers the most disruption. On ini- ation, and suturing; therefore, a forced duc- small burr holes, retrieving the double-
tial inspection, the coronal CT scans may tion test should be performed at the com- armed wire on the side to be fixated, and
not reveal the degree of orbital floor dis- pletion of these phases. The primary defects withdrawing the needle canula. The can-
ruption, but if one envisions the outward associated with NOE injuries are medial thus is then sutured to the wire loop with a
reduction of the zygomatic buttress and canthal disruption with telecanthus and half-round needle (4.0 Mersilene S-2 nee-
the resulting medial floor void, the magni- increased bony volume resulting in enoph- dle), and the wire is drawn to the contralat-
tude of the injury can be appreciated. Only thalmos. If there are no other indications eral side and the limbs twisted gradually
after reduction and stabilization of the for coronal dissection, such as frontal bone around a short section of plate to fine-tune
entire external orbital framework and sur- or zygomatic arch fractures, then the medi- the canthal position (see Figure 24-12).
rounding facial bones should the internal al orbital component of the NOE fracture is This is a much easier way to accomplish
orbital defects be repaired (see Figure 24- best approached directly through a lateral precise canthal positioning than are direct
16CG). The internal orbital injuries asso- nasal (Lynch) incision. Often accessing the suturing techniques.
ciated with fragmented ZMC fractures inferior medial wall or positioning the infe-
usually involve multiple orbital walls and rior edge of the medial wall graft requires Summary
larger defects. Therefore, more extensive an additional inferior rim and orbital floor Orbital fractures are often associated with
exposure is generally necessary and more approach, such as the subciliary or ocular injuries and midfacial fractures. A
rigid materials are usually required for transconjunctival approach. Traumatic thorough ophthalmologic evaluation is
reconstruction. telecanthus should be treated by direct fix- mandatory to detect ocular injuries and to
NOE injuries result mainly from ation techniques, using 1.0 to 1.7 mm plat- preserve vision. Surgical intervention
extreme blunt force trauma and have a high ing systems. External splinting may provide should be based on either a functional
degree of associated intracranial and neu- some reasonable nasal bone molding, but it deficit or a cosmetic deformity. The surgical
rologic injuries. Additionally, injuries to the generally does little to improve traumatic sequencing and timing of the repair should
nasal airway and lacrimal system can telecanthus. Generally, the medial canthal be well thought out. When visual compro-
occur.82 Injuries to the lacrimal system can ligament heals in a position that is too mise exists, an ophthalmologist should be
be managed by the placement of small sili- superficial and inferior. Postoperatively the involved in the treatment planning.
cone tubes. Even though canalicular dis- entire area fills with dense scar tissue, and it
ruption is more common with laceration- is difficult to secondarily dissect and reposi- References
type injuries, these tubes can still be tion the canthus in its normal position. 1. Rontal E, Rontal M, Guilford FT. Surgical
inserted with blunt trauma when a fair With NOE fractures the medial canthal ten- anatomy of the orbit. Ann Otol Rhinol
amount of edema is present and the sur- dons usually maintain their attachment to Laryngol 1979;88(3 Pt 1):3826.
Orbital and Ocular Trauma 489
2. Waitzman AA, Posnick JC, Armstrong DC, 18. Lindahl S. Computed tomography of intra- retinal and vitreous injuries. In: Spoor TC,
Pron GE. Craniofacial skeletal measure- orbital foreign bodies. Acta Radiol 1987; Nesi FA, editors. Management of ocular,
ments based on computed tomography. 28:23540. orbital, and adnexal trauma. New York:
Part II. Normal values and growth trends. 19. Gillespie JE, Isherwood L, Barker GR. Three Raven Press; 1988. p. 81128.
Cleft Palate Craniofac J 1992;2:11828. dimensional reformations of computed 34. Seiff SR. High-dose corticosteroids for treat-
3. Ochs MW, Buckley MJ. Anatomy of the orbit. tomography in the assessment of facial ment of vision loss due to indirect injury to
Oral Maxillofac Surg Clin North Am trauma. Clin Radiol 1987;38:5236. the optic nerve. Ophthalmic Surg 1990;
1993;5:41929. 20. Roberts CF, Leehey PJ III. Intra-orbital wood 21:38995.
4. Frenkel REP, Spoor TC. Neuro-ophthalmolog- foreign bodies mimicking air at CT. Radiol- 35. Spoor TC, Hartel WC, Lensink DB, Wilkinson
ic manifestations in trauma. In: Spoor TC, ogy 1992;185:5078. MJ. Treatment of traumatic optic neuropa-
Nesi FA, editors. Management of ocular, 21. Kelly WM, Paglen PG, Pearson JA, et al. Ferro- thy with corticosteroids. Am J Ophthalmol
orbital, and adnexal trauma. New York: magnetism of intraocular foreign body 1990;110:6659.
Raven Press; 1988. p. 195245. causes unilateral blindness after MR study. 36. Mauriello JA, DeLuca J, Krieger A, et al. Man-
5. Rootman J. Basic anatomic considerations. In: AJNR Am J Neuroradiol 1986;7:2435. agement of traumatic optic neuropathya
Rootman J, editor. Diseases of the orbit. 22. Otto PM, Otto RA, Virapongse C, et al. Screening study of 23 patients. Br J Ophthalmol
Philadelphia: JB Lippincott; 1988. p. 318. test for detection of metallic foreign objects in 1992;76:34952.
6. Hollinshead WH. The head and neck. 3rd ed. the orbit before magnetic resonance imaging. 37. Fujino T, Makino K. Entrapment mechanisms
Philadelphia: Harper and Rowe; 1982. p. Invest Radiol 1992;27:30811. and ocular injury in orbital blow-out frac-
93155. 23. Sprecht CS, Varga JH, Jalai MM, Edelstein JP. tures. Plast Reconstr Surg 1980;65:5716.
7. Som PM, Shugar JM, Brandwein MS. Anatomy Orbitocranial wooden foreign body diag- 38. Smith B, Regan W. Blowout fractures of the
and physiology of the sinonasal cavities. In: nosed by magnetic resonance imaging: dry orbit. Am J Ophthalmol 1957;44:7339.
Som PM, Curtin HD, editors. Head and wood can be isodense with air and orbital 39. Converse JM, Smith B. Blowout fractures of the
neck imaging. St. Louis: Mosby; 2003. p. fat by computed tomography. Surv Oph- orbit. Trans Am Acad Ophthalmol Oto-
87147. thalmol 1992;36:3414. laryngol 1960;64:67688.
8. Zide BM, Jelks GW. Surgical anatomy of the 24. Byrne SF, Green RL. Trauma and periodontal 40. Crikelair G, Rein J, Potter G. A critical look at
orbit. New York: Raven Press; 1985. disease. In: Byrne SF, Green RL, editors. the blowout fracture. Plast Reconstr Surg
9. Bergin DJ. Anatomy of the eyelids, lacrimal Ultrasound of the eye and orbit. St. Louis: 1972;49:3749.
system, and orbit. In: McCord CD Jr, Mosby Year Book; 1992. p. 43161. 41. Nicholoson D, Guzak S. Visual loss complicat-
Tanenbaum M, editors. Oculoplastic 25. Reshef DS, Osoinig KC, Nerad JA. Diagnosis ing repair of orbital floor fractures. Arch
surgery. 2nd ed. New York: Raven Press; and intraoperative localization of a deep Ophthalmol 1971;86:36976.
1987. p. 4171. orbital organic foreign body. Orbit 42. Putterman AM, Stevens T, Urist MJ. Nonsurgi-
10. Hart WM Jr. The eyelids. In: Hart WM Jr, edi- 1987;6:315. cal management of blowout fractures of the
tor. Adlers physiology of the eye. 9th ed. St. 26. Berges O. Color Doppler flow imaging of the orbital floor. Am J Ophthalmol 1974;
Louis: Mosby; 1992. p. 116. orbital veins. Acta Ophthalmol 1992; 77:2328.
11. Nakamura T, Gross C. Facial fractures: analysis 204:558. 43. Dulley B, Fells P. Orbital blowout fractures. Br
of five years of experience. Arch Otolaryn- 27. McCoy FJ. Applications to new advances to Orthoped J 1974;31:4754.
gol 1973;97:28890. treatment of facial trauma. Ann Plast Surg 44. Crumley R, Leibsahn J, Krause C, Burton T.
12. Gwyn PP, Carraway JH, Horton CE, et al. Facial 1986;17:3545. Fractures of the orbital floor. Laryngoscope
fracturesassociated injuries and complica- 28. Tschanz A, Hammer B, Prein J. Visusverlust bei 1976;87:93447.
tions. Plast Reconstr Surg 1971;47:22530. verletzungen der orbita [unpublished med- 45. Converse JM, Smith B. Editorial on the treat-
13. Ellis E III. Fractures of the zygomatic complex ical thesis]. University Hospital, Basel ment of blowout fractures of the orbit. Plast
and arch. In: Fonseca RJ, Walker RF, editors. (Switzerland); 1994. Reconstr Surg 1978;62:1004.
Oral and maxillofacial trauma. Vol 1. 29. Katz B, Herschler J, Brich DC. Orbital hemor- 46. Wilkins RB, Havins WE. Current treatment of
Philadelphia: WB Saunders; 1991. p. 435514. rhage and prolonged blindness: a treatable blowout fractures. Ophthalmology 1982;
14. Hammer B. Orbital fractures, diagnosis, opera- posterior optic neuropathy. Br J Ophthal- 89:4646.
tive treatment and secondary corrections. mol 1983;67:54953. 47. Koorneef L. Current concepts on the manage-
Gottingehn (Germany): Hogrefe and 30. Kersten RC, Rice CD. Subperiosteal orbital ment of orbital blowout fractures. Ann
Huber; 1995. p. 1011. hematoma: visual recovery following Plast Surg 1982;9:185200.
15. Kelly JK, Lazo A, Metes JJ. Radiology of orbital delayed drainage. Ophthalmic Surg 48. Smith B, Lisman RD, Simonton J, DellaRocca
trauma. In: Spoor TC, Nesi FA, editors. 1987;18:4237. R. Volkmanns contracture of the extraocu-
Management of ocular, orbital and adnexal 31. Ord RA, El Attar H. Acute retrobulbar hemor- lar muscles following blowout fractures.
trauma. New York: Raven Press; 1988. p. rhage complicating a malar fracture. J Oral Plast Reconstr Surg 1984;74:20016.
24768. Maxillofac Surg 1982;40:2346. 49. Hawes M, Dortzbach RL. Surgery on orbital
16. Unger JM. Orbital apex fractures: the contribu- 32. Ahn BH, Baek NH, Shin DH. Management of floor fractures: influence of time on repair
tion of computed tomography. Radiology traumatic hyphema. In: Spoor TC, Nesi FA, and fracture size. Ophthalmology 1983;
1984;150:7137. editors. Management of ocular, orbital, and 90:106670.
17. Guyon JJ, Brant-Zawadzki M, Seiff SR. CT adnexal trauma. New York: Raven Press; 50. deMann K. Fractures of the orbital floor: indica-
demonstration of optic canal fractures. AJR 1988. p. 6980. tions for exploration and for the use of a floor
Am J Roentgenol 1984;143:10314. 33. Hammer ME, Grizzard WS. Management of implant. J Oral Maxillofac Surg 1984;12:737.
490 Part 4: Maxillofacial Trauma
51. Dortzbach R, Elner V. Which orbital floor incisions for orbital fractures. Br J Plast 72. Al-Kayat A, Bramley P. A modified preauricu-
blowout fractures need surgery [editorial]? Surg 1983;10:30913. lar approach to the temporomandibular
Adv Ophthalmic Plast Reconstr Surg 62. Heckler F, Songcharoen S. Subciliary incision joint and malar arch. Br J Oral Surg 1979;
1987;6:2879. and skin-muscle eyelid flap for orbital frac- 17:91103.
52. Dutton JJ, Manson P, Putterman A. Management tures. Ann Plast Surg 1983;10:30913. 73. Rubin L. Biomaterials in reconstructive
of blowout fractures of the orbital floor [edi- 63. Pospisil OA, Fernando TD. Review of the ble- surgery. St. Louis: CV Mosby; 1983.
torial]. Surv Ophthalmol 1991;35:27980. pharoplasty incisions as a surgical approach 74. Berghaus A. Porous polyethylene in recon-
53. Parsons GS, Mathog RH. Orbital wall and vol- to zygomatic orbital fractures. Br J Oral structive head and neck surgery. Arch Oto-
ume relationships. Arch Otolaryngol Head Maxillofac Surg 1984;22:2618. laryngol Head Neck Surg 1985;111:15460.
Neck Surg 1988;114:7437. 64. Tessier P. The conjunctival approach to the 75. Ilizuka T, Mikkonen P, Paukku P, Lindqvist C.
54. Roncevic R, Malinger B. Experience with vari- orbital floor and maxilla in congenital mal- Reconstruction of orbital floor with poly-
ous procedures in the treatment of orbital formation and trauma. J Oral Maxillofac dioxanone plate. Int J Oral Maxillofac Surg
floor fractures. J Oral Maxillofac Surg Surg 1973;1:38. 1991;20:837.
1981;9:814. 65. Converse JM, Firmin F, Wood-Smith D, Fried- 76. Loftfield K, Jordan DR, Fowler J, Anderson RL.
55. Zingg M, Chowdhury K, Ladrach K. Treatment land J. The conjunctival approach in orbital Orbital cyst formation associated with
of 813 zygoma-lateral orbital complex frac- floor fractures. Plast Reconstr Surg Gelfilm use. Ophthal Plast Reconstr Surg
tures. Arch Otolaryngol Head Neck Surgery 1973;52:6567. 1987;3:18791.
1991;11:61120. 66. Ochs MW. Use of preseptal transconjunctival 77. Rubin PA, Shore JW, Yaremchuk MJ. Complex
56. Thaller S, Yvorchuk W. Exploration of the approach in orbital reconstruction surgery orbital fracture repair using rigid fixation
orbital floor: an indicated procedure? J [discussion]. J Oral Maxillofac Surg 2001; of the internal orbital skeleton. Ophthal-
Craniomaxillofac Surg 1990;1:18790. 59:2912. mology 1999;99:5539.
57. Sacks A, Friedland J. Orbital floor fractures: 67. Manson PN, Ruas E. Single eyelid incision for 78. Ilankovan V, Jackson T. Experience in the use of
should they be explored early? Plast Recon- exposure of the zygomatic bone and orbital calvarial bone grafts in orbital reconstruc-
str Surg 1979;64:1903. reconstruction. Plast Reconstr Surg tion. Br J Oral Maxillofac Surg 1992;30:926.
58. deMann K, Hes WJ, deJong PT, Wijingaarde R. 1987;79:1206. 79. Gruss JS, MacKinnon SE. The role of primary
Influence of age on the management of 68. McCord C, Moses J. Exposure of the inferior bone grafting in complex craniomaxillofacial
blowout fractures of the orbital floor. Int J orbit with fornix incision and lateral can- trauma. Plast Reconstr Surg 1985;75:1724.
Oral Maxillofac Surg 1991;20:3306. thotomy. Ophthalmic Surg 1979;10:5363. 80. Cestero HJ, Salyes KE, Toranto IR. Bone
59. Manson PN, Clifford CM, Su CT, Iliff NT. 69. Baumann A, Ewers R. Use of preseptal growth into porous carbon, polyethylene,
Mechanisms of global support and post- transconjunctival approach in orbital and polypropylene prostheses. J Biomed
traumatic enophthalmos. I. The anatomy of reconstruction surgery. J Oral Maxillofac Mater Res 1975;9:17.
the ligament sling and its relation to intra- Surg 2001;59:28791. 81. Whitehouse RW, Batterbury M, Jackson A, Noble
muscular cone orbital fat. Plast Reconstr 70. Ellis E III, Zide MF, editors. Coronal approach. JL. Prediction of enophthalmos by computed
Surg 1986;77:193202. In: Surgical approaches to the facial skele- tomography after blowout orbital fracture.
60. Converse JM. Two plastic operations for repair ton. Philadelphia: Williams and Wilkins; Br J Ophthalmol 1994;78:61820.
of the orbit following severe trauma and 1995. p. 6394. 82. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The
extensive comminuted fracture. Arch Oph- 71. Stuzin JM, Wagstron L, Kawamoto H, et al. pattern and incidence of nasolacrimal injury
thalmol 1944;31:3235. Anatomy of the frontal branch of the facial in naso-orbital-ethmoid fracture: the role of
61. Wray RC, Holtman BN, Rebaudo JM, et al. A nerve: the significance of the temporal fat delayed assessment and dacryocystorhinoso-
comparison of conjunctival and subciliary pad. Plast Reconstr Surg 1989;83:26571. tomy. Br J Plast Surg 1985;38:11621.
CHAPTER 25
Fractures of the frontal bone and the naso- lished frequency of fractures of the anteri- develop from one or several different sites:
orbitoethmoid (NOE) complex are infre- or wall, the posterior wall, and the floor of as a rudiment of the ethmoid air cells, as a
quent, occurring among 2 to 15% of the frontal sinus varies rather widely: 43 to mucosal pocket in or near the frontal
patients with facial fractures.14 When 61% of reported patients had anterior recess, as an evagination of the frontal
these fractures occur, they can cause devas- table fractures only, 19 to 51% had anteri- recess, or from the superior middle mea-
tating complications because of their prox- or and posterior table fractures, 2.5 to 25% tus.20 Initial pneumatization begins during
imity to the brain, eyes, and nose. Compli- had injuries to the nasofrontal duct, and the fourth month in utero. Secondary
cations include blindness or other forms of 0.6 to 6% had posterior fractures only.2,3,8 pneumatization begins at the age of
visual disturbance, orbital cellulitis or 6 months to 2 years and develops laterally
abscess, meningitis, brain abscess, and Anatomy and Physiology and vertically. The sinus is radiographical-
facial deformation. Although reports of the ly identifiable by the time the child reach-
surgical management of the diseased Embryology of the Sinus es the age of 6 years.29 Most pneumatiza-
frontal sinus have existed for > 100 years,5 The frontal bone is an intramembranous tion is completed by the time the child is
no consensus has yet been reached on ideal bone that develops from two paired struc- 12 to 16 years old, but it continues until
care after traumatic injury.57 tures that begin to ossify at the eighth or the age of 40 is reached.5,20,26,30 The config-
Most victims are male (6691%) and ninth week in utero.10,26 The ossification uration of the sinus and the position of the
young (usually 2030 yr of age, range 6 begins in the frontal processes of the squa- septa are extremely variable.
72 yr),1,720 and most frontal sinus and NOE mous regions, progresses to the orbital
injuries are sustained in motor vehicle or and squamous regions, and reaches the Physiology of the Sinus
motorcycle collisions (4485%).1,3,7,8,10,11,1424 frontal and temporal regions by the The entire surface area of the frontal sinus
NOE fractures can occur in isolation, but twelfth week. The metopic suture in the is covered with respiratory epithelium
they most often occur in association with midline closes during the second year of ranging in thickness from 0.07 to
other midface fractures.23,25 As many as 60% life.27 The forehead is displaced anteriorly 2.0 mm.31 The mucosa consists of pseu-
of patients with NOE fractures have associat- by sutural growth, inner table resorption, dostratified ciliated epithelium, mucus-
ed nonfacial injuries.24 and outer table deposition.28 producing goblet cells, a thin basement
The distribution between fractures of The frontal sinus is a small outpouch- membrane, and a thin lamina propria that
the supraorbital rim and fractures of the ing at birth and undergoes almost all of its contains seromucous glands.31 When the
frontal sinus is almost equal. The pub- development thereafter. The sinus may mucosa is healthy, a blanket of mucin
492 Part 4: Maxillofacial Trauma
overlies the epithelium. The cilia flow at 8.0 cm laterally, and 5.5 cm posteriorly. cavity exists on the frontal bone along the
250 cycles/min. The mucin blanket flows Two frontal tuberosities are noted lateral to medial anterior orbital roof; the trochlea of
in a spiral fashion in a medial-to-lateral the midline and superior to the supraor- the superior oblique muscle is attached to
direction; the flow is slowest at the roof bital run. The thickest area of the bone is this spine (Figure 25-1).34,35
and fastest at the nasofrontal duct.32 The the supraorbital rim from the frontozygo- Paired triangular sinuses are found
mucin empties at the nasofrontal duct at a matic process to the nasal bones. The eth- within the frontal bone. These sinuses
rate of 5.0 g/cm2. The physiologic charac- moid plate is bound on three surfaces are asymmetric and are separated by a
teristics of the sinus and the status of the along the floor of the frontal bone in the frontal septum. The average height of the
nasofrontal duct dictate the treatment of midline. As the floor of the frontal bone sinuses is 32 mm, and their average width
the frontal sinus in trauma.33 extends laterally, it becomes concave and is 26 mm.29,35 The surface area is approx-
forms the orbital roof. The supraorbital imately 720 mm2.32 The frontal bone is
Osteology and frontal foramen are located at the most thinnest in the region of the glabella at
The frontal bone is shaped as a concave superior portion of the orbital rim. The the anterior wall and floor of the sinus.
disk with a horizontal table forming the supratrochlear foramen is located medial The duct of the frontal sinus empties
orbital rim. From the nasion the bone to the supraorbital foramen or notch and into the ethmoid air cells of the middle
extends approximately 12.5 cm superiorly, lateral to the nasal bones. A spine or con- meatus of the nose.
Frontal sinus
Frontal sinus
Superior concha
Cribriform plate (turbinate)
Nasofrontal duct
Ethmoid sinus
Superior concha
Ethmoid sinus
Middle concha Middle concha
(turbinate)
Maxillary sinus Lower concha
Inferior concha (turbinate)
A B
Nasofrontal duct
Frontal sinus
Mucosal lining
FIGURE 25-1 A, Frontal bone and frontal sinus showing the
relation of the nasofrontal duct and nose. The arrows represent
the flow from the sinuses to the nose. B, Lateral view of the nor-
mal nasofrontal duct. The arrows represent the flow from the
sinuses to the nose. C, Superior view of the normal nasofrontal
duct. Adapted from Zide MF. Nasal and nasoorbital ethmoid
fractures. In: Peterson LJ, Indresano AT, Marciani RD, Roser SM.
Principles of oral and maxillofacial surgery. Vol. 2. Philadelphia
(PA): JB Lippincott Company: 1992. p. 5767.
C
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 493
The internal concave surface of the Further posterior along the medial turbinate. The length of the duct may vary
frontal bone forms the anterior cranial orbital wall, the optic nerve exits through from a few millimeters to a centimeter or
fossa that houses the brain. The floor of the body of the sphenoid bone, 3.5 to more (Figure 25-2).
the frontal bone outlines the roof of the 5 mm behind the posterior ethmoidal fora-
orbit. The convex outer table is bounded men in a line parallel to the two foramina. Medial Canthal Tendon
by the scalp and the frontalis, orbicularis, The frontal bone is supplied by the supra- The orbicularis oculi muscle has three
and procerus muscles. The osseous struc- orbital, anterior superficial temporal, ante- portions: the orbital, the preseptal, and the
tures that abut the frontal bone are the rior cerebral, and middle meningeal arter- pretarsal. The pretarsal portions of the
lacrimal and ethmoid bones inferiorly, the ies.27,34,35 Venous drainage is transosseous upper and lower lids unite at the canthus
sphenoid inferiorly and posteriorly, the through the anastomosis of vessels of the to form the medial canthal tendon (MCT).
parietal posteriorly and superiorly, the subcutaneous, orbital, and intracranial The MCT may be subdivided into a
zygoma laterally, the nasal bones anterior- structures. The primary venous drainage is superficial portion and a deeper portion
ly, and the maxilla anteriorly and inferior- through the supratrochlear, supraorbital, with the lacrimal sac between them. The
ly. The ethmoid air cells and nasal appara- superficial temporal, frontal diploic (veins superficial portion has two legs and
tus are situated inferiorly. of Breschet), superior ophthalmic, and inserts into the frontal process of the max-
The nasal part of the frontal bone superior sagittal sinuses.27,34 The relation- illa, providing support to the eyelids and
extends inferiorly deep to the nasal bones ship of the diplo to the anterior cranial maintaining the integrity of the palpebral
and the frontal process of the maxilla, fossae is important to understand because fissure.36,37 The anterior leg attaches to the
adding support to the NOE complex. The these structures can become a conduit for posterolateral surface of the nasal bones,
nasal bones and the maxilla make up the the spread of infection. and the superior leg inserts at the junction
piriform rim. The articulation of the of the frontal process of the maxilla and
nasal bones forms a crest posteriorly and Interorbital Space the angular process of the frontal bone.
inferiorly; this crest articulates with the The nasofrontal suture is the continuation The deeper portion (also known as
frontal bone, the perpendicular plate of of the frontoethmoid suture and corre- Horners muscle or the pars lacrimalis)
the ethmoid (forming the upper third of sponds to the plane of the base of the skull attaches to the posterior lacrimal crest.
the nasal septum), and the septal carti- or frontal sinus. The interorbital space is NOE injuries may cause avulsion of
lage. The NOE region is supported struc- bounded laterally by the medial wall of the the tendons from the bone or, more com-
turally by a vertical buttressthe frontal orbits. In the middle is the perpendicular monly, fractures of the bone that contains
process of the maxillaand two horizon- plate of the ethmoid and nasal septum. the attachment of tendons. This portion of
tal buttresses: the supraorbital and infra- The anterior wall is composed of the the orbital rim is an important anatomic
orbital rims.36 paired nasal bones, the frontal processes of region with regard to reconstruction of
The medial walls of the orbit begin the maxilla, and the nasal processes of the NOE fractures.36
behind the frontal process of the maxilla. frontal bone.
The thin lacrimal bone and a frail lamina The ethmoid air cells within the Lacrimal Apparatus
papyracea in the anterior are weak and interorbital space occupy the upper half of The lacrimal drainage system is intimately
susceptible to fracture. Higher up, the the wall lateral to the nasal fossa. The related to the NOE region and can be dam-
frontoethmoid suture delineates the level dimensions of the anterior end of the eth- aged during trauma to or reconstruction of
of the cribriform plate and crista galli. moid labyrinth are approximately 2.5 cm this area. The system removes any excess
vertically and 1 cm transversely. The pyra- tears that accumulate after lubrication of
Neurovascular Structures mid-shaped sinus measures 3.5 to 5 cm the surface of the globe. The superior and
The arterial blood supply to the frontal from front to back. inferior lacrimal canaliculi drain the
sinus is from the supraorbital and anterior The ethmoid air cells drain into the lacrimal lake. The puncta of the canaliculi
ethmoid arteries. Two foramina are pre- middle meatus, as does the nasofrontal open just lateral to the lacrimal lake and
sent along the suture line: the anterior eth- duct. The nasofrontal duct is located in the are surrounded by Horners muscle. The
moid foramen, through which course the posterior medial floor of the frontal sinus orifice of the upper punctum faces down-
nasociliary nerve and the anterior eth- at the junction of the ethmoid and nasal ward and backward, and the orifice of the
moidal artery; and the posterior eth- portions of the floor, and it courses lower punctum faces upward and back-
moidal foramen, through which pass the through the anterior ethmoid in the mid- ward. The superior punctum is approxi-
vessel and nerve of the same name. dle meatus or just anterior to the middle mately 3 mm medial to the inferior
494 Part 4: Maxillofacial Trauma
Nasofrontal duct
Frontal sinus
Cribriform plate Frontal sinus
Ethmoid sinus (aircells)
Orbit
Superior turbinate Nasofrontal duct
Infraorbital neurovascular
bundle Cribriform plate
Middle turbinate
Maxillary sinus
Perpendicular plate
of ethmoid
Inferior turbinate
Vomer (sectioned)
Palate (sectioned)
FIGURE 25-2 A, Section through the intraorbital space revealing the rela-
tionship of the frontal sinus and the ethmoid sinuses to the nose. The arrows
represent the flow from the sinuses to the nose. B, The drainage of the
nasofrontal duct into the nose is located in the posterior medial floor of the
frontal sinus and at the junction of the ethmoid and nasal portions of the
floor. The arrows represent the flow from the sinuses to the nose. Adapted from B
Zide MF. Nasal and nasoorbital ethmoid fractures. In: Peterson LJ, Indresano
AT, Marciani RD, Roser SM. Principles of oral and maxillofacial surgery. Vol.
2. Philadelphia (PA): JB Lippincott Company; 1992. p. 560.
punctum. The two canaliculi pierce the which is housed in a bony canal. The duct Fractures of the NOE complex can pro-
lacrimal fascia and enter the lacrimal sac empties into the inferior meatus in the duce the following signs: nasal deformity,
at or very near a common point. The nasal cavity.38 edema and ecchymosis of the eyelids, sub-
canaliculi lie mostly behind the medial conjunctival hemorrhage, cerebrospinal
palpebral ligament and are surrounded by Patient Evaluation fluid (CSF) leakage, hyposmia, traumatic
the pars lacrimalis.38,39 The lacrimal telecanthus, increased canthal angles, and
canaliculi are lined with nonkeratinized Clinical Findings blindness (Figure 25-3).23,45
and nonmucin-producing stratified Periorbital ecchymosis and pain are the Soft tissue lacerations in the region of
squamous epithelium. The epithelium is most common signs and symptoms asso- the glabella and the supraorbital rims are
75 to 150 thick and consists of a few lay- ciated with fractures of the frontal also commonly found in association with
ers of squamous cells, polyhedral cells, bone.5,4044 When the bone bleeds and the frontal bone fractures and may be associ-
and a basal cell layer.39 periosteum is interrupted, leakage of ated with anesthesia or paresthesia of the
The lacrimal sac lies in a fossa on the blood into the adjacent facial planes distribution of the supraorbital and supra-
anteromedial wall of the bony orbit. It is results in periorbital ecchymosis. Through trochlear nerves.5,4044 Depression of the
lined with pseudostratified columnar this same mechanism, subconjunctival bone with flatness and cosmetic deformity
epithelium and is approximately 12 mm hemorrhage may occur. If the nose and is noted if the patient is examined soon
long.39 The apex of the sac ends blindly in zygomas are unaffected, a finding of sub- after injury. Examination of a patient with
a superior fundus, and the sac continues conjunctival hemorrhage is sufficient for NOE fractures detects mobility of the
inferiorly into the nasolacrimal duct, the diagnosis of frontal bone fracture. nasal bones, traumatic telecanthus,
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 495
The depression of bone fragments associated with NOE fractures can also
into the orbit may cause exophthalmos, cause enophthalmos.
proptosis, or ptosis. A depressed injury A thorough examination is important
also causes restricted ocular movement if to distinguish between a nasal fracture and
the superior rectus muscle, the superior an unstable NOE fracture. The examiner
oblique muscle, or the trochlea is dam- should place the thumb and index finger
aged.43,44 Medial orbital wall fractures over the medial canthus bilaterally. Mobility
Table 25-1 Normal Values of Constituents of CSF, Serum, and Nasal Secretions
Constituent CSF Serum Nasal Secretions
Osmolarity 295 mOsm/L 295 mOsm/L 277 mOsm/L
Sodium 140 mEq/L 140 mEq/L 150 mEq/L
Potassium 2.53.5 mEq/L 3.34.8 mEq/L 1241 mEq/L
Chloride 120130 mEq/L 100106 mEq/L 119125 mEq/L
Glucose 5890 mg/100 mL 80120 mg/100 mL 1432 mg/100 mL
Albumin 5075% 55% 57%
Total protein 545 mg/dL 6.08.4 mg/dL 335636 mg/dL
(% of total protein)
Immunoglobulin G 3.5 mg/100 mL 1,140 mg/100 mL 51 mg/100 mL
2-Transferrin (% of 15% 0% 0%
total transferrin)
FIGURE 25-3 Initial appearance of a patient
Adapted from Brandt MT et al.47
with a frontal sinus fracture. Note the bilateral CSF = cerebrospinal fluid.
periorbital ecchymosis and forehead laceration.
496 Part 4: Maxillofacial Trauma
of these fragments may vary, but any move- allows an assessment of the instability of high degree of detail required for imaging
ment implies instability and requires open the tendon attachment and the necessity NOE fractures necessitates axial and coro-
reduction and stabilization.36 A ruler or for open reduction.51 nal views with slice thicknesses of 1.0 or
caliper should be used to measure the inter- 1.5 mm.25,36 Indeed, it has been shown that
canthal distance. The normal distance is Imaging for severe fractures of the NOE region, two-
28.6 mm to 33.0 mm for adult women; it Poor outcomes after the treatment of NOE and three-dimensional CT scans provide
is 28.9 mm to 34.5 mm for adult men. fractures and frontal sinus fractures typi- the most information about the medial
Increased widths suggest an NOE fracture. cally result from misdiagnosis, inadequate orbital wall, the medial maxillary buttress,
Two tests that can aid in the diagnosis of planning, lack of exposure, inadequate and the piriform aperture.36,57
instability of the medial canthus are the reduction or fixation of soft tissue or bone,
bowstring test and the bimanual exami- stripping of the medial canthi, or loss of Patency of the Nasofrontal Duct
nation. The bowstring test involves pulling nasal contour with insufficient primary Although the newest CT scanners provide
the lid laterally while palpating the tendon grafting.36,52 In the past, Waters projec- exceptional views and can often provide
area to detect movement of fracture seg- tions, reverse Townes projections, lateral slices through the nasofrontal duct, evi-
ments.48,49 The Furness test may also be skull films, and laminar tomograms were dence of their reliability in detecting
performed by grasping the skin overlying used to visualize midface and upper-face obstruction of the ducts is scant.54,55 Duct
the medial canthus with a small-tissue for- fractures. It is clear that appropriate preop- obstruction should be suspected with frac-
ceps (Figure 25-5). A lack of creasing or erative imaging can help to prevent misdi- tures involving the medial supraorbital rim
resistance by the underlying bone is agnosis and can aid in proper treatment or the frontal bone with nasal ethmoidal
indicative of an underlying fracture.50 The planning. Today computed tomography component fractures, and it should always
bimanual examination requires placing an (CT) scans are the gold standard for imag- be considered when a CSF leak is present.12
instrument (eg, a Kelly clamp) high into ing these fractures (Figure 25-6).5,10,36,5256 In these situations an open or intraopera-
the nose, with its tip directly beneath the The plane of choice for frontal sinus tive evaluation of patency is indicated. This
MCT. Gentle lifting with the contralateral imaging is the axial view, preferably with evaluation is important because the condi-
finger palpates the canthal tendons and slice thicknesses of 1.0 or 1.5 mm.22,26,30 The tion of the nasofrontal duct has the most
influence on the health of the frontal sinus
(Figure 25-7).12,20,22,33,54,5862
FIGURE 25-5 Illustrations of Classification of NOE Fractures
the bowstring (A) and biman- Bimanual palpation
ual examination (B) for possi- As with all fractures, NOE fractures are
ble NOE fractures. Adapted classified as unilateral or bilateral, open or
from Zide MF. Nasal and
nasoorbital ethmoid fractures.
closed, and simple or comminuted. Three
In: Peterson LJ, Indresano AT, types of NOE fractures have been well
Marciani RD, and Roser SM. described.25,36,38,63 A type I fracture main-
Principles of oral and maxillo- tains the attachment of the MCT to a large
facial surgery. Vol. 2. Philadel-
phia (PA): JB Lippincott Com- single nasoethmoidal fracture segment;
Medial canthus moves repairing this type of fracture is straight-
pany; 1992. p. 562. B laterally if fractured
forward. A type II fracture shows more
comminution yet maintains the attach-
ment of the medial canthus to a sizable
Kelly forceps bony segment. Type III fractures display
in nasal vault
severe comminution with possible avul-
sion of the MCT from its bony attachment
(Figure 25-8).
incised, and the reflection of the flap con- table inspection, and sinus floor can be adapted before the removal of the
tinues deep to the pericranium so that the (nasofrontal duct) evaluation. remaining anterior table segment.
branches of the facial nerve can be pro- If a more extensive neurosurgical pro-
tected. Further reflection can be obtained cedure is anticipated, osseous recovery Intraoperative Evaluation of the
with greater exposure by extension of the may be performed in concert with a cran- Nasofrontal Duct
preauricular incision, galeal splitting (if a iotomy bone flap. Before small fragments After access has been obtained and oss-
vascularized galeal flap is not anticipated), are recovered, the osseous flap design eous exploration and recovery have been
or release of the supraorbital nerve from should be mapped out on the frontal bone performed, the condition of the frontal
its foramen or notch. (with care taken to avoid the sagittal sinus floor and the nasofrontal ducts can
sinus). Bur holes are created at three or be assessed by direct visualization (see
Osseous Recovery and Access four corners of the frontal bone. The ten- Figure 25-7). The relative patency of the
Recovery of bony fragments in comminut- uous and adherent dura is released duct can then be evaluated by placing an
ed fractures is best undertaken during the through the bur holes, and a craniotome is
reflection of the coronal flap. Fragments of used to connect the bur holes. The dura is
the anterior table should be released from carefully reflected as the bone flap is
the periosteum and removed one at a time. removed. Recovery of the rest of the
Some method of organizing the fragments osseous fragments can then be completed.
should be used. For example, the frag- A perimeter-marking technique can
ments could be numbered and their posi- be used for removal of the anterior table
tions recorded on a map. They should be that is unfractured.67 The removal of the
arranged in the same order on a back table entire anterior table is important when
(Figure 25-9). If contaminated, segments obliteration of the sinus is anticipated
of bone may be cleansed with copious irri- because this procedure requires thorough
gation, scrubbing, and even povidone- removal of sinus mucosa. One side of a
iodine solution, and then used for recon- hemostat or pick-up instrument can be
struction as free grafts.66 Once the anterior inserted into the sinus, and a small bur
table has been removed, access should be hole can be made at the tip of the superfi- FIGURE 25-9 Comminuted frontal sinus seg-
adequate for sinus exploration, posterior cial arm of the instrument. Fixation plates ments arranged prior to reconstruction.
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 499
The surgeon should check carefully ed, a galeal flap should be reflected, the
for displacement of the fracture, CSF leak, sinus obliterated, and the nasofrontal duct
entrapment of sinus membranes, and obstructed. The free osseous fragments
dural tears. If the injury is not substantial that have been recovered, mapped, and
and the nasofrontal duct is patent, the arranged on a back table should be rigor-
anterior table is replaced and fixed and the ously curetted for removal of any respira-
soft tissue injuries are repaired. Com- tory epithelium that could become
minution of the posterior table, penetrat- entrapped between them during recon-
ing injury, CSF leak with extensive dural struction. Every remnant of respiratory
damage, or frontal lobe damage requires epithelium should be removed from every
frontal sinus cranialization: complete crevice and cul-de-sac so that the possibil-
removal of the posterior table, thereby ity of future mucocele formation is mini-
effectively increasing the size of the anteri- mized. This procedure is followed with
or cranial fossa.5,20,58,59,62,64 In one review local ostectomy with a no. 8 round dia-
of cases, as many as 16% of patients mond bur and copious amounts of saline.
undergoing frontal sinus surgery required The arranged bone fragments should be
a cranialization procedure.5 In such a case consolidated with titanium microscrews
the posterior table would be gently (1.01.3 mm) and with appropriate plates,
removed, either with a diamond bur or mesh, or both.75,76 Mesh has an advantage A
with rongeurs. Care should be taken in the in that it provides support and consolida-
area of the sagittal sinus to avoid severe tion of the segments in three planes of
bleeding. All irregularities of the sinus are space (Figure 25-13).75,76 Titanium mesh
smoothed with a bur. After bone removal has been shown to be compatible with soft
the dura should be repaired with primary tissue, undergoing incorporation with
closure, a fascia or synthetic patch, or a indigenous cells.77 Resorbable technology
galeal or pericranial flap.5,64 continues to show promise, even for
The wound is closed in layers. Strict frontal bone injury78; however, the
attention must be given to meticulous resorbable systems currently available are B
removal of all of the mucosal elements not as versatile as titanium mesh in their
FIGURE 25-13 Reconstruction of the frontal bar
from the walls, cul-de-sacs, and septa of ability to be contoured or to stabilize small and frontal sinus with titanium mesh. A, The
the sinus and from all bone frag- bone fragments. Before final placement of mesh is adapted to a dried skull and then steril-
ments.7274 Failure to remove such ele- the consolidated titanium and bone seg- ized prior to surgery. B, Intraoperative view of
ments may result in a mucocele or ments, the sinus should be copiously irri- reconstruction of the frontal bar and nasal dor-
sum with mesh.
pyocele. The mucosa is then reflected gated and hemostasis achieved. Once this
down into the nasofrontal duct, and the phase of the procedure has been complet-
orifice is obstructed by local bone or mus- ed, the nasofrontal ducts may be obstruct- As stated above, the condition of the
cle. The harvested fat is placed into the ed (if indicated), the sinus obliterated, the nasofrontal duct is the most important fac-
sinus and packed until the sinus is full. brain isolated with a galeal flap (if indicat- tor in maintaining the health of the frontal
Finally, the outer table is reassembled and ed), and, finally, the anterior table replaced. sinus.12,20, 22,33,54,5862 This duct permits the
restored as would be done for a simple exit of mucin, seroma, or hematoma after
anterior wall fracture. Nasofrontal Duct Obstruction injury. If the duct is injured and obstruct-
Nasofrontal duct obstruction should not ed, sinusitis, meningitis, or osteomyelitis
Orbital Roof and Supraorbital be confused with sinus obliteration. Sinus may develop. The condition of the duct
Bar Reconstruction obliteration is the elimination of dead should be considered in the evaluation of
Once the posterior wall and the sinus floor space by the introduction of another fractures of the NOE complex, the supraor-
have been explored, inspected, and evalu- material. Duct obstruction is one of the bital rim, or the sinus floor. If the duct is
ated for damage, the orbital roof and methods of isolating the sinus (or brain) not patent, thorough removal of every pos-
supraorbital bar may be reconstructed. from nasal contamination, basically by sible remnant of sinus mucosa is performed
After these procedures have been complet- plugging it with another material. by curettage.20,58,68,73,74 This procedure is
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 501
Complications may lead to the formation of mucoceles or placed posterior to the lacrimal crest. The
pyoceles. The size of the growth determines deep surface of the bone in this region is
Complications of frontal bone injury
how much damage occurs to adjacent bone lined with nasal mucosa, which should
vary in severity and may occur many
and neurologic tissue. Frontal sinus imag- remain intact during the osteotomy. Place-
years after the injury. The principal types
ing (CT or magnetic resonance imaging) ment of a lacrimal probe can facilitate
of complications are those that occur
directly at the time of injury, those of an should be ordered to detect a postoperative visualization of the lacrimal sac. After the
infectious nature, and those that are mucocele or pyocele. Imaging studies sac has been freed, it is incised on its medi-
chronic problems. should be performed at 1, 2, and 5 years al surface, and superior and inferior
The most devastating complications after surgery or whenever symptoms releasing incisions are made on the super-
are neurologic problems resulting from appear.107 Complications can occur as late ficial side of the sac (posterior flap). This
displacement or penetration of the frontal as up to 20 years postoperatively, and procedure is followed by a vertical incision
bones into the brain. These injuries can patients should be encouraged to have rou- of the nasal mucosa and anterior releasing
result in concussion, severe brain injury, or tine yearly follow-ups.59 incisions (anterior flap). At this point
death. Displacement of the floor of the Pain and headache may be chronic and Crawford tubes are used to intubate both
frontal bone can cause orbital damage. The may persist without an identifiable cause.13 the superior and the inferior canaliculi.
most frequent ocular complication is Cosmetic deformities such as contour When intubation is complete, the ends of
diplopia. Damage to the superior oblique deficits and irregularities stem from sever- the Crawford tubes are visible in the
muscles or trochlea may result in limited al causes. Bone loss at the time of injury lacrimal sac and can be inserted through
range of motion of the globe. Severing of may not be noticed for months. the lacrimal osteotomy and retrieved
the supraorbital nerve by the injury or dur- Osteomyelitis with subsequent dbride- intranasally inferior to the middle
ing reflection of the osteoplastic flap leaves ment leaves voids in bone. Even if the frac- turbinate. These ends are then cut to
a permanent anesthesia of the distribution tures are properly treated at the time of extend to the nasal vestibule and are
of the forehead.102 Trauma to the floor of injury, remodeling may leave irregularities. sutured in place to the lateral nasal wall
the frontal sinus or displacement of the Anosmiathe loss of the sense of (Figure 25-16).39,110
medial supraorbital rim may cause a CSF smelland hyposmia are known complica- Closure is then begun with anastomo-
leak. Generally, reduction of the fractures tions of NOE fractures and can occur in as sis of the lacrimal sac and the nasal
corrects this problem. If it is persistent, many as 38% of patients with high central mucosa. The anterior flap of the nasal
however, neurosurgical repair is indicated. midface fractures.108 In addition, 23% of mucosa is closed to the posterior flap of
Infectious complications most fre- patients with high midface fractures report the lacrimal sac. Often this is technically
quently arise from occlusion of the a decreased sense of taste (hypogeusia).108 challenging, and an alternative is to suture
nasofrontal duct or contamination of the the anterior lacrimal sac flap to perios-
sinus by penetrating foreign bodies. The
Dacryocystorhinostomy teum to maintain the opening between the
most frequently encountered infection is Dacryocystorhinostomy (DCR) is the lacrimal sac and the nasal mucosa. Care
meningitis.88 If the nasofrontal duct is repair of the lacrimal drainage system should be taken to avoid suturing the
occluded, blood may accumulate in the through the creation of a new ostomy or retained polymeric silicone tubing during
sinus, creating an environment that is track from the lacrimal canaliculi to the flap closure. The remainder of the incision
conducive to the growth of anaerobic bac- nasal cavity. Techniques that have been is closed in two layers. The tubing is left in
teria.13,103 Frontal sinus abscess is spread described include open (external), place for 4 to 6 months, and patients
by direct extension through small frac- endonasal, and soft tissue conjuctivorhi- should use saline nasal sprays to prevent
tures of the frontal bone or through tran- nostomy.109111 crusting of the tubes (Figure 25-17).
sosseous anastomotic vessels.59 The result Perhaps the best-described technique The endonasal approach is conceptu-
is brain abscess, meningitis, cavernous is the open DCR. This procedure is per- ally the same procedure, except that the
sinus thrombosis, or (if the abscess is long formed through a 10 mm vertical incision dissection is performed from inside of the
term) osteomyelitis. placed 10 to 12 mm medial to the medial nose with the aid of endoscopic instru-
Mucoceles are the most common canthus of the affected eye. Blunt dissec- ments and a fiber-optic light, which are
chronic problems.104106 Respiratory mucosa tion is then used to approach the lacrimal introduced into the sac through the
trapped between fracture segments or left crest. A periosteal incision is followed by canaliculi. The nasal mucosa is incised
behind during obliteration procedures may careful dissection of the lacrimal sac away and reflected over an area transilluminat-
continue to grow. This continued growth from the bony fossa, and an osteotomy is ed from above. The illuminated area is
504 Part 4: Maxillofacial Trauma
C D
most commonly seen beneath the middle Correction of Post-traumatic procedures for correcting such defects
turbinate, which may need to be displaced Deformity involve one-stage indirect prosthetic tech-
medially so that appropriate exposure can niques, two-stage techniques, single-stage
Six months to 1 year after the initial surgi-
be obtained. The transilluminating light direct techniques, or computer-generated
cal correction, secondary deformities of
can be seen most readily through the single-stage techniques.114116 The one-
the frontal bone may be addressed. Con-
lacrimal bone posterior to the frontal stage indirect technique requires that an
process of the maxilla. The frontal process tour defects result from failure to fully ele- impression be taken of the defect through
can be removed with a Freer elevator or vate depressed fractures, from voids in the skin. The impression negative is then
with a 2 mm Kerrison rongeur. The bone lost at the time of the trauma, and filled with plaster to form a positive image
lacrimal sac is then gently lifted free from from infection. A multiplicity of materials on which an onlay prosthesis may be fab-
the lacrimal bone with a Freer elevator. has been used to correct contour defects, ricated. Acrylic, polyethylene, tantalum,
The thin lacrimal bone overlying the sac is including bone from the adjacent calvaria, titanium, and cobalt-chromium prosthe-
then removed. An opening is then made ileum, or rib; cartilage; titanium or stain- ses may be fabricated with this technique.
into the lacrimal sac, and the Crawford less steel; polymeric silicone, methyl- A full-thickness flap is then reflected, and
tubing is inserted as before. Polymeric sil- methacrylate, hydroxylapatite granules, the prosthesis is secured.
icone tubes are left in place for 1 month, silver, a cobalt-chromium alloy, polytef, The single-stage direct technique
and saline spray and lacrimal irrigation polyethylene terephthalate fiber, nylon, requires that a full-thickness flap be
are recommended.111 polyethylene, and aluminum.112,113 The reflected beyond the margins of the defect.
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 505
Onlay cartilage or bone grafts then may be Acknowledgment III. Comparison of complications following
secured if an autograft is desired. Other- frontal sinus fractures managed with explo-
The authors thank Flo Witte, MA, ELS, for ration with or without obliteration over 10
wise, an acrylic resin may be used. The
her expert editorial assistance. years. Laryngoscope 1988;98:51620.
bone is moistened, and acrylic is mixed 10. Helmy ES, Koh ML, Bays RA. Management of
and placed on a glass or polytef slab and References frontal sinus fractures. Review of the litera-
rolled to a uniform thickness. The acrylic ture and clinical update. Oral Surg Oral
1. Schultz RC. Supraorbital and glabellar frac-
is placed directly over the bone and cov- Med Oral Pathol 1990; 69:13748.
tures. Plast Reconstr Surg 1970;45:22733.
11. Donald PJ. Frontal sinus ablation by cranializa-
ered with a sheet of separating foil. The 2. Onishi K, Nakajima T, Yoshimura Y. Treatment
and therapeutic devices in the management tion. Report of 21 cases. Arch Otolaryngol
full-thickness flap is replaced to ensure 1982;108:1426.
of frontal sinus fractures. Our experience
proper contour and then is again reflected. with 42 cases. J Craniomaxillofac Surg 12. Stanley RB Jr, Becker TS. Injuries of the
A copious amount of saline is used to irri- 1989;17:5863. nasofrontal orifices in frontal sinus frac-
tures. Laryngoscope 1987;97:72831.
gate the area so that the material does not 3. Xie C, Mehendale N, Barrett D, et al. 30-year
retrospective review of frontal sinus frac- 13. Duvall AJ III, Porto DP, Lyons D, Boies LR Jr.
cause thermal damage to the skull. The Frontal sinus fractures. Analysis of treat-
tures: the Charity Hospital experience. J
flap is then replaced and sutured. Craniomaxillofac Trauma 2000;6:715. ment results. Arch Otolaryngol Head Neck
Improvements in computer design 4. May M, Ogura JH, Schramm V. Nasofrontal Surg 1987;113:9335.
and technology now enable the fabrica- duct in frontal sinus fractures. Arch Oto- 14. Wallis A, Donald PJ. Frontal sinus fractures: a
laryngol 1970;92:5348. review of 72 cases. Laryngoscope 1988;
tion of prostheses for one-stage recon-
5. Manolides S. Management of frontal sinus 98:5938.
structions. The patient undergoes a three- 15. Ioannides C, Freihofer HP, Bruaset I. Trauma of
trauma. Semin Plast Surg 2002;16:26171.
dimensional CT before the operative 6. Coleman CC. Fracture of the skull involving the upper third of the face. Management and
procedure is performed.114 A computer- the paranasal sinuses and mastoids. JAMA follow-up. J Maxillofac Surg 1984;12:25561.
assisted diagnosis/computer-assisted 1937;109:16136. 16. Larrabee WF Jr, Travis LW, Tabb HG. Frontal
7. Gonty AA, Marciani RD, Adornato DC. Man- sinus fracturestheir suppurative compli-
manufacturing (CAD/CAM) protocol is
agement of frontal sinus fractures: a review cations and surgical management. Laryn-
then used to create a model of the frontal of 33 cases. J Oral Maxillofac Surg 1999; goscope 1980;90:18103.
bone and defect. A prosthesis may be cre- 57:37281. 17. Peri G, Chabannes J, Menes R, et al. Fractures
ated from polymeric silicone, acrylic, a 8. Gerbino G, Roccia F, Benech A, Caldarelli C. of the frontal sinus. J Maxillofac Surg
cobalt-chromium alloy, or hydroxylap- Analysis of 158 frontal sinus fractures: cur- 1981;9:7380.
rent surgical management and complica- 18. Lee TT, Ratzker PA, Galarza M, Villanueva PA.
atite-coated metals. During the operative Early combined management of frontal
tions. J Craniomaxillofac Surg 2000;
procedure, the prosthesis is inserted as 28:1339. sinus and orbital and facial fractures. J
described above. 9. Wilson BC, Davidson B, Corey JP, Haydon RC Trauma 1998;44:6659.
506 Part 4: Maxillofacial Trauma
19. Wright DL, Hoffman HT, Hoyt DB. Frontal revisitedan anatomical basis for can- Frontal sinus fractures: evaluation of CT
sinus fractures in the pediatric population. thopexy. Ann Plast Surg 1983;11:19. scans in 132 patients. AJNR Am J Neurora-
Laryngoscope 1992;102:12159. 38. Lew D, Sinn DP. Diagnosis and treatment of diol 1992;13:897902.
20. Rohrich RJ, Hollier LH. Management of midface fractures. In: Walker RV, editor. Oral 54. Heller EM, Jacobs JB, Holliday RA. Evaluation
frontal sinus fractures. Changing concepts. and maxillofacial trauma. Vol 2. Philadel- of the frontonasal duct in frontal sinus frac-
Clin Plast Surg 1992;19:21932. phia: W. B. Saunders Co.; 1997. p. 653713. tures. Head Neck 1989;11:4650.
21. Whited RE. Anterior table frontal sinus frac- 39. Kominami R, Yasutaka S, Taniguchi Y, Shino- 55. Harris L, Marano GD, McCorkle D.
tures. Laryngoscope 1979;89:19515. hara H. Anatomy and histology of the Nasofrontal duct: CT in frontal sinus trau-
22. Fedok FG. Comprehensive management of lacrimal fluid drainage system. Okajimas ma. Radiology 1987;165:1958.
nasoethmoid-orbital injuries. J Craniomax- Folia Anat Jpn 2000;77:15560. 56. Manson PN, Markowitz B, Mirvis S, et al.
illofac Trauma 1995;1:3648. 40. Holt GR. Ethmoid and frontal sinus fractures. Toward CT-based facial fracture treatment.
23. Ashar A, Kovacs A, Khan S, Hakim J. Blindness Ear Nose Throat J 1983;62:35764. Plast Reconstr Surg 1990;85:20212.
associated with midfacial fractures. J Oral 41. Sataloff RT, Sariego J, Myers DL, Richter HJ. 57. Remmler D, Denny A, Gosain A, Subichin S.
Maxillofac Surg 1998;56:114650. Surgical management of the frontal sinus. Role of three-dimensional computed
24. Cruse CW, Blevins PK, Luce EA. Naso-ethmoid- Neurosurgery 1984;15:5936. tomography in the assessment of nasoor-
orbital fractures. J Trauma 1980;20:5516. 42. Lanigan DT, Stoelinga PJ. Fractures of the supra- bitoethmoidal fractures. Ann Plast Surg
25. Leipziger LS, Manson PN. Nasoethmoid orbital rim. J Oral Surg 1980;38:76470. 2000;44:55363.
orbital fractures. Current concepts and 43. Miller SH, Lung RJ, Davis TS, et al. Manage- 58. Stanley RB Jr. Management of severe fronto-
management principles. Clin Plast Surg ment of fractures of the supraorbital rim. J basilar skull fractures. Otolaryngol Clin
1992;19:16793. Trauma 1978; 18:50712. North Am 1991;24: 13950.
26. Stevens M, Kline SN. Management of frontal 44. Rowe N, Kiley H. The surgical anatomy, diag- 59. Ioannides C, Freihofer HP. Fractures of the
sinus fractures. J Craniomaxillofac Trauma nosis, and treatment of fractures of the frontal sinus: classification and its implica-
nasal region, frontal sinus and paranasal air tions for surgical treatment. Am J Oto-
1995;1:2937.
sinus. In: Kiley H, editor. Fractures of the laryngol 1999;20:27380.
27. Salentijn L. Anatomy and embryology. In: Freid-
facial skeleton. Baltimore: Williams & 60. Pollak K, Payne EE. Fractures of the frontal
man W, editor. Surgery of the paranasal
sinus. Otolaryngol Clin North Am
sinuses. Vol 1. Philadelphia: W. B. Saunders; Wilkins Co.; 1970. p. 25175.
1976;9:51722.
1985. p. 159. 45. Zide MF. Nasal and naso-orbital ethmoid frac-
61. Haug RH, Likavec MJ. Frontal sinus recon-
28. Enlow D. The facial growth process. In: Enlow tures. In: Peterson LJ, editor. Principles of
struction. Atlas Oral Maxillofac Surg Clin
D, editor. Handbook of facial growth. oral and maxillofacial surgery. Vol 1.
North Am 1994; 2:6583.
Philadelphia: WB Saunders; 1982. p. Philadelphia: J. B. Lippincott Co.; 1992.
62. McGraw-Wall B. Frontal sinus fractures. Facial
66186. p. 54774.
Plast Surg Clin North Am 1998;14:5966.
29. Brown WA, Molleson TI, Chinn S. Enlarge- 46. Ginsburg CM. Frontal sinus fractures. Pediatr
63. Markowitz BL, Manson PN, Sargent L, et al.
ment of the frontal sinus. Ann Hum Biol Rev 1997;18:1201.
Management of the medial canthal tendon
1984;11:2216. 47. Brandt MT, Jenkins WS, Fattahi TT, Haug RH.
in nasoethmoid orbital fractures: the
30. Godin DA, Miller RH. Frontal sinus fractures. J Cerebrospinal fluid: implications in oral
importance of the central fragment in clas-
La State Med Soc 1998;150:505. and maxillofacial surgery. J Oral Maxillofac
sification and treatment. Plast Reconstr
31. Tos M, Mogensen C, Novotny Z. Quantitative Surg 2002;60:104956. Surg 1991;87:84353.
histologic features of the normal frontal 48. Furnas DW, Bircoll MJ. Eyelash traction test to 64. Haug RH, Cunningham LL. Management of
sinus. Arch Otolaryngol 1980;106:1438. determine if the medial canthal ligament is fractures of the frontal bone and frontal
32. Urken ML, Som PM, Lawson W, et al. The detached. Plast Reconstr Surg 1973;52:3157. sinus. Selected Readings Oral Maxillofac
abnormally large frontal sinus. I. A practical 49. Achauer BM, Allyn PA, Furnas DW, Bartlett Surg 2002;10:132.
method for its determination based upon RH. Pulmonary complications of burns: 65. Ellis E, Zide MF. Surgical approaches to the
an analysis of 100 normal patients. Laryn- the major threat to the burn patient. Ann facial skeleton. Baltimore: Williams &
goscope 1987;97:6025. Surg 1973;177:3119. Wilkins; 1995. p. 635.
33. Rohrich RJ, Hollier L. The role of the 50. Haug RH, Indresano AT. Management of max- 66. Nadell J, Kline DG. Primary reconstruction of
nasofrontal duct in frontal sinus fracture illary fractures. In: Peterson LJ, editor. Prin- depressed frontal skull fractures including
management. J Craniomaxillofac Trauma ciples of oral and maxillofacial surgery. Vol those involving the sinus, orbit, and cribri-
1996;2:3140. 1. Philadelphia: J. B. Lippincott Co.; 1992. form plate. J Neurosurg 1974;41:2007.
34. Williams PL, Bannister LH, Berry MM, et al. p. 46988. 67. Schmitz JP, Lemke RR, Smith BR. The perime-
Grays anatomy: the anatomical basis of 51. Paskert JP, Manson PN. The bimanual exami- ter marking technique for rigid fixation of
medicine and surgery. New York: Churchill nation for assessing instability in naso- frontal sinus fractures: procedure and
Livingstone; 1995. orbitoethmoidal injuries. Plast Reconstr report of cases. J Oral Maxillofac Surg
35. Williams P, Warwick R. The paranasal sinuses. Surg 1989;83:1657. 1994;52:11205.
In: Warwick R, editor. Grays anatomy. 52. Manson PN, Clark N, Robertson B, et al. Sub- 68. Hybels RL. Posterior table fractures of the
Philadelphia: WB Saunders; 1980. p. 3324, unit principles in midface fractures: the frontal sinus: II. Clinical aspects. Laryngo-
11489. importance of sagittal buttresses, soft-tissue scope 1977;87:17405.
36. Sargent LA, Rogers GF. Nasoethmoid orbital reductions, and sequencing treatment of 69. Levine SB, Rowe LD, Keane WM, Atkins JP Jr.
fractures: diagnosis and management. J segmental fractures. Plast Reconstr Surg Evaluation and treatment of frontal sinus
Craniomaxillofac Trauma 1999;5:1927. 1999;103:1287306. fractures. Otolaryngol Head Neck Surg
37. Zide BM, McCarthy JG. The medial canthus 53. Olson EM, Wright DL, Hoffman HT, et al. 1986;95:1922.
Management of Frontal Sinus and Naso-orbitoethmoid Complex Fractures 507
70. McGrath MH, Smith CJ. A simple method to cy of a new human fibrin sealant: is an antimicrobial prophylaxis in surgery. Am J
maintain reduction of unstable fractures of antifibrinolytic agent necessary? J Trauma Health Syst Pharm 1999;56:183988.
the frontal sinus. Plast Reconstr Surg 2002;52:110715. 101. Peterson LJ. Principles of surgical and antimi-
1981;68:9489. 86. Rosen G, Nachtigal D. The use of hydroxyap- crobial infection management. In: Hupp
71. Nichols RD. Treatment of frontal sinus frac- atite for obliteration of the human frontal JR, editor. Oral and maxillofacial infections.
tures. In: Mathog RH, editor. Maxillofacial sinus. Laryngoscope 1995;105:5535. Philadelphia: W. B. Saunders Co.; 2002.
trauma. Baltimore: Williams & Wilkins; 87. Failla A. Operative management of injuries p. 99111.
1984. p. 28896. involving the frontal sinuses. A study of 102. Lindorf HH. A contribution on revisional and
72. Hybels RL, Newman MH. Posterior table frac- eighteen operated cases. Laryngoscope drainage of the frontal sinus by osteoplastic
tures of the frontal sinus: I. An experimen- 1968;78:183352. operation. J Maxillofac Surg 1986;14:349.
tal study. Laryngoscope 1977;87:1719. 88. Sessions RB, Alford BR, Stratton C, et al. Cur- 103. Schenck NL, Tomlinson MJ. Frontal sinus trau-
73. Dickinson JT, Cipcic JA, Kamerer DB. Princi- rent concepts of frontal sinus surgery: an ma: experimental reconstruction with Pro-
ples of frontal reconstruction. Laryngo- appraisal of the osteoplastic flapfat oblit- plast. Laryngoscope 1977;87:398407.
scope 1969;79: 101974. eration operation. Laryngoscope 1972; 104. Schenck NL, Rauchbach E, Ogura JH. Frontal
74. Valenzela C. Treatment of traumatic disease of 82:91830. sinus disease. II. Development of the frontal
the frontal sinus by adipose implant oblit- 89. Denneny JC III. Frontal sinus obliteration sinus model: occlusion of the nasofrontal
eration. Laryngoscope 1967;77:1695705. using liposuction. Otolaryngol Head Neck duct. Laryngoscope 1974;84:123347.
75. Lazaridis N, Makos C, Iordanidis S, Zouloumis Surg 1986;95:159. 105. Abramson AL, Eason RL. Experimental frontal
L. The use of titanium mesh sheet in the 90. Petruzzelli GJ, Stankiewicz JA. Frontal sinus sinus obliteration: long-term results follow-
fronto-zygomatico-orbital region. Case obliteration with hydroxyapatite cement. ing removal of the mucous membrane lin-
reports. Aust Dent J 1998;43:2238. Laryngoscope 2002; 112:326. ing. Laryngoscope 1977; 87:106673.
76. Lakhani RS, Shibuya TY, Mathog RH, et al. 91. Sailer HF, Gratz KW, Kalavrezos ND. Frontal 106. Larson CH, Adkins WY, Osguthorpe JD. Post-
Titanium mesh repair of the severely com- sinus fractures: principles of treatment and traumatic frontal and frontoethmoid muco-
minuted frontal sinus fracture. Arch Oto- long-term results after sinus obliteration celes causing reversible visual loss. Oto-
laryngol Head Neck Surg 2001;127:6659. with the use of lyophilized cartilage. J Cran- laryngol Head Neck Surg 1983;91:6914.
77. Schubert W, Gear AJL, Lee C, et al. Incorpora- iomaxillofac Surg 1998;26:23542. 107. Constantinidis J, Steinhart H, Schwerdtfeger K,
tion of titanium mesh in orbital and mid- 92. Wolfe SA, Johnson P. Frontal sinus injuries: et al. Therapy of invasive mucoceles of the
face reconstruction. Plast Reconstr Surg primary care and management of late com- frontal sinus. Rhinology 2001;39:338.
2002;110:102230. plications. Plast Reconstr Surg 1988; 108. van Damme PA, Freihofer HP. Disturbances of
78. Wiltfang J, Merten HA, Schultze Mosgau S, et 82:78191. smell and taste after high central midface
al. Biodegradable miniplates (LactoSorb): 93. Benninger MS, Anon J, Mabry RL. The medical fractures. J Craniomaxillofac Surg 1992;
long-term results in infant minipigs and management of rhinosinusitis. Otolaryngol 20:24850.
clinical results. J Craniomaxillofac Surg
Head Neck Surg 1997;117:S419. 109. Murube J, Rojo P, Chenzhuo L. Soft tissue
2000;11:23943.
94. Rivero DH, Lorenzi Filho G, Pazetti R, et al. conjunctivo-rhinostomy. Eur J Ophthal-
79. Stanley RB Jr, Schwartz MS. Immediate recon-
Effects of bronchial transection and reanas- mol 2001;11:3237.
struction of contaminated central craniofa-
tomosis on mucociliary system. Chest 110. Barna NJ, Piacentini MA, Della Rocca RC.
cial injuries with free autogenous grafts.
2001;119:15105. External dacryocystorhinostomy. In:
Laryngoscope 1989;99:10115.
95. Ochi K, Sugiura N, Komatsuzaki Y, et al. Paten- Arthurs BP, editor. Ophthalmic plastic
80. Davis BR, Sandor GK. Use of fibrin glue in
cy of inferior meatal antrostomy. Auris surgery: decision making and techniques.
maxillofacial surgery. J Otolaryngol 1998;
Nasus Larynx 2003;30 Suppl:S57S60. New York: McGraw-Hill; 2002. p. 18998.
27:10712.
96. Sapci T, Sahin B, Karavus A, Akbulut UG. 111. Codere F, Arthurs BP. Endonasal dacryocys-
81. Siedentop KH, Park JJ, Shah AN, et al. Safety and
Comparison of the effects of radiofrequen- torhinostomy. In: Arthurs BP, editor. Oph-
efficacy of currently available fibrin tissue
cy tissue ablation, CO2 laser ablation, and thalmic plastic surgery: decision making
adhesives. Am J Otolaryngol 2001;22:2305.
82. Al-Yamany M, Del Maestro RF. Prevention of partial turbinectomy applications on nasal and techniques. New York: McGraw-Hill;
subdural fluid collections following mucociliary functions. Laryngoscope 2002. p. 199204.
transcortical intraventricular and/or par- 2003;113:5149. 112. McNulty JS. Frontal sinus reconstruction with
aventricular procedures by using fibrin 97. Hoffman BB. Catecholamines, sympath- bone or cartilage grafts. Ear Nose Throat J
adhesive. J Neurosurg 2000;92:40612. omimetic drugs, and adrenergic receptor 1986;65:5126.
83. Man D, Plosker H, Winland-Brown JE. The use antagonists. In: Limbird LE, editor. The 113. Zide MF, Kent JN, Machado L. Hydroxylapatite
of autologous platelet-rich plasma (platelet pharmacological basis of therapeutics. New cranioplasty directly over dura. J Oral Max-
gel) and autologous platelet-poor plasma York: McGraw-Hill; 2001. p. 21565. illofac Surg 1987;45:4816.
(fibrin glue) in cosmetic surgery. Plast 98. Delafuente JC, Davis TA, Davis JA. Pharma- 114. Kaplan EN. 3-D CT images for facial implant
Reconstr Surg 2001;107:22939. cotherapy of allergic rhinitis. Clin Pharm design and manufacture. Clin Plast Surg
84. Stover EP, Siegel LC, Hood PA, et al. Platelet- 1989;8:47485. 1987;14:66376.
rich plasma sequestration, with therapeutic 99. Namias N, Harvill S, Ball S, et al. Cost and 115. Remsen K, Lawson W, Biller HF. Acrylic frontal
platelet yields, reduces allogeneic transfu- morbidity associated with antibiotic pro- cranioplasty. Head Neck Surg 1986;9:3241.
sion in complex cardiac surgery. Anesth phylaxis in the ICU. J Am Coll Surg 116. Conroy B. Maxillofacial prosthetics and tech-
Analg 2000;90:50916. 1999;188:22530. nology. In: Williams JL, editor. Maxillofacial
85. Kheirabadi BS, Pearson R, Tuthill D, et al. 100. American Society of Health System Pharma- injuries. New York: Churchill Livingstone;
Comparative study of the hemostatic effica- cists. ASHP therapeutic guidelines on 1985. p. 3241.
CHAPTER 26
Gunshot Injuries
Jon D. Holmes, DMD, MD
The greater the ignorance, jectiles and firearms led to increasing reports likely underestimate unintentional
the greater the dogmatism. numbers of more devastating wounds. firearm-related deaths and injuries over-
Surgeons accustomed to dealing with a all.5,6 Interestingly, Patton and Woodward
William Osler
variety of wounds from blunt, bladed, and reported that although GSW admissions
Management of gunshot injuries to the face pointed weapons were faced with blast and decreased at the Henry Ford Hospital in
led in many ways to the development of projectile injuries of a completely different Detroit by 45%, the number of patients
modern maxillofacial surgery, and it nature. Contamination and devitalized tis- who required operations actually
remains a cornerstone of the specialty of sues led to increasing numbers of infec- increased by 17%. The number of gunshot
oral and maxillofacial surgery. There is an tions, which surgeons of the day incorrect- victims dead on arrival remained steady. A
aura that surrounds the management of ly attributed to the gunpowder itself, and possible explanation is that an increased
these complex wounds that affects residents to the anticipation of laudable pus. Sub- number of patients are discharged from
as well as experienced clinicians. The mys- sequent advances in surgical knowledge the emergency department after signifi-
tique that developed in the earliest accounts went on to closely parallel the evolution of cant injury requiring admission has been
of management of gunshot wounds firearms. Knowledge gained on the battle- ruled out; these patients are therefore not
(GSWs) persists with the passing along of field by famed military surgeons such as counted as admissions.7
myths and dogma to subsequent genera- Ambroise Par (15101590) elevated the The demographics of gunshot injuries
tions of residents. Readers are encouraged art of surgery to a learned profession.1 are telling. Most victims are young males
to use the information in this chapter as a Unfortunately, the battlefield has moved (< 38 yr). Suicides and assaults far out-
guide, to combine it with their own experi- to the urban areas with increasing num- number unintentional and accidental
ence, and hopefully to continue the evolu- bers of civilian gunshot injuries. shootings. Firearms are implicated in 58%
tion in treatment of these unique wounds. of male suicides and 37% of female sui-
Demographics cides. Importantly, the number of patients
History GSWs are second only to motor vehicle surviving and requiring treatment of gun-
The introduction of Chinese gunpowder accidents as a source of injury and death, shot injuries outnumber firearm fatalities
to Europe around the thirteenth century and rank as the eighth leading cause of by approximately 5:1.8,9
was quickly followed by the development death in the United States.2 Recently the Currently there are an estimated
of projectile weapons based on its explo- number of firearm-related deaths and 135,000 GSWs treated annually in the Unit-
sive properties. The first recorded use of a injuries in children and adolescents has ed States. The incidence of firearm-related
cannon was by Edward III against the declined.3 According to the National Cen- injury and death in the United States
Scots in 1327, and small arms carried by ter for Injury Prevention and Control, exceeds that of other developed countries.10
one or two soldiers began appearing in the firearm-related deaths have shown a con- Although there appears to be a relationship
fourteenth century.1 Early weapons that tinual decline from approximately 15 per between the rate of household firearm own-
used modified arrows were replaced with 100,000 in 1993 to approximately 11 per ership and the homicide rate, most agree
more efficient stone and, ultimately, 100,000 in 1998.4 Because of past difficul- that other social factors are required to
metallic projectiles. Improvements in pro- ties with surveillance, however, most explain the number of firearm injuries in
510 Part 4: Maxillofacial Trauma
the United States in comparison with other firearm-related injuries in the United 2. External ballistics refers to forces that
developed countries.9 Indeed, in countries States yearly, with an annual cost of treat- act on the bullet in flight. The primary
in which firearm ownership is required for ing firearm injuries of approximately $2.3 factors that govern external ballistics
militia duty, firearm injuries are lower on a billion; of this, taxpayers pay $1.1 billion. are the weight and shape of the bullet.
per-capita basis than in the United States. Although this cost represents only one- 3. Terminal ballistics is the study of bullet
The majority of civilian firearm injuries are quarter of 1% of the US health care budget behavior once it impacts the target and
sustained from handguns (86%), followed of $950 billion, it is significant considering is primarily concerned with how much
by shotguns (8%) and rifles (5%). Approxi- that the group most affected typically energy is transferred to the target mate-
mately 12 to 14% of unintentional and involves younger healthier patients that rial and the resultant damage. The sci-
assault gunshot injuries involve the head usually require very little medical care.13 ence of terminal ballistics is most
and neck, whereas 51% of self-inflicted gun- important to the surgeon and is the
shot injuries involve the head and neck.4 Ballistics most common source of controversy
Clark and colleagues reported on their Ballistics is the science of projectile motion. when discussing ballistic wounding.
experience at the Maryland Shock Trauma A prerequisite to understanding the injuries Attempts to reproduce the interaction
Center and found that of 178 GSWs to the caused by various firearms is knowledge of of bullets with living tissue by using
face, 40% involved the frontal bone and cra- the language of ballistics. The potential various target media such as ballistic gel
nium, 9% involved the orbits, 14% involved problems of a wound caused by a projectile have led to many myths surrounding
the lower midface (maxilla), 13% involved can be better anticipated if one has some wounding and the stopping power of
the mandible, and 24% involved multiple knowledge of the weapon and projectile various bullets and weapons. Similarly,
sites. Shotgun injuries more commonly type that caused the wound. For example, if surgeons have passed on many myths of
involved the mandible and midface.11 the surgeon is aware that a patient suffered a their own regarding GSWs and the
Demetriades and colleagues reported on the high-energy wound caused by a high- firearms that cause them.
extensive experience of the University of power, high-velocity cartridge, he can better
California at Los Angeles. Of 4,139 patients appreciate the potential for extensive areas
admitted with gunshot injuries over a of devitalized tissue that may declare later. Energy and Wounding Power
4-year period, 6% (247) had GSWs to the In addition, an understanding of firearm Traditionally, kinetic energy has been used
face. Thirty-eight percent of these had iso- nomenclature allows the surgeon some abil- as the basis to explain wounds caused by a
lated wounds to the face, whereas the ity to predict the types of weapons that are gunshot. Simple physics can be applied to
remaining 62% had associated injuries to commonly involved in various types of the projectile using the following formula:
other body areas. They reported that the civilian gunshot injuries. For this reason, the
mandible was the most commonly involved clinician dealing with gunshot injuries KE = mv2
facial bone (54 cases), followed by the max- should be conversant in the rudiments of where KE is kinetic energy, m is the mass
illa and zygoma (21 cases each). The orbits ballistics, types of firearms, and projectiles. of the projectile, and v is the velocity of the
and nasal bones were involved in 18 and 15 Ballistic science seeks to explain the projectile.
cases, respectively. Thirty-six patients died behavior of the projectile and is typically Wounding power is typically related to
following admission. All of the deaths were divided into three stages: the amount of kinetic energy transferred
secondary to injuries to the chest, abdomen, to the target:
or brain. There were no deaths associated 1. Internal (or interior) ballistics describes
P = m(Vimpact Vexit)2
with isolated facial injuries.12 the forces that apply to a projectile from
Aside from the tragedy of firearm- the time the propellant is ignited to the where P is power, m is mass of the projec-
related injuries and the emotional toll such time the projectile leaves the barrel. An tile, and V is velocity.
injuries take on victims, their families, and important consideration is barrel Based on these formulas, the velocity
communities, the financial burden to soci- length. In general, longer barrels (rifles) of a projectile has traditionally been con-
ety of firearm-related injuries is significant. allow the force of the propellant to act sidered far more important than its mass in
This is especially true with regard to the on the projectile longer and generate wounding power. Indeed, often guns are
long-term rehabilitation and multiple higher velocities than do shorter-bar- classified as low velocity (< 350 m/s),
reconstructive surgeries that many victims reled weapons. In addition, a longer medium velocity (350600 m/s), and high
of facial GSWs require. Cook and col- barrel serves to stabilize the bullet over velocity (> 600 m/s). Considering a typi-
leagues reported approximately 115,000 longer distances. cally sized projectile, a velocity of approxi-
Gunshot Injuries 511
mately 50 m/s is required to penetrate the amount of energy transferred to the target mation and rupture, and nerves may fail
skin, and a velocity of around 65 m/s will and resultant tissue wounding. These fac- to recover function.
fracture bone.14 See Table 26-1 for a com- tors govern the four components of pro- Fragmentation, which may not be pre-
parison of commonly encountered pistol jectile wounding: penetration, permanent sent in a GSW, refers to the projectile (cer-
and rifle cartridges. cavity formation, temporary cavity forma- tain projectiles are designed to fragment;
In general, there is an inverse relation- tion, and fragmentation. see below) or secondary fragments such as
ship between a bullets diameter (caliber) Penetration allows the projectile to clothing or bone that develop from being
and velocity. Unfortunately, the realities of transmit kinetic energy and destroy tissue. struck by the projectile.
wounding are not as clear cut, and the A bullet must penetrate to a sufficient Despite claims by many bullet manu-
emphasis on velocity and kinetic energy of depth to cause damage. Likewise, a projec- facturers, fragmentation of the projectile
the weapon as it relates to treatment tile that over-penetrates or passes com- does not reliably occur in most handgun
strategies is excessive.15 In an excellent pletely through nonvital tissue may result wounds. Bullets specifically designed as
review, Fackler debunks many of the com- in little damage. fragmentation rounds typically suffer from
monly held beliefs of ballistic injury, The permanent cavity describes the low-penetration ability. High-velocity rifle
including the idolatry of velocity, the exag- space that results from direct tissue dis- rounds are known, however, for their dev-
geration of the effects of temporary cavita- ruption and destruction. It is a function of astating fragmentation.
tion and pressure, bullet tumbling, the the penetration and size of the projectile. The effects of the temporary cavity on
exaggerated role of kinetic energy transfer, It is generally considered to be the most wounding are often exaggerated in ballis-
and, most importantly, the emphasis on important factor in the wounding and tic literature. Because most tissue has an
extensive wound dbridement.16 The het- stopping power of a particular cartridge elastic nature and ability to recover from
erogeneity of the human body, which is and bullet. stretching (certain tissues such as brain are
composed of tissues of varying densities The temporary cavity is produced as exceptions), damage from temporary cav-
and elasticities, does not allow formulas to the projectile travels through the target itation is not as important as many
explain all of the nuances of wounding tissue. Transfer of kinetic energy results in expound. The massive zones of necrotic
caused by projectiles of different velocities, a stretching of elastic tissues. Although tissue that were felt to develop from tem-
sizes, and weights. Practically, there is a they may remain intact, some of these tis- porary cavitation do not exist in reality.
balance between velocity, projectile mass, sues may be irrecoverably damaged. The most important factors in projectile
and projectile size that governs the Arteries may suffer pseudoaneurysm for- wounding remain penetration and the size
of the permanent cavity. A very small pro-
jectile traveling at high velocity striking an
Table 26-1 Comparison of Approximate Cartridge Velocities and Muzzle Energy* area of low density (eg, fat) may impart far
Bullet Weight Velocity Muzzle Energy less damage than a larger projectile travel-
Cartridge (grains) (ft./s) (ft./lb.) ing at a lower velocity and striking an area
.22 LR 29 1,225 140
of high density (eg, bone). The realities of
.32 auto 71 900 129 stopping power further call into question
.380 auto (9 mm short) 95 955 190 many of the claims promulgated through
.38 special 145 680 170 ballistic literature as well as surgical prac-
.357 magnum 110 1,565 535 tices. In reality, the power transferred to
9 mm 124 1,100 345 the victim is the same as what the recoil
.45 auto 230 790 370 imparts on the shooter. Again, simple
.44 magnum 240 1,420 741 physics explains that the impact of a 9 mm
.223 (NATO 5.56 45) 55 3,100 1,280 pistol round (see below) is the same as that
.308 (NATO 7.62 51) 110 3,000 2,650 created by a 0.45 kg weight dropped from
.300 magnum 180 2,900 3,500 a height of 1.82 m or of a 4.53 kg weight
20-gauge shotgun 547 1,185 1,400
dropped from a height of 1.82 cm. In more
12-gauge shotgun 820 1,250 2,600
practical terms, the amount of energy
Adapted from Federal Ammunition Company high power ammunition handbook. Minneapolis; 1983.
*Velocities and muzzle energy can vary within different cartridges depending on the weight of bullet, powder type, and other delivered to a body by a bullet is approxi-
variables such as barrel length. mately equivalent to that transmitted
1 oz. = 437.5 grains.
when one is hit with a baseball.17
512 Part 4: Maxillofacial Trauma
It is important to understand that the diameter. Firearms of European origin, are usually referred to by gauge, which is an
science of wounding power is more than such as the 9 mm, have classically used the English measurement that describes how
simple physics; it is a complex interplay of metric system. The American military many lead balls equaling 1 lb. (0.45 kg)
projectile and target tissue characteristics round for the M-16 (military version of would fit into a particular diameter of the
that makes each wound unique. For this rea- the AR-15) is usually the 223, which is barrel. For example, it would take 12 lead
son, categorization of wounds based on 0.223 in. (0.57 cm) in diameter, whereas balls equal in diameter to the internal
projectile characteristics such as velocity, the Soviet AK-47 fires a 30-caliber projec- diameter of a 12-gauge shotgun barrel to
although useful, should not promote dog- tile, or 7.62 39 (39 refers to the length of make 1 lb. A 12-gauge shotgun has an
matic management schemes but instead the case containing the propellant in mil- internal barrel diameter of 1.85 cm, where-
should serve as guides. Surgeons should be limeters; Figure 26-1). as a 28-gauge shotgun has an internal bar-
wary of strict categorization schemes and Shotguns were originally designed to rel diameter of 1.41 cm. It is clear that the
treatment algorithms based only on velocity be used on small fast-moving game and higher the gauge, the smaller the diameter
or another bullet characteristic and should typically fired small pellets that dispersed of the barrel (Figure 26-2A). There are
bear in mind Lindseys statement, I will in flight to form a pattern. Typical muzzle some exceptions to this classification
keep treating the wound, not the weapon.15 velocities range from 335 to 427 m/s. They scheme. For example, a 410 shotgun has a
Firearm Terminology
As with ballistics, some knowledge of
firearms is necessary for surgeons manag-
ing GSWs. It is a prerequisite for commu-
nicating with law enforcement officers and
other clinicians.
Firearms are generally classified as
handguns, rifles, and shotguns. Handguns
are also referred to as pistols and revolvers,
depending on their mechanical actions.
With few exceptions, most are low or
medium velocity, typically < 600 m/s, and
usually cause tissue damage along the bul- FIGURE 26-1 A, Representa-
let tract only. Rifles range from low to high tive rifle cartridges. From left
to right: .300 Winchester mag-
velocities. Shotguns typically are smooth- num, 30-06, .308 (7.62 51
bore weapons that fire shells filled with NATO), .223 (5.56 45
lead shot of various sizes. Some shotguns NATO), 7.39 (AK-47 round),
and .17 rimfire. B, Representa-
may be modified with rifled barrels to fire tive pistol cartridges. From left
shells containing a solid lead projectile to right: .44 magnum, .357
referred to as a slug. Although they are of A magnum, .38 special, .45 auto,
low velocity, close-range shotgun injuries .40 auto, 9 mm auto, .380 auto
(9 mm short), .22 rimfire.
are devastating, especially with larger lead
shot such as buckshot (see below).
Rifles and handguns are classified by
caliber. The caliber of a weapon is the
diameter of the muzzle bore, which is the
same as the diameter of the projectile (bul-
let). Cartridge or round refers to the case
containing the ignition system (primer),
the propellant, and the projectile (bullet).
Measurements for American firearms are
typically in inches. For example, the .45
B
caliber pistol bullet is 0.45 in. (1.14 cm) in
Gunshot Injuries 513
A B
FIGURE 26-2 A, Representative shotgun shells. From left to right: 10 gauge; 3 in. 12 gauge; 234 in. 12 gauge; 20 gauge Demonstrator shell with
shot, wadding, and powder visible; .410 gauge. B, Plastic and felt shotgun wadding.
barrel whose internal diameter is 0.410 in. different makeup of a shotgun shell (see fices in long-range accuracy were a trade-
(1.04 cm). In general, the lower the gauge, Figure 26-2A). The pellets are typically sep- off for rapid rates of fire. This obstacle was
the more powder and shot the shell arated from the propellant by wadding overcome in 1847 by Captain Mini, who
can contain. that helps to contain and transfer the developed a projectile with a hollow coni-
Shot is also classified by size. Com- power of the charge to the pellets. This cal base that loaded easily but expanded
monly encountered shot sizes range from partition can be made of felt or plastic and for a tight fit when the propellant enlarged
8 shot (0.23 cm), with approximately 500 may be found embedded in close-range behind it (Figure 26-3). Ultimately,
pellets in a 12-gauge shell, to number 00 wounds (Figure 26-2B). breech-loading weapons, in which a self-
buckshot (0.83 cm), with 9 to 15 pellets in Most handguns and rifles have barrels contained round enclosing the ignition
a 12-gauge shell. Shells come in different with internal grooves referred to as rifling system (primer), propellant, and projectile
lengths within the same gauge as well. For that impart a spin to the bullet. This keeps was loaded from the beginning of the bar-
example, a 12-gauge shell may be a 234 in. the projectile stable in flight over longer rel instead of the end, overcame these dif-
(6.99 cm) or 3 in. (7.62 cm) shell. Longer distances. In early firearms that were ficulties. The development of rifling, how-
shells hold a larger charge of powder and loaded from the muzzle (muzzleloaders), ever, allowed high-velocity projectiles that
shot, which can be used for larger game or the tight fit between the bullet and the bar- would remain stable in flight over long
game at further distances. As a general rel that resulted from rifling significantly distances. Eventually, all projectiles
rule, longer-barreled shotguns and those slowed loading. For this reason, most early become unstable in flight because the cen-
with a full choke (a constriction of the end military weapons were smoothbore. Sacri- ter of gravity lies well behind the center of
of the barrel) keep the pellets in a tighter
pattern over longer distances. Finally, FIGURE 26-3 Left, Early
some shotguns may be modified with round projectile and Mini
rifled barrels to fire shells containing a ball with expanding base.
Right, Modern full-jacketed
solid lead projectile referred to as a slug.
and soft point rounds with
Shot is usually selected based on the size of boat tail to improve flight
game. Buckshot refers to larger pellets characteristics.
meant for large game or human targets; it is
particularly devastating because its impact
is similar to multiple low- to medium-
velocity handgun wounds, depending on
the range.18 It is also important to note the
514 Part 4: Maxillofacial Trauma
injuries are caused by low- or medium- and loss of energy. Penetration may occur
velocity weapons. through deep fascia, but fractures are rare.
One of the earliest and simplest classi- Ocular injuries can occur as well as
fication schemes classifies GSWs as non- embolization of lead pellets, but mortality
penetrating (grazing or blast wound), is less (1520%). At distances > 12 m (type
penetrating (bullet does not exit), perfo- III), usually only the skin is penetrated and
rating (in and out), and avulsive. The mortality is rare (05%).24,25 Because spe-
International Committee of the Red Cross cific information on shooting distances is
introduced the armed conflict classifica- not often available to the clinician, a system
tion system to improve information gath- was suggested that evaluated the maximum
ering and communication regarding war distance of pellet scatter. Type I injuries
wounds. Because of the diversity of battle- had > 25 cm of pellet scatter. Type II
field weaponry, by necessity the system injuries had 10 to 25 cm of scatter. Type III FIGURE 26-5 Submental entrance wound with
powder burns characteristic of a suicide attempt
ignores weapon type and instead concen- injuries had < 10 cm of scatter and would by placing a gun under the chin.
trates on wound severity in terms of tissue roughly correspond to a type I injury in the
damage and anatomic structures classification of Sherman and Parrish.24
involved.22,23 Gugala and Lindsey suggest- This classification scheme was developed
ed a civilian gunshot injury classification and applied to abdominal shotgun wounds Management
scheme. It takes into account energy (high in an attempt to guide therapy.26 Again, the
or low), involvement of vital structures difficulty lies in applying this scheme, or General Principles
(neural and vascular), wound type (non- any scheme, universally to GSWs involving On admission victims of gunshot injuries
penetrating, penetrating, perforating), different anatomic sites and weapon types. are best managed by standard advanced
fracture (intra-articular and extra-articu- It should be noted that rifle and shot- trauma life support (ATLS) protocols.
lar), and contamination. Primarily used in gun injuries, although rare in assaults, are Even seemingly innocuous wounds
orthopedics, its usefulness in gunshot frequently encountered in attempted sui- deserve attention, given the erratic nature
injuries to the head and neck is limited. 23 cide patients. A characteristic wound pro- of the wounds. Specific attention must be
file is seen because of the head position given to the possibility of multiple
Shotgun Wounds assumed when the patient places the barrel injuries; it is imperative to thoroughly
Because of their unique ballistic profile, of the weapon in the mouth or under the inspect the patient for multiple entrance
shotgun injuries are often classified based chin and subsequently hyperextends to and exit wounds. Visually disturbing but
on the distance to the target. Shotgun pel- reach the trigger. Characteristic powder nonlife-threatening facial gunshot injuries
lets have significant aerodynamic resis- burns are seen at the entrance wound (Fig- can distract medical personnel from other
tance and give up substantial amounts of ure 26-5). The face frequently takes the full more subtle lethal injuries such as a pene-
kinetic energy during flight. In type I shot- effect of the blast, whereas lethal intracra- trating thoracic wound that entered
gun injuries (< 5 m), the pellets strike the nial involvement is avoided.27 If a high- through the back. Ophthalmologic and
target as a single mass, resulting in massive energy weapon such as a shotgun or rifle is neurosurgical consultations are obtained
kinetic energy transfer, tissue avulsion, and used, the injury can be devastating with when indicated. Approximately 17% of
a high mortality rate (8590%). Patients significant tissue loss. patients with a GSW to the face have asso-
that survive suicide attempts with shotguns Although classification schemes can ciated brain injuries, and 8% have associ-
typically survive because, in an attempt to serve useful purposes in research as well as ated C-spine injuries.12,28 Eye injuries are
reach the trigger with the muzzle under the clinical practice, strict adherence to treat- present in approximately 13% (Figure 26-
chin or in the mouth, the head is hyperex- ment algorithms based on wound classifi- 6).28 Certain considerations for gunshot
tended, which causes the pellets to create cation can lead to mismanagement. injuries should be emphasized.
devastating injuries to the face but avoid Importantly, information regarding types
the cranium. Fragments of paper or plastic of firearm and other details of the shoot- Airway
wadding may be found in the wound. Type ing are frequently not available, and clini- Loss of the airway is the single most likely
II injuries (512 m) usually result in much cal assessment of the wound remains the cause of death in an isolated GSW to the
less tissue destruction. At these distances most reliable method for determining face. When confronted with a patient with
there is significant dispersal of the pellets treatment approaches. a facial GSW, surgeons should have a low
516 Part 4: Maxillofacial Trauma
nial nerves X, XI, and XII. It is the management. In the absence of urgent Penetrating injuries to zone II are the
largest area and therefore the most management needs, the surgeon must most common and are most amenable to
commonly involved zone in penetrat- rule out occult injuries based on the surgical exploration, if warranted. For
ing neck trauma. zones involved. asymptomatic patients, computed tomo-
Zone III spans the region from the Injuries to zone I can be associated graphic angiography is becoming an impor-
skull base to the angle of the mandible. with significant bleeding because of the tant tool for screening and can assist in
It contains the carotid arteries, the large vessels in this area. This is especially determining whether operative exploration
internal jugular veins, and the pharynx true with regard to injuries caused by high- is warranted. Patients can undergo serial
along with multiple cranial nerves energy weapons. Although serving to pro- examinations over 24 hours if the angiogra-
exiting the skull base. It should be tect the vessels, the clavicles are a hindrance phy results are negative. Computed tomo-
appreciated that gunshot wounds that to the application of direct pressure to the graphic angiography is faster and less inva-
involve mandibular fractures are area and to rapid surgical exposure. In the sive than angiography but is of lower
accompanied by injuries to zone III. stable patient most surgeons advocate rou- specificity. It should also be noted that
tine angiography and an evaluation of the injuries that have tamponaded themselves
Van As and colleagues reported on 116 esophagus via rigid esophagoscopy or a can be missed on either (see Figure 26-10C).
patients shot in the neck in South Africa. barium swallow. The choice between bari- Some surgeons recommend the use of a
Of these, 70 suffered a direct hit to the um swallow and esophagoscopy varies barium swallow or rigid esophagoscopy,
neck; in 46 patients the bullet traversed the according to the surgeons preference as whereas others recommend observation
face or chest first. Of the 116 patients 85 both are reasonably accurate at diagnosing only if the index of suspicion for injury is
suffered some vascular injury, although injury (90% and 86%, respectively). In low, as with wounds from low-energy guns.
most were minor branches, 61 had some addition, there is some controversy regard- If patients have associated mandible frac-
injury to the airway, and 32 had an injury ing the appropriate contrast media. tures, the neck can be explored while the
to the pharynx or esophagus.35 Many Although meglumine diatrizoate causes mandible fractures are exposed for fixation.
patients had more than one injury. Man- less inflammatory response than does bar- Imaging is required in zone III injuries
agement strategies for penetrating neck ium when it extravasates into tissues owing if the patient is stable. Diagnosis of vascular
injuries are typically based on the zone(s) to an esophageal perforation, it results in a injuries at the skull base typically requires
involved.36,37 Gunshot wounds to the head severe chemical pneumonitis if aspirated. angiography, which can also allow interven-
and neck frequently involve projectiles For this reason, barium should be used if tion if indicated. Injuries to zone III are
that traverse or involve more than one there is any impairment to the gag and rarely amenable to surgical intervention.
zone. For this reason, surgeons may have cough reflexes; if there is a leak, early oper- Overall, angiography remains the
to modify management plans based on the ative intervention allows it to be washed gold standard for exploration of vascular
situation at hand. Although a complete out during surgery. Penetrating injuries to injuries of the neck. In Van As and col-
discussion of penetrating neck trauma is the left neck, and rarely to the right, can leagues report, 89 patients underwent
beyond the scope of this chapter, general result in a chyle leak (Figure 26-12). The angiography for GSWs to the neck; results
principles should be understood by sur- surgeon should take care to exclude this at were positive in 12 patients, with most
geons managing facial gunshot injuries. the initial exploration, if possible, and to lesions occurring in the common carotid
Initially the patients stability from repair it by oversewing the duct with local followed by the internal and external
an airway and hemodynamic status tissues. It is useful to have the anesthesiol- carotids (3 cases each), the vertebral
guides the decision-making for pene- ogist apply positive pressure and to place artery (2 cases), and the subclavian artery
trating neck injuries (Figure 26-11). In the patient in Trendelenburgs position. (1 case).35 Currently ultrasonography is
the stable patient, a complete examina- Delayed management is much more diffi- gaining popularity as a rapid noninvasive
tion is part of the secondary survey of cult after the tissues have been exposed to technique for the evaluation of a variety
ATLS. Signs of tracheal injury, such as chyle. Conservative management with a of traumatic injuries in the emergency
subcutaneous emphysema, stridor, diet of medium-chain triglycerides, which department. Ginzburg and colleagues
hoarseness, dysphonia, or hemoptysis are not carried by the gut lymphatics, and evaluated the usefulness of duplex ultra-
require urgent intervention. Hard signs drainage should be attempted initially if sonography to evaluate vascular injuries
of vascular injury, such as expanding the leak presents in the postoperative set- in a double-blind study using angiogra-
hematoma, and pulse or neurologic ting. Exploration is indicated for leaks of phy as a control. They reported a 100%
deficit, also signal the need for urgent > 400 to 500 cc/d for a week. true-negative rate, 100% sensitivity, and
Gunshot Injuries 519
Symptomatic patient
Penetrating neck wound
Follow ATLS protocol for airway control and primary survey Shock Stable vital signs
A B
FIGURE 26-11 A, Initial decision tree for penetrating neck trauma. B, Management of the symptomatic patient with a penetrating neck wound. ATLS = advanced trau-
ma life support.
85% specificity in detection of arterial bypass of the oral cavity and improved in dealing with gunshot injuries to the face.
injury. Ultrasonography will most likely hygiene in the early days following injury. Spiral computed tomography combined
continue to grow in popularity as a Consideration should be given to percuta- with three-dimensional reconstructions
screening tool because of its cost and the neous endoscopic gastrostomy if long- allows the surgeon an unparalleled view of
speed at which it can be performed.38 Fur- term bypass of the oral cavity is necessary,
ther improvements in noninvasive vascu- the patient will be unable to eat, or the
lar evaluation techniques, such as helical patient has a preexisting nutritional deficit.
computed tomographic angiography and
ultrasonography, will reduce the number Imaging
of patients undergoing traditional Following the ATLS protocol, standard C-
angiography and improve patient selec- spine and chest radiographs should be
tion for nonoperative management. obtained. These can be valuable for visual-
izing the bullet fragments and in gaining
Nutrition some insight into the path of the bullet
The majority of civilian gunshot wounds (see Figure 26-10B). It is important to
affect young healthy males. Nutritional sta- recall, however, that projectiles rarely fol-
tus becomes an issue only in patients low a straight path once they enter tissue.
FIGURE 26-12 Chyle leak following penetrating
whose injuries preclude oral alimentation The ability to obtain accurate three- injury to zone I of neck oversewn with nonab-
for an extended period (> 4 or 5 d). Feed- dimensional images in a rapid fashion has sorbable suture and covered with a flap from the
ing via nasogastric intubation allows been one of the most important advances sternocleidomastoid muscle.
520 Part 4: Maxillofacial Trauma
B C
FIGURE 26-15 A, Gunshot wound resulting from the placement of a low-velocity handgun into the mouth.
B, Initial closure demonstrating no true tissue loss. C, Three-month postoperative photograph demonstrat-
A
ing minimal residual deformity following closure. The facial nerve is intact.
wounds, which generally are inflicted with ble to aid in restoration of occlusion and wound washouts and dbridement of only
low-velocity weapons. proper jaw relations. Drains are often indi- obviously dead tissue, which have gained
An operative plan for a gunshot injury cated; whether closed suction or Penrose is popularity in orthopedics, have great util-
to the face is best formulated after charac- used depends on the wound. Pressure ity in injuries to the maxillofacial skeleton.
terization of the wound as low or high dressings can also be used to minimize Second dbridements should be per-
energy (Figures 26-15 and 26-16). The dead space. In cases of true soft tissue formed 24 to 48 hours after the initial
surgeon facing a gunshot injury should avulsion, a decision must be made regard- surgery. This allows for the maintenance
consider the concept introduced by Man- ing whether primary flaps or grafting is of tissue considered borderline, which
son for evaluation of four components: indicated. In wounds that are relatively can be excised if it truly becomes devital-
soft tissue injury, bone injury, soft tissues clean, local flaps and skin grafts may be ized. Skin grafts can be used as permanent
loss (true avulsion), and bone loss.43 After appropriate. In grossly contaminated or temporary replacement for missing tis-
evaluation of the wound, a decision is wounds, delayed closure or grafting may sue to reduce deformity from scar contrac-
made regarding early definitive repair ver- be necessary. Closing mucosa to skin can
sus the need for delayed repair. The major- be a useful technique, but many cases can
ity of civilian gunshot wounds resulting be managed with dressing changes and
from assaults can be managed with early incorporation of an early flap procedure.
definitive repair because these injuries Free tissue transfer, although useful,
usually result in injury to the soft tissue should be delayed until the initial phase of
and bone but rarely loss of these tissues. wound healing, when its accompanying
Impressive soft tissue injuries are usually vascular spasm and attendant hypercoagu-
not avulsive, and most can be closed pri- lable state has decreased.
marily (see Figure 26-15). Extensive In wounds with extensive soft and
dbridement of soft tissue is not indicated. hard tissue damage and true loss of soft
Wound debris should be removed, and and hard tissue, an approach using early
wounds should be lavaged with normal stabilization of bone fragments with max-
saline. Antibiotic solutions such as saline illomandibular fixation, external fixation,
and bacitracin (50,000 U/L) have not been or internal fixation with reconstruction
shown to be more effective than normal plates combined with conservative man-
saline but are still popular. A pulsating agement of soft tissue is indicated. In this
irrigator is useful to mechanically agitate era of rigid internal fixation, the utility of
debris from the tissue. Obvious devitalized maxillomandibular fixation should not be
and loose teeth should be removed. Frac- overlooked.12,28 In addition, external fixa-
tures are reduced and fixed rigidly. Other- tion devices are still useful in select cases. FIGURE 26-16 Extensive wound resulting from a high-
wise, teeth should be maintained if possi- Second-look operations with conservative velocity weapon.
522 Part 4: Maxillofacial Trauma
ture. Once the soft tissues have stabilized, a removal of bullet fragments.47 Removal of sibility that grafts will be required to span
decision can be made regarding early intra-articular bullet fragments should be damaged segments. Beyond 72 hours dis-
replacement of lost tissues with free tissue considered when the increased risk of lead tal branches of the facial nerve will not
transfer or delayed reconstruction. In toxicity is associated with fragments with- respond to a nerve stimulator, making
general, earlier repair leads to improved in joint spaces and the potential for long- their identification difficult. If possible,
outcomes with less scar contracture and term deterioration of the joint.48 Finally, tagging the branches with suture at the
resultant deformity. Bone grafts at the consideration may be given to the removal initial surgery is invaluable. Extensive
time of initial surgery may be indicated in of brass- or copper-jacketed bullets that damage to the proximal nerve may
the midface (see below). Again, manage- are in close proximity to central or major require a temporal bone dissection to
ment strategies should be considered a peripheral nerves because of potential identify a viable proximal nerve for graft-
continuum that is modified as necessary neurotoxicity.49,50 ing. Injuries distal to a line dropped verti-
rather than strict distinct stages. It is important to remember that bul- cally from the lateral canthus (zone of
let fragments are potential evidence and arborization) do not typically require
Contamination an appropriate chain of custody is repair because of the multiple intercon-
It should be remembered that projectiles required. Most hospitals have a protocol in nections distal to this line and the reason-
from firearms are not sterile. This fact is place to ensure that this chain is unbroken able expectation of return of function,
well known to those who have dipped from the time they are retrieved to when even if the nerve is temporarily nonfunc-
their bullets in feces prior to assassination they are logged in as evidence. This usual- tioning (see Figure 26-15).
attempts but lost on clinicians who have ly involves a police officer or other
taught that gunshot wounds are indeed designee taking direct possession of the Salivary Ducts
sterile. The heat generated by the discharge bullet or fragments in the operating room Transected salivary ducts may be repaired
of the propellant as well as the friction or nearby. Documentation of injuries with or ligated depending on the amount of
between the bullet and barrel is not suffi- photographs can aid in reconstructing the damage. The parotid duct can be repaired
cient to sterilize the bullet.44,45 Contamina- events leading to the injury and recording over an intravenous catheter or polymeric
tion can occur from the bullet and also where fragments were retrieved. Since silicone tubing, which is then sutured to
from skin flora and foreign bodies (cloth- some assaults have injury patterns similar the buccal mucosa. It is best to avoid
ing) carried into the wound. Historically, to suicides, it is important to consider this bringing the tubing out of the mouth
streptococcal bacteremia was the most chain of custody because subsequent because of the tendency for it to be dis-
important cause of death on the battlefield investigations may reveal that an apparent lodged. In injuries that penetrate the
in the preantibiotic era.46 Wounds in suicide was actually an assault.51 parotid-masseteric fascia, there is a poten-
which the bullet traverses the aerodigestive tial for development of a sialocele or fistu-
tract or paranasal sinuses are at particular Specialized Structures la. These typically resolve with drainage
risk. Devitalized tissue and vascular con- and pressure dressings. Aspiration may be
gestion leads to an ideal environment for Facial Nerve required multiple times, and, rarely, anti-
bacterial growth. Prophylactic coverage Damage to the facial nerve is present in sialagogues may be indicated. In addition,
with broad-spectrum antibiotics, typically only 3 to 6% of civilian GSWs to the removal of any associated foreign bodies
a second-generation cephalosporin, and face.12,28 This is most likely because low- may be necessary to resolve the fistula and
tetanus prophylaxis, when indicated, energy weapons are involved in most of hasten healing. Dermal grafts can be used
should be initiated in all gunshot wounds. these cases. However, such damage is not at the time of repair (Figure 26-17).
Extensive surgical dbridement is rarely uncommon in injuries inflicted by higher-
indicated in wounds consistent with low- velocity firearms. Careful documentation Controversies: Delayed versus
velocity projectiles to prevent infection. at the earliest possible opportunity is Early Management and Closed
Removal of projectiles, a well-worn important. If a functioning nerve becomes versus Open Fracture
tradition in Hollywood, is less commonly nonfunctional secondary to swelling, the Management
indicated in reality. The need for the surgeon can be reasonably confident that Proponents exist both for closed manage-
removal of bullets must be balanced function will return. Obvious transection ment of fractures with delayed reconstruc-
against the real risk of increasing damage. of the nerve requires repair. In heavily tion as well as aggressive early management
Lead toxicity is a rare complication that contaminated wounds, repair should be with open reduction of fractures and
does not typically justify the routine delayed for 48 to 72 hours, given the pos- replacement of missing tissue as soon as
Gunshot Injuries 523
Bone Grafting
Bone grafts are frequently required in the
management of GSWs to the face,
whether for replacement of true loss of
bone (avulsive injuries) or in cases in
which comminuted and misplaced frag-
ments need to be replaced or reinforced.
Reconstruction with bone grafts gained
A B
popularity in World War I, and much of
FIGURE 26-17 A, Salivary-cutaneous fistula associated with a retained bullet fragment. B, The bullet was what we know about the healing of free
removed and a dermal graft was placed. bone grafts was learned following their
introduction for late reconstruction of
possible. Both groups point to failures and should instead rely on a careful appraisal of gunshot injuries in wartime. Iliac bone
shortcomings of the other to justify their the wound and decide on the amount of grafts were popular for late reconstruc-
approach. Advocates of delayed repair early repair that is indicated. tion. Surgical dogma was against early or
point to a higher incidence of infection and
to benefits of closed treatment, whereas
those advocating more aggressive manage-
ment report improved functional and
esthetic outcomes.52,53 Since neither
approach is likely to ever be subjected to a
randomized trial measuring outcomes,
surgeons must base their treatment deci-
sions on a critical review of the literature
and their own experience. As with most
arguments in surgical science, the truth A B
most likely lies somewhere in the middle.
Certainly the advantages of aggressive early
management are appealing (Figure 26-18).
Early return to function and decreased
numbers of revision surgeries are laudable
goals. Currently techniques involving open
reduction and fixation of fractures result-
ing from GSWs seem to be gaining in pop-
ularity, and patients are less likely to be
treated with closed reduction. Given that D
C
most of these injuries are low energy, this is
acceptable. The main disadvantage of open FIGURE 26-18 A, Grazing shotgun facial wound, sus-
reduction is infection, which primarily tained in hunting accident, associated with avulsion
of the upper third of the nose, including the skin, nasal
affects the mandible. The reported rate of bones, a portion of the upper lateral cartilages, and the
infection with open reduction and fixation skin of upper eyelid. B, Use of immediate cranial bone
of mandible fractures resulting from a grafting to replace the lost nasal support. C, Develop-
ment of a pericranial flap to envelope the cranial bone
gunshot is around 16 to 17%.54 However, and provide a vascularized tissue bed to support a
rigid fixation can frequently be maintained full-thickness skin grafting. D, Early postoperative
in the event of wound problems and still photograph demonstrating the full take of skin graft.
serves to stabilize mandibular segments. E, Late (1 yr) postoperative photograph demonstrat-
ing good nasal support and prosthetic rehabilitation of
Surgeons should avoid the application of a the left globe; photograph was taken prior to the
set protocol to every GSW situation and E
reconstruction of the ala with a graft from the helix.
524 Part 4: Maxillofacial Trauma
primary bone grafting and stipulated nounced when wounds are opened. In Conclusions
waiting until soft tissue healing had these cases vascularized tissue transfer
The development of firearms heralded a
occurred. More recently the use of bone offers the ability to import soft tissue
new era in surgery as well as warfare. Evo-
grafts in the early setting has gained and/or bone into the site. As noted previ-
lution of more efficient weapons contin-
popularity. Gruss and colleagues have ously, free tissue transfer is usually delayed
ues to force surgeons to improve tech-
published extensively on their success until after the acute setting to decrease the
niques. Similarly, improvement in the
with early bone grafting to stabilize and incidence of flap loss secondary to clotting
management of GSWs to the face has par-
support soft tissues, and to decrease scar of the vascular pedicle. Preoperative
alleled the advancement of oral and max-
contracture and distortion.55 The use of angiography often is beneficial to identify
illofacial surgery. Advances by Varaztad
cranial bone in blunt injuries was extend- appropriate vessels in the neck. Vascular-
Kazanjian, the miracle man of the West-
ed to include GSWs with some success. ized bone grafts can support osseointe-
ern front during World War I, continued
Currently many surgeons advocate the use grated implants to complete the recon-
through the wars of the twentieth century.
of primary bone grafting in the midface. struction. Anthony and colleagues
Improvements in casualty management
Some surgeons also advocate immediate reported on the use of the fibula in
and triage in the Korean and Vietnam
bone grafting of mandible defects.56 Most patients in whom previous reconstructive
conflicts led to increased survival of those
agree, however, that delayed grafting of attempts for gunshot injuries had failed.57
with devastating facial injuries. Tech-
discontinuity defects of the mandible is Both cases involved secondary reconstruc-
niques and skills developed by oral and
still indicated because of the high risk of tions. Some surgeons have advocated
maxillofacial surgeons in the manage-
exposure and loss of bone grafts in this delayed reconstruction in gunshot wounds
ment of these injuries translated directly
site, and that immediate grafting in the that resulted from suicide attempts
to other areas such as bone grafting, and
mandible should be avoided.11,52 Clark because of the potential for repeat suicide
promoted the growth and expanding
and colleagues reported a 35% incidence attempts, arguing that there is a high rate
scope of the specialty. These efforts are
of wound complications in patients of recidivism and that patients should be
continued today in urban trauma centers
undergoing immediate reconstruction of stabilized psychologically for some period
dealing with gunshot injuries to the face.
significantly comminuted mandible frac- of time prior to undertaking an extensive
Improvements in imaging and fixation
tures resulting from GSWs. Conversely, (and expensive) reconstructive effort.
techniques have resulted in an evolution
primary bone grafting was uniformly suc- However, Cusick and colleagues found an
in management, with an emphasis on ear-
cessful in the cranium and midface.11 incidence of only 8% confirmed mortality
lier repair and a focus on improvement in
Rigid fixation maintains the mandibular in the follow-up of 91 patients who had
quality of life.
segments. Even if the titanium plate attempted suicide.58 All were patients who
becomes exposed, wound care will allow it had long-standing chronic mental illness. Acknowledgment
to be maintained until definitive recon- De Leo and colleagues found a higher rate
Special thanks to David H. Holmes, DDS,
struction.43,55 In summary, primary bone in an elderly European population. In a
for his assistance and guidance with the
grafting in the early phase of gunshot 1-year follow-up, they found 24% had
section on ballistic science.
wound management can be useful, but it attempted suicide again, with approxi-
should be limited to the upper and mid- mately half being successful in their sec- References
face. Maintenance of mandibular seg- ond attempt.59 With modern techniques,
1. Ellis H. The surgery of warfare. In: A history of
ments with rigid reconstruction plates however, primary reconstruction has surgery. London: Greenwich Medical Media
combined with delayed grafting or free become more attractive in most patients Limited; 2001. p. 12550.
flap reconstruction offers a predictable who have self-inflicted gunshot wounds. 2. Burney RE, Maio RF, Maynard F, Karunas R.
result, and in most cases primary grafting 1,60
It should be noted, however, that some Incidence, characteristics, and outcome of
spinal cord injury at trauma centers in
of the mandible is not indicated. authors still recommend delayed recon-
North America. Arch Surg 1993;128:5969.
structive efforts. Siberchicot and col- 3. Fingerhut LA, Christoffel KK. Firearm related
Late Reconstruction leagues reviewed 165 patients with self- death and injury among children and ado-
Delayed bone reconstructions frequently inflicted gunshot injuries between 1982 lescents. Future Child 2002;12:2437.
suffer from a scarred hypovascular envi- and 1996 and suggested that delayed 4. Goetsch KE, Annest JJ, Mercy JA, et al. Surveil-
lance for fatal and nonfatal firearm related
ronment that does not support the graft. definitive reconstruction was more likely
injuries: United States, 19931998. MMWR
In addition, there is typically a deficiency to achieve satisfactory results in appear- Morb Mortal Wkly Rep 2001;50:134.
in soft tissue that becomes more pro- ance and function.53 5. Barber C, Hemenway D, Hochstadt J, Azrael D.
Gunshot Injuries 525
Underestimates of unintentional firearm paintball guns. Int Ophthalmol 19981999; based on cervical level of injury. Am J Surg
fatalities: comparing supplementary homi- 22:16973. 1997;174:67882.
cide report data with the National Vital Sta- 21. Mahajna A, Aboud N, Harbaji I, et al. Blunt 38. Ginzburg E, Montalvo B, LeBlang S, et al. The
tistics System. Inj Prev 2002; 8:2526. and penetrating injuries caused by rubber use of duplex ultrasonography in penetrat-
6. Mercy JA, Ikeda R, Powell KE. Firearm related bullets during the Israeli-Arab conflict in ing neck trauma. Arch Surg 1996;131:6913.
injury surveillance. An overview of progress October, 2000: a retrospective study. Lancet 39. Kazanjian VH, Converse JM. Gunshot wounds.
and the challenges ahead. Am J Prev Med 2002;359:1795800. In: The surgical treatment of facial injuries.
1998;15:616. 22. Rowley DI. The management of war wounds Baltimore: Williams and Wilkins; 1949.
7. Patton JH, Woodward AM. Urban trauma cen- involving bone. J Bone Joint Surg 1996; p. 78.
ters: not quite dead yet. Am Surg 2002; 78B:7069. 40. Broadbent TR, Wolf RM. Gunshot wounds of
68:31922. 23. Gugala Z, Lindsey R. Classification of gunshot the face: initial care. J Trauma 1972;
8. Wintemute GJ. Firearms as a cause of death in injuries in civilians. Clin Orthop 2003; 12:22933.
the United States, 19701982. J Trauma 408:6581. 41. Hallock GG. Self-inflicted gunshot wounds of
1987;27:5326. 24. Sherman RT, Parrish RA. Management of shot- the lower half of the face; the evolution
9. Miller M, Azrael D, Hemenway D. Rates of gun injuries: a review of 152 cases. J Trau- toward early reconstruction. J Craniomax-
household firearm ownership and homicide ma 1963;3:7685. illofac Trauma 1995;1:505.
rates across US regions and states, 19881997. 25. Ordog GJ, Wasserberg J, Balasubramanian S. 42. Haug RH. Gunshot wounds to the head and
Am J Public Health 2002;92:198893. Shotgun wound ballistics. J Trauma 1988; neck. In: Kelly JP, Piecuch JF, Assael LA, edi-
10. Bostman O, Marttinen E, Makitie I, Tikka S. 28:62431. tors. Oral and maxillofacial surgery knowl-
Firearm injuries in Finland 19851989. 26. Glezer JA, Minard G, Croce MA, et al. Shotgun edge update. Vol 1, Pt II. Chicago: American
Ann Chir Gynaecol Suppl 1993;82:479. wounds to the abdomen. Am J Surg 1993; Association of Oral and Maxillofacial Sur-
11. Clark N, Birely B, Manson PN, Slezak S. High- 59:12932. geons; 1995. p. 6582.
energy ballistic and avulsive facial injuries: 27. Henriksson TG. Close range blasts toward the 43. Thorne CH. Gunshot wounds to the face: cur-
classification, patterns and an algorithm for rent concepts. Advances in craniomaxillofa-
maxillofacial region in attempted suicide.
primary reconstruction. Plast Reconstr cial fracture management. Clin Plast Surg
Scand J Plast Reconstr Surg Hand Surg
Surg 1996;98:583601. 1992;19:23344.
1990;24:816.
12. Demetriades D, Chahwan S, Gomez H, et al. Ini- 44. Thoresby FP, Darlow HM. The mechanisms of
28. Kihtir T, Ivatury RR, Simon RJ, et al. Early
tial evaluation and management of gunshot primary infection of bullet wounds. Br J
management of civilian gunshot wounds to
wounds to the face. J Trauma 1998;45:3941. Surg 1967;54:35961.
the face. J Trauma 1993;35:56977.
13. Cook PJ, Lawrence BA, Ludwig J, Miller TR. 45. Wolf AW, Benson DR, Shoji H, et al. Autoster-
29. Dolin J, Scalea T, Mannor L, et al. The manage-
The medical costs of gunshot wounds ilization in low-velocity bullets. J Trauma
ment of gunshot wounds to the face. J Trau-
injuries in the United States. JAMA 1978;18:637.
ma 1992;33:50814.
1999;282:44754. 46. Ireland MW, Callender GR, Coupal JF. The
30. Cole RD, Browne JD, Phipps CD. Gunshot
14. Belkin M. Wound ballistics. Prog Surg 1978; Medical Department of the US Army in
wounds to the mandible and midface: eval-
16:724. World War I. Washington: US Government
uation, treatment, and avoidance of com-
15. Lindsey D. The idolatry of velocity, or lies, Printing Office; 1929.
plications. Otolaryngol Head Neck Surg
damn lies, and ballistics. J Trauma 1980; 47. Selbst SM, Henritig F, Fee MA, at al. Lead poi-
20:10689. 1994;111:73945. soning in a child with a gunshot wound.
16. Fackler ML. Whats wrong with wound ballistic 31. Chen AY, Stewart MG, Raup G. Penetrating Pediatrics 1986;3:4136.
literature and why. Letterman Army Insti- injuries to the face. Otolaryngol Head Neck 48. Kent JN, Neary JP, Silvia C, Zide MF. Open
tute of Research Report; 1987. Report No.: Surg 1996;115:46470. reduction of fractured mandibular
239. J Internl Wound Ballistics Assoc 32. Yao ST, Vanecko RM, Corley RD, et al. Gunshot condyles. Oral Maxillofac Surg Clin North
2001;5(1):3742. wounds of the face. J Trauma 1972;12:5238. Am 1990;2:69102.
17. Goddard S. Some issues for consideration in 33. May M, Cutchavaree A, Chadaratana P. 49. Messer HD, Cerza PF. Copper jacketed bullets
choosing between 9 mm and .45 ACP hand- Mandibular fractures from gunshot in the central nervous system. Neuroradiol-
guns. Presented to the FBI Academy. wounds: a study of 20 cases. Laryngoscope ogy 1976;12:1219.
Columbus (OH): Battelle Labs, Ballistic Sci- 1973;83:36973. 50. Sherman IJ. Brass foreign body in the brain
ences, Ordnance Systems and Technology 34. Monson DO, Saletta JD, Freeark RJ. Carotid system. J Neurosurg 1960;17:4835.
Section; 1988. http://www.firearms-tacti- vertebral trauma. J Trauma 1969;9:98799. 51. Azmak D, Altun G, Koc S, et al. Intra- and
cal.com/hwfe.htm (accessed Oct 25, 2003). 35. Van As AB, van Deurzen DF, Verleisdonk EJ. perioral shooting fatalities. Forensic Sci Int
18. Demuth WE, Nicholas GG, Munger BL. Buck- Gunshots to the neck: selective angiography 1999;101:21727.
shot wounds. J Trauma 1976;18:537. as part of conservative management. Injury 52. Deveci M, Sengenzer M, Selmanpakoglu M.
19. Osborne TE, Bays RA. Pathophysiology and 2002;33:4536. Reconstruction of gunshot wounds of the
management of gunshot wounds to the 36. Holmes JD, Koehler JR. Management of pene- face. Gazi Med J 1998;9:4756.
face. In: Fonseca RJ, Walker RV, editors. trating neck trauma: current practices and 53. Siberchicot F, Pinsolle J, Majoufre C, et al. Gun-
Oral and maxillofacial trauma. Vol 2. report of a case. J Oral Maxillofac Surg shot injuries of the face. Analysis of 165 cases
Philadelphia: WB Saunders; 1991. p. 2003.[Submitted] and reevaluation of the primary treatment.
672701. 37. Biffl WL, Moore EE, Rehse DH, et al. Selective Ann Chir Plast Esthet 1998;43:13240.
20. Farr AK, Fekrat S. Eye injuries associated with management of penetrating neck trauma 54. Neupert EA, Boyd SB. Retrospective analysis of
526 Part 4: Maxillofacial Trauma
low-velocity gunshot wounds of the and clinical considerations. Clin Plast Surg a level I trauma center. Am J Surg 1999;
mandible. Oral Surg Oral Med Oral Pathol 1992;19:20717. 65:6436.
1991;72:38397. 57. Anthony JP, Foster RD, Pogrel MA. The free 59. De Leo D, Padoani W, Lonnqvist K, et al. Rep-
55. Gruss JS, Mackinnon SE, Kassell EE, Copper fibula bone graft for salvaging failed etition of suicidal behaviour in elderly
PW. The role of primary bone grafting in mandibular reconstructions. J Oral Max- Europeans: a prospective longitudinal
complex craniomaxillofacial trauma. Plast illofac Surg 1997;55:141721. study. J Affect Disord 2002;72:2915.
Reconstr Surg 1985;15:1724. 58. Cusick TE, Chang FC, Woodson TL, Helmer 60. Suominen E, Tukianen E. Close range shotgun and
56. Dufresne CR. The use of immediate grafting in SD. Is resuscitation after traumatic suicide rifle injuries to the face. Head and neck recon-
facial fracture management: indications attempt a futile effort? A five year review at struction. Clin Plast Surg 2001;28:32337.
CHAPTER 27
Pediatric Craniomaxillofacial
Fracture Management
Jeffrey C. Posnick, DMD, MD
Bernard J. Costello, DMD, MD
Paul S. Tiwana, DDS, MD, MS
Historic Perspectives The extensive surgical procedures that were struction of the trauma patient followed
often required to improve the quality of life by rapid transport to the trauma center,
The management of craniomaxillofacial
of the multiply traumatized patient also was pioneered by R.A. Cowley with the
trauma, and the treatment of facial fractures
became a reality. development of the University of Mary-
in children in particular, has evolved gradu-
ally. A review of the historic landmarks in its
Knowledge of the successful repair of lands shock trauma center.8 This concept
treatment is important for understanding traumatic facial injuries brought hope to of accurate and rapid verification of
what has yet to be accomplished. people with congenital facial deformities. injuries by the trauma surgeon, combined
At the turn of the century Rene Le Fort Gillies and Harrison pioneered the elective with well-trained and immediately avail-
was the first to document a tendency for the (extracranial) total midface advancement able surgical subspecialists, hospital sup-
occurrence of specific patterns of midface (Le Fort III osteotomy) for Crouzon syn- port staff, and technology, led to remark-
fractures after direct facial trauma.1 Within drome.3 In 1967 Tessier described a cranial able patient recoveries in otherwise
a few years thousands of combined soft and base approach to the management of hopeless situations.
hard tissue facial injuries resulted from the skeletal deformities associated with The importance of managing the facial
trench warfare of World War I and required Crouzon syndrome and Apert syndrome. injuries of the multiple-trauma patient
urgent treatment and secondary recon- His landmark presentation and publica- became evident early in the trauma centers
struction. Two physicians in particular, V.H. tions were the beginning of modern cranio- experience. Following the basic philosophy
Kazanjian and H. Gillies, stand out for their facial surgery. In 1968, Hans Luhr, a young of total patient rehabilitation, Gruss and
work during this period.2,3 During and after maxillofacial surgeon, proposed that colleagues in Canada and Manson and col-
World War I and again during World War miniature (metal) bone plates and screws leagues in the United States developed new
II, these men laid the foundation for what could be constructed and used effectively concepts for the management of cran-
we now know as craniomaxillofacial to fixate a mandibular fracture together iomaxillofacial trauma.913 Their basic
surgery. Rowe and Killey, Dingman and for improved healing. 7 Despite his approach incorporated the early accurate
Natvig, and others refined the basic princi- enthusiasm these concepts of internal preoperative diagnosis of all skeletal
ples laid down by their mentors, set out to fixation for the craniomaxillofacial skele- injuries by clinical examination with verifi-
educate their peers, and brought these ton were not put into wide practice until cation using computed tomography (CT)
treatment principles to the civilian popula- the mid-1980s. scanning techniques, wide (direct) surgical
tion after the two world wars.4,5 At the same The concept of a hospital-based civilian exposure of all fractures for open reduction
time, the use of antibiotics and improved trauma service that functioned 24 hours of displaced and mobile segments, use of
airway and metabolic management of the a day, 7 days a week, coupled with imme- stable internal fixation techniques (plates
trauma patient increased survival rates.6 diate in-the-field emergency recon- and screws), and primary autogenous bone
528 Part 4: Maxillofacial Trauma
grafting to replace missing or irreversibly Children frequently swallow air when sisting of 262 and 137 pediatric facial trau-
damaged skeletal units. The rapid dissemi- they are injured or frightened, resulting ma patients, respectively.30,53 Also cervical
nation of their concepts and basic clinical in gastric dilatation. This may be a spine injuries are exceedingly rare.30,53,54
approach to everyday surgical practice source of confusion when evaluating the
around the world is a tribute to Gruss and patient to rule out an acute abdomen. Anatomic Considerations
Manson, who remain dedicated to the Abdominal girth and the volume of Maxillofacial injuries are much less com-
highest standards of clinical care, research, the peritoneal cavity in infants and mon in younger children than in adoles-
and education. young children are relatively small. cents and adults. This lower incidence of
Children with facial injuries have not Significant intra-abdominal bleeding facial trauma in infants and young chil-
benefited equally from this rapid refine- results in a rapid change in girth. dren is a result of socioenvironmental,
ment in the management of facial trauma Children may maintain a normal or general physical, and craniomaxillofacial
in adults. In 1943 Waldron and colleagues borderline blood pressure level despite anatomic factors.55,56
were the first to bring to the maxillofacial significant fluid loss and then decom- Before the age of 5 years most children
surgeons attention the often unique facial pensate rapidly. live a relatively protected existence, with
injuries in the traumatized child.14 Children have a larger body surface area- close adult supervision, strict limitations
MacLennan, and then Rowe, wrote about to-overall mass ratio than adults and are on their physical environment, and con-
the rarity of facial fractures in children therefore more prone to hypothermia. stant safeguards to limit injury. Although
and suggested a basic approach with a phi- falls from limited heights are frequent the
losophy toward conservatism.15,16 Other Children are generally injured in low- momentum gained by the childs small
published articles have also tended toward velocity accidents secondary to falls from body is of a low velocity. These low-impact
conservatism, with only limited incorpo- low heights, playground equipment, or forces can usually be absorbed by their
ration of the principles described earlier riding toys. Most commonly they arrive at well-padded skin, elastic skeleton, and car-
by Gruss and Manson.1739 Only recently the emergency room in a state of hemody- tilaginous growth centers.
have the distinct advantages of accurate namic stability. With regard to the fre- After the age of 5 to 7 years, rapid pro-
primary repair and the stable fixation of quency of organs injured, the kidney is the gression of neuromotor development
facial fractures been applied to the rehabil- solid organ that is the most frequently results in a general desire for independent
itation of injuries in children.4047 Also, injured, followed by the spleen, liver, and activity, more frequent social interactions
resorbable materials have been made pancreas. Hollow viscus perforations are with other children, and a wider range of
available as a fixation option for pediatric much less common compared with adult activities outside of the house, with less
craniomaxillofacial fracture management. injury patterns. In contrast nonaccidental stringent parental and adult supervision.
trauma is more insidious and devastating. These factors result in increased opportu-
Special Considerations in The pattern of organs injured, especially in nity for direct facial trauma. Additionally,
Children the toddler, is the reverse of that seen in increasing numbers of automobiles on the
The general principles for resuscitating accidental trauma. With child abuse the road and participation in pedestrian activ-
multiply injured patients follow the history is often vague and inconsistent.49,50 ities in public areas result in competition
advanced trauma life-support principles A history of prior injuries and hollow vis- for space with motorized vehicles.
created by the American College of Sur- cus perforation is common. Ongoing craniomaxillofacial growth
geons.48 This systematic approach to trauma Airway management in children with results in a changing anatomy (Figure
in adult patients has been modified for the facial trauma has undergone significant 27-1).57 For the first several years of life
management of trauma in the child, taking change. With the widespread use of soft the cranium follows the rapid pace of
into account several critical differences: endotracheal tubes in the 1960s, the number brain growth and results in a relatively
of tracheostomies carried out for periopera- large and prominent forehead. The ocular
Infants are obligate nasal breathers; at tive airway management decreased.51,52 Use globes and orbits also develop rapidly
the same time their nasal air passages are of fiberoptic laryngoscopy has further early in life and join the forehead in their
relatively narrow and easily obstructed. decreased the incidence of tracheostomy relative prominence early in life. This
The chest wall in children is pliable; for acute airway management in the pedi- early period of life is marked by a lack of
major thoracic injuries may exist atric trauma patient. Kaban and Posnick paranasal sinus and dental development,
with fewer than expected signs of and colleagues reported no tracheostomies resulting in limited vertical height, hori-
external trauma. for airway management in their series con- zontal projection, and transverse width of
Pediatric Craniomaxillofacial Fracture Management 529
part supplanted standard radiography as All patients with acute facial fractures group 3 included multiple fractures occur-
the preferred method of imaging pediatric evaluated at a single tertiary care pediatric ring in multiple anatomic regions within
facial trauma.62,63 Multiple CT scan planar hospital over a 4-year period and treated the facial skeleton. Because of the hospi-
views (coronal, axial, sagittal) performed by the author (J.C.P.) were enrolled in the tals entrance restrictions the oldest child
with spiral scanning through all of the study.53 The mechanism of injury, location in this population was 18 years.
facial structures of interest, with three- and pattern of facial fractures, and extent The facial trauma population con-
dimensional reformation of the CT scan of associated soft tissue injuries were eval- sisted of 137 patients (318 fractures) seen
data, confirm the location and extent of uated. For each fracture the method of over a 4-year period.53 Most of the patients
skeletal, soft tissue, and visceral injuries reduction, the type of fixation, and the (42%) were between 6 and 12 years of
(ie, brain or eye trauma). The patient is need for primary bone grafts were record- age, and the total population averaged
placed in the CT gantry and when neces- ed. Patients were placed into two groups: 10.2 years of age. Boys (63%) outnum-
sary given sedation or, occasionally, gener- (1) those requiring acute care who received bered girls (37%) in the study (see Table
al anesthesia. The radiation doses required their primary treatment and evaluation at 27-2). Of the 137 patients, 81 were treated
for imaging are generally much lower than a single hospital, by Posnick; and (2) those for acute fractures (171 fractures) and 56
that for standard tomograms and have treated for secondary (or residual) defor- were evaluated for reconstruction of sec-
more limited scatter. Spiral and multislice mity, who were referred to Posnick for ondary deformities resulting from the ini-
techniques have reduced the dose of radi- management at varying times after their tial fractures (147 fractures). Of the 171
ation significantly when compared with injuries. All perioperative complications acute fractures, 121 were treated surgically.
older CT methods.64 These techniques also were catalogued. Follow-up of the patient Fifty percent of the patients were
allow for reformatted images in other group ranged from 1 to 5.5 years at the injured in traffic accidents, followed in fre-
planes (eg, coronal views) that are of excel- close of the study. quency by falls and injuries related to
lent quality. This is helpful in patients who Fracture patterns were classified sports and altercations (see Table 27-1).
have been immobilized in a cervical collar. according to their complexity. Group 1 Causal mechanisms appeared to be dis-
For isolated mandibular injury the included all isolated fractures limited to tributed similarly between sexes, except for
panoramic tomogram still gives the best one bone, group 2 included all multiple a slightly higher number of males with
overall perspective of dentoalveolar and fractures occurring in a single bone, and fractures attributable to an altercation or
condylar head (of the mandible) anatomy
and injuries and can be taken with a cervi-
Table 27-1 Mechanism of Pediatric Facial Fracture by Age Category
cal collar in place.
Age Group Sports-Related
Epidemiology and General (year) Traffic Accident Falls and Altercations Other
Treatment Concepts <3 1 9 0 2
The patterns of facial injury in the pedi- 3 to 5 12 8 4 1
atric population are considerably different 6 to 12 32 12 9 4
than those for adults. Understanding these 13+ 23 3 15 2
differences in injury presentation helps the Total 68 32 28 9
surgeon during the evaluation and treat- Adapted from Posnick JC et al.53
ment phases. The objectives of the study
previously published by Posnick and col-
leagues were to record the pattern of facial Table 27-2 Patient Age and Occurrence of Pediatric Fractures by Region
injuries treated over a 4-year period at a Age Group (year) Cranium Orbit Zygoma Midface Mandible
pediatric tertiary trauma unit and to doc- <1 0 1 0 0 3
ument the treatment provided and any 1 to 2 2 2 1 0 4
complications that occurred (Tables 3 to 5 2 5 2 3 19
27-127-4).53 The information gained 6 to 12 8 16 9 8 27
from this study remains pertinent because 13+ 4 17 9 12 22
it illustrates the common injury patterns
Total 16 41 21 23 75
seen in pediatric facial trauma at a major
Adapted from Posnick JC et al.53
referral center for acute treatment.
Pediatric Craniomaxillofacial Fracture Management 531
to recreational vehicle accidents. The like- Table 27-3 Pediatric Fracture Pattern by Anatomic Region and Complexity
lihood of high-velocity injuries increased
Fracture Complexity*
with age (10% in the 1- to 2-year age
group, increasing to 55% in the 6- to Anatomic Region No. of Subjects No. of Fractures Group 1 Group 2 Group 3
12-year age group). Falls as a cause Cranium 25 27 9 1 15
declined with age (55% in the 1- to 2-year Orbit 41 73 7 5 29
age group, dropping to 8% in the 13+ year Zygoma 21 22 4 0 17
age group). The number of facial fractures Midface 23 31 2 0 21
tended to increase in the summer months; Nose 17 23 6 4 7
45% of all fractures occurred between the Mandible 75 107 38 17 20
months of May and August. Dentoalveolar 32 44 8 11 13
Of the 137 children with facial frac- Adapted from Posnick JC et al.53
*Fracture complexity resulting from trauma was represented by three groups: group 1, trauma involving a single fracture
tures, 66 (48%) sustained isolated frac- in a single anatomic region; group 2, trauma involving multiple fractures in a single anatomic region; and group 3,
trauma involving multiple fractures in multiple anatomic regions.
tures (group 1), 27 (20%) had multiple
fractures in a single bone (group 2), and
44 (32%) had multiple fractures in multi-
ple sites within the craniofacial skeleton significantly more operations than girls. microplates) and screws accounted for 82%
(group 3). Children younger than 3 years Necessity for operative intervention (40 of 49) of the internal fixation methods
were more likely to sustain only single increased significantly with the increasing used. Although age was not a factor in the
fractures (see Tables 27-2 and 27-3). The complexity of facial fractures (group 1 to choice of plate-and-screw fixation, review
children experienced one or more frac- group 3) but not with age. of the data indicated that this method was
tures in the following craniofacial regions: Open or closed reduction techniques not used on any patient younger than
mandibular (55%), orbital (30%), den- were used with approximately the same fre- 3 years (only three of the children in our
toalveolar (23%), midface (17%), nasal quency. When closed reduction was used, population were younger than 3 years).
(15%), zygoma (14%), and cranium most patients (93%) underwent reduction Plates and screws were used most often in
(12%). Fracture pattern profiles were sim- and stabilization of the fracture with maxil- the mandible (40%) and orbits (26%).
ilar in both the acute care and secondary lomandibular fixation (eg, Erich arch bars, Bone grafts (21) were used for fractures of
treatment groups. Midface (20 of 23) and skeletal suspension wires, Stout wires). An the orbit (16), cranial vault (2), mandible
zygoma (18 of 21) fractures were more external fixation device was used for only (2), and nose (1). The preferred donor sites
likely to occur in children older than one patient. Only four fractures were included cranium (10), anterior maxillary
6 years of age (see Table 27-2). reduced and not stabilized. Thirteen frac- wall (4), and hip (2).
The distribution of fractures by tures (20%) were opened and explored Complications in treating pediatric
anatomic region and degree of complexity without any form of fixation. Most of these facial trauma are rare if good principles
is presented in Table 27-3. Similar anatom- were orbital floor fractures with associated are adhered to and precise surgical execu-
ic patterns were seen in both the acute and bone-grafting procedures. Of the fractures tion is achieved. This is due, at least in
secondary cases. Most of the fractures treated by open reduction, 35 (55%) were part, to the excellent healing capabilities of
occurred as part of a complex injury pat- managed with only one form of fixation to most children. Nonunion is very rare due
tern, with the exception of mandibular stabilize the reduction and 14 (21%) with to the excellent healing potential of pedi-
fractures, which occurred as isolated frac- multiple forms. Use of plates (miniplates or atric bone. Malunion may occur but is
tures with nearly equal frequency.
Table 27-4 Management of Acute Pediatric Fractures*
Eighty-one patients with acute
injuries were seen for evaluation during No Surgical Closed Reduction Open Reduction
the period of the study. These patients sus- Treatment (No. of Fractures) (No. of Fractures)
tained 175 fractures, requiring 121 opera- 50 Reduction only (4) Exploration only (13)
tive interventions. Injuries occurring at Maxillomandibular fixation Single fixation method (35)
high velocity, such as traffic-related events External fixation More than 1 fixation
(74%), more frequently required interven- method (14)
tions than those occurring at low velocity, *N = 171.
Adapted from Posnick JC et al.53
such as falls (51%). Boys did not require
532 Part 4: Maxillofacial Trauma
usually due to inadequate reduction. In cial trauma occurs (Figure 27-2).53 Isolated third of the face made up only 0.5% of all
Posnick and colleagues study no deaths, cranial vault fractures (18 of 318 fractures, pediatric fractures.16 Kaban and colleagues
tooth loss, or injuries to the eye or brain 6%) occurred infrequently in this series. reported no midface fractures in 109 pedi-
were directly attributable to any operative When they did occur, the anterior cranial atric facial fracture patients from 1965 to
procedure. Two patients developed soft tis- vault was the most common location (13), 1975.31 During the next 10 years, with
sue infections that responded to treatment followed by the posterior vault (4) and another 184 fractures, they reported only
by incision, drainage, and administration frontal sinus (1). Complete evaluation 5 midface fractures, all Le Fort III level
of antibiotics. Another developed a small using CT scanning of the brain, eyes, and injuries. Posnick and colleagues reported
area of alopecia after a coronal flap proce- craniofacial skeleton, combined with neu- that midface injuries seen at a major pedi-
dure. One patient, in whom a fracture rosurgical, ophthalmologic, and craniofa- atric trauma center during a 4-year period
extended through a tooth root, developed a cial assessment, should be performed to made up 17% of a series of 318 fractures in
periapical tooth abscess. This condition evaluate the injuries completely. A com- 137 patients.53 Kaban associated this
was treated with extraction and systemic bined neurosurgical and craniofacial increased prevalence of midface injuries
antibiotic therapy. One miniplate was reconstructive procedure is necessary for with the increase in survival of persons
removed 1 year later because it was palpa- repair of the injured brain, dura, and involved in serious motor vehicle acci-
ble and visible below thin forehead skin. skeleton. A coronal (skin) incision pro- dents, which may result in more extensive
Of the 137 patients in this series, vides the best exposure of the fractured facial injuries in the survivors.65 When dis-
77 (56%) had associated soft tissue injuries. regions and surrounding normal struc- placed naso-orbitoethmoid fractures do
These included lacerations to the scalp tures. Once the brain and dural injuries occur in children, we have adopted the
(31%), and injuries to the ear (20%), chin have been managed by the neurosurgeon, same open reduction and internal fixation
(13%), tongue (8%), forehead (6%), and reduction and stable fixation (microplates (ORIF) techniques generally accepted for
eyelid (6%). Thirty-three percent in the and screws) of all fractures are completed adult-type injuries. Stable internal fixation
facial fracture group had injuries to other by the craniofacial surgeon. When massive techniques (micro- and miniplates and
organ systems. Associated head injuries comminution exists, bony defects are pre- screws) and primary autogenous cranial
accounted for 42% of this group, followed sent, or complete orbital roof reconstruc- bone grafts when indicated, result in the
by damage to the extremities (24%), eyes tion is required, then autogenous cranial anatomic healing required to achieve satis-
(22%), thorax (10%), and abdomen (2%). bone is harvested and used. In a normally factory rehabilitation of the child with
None of our patients sustained injuries to developing child the skull will mature into facial injury.28,33,6674
the cervical spine. As expected, the more three clinically reliable layers (outer table, As in the adult, when the medial can-
complex the facial injury, the greater the medullary cavity, inner table) between the thal ligament is displaced, it usually
likelihood of associated injury (p = .03); ages of 2 and 5 years. In these instances the remains attached to a bone fragment. The
19% of group 1, 26% of group 2, and 36% bone of the cranial vault is suitable for medial canthal ligament and bone frag-
of group 3 patients had an associated injury. splitting, yielding bone for grafting. These ment are repositioned and fixed without
Six percent required emergency endotra- techniques and a team approach to the the need for a direct medial canthopexy.
cheal intubation when first evaluated; no early diagnosis and management of com- Formal medial canthopexies often con-
emergency tracheostomies were required. bined injuries are cost effective and result tribute to an unnatural appearance and
in a rapid facial rehabilitation for the should be avoided if possible. Often the
Patterns of Pediatric Facial injured child. bony fragment(s) can be repositioned with
Fracture Injury and Methods the aid of microplates and screws with or
of Management Naso-orbitoethmoid and without the use of a transnasal wire.
Frontal Sinus Fractures Frontal sinus injuries in children are
Anterior Cranial Vault and The prevalence of naso-orbitoethmoid approached in a similar way to those in
Supraorbital Ridge Fractures fractures closely follows the development their adult counterparts.75,76 Anterior
Fractures of the forehead and upper orbital of the paranasal sinuses. They are rarely frontal sinus wall fractures are anatomically
regions, combined with brain injury and seen in children younger than 5 years, but reconstructed and stabilized to prevent
dural tears with cerebrospinal fluid (CSF) they become progressively more common contour deformity. When the fracture com-
leakage, constitute a frequent pattern of in adolescents and adults (Figure 27-3). ponents are severely comminuted, autoge-
injury in infants and in children younger Rowe reviewed his series of pediatric frac- nous cranial bone grafts can be used to
than 5 years when major anterior craniofa- tures and found that injuries to the middle replace the entire unit. Depending on the
Pediatric Craniomaxillofacial Fracture Management 533
A B C D
E
F
G H
FIGURE 27-2 A 16-year-old girl sustained frontal and upper orbital trauma when she hit her forehead on the dashboard in a motor vehicle accident. Initially the cere-
brospinal fluid (CSF) leak was repaired through a local scalp laceration; minimal attention was given to her frontal and orbital fractures. Ongoing CSF leak with
meningitis and loss of the frontal bone flap occurred, after which she was referred to Posnick and colleagues, and a delayed combined neurosurgical/craniofacial
approach was carried out. A, Frontal view before the delayed surgery. B, Frontal view 1 year after reconstruction. C, Oblique view before the delayed surgery. D, Oblique
view 1 year after reconstruction. E, Three-dimensional computed tomography (CT) scan of frontal bone defect. F, Intraoperative view of dural tear resulting in trau-
matic encephalocele. Access craniotomy/osteotomies allow exposure for reconstruction of orbital roof/medio-orbital wall defects. G, CT scan of the anterior cranial base
and orbital roof/medio-orbital wall defects. H, Intraoperative view of frontal bone defect and displaced orbital rim fractures. (CONTINUED ON NEXT PAGE)
extent of frontal sinus development and the duct. If the posterior frontal sinus wall with dural tears in these injuries, it is often
injury, the mucous membranes may require is injured, neurosurgical consultation helps helpful to place bone, fibrin glue, and a
dbridement with maintenance of a patent determine whether cranialization of the pericranial flap in the defect to prevent CSF
frontonasal duct or, in cases of fractures of sinus through an intracranial approach is leaking. A double-ring sign is seen on filter
the ducts, sinus obliteration with sealing of required.77 Since CSF leaks are common paper when CSF is present within nasal
534 Part 4: Maxillofacial Trauma
A B C D
E F G
FIGURE 27-3 A 5-year-old girl who was in a motor vehicle accident sustained orbitonasal, ethmoid, and frontal bone fractures with associated brain and dural
injury with cerebrospinal fluid leak. She required a combined neurosurgical/craniofacial procedure. A, Frontal view 6 days after surgery. B, Frontal view 2 years
after (single-stage) reconstruction. C, Oblique view 6 days after surgery. D, Oblique view 2 years after reconstruction. E, Worms-eye view 6 days after surgery.
F, Worms-eye view 2 years later.G, Intraoperative view of reconstructed orbitonasal and frontal fractures. Stabilization is with titanium plates and screws.
H, Intraoperative close-up view of reduced orbitonasal and frontal fractures stabilized with titanium plates and screw fixation. Medial canthopexies were also car-
ried out (note location of wires). Reproduced with permission from Posnick JC.134
fractures within the orbital floor frequently fractures were comminuted injuries that with a displaced zygomatic complex frac-
require management in conjunction with were treated with open reduction and inter- ture, a coronal (scalp) incision may be used
repositioning of the zygoma. Some injuries nal fixation. Three of these fractures were with intraoral and subciliary (or lower lid
require reconstruction of the orbital floor stabilized with plates and screws. or transconjunctival) incisions to expose,
with autogenous bone or synthetic materi- Most zygomatic complex fractures can explore, reduce, graft, and internally fix all
als. Of the eight acute zygoma fractures be approached and reduced using multiple fractured regions.78 With a minimally dis-
observed in Posnick and colleagues study, approaches such as maxillary vestibular, placed or incomplete fractured zygoma,
three were minimally displaced and man- lower eyelid, and brow incisions. If a badly more limited treatment is used to achieve
aged without surgery. The five displaced comminuted zygomatic arch is associated adequate fracture reduction. This can be
536 Part 4: Maxillofacial Trauma
A B D
FIGURE 27-4 A 14-year-old boy sustained combined Le Fort I and II fractures with bilateral orbital blow-out fractures
when he was accidentally kicked in the face while playing competitive soccer. A, Frontal view before repair. B, Frontal view
1 year after (single-stage) reconstruction. C, Occlusal view before repair. D, Occlusal view 1 year after reconstruction.
E, Illustration before and after reduction and fixation. (CONTINUED ON NEXT PAGE)
done through a Gillies approach within (eg, anterior cranial vault/upper orbital, blow-out fractures are recognized. The
the temporal scalp, an eyebrow incision, or naso-orbitoethmoid, Le Fort midface, or ophthalmologic assessment may require
a Keene approach from an intraoral zygomatic complex fractures) or may pupillary dilatation and slit-lamp evalua-
vestibular incision. occur as isolated injuries.8083 The key to tion in the ophthalmologic suite.
thorough evaluation is complete clinical, Orbital fractures are common in chil-
Blow-Out and Blow-In ophthalmologic, and CT scan assess- dren and were frequent in Posnick and
Fractures of the Orbit ments.84 A thin-sliced axial and coronal CT colleagues study; 41 patients sustained 73
Blow-in and blow-out fractures of one or scan is completed to visualize all four separate fractures of the orbit. The distrib-
more orbital walls and/or floor may be orbital walls and/or floors to ensure that ution of fractures within the orbit includ-
associated with more complex fractures the presence and extent of all blow-in or ed the floor (23 of 73, 32%), medial wall
Pediatric Craniomaxillofacial Fracture Management 537
H G
FIGURE 27-4 (CONTINUED) F, Computed tomography (CT) scan demonstrating nasofrontal bone separation and com-
minuted medial orbital walls. G, Three-dimensional CT views demonstrate Le Fort II fracture with nasofrontal separa-
tion and location of the infraorbital rim and maxillary fractures. H, CT scans demonstrating the morphology of the mid-
face after reconstruction. AD, FH reproduced with permission, E adapted from Posnick JC.132
(14 of 73, 19%), and orbital roof (13 of 73, recognized, early exploration and reposi- on an outpatient basis. The nasal fractures
18%). Only 7 of these orbital fractures tioning of the soft tissues back into the orbit seen by Posnick and colleagues in this study
were sustained as isolated injuries. Of the with simultaneous reconstruction of injured were generally associated with other facial
acute fracture group, 21% of the fractures orbital walls and/or floor to appropriate fractures and were therefore not represen-
were orbital fractures. These were treated dimensions and overall intraorbital volume tative of nasal fractures seen in general at
both surgically (59%) and nonsurgically is carried out.80,85 Because the complications the hospital (emergency department).
(41%) (see Table 27-4). Most of the orbital of extraocular muscle entrapment, diplopia, Development of the nasal septum is
injuries that were managed operatively and enophthalmos are difficult to treat later, thought to be a major factor in midface
were minimally displaced floor fractures. early evaluation of patients at high risk, fol- growth. In theory, trauma to the nasal
Thirtytwo percent of orbital fractures lowed by prompt surgical intervention, is region early in childhood will negatively
were managed by exploration, reduction, encouraged. Orbital wall and/or floor frac- impact on midface growth.86 Although the
and grafting with autogenous material but tures heal rapidly in children and result in a nose is the most frequently fractured part
without graft fixation (Figure 27-5). Plate- higher incidence of scar cicatrization of the of the face in a child, extensive midface
and-screw fixation was used in six orbital herniated orbital soft tissues than in adults. growth retardation after trauma has only
rim fractures and three roof fractures. rarely been documented.86
With the collaboration of a neurosurgeon, Nasal Fractures Nasal injuries are often recognized but
displaced roof fractures (blow-in frac- Nasal fractures are also common in the then ignored as unimportant. Two serious
tures) were routinely treated with open pediatric population. Of the few acute nasal pitfalls in treating nasal fractures in chil-
reduction via an intracranial approach. fractures that occurred in the authors series dren are (1) failure to recognize adjacent
The roof was reconstructed with con- (12 of 171, 7%), 58% were minimally dis- bony injuries extending outside the nose
toured calvarial bone grafts fixed with placed and did not require surgery, and and (2) septal hematoma after nasal trau-
plates and screws. 33% were treated by closed means. Only ma (which may in theory result in septal
Once a clinically and radiographically one fracture required open reduction. necrosis and perforation). Diagnosis of
significant orbital wall and/or floor injury is Many isolated nasal fractures were treated nasal and septal fractures is usually based
538 Part 4: Maxillofacial Trauma
A B C
FIGURE 27-6 Illustration of three skulls of various ages (A, 2 years; B, 6 years; C, 12 years). Different methods of achieving arch bar stabilization at dif-
ferent ages including circum-mandibular, circumzygomatic, infraorbital, and piriform aperture wires. Adapted from Posnick JC.135
ipsilateral side, resulting in facial asymmetry the highly differentiated and specialized Bilateral fractures of the condyles with
and malocclusion. TMJ structure. Despite a great deal of sur- comminuted midface fractures
Once a mandibular condylar fracture geon interest and experience over the years
occurs, a degree of TMJ degenerative with open reduction techniques, its propo- We continue to advocate a nonopera-
changes or growth restriction is a likely sce- nents have not been able to convincingly tive approach for most condylar and sub-
nario despite the treatment option selected. demonstrate a lower incidence of growth condylar fractures in young children. A
Condylar injuries represent a wide spec- disturbance, TMJ ankylosis, internal short period of partial immobilization with
trum of fractures, dislocations, and com- derangement of the TMJ, loss of posterior elastics is generally useful for patient com-
pression injuries. They may be intracapsular facial height, or malocclusion in their fort, to encourage soft tissue healing, and to
or extracapsular, displaced or nondisplaced, patients. Although endoscopic techniques limit the conversion of a greenstick or min-
comminuted or noncomminuted, open or have been reported, a detailed analysis of imally displaced fracture into a complete or
closed, located low or high in the condylar outcomes is lacking and the benefits fully displaced one. Ten to 14 days of use of
neck, medial or lateral pole fractures, and remain to be seen.125 firm elastics is generally enough to accom-
isolated injuries or associated with more Open reduction of a condyle fracture plish these goals and still allow early
complex facial fractures. may be warranted in a child in some increased range of motion to limit the like-
The treatment of a fracture of the instances.122124 Indications may include lihood of the development of TMJ fibrosis
mandibular condyle remains controver- the following: or ankylosis. Instituting a regimen of physi-
sial.110124 Most authors and clinicians con- cal therapy for several months is important
tinue to advocate a nonoperative approach, Displacement into the middle cranial to avoid TMJ fibrosis or ankylosis.
whereas a few prefer the use of open reduc- fossa When a condyle fracture occurs and the
tion techniques. The frequency of less than Unacceptable occlusion after a closed use of firm elastics needs to be limited to
ideal results seen with varied treatments technique trial has failed reduce the incidence of TMJ sequelae, the
given for similar injuries is a reflection of Avulsion of the condyle from the fixation technique selected for additional
the irreversible injury that may occur to capsule simultaneous maxillary and mandibular
540 Part 4: Maxillofacial Trauma
A B C D
FIGURE 27-7 An 11-year-old boy sustained multiple facial trauma in a waterskiing accident. The
injuries included a left intracapsular condyle fracture, a right low condylar neck fracture, a right
parasymphyseal fracture, dentoalveolar injuries, and multiple facial lacerations. A, Frontal view
before fracture reduction. B, Full-face view 2 years after reconstruction, with facial symmetry and
good facial nerve function. C, Oblique view 2 years after reconstruction. D, Demonstration of
40 mm of vertical opening 2 years after reconstruction. E, Occlusal view 2 years after reconstruc-
tion. F, Illustration of fractures before and after reduction and fixation. G, Intraoral view of dis-
G
placed right parasymphyseal fracture. (CONTINUED ON NEXT PAGE)
fractures should be carefully considered. time period even after firm elastic use may The advantages of continuous passive
The common occurrence of a combined be helpful in preventing displacement of motion (CPM) for the healing of injured
parasymphyseal and condylar fracture will parasymphysis or body fractures. When a joint surfaces have been well documented in
warrant a more stable form of parasymphy- mandibular angle fracture occurs in the experimental animals.126128 Salter and col-
seal fracture fixation (miniplates and presence of a condyle fracture, the com- leagues concluded that chondrogenesis in
screws) so that early active mandibular bined forces may be significant enough to the healing of full-thickness defects in the
range of motion with TMJ function can cause displacement unless ORIF at the angle rabbit femur occurs through differentiation
occur. Instituting a liquid diet for a limited fracture is carried out. of the pluripotential cells of the subchondral
Pediatric Craniomaxillofacial Fracture Management 541
H I
FIGURE 27-7 (CONTINUED) H, Intraoral view of reduced and plate/screw stabilized right parasymphyseal fracture.
I, Computed tomography (CT) scans demonstrating left intracapsular condyle fracture and right condylar neck fracture.
J, CT scans demonstrating right parasymphyseal fracture. K, Postoperative Panorex radiograph demonstrating reduction
and fixation of fractures. AE, GK reproduced with permission, F adapted from Posnick JC.135
bone to chondrocytes as a result of the stim- bance is a concern with these injuries, long- pull vectors on the segments, which
ulation provided by CPM of the joint.126,127 term follow-up is necessary to evaluate the encourage reduction rather than displace-
They documented improved healing of possible development of asymmetry. ment. In these situations closed reduction
intra-articular fractures with the use of CPM techniques with maxillomandibular fixa-
compared with immobilization.128 The use Parasymphyseal Fractures When mar- tion generally suffice. Alternatively the
of CPM in the treatment of TMJ disorders ginal reduction and fixation techniques skilled surgeon can place inferior border
and for the early management of acute TMJ are used for parasymphyseal or symphy- plates and screws with the aid of a trans-
injuries seems to have promise but has not seal fractures, a small dentoalveolar gap cutaneous trocar and intraoral incision.
been used often. Conversely the use of often occurs between the two teeth adja- When extended maxillomandibular fixa-
extended periods of immobilization of the cent to the fracture site. Using open reduc- tion must be avoided (eg, associated
acutely injured TMJ appears to be counter- tion techniques with stable (miniplate and condyle fracture or severe trauma), more
productive. A regimen of physical therapy screw) fixation at the inferior border, com- stable forms of internal fixation (plates
for the TMJ after an initial phase of immo- bined with reduction and stabilization at and screws) are indicated.
bilization is recommended for optimal reha- the dentition with an arch bar, gives a
bilitation. Also, functional appliances have more reliable bony union of the injury Dentoalveolar Injuries Anterior maxil-
been used in an attempt to reestablish verti- without displacement. Plating at the lary and mandibular teeth and their sup-
cal height to foreshortened fracture sites in tension-band zone is not recommended in porting alveolar structures often bear the
the early injury phase. Although case series the mixed dentition. brunt of lower face injuries, and as a result
have shown good results, no outcome data dentoalveolar injuries are very common
are available that show a clear advantage to Body Fractures Body fractures of the in the pediatric population.43,111,129131
using this technique.104 Since growth distur- mandible usually have favorable muscle The teeth may be concussed, subluxed,
542 Part 4: Maxillofacial Trauma
partially or totally avulsed, or intruded. In Degradation of the material by the cit- References
Posnick and colleagues study dentoalveo- ric acid cycle into CO2 and H2O 1. Le Fort R. Experimental study of fractures of
lar fractures were evenly distributed No interference with imaging (CT, the upper jaw: parts I and II. Rev Chir Paris
between the mandible and the maxilla. magnetic resonance imaging, standard 1901;23:20827, 36079.
Thirty-two children sustained 44 fractures, 2. Converse JM, Kazanjian VH. Surgical treat-
radiographs)
ment of facial injuries. 2nd ed. Baltimore
8 of which were isolated. Teeth that are No effect on postoperative radiation (MD): Williams & Wilkins; 1949. p. 1574.
loosened should be returned to their nor- treatment 3. Gillies H, Millard DR Jr. The principles and art
mal position in the tooth socket and alveo- The possibility of integrating sub- of plastic surgery. Boston (MA): Little,
lar segments reduced to their preinjury stances such as antibiotics within the Brown; 1957. p. 1652.
4. Rowe NL, Killey HC. Fractures of the facial
position. The reduced teeth and alveolar fixation material skeleton. 2nd ed. Baltimore (MD): Williams
segments should be immobilized until & Wilkins; 1968, p. 1894.
healing occurs. Isolated dentoalveolar Possible disadvantages of resorbable
5. Dingman RE, Natvig P. Surgery of facial frac-
injuries may be adequately reduced under fixation include the following: tures. Philadelphia (PA): W.B. Saunders;
local anesthesia and then stabilized with 1964.p. 1380.
Less mechanical strength when com-
6. Wainwright M. Miracle cure: the story of peni-
the application of acid-etch bonding tech- pared with titanium alloys of similar cillin and the golden age of antibiotics. Cam-
niques and a braided wire. Arch bars can be sizes bridge (MA): Basil Blackwell; 1990. p. 134.
helpful in select cases but often will extrude Memory of the material, which may 7. Luhr HG. Zur stabilen osteosynthese bei
the teeth. The selected splinting techniques unterkieferfrakturen. Dtsch Zahnarztl Z
distort reduction of fracture
1968;23:754.
must meet certain criteria, including easy Increased reactivity during the degra- 8. Cowley RA, Dunham CM. Shock trauma: crit-
fabrication, maintenance of only passive dation phase ical care manual. Baltimore (MD): Mary-
forces on the teeth, lack of irritation to the Increased operative working time land University Press; 1982.
soft tissues, maintenance of normal occlu- 9. Gruss JS, MacKinnon SE, Kassel EE, et al. The
sion, allowance of good oral hygiene, access role of primary bone grafting in complex
Summary craniomaxillofacial trauma. Plast Reconstr
for subsequent endodontic treatment, and
The pattern of craniomaxillofacial frac- Surg 1985;75:1724.
easy removal. Longitudinal reassessment 10. Gruss JS, MacKinnon SE. Complex maxillary
with a pediatric or general dentist is tures seen in children and adolescents fractures: the role of buttress reconstruc-
important because ankylosis of primary varies with evolving skeletal anatomy tion and immediate bone grafts. Plast
teeth may prevent the normal eruption of and socioenvironmental factors. Facial Reconstr Surg 1986;78:922.
fractures in children may go unrecog- 11. Manson PN, Crawley WA, Yaremchuk MJ, et al.
permanent teeth. Midface fractures: advantages of immediate
nized as a result of limited communica- extended open reduction and bone graft-
Resorbable Fixation Materials tion, incomplete radiographic examina- ing. Plast Reconstr Surg 1985;76:112.
Titanium alloy plates and screws are the tion, or the late presentation of the 12. Manson PN. Skull and midface injuries. In:
patient by the family. Recognition of the Mustarde JC, Jackson IT, editors. Plastic
standard for craniomaxillofacial fixation.
surgery in infancy and childhood. 3rd ed.
The use of plate and screw titanium fixa- differences between children and their
New York (NY): Churchill Livingstone;
tion in the craniomaxillofacial skeleton adult counterparts is important in facial 1988. p. 31745.
has consistently resulted in low compli- rehabilitation. Consideration should be 13. Manson PN. Facial injuries. In: McCarthy JG,
cation rates and excellent biocompatibil- given to open reduction of the fractures, editor. Plastic surgery. Vol 2: the face.
Philadelphia (PA): W.B. Saunders; 1990.
ity. However, controversy associated with primary autogenous cranial bone graft-
p. 1108.
their use in growing bones has led to the ing, and the use of stable forms of frac- 14. Waldron CW, Balkan SG, Peterson RG. Frac-
development of resorbable fixation ture fixation (miniplates and microplates tures of the facial bones in children. J Oral
materials. Issues of biocompatibility, and screws). Late sequelae of pediatric Surg 1943;1-215.
fractures occur even when appropriate 15. MacLennan WD. Fractures of the mandible in
strength, bulk, inflammatory response,
children under the age of 6 years. Br J Plast
and predictable resorption rates contin- and prompt treatment is instituted. The Surg 1956;9:125.
ue to be discussed. Most resorbable plate effects of the trauma event as well as the 16. Rowe NL. Fractures of the facial skeleton in
and screw fixations use isomer configu- surgical intervention or lack of treatment children. J Oral Surg 1968;26: 497507.
rations of alpha-hydroxy polylactic and on growth and development may be con- 17. Adekey EO. Pediatric fractures of the facial
skeleton: a survey of 85 cases from Kaduna,
polyglycolic acids. tributing factors. Long-term follow-up
Nigeria. J Oral Surg 1975;38:3558.
Possible advantages of resorbable fixa- by appropriate practitioners is mandato- 18. Anderson PJ. Fractures of the facial skeleton in
tion include the following: ry to monitor these events. children. Injury 1995;26:4750.
Pediatric Craniomaxillofacial Fracture Management 543
19. Bales CR, Randall P, Lehr HB. Fractures of the epidemiological study of patterns of condy- 56. Pasternack JS, Veenema KR, Callahan CM.
facial bones in children. J Trauma 1972; lar fractures in children. Br J Oral Maxillo- Baseball injuries: a little league survey. Pedi-
12:5666. fac Surg 1997;35:30611. atrics 1996;98:4458.
20. Bernstein L. Maxillofacial injuries in children. 40. Khosla VM, Boren W. Mandibular fractures in 57. Maisel H. Postnatal growth and anatomy of the
Otolaryngol Clin North Am 1969;2:397. children and their management. J Oral Surg face. In: Mathog RH, editor. Maxillofacial
21. Carroll MJ, Hill CM, Mason DA. Facial frac- 1971;29:11621. trauma. Baltimore (MD): Williams &
tures in children. Br Dent J 1987;163:289. 41. Lehman JA Jr, Saddawi ND. Fractures of the Wilkins; 1984, p. 1415.
22. Fortunato MA, Fielding AF, Guernsey LH. mandible in children. J Trauma 1976;16:7737. 58. Bull MJ, Sheese J. Update for the pediatrician
Facial bone fractures in children. Oral Surg 42. Lustmann J, Milhem I. Mandibular fractures in on child passenger safety: five principles for
1982;53:22530. infants: review of the literature and report safer travel. Pediatrics 2000;106:11136.
23. Freid MG, Baden E. Management of fractures of seven cases. J Oral Maxillofac Surg 59. Dodson TH, Kaban LB. California mandatory
in children. J Oral Surg 1954;12:129. 1994;52:2406. seat belt laws: the impact on maxillofacial
24. Gwyn PP, Carraway JH, Horton CE, et al. Facial 43. Moos K, El-Attar A. Mandible and dental injuries. J Oral Maxillofac Surg 1988;
fractures: associated injuries and complica- injuries. In: Mustarde JC, Jackson IT, edi- 46:87580.
tions. Plast Reconstr Surg 1971;47:22530. tors. Plastic surgery in infancy and child- 60. Demas PN, Braun TW. Pediatric facial injuries
25. Hall RK. Injuries of the face and jaws in chil- hood. 3rd ed. New York (NY): Churchill associated with all-terrain vehicles. J Oral
dren. Int J Oral Surg 1972;1:6572. Livingstone; 1988. p. 34564. Maxillofac Surg 1992;50:12803.
26. Hall RK. Facial trauma in children. Aust Dent J 44. Posnick JC. Pediatric cranial base surgery. In: 61. Ledbetter DJ, Tapper D. Injuries caused by
1974;19:33645. Janecka IP, editor. Problems in plastic and child abuse. Compr Ther 1989;15:913.
27. Haug RH, Foss J. Maxillofacial injuries in the reconstructive surgery. Philadelphia (PA): 62. Fiala TGS, Novelline RA, Yaremchuk MJ. Com-
pediatric patient. Oral Surg Oral Med Oral J.B. Lippincott; 1993. p. 10729. parison of CT imaging artifacts from cran-
Pathol Oral Radiol Endosc 2000;90:12634. 45. Morgan WC. Pediatric mandibular fractures. iomaxillofacial internal fixation devices.
28. Iizuka T, Thoren H, Anaino DJ, et al. Midfacial Oral Surg 1975;40:3206. Plast Reconstr Surg 1993;92:122732.
fractures in pediatric patients. Arch Otol 46. Panagopoulos AP. Management of fractures of 63. Kassel EE, Noyek AM, Cooper PW. CT in facial
Head Neck Surg 1995;121:136671. the jaws in children. J Int Coll Surg trauma. J Otolaryngol 1983;12:215.
29. James D. Maxillofacial injuries in children. In: 1957;8:806. 64. Hirabayashi A, Unamoto N, Tachi M, et al. Opti-
Rowe NL, Williams JL, editors. Maxillofa- 47. McGowan DA. Neurosensory disturbances of mized 3-D CT scan protocol for longitudinal
cial injuries. London (UK): Churchill Liv- the trigeminal nerve: a long-term follow-up morphological estimation in craniofacial
ingstone; 1985. p. 53858. of traumatic injuries [discussion]. J Oral surgery. J Craniofac Surg 2001;12:12640.
30. Kaban LB. Diagnosis and treatment of frac- Maxillofac Surg 1995;53:505. 65. Kaban LB. Facial trauma: I. Midface fractures.
tures of the facial bones in children. J Oral 48. American College of Surgeons. Advanced trau- In: Kaban LB, editor. Pediatric oral and
Maxillofac Surg 1993;51:7229. ma life support courses. Chicago (IL): maxillofacial surgery. Philadelphia (PA):
31. Kaban LB, Mulliken JB, Murray JE. Facial frac- American College of Surgeons; 1989. W.B. Saunders; 1990. p. 20932.
tures in children: an analysis of 122 frac- 49. Needleman HL. Orofacial trauma in child 66. Alpert B, Seligson D. Clinical controversies in
tures in 109 patients. Plast Reconstr Surg abuse: types, prevalence, management, and oral and maxillofacial surgery: II. Removal
1977;59:1520. the dental professional involvement. Pedi- of asymptomatic bone plates used for
32. Kim DB, Sacapano M, Hardesty RA. Facial atr Dent 1986;8:7180. orthognathic surgery and facial fractures.
fractures in children. West J Med 1997; 50. Warlock P, Stower M, Barbor P. Patterns of J Oral Maxillofac Surg 1996;54:61821.
167:100. fractures in accidental and non-accidental 67. Beiser IH, Kanat IO. Biodegradable internal
33. Koltai PJ, Rabkin D. Management of facial dental injury in children: a comparative fixation: a literature review. J Am Podiatr
trauma in children. Pediatr Clin North Am study. Br Med J 1986;293:1002. Med Assoc 1990;80:725.
1996;43:125375. 51. Bridges CP, Ryan RF, Longnecker CG, et al. 68. Borah GL, Ashmead D. The fate of teeth trans-
34. Koumakis SE, Raife J, Ghorayeb B, Stiernberg Tracheostomy on children: a 20 year study fixed by osteosynthesis screws. Plast Recon-
CM. Pediatric gunshot wounds to the head at Charity Hospital in New Orleans. Plast str Surg 1996;97: 7269.
and neck. Otolaryngol Head Neck Surg Reconstr Surg 1966;37:11720. 69. Ellis E III. Rigid skeletal fixation of fractures.
1996;114:75660. 52. Line WAS, Hawkins DB, Kahistrom EJ, et al. J Oral Maxillofac Surg 1993;51:16373.
35. Maniglia AJ, Kline SN. Maxillofacial trauma in Tracheostomy in infants and young chil- 70. Haug RH. Clinical controversies in oral and
the pediatric age group. Otolaryngol Clin dren: the changing perspective, 19701985. maxillofacial surgery: I. Retention of
North Am 1983;16:71730. Laryngoscope 1986;96:5105. asymptomatic bone plates used for orthog-
36. McCoy FJ, Chandler RA, Crow ML. Facial frac- 53. Posnick JC, Wells M, Pron G. Pediatric facial nathic surgery and facial fractures. J Oral
tures in children. Plast Reconstr Surg fractures: evolving patterns of treatment. J Maxillofac Surg 1996;54:6117.
1966;37:20915. Oral Maxillofac Surg 1993;51:83644. 71. Manson P. The long-term effects of rigid fixa-
37. Ramba J. Fractures of the facial bones in chil- 54. Lewis VL Jr, Manson PN, Morgan RF, et al. tion on the growing craniomaxillofacial
dren. Int J Oral Surg 1985;14:4728. Facial injuries associated with cervical frac- skeleton [commentary]. J Craniofac Surg
38. Schultz RC. Facial trauma in children. In: Mar- tures: recognition, patterns and manage- 1991;2:69.
shall DK, editor. Facial injuries. 3rd ed. ment. J Trauma 1985;25:903. 72. Posnick JC. The effects of rigid fixation on the
Chicago (IL): New York Medical Publishers; 55. McGraw BL, Cole RR. Pediatric maxillofacial craniofacial growth in rhesus monkeys [dis-
1988, p. 1682. trauma: age-related variations in injury. Arch cussion]. Plast Reconstr Surg 1994;93:11.
39. Thoren H, Iizuka T, Hallikainen D, et al. An Otolaryngol Head Neck Surg 1990;116:415. 73. Resnick JI, Kinney BM, Kawamoto HK, et al.
544 Part 4: Maxillofacial Trauma
The effect of rigid internal fixation on cra- an analysis of 220 fractures in 157 patients. J 108. Walker RV. Traumatic mandibular condylar
nial growth. Ann Plast Surg 1990;25:3724. Craniomaxillofac Surg 1992;20:2926. fracture dislocations: effect of growth in the
74. Sarnet BG. Differential craniofacial skeletal 92. Anderson MF, Alling CC. Subcondylar fracture Macaca rhesus monkey. Am J Surg
changes after postnatal experimental in young dogs. Oral Surg 1965;19:263. 1960;100:850.
surgery in young and adult animals. Ann 93. Boyne PJ. Osseous repair and mandibular 109. Winstanley RP. Collapse of the condylar head
Plast Surg 1978;1:13145. growth after subcondylar fractures. J Oral of the mandible in children and subsequent
75. Burstein F, Cohen S, Hudgins R, et al. Frontal Surg 1967;25:3009. ankylosis. Br J Oral Surg 1978;16:311.
basilar trauma: classification and treat- 94. Chalmers J, Lyons C. Fractures involving the 110. Alexander R, Stark MM. An accurate method
ment. Plast Reconstr Surg 1997;99:131421. mandibular condyle: a posttreatment sur- for open reduction and internal fixation of
76. Markowitz BL, Manson PN. Frontal basilar vey of 120 cases. J Oral Surg 1947;5:45. high and low condylar process fractures.
trauma: classification and treatment [dis- 95. Coccaro PJ. Restitution of mandibular form J Oral Maxillofac Surg 1994;52:80812.
cussion]. Plast Reconstr Surg 1997;99:1322. after condylar injury in infancy (a 7-year- 111. Andreasen JO, Ravn JJ. The effect of traumatic
77. Wolfe SA, Johnson P. Frontal sinus injuries: pri- study of a child). Am J Orthod Dentofac injuries to primary teeth on their perma-
mary care and management of late complica- Orthop 1969;55:3249. nent successors: II. A clinical and radi-
tions. Plast Reconstr Surg 1988;82:78191. 96. Dahlstrom L, Kahnberg KE, Lindahl L. Fifteen ographic follow-up study of 213 teeth.
78. Posnick JC. Craniomaxillofacial fractures in years follow-up on condyle fractures. Int J Scand J Dent Res 1971;79:28494.
children. Oral Maxillofac Clin North Am Oral Maxillofac Surg 1989;18:1823. 112. Chen CT, Lai JP, Chen YR. Costochondral graft
1994;1:16985. 97. Gilhaus-Moe O. Fractures of the mandibular in acute mandibular condylar fracture.
79. Sandstedt P, Sorensen S. Neurosensory distur- condyle in the growth period. Stockholm: Plast Reconstr Surg 1997;100:12349.
bances of the trigeminal nerve: a long-term Scandinavian University Books; 1969. 113. Hall MB. Condylar fractures: surgical management.
follow-up of traumatic injuries. J Oral 98. Jeter TS. Analysis of possible factors leading to J Oral Maxillofac Surg 1994; 52:118992.
Maxillofac Surg 1995;53:498505. problems after nonsurgical treatment of 114. Kaplan SL, Mark HI. Bilateral fractures of the
80. Posnick JC. Pediatric orbital fractures. Oral condylar fractures [discussion]. J Oral mandibular condyles and fracture of the sym-
Maxillofac Surg 1994;52:7939. physis menti in an 18-month-old child: two
Maxillofac Clin North Am 1993;5:495506.
99. Leake D, Doykos J III, Habal MB, et al. Long- year preliminary report with a plea for con-
81. Messinger A, Radkowski MA, Greenwald MA, et
term follow-up of fractures of the servative treatment. Oral Surg 1962;15:136.
al. Orbital roof fractures in the pediatric pop-
mandibular condyle in children. Plast 115. MacLennan WD, Simpson W. Treatment of
ulation. Plast Reconstr Surg 1989;84:2136.
Reconstr Surg 1971;47:12731. fractured mandibular condylar processes in
82. Nahum AM. The biomechanics of maxillofa-
100. Miller RI, McDonald DK. Remodelling of children. Br J Plast Surg 1965;18:4237.
cial trauma. Clin Plast Surg 1975;2:5964.
bilateral condylar fractures in a child. J Oral 116. MacLennan WD. Consideration of 180 cases of
83. Raflo GT. Blow-in and blow-out fractures of the
Maxillofac Surg 1986;44:100810. typical fractures of the mandibular condy-
orbit: clinical correlations and proposed mech-
101. Nrholt SE, Krishnan V, Sindet-Pedersen S, et lar process. Br J Plast Surg 1952;5:122.
anisms. Ophthalmic Surg 1984;15:1149.
al. Pediatric condylar fractures: a long-term 117. McGrath CJR, Egbert MA, Tong DC, et al.
84. Manson PN, Clifford CM, Su CT, et al. Mecha-
follow-up study of 55 patients. J Oral Max- Unusual presentations of injuries associated
nisms of global support and posttraumatic
illofac Surg 1993;51:130210. with the mandibular condyle in children. Br J
enophthalmos: I. The anatomy of the ligament
102. Nowak AJ, Casamassimo PS. Oral opening and Oral Maxillofac Surg 1996;34:3114.
and its relation to intramuscular cone orbital
other selected facial dimensions of children 118. Rakower W, Protzell A, Rosencrans M. Treat-
fat. Plast Reconstr Surg 1986;77:193202. 6 weeks to 36 months of age. J Oral Max- ment of displaced condylar fractures in
85. Wolfe SA. Application of craniofacial surgical illofac Surg 1994;52:8457. children: report of cases. J Oral Surg
principles in orbital reconstruction follow- 103. Posnick JC, Goldstein JA. Surgical manage- 1961;19:517.
ing trauma and tumor removal. J Maxillo- ment of temporomandibular joint ankylo- 119. Rowe NL. Mandibular joint lesions in infants
fac Surg 1982;10:21223. sis in the pediatric population. Plast Recon- and adults. Int Dent J 1960;10:484.
86. Moss ML, Bromberg BE, Song IC, et al. The str Surg 1993;91:7918. 120. Schettler D, Rehrmann A. Long-term results of
passive role of nasal septal cartilage in mid- 104. Proffitt WR, Vig KW, Turvey TA. Early frac- functional treatment of condylar fractures
facial growth. Plast Reconstr Surg tures of the mandibular condyles: frequent- with the long bridle according to A.
1968;41:53642. ly an unsuspected cause of growth distur- Rehrmann. J Maxillofac Surg 1975;3:1422.
87. Graham GG, Peltier R. The management of bances. Am J Orthod Dentofac Orthop 121. Walker RV. Condylar fractures: nonsurgical
mandibular fractures in children. J Oral 1980;78:124. management. J Oral Maxillofac Surg
Surg 1960;18:416. 105. Rubenstein LK. Oral opening and other select- 1994;52:11858.
88. Keniry AJ. A survey of jaw fractures of chil- ed facial dimensions of children 6 weeks to 122. Zide MF, Kent JN. Indications for open reduc-
dren. Br J Oral Surg 1971;8:2316. 36 months of age [discussion]. J Oral Max- tion of mandibular condyle fractures. J Oral
89. Posnick JC. Mandibular fractures in infants: illofac Surg 1994;52:848. Maxillofac Surg 1983;41:8998.
review of the literature and report of seven 106. Silvennoinen U, Iizuka T, Oikarinen K, et al.Analy- 123. Zide MF. Open reduction of the mandibular
cases [discussion]. J Oral Maxillofac Surg sis of possible factors leading to problems after condyle fractures: indications and tech-
1994;52:245. nonsurgical treatment of condylar fractures. J niques. Clin Plast Surg 1989;16:6976.
90. Rowe NL. Fractures of the jaws in children. J Oral Maxillofac Surg 1994;52:7939. 124. Zide MF. An accurate method for open reduc-
Oral Surg 1969;27:497507. 107. Walker DG. Mandibular condyle: fifty cases tion and internal fixation of high and low
91. Thoren H, Iizuka T, Hallikainen D, et al. Different demonstrating arrest in development. Dent condylar process fractures [discussion]. J
patterns of mandibular fractures in children: Pract 1957;7:160. Oral Maxillofac Surg 1994;52:812.
Pediatric Craniomaxillofacial Fracture Management 545
125. Troulis M, Kaban LB. Endoscopic approach to interphalangeal joint. J Hand Surg Am iomaxillofacial skeleton. Stoneham (MA):
the ramus/condyle unit: clinical applica- 1986;1:8508. Butterworth-Heinemann; 1992. p. 396419.
tions. J Oral Maxillofac Surg 2001;59:5039. 129. Gelbier S. Injured anterior teeth in children: a 133. Posnick JC, Goldstein JA, Armstrong D. Recon-
126. Salter RB, Ogilvie-Harris DJ. The healing of preliminary discussion. Br Dent J 1967; struction of skull defects in children and
intra-articular fractures with continuous 123:3315. adolescents by the use of fixed cranial bone
passive motion. In: Cooper R, editor. AAOS 130. Lu M. Reimplantation of an avulsed anterior grafts: long-term results. Neurosurgery
Instructional Course Lectures. St Louis teeth in patients with jaw fractures. Plast 1993;32:78591.
134. Posnick JC. Management of facial fractures in
(MO): C.V. Mosby; 1979. p. 102. Reconstr Surg 1973;51:37783.
children and adolescents. Ann Plast Surg
127. Salter RB, Simmonds DF, Malcolm BW, et al. 131. MacLennan WD. Injuries involving the teeth
1994;33:44257.
The biological effect of continuous passive and jaws in young children. Arch Dis Child 135. Posnick JC. Diagnosis and management of
motion on the healing of full-thickness 1957;37:492. pediatric craniomaxillofacial fractures. In:
defects in articular cartilage. J Bone Joint 132. Posnick JC. The role of plate and screw fixation Peterson LJ, Indressano AT, editors. Princi-
Surg Am 1980;62:123251. in the treatment of pediatric facial frac- ples of oral and maxillofacial surgery. Vol I.
128. Schenck RR. Dynamic traction and early pas- tures. In: Yaremchuk MJ, Gruss JS, Manson Part V. Philadelphia (PA): J.B. Lippincott;
sive movement for fractures of the proximal PN, editors. Rigid fixation of the cran- 1992. p. 62340.
CHAPTER 28
Frontal
Nasomaxillary
Zygomatic
Zygomaticomaxillary
Maxillary
Pterygomaxillary
Mandibular
Posterior mandibular
ramus/condyle
FIGURE 28-1 Vertical buttresses of the face. FIGURE 28-2 The horizontal buttresses of the face.
ramus make up yet another buttress estab- Key Landmarks palatal split and the mandible is also frac-
lishing posterior facial height. tured along the tooth-bearing region,
When there are multiple facial fractures
The horizontal buttresses are also with associated condyle fractures. This
involving the upper, middle, and lower
described as anterior posterior buttresses.10 can easily lead to widening of the entire
face, reconstruction should be approached
These include the frontal, zygomatic, facial complex if these segments are not
as a puzzle. Known landmarks and anato-
maxillary, and mandibular buttresses properly reduced. One approach to this
my can be used to reconstruct more pre-
(Figure 28-2). The frontal buttress is problem is to reestablish the maxillary
cisely those areas that have been damaged.
composed of the supraorbital rims and width by exposing the palatal fracture,
the glabellar region. The zygomatic but- Some key landmarks that may help in then reducing and fixating the region
tress consists of the zygomatic arch, zygo- establishing the proper positioning of the (Figure 28-3).3437 This approach works
matic body, and infraorbital rim. The facial skeleton include the dental arches, well if there is a solitary midpalatal frac-
maxillary and mandibular buttresses are mandible, sphenozygomatic suture, maxil- ture without comminution or avulsion. A
composed of the basal bone of the maxil- lary buttress, and intercanthal region. second approach is to obtain impressions
la and mandible arches. for fabrication of dental models. Simulat-
Dental Arches
None of these buttresses exists in a ed surgery can then be performed on the
vacuum. Together they give the facial When one or both of the dental arches are upper and lower casts and a surgical splint
skeleton its structural integrity. The bone intact, they can be used as guides. For fabricated (Figure 28-4).38,39 This is by no
is generally thicker over these described example, if the patient has suffered a Le means a foolproof method when both the
areas to neutralize the forces of mastica- Fort fracture but no midpalatal split, the upper and lower arches are fractured. The
tion or impact. With the proper reduction maxilla, as an intact arch, can be used to more severe the injury (ie, multiple seg-
of these buttresses, we are able to recon- set the mandibular arch and establish ments), the more difficult it is to establish
struct the height, width, and projection of proper width. Particularly problematic is a preinjury occlusion. If the patient has
the face. the situation in which there is a mid- dental models of his preinjury occlusion
Management of Panfacial Fractures 549
of the inferior border and, to a lesser orbital roof and superior lateral orbit are
degree, the lingual cortex. The reduction intact, this suture can be an important
of both the buccal and lingual cortical landmark for the proper positioning of the
surfaces prior to fixation yields better zygoma and zygomatic arch. The sphe-
results (Figure 28-5).40,41 When bilateral nozygomatic suture is usually exposed
subcondylar fractures are present, they along the internal surface of the lateral
must be treated to establish the posterior orbital wall (Figure 28-6).
facial height and facial width. When Once reduced, a small plate is placed
bilateral subcondylar fractures are pre- across this fracture for fixation. Since the
sent and there is an associated fracture
along the symphysis and/or body region,
the mandible may undergo splaying,
with a resultant increase in facial width.
The lateral pterygoid muscle attachment
FIGURE 28-3 Reduction and fixation of a at the pterygoid fovea, as well as the lat-
palatal fracture using a miniplate. eral capsular ligament of the temporo-
mandibular joint, acts to prevent
extremes of movement laterally. The
from previous orthodontic or prosthetic mandibular condyle can be reconstituted
rehabilitation, these can provide invalu- to the mandibular ramus to help estab- A
able clues to establishing the proper arch lish facial height and width.
form. A third option is to reconstruct the
mandible since this is generally a robust Sphenozygomatic Suture
bone that can undergo anatomic reduc- The sphenozygomatic suture, along the
tion if attention is paid to detail. internal surface of the lateral orbital wall,
has been shown in cadaver studies to be a
The Mandible key landmark for both the reduction and
Anatomic reduction at the symphysis fixation of the zygomaticomaxillary com-
and/or body can be achieved with an plex.4244 If other aspects of the facial
extraoral exposure of the fracture. Such skeleton are ignored, use of this suture
exposure allows for direct visualization alone can result in errors; however, if the B
Intercanthal Region
The intercanthal region may also be used to
reestablish midfacial width since the inter-
canthal distance is fairly constant in the
adult facial skeleton.45 Restoration of the
proper intercanthal distance via reduction
of the naso-orbitoethmoid complex can
help to determine facial width (Figure 28-
7).10 This depends mainly on the fracture
type. If there is minimal or no comminu-
tion in the region, proper reduction can aid
in reestablishment of facial form. Unfortu-
nately, many times this area is severely com-
minuted and is of little help. Establishing
the proper intercanthal distance through A B
measurement is usually performed in cases FIGURE 28-8 Computed tomography showing midfacial fractures and a left condylar head fracture
with severe comminution. on the axial view (A), and a left condylar head fracture on the coronal view (B).
Management of Panfacial Fractures 551
primary bone grafting and resuspension of long-term facial esthetics.42,52,53 Resuspen- the frontal sinus and naso-orbitoethmoid
the soft tissue after extensive exposure of sion may be especially beneficial in the region is hindered.
the facial skeleton.79 As previously dis- midface region. For repair of midface frac- Oral intubation may be an option when
cussed, the facial buttresses are areas that tures, the region is usually exposed transo- maxillomandibular fixation is either not
can serve as guides in the reduction of the rally and from a periorbital approach.52 possible or not indicated. When prolonged
facial skeleton and provide stabilization of The soft tissue attachment over the mid- intubation is not anticipated, options
fractures. With high-velocity trauma, com- face is customarily completely stripped. include submental intubation60,61 or passing
minution and loss of bony segments can This frequently results in sagging of the the tube behind the dentition, if space per-
occur in the buttress and nonbuttress soft tissue, with reattachment at a more mits. If an extraoral approach is indicated to
areas of the face. When these defects are inferior position. Manson and colleagues manage a mandibular body/angle fracture
significant, the surgeon may consider the stated that there are two steps to placing or a symphysis fracture, submental intuba-
use of bone grafting to prevent soft tissue the soft tissue back into proper position tion may hinder access.
collapse and to allow for structural support after exposure of the facial skeleton: refixa-
of the facial skeleton. Previous articles have tion of the periosteum or fascia to the Fracture Management
reported on primary bone grafting with skeleton, and closure of the periosteum, Much has been written about the proper
few complications.79 Even when the bone muscle fascia, and skin where incisions sequencing of treatment for panfacial frac-
graft becomes exposed, secondary wound have been made.42 The periosteum is tures.10,28,42,52,62 Sequences such as bottom
healing generally occurs. Common areas inflexible and limits soft tissue lengthening up and inside out or top down and out-
that may require primary bone grafting and migration. Its reattachment is usually side in have been used to describe two of
include the frontal bone, nasal dorsum, accomplished by drilling holes in key loca- the classic approaches for the management
orbital floor, medial orbital wall, and zygo- tions to fix the periosteum to the bone. of panfacial fractures. To my knowledge
maticomaxillary buttress. Areas where periosteal closure should be there have been no randomized studies to
There are many potential sources of obtained include the frontozygomatic ascertain whether one approach is superior
bone for a graft, but calvarial bone may be suture, infraorbital rim, deep temporal fas- to the other. The bottom up and inside out
the best. Access is often achieved through cia, and muscular layers of maxillary and approach predates the use of rigid fixation
a bicoronal flap that has already been cre- mandibular incisions.32,42,52,54 Areas where but it is still a valid approach. It establishes
ated during the management of the frac- periosteal reattachment should be the mandible as a foundation for setting the
tures. These grafts have been shown to obtained include the malar eminence and rest of the face and includes open reduction
resist resorption better than endochon- infraorbital rim, temporal fascia over the and internal fixation of subcondylar frac-
dral bone.8 Rigid fixation of these grafts zygomatic arch, medial and lateral canthi, tures, as well as the remainder of the
has been shown to decrease resorption and mentalis muscle.42 mandible. The occlusion is set by placing
(Figure 28-11).8 the patient in maxillomandibular fixation;
Soft tissue resuspension after surgical Sequence of Treatment then, the maxilla should be in the proper
access to facial fractures is important for position. Realignment of the zygomatic
Airway Management buttresses follows in this sequence; howev-
How to maintain the airway is a crucial er, fixation at this point may lead to inaccu-
decision in the management of panfacial racies in upper midface position. Instead, a
fractures. There are several options that are break in the sequence is usually preferred
dictated by the fracture pattern and extent here. The zygomaticomaxillary complex is
of other injuries. When there are extensive reduced and fixated first. This allows for a
head injuries and prolonged intubation is more accurate repositioning of the upper
anticipated, tracheostomy should be con- midface before fixation at the zygomatic
sidered.5557 Likewise, tracheostomy is an buttress. The maxilla is now fixated along
appropriate option to facilitate the man- the zygomaticomaxillary buttress. Last, the
agement of multiple facial fractures.10,56,57 naso-orbitoethmoid fracture is reduced
FIGURE 28-11 Primary bone graft rigidly In many cases there are extensive injuries and stabilized (Figure 28-12).62
fixed into position to reconstruct the anterior The opposite approach, top down and
to the naso-orbitoethmoid region, making
maxillary sinus wall including the nasomaxil-
lary and zygomaticomaxillary buttress. (Cour- nasal intubation difficult and haz- outside in, starts at the zygomatic region.
tesy of James Koehler, DDS, MD.) ardous.58,59 With nasal intubation, access to The sphenozygomatic suture is reduced
Management of Panfacial Fractures 553
A B C
D E F
G H
554 Part 4: Maxillofacial Trauma
A B C
D E F
G H
Management of Panfacial Fractures 555
and fixated inside the orbit. The zygomatic caudally and proceeds cranially may stabilized with plates, which can then be
arch is reduced and plated. If the arches are achieve more optimal results, allowing the sterilized and used at the time of surgery.
not properly reduced, underprojection of surgeon to reconstruct the damaged cra- This technique and the use of proper land-
the midface can result. The alignment of nial portion last. On the other hand, if marks can aid in the proper reduction and
the arch can be verified by the proper posi- there is significant comminution of the fixation of the fractures.
tion of the sphenozygomatic suture. From mandible or if key segments are missing, it
this point the zygomas can be further posi- may be more appropriate to start cranially Conclusions
tioned and fixated at the frontozygomatic and proceed caudally. Thus, the maxillofa- The management of panfacial fractures is
suture. The naso-orbitoethmoid complex is cial trauma surgeon must be comfortable extremely complex. There are, however,
then positioned to the supraorbital rims, with both approaches and use known many technologic advances that can aid the
infraorbital rims, and maxillary process of landmarks to achieve optimal results. surgeon in the proper management of these
the frontal bones. The maxilla is addressed In Tables 28-1 and 28-2, two common fractures. The most important of these
next using the position of the zygomatico- sequences of management of facial frac- advancements is imaging. With the advent
maxillary buttress and piriform rim as a tures are illustrated. Other sequences of high-resolution scanners, the surgeon
guide. Maxillomandibular fixation can then exist, but they are variations of these two has a more accurate picture of the fracture
be established (Figure 28-13).52 Reduction major approaches.
and fixation of the mandibular condyle and
the symphysis/body/angle fractures are Complications Table 28-1 Sequence A: Bottom Up and
Inside Out*
then performed. There are many complications that are
Some surgeons feel that there is a sig- associated with various fractures; these are 1. Tracheostomy
nificant advantage to the top down and discussed elsewhere in the text, with refer- 2. Repair of palatal fracture
outside in approach because open treat- ence to the specific fracture type. However, 3. Maxillomandibular fixation
4. Repair of condyle fracture
ment of the condyles may not be neces- a significant complication associated with
5. Repair of mandibular fractures
sary. The patient is treated with varying panfacial fractures that I will discuss here is
(body/symphysis/ramus)
periods of maxillomandibular fixation, widening of the facial complex. This occurs 6. Repair of zygomaticomaxillary
which may be a valid approach in the case when the surgeon fails to properly reduce complex fracture (including arches)
of comminuted intracapsular fractures. key areas that guide in establishing facial 7. Repair of frontal sinus fracture
Although this is a viable option in some width.42 If the first area approached is fix- 8. Repair of naso-orbitoethmoid complex
cases, there are two potential complica- ated in an improper location, subsequent fracture
tions. One is an unrecognized rotation of fragments will be reduced and fixed in an 9. Repair of maxilla
the body or ramus of the mandible, result- improper spatial arrangement, resulting in *See Figure 28-12.
ing in widening. A second complication is a series of errors and, usually, a widened
temporomandibular joint ankylosis facial complex. To prevent this, the surgeon
caused by the inability to begin early phys- must use stable segments, known land- Table 28-2 Sequence B: Top Down and
ical therapy. One author reviewed closed marks, and anatomic reduction in the Outside In*
treatment of mandibular condyle fractures management of panfacial fractures. 1. Tracheostomy
and showed compromised results.63 Early If the complication does occur, the 2. Repair of frontal sinus fracture
function of patients with condylar head surgeon must assess the patient and deter- 3. Repair of bilateral zygomati-
fractures is usually indicated, along with mine the severity and location of the prob- comaxillary complex (including arch)
guiding elastics to maintain the range of lem. This is done through physical exami- fracture
motion of the temporomandibular joint. nation and CT imaging (Figure 28-14). In 4. Repair of naso-orbitoethmoid fracture
Neither one of these techniques will severe cases three-dimensional computed 5. Repair of Le Fort fracture (including
midpalatal split)
achieve optimal results in every situation. tomographic reconstruction of the entire
6. Maxillomandibular fixation
Instead, an approach that goes from facial skeleton can be obtained and, if indi-
7. Repair of bilateral subcondylar
known to unknown is certainly more cated, a three-dimensional stereolitho-
fractures
accurate. For example, if there is a signifi- graphic model can be made.64,65 The model 8. Repair of mandibular fracture
cant calvarial injury, it may be difficult to allows the surgeon to identify and recreate (symphysis/body/ramus)
start from the cranium and proceed cau- the fractures during model surgery. The *See Figure 28-13.
dally. In this case, a sequence that starts fracture may be reduced anatomically and
556 Part 4: Maxillofacial Trauma
D E F
G H
FIGURE 28-14 A and B, Twenty-one-year-old male who fell from a height of two stories. Facial fractures included the frontal sinus, naso-orbitoethmoid,
bilateral zygomaticomaxillary complex, Le Fort I with midpalatal split and avulsion of tooth no. 9, mandibular symphysis, and bilateral intracapsular
condyle fractures. In this photograph it is evident that the patient has significant facial widening owing to a failure to establish proper facial width. He also
has bilateral bony ankylosis of the condyles secondary to a closed reduction of the condyle fractures. C and D, Three-dimensional stereolithographic mod-
els generated from CT imaging. Note the significant widening of the mandible and midface. E and F, Simulated surgery was performed on this model and
mandibular plates were prebent. Note the significant narrowing of the model. Mandibular condyles are now positioned in the fossae. G and H, Model
surgery was performed on the dental cast, based on the preorthodontic models that were brought in by the family. A surgical splint was fabricated. (CONTINUED
ON NEXT PAGE)
Management of Panfacial Fractures 557
I J K
L M
FIGURE 28-14 (CONTINUED) I and J, During the surgical management, the old fractures are exposed via a
bicoronal incision with preauricular extension, transconjunctival incisions with lateral canthotomies, a maxil-
lary vestibular incision, and the use of the previous chin scar. The hardware was removed. The previous fractures
were recreated by performing bilateral condylar process osteotomies, a symphysis osteotomy, and a Le Fort I with
left paramidline split. With the aid of the presurgical splint, the patient was placed in maxillomandibular fixa-
tion. The mandible was reconstructed first by reducing and fixating the condyles and with the aid of the prebent
plates, and by reducing and fixating the symphysis. The arrow points to the condylar process osteotomy and fix-
ation plate. K and L, A Le Fort III osteotomy is created to imitate the initial fractures. This portion of the upper
midface is mobilized and advanced. Greenstick fractures of the zygomatic components of the upper midface are
also performed to rotate the posterior aspect medially. Once reduced, these fractures are fixated with miniplates.
N
M, Last, the maxilla is fixated at the piriform rims and the zygomaticomaxillary buttress with miniplates. The
patient is taken out of fixation to verify the occlusion and begin early function. N, Early postoperative result. Note
the decrease in facial width and increase in facial height. Patient also had zygomatic and recontouring nasal aug-
mentation, bone grafting to the orbits, lateral canthopexy, midface resuspension, and genioplasty. (Courtesy of
Dr. Patrick Louis and Dr. John Grant.)
pattern. Once the proper diagnosis is estab- 5. Gruss JS, Phillips JH. Complex facial trauma: Midface fractures: advantages of immediate
lished, the surgeon should be able to insti- the evolving role of rigid fixation and extended open reduction and bone graft-
immediate bone graft reconstruction. Clin ing. Plast Reconstr Surg 1985;76:112.
tute an appropriate sequence of treatment. Plast Surg 1989;16:93104. 10. Markowitz BL, Manson PN. Panfacial frac-
6. Schilli W, Weers R, Niederdellmann H. Bone tures: organization of treatment. Clin Plast
References fixation with screws and plates in the max- Surg 1989;16:10514.
1. Noyek AM, Kassel EE, Wortzman G, et al. illofacial region. Int J Oral Surg 1981:10 11. Tullio A, Sesenna E. Role of surgical reduction
Sophisticated CT in complex maxillofacial Supp 1: 32932. of condylar fractures in the management of
trauma. Plast Reconstr Surg 1980;66:117. 7. Gruss JS, Mackinnon SE, Kassel EE, et al. The panfacial fractures. Br J Oral Maxillofac
2. Rowe LD, Miller E, Brandt-Zawadzki M. Com- role of primary bone grafting in complex Surg 2002;36:4726.
puted tomography in maxillofacial trauma. craniomaxillofacial trauma. Plast Reconstr 12. Okeson JP. Management of temporomandibu-
Laryngoscope 1981;91:74557. Surg 1985;75:1724. lar disorders and occlusion. 3rd ed. St.
3. Tessier P, Hemmy D. Three dimensional imag- 8. Phillips JH, Forrest CR, Gruss JS. Current con- Louis: Mosby Year Book; 1993. p. 510.
ing in medicine. A critique by surgeons. cepts in the use of bone grafts in facial frac- 13. Jacobs R, Schotte A, van Steenberghe D. Influ-
Scand J Plast Reconstr Surg 1986;20:311. tures. Basic science considerations. Clin ence of temperature and foil hardness on
4. Wenig BL. Management of panfacial fractures. Plast Surg 1992;19:4158. interocclusal tactile threshold. J Periodont
Otolaryngol Clin North Am 1991;24:93101. 9. Manson PN, Crawley WA, Yaremchuk M, et al. Res 1992;27:5817.
558 Part 4: Maxillofacial Trauma
14. Gnoy AR, Gannon PJ, Ganjian E, et al. A poten- 31. Zaytoun GM, Shikhan AH, Salman SD. Head 45. Freihofer HPM. Inner intercanthal and
tial role for nasal obstruction in develop- and neck war injuries: 10-year experience at interorbital distances. J Maxillofac Surg
ment of acute sinusitis: an infection study the American University of Beirut Medical 1980;8:324.
in rabbits. Am J Rhinol 1998;12:399404. Center. Laryngoscope 1986;96:899903. 46. Ingram FL. Radiology of the teeth and jaws.
15. Alwani A, Rubinstein I. The nose and obstruc- 32. Manson PN, Hoopes JE, Su CT. Structural pil- 2nd ed. London: Edward Arnold; 1965.
tive sleep apnea. Curr Opin Pulm Med lars of the facial skeleton: an approach to 47. Massiot J. History of tomography medicine.
1998;4:3612. the management of Le Fort fractures. Plast Mundi 1974;19:10615.
16. Dalton RM, Warren DW, Dalston ET. A prelim- Reconstr Surg 1980;66:5462. 48. Oldendorf WH. The quest for an image of
inary investigation concerning the use of 33. Gruss JS, Mackinnon SE. Complex maxillary brain: a brief historical and technical review
nasometry in identifying patients with fractures: role of buttress reconstruction of brain imaging techniques. Neurology
hyponasality and/or nasal airway impair- and immediate bone grafts. Plast Reconstr 1978;28:51733.
ment. J Speech Lang Hear Res 1991;34:118. Surg 1986;78:922. 49. Houndfield GN. Computerized transverse
17. Converse JM, Smith B. Enophthalmos and 34. Manson PN, Glassman D, Vander Kolk C, et al. axial scanning (tomography): part I.
diplopia in fractures of the orbital floor. Br Rigid stabilization of sagittal fractures of Description of system. Br J Radiol
J Plast Surg 1957;9:26574. the maxilla and palate. Plast Reconstr Surg 1973;46:101622.
18. Grant MP, Iliff NT, Manson PN. Strategies for 1990;85:71117. 50. Hoeffner EG, Quint DJ, Peterson B, et al.
the treatment of enophthalmos. Clin Plast 35. Mosby EL, Markle TL, Zulian MA, Hiatt WR. Development of a protocol for coronal
Surg 1997;24: 53950. Technique for rigid fixation of Le Fort and reconstruction of the maxillofacial region
19. Kleck RE, Rubenstein C. Physical attractiveness, palatal fractures. J Oral Maxillofac Surg from axial helical CT data. Br J Radiol
perceived attitude, similarity, and interper- 1986;44:9212. 2001;74:3237.
sonal attraction in opposite-sex encounter. J 36. Hendrickson M, Clark N, Manson PN, et al. 51. Rosenthal E, Quint DJ, Johns M, et al. Diag-
Pers Soc Psychol 1975;31:10714. Palatal fractures: classification patterns and nostic maxillofacial coronal images refor-
20. Kleck RE. Emotional arousal in interactions treatment with internal rigid fixation. Plast matted from helically acquired thin-section
with stigmatized persons. Psychol Rep Reconstr Surg 1998;101:31932. axial CT data. AJR Am J Roentgenol
1996;19:1226. 37. Denny AD, Celik N. A management strategy 2000;175:117781.
21. Kleck RE. Physical stigmata and task oriented for palatal fractures: a 12-year review. J 52. Phillips JH, Gruss JS, Chir B, et al. Periosteal
interactions. Hum Rel 1969;22:5360. Craniomaxillofac Surg 1999;10:4957. suspension of the lower eyelid and cheek
22. Sawhney CP, Ahuja RB. Faciomaxillary frac- 38. Gunning TB. Treatment of fractures of the following subciliary exposure of facial frac-
tures in North India: a statistical analysis lower jaw by interdental splints. Br J Dent tures. Plast Reconstr Surg 1991;88:1458.
and review of management. Br J Oral Max- Sci 1866;9:4819, 52949. 53. Manson PN. Facial fractures. Perspect Plast
illofac Surg 1998;26:4304. 39. Cohen SR, Leonard DK, Markowitz BL, Man- Surg 1998;2:136.
23. Hansmann M. Eine neve Methode der fix- son PN. Acrylic splints for dental alignment 54. Kelly KJ, Manson PN, Van der Kolk C, et al.
ierung der Fragmente bei Komplizierten in complex facial injuries. Ann Plast Surg Sequencing Le Fort fracture treatment.
frankturen. Verh Dtsch Ges Chir 1993;31:40612. J Craniomaxillofac Surg 1990;1:16878.
1836;15:134. 40. Vogel R. Interfragmentare druckwerte bei der 55. Stone DJ, Bogdonoff DL. Airway considera-
24. Michelet FX, Daymes J, Dessus B. Osteosynthe- anwendung verschiedener dynamischer tions in the management of patients requir-
sis with miniaturized screw plates in max- kompressionsplatten. Eine experimentelle ing long-term endotracheal intubation.
illofacial surgery. J Maxillofac Surg Studie am unterkiefer [dissertation]. Basel: Anesth Analg 1992;74:27687.
1973;1:7984. Universitat Basel; 1984. 56. Haug RH, Indresano AT. Management of max-
25. Horster W. Experience with functionally stable 41. Spiessl B. Internal fixation of the mandible. A illary fractures. In: Peterson LJ, editor. Prin-
plate osteosynthesis. J Maxillofac Surg manual of AO/ASIF principles. Berlin: ciples of oral and maxillofacial surgery.
1980;8:17681. Springer-Verlag; 1989. Philadelphia: JB Lippincott; 1992. p. 46988.
26. Chopart F, Desault PJ. Traite des maladies 42. Manson PN, Clark N, Robertson B, et al. Sub- 57. Demas PN, Sotereanos GC. The use of tra-
chirurgicales et des operations qui leur con- unit principles in midface fractures: the cheostomy in oral and maxillofacial surgery.
viennent. Paris: Villier, IV; 1795. p. 392. importance of sagittal buttresses, soft tissue J Oral Maxillofac Surg 1988;46:4836.
27. Von Graefe CF. J Chir Augenheilk reductions and sequencing treatment of 58. Seebacher J, Nozik D, Mathieu A. Inadvertent
1823;IV:5923. segmental fractures. Plast Reconstr Surg intracranial introduction of a nasogastric
28. Wolfe SA, Baker S. History of facial fracture 1999;103:12871306. tube, a complication of severe maxillofacial
treatment. In: Goin JM, editor. Facial frac- 43. Stanley RB Jr. The zygomatic arch as a guide to trauma. Anesthesiology 1975;42:1002.
tures. New York: Thieme Medical Publish- reconstruction of comminuted malar frac- 59. Muzzi DA, Losasso TJ, Cucchiara RF. Compli-
ers Inc; 1993. p. 15. tures. Arch Otolaryngol Head Neck Surg cation from a nasopharyngeal airway in a
29. Khan AA. A retrospective study of injuries to 1989;1150:145962. patient with a basilar skull fracture. Anes-
the maxillofacial skeleton in Harare, Zim- 44. Rohner D, Tay A, Meny CS, et al. The sphenozy- thesiology 1991;74:3668.
babwe. Br J Oral Maxillofac Surg gomatic suture as a key site for osteosynthe- 60. Gordon NC, Tolstunov L. Submental approach
1988;26:4359. sis of the orbitozygomatic complex in panfa- to oroendotracheal intubation in patients
30. Cohen MA, Shakenovsky BN, Smith I. Low cial fractures: a biomechanical study in with midfacial fractures. Oral Surg Oral
velocity handgun injuries of the maxillofa- human cadavers based on clinical practice. Med Oral Pathol Oral Radiol Endod
cial region. J Maxillofac Surg 1986;14:2633. Plast Reconstr Surg 2002;110:1463071. 1995;79:26972.
Management of Panfacial Fractures 559
61. Caron G, Paquin R, Lessard MR, et al. Sub- maxillofacial surgery. Philadelphia: JB Lip- tions for use in the management of trauma.
mental endotracheal intubation: an alterna- pincott Co; 1992. p. 61522. J Craniomaxillofac Trauma 1998;4:1623.
tive to tracheotomy in patients with midfa- 63. Hlawitschka M, Eckelt U. Assessment of patients 65. Kermer C, Linder A, Friede I, et al. Preoperative
cial and panfacial fractures. J Trauma treated for intracapsular fractures of the stereolithographic model planning for pri-
2000;48:23540. mandibular condyle by closed techniques. J mary reconstruction in craniomaxillofacial
62. Mercuri LG, Steinberg MJ. Sequencing of care Oral Maxillofac Surg 2002;60:78491. trauma surgery. J Craniomaxillofac Surg
for multiple maxillofacial injuries. In: 64. Powers DB, Edgin WA, Tabatchnick L. Stere- 1998;26:1369.
Peterson LJ, editor. Principles of oral and olithography: a historical review and indica-
Part 5
MAXILLOFACIAL PATHOLOGY
CHAPTER 29
Differential Diagnosis
of Oral Disease
John R. Kalmar, DMD, PhD
Carl M. Allen, DDS, MSD
One of the major roles of the oral and evaluation of the patient. Occasionally the sis is known as the diagnostic process or
maxillofacial surgeon is that of diagnosti- diagnosis is relatively straightforward. method. A case example is provided below.
cian. From private practices in small com- Usually, however, a variety of conditions Although the determination of a final
munities to large tertiary care medical cen- with similar clinical features need to be diagnosis often represents the end of the
ters, these specialists are called upon to considered, and a differential diagnosis is diagnostic phase of patient care, it is worth
evaluate and diagnose a wide variety of prepared. The differential diagnosis repre- remembering that the final diagnosis is
conditions affecting the face, jaws, head, sents a listing of the more likely diagnostic not always correct. As is stressed below,
and neck as well as the tissues of the oral considerations for a particular pathologic observation of the patients response to
cavity. The term diagnose comes from the finding or condition, ranked in descend- therapy and careful monitoring of the
Greek words dia (through, apart) and ing order of probability. Therefore, the subsequent disease course are essential
gnosis (knowledge), meaning literally to number one consideration from the initial aspects of comprehensive patient manage-
know apart or to distinguish. Indeed, differential diagnosis should represent the ment. Should a lesion or condition not
although the ability to correctly diagnose culmination of the clinicians evaluation behave in the expected manner, reevalua-
is important to virtually all professions, it and is termed the clinical diagnosis (ie, tion and revision of the final diagnosis
is perhaps most strongly linked to the clin- working or tentative diagnosis, clinical may ultimately be required.
ical practice of medicine and dentistry. For impression). Although construction of the
health care practitioners, a diagnosis is differential is initially based upon clinical The Diagnostic Process
defined as the determination of the nature signs, symptoms, and history, this list of The clinician begins the diagnostic process
of a disease or pathologic condition. An diagnoses is subject to modification or by gathering or accumulating informa-
accurate diagnosis is obviously important refinement following additional studies tion. In some instances this information
and occasionally critical to the patient so such as radiographic imaging and hemato- includes a significant historic component,
that the most appropriate treatment can logic or serum analysis (Figure 29-1).1,2 As whereas in other cases (eg, asymptomatic
be initiated as soon as possible. Early is discussed below, the differential listing lesions discovered upon routine examina-
determination of the true diagnosis can may vary widely depending upon the tion) the data may be limited strictly to the
further benefit the patient by avoiding the experience and knowledge base of the findings of the physical examination,
need for expensive unnecessary laboratory treating clinician. The designation of final together with any necessary diagnostic
studies, the use of ineffective or improper diagnosis is used when the clinician studies or tests. Depending upon the expe-
medications, and the inconvenience of believes that the nature of the disease has rience and expertise of the practitioner, a
additional costly consultation(s). been identified to a reasonable degree of confident final diagnosis may require
A variety of terms related to the diag- certainty. This progression from informa- nothing more than clinical inspection. In
nostic process may be used during the tion to possible diagnoses to final diagno- many cases, however, even the most
564 Part 5: Maxillofacial Pathology
History
Treat patient Refer patient to specialist
for treatment Most attempts at formulating a differential
diagnosis begin with data gathering that
includes the history of the specific problem
Patient follow-up in coordination with other specialist(s) being investigated as well as the patients
medical and social history. The patients
perception of the duration of the lesion can
Revision of final diagnosis as indicated be important as long-standing lesions may
suggest a developmental or benign process,
FIGURE 29-1 The diagnostic process. Adapted from Ellis E III.1
whereas rapidly evolving problems often
represent reactive, infectious, or malignant
experienced diagnostician requires addi- jaw. His medical history is unremarkable, disease. Exceptions to these generalizations
tional information from appropriate and he denies recent trauma to the area. are numerous, however, since mycobacterial
imaging or laboratory studies. Clinical examination reveals a 1.5 cm bony infections may develop slowly, as do some
firm swelling of the right mandibular alve- neoplasms that are considered malignant
Case Study: From Differential olus in the area of teeth no. 26 and 27 (eg, basal cell carcinoma). Furthermore, the
Diagnosis to Final Diagnosis causing primarily buccal expansion with reliability of the patient to provide an accu-
A 25-year-old male presents with a an unremarkable overlying mucosa. The rate history is occasionally compromised
3-month history of gradual painless area is nontender to palpation, and the owing to the patients inattention, limited
enlargement of the right anterior lower adjacent teeth are vital. mental capacity, or denial of disease.
Differential Diagnosis of Oral Disease 565
Symptoms, particularly related to pain Lesion size can have diagnostic impli- of color change. A brown or black macule
or tenderness, are important in developing cations, particularly when combined with is often the result of melanin pigment; a
a differential diagnosis. Pain and tender- an estimate of lesion duration to give an red or purple macule usually represents
ness (pain on palpation) are often signs of approximate rate of growth or enlarge- hemoglobin in either its oxygenated or
an inflammatory or infectious process, ment. The finding of a large lesion may reduced form, respectively. A dull flat
although malignancies can also produce indicate a locally aggressive or malignant white implies keratin production, an area
such symptoms, particularly late in their neoplasm if the history suggests a relative- of translucent whitish change may mean
course. A notable exception to this is ade- ly recent onset. Yet, even when abnormal increased epithelial edema, and a shiny
noid cystic carcinoma, which is infamous tissue has been noted for several months creamy yellow-white appearance is usually
for the early onset of low-grade intractable or years, a history of progressive increase a sign of an ulcers fibrinous pseudomem-
pain. Other symptoms such as paresthesia in the size of the affected area should be brane. A blue or grayish macule is fre-
or numbness can also be significant and viewed suspiciously (Figure 29-2). As quently associated with exogenous (amal-
may be related to pressure on nerves mentioned above, relying on the accuracy gam, foreign body) or endogenous
caused by a cystic lesion or tumor mass. (or veracity) of the patient history can be (melanin) pigmented material that is
Reported changes in the lesion may also problematic and should be weighted deposited within the connective tissue
provide important insights. If a mass gradu- accordingly in the differential diagnosis. below the level of the epithelium.
ally enlarges, the possibility of neoplasia has Confirmation of the clinical history Although additional information regard-
to be entertained, whereas a mass that fluc- through other health care practitioners ing the margin or border of a lesion is pro-
tuates in size is more suggestive of a reactive can be helpful in this regard. vided below, it should be mentioned that
process. In addition, changes in symptoms Establishing the character of the lesion most pigmented lesions in the oral cavity
may be significant. Decreasing pain or ten- is an essential aspect of the clinical evalua- are relatively homogeneous in color and
derness likely represents a resolving inflam- tion. Ulcers can be seen with traumatic, have a smooth well-defined margin. By
matory or infectious process, whereas pain infectious, or neoplastic conditions, where- contrast, a pigmented lesion that exhibits
that develops in a long-standing previously as masses or swellings more commonly significant border irregularity and color
asymptomatic mass may be an indication of indicate neoplasms, reactive proliferations, variegation should be considered as suspi-
malignant transformation (eg, carcinoma cysts, or enlarged lymph nodes. A history cious for melanoma (Figure 29-3).
arising in pleomorphic adenoma). or evidence of vesicle or bulla formation The surface morphology of a lesion
might be suggestive of a viral condition, an can be virtually diagnostic for certain con-
Clinical Examination immunobullous disorder, or possibly an ditions. Examples include the tapioca
Following a review of the patients medical inherited mucocutaneous disease. pudding appearance of the surface of a
history and history of the present lesion or Macular lesions, which are completely lymphangioma or the papillary epithelial
condition, the clinician typically proceeds flat by definition, usually represent an area fronds of squamous papilloma. Similarly,
with gathering objective data through
careful clinical examination. A variety of
lesional parameters should be evaluated
and recorded, including (1) site, (2) size,
(3) character (eg, macule, ulcer, mass), (4)
color, including an assessment of its
homogeneity, (5) surface morphology (eg,
smooth, pebbly, granular, verrucous), (6)
the border (eg, smooth, irregular, indis-
tinct, sharply defined), (7) consistency on
palpation, (8) local symptoms, and (9) the
distribution if multiple or confluent A B
lesions are observed.
The precise anatomic site or location FIGURE 29-2 A, Asymptomatic papillary epithelial lesion in a 50-year-old male that has been pre-
sent for approximately 2 years without apparent increase in size. Clinical diagnosis: squamous
of a lesion can provide essential diagnostic
papilloma. B, Asymptomatic epithelial lesion in a 65-year-old male with a papillary or granular
information and is discussed later in surface that has been present for approximately 2 years with slow progressive enlargement. Clinical
greater detail. diagnosis: verrucous carcinoma.
566 Part 5: Maxillofacial Pathology
tender to palpation, an inflammatory consistent with a gingival cyst of the biopsy be performed. In this situation, the
process would be more likely. adult. A nonhealing relatively insensitive patient has invested several months time
Another useful approach to develop- ulceration of the lateral tongue in an and spent hundreds of dollars on inappro-
ing a differential diagnosis is to consider adult patient that has no identifiable priate or ineffective medicationsall in
whether the clinical and historic aspects source of irritation or trauma would be the absence of a clear diagnosis.
of the lesion can be explained by any, highly suspicious for squamous cell carci- For the experienced diagnostician
some, or all of the broad categories of dis- noma. Salivary gland neoplasia would be who is more familiar with oral conditions,
ease histogenesis. These categories include a strong consideration for a rubbery firm the differential would be much smaller:
developmental, inflammatory/immune- mass of the posterior hard palate. cicatricial pemphigoid or pemphigus vul-
mediated, infectious, neoplastic, and garis. With a greater understanding of oral
metabolic conditions. This is a time- Case Study: Neophyte versus disease, the specialist should be able to
honored systematic method of diagnosis, Expert Clinician eliminate many of the considerations that
and many clinicians find it useful to criti- An otherwise healthy 72-year-old woman the first clinician entertained. For exam-
cally consider diagnostic possibilities complains of sores in her mouth for the ple, recurrent herpesvirus infection does
from each category. For example, an past year. Her medical history is unre- not typically affect nonkeratinized mucosa
asymptomatic lesion that has been pre- markable and she is not taking any med- in an immunocompetent patient and
sent for several years and feels encapsulat- ications. She has not been aware of any would not wax and wane in severity.
ed upon clinical palpation would be most blisters, and she feels the problem is get- Although aphthous ulcers often exhibit a
consistent with a developmental or ting worse. The lesions tend to wax and waxing-and-waning course, the lesional
benign neoplastic process. Although wane in severity and have affected several margins are usually smooth, not ragged.
inflammatory conditions, malignant neo- areas of the mouth, including the hard and Erosive lichen planus would be considered
plasms, and metabolic conditions might soft palates, the labial mucosa, and the unlikely owing to the lack of radiating
not be excluded completely, they would ventral tongue. white striae at the periphery of the oral
not receive primary consideration in the Examination shows several shallow lesions, as well as the lack of buccal
initial differential. Similarly, if the lesion erosions and ulcerations with ragged mucosa involvement. Squamous cell carci-
presented as a chronic ulceration of the margins. The lesions range from 0.5 to noma would not be reasonable because of
lateral tongue in an adult patient, disor- 1.0 cm in diameter and involve the lower the multifocal presentation and the histo-
ders from the neoplastic (especially malig- labial mucosa, the ventral tongue bilater- ry of waxing and waning. Finally, although
nancies), infectious (eg, mycobacterial or ally, and the anterior soft palate. No vesi- candidiasis is occasionally associated with
deep fungal infections), and immune- cles or bullae are seen, and no white stri- tenderness or irritation of the oral
mediated (eg, Wegeners granulomatosis ae are evident. mucosa, it does not induce true ulceration
or regional enteritis) categories would The inexperienced diagnostician who and would therefore have a low probabili-
have to be considered. is not very familiar with oral lesions might ty of representing the actual diagnosis.
The third diagnostic grouping strate- provide a differential diagnosis based on Based on the patients age, the distrib-
gy relies on the identification of lesions conditions that are primarily ulcerative: ution of the lesions, the history of the
that most commonly present in a partic- herpesvirus infection, aphthous ulcers, process, and the clinical appearance of the
ular anatomic location. The tendency for erosive lichen planus, squamous cell carci- lesions, a differential diagnosis that cen-
certain conditions to occur with noma, and candidiasis. On the basis of this ters on immune-mediated disease would
increased frequency at certain sites is well list, the patient would likely be placed on be most appropriate. In this situation
recognized. For example, a nontender one or possibly more courses of antiviral biopsies for examination with both light
bluish fluctuant mass of recent onset medication. The patients condition would microscopy and direct immunofluores-
involving the lower labial mucosa very not improve, and she might then be cence (DIF) would be requested or per-
likely represents a mucocele. By contrast, switched to antifungal medication(s). formed after the initial consultation.
mucocele would not be included in the After that approach has failed to resolve Histopathologic evidence of acantholysis
differential diagnosis of a painless persis- the problem, topical corticosteroids might and DIF findings of interepithelial
tent bluish mass of the attached gingiva be prescribed. Following several weeks of deposits of immunoglobulin G (IgG) and
as salivary gland tissue is not normally topical corticosteroid use with little or no complement component 3 (C3) would
present at that site. This latter clinical impact on the patients oral sores, the establish the final diagnosis of pemphigus
finding would, however, be completely diagnostician may recommend that a vulgaris in a relatively rapid and
568 Part 5: Maxillofacial Pathology
cost-effective manner. Besides the mone- surgery occasionally provide important A similar-appearing radiolucency below
tary savings, a more timely and correct diagnostic clues, such as the presence of the level of the inferior alveolar canal in the
diagnosis often saves the patient from cheesy keratotic debris within a cystic posterior mandible more likely represents
unnecessary suffering and mental lesion associated with an impacted tooth, a Stafne defect. Sharply defined margins
anguish, both by initiating effective treat- suggestive of an odontogenic keratocyst, indicate a benign process in most
ment earlier and by relieving the anxiety or the empty bone cavity seen with trau- instances, whereas poorly defined margins
that many patients experience when they matic bone cyst. Finally, follow-up evalua- can sometimes signify malignancy. Notable
do not know the nature of their disease. tion of a lesion is a straightforward proce- exceptions to this rule include osteo-
Early diagnosis and treatment of condi- dure that can provide important myelitis and fibrous dysplasia, both of
tions such as pemphigus vulgaris may also diagnostic insight with respect to biologic which typically have borders that blend
reduce disease progression or the need for behavior. Those conditions that persist or with the surrounding bone. Radiolucent
more aggressive therapy. progress 2 weeks after initial inspection lesions are produced by conditions that do
often require additional tests to establish not generate a calcified product.
Determining the Final Diagnosis: the diagnosis. Radiopaque and mixed lesions represent
Additional Diagnostic Methods conditions that can produce a mineralized
If the final diagnosis cannot be deter- Diagnostic Imaging product, such as bone, cementum, dentin,
mined based on historic findings and Depending on the clinical setting, imaging or enamel. It is generally safe to assume
physical examination alone, a variety of studies may be both appropriate and nec- that the vast majority of lesions associated
procedures and tests can be used to assist essary to the work-up of an oral lesion. with the crown of an impacted tooth are
in the diagnostic process. Generally, diag- Additional information on this topic is odontogenic in origin. If the teeth are
nostic tests should be ordered so that the available in an excellent radiology text erupted, however, determining whether a
most likely diagnosis can be either con- edited by White and Pharoah.3 Briefly, lesion is of odontogenic origin can be
firmed or eliminated. The methodic appli- imaging studies can include plain radi- problematic since there are few areas in the
cation of this process together with a ographic films, sialography, ultrasonogra- jaws in which a 2 cm lesion does not
proper rationale for selecting each test phy, computed tomography (CT), magnet- appear to be tooth-related. Symptoms such
typically leads to the correct diagnosis in ic resonance imaging (MRI), radionuclide as pain or paresthesia may suggest infec-
the most rapid cost-effective manner. Tests imaging, and positron emission tomogra- tion or malignancy, but benign conditions
that do not address the most likely diag- phy (PET). can occasionally present in this fashion.
nostic possibilities should be delayed as
the probability that they will provide use- Plain Films For evaluation of bone Sialography Sialography has almost
ful information is small, yet they can dra- lesions, plain films are the most commonly become a lost art. This technique relies on
matically increase costs to the patient. An employed imaging modality and, together retrograde injection of a radiopaque fluid,
exception to this statement would be a sit- with CT, are often the most useful. With also known as contrast medium, into the
uation in which a particular test is per- the increased use of panoramic radi- duct system of either the parotid or sub-
formed to rule out a rare or unusual con- ographs as a screening study in many cur- mandibular salivary gland. A plain radi-
dition of serious clinical significance. rent dental practices, it is not unusual for ograph is made, and the pattern of distri-
Finally, diagnostic tests should be inter- these films to detect a previously unidenti- bution of the contrast medium is assessed.
preted by individuals with specialty train- fied skeletal abnormality. Evaluation of Many of the previous indications for
ing in that area whenever possible to such a lesion includes an assessment of fea- sialography such as evaluation of salivary
ensure the most timely and accurate result tures such as localization (single, multifo- gland neoplasia have been supplanted by
or final diagnosis. cal, generalized), margins (well defined, newer imaging modalities such as MRI.
Diagnostic studies are not necessarily poorly defined), internal structure (radi- Nonetheless, sialography can be useful in
complex or expensive. For example, a olucent, radiopaque, mixed), effects on assessing chronic obstructive salivary
putative vascular lesion can be evaluated surrounding structures (teeth, inferior gland disease and gland function. The
easily by pressing it with a glass slide to test alveolar canal, cortical bone), and whether characteristic sialographic finding of
for possible blanching (diascopy). The there have been any associated symptoms. punctate sialectasis (blossoms on a
bruit of a vascular malformation may be For example, a single radiolucent lesion at branchless tree pattern) seen in patients
heard upon auscultation using a stetho- the apex of a nonvital tooth most likely affected by Sjgrens syndrome is helpful
scope. Operative findings at the time of represents a periapical cyst or granuloma. in supporting that diagnosis.
Differential Diagnosis of Oral Disease 569
Ultrasonography Ultrasonography is types of tissues or cells. Localization of the complementary DNA studies are per-
most useful in the evaluation of deeply isotope is determined by examining the formed. As with imaging, a variety of
seated masses and is often helpful in dis- patient with a gamma scintillation camera. techniques are available to the patholo-
tinguishing a solid mass from one that is The most commonly used isotope, tech- gist, and their selection varies on a case-
cystic. This technique relies on the fact netium 99m pertechnetate, can demon- by-case basis, depending on the diagnos-
that different tissue densities result in dif- strate areas of high metabolic activity. It is tic challenges posed by the individual
ferent degrees of reflection or echo pro- useful in identifying inflammatory condi- patient specimen.
duction of a beam of high-frequency tions such as osteomyelitis, areas of active
sound waves. Although ultrasonography skeletal lesions of fibrous dysplasia or Exfoliative Cytology Exfoliative cytol-
does not expose the patient to ionizing osteitis deformans, and metastatic disease. ogy is a relatively inexpensive noninva-
radiation, the tissue resolution is typically sive technique that may be used to pro-
less than that achieved with either CT or PET Scan PET scan is the most recently vide additional information related to
MRI technology. developed cross-sectional imaging tech- lesions of surface origin. The utility of
nology. This technique relies on the iden- this technique in the diagnosis of condi-
CT CT is a cross-sectional radiologic tification of metabolically active cells, such tions such as candidiasis, herpesvirus
imaging technique that is particularly use- as metastatic deposits of squamous cell (herpes simplex virus, human her-
ful in the evaluation of bone lesions. Not carcinoma, that exhibit preferential uptake pesviruses 1 and 2) infections, and pem-
only can the density and margins of the of radionuclide-labeled glucose. In con- phigus vulgaris is well documented.
lesion in question be evaluated with this junction with CT/MRI, preoperative PET More recently a modified form of
technique but cortical expansion and fine imaging of patients with head and neck cytologic sampling that employs an oral
internal details can often be more readily cancer has lead to increased sensitivity and brush instrument to collect epithelial cells
appreciated compared with plain film specificity for detection of oral cavity car- followed by automated histopathologic
images. Use of contrast media has extend- cinoma, esophageal carcinoma, and clini- evaluation has been introduced to den-
ed the utility of this technique in areas of cally occult metastatic disease in the tistry. Suggested advantages include
soft tissue pathology. Furthermore, more neck.48 PET scans have proved particular- improved sampling of all epithelial layers
recent designs such as spiral CT scanners ly useful in the post-treatment follow-up and increased sensitivity and specificity in
have made data acquisition much more by helping to distinguish altered anatomic the detection of precancerous and cancer-
rapid and have reduced radiation dose to landmarks or areas of fibrosis from recur- ous lesions versus results with routine
the patient while maintaining or improv- rent tumor as well as the detection of dis- exfoliative cytology. This new technique
ing resolution. tant metastases from head and neck pri- does not provide a definitive diagnosis,
maries.68 The technique is not however, and cannot be used as a substi-
MRI MRI is a newer form of cross- recommended for neoplasms that are rela- tute for scalpel biopsy and routine
sectional imaging that does not expose tively inactive metabolically (eg, low-grade histopathologic examination (see below).
patients to ionizing radiation. Although pri- mucoepidermoid carcinoma). In addition, Therefore, in a clinical setting where the
marily used in the evaluation of soft tissue the lower limit of tumor mass detection by index of suspicion for possible precancer-
lesions, it is also capable of providing diag- current technology is no better than that ous or cancerous change is high, such as
nostic information regarding bony lesions. of CT/MRI, and false-positives owing to the high-risk areas for oral cancer (ie, ven-
Two distinct views are typically generated: inflammatory changes are reported. trolateral tongue, floor of mouth, tonsillar
T1 and T2. Adipose tissue has the highest pillars, soft palate), or in a patient with sig-
signal in the T1-weighted image, and this Analysis of Lesional Tissue: nificant risk factors (ie, heavy smoking,
view is often used for identifying anatomic Histopathologic, Immunopatho- heavy alcohol use, or both), use of brush
structures. By comparison, the T2 image logic, and Molecular Evaluation cytology would not be recommended due
highlights tissues with high water content In a large number of cases, the final diag- to the inherent delay in definitive diagno-
and is especially useful in depicting inflam- nosis depends on the results of sis of the lesional tissue and any subse-
matory processes and neoplasms. histopathologic examination of lesional quent treatment. In cases in which a per-
tissue. In some situations the diagnosis is sistent mucosal lesion is identified but the
Radionuclide Imaging Radionuclide straightforward, whereas in others a index of suspicion is low, the brush cytol-
imaging relies on the specific uptake of definitive diagnosis cannot be made until ogy technique may be useful in excluding
any one of several isotopes by various sophisticated immunohistochemical or the presence of precancerous or malignant
570 Part 5: Maxillofacial Pathology
epithelial changes. For such innocuous pected malignant lesion unless the per- the clinical setting. Lacking this informa-
lesions, a finding of abnormal cells could forming clinician is involved in definitive tion, the pathologist may not be able to
trigger scalpel biopsy (and definitive diag- treatment. Otherwise, the surface mucosa provide a completely accurate or specific
nosis) before the surgical procedure might may be completely healed by the time the diagnosis. Pertinent details from the med-
otherwise have been deemed necessary. patient is referred to the oncologist, ical or dental history, the history of the
obscuring the extent of the original lesion lesion, the location and physical character-
Fine-Needle Aspiration Fine-needle aspi- and unnecessarily hindering definitive istics of the lesional tissue, and, when
ration (FNA) is a useful method for evalu- treatment planning. applicable, the radiographic features can
ating subcutaneous or more deeply situated Specimen orientation is recommended assist with the histopathologic analysis.
mass lesions, although obtaining a diagnos- whenever a clinician suspects that a neo- Clinical findings at the time of biopsy can
tic sample and interpreting the results accu- plastic process may have recurrent or also provide essential information. A good
rately requires specialized training. This malignant potential, including conditions example is the discovery of an empty cavi-
type of procedure is most widely used in such as epithelial dysplasia or pleomorphic ty during the exploration of a radiolucent
determining the nature of salivary gland or adenoma. This can be accomplished by lesion of bone. This situation often means
neck masses. Currently FNA is available in careful identification of the anatomic mar- that only minimal tissue can be submitted
most large urban areas throughout the gins of the biopsy specimen with suture(s), for review; however, the operative finding
United States, usually in conjunction with an accompanying sketch of the specimen, is virtually pathognomonic for traumatic
tertiary care medical centers. and its orientation to the surrounding tis- bone cyst. Quality close-up clinical pho-
sues or both. Such anatomic orientation of tographs including digital images can be
Incisional Biopsy Incisional biopsy is the tissue sample allows the pathologist to helpful, particularly for specialists who
generally indicated for large lesions properly subdivide and process the speci- have dental training such as oral and max-
(> 2 cm) and those that could represent men so that the adequacy of excision can illofacial pathologists. Biopsies of bony
unencapsulated or potentially malignant be assessed at all surgical margins. The pathology should be accompanied by radi-
neoplasms. By definition an incisional terms negative or clear margins are used ographs (originals or copies), whenever
biopsy is a diagnostic surgical procedure in when the surgical margins appear free possible, as correlation may be needed to
which a sample or portion of a lesion is from tumor involvement. When tumor is help distinguish conditions such as fibrous
removed for histopathologic review, leav- transected or lies immediately adjacent to dysplasia, ossifying fibroma, and focal
ing the remainder of the lesion at the biop- the surgical margin without evidence of a cemento-osseous dysplasia.
sy site. In cases of suspected malignancy, an capsule, proper specimen orientation per- A final piece of information that
incisional biopsy is usually the procedure mits the location of the positive margin(s) should always be submitted together with
of choice unless the clinician performing to be determined as precisely as possible. the biopsy specimen is the clinical diagno-
the biopsy will also be involved in defini- With this information the surgeon can sis. The clinical diagnosis is important at
tive treatment of the cancer (see below). then plan the most conservative surgical two levels. First, it helps the pathologist by
approach that will also accomplish the pri- providing an educated best guess as to
Excisional Biopsy Excisional biopsy is mary goal of therapy: complete removal of what the lesional tissue was thought to
typically used to manage clinically benign residual neoplastic tissue. most likely represent by the clinician.
lesions that are < 2 cm in diameter. An Should the initial histopathology of the
excisional biopsy is defined as a diagnostic Specimen Information Although obtain- submitted specimen appear substantially
surgical procedure in which all clinically ing an adequate biopsy specimen is an different from the clinical diagnosis, the
abnormal tissue is removed for microscop- important result of proper surgical tech- pathologist may request deeper sections,
ic analysis. Excision of a small but poten- nique, proper diagnostic technique rotation of the specimen, or special stud-
tially malignant lesion (eg, squamous cell requires that the surgeon also transmit ies to ensure that all aspects of the biopsy
carcinoma with a primary tumor [T], adequate clinical information to the material have been thoroughly examined.
regional nodes [N], and metastasis [M] pathologist through use of the specimen or Second, in cases where the final histo-
staging of T1N0M0) may be appropriate in biopsy data sheet. Inflammatory, reactive, pathologic diagnosis varies significantly
settings in which the surgeon performing and even neoplastic conditions can have from the working diagnosis, it is the clin-
the biopsy is also responsible for final treat- overlapping histopathologic features that ician who should proceed cautiously.
ment. With rare exceptions, an excisional are difficult (if not impossible) to distin- After discussing the case directly with the
biopsy should not be performed on a sus- guish without an adequate description of sign-out pathologist, the surgeon may be
Differential Diagnosis of Oral Disease 571
satisfied with the unexpected diagnosis The Microscopic Differential Diagnosis generally be used to perform most IHC
and plan accordingly. If not, the clinician On occasion a final diagnosis cannot be studies, an important exception involves
may request a second opinion on the orig- made after examining routine hema- tumors that require analysis by flow cytom-
inal biopsy material or choose to perform toxylin and eosinstained sections of a etry. Typically used to permit rapid and
a second biopsy procedure. In essence, the lesion. In such a situation, the pathologist highly specific subclassification of lym-
clinical diagnosis serves as a litmus test is faced with a microscopic or histopatho- phomas and leukemias, flow cytometry
for both the pathologist and surgeon, an logic differential diagnosis. For some cases, employs IHC probes, but the tissue sam-
important function that ultimately bene- special chemical stains may be useful in ples must not be fixed and should be ana-
fits the patient. the detection of suspected microorgan- lyzed immediately following collection.
For the oral and maxillofacial sur- isms or the identification of tissue prod- Another exception to this rule concerns the
geon, this type of discordance may be ucts such as mucin or amyloid. In other definitive diagnosis of immunobullous dis-
minimized if the tissue specimen is ini- cases, particularly spindle-cell malignan- orders such as cicatricial pemphigoid.
tially reviewed by an oral and maxillofa- cies and a group of undifferentiated neo- When such conditions are considered
cial pathologist. The oral and maxillofa- plasms termed small blue-cell tumors, the within the differential, perilesional tissue
cial pathologist receives highly final diagnosis can be even more challeng- should be obtained and submitted in a spe-
specialized training in the pathology of ing. Thankfully, even though these tumors cial holding medium known as Michels
the head and neck, including odonto- may appear undifferentiated at the light solution (Michels Media). A holding
genic cysts and tumors and salivary microscopic level, they often continue to medium is necessary because the molecu-
gland diseases. The typical general surgi- produce molecules that relate either to lar structure of the diagnostic antigens in
cal pathologist, by comparison, has a their cellular origin or to their newly these conditions (eg, immunoglobulins,
modest degree of experience with acquired form of differentiation. To more complement, and fibrinogen) is usually
respect to oral conditions and may be accurately classify such tumors, these mol- destroyed by formalin fixation. These spec-
unfamiliar with the unique microscopic ecular products of origin or differentiation imens are processed as frozen sections and
features of lesions from this area. To give are routinely assessed in the lesional cells are evaluated by DIF, a special form of IHC
some perspective, individuals trained in through the use of immunohistochemical that employs antibodies tagged with fluo-
oral and maxillofacial pathology pro- (IHC) studies. These techniques employ a rescent markers. When a special ultraviolet-
grams review tens of thousands of oral wide variety of monoclonal and polyclon- capable microscope is used, these markers
biopsy specimens prior to graduation. al antibodies that are directed against spe- reveal the presence and pattern of
By contrast, it is unusual for general sur- cific cellular or integrated viral antigens immunoreactants necessary to confirm or
gical (anatomic) pathology residents to (eg, those produced by the Epstein-Barr refute a potential autoimmune disease
examine more than a few hundred spec- virus) that are usually expressed even in process. Indirect immunofluorescence (IIF)
imens from the orofacial region during otherwise undifferentiated neoplasms. is used for conditions such as pemphigus
their training. Furthermore, the oral and The antibodies are linked to an enzyme vulgaris, in which elevated levels of circu-
maxillofacial pathologist has a com- that is capable of cleaving a selected chem- lating autoantibody are often seen. For
mand of the terminology used by the ical substrate. This activity produces a pig- indirect immunofluorescent studies,
dental profession to describe oral disease mented product (often brown; hence the patient serum is incubated with a segment
and can more readily correlate the clini- term brown stains) that is deposited in of control substrate (typically monkey
cal and radiographic features with the the tissues wherever the target antigens are esophagus). The serum is removed and the
microscopic findings. Just as a general expressed. The diagnosis of a particular substrate is then incubated with antibody
surgeon may be able to remove a set of tumor often requires the analysis of a probes similar to those used in DIF studies.
impacted third molars, the general number of antigens to fully explore the As with DIF, ultraviolet microscopy is used
pathologist may be able to provide an histopathologic differential. In cases of to examine the substrate for evidence of
adequate diagnosis for an oral biopsy. In malignant lymphoma, for example, it is serum-derived antibody binding to epithe-
most situations, however, the profes- not uncommon for a panel of 10 or more lial or basement membrane components.
sionals who are trained specifically to probes to be used to characterize the In a few instances even the more
manage problems related to the oral and neoplastic process and permit a therapy sophisticated immunohistochemical tech-
maxillofacial region are able to accom- that is optimized for that particular tumor. niques cannot provide a definitive diagno-
plish their respective tasks more effi- Although routine formalin-fixed sis. In those situations newly developed
ciently and accurately. paraffin-embedded tissue sections can molecular techniques are being used with
572 Part 5: Maxillofacial Pathology
greater frequency. These techniques the differential considerations is warrant- both. Whenever available, referral to an
include sophisticated cytogenetic studies ed such as biopsy and histopathologic oral and maxillofacial pathologist may be
such as fluorescence in situ hybridization review. Finally, careful follow-up should helpful in this regard. If the patient and
(FISH) as well as molecular probes that be considered mandatory for patients who clinician decide to defer biopsy, this deci-
use complementary deoxyribonucleic acid have been previously diagnosed with or sion should be documented and re-evalua-
(cDNA) to identify disease-specific DNA treated for oral dysplasia or carcinoma. tion of the area should be scheduled at 1, 3,
sequences in human tissue samples. Exam- Although an important part of the 6, and 12 months following the initial
ples include restriction fragment length practice of dentistry and medicine, formal examination. During the follow-up period,
polymorphism analysis with Southern guidelines for the management of oral diagnostic options include the brush cytol-
blot or antigen receptor gene rearrange- lesions that are not clearly premalignant or ogy technique (to identify evidence of
ment analysis by polymerase chain reac- cancerous have only recently been suggest- atypical epithelial cells in surface lesions)
tion for the determination of clonality in ed.9 Such guidelines are helpful to clinicians or incisional biopsy (to establish a firm
B- or T-cell proliferations. as they provide systematic protocols for the diagnosis). The need for these options
management of oral pathologic conditions varies depending on the concerns of the
Patient Follow-Up and serve to reduce the medicolegal risk patient or the experience and expertise of
One of the most important aspects in the associated with this important aspect of the clinician. At any time point, however,
diagnosis and management of a given oral patient care (Table 29-1). evidence of significant lesional change
lesion or condition is the follow-up evalu- After the initial evaluation and careful should immediately trigger a recommen-
ation. This appointment permits the clini- documentation of an oral lesion, a follow- dation of biopsy. After a year most
cian to assess the abnormality for physical up examination should be scheduled for 7 unchanged lesions can be monitored at
or symptomatic changes, gain insight into to 14 days later, with or without any treat- routine semiannual or annual dental visits.
the kinetics of growth or rate of resolu- ment. If there is evidence of lesion enlarge- Finally, it should be recognized that
tion, and assess the impact of initial con- ment or other physical or symptomatic these recommendations, although
servative treatment measures or recom- changes that do not suggest normal healing sound, do not represent rigid guidelines
mendations to the patient. These or resolution, then biopsy is indicated. If or medicolegal standards of care that
additional pieces of information may sup- the lesion remains relatively unchanged cover every clinical scenario. Each
port the working diagnosis, and no further and the index of suspicion for malignancy patient and abnormality deserves indi-
work-up may be required (see Figure 29- is low, the clinician should help the patient vidual attention and management that
1). Alternatively, the follow-up findings decide the next course of action based may vary from the protocol above, based
may indicate that further investigation of upon experience, advanced training, or upon training, experience, and the clini-
cal judgement of the practitioner.
5. Kato H, Kuwano H, Nakajima M, et al. Com- ods and modalities. Clin Positron Imaging gional advanced squamous cell carcinoma
parison between positron emission tomog- 2000;3:716. of the head and neck. Laryngoscope
raphy and computed tomography in the 7. McGuirt WF, Greven K, Williams D III, et al. 2003;113:88991.
use of the assessment of esophageal carci- PET scanning in head and neck oncology: a 9. Alexander RE, Wright JM, Thiebaud S. Evalu-
noma. Cancer 2002;94:9218. review. Head Neck 1998;20:20815. ating, documenting and following up oral
6. Hubner KF, Thie JA, Smith GT, et al. Clinical 8. Schmid DT, Stoeckli SJ, Bandhauer F, et al. pathological conditions: a suggested proto-
utility of FDG-PET in detecting head and Impact of positron emission tomography col. J Am Dent Assoc 2001;132:32935.
tumors: a comparison of diagnostic meth- on the initial staging and therapy in locore-
CHAPTER 30
Odontogenic cysts and tumors are rela- evolves into a bell shape. After forming the
tively uncommon lesions of the oral and enamel organ, the cord of dental lamina
maxillofacial region that must be consid- normally fragments and degenerates;
ered whenever examining and formulating however, small islands of the dental lami-
a differential diagnosis of an expansile na may remain after tooth formation and
process of the jaws. The clinical presenta- are believed to be responsible for the
tion, radiographic appearance, and natur- development of several of the odontogenic
al history of these lesions varies consider- cysts and tumors.
ably, such that odontogenic cysts and The enamel organ has four types of
tumors represent a diverse group of epithelium. The innermost lining is
lesions of the jaws and overlying soft tis- referred to as the inner enamel epithelium
sues. Collectively speaking, their occur- and becomes the ameloblastic layer that
rence is frequent enough to warrant a forms tooth enamel. The second layer of
thorough discussion. As a whole, these cells adjacent to the inner enamel epitheli-
pathologic entities have been studied and um is the stratum intermedium. Adjacent
reported on extensively. to this layer is the stellate reticulum, fol-
Purely defined, odontogenic refers to lowed by the outer enamel epithelium. Sur-
derivation from a tooth-related apparatus. rounding the enamel organ is loose con-
Tooth formation is a complex process that nective tissue known as the dental papilla.
involves both connective tissues and Contact with the enamel organ epithelium
epithelium. Three major tissues are induces the dental papilla to make odonto-
FIGURE 30-1 The enamel organ is seen emanat-
involved in odontogenesis including the blasts that form dentin. As the odonto-
ing from the dental lamina (hematoxylin and
enamel organ, the dental follicle, and the blasts deposit dentin, they induce the eosin; original magnification 20) Reproduced
dental papilla. The enamel organ is an ameloblasts to begin forming enamel. with permission from Cawson RA, Eveson JW,
epithelial structure that is derived from Following the initial formation of the editors. Oral pathology and diagnosis. Color
atlas with integrated text. Philadelphia (PA):
oral ectoderm. The dental follicle and den- crown, a thin layer of the enamel organ
W.B. Saunders; 1987.
tal papilla are considered ectomesenchy- epithelium known as Hertwigs root
mal in nature because they are in part sheath proliferates apically to provide the
derived from neural crest cells. stimulus for odontoblastic differentiation believed to be the source of epithelium for
For each tooth, odontogenesis begins in the root portion of the developing most periapical cysts but generally are not
with the apical proliferation from the oral tooth. This epithelial extension later believed to give rise to any of the odonto-
mucosa of epithelium known as the dental becomes fragmented but leaves behind genic neoplasms, with the possible excep-
lamina (Figure 30-1). The dental lamina, small nests of epithelial cells known as tion of the squamous odontogenic tumor.
in turn, gives rise to the enamel organ, a rests of Malassez in the periodontal liga- In the development of a tooth, follow-
cap-shaped structure that subsequently ment space. The rests of Malassez are ing completion of enamel formation, the
576 Part 5: Maxillofacial Pathology
enamel organ epithelium atrophies to phase, may be carried into the S phase and from the inclusion of epithelium along
form a thin flattened layer of cells that cov- perpetuated in subsequent cell divisions. embryonic lines of fusion, most jaw cysts
ers the enamel of the unerupted tooth. The G1-S checkpoint is normally regulated are lined by epithelium that is derived
This layer of epithelium is known as the by a well-coordinated and complex system from odontogenic epithelium, hence the
reduced enamel epithelium. In the normal of protein interactions whose balance and term odontogenic cysts. These cysts are sub-
sequence of events, this reduced enamel function are critical to normal cell divi- classified as developmental or inflamma-
epithelium later merges with the surface sion.1 As can be seen in Figure 30-2, once tory in nature. Although the cell type is
epithelium and forms the initial gingival genetic change occurs that encourages the often known, developmental cysts are of
crevicular epithelium of the newly erupted development of an odontogenic cyst or unknown origin; however, they do not
tooth. However, if fluid accumulates tumor, a series of events mediated by the seem to be the result of an inflammatory
between the reduced enamel epithelium odontogenic lesion occur that may pro- reaction. Inflammatory cysts, on the other
and the crown of the tooth before tooth mote proliferation. Such events support hand, are the result of inflammation
eruption, a cyst is formed that is known as the pathogenetic mechanism involved in (Table 30-1).
a dentigerous or follicular cyst. the progression of the cyst or tumor.
An understanding of the progression It is the purpose of this chapter to Dentigerous Cyst
of odontogenic cysts and tumors within review the clinically significant and more By definition, a dentigerous cyst occurs in
the oral and maxillofacial region requires a commonly encountered odontogenic cysts association with an unerupted tooth, most
thorough knowledge of the cell cycle of and tumors. In so doing, salient clinical commonly mandibular third molars.
these lesions and an appreciation of the and radiographic features are discussed, as Other common associations are with max-
concept of proliferation versus apoptosis are the pathogenetic mechanisms support- illary third molars, maxillary canines, and
(programmed cell death). Most of the ing proliferation of some of the more mandibular second premolars.2 They may
pathogenetic mechanisms of odontogenic aggressive odontogenic cysts and tumors. also occur around supernumerary teeth
cysts and tumors can be explained via the Recommendations for treatment and and in association with odontomas; how-
cell cycle (Figure 30-2). Normally cell divi- prognostic information are also offered. ever, they are only rarely associated with
sion is divided into four phases: G1 (gap primary teeth.2,3 Although dentigerous
1), S (deoxyribonucleic acid synthesis), G2 Odontogenic Cysts cysts occur over a wide age range, they are
(gap 2), and M (mitosis). A key event is the With rare exceptions, epithelium-lined most commonly seen in 10- to 30-year-
progression from G1 to the S phase. Genet- cysts in bone are seen only in the jaws.2 olds. There is a slight male predilection,
ic alterations, if unrepaired in the G1 Other than a few cysts that may result and their prevalence appears to be higher
in Whites than in Blacks. Many dentiger-
G0 ous cysts are small asymptomatic lesions
BCL2, BCLXL, that are discovered serendipitously on
others routine radiographs, although some may
BAX, P53
grow to considerable size causing bony
Apoptosis Inhibitor proteins expansion that is usually painless until sec-
M (p16, p21, p27)
ondary infection occurs.
G1 BAK, BCLXS, Radiographically, the dentigerous cyst
others presents as a well-defined unilocular radi-
olucency, often with a sclerotic border
Cell cycle pRb
(PCNA, Ki-67) E2F Proliferation (Figure 30-3). Since the epithelial lining is
(cyclins + kinases) derived from the reduced enamel epitheli-
um, this radiolucency typically and prefer-
G2
entially surrounds the crown of the tooth.
A large dentigerous cyst may give the
Growth/mitogenic
S factors
impression of a multilocular process
because of the persistence of bone trabec-
ulae within the radiolucency. However,
FIGURE 30-2 The cell cyclea concept of proliferation versus apoptosis. PCNA = proliferating cell dentigerous cysts are grossly and
nuclear antigen. histopathologically unilocular processes
Odontogenic Cysts and Tumors 577
A B C
FIGURE 30-6 A, This large biopsy-proven dentigerous cyst occurred in an elderly patient who had coronary artery disease. Owing to the size of the cyst and the
compromised cardiac status of the patient, a relatively noninvasive marsupialization was performed. B, An acrylic plug with a wire handle was placed in a small
surgical entrance into the cyst cavity. The cyst shrunk considerably, after which time the etiologic impacted tooth was removed with a small remnant of dentiger-
ous cyst. C, The 5-year postmarsupialization radiograph shows an excellent fill of bone.
Odontogenic Cysts and Tumors 579
be removed in one piece, which requires results of resection over all other thera-
acceptable access and lighting (Figure 30- peutic undertakings.20
9). As such, many patients are suitably The reported frequency of recurrence
treated in an operating room setting under of the odontogenic keratocyst ranges from
general anesthesia. This is particularly 2.5% to 62.5% in various studies.11 This
helpful when removing large cysts. It is my wide variation may be related to the total
experience and that of others that a large number of cases studied, the length of fol-
majority of sporadic odontogenic kerato- low-up periods, and the inclusion or
cysts may be effectively managed with a exclusion of orthokeratinized cysts in the
thorough enucleation and curettage study group. Several reports that include
surgery.18,19 MacIntosh has advocated the large numbers of cases indicate a recur-
resection of odontogenic keratocysts with rence rate of approximately 30%.2 Regezi
FIGURE 30-7 This multilocular radiolucency, pre- 5 mm linear margins as the preferred pri- and colleagues point out that the recur-
sent in a 54-year-old man, should suggest an
mary method of treatment, and has rence rate for solitary odontogenic kerato-
odontogenic keratocyst when formulating a differ-
ential diagnosis. reported on 37 patients with 43 lesions cysts is 10 to 30%.21 They indicate that
emphasizing the efficacy and superior approximately 5% of patients with odon-
togenic keratocysts have multiple sporadic
appear unilocular and can therefore be con- Table 30-2 Clinical Features of the jaw cysts (nonsyndromic) and that their
fused with dentigerous cysts. It is clear, Basal Cell Nevus Syndrome recurrence rate is greater than that for soli-
therefore, that the differential diagnosis of a tary lesions.21 Brannon has suggested three
50% frequency
unilocular radiolucency must include both mechanisms responsible for recurrence:
Multiple basal cell carcinomas
entities and that treatment should include (1) remnants of dental lamina within the
Odontogenic keratocysts
curettage in the event that the diagnosis is Epidermal cysts of the skin jaws not associated with the original
odontogenic keratocyst. When multiple Palmar/plantar pits odontogenic keratocyst being responsible
multilocular radiolucencies are noted on a Calcified falx cerebri for de novo cyst formation; (2) incomplete
panoramic radiograph, the clinician must Enlarged head circumference removal (persistence) of the original cyst
perform an incisional biopsy and investi- Rib anomalies (splayed, fused, partially secondary to a thin friable lining and cor-
gate the possibility of nevoid basal cell car- missing, bifid) tical perforation with adherence to adja-
cinoma syndrome (Table 30-2). Mild ocular hypertelorism cent soft tissue; and (3) remaining rests of
Histologically, the odontogenic kera- Spina bifida occulta of cervical or dental lamina and satellite cysts following
tocyst is readily recognized. A uniform thoracic vertebrae enucleation.22 Vedtofte and Praetorius
layer of stratified squamous epithelium, 1549% frequency reviewed 72 patients with 75 odontogenic
usually six to eight cells in thickness, is Calcified ovarian fibromas keratocysts and observed remnants of
present (Figure 30-8). The parakeratotic Short fourth metacarpals dental lamina between the cyst membrane
surface is characteristically corrugated. Kyphoscoliosis or other vertebral
The wall is usually thin and friable, which anomalies
can pose problems for removal in one Pectus excavatum or carinatum
piece intraoperatively. Epithelial budding Strabismus (exotropia)
and the presence of daughter cysts may be < 15% frequency (but not random)
noted in the connective tissue wall. It is Medulloblastoma
generally advisable to ask the pathologist Meningioma
to examine the sections carefully for these Lymphomesenteric cysts
two features as they generally impart a Cardiac fibroma
more aggressive character to the cyst. Fetal rhabdomyoma
Marfanoid build
Cleft lip and/or palate
Treatment and Prognosis Like the treat-
Hypogonadism in males FIGURE 30-8 The classic histologic appearance
ment of most odontogenic cysts, the
Mental retardation of an odontogenic keratocyst from the incisional
odontogenic keratocyst may be treated biopsy of the lesion in Figure 30-7 (hematoxylin
Adapted from Gorlin FJ.14
with enucleation and curettage and must and eosin; original magnification 40).
580 Part 5: Maxillofacial Pathology
most significant clinical feature is the ten- cell carcinoma syndrome can be difficult of aggressive behavior and recurrence.
dency to develop multiple basal cell carci- owing to the large number of recur- Although it is generally accepted as being
nomas that may affect both exposed and rences in these patients. As a matter of of odontogenic origin, it shows glandular
nonsun-exposed areas of the skin. Pitting point, I choose to refer to these as new or salivary features that seem to point to
defects on the palms and soles can be primary cysts owing to the autosomal- the pluripotentiality of odontogenic
found in nearly two-thirds of affected dominant penetrance of the syndrome epithelium as cuboidal/columnar cells,
patients (Figure 30-11). The discovery of and cyst development. It is certainly pos- mucin production, and cilia are noted in
multiple odontogenic keratocysts is usual- sible that many of these cysts are persis- these cysts. Glandular odontogenic cysts
ly the first manifestation of the syndrome tent, particularly when considering how occur most commonly in middle-aged
that leads to the diagnosis. For this reason, common it can be to retain rests of the adults, with a mean age of 49 years at the
any patient with an odontogenic kerato- dental lamina when enucleating an odon- time of diagnosis.2 Eighty percent of
cyst should be evaluated for this condi- togenic keratocyst. Whatever the mecha- cases occur in the mandible,21 and a
tion. Although the cysts in patients with nism, a resection hardly seems to be war- strong predilection for the anterior
nevoid basal cell carcinoma syndrome ranted. Marsupialization is a more region of the jaws has been reported,
cannot definitely be distinguished micro- desirable procedure (Figure 30-12) and with many mandibular lesions crossing
scopically from those not associated with has been shown to result in complete res- the midline (Figure 30-13). These cysts
the syndrome, they often demonstrate olution of the sporadic cyst, with no his- may appear either unilocular or multi-
more epithelial proliferation and daughter tologic signs of cystic remnants, daughter locular radiographically.
cyst formation in the cyst wall. cysts, or budding of the basal layer of the There is a histologic similarity between
The treatment of the odontogenic epithelium.27 Although all of the eight the glandular odontogenic cyst and the pre-
keratocyst in patients with nevoid basal cases in the series by Pogrel and Jordan dominantly cystic intraosseous mucoepi-
were sporadic cysts,27 a similar approach dermoid carcinoma. However, the epithelial
to syndrome patients with odontogenic lining of the glandular odontogenic cyst is
keratocysts that had been operated on typically thinner and does not show evi-
multiple times has been performed with dence of the more solid or microcystic
success in a small sample size.18 epithelial proliferations seen in mucoepi-
dermoid carcinoma (Figure 30-14). Wal-
Glandular Odontogenic Cyst dron and Koh reviewed the similarities
The glandular odontogenic cyst (sialo- between the two lesions and concluded that
odontogenic cyst) is a rare and recently it is entirely possible that some cases previ-
described cyst of the jaws that is capable ously diagnosed as central mucoepidermoid
A B
A B C
been recommended, ranging from simple decades before this persistent disease ated with neoplastic transformation of
enucleation and curettage to resection.5359 becomes clinically and radiographically evi- ameloblastomatous epithelium.65 These
The solid or multicystic ameloblastoma dent, and long after a surgeon falsely pro- histologic changes were (1) hyperchroma-
tends to infiltrate between intact cancellous claimed the patient to be cured. tism of basal cell nuclei of the epithelium
bone trabeculae at the periphery of the Owing to the highly infiltrative and lining the cystic cavities, (2) palisading and
tumor before bone resorption becomes aggressive nature of the solid or multicystic polarization of basal cell nuclei of the
radiographically evident. Therefore, the ameloblastoma, I recommend resection of epithelium lining the cystic cavities, and (3)
actual margin of the tumor often extends the tumor with 1.0 cm linear bony margins cytoplasmic vacuolization, particularly of
beyond its apparent radiographic or clinical (Figure 30-20). This linear bony margin basal cells of cystic linings. They referred to
margin.60 Attempts to remove the tumor by should be confirmed by intraoperative these changes as early histopathologic fea-
curettage, therefore, predictably leave specimen radiographs. Soft tissue margins tures of neoplasia. Unicystic ameloblastoma
behind small islands of tumor within the are best managed according to the anatom- refers to a pattern of epithelial proliferation
bone, which are later determined to be ic barrier margin principles whereby one that has been described in dentigerous cysts
recurrent disease. These must be realized as uninvolved surrounding anatomic barrier of the jaws that does not exhibit the histo-
persistent disease as the tumor was never is sacrificed on the periphery of the speci- logic criteria for ameloblastoma published
controlled from the outset. When a small men.61 When all soft and hard tissue mar- by Vickers and Gorlin.6669 This entity
burden of tumor is left behind, it may be gins are histologically negative, the patient deserves separate consideration based on its
is likely to be cured of this neoplasm. clinical, radiographic, and pathologic fea-
Unfortunately, any less aggressive treatment tures. Moreover, in many cases it may be
modality may be fraught with inevitable treated more conservatively than the solid
persistence discovered at variable times or multicystic ameloblastoma with the
postoperatively.62 Moreover, although the same degree of cure.70
persistent and occasionally nonresectable Unicystic ameloblastomas are most
ameloblastoma is radiosensitive, once this commonly seen in young patients, with
otherwise benign tumor defies curative sur- about 50% of these tumors being diag-
gical therapy, radiation is of questionable nosed during the second decade of life.
use in salvaging these patients.63,64 The average age of patients with unicystic
ameloblastomas has been reported as
FIGURE 30-19 The incisional biopsy of the
patient in Figure 30-17 shows follicular variant
Unicystic Ameloblastoma In 1970 Vick- 22.1 years, compared with 40.2 years for
of the solid/multicystic ameloblastoma (hema- ers and Gorlin published their findings the solid or multicystic variant.42 More
toxylin and eosin; original magnification 60). regarding the histologic alterations associ- than 90% of these tumors are found in the
586 Part 5: Maxillofacial Pathology
ameloblastoma is probably more aggres- (see Figure 30-24) with significant expan-
sive than the luminal and intraluminal sion such that an enucleation and curet-
variants of the unicystic ameloblastoma tage surgery would effectively result in a
owing to the presence of tumor in the cyst resection of the involved jaw.
wall and therefore closer to the surround-
ing bone. It seems logical to approach Peripheral Ameloblastoma The periph-
these tumors with a surgery similar to that eral or extraosseous ameloblastoma is the
for the solid or multicystic ameloblastoma most rare variant of the ameloblastoma.
(Figure 30-24). The final indication for This tumor probably arises from rests of
resection of a unicystic ameloblastoma is dental lamina or the basal epithelial cells
in the management of very large tumors of the surface epithelium and shows the
ameloblastoma that has cytologic features body region. The 5-year survival rate is Malignant Epithelial Odontogenic
of malignancy in the primary tumor (Fig- 30 to 40%.74 Squamous cell carcinomas Ghost Cell Tumor The epithelial odon-
ure 30-28), in a recurrence, or in any may also arise from the linings of odon- togenic ghost cell tumor, also known as
metastatic deposit. Although ameloblas- togenic cysts. Cystogenic carcinomas are dentinogenic ghost cell tumor, is the
tic carcinomas have been reported to seen in patients > 50 years of age and solid variant of the calcifying odonto-
metastasize to the lungs and distant typically occur in the mandible. Finally, genic cyst. Both epithelial and ectomes-
organs,79,80 many cases do not metasta- dentigerous cysts can undergo glandular enchymal odontogenic elements are pre-
size. In Corio and colleagues series of metaplasia, and there are rare instances sent; however, only the epithelial
eight cases of ameloblastic carcinoma, of central mucoepidermoid carcinomas component shows cytologic features of
rapid growth and pain were common reported to arise from odontogenic malignancy.
symptoms.81 These symptoms are recog- cyst lining.
nized as being uncommon in patients Ameloblastic Fibroma
with benign ameloblastomas. Clear Cell Odontogenic Carcinoma The ameloblastic fibroma is considered to
Although the clear cell odontogenic carci- be a true tumor in which the epithelial
Primary Intraosseous Squamous Cell noma is of putative odontogenic origin, and mesenchymal tissues are both neo-
Carcinoma Squamous cell carcinomas histologic similarities to the developing plastic. This is in distinction to the
that are encountered in the jaws, lack any tooth germ are lacking in many ameloblastic fibro-odontoma and odon-
continuity with the oral or antral instances.74 The differential diagnosis toma that represent developmental stages
mucosa, and occur in the absence of a includes metastasis from a distant site, of the same hamartomatous lesion.82,83
primary carcinoma located elsewhere are especially the kidney. The clear cell variant The ameloblastic fibroma tends to occur
termed primary intraosseous squamous of renal cell carcinoma is the chief entity in young patients in the first two decades
cell carcinomas. These cases are assumed to consider. The clear cell odontogenic of life. The posterior mandible is affected
to arise from odontogenic epithelium. carcinoma is generally seen in elderly in 70% of cases (Figure 30-29). Radi-
They typically occur in elderly patients women, with the maxilla and mandible ographically, either a unilocular or multi-
and tend to occur in the mandibular being affected equally. locular lesion is observed.
A B C
D E
590 Part 5: Maxillofacial Pathology
30-30). Although recurrence is rare under with an enucleation and curettage surgery
the circumstances, resection should be (Figure 30-32). Recurrence after this
reserved for recurrent lesions. Approxi- approach is very rare. Malignant transfor-
mately 45% of ameloblastic fibrosarcomas mation of ameloblastic fibro-odontoma
develop in the setting of a recurrent has been reported but is exceedingly rare.84
ameloblastic fibroma.2
Odontoma
Ameloblastic Fibro-odontoma Odontomas are the most frequently
The ameloblastic fibro-odontoma, as previ- occurring odontogenic tumors, with
ously discussed, probably represents a prevalence exceeding that of all other
hamartoma. Moreover, some investigators odontogenic tumors combined. As stated
A
believe that this lesion is only a stage in the
development of an odontoma and does not
represent a separate entity. Slootweg points
out that when one considers the data on age,
site, and sex, it seems that the ameloblastic
fibro-odontoma is an immature complex
odontoma.82 As with ameloblastic fibromas,
the ameloblastic fibro-odontoma occurs
more frequently in the posterior regions of
the jaws. This lesion is commonly asympto-
matic and is discovered serendipitously or
B when radiographs are exposed to provide a A
diagnosis for asymmetric eruption of the
FIGURE 30-29 A, A destructive unilocular dentition in children (Figure 30-31). These
radiolucency is present in a 15-year-old boy. B,
lesions are distinctly well circumscribed
Incisional biopsy confirmed ameloblastic
fibroma (hematoxylin and eosin; original and appear as mixed radiopaque/radiolu-
magnification 40). cent masses.
Treatment and Prognosis The ameloblas- Treatment and Prognosis The ameloblas-
tic fibroma is recognized as an indolent tic fibro-odontoma is treated effectively
tumor that is effectively treated by an enu-
cleation and curettage surgery (Figure B
30-37). These tumors are not encapsulated genic tumor among a collective series of
and tend to infiltrate the surrounding bone 1,440 odontogenic tumors. Fewer than
such that complete removal by curettage is 200 cases have been reported in the inter-
nearly impossible. Resection of the tumor national literature. Although this tumor
with a normal surrounding margin of has been reported over a wide age range,
bone and soft tissue that shows negative it is most often encountered in patients
margins should be curative. between 30 and 50 years of age. 86
Approximately two-thirds of these neo-
Calcifying Epithelial plasms occur in the mandible.87 A pain-
Odontogenic Tumor less slow-growing mass is the most com-
The calcifying epithelial odontogenic mon presenting sign. Radiographically,
tumor, also known as the Pindborg the most common presentation is a A
tumor, is an uncommon lesion that mixed radiopaque/radiolucent lesion,
accounts for < 1% of all odontogenic frequently associated with an impacted
tumors. It is particularly noteworthy that tooth (Figure 30-38).
the three studies depicted in Table 30-4 Histologically, the Pindborg tumor is
reported only 15 cases of this odonto- quite unique. Discrete islands, strands, or
sheets of polyhedral epithelial cells in a
fibrous stroma are noted. Large areas of
amorphous eosinophilic hyalinized
(amyloid-like) material are also present.
Calcifications, which are a distinctive fea-
ture of the tumor, develop within the amy-
loid-like material and form concentric
rings, known as Liesegang rings (Figure B
30-39). The precise nature of the amyloid-
like material is unknown. The material
does stain as amyloid when stained with
Congo red or thioflavine T. After Congo
red staining, the amyloid exhibits apple-
A green birefringence when viewed with
polarized light. It has been illustrated that
the amyloid-like material may actually
represent amelogenins or other enamel
proteins secreted by the tumor cells.88
6. Johnson LM, Sapp JP, McIntire DN. Squamous pathologic correlations. St. Louis: WB
cell carcinoma arising in a dentigerous cyst. Saunders; 2003. p. 24165.
J Oral Maxillofac Surg 1994;52:98790. 22. Brannon RB. The odontogenic keratocyst: a
7. Eversole LR, Sabes WR, Rovin S. Aggressive clinicopathologic study of 312 cases. Part II:
growth and neoplastic potential of odonto- histologic features. Oral Surg Oral Med
genic cysts. With special reference to central Oral Pathol 1977;43: 23355.
epidermoid and mucoepidermoid carcino- 23. Vedtofte P, Praetorius F. Recurrence of the
mas. Cancer 1975; 35:27082. odontogenic keratocyst in relation to clini-
8. Leider AS, Eversole LR, Barkin ME. Cystic cal and histologic features. A 20 year follow-
ameloblastoma. Oral Surg Oral Med Oral up study of 72 patients. Int J Oral Surg
Pathol 1985; 60:62430. 1979;8:41220.
9. Donoff RB, Harper E, Guralnick WC. Col- 24. Li TJ, Browne RM, Matthews JB. Immunocyto-
A lagenolytic activity in keratocysts. J Oral chemical expression of parathyroid hor-
Surg 1972;30:87984. mone related protein (PTHrP) in odonto-
10. Ahlfors E, Larsson A, Sjogren S. The odonto- genic jaw cysts. Br J Oral Maxillofac Surg
genic keratocyst: a benign cystic tumor? J 1997;35:2759.
Oral Maxillofac Surg 1984;42:109. 25. Slootweg PJ. p53 protein and Ki-67 reactivity
11. Williams TP, Connor FA. Surgical management in epithelial odontogenic lesions. An
of the odontogenic keratocyst. Aggressive immunohistochemical study. J Oral Pathol
approach. J Oral Maxillofac Surg 1994; Med 1995;24:3937.
52:9646. 26. Piattelli A, Fioroni M, Santinelli A, Rubini C.
12. Mustaciuolo VW, Brahney CP, Aria AA. Recur- Expression of proliferating cell nuclear
rent keratocysts in basal cell nevus syn- antigen in ameloblastomas and odonto-
drome: review of the literature and report of genic cysts. Oral Oncol 1998; 34:40812.
a case. J Oral Maxillofac Surg 1989;47:8703. 27. Pogrel MA, Jordan RCK. Marsupialization as a
13. Pritchard LJ, Delfino JJ, Ivey DM, et al. Variable definitive treatment for odontogenic kera-
expressivity of the multiple nevoid basal tocysts. American Association of Oral and
B
cell carcinoma syndrome. J Oral Maxillofac Maxillofacial Surgeons Scientific Sessions;
FIGURE 30-43 A, An enucleation and curettage Surg 1982;40:2619. 2002 Oct 4; Chicago: American Association
surgery is performed for the patient in Figure 14. Gorlin FJ. Nevoid basal cell carcinoma syn- of Oral and Maxillofacial Surgeons; 2002.
30-41, along with removal of the involved teeth. drome. Medicine 1987;66:98113. 28. Waldron CA, Koh ML. Central mucoepidermoid
Erosion of the cementum of the premolar tooth is 15. Meara JG, Li KK, Shah SS, Cunningham MJ. carcinoma of the jaws: report of four cases
noted. B, The 5-year postoperative radiograph Odontgogenic keratocysts in the pediatric with analysis of the literature and discussion
shows acceptable bony healing. population. Arch Otolaryngol Head Neck of the relationship to mucoepidermoid,
Surg 1996;122:7258. sialodontogenic and glandular odontogenic
16. Brannon RB. The odontogenic keratocyst: a cysts. J Oral Maxillofac Surg 1990;48:8717.
References clinicopathologic study of 312 cases. Part I: 29. Hussain K, Edmondson HB, Browne RM.
1. Regezi JA, Sciubba JJ, Jordan RCK. Ulcerative clinical features. Oral Surg Oral Med Oral Glandular odontogenic cysts. Diagnosis
conditions. In: Regezi JA, Sciubba JJ, Jordan Pathol 1976 ;42:5472. and treatment. Oral Surg Oral Med Oral
RCK, editors. Oral pathology. Clinical 17. Woolgar JA, Rippin JW, Browne RM. The Pathol 1995;79:593602.
pathologic correlations. St. Louis: WB odontogenic keratocyst and its occurrence 30. Hong SP, Ellis GL, Hartman KS. Calcifying
Saunders; 2003. p. 2374. in the nevoid basal cell carcinoma syn- odontogenic cyst. A review of ninety-two
2. Neville BW, Damm DD, Allen CM, Bouquot drome. Oral Surg Oral Med Oral Pathol cases with reevaluation of their nature as
JE. Odontogenic cysts and tumors. In: 1987;64:72730. cysts or neoplasms, the nature of ghost
Neville BW, Damm DD, Allen CM, 18. Eyre J, Zakrzewska JM. The conservative man- cells, and subclassification. Oral Surg Oral
Bouquot JE, editors. Oral and maxillofacial agement of large odontogenic keratocysts. Med Oral Pathol 1991;72:5664.
pathology. Philadelphia: WB Saunders; Br J Oral Maxillofac Surg 1985;23:195203. 31. Buchner A. The central (intraosseous) calcify-
2002. p. 589642. 19. Meiselman F. Surgical management of the odon- ing odontogenic cyst: an analysis of 215
3. Kusukawa J, Irie K, Morimatsu M, et al. togenic keratocyst: conservative approach. J cases. J Oral Maxillofac Surg 1991;49:3309.
Dentigerous cyst associated with a decidu- Oral Maxillofac Surg 1994;52:9603. 32. Kramer IRH, Pindborg JJ, Shear M. The WHO
ous tooth. A case report. Oral Surg Oral 20. MacIntosh RB. The role of osseous resection in histological typing of odontogenic
Med Oral Pathol 1992;73:4158. the management of odontogenic kerato- tumours. A commentary on the second edi-
4. Suarez PA, Batsakis JG, El-Naggar AK. Dont cysts. American Association of Oral and tion. Cancer 1992;70:298894.
confuse dental soft tissues with odonto- Maxillofacial Surgeons Scientific Sessions; 33. Grodjesk JE, Dolinsky HB, Schneider LC, et al.
genic tumors. Ann Otol Rhinol Laryngol 2002 Oct 5; Chicago: American Association Odontogenic ghost cell carcinoma. Oral
1996;105:4904. of Oral and Maxillofacial Surgeons; 2002. Surg Oral Med Oral Pathol 1987;63:57681.
5. Kim J, Ellis GL. Dental follicular tissue: misin- 21. Regezi JA, Sciubba JJ, Jordan RCK. Cysts of the 34. Regezi JA, Kerr DA, Courtney RM. Odonto-
terpretation as odontogenic tumors. J Oral jaws and neck. In: Regezi JA, Sciubba JJ, Jor- genic tumors: analysis of 706 cases. J Oral
Maxillofac Surg 1993;51:7627. dan RCK, editors. Oral pathology. Clinical Surg 1978;36;7718.
Odontogenic Cysts and Tumors 595
35. Daley TD, Wysocki GP, Pringle GA. Relative AC. Gigantic ameloblastoma of the 67. Gardner DG. Plexiform unicystic ameloblas-
incidence of odontogenic tumors and oral mandible: report of case. J Oral Surg toma; a diagnostic problem in dentigerous
and jaw cysts in a Canadian population. 1974;32:449. cysts. Cancer 1981;47:135863.
Oral Surg Oral Med Oral Pathol 1994; 51. Regezi JA, Sciubba JJ, Jordan RCK. Odonto- 68. Haug RH, Hauer CA, Smith B, Indresano AT.
77:27680. genic tumors. In: Regezi JA, Sciubba JJ, Jor- Reviewing the unicystic ameloblastoma:
36. Odukoya O. Odontogenic tumors: analysis of dan RCK, editors. Oral pathology. Clinical report of two cases. J Am Dent Assoc
289 Nigerian cases. J Oral Pathol Med pathologic correlations. St. Louis: WB 1990;121:7035.
1995;24:4547. Saunders; 2003. p. 26788. 69. Gardner DG, Corio RL. The relationship of
37. Daramola JO, Ajagbe HA, Oluwasanmi JO. 52. Gold L. Biologic behavior of ameloblastoma. plexiform unicystic ameloblastoma to con-
Recurrent ameloblastoma of the jawsa Oral Maxillofac Surg Clin North Am ventional ameloblastoma. Oral Surg Oral
review of 22 cases. Plast Reconstr Surg 1991;3:2171. Med Oral Pathol 1983;56:5460.
1980;65:5779. 53. Feinberg SE, Steinberg B. Surgical manage- 70. Gardner DG, Corio RL. Plexiform unicystic
38. Adekeye EO, Lavery KM. Recurrent ameloblas- ment of ameloblastoma. Current status of ameloblastoma. A variant of ameloblas-
toma of the maxillofacial region. Clinical the literature. Oral Surg Oral Med Oral toma with a low recurrence rate after enu-
features and treatment. J Maxillofac Surg Pathol 1996;81:3838. cleation. Cancer 1984;53:17305.
1986;14:1537. 54. Huffman GG, Thatcher JW. Ameloblastoma 71. Gardner DG, Morton TH, Worsham JC. Plexi-
39. Raubenheimer EJ, Heerden WFP, Noffke CEE. the conservative surgical approach to treat- form unicystic ameloblastoma of the max-
Infrequent clinicopathological findings in ment: report of four cases. J Oral Surg illa. Oral Surg Oral Med Oral Pathol
108 ameloblastomas. J Oral Pathol Med 1974;32:8504. 1987;63:2213.
1995; 24:22732. 55. Vedtofte P, Hjorting-Hansen E, Jensen BN, 72. Woo SB, Smith-Williams JE, Sciubba JJ, Lipper
40. Adekeye EO. Ameloblastoma of the jaws: a sur- Roed-Petersen B. Conservative surgical S. Peripheral ameloblastoma of the buccal
vey of 109 Nigerian patients. J Oral Surg treatment of mandibular ameloblastomas. mucosa: case report and review of the Eng-
1980;38:3641. Int J Oral Surg 1978;7:15661. lish literature. Oral Surg Oral Med Oral
41. Olaitan AA, Adeola DS, Adekeye EO. 56. Gardner DG, Pecak AMJ. The treatment of Pathol 1987;63:7884.
Ameloblastoma: clinical features and man- ameloblastoma based on pathologic and 73. Tajima Y, Kuroda-Kawasaki M, Ohno J, et al.
agement of 315 cases from Kaduna, Nigeria. anatomic principles. Cancer 1980;46:25149. Peripheral ameloblastoma with potentially
J Craniomaxillofac Surg 1993;21: 3515. 57. Muller H, Slootweg PJ. The ameloblastoma, the malignant features: report of a case with
42. Reichart PA, Philipsen HP, Sonner S. controversial approach to therapy. J Max- special regard to its keratin profile. J Oral
Ameloblastoma: biological profile of 3677 illofac Surg 1985;13:7984. Pathol Med 2001;30:4948.
cases. Eur J Cancer Oral Oncol 1995; 58. Sampson DE, Pogrel MA. Management of 74. Eversole LR. Malignant epithelial odontogenic
31B:8699. mandibular ameloblastoma: the clinical tumors. Semin Diagn Pathol 1999;16:31724.
43. Ueno S, Nakamura S, Mushimoto K, Shirasu R. basis for a treatment algorithm. J Oral Max- 75. Slootweg PJ, Muller H. Malignant ameloblas-
A clinicopathologic study of ameloblas- illofac Surg 1999;57:10747. toma or ameloblastic carcinoma. Oral Surg
toma. J Oral Maxillofac Surg 1986; 59. Gardner DG. A pathologists approach to the Oral Med Oral Pathol 1984;57:16876.
44:3615. treatment of ameloblastoma. J Oral Max- 76. Byrne MP, Kosmala RL, Cunningham MP.
44. Takahashi K, Miyauchi K, Sato K. Treatment of illofac Surg 1984; 42:1616. Ameloblastoma with regional and distant
ameloblastoma in children. Br J Oral Max- 60. Kramer IRH. Ameloblastoma: a clinicopatho- metastases. Am J Surg 1974;128:914.
illofac Surg 1998;36:4536. logical appraisal. Br J Oral Surg 1963; 77. Newman L, Howells GL, Coghlan KM, et al.
45. Williams T. The ameloblastoma: a review of 1:1328. Malignant ameloblastoma revisited. Br J
the literature. Selected readings in oral and 61. Carlson ER. Pathologic facial asymmetries. Oral Maxillofac Surg 1995;33:4750.
maxillofacial surgery. Vol 2. San Francisco: Atlas Oral Maxillofac Surg Clin North Am 78. Laughlin EH. Metastasizing ameloblastoma.
The Guild for Scientific Advancement in 1996;4:1935. Cancer 1989;64:77680.
Oral and Maxillofacial Surgery; 1991. 62. Oka K, Fukui M, Yamashita M, et al. Mandibu- 79. Dorner L, Sear AJ, Smith GT. A case of
p. 117. lar ameloblastoma with intracranial exten- ameloblastic carcinoma with pulmonary
46. Nastri AL, Wiesenfeld D, Radden BG, et al. sion and distant metastasis. Clin Neurol metastases. Br J Oral and Maxillofac Surg
Maxillary ameloblastoma: a retrospective Neurosurg 1986;88:3039. 1988;26:50310.
study of 13 cases. Br J Oral Maxillofac Surg 63. Atkinson CH, Harwood AR, Cummings BJ. 80. Simko EJ, Brannon RB, Eibling DE. Ameloblas-
1995;33:2832. Ameloblastoma of the jaw. A reappraisal of tic carcinoma of the mandible. Head Neck
47. Jackson IT, Callan PP, Forte RA. An anatomical the role of megavoltage irradiation. Cancer 1998;20:6549.
classification of maxillary ameloblastoma 1984;53:86973. 81. Corio RL, Goldblatt LI, Edwards PA, Hartman
as an aid to surgical treatment. J Cran- 64. Gardner DG. Radiotherapy in the treatment of KS. Ameloblastic carcinoma: a clinico-
iomaxillofac Surg 1996; 24:2306. ameloblastoma. Int J Oral Maxillofac Surg pathologic study and assessment of eight
48. Sehdev MK, Huvos AG, Strong EW, et al. 1988; 17:2015. cases. Oral Surg Oral Med Oral Pathol
Ameloblastoma of maxilla and mandible. 65. Vickers RA, Gorlin RJ. Ameloblastoma: delin- 1987;64:5706.
Cancer 1974;33:32433. eation of early histopathologic features of 82. Slootweg PJ. An analysis of the interrelation-
49. Komisar A. Plexiform ameloblastoma of the neoplasia. Cancer 1970;26:699710. ship of the mixed odontogenic tumors
maxilla with extension to the skull base. 66. Robinson L, Martinez MG. Unicystic ameloblastic fibroma, ameloblastic fibro-
Head Neck Surg 1984;7:1725. ameloblastoma. A prognostically distinct odontoma, and the odontomas. Oral Surg
50. Petriella VM, Rogow PN, Baden E, Williams entity. Cancer 1977;40: 227885. Oral Med Oral Pathol 1981;51:26676.
596 Part 5: Maxillofacial Pathology
83. Gardner DG. The mixed odontogenic tumors. 89. Baunsgaard P, Lontoft E, Sorensen M. Calcify- nomatoid tumor. A comprehensive study of
Oral Surg Oral Med Oral Pathol 1984; ing epithelial odontogenic tumor twenty new cases. Oral Surg Oral Med Oral
57:3957. (Pindborg tumor): an unusual case. Laryn- Pathol 1975;39:42435.
84. Howell RM, Burkes J. Malignant transforma- goscope 1983;93:6358. 95. Mendis BRRN, MacDonald DG. Adenomatoid
tion of ameloblastic fibro-odontoma to 90. Berk RS, Baden E, Ladov M, Williams AC. Ade- odontogenic tumour. A survey of 21 cases
ameloblastic fibrosarcoma. Oral Surg Oral noameloblastoma (odontogenic adenoma- from Sri Lanka. Int J Oral Maxillofac Surg
Med Oral Pathol 1977; 43:391401. toid tumor): report of case. J Oral Surg 1990;19:1413.
85. Barker BF. Odontogenic myxoma. Semin 1972;30:2018. 96. Lee KW. A light and electron microscopic
Diagn Pathol 1999;4:297301. 91. Halperin V, Carr RF, Peltier JR. Follow-up of study of the adenomatoid odontogenic
86. Regezi JA. Odontogenic cysts, odontogenic adenoameloblastomas. Review of thirty- tumor. Int J Oral Surg 1974;3:18393.
tumors, fibroosseous, and giant cell five cases from the literature and report of 97. Smith RRL, Olson JL, Hutchins GM, et al. Ade-
lesions of the jaws. Mod Pathol 2002; two additional cases. Oral Surg Oral Med nomatoid odontogenic tumor. Ultrastruc-
15:33141. Oral Pathol 1967;24:6427. tural demonstration of two cell types and
87. Franklin CD, Pindborg JJ. The calcifying 92. Poulson RC, Greer RO. Adenomatoid odonto- amyloid. Cancer 1979; 43:50511.
epithelial odontogenic tumor. A review and genic tumor: clinicopathologic and ultra- 98. Yamamoto H, Kozawa Y, Hirai G, et al. Adeno-
analysis of 113 cases. Oral Surg Oral Med structural concepts. J Oral Maxillofac Surg matoid odontogenic tumor: light and elec-
Oral Pathol 1976; 42:75365. 1983;41:81824. tron microscopic study. Int J Oral Surg
88. Veness MJ, Morgan G, Collins AP, Walker DM. 93. Toida M, Hyodo I, Okuda T, Tatematsu N. Ade- 1981;10:2728.
Calcifying epithelial odontogenic (Pind- nomatoid odontogenic tumor: report of 99. Philipsen JP, Reichart PA, Zhang KH, et al.
borg) tumor with malignant transforma- two cases and survey of 126 cases in Japan. Adenomatoid odontogenic tumor: biologic
tion and metastatic spread. Head Neck J Oral Maxillofac Surg 1990; 48:4048. profile based on 499 cases. J Oral Pathol
2001;23:6926. 94. Courtney RM, Kerr DA. The odontogenic ade- Med 1991;20:14958.
CHAPTER 31
Benign Nonodontogenic
Lesions of the Jaws
M. Anthony Pogrel, DDS, MD
Benign nonodontogenic lesions of the clusively between bone and cementum with The jaws are commonly associated with all
jaws represent a mixed group of tumors, light microsurgery. forms of fibrous dysplasia. In the jaws the
which in many cases are difficult to classi- For the purposes of this chapter, the onset is usually during the first and second
fy. Additionally, there are some lesions term fibro-osseous disease is taken to decades, and it produces painless swelling
within this group that actually only seem include the following groups of lesions: of the involved bones (Figure 31-1). Classi-
to occur in the jaws, and, therefore, fibrous dysplasia, cemento-osseous dys- cally, the radiographic appearance shows a
although they do not contain any histolog- plasia, and fibro-osseous neoplasms. ground-glass opacity without clearly
ic or immunohistochemical evidence of defined borders (Figure 31-2). In its cranio-
odontogenic structures, the mere fact that Fibrous Dysplasia facial form the maxilla, zygoma, sphenoid,
they only occur in the jaws may mean that Fibrous dysplasia is considered to be a frontal bones, nasal bones, and base of the
they are in fact odontogenic. developmental hamartomatous fibro- skull can be involved. Expansion can cause
The subjects discussed in this chapter osseous disease of unknown etiology. It compression of nerves and blood vessels.
are fibro-osseous disease, osteoblastoma may represent developmental arrest in a The optic canal can be narrowed by fibrous
and osteoid osteoma, aggressive mesenchy- benign fibro-osseous proliferation that dysplasia, although it seems unlikely that
mal tumors of childhood, benign tumors of lacks the ability to fully differentiate.2
bone-forming cells, synovial chondromato- Somatic mutations in the GS -gene
sis and osteochondroma, lesions containing have been proposed to cause monostotic
giant cells, vascular malformations, Langer- and polyostotic conditions and Albrights
hans cell histiocytosis, nonodontogenic syndrome.3,4
cysts of the jaws, neurogenic tumors, Pagets Fibrous dysplasia is normally subdi-
disease, massive osteolysis (Gorhams dis- vided into four different forms:
ease), and tori.
1. Monostotic fibrous dysplasia affecting
Benign Fibro-osseous Disease only one bone
Differences remain in the classification and 2. Polyostotic fibrous dysplasia affecting
diagnosis of fibro-osseous disease.1 There is multiple bones
a general consensus that the common enti- 3. Albrights syndrome in which multi-
ty for all of the lesions is the replacement of ple lesions are associated with hyper-
normal bone with a tissue composed of col- pigmentation and endocrine distur-
lagen fibers and fibroblasts that contain bances, predominantly precocious
varying amounts of mineralized substance, puberty and/or hyperthyroidism5
which can be either bone or cementum-like 4. Craniofacial fibrous dysplasia confined FIGURE 31-1 Swelling of the left mandible and
material. It is difficult to differentiate con- to bones of the craniofacial complex maxilla owing to fibrous dysplasia.
598 Part 5: Maxillofacial Pathology
A swelling increases, and the lesions appear however, since they are frequently asympto-
hot on a bone scan (Figure 31-3) and can, matic and require no treatment, they are
in fact, mimic osteomyelitis.711 In a quies- less of a diagnostic and clinical dilemma
cent phase they may be totally asympto- than are the other forms of fibro-osseous
matic. Teeth can be displaced by the lesion disease. In this condition there is a disor-
(Figure 31-4). Familial cases of fibrous dys- dered production of bone and cementum-
plasia have been noted.12 like tissue in the jaws. The three forms
The lesions of fibrous dysplasia may be include periapical, focal, florid osseous dys-
under hormonal control, particularly in plasias, and familial gigantiform cemen-
B
Albrights syndrome, and cases of increased toma, which are probably variants of the
activity and reactivation during pregnancy same pathologic process but which can be
have been noted.13,14 Although not normal- differentiated by clinical and radiographic
ly recognized as a premalignant lesion, sar- features. The etiology of these lesions
comatous change has been noted in fibrous remains in doubt, but local trauma may
dysplasia.15,16 Early cases appear to have play some part, even such benign trauma as
been associated with the use of radiation abnormal occlusal forces. There is a pre-
therapy for treatment,17,18 but cases of dominance of cases occurring in females
spontaneous sarcomatous degeneration and also in African Americans.22 It is sus-
have been noted.19 Additionally, some cases pected that the periodontal ligament may
FIGURE 31-2 A, Radiographic appearance of
patient in Figure 31-1 showing ground-glass have been difficult to diagnose and may be the origin of the fibrous tissue found in
appearance of lesions. B, Periapical view of typi- have represented a low-grade osteosarcoma the cemento-osseous dysplasias. Histologi-
cal ground-glass appearance of fibrous dysplasia. from the outset.20 cally the three types of cemento-osseous
Classically, fibrous dysplasia appears to dysplasia are indistinguishable, showing
any associated vision loss can be relieved by be a lesion that burns itself out when the new woven bone trabeculae and/or
orbital decompression.6 The maxilla patient is in the late teens or early twenties, spherules of cementum-like material,
appears to be affected more often than the although cases of active fibrous dysplasia which often blend into the cortical bone. A
mandible, and females are affected more have been noted much later than this. fibrous tissue stroma is present. There is
commonly than males. Typically lesions Treatment is generally symptomatic; if very little inflammatory component. Trau-
undergo periods of activity and periods of the lesions are asymptomatic, a biopsy matic bone cysts have been reported in con-
quiescence. When they are active, they are diagnosis alone may be adequate without junction with this lesion.23
often symptomatic in that the patient may carrying out any definitive treatment. Sur-
perceive a throbbing or discomfort, the gical treatment should be limited during an Periapical Cemento-osseous Dysplasia
active phase because the lesions are vascular Periapical cemento-osseous dysplasia pre-
and can bleed quite profusely. Treatment is sents as circumscribed lesions in periapical
best reserved for quiescent periods, at areas associated with vital teeth, with the
which time cosmetic recontouring is the anterior mandible being most usually
normal treatment of choice. Regrowth,
however, can be expected following this
treatment in 25 to 50% of cases, particular-
ly if undertaken at a young age. Some inves-
tigators have suggested more aggressive
surgical procedures including mandibular
and maxillary resections.21
Cemento-osseous Dysplasia
FIGURE 31-3 Bone scan of patient in Figures The cemento-osseous dysplasias represent a
31-1 and 31-2 showing area of increased uptake pathologic process of the tooth-bearing
of isotope in both sides of the mandible and the
left maxilla (arrow). The isotope used was Tc areas and probably represent the common- FIGURE 31-4 Teeth displaced by lesions of
99m diphosphonate. est manifestation of fibro-osseous disease; fibrous dysplasia.
Benign Nonodontogenic Lesions of the Jaws 599
localized surgical resection, and segmental been reported, and recurrences may be
mandibular resection.40,41 When present in commoner in younger patients.1
the craniofacial complex, treatment may
have to be more aggressive to protect the Osteoblastoma and
vital structures.42 Osteoid Osteoma
Osteoblastoma and osteoid osteoma are
Juvenile Aggressive Ossifying Fibroma generally felt to be variants of the same
Juvenile aggressive ossifying fibroma was lesion and are related to fibro-osseous dis-
first described in 1952 as a variant of ossi- ease. Cementoblastoma and gigantiform
fying fibroma.43 The lesions classically cementoma are the equivalent cemental
occur in younger children and adolescents lesions and are associated with teeth. The FIGURE 31-8 Osteoblastoma of the left mandible
and present with an aggressive behavior, alternative name for the osteoblastoma is in 24-year-old female. Note mixed radiolucen-
but they have been noted in older patients giant osteoid osteoma, and it is generally cy/radiopacity with a radiolucent rim.
and are not always particularly aggressive. felt to represent a larger version of the
The World Health Organization defines osteoid osteoma. Both are benign process- must be made from the ossifying fibroma,
juvenile aggressive ossifying fibroma as an es and are felt to represent true neoplasms. fibrous dysplasia, and osteosarcoma.
actively growing lesion mainly affecting The osteoblastoma occurs primarily in the Treatment of the osteoblastoma is gen-
individuals below the age of 15 years, vertebrae and long bones, but it has been erally confined to conservative surgical exci-
which is composed of a cell-rich fibrous described in the jaws.4547 Clinically it sion either with curettage or local excision.
tissue containing bands of cellular osteoid often grows rapidly and the predominant Recurrences are rare but have been reported
without osteoblastic rimming together clinical feature is pain, which is generally and may necessitate more aggressive treat-
with trabeculae of more typical woven localized to the lesion itself. Although felt ment such as en bloc resection.49 Rare
bone. Small foci of giant cells may be pre- to be a true neoplasm, there have been examples of malignant transformation have
sent, and in some parts there may be abun- reports of regression after biopsy or been reported,50,51 but some of these may be
dant osteoclasts related to the woven bone. incomplete removal, which could point to related to an incorrect initial diagnosis.45
Usually no fibrous capsule can be demon- it being a reactive process of some kind.48 The osteoid osteoma represents a
strated, but the lesion is well demarcated Most cases of osteoblastoma occur in the smaller version of the osteoblastoma and is
from the surrounding bone.44 Two vari- second decade of life; they rarely occur felt to be a true neoplasm. It is normally
ants have been described: trabecular and after age 30 years. Males appear to be < 2 cm in diameter clinically and radi-
psammomatous. The trabecular variant affected more commonly than females. In ographically. It again occurs in the second
usually occurs in childhood, with a slight the head and neck, the mandible is the and third decades of life with a male pre-
maxillary predominance, and may contain most common site. dominance. Pain is again the major clinical
clustered multinuclear giant cells. The Radiographic features are variable, feature. Classically, the pain is worse at night
psammomatous variant can occur in usually consisting of a combination of radi- and is relieved by acetylsalicylic acid. If the
adults as well as adolescents and often olucency and radiopacity (Figure 31-8). lesion is located near the cortex, it may pro-
affects the orbit and paranasal tissues; fre- The designation osteoblastoma is normally duce a localized tender swelling. Radi-
quently it contains a whorled pattern of reserved for lesions > 2 cm in diameter. ographically the lesion again shows a well-
closely packed spheric ossicles and a myx- They are well circumscribed radiographi- defined mixed radiolucency/radiopacity
oid component with aneurysmal bone cally with a thin radiolucency surrounding with a small radiolucent rim around the
cystlike areas. the variably calcified contents. A sunray lesion, which is walled by sclerotic bone.
Although felt to be more aggressive pattern of new bone formation similar to Histologically it resembles the osteoblas-
than the commoner ossifying fibroma that that described in malignant bone tumors toma with a rich vascular stroma with tra-
is found at a later age, this condition is not may be evident. beculae of osteoid and immature bone. The
considered to necessitate truly aggressive The histologic appearance shows irreg- bone is rimmed by layers of active
surgery; conservative excision is still the ular trabeculae of osteoid and immature osteoblasts. Histologically it is impossible to
recommended treatment, although lesions bone within a predominantly vascular stro- differentiate it from the osteoblastoma.
involving the craniofacial structures may mal network. There are various degrees of Treatment is again conservative surgical
require more extensive surgery. Recur- calcification present. Stromal cells are gen- excision. Spontaneous regression has also
rence rates of between 20 and 50% have erally small and slender. Differentiation been reported clinically.
Benign Nonodontogenic Lesions of the Jaws 601
the fact that it only occurs in the jawbones are normally found in areas where decidu-
probably indicates some relationship to ous teeth were present and are found after
the teeth or tooth-bearing structures. It the deciduous teeth have resorbed.
occurs primarily in the anterior parts of Radiographically the central giant cell
the jaws in people in the second and third granuloma can take a number of forms
decades of life, but it has been recorded in from a well-defined radiolucency, a more
all sites at all ages. Its histogenesis remains ill-defined radiolucency or a multilocular
speculative. When first described it was radiolucency. Teeth can be displaced by
called a reparative giant cell granulo- the lesion, although resorption of teeth is
ma,8385 and it was considered a reparative uncommon (Figures 31-18 and 31-19).
lesion that was essentially self-healing. Histologically these granulomas con-
FIGURE 31-16 A desmoplastic fibroma present- There was little evidence of this, however, tain focal arrangements of giant cells with-
ing as an ill-defined radiolucency of the left
and only oblique references to its self- in a vascular stroma with thin-walled cap-
mandible causing displacement of teeth in a
patient aged 8 years. healing properties can be found. Worth illaries adjacent to the giant cells. There is
showed in a study of a number of non- a spindle cell stroma. Immunohistochem-
treated lesions that resolution often did istry has shown that the giant cells are in
Lesions Containing Giant Cells occur as seen radiographically; even when fact osteoclasts,90 and the spindle cells are
There are a number of lesions that occur the lesions did not resolve completely probably the cells of origin of this lesion.91
in the jaws that contain giant cells within radiographically, only a fibrous scar was Treatment is usually surgical and con-
them. Their relationship to each other, noted on surgical exploration.86 The cur- sists of local curettage, which is usually
however, is ill defined. Histologically all of rent consensus, however, is that these are curative.92 However, there is a 15 to 20%
the giant cell lesions appear similar, if not not reparative lesions and that if they are recurrence rate, and if the lesions are large,
identical, and they usually cannot be dis- not treated, they are progressive. Most even conservative curettage may involve
tinguished on light microscopy alone. The appear to follow a fairly benign course, but the loss of many teeth and possibly the
clinical history, immunohistochemistry, or more aggressive lesions have been inferior alveolar nerve in the mandible,
genetic markers have to be used to differ- noted.8789 The true nature of the central and it may have sinus and nasal implica-
entiate the lesions. giant cell granuloma remains speculative. tions in the maxilla. With the aggressive
It has been suggested that it may be an variants, more aggressive surgery has been
Central Giant Cell Granuloma inflammatory lesion, a reactive lesion, a suggested including mandibular resection
Central giant cell granuloma is a lesion true tumor, or an endocrine lesion. It may and appropriate reconstruction.93
occurring almost exclusively in the jaws. behave most like a reactive lesion. Since the central giant cell granuloma
(A similar lesion has been described in the Older theories about the origin of and the brown tumor of hyperparathy-
small bones of the fingers and toes, but its these lesions suggested that they may be roidism cannot be separated histologically,
relationship to the central giant cell gran- derived from the odontoclasts that were it is advocated that hyperparathyroidism
uloma is unknown.82) Although not nor- responsible for resorption of the decidu- be excluded from the diagnosis by serum
mally considered an odontogenic lesion, ous teeth; this was said to explain why they calcium, phosphate, and parathormone
A B
FIGURE 31-18 A central giant cell granuloma of
FIGURE 31-17 A, Resected specimen from the patient in Figure 31-15. B, Immediate reconstruction the anterior mandible causing the displacement
with ribs can often be performed in young children. Reconstruction plate and rib grafts in place. of teeth.
604 Part 5: Maxillofacial Pathology
A B
Diagnosis is by biopsy, which normal-
ly shows a pseudostratified columnar FIGURE 31-35 A, Palatine duct cyst appearing as a well-defined midline radi-
epithelium lining. Treatment, if required, olucency. B, The same cyst enucleated.
is surgical and consists of local curettage.
This almost inevitably requires the sacri- ographs. It occurs most commonly in the blood clot liquefies and is then resorbed,
fice of the nasopalatine vessels and nerves, mandible, particularly in the posterior leaving an empty space. On surgical explo-
which results in a small area of anesthesia mandible. It classically appears on a radi- ration these lesions are normally found to
over the anterior palate behind the upper ograph as a fairly well-defined radiolucen- have either no lining whatsoever or just a
incisor teeth. Some patients (particularly cy, which usually has a scalloped margin very thin filmy lining. They are normally
more elderly patients) find this particular- beneath the tooth roots (Figure 31-36). It empty except, possibly, for a little straw-
ly troublesome in the articulation of some is not quite as well defined as an odonto- colored fluid in the base of the lesion,
words. Recurrence rate is very low follow- genic cyst, and the description made by which could represent the last remnants of
ing treatment. Howe was that it appears as a pencil an absorbing blood clot. Studies have
sketch for a final pen and ink drawing.128 shown that the gaseous contents of the
Traumatic Bone Cyst The etiology of this lesion is in doubt, lesion are mainly nitrogen, and this is pre-
Traumatic bone cyst has been called a and suggestions have included that it may sumably because they contain air and the
number of names, including idiopathic result from intramedullary hemorrhage oxygen is absorbed preferentially into the
bone cyst, simple bone cyst, and latent from trauma, which can be quite mild. blood stream.129
bone cyst. It is almost always asympto- Instead of organization and new bone for- Although these lesions have been
matic and a chance finding on radi- mation occurring, for some reason the shown to regress spontaneously, a biopsy
is almost always performed to determine a
diagnosis. The biopsy is normally curative
since anything that causes bleeding into
the lesion causes resolution. Suggested
treatments have included everything from
no treatment whatsoever to curettage or
injection of autologous blood or packing
with an absorbable gelatin sponge.130
Recurrences are extremely rare but have
been reported, as have bilateral cases.130
Neurogenic Tumors
B from interosseous lesions. In cases associat-
Schwannoma ed with the inferior alveolar nerve, pain or
FIGURE 31-36 A, Bilateral poorly defined trau-
matic bone cysts. (Bilateral cysts are unusual.) B, The schwannoma is a benign tumor of the paresthesia can result.
Same radiograph shown in Figure A with cysts neurilemoma or nerve sheath. Although The normally recommended treatment
outlined, showing the size and scalloped margins
usually found in the soft tissues, it can following biopsy is localized excision. The
around teeth.
occur in bone, where it usually exists as a lesions are often vascular, and extensive
well-defined radiolucency. Following blood loss has been reported from surgical
presents as a well-defined radiolucency on biopsy to confirm the diagnosis, treatment management of mandibular lesions.
the lower border of the mandible, below usually consists of surgical excision. Mandibular resection has been advocated
the inferior alveolar nerve (Figure 31-37). Recurrences are rare. Histologically lesions by some authorities. The malignant trans-
The appearance is so diagnostic that biop- are well encapsulated and predominantly formation rate to neurogenic sarcoma of
sy is often not required. When this defect is of spindle cells showing either an Antoni A
explored surgically, one normally finds (spindle cells arranged in palisaded whorls
that it is not a totally intrabony lesion but, and waves) or Antoni B (spindle cells with
in fact, an indentation of the mandible on a more haphazard appearance).
the lingual side (Figure 31-38). The inden-
tation is normally filled with an offshoot Neurofibroma
of the submandibular salivary gland. This Neurofibromas are felt to be derived from
can be confirmed by sialography, which the fibrous elements of the neural sheath
and may exist as solitary lesions or as part
of generalized neurofibromatosis or von
Recklinghausens disease. This latter con-
dition is autosomal dominant, and two
distinct subsets have been defined associ-
ated with the NF1 and NF2 genes.
Although most commonly reported in
soft tissues, neurofibromas do occur in bone
and have been reported on the inferior alve-
olar nerve, where they appear as a fusiform
swelling in continuity with the inferior alve-
olar canal (Figure 31-39). Other bone FIGURE 31-39 A neurofibroma on the left infe-
FIGURE 31-37 Appearance of a Stafnes bone rior alveolar nerve presenting as a large fairly
changes associated with neurofibromatosis
defect on panoramic radiograph below the infe- well-defined radiolucency in the mandibular
rior alveolar nerve on the right body of the can include cortical erosion from adjacent ramus (arrow). The patient also had caf-au-
mandible. soft tissue lesions or medullary resorption lait spots.
Benign Nonodontogenic Lesions of the Jaws 611
5 to 15% in the generalized form of the dis- grafts, with some success.132 The approach
ease could be a further indication for surgi- can be either intraoral or extraoral, but the
cal removal of these lesions. extraoral approach generally gives better
access and clinical results. However, it does
Traumatic Neuroma have a higher morbidity, with possible risks
Traumatic neuroma represents a misguided of scarring and of damage to the mandibu-
attempt at nerve regeneration whereby fol- lar branch of the facial nerve.
lowing an injury to a nerve, neurons sprout
from the site of injury but for anatomic or Pagets Disease
physiologic reasons cannot result in a func- First described by Sir James Paget in
tional nerve repair. If a nerve is sectioned, 1876,133 this entity still carries his name. Its
an amputation neuroma can develop on alternative name is osteitis deformans. It is FIGURE 31-41 An incontinuity neuroma on the
the stump; if a nerve is injured along its a slowly progressive bone condition of inferior alveolar nerve (arrow) as a result of the
length, either an incontinuity or lateral unknown etiology, predominantly affect- removal of a third molar. The nerve is exposed via
neuroma can result (Figure 31-40). In the ing males over the age of 50 years. One an extraoral approach and lateral corticotomy.
oral cavity these latter neuromas are most unproven theory is that Pagets disease
often noted on the lingual and inferior alve- may be a delayed or slow reaction to a The histopathology shows the typical
olar nerves. On the inferior alveolar nerve myxovirus stimulus. reversal lines of alternate resorption and
they can occur as a fusiform enlargement of Clinically there is hyperactive bone bone deposition (Figure 31-43). Classical-
the inferior alveolar canal and result most turnover with alternate resorption of ly, patients have markedly elevated serum
commonly following mandibular trauma, bone, a vascular phase, and finally a scle- alkaline phosphatase levels.
resection of pathologic lesions, and nerve rosing phase. Most bones of the body are Treatment is both systemic and local.
involvement following dentoalveolar involved, and the disease can result in con- Systemic treatment currently consists of
surgery (Figure 31-41). siderable deformity. In the facial region
If the symptoms are severe, appropriate the maxilla is affected more often than the
treatment is resection of the neuroma and mandible. Family histories have been
appropriate nerve reconstruction. Since the obtained in this disease, and the genetic
inferior alveolar nerve cannot be stretched basis of the condition is being defined.
significantly in the canal, repair normally The classic presentation used to be a
involves a graft of some kind. Nerve grafts patient whose hat or gloves no longer fit-
from the sural nerve or great auricular ted correctly, or in whom false teeth, par-
nerve have been reported, as have vein ticularly the maxillary denture, did not fit
owing to bone swelling. Today these pre-
sentations are much fewer since well-
fitting hats, gloves, and dentures are less A
commonly encountered. Initial presenta-
tion is usually related to bone deformity or
pain. In the head and neck, headaches and
symptoms owing to vascular and nerve
compression have been noted.
The classic radiographic appearance is
of a cotton-wool appearance in the skull
and maxilla of affected patients (Figure
31-42), with hypercementosis around the
roots of teeth, and loss of lamina dura and
obliteration of the periodontal ligament B
space. This does make tooth extraction
FIGURE 31-42 A, Lateral and B, frontal radi-
FIGURE 31-40 An excised lateral neuroma that extremely difficult in these patients. Root ographs of a patient with Pagets disease showing
was on the lingual nerve. resorption has also been noted. typical cotton wool appearance.
612 Part 5: Maxillofacial Pathology
References
1. Brannon RB, Fowler CB. Benign fibro-osseous
FIGURE 31-47 Torus palatinus in Figure 31-46 FIGURE 31-50 Dressing plate sutured in place lesions: a review of current concepts. Adv
exposed via a double Y-shaped incision. over the wound. Anat Pathol 2001;8:12643.
2. Eversole LR. Craniofacial fibrous dysplasia and
ossifying fibrous. Oral Maxillofac Surg Clin
Torus Mandibularis bilateral. Again, they present in early
North Am 1997;9:62542.
midlife and tend to grow with age. Larger 3. Song HD, Chen FL, Shi WJ, et al. A novel, com-
Mandibular tori are bony exophytic
versions may require removal because they plex heterozygous mutation within Gsalpha
growths that present on the lingual aspect
interfere with tongue positioning, speech, gene in patient with McCune-Albright syn-
of the mandible opposite the bicuspids drome. Endocrine 2002;18:1218.
and prosthodontic reconstruction, as well
(Figure 31-51). They are virtually always 4. Pollandt K, Engels C, Kaiser E, et al. Gsalpha
as with oral hygiene around the lower pos-
gene mutations in monostotic fibrous dys-
terior teeth. The etiology of these lesions is plasia of bone and fibrous dysplasialike
in doubt; again, it is tempting to think of low-grade central osteosarcoma. Virchows
them as being embryologic lesions formed Arch 2001;439:1705.
at the junction of the original Meckels 5. Bolger WE, Ross AT. McCune-Albright syn-
drome: a case report and review of the liter-
cartilage and the neomandible, but this is
ature. Int J Pediatr Otorhinolaryngol
almost certainly not correct. 2002;65:6974.
If surgical removal is required, it is 6. Lee JS, FitzGibbon E, Butman JA, et al. Normal
carried out via an extensive gingival mar- vision despite narrowing of the optic canal
gin incision with a possible lingual- in fibrous dysplasia. N Engl J Med
2002;347:16706.
releasing incision, followed by removal of
7. Suei Y, Tanimoto K. Diffuse sclerosing
the bone. This is carried out by making a osteomyelitis and florid osseous dysplasia.
number of vertical cuts with a fissure bur, Oral Surg Oral Med Oral Pathol Oral Radi-
as with the maxillary torus, and then snap- ol Endod 1996;82:3601.
ping off the intervening ridges of bone 8. Groot RH, van Merkesteyn JP, Bras J. Diffuse
FIGURE 31-48 Diagram of the method of
sclerosing osteomyelitis and florid osseous
reducing a large torus palatinus with a number with a periosteal elevator. The residual
dysplasia. Oral Surg Oral Med Oral Pathol
of parallel grooves. irregularities are then smoothed with a Oral Radiol Endod 1996;81:33342.
larger bur. Occasionally mandibular tori 9. Kozlowski K, Barrett I. Polyostotic fibrous dys-
plasia and chronic osteomyelitis in a 12-
year-old boy. Diagnostic difficulties in dou-
ble bone pathology. Radiol Med (Torino)
1987;73:1513.
10. von Wowern N, Hjorting-Hansen E, Edeling
CJ. Bone scintigraphy of benign jaw lesions.
Int J Oral Surg 1978;7:52833.
11. Johannsen A. Chronic sclerosing osteomyelitis
of the mandible. Radiographic differential
diagnosis from fibrous dysplasia. Acta Radi-
ol Diagn (Stockh) 1977;18:3608.
12. Hunter AG, Jarvis J. Osteofibrous dysplasia:
two affected male sibs and an unrelated girl
FIGURE 31-49 Torus palatinus in Figures 31-46 with bilateral involvement. Am J Med
and 31-48 removed with the technique described Genet 2002;112:7985.
in the text. FIGURE 31-51 Large bilateral torus mandibularis. 13. Obuobie K, Mullik V, Jones C, et al. McCune-
614 Part 5: Maxillofacial Pathology
Albright syndrome: growth hormone corrodens from patients with chronic dif- 44. Kramer IR. The World Health Organization:
dynamics in pregnancy. J Clin Endocrinol fuse sclerosing osteomyelitis. J Oral Max- histological typing of odontogenic
Metab 2001;86:24568. illofac Surg 1994;52:2634. tumours: an introduction to the second
14. Daly BD, Chow CC, Cockram CS. Unusual 30. Jacobsson S, Dahlen G, Moller AJ. Bacteriolog- edition. J Dent Assoc S Afr 1992;47:20810.
manifestations of craniofacial fibrous dys- ic and serologic investigation in diffuse 45. Stewart J. Clinical pathologic correlations. In:
plasia: clinical, endocrinological and com- sclerosing osteomyelitis (DSO) of the Regezi JA, Sciubla JJ, Jordan RCK, editors.
puted tomographic features. Postgrad Med mandible. Oral Surg Oral Med Oral Pathol Oral pathology. 4th ed. Philadelphia: Saun-
J 1994;70:106. 1982;54:50612. ders; 2003. p. 2956.
15. Gross CW, Montgomery WW. Fibrous dyspla- 31. Young SK, Markowitz NR, Sullivan S, et al. 46. Gordon SC, MacIntosh RB, Wesley RK. A
sia and malignant degeneration. Arch Oto- Familial gigantiform cementoma: classifi- review of osteoblastoma and case report of
laryngol 1967;85:6537. cation and presentation of a large pedigree. metachronous osteoblastoma and unicystic
16. Chetty R, Kalan MR, Kranold DH. Malignant Oral Surg Oral Med Oral Pathol ameloblastoma. Oral Surg Oral Med Oral
transformation in fibrous dysplasia. A 1989;68:7407. Pathol Oral Radiol Endod 2001;91:5705.
report of 3 cases. S Afr J Surg 1990;28:802. 32. Gollin SM, Storto PD, Malone PS, et al. Cytoge- 47. Miller AS, Rambo HM, Bowser MW, Gross M.
17. Tanner H, Dahlin, DC, Childs, DS. Sarcoma netic abnormalities in an ossifying fibroma Benign osteoblastoma of the jaws: report of
complicating fibrous dysplasia. Probable from a patient with bilateral retinoblastoma. three cases. J Oral Surg 1980;38:6947.
role of radiation therapy. Oral Surg Oral Genes Chromosomes Cancer 1992;4:14652. 48. Eisenbud L, Kahn LB, Friedman E. Benign
Med Oral Pathol 1961;14:83746. 33. Dal Cin P, Sciot R, Fossion E, et al. Chromosome osteoblastoma of the mandible: fifteen year
18. Mock D, Rosen IB. Osteosarcoma in irradiated abnormalities in cementifying fibroma. Can- follow-up showing spontaneous regression
fibrous dysplasia. J Oral Pathol 1986;15:14. cer Genet Cytogenet 1993;71:1702. after biopsy. J Oral Maxillofac Surg
19. Slow IN, Friedman EW. Osteogenic sarcoma 34. Sissons HA, Steiner GC, Dorfman HD. Calcified 1987;45:537.
arising in a preexisting fibrous dysplasia: spherules in fibro-osseous lesions of bone. 49. Colm SJ, Abrams MB, Waldron CA. Recurrent
report of case. J Oral Surg 1971;29:1269. Arch Pathol Lab Med 1993;117:28490. osteoblastoma of the mandible: report of a
20. Koury ME, Regezi JA, Perrott DH, Kaban LB. 35. Sissons HA, Kancherla PL, Lehman WB. Ossi- case. J Oral Maxillofac Surg 1988;46:8815.
Atypical fibro-osseous lesions: diagnostic fying fibroma of bone. Report of two cases. 50. Ohkubo T, Hernandez JC, Ooya K, Krutchkoff
challenges and treatment concepts. Int J Bull Hosp Jt Dis 1983;43:114. DJ. Aggressive osteoblastoma of the max-
Oral Maxillofac Surg 1995;24:1629. 36. Povysil C, Matejovsky Z. Fibro-osseous lesion illa. Oral Surg Oral Med Oral Pathol
21. Chen YR, Noordhoff MS. Treatment of cran- with calcified spherules (cementifying 1989;68:6973.
iomaxillofacial fibrous dysplasia: how early fibromalike lesion) of the tibia. Ultrastruct 51. Benoist M. Experience with 220 cases of
and how extensive? Plast Reconstr Surg Pathol 1993;17:2534. mandibular reconstruction. J Maxillofac
1990;86:83544. 37. Hamner JE III, Scofield HH, Cornyn J. Benign Surg 1978;6:409.
22. Waldron CA. Fibro-osseous lesions of the jaws. fibro-osseous jaw lesions of periodontal 52. Webber PA, Hussain SS, Radcliffe GJ. Cartilagi-
J Oral Maxillofac Surg 1993;51:82835. membrane origin. An analysis of 249 cases. nous neoplasms of the head and neck (a
23. Melrose RJ, Abrams AM, Mills BG. Florid Cancer 1968;22:86178. report on four cases). J Laryngol Otol
osseous dysplasia. A clinical-pathologic 38. Waldron CA, Giansanti JS. Benign fibro- 1986;100:6159.
study of thirty-four cases. Oral Surg Oral osseous lesions of the jaws: a clinical- 53. Lingen MW, Solt DB, Polverini PJ. Unusual
Med Oral Pathol 1976; 41:6282. radiologic-histologic review of sixty-five presentation of a chondromyxoid fibroma
24. Neville BW, Albenesius RJ. The prevalence of cases. II. Benign fibro-osseous lesions of of the mandible. Report of a case and
benign fibro-osseous lesions of periodontal periodontal ligament origin. Oral Surg Oral review of the literature. Oral Surg Oral Med
ligament origin in black women: a radi- Med Oral Pathol 1973;35:34050. Oral Pathol 1993;75:61521.
ographic survey. Oral Surg Oral Med Oral 39. Dehner LP. Tumors of the mandible and max- 54. Batsakis JG, Raymond AK. Chondromyxoid
Pathol 1986;62:3404. illa in children. I. Clinicopathologic study fibroma. Ann Otol Rhinol Laryngol
25. Summerlin DJ, Tomich CE. Focal cemento- of 46 histologically benign lesions. Cancer 1989;98:5712.
osseous dysplasia: a clinicopathologic study 1973;31:36484. 55. Fujii N, Eliseo ML. Chondromyxoid fibroma of
of 221 cases. Oral Surg Oral Med Oral 40. Eversole LR, Leider AS, Nelson K. Ossifying the maxilla. J Oral Maxillofac Surg
Pathol 1994;78:61120. fibroma: a clinicopathologic study of sixty- 1988;46:2358.
26. Ariji Y, Ariji E, Higuchi Y, et al. Florid cemento- four cases. Oral Surg Oral Med Oral Pathol 56. Lustmann J, Gazit D, Ulmansky M, Lewin-
osseous dysplasia. Radiographic study with 1985;60:50511. Epstein J. Chondromyxoid fibroma of the
special emphasis on computed tomogra- 41. Said-al-Naief NA, Surwillo E. Florid osseous jaws: a clinicopathological study. J Oral
phy. Oral Surg Oral Med Oral Pathol dysplasia of the mandible: report of a case. Pathol 1986;15:3436.
1994;78:3916. Compend Contin Educ Dent 1999;20: 57. Browne RM, Rivas PH. Chondromyxoid fibro-
27. Slater L. Fibro-osseous lesions. Oral Maxillofac 10179, 102232. ma of the mandible: a case report. Br J Oral
Knowledge Update 1995;1:3347. 42. Commins DJ, Tolley NS, Milford CA. Fibrous Surg 1977;15:1925.
28. Schneider LC, Mesa ML. Differences between dysplasia and ossifying fibroma of the 58. Gallia L, Tideman H, Bronkhorst F. Chon-
florid osseous dysplasia and chronic diffuse paranasal sinuses. J Laryngol Otol 1998; drosarcoma of mandible misdiagnosed as
sclerosing osteomyelitis. Oral Surg Oral 112:9648. chondromyxoid fibroma. Int J Oral Surg
Med Oral Pathol 1990;70:30812. 43. Johnson L. Proceedings of the Seminar of the 1980;9:2214.
29. Marx RE, Carlson ER, Smith BR, Toraya N. Iso- Southwestern and South-Central Regions, 59. Chandu A, Spencer JA, Dyson DP. Chondroma
lation of Actinomyces species and Eikenella College of American Pathologists; 1952. of the mandibular condyle: an example of a
Benign Nonodontogenic Lesions of the Jaws 615
rare tumour. Dentomaxillofac Radiol droma of the mandibular condyle: literature 90. Flanagan AM, Nul B, Tinkler SM, et al., The
1977;26:2425. review and report of two atypical cases. J multinucleate cells in giant cell granulomas
60. Lurie R. Solitary enchondroma of the Oral Maxillofac Surg 1995;53:95463. of the jaw are osteoclasts. Cancer
mandibular condyle: a review and case 75. Wang-Norderud R, Ragab RR. Osteocartilagi- 1988;62:113945.
report. J Dent Assoc S Afr 1975;30:58993. nous exostosis of the mandibular condyle. 91. OMalley MP, Pogrel MA, Stewart JC, Silva RG,
61. Schneider LC, Dolinsky HB, Grodjesk JE. Soli- Case report. Scand J Plast Reconstr Surg Regezi JA. Central giant cell granulomas of
tary peripheral osteoma of the jaws: report 1975;9:1659. the jaws; phenotype and proliferation-
of case and review of literature. J Oral Surg 76. Peroz I, Scholman HJ, Hell B. Osteochondroma associated markers. J Oral Pathol Med
1980;38:4525. of the mandibular condyle: a case report. 1997;26:15963.
62. Gardner E, Stevens F. Cancer of the lower Int J Oral Maxillofac Surg 2002;31:4556. 92. Stern ME, Eisenbud L. Manangement of giant
digestive tract in one family group. Am J 77. Wolford L, Mehra P, Franco P. Use of conserv- cell lesions of the jaws. Oral Maxillofac Surg
Hum Genet 1955;2:418. ative condylectomy for treatment of osteo- Clin North Am 1991;3:16571.
63. Payne M, Anderson J, Cook J. Gardners syn- chondroma of the mandibular condyle. J 93. Whitaker S. Giant cell lesions of the jaws. Oral
dromea case report. Br Dent J 2002; Oral Maxillofac Surg 2002;60:2628. Surg Oral Med Oral Pathol 1993;
193:3834. 78. Hopkins KM, Huttula CS, Kahn MA, Albright 75:199208.
64. Takeuchi T, Takenoshita Y, Kubo K, Iida M. JE. Desmoplastic fibroma of the mandible: 94. Pogrel MA, Regezi JA, Harris ST, Goldring SR.
Natural course of jaw lesions in patients review and report of two cases. J Oral Max- Calcitonin treatment for central giant cell
with familial adenomatosis coli (Gardners illofac Surg 1996;54:124954. granulomas of the mandible: report of two
syndrome). Int J Oral Maxillofac Surg 79. Iwai S, Matsumoto K, Sakuda M. Desmoplastic cases. J Oral Maxillofac Surg 1999;57:84853.
1993;22:22630. fibroma of the mandible mimicking 95. Jacoway J, Howell FV, Terry BC. Central giant
65. Halling F, Merten HA, Lepsien G, Honig JF. osteogenic sarcoma: report of a case. J Oral cell granuloma: an alternative to surgical
Clinical and radiological findings in Gard- Maxillofac Surg 1996;54:13703. therapy. Oral Surg Oral Med Oral Pathol
ners syndrome: a case report and follow-up 80. Sanfilippo NJ, Wang GJ, Larner JM. Desmo- 1988;66:572.
study. Dentomaxillofac Radiol 1992; plastic fibroma: a role for radiotherapy? 96. Terry BJJ. Management of central giant cell
21:938. South Med J 1995;88:12679. lesions: an alternative to surgical therapy.
66. Yuwono M, Rossi TM, Fisher JE, Tjota A. 81. Kwon PH, Horswell BB, Gatto DJ. Desmoplas- Oral Maxillofac Surg Clin North Am
Oncogene expression in patients with tic fibroma of the jaws: surgical manage- 1994;6:579600.
familial polyposis coli/Gardners syndrome. ment and review of the literature. Head 97. Kermer C, Millesi W, Watzke IM. Local injec-
Int Arch Allergy Immunol 1996;111:8995. Neck 1989;11:6775. tion of corticosteroids for central giant cell
67. Davies DR, Armstrong JG, Thakker N, et al. 82. Yamaguchi T, Dorfman HD. Giant cell repara- granuloma. A case report. Int J Oral Max-
Severe Gardner syndrome in families with tive granuloma: a comparative clinico- illofac Surg 1994;23:3668.
mutations restricted to a specific region of pathologic study of lesions in gnathic and 98. Carlos R, Sedano HO. Intralesional cortico-
the APC gene. Am J Hum Genet extragnathic sites. Int J Surg Pathol steroids as an alternative treatment for cen-
1995;57:11518. 2001;9:189200. tral giant cell granuloma. Oral Surg Oral
68. Dangel A, Meloni AM, Lynch HT, Sandberg 83. Jaffe H. Giant cell reparative granuloma, trau- Med Oral Pathol Oral Radiol Endod
AA. Deletion (5q) in a desmoid tumor of a matic bone cysts and fibrous (fibroosseous) 2002;93:1616.
patient with Gardners syndrome. Cancer dysplasia of jaw bones. J Oral Surg 99. Harris M. Central giant cell granulomas of the
Genet Cytogenet 1994;78:948. 1953;6:15975. jaws regress with calcitonin therapy. Br J
69. Miyamoto H, Sakashita H, Wilson DF, Goss 84. Bernier J, Cahn LR. The peripheral giant cell Oral Maxillofac Surg 1993;31:8994.
AN. Synovial chondromatosis of the tem- reparative granuloma. J Am Dent Assoc 100. ORegan EM, Gibb DH, Odell EW. Rapid
poromandibular joint. Br J Oral Maxillofac 1954;49:1418. growth of giant cell granuloma in pregnan-
Surg 2000;38:2058. 85. Bernier J. The management of oral diseases. St. cy treated with calcitonin. Oral Surg Oral
70. Tominaga K, Fujiki T, Mizuno A, et al. Synovial Louis: Mosby; 1955. Med Oral Pathol Oral Radiol Endod
chondromatosis of the temporomandibular 86. Worth H. Principles and practice of oral radi- 2001;92:5328.
joint. Dentomaxillofac Radiol 1995;24:5962. ology interpretation. Chicago: Chicago Year 101. Lannon DA, Earley MJ. Cherubism and its
71. Reinish EI, Feinberg SE, Devaney K. Primary Book Medical Publishers; 1963. charlatans. Br J Plast Surg 2001;54:70811.
synovial chondromatosis of the temporo- 87. Chuong R, Kaban LB, Kozakewich H, Perez- 102. de Lange J, Rosenberg AJ, van den Akker HP, et
mandibular joint with suspected traumatic Atayde A. Central giant cell lesions of the al. Treatment of central giant cell granulo-
etiology. Report of a case. Int J Oral Max- jaws: a clinicopathologic study. J Oral Max- ma of the jaw with calcitonin. Int J Oral
illofac Surg 1997;26:41922. illofac Surg 1986;44:70813. Maxillofac Surg 1999;28:3726.
72. Avdin M, Kurtay A, Celebioglu S. A case of syn- 88. Eckardt A, Pogrel MA, Kaban LB, et al. Central 103. Rosenberg AJ, Bosschaart AN, Jacobs JW, et al.
ovial chondromatosis of the TMJ: treat- giant cell granulomas of the jaws. Nuclear [Calcitonin therapy in large or recurrent cen-
ment based on stage of the disease. J Cran- DNA analysis using image cytometry. Int J tral giant cell granulomas of the lower jaw].
iomaxillofac Surg 2002;13:6705. Oral Maxillofac Surg 1989;18:36. Ned Tijdschr Geneeskd 1997;141:3359.
73. Saito T, Utsunomiya T, Furutani M, Yamamoto 89. Ficarra G, Kaban LB, Hansen LS. Central giant 104. Penfold CN, Evans BT. Giant cell lesions com-
H. Osteochondroma of the mandibular cell lesions of the mandible and maxilla: a plicating Pagets disease of bone and their
condyle: a case report and review of the lit- clinicopathologic and cytometric study. response to calcitonin therapy. Br J Oral
erature. J Oral Sci 2001;43:2937. Oral Surg Oral Med Oral Pathol Maxillofac Surg 1993;31:267.
74. Vezeau PJ, Fridrich KL, Vincent SD. Osteochon- 1987;64:449. 105. Pogrel MA. Alternative therapies for the central
616 Part 5: Maxillofacial Pathology
giant cell granuloma. J Oral Maxillofac Surg mandible by direct puncture and embolisa- 125. Jaffe R. The histiocytoses. Clin Lab Med 1999;
2003;61:64953. tion with N-butyl-cyanoacrylate (NBCA). 19:13555.
106. Kaban LB, Mulliken JB, Ezekowitz RA, et al. Oral Oncol 2001;37:6058. 126. Watzke IM, Millesi W, Kermer C, Gisslinger H.
Antiangiogenic therapy of a recurrent giant 117. Bunel K, Sindet-Pedersen S. Central heman- Multifocal eosinophilic granuloma of the
cell tumor of the mandible with interferon gioma of the mandible. Oral Surg Oral Med jaw: long-term follow-up of a novel
alfa-2a. Pediatrics 1999;103:11459. Oral Pathol 1993;75:56570. intraosseous corticoid treatment for recal-
107. Kaban LB, Troulis MJ, Ebb D, et al. Antiangio- 118. Ozdemir R, Alagoz S, Uysal AC, et al. citrant lesions. Oral Surg Oral Med Oral
genic therapy with interferon alpha for Intraosseous hemangioma of the mandible: Pathol Oral Radiol Endod 2000; 90:31722.
giant cell lesions of the jaws. J Oral Maxillo- a case report and review of the literature. J 127. Roper-Hall HT. Cysts of developmental origin in
fac Surg 2002;60:110313. Craniomaxillofac Surg 2002;13:3843. the premaxillary region, with special reference
108. Hunter D. Hyperparathyroidism: generalised 119. Beziat J, Marcelino J, Bascoulergue Y, Vitrey D. to their diagnosis. Br Dent J 1938;65:40534.
osteitis fibrosa. Br J Surg 1931;19:20384. Central vascular malformation of the 128. Howe GL. Hemorrhagic cysts of the mandible.
109. Jones WA. Familial multi-locular cystic disease mandible: a case report. J Oral Maxillofac Br J Oral Surg 1965;3:5576.
of the jaws. Am J Cancer 1933;17:94650. Surg 1997;55:4159. 129. Toller P. Radioactive isotope and other investi-
110. Tiziani V, Reichenberger E, Buzzo CL, et al. The 120. Lichtenstein L. Histiocytosis X. Integration of gations in case of haemorrhagic cyst of the
gene for cherubism maps to chromosome eosinophilic granuloma of bone, Letterer- mandible. Br J Oral Surg 1964;2:8693.
4p16. Am J Hum Genet 1999;65:15866. Siwe disease and Schuller-Christian disease 130. Pogrel M. Bilateral solitary bone cysts: report
111. Mangion J, Rahman N, Edkins S, et al. The as related manifestations of a single nosolog- of case. J Oral Surg 1978;36:558.
gene for cherubism maps to chromosome ic. AMA Arch Pathol 1953;56:84102. 131. Stafne EC. Bone cavities situated near the angle
4p16.3. Am J Hum Genet 1999;65:1517. 121. Arico M, Danesino C. Langerhans cell histio- of the mandible. J Am Dent Assoc
112. Southgate J, Sarma U, Townend JV, et al. Study cytosisis there a role for genetics? 1942;29:196972.
of the cell biology and biochemistry of Haematologica 2001;86:100914. 132. Pogrel MA. The results of microneurosurgery
cherubism. J Clin Pathol 1998;51:8317. 122. Willman C, Busque L, Griffith B, et al. Langer- of the inferior alveolar and lingual nerve.
113. Kaban LB, Mulliken JB. Vascular anomalies of hans cell histiocytosis (histiocytosis X)a J Oral Maxillofac Surg 2002;60:4859.
the maxillofacial region. J Oral Maxillofac clonal proliferative disease. N Engl J Med 133. Paget J. On a form of chronic inflammation of
Surg 1986;44:20313. 1994;331:1546. bone (osteitis deformans). Trans R Medico
114. Lamberg MA, Tasanen A, Jaaskelainen J. Fatal- 123. Kawakubo Y, Kishimoto H, Sato Y, et al. Chirurg Soc 1876;60:3763.
ity from central hemangioma of the Human cytomegalovirus infection in foci 134. Schneider D, Hofmann M, Peterson J. Diagno-
mandible. J Oral Surg 1979;37:57884. of Langerhans cell histiocytosis. Virchows sis and treatment of Pagets disease of bone.
115. Perrott D, Schmidt B, Dowd C, Kaban L. Treat- Arch 1999;434:10915. Am Fam Physician 2002;65:206972.
ment of a high-flow arteriovenous malfor- 124. Boutsen Y, Esselinckx W, Delos M, Nisolle JF. 135. Fisher K, Pogrel MA. Gorhams syndrome
mation by direct puncture and coil Adult onset of multifocal eosinophilic (massive osteolysis): a case report. J Oral
embolization. J Oral Maxillofac Surg granuloma of bone: a long-term follow-up Maxillofac Surg 1990;48:12225.
1994;52:10836. with evaluation of various treatment 136. Gorham LW, Wright AW, Schultz HH, et al.
116. Kaneko R, Tohnai I, Ueda M, et al. Curative options and spontaneous healing. Clin Disappearing bones: a rare form of massive
treatment of central hemangioma in the Rheumatol 1999;18:6973. osteolysis. Am J Med 1954;17:67482.
CHAPTER 32
Estimates indicate that more than vival again fails to hold true for the combination of various carcinogens with-
1.3 million new cancers will be diagnosed African American population.1 in tobacco, combined with the heat, may
in the United States this year, and 27,700 Approximately 85 to 95% of all oral lead to a variable number of genetic muta-
will be located in the mouth and cancer is squamous cell carcinoma tions in the epithelium of the upper
oropharynx.1 This number represents (SCC).3,4 However, multiple other malig- aerodigestive tract. At some point these
approximately 3% of all cancers and is nant lesions can be found in the oral cavi- continued mutations, coupled with the
the eighth most common cancer affecting ty such as sarcoma, minor salivary gland patients own inherent genetic susceptibil-
males in the United States. Globally, more tumors, mucosal melanoma, lymphoma, ity, expressed in the hetero- or homogene-
than 360,000 new cases of oral cancer will or metastatic disease from nearly any site ity of certain tumor suppressor genes or
be diagnosed this year.2 Mortality rates in the body. oncogenes (TP53, c-myc), may lead to the
remain high despite some advances in development of a cell line capable of
locoregional control. There will be Risk Factors for SCC of the unregulated growth.
approximately 200,000 deaths worldwide, Oral Cavity Alcohol in itself is not a recognized
of which 7,200 will occur in the United The etiology of SCC of the oral cavity has initiator in the development of oral SCC.
States. Most patients will present for been studied extensively. Numerous risk However, the role of alcohol as a promot-
diagnosis with either regional or distant factors have been suggested as etiologic er in the development of oral cancer
disease. Data have shown a trend for agents for the development of these malig- when coupled with the use of smoking
African Americans to have more nancies. While no single causative agent tobacco has been shown.10 This may be
advanced disease compared with white can be attributed to the development of all related to the effects of contaminants in
Americans (68% vs 52%) at the time of oral cancers, several carcinogens have been alcohol and its ability to solubilize car-
diagnosis. Even more alarming is the fact identified, and of those tobacco and alco- cinogens and enhance their penetration
that, when compared with equal stages at hol appear to have the greatest impact on into oral mucosa.5,11
the time of diagnosis, African Americans malignancy development. Both extrinsic A possible viral etiology has been
have a poorer 5-year relative survival rate and intrinsic factors likely play a role in demonstrated in oral cancers, especially by
compared with other races. A review of the development of SCC of the oral cavity. the human papilloma virus (HPV). The
trends in 5-year relative survival rates The risk of oral cancer associated with HPV subtypes 16 and 18, similar to those
over the past three decades has shown a tobacco use is noted to be 2 to 12 times causing cervical cancer, have been implicat-
statistical difference between the time higher than in the nonsmoking popula- ed. Smith and colleagues showed that when
periods of 1974 to 1976 and 1992 to 1996 tion, and 90% of individuals with oral individuals in his study had other risk fac-
(54% vs 59%); the improvement in sur- cancer will have a smoking history.59 The tors adjusted, such as smoking, alcohol, and
618 Part 5: Maxillofacial Pathology
age, the presence of HPV in the oral cavity not necessarily alter the appearance of the
was associated with a 3.7 times greater mucosa but may be associated with a
chance of cancer development than in the greater risk for the development of can-
noninfected individual.12 Other authors cer.21 Precancerous lesions are broadly
have noted a unique subset of characteris- classified as leukoplakia and erythroplakia.
tics in individuals that may develop SCC as Leukoplakia is defined as a white
a result of HPV infection, showing less patch or plaque that cannot be character-
association with tobacco or alcohol abuse, ized clinically or ascribed to any other
frequently involving the tonsils, and having pathologic disease.22 Leukoplakia cannot
an improved prognosis.13 be scraped or rubbed off and is therefore
The study of the tumor biology of primarily a diagnosis of exclusion. Lesions FIGURE 32-2 Common presentation of prolifer-
SCC has exploded in the past decade. The caused by lichen planus, white sponge ative verrucous variant of leukoplakia on gingiva.
accepted molecular theory concerning nevus, nicotine stomatitis, or other
genetic alterations of SCC is that of a plaque-causing diseases do not qualify as The only consistent histology found in
multihit tumorigenesis ultimately lead- leukoplakia. Leukoplakia is strictly a clini- all leukoplakia is the presence of hyperker-
ing to unregulated cell growth and func- cal diagnosis and does not imply any spe- atosis. The underlying epithelium may range
tion.14,15 It is thought that multiple exoge- cific histologic diagnosis. Leukoplakia is from normal to invasive carcinoma. The true
nous insults (tobacco, alcohol, viral) can generally asymptomatic and clinically etiology for the development of leukoplakia
lead to activation of oncogenes or inacti- appears as a white or off-white lesion that is unknown; however, several causative fac-
vation of tumor suppressor genes. Onco- may be flat, slightly elevated, rugated, or tors have been proposed. Tobacco use,
gene dysregulation leads to a gain of func- smooth (Figure 32-1). It may be found as whether smoked or smokeless, is most close-
tion alteration, and transforming growth isolated or multifocal lesions and may ly associated with the development of leuko-
factor alpha (TGF-) and eukaryotic initi- change in morphology over time. More plakia, and more than 70% of patients with
ation factor 4E (eIF4E) are two examples than 70% of the time leukoplakia occurs leukoplakia are smokers.23 While several
of well-studied genes that have proven up- on two or more surfaces and has a strong studies have shown elimination of tobacco
regulation in SCC.16 Loss of tumor sup- male predilection.23,24 A more aggressive use to be associated with resolution or
pressor gene function requires loss of both variant exists and is referred to as prolifer- decrease in the size of the lesion, others have
normal alleles, which leads to the inactiva- ative verrucous leukoplakia (Figure 32-2). shown poor improvement with its cessation.
tion of the critical function of that gene. The lower lip vermilion, buccal mucosa, Ultraviolet radiation to the lower lip
The most studied of the tumor suppressor and gingiva account for most oral cavity is frequently observed in the development
genes are TP53 and P16.15,1719 No single leukoplakia; however, lesions found on the of lower lip vermilion leukoplakia. Indi-
gene alteration is responsible for carcino- tongue and floor of the mouth account for viduals with chronic unprotected expo-
genesis, but rather a host of altered genes most lesions exhibiting dysplasia or carci- sure to sunlight are at highest risk for
contribute. Attempts have been made to noma.2326 These relative frequencies development. These leukoplakia lesions
use genes and their products to identify change with different geographic locations are frequently associated with actinic
oncologically safe margins operatively and are based on local habits. cheilitis (Figure 32-3).27
with minimal success.20 Gene therapy tri-
als that target these specific genes hold
better promise.
Premalignant Disease
Premalignant disease can be divided into
that occurring as an isolated lesion or that
associated with a condition. A precancer-
ous lesion is defined as morphologically
altered tissue in which the development of
malignancy is more likely than with nor-
mal mucosa. A precancerous condition is a FIGURE 32-1 Typical appearance of floor-of- FIGURE 32-3 Actinic cheilitis of the lower lip
condition or generalized disease that does mouth leukoplakia. secondary to chronic unprotected sun exposure.
Oral Cancer: Classification, Staging, and Diagnosis 619
Trauma is also associated with the disease (Figure 32-4). Almost all true ery-
development of leukoplakic lesions. Ill- throplakia demonstrates dysplasia, carci-
fitting dentures, sharp edges on oral pros- noma in situ, or invasive carcinoma.
theses or teeth, or parafunctional oral Shafer and Waldrons review of biopsies
habits with objects such as toothpicks can submitted under this clinical diagnosis
be associated with leukoplakia. Obvious revealed that 51% were invasive SCC, 40%
traumatic lesions to the buccal mucosa were carcinoma in situ or severe dysplasia,
such as the development of a linea alba are and 9% were mild to moderate dysplasia.29
not considered leukoplakia. The most common sites of occurrence are
The frequency of dysplasia and carci- the floor of the mouth and retromolar
noma within leukoplakia is most closely trigone. Lesions appear as bright red, are FIGURE 32-5 Typical appearance of ery-
associated with the lesions location and frequently velvety in appearance, and throleukoplakia on labial and buccal mucosa.
patients habits. Waldron and Shafer in have a sharply demarcated border. The eti-
their study of 3,256 lesions submitted to ology of these lesions is unknown but and difficulty with speech and swallowing.
their respective oral pathology depart- thought to be the same as that for leuko- Unlike tobacco pouch keratosis, OSF does
ments as leukoplakia found that 43% of plakia. Frequently these lesions are noted not regress with the cessation of betel quid
floor-of-mouth lesions and 24% of both to be nonhomogeneous in appearance use. Longitudinal studies have shown a
tongue and lip lesions contained some with adjacent or intralesional leukoplakia. malignant transformation rate of 7.6%
degree of dysplasia or carcinoma.25 Sever- When observed with this morphology, over a 17-year period.32
al studies have also looked at malignant they are referred to as erythroleukoplakia
transformation over time and found it to or speckled erythroplakia (Figure 32-5). Cervical Lymph Node Levels
vary from 0.13 to 17.5%.2326,28 The results These lesions also harbor an ominous The neck is divided into six surgical lev-
of these studies vary according to suspect- potential as rates of malignant transfor- els based on anatomic structures (Figure
ed causes of the leukoplakia (geographic mation have been noted of up to 23%.23 32-6). Each anatomic area of the oral cav-
habits) and the length of follow-up or time Oral submucous fibrosis (OSF) is a ity has a predictable lymphatic drainage
to biopsy of the lesion. The malignant precancerous condition seen predomi- pattern to the over 300 lymph nodes in the
transformation of these lesions has been nantly in India and Southeast Asia. It is a
studied extensively by Silverman and col- chronic, progressive mucosal disorder
leagues.23 They note that, while a definite most frequently associated with the habit
rate of transformation cannot be stated, of chewing betel quids; however, there is
their 257 patients had a 17.5% transfor- evidence that this lesion is multifactorial
mation rate with an average follow-up in nature with genetic, immunologic,
time of 7.1 years. The second year of nutritional, and autoimmune factors pos-
follow-up in their series exhibited the sibly involved.30,31 The condition is charac-
greatest rate of malignant transformation terized by a mucosal rigidity that leads to
at 5%. If those lesions initially noted to be trismus, odynophagia with spicy foods,
dysplastic on biopsy were followed, they
had an even higher rate of malignant I
II
transformation, at 36.4%. Earlier studies V
neck.33 By grouping defined nodal groups clavicle, superiorly by the horizontal plane aries, and in developing these sites the
into surgical levels, clinicians are afforded created by the inferior border of the cricoid AJCC has attempted to produce a means
the ability to communicate with each cartilage, anteriorly by the lateral border of of better studying and treating oral cancer.
other. It also allows clinicians to tailor the sternohyoid musculature, and posteri-
their surgical management of the neck orly by the lateral border of the SCM or Mucosal Lip
based on these known drainage patterns. sensory branches of the cervical plexus.34,35 The lip begins at the junction of the ver-
Level I includes the submental and Level V includes all the nodes in the milion border with the skin and includes
submandibular nodal groups. posterior triangle, the spinal accessory and only the vermilion surface or that portion
Level IA, the submental group, is transverse cervical nodes, and all of the of the lip that comes into contact with the
bounded by the hyoid bone inferiorly, upper, middle, and lower jugular lymph opposing lip. It is well defined into an
the mandibular symphysis superiorly, nodes on the posterior aspect of the SCM. upper and lower lip joined at the commis-
and the anterior bellies of the digastric Level VA is bounded inferiorly by the sures of the mouth.26 It is supported by the
muscles laterally. horizontal plane created by the inferior orbicularis oris muscle and receives its
Level IB, the submandibular group, is border of the cricoid cartilage, superiorly blood supply from branches of the facial
bounded by the posterior belly of the at the apex found at the convergence of artery. Sensory innervation is provided by
digastric inferiorly, the mandibular body the SCM and trapezius muscles, anterior- the mental nerve and motor function via
superiorly, the anterior belly of the digas- ly by the posterior belly of the SCM or branches of the facial nerve.
tric muscle anteriorly, and the stylohyoid sensory branches of the cervical plexus, Mucosal lip cancers represent
muscle posteriorly.34,35 and posteriorly by the anterior belly of the approximately 2 to 42% of oral cavity
Level II includes upper jugular lymph trapezius muscle. cancers.4,3741 Mucosal lip cancer is seen
nodes surrounding the internal jugular Level VB is bounded inferiorly by the almost exclusively in older white men as
vein and adjacent spinal accessory nerve. clavicles, superiorly by the horizontal plane a result of chronic sun exposure (Figure
Level IIA is bounded inferiorly by a created by the lower border of the hyoid 32-7). Its infrequent occurrence in dark-
horizontal plane made by the inferior bone, anteriorly by the posterior belly of skinned races is further evidence of its
body of the hyoid bone, superiorly by the the SCM or sensory branches of the cervi- etiology. Nodal metastasis in lip cancer is
skull base, anteriorly by the stylohyoid cal plexus, and posteriorly by the anterior infrequent, 10% of lower lip cancers and
muscle, and posteriorly by a vertical plane border of the trapezius muscle.34,35 20% of cancers in the upper lip and com-
defined by the spinal accessory nerve. Level VI includes the pretracheal, missure are found to metastasize to the
Level IIB is bounded inferiorly by a paratracheal, and prelaryngeal or so-called nodes.42 Metastasis from the lower lip is
horizontal plane made by the inferior Delphian lymph nodes. It is bounded infe- to the submental, submandibular, and
body of the hyoid bone, superiorly by the riorly by the suprasternal notch, superior- perifacial nodes (level I more commonly
skull base, anteriorly by a vertical plane ly by the hyoid bone, and laterally by the than level II). Preauricular, periparotid,
defined by the spinal accessory nerve, and common carotid arteries. This level is also and submandibular nodes drain cancers
posteriorly by the lateral border of the known as the anterior compartment.34,35 of the upper lip and commissure (level II
sternocleidomastoid muscle (SCM).34,35 more commonly than level I). Bilateral
Level III includes middle jugular Clinical Correlation
lymph nodes surrounding the internal Based on Site
jugular vein. It is bounded inferiorly by a The boundaries of the oral cavity extend
horizontal plane defined by the inferior from the vermiliocutaneous junction of
border of the cricoid cartilage, superiorly the lips to the junction of the hard and soft
by the horizontal plane defined by the palate posterior-superiorly and to the line
inferior body of the hyoid bone, anteriorly created by the circumvallate papilla poste-
by the lateral border of the sternohyoid rior-inferiorly. Posterior-laterally the
musculature, and posteriorly by the lateral boundaries are represented by the anterior
border of the SCM or sensory branches of faucial pillars. The American Joint Com-
the cervical plexus.34,35 mittee on Cancer (AJCC) has divided the
Level IV includes the lower jugular oral cavity into seven distinct anatomic
lymph nodes surrounding the internal locations from which primary lesions may FIGURE 32-7 Neglected carcinoma of the
jugular vein. It is bounded inferiorly by the develop.36 The sites have defined bound- lower lip.
Oral Cancer: Classification, Staging, and Diagnosis 621
neck metastasis may develop if the lower level of the posterior surface of the last
lip lesion is near or has crossed the mid- molar tooth superiorly to the tuberosity of
line; however, the upper lip rarely the maxilla. Laterally this area merges with
exhibits crossover between right- and buccal mucosa and medially is in continu-
left-side lymphatics.43 ity with the soft palate, anterior tonsillar
pillar, and floor of the mouth.36
Buccal Mucosa Tumors of the retromolar trigone fre-
Buccal mucosa includes all the lining of the quently involve adjacent anatomic sites at
inner surface of the cheeks and lips from the time of diagnosis (Figure 32-10). Pri-
the line of contact of the opposing lips mary symptomatic complaints with these
(mucovermilion junction) to the line of tumors are sore throat, otalgia, and tris-
attachment of mucosa to the alveolar ridge mus. Tumors of the retromolar trigone
(upper and lower) and pterygomandibular represent 2 to 6% of all oral cavity carci-
raphe.36 The buccal mucosa is supported nomas.4,38,39 Lymphatic drainage from this
by the buccinator muscle posteriorly and area is predominantly to the submandibu-
the obicularis oris anteriorly. The vascular lar nodes (level IB) and the upper jugu-
supply to the posterior aspect is derived lodigastric nodes (level II).46,52 Lesions of
from the buccal artery, a branch of the this region tend to be more aggressive in
internal maxillary artery; innervation is nature with regard to developing cervical
from the buccal branches of the facial metastasis, because 27 to 56% of individu-
nerve along with the long buccal branch of als present with metastatic disease.5355
FIGURE 32-8 Squamous cell carcinoma of the
the third division of the trigeminal nerve. left buccal mucosa.
Carcinoma of the buccal mucosa rep- Floor of the Mouth
resents 2 to 10% of all SCC of the oral The floor of the mouth is a semilunar
cavity (Figure 32-8).4,37,38,44 In Central terior margin is the upper end of the space over the mylohyoid and hyoglossus
and Southeast Asia the use of pan (a pterygopalatine arch.36 muscles, extending from the inner surface
combination of tobacco, betel nut, and Alveolar ridge or gingival carcinoma of the lower alveolar ridge to the under-
lime) has been linked to buccal mucosa represents 2 to 18% of oral cancers and surface of the tongue. Its posterior bound-
carcinoma and represents more than 40% occurs predominantly on the mandibular ary is the base of the anterior faucial pillar
of all oral cavity SCC.45 First-echelon alveolus (64 to 76%).4,3741,49,50 At diagno- of the tonsil. It is divided by the frenulum
lymphatic drainage from the buccal sis, approximately one-third of these of the tongue and contains the ostia of the
mucosa is level I followed by level II.46 tumors exhibit some bony involve- submandibular and sublingual salivary
Cervical metastases are observed in 10 to ment.50,51 Lymph node metastasis tends to glands.36 Anatomically it consists of the
27% of presenting patients.44,47,48 occur more frequently in mandibular
ridge tumors than in maxillary tumors.
Alveolar Ridge Nodal drainage is principally to levels I
The alveolar ridge mucosa may be divided and II for both the maxillary and
into lower (mandibular) and upper (max- mandibular lesions and is found in 24 to
illary) components. The mucosa overlying 28% of patients at diagnosis.46,49-51 Alveo-
the alveolar process of the mandible lar ridge carcinomas are frequently insidi-
extends from the line of attachment of ous tumors masquerading as inflammato-
mucosa in the buccal gutter to the line of ry lesions, periodontitis or gingivitis, tooth
free mucosa of the floor of the mouth. abscesses, or denture sores (Figure 32-9).
Posteriorly it extends to the ascending
ramus of the mandible.36 The mucosa Retromolar Gingiva
overlying the alveolar process of the max- (Retromolar Trigone)
illa extends from the line of attachment of The retromolar gingiva is a triangular FIGURE 32-9 Biopsy-proven squamous cell car-
cinoma of the mandibular alveolar ridge result-
mucosa in the upper gingival buccal gutter region of attached mucosa overlying the ing in erosion of underlying bone and loosening
to the junction of the hard palate. Its pos- ascending ramus of the mandible from the of dentition.
622 Part 5: Maxillofacial Pathology
middle jugulodigastric nodes (levels I, II, among individuals who develop disease at
and III). Studies have shown that nearly this site.
one-half of all patients presenting with a
floor-of-mouth carcinoma will have Anterior Two-Thirds of the
metastatic disease at presentation.5759 Tongue (Oral Tongue)
Shaha and colleagues demonstrated that The anterior two-thirds of the tongue is
60% of individuals with metastatic disease the freely mobile portion that extends
will have multiple levels involved.57 anteriorly from the line of circumvallate
papillae to the undersurface of the tongue
Hard Palate at the junction of the floor of the mouth.
The hard palate is between the upper alve- It has four areas: the tip, the lateral bor-
olar ridge and the mucous membrane cov- ders, the dorsum, and the undersurface
ering the palatine process of the maxillary (nonvillous ventral surface of the tongue).
bones. It extends from the inner surface of The undersurface of the tongue is consid-
the posterior edge of the palatine bone and ered a separate category by the World
can be divided into a hard and soft com- Health Organization.36 The tongue is
ponent.36 In the United States, only 25% of entirely a muscular structure composed of
palatal SCC occurs in the hard palate with the extrinsic muscles, the genioglossus,
75% occurring in the soft palate (anatom- hyoglossus, styloglossus, and palatoglos-
FIGURE 32-10 Ulcerative carcinoma of left ically a part of the oropharynx).6062 In sus, as well as the intrinsic muscles of the
retromolar trigone with extension towards the India and Southeast Asia, where reverse tongue. Blood supply to the tongue is from
anterior tonsillar pillar.
smoking is popular, the proportion of the paired lingual, sublingual, and deep
hard palate lesions is greater. lingual arteries. The tongue receives motor
unattached mucosa overlying the mylohy- The hard palate represents 3 to 6% of innervation via the hypoglossal nerve and
oid and hyoglossus muscles. all oral cavity SCC (Figure 32-12).4,3739 taste and sensation from lingual branches
Carcinoma of the floor of the mouth There is a paucity of lymphatics to the of the trigeminal nerve.
represents 8 to 25% of oral cavity SCC, and hard palate. Approximately 10 to 25% of In the United States, SCC of the
several studies have shown a fairly dramatic individuals present with evidence of tongue is found mainly on the anterior
increase in incidence (Figure 32-11).4,3841 metastasis, generally to levels I and II.61,63 two-thirds (75%), versus the posterior
Two distinct lymphatic drainage systems Hard palate lesions may also metastasize one-third (25%).64 Tongue carcinoma rep-
have been identified in the floor of the to retropharyngeal nodes or nodes that are resents 22 to 49% of all oral cancer diag-
mouth.56 The superficial system drains not palpable on a clinical examination or nosed (Figure 32-13).4,3741 Several epi-
bilaterally into the submandibular nodes readily removable with a traditional neck demiologic reviews have shown the
(level I), while the deep system drains into dissection. Nonhealing ulcers and poor- unfortunate trend of an increase in tongue
the ipsilateral submandibular, upper and fitting dentures are common complaints cancer and an alarming increase in the
FIGURE 32-11 Carcinoma of anterior floor of FIGURE 32-12 Carcinoma of the hard palate FIGURE 32-13 Carcinoma proliferating from
the mouth presents with induration, ulcera- with extension to alveolar mucosa. ventral tongue to encompass full thickness of the
tion, and mild tongue fixation. tongue.
Oral Cancer: Classification, Staging, and Diagnosis 623
incidence of those diagnosed before 45 Table 32-2 Regional Lymph Nodes (N)
years of age.40,41,6567 Lymphatic drainage
Node Description
of the oral tongue is principally to level II,
followed by levels III and I.46,52 Carcinoma NX Regional lymph nodes cannot be assessed
of the lateral border generally metastasizes N0 No regional lymph node metastasis
ipsilaterally, but SCC of the tip or body of N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
the tongue may exhibit bilateral metas- N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more
tases. Approximately 40% of patients have than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes,
evidence of clinical node metastasis at the none more than 6 cm in greatest dimension; or in bilateral or contralateral
time of diagnosis.68 lymph nodes, none more than 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more
Staging than 6 cm in greatest dimension
The TNM system devised by the AJCC is N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in
designed to stratify cancer patients into greatest dimension
different stages based on the characteris-
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm
tics of the primary tumor (T), regional in greatest dimension
lymph node metastasis (N), and distant N3 Metastasis in a lymph node more than 6 cm in greatest dimension
metastasis (M). It is an attempt to help Adapted from Greene FL et al.35,36
guide treatment and estimate patients
5-year survivability. T refers to the prima-
ry lesion and is graded on greatest dimen-
sion and presence of adjacent tissue infil- resection and designated with a p prefix measurement of the primary lesion
tration (Table 32-1). N refers to regional (pTNM) or at autopsy with an a (aTNM). before biopsy is essential. Often, biopsied
lymph node involvement and is graded on If synchronous tumors are found at pre- SCCs are referred without accurate mea-
the presence of nodes, greatest dimension, sentation, the higher stage tumor should surements, leaving the treating surgeon
and side of involvement in relation to the be used for stage designation, and an m in a difficult situation relative to proper-
primary tumor (Table 32-2). M grades dis- suffix may be used to denote the multiple ly assigning a T group. Additionally,
tant metastasis and is based simply on its primary tumors (TmNM).36,69 postbiopsy inflammation could lead to
presence (M1) or absence (M0). The AJCC over- or underestimates of the lesions
staging system (Table 32-3) is designed for Assessment of Primary Lesion true dimensions.
clinical use; however, the patient may be Proper lesional assessment is based on a A complete evaluation of all anatomic
restaged based on final pathology after thorough clinical evaluation. Accurate locations within the oral cavity must be
performed by visual examination and pal-
Table 32-1 Primary Tumors (T) pation to detect any mucosal abnormality.
The goal in evaluating the patient is to
Tumor Description
detect any abnormal tissue and assess the
TX Primary tumor cannot be assessed extent of disease. Patients may present with
T0 No evidence of primary tumor myriad complaints such as a nonhealing
Tis Carcinoma in situ sore in the mouth, loosening of teeth, ill-
T1 Tumor 2 cm or less in greatest dimension
fitting dental prosthesis, trismus, otalgia, or
weight loss. Examination of the oral cavity
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension
should include removal of all dental appli-
T3 Tumor more than 4 cm in greatest dimension ances and use of a dental mirror for indi-
T4a* Tumor invades adjacent structures (eg, through cortical bone, into deep rect evaluation of the nasopharynx and
[extrinsic] muscle of the tongue, maxillary sinus, skin of face) (resectable) hypopharynx. Bimanual palpation is criti-
T4b Tumor invades masticator space, pterygoid plates, or skull base or encases cal to assess any involvement of structures
internal carotid artery (unresectable) such as the deep musculature of the
*Superficial erosion alone of bone or tooth socket by an alveolar primary is not sufficient to classify a tumor as T4. tongue, floor of the mouth, buccal mucosa,
Adapted from Greene FL et al.35,36
salivary structures, or bony mandibular
624 Part 5: Maxillofacial Pathology
Table 32-3 Stage Grouping patients versus patients whose primary an often asymptomatic synchronous
tumor was thick (> 2 mm), who had a lesion. McGuirt reported a synchronous
Stage Characteristics
45.6% failure rate and metastatic node dis- primary lesion rate of 16% in his prospec-
Stage 0 Tis N0 M0 ease was present in 38%. Rarely, primary tive study of 100 head and neck cancer
tumors may be located in areas that are patients.76 The discovery of the synchro-
Stage I T1 N0 M0 difficult to assess or may be painful to nous lesions frequently led to an alteration
assess, requiring an evaluation under anes- in the treatment plan of the index lesion.
Stage II T2 N0 M0
thesia along with panendoscopy. Other reported incidences of synchronous
Panendoscopy, or triple endoscopy, primary tumors range from 2 to 9%.7781
Stage III T3 N0 M0
T1 N1 M0
involves the use of a rigid bronchoscope, Panendoscopy can be performed quickly
T2 N1 M0 esophagoscope, and laryngoscope to and at a minimal price for the patient in
T3 N1 M0 sequentially examine and take biopsies, if terms of cost and added morbidity.
required, from the aerodigestive tract. The availability of flexible endoscopes,
Stage IVA T4a N0 M0 Warren and Gates first described the especially nasopharyngoscopes, has led to
T4a N1 M0 notion of synchronous and metachronous their use in many institutions, along with
T1 N2 M0 tumors in 1932.73 A synchronous tumor is the conversion to flexible bronchoscopes
T2 N2 M0 described as a second histologically con- and esophagoscopes. Additionally with the
T3 N2 M0 firmed malignancy. This malignancy must advent of tomographic imaging, routine
T4a N2 M0 be distinct and geographically separated preoperative panendoscopy is currently
by normal non-neoplastic mucosa and not undergoing reevaluation in many institu-
Stage IVB Any T N3 M0
of metastatic origin from the index lesion. tions. Many authors believe that the low
T4b Any N M0
It must also be discovered at the time of yield of bronchoscopy compared with
Stage IVC Any T Any N M1
initial tumor evaluation. If the second pri- chest imaging should preclude its use,
35,36
mary tumor is discovered at a later time it while others have called for selective
Adapted from Greene FL et al.
is considered a metachronous tumor. endoscopy to investigate only symptom-
Slaughter and colleagues described the driven complaints.8184 Should multiple
structures. Assessment of the lateral tongue concept of field cancerization secondary primary tumors be discovered during
and posterior pharynx is assisted by anteri- to the panmucosal effects of smoked tobac- patient evaluation, each lesion should be
or and lateral traction on the tongue with co irritants and alcohol.74 This theory staged separately.
cotton gauze (Figure 32-14). explains the relatively high prevalence of
The AJCC describes the possible second primary malignancies in the upper Assessment of
growth patterns of a tumor as endophytic, aerodigestive tract and has been described Regional Metastasis
exophytic, or ulcerated.36 These character- on a molecular level.75 Panendoscopy Evaluation of the neck is perhaps the most
istics play no part in staging the primary became the gold standard for discovering critical and difficult aspect of staging oral
tumor. While depth of invasion is not used or any head and neck cancer. The presence
to clinically stage the patient, several stud- of a single lymph node with metastatic dis-
ies have shown that depth of invasion does ease reduces the patients 5-year survival by
play a prognostic role in the development 50%. In turn, the presence of extracapsular
of regional metastasis, especially in tongue spread decreases this survival by another
and floor-of-mouth cancers.7072 The 50%.85 A retrospective study by Snow and
study performed by Spiro and coworkers colleagues showed a surprisingly high rate
at Memorial Sloan-Kettering Cancer Cen- of extracapsular tumor spread in even
ter looked at primary tumor thickness in small lymph nodes. His analysis showed
relation to risk of cervical node metastasis that lymph nodes greater than 3 cm had a
in SCC of the tongue and floor of the 73.7% chance of extracapsular spread, 2 to
mouth.70 They found that patients with 3 cm a 53.3% chance, 1 to 2 cm a 44.3%,
FIGURE 32-14 Anterior manual traction of
thin (< 2 mm) cancer of these respective and less than 1 cm a 28.8% chance.86 Other
the tongue with the aid of a cotton gauze
areas had a failure rate of 1.9% and lymph improves visualization of this lateral and ven- studies have concurred with this high rate
node metastasis present in 7.5% of tral tongue mass. of extracapsular spread.87,88 These drastic
Oral Cancer: Classification, Staging, and Diagnosis 625
reductions in long-term survival under- clinically palpable node and also in the
score the importance of preoperative stag- ability to assess its size. A study by Alder-
ing for an appropriate prognosis and treat- son and colleagues showed that both res-
ment plan. It should be noted that staging idents and staff involved in the treatment
depends not on specific lymph node level of head and neck malignancies consis-
involvement, but rather on presence of tently underestimated the size of smaller
nodes, size, number, and whether they are nodes, and accuracy of assessment was
ipsilateral, contralateral, or bilateral in rela- independent of experience.90
tion to the lesion. With the advent of advanced imaging,
Traditionally, the gold standard in both computed tomography (CT) and mag-
staging the neck has been through digital netic resonance imaging (MRI) have been
palpation of all levels of the neck bilateral- used as adjuncts to the physical examination
FIGURE 32-15 Axial computed tomography
ly. The neck has a large number of palpa- for both evaluating nodal disease and help-
scan with contrast demonstrates large right cer-
ble structures and a large area to be sur- ing to delineate the nodes in relation to vital vical node with criteria for regional metastasis.
veyed for the presence of lymph nodes. structures such as the carotid artery. Studies
While there is no correct order in which to have shown that clinically negative tumor-
evaluate the neck, each clinician should positive nodes may be detected on CT or lymph node pathology; however, the fat
develop a sequence to use consistently to MRI in 7.5 to 19% of cases.9196 that surrounds the cervical lymph nodes
avoid missing any part of the examination. can interfere with imaging detection. The
Observation of the neck is important to Computed Tomography T1-weighted, fat-suppressed contrast-
note any asymmetries or skin changes. CT is generally performed preoperatively enhanced image is perhaps the optimal
Most clinicians prefer to palpate the neck with intravenous contrast to help delineate sequence to evaluate cervical metastatic
standing behind the patient, simultane- vascular from lymph structures. The scan disease.92,97 MRI provides the distinct
ously palpating each aspect of the neck. generally involves 3- to 5-mm slices from advantage of viewing the neck and prima-
We find it helpful to break the neck down the skull base to the clavicles. Important ry tumor in planes not available by CT.
into muscular triangles and examine them radiographic markers for the presence of Difficulty with the use of MRI concerns
sequentially from the submandibular tri- suspicious adenopathy include lymph node both the time and motionlessness
angle to the posterior triangle. Lymph size, shape, and central necrosis. A lymph required for an acceptable study to be per-
node chains should be evaluated for the node is considered abnormal when it is formed. Individuals with oral cancer fre-
presence of palpable masses, noting their greater than 1.5 cm in the jugulodigastric quently have large lesions that may com-
size, surgical neck level, and whether the region or greater than 1 cm in other regions promise the airway while supine for
mass is fixed or moveable. Bending the of the neck.92,96 Shape has been suggested as extended periods of time. When using
patients head forward or slightly to the a criterion to help distinguish pathologic MRI for evaluating the neck the same cri-
side will ease taut tissues of the neck allow- nodes. The shape of a normal or hyperplas- teria concerning nodal size, shape, and
ing for better palpation. Other important tic lymph node resembles a bean, as central necrosis should be applied as
palpable structures of the neck to be eval- opposed to round or sphere-like metastatic when evaluating with CT.
uated in the examination include the nodes frequently present. Next to size, the
parotid gland, the thyroid gland, and the most specific indicator of metastatic nodal Ultrasound
postauricular, occipital, and supraclavicu- disease on tomographic imaging is the Ultrasound (US) evaluation of the neck
lar lymph node chains. The parotid gland presence of intranodal necrosis, indepen- has become increasingly popular in Euro-
should be evaluated for the presence of dent of size and shape (Figure 32-15). Only pean countries. Sonography is relatively
any palpable disease or masses and the an intranodal abscess or fatty hilar metapla- inexpensive and is tolerated well. It may be
thyroid gland for any nodule, masses, or sia can simulate central tumor necrosis. used as an initial study to help guide the
thyromegaly. The trachea should be clinician in deciding whether further imag-
inspected for any deviation or fixation. Magnetic Resonance Imaging ing studies of the neck may be required.
The past decade has seen a relatively MRI is another method of neck imaging This is especially true in the clinically N0
high incidence of observer error. 89,90 that has gained popularity in the past neck. Sensitivity of sonography in the
Deficiencies have been observed in both decade. With superior soft tissue detail, detection of cervical lymph node metasta-
the ability to recognize the presence of a one would expect better delineation of sis is 89 to 95%, and specificity is 80 to
626 Part 5: Maxillofacial Pathology
95%.98100 This specificity can be increased unique in that it represents a functional distant metastatic oral cancer is its whole
with the use of US-guided fine-needle imaging scan as opposed to a morpholog- body imaging of possible tumor spread.
aspiration.101 Criteria for the evaluation of ic imaging scan. A prospective study by The infrequency of distant metastasis
potentially malignant cervical nodes with Adams and colleagues showed a higher was recognized early by Crile.110 Studies
sonography also involve the assessment of sensitivity and specificity for FDG-PET produced from the patient database at
nodal size, shape, and presence of central (90%, 94%) compared with CT (82%, Memorial Sloan-Kettering Cancer Center
necrosis. Metastatic nodes are characteris- 85%) and MRI (80%, 79%).102 Several have also shown relatively low rates in the
tically round to spherical in shape and are other studies have produced similar eventual development of distant metasta-
frequently hypoechogenic. In the presence results.103105 As with ultrasound, FDG- sis, ranging from 13% in individuals with
of extracapsular spread, loss of border def- PET may have a unique role in the evalu- floor-of-mouth cancer to 15% in patients
inition is observed. Normal lymph nodes ation of the clinically N0 neck.106 FDG- with carcinoma of the tongue.57,111 As new
are frequently difficult to detect because of PET has found a place in the evaluation of therapies lead to better locoregional con-
their high echogenicity mimicking that of an unknown primary with success rates trol of disease, we can expect to see a
the surrounding fatty tissue. reported from 10 to 60% in the identifica- greater incidence of distant metastasis in
tion of the index lesion.107109 long-term follow-up.
Positron Emission Tomography Drawbacks to the use of FDG-PET for
The use of 2-18F-fluoro-2-deoxy-D- evaluation of the neck include the inabili- Diagnosis
glucose (FDG) positron emission tomog- ty to differentiate between cancerous and A thorough clinical examination is the
raphy (PET) relies on the enhanced meta- reactive inflammatory lymph nodes and first line of defense in the detection of
bolic activity of tumoral tissue in the the poor anatomic delineation of the pri- oral cancer. Prognosis is directly depen-
body, of which increased glycolysis is usu- mary tumor and neck nodes in relation to dent on the tumor stage at diagnosis.
ally the biochemical hallmark. FDG, a surrounding structures, particularly those Nearly one-half of all oral cancers are not
radiolabeled glucose analog, is preferen- of a vascular nature. detected until they are in advanced stages.
tially taken up within tumor cells that This delay may be because symptoms
exhibit increased glycolysis; they can be Assessment of Distant Metastasis may not develop until later in the disease
detected from the increased signaling in Final evaluation of the oral cancer patient process or the socioeconomic group most
that tissue (Figure 32-16). This study is involves a work-up for possible distant likely to develop oral cancer is unable to
metastasis. Although the percentage of seek treatment until it has reached an
individuals who present with an untreated advanced stage. Studies have shown that
primary tumor who already have distant only 14% of adults in the United States have
metastasis is low, it is prudent to have ever had an oral cancer examination.112
thoroughly staged the individual for opti- A study by Holmes and colleagues showed
mal treatment planning. Distant metastasis that detection of oral and oropharyngeal
from the oral cavity most frequently SCC during nonsymptom-driven exami-
involves the lung, followed by liver and nations was associated with a lower stage
bone. Therefore, routine posterior-anterior at diagnosis.113 These detections occurred
and lateral chest radiographs and the eval- in the dental office, whether by a dentist,
uation of liver function tests (LFTs) are dental hygienist, or oral and maxillofacial
considered the minimum metastatic surgeon.
work-up for head and neck cancer
patients. Depending on abnormalities Toluidine Blue
found in the chest radiograph or LFTs, Oral cancer can have various clinical
locoregional extent of the disease, and appearances, ranging from subtle mucos-
degree of clinical suspicion, the surgeon al color or texture changes to gross ulcer-
may also choose to obtain a CT of the ation or a fungating lesion. These mucos-
chest or abdomen and pelvis. Obtaining al alterations are particularly difficult to
other studies such as bone scans should be assess in early cancers and dysplasia. It
FIGURE 32-16 Preoperative positron emission
tomography scan demonstrates increased activity symptom-driven. An added advantage of was recognized in the 1960s that toluidine
in right tongue and right neck at levels II and III. an FDG-PET study in the evaluation of blue stained malignant cells in vivo. Tolu-
Oral Cancer: Classification, Staging, and Diagnosis 627
idine blue is a metachromic dye that has lesion should be acquired prior to biopsy she may encounter epithelial abnormali-
been used as a nuclear stain. The dye in order to properly stage the lesion. When ties on a daily basis and is reluctant to
uptake has been shown to aid in the early faced with a large lesion, it is best to take refer the patient for biopsy. It is our
recognition and diagnosis of oral SCC.114 several biopsies from different sites in an opinion that brush cytology is only a
While the dyes exact mechanism of attempt to decrease any sampling error screening tool, and any atypical or posi-
action is unknown, theories have been that might be read as dysplasia, necrosis, tive results must be confirmed by an inci-
proposed that the dye selectively stains or inflammation. sional biopsy. The same should be said
cells with increased deoxyribonucleic acid Brush cytology has gained acceptance about highly suspicious lesions read as
synthesis or quantitatively more nucleic in the dental community as a safe, mini- negative. If clinical suspicion remains
acids than other cells.115 It has also been mally invasive technique for use in the high despite a negative cytology result, a
suggested that the dye binds to sulfated screening of clinically suspicious biopsy should be obtained.
mucopolysaccharides, found in higher lesions.118 Brush cytology differs from
quantities in actively growing cells. Sever- exfoliate cytology in that it removes an Conclusions
al studies have borne out toluidine blues entire transepithelial layer for cytologic SCC of the oral cavity continues to be a
sensitivity (89 to 100%) and specificity evaluation as opposed to the sloughing common disease worldwide including in
(62 to 90%) for oral SCC.115117 This surface layer of the mucosa. Commercially the United States. Despite research and
specificity increases when a protocol is available kits exist that include a brush advances in surgical and adjuvant therapy,
followed involving a second rinse 14 days biopsy instrument, glass slide, and fixative. long-term survival remains poor. It is a dis-
after the initial application to allow for The suspicious lesion is sampled by rub- ease all clinicians will be faced with, and
resolution of any inflammatory lesions bing or rotating the sampling brush early recognition and diagnosis of premalig-
that may be present. The sensitivity of against its surface until pinpoint bleeding nant and malignant disease is directly relat-
toluidine blue in detecting dysplastic at the biopsy site is obtained, indicating ed to outcome. Proper staging of the prima-
lesions is not as high as that for SCC. Sen- sampling to the basement membrane and ry lesion and neck with a thorough clinical
sitivity rates have been recorded ranging an adequate specimen. This specimen is examination and imaging is paramount to
from 74 to 84.6%.115,117 These dysplastic then transferred to the slide, fixed in the designing a successful treatment plan.
lesions stain inconsistently, and toluidine office, and sent to the corporation for eval-
blue cannot be used as reliably. uation by both a computer and oral References
Toluidine blue is currently marketed cytopathologist. Brush biopsy results are 1. Jemal A, Murray T, Samuels A, et al. Cancer sta-
as a commercially available kit. Our opin- classified as negative when no epithelial tistics, 2003. CA Cancer J Clin 2003;53:526.
ion is that its use should be limited to the abnormality is noted, positive when def- 2. Parkin DM, Pisani P, Ferlay J. Global cancer
statistics. CA Cancer J Clin 1999;49:3364.
screening of high-risk individuals, and inite cellular evidence of dysplasia or car-
3. Funk GF, Karnell LH, Robinson RA, et al. Pre-
assisting in directing biopsies from a large cinoma is found, atypical when abnor- sentation, treatment, and outcome of oral
area of abnormal-appearing tissue. In the mal epithelial changes of uncertain cavity cancer: a national cancer data base
end, toluidine blue cannot be substituted diagnostic significance are observed, and report. Head Neck 2002;24:16580.
for a thorough oral examination and biop- inadequate when an incomplete 4. Strong EW, Spiro RH. Cancer of the oral cavi-
ty. In: Myers EN, Suen JY, editors. Cancer of
sies when clinical suspicion is high. transepithelial specimen was submitted.
the head and neck. 2nd ed. New York:
The largest study of brush cytology by Sci- Churchill Livingstone; 1987. p. 41764.
Biopsy ubba and colleagues found a sensitivity 5. Blot WJ, McLaughlin JK, Winn DM, et al. Smok-
Once a clinically suspicious lesion is iden- and specificity of 100%.119 However, as ing and drinking in relation to oral and pha-
tified in the oral cavity, tissue diagnosis some authors have pointed out, a lack of ryngeal cancer. Cancer Res 1988;48:32827.
must be obtained prior to rendering any investigation with scalpel biopsy of atypi- 6. Jovanovic A, Schulten EA, Kostense PJ, et al.
Tobacco and alcohol related to the anatom-
treatment. This biopsy can usually be done cal results in innocuous-appearing ical site of oral squamous cell carcinoma. J
in an office setting or rarely under general lesions has resulted in a possible specifici- Oral Pathol Med 1993;22:45962.
anesthesia with panendoscopy if the lesion ty exaggeration of this technique; other 7. Mashberg A, Boffetta P, Winkelman R, et al.
is difficult to access and patient tolerance studies have borne this result out with Tobacco smoking, alcohol drinking, and can-
is low. The traditional biopsy, whether reported sensitivities of approximately cer of the oral cavity and oropharynx among
U.S. veterans. Cancer 1993;72:136975.
incisional or excisional (for small lesions), 90% but a specificity of only 3%.120 8. Neville B, Day TA. Oral Cancer and precancerous
is the gold standard. It should be empha- Brush biopsies best value may lie in lesion. CA Cancer J Clin 2002;52:195215.
sized that an accurate dimension of the the general dentists hand where he or 9. Klotch DW, Muro-Cacho C, Gal TJ. Factors
628 Part 5: Maxillofacial Pathology
affecting survival for floor of mouth carci- 27. Neville BW, Damm DD, Allen CM, Bouquot 43. Zitsch RP. Carcinoma of the lip. Otolaryngol
noma. Otolaryngol Head Neck Surg JE, editors. Epithelial pathology. In: Oral Clin North Am 1993;26:26577.
2000;122:4958. and maxillofacial pathology. Philadelphia: 44. Diaz EM, Holsinger PC, Zuniga ER, et al. Squa-
10. Rothman K, Keller A. The effect of joint expo- WB Saunders; 1995. p. 31587. mous cell carcinoma of the buccal mucosa:
sure to alcohol and tobacco on risk of can- 28. Silverman S, Rosen RD. Observations on the one institutions experience with 119 previ-
cer of the mouth and pharynx. J Chronic clinical characteristics and natural history of ously untreated patients. Head Neck
Dis 1972;25:7116. leukoplakia. J Am Dent Assoc 1968;76:7726. 2003;25:26773.
11. Kato I, Nomura A. Alcohol in the etiology of 29. Shafer WG, Waldron CA. Erythroplakia of the 45. Rao DN, Ganish B, Rao RS, et al. Risk assess-
upper aero-digestive tract cancer. Eur J oral cavity. Cancer 1975;36:10218. ment of tobacco, alcohol and diet in oral
Cancer B Oral Oncol 1994;30:7581. 30. Pillai R, Balaram P, Reddiar KS. Pathogenesis of cancer- a case-control study. Int J Cancer
12. Smith EM, Hoffman HT Sumersgill KS, et al. oral submucosal fibrosis. Relationship to 1994;58:46973.
Human papillomavirus and risk of oral risk factors associated with oral cancer. 46. Shah JP, Candela FC, Poddar AK. The patterns
cancer. Laryngoscope 1998;108:1098103. Cancer 1992;69:201120. of cervical lymph node metastases from
13. Gillison ML, Koch WM, Capone RB, et al. Evi- 31. Canniff JP, Harvey W, Harris M. Oral submu- squamous carcinoma of the oral cavity.
dence for a causal association between cous fibrosis: its pathogenesis and manage- Cancer 1990;66:10913.
human papillomavirus and a subset of head ment. Br Dent J 1986;160:42934. 47. Urist MM, OBrien CJ, Soong SJ, et al. Squa-
and neck cancers. J Natl Cancer Inst 32. Murti PR, Bhonsle RB, Pinborg JJ, et al. Malig- mous cell carcinoma of the buccal mucosa:
2000;92:70920. nant transformation rate in oral submucos- analysis of prognostic factors. Am J Surg
14. Vogelstein B, Kinzler KW. The multistep nature al fibrosis over a 17-year period. Communi- 1987;154:4114.
of cancer. Trends Genet 1993;9:13841. ty Dent Oral Epidemiol 1985;13:3401. 48. Chhetri DK, Rawnsley JD, Calcaterra TC. Car-
15. Jeffries S, Foulkes WD. Genetic mechanisms in 33. Rouviere H. Anatomy of the human lymphatic cinoma of the buccal mucosa. Otolaryngol
squamous cell carcinoma of the head and system. Tobies MJ, translator. Ann Arbor Head Neck Surg 2000;123:56671.
neck. Oral Oncol 2001;37:11526. (MI): Edwards Brother; 1938. 49. Gomez D, Faucher A, Picot V, et al. Outcome of
16. Wong DTW. TGF- and oral carcinogenesis. 34. Robbins KT, Clayman G, Levine PA, et al. Neck squamous cell carcinoma of the gingiva: a
Eur J Cancer 1993;29(B):37. dissection classification update: Revisions follow-up study of 83 cases. J Craniomax-
17. Weinberg RA. Tumor suppressor genes. Sci- proposed by the American Head and Neck illofac Surg 2000;28:3315.
ence 1991;254:113846. Society and the American Academy of 50. Soo KC, Spiro RH, King W, et al. Squamous
18. Shin DM, Kim J, Ro JY, et al. Activation of p53 Otolaryngology-Head and Neck Surgery. carcinoma of the gums. Am J Surg 1988;
gene expression in premalignant lesions Arch Otolaryngol Head Neck Surg 2002; 156:1059.
during head and neck tumorigenesis. Can- 128:7518. 51. Overholt SM, Eicher SA, Wolf P, et al. Prognos-
cer Res 1994;54:3216. 35. Greene FL, Page DL, Fleming ID, et al, editors. tic factors affecting outcome in lower gingi-
19. Pfeifer GP, Denissenko MF, Olivier M, et al. Head and neck sites. In: AJCC cancer stag- val carcinoma. Laryngoscope 1996;
Tobacco smoke carcinogenesis, DNA dam- ing manual. 6th ed. New York: Springer- 106:13359.
age and p53 mutations in smoking associat- Verlag; 2002. p. 1722. 52. Lindberg, R. Distribution of cervical lymph
ed cancers. Oncogene 2002;21:743551. 36. Greene FL, Page DL, Fleming ID, et al, editors. node metastases from squamous cell carci-
20. Tabor MP, Brakenhoff RH, van Houten VMM, Lip and oral cavity. In: AJCC cancer staging noma of the upper respiratory and digestive
et al. Persistence of genetically altered fields manual. 6th ed. New York: Springer-Verlag; tracts. Cancer 1972;29:14469.
in head and neck cancer patients: biological 2002. p. 2332. 53. Lo K, Fletcher GH, Byers RM, et al. Results of
and clinical implications. Clin Cancer Res 37. Krolls SO, Hoffman S. Squamous cell carcino- irradiation in the squamous cell carcino-
2001;7:152332. ma of the oral soft tissues: a statistical analy- mas of the anterior faucial pillar-retromo-
21. Pindborg JJ. Oral cancer and precancer. Bristol: sis of 14,253 cases by age, sex and race of lar trigone. Int J Radiat Oncol Biol Phys
John Wright and Sons Ltd.; 1980. patients. J Am Dent Assoc 1976;92:5714. 1987;13:96974.
22. WHO Collaborating Centre for Oral Precan- 38. Chen J, Eisenberg E, Krutchkoff DJ, et al. 54. Byers RM, Anderson B, Schwartz EA. Treatment
cerous Lesions. Definition of leukoplakia Changing trends in oral cancer in the United of squamous carcinoma of the retromolar
and related lesions: an aid to studies on oral States, 1935 to 1985: a Connecticut Study. J trigone. Am J Clin Oncol 1984;7:64752.
precancer. Oral Surg Oral Med Oral Pathol Oral Maxillofac Surg 1991;49:11528. 55. Kowalski LP, Hashimoto I, Magrin J. End
1978;46:51839. 39. Antunes JLF, Biazevic MGH, de Araujo ME, et results of 114 extended commando oper-
23. Silverman S, Gorsky M, Lozada F. Oral leuko- al. Trends and spatial distribution of oral ations for retromolar trigone carcinoma.
plakia and malignant transformation: A cancer mortality in Sao Paulo, Brazil, 1980- Am J Surg 1993;166:3749.
follow up study of 257 patients. Cancer 1998. Oral Oncol 2001;37:34550. 56. Ossoff RH, Bytell DE, Hast MH, et al. Lym-
1984;53:5638. 40. Worrall SF. Oral cancer incidence between phatics of the floor of mouth and perios-
24. Banoczy J. Follow-up studies in oral leuko- 1971 and 1989. Br J Oral Maxillofac Surg teum: anatomic studies with possible clini-
plakia. J Maxillofac Surg 1977;5:6975. 1995;33:1956. cal correlations. Otolaryngol Head Neck
25. Waldron CA, Shafer WG. Leukoplakia revisit- 41. Crosher R, Mitchell R. Incidence of oral cancer Surg 1980;88:6527.
ed. Cancer 1975;36:138692. in Scotland 1971-1989. Br J Oral Maxillofac 57. Shaha AR, Spiro RH, Shah JP, et al. Squamous
26. Silverman S, Bhargava K, Mani J, et al. Malig- Surg 1995;33:3334. carcinoma of the floor of the mouth. Am J
nant transformation and natural history of 42. Jorgensen K, Elbroud O, Anderson AP. Carci- Surg 1984; 148:1004.
oral leukoplakia in 57,518 industrial workers noma of the lip: a series of 869 cases. Acta 58. Nason RW, Sako K, Beecroft WA, et al. Surgical
of Gujarat, India. Cancer 1976;38:17905. Radiol Ther Phys Biol 1973;12:17790. management of squamous cell carcinoma
Oral Cancer: Classification, Staging, and Diagnosis 629
of the floor of the mouth. Am J Surg cerization in oral and oropharyngeal can- with physical examination. Arch Otolaryn-
1989;158:2926. cer: Molecular techniques provide new gol Head Neck Surg 1997;123:14952.
59. Tomich CE. Squamous-cell carcinoma of the insights and definitions. Head Neck 90. Alderson DJ, Jones TM, White SJ, et al. Observ-
floor of the mouth. Oral Surg Oral Med 2002;24:198206. er error in the assessment of nodal disease
Oral Pathol 1978;45:56879. 76. McGuirt WF. Panendoscopy as a screening in head and neck cancer. Head Neck
60. Martin H. Tumors of the palate (benign and examination for simultaneous primary 2001;23:73943.
malignant). Arch Surg 1942;44:599635. tumors in head and neck cancer: a prospec- 91. Mancuso AA, Harnsberger HR, Muraki AS, et
61. Ratzer ER, Schweitzer RJ, Frazell EL. Epider- tive sequential study and review of the liter- al. Computed tomography of cervical and
moid carcinoma of the palate. Am J Surg ature. Laryngoscope1982;92:56976. retropharyngeal lymph nodes: normal
1970;119:2947. 77. Vrabec DP. Multiple primary malignancies of anatomy, variants of normal, and applica-
62. Evans JF, Shah JP. Epidermoid carcinoma of the upper aerodigestive system. Ann Otol tions in staging head and neck cancer. Radi-
the palate. Am Surg 1981;142:4515. Rhinol Laryngol 1979;88:84654. ology 1983;148:71523.
63. Chung CK, Johns ME Cantrell RW, et al. 78. Vaamonde P, Martin C, Rio MD, et al. Second 92. Som P. Detection of metastasis in cervical
Radiotherapy in the management of prima- primary malignancies in patients with can- lymph nodes: CT and MR criteria and dif-
ry of the hard palate. Laryngoscope cer of the head and neck. Otolaryngol Head ferential diagnosis. AJR Am J Roentgenol
1980;90:57684. Neck Surg 2003;129:6570. 1992;158:9619.
64. Frazell EL, Lucas JC Jr. Cancer of the tongue. 79. Shikhani AH, Matanoski GM, Jones MM, et al. 93. van den Brekel MWM, Stel HV, Castelijins JA,
Report of the management of 1,554 Multiple primary malignancies in head and et al. Cervical lymph node metastasis:
patients. Cancer 1962;15:108599. neck cancer. Arch Otolaryngol Head Neck assessment of radiologic criteria. Radiology
65. Atula S, Grenman R, Laippala P, et al. Cancer of Surg 1986;112;11729. 1990;177:37984.
the tongue in patients younger than 40 80. Leipzig B, Zellmer JE, Klug D, et al. The role of 94. Feinmesser R, Freeman JL, Nojek AM, et al.
years. A distinct entity? Arch Otolaryngol endoscopy in evaluating patients with head Metastatic neck disease: a clinical/radi-
Head Neck Surg 1996;122:13139. and neck cancer. Arch Otolaryngol 1985; ographic/pathologic correlative study. Arch
66. Martin-Granizo R, Rodriguez-Campo F, Naval 11:58994. Otolaryngol Head Neck Surg 1987;
L, et al. Squamous carcinoma of the oral 81. Maisel RH, Vermeersch H. Panendoscopy for 113:130710.
cavity in patients younger than 40 years. second primaries in head and neck cancers. 95. Mancuso AA, Maceri D Rice D et al. CT of cer-
Otolaryngol Head Neck Surg 1997;117:275. Ann Otol Rhinol Laryngol 1981;90:4604. vical lymph node cancer. AJR Am J
67. Myers JN, Elkins T, Roberts D et al. Squamous 82. Benninger MS, Enrigue RR, Nichols RD. Roentgenol 1981;136:3815.
cell carcinoma of the tongue in young Symptom-directed selective endoscopy and 96. Sakai O, Curtin HD, Romo LV, et al. Lymph
adults: increasing incidence and factors that cost containment for evaluation of head node pathology: benign proliferative, lym-
predict treatment outcomes. Otolaryngol and neck cancer. Head Neck 1993;15:5326. phoma, and metastatic disease. In: Weber
Head Neck Surg 2000;122:4451. 83. Shaha A, Hoover E, Marti J, et al. Is routine AL, editor. The radiology clinics of North
68. Spiro RH. Squamous cancer of the tongue. CA triple endoscopy cost effective in head and America. Radiologic evaluation of the neck.
Cancer J Clin 1985;35:2526. neck cancer? Am J Surg 1988:155:7503. Philadelphia: WB Saunders Company;
69. Greene FL, Page DL, Fleming ID, et al, editors. 84. Davidson J, Gilbert R, Irish J, et al. The role of 2000. p. 97198.
Purposes and principles of staging. In: panendoscopy in the management of 97. van den Brekel MWM, Castelijins JA, Stel HV,
AJCC cancer staging manual. 6th ed. New mucosal head and neck malignancy- a et al. Detection and characterization of
York: Springer-Verlag; 2002. p. 38. prospective evaluation. Head Neck 2000; metastatic cervical adenopathy by MR
70. Spiro RH, Huvos AG, Wong GY, et al. Predic- 22:44954. imaging: comparison of different MR tech-
tive value of tumor thickness in squamous 85. Som PM. Lymph nodes. In: Som PM, Cutin niques. J Comput Assist Tomogr 1990;
cell carcinoma confined to the tongue and HD, editors. Head and neck imaging. 3rd 14:5819.
the floor of the mouth. Am J Surg ed. St. Louis (MO): Mosby-Year Book; 98. Delorme S. Sonography of enlarged cervical
1986;152:34550. 1996. p. 77293. lymph nodes. Imaging 1993;60:26772.
71. Mohit-Tabatabi M, Sobel HJ, Rush BF, et al. 86. Snow GB, Annyas AA, Van Slooten A, et al. 99. Eichhorn T, Schroder HG. Ultrasound in
Relation of thickness of floor of mouth Prognostic factors of neck node metastasis. metastatic neck disease. ORL J Otorhino-
stage I and II cancers to regional metastasis. Clin Otolaryngol 1982;7:18592. laryngol Relat Spec 1992;55:25862.
Am J Surg 1986;152:3513. 87. Coatesworth AP, MacLennan K. Squamous 100. Vassallo P, Wernecke K, Roos N, et al. Differen-
72. Brown B, Barnes L, Mazariegos J, et al. Prognos- cell carcinoma of the upper aerodigestive tiation of benign from malignant superfi-
tic factors in mobile tongue and floor of tract: the prevalence of microscopic extra- cial lymphadenopathy: the role of high res-
mouth carcinoma. Cancer 1989;64:1195202. capsular spread and soft tissue deposits in olution US. Radiology 1992;183:21520.
73. Warren S, Gates O. Multiple primary malig- the clinically N0 neck. Head Neck 101. Koischwitz D, Gritzmann N. Ultrasound of the
nant tumors. A survey of the literature and 2002;24:25861. neck. In: Weber AL, editor. The Radiology
a statistical study. Am J Cancer 1932; 88. Grandi C, Alloisio M, Moglia D, et al. Prognos- Clinics of North America. Radiologic eval-
16:1358414. tic significance of lymphatic spread in head uation of the neck. Philadelphia: WB Saun-
74. Slaughter DP, Southwick HW, Smejkal W. and neck carcinomas: therapeutic implica- ders Company; 2000. p. 102945.
Field cancerization in oral stratified squa- tions. Head Neck Surg 1985;8:6773. 102. Adams S, Baum RP, Stuckensen T, et al.
mous epithelium. Cancer 1953;6:9638. 89. Merritt RM, Williams MF James TH, et al. Prospective comparison of 18F-FDG PET
75. Braakhuis BJM, Tabor MP, Leemans R, et al. Detection of cervical metastasis: a meta- with conventional imaging modalities
Secondary primary tumors and field can- analysis comparing computed tomography (CT,MRI,US) in lymph node staging of
630 Part 5: Maxillofacial Pathology
head and neck cancer. Eur J Nucl Med 108. Davis JP, Maisey NM, Chevreton EB. Positron squamous cancers. CA Cancer J Clin
1998;25:125560. emission tomography, a useful imaging tech- 1995;45:32851.
103. Stuckensen T, Kovacs AF, Adams S, et al. Staging nique for otolaryngology, head and neck 115. Silverman S Jr, Dillon WP, Fischbein NJ. Diag-
of the neck in patients with oral cavity squa- surgery? J Laryngol Otol 1998;112:1257. nosis. In: Silverman S Jr, editor. Oral cancer.
mous cell carcinomas: a prospective com- 109. Keyes JW, Watson NE, Williams DW, et al. FDG 4th ed. Lewiston: BC Decker, 1998. p.
parison of PET, ultrasound, CT, and MRI. J PET in head and neck cancer. AJR Am J 4166.
Craniomaxillofac Surg 2000;28:31924. Roentgenol 1997; 169:16639. 116. Mashberg A. Final evaluation of tolonium
104. Sigg MB, Steinert H, Gratz K, et al. Staging of 110. Crile G. Excision of cancer of the head and chloride rinse for screening of high-risk
head and neck tumors: (18F) Fluo- neck with special reference to the plan of patients with asymptomatic squamous car-
rodeoxyglucose positron emission tomog- dissection based on one hundred and thir- cinoma. J Am Dent Assoc 1983;106:31923.
raphy compared with physical examination ty-two operations. JAMA 1906;47:17808. 117. Warnakulasuriya KAAS, Johnson NW. Sensi-
and conventional imaging modalities. J 111. Callery CO, Spiro RH, Strong EW. Changing tivity and specificity of Orascan toluidine
Oral Maxillofac Surg 2003;61:10229. trends in the management of squamous blue mouth rinse in the detection of oral
105. Laubenbacher C, Saumweber D, Wagner- carcinoma of the tongue. Am J Surg cancer and precancer. J Oral Pathol Med
Manslau C, et al. Comparison of fluorine- 1984;148:44954. 1996;25:97103.
18-fluorodeoxyglucose PET, MRI, and 112. Horowitz AM, Nourjah PA. Factors associated 118. Christian DC. Computer-assisted analysis of oral
endoscopy for staging head and neck squa- with having oral cancer examinations brush biopsies at an oral cancer screening
mous-cell carcinomas. J Nucl Med 1995; among US adults 40 years of age or older. J program. J Am Dent Assoc 2002;133:35762.
36:174757. Public Health Dent 1996; 56:3315. 119. Sciubba JJ, US Collaborative Oral CDX Study
106. Myers LL, Wax MK, Nabi H, et al. Positron 113. Holmes JD, Dierks EJ, Homer LD, et al. Is detec- Group. Improving detection of precancer-
emission tomography in the evaluation of tion of oral and oropharyngeal squamous ous and cancerous oral lesions. J Am Dent
the N0 neck. Laryngoscope 1998;108:2326. cancer by a dental health care provider asso- Assoc 1999;130:144557.
107. Braams JW, Pruim J, Kole AC, et al. Detection ciated with a lower stage at diagnosis? J Oral 120. Rick GM, Slater L. Oral brush biopsy: the
of unknown primary head and neck Maxillofac Surg 2003;61:28591. problem of false positives. Oral Surg Oral
tumors by positron emission tomography. 114. Mashberg A, Samit A. Early diagnosis of Med Oral Pathol Oral Radiol Endod
Int J Oral Maxillofac Surg 1997;26:1125. asymptomatic oral and oropharyngeal 2003;96:252.
CHAPTER 33
Oral cavity cancers account for 30% of increased in recent years because of public are a multistep process, the histologic pro-
head and neck cancers and represent a sig- awareness campaigns. Only recently, how- gression of benign mucosa to invasive can-
nificant challenge to clinicians. Treatment ever, has oral cancer begun to receive some cer typically follows an orderly progres-
requires multidisciplinary expertise and is of the same attention. The American Can- sion. Although squamous cell carcinoma is
complicated by the complex role that the cer Society recommends a cancer-related the most common, other variations
oral cavity plays in speech, mastication, and check-up, including examination for can- require alterations in treatment.
swallowing. Oral squamous carcinomas cers of the oral cavity, every 3 years for Verrucous carcinoma is generally con-
account for 90% of malignancies affecting asymptomatic men and women aged 20 to sidered an uncommon variant of squa-
the oral cavity, and will be the focus of this 39 years and yearly for men and women mous cell carcinoma, representing only 5%
chapter. Although discussion will be limited aged 40 years and older.8 Although the oral of oral cancers.12 It has a predilection for
to the treatment of squamous cell cancers, cavity is readily accessible for examination, the buccal mucosa, and typically appears as
oncologic principles outlined in this chap- results of a study by Holmes and colleagues a thick white cauliflower-like growth (Fig-
ter can be applied to other malignancies questioned whether health care profession- ure 33-1). The basement membrane is typ-
affecting the oral cavity.13 als were screening for asymptomatic can- ically intact and the cells are very well dif-
Regardless of advances in diagnosis cers.9 Additionally, smaller symptomatic ferentiated. It is not uncommon to find
and treatment, mortality from oral cancer cancers often went undetected in their focal areas of invasive squamous cell carci-
has not changed significantly in the past study and were ultimately detected at a noma within the excised specimen, and
50 years. Approximately 50% of patients later stage. Interestingly all asymptomatic patients should be prepared for this even-
diagnosed with oral cancer will ultimately cancers were referred from dental prac- tuality. The prognosis is excellent following
die of their disease.4,5 Early detection and tices, and the average clinical and patho- adequate excision.
appropriate treatment of cancers remain logic stage of cancers referred from physi-
the most effective weapons against cancers cian offices were statistically higher.9 This is
of the oral cavity. Unfortunately public and unfortunate since the population at high-
professional awareness and knowledge of est risk for development of an oral cancer is
oral cancer is low. A recent editorial four to six times more likely to seek care
referred to oral cancer as The Forgotten from a physician than a dentist.10,11 Clearly
Disease.6 Incidence and mortality for oral there is a need for increasing the publics
cancer is nearly double that of cancer of the awareness of oral cancer and improving
cervix (30,300 vs 13,500 and 8,000 vs screening for early oral cancers in order to
4,400, respectively); yet few adults can improve outcomes regardless of treatment
remember their last oral cancer examina- modality employed.
tion, whereas most women are aware of
their last gynecologic examination and Pap Histology
FIGURE 33-1 Verrucous carcinoma of buccal
smear.7 Patient knowledge of other can- Just as the molecular events leading to the mucosa with extension onto the adjacent maxil-
cers, such as skin, breast, and prostate, has development of squamous cell carcinoma lary alveolus.
632 Part 5: Maxillofacial Pathology
Basaloid squamous cell carcinoma rep- 2.6%.16 Lower socioeconomic status seems ing surgical excision. Chemopreventive
resents a rare aggressive form of squamous to be associated with higher prevalence.17 agents including retinoids, beta carotene,
carcinoma. It affects males predominately, The potential for malignant transforma- green tea, and bleomycin were evaluated.
and is associated with a high rate of cervical tion of oral leukoplakia to invasive squa- Retinoids held the most promise and were
and distant metastases.13 Histologically mous cell carcinoma is well recognized, associated with resolution of lesions. The
basaloid cells are arranged in nests or cords. and leukoplakia can be considered a pre- ultimate goal remains prevention of sub-
Perineural invasion and a high mitotic cancerous lesion (ie, a morphologically sequent malignant transformation, and
index are common and coincide with its altered tissue in which cancer is more like- unfortunately none of the agents demon-
tendency to recurrence and worse progno- ly to occur than in its apparent normal strated this reliably. In addition associated
sis, with a 38% mortality at 17-month counterpart).15 Estimated rates of trans- side effects were problematic (see section
follow-up.14 Given the aggressive nature of formation, however, vary widely. This Chemoprevention in this chapter).20,21
basaloid squamous cell carcinoma, elective most likely relates to the heterogeneity of Surgical excision remains an alterna-
treatment of the neck and postoperative the lesions included in most studies. While tive for dealing with worrisome lesions.
radiotherapy with or without adjunct homogeneous white leukoplakia has a rel- CO2 laser excision has been used to treat
chemotherapy are probably indicated. atively low risk, erythroleukoplakia has a widespread superficial lesions in an
It is helpful to request from the pathol- high incidence of associated dysplasia, car- attempt to limit scarring and morbidity
ogist a depth-of-invasion measurement on cinoma in situ, and frank carcinoma. In associated with large excisions. Laser abla-
more superficial lesions, given its predic- their oft-quoted study of 257 patients fol- tion allows the destruction of large super-
tive value in regard to occult metastases, lowed for a mean of 8 years, Silverman and ficial lesions. It does not provide a histo-
and determining the need for elective neck colleagues found transformation rates for logic specimen, however, and biopsies
dissection (see discussion on elective neck leukoplakia to range from 6.5% for homo- from any areas of ulceration or erythro-
dissection in this chapter). Depth of inva- geneous lesions to 23.4% in erythropla- plasia are probably indicated prior to abla-
sion will not influence treatment of deep sia.18 Lesions containing dysplasia had a tion. Unfortunately recurrence following
indurated or fixed lesions. Slowly resorbing transformation rate of 36.4%.18 The annu- laser excision or ablation is not uncom-
sutures, which will serve as a marker if an al transformation rate in one population mon, and it does not necessarily prevent
excisional biopsy is performed, is best if was less than 1%, which still demonstrated malignant transformation.22
closure is required. a 36-fold risk increase for squamous cell Given the high rates of multiple
carcinoma in patients with oral leuko- lesions and their propensity to recur, pho-
Management of plakia over the population in general.19 todynamic therapy (PDT) is gaining pop-
Premalignant Lesions Predicting which lesions will ultimate- ularity as a potential method for dealing
Leukoplakia is defined as a predominately ly transform is currently not possible. with multiple diffuse lesions. PDT relies
white lesion of the oral mucosa that can- Given its asymptomatic nature, the sole on a complex interaction of a photosensi-
not be characterized as any other definable indication for treatment of leukoplakia is tizing agent, which is preferentially con-
lesion (Figure 33-2).15 Worldwide esti- an attempt to prevent subsequent malig- centrated in abnormal tissue, with light of
mates of its prevalence range from 1.5 to nant transformation. Treatment modali- various wavelengths, depending on the
ties include excision, ablation, and chemo- photosensitizer, to create necrosis through
prevention. Unfortunately no treatment a nonthermal reaction. Tissue necrosis is
modality has been shown to prevent sub- mediated through the creation of singlet
sequent development of squamous cell oxygen, a highly reactive species that
carcinoma. induces cellular damage through several
The first Cochrane review on therapy mechanisms. Advantages of PDT include
for leukoplakia did not find any reliable minimal damage to surrounding tissues
therapy to prevent the transformation of and no cumulative damage, which theo-
leukoplakia to oral squamous cell carcino- retically allows unlimited treatments.
ma.20 Also, there were no effective preven- Given the propensity for these patients to
tive measures to halt the development of develop multiple lesions, this is an impor-
oral leukoplakia. No surgical procedures tant advantage over excision or ablation
were included in this review because of the using traditional methods. Disadvantages
FIGURE 33-2 Leukoplakia of the ventral tongue. lack of randomized clinical trials evaluat- include marked photosensitivity, especially
Oral Cancer Treatment 633
with regard to sun exposure, for variable surgical emergency and that the growth ability to perform an examination of the
lengths of time after the administration of rate of epithelial malignancies allows for an larynx with flexible nasopharyngoscopy
the agent. Areas treated undergo healing appropriate evaluation that must be com- mitigate against the usefulness of rigid
through mucosalization with minimal or pleted prior to making treatment recom- laryngoscopy and bronchoscopy. Also, the
no scarring. Although a complete review mendations. It should also be remembered majority of patients with cancer of the
of PDT is beyond the scope of this chapter, that there is a high incidence of depression head and neck receive a flexible
excellent reviews are available.2325 in the head and neck cancer patient popu- esophagoscopy along with placement of a
PDT has been used with some success lation. The level of family and community percutaneous endoscopic gastrostomy
in the endoscopic treatment of dysplastic support should be gauged, and appropriate tube. For these reasons panendoscopy
Barretts esophagitis to prevent its trans- referrals should be made if deemed neces- should probably be symptom driven.30
formation to adenocarcinoma.26 Similarly sary. The patients overall medical condi-
attempts have been made to treat diffuse tion should also be assessed in preparation Choosing a Treatment
oral leukoplakia with PDT with some suc- for any planned treatment. Aside from the Once the initial evaluation, data collection,
cess.27 In addition to its role in the man- standard history and physical examination, and staging are complete, a discussion
agement of leukoplakia, initial trials of including head and neck examination, regarding treatment is undertaken. The
PDT applied to invasive squamous cell nasopharyngoscopy or indirect laryn- clinician and the patient are faced with
carcinoma of selected sites in the head and goscopy in the office should be considered. deciding which treatment modality or
neck are being reported. Copper and col- This evaluation may be forgone if panen- combination offers not only the best chance
leagues reported on 25 patients with T1 doscopy or triple endoscopy is planned to for cure, but also quality of life. Quality-of-
and T2 lesions of the oral cavity and search for synchronous primary cancers. life issues are becoming increasingly impor-
oropharynx treated with PDT. Complete Following McGuirts 1982 study of tant in treatment planning. Despite media
remission was noted in 86% of lesions. panendoscopy, examination of the esoph- hyperbole on cancer treatment break-
Recurrences were salvaged with conven- agus, larynx, and bronchus was considered throughs, cancer treatment still falls into
tional therapy.28 In addition to its applica- mandatory in the work-up of the patient three basic categories: surgery, radiation, or
tion to mucosal lesions, interstitial deliv- with cancer of the head and neck.29 A mir- chemotherapy, or some combination there-
ery of light may allow treatment of more ror examination of the nasopharynx was of. Choosing the appropriate treatment
deeply situated tumors. Although results also frequently included. McGuirts find- relies on many factors, including the
are promising, PDT for leukoplakia and ing of synchronous tumors in 16% of patients medical condition as well as the
oral cavity cancers remains investigational, patients led most clinicians to include modalities available to the clinician. Certain
and its role in the management of leuko- panendoscopy in their evaluation.29 therapeutic modalities, such as neutron
plakia and squamous cell cancers of the Recently its routine use has been called beam radiotherapy, may hold promise for
head and neck awaits clarification. into question for a variety of reasons, certain tumors, but are limited in their
including cost containment, improved availability. Although each will be discussed
Role of Panendoscopy in imaging modalities, and lower rates of separately in the upcoming sections, most
Treatment Planning synchronous primary tumors of the head patients will ultimately receive more than
Once a histologic diagnosis of oral cancer and neck than previously expected. Some one form of treatment.
has been made, a patient evaluation is initi- clinicians still feel there is a role for an
ated in an attempt to define the extent of examination of the primary cancer under Surgery
the locoregional disease, as well as the exis- general anesthesia, along with panen- Surgery remains the cornerstone of most
tence of distant metastases. The discussion doscopy. They argue that the ability to treatment regimens for oral cavity cancer.
that was started with the patient when the examine some larger primary cancers is Surgery offers several advantages, includ-
biopsy was performed is now continued compromised in the clinical setting ing the harvest of a specimen for
with the knowledge that a malignancy is because of patient discomfort, and that the histopathologic analysis and the possibili-
present, but that continued work-up is nec- panendoscopy affords the clinician an ty of removing the cancer with one treat-
essary to define the extent of disease. invaluable opportunity to examine the ment modality at one session. For most
Patients frequently feel a sense of urgency primary cancers without this constraint. stage I and stage II cancers of the oral cavi-
once a diagnosis of cancer is rendered. They Others argue that the low yield of bron- ty, surgical resection with frozen section
want treatment initiated quickly. It is choscopy over chest radiographs and com- analysis of the margins is advocated by most
important to convey that cancer is not a puted tomography (CT) scans and the clinicians. Although primary radiation to
634 Part 5: Maxillofacial Pathology
and recurrence rates are high, suggesting cally may actually increase its likelihood release antithrombogenic factors and pre-
that patients with positive bone margins because of tethering of the trachea and vent stasis. It is important that these be
should be strongly considered for re-exci- impaired glottic closure. Tracheotomy is placed and activated before surgery. Phar-
sion. Recent reports illustrate that patho- not without its own risks, and the nursing macologic agents are generally reserved for
logic margins that are positive on final staff performing tracheotomy care must be known cases of thrombosis because of their
analysis are more likely a reflection of the well versed in suctioning and maintenance. propensity to cause bleeding in the postop-
aggressiveness of the particular cancer Decanulation can generally be performed erative setting. Low-molecular-weight
than a reflection on the surgical proce- soon after edema has decreased. heparin may be an option in this setting. If
dure. Sutton and colleagues found that the patient has undergone microvascular
final positive margins had a high correla- Perioperative Antibiotics Operations on reconstruction, aspirin or low-molecular-
tion with aggressive histologic parameters the oral cavity are considered clean- weight dextran may be indicated.
such as perineural and lymphovascular contaminated, and therefore, periopera-
invasion.39 Thus, the biologic aggressive- tive antibiotics are indicated. Several well- Fluid Management Most patients
ness suggested by positive margins may in controlled studies have demonstrated that undergoing surgery for oral cavity cancers
itself account for the poorer outcome of antibiotics started prior to the incision can be managed without invasive moni-
patients with positive surgical margins, and continued for no more that 24 hours toring of fluid status. Colloids may be
and be an indication for multimodality serve to minimize perioperative infections needed to prevent undue amounts of crys-
therapy instead of attempts at re-excision. and emergence of resistant strains. First- talloid leading to a significant increase in
Surgery in patients with head and generation cephalosporins and clin- edema. Preoperative and daily weights can
neck squamous cancer presents unique damycin represent the most commonly be used to track fluid status. In patients
challenges that surgeons should be pre- used prophylactic antibiotics in oral can- with compromised cardiovascular reserve
pared to face. The following discussion cer surgery. Topical antimicrobials such as or in those undergoing large resections
offers an overview of some of the periop- chlorhexidine and clindamycin rinses have and free-flap reconstruction, invasive
erative issues facing patients and surgeons. also been shown to successfully reduce the monitoring with central venous monitor-
Subsequent sections will review surgical incidence of infections.41,42 ing or via a Swan-Ganz catheter may be
points pertinent to specific sites within the necessary. Although uncommonly per-
oral cavity. Alcohol Withdrawal Many patients with formed, patients requiring bilateral resec-
oral cavity cancer will be dependent on tion of the internal jugular veins will need
Perioperative Issues in alcohol. Alcohol withdrawal is common if fluid restriction.
Oral Cavity Cancer Treatment precautions are not taken and can culmi-
The decision to operate on a patient with nate in delirium tremens leading to car- Transfusion Opinions regarding the need
head and neck cancer must involve consid- diovascular collapse and death. Appropri- for transfusion vary. In general a hemat-
eration of potential complications. Studies ate prophylaxis with benzodiazepines is ocrit less than 25 requires transfusion, and
have demonstrated that age itself is not recommended if the patient drinks daily. those between 25 and 30 may need transfu-
associated with increased complications, Lorazepam is commonly used because of sion based on clinical parameters.
but comorbidities are associated with its predictable onset and lack of active
increased complications and lengthy hos- metabolites. Intravenous alcohol (5 to Nutrition Many patients with head and
pital stays. This is especially true regarding 10% alcohol with 5% dextrose in water) neck cancer will present with decreased
complex reconstructive efforts, such as can be used in the postoperative period nutrition reserves. Even patients without
vascularized tissue transfer.40 Several fac- and slowly tapered as the patient recovers weight loss are often faced with therapies
tors deserve special attention in the patient from surgery. that will leave them unable to maintain
undergoing surgery for a malignancy of their nutrition. The ability to bypass the
the upper aerodigestive tract. Deep Venous Thrombosis Patients who upper digestive tract during intense multi-
will be immobilized for a significant time modality therapy by the endoscopic place-
Airway If there is any doubt concerning during surgery or following surgery should ment of a gastric feeding tube (percuta-
the ability of a patient to maintain an air- receive prophylaxis for deep venous throm- neous endoscopic gastrostomy or PEG
way in the perioperative period, a tra- bosis. This prophylaxis most commonly tube) is invaluable. This procedure offers a
cheotomy is advisable. A tracheotomy tube takes the form of mechanical compression minimally invasive lifeline for patients
does not prevent aspiration, and paradoxi- devices that cause endothelial cells to undergoing intensive therapy to the head
636 Part 5: Maxillofacial Pathology
and neck. Placement of a PEG tube has lular genetic material, or apoptosis, which given in daily doses of 200 cGy, except in
become commonplace in head and neck is programmed cell death. Reproductive altered fractionation schedules.
cancer patients. Although rare there have cell death can occur as a result of single Fractionation refers to the schedule on
been anecdotal reports of seeding squa- DNA strand breaks, which are common which the radiation dose is administered.
mous cell carcinoma to the abdominal and easier for the cell to repair, or double- Standard radiotherapy is administered
wall if the PEG is placed prior to resec- strand breaks, which are more difficult for daily, 5 days a week, with weekends off. In
tion.43 This complication, although rare, the cell to recover. Apoptosis occurs when an effort to maximize damage to the more
has led some surgeons to recommend a cell enters a programmed cell death rapidly dividing tumor cells while sparing
placement in the postoperative period. mode as a result of damage. Radiation can normal tissues as much as possible, frac-
Even if a PEG is placed, the patient should cause either type of cell death and also tionation schedules have been altered.
be encouraged to continue some oral slows cellular division. Classically radia- Although used primarily in clinical trials,
intake, as the risk of esophageal stenosis tion is discussed in terms of the four Rs: clinicians should be familiar with the
increases if the patient completely stops repair, reoxygenation, redistribution, and advantages and disadvantages of other
oral alimentation during radiation treat- regeneration. fractionation schedules because it is likely
ment. This is especially true during com- Radiotherapy is primarily given by that their use will become more wide-
bined chemoradiation protocols. external beam using electromagnetic radi- spread. Accelerated fractionation refers to
ation or particulate components. X-rays an overall reduction in treatment time
Complications of Surgery and gamma rays represent photons. X-rays accomplished by giving two or more daily-
Complications of surgical resection are are produced by a man-made source and dose fractions of close to conventional
many and vary directly with the patients gamma rays are produced by radioactive size. Hyperfractionation implies that the
comorbidities, such as ischemic cardiac dis- decay, most commonly of cobalt 60. Par- overall treatment time is conventional or
ease, chronic pulmonary disease, and alco- ticulate radiation using electrons plays an slightly reduced, but an increase in total
holism. Medical manifestations of preexist- important role in head and neck cancer. dose is achieved by giving two or more
ing chronic disease states, such as Another form of particulate radiation is small-dose fractions on each treatment
myocardial infarction, stroke, and pneumo- neutron radiotherapy, which may have a day. Each of these regimens is associated
nia, can be precipitated by major surgery, a specific role in salivary gland malignan- with varying degrees of early and late tox-
long general anesthetic, and a prolonged cy.45 Regardless of the source, radiation icities. For example, some clinicians feel
intensive care unit stay. Significant morbid- interacts with tissue to produce several that long-term effects such as osteora-
ity or death can be the result. Technical sur- types of damage to cells. The radiation dionecrosis are increased with hyperfrac-
gical complications, such as failure of recon- particle-cell interaction may be either tionated schedules, especially when com-
structive flaps, development of fistulas, and direct, or more commonly impact with bined with concomitant chemotherapy.
the other myriad problems that may require H2O molecules to create secondary parti- This view is not universal, however, and as
return to surgery for management, pale in cles that interact with cellular DNA. more experience is gained, questions
significance to the greatest complication Absorbed dose is reported as a gray (Gy), regarding toxicity will be answered.46,47
locoregional recurrence of the cancer. which is one joule of absorbed dose per Aside from changes in radiation
kilogram. Previously dose was reported as schedules, other facets of radiation deliv-
Radiation a rad, which was defined as 100 ergs ery technique have undergone recent
A complete review of radiation physics absorbed per gram. One gray is equal to changes. Radiation is delivered to a specif-
and medicine is beyond the scope of this 100 rad and one centigray (cGy) equals ic target area that is limited by shielding
chapter, and excellent reviews on the topic one rad (1 cGy = 1 rad). (defined as radiation portals or ports)
are available.44 Surgeons dealing with oral In the early to mid-twentieth century, that is placed to protect areas that are not
cancer should have an understanding of radiation was given as orthovoltage (125 suspected of harboring tumor or that are
radiation therapy and its advantages and to 500 KeV). Currently radiation is deliv- less tolerant of radiation (ie, the spinal
disadvantages. This entails a familiarity ered as megavoltage (> 1 MeV). Megavolt- cord). The radiation treatment plan is typ-
with radiation biology and the interaction age results in more radiation delivered to ically standardized for each subsite in the
of radiation with living tissue, as well as deeper tissues with less superficial (skin) oral cavity. Conformal radiation treatment
the biology of cell death. Cell death can be damage. In comparison a superficial radi- refers to more localized delivery of radia-
divided into two types: reproductive cell ograph unit (x-ray machine) delivers 30 to tion to the suspect site. By linking CT
death, which results from damage to cel- 125 KeV. Radiation therapy is typically images with the ability to manipulate the
Oral Cancer Treatment 637
radiation beams, radiation therapists are oped a reputation for creating chronic when there is potential for persistent dis-
able to more accurately focus the radiation wounds and may lead to osteoradionecro- ease. Clinical protocols vary among insti-
dose on the tumor bed and avoid adjacent sis when used adjacent to the mandible. Its tutions, but there are accepted indications
uninvolved areas that may be more sus- current use is generally limited to treat- for postoperative radiation therapy:
ceptible to radiation damage (Figure 33- ment of tongue or tongue base primaries,
Two or more lymph nodes containing
4). There is still concern that highly con- and is usually combined with external
metastatic disease in a neck dissection
formal treatment plans may result in beam radiation. Brachytherapy has also
(many clinicians contend that one
increased recurrence rates because of the been advocated for treatment of close or
positive node is an indication)
more limited field of radiation. Intensity positive margins following surgical exci-
Extracapsular extension (ECS) of can-
modulated radiotherapy is an example of a sion.35 Brachytherapy patients may require
cer beyond the confines of a node
conformal treatment plan combined with a tracheotomy for airway control because
Poor histologic factors: extensive per-
varying radiation doses to limit the collat- of airway compromise from edema.
ineural or perivascular invasion, posi-
eral damage to surrounding areas.48,49 Wound healing is also severely compro-
tive (close) soft tissue margins
Brachytherapy or interstitial radio- mised. Some clinicians have recommend-
Large (T3 or T4) primary cancers
therapy is administered by placing a ed only limited biopsies in the treated area
radioactive source, typically radium if recurrence is suspected because chronic Reports have found ECS to be associat-
(226Ra) or iridium (192Ir), directly in the nonhealing wounds can develop.50,51 ed with decreased survival: disease limited
tumor mass using needles or loop Radiation can be administered with to the node was associated with a 70% sur-
catheters. In this manner radiation is curative intent in the preoperative setting vival, whereas ECS was associated with a
delivered continuously. This does not or as an attempt to shrink a tumor presur- 27% survival at 5 years.52 Million and col-
allow the tumor cells to repopulate gically (neoadjunct). When the primary leagues found that 35% of patients with
between fractions as in external beam tumor is to be treated with radiation, the clinically negative necks converted to posi-
therapy. Unfortunately cells native to the clinician must also consider elective radia- tive if the primary cancer was treated with
area cannot recover either, resulting in tion of the neck for control of occult surgery alone.53 This dropped to 5% if radi-
extensive radiation-induced fibrosis and metastases. Because of its dependence on ation therapy was added. Even microscopic
osteoradionecrosis. This technique allows oxygen for effectiveness, bulky neck disease evidence of extracapsular extension is asso-
a higher total dose of radiation to be given with its attendant hypoxic core should ciated with a higher rate of recurrence and
to a primary site than does external beam probably be treated with neck dissection, death.54 The decision to add radiation treat-
because the radiation is placed directly in either before radiation or as a planned pro- ment must be made with a clear under-
the tumor mass. Brachytherapy has devel- cedure within 4 weeks of completion of standing of the morbidity of its use.
radiation. Early-stage oral cavity cancer In advanced disease, clinicians are faced
(T1 or T2) responds equally well to radia- with a choice of preoperative or postopera-
tion or surgery. The morbidity of radiation tive radiation treatment. Planned preopera-
and the inability to use it again in the case tive radiation treatment is rarely used but
of a second primary cancer or recurrent may lower the probability of positive mar-
disease makes surgery a more attractive gins and may allow smaller surgery (con-
modality in most situations. Larger tumors troversial). Lower doses of radiation are
(T3 and T4) generally respond poorly to required because of the improved oxygena-
radiation alone. Preoperative radiation tion in areas not disturbed by surgery. Post-
given in an attempt to shrink larger tumors operative radiation treatment allows easier
is hampered by the fact that tumors do not surgery and better healing in tissues not
shrink concentrically. Viable islands of disturbed by radiation-induced fibrosis.
tumor cells can be left beyond the new Frozen-section analysis of margins is easier
clinically evident margins. In theory sur- in this setting, and surgery allows improved
geons are committed to excising to the treatment planning based on final patholo-
FIGURE 33-4 Three-dimensional conformal original margins, something that seldom gy. Postoperative radiation therapy remains
mapping of postoperative radiotherapy for esthe- happens in clinical practice. the mainstay in most cases of resectable
sioneuroblastoma of the olfactory bulb. Globes
and optic nerves are depicted to ensure minimal The primary role for radiation in oral cancers of the oral cavity. A study by the
radiation damage to these structures. cavity cancer is in the postoperative setting Radiation Therapy Oncology Group,
638 Part 5: Maxillofacial Pathology
RTOG 73-03, compared 50 Gy preoperative ciated with side effects, such as hypoten- behind a certain amount of resistant cells.
radiotherapy to 60 Gy postoperative radio- sion, and some patients do not tolerate it. It These resistant cells subsequently divide
therapy. The 10-year follow-up demon- is costly and there remains some fear that and the tumor mass once again increases.
strated no survival advantage to either reg- its radioprotective effects might extend to In infectious diseases the bodys immune
imen, but postoperative radiation the cancer cells as well, resulting in higher system aids in the destruction of the
treatment demonstrated superior locore- recurrence rates. Radiosensitizers are decreased burden of cells, whereas in can-
gional control.55 How much is enough? chemotherapeutic agents that enhance that cer the patient usually does not have an
Results from an MD Anderson Cancer effectiveness of radiation (see section immune system that can deal with the
Center (University of Texas, USA) study Chemotherapy below). rogue cell line. Similar to infections with
showed that 54 Gy was needed in the post- resistant strains, multidrug protocols have
operative setting, and 57.6 Gy was needed if Chemotherapy been developed to counter the develop-
extracapsular extension was present.56 Until 1991 the role of chemotherapy in ment of resistant cell lines in cancer. Prin-
Timing of initiation of radiation ther- head and neck cancer was limited to it use ciples of chemotherapy have been devel-
apy following surgery is controversial. in the management of recurrent and/or oped to overcome the development of
Vikram demonstrated a clear survival metastatic disease. A landmark study that resistant cell lines such as the use of multi-
advantage in patients whose radiation changed our view of chemotherapy was ple agents that have demonstrated inde-
therapy was started within 6 weeks of reported by the Cooperative Studies Pro- pendent activity against the cancer type,
surgery.57 For this reason reconstructive gram of the Department of Veterans Affairs the combination of drugs with differing
options that led to reliable healing in this Laryngeal Cancer Study Group who report- toxicities to allow maximum dosing of
amount of time were advocated.57 A more ed a multi-institutional trial on patients each agent, and the maintenance of short
recent study failed to replicate Vikrams with advanced laryngeal cancer.63 Their intervals between dosing agents while
earlier findings, leading some to challenge study demonstrated larynx preservation allowing adequate recovery of normal tis-
the supposed impact of timing on ultimate and equivalent survival among patients sues. Solid tumor growth is governed by
outcome. Other studies have reported who received induction chemotherapy fol- Gompertzian kinetics, which means that
improved outcomes when postoperative lowed by radiation, as opposed to tradition- growth slows as tumor bulk increases.
radiation begins within 6 weeks and ends al laryngectomy and postoperative radia- Since chemotherapeutic agents are most
within 100 days of surgery for oral cavity tion.63Although criticized by some for its effective against cells undergoing replica-
squamous cancers.58,59 lack of a radiation-only control group, the tion, smaller and faster growing tumors
The future direction for radiation results fostered a renewed interest in use of are more susceptible.64
treatment may include the development of chemotherapy in the management of Assessment of the literature regarding
effective radioprotectants and radiosensi- advanced head and neck malignancy, chemotherapy is complicated if one does
tizers. Radioprotectants, such as amifos- including squamous cell carcinoma of the not understand the definitions of com-
tine, are given in an attempt to protect nor- oral cavity. Several reviews are available on plete response, partial response, stable
mal tissues. Amifostine was developed by the evolving role of chemotherapy in head disease, and progression. Each of these is
the military as a possible protection from and neck cancer. The following summarizes determined by the sum of the product of
nuclear attack and has recently been the basics of chemotherapy in oral cavity the perpendicular diameters of all mea-
applied to head and neck cancer patients to cancer and discusses several potential surable tumors. Measurements are
protect salivary gland function during future applications. obtained at the beginning of treatment
radiation therapy.60 Xerostomia is a long- Prior to analyzing the results of and at completion.
term problem that has a significant effect chemotherapy in oral cavity cancer, an
on patients treated with radiation therapy understanding of the basic biology of Complete response: Defined as the dis-
to the head and neck, with 64% of patients chemotherapy and the associated termi- appearance of all evidence of disease
reporting moderate to severe permanent nology is necessary. In many ways Partial response: At least a 50% reduc-
xerostomia.61 Decreased incidence of can- chemotherapy for cancer is conceptually tion in size as defined by the formula
didiasis, a frequent side effect observed in similar to chemotherapy for infections; above
patients with radiation-induced xerosto- however, the immune system in general is Stable disease: Less than a 50% reduc-
mia, has been used as an end point in ami- not inherently competent to destroy the tion in tumor size
fostine therapy used for its protective effect cancer. Chemotherapeutic agents kill a Progression: An increase of 25% or
on salivary gland function.62 Its use is asso- constant fraction of cancer cells leaving appearance of new lesions
Oral Cancer Treatment 639
An important point to remember is chosen in an attempt to decrease the size the beginning of radiation treatment and
that tumor regression must only last for of the primary cancer to make definitive frequently at the completion of radiation.
4 weeks. It is understandable, therefore, treatment possible. For example, a tumor Sometimes radiation therapy is interrupt-
that reports of a complete response often deemed unresectable may be down- ed (split-course radiation) on purpose,
have little impact on improved survival. staged by neoadjuvant chemotherapy to a and chemotherapy is given. Again, radia-
The response rate represents the total per- resectable tumor. As stated earlier tumors tion breaks are considered to be associated
cent of patients achieving complete and do not shrink concentrically and islands of with decreased control and are therefore
partial responses. An additional problem tumor may remain beyond the visible not recommended.
with chemotherapy trials is patient selec- margin. An additional advantage to Chemotherapeutic agents are under
tion bias. Increasingly the role of comor- neoadjuvant therapy is the ability to eval- constant development and a complete dis-
bidities in ultimate outcome and the uate response. Squamous cell carcinomas cussion of available agents is beyond the
impact of performance status on survival represent a heterozygous population even scope of this chapter. Several principles
are being recognized as important con- within the same tumor. Some will be deserve mention. In general drugs can be
tributors to survival in head and neck can- exquisitely responsive to a particular regi- divided into cell cyclespecific and noncell
cer (see discussion below). Performance men, whereas others will not. Medical cyclespecific agents, depending on
status is typically reported using the oncologists can tailor their treatment whether the particular agent requires that
Karnofsky performance status (PS), which more accurately if visible or palpable the target cell be in a certain phase (G0, S,
rates patients on a scale of 0 (death) to 100 tumor is available to evaluate response. G1, or mitosis) to be effective. Agents can
(normal, no evidence of disease) or the The biggest criticism of neoadjuvant ther- also be categorized based on their princi-
Eastern Cooperative Oncology Group apy is that it delays the definitive treat- ple mode of action. Antimetabolites, such
scale, which rates patients on a scale of PS ment of the primary cancer. Local failure is as methotrexate and 5-fluorouracil, block
0 (fully active) to PS 5 (death).65,66 Most still the biggest cause of death in oral cav- development of certain metabolites criti-
clinical trials require a certain PS to quali- ity cancer, and delaying treatment of the cal for cell metabolism. 5-Fluorouracil is a
fy, leading to enrollment of healthier primary site increases the difficulty of fluoridated pyrimidine analog that
patients and improved outcomes. obtaining control of the primary cancer. inhibits thymidylate synthetase, blocking
Timing of chemotherapy has been the In addition initial chemotherapy can theo- the generation of thymidine, which is nec-
subject of much investigation. Again, defi- retically select more hardy cell lines that essary for DNA synthesis. It is frequently
nitions are the key to understanding and are resistant to all therapy. Indeed critics of used in the treatment of head and neck
interpretation of results of clinical trials. the Department of Veterans Affairs Laryn- squamous cell carcinoma. Typically it is
Palliative chemotherapy is given to patients geal Cancer Study Group larynx trial con- combined with other agents, and it is a
with incurable disease to temporarily tend that neoadjuvant chemotherapy sim- radiosensitizer. Methotrexate, an analog of
reduce tumor volume in the hope of ply selected out less aggressive cancers that folic acid, blocks conversion of dihydrofo-
improving quality of life and lengthening would respond to radiation treatment. late to tetrahydrofolic acid, which is a pre-
survival. This is typically the arena that Currently the role of chemotherapy that cursor of thymidylic acid and purine. This
serves as a testing ground for new thera- has generated the most interest is combi- results in an interruption of DNA, RNA,
peutic agents. Adjuvant chemotherapy is nation with radiation treatment for an and protein synthesis. Once a standard for
given to patients who have undergone organ sparing approach. Chemotherapy head and neck squamous cell carcinoma,
treatment of their primary cancer site with in combination with radiation treatment methotrexate is now typically only used
surgery and/or radiation. Goals of treat- can be given in a sequential or a concur- for palliation. Its side effect profile and
ment include elimination of occult dis- rent strategy. Concurrent therapy takes ability to be administered intramuscularly
ease, especially distant metastases. As the advantage of the radiosensitization of cer- on an outpatient basis make it a good
patient no longer has visible or palpable tain drugs and avoids delay in treating the option for this purpose. Cisplatin and car-
tumor with which to gauge response, primary cancer site. The downside is a boplatin are alkylating agents that form
agents must be selected that have proven marked increase in side effects and toxici- cross-links in DNA and arrest cell division.
activity against the cancer type. Neoadju- ty that can lead to breaks in radiation Cisplatin is more effective in squamous
vant chemotherapy (also known as induc- treatment, which have been shown to be cell cancer but is associated with more
tion chemotherapy) is given to patients associated with a decrease in local control. renal and neurologic side effects than car-
prior to definitive treatment of the prima- In an attempt to control some of these tox- boplatin. Other agents used less frequently
ry cancer site.64 This tactic is generally icities, chemotherapy is usually given at in head and neck squamous cell cancer
640 Part 5: Maxillofacial Pathology
include paclitaxel, which stabilizes micro- concurrent treatment is better than indication for chemotherapy in oral can-
tubular formation and arrests cells in G2, neoadjuvant therapy. Locoregional control cer is in metastatic and recurrent disease.
and bleomycin, which creates DNA breaks. and survival were improved in advanced The most commonly used chemothera-
Agents under development include head and neck cancers.73,74 peutic regimen for metastatic or recurrent
flavopiridol, a cyclin-dependent kinase In an attempt to avoid the systemic oral cavity squamous cell carcinoma
inhibitor that has been shown to induce effects of chemotherapy, investigators have involves combinations of cisplatin or car-
apoptosis (programmed cell death) in attempted to deliver agents topically, as well boplatin and 5-fluorouracil. Median sur-
squamous cell cancer lines in vitro, and for as intratumorally with both intra-arterial vival rates of 5 to 7 months and 1-year sur-
which a phase 1 trial is underway.67,68 injections and intratumoral depot forms vival of 20% demonstrate the need for
Standard therapy for resectable disease via polymers and gels (see section in this improved regimens. Investigations contin-
remains surgery followed by radiotherapy, chapter on recurrent tumors). A novel form ue to define a role for chemotherapy in
if indicated. To date, induction chemother- of concurrent chemoradiation is the intra- advanced squamous cell carcinomas of the
apy followed by surgery has not shown a arterial cisplatin and radiotherapy (RAD- oral cavity. Unfortunately early responses
survival benefit in oral cavity cancer. The PLAT) protocol popularized by researchers to chemotherapy have not demonstrated
question of adding chemotherapy in the at the University of California, San Diego, improvement in overall survival and only
postoperative setting remains unanswered. and University of Tennessee at Memphis, modest gains in median survival time.76
Currently no study has shown definitive which has shown promise for advanced Current research in chemotherapeutic
improvement. Cooper and colleagues cancers with bulky primary cancers and agents focuses on agents that bind to spe-
reported on the results of the RTOG 95- nodal disease.75 Treatment involves supra- cific receptors in an attempt to limit effects
01/Intergroup phase 3 trial that evaluated dose cisplatin delivered directly into feeder to target cells. Similar to the hormonal
concurrent chemoradiotherapy in postop- vessels of the tumor bed by microarterial therapy used in breast and prostate can-
erative treatment of high-risk squamous catheters placed under angiography. Sodi- cers, investigators are experimenting with
cell carcinoma of the head and neck, um thiosulfate, which is a neutralizing agents such as epidermal growth factor
defined as multiple lymph nodes involved, agent for cisplatin, is administered systemi- inhibitors.77 Gene therapy that targets
extracapsular disease, and positive mar- cally, allowing doses five times larger than known alterations in head and neck squa-
gins. The locoregional control and overall standard protocols. Results of patients with mous cell cancer lines, such as TP53, is also
2-year survival were not improved signifi- T4 N23 disease treated with the protocol an area of growing research.78 Restoration
cantly, and the small improvement in revealed 4-year local control of 84%, of these altered genes, possibly through
disease-free survival was at the expense of a disease-specific survival of 46%, and overall viral vectors, holds promise in certain
significant increase in toxicity.69 Adding survival of 29%.75 Unfortunately, the proto- populations.79 A recent review by Milas
chemotherapy following surgery and radi- col is associated with significant toxicity, and colleagues at the MD Anderson Can-
ation has been shown to decrease the inci- including death. Use of the RADPLAT pro- cer Center offers insight into the current
dence of distant metastases, but this has tocol is currently limited to centers that state of chemotherapy in head and neck
not been associated with improved sur- have gained familiarity with the technique cancer, as well as newer chemotherapeutic
vival. At this point chemotherapy in the and management of the toxicities associat- agents on the horizon.80
postoperative setting is not indicated ed with it. Most of these concurrent
except in cases of known metastatic dis- chemoradiation protocols involved Chemoprevention
ease, and its use outside of clinical trials oropharyngeal and hypopharyngeal can- An additional area of intensive research is
should probably be discouraged.7072 cers, and are plagued by noncompliance development of chemoprevention agents,
Currently the role for chemotherapy because of toxicity and side effects. Mucosi- which are defined as agents that reverse or
in oral cavity cancer is limited to use in tis is intense and placement of a PEG tube suppress premalignant carcinogenic pro-
unresectable disease in which it is com- is usually mandatory.75 gression to invasive malignancy (see sec-
bined with radiation treatment, metastatic Other novel techniques for minimiz- tion Management of Premalignant
disease, or recurrence. Organ preservation ing the systemic side effects of chemother- Lesions, above). The role of such agents
(not to be confused with organ function) apeutic regimens are under development, would be twofold: (1) to treat premalig-
through the use of concurrent chemoradi- including the PDT discussed above under nant lesions to prevent their evolution to
ation protocols has received much atten- the management of leukoplakia. invasive carcinoma, and (2) to prevent
tion. Meta-analyses by El-Sayed and Nel- Trials of chemotherapy limited to the development of second primary squa-
son, and Munro have demonstrated that oral cavity are few. At this time the clearest mous cell cancers in patients who have
Oral Cancer Treatment 641
already undergone treatment of cancer. a novel tretinoin biofilm that allows sus- greatest. Most lip cancers are treated by sur-
Given its accessibility to clinical observa- tained topical delivery to the oral cavity.83 gical resection using 0.5 to 1.0 cm margins
tion, leukoplakia has been used to monitor Investigators continue to search for and frozen-section control. Although often
responsiveness to certain chemopreven- chemotherapeutic agents with more referred to as a wedge resection, the actual
tion agents in clinical trials. Of the agents acceptable side effect profiles. One of specimen more closely resembles a shield
evaluated, including retinoids, beta these agents is the Bowman-Birk with parallel sides and a tapering base.
carotene, and vitamin E derivatives, inhibitor, a protein derived from soybeans Wedge excisions may be combined with a
retinoids have demonstrated the most effi- that has shown clinical activity against vermilionectomy or lip shave procedure,
cacy in eliminating leukoplakia. It is leukoplakia without the attendant side removing vermilion that has suffered exten-
important to note, however, that reversal effects of retinoids.84 Nonsteroidal anti- sive actinic damage or contains carcinoma
of these lesions has not been demonstrat- inflammatory drugs have also being inves- in situ (Figure 33-5). CO2 laser ablation of
ed to reduce the risk of developing cancer, tigated since chemoprevention activity the surface of the lip is also useful as an
and the lesions soon return after cessation was found in some cyclooygenase-2 alternative to vermilionectomy for diffuse
of treatment. 13-Cis-retinoic acid, which is (COX-2) inhibitors. COX-2 influences actinic changes. Squamous cell carcinoma
more commonly used to treat acne, has several steps in the development of malig- of the lip shares with squamous cell carci-
been studied extensively in both the treat- nancies, such as apoptosis, angiogenesis, noma of other cutaneous sites a potential
ment of premalignant lesions and in the invasiveness, and immune surveil- for perineural invasion. A large perineural
prevention of second primary cancers. It lance.85,86 COX-2 expression has been tumor deposition along the inferior alveolar
may act through the up-regulation of a noted in high-risk premalignant lesions.87 nerve, several years after a lip cancer, can be
distinct retinoic acid receptor, RAR-, In addition to their potential role in mistaken for primary intraosseous carcino-
whose down-regulation is associated with chemoprevention, COX-2 inhibitors hold ma (Figure 33-6).
development of head and neck cancer. promise in the treatment of invasive squa- Neck dissection is usually not indicated
Results of trials to date have been mixed. mous cell carcinomas.88 Although chemo- for lip cancer unless there is clinical evi-
Although effective in eliminating leuko- prevention offers hope for patients at high dence of lymph node involvement by exam-
plakia, side effects limit its use, and lesions risk for development of second primary ination or imaging. Cancers of the upper lip
return after discontinuing the drug. Sec- cancers and treatment of patients with and commissure can metastasize to the peri-
ondary primary tumors occur in 4 to 7% high-risk lesions (see discussion on pre- parotid lymph nodes, and superficial
of patients treated for head and neck squa- malignant lesions above), its use is cur- parotidectomy may be required if there are
mous cancer and are the major concern- rently restricted to clinical trials and off- clinically enlarged nodes. Some larger
related cause of death in early-stage can- label use. Further work is needed to lesions can be treated with radiation alone if
cer. The prevention of these tumors is establish a safe and effective chemopre- surgical resection will result in unacceptable
therefore important. Studies of 13-cis- ventive regimen. compromise in appearance and function.
retinoic acid have shown decreased inci- Five-year survival for lip cancer is
dence of second primary cancer but no Special Treatment good for early-stage disease (90% for
effect on primary disease recurrence. This Considerations by Site stages I and II).89,90
suggests that retinoids may prevent can-
cerous development in damaged cells but The Lip
will not treat fully transformed cancer Although classified as an oral cancer, squa-
cells. Also, overall survival was not affect- mous cell carcinomas of the lip typically fol-
ed. Required doses of retinoids have side low a different clinical course than those of
effects, including mucocutaneous toxicity oral mucosal cancers. The primary etiologic
(peeling and cheilitis) and elevation of agent, sun exposure, is different from oral
liver function tests. Development of cancers, and the location of lip cancers usu-
second-generation retinoids may attenu- ally leads to earlier discovery. The behavior
ate some of these side effects. One study of squamous cell cancers of the vermilion
demonstrated a worrisome increased inci- border is usually intermediate between
dence of primary lung cancer in patients squamous cell carcinoma of the skin and
FIGURE 33-5 Vermilionectomy combined with
treated with beta carotene.81,82 In addition, that of the mucosa. The vast majority arise wedge resection of lip cancer associated with dif-
Wang and colleagues recently reported on on the lower lip where sun exposure is fuse actinic changes across the remainder of the lip.
642 Part 5: Maxillofacial Pathology
33-14). Cancers arising from the hard sion occurs most commonly through the
palate may extend onto the soft palate and periodontal ligament in the dentate
vice versa. The periosteum of the palate mandible and through the porous occlusal
acts as a significant barrier, and smaller surface of the edentulous mandible.110
lesions can be treated with wide local exci- OBrien and colleagues also demonstrated
sion. Healing by secondary intention that an inflammatory front preceded can-
under a protective stent secured to the cer that stimulated subperiosteal resorp-
palate is a viable reconstructive option if tion and the creation of bony clefts that
the palatal bony structure is not removed. allowed cancer to invade the cortex.111
Oral-nasal communications in the hard Once the cortex was invaded, the inferior
palate can be treated with an obturator or alveolar canal was usually involved, espe-
a local flap, such as an anteriorly based cially in edentulous mandibles.111,112 This
midline tongue flap. Oral-nasal fistulas in finding has led to surgeons advocating
the soft palate are best treated with tempo- preservation of mandibular continuity
FIGURE 33-13 Le Fort I island approach to a rary obturation, as the majority will close through the use of a marginal mandibul-
posterior maxillary tumor, without Weber- spontaneously. Occult cervical metastases ectomy, in cases without obvious bony
Fergusson incision. are rare among hard palate cancers (10 to involvement. These principles apply only
25%), and elective treatment of the neck is to the nonirradiated mandible. Cancer
offers several advantages, including a sim- generally not indicated except in T3 or T4 invasion of a previously irradiated
pler operation, easier early detection of lesions.107,108 Also, metastases may occur to mandible occurs through multiple sites.
recurrence, and replacement of teeth. the retropharyngeal nodes, and considera- The clinical and radiographic evaluations
Most maxillary alveolus and gingival tion should be given to irradiation of the of mandibular involvement, however, are
squamous cells that invade the sinus neck to include this area if suspected. frequently inaccurate. Clinical findings
involve the infrastructure lying below such as impairment of inferior alveolar
Ohngrens line, an artificial line that runs Management of the Mandible in nerve function or fixation of the tumor to
from the medial canthus to the angle of Oral Cavity Cancer the mandible raise the index of suspicion.
the mandible and separates the maxillary Management of the mandible in oral cavity The history of an extraction of a tooth in
sinus into an infra- and supra-structure. cancer has been the subject of much con- an area of a cancer may suggest local
Defects arising from cancers resected troversy. In the past the mandible was rou- mandibular invasion. Although used by
below this line are easily reconstructed tinely sacrificed in the treatment of FOM some, bone scans are cumbersome to
with obturators. Cancers that require true and tongue cancers, as it was felt that the obtain and interpret accurately. A high-
total maxillectomy (resection of one of the regional lymphatics coursed through the quality panoramic radiograph is probably
paired maxillas, including the orbital mandibular periosteum, necessitating an the most commonly used tool to decide on
floor) tend to require flap reconstruction. in-continuity resection of the tongue, mandibular resection versus segmental
If dura mater is exposed as part of a skull FOM, mandible, and neck dissection resection. CT scanning using DentaScan
base resection, flap coverage is advisable. (Commandos operation). The morbidity
Overall 5-year survival for alveolar of this approach was felt necessary to erad-
ridge carcinoma is 50 to 65% for both the icate in-transit metastases, a belief that was
upper and lower alveolar ridge. Poor out- likely based on mistranslation by McGregor
come is associated with advanced stage, of an article published by Polya and von
perineural spread, and positive margins. Navratil in 1902, in which they actually rec-
Adjunctive radiation is recommended if ommended removal of the periosteum or
nodal metastases, perineural spread, or rim of mandible and not a segment.109
positive margins are present.106 Marchetta and colleagues subsequent-
ly demonstrated that lymphatics did not
The Palate flow through the mandible, and that the
Squamous cell cancers of the palate, hard periosteum of the mandible actually
FIGURE 33-14 Squamous cell carcinoma of the
and soft, are rare. The soft palate is consid- served as a barrier to invasion.110 It was right soft palate invading posteriorly to involve
ered an oropharyngeal subsite (Figure found that squamous cell carcinoma inva- the anterior pole of the tonsil.
646 Part 5: Maxillofacial Pathology
software has also been used, although necessitating a segmental resection and
recent studies have shown that an MRI more elaborate reconstruction.
demonstrating enhancement of the mar- Splitting the mandible, or mandibulo-
row signal was a better predictor of tomy, is often necessary for access to large
mandibular involvement. Also, newer cancers, especially of the posterior tongue
techniques that modulate the magnetic (Figure 33-16). Technical refinement of
field in an attempt to examine changes in mandibulotomy helps avoid complica-
the bone marrow hold promise for evalu- tions. Mucosal incisions should not be
ating mandibular involvement. Tumor placed directly overlying the proposed
invasion into the marrow space is accom- osteotomy site. Division of the mandible
panied by a lower intermediate signal. A at the parasymphysis or symphysis is pre-
strong bright marrow signal associated ferred over an osteotomy in the body
with normal marrow fat underlying the region. If the mandibular osteotomy is
dark cortex typically excludes mandibular being performed for access to the tongue,
FIGURE 33-15 Outline of marginal mandibulec-
involvement.38 tomy suitable for resection of tumors of the retro- the cut should be made anterior to the
At this time the most accurate assess- molar trigone and posterior maxillary alveolus. mental nerve to preserve it. Preadaptation
ment of mandibular involvement occurs at of plates will allow reestablishment of the
the time of surgery when the surgeon can preoperative occlusion and contour.
inspect the bone. In addition, some sur- anticipating a marginal resection, and a
geons send periosteum for frozen-section segmental resection becomes indicated Management of the Cervical
analysis, whereas others submit cancellous based on operative findings, he or she is Lymph Nodes in Oral Cavity
scrapings for frozen analysis.113 Once a faced with a surgery for which both sur- Squamous Cancer
decision has been made to perform a mar- geon and patient might not be prepared. Management of the regional lymphatics is
ginal mandibulectomy, the surgeon has Frank discussions before surgery help pre- a consideration in any cancer. The ability
several choices for osteotomy design. pare the patient and their family for this of a cancer to metastasize most commonly
Some surgeons advocate rim mandibulec- eventuality. Mention should be made of manifests itself by growth of cancer in
tomy, preserving at least a 1 cm inferior the possible return to the operating room lymph nodes. Surgical treatment of the
border, whereas others advocate a sagittal if final pathologic analysis reveals an unex- neck is justified for two reasons: the
marginal mandibulectomy or a variation pected amount of bone involvement removal of gross disease in patients with
thereof.114 An important point is the
avoidance of right angles in the osteotomy
design that serve as stress risers and may
lead to fracture. We prefer an osteotomy
that begins in the sigmoid notch and
sweeps inferiorly and anteriorly for lesions
located in the posterior mandible (Figure
33-15). It is important to note that the
thick cortical bone along the posterior
ramus is rarely involved, even when the
mandible is invaded, and it can usually be
preserved and serves as an area for plating.
Edentulous mandibles are generally not
candidates for marginal resection
although this is not an absolute rule. Wax
and colleagues, and Shah have published
excellent reviews of the topic of segmental
and marginal resection, and the reader is A B
directed to their reviews for a more in- FIGURE 33-16 A, Outline of incision for lip-splitting approach to the posterior oral cavity and
depth discussion.115,116 If the surgeon is oropharynx. B, Midline division of the tongue following midline mandibulotomy.
Oral Cancer Treatment 647
Type III preserves the spinal acces- by a radical neck dissection. For exam-
sory nerve, the sternocleidomas- ple, mediastinal nodes or nonlymphat-
toid muscle, and the internal jugu- ic structures such as the carotid artery
lar vein. or hypoglossal nerve.
Selective neck dissection: Refers to the
It is important to remember that clas-
preservation of one or more lymph
sification schemes are continually chang-
node groups normally removed in a
ing, and as science evolves the indications
radical neck dissection. In the 1991
for different dissections will certainly
classification scheme there were sever-
change. For an oral cavity primary without
al named selective neck dissections.
evidence of lymph node metastases, a
For example, the supraomohyoid neck
selective neck dissection removing lymph FIGURE 33-21 Denervation of a patients left
dissection removed the lymph nodes
nodes from levels I to III is the generally trapezius following sacrifice of spinal accessory
from levels I to III (Figure 33-20). The nerve during radical neck dissection.
accepted procedure. Shah and colleagues
subsequent proposed modification in
demonstrated supraomohyoid neck dis-
2001 sought to eliminate these
section to eradicate occult metastatic dis-
named dissections. The committee neck if positive nodes are ultimately found
ease in 95% of patients.133 Some surgeons,
proposed that selective neck dissec- in the pathologic specimen. This can be
however, advocate including level IV
tions be named for the cancer that the improved by the addition of postoperative
(extended supraomohyoid neck dissec-
surgeon was treating and to name the radiation treatment.136 The question
tion) to decrease the risk, however small,
node groups removed. For example, a remains as to whether this is due to the
of missed occult metastases. Extension on
selective neck dissection for oral cavi- type of neck dissection or simply the biol-
the left side does entail an increased risk to
ty cancer would encompass those ogy of the tumor.137,138 Most surgeons
the thoracic duct and attendant chyle
node groups most at risk (levels I to advocate some form of neck dissection if
leak.98 Modifications of neck dissections
III) and be referred to as a selective there is demonstrable evidence of metasta-
have been made in an attempt to prevent
neck dissection (levels I to III). tic disease in the neck, and a diminishing
the morbidity of radical neck dissection
Extended neck dissection: Refers to the number of surgeons maintain that the evi-
(Figure 33-21). Preservation of the spinal
removal of one or more additional dence of lymph node metastases is justifi-
accessory nerve decreases the incidence of
lymph node groups, nonlymphatic cation for nothing less than a standard
painful shoulder syndrome. Extensive
structures, or both, not encompassed radical neck dissection.
skeletonization of the nerve, however, can
result in significant dysfunction even if the
nerve is preserved (Figure 33-22). Several
studies have suggested that dissection of
level IIb (above the nerve) is unnecessary
in the clinically negative neck because of
the low incidence of metastases in this area
(1.6%), and is recommended only if bulky
disease is present in level IIa.134
If there is clinical evidence of lymph
node metastases, controversy exists over
the proper type of neck dissection (see sec-
tion Therapeutic Neck Dissection,
below). The application of supraomohy-
oid neck dissection to the N positive neck
(therapeutic neck dissection) has yielded
mixed results.135 Previous studies have
FIGURE 33-20 Supraomohyoid neck dissection, or
demonstrated that patients undergoing
selective neck dissection, levels I to III. The stern- FIGURE 33-22 Dissection and skeletonization of
ocleidomastoid muscle, nerve XI, and internal selective neck dissections for N0 necks spinal accessory nerve can produce shoulder dys-
jugular vein are preserved. have a higher rate of recurrence in the function even if nerve is preserved.
650 Part 5: Maxillofacial Pathology
Another controversy regarding the N0 neck (staging neck dissection or elec- with N0 necks.147 They compared sentinel
evolution of neck dissection concerns the tive neck dissection) is becoming increas- node biopsy to CT images and PET images
concept of in-continuity versus discontin- ingly limited. The sentinel node technique, by obtaining a CT and PET followed by
uous neck dissections. In the past it was first popularized for melanoma, has been sentinel node biopsy and neck dissection.
considered mandatory to remove the pri- investigated for use in head and neck can- They found 10 true-positives, 6 positive
mary tumor in direct continuity with the cer.143,144 Theoretically it allows the identi- nodes identified on frozen section, 2 pos-
neck dissection, in one specimen. Work by fication and removal of the first-echelon tive notes on evaluation of permanent
Spiro and Strong found no adverse impact lymph node (sentinel node) that would pathologic specimens, and 2 on immuno-
on survival when neck dissection was per- first receive metastases from a given site. peroxidase staining for cytokeratin. In
formed in a discontinuous manner. Bias The technique involves injecting the area 6 specimens, the sentinel node was the only
might have occurred, however, as smaller surrounding the primary site with a positive node. They also found 7 true-
lesions were in the discontinuity group.139 radioactive-labeled material, 99mTc-sulfur negatives and 1 false-negative. In 1 case the
A study by Leemans and colleagues found colloid. Various molecular weights can be sentinel node identified by the radioactive
worse outcomes in stage II cancer of the chosen depending on the transit time colloid did not contain cancer, but another
tongue with discontinuous neck dissec- desired. A radiograph is then taken to iden- cervical node did. They also found that
tion, with local recurrence rates of 19.1% tify and locate the sentinel node. The tumor in the node can lead to obstruction
versus 5.3% and a 5-year survival of 63% patient is then taken to the operating room and redirection of lymphatic flow.147 Pit-
versus 80%.140 Most surgeons prefer an in- where the surgeon may inject isosulfan man and colleagues further demonstrated
continuity approach if technically feasible, blue dye around the primary tumor site. the use of the sentinel node biopsy tech-
without the resection of obviously unin- The dye will also drain to the sentinel node nique for the N0 neck.148 Hyde and col-
volved structures such as the mandible. and stain it blue, assisting the surgeon in leagues reported on 19 patients whose
The controversy surrounding elective identification during surgery (Figure 33- radiographic and clinical test results on
neck dissection versus elective neck irradi- 23). The surgeon will also use a gamma their necks were negative and who under-
ation (without neck dissection) continues. detection probe counterprobe to identify went sentinel lymph node biopsy and PET
Advantages of surgery include the produc- the node with the highest concentration of scanning followed by conventional neck
tion of a surgical specimen that guides the radioactive colloid. The node is then dissection.149 In 15 of the 19 patients the
need for further treatment. If no lymph removed, and if it is histologically positive, sentinel node as well as the remaining
nodes are identified, radiation can be held. further treatment such as radiation may be nodes were negative. In 3 of the 19 patients
The possibility of future second, third, or indicated. In melanoma, sentinel node the sentinel node was positive along with
even fourth primary cancer arising in this biopsy has a reported sensitivity of 82 to other nodes. In 1 patient the sentinel node
at-risk population makes reserving radia- 100%, and very few false-negatives.145,146 was negative, but another node removed in
tion attractive. A comprehensive discus- The technique has been investigated in the neck dissection was positive. The node
sion of the management of cervical lymph the head and neck with varying results. was located close to the primary cancer,
nodes in head and neck cancer is beyond Problems with the application of the sen- which often leads to difficulty discriminat-
the scope of this chapter. Three excellent tinel node technique to squamous cell can- ing activity due to the tumor and that of
reviews are available and recommend- cer of the oral cavity relate to the rich lym- adjacent nodes. Interestingly PET failed to
ed.117,141,142 Although several studies have phatic drainage with possible bilateral
failed to demonstrate a survival advantage drainage as well as the complex anatomy in
in patients who undergo elective neck dis- the neck, leading to difficulty in dissecting
section versus careful follow-up and ther- out a single node. In addition close prox-
apeutic neck dissection if a metastasis imity of the sentinel node to the primary
develops, most surgeons would agree that cancer, for example, an FOM primary can-
the morbidity associated with a selective cer and submental node, can lead to the
neck dissection is minimal and would have accumulation of colloid around the prima-
a low threshold for performing it. ry cancer, which obscures the sentinel
node. The rich lymphovascular network
Sentinel Node Biopsy can also lead to drainage to several nodes.
As the evolution toward less invasive surgi- Cevantos and colleagues used the sentinel FIGURE 33-23 Sentinel node biopsy. Note the
cal modalities proceeds, dissection of the node technique in 18 oral cavity cancers dark staining of the sentinel node.
Oral Cancer Treatment 651
reveal cancer in the 4 patients with subse- others plan a neck dissection 4 to 6 weeks modality therapy for head and neck can-
quently identified cervical metastasis (see after treatment regardless of response. Still cer.157159 This classic series of articles out-
discussion on PET scanning, above).149 In others recommend a CT scan at 4 weeks lined failure characteristics at the local site,
the future the sentinel node biopsy may and CT-guided biopsy of any suspicious neck, distant sites, as well as development
become the operative procedure of choice nodes. This is followed by neck dissection of second malignant neoplasms in patients
for dealing with the N0 neck. In an excel- if the node biopsy is positive for cancer. treated at Memorial Sloan-Kettering Can-
lent review Pitman and colleagues con- McHam and colleagues found that clinical cer Center, NY, USA.136,157159 Ninety per-
cluded that sentinel lymph node biopsy factors did not predict patients with resid- cent of patients who will suffer a recur-
remains an experimental technique in head ual disease following chemoradiation rence of oral cavity cancer will do so in the
and neck cancers and has not become a therapy and recommended neck dissec- first 2 years. For this reason patients are
standard of care.150 tion in all patients initially seen with N2 to placed in a structured follow-up. Stage at
N3 disease.152 This recommendation was recurrence is the most important predic-
Therapeutic Neck Dissection made in light of a 26 to 35% complication tor of survival, with stage I at recurrence
Patients presenting with nodal disease will rate in patients undergoing neck dissec- associated with a median survival of
usually undergo some type of therapeutic tions following chemoradiation therapy.152 24.3 months and a disease-free survival at
neck dissection, the nature of which varies The role of PET scanning in this situation 2 years of 73%, whereas stage IV recur-
with surgeons preference. Some surgeons is unclear, but patients with recurrent can- rence was associated with a median sur-
will treat all patients with suspected cervi- cer following multimodality therapy typi- vival of 9.3 months and a 2-year disease-
cal metastases with a radical neck dissec- cally have a poor outcome, making salvage free survival of 22%.160 Follow-up
tion. Most consider a modified radical surgery an unattractive alternative. protocols vary widely and are intended to
neck dissection adequate, removing the Surgical management of cervical detect recurrences early. De Visscher and
internal jugular vein or sternocleidomas- lymph node metastasis, both occult and Manni suggested the following 161:
toid muscle if indicated. There is some evi- evident, continues to evolve. It is clear that
1. Every 2 months for 1 year
dence that selective neck dissection may be metastases are an indication of aggressive-
2. Every 3 months for year 2
adequate for the N positive neck in certain ness and portend a poorer prognosis.
3. Every 4 months for year 3
carefully selected patient populations (see Once the cancer has developed the neces-
4. Every 6 months for years 4 and 5
discussion of selective neck dissections, sary genetic mutations to break free and
5. Then yearly
above). Anderson and colleagues reported colonize independent of the primary
the results of three academic centers in tumor, the chance of cure with single Despite this and other suggested fol-
which patients with previously untreated modality therapy diminishes. In his presi- low-up protocols, the follow-up schedule
clinically and pathologically N positive dential address to the New England Surgi- must be tailored to the individual patient
necks underwent neck dissection.151 They cal Society, Blake Cady referred to and must take into account the patients
reported a regional control rate of 94.3%. lymph node metastases as the speedome- likelihood of having a recurrence, possible
Their results were comparable to patients ters of the oncologic vehicle, not the continuation of smoking or other habits,
undergoing more extensive neck dissec- engine. Indicators, not governors of sur- ability to travel and keep appointments,
tions.151 Patients presenting with massive vival.153 Clearly the role for the radical and the potential availability of local med-
nodal disease who are going to be treated neck dissection has diminished greatly ical or dental care that might assist in
with chemoradiation therapy or combina- over the past few decades, as less invasive follow-up surveillance. Follow-up appoint-
tion of brachytherapy and external beam surgical techniques for dealing with the ments include an update of patient history
therapy can present a challenge to sur- cervical lymphatics have gained populari- and review of systems as well as clinical
geons who are faced with the option of ty. This trend will likely continue, as the examination for recurrence or detection of
surgery before or following radiation. Not role of surgery in the control of metastatic new primaries. Questions raised by physical
infrequently surgeons are faced with com- disease is better defined.154156 examination should prompt an appropriate
plete clinical resolution of disease and the imaging study, rebiopsy, or examination
prospects of a neck dissection in a heavily Recurrence and Follow-Up under anesthesia. Caution should be used,
irradiated field. There is some variation in Surveillance however, in performing biopsies in patients
approaches to this dilemma. Some sur- In 1984 Vikram and colleagues published a who have received intensive multimodality
geons recommend pretreatment neck dis- series of reports that discussed patterns of therapy, such as RADPLAT, brachytherapy,
section to remove bulky disease, whereas failure in patients treated with multi- or hyperfractionated radiation schedules
652 Part 5: Maxillofacial Pathology
combined with chemotherapy. Extensive to be a more valuable alternative for detec- cancers, and found benefit in stages I and
biopsy wounds are notorious for slow heal- tion of distant disease. Yearly lab work to II.160 Success was limited in more
ing and can lead to chronic wounds. include liver function studies is also rec- advanced disease.160 Clearly defined goals
Appropriate imaging, including a ommended. In patients who have received should be established between surgeon
baseline CT or MRI at the completion of radiation as part of their treatment, peri- and patient for salvage surgery. Is the
multimodality therapy, is invaluable. The odic thyroid function tests are helpful, as operation for cure or palliation? Palliative
role of PET scanning in follow-up contin- many will ultimately become hypothyroid surgery should be undertaken very cau-
ues to evolve. with attendant fatigue and decreased tiously as surgical complications may
Failure at the primary cancer site will wound healing ability. greatly overshadow the palliative goals.
ultimately occur in approximately 20% of Collins stated that patients with head Patients and their families must have real-
patients, and regional recurrence in the and neck cancer are probably never cured, istic expectations as well as understand
neck will occur in 10%. Death from dis- and that it is better to consider that the that there is no benefit from repeated sur-
tant metastases is rare, occurring in only host-tumor relationship has been durably gical intervention for recalcitrant cancer.
about 1 to 4% of cases in which locore- altered in favor of the host.164 It is impor- Patients with inoperable cancer pose
gional control is maintained. An unfortu- tant to realize that approximately one- a unique challenge to the clinician. As
nate consequence of improved control at third of patients with presumed localized cure is no longer a realistic option, treat-
the primary cancer site with multimodali- disease will relapse and die of cancer. In ment modalities to prolong life and
ty therapy is an increasing incidence of advanced head and neck squamous cell improve quality of life assume a higher
distant metastases. In addition to recur- carcinoma 20 to 30% will survive, 40 to priority. Pain control becomes a signifi-
rences, prospective studies have demon- 60% of patients will suffer locoregional cant issue in patients with recurrent head
strated that second primary cancers devel- recurrence, and 20 to 30% will succumb to and neck cancer. Long-acting sustained
op at a rate of 4 to 7% annually in patients distant metastases. Hence the majority of release formulations such as transdermal
who have had a head and neck squamous treatment failures remain recurrence of narcotic patches combined with short-
cancer. Second primary cancers are the locoregional disease.164 Patients with acting narcotics for breakthrough pain
leading cause of death among patients recurrent disease are restaged, which are typically required. Rhizotomy is an
who have undergone treatment for early- requires a similar evaluation as the origi- option for intractable pain. Pain control
stage oral cancers.136,157159 nal. Panendoscopy and examination under can be a goal of palliative chemotherapy
The ability of a cancer to metastasize anesthesia take on greater importance or radiotherapy. Novel methods for the
depends on the development of a series of when a clinician is faced with examination targeted delivery of chemotherapeutic
genetic mutations, allowing for cells to of tissue scarred and distorted by previous agents into the tumor are under develop-
disseminate from the primary tumor, surgery and radiation. Distant metastases ment. A combination of cisplatin and
arrest in the microcirculation, extravagate, should be ruled out to the extent possible epinephrine gel injected into recurrent
infiltrate into stroma, and survive and prior to deciding on aggressive re- tumors demonstrated significant pallia-
proliferate as a new colony. Surveillance treatment. It the patient does have recur- tion without significant side effects in
for distant metastases therefore becomes rence that is confined to the locoregional most.167 Wound management becomes an
an important component of the follow-up area, treatment decisions are limited by important issue, and dealing with large
evaluation. The lungs are the most com- previous therapy. Reirradiation protocols malodorous wounds can be taxing on
mon site for distant metastases, followed exist but are accompanied by significant patients and families. Patients presenting
by the liver and bone. Yearly or biannual morbidity.165 Intensive reirradiation and with advanced head and neck cancer will
chest radiographs allow for detection of chemotherapy protocols are being investi- typically survive 6 to 12 months without
lung metastases, the most common distant gated and show some promise.166 The treatment, and patients with end-stage
site metastasized for oral cavity cancer, morbidity of such treatments is signifi- head and neck cancer will have a median
and primary lung cancers, which are not cant, and their use should be restricted to survival of 101 days.164
uncommon in the population at risk for clinical trials at this time. Surgical salvage There is a natural tendency for clini-
oral cancer.162 Given the current unavail- remains the primary option, but the extent cians to avoid the dying patient. There is
ability of an effective treatment regimen, of salvage surgery must be considerably a reluctance to face a disease whose biol-
however, some authors have questioned broader than might initially be considered. ogy has resisted their best efforts and
the use of annual or semiannual chest Goodwin reported on the outcome of sal- whose treatment has left patients debili-
radiographs.163 PET scanning may prove vage surgery for recurrent head and neck tated and frequently deformed. While
Oral Cancer Treatment 653
family members and clinicians are dis- smoking, poor body mass index, and other before them. They must interact effective-
cussing further treatment options, comorbidities had an independent impact ly with colleagues of other disciplines with
patients are frequently simply concerned on prognosis.170 As discussed earlier there the patients benefit their foremost con-
with pain control and the effects of mas- may indeed be a more aggressive form of cern. They must execute the surgical com-
sive doses of narcotics on bowel function. squamous cell carcinoma that affects ponents of the treatment plan with accu-
Frank, thoughtful discussions must be younger patients, but data from the racy and skill. They must be supportive to
held with the patients and their families National Cancer Data Base indicate that their patients and their patients families at
regarding end-of-life issues and will help younger patients have a survival advantage a time of great stress in their lives and
surgeons deal with these very real con- that is most likely related to their lack of must not turn away from adversity or
cerns. Hospice provides an excellent comorbidities.171Frequently 5- and 10- complication. They must accept the fact
resource, and once enrolled most families year survival curves are impacted more by that not all patients can be cured. They
are appreciative of the support offered by these comorbidities than the tumor char- should derive inspiration from those who
these professionals in end-of-life care. acteristics recorded in the TNM system survive and satisfaction from those who
In this era of improved treatment (see discussion below).172 The TNM stag- might succumb in a way made more favor-
modalities for local and regional disease, ing system will continue to undergo revi- able by the surgeons input.
clinicians are finding that factors unrelat- sions to enhance its use.
ed to the primary cancer and beyond their References
control are influencing survival. It is Future Treatments 1. Parkin DM, Pisani P, Farley J. Global cancer
statistics. CA Cancer J Clin 1999;49:3364.
becoming increasingly evident that factors In the future, biologic markers hold out
2. Jemal A, Murray T, Samuels A, et al. Cancer sta-
affecting outcome in oral cancer patients promise as the key to treatment of head tistics, 2003. CA Cancer J Clin 2003;
are multiple and may relate more to and neck squamous cancers. Serving as 53:2347.
patient characteristics than the cancer potential targets for gene therapy, biologic 3. Canto MT, Devesa SS. Oral cavity and pharynx
itself or the treatment they receive. markers may also determine appropriate cancer incidence rates in the United States,
19751998. Oral Oncol 2002;38:6107.
Researchers are finding that genetic factors treatment strategies and may select which
4. Greenlee RT, Murray T, Bolden S, et al. Cancer
of the primary cancer have an impact on patients should be treated with surgery, statistics, 2000. CA Cancer J Clin 2000;
the response of the particular tumor to radiation treatment, chemotherapy, or 50:733.
any treatment.168 High expression of epi- combination treatment. Certain subpopu- 5. Swango PA. Cancers of the oral cavity and
dermal growth factor receptors is associat- lations of squamous cancers, those with pharynx in the United States: an epidemio-
logic overview. J Public Health Dent
ed with poor outcome, and may indicate high levels of TP53 expression and low lev- 1996;56:30918.
the need for more intensive multimodality els of the marker Ki-67 for example, have 6. Meskin LH. Oral cancer: the forgotten disease
therapy. Alterations in TP53 have been higher relapse rates following initial thera- [editorial]. J Am Dent Assoc 1994;125:
associated with recurrence in squamous py. These patients may benefit from more 10425.
7. Smart CR. Screening for cancer of the aerodi-
cell cancer of the head and neck that was aggressive combination treatments.168,169
gestive tract. Cancer 1993;72 Suppl:10615.
refractory to radiation treatment. Future Every few years a new cancer therapy 8. Smith RA, Cokkinides V, Eyre HJ. American
treatments may include restoration of is heralded as the end of cancer surgery. Cancer Society guidelines for the early
TP53 function.169 For the present, surgery will continue to detection of cancer, 2003. CA Cancer J Clin
Importantly studies are also demon- play the key role in management of oral 2002;53:2743.
9. Holmes J, Dierks E, Homer L, Potter B. Is
strating that comorbidities and perfor- cavity cancers, and surgeons must be detection of oral and oropharyngeal squa-
mance status predict survival independent knowledgeable in all diagnostic and treat- mous cancer by a health care provider asso-
of stage at diagnosis. Performance status ment modalities as they continue their ciated with a lower stage at diagnosis? J Oral
has been shown to be a predictor of sur- captainship of the oral cancer team. The Maxillofac Surg 2003;61:28591.
10. Guggenheimer J, Weissfield JL, Kroboth FJ. Who
vival independent of tumor, regional surgeons treating oral cancer, regardless of
has the opportunity to screen for oral can-
nodes, and metastasis (TNM) stage. Many their discipline, must learn from the con- cer? Cancer Causes Control 1993;4:636.
head and neck cancer patients suffer other tributions and mistakes of their forebears 11. Choido GT, Eigner T, Rosenstein DI. Oral can-
medical problems related to tobacco and and add the benefit of their own training cer detection: the importance of routine
alcohol use, and these can result in and experience. They must then use their screening for prolongation of survival.
Postgrad Med 1986;80:2316.
decreased overall survival despite cancer- knowledge base and the input of other
12. Elliott GV, MacDougal JA, Elliott JD. Problems
specific survival. Ribeiro and colleagues treating colleagues to synthesize a plan of of verrucous squamous carcinoma. Ann
found that daily alcohol consumption, treatment tailored to the patient who sits Surg 1973; 177:219.
654 Part 5: Maxillofacial Pathology
13. Coppoal D, Catalano E, Tang C, et al. Basaloid 27. Sieron A, Adamek M, Kawczyk-Krupka A, et al. complications in major surgery of the oral
squamous cell carcinoma of floor of Photodynamic therapy (PDT) using topi- cavity and oropharynx with microvascular
mouth. Cancer 1993;72:2299305. cally applied delta-aminolevulinic acid soft tissue reconstruction. Head Neck
14. Raslan WF, Barnes L, Krause JR, et al. Basaloid (ALA) for the treatment of oral leukoplakia. 2003;25:80815.
squamous cell carcinoma of the head and J Oral Pathol Med 2003;32:3306. 41. Becker GD, Parell GJ. Cefazolin prophylaxis in
neck: a clinicopathologic and flow cytomet- 28. Copper MP, Tan IB, Oppelaar H, et al. Meta- head and neck cancer surgery. Ann Otol
ric study of 10 new cases with review of the tetra(hydroxyphenyl)chlorine photody- 1979;88:1836.
English literature. Am J Otolaryngol namic therapy in early stage squmaous cell 42. Mombelli G, Coppens L, Dor P, Klastersky J.
1994;15:2048. carcinoma of the head and neck. Arch Oto- Antibiotic prophylaxis in surgery for head
15. Axell T, Pindborg JJ, Smith CJ, Van der Waal I. laryngol Head Neck Surg 2003;129:70911. and neck cancer: comparative study of
Oral white lesions with special reference to 29. McGuirt WF. Panendoscopy as a screening short and prolonged administration of car-
precancerous and tobacco related lesions: examination for simultaneous primary bencillin. J Antimicrob Chemother 1981;
conclusions of an international symposium tumors in head and neck cancer: a prospec- 7:66571.
held in Uppsala, Sweden, May 1821, 1994. tive, sequential study and review of the lit- 43. Ananth S, Amin M. Implantation of oral squa-
International Collaborative Group on oral erature. Laryngoscope 1982;92:56976. mous cell carcinoma at the site of a percuta-
white lesions. J Oral Pathol Med 1996;2 30. Benninger MS, Enrique RR, Nichols RD. neous endoscopic gastrostomy: a case report.
5:4954. Symptom-driven selective endoscopy and Br J Oral Maxillofac Surg 2002;40:12530.
16. Petti, S. Pooled estimates of world leukoplakia cost-containment for evaluation of head 44. Janjan N, Miller M, Schusterman MA. Thera-
prevalence: a systemic review. Oral Oncol and neck cancer. Head Neck 1993;15:5326. peutic principles and options in radiation
2003;39:77080. 31. Slaughter DP, Southwick HW, Smejkal W. Field oncology. Plast Reconstr Surg 1995;
17. Hashibe M, Jacob BJ, Thomas G, et al. Socioe- cancerization in oral stratified squamous 96:146373.
conomic status, lifestyle factors and oral epithelium: clinical implications of multi- 45. Buchholz TA, Laramore GE, Griffin BR, et al.
premalignant lesions. Oral Oncol 2003; centric origin. Cancer 1953;6: 9638. The role of fast neutron radiation therapy
39:66471. 32. Nathan CA, Amirghahri N, Rice C, et al. Mole- in the management of advanced salivary
18. Silverman S, Gorsky M, Lozada F. Oral leuko- cular analysis of surgical margins in head gland malignant neoplasms. Cancer
plakia and malignant transformation: a and neck squamous cell carcinoma 1992;69:277988.
follow-up study of 257 patients. Cancer patients. Laryngoscope 2002;112:212940. 46. Vikram B. Does hyperfractionation reduce late
1984:53:5638. 33. Thomson PJ. Field change and oral cancer: complications in head and neck cancer [let-
19. Scheifele C, Reichart PA. Is there a natural limit new evidence for widespread carcinogene- ter]? Int J Radiat Oncol Biol Phys
of the transformation rate of oral leuko- sis? Int J Oral Maxillofac Surg 2002; 1992;23:10978.
plakia? Oral Oncol 2003;39:4705. 31:2626. 47. Taylor JM, Mendenhall WM, Lavey RS. Dose,
20. Lodi G, Sardella A, Bez C, et al. Interventions for 34. Jacobs JR, Ahmad K, Casiano R, et al. Implica- time and fraction size for late effects in head
treating oral leukoplakia (Cochrane review). tions of positive surgical margins. Laryngo- and neck cancers. Int J Radiat Oncol Biol
In: The Cochrane Library. Issue 4. Oxford: scope 1993;103:648. Phys 1992;22:311.
Update Software; 2002. 35. Beitler JJ, Smith RV, Silver CE, et al. Close or 48. Eisbruch A, Marsh LH, Martel MK, et al. Com-
21. Lodi G, Sardella A, Bex C, et al. Systematic positive margins after surgical resection for prehensive irradiation of head and neck
review of randomized trails for the treat- the head and neck cancer patient: the addi- cancer using conformal multisegmental
ment of oral leukoplakia. J Dent Educ tion of brachytherapy improves local con- fields: assessment of target coverage and
2002;66:896902. trol. Int J Radiat Oncol Biol Phys noninvolved tissue sparing. Int J Radiat
22. Ishii J, Fujita K, Komori T. Laser surgery as a 1998;40:3137. Oncol Biol Phys 1998;41:55968.
treatment for oral leukoplakia. Oral Oncol 36. Ord RA, Aisner S. Accuracy of frozen sections 49. Eisbruch A, Foote RL, OSullivan B, et al.
2003;39:75969. in assessing margins in oral cancer resec- Intensity-modulated radiation therapy for
23. Hopper C. Photodynamic therapy: a clinical tion. J Oral Maxillofac Surg 1997;55:6639; head and neck cancer: emphasis on the
reality in the treatment of cancer. Lancet discussion 66971. selection and delineation of the targets.
Oncol 2000;1:2129. 37. Dinardo LJ, Lin J, Karageorge LS, Powers CN. Semin Radiat Oncol 2002;12:23849.
24. Grant WE, Speight PM, Hopper C, Brown SG. Accuracy, utility and cost of frozen section 50. Langlois D, Hoffstetter S, Malissard L, et al. Sal-
Photodynamic therapy: an effective but margins in head and neck cancer surgery. vage irradiation of oropharynx and mobile
non-selective treatment for superficial can- Laryngoscope 2000; 110:17736. tongue with 192-Iridium brachytherapy in
cers of the oral cavity. Int J Cancer 38. Ribeiro NF, Godden DR, Wilson GE, Butter- Centre Alexis Vautrin. Int J Radiat Oncol
1997;71:93742. worth RT. Do frozen sections help achieve Biol Phys 1988;14:84953.
25. Zhao FY, Zhang KH, Jiang F, Wu MJ. Photody- adequate surgical margins in the resection 51. Matsumoto S, Takeda M, Shibuya H, Suzuki S.
namic therapy for treatment of cancers of the of oral carcinoma? Int J Oral Maxillofac T1 and T2 squamous cell carcinomas of the
oral and maxillofacial regions: a long term Surg 2003;32:1528. floor of mouth: results of brachytherapy
follow up study in 72 complete remission 39. Sutton DN, Brown JS, Rogers SN, et al. The mainly using 98 Au grains. Int J Radiat
cases. Lasers Med Sci 1991;6:2014. prognostic implications of the surgical Oncol Biol Phys 1996;34:83341.
26. Ackroyd R, Kelty CJ, Brown NJ, et al. Eradica- margin in oral squamous cell carcinoma. 52. Noone RB, Bonner H, Raymond S, et al.
tion of dysplastic Barretts oesophagus Int J Oral Maxillofac Surg 2003;32:304. Lymph node metastases in oral carcinoma.
using photodynamic therapy: long-term 40. Borggreven PA, Kuik DJ, Quak JJ, et al. Comor- A correlation of histopathology with sur-
follow-up. Endoscopy 2003; 35:496501. bid condition as a prognostic factor for vival. Plast Recontr Surg 1974;53:15866.
Oral Cancer Treatment 655
53. Mendenhall WM, Million RR, Cassisi NJ. Elec- A. Reporting results of cancer treatment. gene therapy in head and neck cancer. Eur J
tive neck irradiation in squamous cell carci- Cancer 1981;47:20710. Surg Oncol 2000;26:33843.
noma of the head and neck. Head Neck 66. DeVita VT Jr. Principles of chemotherapy. In: 79. Yarbrough WG. The ARF-p16 gene locus in
1980; 3:1520. DeVita VT Jr, Hellman S, Rosenberg SA, carcinogenesis and therapy of head and
54. Woolger JA, Rogers SN, Lowe D, et al. Cervical editors. Cancer: principles and practices of neck squamous cell carcinoma. Laryngo-
lymph node metastasis in oral cancer: the oncology. Philadelphia (PA): JB Lippincott scope 2002;112:211428.
importance of even microscopic extracap- Co.; 1993. p. 27692. 80. Milas L, Mason KA, Zhongxing L, Ang KK.
sular spread. Oral Oncol 2003;39:1307. 67. Mihara M, Shintani S, Nakashiro K, Chemoradiotherapy: emerging treatment
55. Tupchong L, Scott CB, Blitzer PH, et al. Ran- Hamakawa H. Flavopiridol, a cyclin depen- improvement strategies. Head Neck
domized study of preoperative versus post- dent kinase (CDK) inhibitor, induces apop- 2003;25:15267.
operative radiation therapy in advanced tosis by regulating Bcl-x in oral cancer cells. 81. Hong WK, Lippman SM, Wolf GT. Recent
head and neck carcinoma: long-term follow- Oral Oncol 2003;39:4955. advances in head and neck cancer larynx
up of RTOG 73-03. Int J Radiat Oncol Biol 68. Patel V, Senderowicz AM, Pinto D, et al. preservation and cancer chemoprevention:
Phys 1991;20:218. Flavopiridol, a novel cyclin-dependent the Seventh annual Richard and Hinda
56. Peters LJ, Goepfert H, Ang KK, et al. Evaluation kinase inhibitor, suppresses the growth of Rosenthal Foundation award lecture. Can-
of the dose for post-operative radiation head and neck squamous cell carcinomas cer Res 1993;53:511320.
therapy of head and neck cancer: first by inducing apoptosis. J Clin Invest 1998; 82. Garewal HS, Katz RV, Meyskens F, et al. Beta-
report of a randomized trial. Int J Radiat 102:167481. carotene produces sustained remissions in
Oncol Biol Phys 1993;26:311. 69. Cooper JS, Pajak TF, Forastiere AA, et al. 2002 patients with oral leukoplakia. Arch Oto-
57. Vikram B. Importance of time interval abstract ASCO online. Available at: laryngol Head Neck Surg 1999;125:130510.
between surgery and postoperative radia- http://www.asco.org (accessed November 83. Wang Z, Polavaram R, Fuentes CF, et al. Topical
tion therapy in the combined management 21, 2003). chemoprevention of oral cancer with
of head and neck cancer. Int J Radiat Oncol 70. Cmelak AJ, Murphy BA, Day T. Combined tretinoin biofilm. Arch Otolaryngol Head
Biol Phys 1979;5:183740. modality therapy for locoregionally Neck Surg 2003;129:86973.
58. Schiff PB, Harrison LB, Strong EW, et al. advanced head and neck cancer. Oncology 84. Armstrong WB, Wan XS, Kennedy AR, et al.
Impact of the time interval between surgery 1999;13:8391. Candidates thesis: development of the
and postoperative radiation therapy on 71. Robbins KT. The evolving role of combined Bowman-Birk inhibitor for oral chemopre-
locoregional control in advanced head and modality therapy in head and neck cancer. vention and analysis of Neu immunohisto-
neck cancer. J Surg Oncol 1990;43:2038. Arch Otolaryngol Head Neck Surg chemical staining intensity with Bowman-
59. Parsons JT, Mendenhall WM, Stringer SP, et al. 2000;126:2659. Birk inhibitor concentrate treatment.
An analysis of factors influencing the out- 72. Dimery IW, Hong WK. Overview of combined Laryngoscope 2003;113:1687702.
come of postoperative irradiation for squa- modality therapies for head and neck cancer. 85. Mohan S, Epstein JB. Carcinogenesis and
mous cell carcinoma of the oral cavity. Int J 1993;85:95111. cyclooxygenase: the potential role of COX-
Radiat Oncol Biol Phys 1997;39:13748. 73. El-Sayed S, Nelson N. Adjuvant and adjunctive 2 inhibition in upper aerodigestive tract
60. Brizel DM, Wasserman TH, Henke M, et al. chemotherapy in the management of squa- cancer. Oral Oncol 2003;39:53746.
Phase III randomized trial of amifostine as mous cell carcinoma of the head and neck 86. Dempke W, Rie C, Grothey A, et al. Cyclooxyge-
a radioprotector in head and neck cancer. J region: a meta analysis of prospective and ran- nase-2: a novel target for cancer chemother-
Clin Oncol 2000; 18:333945. domized trials. Clin Oncol 1996;14:83847. apy? Am J Pathol 2002;160:389401.
61. Wijers OB, Levendag PC, Braaksma MM, et al. 74. Munro AJ. An overview of randomized con- 87. Sudbo J, Ristimaki A, Sondresen JE, et al.
Patients with head and neck cancer cured trolled trials of adjuvant chemotherapy in Cyclooxygenase-2 (COX-2) expression in
by radiation therapy: a survey of the dry head and neck cancer. Br J Cancer high-risk premalignant oral lesions. Oral
mouth syndrome in long-term survivors. 1995;71:8391. Oncol 2003;39:497505.
Head Neck 2002;24:73747. 75. Robbins KT, Kumar P, Regine WF, et al. Effica- 88. Lin DT, Subbaramaiah K, Shah JP, et al.
62. Nicolatou-Galitis, O, Sotiropoulou-Lontou A, cy of supradose intra-arterial targeted (SIT) Cyclooxygenase-2: a novel molecular target
Velegraki A, et al. Oral candidiasis in head cisplatin (P) and concurrent radiation for the prevention and treatment of head and
and neck cancer patients receiving radio- treatment (RT) in the treatment of unre- neck cancer. Head Neck 2002;24:79299.
therapy with amifostine cytoprotection. sectable stage III-IV head and neck carcino- 89. Baker SR, Krause CJ. Carcinoma of the lip.
Oral Oncol 2003;39:397401. ma: the Memphis experience. Int J Radiat Laryngoscope 1980;90:1925.
63. Wolf GT, Hong KT, Fisher SG, et al. Induction Oncol Biol Phys 1997;38:26371. 90. Duplechain G, Amedee RG. Carcinoma of the
chemotherapy plus radiation compared 76. Andreadis C, Vahtsevanos K, Sideras T, et al. 5- lip. J La State Med Soc 1992;144:4412.
with surgery plus radiation in patients with Fluorourocil and cisplatin in the treatment 91. Bloom ND, Spiro RH. Carcinoma of the cheek
advanced laryngeal cancer. N Engl J Med of advanced head and neck cancer. Oral mucosa: a retrospective analysis. Am J Surg
1991;324:168590. Oncol 2003;39:3805. 1980;140:55660.
64. Karnofsky DA, Burchenal JH. The clinical eval- 77. Myers JN, Holsinger C, Bekele N et al. Targeted 92. Vikram B, Farr HW. Adjuvant radiation thera-
uation of chemotherapeutics in cancer. In: molecular therapy for oral cancer with epi- py in locally advanced head and neck can-
Macleod CM, editor. Evaluation of dermal growth factor receptor blockade: a cer. CA Cancer J Clin 1983;33:1348.
chemotherapeutic agents. New York: preliminary report. Arch Otolaryngol Head 93. Diaz EM, Holsinger FC, Zuniga ER, et al.
Columbia Press; 1949. p. 191205. Neck Surg 2002;128:8759. Squamous cell carcinoma of the buccal
65. Miller AB, Hoogstraten B, Staquet M, Winkler 78. Ganly I, Soutar DS, Kaye SB. Current role of mucosa: one institutions experience with
656 Part 5: Maxillofacial Pathology
119 previously untreated patients. Head periosteum of the mandible and intraoral needle aspiration cytology in the evaluation
Neck 2003;25:26773. carcinoma. Am J Surg 1971;122:7113. of head and neck masses. Am J Surg
94. Kowalski LP, Hasimoto I, Magrin J. End results 111. OBrien CJ, Carter RL, Soo RC, et al. Invasion 1990;159:4829.
of 114 extended commando operations. of the mandible by squamous carcinomas 125. Knappe M, Louw M, Gregor RT. Ultrasonogra-
Am J Surg 1993;166:3749. of the oral cavity and oropharynx . Head phy-guided fine needle aspiration for the
95. Genden EM, Ferlito A, Shaha A, Rinaldo A. Neck 1986;8:24756. assessment of cervical metastases. Arch
Management of cancer of the retromolar 112. Barttelbort SW, Aryan S. Mandible preservation Otolaryngol Head Neck Surg 2000;
trigone. Oral Oncol 2003;39:6337. with oral cavity carcinoma: rim mandibulec- 126:10916.
96. Fakih AR, Rao RS, Borges AM, Patel AR. Elec- tomy versus sagittal mandibulectomy. Am J 126. Jungehulsing M, Scheidhauer K, Damm M, et al.
tive versus therapeutic neck dissection in Surg 1993;166:4115. 2[18F]-fluoro-2-deoxy-D-glucose positron
early carcinoma of the oral tongue. Am J 113. Forrest LA, Schuller DE, Lucas JG, Sullivan MJ. emission tomography is a sensitive tool for
Surg 1989;158:30913. Rapid analysis of mandibular margins. the detection of occult primary cancer (car-
97. Crean S, Hoffman A, Potts J, et al. Reduction of Laryngoscope 1995;105:4757. cinoma of unknown primary syndrome)
occult metastatic disease by extension of the 114. White RD. Modified sagittal osteotomy of the with head and neck lymph node manifesta-
supraomohyoid neck dissection to include mandible for marginal oncologic resection. tion. Otolaryngol Head Neck Surg 2000;
level IV. Head Neck 2003;25:75862. J Oral Maxillofac Surg 2003;61:2724. 126:145761.
98. Harrison LB, Ferlito A, Shaha AR, et al. Current 115. Wax MK, Bascom DA, Myers LL. Marginal 127. Lonneux M, Lawson G, Ide C, et al. Positron
philosophy on the management of cancer mandibulectomy versus segmental emission tomography with fluorodeoxyglu-
of the base of the tongue. Oral Oncol mandibulectomy: indications and contro- cose for suspected head and neck tumor
2003;39:1015. versies. Arch Otolaryngol Head Neck Surg recurrence in the symptomatic patient.
99. Lydiatt DD, Robbins KT, Byers RM, Wolfe PF. 2002;128:6003. Laryngoscope 2000;110:14937.
Treatment of Stage I and II oral tongue can- 116. Shah JP. The role of marginal mandibulectomy 128. Fischbein N, Anzai Y, Mukherji SK. Application
cer. Head Neck 1993;15:30812. in the surgical management of oral cancer. of new imaging techniques for the evalua-
100. Krupala JL, Gianoli R. Carcinoma of the oral Arch Otolaryngol Head Neck Surg tion of squamous cell carcinoma of the
tongue. J La State Med Soc 1993;145:4216. 2002;128:6045. head and neck. Semin Ultrasound CT MR
101. Vargas H, Pitman KT, Johnson JT, Galati LT. 117. Collins SL. Controversies in management of 1999;20:187212.
More aggressive behavior of squamous cell cancer of the neck. In: Thawley SE, Panje 129. Martin H, Delvalle B, Ehrlich H, et al. Neck dis-
carcinoma of the anterior tongue in young WP, Batsakis JG, Lindberg RD, editors. section. Cancer 1951; 4:44199.
women. Laryngoscope 2000;110:16236. Comprehensive management of head and 130. Crile G. Excision of cancer of the head and
102. Pitman KT, Johnson JT, Wagner RL, Myers EN. neck tumors, Philadelphia (PA): W.B. Saun- neck with special reference to the plan of
Cancer of the tongue in patients less than ders; 1999. p. 1479563. dissection based upon one-hundred thirty-
forty. Head Neck 2000;22:297302. 118. Van den Brekel MW. Computed tomography, two operations. JAMA 1906;47:17806.
103. McGuirt WF, Johnson JT, Myers EN, et al. magnetic resonance, ultrasound guided 131. Robbins KT, Medina JE, Wolfe GT, et al. Stan-
Floor of mouth carcinoma the manage- aspiration cytology for the assessment of dardizing neck dissection terminology offi-
ment of the clinically negative neck. Arch the neck. In: Van den Brekel MV, doctoral cial report of the Academys Committee for
Otolaryngol Head Neck Surg 1995; thesis. The Netherlands, Amsterdam: Free Head and Neck Surgery and Oncology.
121:27882. University; 1992. Arch Otolaryngol Head Neck Surg 1991;
104. Rodgers LW, Stringer SP, Mendenhall WM, et 119. Close LG, Merkle M, Vultch MF, et al. Comput- 117:6015.
al. Management of squamous cell carcino- ed tomographic evaluation of regional 132. Robbins KT, Clayman G, Levine PA, et al. Neck
ma of the floor of mouth. Head Neck lymph node involvement in cancer of the dissection classification update: revisions
1993;15:169. oral cavity and oropharynx. Head Neck proposed by the American Head and Neck
105. Dierks EJ, Holmes JD. The LeFort island 1989;11:30914. Society and the American Academy of Oto-
approach: an alternative access for partial 120. Spiro RH, Huvos AG, Wong GY, et al. Predic- laryngology Head and Neck Surgery. Arch
maxillectomy. J Oral Maxillofac Surg tive value of tumor thickness in squamous Otolaryngol Head Neck Surg 2002;
2002;60:13779. cell carcinoma confined to the tongue and 128:7518.
106. Byers RM, Newman R, Russell N, et al. Results floor of the mouth. Am J Surg 1986; 133. Shah JP, Candela FC, Poddar AK. The patterns
of treatment of squamous cell carcinoma of 152:34550. of cervical lymph node metastases from
the lower gum. Cancer 1981;47:22368. 121. Snow GB, Annyas AA, vanSloote EA, et al. squamous cell carcinoma of the oral cavity.
107. Patzer ER, Schweitzer RJ, Frazell EL. Epider- Prognostic factors of neck node metastasis. Cancer 1990;66:10913.
moid carcinoma of the palate. Am J Surg Clin Otolaryngol 1982;7:18592. 134. Silverman DA, El-Hajj M, Strome S, Esclamado
1970;119:2948. 122. O-charoenrat P, Pillai G, Patel S, et al. Tumour RM. Prevalance of nodal metastases in the
108. Chung CK, Johns ME, Cantrell RW, et al. thickness predicts cervical nodal metastases submuscular recess (level IIb) during selec-
Radiotherapy in the management of prima- and survival in early tongue cancer. Oral tive neck dissection. Arch Otolaryngol
ry malignancies of the hard palate. Laryn- Oncol 2003;39: 38690. Head Neck Surg 2003;129:7248.
goscope 1980;90:57684. 123. Kurokawa H, Yamashita Y, Takeda S, et al. Risk 135. Kowalski LP, Carvalho AL. Feasibility of
109. McGregor ED. A classic paper revisited: Polya factors for late cervical lymph node metas- supraomohyoid neck dissection in N1 and
and Von Navratil (1902). Head Neck Surg tases in patients with stage I or II carcinoma N2a oral cancer patients. Head Neck
1987;9:3258. of the tongue. Head Neck 2002;24:7316. 2002;24:9214.
110. Marchetta FA, Kumao S, Murphy BJ. The 124. Schwartz R, Chan NH, MacFarlane JK. Fine 136. Vikram B, Strong EW, Shah JP, Spiro R. Failure
Oral Cancer Treatment 657
in the neck following multimodality treat- of the N0 neck in oral squamous cell carci- make sense? Arch Otolaryngol Head Neck
ment for advanced head and neck cancer. noma: the role of sentinel node biopsy and Surg 1994;120:9349.
Head Neck Surg 1984;6:7249. positron emission tomography. Oral Oncol 162. Stalpers LJ, Vierzen PB, Brouns JJ, et al. The role
137. Spiro JD, Spiro RH, Shah JP, et al. Critical 2003;39:35060. of yearly chest radiography in the early detec-
assessment of supraomohyoid neck dissec- 150. Pitman KT, Ferlito A, Devaney KO, et al. Sen- tion of lung cancer following oral cancer. Int
tion. Am J Surg 1988;156:2869. tinel lymph node biopsy in head and neck J Oral Maxillofac Surg 1989;18:99103.
138. Kerrebijin JDF, Freeman JL, Irish JC, et al. cancer. Oral Oncol 2003;39:3439. 163. Merkx MA, Boustahji JH, Kaanders AM, et al. A
Supraomohyoid neck dissection. Is it diag- 151. Anderson PE, Warren F, Spiro J, et al. Results of half-yearly chest radiograph for early detec-
nostic or therapeutic? Head Neck selective neck dissection in management of tion of lung cancer following oral cancer. Int
1999;21:3942. the node positive neck. Arch Otolaryngol J Oral Maxillofac Surg 2002;31:37882.
139. Spiro RH, Strong EW. Discontinuous partial Head Neck Surg 2002;128:11804. 164. Collins SL. Controversies in multi-modality
glossectomy and radical neck dissection in 152. McHam SA, Adelstein DJ, Rybicki LA, et al. therapy for head and neck cancer: clinical
selected patients with epidermoid carcino- Who merits a neck dissection after defini- and biologic perspectives. In: Thawley SE,
ma of the mobile tongue. Am J Surg tive chemoradiotherapy for N2-N3 squa- Panje WP, Batsakis JG, Lindberg RD, edi-
1973;126:5446. mous cell head and neck cancer? Head tors. Comprehensive management of head
140. Leemans CR, Tiwari R, Nauta JJ, et al. Discon- Neck 2003;25:7917. and neck tumors. , Philadelphia (PA): W.B.
tinuous vs in-continuity neck dissection in 153. Cady B. Lymph node metastases: indicators but Saunders; 1999. p. 157281.
carcinoma of the oral cavity. Arch Oto- not governors of survival. Arch Surg 165. Crevoisier DR, Bourhis J, Domenge P, et al. Full-
laryngol Head Neck Surg 1991;117:10036. 1984;119:106772. dose reirradiation for unresectable head and
141. Ghali GE, Li BD, Minnard EA. Management of 154. Robbins KT, Atkinson JL, Byers RM, et al. The neck carcinoma: experience at the Gustave-
the neck relative to oral malignancy. Select- use and misuse of neck dissection for head Roussy Institute in a series of 169 patients. J
ed Readings Oral Maxillofac Surg 1998; and neck cancer. J Am Coll Surg 2001; Clin Oncol 1998;16:355662.
6(2):136. 193:91102. 166. Spencer S, Wheeler R, Peters G, et al. Phase I
142. Pillsbury HC, Clark M. A rationale for therapy 155. Ferlito A, Rinaldo A, Robbins KT, et al. Chang- trial of combined chemotherapy and reirra-
of the N 0 neck: Joseph H. Ogura Lecture. ing concepts in the surgical management of diation for recurrent unresectable head and
Laryngoscope 1997;107:1294315. cervical node metastasis. Oral Oncol neck cancer. 2003;25:11822.
143. Morton DL, Wen DR, Wong JH, et al. Technical 2003;39:42935. 167. Castro DJ, Sridhar KS, Garewal HS, et al. Intra-
details of intraoperative lymphatic map- 156. Kowalski LP, Magrin J, Waksman F, et al. tumoral cisplatin/epinephrine gel in
ping for early stage melanoma. Arch Surg Supraomohyoid neck dissection in the advanced head and neck cancer: a multi-
1992;127:39299. treatment of head and neck tumors: sur- center, randomized, double-blind, phase III
144. Morton DL, Wen DR, Foshag LJ, et al. Intraop- vival results in 212 cases. Arch Otolaryngol study in North America. Head Neck
erative lymphatic mapping and selective Head Neck Surg 1993;119:95863. 2003;25:71731.
cervical lymphadenectomy for early stage 157. Vikram B, Strong EW, Shah JP, Spiro R. Failure 168. Ganly I, Soutar DS, Brown R, Kaye SB. p53
melanomas of the head and neck. J Clin at the primary site following multi-modality alterations in recurrent squamous cell can-
Oncol 1993;11:17516. treatment in advanced head and neck can- cer of the head and neck refractory to
145. Krag DN, Meijer SJ, Weaver DL, et al. Minimal cer. Head Neck Surg 1984;6:7203. radiotherapy. Br J Cancer 2000; 82:3928.
access surgery for staging of malignant 158. Vikram B, Strong EW, Shah JP, Spiro R. Failure 169. Raybaud-Diogene H, Fortin A, Morency R, et
melanoma. Arch Surg 1995;130:6548. at distant sites following multi-modality al. Markers of radioresistance in squamous
146. Glass LF, Messina JL, Cruse W, et al. The use of treatment in advanced head and neck can- cell carcinomas of the head and neck: a clin-
intraoperative radiolymphoscintigraphy cer. Head Neck Surg 1984;6:7303. icopathologic and immunohistochemical
for sentinel node biopsy in patients with 159. Vikram B, Strong EW, Shah JP, Spiro R. Second study. J Clin Oncol 1997;15:10308.
malignant melanoma. Dermatol Surg primary neoplasms in patients successfully 170. Ribeiro KC, Kowalski LP, Latorre MR. Periop-
1996;22:71520. treated with multimodality treatment for erative complications, comorbidities, and
147. Cevantos FJ, Gomez C, Duque C, et al. Sentinel advanced head and neck cancer. Head Neck survival in oral and oropharyngeal cancer.
node biopsy in oral cavity cancer: correla- Surg 1984;6:7347. Arch Otolaryngol Head Neck Surg 2003;
tion with PET scan and immunohisto- 160. Goodwin WJ. Salvage surgery for patients with 129:21928.
chemistry. Head Neck 2003;25:19. recurrent squamous cell carcinoma of the 171. Funk GF, Karnell LH, Robinson RA. Presenta-
148. Pitman KT, Johnson JT, Brown ML, et al. Sen- aerodigestive tract: when do the ends justi- tion, treatment and outcome of oral cavity
tinel lymph node biopsy in head and neck fy the means? Laryngoscope 2000;110:118. cancer: a national cancer data base report.
squamous cell carcinoma. Laryngoscope 161. De Visscher AV, Manni JJ. Routine long-term Head Neck 2002;24:16580.
2002;112:210113. follow-up in patients treated with curative 172. Piccirillo JF. Inclusion of comorbidity in a stag-
149. Hyde NC, Prvulovich E, Newman L, et al. A intent for squamous cell carcinoma of the ing system for head and neck cancer. Oncol-
new approach to pre-treatment assessment larynx, pharynx and oral cavity. Does it ogy 1995;9:8316.
CHAPTER 34
Lip Cancer
James W. Sikes Jr, DMD, MD
G. E. Ghali, DDS, MD
Lip cancer, one of the most common can- lip and 4% at the oral commis- hygiene, exposure to chemicals, mechanical
cers of the head and neck region, is one of sures.1,46,1113 The most common age at irritants, immunosuppression, and chronic
the most easily diagnosed, with generally a diagnosis is 54 to 65 years.4 Although a infections.1113,16,1823 Several case series
good prognosis. In some individuals, lip condition seen in middle age, lip cancer have reported that a large proportion of lip
cancer may behave aggressively, manifest- occasionally occurs in patients under age cancer patients regularly use tobacco, indi-
ed by recurrence or mortality in up to 15% 30 years.14 Lip cancer has a predilection cating that tobacco use is etiologically asso-
of patients.14 The most common malig- for men, with men to women ratios rang- ciated with lip cancer develop-
nancy of the lip is squamous cell carcino- ing from 35:1 to 6:1, depending on the ment.5,11,15,19,2428 In 1984, Douglass and
ma, whereas basal cell carcinoma accounts location of the lesion.4 Gammon reassessed the epidemiology of
for only 1% of all lip carcinomas.46 Other The etiology of lip cancer is incom- oral cancer and declared that there was
malignancies of the lip have been reported pletely understood at present. Several fac- insufficient proof for declaring tobacco as
but are less common.7,8 tors have been associated with lip cancer an etiologic factor in the development of lip
development, but direct cause and effect cancer.10 Additional case-controlled studies
Epidemiology and Etiology has not been proven. Approximately one- concluded that no statistically significant
The incidence of lip cancer varies third of patients with lip cancer have out- relation exists between tobacco exposure
throughout the world, resulting in 30% of door occupations, suggesting that sun and lip carcinoma.29,30 The smoking of cig-
all malignant tumors of the oral cavity in exposure may be an etiologic factor. ars and pipes is often considered an impor-
certain regions. In the sunbelt region of Because of its prominence, the lower lip is tant etiologic factor; however, no convinc-
the United States, lip cancer is the most at a higher risk for exposure to the sun, ing evidence exists that supports a causal
common cancer of the oral cavity, and its compared with the upper lip. Hence, this relationship between tobacco use and
incidence is second only to skin malignan- results in the discrepancy in the distribu- developing lip carcinoma. Cigar and pipe
cy of the head and neck. Australia, north- tion between upper and lower lip can- smoking today, at best, are likely responsi-
ern Spain, and Newfoundland have a cers.15,16 Carcinoma of the lip principally ble for only a small fraction of lip cancers.
reported annual incidence ranging from affects those individuals with fair skin Because alcohol and tobacco exposure
11 to 50 cases per 100,000 population.9 complexions. The prevalence of lip cancer the two factors most strongly associated
In the United States, the incidence of is at least 10 times higher in whites than in with developing oral carcinomaseem to
lip cancer is 1.8 per 100,000 population, those with darker skin and is extremely have limited influence on the developing lip
with the state of Utah having the highest rare among Blacks.11,17 Although it has carcinoma, the most consistently associated
regional rate of almost 12 cases per never been proven, darker-skinned indi- factor with lip cancer appears to be pro-
100,000.10 Generally, the behavior of lip viduals are believed to have a protective longed and cumulative exposure to ultravi-
cancer resembles skin cancer more than pigment in the vermilion of the lips that olet radiation from sunlight.4,1820, 24, 29, 31
carcinoma of mucosal origin in the oral provides protection from solar injury.10
cavity proper. The lower lip is the most Multiple factors have been linked to lip Anatomic Considerations
common site for lip cancer (88 to 98%), cancer, including tobacco use, pipe smok- Embryologically, the upper lip forms by
with only 2 to 7% arising from the upper ing, thermal injury, lip trauma, poor oral fusing the two maxillary processes with a
660 Part 5: Maxillofacial Pathology
central median nasal process (Figure 34- defined into an upper and lower lip joined upper lip that do not cross the midline and
1). As a result, a central midline mass with at the commissures of the mouth.32 This for lower lip cancers that do not involve
two larger lateral segments is formed. The definition focuses on the unique epithelial the central one-third of the lower lip.
separation of the lateral segments by this surface of the lip vermilion and excludes Metastasis from the lower lip is pri-
central midline mass makes metastasis cancers that arise from the adjacent skin or marily to the submental, submandibular,
from upper lip cancers to the contralateral labial mucosa. In statistical reporting, can- and perifacial nodes. Metastasis is found in
neck exceedingly rare. Conversely, the cers of the lip are commonly grouped with the submandibular lymph nodes in about
lower lip, formed by fusion in the midline those of the oral cavity, because the lip is 80 to 90% of patients with metastasis from
of two mandibular processes, is at an defined as part of the oral cavity by the cancer of the lower lip.5,37 Although the
increased risk for contralateral neck American Joint Committee on Cancer.9,32 upper lip is responsible for fewer than 10%
metastasis, particularly with lesions near Lymphatic drainage of the lower lip of lip cancer cases, its pattern of metastasis
the midline. The lateral and superior bor- originates as an interconnecting network is fairly predictable, with the submandibu-
ders of the upper lip are well defined at the of lymph vessels beneath the submucosa of lar and parotid lymph node groups being
nasolabial creases bilaterally and at the the vermilion.33 It subsequently gives rise most commonly involved.38 Carcinoma of
nasal base superiorly. The inferior border to five or six lymphatic collecting trunks the commissure and upper lip spreads to
of the lower lip is defined along the trans- that eventually terminate into regional the preauricular, periparotid, and sub-
versely oriented labiomental crease. lymph nodes. The lymphatic trunks of the mandibular nodes. Bilateral metastasis
The formal definition of lip cancer, central one-third of the lower lip typically may develop if the lesion is near or has
established by the American Joint Commit- drain into the submental lymph nodes. crossed the midline of the lip. Crossover
tee on Cancer for the purpose of staging lip The trunks that arise from each lateral one- between the lymphatics of the right and
cancer, describes the lip as beginning at the third of the lower lip typically drain into left sides of the upper lip rarely occurs.4
junction of the vermilion border with the the ipsilateral submandibular lymph Cervical metastasis occurs late in the
skin and including only the vermilion sur- nodes. In certain individuals, the lymphat- course of lip cancer in fewer than 10% of
face or that portion of the lip that comes ic trunks from the central one-third of the patients with cancer of the lower lip and
into contact with the opposing lip. It is well lip may drain to the submandibular lymph up to 20% in cancer of the upper lip and
nodes on either side. commissure.5 Lymph node metastasis to
Cervical metastasis from lip cancer the upper jugular digastric chain is seen in
occurs in fewer than 10% of patients with only about 15% of all patients who have
cancer of the lower lip and in up to 20% in lymph node metastasis and is almost
cancer of the upper lip and commissure.5 always seen in conjunction with ipsilateral
In the upper lip, crossover of lymphatic submandibular metastasis.5,37
drainage between the right and left halves
typically does not occur.33 The upper lip Management
also possesses five or six collecting trunks
on each side of the midline that originate Evaluation
as delicate lymphatic vessels in the submu- Because carcinomas of the lip occur on a
cosa of the vermilion. The trunks ulti- highly visible and constantly exposed
mately terminate in the submandibular region of the body, a relatively early diagno-
lymph nodes but occasionally also drain to sis is often feasible. The clinical presenta-
the ipsilateral preauricular or infra- tion of lip carcinomas is quite characteris-
auricular parotid lymph nodes. Metastasis tic, generally presenting as an exophytic or
that results from cancer of the lip most ulcerated lesion on the vermilion border,
Medial nasal process commonly involves the submandibular along with variable degrees of infiltration of
Mandibular process and submental lymph nodes (level 1).3436 the underlying musculature or invasion of
Maxillary process Metastasis to level II of the jugular chain the overlying skin or labial mucosa (Figure
rarely occurs. Cancer involving the upper 34-2). Well-differentiated squamous cell
FIGURE 34-1 Developing upper lip, receiving contribu-
tions from a central medial nasal process and bilateral
lip may occasionally metastasize to the carcinomas are often associated with
maxillary processes. Developing lower lip receiving con- parotid lymph nodes, but contralateral hyperkeratosis and leukoplakia of the ver-
tributions solely from bilateral mandibular processes. metastasis is unusual for cancers of the milion border of the lip. Any lip lesion that
Lip Cancer 661
lip cancers, and surgery is the most com- thickness lip excision, in individuals pos-
mon treatment selected for managing lip sessing invasive lip carcinoma and prema-
carcinoma of any size, particularly the larg- lignant vermilion changes. Following the
er T3 and T4 tumors. vermilionectomy, the residual defect is pri-
The determination of an adequate marily closed with labial mucosal advance-
surgical margin around a lip cancer is ment flaps.
somewhat nebulous, and few objective In situations with invasive lesions, the
data have been gathered to substantiate lip shave procedure is contraindicated, and
any recommendations for adequate exci- full-thickness excision of the involved por-
sion margins. The size of the primary tion of the lip is the traditional procedure
lesion is the most common factor that we for management. The most commonly FIGURE 34-4 The proposed incisions for a shield
use to determine the extent of the margin- selected configuration of lip excision is a excision of lower lip are delineated.
al excision. Larger cancers have typically V, W, or a shield (Figure 34-4). The defects
mandated wider margins than have small- resulting from the V and W excisions can muscle following resections that exceed
er cancers. Based on these general guide- easily be closed primarily with no addi- two-thirds to three-quarters of the lip
lines, a minimum of 8 to 10 mm of normal tional mobilization of adjacent tissues length will create microstomia.
tissue around a lip cancer is recommended (Figure 34-5). The rectangular form of Defects of the vermilion resulting
to facilitate its complete removal.2,11,25,4244 excision, however, requires advancement from a lip shave procedure are generally
Smaller lip cancers, less than 1 cm in great- of laterally based lip flaps to achieve a sat- restored with labial mucosal advancement
est dimension, can often be managed with isfactory closure. These forms of excision flaps.5557 The labial mucosal flap develops
slightly smaller margins of 5 mm.44 In our are selected purely on the basis of cosmet- by creating a plane between the minor sali-
experience, the locally advanced T4 squa- ic and functional considerations for all T1 vary glands and the inner surface of the
mous cell carcinomas of the lip are opti- and most T2 lip carcinomas. orbicularis oris muscle. This flap may be
mally treated with a slightly larger margin Invasion of the mandible, involvement mobilized into the buccal vestibule if nec-
of approximately 15 to 20 mm. of the mental or inferior alveolar nerve, essary. The flap is secured to the anterior
The lip shave, or vermilionectomy pro- tumor sizes of T3 or greater, or associated cutaneous margin of the excision to create
cedure, is ideal for those situations wherein regional lymph node metastasis generally a new vermilion cutaneous border (Figure
areas of leukoplakia, actinic cheilitis, or car- necessitate a more aggressive resection. 34-6). Other less commonly used flaps for
cinoma in situ involve the vermilion of the Aggressive treatment requires an excision vermilion reconstruction after a lip shave
lips (Figure 34-3).4554 These premalignant and reconstruction that is more complex include cross-lip buccal mucosa flaps and
conditions require treatment but not com- than the standard full-thickness V or W tongue flaps.5759
plete full-thickness excision of the lip. This excision, and will be discussed in detail in Closure may be achieved primarily
operation involves partial or entire excision the following section on lip reconstruc- when a full-thickness excision of the upper
of the lip vermilion. The vermilionectomy tion. Include a marginal mandibulectomy or lower lip results in a defect of up to one-
may also be used, in conjunction with a full- with the resection of lip cancers that third of the lip length (Figure 34-7). The
approximate the alveolar ridge or outer
labial cortex of the mandible. Likewise, for
rare lesions that actually demonstrate
radiographic invasion of the mandible,
include a segmental mandibulectomy in
the treatment plan.
Lip Reconstruction
Lip reconstruction following surgical exci-
sion of cancer should reestablish the func-
tion and appearance of the lip. The key to
functional restoration is the reconstitution
FIGURE 34-3 Actinic cheilitis involving the of the orbicularis oris muscle. Primary FIGURE 34-5 Primary closure of a W excision of
vermilion of the lower lip. surgical restoration of the orbicularis the lower lip.
Lip Cancer 663
C D E
V-shaped excision design is most com- Lip cancers that extend more deeply to the development of various circumoral
monly used when a primary closure is into the lip substructure but still involve a flap advancement techniques.5658,60,6264
anticipated. Typically, the apex of the V is superficial length of vermilion that would The most popular of these techniques
placed at or slightly above the nasolabial otherwise produce a defect may be closed includes the Karapandzic reconstruction
fold or labiomental crease.5558,6062 A min- primarily via the W-shaped modification of flap (Figure 34-9). This flap consists of a
imum of a three-layered closure compris- the V configuration (Figure 34-8). This transfer of the remaining lip tissue to
ing mucosa, muscle, and skin is necessary excision uses an M-plasty in place of the reconstitute the lips and mouth opening.
to avoid unesthetic notching of the lip as single apex of the V. A three-layered closure The Karapandzic flap uses release inci-
the scar matures. of the defect, with careful attention to detail sions within the labiomental crease,
in the reconstruction of the orbicularis oris extending around the region of the oral
muscle layer is achieved (see Figure 34-5). commissures and continuing superiorly
The need to reconstruct lip defects within the nasolabial creases bilaterally.
greater than one-third of the lip length led Combining sharp and blunt dissection
A B C
FIGURE 34-9 A, Defects greater than one-third of the lip may require circumoral flaps, such as the Karapandzic flap depicted by this schematic.
B, Schematic depicting the closure of the Karapandzic flap. C, Esthetic postoperative results of a Karapandzic flap can be achieved. Note the recurrence of
the lesion in the midline.
separates the orbicularis muscles from the tissue from the lower lip to a defect in the oral commissure (Figure 34-11). All cross-
surrounding facial expression muscles. central component of the upper lip. It is, lip flaps are generally referred to as Abbe-
Neurovascular structures are preserved however, most often used to reconstruct Estlander type flaps.
and transposed medially, along with the lower lip defects by transferring tissue The principle of the Abbe-Estlander
flap, and intraoral buccal mucosal release from the upper lip (Figure 34-10). The flap repair is that the width of the base of
incisions are often necessary. Estlander flap was used to reconstruct the triangular flap is one-half that of the
For this reason, the Karapandzic flap is defects of the upper or lower lip in a single width of the base of the triangular surgical
ideally suited in situations where two- stage by transferring lip tissue around the defect. The vertical length of the flap
thirds to three-quarters, or more, of the
lower lip is resected, particularly when the
resection is centrally located and leaves the
lateral ends near the commissures intact.
The incisions for elevation of the Kara-
pandzic flap require mobilization of the
skin and subcutaneous tissues that are
superficial to the orbicularis oris muscle
and mucosa and deep to the orbicularis
oris muscle. At the same time, the muscle
itself must be kept intact, with its nerve
and blood supply preserved as tissues are
rotated and sutured medially.
Among other reconstructive options
for the lip, the cross-lip flaps are particu-
larly useful in repairing moderate lip
defects of one-third the length of one
lip.60,6567 These techniques transfer a full-
thickness segment of lip tissue into a
defect on the opposite lip. Estlander and
Abbe developed the most commonly used
FIGURE 34-10 A drawing of the two-stage Abbe FIGURE 34-11 A schematic drawing of the
cross-lip flap repair techniques.66,67 The flap, demonstrating the cross-lip transfer that is one-stage Estlander flap with the classic round-
Abbe flap, as originally described, transfers divided at approximately 3 weeks postoperatively. ing of the commissure region.
Lip Cancer 665
of distant flaps, such as the deltopectoral or in size.4 This report confirms a much larg-
pectoralis major myocutaneous flap. Alter- er rate of metastasis than that usually seen
natively, use free vascularized composite in clinical practice.
flaps to reconstruct these large defects. A With advanced disease (stages III and
free flap that has recently shown to be par- IV), elective neck dissection of levels I
ticularly useful is the composite radial through III is recommended (Figure
forearm-palmaris longus free flap.71,72 34-18). Thus, even if the patient has no
palpable adenopathy (N0 neck), the clini-
Cervical Lymphadenectomy cian should still use elective radiation
Patients with early cancer of the lip (stages therapy or elective neck node dissection in
I and II) do not generally need elective managing patients, owing to the high rate
treatment of the cervical lymph nodes, of microscopic lymph node metastasis in
because the rate of occult metastasis is low. these patients. In patients with lesions of
The risk for cervical metastasis increases the upper lip, commissure, or both,
with poorly differentiated cancer, recur- include a superficial parotidectomy. Clini-
FIGURE 34-16 In situations requiring complete rent cancer, or with cancer that extends cally apparent lymph nodes require either
excision of the lower lip, the Bernard flap may into the labial mucosa or that invades the radiation therapy or neck dissection for N1
provide a means for reconstruction with circum- mandible. Given the infrequency with nodes and combined therapy (neck dissec-
oral tissues, depicted in this schematic drawing. which stage I and stage II lip cancers tion and radiation) for N2 and N3 nodes.73
spread to regional lymph nodes, elective
mouth, up to the nasolabial crease, treatment of the neck is not always Treatment Results
depending on the width of the cheek flap required. One report indicated that there The cure rate for T1 and T2 lip cancers
to be mobilized (Figure 34-17A). After was delayed cervical metastasis between 35 without regional metastasis is greater than
excising the triangular wedges, incise the and 40% from lip cancer tumors 2 to 4 cm 90% with surgery or radiation.4,48 The
mucosae from their inner aspect, except
for the base, and shift the triangular flaps
of the upper lip mucosa medially, along
with the flaps (Figure 34-17B). Make a
counter incision in the lower mucogingi-
val sulcus bilaterally, and mobilize both
cheek flaps medially. Perform a closure of
the lip musculature on both sides with
interrupted sutures. The triangular wedges
of the mucosa from the upper lip are
everted and rolled inferiorly to provide a A B
new vermilion surface. Mucosal closure is
completed inferiorly in the mucogingival
sulcus (Figure 34-17C and D).
The main advantage of the Bernard
flap is its ability to reconstruct almost the
whole lower lip in a single-stage procedure.
The main disadvantage is reducing the size
of the orifice and creating a so-called per-
manent smile deformity of the lips, most
often produced in edentulous individuals. C D
The reconstruction of more massive
FIGURE 34-17 A, Proposed incisions for a classic Bernard flap reconstruction of the lower lip. B, The
defects that include total lip excision, as
development of the Bernard flap after resection of the lower lip. C, Closure of the wound includes the
well as excising the adjacent floor of the mucosal layer, orbicularis oris layer, dermal layer, and the skin closure. D, Postoperative follow-up at
mouth, skin, or mandible, requires the use 1 year demonstrates no recurrence and good esthetic results.
Lip Cancer 667
nodal involvement.1,81,82 Without ques- meni JF Jr, Muir CS, editors. Trends in can-
cer incidence and mortality. Plainview
tion, the presence of cervical lymph node
(NY): Cold Spring Harbor Laboratory
metastasis affects survival. The average Press; 1994. p. 2342.
5-year survival for patients with cervical 10. Douglass CW, Gammon MD. Reassessing the
metastasis of lip carcinoma is approxi- epidemiology of lip cancer. Oral Surg
mately 50%, with a range of 29 to 68%. 1984;57:63142.
11. Martin H, MacComb WS, Blady JV. Cancer of
Recurrence rates in the neck after treat-
the lip. Part I. Ann Surg 1941;114:226.
ment of regional metastasis are 40% for 12. Linqvist C, Teppo L. Is upper lip cancer true
a N1 disease and up to 100% for N3 dis- lip cancer? J Cancer Res Clin Oncol
b
e ease.1 The risk of developing a metachro- 1980;97:18791.
nous lip cancer is estimated at about 20% 13. Broders AC. Squamous-cell epithelioma of the
lip: a study of five hundred and thirty-seven
by 10 years follow-up.83
c f cases. JAMA 1920;74:65664.
14. Teichgraeber JF, Larson DL. Some oncologic
Conclusions considerations in the treatment of lip can-
d Lip cancer accounts for a significant per- cer. Otolaryngol Head Neck Surg 1988;
centage of all head and neck malignancies 98:58992.
15. Lee ES, Wilson JSP. Cancer of the lip. Proc R Soc
in the United States. Lip cancer arises from Med 1970;63:685-90.
the lower lip in nearly 90% of cases. Etio- 16. Ju DM. On the etiology of cancer of the lower
FIGURE 34-18 Diagram depicting the levels of logic factors associated with lip cancer lip. Plast Reconstr Surg 1973:52:1514.
the neck. a = level one; b = level two; c = level include sun exposure, alcohol, and tobac- 17. Keller AZ. Cellular types, survival, race, nativi-
three; d = level four; e = level five; f = level six. ty, occupations, habits and associated dis-
co abuse. Commissure involvement is an
eases in the pathogenesis of lip cancer. Am J
adverse prognostic factor. Regional cervi- Epidemiol 1969;91:48699.
cal lymph node metastasis is directly relat- 18. Penn I. Cancer in the immunosuppressed organ
5-year determinate survival is approxi- ed to a poor prognosis. With overall cure recipient. Transplant Proc 1991;23:17712.
mately 80%.1 The cure rates for cancer of rates of 80 to 90%, lip cancers have a more 19. Molnar L, Ronay P, Tapolesany I. Carcinoma of
the lips suggest a better prognosis than for the lip. Oncology 1974;29:101-21.
favorable prognosis than most other head
other cancers of the oral cavity. Cancer 20. Ward GE, Hendrick JW. Results of treatment of
and neck cancers. carcinoma of the lip. Surgery 1950;
involving the oral commissure is more 27:32142.
aggressive, with a 5-year cure rate ranging References 21. Figi FA. Epithelioma of the lower lip. Surg
between 34 and 50%. Cancers that include 1. Baker SR, Krause CG. Carcinoma of lip. Laryn- Gynecol Obster 1934;59:810819.
areas larger than 2 cm have cure rates of goscope 1980;90:1927. 22. Bradford CR, Hoffman HT, Worf GT, et al.
< 80%, and those that invade deep enough 2. Cruse CW, Radocha RF. Squamous cell carci- Squamous carcinoma of the head and neck
noma of the lip. Plast Reconstr Surg in organ transplant recipients: possible role
to involve the mandible have a cure rate of of oncogenic viruses. Laryngoscope
1987;80:78791.
< 50%.4,74 The primary cause of failure is 3. Heller KS, Shah JP. Carcinoma of the lip. Am J 1990;100:1904.
local recurrence, rather than regional node Surg 1979;138:600-3. 23. Brewer GE. Carcinoma of the lip and cheek.
metastasis. Other adverse prognostic fac- 4. Zitsch RP, Park CW, Renner GJ, et al. Outcome Surg Gynecol Obstet 1923;36:169184.
analysis for lip carcinoma. Otolaryngol 24. Creely JJ, Peterson HD. Carcinoma of the lip.
tors include poor histologic grade, tumor
Head Neck Surg 1995;113:58996. South Med J 1974;67:77984.
thickness > 6 mm, desmoplasia, stromal 5. Jorgensen K, Elbron O, Andersen AP. Carcino- 25. Wurman LH, Adams GL, Meyerhoff WL. Carci-
sclerosis, muscular invasion, and perineur- ma of the lip: a series of 869 cases. Acta noma of the lip. Am J Surg 1975;130:4704.
al invasion.7577 Angiogenesis has not been Radio 1973:12:17790. 26. Ashley FL, McConnell DV, Machida R, et al.
shown to have prognostic significance.78 6. MacKay EN, Sellers AH. A statistical review of Carcinoma of the lip: a comparison of five
carcinoma of the lip. Can Med Assoc J year results after radiation and surgical ther-
While TP53 mutations are seen in 50% of
1964;90:6702. apy. Am J Surg 1965;110:54951.
lip cancers, the clinical significance of this 7. Bailey BM. A rare malignant connective tumor 27. Marshall KA, Edgerton MT. Indications for
observation is unknown.79 arising in the upper lip. Br J Oral Surg neck dissection in carcinoma of the lip Am J
Generally, elective lymph node dis- 1983;21:12935. Surg 1976; 133:2167.
section in the N0 neck is reserved for 8. Miller RI. Non-Hodgkins lymphoma of the lip: 28. Cross JE, Guralnick E, Daland EM. Carcinoma
a case report. J Oral Maxillofac Surg of the lip; a review of 563 case records of
advanced stage disease (stage III and 1993;51:4202. carcinoma of the lip at the Pondville Hospi-
stage IV).74,80 About 5 to 10% of patients 9. Blot WF, Devesa SS, McLaughlin JK, et al. Oral tal. Surg Gynecol Obstet 1948;87:153.
with lip cancer will develop evidence of and pharyngeal cancers. In: Doll R, Frau- 29. Dardanoni L, Lorenzo G, Rosario P, et al. A
668 Part 5: Maxillofacial Pathology
case-control study on lip cancer risk factors 46. Birt BD. The lip shave operation for pre- 63. Clairemont AA. Versatile Karapandzic lip
in Ragusa (Sicily). Int J Cancer 1984 malignant conditions and micro-invasive reconstruction. Arch Otolaryngol 1977;
;34:3557. carcinoma of the lower lip. J Otolaryngol 103:6313.
30. Blomqvist G, Hirsch JM, Alberius P. Association 1977;6:40711. 64. Karapandzic M. Reconstruction of lip defects
between development of lower lip cancer 47. Brufeau C, Canteras M, Armijo M. Our experi- by local arterial flaps. Br J Plast Surg 1974;
and tobacco habits. J Oral Maxillofac Surg ence in the surgical treatment of cancer and 27:937.
1991;49:10447. precancerous lesions of the lower lip. J Der- 65. Abbe RA. A new plastic operation for the relief
31. Baker SR. Risk factors in multiple carcinomas matol Surg Oncol 1985;11:90812. of deformity due to double harelip. Plast
of the lip. Otolaryngol Head Neck Surg 48. Frierson HF, Cooper PH. Prognostic factors in Reconstr Surg 1968;42:4813
1980;88:24851. squamous cell carcinoma of the lower lip. 66. Estlander JA. Eine methode aus der linen lippe
32. American Joint Committee on Cancer. Manual Hum Pathol 1986;17:34654. substanzuerluste der anderen zu ersetzen.
for staging of cancer. 6th ed. New York 49. Hjortdal O, Naess A, Berner A. Squamous cell Arch Klin Chirurg 1872;14:622. Reprinted
(NY): Springer-Verlag; 2002. p. 2332. carcinomas of the lower lip. J Craniomax- with English translation. Plast Reconstr
33. Feind CR. The head and neck. In: Haagensen illofac Surg 1995;23:347. Surg 1968;442:361.
CD, Feind CR, Herter FP, et al, editors. The 50. Mehregan DA, Roenignk RK. Management of 67. Templer J, Renner G, Davis WE, et al. A modi-
lymphatics in cancer. Philadelphia (PA): WB superficial squamous cell carcinoma of the fication of the Abbe-Estander flap for
Saunders; 1972. p. 59230. lip with Mohr micrographic surgery. Cancer defects on the lower lip. Laryngoscope
34. Shah JP, Candela FC, Poddar AK. The patterns 1990;66:4638. 1981;91:1536.
of cervical lymph node metastasis from 51. Picascia DD, Robinson JK. Actinic cheilitis: a 68. Webster RE, Coffey RJ, Kellcher RE. Total and
squamous carcinoma of the oral cavity. review of the etiology, differential diagnosis, partial reconstruction of the lower lip with
Cancer 1990;66:10913. and treatment. J Am Acad Dermatol innervated muscle-bearing flaps. Plast
35. Spiro RH. The management of neck nodes in 1987;17:25564. Reconstr Surg 1960;25:3607.
head and neck cancer: a surgeons view. Bull 52. van der Wal JE, de Visscher JGA, Baart JA, et al. 69. von Burow CA. Beschreibung einer neuen
NY Acad Med 1985;61:62937. Oncologic aspects of vermilionectomy in
Transplantations-Methode (Meth ode der
36. Lindberg R. Distribution of cervical lymph microinvasive squamous cell carcinoma of
seitlichen dreiecke) zum weiderersatz ver-
node metastasis from squamous cell carci- the lower lip. Int J Oral Maxillofac Surg
lorengegangener Teile des Gesichts. Berlin:
noma of the upper respiratory and digestive 1996;25:4468.
Nauck; 1855.
tracts. Cancer 1972; 29:1446-9. 53. Robinson JK. Actinic cheilitis. A prospective
70. Bernard C. Cancer de la leure inferieure opere
37. Sack JG, Ford CN. Metastatic squamous cell study comparing four treatment methods.
par un procede nouveau. Bull Mem Soc
carcinoma of the lip. Arch Otolaryngol Arch Otolaryngol Head Neck Surg
Chir Paris 1853;3:357.
1978;104:2825. 1989;115:84852.
71. Sadove RC, Luce EA, McGrath PC. Reconstruc-
38. Brown RG, Poole MD, Calamel PM, et al. 54. Sanchez-Conejo-Mir J, Perez-Barnal AM,
tion of the lower lip and chin with the com-
Advanced and recurrent squamous carcino- Moreno-Gimenez JC, et al. Follow-up of
posite radial forearm-palmaris longus free
ma of the lower lip. Am J Surg 1976; vermilionectomies: evaluation of the tech-
flap. Plast Reconstr Surg 1991;88:20914.
132:4927. nique. J Dermatol Surg Oncol 1986;
72. Furuta S, Sukaguchi Y, Imasarva M, et al.
39. Byers RM, OBrien J, Waxler J. The therapeutic 12:1804.
Reconstruction of the lips, oral commissure,
and prognostic implications of nerve inva- 55. Renner GJ. Cancer of the lip. In: Gates G, editor.
sion in cancer of the lower lip. Int J Radiat Current therapy in otolaryngology-head and full-thickness cheek with a composite
Oncol Biol Phys 1978;4:2157. and neck surgery. Vol 4. Philadelphia (PA): radial forearm-palmaris longus free flap.
40. Anderson C, Krutchkoff D, Ludwig M. Carci- BC Decker; 1989. p. 188. Ann Plast Surg 1994;33:5447.
noma of the lower lip with perineural exten- 56. Renner G, Zitsch RP. Reconstruction of the lip. 73. Duplechain G, Amedee RG. Carcinoma of the
sion to the middle cranial fossa. Oral Surg Otolaryngol Clin 1990;23:97590. lip. J La State Med Soc 1992;144:4412.
Oral Med Oral Pathol 1991;69:6148. 57. Zide BM. Deformities of the lips and cheeks. In: 74. Zitsch RP. Carcinoma of the lip. Otolarngol
41. Kolin ES, Castro D, Jabour BA, et al. Perineural McCathy JG, editor. Plastic surgery. The Clin North Am 1993;26:26577.
extension of squamous cell carcinoma. Ann face. Vol 3. Philadelphia (PA): WB Saunders; 75. Saywell MS, Weedon D. Histological correlates
Otol Rhinol Laryngol 1991; 100:10324. 1990. p. 2009. of metastasis in primary invasive squamous
42. Lore JM, Kaufman S, Grabau JC, et al. Surgical 58. Mazzola RF, Lupo G. Evolving concepts in lip cell carcinoma of the lip. Australas J Pathol
management and epidemiology of lip can- reconstruction. Clin Plast Surg 1984; 1996;36:1935.
cer. Otolaryngol Clin North Am 1979; 11:583617. 76. Breuninger H, Schaumburg-Lever G,
12:8195. 59. McGregor IA. The tongue flap in lip surgery. Br Holzschuh J. Desmoplastic squamous cell
43. Luce EA. Carcinoma of the lower lip. Surg Clin J Plast Surg 1966;19:25363. carcinoma of skin and vermilion surface: a
North Am 1986;66:311. 60. Calhoun KH, Stiernberg CM. Surgery of the lip. highly malignant subtype of skin cancer.
44. Brodland DG, Zitelli JA. Surgical margins for New York (NY): Thieme Medical Publish- Cancer 1997;79:9159.
excision of primary cutaneous squamous ers; 1992. 77. Dos Santos LR, Cernea CR, Kowalski LP. Squa-
cell carcinoma. J Am Acad Dermatol 61. Panje WR. Lip reconstruction. Otolaryngol mous cell carcinoma of the lower lip: a ret-
1992;27:241-8. Clin North Am 1982;15:16978. rospective study of 58 patients. Rev Paulista
45. van Zile WN. Early carcinoma of the lip: diag- 62. Smith PG, Muntz HR, Thawley SE. Local Med 1996;114:111726.
nosis and treatment. J Oral Surg 1965; myocutaneous advancement flaps. Arch 78. Tahan SR, Stein AL. Angiogenesis in invasive
23:509. Otolaryngol 1982;108:7148. squamous cell carcinoma of the lip: tumor
Lip Cancer 669
vascularity is not an indicator of metastatic cell carcinoma of the upper lip. J Dermatol mous cell carcinoma of the lip. Clin Oto-
risk. J Cutan Pathol 1995;22:23640. Surg Oncol 1982;8:48791. laryngol 1981;6:4159.
79. Ostwald C, Gogacz P, Hillmann T, et al. p 53 81. Sack JG, Ford CN. Metastatic squamous cell 83. McCombe D, MacGill K, Ainslie J, Beresford J,
Mutational spectra are different between carcinoma of the lip. Arch Otolaryngol Matthews J. Squamous cell carcinoma of the
squamous-cell carcinoma of the lip and the 1978;104:2825. lip: a retrospective review of the Peter Mac-
oral cavity. Int J Cancer 2000;88:826. 82. Nuutinen J, Karja J. Local and distant metasta- Callum Cancer Institute experience. ANZ J
80. Krabel MR, Koranda FC, Panje WR. Squamous sis in patients with surgically treated squa- Surg 2000;70:35861.
CHAPTER 35
The salivary glands consist of three major sis and the surgical principles dictated by tumor. Attempts at enucleation of the
paired glands (the parotid, submandibular, the site of the tumor. tumor from within its capsule will
and sublingual) as well as numerous minor inevitably leave viable tumor cell nests and
salivary glands, situated mostly in the oral Histopathology predispose the patient to multifocal recur-
cavity but also found in the pharynx, larynx, The large variety of tumors that occur in rence. Some authorities believe that
trachea, and sinuses. In the oral cavity 700 to the salivary glands make an exhaustive list younger patients with pleomorphic ade-
900 minor salivary glands are found, the of all types impossible in a chapter of this nomas have a higher chance of tumor
majority of which are located at the junc- length. The most common epithelial sali- recurrence and increased growth during
tion of the hard and soft palates. These vary gland tumors will be reviewed in pregnancy. Malignant change is rare and
glands produce saliva, which functions as a order to illustrate the fundamentals of usually takes place in long-standing
lubricant for speech and swallowing, assists management of salivary neoplasia. tumors, the most common type being car-
taste, has antibacterial and immunologic cinoma ex pleomorphic adenoma. Prog-
properties, and contains digestive enzymes. Benign Tumors Pleomorphic Adenoma nosis will depend on the type of malig-
The salivary glands are affected by many dif- The pleomorphic adenoma is the most nancy and involvement of the capsule.
ferent disease processes, some of which are common benign salivary tumor at all sites. Rarely, malignant change in both ele-
surgical in nature while others have a med- Approximately 80% of all pleomorphic ments of the pleomorphic adenoma (duc-
ical basis. Surgical diseases include tumors, adenomas (PSAs) occur in the parotid, tal and myoepithelial) will occur giving
stones, and cysts, whereas medical diseases and despite their slow growth they can rise to the carcinosarcoma or true mixed
include viral infections, autoimmune dis- become extremely large if neglected. This malignant (biphasic) pleomorphic adeno-
eases, and sarcoidosis. This chapter will con- tumor is thought to arise from both sali- ma. On rare occasions, an apparently his-
centrate on the salivary gland diseases that vary ducts and myoepithelial cells and is a tologically benign tumor will metastasize
are of most interest to the surgeon. true mixed tumor. Because of its deriva- into the so-called benign metastasizing
tion, histologically, many different pat- pleomorphic adenoma.
Tumors terns can occur, from cellular, glandular,
Tumors of the salivary glands show a wide and myxoid types to cartilagenous and Warthins Tumors This benign tumor is
variety of pathologic types varying from even ossified forms. These features can be almost exclusively found in the parotid. It
benign to highly malignant. Salivary can- seen in different areas of the same tumor, occurs mostly in men and is more common
cers are comparatively rare and comprise accounting for its name, pleomorphic in smokers. It is thought to derive from sali-
3% of head and neck cancers, which in (Greek for many forms). The important vary duct cells that are entrapped in lymph
turn account for 3% of all malignancies. feature from a surgical standpoint is the nodes during embryonic development. The
These neoplasms will be discussed presence of a pseudo capsule, which con- tumor consists of large cystic spaces with a
according to their histopathologic diagno- tains outgrowths or pseudopodia of the surrounding columnar epithelium and a
672 Part 5: Maxillofacial Pathology
stroma of lymphocytes. Surgically these survival rates.4 Adenoid cystic carcinoma is need to preserve the facial nerve. Diag-
tumors may be multiple in one parotid the most common malignancy of the sub- nostic imaging with computed tomogra-
gland or bilateral, or involve lymph nodes mandibular gland and is the second most phy (CT) or magnetic resonance (MR) is
adjacent to the parotid gland.1,2 common salivary gland cancer overall. desirable for superficial lobe tumors but
Three histologic types are seen: tubular, is essential for suspected deep-lobe neo-
Hemangioendothelioma In children the cribriform (the classic Swiss cheese pat- plasms, especially those with a parapha-
most common cause of parotid mass is a tern), and solid. The solid type has the worst ryngeal component. Since 80% of parotid
hemangioma or hemangioendothelioma.3 prognosis, especially when areas of necrosis tumors are benign and 80% of these are
These are benign tumors that may appear are present. The infiltrative nature of this pleomorphic adenomas, a solitary mass
soon after birth and grow rapidly. Usually, lesion and the frequency of perineural in the parotid with no features of malig-
conservative treatment while waiting for involvement with spread along the nerve nancy is most likely a PSA. Open biopsy
involution is recommended. mandate wide resection margins. Perineural of such a mass is therefore contraindicat-
spread is a bad prognostic sign for both local ed as this will rupture the capsule and
Malignant Tumors Mucoepidermoid recurrence and distant metastasis. Clinical seed the PSA, increasing the complexity
Carcinoma Mucoepidermoid carcinoma and radiologic examination of this tumor of subsequent surgery and chances of
(MEC) is the most common malignant frequently underestimate its true extent, and recurrence. Fine-needle aspiration biopsy
salivary gland neoplasm in both adults and follow-up of 15 to 20 years is required as late (FNAB) for cytology is the preferred
children, and the most common salivary recurrences occur. method of diagnosis.6 Clinically only
gland cancer of the parotid and minor sali- one-third of malignant tumors will have
vary glands. This tumor can be of low grade Low-Grade Polymorphous Adenocarcinoma symptoms or signs of malignancy, such as
or high grade depending on its histology. Low-grade polymorphous adenocarcinoma pain, ulceration of skin, facial nerve palsy,
Low-grade MECs have multiple macrocysts occurs almost exclusively in the minor sali- or metastatic cervical nodes.7 Thus virtu-
and abundant mucus-producing cells. vary glands and is second only to mucoepi- ally all parotid tumors will initially be
High-grade varieties have multiple squa- dermoid carcinoma at these sites. It arises treated as benign unless FNAB shows def-
mous cells and very few mucus-producing from terminal duct cells and is characterized inite malignancy or there is clinical evi-
cells or cysts, and mucicarmine or periodic by cytologically bland monotonous cells that dence of malignancy (Figure 35-1). The
acidSchiff stains may be needed to identi- can assume many different patterns (glan- majority of tumors occur in the superfi-
fy intracellular mucus to characterize this dular, cribriform, and lobular) within the cial lobe, and superficial lobectomy with
tumor. There are three cell types of MEC: same tumor. Characteristically Indian file preservation of the facial nerve has been
mucus producing, intermediate, and squa- cells and perineural involvement are seen. the standard operation for many years.
mous. The respective ratio of mucus- Although this tumor behaves in a very low- Recent minor modifications have includ-
producing cells to squamous cells will grade manner, local recurrence will occur ed the use of a face-lift incision, the use of
determine the clinical aggressiveness of the with inadequate excision.5 The important the superficial musculoaponeurotic sys-
tumor (see above). Low-grade MECs can pathologic features seen from the surgeons tem to prevent Freys syndrome, the use
be very slow growing and nonmetastasiz- viewpoint are frequent misdiagnosed on ini- of flaps or alloplasts to augment defects,
ing, and can generally behave like a benign tial biopsy, due to the different patterns that and the suggestion that capsular dissec-
tumor. High-grade MECs can exhibit may be sampled. Common misdiagnoses are tion without the need to remove the
aggressive growth and invasion resulting in adenoid cystic carcinoma, pleomorphic ade- entire superficial parotid may be suffi-
widespread metastasis and death. High- noma, and malignant pleomorphic ade- cient.810 Superficial lobectomy is suitable
grade tumors usually show increased pleo- noma. It is also important to be aware that for benign and low-grade malignant
morphism and meiotic figures. High-grade the frequent presence of perineural involve- tumors, and even in high-grade malig-
lesions may metastasize to cervical lymph ment does not lead to a worse prognosis, as nancies only branches of the nerve that
nodes or spread hematogenously to the is the case for adenoid cystic carcinoma. are actually infiltrated will be sacrificed.
lung, liver, and bone. If the nerve or portions of it have to be
Site of Tumor resected, immediate grafting is recom-
Adenoid Cystic Carcinoma Although this mended. In deep-lobe tumors a total
tumor is very slow growing, its relentless Parotid Gland The surgical principles parotidectomy is performed, with the
course, with repeated recurrence and metas- of treating parotid tumors are dictated by superficial lobe being dissected first to
tasis via the blood stream, gives low 20-year the histopathology of the tumor and the expose the nerve. Good margins with
Salivary Gland Disease and Tumors 673
are used. Local flap reconstruction or the Intrabony Tumors Although intrabony (most common in the submandibular
use of a palatal plate with subsequent sec- (central) salivary gland tumors are rare, gland) or mucous plugs (most common in
ondary healing by granulation is used for the vast majority are malignant low- the parotid) or strictures of the duct. Stone
reconstruction. Where bone invasion has grade mucoepidermoid carcinomas.13 formation is classically due to stasis of
occurred, as in adenoid cystic carcinoma or These are mostly seen in the third molar flow, infection, and alteration of the duct
high-grade tumors, a partial maxillectomy region of the mandible and are frequent- contents. Calcified stones are formed by
will be required. In the case of adenoid cys- ly multilocular. The tumors are often the precipitation of calcium salts around a
tic carcinoma, attention must be given to diagnosed radiologically as ameloblas- nidus of mucous plugs, epithelial cells, or
the greater palatine nerve, with frozen sec- tomas, or odontogenic keratocysts. Resec- microorganisms. Approximately 80% of
tion clearance obtained. Cranial extension, tion with a 1 cm margin and sacrifice of sialoliths occur in the submandibular
orbital involvement, and infiltration poste- the inferior alveolar nerve and overlying gland.14 Microliths in the minor salivary
riorly into the pterygoids will increase the soft tissue in areas of perforation are glands have been described.
extent of surgery and its morbidity, with a required. Neck dissection is usually not As calcified sialoliths increase in size
decrease in survival (Figure 35-3). Recon- necessary, but if the neck has been they may give rise to symptoms, especially
struction is usually with an obturator, opened widely for mandibular resection a when they are present in the duct. Classi-
although primary maxillary reconstruction supraomohyoid neck dissection can be cally the patient reports pain and swelling
has been revisited with the development of undertaken. A reconstruction plate is when eating or drinking or sometimes
interosseous implants and composite placed and either primary reconstruction even from the smell of food (Figure 35-4).
microvascular free flaps. with a fibular or deep circumflex iliac Examination of the gland may show a ten-
artery microvascular flap or secondary der swelling with inability to milk saliva
The Retromolar Fossa Although this is a posterior iliac crest corticocancellous from the duct orifice.
relatively unusual site for minor salivary reconstruction may be used. Plain radiography is used to demon-
gland tumors, virtually 100% are malig- strate calcified stones, the lower occlusal
nant and are low-grade mucoepidermoid Other Intraoral Sites Interestingly, the film for the submandibular gland, and an
carcinomas. The surgeon should be aware proportion of benign to malignant tumors occlusal or periapical dental film held in
that a cystic soft tissue mass distal to the varies according to site, with virtually all the cheek for the parotid. Lateral oblique
third molar, with or without radiographic upper lip tumors being benign and a high- mandibular films or panoramic radi-
mandibular involvement, is unlikely to be er proportion of lower lip tumors being ographs will show parotid duct stones and
a mucocele, and incisional biopsy should malignant. Salivary gland neoplasms of calcified stones in the hilum or glandular
be undertaken to confirm the diagnosis. the tongue and buccal mucosa tend to be substance of the submandibular gland. CT
malignant and require wide soft tissue dis-
section to obtain margins.
Obstructive Disease
Obstruction to the salivary glands is usual-
FIGURE 35-3 Recurrent low-grade polymorphous FIGURE 35-4 Right submandibular gland
adenocarcinoma of the palate postmaxillectomy ly seen in the submandibular and parotid swelling and sialadenitis secondary to an
with invasion of the orbital floor and orbital fat. glands. It may be due to calcified stones obstructing sialolith.
Salivary Gland Disease and Tumors 675
scans and ultrasonography have also been behind the sialolith around Whartons the deep surface of the gland. The authors
used. When a noncalcified (mucous plug) duct to use as a traction suture, tenting the do not routinely tie the facial artery and
obstruction is suspected, sialography may duct upward and preventing posterior dis- vein at this stage as these can usually be
demonstrate a filling defect (Figure 35-5). placement of the stone during surgical dissected off the gland, although clipping
Acute infection should be managed with manipulation. An incision in line with the
antibiotics prior to sialography. Treatment duct is made through the mucosa and dis-
of the stone will depend on its location. section carried down to the duct. This is
opened in its long axis allowing removal of
Submandibular Gland the stone. The posterior suture is removed
and the gland is milked or explored with a
Anterior Duct If the stone is palpable in lacrimal probe to find other stones. The
the anterior floor of the mouth close to the duct is sutured open to the edges of the
orifice of Whartons duct, an intraoral mucosa (fish tailed) to prevent stricture.
approach may be used. Although the ante-
rior duct is traditionally regarded as a line Posterior Duct Stones in the posterior
between the first molars, the floor of the submandibular duct are much more tech-
mouth slopes downward following the nically difficult to remove intraorally,
mylohyoid muscle as the premolars are requiring general anesthesia, excellent
reached, and technical difficulty is light, and retraction, as well as the help of FIGURE 35-6 Lateral oblique radiograph of the
increased as the stone is more distal (Fig- an assistant to push the gland upward into mandible showing the entire Whartons duct
ure 35-6). Initially a suture is passed the mouth from extraorally. Even so, irri- occupied by calcified sialolith. Note how the
stone passes inferiorly and deeply, the farther
tating bleeding can occur and the lingual posteriorly it is placed (arrows).
nerve must be visualized and protected
(see Figure 35-6).
multiple arterial branches to the gland can improvement in many patients. In dissection may be challenging due to
be tedious. The anterior pole of the sub- advanced cases with no improvement, extensive fibrosis (Figure 35-9).
mandibular gland is mobilized off the parotidectomy may be required.
mylohyoid muscle, and in cases of chronic Nonsurgical Approaches
sialadenitis, sharp dissection may be neces- Stones in the Terminal Duct Radi- Miniature endoscopes have been used to
sary due to dense fibrosis. The superior ographically opaque stones at Stensens visualize sialoliths and remove them with
pole of the gland is dissected in a subcapsu- papilla can be managed intraorally in a baskets.18 Lithotripsy has also been
lar plane and the gland mobilized posteri- similar manner to those of the anterior attempted either via endoscopes (intracor-
orly. The posterior edge of the mylohyoid portion of Whartons duct. Following poreal) or extracorporeally. Intracorporeal
muscle is retracted to expose the lingual placement of a posterior traction suture, lithotripsy uses shock waves produced by
nerve and the branch to the gland is tied the duct is opened with an incision run- lasers, electrohydraulic sources, or a pneu-
and sectioned (see Figure 35-7B). The sub- ning in the long axis of the duct. moballistic source. In a review of 6 series
mandibular duct is dissected superiorly of extracorporeal lithotripsy ranging from
into the floor of the mouth as far as possi- Stones in the Posterior Duct When the 33 to 104 stones, Escudier reported a
ble, tied, sectioned, and the gland removed. stone involves the extraglandular portion stone-free range of 18.2 to 52.9% with
of the duct lateral to the buccinator mus- residual fragments occurring in 47.1 to
Parotid Gland cle, both intraoral and extraoral approach- 81.8% of cases.19
Most obstructive symptoms in the parotid es are described.16,17 The intraoral
gland are associated with noncalcified approach involves a Y-shaped mucosal Mucoceles and Ranulas
stones or mucous plugs. Although these incision, dissection through the buccina- Mucoceles are mostly due to extravasation
can sometimes be removed with tweezers tor muscle, and the use of a traction suture of mucus from a salivary gland, although a
following duct dilatation or milked to pull the duct into the mouth. The extra- few are true retention phenomena. The
from the duct, they often cause repeated oral approach requires the duct to be dis- most common site is the lower lip, due to
bouts of pain and swelling. Sialography is placed laterally with a finger placed in the trauma (usually following an accidental
helpful in evaluating the extent of damage mouth, with blunt dissection down to the bite in a child). Mucoceles are simple to
to the ductal architecture. Sialograms may stone, avoiding the facial nerve. treat and they should not recur if the
show changes varying from mild sialecta- underlying damaged minor salivary gland
sis to gross dilatation of Stensens duct Parotid Gland Stones Stones at the has been removed. Following a vertical inci-
with loss of secondary and tertiary ducts hilum of the gland or intraglandular sion through the mucosa over the muco-
(Figure 35-8). Sialograms are frequently stones usually require a parotidectomy if cele, a number of minor salivary glands are
helpful symptomatically, with cure or they are symptomatic. The facial nerve usually identified. As it may be impossible
A B
FIGURE 35-8 Sialogram showing gross destruc- FIGURE 35-9 A, Computed tomography scan
tion of the parotid ductal architecture with showing a large parotid stone at the hilum of the
dilatation of the glandular ducts into large gland. B, Parotid duct opened to show the
mucus-filled sacs. sialolith in situ, following parotidectomy.
Salivary Gland Disease and Tumors 677
ranulas should be treated by sublingual 10. Gooden EA, Gullane PJ, Irish J, et al. Role of the
gland excision. sternocleidomastoid muscle flap preventing
Freys syndrome and maintaining facial
An intraoral approach is made with an contour following superficial parotidecto-
incision along the axis of the gland lateral to my. J Otolaryngol 2001;30:98101.
the ductal orifices. The submandibular duct 11. Kaplan MJ, Johns ME. Salivary gland cancer.
is identified, either by dissection or follow- Clin Oncol 1986;5:52547.
12. Pogrel MA. The diagnosis and management of
ing cannulation with a lacrimal probe. The
salivary gland tumors. Atlas Oral Maxillo-
gland is dissected in a subcapsular plane fac Surg Clin N Am 1993;5:31930.
with meticulous hemostasis. At its posterior 13. Brookstone MS, Huvos AG. Central salivary
pole the lingual nerve is identified as it gland tumors of the mandible and maxilla:
crosses the duct and is preserved. The sub- a clinicopathologic study of 11 cases with
review of the literature. J Oral Maxillofac
lingual gland is dissected from anteriorly,
Surg 1992;50:22936.
and the final excision is the posterior pole 14. Berry RL. Sialadenitis and sialolithiasis: diag-
FIGURE 35-10 Large ranula overlapping the after visualizing the lingual nerve. nosis and management. Atlas Oral Maxillo-
occlusal plane in a 10-year-old boy. fac Surg Clin N Am 1995;7:479504.
References 15. Miloro M. The surgical management of sub-
1. Lamelas J, Terry JH, Alfonso JE. Warthins tumor; mandibular gland disease. Atlas Oral Max-
to identify the damaged gland, all these illofac Surg Clin N Am 1998;6:2950.
multicentricity and increasing incidence in
minor glands should be removed before women. Am J Surg 1987;154:34751. 16. Baily BJ, editor. Anatomy and physiology of the
carefully suturing the mucosal incision. 2. Snyderman C, Johnson JT, Barnes EL. Extra- salivary glands. In: Head and neck surgery
Ranulas are large retention phenomena parotid Warthins tumor. Otolaryngol Head otolaryngology. Vol 1. Philadelphia (PA): JB
Neck Surg 1986;94:16975. Lippincott; 1993. p. 453.
that occur in the floor of the mouth in rela- 17. Ord RA. Salivary gland disease. In: Fonseca RJ,
3. Lack EE, Upton MP. Histopathlogic review of
tion to the sublingual gland. They may be editor. Oral and maxillofacial surgery. Vol 5.
salivary gland tumors in childhood. Arch
large enough to elevate the tongue and Otolaryngol Head Neck Surg 1988; Philadelphia (PA): WB Saunders; 2000. p.
interfere with speech and swallowing (Fig- 114:898906. 27980.
ure 35-10). Where dehiscence in the mylo- 4. Ampil FL, Misra PP. Factors influencing sur- 18. Nahlieli O, Baruchin AM. Sialoendoscopy:
vival of patients with adenoid cystic carci- three years experience as a diagnostic and
hyoid muscle occurs, the mucus can drain treatment modality. J Oral Maxillofac Surg
noma of salivary glands. J Oral Maxillofac
into the submandibular space as a plung- Surg 1987;45:110010. 1997;55:9128.
ing ranula. The treatment of ranulas has 5. Castle JT, Thompson LD, Frommelt RA, et al. 19. Escudier MP. The current status and possible
been reviewed at length in a classic paper by Polymorphous low grade adenocarcinoma: future for lithotripsy of salivary calculi.
a clinicopathologic study of 164 cases. Can- Atlas Oral Maxillofac Surg Clin N Am
Catone.20 He concluded that definitive
cer 1999;86:20719. 1998;6:11731.
therapy was removal of the sublingual 6. Lindberg LG, Ackerman M. Aspiration cytol- 20. Catone GA. Sublingual gland mucous escape.
gland. Several large series have been report- ogy of salivary gland tumors diagnostic Pseudocysts of the oro-cervical region.
ed comparing sublingual gland excision experience for 6 years of laboratory work. Atlas Oral Maxillofac Surg Clin N Am
with so-called marsupialization, demon- Laryngoscope 1976;86: 58494. 1995;7:43177.
7. Ord RA. Surgical management of parotid 21. Yoshimura Y, Obara S, Kondoh T, Naitoh ST. A
strating 100% cure for gland excision and tumors. Atlas Oral Maxillofac Surg Clin N comparison of three methods used for the
43 to 63% cure for marsupialization.21,22 Am 1995;7:52964. treatment of ranula. J Oral Maxillofac Surg
Despite this evidence some authorities 8. Witt RL. The significance of the margin in 1995;53:2802.
still plead the case for marsupialization or parotid surgery for pleomorphic adenoma. 22. Crysdale WS, Mandelsohn JD, Conley S. Ranulas-
Laryngoscope 2002;112:214154. mucocoeles of the oral cavity experience in 26
marsupialization with packing, which
9. To EW, Pang PC, Chiu GM. The use of modi- children. Laryngoscope 1988;98:2968.
they claim has a lower recurrence rate of fied rhytidectomy for parotidectomy [let- 23. Baurmash HD. Mucocoeles and ranulas. J Oral
10 to 12%.23 We subscribe to the view that ter]. Br J Plast Surg 2000;531:80. Maxillofac Surg 2003;61:36978.
CHAPTER 36
Fungal Disease of the candidiasis to describe the same disease, usually shows diffuse patches of papillary
Oral Cavity even though the suffix -iasis is character- atrophy (Figure 36-2). Occasional small or
istically used to describe parasitic infec- confluent ulcerations may be noted. Angu-
Fungal diseases of the oral cavity can be
tions such as schistosomiasis or amebiasis. lar cheilitis is a prominent clinical feature
classified as superficial or deep in relation
One or more species of Candida can be of oral candidosis. Patients characteristi-
to the primary tissue(s) involved in the
found as a component of the normal oral cally complain of an oral burning sensa-
infection. Most oral fungal infections are
flora in about 60% of healthy adults. The tion. Denture-sore mouth (denture stom-
opportunistic in nature. Persons living in
geographic areas endemic to one or more organism can exist in one of three states: the atitis) is a clinical term used to describe
of these fungi may show immunologic yeast form consisting of blastospores mea- patients with mucosal erythema or
reactivity to the surface antigens without suring 1.5 m to 5 m in diameter, elongat- inflammatory papillary hyperplasia, usu-
having historic features of active disease. ed pseudohyphae, and chlamydospores ally related to a localized candidosis under
The deep fungi usually infect the lungs measuring 7 m to 17 m in diameter. In its a removable prosthodontic appliance.
before dissemination to other organ sys- commensal state, the organism usually Clinical features of oral candidosis
tems, including the oral cavity. Deep fun- exists only as spores or pseudohyphae. usually include foci of mucosal erythema,
gal diseases, including histoplasmosis, coc- Candidosis is usually an opportunis- which is the result of inflammation and
cidioidomycosis, blastomycosis, and tic infection caused by a localized or sys- mucosal atrophy, areas of ulceration, and
cryptococcosis, present clinically as chron- temic suppression of the immune sys- sometimes white pseudomembranous
ic proliferative ulcerated granulomatous tem. Commonly recognized causes of plaques, which are seen to consist of can-
tissue lesions that may be single or multi- candidosis include the use of broad- didal pseudohyphae and spores if exam-
ple and painful or asymptomatic. They spectrum antibiotics, xerostomia, chron- ined microscopically (Figure 36-3). These
may simulate clinical features of a malig- ic diseases of the immune system, and pseudomembranous plaques, although
nant neoplasm. therapy for malignant disease including usually present in acute-onset cases of
chemotherapy or radiation. candidosis, are frequently absent in cases
Candidosis Oral infections involving Candida of chronic candidosis such as those related
Although numerous deep and superficial species may appear as one of three clinical to prosthetic appliances. The lack of white
fungal diseases can involve the oral cavity, forms: acute, chronic, and mucocuta- pseudomembranes should not therefore
candidosis is by far the most common. The neous. Candidosis characteristically shows preclude consideration of candidosis in
term candidosis is the correct nomencla- erythematous mucosa with or without cases of chronic mucositis. Candidosis has
ture describing an infection with one of overlying white plaques, which may be also been noted in lesions characterized by
several species of Candida organisms. rubbed away with light abrasive pressure focal increases in keratinization such as
However, many publications use the term (Figure 36-1). The dorsum of the tongue lichen planus, focal keratosis with or
680 Part 5: Maxillofacial Pathology
The diagnosis of syphilis is usually Generalized Pigmentations Table 36-1 Generalized Pigmentations
made following serologic studies, includ- of Skin and Oral Mucosa
Some of the common causes of general-
ing Venereal Disease Research Laboratory
ized pigmentations are listed in Table 36-1. Hereditary (racial)
and fluorescent treponemal antibody
The most common type of generalized Pregnancy (chloasma, melasma)
absorption tests. The treatment of choice
pigmentation is hereditary or racial. The Smoking (smokers melanosis)
for syphilis remains 2.4 million U of ben- pigmentation is diffuse, symmetric, and Medications
zathine penicillin. For patients allergic to most commonly located on the gingiva and Antimalarials
penicillin, erythromycin or tetracycline labial mucosa. Pregnancy and ingestion of Oral contraceptives
may be substituted. oral contraceptives may produce melanin Busulfan
pigmentation called chloasma or melasma. Cyclophosphamide
Gonorrhea Bleomycin
Pigmented macules occur on the labial
Gonorrhea is currently the most wide- Phenytoin
mucosa, forehead, malar prominences, and
spread human bacterial infection in the Phenothiazines
around the eyes and lips.1013
world and is caused by Neisseria gonor- Minocycline
Smokers sometimes have melanin pig- Heavy metals
rhoeae, a gram-negative diplococcus. mentation of the attached gingiva. Numer- Bismuth
Transmission is usually venereal, ous medications may cause pigmentation Lead
involving genital, oral, or pharyngeal of skin and/or oral mucosa. Antimalarials Silver
mucosa. The incubation period is about such as quinine, chloroquine, and amodi- Gold
1 week with the initial features ranging from aquine may cause pigmentation in approx- Arsenic
no evidence of disease to mucosal ulcers and imately 25% of patients taking them for Mercury
regional lymphadenopathy. These features, > 3 to 4 months. Cancer chemotherapeutic Syndromes and systemic diseases
although reported in the oral cavity, are rare drugs such as busulfan, cyclophosphamide, Peutz-Jeghers syndrome
compared with the much more common and bleomycin have been reported to cause Addisons disease
pharyngeal infection. Therefore, in pigmentation, primarily of skin. Hydan- Neurofibromatosis
patients who present with chronic apht- toin may produce facial pigmentation Albrights syndrome
hous-like ulcerations and erythema pre- resembling chloasma. Minocycline may
dominantly involving the pharyngeal cause pigmentation of skin, bones, teeth,
mucosa rather than the oral mucosa, a oral mucosa, and the thyroid. Pigmenta- Neurofibromatosis is a relatively com-
gonorrheal infection should be part of the tion secondary to heavy metals is due to mon autosomal dominant inherited syn-
clinical differential diagnosis. The micro- deposition of metals in the skin and oral drome. Virtually all patients have six or
scopic features are nonspecific, and the mucosa. This type of pigmentation is not more brown cutaneous macules > 1.5 cm
clinical features of the disease seldom indi- commonly seen today because of their in diameter known as caf au lait spots.
cate a biopsy. The diagnosis is based on decreased value as therapeutic agents. Numerous freckles 2 or 3 mm in diameter
demonstration of the organism in culture Peutz-Jeghers syndrome is character- are often present in the axilla and other
media or through the use of immunofluo- ized by multiple pigmented macules of the intertriginous regions. Other features of
rescent antibody techniques.8,9 hands and feet; areas surrounding the neurofibromatosis include multiple neu-
The treatment of choice for gonorrhea mouth, eyes, and nose; and intraorally on rofibromas, central nervous system
continues to be penicillin. Occasional the buccal mucosa, labial mucosa, gingiva, tumors, seizures, intellectual handicap,
penicillin-resistant strains are noted dur- and palate. Multiple hamartomatous and speech impediments.
ing sensitivity cultures and require man- polyps are present in the gastrointestinal Albrights syndrome consists of
agement with alternative antibiotics. tract. Patients with this syndrome have an polyostotic fibrous dysplasia plus multiple
increased incidence of cancer both within caf au lait spots. Endocrine abnormali-
Pigmented Lesions of Oral and outside the gastrointestinal tract. ties, most commonly precocious puberty
Mucosa and Skin Patients with Addisons disease have in young females, are also present.
Pigmented lesions of oral mucosa and increased pigmentation of the skin, lips,
skin can be divided into generalized gingiva, buccal mucosa, and tongue. Sys- Localized Pigmented Lesions
lesions, which are diffuse and multifocal, temic manifestations are prominent and Localized pigmented lesions can be divid-
and localized lesions involving one or include malaise, weakness, nausea, vomit- ed into four classes based on their cause
several locations. ing, diarrhea, weight loss, and hypotension. and clinical features: (1) melanocytic,
Management of Mucosal and Related Dermatologic Disorders 683
(2) vascular, (3) extravasated blood, and any skin surface. It is not premalignant and melanoma, they should be removed. In
(4) tattoos. requires excision only for microscopic diag- patients with numerous dysplastic nevi,
nosis. Microscopically, lentigo simplex the lesions should be closely monitored
Melanocytic Lesions Melanocytic lesions demonstrates an increased number of and excised if they change.
are due to increased amounts of melanin melanocytes in the basal cell layer, an Nevi of the oral mucosa are usually
pigment in the tissue and/or a proliferation increased amount of melanin in the between 1 and 6 mm in diameter and are
of melanocytes or nevus cells. Melanocytic melanocytes and the basal keratinocytes, and most commonly located on the hard
lesions are gray, brown, black, or blue and elongation of the rete ridges. Macrophages palate and buccal mucosa. They are occa-
do not blanch on pressure. containing melanin (melanophages) are pre- sionally nonpigmented. The majority of
sent in the upper dermis.16 oral nevi are raised and thickened, but a
Ephelides The ephelis or freckle is a significant number may be flat.
small circumscribed brown or black mac- Nevi A nevus is a proliferation of nevus Microscopically, the majority of oral
ule that occurs on sun-exposed areas of cells or melanocytes. Nevi are extremely nevi have been reported as intramucosal,
skin. It appears in childhood and darkens common lesions on skin but are relatively but blue, compound, and junctional nevi
in the summer and fades during the win- uncommon on oral mucosa. Most nevi of also occur.17
ter. Microscopically, the ephelis shows skin are absent at birth and appear in Because of the small number of
increased melanin in the basal cell layer of childhood. They progress through a series reported cases of oral nevi, their potential
the epidermis but no increase in the num- of stages, and then decline in number with for evolving into melanoma is not known.
ber of melanocytes. Ephelides are not pre- increasing age. Nevi begin as junctional Because of this, lesions in which nevus is
malignant and require no treatment once nevi, with nests of nevus cells at the part of the clinical differential diagnosis
the diagnosis is established. dermal-epidermal junction. Compound should be completely excised.
nevi demonstrate nevus cell nests in the epi-
Oral Melanotic Macules The oral melan- dermis and upper dermis. Intradermal nevi Melanomas Melanoma is a malignant
otic macule is an oral mucosal pigmenta- have nevus cell nests only in the dermis. neoplasm of nevus cells or melanocytes.
tion with similar microscopic features to Clinically, junctional nevi are flat pig- Microscopically, melanomas begin at the
ephelis. The lesions are well-circumscribed mented macules. The compound nevus is dermal-epidermal junction and then may
flat macules that are gray, brown, blue, or slightly elevated and sometimes has a demonstrate two different patterns of
black. Most are 1 to 3 mm in diameter. The papillomatous surface. Intradermal nevi growth. In radial growth, or melanoma in
most common locations are the vermilion are dome shaped and pedunculated. Com- situ, melanoma cells grow laterally along
border of the lip, gingiva, and buccal pound and intradermal nevi may not be the dermal-epidermal junction but do not
mucosa. They are often confused clinically pigmented. Normal nevi are round to oval, invade the underlying dermis. A melanoma
with tattoos and nevi.14,15 have a smooth border, and are sharply may remain in the radial growth phase for
Microscopically, oral melanotic mac- demarcated from the surrounding skin. years, and during this time it does not
ules show increased melanin in the basal cell They are most commonly found on sun- metastasize. During vertical growth the
layer, lamina propria, or both. The cause of exposed skin above the waist.17,18 melanoma cells grow into the dermis and
oral melanotic macules is unknown, Dysplastic nevi are precursors to are capable of invading vascular channels
although they may be an atypical manifesta- melanoma. They may occur sporadically and nerves and metastasizing.1922
tion of physiologic pigmentation because or in an autosomal dominant inherited Microscopically, melanoma cells are
the microscopic appearance is identical to syndrome in which they are quite numer- described as epithelioid or spindle
racial pigmentation. These macules do not ous. Dysplastic nevi have irregular borders shaped. Epithelioid cells are round to
recur or undergo transformation into that are indistinct and fade into the sur- cuboidal and form nests. The spindle cells
melanoma, but they may be difficult to dis- rounding skin. They may demonstrate a are elongated and do not form nests. The
tinguish it from nevi or melanoma in situ. mixture of colors, including tan, dark tumor cells demonstrate nuclear pleo-
They should be excised for microscopic brown, and pink. Dysplastic nevi are typi- morphism, anaplasia, and mitotic figures.
diagnosis or checked frequently. cally larger than normal nevi. The amount of melanin within tumor
It is not necessary to remove normal cells is variable. The Fontana-Masson
Lentigo Simplex Lentigo simplex is a mac- cutaneous nevi unless they are irritated by stain demonstrates melanin in some of
ular brown-to-black lesion that is not associ- clothing. Since dysplastic nevi have an the amelanotic-appearing tumor cells.
ated with sun exposure and may occur on increased potential for developing into The dopa reaction is more reliable for
684 Part 5: Maxillofacial Pathology
demonstrating melanin, but it requires Acral-lentiginous melanoma is the Hemangioma Hemangioma is a prolif-
fresh tissue. most common melanoma in black per- eration of blood vessels that is usually con-
There are four types of cutaneous sons. It occurs primarily on the palms, genital and may regress spontaneously. It
melanoma: lentigo maligna melanoma, soles, and in association with nails. It can is commonly found on the skin and in the
superficial spreading melanoma, acral- metastasize early. oral cavity.
lentiginous melanoma, and nodular Nodular melanoma presents as a Hemangioma of skin may present as a
melanoma. rapidly growing darkly pigmented nodule soft tissue enlargement or a flat surface
Lentigo maligna (melanotic freckle of that is often ulcerated. It is not associated lesion. Nevus flammeus, or port-wine
Hutchinson) represents lentigo maligna with sun exposure. Since it grows vertical- stain, is a red-to-blue macule present at
melanoma in situ. It presents as a brown ly from the beginning, it is often deeply birth. Sturge-Weber syndrome (encephalo-
macule with black flecks and irregular invasive by the time it is diagnosed. trigeminal angiomatosis) includes con-
margins located on sun-exposed surfaces Treatment of cutaneous melanoma genital port-wine stain in the distribution
of elderly persons. It may remain in the usually consists of wide surgical excision. of the trigeminal nerve, hemangiomas of
radial growth phase for 10 to 15 years Chemotherapy is sometimes used, but the leptomeninges, and ipsilateral heman-
before progressing to invasive lentigo radiation therapy has not proven effective. giomas of the face, skull, jaws, and oral
maligna melanoma, indicated by the devel- Incisional biopsy is not thought to cause cavity. The hemangiomas often contain
opment of nodularity. metastasis of melanomas. calcifications and may result in seizure
Superficial spreading melanoma consti- The most important prognostic factor disorders and other neurologic problems.
tutes about 70% of cutaneous melanomas. for cutaneous melanoma is the thickness Hemangiomas of the oral cavity are
It occurs on both exposed and unexposed of the lesion. One study reported a 10-year compressible red or blue soft tissue
surfaces, most commonly on the upper back survival rate of 99.5% for patients with enlargements that blanch on pressure.
in men and lower legs in women. This melanomas < 0.76 mm thick, as opposed They present most commonly in the lips,
melanoma has irregular borders and great to 48% survival for those with melanomas tongue, and buccal mucosa.
variation in color within one lesion, includ- 3 mm and greater in thickness.23 Microscopically, hemangiomas are
ing tan, brown, black, pink, blue, and white Melanoma of oral mucosa is a rare classified as cavernous or capillary. Cav-
areas (Figure 36-5). It often demonstrates neoplasm most commonly located on the ernous hemangiomas consist of large
nodularity and ulceration. Superficial hard palate and maxillary gingiva of vessels lined with a single layer of
spreading melanoma remains in the radial patients > 50 years of age. About one- endothelial cells, whereas capillary
growth phase for a shorter time than does third of patients have preexisting hemangiomas contain numerous smaller
lentigo maligna melanoma and thus has a melanosis, or macular hyperpigmenta- vessels. During their period of growth,
poorer prognosis. tion, which probably represents radial capillary hemangiomas demonstrate
growth of the lesion. This may be present marked endothelial proliferation and
for years before vertical growth occurs. At only a few capillary lumina.
the time of diagnosis, many oral Hemangiomas are unencapsulated
melanomas are large, ulcerated, and have lesions and can be difficult to remove sur-
caused bony erosion. A significant num- gically. Other treatment modalities
ber of tumors are amelanotic. include sclerosing agents, cryotherapy, and
Treatment of oral melanoma is wide laser surgery. Treatment is not recom-
local excision with or without lymph node mended unless lesions are a functional or
dissection. The prognosis is quite poor. The cosmetic problem.
5-year survival in one series was only 13%.23
This may be due to the advanced stage of Varix A varix is a dilated vein. It occurs
oral melanomas at the time of diagnosis. most commonly on the lip, buccal mucosa,
and ventral surface of the tongue. It
Vascular Lesions Vascular lesions are increases in frequency with increasing age.
due to increased numbers of blood vessels, The typical varix is blue, compressible,
or blood vessels of increased diameter. and blanches on pressure. A thrombosed
FIGURE 36-5 Melanoma. Alteration in color of
a nevocellular nevus with apparent expansion These lesions are compressible, blanch on varix is firm to palpation, does not blanch,
into the surrounding normal skin. pressure, and are red, blue, or purple. and resembles a nevus.
Management of Mucosal and Related Dermatologic Disorders 685
No treatment is necessary for a varix Hematoma A hematoma is a blood blis- Excision of a tattoo is necessary only
unless nevus or melanoma is included in ter or a circumscribed pool of blood out- when a nevus or melanoma is included in
the clinical differential diagnosis. side of a vessel. It is typically caused by the clinical diagnosis.
trauma and is most commonly found on
Kaposis Sarcoma Kaposis sarcoma is a the buccal mucosa along the occlusal Vesicular, Ulcerated, and
malignancy of endothelial cell origin that plane. It appears blue to purple and is Erythematous Lesions
occurs in three settings. It was first described compressible to palpation. A hematoma Numerous diseases cause vesicles and/or
as a disease involving the skin of the distal requires no treatment and resolves sponta- ulcers of the oral cavity. Some diseases such
portion of the lower extremities in elderly neously in several weeks. as herpes simplex and aphthous ulcers are
males of Mediterranean or Jewish origin. It important because they are frequently
is also endemic in black African children Ecchymosis and Petechiae An ecchymosis, encountered in practice. Other diseases
and adults. The African form involves vis- or bruise, is caused by diffuse bleeding into such as epidermolysis bullosa and pemphi-
cera and lymph nodes as well as skin. the tissue secondary to trauma. It is not pal- gus are serious life-threatening diseases.
Recently it has become a common lesion in pable. It is initially blue but evolves through Because vesicles are so transient in
patients with immunosuppression sec- many color changes before resolving. the oral cavity, it is usually impossible to
ondary to organ transplantation or human Petechiae are multiple discrete round determine if an ulcer was preceded by a
immunodeficiency virus (HIV) infection. hemorrhagic spots < 2 mm in diameter. vesicle. If a vesicle was present, then aph-
Kaposis sarcoma frequently involves They are more reddish than are ecchy- thous ulcers, ulcers of infectious
the oral cavity, especially in patients with moses or hematomas. Petechiae are a mononucleosis, traumatic ulcers, and
HIV infection. Oral lesions are most com- result of capillary bleeding. They may be ulcers owing to bacteria can be excluded
mon on the hard palate and gingiva. The associated with a viral disease or a blood from the clinical diagnosis.
lesions may be single or multiple, flat or dyscrasia. A thorough history should be obtained
exophytic, and red, blue, or brown. The from patients with vesicular/ulcerative dis-
exophytic lesions blanch on pressure. Tattoos Tattoos are the most common eases and should include the following
The microscopic appearance of early oral pigmentation. They are the result of questions:
lesions of Kaposis sarcoma resembles intentional or accidental implantation of
1. How long have the lesions been present?
granulation tissue. Increased numbers of foreign material, such as amalgam,
2. Are the lesions recurrent?
dilated capillaries and a chronic inflam- graphite, ink, or metal, into the skin or
3. If yes, how often do they recur?
matory infiltrate are present. Advanced oral mucosa. A tattoo on the hard palate
4. Do they recur in the same locations?
lesions have vascular and spindle cell com- is often a result of a child falling on a
5. Have you noticed vesicles?
ponents. The vascular channels are lined pencil held in his or her mouth and
6. Have you noticed lesions on the skin,
with prominent endothelial cells. Strands pushing graphite into the tissue. Amal-
eyes, or genitals?
of pleomorphic spindle cells line narrow gam tattoo is usually seen on the gingiva,
7. Have you been aware of fever, malaise,
slits containing erythrocytes. Extravasated alveolar mucosa, buccal mucosa, and
and lymphadenopathy in association
erythrocytes and hemosiderin in the stro- floor of the mouth.
with the lesions?
ma help distinguish Kaposis sarcoma The most common presentation of a
8. What medications do you take?
from fibrosarcoma. tattoo is an asymptomatic flat nonthick-
Treatment of Kaposis sarcoma includes ened blue-to-black pigmentation. Occa- Since there are a large number of dis-
radiation therapy, surgery, and/or sionally, however, a tattoo may be thick- eases that can cause vesicles or ulcers, one of
chemotherapy. African patients and patients ened owing to fibrosis or may enlarge the convenient ways to classify the diseases is
with Kaposis sarcoma secondary to because of phagocytosis of the foreign by their cause. The discussion of vesicular,
immunosuppression have a poor prognosis. material by macrophages or incorporation ulcerated, and erythematous lesions below
The disease causes death in 10 to 20% of of the material into collagen fibers. Rarely, is arranged by the cause of lesions, for
elderly males with the disease. the foreign material may incite a foreign example, hereditary, viral, or autoimmune.
body granuloma with multinucleated giant
Lesions Owing to Extravasated Blood cells and macrophages. Radiographs may Hereditary Diseases
Because these lesions are due to the pres- be helpful in detecting foreign material in
ence of blood outside of blood vessels, the tissue, but not all foreign material can Epidermolysis Bullosa The most impor-
they do not blanch on pressure. be visualized radiographically. tant hereditary vesicular/ulcerative disease
686 Part 5: Maxillofacial Pathology
is epidermolysis bullosa (EB). There are at blisters of the ankles, knees, hands, elbows, HSV The primary infection with HSV
least 18 types of EB including some that and feet that produce scars. Milia (epider- may occur in seronegative patients of any
are not inherited. mal cysts) are common. Nails are thick age and results in acute herpetic gingivo-
The current classification of EB is and dystrophic. Onset is birth to 5 years of stomatitis. The patient experiences the
based on where the split that forms the age, and the condition improves with age. abrupt onset of malaise, fever, and tender
blisters occurs, inheritance, and clinical Some patients have oral bullae. cervical lymphadenopathy. Multiple vesi-
findings. Intraepidermal forms are non- Another dermal type is EB dystrophi- cles and ulcers can involve any oral mucos-
scarring and have autosomal dominant or ca Hallopeau-Siemens. It has autosomal al surface and are accompanied by gingival
X-linked inheritance. The split occurs recessive inheritance. Blisters are present swelling and erythema. The fluid-filled
within the epithelium and is associated shortly after birth and may involve any vesicles contain numerous virions and are
with defective tonofilaments of the basal skin surface. Scars form and cause con- infectious. The mouth can become
squamous epithelial cells. Junctional traction. Formation of a clawhand and/or extremely painful, resulting in difficulty
forms of EB have autosomal recessive mitten-like hand are common. Nails are eating and drinking (Figure 36-6).
inheritance and demonstrate skin atrophy. dystrophic or absent. The larynx, pharynx, After primary infection of the oral
The split occurs within the basement and esophagus may be involved. Oral bul- mucosa, HSVs travel centripetally along
membrane and is due to decreased num- lae and scarring may result in diminished peripheral nerves to nerve cell bodies of
bers of hemidesmosomes and tonofila- oral opening, ankyloglossia, tongue atro- the trigeminal ganglion. The viruses
ments. Dermal forms have autosomal phy, loss of buccal and vestibular sulci, and remain latent in the ganglion. Reactivation
dominant or recessive inheritance with perioral stricture. Teeth have hypoplastic of the latent virus causes transport of viral
atrophy and scarring of skin and mucosa. enamel, delayed eruption, and retention.
The split occurs in the upper dermis or EB bullosa acquisita is a noninherited
lamina propria owing to defects in type that begins in adulthood. Blisters
anchoring fibrils associated with the basal form in areas of trauma. Oral lesions have
lamina. Typing of patients requires the use been reported but are rare.27
of electron microscopy, immunofluores- EB is a disease that cannot be cured.
cence, and immunohistochemistry.2426 The treatment is supportive and sympto-
EB simplex Koebner type is an matic and includes corticosteroids and
intraepidermal form. Blisters mainly antibiotics to fight secondary infections.5
involve the feet, hands, and neck. They
begin in infants and are exacerbated by Viral Infections
heat. Abnormal nails are sometimes pre- The majority of viral infections are sub-
sent. Oral blisters are occasionally seen, clinical and asymptomatic. We know of
A
but the teeth are normal. The disease their existence because of the development
improves at puberty and is compatible of antibodies in the patients. Symptomatic
with a normal life span. viral vesicular and ulcerative diseases often
EB atrophicans generalisata gravis have systemic manifestations of malaise,
Herlitz type is a junctional form with fever, tender lymphadenopathy, and lym-
autosomal recessive inheritance. Blisters phocytosis. They generally have an acute
begin within a few days after birth and onset and a vesicular stage, with the excep-
involve the hands and feet, followed by the tion of infectious mononucleosis. Multiple
trunk, face, and scalp. The nails are lost or lesions are present.
dystrophic. Death within the first few The herpesvirus family consists of
months of life is common. Oral blisters herpes simplex virus (HSV) types 1 and 2,
and ulcers are found in almost all patients. varicella-zoster virus, Epstein-Barr virus
Enamel is hypoplastic, pitted, and exten- (EBV), and cytomegalovirus. Herpesvirus- B
sively involved with caries. es can assume a latent state in the patient.
FIGURE 36-6 A and B, Primary herpetic gin-
EB dystrophica Cockayne-Touraine Cytomegalovirus is important in neonates
givostomatitis. Acute-onset vesicles rupture
type is a dermal form with autosomal and immunocompromised patients; it is almost immediately leaving 1 to 2 mm ulcers of
dominant inheritance characterized by not discussed further in this chapter. keratinized and nonkeratinized oral mucosa.
Management of Mucosal and Related Dermatologic Disorders 687
genomes to the epithelial surface, where Either HSV-1 or -2 can infect the oral
replication occurs. Recurrent lesions may mucosa and skin. HSV-1 has a predilection
result. The most important factors associ- for oral mucosa and skin outside of the
ated with recurrent lesions are ultraviolet genital area, whereas HSV-2 prefers the
radiation, immunosuppression, and local genital region. Genital HSV-1 infections
trauma. With regard to immunosuppres- and oral HSV-2 infections have a greatly
sion, patients with defects in cell-mediated decreased incidence of recurrence.
immunity have herpes infections that are The diagnosis of mucocutaneous her-
more frequent and severe.2831 pes is usually apparent on the basis of clin- FIGURE 36-8 Herpes cytology. Cytologic prepa-
The vesicles and ulcers of recurrent ical features, so biopsy is rarely done. ration showing epithelial cells with enlarged
(secondary) herpes occur in small clusters Microscopic examination of a fluid-filled nuclei resulting from viral replication (160
original magnification; stained with Papanico-
on the lip, gingiva, and hard palate, and herpetic lesion demonstrates an intraep- laous stain).
they tend to recur in the same location. The ithelial vesicle with marked acantholysis.
lesions are often preceded by a prodrome of The epithelial cells have swollen homoge- manner, but the medication must be
tingling, pain, or numbness in the area. Sys- neous eosinophilic cytoplasm, known as administered during the first 3 days.
temic manifestations are not present. ballooning degeneration, and one or mul- The use of topical acyclovir in healthy
Recurrent herpetic lesions are often tiple nuclei. Inclusion bodies may be seen patients with recurrent herpes labialis has
confused with aphthous ulcers. They in the nuclei of balloon cells as given conflicting results. To have any
occur on the lip and keratinized oral eosinophilic structures surrounded by a effect, the medication must be used during
mucosa, whereas aphthae occur on clear halo. Cytologic preparation of a the prodrome, or within the first few
nonkeratinized mucosa. Recurrent herpet- fluid-filled vesicle can also demonstrate hours after onset of lesions. Topical sun-
ic lesions consist of multiple small ulcers multinucleated epithelial cells, and the blocking agents are useful in reducing the
in a group; aphthae consist of one to sev- diagnosis can be augmented by using frequency of recurrences of herpes labialis.
eral larger widely distributed ulcers. immunoperoxidase techniques to show In summary, acyclovir is most helpful
Herpes simplex infection of the finger antibodies to HSV (Figure 36-8). The in the treatment of herpes simplex infec-
is called herpetic whitlow (Figure 36-7). diagnosis can also be confirmed by isolat- tions in immunocompromised patients
The primary infection presents abruptly ing the virus in tissue culture. and in patients with frequent or severe
with edema, erythema, vesicles, and pain Lesions of primary and recurrent her- recurrences. It appears to have little value
in the infected finger, often accompanied pes resolve spontaneously in 10 to 14 days, in healthy patients with infrequent minor
by fever and axillary and epitrochlear lym- and treatment is often unnecessary. When recurrences of herpes labialis.
phadenopathy. The lesions may recur. treatment is required, acyclovir is the cur-
rent drug of choice. Acyclovir inhibits viral Varicella-Zoster Virus The primary
replication but has no effect on normal infection with varicella-zoster virus causes
host cell function. However, it does not varicella, or chickenpox. Varicella typically
prevent or eliminate the latent viral state. has mild systemic manifestations accom-
Acyclovir is very useful in the treat- panied by papules, vesicles, and ulcers on
ment of herpes simplex infections in the skin and mucosa. Successive crops of
immunocompromised patients. It has lesions begin on the trunk and move to the
been reported to decrease the duration of face and extremities. Lesions in various
viral shedding from lesions, the duration stages are present at the same time and are
of pain, the time to scabbing, and the time quite pruritic. Vesicles and ulcers resem-
to healing of lesions. It can reduce the bling primary herpes sometimes occur on
number of recurrences, but infection can oral mucosa.
recur after the medication is discontinued. Therapeutic management for varicella
Acyclovir can decrease viral shedding, is symptomatic and is aimed at reducing
time to healing, new lesion formation, and the pruritus. Antihistamines and topical
duration of symptoms in primary genital lotions are helpful in this respect. Varicella
FIGURE 36-7 Herpetic whitlow. Epidermal vesi- HSV infections. Primary oral herpes typically has a mild clinical course, and
cles of the index finger. would be expected to respond in a similar complications are rare, except in neonates,
688 Part 5: Maxillofacial Pathology
the elderly, and immunocompromised EBV The EBV causes infectious mononu- nuclear debris and numerous mitoses.
patients. Complications include bacterial cleosis and is also associated with hairy Sometimes very large cells with multilobed
infections of skin, encephalitis, Reyes syn- leukoplakia, Burkitts lymphoma, nasopha- nuclei and prominent nucleoli resemble
drome, and pneumonia. ryngeal carcinoma, and lymphoblastic Reed-Sternberg cells of Hodgkins disease.32
Infection with the varicella-zoster leukemia. EBV infects B lymphocytes and There have been reports of a chronic
virus results in a latent state, as in herpes salivary glands and persists within these tis- fatigue syndrome associated with EBV.
simplex. The recurrent disease is called sues for the lifetime of the host. The ability Patients describe this as a flulike illness
herpes zoster, or shingles. Reactivation of of EBV to reactivate depends on the com- with muscle aches, pharyngitis, tender
varicella-zoster virus is not as common as petency of the cellular immune system. lymphadenopathy, low-grade fever, and
with HSV, except in elderly or immuno- Infants and children infected with EBV persistent severe fatigue. Elevated titers
compromised patients. usually have an asymptomatic course, but of immunoglobulin G (IgG) antibodies
Zoster has a prodrome of pain, burn- about one-half of infected adolescents and to viral capsid or early antigens of EBV
ing, or paresthesia, followed by grouped adults develop acute infectious mononucle- are present.
vesicles on an erythematous base. The osis. The clinical features include malaise, Treatment of infectious mononucleo-
lesions are unilateral and follow the distri- fever, pharyngitis, and lymphadenopathy of sis is supportive. The acute disease usually
bution of a peripheral sensory nerve. They cervical, axillary, and inguinal chains. resolves within 2 to 4 weeks. Splenic rup-
are most common on the trunk and in the Splenomegaly, hepatomegaly, and hepatitis ture is one of the few fatal complications
distribution of the trigeminal nerve (Fig- with abnormal liver function tests may be of the disease, but it is extremely rare.
ure 36-9). Oral lesions can have a painful present. Occasionally an erythematous skin
prodrome that mimics a toothache in some rash is seen. Group A Coxsackievirus The two most
cases. The lesions in zoster resolve in sever- Ulcers may involve the oral mucosa, important group A coxsackievirus infec-
al weeks, but severe pain in the nerve dis- but a vesicular stage does not occur. The tions involving the oral cavity are herpan-
tribution (postherpetic neuralgia) can per- ulcers are secondary to decreased host resis- gina and hand, foot, and mouth disease.
sist for weeks to months after the lesions tance and appear after the systemic mani- Herpangina begins with fever, pharyngitis,
have resolved. The prevalence and duration festations. Petechiae occur on the palate in and anorexia. Vesicles and ulcers occur pri-
of pain increases with age. Involvement of about one-third of patients. The orophar- marily on the soft palate, uvula, and anteri-
the facial nerve can cause Bells palsy. ynx is inflamed and may be ulcerated. or tonsillar pillar. The disease resolves in
The microscopic features of tissues Laboratory features of acute infection several days and requires only sympto-
infected with varicella-zoster are identical include an increase in relative and absolute matic treatment.
to those infected with herpes simplex. numbers of lymphocytes and monocytes Hand, foot, and mouth disease has a
Valacyclovir has been shown to be of exceeding 50%, with > 10% atypical lym- prodrome of fever, malaise, and headache,
some value in the treatment of zoster phocytes in the peripheral blood. The followed by macules and vesicles on the
when the drug is started within the first atypical lymphocytes are called Downey palms and soles. Vesicles and ulcers can be
few days of onset of infection. cells, and they have indented or horseshoe- located anywhere in the oral cavity. Treat-
shaped nuclei and abundant basophilic ment is symptomatic, and the disease
foamy cytoplasm. The total leukocyte resolves within several weeks.
count is between 10,000 and 20,000 by the
second or third week of the illness. Sero- Measles Although a vaccine for measles
logic findings include high titers of het- exists, outbreaks of the disease still occur,
erophil antibodies, which clump red blood primarily on college campuses. Measles
cells of sheep. The antibodies may not begins with high fever, conjunctivitis, pho-
appear until several weeks after the onset of tophobia, cough, and nasal discharge.
signs and symptoms, and they decline dur- Leukopenia is common during this pro-
ing the ensuing 3 to 6 months. dromal phase. Red vesicles with white cen-
Involved lymph nodes microscopically ters (Kopliks spots) appear on the buccal
show reactive lymphadenitis. Lymphoid mucosa, followed in several days by an ery-
nodules in the inner cortex are hyperplas- thematous maculopapular skin rash. The
FIGURE 36-9 Herpes zoster. Acute-onset ulcera- tic. The germinal centers are markedly rash first appears on the face and then
tion localized to left maxillary soft tissues. enlarged and contain macrophages with spreads to the trunk and extremities.31
Management of Mucosal and Related Dermatologic Disorders 689
Microscopic examination of the oral HIV is transmitted by sexual inter- strating hyper-keratosis, acanthosis, and
mucosal vesicles reveals epithelial necrosis, course, through contact with blood or swollen ballooning epithelial cells.
intercellular edema, cytoplasmic and blood products, and perinatally. It is Hairy leukoplakia is usually an asymp-
nuclear inclusions, and multinucleated found in saliva, but transmission by saliva tomatic infection requiring no treatment.
epithelial giant cells. Lymph nodes and is unlikely. For those patients requiring treatment,
tonsils show lymphoid hyperplasia and The clinical spectrum of HIV infec- acyclovir 200 mg tablets 12 times per day
giant cells (Warthin-Finkeldey cells). tion includes an acute viral syndrome with for 3 weeks has been used with some tem-
Therapeutic management for measles malaise, fever, and lymphadenopathy; an porary success. In addition, cytology
is symptomatic. It is usually a self-limited asymptomatic carrier state in which there smears for candidosis should be performed
disease but may have a number of serious are circulating antibodies to HIV, and a and antifungal medication prescribed for
complications, including croup, bacterial wasting syndrome. Neurologic disorders patients with candidal organisms.
pneumonia, otitis media, and encephalitis. are common and range from subtle mem- Herpes simplex and herpes zoster are
ory loss to dementia. Numerous oppor- more frequent and severe in HIV
Rubella Rubella (German measles) is a tunistic infections, both fatal and nonfatal, patients as are nonspecific aphthous-like
mild infectious disease, but it can cause and malignant neoplasms are a character- ulcers. Prolonged postzoster neuralgia
serious fetal malformations when it istic part of acquired immunodeficiency can be extremely painful. High-dose acy-
occurs in pregnant women. The pro- syndrome (AIDS). Many of these can be clovir can be useful in the treatment of
drome consists of malaise, fever, mild present in the oral cavity.35 either disease.38, 39
conjunctivitis, and lymphadenopathy. PERIODONTAL DISEASE A unique form
Oral vesicles and ulcers may be present, Oral Manifestations OPPORTUNITISTIC of periodontal disease is present in many
but they are not distinctive. A macu- INFECTIONS A common oral disease in HIV patients. Clinical features include
lopapular skin rash begins on the face HIV-infected patients is candidosis. Four chronic gingival erythema, severe pain,
and spreads downward to the trunk and clinical types of candidosis can be present soft tissue necrosis, and rapid destruction
extremities. It usually lasts for about in HIV patients. Pseudomembranous can- of alveolar bone and the periodontal
3 days. Arthralgia may involve wrists, fin- didosis appears as white plaques that rub attachment. Pocket formation is minimal
gers, and knees. Rubella may be com- off, leaving an erythematous and/or bleed- or absent. The cause of HIV periodontitis
pletely asymptomatic or consist of lym- ing base. Hyperplastic candidosis presents may be an overgrowth of virulent organ-
phadenopathy without the rash.33,34 as white rough plaques that do not rub off. isms possessing tissue-damaging capabili-
Congenital rubella syndrome usually Erythematous candidosis is characterized ties. This is probably a result of compro-
results from maternal infection during the by diffuse or localized patches of red mised immunity owing to HIV infection.
first trimester of pregnancy. The classic mucosa. Angular cheilitis presents as HIV periodontitis does not respond to
parts of the syndrome include cardiac cracks or fissures of the commissures, conventional therapy alone. However, it
malformations of patent ductus arterio- sometimes associated with white plaques. does reportedly respond to twice-daily
sus, interventricular septal defect, or pul- Candidosis in HIV infection responds to rinsing with chlorhexidine combined with
monic stenosis; eye lesions of cataracts, antimycotic medications, but it is chronic conventional methods.40
chorioretinitis, and microphthalmia; men- and recurrent.36 MALIGNANT NEOPLASMS The most
tal retardation; and deafness. Hairy leukoplakia consists of unilater- common malignant neoplasms involving
Rubella is usually a benign disease al or bilateral white rough plaques that do the oral cavity in HIV patients are Kaposis
requiring only symptomatic treatment. A not rub off, most commonly found on the sarcoma, non-Hodgkins lymphoma, and
live attenuated vaccine is effective, but it lateral surface of the tongue. It is seen squamous cell carcinoma. Most HIV
should not be given to pregnant women or mainly in homosexual males but is also patients with Kaposis sarcoma have oral
to those who may become pregnant with- found in other HIV-risk groups. Deoxyri- lesions, and these may be the first sign of
in 2 months of vaccination. bonucleic acid (DNA) hybridization the disease. The lesions are red, blue, or
demonstrates EBV in epithelial cells of the purple and may be flat or elevated. They are
HIV HIV infects and destroys helper lesion. Hairy leukoplakia is pathognomon- most common on the hard palate and gin-
T lymphocytes, resulting in profound ic of HIV infection and is highly predictive giva. Treatment includes radiation therapy,
immunosuppression that predisposes to that the patient will develop AIDS.36, 37 laser surgery, and/or chemotherapy.4143
opportunistic infections and malignant Microscopically, hairy leukoplakia is a Non-Hodgkins lymphoma of the oral
tumors. lesion of squamous epithelium demon- cavity in HIV patients is characterized by
690 Part 5: Maxillofacial Pathology
continuous deposits of IgG and C3 along Discoid lupus erythematosus (DLE) is and symptoms usually resolve when the
the basement membrane zone. Circulating a skin disease that most commonly drug is withdrawn.
IgG antibodies against the basement involves the face, scalp, and ears. The skin The microscopic appearance of lupus
membrane zone are present in low titer lesions appear as erythematous patches, is variable. The epithelium is hyperkera-
and in only a minority of cases. often scaly and hyperpigmented. Older totic and shows alternating areas of atro-
Topical and/or systemic corticosteroids lesions may have atrophic scarring central- phy and hyperplasia. The lamina propria is
usually control the disease. The most seri- ly and hyperkeratosis at the periphery. edematous and has dense perivascular and
ous aspect of BMMP is conjunctival scar- Oral lesions of DLE are uncommon in deep inflammatory infiltrates. Periodic
ring, which can lead to blindness.4752 the absence of skin lesions. They charac- acid-Schiff stain demonstrates deposits
teristically show central erythema with subjacent to the epithelium and thicken-
Bullous Pemphigoid Bullous pem- white spots and a border zone of white ing of blood vessel walls.
phigoid (BP) and BMMP have similar striae surrounded by telangiectases. Less Direct immunofluorescence on oral
causes and microscopic features but a dif- typical oral lesions can resemble lichen lesions reveals deposits of Ig and C3 in the
ferent distribution of lesions. The skin in planus or hyperkeratosis. basement membrane zone of the epitheli-
all patients with BP demonstrates large Systemic lupus erythematosus (SLE) um in the majority of cases of DLE and SLE.
thick-walled bullae, but oral mucosal is a chronic multisystem disease most Therapeutic management of oral
lesions are less common. common in young women between the lesions of lupus includes topical and/or
Direct immunofluorescent findings are ages of 15 and 40 years. Arthritis is typi- systemic corticosteroids and antimycotic
identical in BMMP and BP. Indirect cally present, often at the onset. Central medications as necessary for candidiasis.
immunofluorescence reveals circulating nervous system manifestations include DLE has a good prognosis. The prognosis
IgG antibodies against the basement mem- seizures and psychoses. The leading cause for SLE depends upon the extent of sys-
brane in the vast majority of BP patients of death is renal disease, leading to temic involvement of the disease.
but only rarely in patients with BMMP. destruction of glomeruli and hyperten-
There appears to be no correlation between sion. Other manifestations include vas- Idiopathic Vesiculoulcerative
antibody titer and disease severity in BP.47, 52 culitis, Raynauds phenomenon, pleurisy, Diseases
and pericarditis. Idiopathic diseases have causes that are
Lupus Erythematosus Lupus erythe- Numerous laboratory abnormalities unknown or poorly understood. They do
matosus is an autoimmune disease in which may be present in SLE. The most impor- not have clinical characteristics common
autoantibodies form to a wide variety of tis- tant include elevated titers of antibody to to the entire class, and they must be con-
sues including skin and oral mucosa. The native DNA, positive LE cell preparation, sidered individually when formulating a
autoantibodies can be directed against the persistent false-positive serologic test for clinical differential diagnosis.
cells nuclear material (antinuclear antibod- syphilis, anemia, leukopenia, thrombocy-
ies [ANA]) or cytoplasmic antigens.53, 54 topenia, proteinuria > 0.5 g/d, and cellular Aphthous Ulcers Aphthous ulcers are
casts in the urine. common painful lesions that have period-
The classic skin lesion of SLE is an ery- ic recurrences. Most patients have only a
thematous rash located on sun-exposed single ulcer during a given episode,
surfaces such as the malar eminences. The although occasionally two or three ulcers
oral lesions are similar to those of DLE. may be present (Figure 36-13). Vesicles do
Oral ulceration is a well-known manifesta- not occur. Unlike recurrent herpes, aph-
tion of SLE. Oral candidiasis secondary to thous ulcers are found on nonkeratinized
corticosteroid therapy is common in SLE. oral mucosal surfaces. They have an acute
Certain medications have been report- onset, and each ulcer heals spontaneously
ed to cause lupus-like reactions. The most without scarring in 10 to 14 days. There
common of these include procainamide, are no systemic manifestations and usual-
hydralazine, phenytoin, penicillamine, ly no lymphadenopathy.5561
FIGURE 36-12 Cicatricial pemphigoid. Uni- methyldopa, trimethadione, primidone, Major aphthae, also known as peri-
form separation of epithelium from underlying thiouracil, and carbamazepine. Systemic adenitis mucosa necrotica recurrens, or
connective tissue at the level of the basement
membrane (60 original magnification; stained involvement is less common with the Suttons disease, is characterized by multi-
with hematoxylin and eosin). drug-induced syndrome, and the signs ple large mucosal ulcers. A patient has at
692 Part 5: Maxillofacial Pathology
and eye lesions. The skin lesions consist of The plaque form appears as white keratotic striations, erythema, and ulceration of
lateroventral glossal mucosa.
erythema nodosumlike eruptions and homogenous plaques. The white lesions
thrombophlebitis. The eye may be affected in both forms are nonpainful, rough to
by recurrent iritis, uveitis, and retinitis, palpation, and do not rub off. The desquamative gingivitis pattern in 25% of
which can lead to blindness. Other less atrophic form consists of erythematous patients. Candidosis is another common
common problems include arthritis, ileal mucosa plus a reticular keratotic pattern finding in patients with lichen planus.
and colonic ulcers, aneurysms, arterial and along the periphery. The erosive form Oral lesions of lichen planus are multifo-
venous occlusion, and a variety of central combines ulcerations with atrophic fea- cal and can involve any mucosal surface.
nervous system diseases. tures (Figures 36-15 and 36-16). The The most common locations are the buc-
Aphthous ulcers have been associated atrophic and erosive forms are typically cal mucosa, followed by gingiva and the
with a number of factors, but the cause is symptomatic. Occasionally, vesicles are tongue. One-fifth of patients with oral
unclear. Aphthae do not appear to be caused seen, which quickly rupture to form lesions have skin lesions.6268
by deficiencies in serum vitamin B12, red painful ulcers. Ulcers and erosions can Drugs can cause lichenoid reactions of
blood cell folate, iron, or total iron-binding involve the attached gingiva producing a skin and mucosa that are clinically similar
capacity, or malabsorption enteropathies.
An allergic response to certain foods such as
walnuts, strawberries, and tomatoes does
not appear to be important.
Genetic factors are significant as the
frequency of human leukocyte DR7 anti-
gen is significantly increased in aphthae
patients, and aphthae are more common
in related persons. Women commonly
state that the ulcers appear with the onset
of menstruation, supporting the role of
endocrine factors.
FIGURE 36-16 Lichen planus. Dorsal tongue
The microscopic features of aphthous FIGURE 36-14 Lichen planus. Hyperkeratotic lichen planus often characterized by hyperkera-
ulcers are those of any nonspecific ulcer striations of the buccal mucosa. totic plaques rather than striations.
Management of Mucosal and Related Dermatologic Disorders 693
to lichen planus. The reactions resolve Lichen planus is a chronic or recurrent skin-colored rings. The lesions are sym-
when the drug is discontinued. The most disease that only rarely undergoes sponta- metrically distributed, most commonly on
commonly implicated drugs include neous remission. The goal of treatment is the extremities and face.
methyldopa, amiphenazole, chloroquine, control of symptoms. Asymptomatic One-fourth to one-half of patients with
hydroxychloroquine, quinacrine, chlor- lesions require no treatment, whereas skin lesions have oral lesions (Figure 36-18).
propamide, tolbutamide, tetracycline, symptomatic cases are usually controlled Ulcers are present, most commonly on the
chlorothiazide, practolol, dapsone, with topical and/or systemic cortico- lips, buccal mucosa, and tongue, as well as
furosemide, phenothiazines, quinidine, steroids. In one study of 570 patients with erythematous mucosa. The oral lesions vary
triprolidine, para-aminosalicylic acid, oral lichen planus, 63% experienced from mild to so severe that patients cannot
arsenicals, bismuth, gold salts, and mercury. improvement and 29% experienced com- speak or eat. The lesions may be accompa-
Lichenoid reactions also occur during the plete remission while maintained on corti- nied by headache, fever, and malaise.70,71
chronic phase of graft-versus-host disease costeroids.69 Antifungal medication is nec- Stevens-Johnson syndrome is a severe
following bone marrow transplantations. essary if candidosis is present. form of EM with more serious systemic
Lichen planus is considered a disease It appears that oral carcinoma occurs manifestations. Extensive skin lesions,
of the cellular immune system involving T in lichen planus patients at a slightly high- conjunctivitis, and oral and genital
lymphocytes, Langerhans cells, and er rate than in the general population. mucosal lesions are present. The oral
macrophages. The Langerhans cells and However, the frequency of malignant lesions often begin as vesicles, which rup-
macrophages process antigens and present transformation is unknown, and the clas- ture forming painful ulcers. Lesions on the
the antigenic material to T lymphocytes. sification of lichen planus as a premalig- labial mucosa may have a bloody crust.
The lymphocytes proliferate and become nant lesion does not appear justified. Peri- Toxic epidermal necrolysis is an even
cytotoxic for basal cells of the squamous odic recall examinations are necessary. more serious form of EM characterized by
epithelium. A similar immune mechanism large flaccid bullae and sloughing of the
has been reported in graft-versus-host dis- Erythema Multiforme Erythema multi- epidermis in large sheets. Oral lesions may
ease and erythema multiforme. forme (EM) can involve skin and oral be prominent, especially on the buccal
The microscopic features of lichen mucosa independently or simultaneously.
planus are variable, and clinical features It has traditionally been described as acute
are important in establishing the diag- and self-limited, requiring an average of 3
nosis. The primary microscopic features weeks for resolution. Some patients have a
include hyperkeratosis and a band-like variable pattern of recurrence. In other
inflammatory infiltrate, consisting pri- patients EM has a chronic course.
marily of lymphocytes, subjacent to the The cause of EM is unknown, although
epithelium (Figure 36-17). The epitheli- it appears to be some type of immune dys-
umconnective tissue interface is function. It may be related to immune
obscured owing to liquefaction degen- complexes deposited in walls of blood ves-
eration of the epithelial basal cell layer sels in the dermis or submucosa. In about
and/or infiltration with lymphocytes. half the cases EM appears to be triggered by
An eosinophilic band may be seen infections or drugs. The most common
between the inflammatory infiltrate and infections reported include herpes simplex
the epithelium. The spinous cell layer is viruses, tuberculosis, and histoplasmosis.
often hyperplastic. Colloid or Civatte The most frequently implicated drugs are
bodies, representing necrotic epithelial sulfonamides, barbiturates, phenylbuta-
cells, are occasionally seen as eosino- zone, oxy-phenbutazone, phenazone, peni-
philic bodies in the lower layers of the cillins, chlorpropamide, phenytoin, and
epithelium. carbamazepine.
Direct immunofluorescence reveals The skin lesions of EM include mac-
fibrinogen deposition in the basement ules, papules, vesicles, and bullae. The FIGURE 36-17 Lichen planus. Focal hyperker-
atosis, basal cell liquefaction degeneration, and a
membrane zone in almost all cases, and most characteristic lesion, known as the
superficial infiltration of lymphocytes (60 orig-
less commonly in colloid bodies and walls iris or target lesion, appears as a central inal magnification; stained with hematoxylin
of blood vessels. vesicle surrounded by erythematous and and eosin).
694 Part 5: Maxillofacial Pathology
York City 19861988. Arch Dermatol 1990; 20. Barker B, Carpenter WM, Daniels TE, et al.
126:2889. Oral mucosal melanomas: the WESTOP
6. Ficarra G, Zaragoza AM, Stendardi L, et al. Banff workshop proceedings. Oral Surg
Early oral presentation of lues maligna in a Oral Med Oral Pathol Oral Radiol Endod
patient with HIV infection: a case report. 1997;83:6729.
Oral Surg Oral Med Oral Pathol 1993; 21. Batsakia JG, Suarez P, El-Naggar A. Mucosal
75:72832. melanomas of the head and neck. Ann Otol
7. Laskaris G. Oral manifestations of infectious dis- Rhinol Laryngol 1998;107:6269.
eases. Dent Clin North Am 1996;49:395423. 22. Weyers W, Euler M, Diaz-Cascajo C, et al. Classi-
8. Darville T. Gonorrhea. Pediatr Rev 1999; fication of cutaneous malignant melanoma.
20:1258. Cancer 1999;86: 28899.
9. Fox KK, Whittington WL, Levine WC, et al. 23. Freidman RJ, Rigel DS, Kopf AW. Early detec-
Gonorrhea in the United States 19811996. tion of malignant melanoma: The role of
Demographic and geographic trends. Sex physician examination and self-examination
FIGURE 36-18 Erythema multiforme. Acute-
Transm Dis 1998;25:38693. of the skin. CA: Cancer J Clinicians 1985;
onset ulcerative mucositis involving palatal, buc-
cal, gingival, and labial mucosa. 10. Levantine A, Almeydn J. Drug induced changes 35:13051.
in pigmentation. Br J Dermatol 1973, 24. Fine JD, Bauer EA, Briggaman RA, et al.
89:10512. Revised clinical and laboratory criteria for
mucosa. Toxic epidermal necrolysis is usu- 11. Argenyi ZB, Finelli L, Bergfeld WP, et al. subtypes of inherited epidermolysis bul-
ally caused by drugs. The patient is acute- Minocycline-related cutaneous hyperpig- losa. J Am Acad Dermatol 1991;24:11935.
mentation as demonstrated by light 25. Woodley D. Clearing of epidermolysis bullosa
ly ill, and the disease is often fatal.
microscopy, electron microscopy and x-ray acquisita with cyclosporin. J Am Acad Der-
The microscopic features of EM are energy spectroscopy. J Cutan Pathol 1987; matol 1990;22:5356.
not diagnostic. The epithelium demon- 14:17680. 26. Wright J, Fine J, Johnson L. Oral soft tissues in
strates edema and necrosis of ker- 12. Odell EW, Hodgson RP, Haskell R. Oral pre- hereditary epidermolysis bullosa. Oral Surg
atinocytes. The connective tissue contains sentation of minocycline-induced black Oral Med Oral Pathol 1991;71:4406.
bone disease. Oral Surg Oral Med Oral 27. Sedano HO, Gorlin RJ. Epidermolysis bullosa.
perivascular infiltrates of lymphocytes,
Pathol Oral Radiol Endod 1995;79:45961. Oral Surg 1989;67:55563
plasma cells, and macrophages. Immuno- 13. Giardiello FM, Welsh SI III, Hamilton SR, et al. 28. Eversol R. Viral infections of the head and neck
fluorescence reveals deposits of IgM and Increased risk of cancer in the Peutz- among HIV-seropositive patients. Oral
C3 in the vascular walls, suggesting Jeghers syndrome. N Engl J Med 1987; Surg Oral Med Oral Pathol 1992;73:15563.
immune complex deposition is important 316:15114. 29. Fiddian A, Ivanyi L. Topical acyclovir in the
14. Buchner A, Hanson LS. Melanotic macule of management of recurrent herpes labialis. Br
in the pathogenesis.
the oral mucosa: a clinicopathologic study J Dermatol 1983;109:3216.
Treatment may not be necessary for of 105 cases. Oral Surg 1979;48:2449 30. Spruance S, Stewart J, Rowe N, et al. Treatment
mild forms of EM, which have a good 15. Kargers GE, Heise AP, Riley WT, et al. Oral of recurrent herpes simplex labialis with
prognosis, although they may be recur- melanotic macules: a review of 353 cases. oral acyclovir. J Infect Dis 1990;161:18590.
rent. More serious types respond well to Oral Surg Oral Med Oral Pathol 1993; 31. Kaplan LJ, Daum RS, Smaron M, et al. Severe
76:5961. measles in immunocompromised patients.
corticosteroids; however, Stevens-Johnson 16. Buchner A, Merrell PW, Hansen LS, et al. J Am Med Assoc 1992;276:123741.
syndrome is occasionally fatal. Melanocytic hyperplasia of the oral 32. Grogan TM. Hodgkins disease. In: Jaffe ES,
mucosa. Oral Surg Oral Med Oral Pathol editor. Surgical pathology of the lymph
References 1991;71:5862. nodes and related organs. Philadelphia:
1. Van der Wall I, Beemster G, van der Kwast W. 17. Buchner A, Hansen LS. Pigmented nevi of the W.B. Saunders; 1985. p. 978.
Median rhomboid glossitis caused by Can- oral mucosa: a clinicopathologic study of 33. Rosa C. Rubella and rubeola. Semin Perinatol
dida? Oral Surg Oral Med Oral Pathol 36 new cases and a review of 155 cases from 1998; 22:31822.
1979;47:315. the literature. Part I: a clinicopathologic 34. Watson JC, Hadler SC, Dykewicz CA, et al.
2. Horning GM, Cohen ME. Necrotizing ulcera- study of 36 new cases. Oral Surg Oral Med Measles, mumps, and rubellavaccine use
tive gingivitis, periodontitis and stomatitis: Oral Pathol 1987;63:56672. and strategies for elimination of measles,
clinical staging and predisposing factors. J 18. Buchner A, Hansen LS. Pigmented nevi of the rubella and congenital rubella syndrome
Periodontol 1995;66:9908. oral mucosa: a clinicopathologic study of and control of mumps: recommendations
3. Rowland RW. Necrotizing ulcerative gingivitis. 36 new cases and a review of 155 cases from of the Advisory Committee on Immuniza-
Am Periodontol 1999;4:6573. the literature. Part II: analysis of 191 cases. tion Practices. MMWR Morb Mortal Wkly
4. The Centers for Disease Control. Primary and Oral Surg Oral Med Oral Pathol 1987; Rep 1998;47(RR-8):157.
secondary syphilis in the United States, 63:67682. 35. MacPhail L, Greenspan D, Feigal D, et al.
1999. MMWR Morb Mortal Wkly Rep 19. Greens MIL, Clark WH, Tucker MA, et al. Recurrent aphthous ulcers in association
2001;50:1137. Acquired precursors of cutaneous malignant with HIV infection. Oral Surg Oral Med
5. Centers for Disease Control. Morbidity and melanoma: the familial dysplastic nevus syn- Oral Pathol 1991;71:67883.
mortality report: congenital syphilis. New drome. N Engl J Med 1985;312:917. 36. Greenspan D, Greenspan JS, Oral manifestations
Management of Mucosal and Related Dermatologic Disorders 695
of human immunodeficiency virus infection. recent advances at the molecular level and employing steroids. Oral Surg Oral Med
Dent Clin North Am 1993;37:2132. relevance to oral mucosal disease. J Oral Oral Pathol 1992;74:7986.
37. Lozada-Nur F, Robinson J, Regezi JA. Oral Pathol Med 1990;19:34150. 62. Vincent SD, Fetus PG, Baker KA, Williams TP.
hairy leukoplakia in immunosuppressed 50. Scully C, Carrozzo M, Gandolfo E, et al. Oral lichen planus: the clinical, historical
patients. Oral Surg Oral Med Oral Pathol Update on mucous membrane pem- and therapeutic features of 100 cases. Oral
1994;78:599602. phigoid. Oral Surg Oral Med Oral Pathol Surg Oral Med Oral Pathol 1991;70:16571.
38. Phelan J, Eisig S, Freedman P, et al. Major Oral Radiol Endod 1999;88:5668. 63. Van der Meij EH, Schepman KP, Smeele LE, et
aphthous-like ulcers in patients with AIDS. 51. Vincent SD, Lilly GE, Baker KA. Clinical, his- al. A review of the recent literature regard-
Oral Surg Oral Med Oral Pathol 1991; toric and therapeutic features of cicatricial ing the malignant transformation of oral
71:6872. pemphigoid. Oral Surg Oral Med Oral lichen planus. Oral Surg Oral Med Oral
39. Flaitz CM, Nichols CM, Hicks MJ. Herpesviri- Pathol 1993;76:4539. Pathol Oral Radiol Endod 1999;88:30710.
dae-associated persistent mucocutaneous 52. Scully C, Porter SR. The clinical spectrum of 64. Boisnic S, Francis C, Branchet MC, et al.
ulcers in acquired immunodeficiency syn- desquamative gingivitis. Semin Cutan Med Immunohistochemical study of oral lesions
drome. Oral Surg Oral Med Oral Pathol Surg 1997;16:30813. of lichen planus: diagnostic and pathophys-
Oral Radiol Endod 1996;81:43341. 53. De Rossi SS, Glick M. Lupus erythematosus: iologic aspects. Oral Surg Oral Med Oral
40. Holmstrup P, Westergaard J. HIV infection and clinical considerations for dentistry. J Am Pathol 1990;70:4625.
periodontal diseases. Periodontol 2000 Dent Assoc 1998;129:3309. 65. Holmstrup P, Scholtz AW, Westergaard J. Effect
1998;18:3746. 54. Lahita RG. Overview of lupus erythematosus. of dental plaque control on gingival lichen
41. Epstein J, Scully C. HIV infection: clinical fea- Clin Dermatol 1993;10:38992. planus. Oral Surg Oral Med Oral Pathol
tures and treatment of thirty-three homo- 55. Lo Muzio L, della Valle A, Mignogna MD, et al. 1990;69:58590.
sexual men with Kaposis sarcoma. Oral The treatment of oral aphthous ulceration 66. Kaliakatsou F, Hodgson TA, Lewsey JD, et al.
Surg Oral Med Oral Pathol 1991;71:3841. or erosive lichen planus with topical clobe- Management of recalcitrant ulcerative oral
42. Miles SA. Pathogenesis of AIDS-related Kaposis tasol propionate in three preparations: a lichen planus with topical tacrolimus. J Am
sarcoma: evidence of viral etiology. Hematol clinical and pilot study on 54 patients. J Acad Dermatol 2002;46:3541.
Oncol Clin North Am 1996;10:101121. Oral Pathol Med 2001;30:6117. 67. Porter SR, Kirby A, Olsen I, et al. Immunolog-
43. Epstein JB. Management of oral Kaposis sarco- 56. Lozada-Nur F, Miranda C, Maliksi R. Double- ic aspects of dermal and oral lichen planus.
ma and a proposal for clinical staging. Oral blind clinical trial of 0.05% clobetasol pro- Oral Surg Oral Med Oral Pathol Oral Radi-
Dis 1997;3(Suppl 1):1248. prionate in orabase and 0.05% fluocinon- ol Endod 1997;83:35866.
44. Dabelsteen E. Molecular biological aspects of ide ointment in the treatment of patients 68. Regezi JA, Dekker NP, MacPhail LA, et al. Vas-
acquired bullous diseases. Crit Rev Oral with oral vesiculoerosive diseases. Oral Surg cular adhesion molecules in oral lichen
Biol Med 1998;9:16278. Oral Med Oral Pathol 1994;77:598604. planus. Oral Surg Oral Med Oral Pathol
45. Nousari HC, Anhalt GJ. Pemphigus and bul- 57. ODuffy J. Behets syndrome. N Engl J Med Oral Radiol Endod 1996;81:68290.
lous pemohigoid. Lancet 1999;354:66772. 1990; 323:3267. 69. Silverman S, Gorsky M, Lozada-Nur F. A
46. Silverman S, Gorsky M, Lozada-Nur F, Liu A. 58. Pedersen A. Recurrent aphthous ulceration: prospective follow-up study of 570 patients
Oral mucous membrane pemphigoid. A virologic and immunologic aspects. APMIS with oral lichen planuspersistence, remis-
study of 65 patients. Oral Surg 1986; 1993;Suppl 37:137. sion, and malignant potential. Oral Surg
61:2337. 59. Ship JA. Recurrent aphthous stomatitis: an Oral Med Oral Pathol 1985;60:304.
47. Anhalt G. Pemphigoid: bullous and cicatricial. update. Oral Surg Oral Med Oral Pathol 70. Paquet R, Pierard GE. Erythema multiforme
Dermatol Clin 1990;8:70116. Oral Radiol Endod 1996;81:1417. and toxic epidermal necrolysis: a compara-
48. Dayan S, Simmons RK, Ahmed AR. Contem- 60. Porter SR, Scully C, Pedersen A. Recurrent tive study. Am J Dermatopathol 1997;
porary issues in the diagnosis of oral pem- aphthous stomatitis. Crit Rev Oral Bio Med 19:12732.
phigoid. Oral Surg Oral Med Oral Pathol 1998;9:30621. 71. Singla R, Brodell RT. Erythema multiforme
Oral Radiol Endod 1999;88:42430. 61. Vincent SD, Lilly GE. Clinical, histories, and due to herpes simplex virus. Recurring tar-
49. Jonsson R, Mountz J, Koopman W. Elucidating therapeutic features of aphthous stomatitis. get lesions are the clue to diagnosis. Post-
the pathogenesis of autoimmune disease: Literature review and open clinical trial grad Med 1999;106:1514.
CHAPTER 37
Skin cancer is the most common cancer istries.3 Reported yearly skin cancer rates Etiology
afflicting mankind. In the United States are approximately 2 in 1,000 in the conti- The etiology of NMSC is multifactorial
alone, an estimated 1 million new lesions nental United States, 1 in 100 on the island but can be broadly categorized into host-
are diagnosed each year.1 Skin cancer may of Kauai, and > 2 in 100 in Australia.8 related and environmental causes. Host
be grouped into two subsets: nonmelanoma Epidemiologic studies demonstrate a factors include an individuals phenotype,
skin cancer (NMSC) and melanoma. positive correlation between ultraviolet genetic syndromes, precursor lesions, and
NMSC comprises 95% of all skin cancers. (UV) radiation exposure and the inci- immunologic issues. Environmental vari-
Melanoma, of which 1 to 8% occurs in the dence of NMSC. NMSC is predominantly ables include exposure to UV radiation,
head and neck, fills the remaining 5%.24 a Caucasian disease ( 98%) but does ionizing radiation, and chemicals.2
Even with this low incidence, occur in Blacks and Hispanics.3 The risk of
melanoma is responsible for about 75% of developing NMSC increases the closer one Host Factors Tanning is the bodys
skin cancer-related deaths. The overall lives to the equator, and the more ones defense mechanism against NMSC. Ones
mortality for NMSC is relatively low, with outdoor activities increase the concentra- ability to tan is directly related to the
an estimated 5-year survival rate of 95%.5,6 tion of sun exposure through reflection.8,9 amount of melanin in the skin, which is
Regardless, NMSC may be locally aggres- Examples of the latter include work genetically determined and cannot be
sive, leading to significant morbidity, dis- around snow, water, cement, and roofing. influenced. Skin melanin determines a
figurement, loss of function, and high For all races 75% of NMSCs appear on persons photosensitivity. The more
health care costs.7 This chapter focuses on body areas most chronically exposed to sun- melanin an individual has, the less damage
the epidemiology, etiology, clinical charac- light, such as the head, face, neck, and dor- UV radiation inflicts. Deleterious effects of
teristics, and management (medical and sum of the hands.5 The incidence of BCC UV radiation are attenuated by the stra-
surgical) of these cutaneous malignancies. and SCC at early ages is comparable for men tum corneum via refraction, reflection,
and women, but men > 45 years have a three and direct absorption by melanin.
Nonmelanoma Skin Cancer times greater incidence of NMSC, specifi- Fitzpatrick classified skin into six dif-
cally SCC.10,11 In men common sites are the ferent groupings or types (Table 37-1).15
Epidemiology ears and nose, whereas in women the nose Each group was categorized based on the
The NMSCs include basal cell carcinoma and lower extremities are most common. results of 30 minutes of direct sunlight to
(BCC; 75% of NMSCs), squamous cell The incidence of NMSC had been the skin in the northern hemisphere. The
carcinoma (SCC; 20% of NMSCs), and a increasing for decades. The mortality rate, groups are based on the amount of
few rarer malignancies, such as Merkel cell however, has recently leveled off and is melanin an individual possesses, inherent
tumor, dermatofibrosarcoma protuberans, now beginning to decrease, perhaps owing pigmentation, and sensitivity to UV light.
and adnexal tumors.5 Incidence data for to public information programs.12 Overall, For example, a person in type 1 is the clas-
the United States should be interpreted NMSC has an excellent prognosis, but sic freckle-faced light-eyed redhead who
skeptically as most NMSCs are treated in approximately 2,000 deaths occur annual- burns and never tans, a Celtic type. People
outpatient clinics or private offices and are ly, three-fourths of which are from in type 1 are highly susceptible to skin
not routinely reported to cancer reg- metastatic SCC.13,14 cancer but remarkably also heal from
698 Part 5: Maxillofacial Pathology
A B
FIGURE 37-1 This 30-year-old woman was first seen 10 years prior for treatment
of multiple odontogenic keratocysts. A, The small pigmented dots are all incipient
or growing basal cell skin cancers, which are slow growing and less aggressive than
most cancers resulting from sun exposure. B, Intraoperatively. Excision is indicat-
ed for the larger lesions; curettage and electrodesiccation or CO2 laser is used for
incipient lesions. C, Improvement is noted after 1 month. C
tumors appear years earlier than in any cancer. UV radiation has been fingered as ment for psoriasis) have all been implicat-
control population.2730 However, most the primary environmental culprit. There ed as originators for NMSC.33 Patients suf-
studies suggest that some other risk factor are three types of UV radiation: UVA fering from chronic inflammatory skin
such as ionizing radiation or viral infec- (320400 nm), UVB (290320 nm), and conditions, such as chronic radiation ker-
tion, along with a decreased immune sys- UVC (200280nm). UVB rays are the atosis, burn scars, and ulcers, have an
tem, is necessary for the development of most carcinogenic, triggering skin cancer increased risk of developing skin cancers.
these tumors in this subset of patients.3,31 via photochemical damage to DNA, injury
to DNA repair mechanisms, and partial Prevention
Environmental Factors Ionizing radia- suppression of cell-mediated immunity.5,32 Although a doctor may be capable of treat-
tion, certain chemicals, and skin damage UVA, originally thought to be harmless, is ing skin cancer effectively, the informed
from the environment can also cause skin now known to enhance the effects of UVB patient is the greatest resource against the
as a cocarcinogen.3 Most UVC is filtered development of new cancers. Preventive
out by the ozone layer. As the ozone layer measures can be classified into three types:
thins, as it has over Antarctica and parts of sunscreens, clothing, and education. Sun
Australia, UVC enhances the development protection is rated by sun protection factor
of skin cancer. The most common historic
reports for NMSC as well as melanoma are
two to three childhood blistering sun-
burns or 3 years of intense sun exposure.
A comment must be made about the
two methods of tanning used in tanning
parlors. The method using UVA light, in
our estimation, enhances new skin can-
cers.32 We have seen skin cancers even in
teenagers who have used tanning parlors.
The California spray tan, a skin dye that
lasts for 3 to 5 weeks, is harmless.
Chemicals such as arsenic, polycyclic FIGURE 37-3 Scaly actinic keratoses on the scalp,
aromatic hydrocarbons, and psoralens some of which have progressed to squamous cell
FIGURE 37-2 Nevus sebaceus. used in combination with UVA (a treat- carcinoma (in situ).
700 Part 5: Maxillofacial Pathology
(SPF). The SPF is a ratio of the smallest mately 75% of all BCCs (see Figure 37-4).35 thematous nodule with raised borders
amount of radiation needed to produce Clinically, they present as well-defined (Figure 37-5). Cutaneous horns or a
erythema on protected skin compared translucent pearly nodules that are either hyperkeratotic crust with ulcerations may
with the same degree of redness produced round or oval with rolled borders and occa- be present. The surrounding skin may
on unprotected skin. Sunscreens function sional ulcerations. Telangiectasias are com- reveal signs of chronic sun damage.
either chemically or physically. Chemical monly seen coursing through the lesion. Unlike BCC, SCC may grow rapidly
sunscreens, such as para-aminobenzoic Pigmented BCCs range from brown to and metastasize. Metastasis is most com-
acid, benzophenones, and cinnamates, blue-black and can be mistaken for mon in lesions > 4 mm deep. The cumula-
reduce UV skin penetration by absorbing melanoma. Morphea-like BCCs present as tive rate of metastasis is between 2 and 6%,
solar rays. Physical sunscreens including firm plaques that are yellow or white with and the 5-year survival rate for metastatic
titanium dioxide, zinc oxide, and kaolin, an ill-defined border. They can be quite SCC is only 34%.11,38 Metastasis can occur
act as physical barriers. large and do not show more than 1 to either through the lymphatics or by
It is now known that regular applica- 2 mm elevation. This tumor is likely to hematogenous spread, with common sites
tion of SPF 30 sunblock may reduce the have positive margins after excision. being the regional lymph nodes, the lungs,
evolution of new actinic keratoses by 50% Basosquamous carcinomas have both and the liver. The location of the primary
after 3 years. Additionally, patients should basal and squamous cell differentiations. lesion influences the rate of recurrence
be told that the application of SPF 30 does They have a higher growth rate as well as and metastasis. SCCs occurring on the lip,
not abrogate the need for behavioral mod- a higher metastatic potential than do ear, melolabial crease, and periorbital and
ification. For example, a farmer who other BCCs. preauricular areas have higher rates of
applies SPF 30 at the start of the day will Micronodular, infiltrative, and morphea- recurrence and metastasis (1014%).38,39
have the protection wear off shortly after a like BCCs are the more aggressive variants The most common precursor for SCC
few hours of sweating. of BCC and together account for 10% of is AK. The rate of transformation of AK to
Clothing may provide some protec- BCCs.7 SCC is 1 in 1,000 per year.39 Approximately
tion, but a wet T-shirt has an SPF of 0 to Death from BCC is rare, with a rate of 40% of people > 40 years have had at least
1.33 High SPF clothing is available, but it is metastasis of 0.0028 to 0.1%.36 Size, depth one AK. Keratoacanthoma is a commonly
expensive and not very comfortable. of invasion, and histologic type are impor- confused with SCC, both clinically and
tant predictors for metastasis.10 Favored histologically. Keratoacanthoma is a self-
Basal Cell Carcinoma sites of metastasis include regional lymph healing raised growth lesion with a central
Basal cell tumors originate from pluripo- nodes, liver, lung, bone, and skin. This rare keratin-filled plug. It grows quickly but
tential cells in the epidermis and hair folli- metastasis is twice as common in males as often spontaneously involutes after 2 to 6
cles. They are often slow growing and may in females.36 months, leaving only a depressed white scar.
take years to enlarge significantly.33 Bowens disease is an in situ SCC pre-
Typically, patients with BCC are cat- Squamous Cell Carcinoma senting as a slow-growing erythematous
egorized as Fitzpatrick types 1 to 3 with SCC is the second most common skin can- scaling plaque with an irregular but sharp
a history of sun exposure. Eighty to 93% cer and accounts for 20% of all NMSC outline. These lesions rarely transform
of the cancers occur on sun-exposed cases. SCC is a malignant proliferation of into invasive SCC.
areas of the head and neck, and 26 to epidermal keratinocytes. Histologically SCC may evolve from chronically
30% occur on the nose.34 BCCs can be SCC is composed of nests and cords of unhealed or unstable wounds, burn scars,
divided into several subtypes: superfi- atypical squamous cells from the epider- or ulcers. These lesions, sometimes called
cial, nodulo-ulcerative (or nodular), pig- mis infiltrating into the dermis; it often Marjolins ulcers, have a 20% higher rate of
mented, infiltrative, micronodular, contains keratin pearls. The lifetime risk of lymph node metastasis than does UV-
morphea-like, and basosquamous. developing SCC is 4 to 14%, and the inci- induced SCC.40,41
Superficial BCC represents approxi- dence has increased by 20% in the past Histologic features, such as the degree
mately 10% of all BCCs (Figure 37-4).35 decade alone.11,37,38 of differentiation, depth of invasion, and
They present as slightly elevated plaques Men with a fair complexion who are perineural involvement, as well as tumor
or discrete macules that may be scaly. They > 50 years and have had heavy sun expo- size are prognostic indicators that may
can resemble eczema or fungal infections. sure in the past several years typically get dictate selection of width of the excision-
Nodulo-ulcerative BCC is the most multiple actinic keratoses and SCC. SCC al margin. More differentiated lesions
common type, accounting for approxi- presents as a painless poorly defined ery- have a lower invasive tendency and, hence,
Head and Neck Skin Cancer 701
A B C
D E F G
FIGURE 37-4 A, Superficial and nodulo-ulcerative basal cell carcinomas (confirmed with biopsy) are excised under local anesthesia in the office. The specimens are
sent for permanent histopathology. B, Five days later, in the operating room, the defects are ready for reconstructive closure. C, Finger pressure (inherent elasticity)
reveals that the largest defect is tight but amenable to advancement flap closure. D, The upper defect is presutured with 3-0 nylon (mechanical creep). E, Margins are
excised (0.51 mm sharp squaring of the rounded edges with scraping of debris) and complex closures of the lower defects are accomplished. F, The nylon sutures are
released and the tension-free upper defect is repaired with an advancement flap and M-plasty. G, Results at suture removal 1 week later.
a better prognosis. Larger tumors and Melanoma dents of Queensland, Australia, having the
those that invade deeply along tissue highest rate of melanoma, approaching 1
Melanoma is a potentially deadly and
planes have a greater risk of recurrence in 14.43 An estimated 1 in 75 people devel-
aggressive neoplasm resulting from the
and metastasis. Tumors > 2 cm have a op melanoma in their lifetime, up from 1
malignant transformation of melanocytes.
twofold increase in recurrence rate and in 150 persons in 1985.44 Melanoma
are three times more likely to metastasize. The incidence of melanoma is increasing accounts for over three times more deaths
Tumors arising in scars or wounds are faster than any other cancer. It is estimated than the combined fatalities from all other
usually more aggressive and have a metas- that the frequency of melanoma will dou- skin malignancies.45
tasis rate between 18 and 38%.7 With SCC ble every 10 to 15 years, and that > 40,000
the first shot at cure is crucial as recurrent new cases of melanoma will be diagnosed Risk Factors
SCCs have a metastatic rate of 24 to 45%; this year in the United States alone.7,41,42 People in Fitzpatrick groups 1 and 2 are
if they metastasize the 5-year survival rate Melanoma occurrence increases the closer the most susceptible to melanoma. The
is around 50%.7 ones residence is to the equator, with resi- role of UV is not precisely known for
702 Part 5: Maxillofacial Pathology
A B C
D E F G
FIGURE 37-5 A, This 60-year-old has confirmed squamous cell cancer on his nasal tip (and basal cell cancers elsewhere). B, Five days after excision of the can-
cers, with permanent histology assuring margin clearance, the patient undergoes Doppler ultrasonography in preparation to identify the location of the axial ves-
sel for a paramedian forehead flap. C, The flap is designed on the right supratrochlear vessels. D, The lower recipient site has been trimmed sharply, and the pink
vascular flap is ready for inset. E, The flap in place. F, The sutured flap revascularizes for 3 weeks. At this time, it may be thinned again or divided and inset accord-
ing to topographic principles. G, Two months postoperatively, the results of surgery are inconspicuous.
melanoma, but lots of freckles and a histo- have a tenfold risk of developing of cases (Figure 37-6). Thirty percent of
ry of three or more blistering sunburns, melanoma.4,48 When combined with a melanomas arise from preexisting lesions,
the use of a tanning bed, and having family history of melanoma, dysplastic whereas 70% arise de novo.
undergone psoralen plus UVA therapy nevi (atypical moles ), which are present
have been implicated.43,46 in approximately 10% of the population, Clinical and Histologic
Several additional risk factors for represent a significantly increased risk of Description
melanoma have been identified. About developing melanoma. Congenital (black The mnemonic ABCD is useful in cate-
10% of patients with melanoma have a hairy) nevi have a 4% lifetime risk of gorizing the characteristics of
first-degree relative with the disease.47 developing into melanomas.43 Lentigo melanomas: asymmetry, border irregu-
Common moles, also known as acquired maligna, or melanotic freckle of Hutchin- larity, color changes or variation, diame-
melanocytic nevi, can be a risk factor. son, is a precursor in situ lesion that ter of lesion (< or > 6 mm). The practi-
Individuals with > 100 of these moles becomes malignant in approximately 5% tioner should not place the patient under
Head and Neck Skin Cancer 703
casual observation (ie, not perform a borders; it can be present for up to 5 years next step is to obtain a full-thickness spec-
biopsy) just because these common indi- prior to invasion of the dermis. imen (via punch or incisional biopsy) to
cators might be absent. Approximately Nodular melanoma is the second ascertain the diagnosis and confirm true
40% of board-certified dermatologists most common variant, accounting for 15 depth. Neither incisional nor excisional
and 50%+ of other clinicians do not to 30% of melanomas. It appears as a biopsy disseminates tumor.
identify melanoma correctly by clinical raised black, brown, blue, or red nodule, Incisional biopsy should be reserved
intuition alone. Other suspicious factors perhaps with ulcerations, bleeding, or for lesions > 2 cm or those located at
include the color pink in a dark lesion crusting. It may look just like a BCC, but anatomically restricted areas (eg, eyelids,
and persistent itching. contrary to BCC, the lesion grows rapidly ears). The biopsy should be at the most
Melanoma in situ is an intraepithelial over a few months. Around 5% of nodu- raised site or the darkest area of the lesion
lesion that can progress to an invasive lar melanomas lack pigmentation and are (Figure 37-7). Full-thickness excisional
lesion. When it is still in the epithelium, it pinkish amelanotic melanomas. Nodu- biopsy with a 2 mm margin is the pre-
is described as being in a horizontal lar melanomas are thicker and metasta- ferred method for lesions < 2 cm.
growth phase, but when it invades dermis size rapidly. Once the diagnosis has been estab-
and approximates blood vessels, it is in a Lentigo maligna melanoma comprises lished, melanoma is staged either by mea-
vertical growth phase and thickens. Hence, 4 to 10% of melanomas. It arises in sun- suring the tumor depth from the granular
deeper melanomas are more deadly. exposed areas and occurs in the elderly. cell layer of the epidermis to the farthest
Histopathologically, malignant melanoma Acral-lentiginous melanoma accounts depth of tumor invasion (Breslow classifi-
presents as a proliferation of atypical for 2 to 8% of all melanomas in Cau- cation) or by determining the anatomic
melanocytes. The tumor originates at the casians but is the most common type in level of invasion (Clark classification).
epidermal-dermal junction. The cells then African Americans, Asians, and Hispanics. Melanomas measuring < 0.76 mm have a
invade upward into the epidermis or Clinically, they present as pigmented 5-year survival rate of > 93%, whereas
extend downward into the dermis. lesions with irregular borders. Papules and lesions > 4 mm thick have a 5-year survival
Melanomas are categorized into four nodules are frequently seen within the rate of < 50%.49,50 Melanomas with ulcera-
main clinical and histologic subtypes: lesion. tion or histologically high mitosis rates
superficial spreading melanoma, nodular Biopsy is the only fail-safe method to predictably worsen prognoses. Discovery
melanoma, lentigo maligna melanoma, prove or disprove melanoma. If melanoma of locoregional or distant metastasis lowers
and acral-lentiginous melanoma. Superfi- is suspected, incisional and excisional 5-year survival to 40% or 5%, respective-
cial spreading melanoma accounts for biopsies are much more diagnostic and ly.51 The most frequent sites of melanoma
70% of all melanomas. Clinically superfi- prognostic than is a shave biopsy. Regard- metastasis include the skin, lymph nodes,
cial spreading melanoma is a flat or slight- less, if a shave biopsy is performed and lung, liver, brain, bone, and gastrointestinal
ly elevated dark lesion with asymmetric melanoma returns as the diagnosis, the tract. On the other hand, the presence of a
704 Part 5: Maxillofacial Pathology
might include liquid nitrogen cryotherapy, Table 37-5 Margin Control for Basal Cell Cancers
standard excision, Mohs micrographic
Tumor Description Margin Control
surgery (MMS), radiation, C and E, topical
chemotherapy, laser ablation, photody- 5 mm or less 2 mm
namic therapy, interferon, and retinoids. 5 mm1 cm 34 mm
We review most of these options below. 12 cm 57 mm
Standard Excision > 2 cm, morphea-like, or unusual 710 mm margin or Mohs micrographic
pathologic behavior surgery or delayed reconstruction
Commonly, skin cancers are excised and following permanent histology
assessed for margin clearance. Exceptions Unusual pathologic behavior, recurrent Mohs micrographic surgery or delayed
include some AKs and some superficial tumors,tumors on lips, ear, nose, reconstruction following permanent
SCCs or BCCs, which may be treated by medial canthus, eyelids histology
other modalities.52 Excision may be done
under local anesthesia or in the outpa-
tient surgery setting. Tables 37-4 and 37- uation. For example, frozen histologic eval- delay eliminates the potential for
5 outline acceptable margins for clearing uations (while the patient is anesthetized hematoma and may allow buildup of a
most lesions. in the operating room) are often three to higher granulation base.
The lesion and indicated margin for four representative loaf-of-bread slices. MMS offers the same delayed
clearance is outlined with a marking pen. You can imagine how much time would be opportunity. The patients entire tumor is
Local anesthesia with epinephrine does consumed should the pathologist section resected prior to reconstruction, which
not affect pathologic margin assessment and examine a large tumor in toto.2 To may be performed on an elective basis
but may reduce the surgeons ability to abrogate the inherent limitations of frozen often up to a week later. The only surgical
monitor vascularity to an adjacent ran- sections, many surgeons routinely delay difference between immediate (within
dom flap. Clearer delineation of tumor reconstruction until after all margins are 24 h) and delayed reconstruction ( 48 h)
margins may be enhanced with adjunctive cleared by permanent histology, or send is that defects reconstructed later are cir-
procedures for melanoma, BCC, and AK. the patient to a specialist in MMS. cumferentially excised for 0.5 to 1 mm to
In the case of melanoma, subcutaneous Permanent histology after office exci- expose a new distinct margin. Debris may
extension should be viewed with a Woods sion and subsequent delayed reconstruc- also need to be curetted from the base.
light. In the cases of BCC and AK, pre- tion provides benefits to surgeon and Regardless, this step-by-step delayed tech-
excision curettage delineates tumor mar- patient alike. Office excision allows the nique is almost painless and does not fos-
gins more accurately. Some BCCs, mor- patient to visualize the extent of the defect ter infection (Figure 37-9).51,53 Antibiotics
phea-like and infiltrative, may not be as and to add input into personal reconstruc- are not necessary.
curettable as soft tumors, but the BCCs tive desires and expectations. The surgeon
that are curettable have a 25% higher has the option to research effective meth- Mohs Micrographic Surgery
chance of being cleared with the first exci- ods of reconstruction away from the oper- MMS is based on two principles: (1)
sion than if excised without curettage ating room and to subsequently go to the most tumors spread by contiguous
(Figure 37-8).52 operating room with a plan; the patient growth and (2) all tumor cells must be
Ideally, specimens should be examined will know prior to the surgery exactly excised for cure. Dermatologist Frederic
histologically on the entire lateral and deep where the scars will be located. Delayed E. Mohs, MD, originated his method in
margin. Circumstances may reduce the reconstruction has been proven beneficial the 1930s and published results in 1941.
likelihood of this beneficial extensive eval- for patients receiving skin grafts as the Mohs technique evaluates the entire cir-
cumference and deep margins after
frozen sections. Unlike the representative
Table 37-4 Margin Control for Squamous Cell Cancers
breadloaf method, in which the patholo-
Tumor Description Margin Control gist might suggest further removal of an
Small, well differentiated 5 mm with orientation entire positive superior margin of the
> 1 cm Increase margin size tumor, Mohs technique pinpoints the
Lesion on upper lips, eyelids, nose, ears, etc. Consider Mohs micrographic surgery
actual location of tumor extension. Iden-
tified tumor extensions are re-excised
706 Part 5: Maxillofacial Pathology
A B C
D E F
FIGURE 37-8 A, This 50-year-old man has what appears to be an imposing basal cell cancer. B, Curettage of the soft
tumor allows easy visualization and control of peripheral and deep margins. C, Seven days after resection and margin
clearance by permanent histology, a cervicofacial-type flap above the superficial musculoaponeurotic system is planned.
D, The flap is advanced superiorly. E, Hairlines and sideburns are realigned. F, At 2 weeks the results are very esthetic.
and rescrutinized until the tumor is that a large SCC of the scalp is better tions, and mapped. Mapped segments are
totally removed. Hence, MMS is more served with an aggressive non-Mohs exci- pressed flat on their freshly cut border,
predictable for total cure and tissue spar- sion. Controversy exists as to whether frozen, and sectioned so that the entire
ing as well.5456 Mohs technique is justified for melanoma fresh border is visualized.
Over the years we have noted certain and dermatofibrosarcoma protuberans, The cure rates for primary BCCs
limitations to Mohs technique, such as for example. < 2 cm treated with MMS approach
overconservative treatment for some For a 1 cm nodulo-ulcerative BCC, 99% (vs 9095% by routine pathologic
aggressive tumors. This deficiency, not Mohs technique proceeds as follows: the examination). 56,57 Standard vertical
inherent in the Mohs technique, is proved lesion is debulked with a curette and then breadloaf sections evaluate < 1% of the
by the fact that not all microscopic exten- excised with a 2 to 3 mm margin angled at surgical margins. Recurrent BCC cure
sions are visible to the human eye; there- 45 toward the center of the tumor. The rates range from 94 to 96% with MMS
fore, even tumors excised with Mohs tech- specimen is anatomically oriented, subdi- versus 85% with other modalities.56,57
niques may recur. As a result, we believe vided into numbered color-coded sec- For primary SCC, MMS boasts a cure
Head and Neck Skin Cancer 707
A D G J
B E H
F I L
FIGURE 37-9 A, In the office the surgeon, donning nonsterile gloves, curettes (with a dermatologic curette, pictured) this
biopsy-proven nasal basal cell cancer. The patient is under local anesthesia. B, Curettage reveals that the tumor is small
and superficial. C, After tagging the tumor for margin identification (always short 12:00 superior and long left or lateral),
the wound is dressed very specifically. (If there is any potential bleeding, a piece of surgicel may be placed at the base).
D, Bacitracin is swabbed only within the defect. E, Mastisol or tincture of benzoin is wiped peripherally. F, A nonadherent
dressing covers the wound base; the overdressing has an absorbent piece of gauze within a conforming mesh bandage, which
C is placed over the wound. One or 2 days later, in the office the surgeon, donning nonsterile gloves, removes the dressing. This
procedure is performed without the use of anesthesia. The area is cleaned with 50:50 peroxide and water, and the patient
is instructed how to redress the wound daily after a shower (which includes washing out the defect with mild soap and
water). G, The patient dresses the wound with bacitracin, a nonadhesive dressing, and tape only. No scabs should form. In
this case the histology analysis returned declaring that the superior tumor margin was within one high-power field. H, On
the day of surgery, a small amount of tissue is planned for excision superiorly (and peripherally to square the margins),
and a bilobed flap is planned as the defect is < 1.5 cm in diameter. I, The excisions have been made. J, During the closure
the entire nasal dorsum is undermined submuscularly and supraperichondrally. K, The second lobe of the flap is oriented
perpendicular to the alar rim to avoid lifting the rim. L, After 2 months the result is excellent.
708 Part 5: Maxillofacial Pathology
rate from 94 to 99% as opposed to 90% 99%.63,64 Liquid nitrogen may be sprayed C and E. BCCs < 5 mm have an 8.5%
for non-Mohs techniques.39,54,58 Recur- on the lesion directly or through a cry- recurrence rate after C and E by an expe-
rent SCC cure rates with MMS approach oprobe. Rapid freezing of the treated skin rienced clinician.66 Lesions of the nose,
90% as opposed to 76% for other treat- occurs as heat is transferred from the skin ear, and perioral and periocular areas
ment modalities.54 to the probe. Intracellular ice crystals may recur at a rate of 16%.66 This rate
Under these circumstances MMS is form, and cell membranes disrupt as the soars to 26% for lesions > 20 mm.66 Ther-
indicated for the treatment of recurrent temperature is lowered to 50C to 60C. apeutic C and E is therefore contraindi-
BCC, histologically difficult BCC (ie, When thawing occurs electrolytes recrys- cated for larger lesions, poorly differenti-
micronodular, infiltrative, and morphea- tallize, resulting in vascular stasis and local ated SCC, or melanoma.
like), and BCCs in which conservation of alterations in the microcirculation, thus
tissue is critical (eg, on the nose, lip, ear). producing further tissue damage.2,65 Topical Chemotherapy
For SCC, MMS might be indicated for Most doctors freeze lesions plus a 4 to Topical 5-FU or 5% imiquimod medically
lower lip cancer, some poorly differentiat- 6 mm margin to account for tumor exten- eliminates surface lesions. Retinoids are
ed SCCs, and areas where maximum tissue sion. Freeze-thaw cycles may be repeated occasionally used concurrently. 5-FU is a
preservation is essential.7 for maximal effect. Healing occurs by sec- thymine analog that interferes with DNA
ondary intention, with a flat hypopig- synthesis causing cell death by acting as an
Radiation Therapy mented scar. inhibitor of thymidylate synthase. Imiquimod
Radiation therapy (RT) has been men- The side effects of cryosurgery induces production of interferon- and mes-
tioned for treatment of skin malignan- include pain, erythema, edema, blistering, senger ribonucleic acid cytokines. Appli-
cies for almost a century, but currently it exudation, and scarring. This technique is cation of 5-FU is recommended twice
plays a role as an adjunctive or salvage inexpensive, and there are no costs for daily for 2 to 3 weeks for superficial AK
measure, rarely a curative role. The cura- pathology. Hence, a lesion chosen for and for 3 to 6 weeks for more diffuse wor-
tive advantage of radiation is preserva- cryotherapy should be relatively small and risome lesions. Imiquimod is applied only
tion of normal tissue next to the irradia- well demarcated. three times per week but currently is
tion site. RT might therefore be much more expensive than 5-FU. Cure
considered for the eyelid, lip, nose, and Curettage and Electrodesiccation rates with 5-FU and imiquimod range
ear. Unfortunately, RT conveys some C and E is a cost-effective but technique- from 92% for SCC in situ to 95% for
unwanted potential side effects: cuta- dependent therapy of NMSC. The lesion superficial BCC and AK.2,67
neous erythema, necrosis, hypopigmen- area is cleaned with alcohol, outlined with Patients need to be warned that there
tation, telangiectasia, atrophy, fibrosis, a provisional margin by a skin marker, and is an ugly inflammatory scabby reaction
hair loss, delayed healing, and risk of the anesthetized. The lesion is curetted aggres- during topical therapy, but the cosmetic
development of future NMSCs when sively with the skin tensed, after which outcome is usually very good as long as
administered to younger patients.59 electrodesiccation (hyfrecation) for hemo- compliance is nurtured.
RT of tumors < 2 mm has a cure rate stasis and adjacent tissue kill occurs. This
of 90% and 85 to 95% for BCC and SCC, cycle may be repeated three to five times. Lasers
respectively.60,61 However, larger lesions The major advantage to C and E is The CO2 laser focuses a beam of light with
have a much lower success rate. For expedience, fostering treatment of multi- a wavelength of 10,600 nm. Laser light is
melanoma, local recurrence rates of up to ple lesions within a single visit. Disadvan- absorbed by water and nonselectively
50% have been reported.62 Thus, RT for tages include prolonged healing, often vaporizes the skin. The CO2 laser can be
melanoma is only a viable option for med- weeks depending on size and care, used as a cutting instrument (in the
ically compromised patients who cannot hypopigmentation, and possibly hyper- focused mode) to excise or ablate lesions
withstand surgery or for patients who trophic scar. Material from curettage may (in a defocused mode) such as multiple
refuse surgery. be sent for initial pathology, but margin AKs, superficial BCC, and SCC. We have
control after C and E is not possible found its greatest benefit in ablation of
Cryosurgery (unless curettage is used as a precursor to superficial AK and superficial SCC, both
Cryosurgery destroys skin cancers and excisional pathology). on the skin and lower lips. Presurgical skin
some adjacent tissue by freezing. The clinicians experience and the preparation with retinoids may foster more
Cryosurgery cure rates for AK, BCC, SCC, tumors anatomic site and size are prog- rapid healing. We have not prescribed pre-
and lentigo maligna range from 94 to nostic factors limiting success following operative antibiotics or antivirals for small
Head and Neck Skin Cancer 709
localized areas but continue to do so when dermis. The epidermis is composed of posed of collagen, elastic tissue, and ground
large areas of the face are treated. four distinct layers. From deep to superfi- substance. Collagen decreases by 1% a year
cial, they are as follows: basal cell (stratum throughout adulthood.75 Topical tretinoin
Photodynamic Therapy basale), prickle cell (stratum spinosum), inhibits dermal collagenase, thus slowing
Photodynamic therapy is not widely granular cell (stratum granulosum), and the degradation rate of collagen.76,77
accepted for skin cancer therapy but has keratin (stratum corneum). Cells from the Elastic fibers in the dermis provide
been applied to lung, breast, colon, and stratum basale divide and migrate upward skin with recoil. With aging, elastic fibers
bladder cancers. Aminolevulinic acid is toward the stratum corneum. The dynam- decrease causing skin laxity, bags, and
wiped on a lesion; it is metabolized in can- ic epidermis turns over and exfoliates jowls. Chronic sun exposure thickens elas-
cer cells to produce porphyrins, which act every 30 days. This is why buried epitheli- tic fibers, and clumps form in the papil-
as photosensitizers. Four to 6 hours later, um from a cyst might continue to produce lary layer. Chemical peels, dermabrasion,
the area is irradiated with visible light sebaceous keratin. and laser resurfacing can remove some of
from a laser or noncoherent light source. The epidermis contains four cell these clumps.78
Reactive O2 species are generated within types: keratinocytes, Langerhans cells, The dermal ground substance is made
the cells producing cell death.68 melanocytes, and Merkel cells. Ker- up of glycosaminoglycans, hyaluronic
Cure rates for photodynamic therapy atinocytes constitute 80% of the epider- acid, chondroitin 4-sulfate, fibronectin,
for AKs, superficial SCC, and BCC are mal cell makeup. and dermatan sulfate. These constituents
reported to be > 90% in some studies, Langerhans cells are antigen- hydrate the skin and maintain tensile elas-
but tumors thicker than 2 mm are presenting cells, which capture and ticity.78 The principle cell of the dermis is
photoresistant.69 process antigens and present them to the fibroblast, whose functions include
skin-specific lymphocytes. Aging and production of collagen, elastin, and
Interferons significant sun exposure both lessen the ground substance. Fibroblasts enhance
Interferons are cytokines that may effect total number of Langerhans cells. This is wound healing through contraction and
cell growth and differentiation and accent one partial explanation for the increase production of scar.
immune responses and antiviral activity. of skin neoplasms in the elderly.72 Aging affects skin quality. Fine wrin-
Intralesional injection of interferon- can Melanocytes are of neural crest origin kling, dermal atrophy, and a decrease in
attain cure rates of > 80% for superficial and are found in the basal layer. subdermal adipose tissue are aging phe-
and nodulo-ulcerative BCC.70,71 Melanocytes produce melanin, which, in nomena. Epidermal regeneration may
turn, protects the nucleus of the ker- slow down by up to 50%, retarding sec-
Retinoids atinocyte from UV radiation. Although ondary wound healing.79 (Note:
Retinoids are vitamin A derivatives that numbers of melanocytes are constant for Isotretinoin retards epithelial regeneration
are crucial for control of cell growth, dif- all individuals, the activity of the chemically; hence, elective surgery should
ferentiation, and apoptosis. Topical melanocytes differs from one race to the be limited on patients having used
retinoids are somewhat effective against next. For example, melanocyte activity in isotretinoin until the medication has been
AKs but much less so against even superfi- darkly pigmented skin is higher than in discontinued for 68 mo.) Natural colla-
cial BCCs and SCCs. Application of light-colored skin. As with Langerhans gen decreases in quality and quantity. Skin
retinoids as a skin cancer preventative is a cells, numbers of melanocytes decrease becomes more compact as the collagen
long-term proposition as the effects of the with age, another explanation for more rearranges itself into thick coarse bundles
drug plateau at around 6 months and skin cancers developing as we get older.73,74 or loosely woven straight fibers. The der-
reverse shortly after discontinuation. Merkel cells, found in the epidermis and mal blood vessels may be collapsed, disor-
Retinoids do appear to act synergistical- dermis, have an unclear function. ganized, or absent in the elderly, potentiat-
ly with 5-FU and may be applied in an exfo- The dermis, situated between the epi- ing a greater risk for flap necrosis.21,80
liation regimen. Noted complaints include dermis and subcutaneous fat, adheres to the Skin has a rich nerve supply. In the
dryness and flaking, minor side effects com- epidermis at the basement membrane. The epidermis the Merkel cell may provide
pared with the clinical effects of 5-FU. basement membrane mechanically sup- touch perception. Meissners corpuscles,
ports the epidermis and acts as a mechani- located in the papillary dermis, provide
Applied Skin Anatomy cal barrier. The two dermal layers are the fine touch sensation. Pacinian corpuscles,
The skin is composed of two layers: the superficial papillary dermis and a deeper located in the deeper subcutaneous tissue,
superficial epidermis and, beneath it, the thicker reticular layer. The dermis is com- mediate deep pressure and vibratory
710 Part 5: Maxillofacial Pathology
sensation. Autonomic efferent nerves Options for defect repair include (1) lation of an inflammatory response, and
innervate blood vessels and appendageal primary closure, (2) local or distant flap, release of vasodilating substances.
structures. Hair-bearing skin is commonly (3) graft, and (4) healing by secondary Esthetic flaps are not mere hole fillers.
referred to as nonglabrous and smooth intention. Elasticity and movability are They are designed to complement natural
nonhair-bearing skin as glabrous. Skin two inherent skin characteristics that esthetic units and facial borders. Defects
conditions vary between individuals and enable relocation and, perhaps, primary that trespass multiple esthetic units are
from region to region with respect to closure. Elasticity is the ability of the designed to reproduce these independent
mobility, color, scars, Fitzpatrick type, tex- skin to stretch. Skin in the cheek and units. For example, a cheek tumor defect
ture, thickness, and adnexal structures.81 neck is very elastic. Movability is not that encroaches on the nose might be
The blood supply to the skin serves related to elasticity. Temple skin is less reconstructed with different flaps and/or
two functions: nutrition and thermal reg- movable than cheek skin, and the scalp is grafts for the cheek and nose.
ulation. Two major routes of blood supply relatively immobile. Grafts are easy to position into recipi-
existmusculocutaneous and septocuta- Flaps move tissue, skin and subcuta- ent defects and are ideal for monitoring
neous arteries.82 The musculocutaneous neous from one area to another with an tumors. Grafts must be placed on a well-
system traverses the muscle and enters the accompanying vascular supply. Flaps are vascularized bed. Sometimes exposed
subcutaneous tissue in a random pattern cosmetic, use well-matched skin, and bone should be allowed to build a granu-
(the basis for random skin flaps). functionally protect underlying struc- lation base before grafting. Grafts may be
Random-pattern blood flow to the tip of tures such as bone or cartilage, which of full thickness or split thickness. Har-
the flap is via the interconnecting subder- may not have adequate blood supply to vesting methods include punching, shav-
mal plexus. The superficial vascular plexus support a graft. Three types of impure ing with a dermatome, and excision. Graft
located in the reticular dermis provides flap movements are classically defined donor sites are selected based on esthetic
the capillary loops in the dermal papillae. advancement, rotation, and transposi- and tumor considerations. Ideally, grafts
The deeper vascular plexus, or subdermal tionalthough some suggest there are to the nose are well matched with preau-
plexus, lies between the dermis and subcu- only two types of movementsliding ricular skin, but any supraclavicular facial
taneous fat. A septocutaneous vessel trav- and lifting.8486 Sliding refers to stretch- graft (from the blush area) matches the
els through the septal fascia and courses ing or mobilizing tissue from one site to facial color better than does any torso or
parallel to the skin surface with an accom- another (advancement and rotation). thigh graft.
panying vein. Named septocutaneous ves- Lifting tissue across a bridge of normal Healing by secondary intention is a
sels (eg, supratrochlear) provide an axially tissue to close a defect is similar to trans- painless but time-consuming process. It is
based flap with a rich blood supply. A large position.84 All flaps (except free flaps) indicated for patients who do not want
interconnecting vascular arcade exists have some pivotal restraint, whether it be more surgery, who can accept or obtain
between the systems.83 Understanding the adjacent skin, subcutaneous tissue, or the daily care, and who can accept a
facial vascular network is crucial to creat- blood vessels. scarred result. Secondary healing can be
ing flaps that survive. Delay increases viability to a flap by used for small defects (< 1 cm) or for larg-
enlarging and realigning the subdermal er defects in areas where the resulting scar
Flaps and Grafts and Secondary vasculature plexus. It is now known that would be inconspicuous or tumor obser-
Intention Healing skin flap reliability is based on angio- vation is critical.
some units; therefore, wide and thin ran- Healing by secondary intention is sim-
Definitions and Concepts The removal dom flaps run out of blood supply in ilar to open-wound therapy. Following
of any tumor leaves a defect. The hole cre- roughly the same location. Delay may aug- tumor excision and hemostasis, the wound
ated after tumor excision may be called the ment survivability. Methods include rais- is dressed with antibiotic ointment (eg,
primary defect. The secondary defect is ing and suturing tissue without disturbing bacitracin and/or polymyxin B sulfate).
the wound created after tissue is trans- the pedicle, and tissue expansion. Subse- The outer edges of the wound are coated
posed to close the primary defect. Every quently (912 d later), the flap is mobi- with an adhesive (eg, adhesive bandage or
flap creates a potential secondary defect. lized.84,87 The mechanisms that increase tincture of benzoin). A nonadherent
Ideally, secondary defects should be easy to the blood flow with delay include the dressing is applied over the wound and a
close, within relaxed skin tension lines depletion of vasoconstricting substances, small rim of peripheral tissue. This is
(RSTLs), in areas of loose adjacent tissue, formation of vascular collaterals and topped with a dry piece of gauze to absorb
and within anatomic boundaries.84 reorientation of vascular channels, stimu- any blood, which is then covered with a
Head and Neck Skin Cancer 711
contour mesh tape. When the defect is of scabs. Areas amenable to secondary sulfate than with bacitracin. Alternatively,
atop bone, the raw bone may be covered epithelialization include the scalp, the petrolatum can be substituted for the
with two layers of moisture-retaining wet retroauricular area, and some concavities antibiotic ointment. Finally, some patients
gauze, but any method that abrogates des- away from mobile apertures. Secondary can be so incapacitated by their medical
iccation is acceptable (Figure 37-10). epithelialization would be a poor choice illnesses that they cannot dress their
Three days later the dressing is around the mouth, for example, where wounds. Home health care nursing can be
removed and the wound inspected. Any retraction might distort the lips. enlisted to aid in their daily wound care.
oozing and crusting should be removed Three caveats regarding secondary
with a 50:50 peroxide and water solution. healing are useful to keep in mind. First, Skin Biomechanics Skin is a heteroge-
The wound is redressed in three layers scabs should not form. Scabs hinder neous material with unique mechanical
antibiotic ointment within the wound fol- epithelialization and harbor bacteria. Sec- properties. As skin is stretched, the ran-
lowed by a nonadherent dressing, which is ond, continuous application of antibiotic domly oriented collagen and elastic fibers
then covered with mesh tape. The patient ointment can lead to allergic reactions and are stretched in the direction of the
redresses the wound in this fashion on a yeast infections. This is more common applied force. This continues until all of
daily basis to keep the area moist and free with ointments that contain neomycin the available collagen and elastic fibers are
A B C
E F
FIGURE 37-10 A, This 60-year-old patient (who has diabetes and congestive heart failure) has a very rapid-
ly growing forehead/scalp squamous cell carcinoma. B, In the operating room the tumor is widely excised.
C, The base shows tumor into the outer table of the skull, which is removed. D, The wound is dressed open
with microfibrillar collagen peripherally to prevent bleeding, and a compression bandage over two layers of
moist ointment-saturated mesh gauze. Permanent histology shows complete tumor clearance, but the
patients medical problems delay reconstruction. E, The patient has an excellent granulation base at 5 weeks.
He elects to allow the defect site to epithelialize secondarily with daily dressing changes at home. F, At 8 weeks
50% epithelialization is evident. G, Total epithelialization has occurred at around 3 months. He has had no
G tumor recurrence or metastasis after a 2-year follow-up and has deferred further reconstruction.
712 Part 5: Maxillofacial Pathology
recruited and no further lengthening that is, it can extend out a little more in Finally, biologic creep is a slow
occurs. After the maximum amount of spite of its thick state. This phenomenon methodic stretching of skin, yielding
stretch is reached, the skin may rupture. is explicable through the two time- brand new skin.88 Skin expanders do just
Permanent striae may scar the skin sur- dependent characteristics: creep and that (Figure 37-13).
face, as is often noted in pregnancy. Over- stress relaxation.88
stretching the skin collagen effaces the Mechanical creep refers to the change Flap Undermining Safe flap closure of a
blood vessels under tension; thus, necrosis in length that is seen when skin is held defect is dependent on harnessing the
secondary to decreased perfusion to a dis- under a constant stress or force. The force inbred stretchable bendable nature of skin
tal flap may occur (Figure 37-11).88 that is exerted to stretch skin decreases without exceeding the limits of stretch or
Skin tension exists in all directions with time.88 The surgeon routinely notes blood supply. Some tissues can be
on the face but is greatest along the this mechanism at work after he tightly stretched for centimeters without under-
RSTLs. Ideally, elective incisions should sutures an avulsive forehead wound. Two mining occurring, whereas others must be
be placed parallel to the RSTLs. Incisions days later the forehead is relaxed again. separated from tethering subcutaneous
made perpendicular to RSTLs (or in the High stress loads therefore produce a tissues. On the other hand, a subcutaneous
lines of maximum extensibility [LME]) degree of creep. The skin may not be total- island flap, totally separated from the teth-
gape and heal with more obtrusive ly relaxed for several months. Serial exci- er of skin, depends on the mobile vascular
scars.89 The rhombic flap, once consid- sion is a technique that harnesses the subcutaneous pedicle.
ered by many as the workhorse facial relaxation of skin over time. Wide defects Undermining releases the vertical
flap, has been used less over time because may be closed sequentially over time. attachments between the dermis and sub-
some of the final legs lie within the LME. Stress relaxation is the decrease in cutaneous planes, thereby reducing shear-
Today flaps are more commonly stress that occurs over time when skin is ing forces and allowing the skin to slide
designed with topographic units and held under tension at a constant strain or and redrape in another position.78 The
RSTLs as primary considerations, rather is cyclically loaded.88 It may be effected mobilization benefits from undermining
than just to fill a hole. intraoperatively with the placement of a facial skin usually occur within the first 2
Skin is elastic and stretches easily at balloon under the skin or by scoring the cm. Animal studies reveal that undermin-
low stress levels. This is related to the scalp galea and pulling the skin. Addition- ing beyond 4 cm produces little skin edge
inherent extensibility of the skin. At high- ally, there are skin stretchers that are made advance and possibly a more difficult
er forces skin may become viscoelastic, for this purpose (Figure 37-12). stretch of tissue.90,91
A correct undermining level provides
the critical balance between mobility and
blood supply. For example, simple random
flaps, undermined in the superficial fat,
are easy to raise on the cheek. Submuscu-
lar flaps maintain a robust blood supply to
small relatively immobile nasal flaps.
A B C
D E F
FIGURE 37-12 A, This 95-year-old woman has a relatively small scalp defect. B, Finger pressure shows that significant
tension is necessary to close it elliptically. C, After limited subgaleal undermining, two pins are placed subcutaneously. D,
A skin stretcher (courtesy of Life Sciences Medical) is hooked onto the pins. Slow loading is applied for 30 minutes. E, After
the end triangles are excised, the wound is stapled closed. F, The site after 2 months.
square, bilateral, Burows triangle reposi- 1. Do nothing; this approach works well 6. Reverse the S loop and hide the excess
tioning, and A- or O- to T-shaped on the scalp as bunched up tissue lies elsewhere (Figure 37-14E)
designs.92 The experienced surgeon real- down with time 7. Advance the dog-ear as a flap (subcu-
izes that the tethering forces of advancing 2. Close opposite lines of uneven lengths taneous island) or use it as a free graft
skin also constrict the size of the leading by spreading out the problemhalv- (Figure 37-14 F; also see Figure 37-6)
edge. Modifications are useful in specific ing (Figure 37-14A)
instances. All flaps, including simple 3. Remove the excess to a hidden areaan Rotational Flaps Curvilinear rotation
advancement flaps, presuppose that the end or middle triangle (Figure 37-14B) flaps rotate from a tethered pivot point.
surgeon can disguise, adjust, transpose, or 4. Lengthen the incision. This eliminates These flaps fill triangular defects. The
eliminate dog-ears or excess tissue that bunching (Figure 37-14C) length of the arc is dependent on many
gathers as tissue is transposed. 5. Perform an M-plasty (sometimes variables, such as existing laxity, the size of
There are seven ways to deal with called a T-plasty), which shortens the the defect, the location, and blood supply
dog-ears9396: problem (Figure 37-14D) to the flap.85,97101 Rotation flaps rarely fit
714 Part 5: Maxillofacial Pathology
RSTL
Tumor
Lengthen
line
3
2
3
1
3
2
3
A B
E F
FIGURE 37-14 Six of the seven ways to deal with dog-ears (the seventh being to do nothing). A, Halving. Close opposite lines of uneven lengths by spreading out
the problem. B, End or middle triangle. Remove the excess in a hidden area. C, Lengthen the incision. This eliminates bunching. D, M-plasty (sometimes called a
T-plasty). This procedure shortens the problem. E, Reverse the S. Hide the excess elsewhere. F, Advance the dog-ear as a flap (subcutaneous island) or use it as a
free graft (see also Figure 37-6). RSTL = relaxed skin tension lines.
716 Part 5: Maxillofacial Pathology
and function. Examples include the multi- Basting sutures may be used to affix the
operated face, upper nasal surface defects, graft to the underlying bed to squeeze out
nasal lining tissue, and medial canthal dead space prior to peripheral sutur-
area. FTSGs resist contraction and may ing.98,103 Peripheral sutures are easier to
possess the texture and color of normal insert when passed from the graft through
skin. In children FTSGs have the potential the host skin with a tapered needle.
to grow.98 Any nonadherent (to the graft) bolster
The FTSG is preferred over the split- of cotton, gauze petrolatum dressing, or
thickness skin graft (STSG) in areas plastic, for example, secured a few millime-
where a wound contracture may lead to a ters outside the grafted tissue is acceptable.
functional deformity. An example is the Some surgeons prefer to remove the bolster
A lower eyelid, where wound contracture after 48 hours to inspect the surgical site
would result in ectropion. An excellent
FTSG for this example would include
upper eyelid skin and orbicularis oculi
muscle, which has been shown to pre-
dictably revascularize.
Selection criteria for a head and neck
FTSG directs the surgeon to carefully con-
sider particulars of a variety of sitesthe
upper eyelid, post- or preauricular skin,
B and the lateral neck or supraclavicular
region. For example, postauricular skin is A
photoprotected and has few adnexal struc-
tures, which may not be suitable for nasal
defects. Preauricular skin grafts in males
can lead to sideburn asymmetry. Supra-
clavicular and neck skin is thin and may be
more photodamaged than the face. In
addition, a supraclavicular scar may be a
nuisance for women who wear clothing
with low necklines.
C
The harvesting of most FTSGs
FIGURE 37-16 A, This 45-year-old woman has involves cutting out a simple template of B
had a basal cell carcinoma for the past 3 years. B, the defect (eg, from suture packaging)
It is repaired with a simple submental transposi- (Figure 37-18). Since an FTSG contracts
tion flap. C, Perhaps the lateral submandibular
bulkiness will need to be removed in the future, but
by 10 to 15% after harvest, the donor graft
the submental fat removal was highly esthetic. pattern must be enlarged by around
20%.102 This contracture issue is critical in
areas of mobility such as in the lower eye-
poor nutrition, and smoking as well as lid. Here, grafts should be enlarged by 150
C
medications such as corticosteroids and to 200% vertically to avoid ectropion/con-
chemotherapeutic agents may compro- traction occurring.98,101 FIGURE 37-17 A, This 70-year-old man has a
mise graft success.99101 The FTSG may be defatted with ser- large basal cell cancer removed by Mohs micro-
rated scissors or by scraping with a blade. graphic surgery. B, Subsequently a midline axi-
ally based Abbe flap is inserted. C, Three weeks
Full-Thickness Skin Grafts Full-thickness Defatting is complete when the shiny der-
later, the Abbe flap is divided and inset as an in-
skin grafts (FTSGs) are chosen when local mis is homogeneously exposed. FTSG office procedure. The esthetic result 2 weeks later
or distant flaps are not feasible or when should fit into a wound bed with maxi- shows the flap is not exactly in the midline but
the FTSG would offer acceptable cosmesis mum surface contact without any tenting. simulates the philtral area effectively.
718 Part 5: Maxillofacial Pathology
A B C
D E
Unlike for an FTSG, a tie-over dress- A major disadvantage to composite color. Grafts that fail develop an eschar
ing may not be necessary for STSG. A grafts is the risk of graft failure, which is with subsequent necroses and sloughing.
good compression dressing and/or bast- higher than for FTSG and STSG and is
ing stitches may suffice to promote attributed to the high metabolic demands Complications There are risks to all pro-
adherence between the graft and under- of the grafts. Harvesting (donor) adjacent cedures. Patients who receive skin cancer
lying tissue and to prevent fluid accumu- dermis attached to the composite graft procedures should be warned of the
lation. A variation to placing interrupted and inserting the de-epithelialized dermis potential for recurrence of the tumor as
basting sutures is the spiral basting into adjacent subcutaneous tunnels well as revision of any reconstructive pro-
stitch. The suture is started at the edge of (recipient) may improve vascularity sub- cedure. Flap problems include necrosis,
the graft with the tail left long.108 The stantially.109 Cooling the composite graft infection, hematoma, wound dehiscence,
suture is then run along the periphery of with ice for 24 hours also helps. and scarring.
the graft, spiraling toward the center, Regardless, composite grafts are tech- Smoking greatly increases the risk of
and then tied to the tail. The graft can nique sensitive. Generally, composite necrosis. Patients who smoke one pack
then be dressed in a similar fashion to grafts should be no larger than 1.5 to per day triple the risk of flap or graft
that for an FTSG. 2.0 cm. Avelar and colleagues have shown necrosis compared with nonsmokers.
composite grafts greater than 2.0 cm Smoking affects the blood supply via two
Composite Grafts Composite grafts grafted successfully to nasal and auricular mechanisms. First, nicotine is a potent
contain two or more tissue layers. Com- defects.110 Similarly, Skouge has effective- vasoconstrictor that may lower tissue
posite grafts are ideal for reconstructing ly grafted larger defects using a tongue oxygenation by > 50%. Nicotine effects
the nasal ala rim, auricular defects, and and groove technique and turndown are visible within 10 minutes and can last
eyebrows. Composite grafts are able to hinged flaps.104 The postoperative up to 50 minutes. Second, carbon
maintain the thinness and contour of the appearance of composite grafts is distinc- monoxide is a competitor with oxygen for
structure with minimal contracture. The tive. At placement, the graft is white or hemoglobin. It has a higher affinity for
most common donor site for composite blanched. Within 6 hours it becomes hemoglobin than does oxygen, resulting
grafts is the ear, including the crus of helix, pink, and by 24 hours it is cyanotic. By in high levels of carboxyhemoglobin.
rim, antihelix, tragus, and earlobe. postoperative day 3, it resumes its pink This leads to tissue hypoxia.
720 Part 5: Maxillofacial Pathology
Infection Infections are rare in vascular- reforming hematoma must be explored. sun reactive skin types I through VI. Arch
ized head and neck tissues, and necrosis Likewise, late collections of jellied blood Dermatol 1988;124:86971.
16. Karagas MR, Stukel, TA, Greenberg, EK, et al.
may be mistaken for infection. More com- should be manually extruded. Risk of subsequent basal cell carcinoma and
mon causes of redness include stitch squamous cell carcinoma of the skin among
abscesses, which are foreign body reac- Poor Cosmetic Results Facial flaps patients with prior skin cancer. JAMA
tions, and allergies to antibiotic ointment. should restore anatomic continuity, 1992;267:330510.
17. Robinson JK. Risk of developing another basal
Infections, handled by drainage (when maintain functional integrity, and pro- cell carcinoma. Cancer 1987;60:11820.
indicated), irrigation, and antibiotics, usu- vide an esthetically pleasing result. In 18. Miller RI, Gerster JF, Owens ML, et al.
ally resolve readily. spite of well-executed surgical tech- Imiquimod applied topically: a novel
niques, less than optimal results may immune response modifier and a new class of
Bleeding Bleeding may be caused by drug. Int J Immunopharmacol 1999;21:114.
occur because of unpredictable scarring
19. Gorlin RJ, Goltz RW. Multiple nevoid basal cell
patient factors or surgical issues. Patient and trapdoor deformity. epithelioma, jaw cysts and bifid ribs: a syn-
factors include medical conditions such as drome. N Engl J Med 1960;262:90812.
renal failure, liver failure, collagen vascular References 20. Rayner CRW, Towers JF, Wilson JSP. What is
disease, various cancers (hematopoietic 1. Housman TS, Williford PM, Feldman SR. Non- Gorlins syndrome? The diagnosis and
melanoma skin cancer: an episode of care management of the basal cell naevus syn-
malignancies), and medications. Medica-
management approach. Dermatol Surg drome based on a study of thirty-seven
tions that can cause bleeding include war- patients. Br J Plast Surg 1976;30:627.
2003;29:70011.
farin, heparin, antithrombotics, non- 2. Hochman M, Lang P. Skin cancer of the head 21. Shumrick KA, Coldiron B. Genetic syndromes
steroidal anti-inflammatory drugs, and neck. Med Clin North Am 1999: associated with skin cancer. Otolarygol Clin
North Am 1993;26:11737.
acetylsalicylic acid, and cold remedies. Fur- 83:26182.
3. Strom SS, Yamamura Y. Epidemiology of non- 22. Marks R, Foley P, Goodman G, et al. Sponta-
thermore, commonly used herbal medica- neous remission of solar keratoses: the case
melanoma skin cancer. Clin Plast Surg
tions such as garlic, feverfew, and vitamin E for conservative management. Br J Derma-
1997;24:62736.
can inhibit thrombocyte function. 4. Swetter SM. Malignant melanoma from the
tol 1986;115:64955.
The surgeon must weigh the benefits of 23. Marks R, Rennie G, Selwood TS. Malignant
dermatologic perspective. Surg Clin North
transformation of solar keratoses to squa-
discontinuing anticoagulants against the Am 1996:76: 128798.
mous cell carcinoma. Lancet 1998;1:7957.
risks of surgery since there have been sever- 5. Gloster HM, Brodland DG. The epidemiology of
24. Graham JH. Selected precancerous skin and
skin cancer. Dermatol Surg 1996;22:21726.
al documented cases of stroke when antico- mucocutaneous lesions. In: Neoplasms of
6. Liu T, Soong S. Epidemiology of malignant
agulants were stopped prior to dermatolog- skin and malignant melanoma. Chicago:
melanoma. Surg Clin North Am 1965;
Year Book; 1976. p. 69121.
ic surgery. Consultation and coordination 76:120522.
25. Schwartz RA. The actinic keratosis: a perspective
with the patients internist and appropriate 7. Padgett J, Hendrix J. Cutaneous malignancies
and update. Dermatol Surg 1997;23:100919.
preoperative laboratory data are helpful. and their management. Otolaryngol Clin
26. Swandbank M. Basal cell carcinoma at the base
North Am 2001;34: 52350.
There is no need to discontinue any antico- of cutaneous horn (cornu cutaneum). Arch
8. Green A, Battistutta D. Incidence and determi- Dermatol 1971;104:9798.
agulant prior to performing a biopsy. nants of skin cancer in a high risk Australian 27. Boyle J, Briggs JD, Mackie RM, Junor BJR. Can-
Surgical issues may arise intraopera- population. Int J Cancer 1990;46:356 61. cer: wart, and sunshine in renal transplant
tively or during the postoperative period. 9. Green A, Beardmore G, Hart V, et al. Skin can- patients: a case control study. Lancet 1984;
Decisions must be made concerning judi- cer in Queensland population. J Am Acad 1:7025.
Dermatol 1988; 19:104552. 28. Purdie KJ, Sexton CJ, Proby CM, et al. Malig-
cious cautery, the use of drains, the effect 10. Randle HW. Basal cell carcinoma: identifica- nant transformation of cutaneous lesions
of vasoconstrictors, and postoperative tion and treatment of the high risk patient. in renal allograft patients. Cancer Res 1993;
pressure. Seepage may occur from any Dermatol Surg 1996;22:25561. 53:532833.
facial flap, but hematoma may necrose the 11. Skidmore RE, Flowers FP. Nonmelanoma skin 29. Johnson TM, Rowe DE, Nelson BR, Swanson
flap. A hematoma, in the space created cancer. Med Clin North Am 1998; NA. Squamous cell carcinoma of the skin
82:130923. (excluding lip and oral mucosa). J Am Acad
between the flap and underlying tissue is 12. Marks R. The epidemiology of non-melanoma Dermatol 1992;26:46784.
detrimental to flap circulation because it skin cancer: who, why and what can we do 30. Pecquex JC, Swartz A, Dieckmann KP, Offer-
creates tension, and it acts as a physical about it. J Dermatol 1995;22:8537. mann G. Cancer incidence in patients on
barrier preventing cohesion to the under- 13. Friedman RJ, Rigel DS, Kopf AW, et al, editors. chronic dialysis and in renal transplanta-
lying tissue base. Additionally, stagnating Cancer of the skin. Philadelphia: WB Saun- tion recipients. Urol Int 1990; 45:2902.
ders; 1991. 31. Gafa L, Filippazo MG, Tumino R, et al. Risk
blood may promote wound infection. 14. Preston DS, Stern RS. Nonmelanoma cancers of factors of nonmelanoma skin cancer in
An early hematoma may often be the skin. N Engl J Med 1992;327:164962. Ragusa, Sicily: a case control study. Cancer
pushed out and washed away, but a 15. Fitzpatrick TB. The validity and practicality of Causes Control 1991;2: 3959.
Head and Neck Skin Cancer 721
32. Diffey BL. Analysis of the risk of skin cancer 50. Clark WHJ. A classification of malignant fluorouracil. J Am Acad Dermatol 1981;
from sunlight and solaria in subjects living melanoma in man correlated with histoge- 4:63345.
in northern Europe. Photodermatol 1987; nesis and biologic behavior. In: Montagna 68. Allison RR, Mang TS, Wilson BD. Photody-
4:11826. W, Hu F, editors. Advances in biology of the namic therapy for the treatment of non-
33. Zbar RI, Cottle WI. Skin tumors I: non- skin. Elmsford (NY): Pergamon Press; melanomatous cutaneous malignancies.
melanoma skin tumors. Selected Readings 1967. p. 62147. Semin Cutan Med Surg 1998; 17:15363.
Plast Surg 2000;9:5. 51. Zide MF. Treatment decisions for skin cancer 69. Morton CA, Mackie RM, Whitehurst C, et al.
34. Shanoff LB, Spira M, Hardy SB. Basal cell carci- of the head and neck. Selected Readings Photodynamic therapy for basal cell carci-
noma: a statistical approach to rational man- Oral Maxillofac Surg 2000;8(5):147. nomas: effect of tumor thickness and dura-
agement. Plast Reconst Surg 1967;39:61724. 52. Werlinger KD, Upton G, Moore AY. Recurrence tion of photosensitizer application on
35. Wade TR, Ackerman AB. The many faces of rate of primary nonmelanoma skin cancers response. Arch Dermatol 1998;134:2489.
basal-cell carcinoma. J Dermatol Surg treated by surgical excision compared to 70. Cornell RC, Greenway HT, Tucker SB, et al.
Oncol 1978;4:238. Intralesional interferon for basal cell carcino-
electrodessicationcurettage in a private
36. Goldberg DP. Assessment and surgical treat- ma. J Am Acad Dermatol 1990;23:694700.
dermatological practice. Dermatolog Surg
ment of basal cell skin cancer. Clin Plast 71. Edwards L, Tucker SB, Perendia D, et al. The effect
2002;28:113842.
Surg 1997;24:67386. of an intralesional sustained-release formula-
53. Escobar V, Zide MF. Delayed repair of skin can-
37. Bernstein SC, Lim KK, Brodland DG, et al. The tion of interferon alfa-2b on basal cell carci-
cer defects. J Oral Maxillofac Surg
many faces of squamous cell carcinoma. noma. Arch Dermatol 1990;126:102932.
1999;57:2719.
Dermatol Surg 1996;22:24354. 72. Thiers BH, Maize JC, Spicer SS, et al. The effect
54. Nelson BR, Railan D, Cohen S. Mohs micro- of aging and chronic skin exposure on
38. Roth JJ, Granick MS. Squamous cell and graphic surgery for nonmelanoma skin car-
adnexal carcinomas of the skin. Clin Plast human Langerhans cell populations.
cinomas. Clin Plast Surg 1997;24:70518. J Invest Dermatol 1984;82:2236.
Surg 1997;4:687703. 55. Robinson JK. Mohs micrographic surgery.
39. Goldman GD. Squamous cell cancer: a practi- 73. Gilchrest BA, Blog FB, Szabo G. Effects of aging
Clin Plast Surg 1993;20:14956. and chronic sun exposure on melanocytes in
cal approach. Semin Cutan Med Surg
56. Shriner DL, McCoy DK, Goldberg DJ, et al. human skin. J Invest Dermatol 1979;73:1413.
1998;17:8095.
Mohs micrographic surgery. J Am Acad 74. Hu F. Aging of melanocytes. J Invest Dermatol
40. Novick M, Gard OA, Hardy SB, et al. Burn scar
Dermatol 1998; 39:7997. 1979;73:709.
carcinoma: a review and analysis of 46
57. Lawrence CM. Mohs micrographic surgery for 75. Shuster S, Black MM, McVitie E. The influence
cases. J Trauma 1977;17:809 17.
basal cell carcinoma. Clin Exp Dermatol of sex and age on skin thickness, skin colla-
41. Akoz T, Erdogan B, Gorgu M, Aslan G. The
1999;24:1303. gen and density. Br J Dermatol 1975;
necessity for aggressive treatment with
58. Holmkvist KA, Roenigk RK. Squamous cell 93:63943.
Marjolins ulcers of the scalp. Plast Reconstr
carcinoma of the lip treated with Mohs 76. Woodley DT, Zelickson AS, Briggaman RA, et
Surg 1997;100:8056.
micrographic surgery: outcome at 5 years. J al. Treatment of photoaged skin with topi-
42. Katsambas A, Nicolaidou E. Cutaneous malig-
Am Acad Dermatol 1998; 38:9606. cal tretinoin increases epidermal-dermal
nant melanoma and sun exposure. Arch
59. Halpern JN. Radiation therapy in cancer: a his- anchoring fibrils. JAMA 1990;263:30579.
Dermatol 1996;132:44450.
torical perspective and current applica- 77. Zelickson AS, Mottaz JH, Weiss JS, et al. Topi-
43. Lang PG Jr. Malignant melanoma. Med Clin cal tretinoin in photoaging: an ultrastruc-
tions. Dermatol Surg 1997;23:108993.
North Am 1998;82:132558. tural study. J Cutan Aging Cosmet Derma-
44. Rigel DS, Friedman RJ, Kopf AW. The incidence 60. Anscher M, Montano G. Radiotherapy. Surv
Ophthalmol 1993;38:20312. tol 1988;1:417.
of malignant melanoma in the United 78. Johnson TM, Nelson BR. Anatomy of the skin. In:
States: issues as we approach the 21st centu- 61. Morrison WH, Garden AS, And KK. Radiation
therapy for nonmelanoma skin carcinomas. Baker SR, editor. Local flaps in facial recon-
ry. J Am Acad Dermatol 1996;34:83947. struction. St. Louis: Mosby; 1995. p. 314.
45. Weinstock MA. Issues in the epidemiology of Clin Plast Surg 1997;24:71928.
79. Grove GL. Age related differences in healing of
melanoma. Hematol Oncol Clin North Am 62. Geara FB, Ang KK. Radiation therapy for
superficial skin wounds in humans. Arch
1998;12:68199. malignant melanoma. Surg Clin North Am
Dermatol 1982;272:3815.
46. Mackie RM. Incidence, risk factors and preven- 1996;76:138398.
80. Montagna W, Carlisle K. Structural changes in
tion of melanoma. Eur J Cancer 1998;34:S36. 63. Kuflik EG. Cryosurgery updated. J Am Acad
aging human skin. J Invest Dermatol
47. Langley RG, Barnhill RL, Mihm MC, et al. Dermatol 1994;31:92544.
1979;73:4753.
Neoplasms: cutaneous melanoma. In: 64. Lindgren G, Larko O. Long term follow up of 81. Bennet RG. Anatomy and physiology of the
Freedberg IM, Eisen AZ, Wolff K, et al, edi- cryosurgery of basal cell carcinoma of the skin. In: Papel ID, Nachlas NE, editors.
tors. Dermatology in general medicine. 5th eyelid. J Am Acad Dermatol 1997;36:7426. Facial plastic and reconstructive surgery. St.
ed. New York: McGraw Hill; 1999. 65. Mallon E, Dawber R. Cryosurgery in the treat- Louis: Mosby; 1992. p. 313.
p. 1080117. ment of basal cell carcinoma. Dermatol 82. Whetzel TP, Mathes SJ. Arterial anatomy of the
48. Holly EA, Kelly JW, Shpall SN, et al. Number of Surg 1996;22:8548. face: an analysis of vascular territories and
melanocytic nevi as a major risk factor for 66. Spencer JM, Tannenbaum A, Sloan L, et al. perforating cutaneous vessels. Plast Recon-
malignant melanoma. J Am Acad Dermatol Does inflammation contribute to the eradi- str Surg 1992;89:591603.
1987;17:45968. cation of basal cell carcinoma following 83. Gaboriau HP, Murakami CS. Skin anatomy
49. Breslow A. Thickness, cross-sectional areas and curettage and electrodesiccation? Dermatol and flap physiology. Otolarygol Clin North
depth of invasion in the prognosis of cuta- Surg 1997;23:62531. Am 2001;34:55569.
neous melanoma. Ann Surg 1970;172:9028. 67. Goette DK. Topical chemotherapy with 5- 84. Swanson NA. Classifications, definitions, and
722 Part 5: Maxillofacial Pathology
concepts in flap surgery. In: Baker SR, edi- 94. Dzubow LM. The dynamics of dog-ear forma- 103. Adnot J, Salasche SJ. Visualized basting sutures
tor. Local flaps in facial reconstruction. St. tion and correction. J Dermatol Surg Oncol in the application of full thickness skin
Louis: Mosby; 1995. p. 6374. 1985;11:7228. grafts. J Dermatol Surg Oncol 1987;
85. Jackson IT. Local flaps in head and neck recon- 95. Salasche SJ, Roberts LC. Dog-ear correction by 13:12369.
struction. St. Louis (MO): CV Mosby Co; M-plasty. J Dermatol Surg Oncol 1984; 104. Skouge JW. Techniques for split-thickness skin
1985. 10:47882. grafting. J Dermatol Surg Oncol 1987;
86. Grabb WC, Meyers MB, editors. Skin flaps. 96. Cox KW, Larabee WF. A study of skin flap 13:8419.
Boston: Little Brown; 1975. advancement as a function of undermin- 105. Bray DA. Clinical applications of the rhomboid
87. Goding GS, Hom DB. Skin flap and physiolo- ing. Arch Otolarygol 1982;108:1515. flap. Arch Otolaryngol 1983;109:3742.
gy. In: Baker SR, editor. Local flaps in facial 97. Zide MF, Fuselier C. The partial-thickness 106. Bray DA. Rhombic flaps. In: Baker SR, editor.
reconstruction. St. Louis: Mosby; 1995. p. cross-lip flap for correction of postoncolog- Local flaps in facial reconstruction. St.
1530. ic surgical defects. J Oral Maxillofac Surg Louis: Mosby; 1995. p. 15164.
88. Ridenour BD, Larrabee WF. Biomechanics of 2001;59:114753. 107. Brodovsky S, Dagan R, Ben-Bassatt M. Nobe-
skin flaps. In: Baker SR, editor. Local flaps 98. Glogau RG, Haas AF. Skin grafts. In: Baker SR, cutane spray as temporary dressing of skin
in facial reconstruction. St. Louis: Mosby; editor. Local flaps in facial reconstruction. graft donor sites. J Dermatol Surg Oncol
1995. p. 318. St. Louis: Mosby; 1995. p. 24771. 1986;12:3868.
89. Borges AF. Relaxed skin tension lines. Derma- 99. Rudolph R, Ballantyne DL. Skin grafts. In: 108. Glogau RG, Stegman SJ, Tromovich TA.
tol Clin 1989;7:16977. McCarthy JG, editor. Plastic surgery, Vol 1. Refinements in split thickness skin grafting
90. Larabee WF. Immediate repair of facial defects. General principles. Philadephia: WB Saun- technique. J Dematol Surg Oncol 1987;
Dermatol Clin 1989;7:66176. ders; 1990. p. 22174. 13:8538.
91. Larabee WF, Holloway GA, Sutton D. Variation 100. Skouge JW. Skin grafting. New York: Churchill 109. Chandawarkar RY, Cervino AL, Wells MD.
of skin stress-strain curves with undermin- Livingstone; 1991. Reconstruction of nasal defects using mod-
ing. Surg Forum 1981;32:5535. 101. Salasche SJ, Feldman BD. Skin grafting: periop- ified composite grafts. Br J Plast Surg
92. Brown MD. Advancement flaps. In: Baker SR, erative technique and management. J Der- 2003;56:2632.
editor. Local flaps in facial reconstruction. matol Surg Oncol 1987;13:86369. 110. Avelar JM, Psillakis JM, Viterbo F. Use of large
St. Louis: Mosby; 1995. p. 91107. 102. Hill TJ. Reconstruction of nasal defects using composite grafts in the reconstruction of
93. Borges AF. Dog ear repair. Plast Reconstr Surg full thickness grafts: a personal reappraisal. deformities of the nose and ear. Br J Plast
1982;69:707 13. J Dermatol Surg Oncol 1983;12:9951001. Surg 1984;37:5560.
INDEX
Alanine aminotransferase (ALAT), 35, 77 management of, 383399 reconstructive surgery of, 180181
Alar base maxillofacial examination, 384386 squamous cell carcinoma, 621f
alterations in, 1256 patient history, 384 Alveoloplasty, 168169
cinch suture, 1237f physical examination, 384 Alveolus
reduction, 1363f radiographic examination, 386387 squamous cell carcinoma, 644645
Alar cinch, 1236, 1441f Alveolar artery, 1248 Ameloblastic carcinoma, 588589
with V-Y closure, 12361237 Alveolar bone Ameloblastic fibroma, 590f
Alar width in edentulous patient Ameloblastic fibro-odontoma, 590, 590f
rhinoplasty, 1353 characteristics of, 157158 Ameloblastoma, 583588
ALAT, 35, 77 injuries benign, 588f, 589f
Albrights syndrome, 597, 682 diagram of, 390f malignant metastasizing, 588
Albumin, 34 loss, 263f mural unicystic, 586
Albuterol preservation of, 167171 peripheral, 587588
for asthma, 29 Alveolar cleft solid or multicystic, 583585, 584f, 585f
Alcohol abuse, 39, 281, 1298 grafting, 859869 unicystic, 585586, 586f, 587f
anesthesia with, 121 allogeneic bone and bone substitutes, American College of Cardiology
immunocompromised, 283 863864 cardiovascular risk factors, 1920, 20t
squamous cell carcinoma, 617 bilateral, 865f perioperative evaluation for noncardiac
Alcohol withdrawal calvarial bone, 863 surgery, 47
oral cancer, 635 central incisor, 861 American M-16, 512
Alfentanil dental vs. chronologic age, 861 American Society of Anesthesiologists (ASA)
chemical structure of, 88f lateral incisor, 861 Classification of Physical Status,
end-stage TMJ disease, 1017 late secondary, 862 66, 66t
pharmacology of, 89 maxillary central incisor, 865f Amide
Alignment, 795f multidisciplinary team, 862 avoiding in malignant hyperthermia, 38
Allens test outcomes, 859 Amifostine, 638
abnormal, 808f pre-vs. postsurgical orthodontics, 864865 Aminocaproic acid, 473
Allergic fungal sinusitis (AFS), 301, 304f primary, 860 Aminosteroids
Allergic rhinitis, 106107, 299 rationale for, 859 pharmacology of, 98
Allevyn spray, 718 secondary, 860862 properties, 99t
AlloDerm, 220221, 221f social issues, 861 Amitriptyline
Allogenic bone implants, 166 source of bone graft, 862864, 863t end-stage TMJ disease, 1022, 1023
Allografts, 786t, 787 sulcular incision, 866f Amoxicillin
Alloplastic chin implants surgical technique, 865866 for bites, 362
soft tissue changes associated with, 1232t timing, 859862, 860t, 861t for infectious endocarditis prophylaxis, 24t
Alloplastic esthetic facial augmentation, unilateral, 862f, 864f for odontogenic infection, 289
14351447 reconstruction for rhinosinusitis, 305, 502
Alloplastic graft, 787 occlusal radiograph, 868f, 869f for sinus infection, 305
Alloplastic materials, 1008 reconstruction of, 859869 Amphetamine abuse
Alopecia, 1403 Alveolar distraction devices, 1293f anesthesia with, 121
Alpha-blockers Alveolar distraction osteogenesis, 183185, Amphotericin B
for hypertension, 32 230231 for fungal sinusitis, 307
Alpha-glucosidase inhibitors dental implants, 12901293 Ampicillin, 944
mechanism of action, 60t Alveolar distractors, 1291f for COPD, 30
Alpha-hydroxy acid, 1422 Alveolar mucosa for infectious endocarditis prophylaxis, 24t
Alpha-interferon treatment, 396397 Amyloidosis, 38
for central giant cell granuloma, 604 Alveolar osteitis, 149, 151 Anakinra
Aluminum oxide, 1008 Alveolar process for rheumatoid arthritis, 36
cemented abutment anterior, 1182 Ancient Egypt, 189
with all-ceramic crown, 257f fractures Andreasen classification, 387
Alveolar and dental fractures treatment, 395396 Anemia, 3031
etiology of, 383384 growth of, 1063 Anemia of chronic disease, 38
hard tissue and pulp, 387397 Alveolar ridge Anesthesia
historic perspectives of, 383 cancer, 621 general
incidence of, 383384 survival, 645 risk after myocardial infarction, 20
Index 725
Articular cartilage, 934, 935f wishboning, 380, 380f Bar attachment, 264, 265f
Articular disk Atrophic maxilla overdenture, 264f
TMJ, 935936 gingival graft, 211 Barbiturates
Articular eminence Atropine, 99, 106, 473 pharmacology of, 8991
endaural view, 973f with ketamine, 111 Barbituric acid
Articular tubercle Attention deficit hyperactivity disorder chemical structure of, 90f
disk impingement, 972f (ADHD) Bar-clip attachments, 265
ASA Classification of Physical Status, 66, 66t anesthesia with, 119 Bardach two-flap palatoplasty, 852
Ascending ramus fracture, 409 Auditory canal Barium swallow
Aseptic necrosis, 1250, 1250f external vs. esophagoscopy
Asian lid crease reformation, 1334f sectioned, 995f for neck gunshot injuries, 518
Asian upper eyelid, 1320 Auricle. See Ear Barlows syndrome, 69
blepharoplasty, 1334 Auriculotemporal nerve, 1390 Barosinusitis, 299
Aspart Auriculotemporal syndrome, 1263 Bar-retained denture, 264f
onset, peak and duration, 61t Austin-Flint murmur, 25 Barton dressing, 287f
Aspartate aminotransferase (AST), 77 Autism Basal cell cancer
Aspergillus flavus, 301 anesthesia with, 119120 nasal, 707f
Aspergillus fumigatus, 300301 Autogenous bone grafts Basal cell carcinoma, 700, 706f, 712f
Aspergillus sinusitis, 304f sites for, 787792 indiscreet temple, 716f
Aspiration, 106 Autogenous conchal cartilage, 1008 of left temple, 714f
Aspirin Autogenous fascia interpositional grafts, 1007 Mohs micrographic surgery removal, 717f
for cerebrovascular disease, 37 Autogenous grafts, 168 NMCS, 697
determining preoperative risk, 18 Autoimmune disease, 690691 nodulo-ulcerative, 701f
for fever, 287 implants, 252 resection, 719f
Aspirin-sensitivity triad, 299 Autologous fat injection, 14131414, 1414f superficial, 718f
AST, 77 Autologous fat transfer, 14121415 Basal cell nevus syndrome, 698
Asthma, 2829, 299 complications, 14141415 clinical features of, 570t
bronchial, 7273 Automatic implantable cardioverter Basaloid squamous cell carcinoma, 632
pulmonary assessment, 5455 defibrillators (AIC), 5253 Base alar reduction
questions about, 29t Avulsions, 361362, 393394 nasal, 1363
Asymmetric hybrid functional appliance, ear, 368f Basic fibroblast growth factor (bFGF), 193
1073f lip, 369f Basic multicellular unit (BMU), 7
Asymmetric skull maxillary fractures, 441 Basilar skull fractures, 471
CT, 1209f splints, 395, 396t Battles sign, 346, 429, 471
Asymmetry. See also Facial asymmetry temporary storage of, 393 Beaking, 974, 977f
anteroposterior arch, 1129 treatment, 393394, 395t Becks triad, 338
zygomatic arch fractures, 457 Axial frontonasal flaps, 772, 773f Behets syndrome, 692
Asymptomatic patients Axial pattern flaps, 716717 Bekhterevs disease, 1036
screening tests for, 79 Azathiaprine Belfast Study Group, 139, 140
Atenolol for rheumatoid arthritis, 36 Bell hand engine, 1430
avoidance in liver disease, 35 Azithromycin Bells phenomenon, 1330
ATLS, 330 for infectious endocarditis prophylaxis, 24t Benign fibro-osseous disease, 597600
Atracurium for rhinosinusitis, 502 cemento-osseous dysplasia, 598599
properties, 99t fibrous dysplasia, 597598
Atrial dysrhythmias, 27 B Benign mucosa membrane pemphigoid
Atrial fibrillation, 24, 27, 51 Babinski sign, 346 (BMMP), 690691
Atrial flutter, 27 Bacteroides (Porphyromonas), 140, 426 Benign ventricular ectopy, 52
Atrioventricular blocks, 2728 Baker-Gordon phenol peel, 14271428 Benzamides
Atrophic mandible, 185f complications from, 1428f children, 117
augmentation, 195197 formula of, 1428t Benzodiazepines, 952t, 953t
gingival graft, 211 frosting from, 1429f for delirium tremens, 39, 635
iliac crest corticocancellous block graft aug- Ballistics, 510 for depression, 39
mentation, 196f Balloon catheters in elderly, 41
implants without grafting, 197 nasal packing, 517f with ketamine, 111
plane radiograph, 196f Bands of Bngner, 824 pharmacology of, 8587
Index 727
for TMJ, 952 Black necrotic eschars, 301 Boat tail bullet, 514
Benzylisoquinolines Blade implants, 190f Body fracture, 409
pharmacology of, 98 Blair, Vilray, 840 Body temperature
properties, 99t Blairs horizontal osteotomy of vertical ramus, restoration and maintenance of, 343
Bernard flap, 666, 666f 1135, 1136f Boltons analysis, 11121113, 1113f
Beta-agonists Blanch test, 338 Bonded orthodontic bracket, 134
for asthma, 29 Bleeding Bone
Beta-antagonist BSSO, 1160 allogenic implants, 166
for hyperthyroidism, 34 control of, 339340 biology of, 785786
Beta blockers, 20, 23 flaps, 720 healing
for atrial fibrillation, 24 gunshot wounds, 516517 osseointegration, 192193
for hypertension, 32 with impacted teeth removal, 150 secondary, 373f, 374f
Beta carotene, 641 internal sites of, 341 indirect healing, 6, 373f, 374f
Beta-lactam Le Fort level fractures, 438 loss
for odontogenic infection, 289 lower eyelid blepharoplasty, 1341 secondary, 159
Beta-sympathetic antagonists mandible, 1249 maturation stages of, 167f
reduction in liver disease, 35 maxilla, 12471249 regeneration of, 6
bFGF, 193 maxillary fractures, 442 principles of, 162164
Bicoronal flap, 551 TMJ remodeling, 7
Bicortical screws, 1259f internal derangement, 1010 tension-stress, 164
Bicuspids upper eyelid blepharoplasty, 1340 volume
mandible Bleeding disorders implant prosthodontics, 252
impacted, 136 assessment of, 78 inadequate posterior, 236f
progressive soft tissue recession, 212f Bleomycin, 682 wound healing, 67
Biguanides Blepharoplasty, 13171342 Bone grafts, 165167, 786t
mechanism of action, 60t adjunctive procedures, 13411342 autogenous
Bilateral alar base wedge, 1243f anatomy, 13171326 sites for, 787792
Bilateral body osteotomy, 1125f anesthesia, 1331 benefits of, 12681269
Bilateral sagittal split osteotomy (BSSO), 1137 chief concern, 13261327 biology of, 786787
bleeding, 1160 complications, 13391341 cleft maxilla/palate, 1269f
complications of, 11551156 lower eyelids, 13341337 timing and sequencing, 12681269
indications for, 1150 patient evaluation, 13261331 cranial, 788, 788f, 789f, 790f
of mandible, 1214 photographic documentation, 1331 cranial onlay
for mandibular horizontal deficiency, physical examination, 13281330 maxilla, 263f
1153f1154f postoperative management of, 13371339 guided
modification, 1155 upper eyelids, 13311334 augmentation, 223
technique, 11501155 Blind finger dissection, 1397f harvesting, 196
illustrated, 1152f Blindness, 464 iliac crest, 268f, 789791, 862863
of vertical ramus, 11501161, 1277 maxillary fractures, 442 inlay, 179180
Bilevel positive airway pressure (Bi-PAP) Blood clot, 4, 4f, 8 intraoral, 787788
OSA, 1304 Blood pressure donor site, 787f
Bilobed flap of Zitelli children, 105, 528 onlay, 177179, 1274f
nasal, 714 in trauma patient, 337 orbital floor
Bilobed flaps, 771f, 773774 Blow-in fractures, 467, 472 zygomatic arch fractures, 457
Bimanual examination, 496, 496f children, 536537 panfacial fractures, 551552, 552f
Biofeedback Blown pupil, 347 sinus, 232234, 241f
for TMJ, 957 Blow-out fractures, 457f, 477, 485 tibial, 791792, 792f
Biologic creep, 712 bilateral, 536f vertical alveolar augmentation, 223234
Biopsy forceps children, 536537 Bone marrow needle, 108, 108f
TMJ arthroscopy, 970 of left orbital floor, 538f Bone morphogenetic proteins (BMP), 13, 785,
Bi-PAP orbital, 484 787
OSA, 1304 Blue bloater, 73 Bone plates, 372f, 378f, 439
Bipolar (manic-depressive) disorders, 39 BMMP, 690691 biomechanical effectiveness of, 377f
Bite appliances, 1009 BMP, 13, 785, 787 device, 185
Bite depth, 1106 BMU, 7 fatigue, 379380
728 Index
vs. lag screws, 379 preoperative evaluation, 13931395 Calcified sialoliths, 674
Le Fort I level fracture, 375f skin care and micropigmentation, Calcifying epithelial odontogenic tumors, 592
load-bearing fixation, 375f 14011402 Calcifying odontogenic cysts (COC), 582, 583f
strong, 380f vessel and nerve anatomy, 13891391 Calcitonin
symphysis fracture, 382f Brown dermatome, 718 for central giant cell granuloma, 604
Bone tunnel fixation, 1399f, 1400 Brown technique, 423f Calcium channel blockers
Booster seats, 529 Bruxism for aortic regurgitation, 25
Botulinum toxin A, 1329 drug-induced, 1023 for hypertension, 32
Botulinum toxin-assisted brow lift, 1401 implants, 252 Calcium hydroxide paste, 388
Bowman-Birk inhibitor, 641 BSSO. See Bilateral sagittal split osteotomy Caldwell-Luc procedure, 152, 232234, 308,
Bowstring test, 496, 496f (BSSO) 309f
Brachycephaly, 889f, 895f, 908f Buccal advancement flaps, 772f Caldwells view
Brachytherapy, 637 Buccal artery, 144 zygomatic complex fractures, 448
Brackets, 1130f Buccal flaps Caliber, 512
Bradycardia, 25 full-thickness mucoperiosteal, 866 Caloric response, 347, 347f
with hypertension, 345 Buccal fragment Calvaria
Brain after osteotomy, 180f bone formation in, 192193
damage caused by hypertension, 32 Buccal mucosa Canaliculus, 364, 365f
growth flap, 1270f Cancellous grafts, 165
craniofacial dysostosis syndrome, squamous cell carcinoma, 621f, 642, 642f Cancer chemotherapy
901902 verrucous carcinoma, 631f adjuvant, 639
limitations, 887888 Buccal object rule, 133 immunocompromised, 283
Brnemark drilling system, 191 Buccal segment, 1257f induction, 639
Brnemark protocol, 201 Buccal space neoadjuvant, 639
Breast-feeding borders of, 278t nonmelanoma skin cancer, 708
cleft lip/palate, 844 infection, 279t oral cancer, 638640
Breast-feeding mothers, 42 Buccinator, 1184 palliative, 639
medications for, 42t Buckshot, 513 Candida, 680
Breath-holding test, 28 Bulimia, 39 Candidosis, 680681, 692
Breathing Bullets HIV, 689
trauma patient, 332337 diameter, 511 oral, 680f, 681f
Bridging fixation. See Load-bearing fixation fragmentation, 511 Canine teeth
Bronchi kinetic energy, 510511 labially impacted
children, 103 velocity, 511 apical repositioned flap, 135f
Bronchial asthma, 72 wounding power, 510511 removal of, 136
Bronchiectasis, 73 Bullous pemphigoid, 691 palatal impacted
Bronchitis, 73 Bundle branch blocks, 28 removal of, 136
Bronchoscope Bngners band, 6 Cannula, 14081409, 1409f
rigid, 624 Bupivacaine TMJ arthroscopy, 970
Bronchospasm, 29 for blepharoplasty, 1331 Canthal ligament
Bronstein and Merrill arthroscopic staging end-stage TMJ disease, 1017 lateral, 13211322
IJD, 968t Burns, 1248f Canthal ligaments, 1322f
Brophy, Truman, 840 TMJ Canthal tendons, 446
Brow arthroscopy, 986 Canthotomy
youthful, 1384f Burows triangle, 367f, 665f, 772 lateral, 453
Brow incision Buser periosteal elevator, 213, 218 Cantilevered fixed partial denture, 263, 263f
lateral, 452, 482 Busulfan, 682 extension of, 265
Brow lift, 13831403, 1395 Buttress, 547548 Cantilevering, 256f
bony landmarks, 13841389 Butyrophenones Capillary filling time, 338
complications, 14021403 for psychotic disorders, 39 Capnography, 59
endoscopic view, 13911393, 13961400, Capsaicin
1396f C end-stage TMJ disease, 1017
muscle and fascial anatomy, 13851386 Cadaveric mandible tray Capsular ligament, 936, 936f
positions, 1383f atrophic mandible, 182f Capsular tightening procedure, 1005f
postoperative care, 1402 Cadaveric mandibular adjustment, 183 Carbamazepine, 691
Index 729
diagnosis of, 529530 soft tissue changes associated with, 1232t for infectious endocarditis prophylaxis, 24t
epidemiology of, 530532 augmentation, 1438f for rhinosinusitis, 502
historic perspectives, 527528 liposuction, 1412 Clavicle
mechanism of, 530t poor esthetic results, 1241 bone formation in, 192193
patterns of, 530, 532542 ptosis, 1242, 1243f Clear cell odontogenic carcinoma, 589
prevention of, 529 Chin cup, 1077f Cleft lip/palate, 839855, 842f, 1206
by region, 530t, 531t Chinese gunpowder, 509 bilateral repair, 847849, 850f, 851f, 852f
treatment, 531t Chin-lift procedure, 330, 332f bone graft reconstruction, 881
dentoalveolar injuries, 383384, 397398, Chin-neck anatomy, 1100 breast-feeding, 844
398t, 541542 Chin point deviation classification, 842, 843f
emergency treatment on full stomach, 106 distraction, 1280f complex facial clefting, 853855
endotracheal intubation, 104 Chisel, 1248f dental and prosthetic rehabilitation,
facial trauma, 540f Chloral hydrate 883884, 883f, 884f
fluid requirements for, 42t children, 115 embryology, 841
FRC, 104 Chlordiazepoxide etiology, 841842
frontal sinus fractures, 532534 reduction in liver disease, 35 feeding, 843844
hypothermia, 528 Chlorhexidine fistula closure, 872875
impacted teeth, 144 for alveolar osteitis, 151 indications for, 872873
impacted tooth removal, 142143 Cholesterol, 19 operative technique, 873875, 873f, 874f
Le Fort (midface) fractures, 534 Chondrocytes, 934 genetics, 841842
mandible, 529 Chondroitin historical perspective of, 840841
mandibular condyle fractures, 538539 TMJ, 942 incidence of, 1267
mandibular fractures, 424425, 538542 Chondroma, 601, 602f lip adhesion, 847
mandibular subcondyle fractures, 538539 Chronic obstructive pulmonary disease midfacial deficiency
maxillary fractures, 441 (COPD), 2930 orthognathic surgery, 881
nasal air passages, 528 Chronic renal disease nasal deformity reconstruction, 881882
nasal fractures, 537538 immunocompromised, 283 orthognathic surgery, 12671275
naso-orbitoethmoid fractures, 532534 Chuck changer, 242f bone grafting with maxillary advance-
neural innervation, 105 Chyle leak, 519f ment, 12721273
paranasal sinuses, 529 Cicatricial pemphigoid, 690691, 690f, 691f presurgical counseling, 12701271
parasymphyseal fractures, 541 Cigarette smoking, 300 outcome, 855
periosteum, 529 involuntary exposure prenatal counseling, 842843
permanent tooth buds, 529 risks of, 58 presurgical taping and orthopedics,
resorbable fixation materials, 542 lip cancer, 659 846853
ribs, 103 perioperative effects of, 5658 reconstruction stages, 871t
sedation, 103123 preoperative cessation of, 30 repair, 849853
anatomic and physiologic considera- Cilia, 297, 298f revisional surgery, 881883
tions, 103105 Ciliary nerve, 1326 scar revision surgery, 882883
perioperative complications, 115116 Cimetidine, 106 secondary procedures, 871884
pharmacologic agents, 110115 Cinch suture staged reconstruction of, 845t
preoperative evaluation, 105106 alar base, 1237f submucous, 880881
routes of administration, 107110 Ciprofloxacin treatment planning and timing, 844846
techniques for, 107115 for odontogenic infection, 289 unilateral repair, 847, 848f, 849f, 853f
substance abuse, 120123 Circle of knowledge and caution, 13731374, velopharyngeal dysfunction, 875880, 875f
supraorbital ridge fractures, 532 1375f complications, 879880
tongue, 103 Circulation operative technique, 878879
tonsils, 103 trauma patient, 337344 timing, 877878
trachea, 103, 104 Circumoral tissue Z-type repair, 849f
upper respiratory infection, 106107 collapsed, 182f Cleft maxilla/palate
urine output in, 42t Circumvestibular incision, 1271, 1271f bone grafting, 1269f
ventilation, 103 intraoral mucosal, 534 timing and sequencing, 12681269
zygomatic complex fractures, 534537 Cisatracurium Cleidocranial dysplasia
Chin properties, 99t multiple impacted teeth in, 132f
alloplastic augmentation, 14351437 Cisplatin, 639, 640 Click-murmur syndrome, 69
alloplastic implants Clarithromycin Clindamycin
Index 731
for infectious endocarditis prophylaxis, 24t Complicated fractures, 410 Conchal hypertrophy, 1453
for sinus infection, 305 Composite grafts, 719 Concussion, 391, 503
Clinical and dental model diagnosis, Compound fracture, 409410, 409f Conduit nerve repair, 833f, 834t
11111118 Compression (Raney) clips, 483 Condylectomy, 1009
Clinical diagnosis, 564 Compression plates, 372f, 378f Condyles, 783784
Clinical examination, 565566 AO/ASIF, 402 adenocarcinoma metastasizing to, 945
Clinical impression, 564 osteosynthesis arthroplasty, 1003f
Clinical neurosensory testing (CNT), 825826, vs. noncompression plate osteosynthesis, asymmetry
826t 378 panoramic radiography of, 1208f
algorithm, 827f Computed tomography (CT), 569 children, 529
Clinician abdominal injuries, 352, 354t classification of, 408
neophyte vs. expert clinician ankylosis, 428f dislocation, 411f
case study, 567568 asymmetric skull, 1209f fractures, 409, 1035f
Clip overdenture retention cervical lymph nodes, 647, 647f abnormal growth from, 1208f
two-implant bar, 194f cervical spine injuries, 351 children
Clonidine condyle mechanical displacement, 1159 open reduction, 539
for hypertension, 32 craniofacial dysostosis syndrome, 905 closed treatment, 382f
for hypertensive crisis, 50t edentulous mandible, 194 complications, 429430
for opioid withdrawal, 3940 facial asymmetry, 1209 endoscopic management of, 421f
Closed lock phenomenon, 990 frontal sinus IMF, 415
Closed pneumothorax, 333, 335f anterior table fractures, 499 mandibular hypoplasia, 427f
Closed reduction, 401 posterior table fractures, 499 with midsymphysis fracture, 381
mandibular fracture, 413414 head trauma, 345, 346f open reduction, 418420
Closed technique implants, 253, 270f indications for, 419420, 419t
subepithelial connective tissue grafting intracerebral hemorrhage, 346f panoramic films, 407, 407f
implants mandibular cancer, 645646 range of motion, 406
recipient-site surgery, 214215, 215 mandibular fracture, 407 stabilization of, 422f423f
Cloverleaf skull anomaly, 925926, 926f mandibular fragmentation surgery, 420
CNT, 825826, 826t gunshot wounds, 520f inappropriate positioning of, 1189f
algorithm, 827f maxillary fractures, 439f mandible, 934f
Coaptation, 832833 maxillary sinuses, 163f mechanical displacement of, 1159
Cobalt NOE fracture, 496, 497f remodeling, 978f
effect on wound healing, 12 oral cancer, 625, 625f resorption
COC, 582, 583f orbital fractures, 468, 470 idiopathic, 1291f
Cocaine, 40 OSA, 1301 spontaneous resorption of, 1160
anesthesia with, 121 osteomeatal complex, 303f trauma, 1208
Coil springs, 1126f osteomyelitis, 315 Condylotomy, 1009
Cold panfacial fractures, 550551, 550f, 551f Conformal radiation, 636637
common, 299 paranasal sinuses, 304f Congenital agenesis
Cold therapy pediatric craniomaxillofacial fractures, premaxilla, 1285
for TMJ, 956 529530 Congenital anomalies, 1205, 12061207
Collateral (diskal) ligaments, 936 preprosthetic and reconstructive surgery, altered anatomy in, 104
Colonial America, 189 161 cleft lip/palate, 1206
Combes formula, 1422t sinus infection, 302303 congenital hemifacial hyperplasia, 1207
Commandos operation, 645 subarachnoid hemorrhage, 346f hemifacial microsomia, 1206, 1206f
Comminuted fractures, 409f, 410 TMJ, 977f plagiocephaly, 12061207
grossly, 410 zygomatic complex fractures, 447448, 448, Congenital hemifacial hyperplasia, 1207
mandible 449f, 450f, 454f Congestive heart failure, 26, 6768
fixation, 375 Computer-databasing program, 1090f decompensated, 50
Commissure height, 1090 Computer-generated scanner, 1431 ECG, 22
Common cold, 299 Computerized cephalometric prediction, symptoms of, 22
Competitive antagonists, 84 11071108 Connective tissue disorders, 36
Complete strip technique, 1362f Concha bullosa, 298 implants, 252
Complex fractures, 410 Conchal cartilage Conscious sedation, 93
Compliance, 22 autogenous, 1008 Contact sports, 383
732 Index
Edentulous mandible, 193197 scanning electron micrograph, 1055f Envelope flap, 144, 146f
flap design for implant placement, 207f Emergence delirium, 93 Envelope incision, 144, 145f
incision design, 194 Emergency treatment on full stomach Environment
osseointegration, 193197 children, 106 craniofacial growth and development,
physical examination, 194 Eminectomy, 1046 10681070
prepared for bone graft, 224f Emphysema, 73 craniofacial malformations, 10661068
radiologic examination, 194 Enalaprilat Enzyme induction, 85
simultaneous gingival grafting, 212f for hypertension, 32 Ephelides, 683
Edentulous maxilla, 197199, 197f, 226f227f, for hypertensive crisis, 50t Epidermis, 709
228f Enamel fractures, 387 Epidermodysplasia verruciformis, 698
atrophy, 236f Enamel organ, 575, 575f Epidermolysis bullosa (EB), 685686
flap design for implant placement, 207f END, 647, 648 atrophicans generalisata gravis Herlitz type,
Parels classification of, 197 vs. elective neck irradiation, 650 686
with severe atrophy, 232f Endocarditis bullosa acquisita, 686
Edentulous patients cardiac conditions associated with, 23t Cockayne-Touraine type, 686
alveolar bone characteristics, 157158 prophylaxis if, 24t dystrophica Hallopeau-Siemens, 686
closed reduction, 417 Endochondral bones simplex Koebner type, 686
Edentulous restorations, 263264 formation of, 192193 Epidural hemorrhage, 345f
FDP, 265266 Endocrine disorders, 3234, 5961, 7477 Epilepsy, 78
implant-retained overdentures, 263264 diabetes, 281, 282, 424 Epinephrine, 95, 338, 340
implant-supported overdentures, 264265 effect on wound healing, 10 for arrhythmias, 52
Edinger-Westphal nucleus, 347 implants, 252 for blepharoplasty, 1331
EDTA, 944 diabetes insipidus, 607 Epiphora, 364, 1263, 1327
Eight-ball hyphema, 472473 diabetes mellitus, 3233, 5961, 7677 Epistat, 438
Elastic fibers, 709 insulin, 60 Epistaxis, 437
Elderly, 4042 type 2, 33, 60 Epithelialized palatal graft technique
displaced zygomatic complex, 486f487f hyperglycemia, 6061 implants, 210111
drug modifications in, 4142 hypoglycemia, 6061 Epstein-Barr virus (EBV), 686, 688
hypertension, 49 thyroid disorders, 3334 ePTFE, 223
impacted teeth, 142143, 144, 149 Endonasal rhinoplasty Erich arch bars, 415f
maxillary fractures, 441 surgical sequence for, 1356t Erythema multiforme, 693694, 694f
orbital injuries, 481 Endoscopic lens system Erythematous lesions, 685686
wound healing, 12 TMJ Erythrocyte sedimentation rate (ESR), 314
Elective lymph node dissection, 667 arthroscopy, 970f Erythromycin
Elective neck dissection (END), 647, 648 Endoscopy for COPD, 30
vs. elective neck irradiation, 650 sinus infection, 302303 Erythroplakia, 618, 619, 619f
Electric drill, 145 complications of, 309 Esmolol
Electrolytes and acid-base disturbances, 5354 Endosseous implants, 191192, 270f for hypertensive crisis, 50t
Electrometric test, 386 long-term Esophagoscopy, 624
Elevators, 13851386 first, 189 vs. barium swallow
Buser periosteal, 213, 218 Endotracheal intubation for neck gunshot injuries, 518
Cottle, 1357f children, 104 ESR, 314
Cryer, 146 for flail chest, 337 ESRD, 31, 77
J-shaped, 1438, 1438f Endotracheal tube stabilizer pad, 980f Essential hypertension, 3132, 37
curved hook, 450 End-stage renal disease (ESRD), 31, 77 Esthetic facial augmentation
periosteal, 866, 1387f End-to-side anastomosis, 805f alloplastic, 14351447
TMJ arthroscopy, 970, 971f Enflurane Esthetic flaps, 710
Elevator technique, 136 avoided with renal patients, 31 Esthetic implants
Elliptic incision chemical structure of, 96f flaps, 207f
for frenum attachment excision, 173 England, 189 Esthetic ridge defect
Ellis classification, 387, 387f Enophthalmos, 468, 479 large-volume combination hard and soft
Ellis technique, 423f zygomatic arch fractures, 457458, 458f tissue
Embryo, 1052f Entubulation (conduit) nerve repair, 833f, reconstruction of, 219f
amnion, 1053f 834t Esthetic tooth wax-up, 200
lateral view, 1053f Entubulation techniques, 833834 Estlander flap, 664
736 Index
panfacial fractures, 550551 determining difficulty of, 143144 soft tissue, 205221
Imbrication, 1371, 1372f fracture, 151 with acellular dermal matrix, 220221
vs. plication, 1372f irrigation, 151 augmentation guidelines, 209
IMF. See Internal maxillary fixation (IMF) nerve disturbances, 151 epithelialized palatal graft technique,
Imipramine rare complications, 152 210111, 210211
end-stage TMJ disease, 1022 technique, 144147 flaps, 205208, 206f, 207f
Imiquimod, 698, 708 surgical exposure, 133134 grafts, 208209
Immunocompromised vs. unerupted teeth, 140 nonsubmerged placement, 206
effect on wound healing, 1011 uprighting, 135136 subepithelial connective tissue grafting,
factors associated with, 282t Impingement lesions 212215
odontogenic infection, 282283 progressive stages, 973t submerged placement, 205206
Impacted fractures, 410 Implant driver, 242f vascularized interpositional periosteal
Impacted teeth, 139153 Implant level transfer impression connective tissue flap, 217220
age, 144 open-tray technique, 258f two, 195
angulation of, 143 Implant prosthodontics, 251271, 254 without grafting
bone removal, 145 biomechanical considerations, 251252 atrophic mandible, 197
children, 144 crown-to-implant ratio, 254255, 255f Implant-supported overdentures
debridement, 146 full-arch restoration, 255, 255f attachment mechanisms for, 265
defined, 132 implant selection, 255256 Incisional biopsy, 570, 704
depth of impaction, 143 occlusion, 255 Incisions. See also specific incisions
etiology, 132133, 132f patient factors, 251252 brow lift, 1400f
evaluation of, 133 periimplant biology, 251 Incisors
incidence of, 131132 radiographic evaluation, 252253 altering axial inclination of, 1122
management of, 131136 complications of, 269270 angulation, 1113
multiple, 131f, 132f abutment fracture, 270 implant
perioperative care, 143149 porcelain fracture, 270 preoperative view of, 213f
relationship to ramus anterior border, 143 radiographic bone loss, 270 progressive soft tissue recession, 212f
removal of, 146f resin base fracture, 270 mandibular
age, 142143 screw loosening, 270 apical fractures, 390f
antibiotics, 147149 soft tissue, 269270 correct underangulated, 1126
bleeding, 150 contemporary techniques, 266267 crowding of, 141
children, 142143 immediate load, 267 impacted, 132f
complications of, 149 immediate placement, 266 maxillary
compromised medical status, 143 immediate restoration, 266267 altering mesiodistal angulation of, 1122
contraindications for, 142143 maxillofacial prostheses, 267268 correct underangulated, 11251126
for dental caries prevention, 141 surgical installation stability, 266 extraction of, 1122
indications for, 140142 edentulous restorations, 263264 subluxation, 392f
irrigation, 147 FPD, 260263 position in facial asymmetry, 1212
for odontogenic cyst and tumor maintenance of, 270271 Indalones
prevention, 141 single-tooth replacement, 258260 for psychotic disorders, 39
orthodontic considerations, 141 cemented single units, 259260 Indirect bone healing, 6, 373f, 374f
pain, 142, 150 esthetic zone, 259 Indirect fixation, 401
for pericoronitis, 140141 nonrestorable tooth, 258259 Indirect fracture, 409f, 410
postoperative course, 149150 screw-retained single units, 260 Induction agents
to prevent jaw fractures, 142 success criteria, 271 children, 113114
root resorption, 142 Implant-retained obturator, 269f Induction chemotherapy, 639
steroids, 149 Implant-retained overdentures, 264 Infants, 42
stiffness, 150 Implants. See also specific implants seat belts, 529
surgical damage to adjacent structures, advances in, 167171 Infection
143 angulation, 200 cervicofacial liposuction, 1411
swelling, 150 bone healing around, 193 flaps, 720
roots, 144 depth, 200201 with impacted teeth removal, 150
surgery of, 133, 135, 143149 four or more, 195 lip cancer, 659
alveolar osteitis, 151 placed too far facially, 260f mandibular fracture, 426
complications of, 150 presurgical planning for placement, 252f maxillary fractures, 442
742 Index
bony reconstruction of, 783798 chemical structure of, 93f glabella, 494
anatomic considerations, 783787 children, 111 maxillary fractures, 442
limitations of, 785 disadvantages of, 111 Lacrimal apparatus, 465, 493494
chondroma, 601 pharmacology of, 9293 Lacrimal glands, 364, 1326
drug-induced clenching, 1023 Ketorolac prolapse, 1332
examination of, 404405 end-stage TMJ disease, 1017 Lacrimal injuries, 475
exercise therapy pharmacology of, 97 Lacrimal probe, 365f
for TMJ, 955 KGF-2, 13 Lacrimal sac, 484
fractures of Ki-67, 653 incision of, 504f
prevention of, 142 Kidneys Lacrimal secretion, 1330
Langerhans cell histiocytosis, 607608 age-related changes, 41 Lacrimal system, 466, 1326, 1326f
lesions with giant cells, 603605 disease, 3031 Lactating mothers, 42
neurogenic tumors, 610611 assessment of, 7778 medications for, 42t
nonodontogenic cysts, 608610 caused by hypertension, 32 Lag screws, 372f, 375, 379f, 1154
osteoblastoma, 600 chronic vs. bone plates, 379
osteochondroma, 601602 immunocompromised, 283 fixation technique, 379, 401
osteoid osteoma, 600 end-stage, 31, 77 placement of, 380f
osteoma, 601 insufficiency, 54 Lambdoid synostosis
pediatric aggressive mesenchymal tumors, chronic, 3031 unilateral, 890
602 normal architecture of, 55f Lamellar bone, 193
rotational mechanics, 972f Kiesselbachs plexus, 1347 Lamotrigine
synovial chondromatosis, 601602 Killian incision for seizure disorders, 37
vascular malformations, 605607 rhinoplasty, 1354 LAN. See Lingual nerve (LAN)
Jaw thrust procedure, 330, 332f Kitayama technique, 423f Lanes osteotomy, 1137f
Jessners solution, 1422t, 1423, 1426f, 1427f Klearway titratable appliance, 1303, 1304f Langerhans cell, 709
Joe Hall Morris external fixator, 417f Klebsiella, 300 histiocytosis, 607608
Johnson, Lanny, 964 Klebsiella pneumoniae, 287 Lanz, Otto, 435
Joint disorders, 36 Kleeblattschadel anomaly, 925926, 926f Lap belts, 529
Joyce, John, 964 Kleins tumescent technique, 1409 Laryngoscope, 624
J-shaped curved hook elevator, 450 Klippel-Feil, 74 Laryngoscopy
J-shaped elevator, 1438, 1438f Knife-edge ridges, 1292 fiberoptic
J stripper, 1188f differential osteotomy, 1294f children, 528
Jug-handle view Kobert technique, 422f Laryngospasm
zygomatic complex fractures, 448 Koles subapical osteotomy, 1138f children, 115116
Juvenile aggressive ossifying fibroma, 600 Kolle, Frederick, 1317 Laser ablation, 641
Juvenile idiopathic arthritis, 1208 Kussmauls sign, 338 leukoplakia, 632
Juvenile rheumatoid arthritis, 1037 Laser-assisted uvulopalatoplasty
L OSA, 13061307
K Labetalol Laser Doppler flowmetry (LDF), 386
Kaban protocol, 1038 for hypertension, 32 Lasers
Kaminishi, Ronald, 964 for hypertensive crisis, 50t skin resurfacing, 1342
Kaposis sarcoma, 685 Labial frenectomy, 172174 TMJ arthroscopy, 970971
Karapandzic flap, 366, 663, 664, 664f, 665 Labial mucosal advancement flaps, 662 vestibuloplasty, 175
Kartageners triad, 302 Labial pedicle Lateral brow incision, 452, 482
Kazanjian, V.H., 527 for anterior maxillary osteotomy, 1195f, Lateral canthal ligament, 13211322
Kazanjian flap vestibuloplasty, 178f 1196f Lateral canthotomy, 453
Kelly clamp Labial splint, 416 Lateral capsular prolapse, 973
for pneumothorax, 333 Labial structures Lateral cartilage
Keloids, 9 maxillary surgical procedures, 1225, 1225f lower
protruding ear, 1458 Labii superioris, 445 anatomy of, 1349f
Keratinized gingiva, 192 Labiomental sulcus, 1229 Lateral cephalometric radiographs
Keratitis sicca, 1330f Lacerations, 360361, 437 facial asymmetry, 1209
Ketamine, 110112 under chin, 405 Lateral crural steal, 1360f
avoiding in malignant hyperthermia, 38 closure of, 362f Lateral dislocation, 411
cardiovascular effect, 111 and facial injuries, 397 Lateral luxation, 392
744 Index
Lateral maxillary osteotomy, 1273f for blepharoplasty, 1331 squamous cell carcinoma, 661f, 663f
Lateral pharyngeal space reduction in liver disease, 35 ultraviolet lip, 618
borders of, 278t Lid retractor, 468 W excision, 662, 662f
infection, 279t Lifting, 710 mucosa, 175f
Lateral pterygoid muscle, 784 Ligaments squamous cell carcinoma, 641645, 642f
Lateral tarsal strip procedure, 1335 TMJ, 936937 vermilion injuries, 360
Lateral temporomandibular ligaments, 936 Limberg flaps, 773 Lip shave, 641, 662
Lateral tuberculectomy, 1003f Lincomycin Lip-splitting approach
Latissimus dorsi myocutaneous flaps, 780 for alveolar osteitis, 151 incision for, 646f
LDF, 386 Linear fracture Lipswitch flap, 775
Lebanon load-sharing fixation, 375 Lipswitch vestibuloplasty, 175, 194
gold wire splinting, 383f orbital, 484 Lip-tooth-gingival relationship
LeClerc procedure, 1046f Linear tomography, 254f direct measurement of, 1091f
Leeches implants, 253 Lispro
medicinal, 780 Lingual frenectomy, 174 onset, peak and duration, 61t
Le Fort, Ren, 435, 527, 1179 Lingual frenum attachment, 174f Lithium carbonate
Le Fort classification system Lingual nerve (LAN), 821 for affective disorders, 39
maxillary fractures, 435436, 435f blocks for bipolar disorders, 39
Le Fort fractures, 405f for genial tubercle reduction, 169 Lithotripsy
bone plates, 375f for mylohyoid ridge reduction, 171 for parotid gland sialoliths, 676
children, 534 exposure technique, 831f Littles area, 1347
hemorrhage, 438 injuries, 820, 822, 1254 Liver disease, 3435
orbital fractures with, 477 Lingual splint, 416, 416f, 1259f assessment of, 77
Le Fort III osteotomy, 527 Lipexeresis, 1407 L-lactic acid resorbable plating system, 441442
Le Fort I maxillary osteotomy Liposculpting, 14071418 Load-bearing fixation
delayed hemorrhage, 1248 Liposuction. See also Cervicofacial liposuction bone plate, 375f
Le Fort I island as adjunctive procedure, 14111412 vs. load-sharing fixation, 375376
maxillary tumor, 645f facial Load-sharing fixation
Left medial canthus postoperative instructions, 1418 vs. load-bearing fixation, 375376
reattachment, 477f syringe system, 1409f Local anesthetics
Left ventricular dysfunction, 2223 Liposuction-assisted rhytidectomy, 1412, 1413f TMJ, 953
Lens Lipping, 974, 977f Local flaps, 769781, 772776
discoloration, 473 Lips Localized pigmented lesions, 682685
Lentigo maligna, 703f avulsive injuries, 369f Locking plate-screw systems, 378379, 379f
Lentigo maligna melanoma, 684, 703 cancer, 659667, 662663 Lockwoods ligament, 446, 466, 1322
Lentigo simplex, 683 anatomic considerations, 659660 Long dolichocephalic faces, 159
Leukocytes, 4, 6, 8 cervical lymphadenectomy, 666 Long drills, 242
Leukoplakia, 618f, 619, 632633 cervical metastasis from, 660 Long-term endosseous implant
proliferative verrucous variant epidemiology, 659660 first, 189
gingiva, 618f etiology, 659660 Loracarbef
transformation to squamous cell neglected, 620f for rhinosinusitis, 502
carcinoma, 632 oral, 641645 Lorazepam
treatment staging, 661t chemical structure of, 86f
Cochrane review, 632 surgery, 661662 for delirium tremens, 39, 635
ventral tongue, 632f treatment, 660661 pharmacology of, 87
Leukotrienes results, 666667 L osteotomy, 1137f, 1294f
end-stage TMJ disease, 1019 tumor node metastasis system, 661t inverted, 1136, 11461150, 1147f, 1148f
Levator aponeurosis excision, 662, 662f reverse, 1290f
cross-sectional view of, 1320f injuries, 366 Lower eyelids
Levator palpebrae superioris muscle, 466, lower blepharoplasty, 13341337
1323, 1325, 1328 actinic cheilitis, 618f complications of, 13401341
Levofloxacin changes with orthodontic incisor ectropion, 1341
for rhinosinusitis, 502 retraction, 1224 fat removal, 1341
Lichen planus, 692693, 692f, 693f lymphatic drainage, 660 lateral canthopexy, 1337
Lidocaine, 359 metastasis from, 660 midfacial rejuvenation, 1337
Index 745
interpositional iliac crest grafts, 181f multidirectional maxillary movements, MEC, 672
mesiodistal teeth diameter, 1112t 1226 Mechanical creep, 712
model, 1182f nasal structures, 12241225, 1225f, Mechanical stimulation, 386
molars 1225t Medial canthal ligament, 13211322
impacted, 132f poor esthetic results with, 1234, 1235f Medial canthal tendon, 465, 484, 493
multiple implant-borne restorations, posterior repositioning, 1226 instability, 496
199200 postoperative hemorrhage, 1248 Medial canthus
nonunion, 12501251 soft tissue, 12241229, 1234 left
orthognathic surgery, 11791201 superior repositioning, 1226 reattachment, 477f
anterior repositioning, 1192 teeth Medial lid lacerations, 477f
historical development of, 1179 bone removal, 145 Medial zygomaticotemporal vein, 1389
inferior repositioning, 1192 eruption of, 1063 Median mandibular cyst, 608
intraoperative positioning, 11801181 extraction, 201t Median rhomboid glossitis, 680681, 681f
models marked for, 1181f third molars Medically compromised patients
osseous structures, 11811183 impacted, 131 mandibular fracture
posterior repositioning, 11921193 delivery of, 149f open reduction, 418
reference marks for, 11801181 tori, 171f Medications
soft tissue envelope, 11841185 removal of, 170171 to avoid during pregnancy, 42t
superior repositioning, 1192 transverse tilting of, 1099f for breast-feeding mothers, 42t
surgical anatomy, 11811185 tuberosities, 1062, 1183 determining preoperative risk, 1718
surgical techniques, 11851193 tumor history
vascular structures, 11831184 Le Fort I island, 645f blepharoplasty, 13271328
orthopedic expansion appliances, 1071f vestibular incision, 551 Medicinal leeches, 780
osteoradionecrosis, 322f vestibuloplasty, 175 Meglumine diatrizoate, 518
osteotomy Maxillary-nasal base esthetic unit Meissners corpuscles, 709
anterior nasal spine reduction, 1241f craniofacial dysostosis syndrome, 904 Melanin pigmentation
first American report of, 1179 Maxillectomy, 254f smoking
lateral, 1273f Maxillofacial area gingiva, 682
stable fixation for, 1193 in trauma patient, 349 Melanocytes, 709
palatal cuspid Maxillofacial examination Melanocytic lesions, 683
impacted, 134 dentoalveolar injuries, 384386 Melanoma in situ, 703
paresthesia, 1253 Maxillofacial imaging Melanomas, 683684, 684f, 701714
posterior segmentalization of, 1179 osteomyelitis, 315 acral-lentiginous, 684, 703
premolar replacement, 199f Maxillofacial injuries, 349 biopsy, 704t
reconstruction of, 795798, 798f Maxillofacial prostheses, 267268 description, 702704
case studies, 795798 craniofacial defects, 268269 lentigo maligna, 684
regions, 784f mandible defects, 267268 nodular, 684, 703
ridge extension procedures, 174175 maxillary defects, 268 risk factors, 701702
segmental distraction, 12841286 radiotherapy, 269 superficial spreading, 684
sensory injury in, 1253 Maxillomandibular advancement survival rates, 704t
setback OSA, 13081310, 1311t Membrane-placement instrument, 213, 215
soft tissue changes associated with, 1228t Maxillomandibular complex Membranous bone
severe atrophy, 237f manual positioning of, 1188f formation of, 192193
single-unit restorations, 200 Maxillomandibular discontinuities, 239f Meningitis, 500
sinus, 464, 1181 Maxillomandibular fixation Mental foramina
CT, 163f skeletal fixation, 1141f radiography, 253f
fungal balls, 303f Maxillomandibular fixation (MMF), 371, Mental status
Waters radiography, 470f 12811282 of trauma patient, 338
sinusitis, 299 McCain, Joseph, 964 Menton
submucosal vestibuloplasty, 176f McGill Pain Questionnaire (MPQ), 825 osseous deposition at, 1232f
surgery, 11851190 MDMA Meperidine
anterior repositioning, 1226 anesthesia with, 121122 chemical structure of, 88f
anterior segmental repositioning, 1225 Measles, 688689 in elderly, 41
inferior repositioning, 1226 Meatus overdose of, 344
labial structures, 1225, 1225f narrowed, 1458 pharmacology of, 88
748 Index
Multiple trauma algorithm, 331f Nasal tip inspection of in trauma patient, 349
Murakami, Ken-Ischiro, 964 defect, 366f levels, 667f
Murmurs, 107 definition, 1352f lymph node levels of, 619f
Muscarinic receptor antagonists rhinoplasty, 1352 oral cavity
children, 117 projection squamous cell carcinoma, 648f
Muscle injections rhinoplasty, 13521353 palpation of, 625
for TMJ, 957 rhinoplasty, 13591363 in trauma patient, 349
Muscle relaxants, 954t rotation Necrotizing fasciitis, 281, 281f
TMJ, 953 rhinoplasty, 1353 Necrotizing ulcerative gingivitis, 681
Muscular dystrophy Nasal valve, 1350 Needle decompression, 284
anesthesia with, 120 alterations in, 1256 Neisseria gonorrhoeae, 682
Musculoaponeurotic system incision, 1376f Nasal wall TMJ, 944
Musculocutaneous arteries, 710 anatomy and physiology of, 297, 297f Neoadjuvant chemotherapy, 639
Mustarde technique, 1453f, 14541456, 1456f Nasoantral window, 298 Neocondyle
Muzzleloaders, 513 Nasociliary nerve, 1325 transport distraction osteogenesis, 12891290
Myelin sheaths, 824 Nasofrontal angle Neonate
Mylohyoid attachment, 175 rhinoplasty, 13511352 cranial base, 1061f
Mylohyoid ridge reduction, 171 Nasofrontal duct, 497f skull
Myocardial infarction, 4950 evaluation of, 499f fontanelles, 1060f
general anesthesia risk after, 20 identifying, 499f sutures, 1060f
Myocardial ischemia, 18, 19, 4849 intraoperative evaluation of, 498499 Neonates, 42
Myocutaneous flaps, 770f obstruction, 500501 Neophyte clinician
latissimus dorsi, 780 patency, 496 vs. expert clinician
pectoralis major, 777778 Nasofrontal suture line, 1385 case study, 567568
trapezium, 779780 Nasolabial cysts, 608, 609f Neovascularization, 8
Myofascial pain and dysfunction (MPD), 941 Nasolabial flap, 774775, 776f Nephrosclerosis, 32
Myositis ossificans progressiva, 941, 1035f Nasolacrimal apparatus Nerve growth factor (NGF), 13
Myotonic dystrophy, 941 soft tissue injuries, 364365 Nerves
Nasolacrimal duct damage
N ostium, 437 BSSO, 11561158
Nalbuphine Nasolacrimal system grafts, 833
pharmacology of, 89 anatomy of, 365f donor size, 833t
Naloxone Nasomaxilla injuries, 12531255
pharmacology of, 89 development of, 10601061 classification of, 824825, 824f
Narcolepsy, 1298, 1299 intramembranous growth, 1061f Seddon vs. Sunderland, 825t
Narcotics malformations, 10651066 mandibular fracture, 426427
avoidance in COPD, 30 Naso-orbitoethmoid (NOE) fractures, peripheral, 827828, 828t
Nasal cavity 467, 488, 495f layer formation, 10511052
lateral wall of, 340f children, 532534 stump preparation, 832, 832f
packing of, 340, 340f classification, 496, 498f treatment algorithms, 829f
Nasal dorsum, 1352f, 13581359 imaging, 496 wound healing, 6
augmentation, 13581359 osseous recovery, 498 Neural complications
reduction, 1358 reconstruction, 501502 horizontal ramus osteotomies, 1164
rhinoplasty, 1352, 1353 Nasopalatine duct cyst, 608609, 609f Neural crest migration, 1053f
Nasal septum, 437 Nasopharyngeal carcinoma, 1036f Neural damage
abnormalities of, 298 Nasotracheal intubation, 439 VSO, 1146
alterations in, 1255 Nausea, 1299 Neural fascicular patterns, 822, 823f
anatomy of, 437f, 1349f Neck. See also Head and neck Neural innervation
anterior aspect of, 1189f dissection children, 105
arteries, 1348f in-continuity vs. discontinuity, 650 Neural wound healing, 823f
cartilage resection, 1357f examination of, 357 Neurocranium
hematomas, 364 gunshot wounds, 517519 formation of, 1055
repositioning, 1357f decision tree, 519f Neurofibroma, 610611, 610f
sensory nerves, 1351f surgery, 520522 Neurofibromatosis, 682
suturing to anterior nasal spine, 1190f injuries, 366367 Neuroleptic malignant syndrome (NMS), 63
750 Index
Neurologic disorders NOE. See Naso-orbitoethmoid (NOE) unilateral coronal synostosis, 891895, 892f
assessment of, 7879 fractures unilateral lambdoid synostosis, 899
cerebrovascular disease, 37 Noel, Suzanne, 1317 Nonunion
epilepsy, 78 No light perception (NLP), 472 mandible, 1251
malignant hyperthermia, 3738 Noncompetitive antagonists, 84 mandibular fracture, 425426
spinal cord disorders, 38 Noncompression plate osteosynthesis maxilla, 12501251
stroke, 37, 78 vs. compression plate osteosynthesis, 378 maxillary fractures, 442
caused by hypertension, 32, 79 Nondepolarizing agents Norepinephrine, 338
TIA, 37, 7879 pharmacology of, 98 Normal radiography of
Neuroma, 6, 611f Nondilated cardiomyopathy, 69 chest, 348f
traumatic, 611 Non-Hodgkins lymphoma, 689690 Normochromic anemia, 3031
types of, 824f Nonischemic heart disease, 6869 Normocytic anemia, 3031
Neuromuscular-blocking medications Nonmelanoma skin cancer, 697700 Nose
pharmacology of, 97 applied skin anatomy, 709710 air passages
properties, 99t chemotherapy, 708 children, 528
Neuromuscular disorders, 3738 cryosurgery, 708 anatomy, 13451360
assessment of, 7879 curettage, 708 anatomy and physiology of, 297
seizure disorders, 37 electrodesiccation, 708 basal cell cancer, 707f
Neuropeptides, 300 epidemiology, 697 base alar reduction, 1363
Neuropraxia, 6 etiology, 697698 bilobed flap of Zitelli, 714
Neuropsychiatric disorders, 888 excision, 705 blood supply, 13461347
Neurorrhaphy, 833, 833f flaps, 710711 bones, 437, 13471348
Neurotmesis, 6 interferon, 709 anatomy of, 437f
Neutrophils, 4, 193 lasers, 708709 cartilage, 13471348
Nevi, 683 Mohs micrographic surgery, 705708 chemicals irritating, 300
Nevoid basal cell carcinoma syndrome, photodynamic therapy, 709 continuous positive airway pressure
580581, 580f prevention, 699700 for OSA, 1302
Nevus sebaceus of Jadassohn, 698, 699f radiation therapy, 708 endoscope, 308f
Newborns. See Neonates retinoids, 709 examination
New York Heart Association cardiac patient treatment, 704705 fiberoptic, 295
classification, 6768, 67t Nonopioid analgesics external
NGF, 13 end-stage TMJ disease, 10181019 arteries of, 1347f
Nicardipine Nonrestorable tooth sensory nerves, 1350f
for hypertension, 32 orthodontic extrusion of, 266f fractures
for hypertensive crisis, 50t replaced with immediate implant, 267f children, 537538
Nicotine Nonrigid internal fixation, 371373 incidence, 488
effect on cardiovascular system, 57 vs. rigid internal fixation, 371382 gull in flight contour, 1098f
Nikolskys sign, 690 Nonsteroidal anti-inflammatory drugs laceration, 476f
Nitroglycerin, 67 (NSAID), 641, 952t lateral wall
Nitroprusside avoidance arteries of, 1347f
for hypertensive crisis, 50t in liver disease, 35 musculature, 1346, 1346f
Nitrous oxide in renal patients, 31 nerves, 13481350
avoidance in COPD, 30 ideal properties, 952t packing
chemical structure of, 96f inhibiting platelet function, 78 balloon catheters, 517f
children, 114 periarticular ectopic bone formation, 1027 polyps, 298
pharmacology of, 93, 9596 for rheumatoid arthritis, 36 projection, 1353f
properties of, 94t for TMJ, 951 secretions
NLP, 472 Nonsyndromic craniosynostosis, 887899 normal values of, 495t
NMS, 63 bilateral coronal synostosis, 892895, 895f skin, 13451346
Nobecutane spray, 718 classification, 888889 soft tissue, 13451346
Nobel Biocare implants, 243 diagnosis, 888 injuries, 364365
Nocturnal myoclonus functional considerations, 887888 structures
sleep-related, 1298 management, 891899 maxillary surgical procedures,
Nodes of Ranvier, 823 metopic synostosis, 896f897f 12241225, 1225f, 1225t
Nodular melanomas, 684, 703 sagittal synostosis, 896897, 898f surface anatomy, 1345, 1345t
Index 751
placement without trauma, 190191 Outpatient anesthesia medications bone removal from, 1197f
restorations, 199200 distribution of, 8485 Palatoplasty
surgical protocol, 190192 pharmacodynamics of, 8385 Bardach two-flap, 852
time for, 191 pharmacokinetics of, 8485 two-flap, 874f
two implants, 195 pharmacology of, 83100 Palliative chemotherapy, 639
wound healing, 192193 Overdentures Palpebral lobe, 466
Osseointegration implants, 251f bar attachment, 264f Pancuronium
ear, 368f bar splint, 237f pharmacology of, 98
Osseous surgery, 11861187 implant-retained, 264 properties, 99t
Ossification, 1055 implant-supported, 254 Panendoscopy, 624
Ossifying fibroma, 599600, 599f attachment mechanisms for, 265 Panfacial fractures, 547557, 556f557f
Osteoarthrosis, 941 long-term overuse, 238f anatomic considerations, 547548
Osteoblastoma, 600, 600f precision detachable, 265f bone grafts, 551552, 552f
Osteoblasts, 7, 165, 192193, 371 Oxazepam complications, 555
Osteochondroma, 601602, 602f for DT, 39 etiology, 547
Osteoclastogenesis inhibitory factor/ Oxidative stress historical perspective, 547
osteoprotegerin (OCIF/OPG) TMJ, 942 soft tissue resuspension, 551552
TMJ, 943 Oxycodone treatment sequence, 552555, 553f, 554f, 555t
Osteoclasts, 8, 166, 786 for TMJ, 951 Panoramic radiograph
Osteoid Oxygenation zygoma implants, 244f
bone formation in, 192193 trauma patient, 336337 Panoramic radiographs
Osteoid osteoma, 600 Oxygen dissociation curve, 57f alveolar ridge, 163f
Osteoma, 601, 601f Oxygen therapy condylar neck fracture, 407, 407f
Osteomeatal complex
for OSA, 1302 condyles asymmetry, 1208f
CT, 303f
Oxymetazoline edentulous mandible, 194
diagram of, 296f
for sinus infection, 305 facial asymmetry, 1209
Osteomyelitis, 313318, 500
Oxymetazoline hydrochloride, 502 implants, 253
classification of, 314
maxillary canine teeth, 133, 133f
clinical characteristics, 314315
P for preprosthetic and reconstructive
malignancy masquerading as, 320f
Pacinian corpuscles, 709 surgery, 160
mandibular fracture, 426
Paclitaxel, 640 Panorex
microbiology of, 314
Pagets disease, 611612, 611f, 612f intrusion, 392f
pathogenesis of, 313314
Pain, 405, 494 Papilla
surgery, 317318
treatment, 316317 frontal sinus, 503 creating/preserving, 252t
Osteons, 371 with impacted teeth removal, 150 Papillary epithelial lesion
Osteopenia, 307 with osteomyelitis, 314 asymptomatic, 565f
Osteoplasty with TMJ end-stage disease, 10161018, Paraformaledhyde-containing paste, 299
arthroscopic, 978f 1016t Parallel walled screw, 256
ridge split, 176177 unexplained, 142 Paranasal sinuses
Osteoporosis, 41, 252, 307, 424 Palate, 1182 anatomy and physiology of, 297
Osteoprogenitor cells, 164 distraction appliance, 1073f children, 529
Osteoradionecrosis, 318322 flaps, 866, 867f CT, 304f
maxilla, 322f rotated, 772 development of, 1057
Osteotomes, 200, 233f incisions, 218 Paraplegia, 38
and condylar arthroplasty, 1003f mucosa, 11841185 Parasymphyseal fractures, 541f
and lateral nasal wall, 1272f pedicle children, 541
and nasal septum separation, 1187f for anterior maxillary osteotomy, 1195f, Parasymphysis fractures, 409
Osteotomy, 645646, 11611164. See also 1196f Pare, Ambroise, 509
specific osteotomy pleomorphic adenoma, 673f Parels classification of edentulous maxilla, 197
Lanes, 1137f recurrent low-grade polymorphous adeno- Parents
lateral wall, 1187f carcinoma, 674f presence during sedative administration, 105
of ramus salivary gland tumors, 673674 Paresthesia
Obwegesers, 1150, 1150f, 1179 squamous cell carcinoma, 645 maxilla, 1253
Ostium Palatine arteries, 1183f, 1184f, 1248 with osteomyelitis, 314
nasolacrimal duct, 437 Palatine bone, 437, 1188f Parotideomasseteric fascia, 994f
754 Index
Parotid gland, 358f, 671 Penrose drain, 285 cardiac assessment, 4753
ducts Pentazocine cigarette smoking, 5658
sialogram, 676f avoidance in liver disease, 35 electrolytes and acid-base disturbances, 5354
injuries, 358359, 359f Pentobarbital endocrine assessment, 5961
pleomorphic adenoma, 673f chemical structure of, 90f malignant hyperthermia, 6263
posterior duct stones, 676 pharmacology of, 91 pulmonary assessment, 5455
squamous cell carcinoma, 642 Peptic ulcer disease, 3536 renal insufficiency, 54
stones, 676 Peptostreptococcus, 140 Perioperative morbidity
terminal duct stones, 676 Percussion sensitivity, 385 risk factors associated with, 47t
tumors, 672673 Periapical cemento-osseous dysplasia, Perioperative risks
Paroxysmal atrial tachycardia (PAT), 27 598599, 599f determinants of, 17
Paroxysmal supraventricular tachycardias Periapical occlusal method, 133 Perioral-periorbital carbon dioxide laser
(PSVT), 51 Periapical radiographs resurfacing, 1426f
Parry-Romberg syndrome, 1207 alveolar and dental fractures, 386387 Periorbital ecchymosis, 437, 494
Partial-thickness curvilinear incision, 213 implants, 252 Periorbital incision sites, 455f
Partial-thickness pedicle flaps Periarticular ectopic bone formation, Periosteum
subepithelial connective tissue graft, 212 10251027 cells, 373f
Partial transfixion, 1348f Pericardial aspiration, 339 children, 529
PASG, 339 Pericardiocentesis, 339f elevator, 866, 1387f
Passive jaw exercise Perichondritis incision, 452
for TMJ, 955, 955f, 1025 protruding ear, 14571458 stripping, 1290
Pasteurella multocida, 362f Perichondrium Peripheral cranial nerves, 357
PAT, 27 identification, 1357f Peripheral nerve injuries
Pathologic fracture, 410 Pericoronitis pharmacologic management, 827828, 828t
Patient follow-up, 572, 572t prevention of, 140 Peritoneal lavage fluid
Patient history, 564565 Pericrestal incisions, 206, 206f evaluation of, 352t
PCP Periimplant soft tissue Permanent cavity, 511
anesthesia with, 122123 papilla regeneration, 207208, 208f Permanent teeth
PDGF-BB, 13, 225 resective contouring, 207, 208f developing buds, 398f
PDT surgical maneuvers, 206208 children, 529
leukoplakia, 632633 Perimandibular space, 278 impacted, 132
Peck graft, 1361f Perinasal incision, 551 PET. See Positron emission tomography (PET)
Pectoralis major myocutaneous flaps, 777778, Periodontal concussion, 389f Petechiae, 685
777f Periodontal disease Petzel technique, 422f
harvesting, 796f HIV, 689 Peutz-Jeghers syndrome, 682
Pediatric patients. See Children implants, 252 Pfannenstiels incision, 501
Pedicled grafts, 183 Periodontal healing Pfeiffer syndrome, 903, 924f, 925f
Pedicle flaps after replantation, 395f Pharyngeal flaps, 12741275
partial-thickness Periodontal injuries inferiorly based, 878
subepithelial connective tissue graft, 212 classification of, 391392 superiorly based, 878
split-thickness Periodontal ligament Pharyngeal space
subepithelial connective tissue graft, 212 cell metabolites abscess, 282f
Pedicles solutions to replenish, 394t computed tomography of, 291f
passive adaptation of, 207 injury, 385 drainage of, 285f
Pelvic fracture, 341f, 353 Periodontal problems lateral
Pemphigus, 690 total alveolar osteotomy, 11671168 borders of, 278t
antibodies, 690f Periodontal subluxation, 389f infection, 279t
Penicillamine, 691 Periodontal tissue injuries, 390395 Phenobarbital
for rheumatoid arthritis, 36 Perioperative analgesic medications chemical structure of, 90f
Penicillin pharmacology of, 97 Phenol, 1341
avoided with renal patients, 31 Perioperative antibiotics Phenothiazines
mandibular fracture, 425 oral cancer, 635 children, 117
for rhinosinusitis, 305, 502 Perioperative cardiovascular evaluation for psychotic disorders, 39
Penicillin V algorithm, 7071 Phentolamine
for odontogenic infection, 289 Perioperative considerations, 4763 for hypertensive crisis, 50t
Index 755
Substance abuse, 3940 Supraorbital nerves, 465, 1325, 1389, 1393f Syncope, 68
children, 120123 Supraorbital notch, 464 Synechiae, 309
inhalational Supraorbital ridge fractures Synovial chondromatosis, 601602
anesthesia with, 122 children, 532 TMJ, 945
maxillofacial trauma, 384 Supraorbital vessels, 1393f Synovial disorders
Substance P, 300 Supratarsal fold incision, 452, 453f classification of, 941t
Succinylcholine Supratrochlear nerve, 1389, 1390 Synovium
avoiding in malignant hyperthermia, 38 Supraventricular tachycardias, 25 TMJ, 934935
children, 116 Surgeons Syphilis, 681682
pharmacology of, 98 experience and training of, 149 Syringe liposuction system, 1409f
properties, 99t Surgical guides, 1288f Systemic lupus erythematosus (SLE), 3637,
Suction-assisted lipectomy Surgically assisted rapid palatal expansion 691
informed consent, 14161417 (SARPE), 11971198 Systemic reserve
Suction device, 1409 arch length discrepancy, 1198 odontogenic infection, 283
Sufentanil arch morphology, 1198
chemical structure of, 88f history, 11971198 T
pharmacology of, 89 surgical technique, 11981200, 1199f, 1200f T3, 33
Suicide vertical dimension, 1198 T4, 33
shotgun wounds, 515, 515f Surgical microscope Tachycardia, 338
Sulbactam, 944 historical development of, 803 with hypotension, 345
Sulcular incision, 225 Surgical mobilization Tagaki, Kenji, 963
Sulfa position in facial asymmetry, 1213 Tanning, 697
avoided with renal patients, 31 Surgical patient Tapered fissure bur
Sulfasalazine medical management of, 1742 702L, 225
for rheumatoid arthritis, 36 Surgical splints Tapered-wall screw implant, 256f
Sulfonylureas maxillary fractures, 440441 Tarsal plate, 466
mechanism of action, 60t Surgical stent Tarsus, 1321, 1322f
Sunder classification, 824, 824f for implant placement, 164f Tattoo deformity, 10
Sunscreens, 700 Suture milia Tattooing, 359, 360, 685
Superficial chemical peeling, 14221423 upper eyelid blepharoplasty, 1339 TCA, 1341
Superficial fascia, 992 Sutures peels, 1427t
Superficial musculoaponeurotic system neonatal skull, 1060f Tear film, 1326
(SMAS), 1318, 13741378 Sweat test, 301 composition, 1326
description of, 1318 Swelling Technetium 99m
and manipulation, 1371 with impacted teeth removal, 150 facial asymmetry, 1209
and rhytidectomy, 1365 Swiss Association for the Study of Internal osteomyelitis, 315
and subcutaneous dissection, 1374, 1376f, Fixation (AO/ASIF) Teeth
1377f compression plates, 402 arch symmetry, 1115, 1115f
Superficial spreading melanoma, 684 fracture management biomechanical prin- missing, 1131
Superficial temporal ciples, 373 permanent
infection, 279t Swiss screw, 201 developing buds, 398f
Superficial temporal artery, 1389 Switching stick, 1187f children, 529
Superior dislocation, 411 TMJ arthroscopy, 971f impacted, 132
Superior joint space, 996f Swivel latches, 266f sectioning, 145
Superiorly based pharyngeal flaps, 878, 879f Symmetry selling for transplantation, 189
Superior meatus rhinoplasty, 13511352 size, 11121113
anatomy and physiology of, 297 Symphysis discrepancy, 11201122
Superior oblique muscle pulley, 465 block graft harvest, 225 vitality, 385
Superior orbital fissure syndrome, 472 donor site morbidity, 228 Telecanthus, 476
zygomatic arch fractures, 459 force, 404f Telephone ear deformity, 1458
Superior orbital rim, 464 fracture, 405, 409 Telescoped fractures, 410
Suprahyoid muscles, 938, 1141 bone plate, 382f Temporal incisions, 450, 1398
Supramandibular muscles, 938 internal wire fixation, 373f Temporalis fascia, 446
Supraomohyoid neck dissection, 649f posteroanterior mandibular view, 414f Temporalis flap, 778779, 778f
Supraorbital bar reconstruction, 500 reconstruction, 1288 Temporalis muscle, 938, 938f, 1007
762 Index
circulation, 337344 with impacted teeth removal, 150 lid crease asymmetry, 1339
initial management of, 327354 with osteomyelitis, 314 preoperative concerns, 13311333
injury severity assessment, 327330 zygomatic arch fractures, 459460 skin excision, 1339
neurologic examination of, 344345 Trocars examination of, 1328
primary survey, 330344, 344f rhytidectomy, 1368f fat pads, 1324
secondary assessment of, 344345 TMJ arthroscopy, 970, 971f laxity, 1394f
stabilization of, 349f Trochlea, 464 transcutaneous blepharoplasty, 1333f
triage decision scheme, 328f T-shaped incision, 996 Upper lips
Trauma Score, 328 Tuberculectomy augmentation, 1443f
Traumatic avulsion lateral, 1003f changes with orthodontic incisor
premaxillary segment, 1287f Tuberosity reduction, 169, 170f retraction, 12231224
Traumatic bone cyst, 609, 610f Tube shift method, 133 developing, 660f
Traumatic hyphema Tumescent solution, 1410t Upper respiratory infection
zygomatic arch fractures, 459 Tumescent technique, 1368f children, 106107
Traumatic loop deformity, 776f Kleins, 1409 UPPP, 1305f
Traumatic neuroma, 611 Turbinate pneumatization, 298 OSA, 13051306
Traumatic optic neuropathy Turbinectomy Urethral meatus
zygomatic arch fractures, 459 rhinoplasty, 1358 blood at, 343f, 353
Trauner, 1150 Turner syndrome, 1066 Urinalysis, 353
TRD Twist drill, 242f Urinary tract disease, 30
OSA, 1303 Two-flap palatoplasty, 874f Urine
Treacher Collins, 74, 104 Bardach, 852 output in children, 42t
Treponema pallidum, 681 Two-implant bar Uvula
Triage decision scheme clip overdenture retention, 194f surgical specimen of, 1306f
trauma patient, 328f Two-point fixation Uvulopalatopharyngoplasty (UPPP), 1305f
Triamcinolone acetonide, 475 one-point fixation, 377 OSA, 13051306
Triazolam Two-staged titanium implants, 189
pharmacology of, 87 V
Tricalcium phosphate, 168 U Vagus nerve, 1451
Trichloroacetic acid (TCA), 1341 Ulcerated lesions, 685686 Valacyclovir, 688
peels, 1427t Ulcers, 565 Valdecoxib
Trichophytic forehead lift, 13951396 Ultrasonography, 569 for rheumatoid arthritis, 36
Tricyclic antidepressants abdominal injuries, 352353, 354t Valvular heart disease, 2324, 68
for affective disorders, 3839 cervical lymph nodes, 647 mitral regurgitation, 24
for TMJ, 952953 oral cancer, 625626 mitral stenosis, 2324
Trigeminal nerve, 1325 TMJ, 956 Vancomycin
anatomy and physiology, 822824, 822f Ultraviolet damage, 1420 for odontogenic infection, 289
fibers, 823t Umbrella graft, 1361f Van Graefe, Carl Ferdinand, 435
injuries, 821 Uncinate Varicella-zoster virus, 686, 687688
demographics, 819820 anatomy and physiology of, 297 Varix, 684685
third division of, 11391140 Unconjugated bilirubin, 77 Vascular compromise
Trigger points Unerupted teeth management of tissue after, 12531254
for TMJ, 957 vs. impacted teeth, 140 Vascularity
Trigonocephaly, 890f, 896f localizing, 133 loss of, 12491250
Triiodothyronine (T4), 33 University of Maryland Vascularized fibular graft to mandible
Trimethadione, 691 shock trauma center, 527 implants, 268f
Trimethaphan camsylate Upper blepharoplasty incision, 482483 Vascularized interpositional periosteal
for hypertensive crisis, 50t Upper eyelid connective tissue flap (VIP-CT),
Trimethoprim crease, 1328 217220, 217f, 218f, 220f
for COPD, 30 crease incision, 551 surgical technique, 217218
Trimethoprim/sulfamethoxazole Upper eyelids Vascular lesions, 684685
for rhinosinusitis, 305, 502 blepharoplasty, 13311334 Vascular malformation
for sinus infection, 305 complications, 13391340 high-flow, 606f, 607f
Triple endoscopy, 624 fat removal, 1339 Vasopressin
Trismus (stiffness), 281 high lid crease, 1339 for arrhythmias, 52
Index 765