andrew stewart consultant maxillofacial · pdf fileoral & maxillofacial surgery a tasting...
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Oral & Maxillofacial Surgery A tasting menu
Andrew Stewart
Consultant Maxillofacial Surgeon Epsom & St Helier
St Georges Kingston
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What is Oral & Maxillofacial Surgery?
• Mouth
• Jaws
• Face
• Neck
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What is Oral & Maxillofacial Surgery?
• TRAUMA • Oral & Cervico-facial infection • Mouth cancer • Skin cancer • Jaw deformity including cleft lip & palate • Salivary gland disease • Oral mucosal disease • Temporomandibular joint disease • Facial pain
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Oral & Maxillofacial surgery in the NHS
• South west London hub and spoke
• St Georges
• Epsom & St Helier
• Kingston
• Croydon
• Ashford & St Peters
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Maxillofacial trauma ‘‘The boy lay for dead a while, and
dozed longer. It appeared a strange sight at first to me, his face being beaten in, and the lower jaw sticking out . . .there I saw the Os palati and the uvula beaten so close backwards . . . . Upon which I got up behind the uvula; then raising it a little upward, pulled it forward with the bone into its former place very easily’’.
Richard Wiseman (1622—1676)
Several Chirurgical Treatises- 1676
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Trauma
• Mechanism • Blunt vs Sharp/Penetrating • High vs low velocity • Soft tissue • Bony injuries
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Trauma
• Interpersonal violence
• RTA
• Falls
• Sports
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Fronto-orbital fracture
• Struck by bottle in night club
• Treated by ORIF
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Fronto-orbital fracture
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Frontal bone fracture
• Play fighting
• Treated by ORIF
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Frontal bone fracture
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Orbital floor fracture
• Blow to globe with tennis ball
• Enophthalmos and diplopia
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Orbital floor fracture
Large bony defect
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Orbital anatomy
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Orbital fracture
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Orbital fracture
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Maxillofacial Infections
• Teeth
• Tonsils
• Sinuses
• Skin
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Dental infection
• Dental decay
• Periodontal disease
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Ludwigs Angina
• Life threatening spreading infection
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Common oral diseases
• Lumps, bumps and swellings
• Inflammation, ulcers, blisters and vesicles
• White and red patches
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Mucocoele
• Typically lower lip
• Soft, translucent hemisphere
• Conservative excision
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Sub-lingual mucocoele
• Ranula
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Filiform papilloma
• Exophytic lesion with narrow base
• Conservative excision
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Fordyce granules • Ectopic sebaceous glands
• Cheeks and lips
• Reassurance only
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Lingual tonsil
• Lymphoid tissue
• Ring of Waldeyer
• Reassurance only
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Fibrous epulis
• Pale exophytic lesion
• Gingival margin
• Associated dental disease
• Conservative excision
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Fibroepithelial polyp
• Pink, firm, sessile non-ulcerated
• Tongue, lips and cheeks
• Conservative excision
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Leaf fibroma
• Pedunculated, flattened fibroepithelial polyp
• Denture
• Conservative excision
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Vascular lesions
• Low flow venous vascular malformation
• Dark blue sessile lesion
• Reassurance or conservative excision
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Vascular lesions
• Extensive low flow venous vascular malformation
• Troublesome dysarthria
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Venous vascular malformation
• Macroglossia and dysarthria
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Crohn’s disease
• Swelling of lip
• Oedema of cheeks and floor of mouth
• Biopsy - granulomatous inflammation
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Lichen planus
• Inflammatory mucocutaneous disease
• Unknown aetiology
• Oral lichenoid reactions
• Tongue, cheeks and gingivae
• Reticular, atrophic and erosive forms
• 10% oral and cutaneous involvement
• Malignant change rare
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Lichen planus
• Reticular lichen planus of tongue
• Topical steroids if sore
• Observation
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Lichen planus and squamous carcinoma
• Malignant transformation rare
• Lichenoid dysplasia
• Biopsy for diagnosis
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Leukoplakia without dysplasia • White patch that can not be wiped away
• 20 per day for 40 years. Little alcohol
• Biopsy no dysplasia
• Cessation of smoking and observation
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Oral ulceration
• ROAU
• Trauma
• Single/multiple
• Recurrent/Persistent/Progressive
• Risk factors for cancer – smoking, alcohol, Betel nut, HPV
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Traumatic ulcer
• White patch of tongue - progression to large ulcer
• LL6 sharp – biopsy benign
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Traumatic ulcer
• Sharp tooth smoothed
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Apthous ulceration • Minor
• Major
• Herpetiform
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Oral cancer
• Squamous cell carcinoma
• M>F
• 6th decade onwards
• Tobacco / Alcohol / Betel nut / HPV / Oral LP
• Sump areas
• Persistent / progressive ulcer or mass
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Oral squamous cell carcinoma
• 2% of all malignancy
• 2 week rule
• Low pick up rate - 4%
• Surgery / radiotherapy
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Antral squamous carcinoma
• Advanced disease
• Palliative care
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Minor salivary gland tumours
• 50% malignant
• Firm lobulated sub-mucosal mass
• Lips, palate and cheeks
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Minor salivary gland tumours
• Low grade polymorphous adenocarcinoma
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Neck lumps
• Midline or lateral
• Nodal, salivary or thyroid
• Benign inflammatory
• Malignant – primary / metastatic
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Obstructive salivary gland disease
• Submandibular gland (enlarged) and tender
• Pain and swelling with meals
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Atypical mycobacterial cervical lymphadenitis
• Large submandibular mass
• No systemic symptoms or signs
• Excision of node
• M.malmoense
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Pleomorphic adenoma of parotid gland
• Slow growing firm ovoid mass
• Tail of parotid
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Pleomorphic adenoma
• Superficial parotidectomy
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Pleomorphic adenoma
• Firm mobile mass
• Superficial lobe
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Pleomorphic adenoma
• Superficial parotidectomy
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Adenocarcinoma ex-pleomorphic adenoma
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Sjogrens syndrome
• Dry eyes and mouth
• Autoimmune salivary and lacrimal destruction
• Rheumatiod arthritis or other connective tissue disease
• Risk of lymphoma
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Post irradiation facial atrophy
• Xerostomia
• Risk of osteoradionecrosis of jaws
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MRONJ • Bisphosphonates
• Denosumab –monoclonal antibody
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MRONJ
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Orthognathic surgery • Literally - straight jaw
• Functional dental occlusion
• Balanced facial proportions
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Classification of jaw relationship
• Class I
• Class II
• Class III
• AOB
• Traumatic overbite
• Asymmetry
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Normal dental occlusion
• Incision
• Grinding
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Well balanced facial proportions • Eye of the beholder
• Racial variation
• Agreement between experts and lay people
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Well balanced facial proportions
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Multidiciplinary treatment
• General dental practitioner
• Orthodontist
• Maxillofacial Surgeon
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Presurgical preparation
• Dental extractions
• Orthodontic treatment
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Le Fort I osteotomy of the maxilla
• Surgical repositioning of the maxilla
• Movements
• Anterior (posterior)
• Superior (inferior)
• Transverse
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Le Fort I osteotomy of the maxilla
• Fixation with mini plates and screws
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Sagittal split osteotomy of the mandible
• Surgical repositioning of the mandible
• Movements
• Anterior / Posterior
• Vertical
• Transverse
• Maxillary position
• Dental occlusion
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Sagittal split osteotomy of the mandible
• Remove overlapping bone
• Fixation
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Class III
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Class III
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Class III
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Class III
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Class III
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Class III
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Class II
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Class II
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ClassII
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Class II
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Class II
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Skin cancer
• Basal cell carcinoma
• Squamous cell carcinoma
• Melanoma
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Skin cancer aetiology
• Excessive sun exposure
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Skin cancer aetiology
• Immunosupression
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Skin cancer aetiology
• Inherited skin cancer syndromes
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Basal cell carcinoma • Nodule or plaque with ulceration
• 6th decade and beyond
• Sun exposed skin – 70% face, head & neck
• Wide local excision
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Cutaneous squamous cell carcinoma • Exophytic nodule
• 6th decade and beyond
• Sun exposed skin – scalp, ears, lower lip
• Metastatic potential
• Wide local excision
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Melanoma
• Brown black plaque or nodule
• IRREGULARITY – edge, surface and colour
• Aggressive behaviour – early metastasis
• Wide local excision
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Basal cell carcinoma
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Basal cell carcinoma
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Merkel cell tumour
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Merkel cell tumour
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Merkel cell tumour
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Merkel cell tumour
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Thank you
• Andrew Stewart
• 0785 3279848
• Secretary Susan Burgess 0208-335-4636