oral surgery

This lecture is really confusing. I emailed him to ask for his lecture.

Sanford Ratner

Cleft Deformities

Facial Clefting

Results from perturbations in signaling centers producing alterations in:

Timing

Rate

Outgrowth

Of facial primordial growth

CLP

Cleft lip and palate is characterized by a vertical defect in the oro-nasal complex, resulting in direct communication between the nose and the mouth. It is one of the most common birth defects in US

Af am: 1:2000

Cac 1: 1000

Asian 1:500

Cleft lip .29:1000

Cleft palate .39:1000

More males have cleft lip than females

More females have cleft palate

Left side: right: bilateral 6:3:1

Asso syn

Downs

Pierre robin

Apert’s syndrome

Crouzon’s

Treacher Collins

Hemi-facial microsomia

Goldenhars

Skicklers

Etiology

genetic contribution to facial morphogenesis plays a role in syndromes asso with CLP-poorly understood. Transforming growth factor-alpha. Retinoic acid receptor – alpha

envi modifying role may effect genetic activation/repression in non-syndromic CLP. Tobacco, anti-epileptic drugs, etc.

Clefting of lip can interfere with palate closure. Isolated clefting of palate is etiologically independent entity from CLP

Genetic involvement

Two hypoth

multi factorial threshold model: major genes, minor genes, environment, developmental

single major gene with reduced penetrance (less than 40% CLP are directly genetic in origin

familial incidence

· both parents unaffected : 0.1% chance for first child

· first child affected: 4% chance for 2^{nd child}

· two affected kids: 9% first child CLP

· one parent: 4% first child

· 1st child: 17% second child

· Both parents affected: 60% chance for all kids

Etiology:

Meckel 1808-failure of the facial primordial to fuse between the fifth and eighth week: FUSION.

Primordial come together by forces of growth. As move together, they touch. And epi degenerates and mesothelium flow thru area and have normal tissues and then u have fusion complete. If epithelium does not degenerate, you get cleft.

2nd theory:

Stark: pieces actually do come together, but not strong enough to stay together (FISSION)

Mx growth

Four mx movements

forward

ant

verti elongation

transverse expansion

growth

· the membranous sutures of the face must be responsive:

· the Vomerine-palatal suture is vital for adequate forces to be transmitted to the developing mx. Scarring of the suture will inhibit all aspects of growth.

· (if upset suture of vomer, mx won’t growth properly)

Clft class

normal bi-palate

unilateral CL

unilateral CLP-incomplete

bilateral CLP-incomplete

CP-incomplete

Unilateral CLP-Complete

Veau classification

Stage I: incomplete CP

Stage II: more

Stage III

Stage IV

The "Y" (Kernahan)

1,4 lip

2,5: alveolus

3,6:

Cleft lip

Cleft palate

Cleft alveolus:

Cleft lip

Unilateral

Microform

Minimal

Complete

Bilateral

Microform: full thickenus off mucosa, muscle never got across. Must open area up and close cleft lip together

Minimal: doesn’t go half way up lip

Incomplete: goes half way up or more

Complete

Anatomy: lip

Musculature:

orbicularis oris: eighth muscle components, arising from modioli at either end of mouth

superior and inferior horizontal band

oblique bands: allow to take lips up and out. (cleft pts can’t bring out but can bring up.) horizontal fibers can bring lips together

anat-cleft lip

normal anat is askew with deviation of philtrum, cupsids bow, tubercle

lateral lip element exhibits vertical discrepancy

mesodermal deficiency: muscle never grew across so can’t fn properly

the muscles remain underdeveloped

cleft palate

class

submucous cleft: cleft of hard palate under mucosa.

uvula

soft palate

soft and hard palate

palate anat:

· tensor palatine

· palatal-glossus, levator, uvular, etc:

· all are imp in speech.

Cleft palate

Cleft soft palate demonstrates abnormal muscle insertion a the post edge of the hard palate, leading to dysfunction of muscles. CAN"T SPEAK.

The valvular system is a continuum of movement that allows sound to be modified thru a change in pressure. Get Otitis media. Can’t equalize pressure. So lose hearing

Goals of palatal surgery

Release abnormal muscle insertion

Establishment of muscle continuity

Correct orientation of the velum to serve as a dynamic sling

Establish functional velo-pharyngeal valve mechanism to allow closure between oral pharynx and nasal pharynx.

Cleft palate:

Vertical deficiency, retrodisplaced

Transverse displacement

Cleft alveolus

Mx alveolus is frequently involved in the cleft lip and palate deformity. It routinely presents as a subtle fistula in the labial vestibule following the repair of the lip.

Complaints

Food and fluid come out of nose

Inability to suck or blow

Poor ability to keep teeth clean

Decayed or deformed front teeth

Missing or extra teeth in the cleft site

Lack of boney support of adjacent teeth

Mobility and deformity of primary palate

Lack of support for nose and lip

Alv cleft

stabilitze mx arch-consolidat to one jaw

establish functional nasal airway

close oro-nsal fistula

get osseous volume to support teeth

eliminate depressed alar base

allow for dental rehab

techniques

· primary gingivoperiosteoplasty- should not be done

· primary alveolar bone grafting- do at time of lip repair.

· secondary gingivoperiosteoplaty-should not be done

· secondary alveolar bone grafting- done at a later time.

Cleft deformity

Depends of type of cleft

Facial characteristics

To understand the facial patterns of CP: questions

does the unoperated cleft ind have same faial growth potential as non cleft ind

do all unoperated cleft types have same growth potential?

Unrepaired

· Skeletal: mx protrusion. No md. Diff.

· Dental- cleft segment has tendency to rotate medially with cuspid crowss bite occurrence.

Effect of lip repair

skeL: ant mx is molded with reduction of protrusion. No md. Diff. overall appear is like non-cleft ind.

Dental;mx and md incisors became more up right.. get post crossbite.

Unrepaired CPO

Skel: mx and md retrusion. Md has steep plane angle

Dent: no effect

Palatal repair-CPO

Skel: no effect on ant postion, however decreased vert ht

Decrease md palne due to rotation. Get more of class III relationship

Dental: see much greater post crossbite. (transverse growth of mx is restricted)

Unrepaired UCLP

Skel: mx is normal but md is rotated backwards

Dental: collapse of segments, get post crossbite

Repaired lip

Mx retruded compared to unodperated cleft lips. Md unaffected. ANB is smaller than unoperated clefts but still pos

Dental: no incr in ant crossbite. But yes post crossbite

Lip and palate repair

Skel: class III

dentL ant crossbite and post cross bite

findings:

mx and md with repaired clefts are related to the presence of the cleft itself. Means: these pts with class III: thought it was result of surgical interference. They have class III because that’s what they have, not what the surgeons are doing.

Multidisciplinary team

Geneticist

Plastic reconstructive surgieon

Oral and mx facial surgeon

Otorhinolaryngologist

Audiologist

Speech and language path

Pediatric dentist

Orthodontist

Psychologist

Pediatrician

Social worker

Management

Immed after birth: feeding,

1-4wks;

Alv bone grafting repair: usually done at age 8 and 9 since canines haven’t erupted yet. so now, do cleft repair at 5-6

Orthodontics for Adults ارتودنسی بزرگسالان

1. Is it unusual for adults to have orthodontic treatment

• More and more adults are having orthodontic treatment to correct crooked or crowded teeth
• Orthodontics can make the teeth more attractive and more functional, by improving jaw alignment, and correcting "the bite"
• Improved techniques have been devised for treating adults
• Modern orthodontic braces are less obtrusive and adults are more willing to wear them

 
2. Is adult orthodontic treatment successful

• Adult orthodontics is particularly successful for correcting crowding and jaw problems
• Healthy teeth can be moved with braces at any age
• Very similar treatments and appliances are used for children and adults

Before

after

 
3. I've always had crooked teeth. Does it really matter

•  Crooked teeth can prevent you from chewing properly, and lead to jaw joint problems
• Improving "the bite" can make eating more efficient and comfortable
• Crooked teeth affect your appearance and most people want to look their best at any age
• People with unattractive teeth are often too embarrassed to smile. Orthodontic treatment enables you to smile with confidence
• Looking better can make you feel better about yourself, and can increase your self-confidence

 
4. What are the most common orthodontic treatments for adults

• Correcting crowding or crooked teeth

  Crowding

• Closing newly developed or old spaces between teeth

  Before

  Treatment

  After

• Correcting the position and alignment of teeth
  Teeth often tilt into gaps left by extractions. These teeth have to be moved into a more upright position
  This correction makes it possible to use replacement crowns, implants, fixed bridges, or removable partial dentures to replace the missing teeth
• The photographs below explain what can be done for an adult, when the orthodontist, periodontist and prosthodontist all work together

Before		Upper crowns Lower brace		Lower teeth straightened
Final result

 
5. What problems could make orthodontic treatment for adults more difficult

• Periodontal Disease
  • Adults may suffer from periodontal disease, which is a deterioration of the gums and underlying bone
  • Periodontal treatment will be necessary before the orthodontic treatment can start
• Tooth decay
  • All dental decay should be treated before orthodontic treatment starts
  • It is less comfortable to have dental treatment after braces have been fitted
• Abnormal jaw relationships
  • The growth of the jaws has been completed in adults, and so this treatment is not always possible
  • In children, the ongoing growth of the jaw can be directed to correct the abnormalities that are present

  Lower jaw protrusion

  Lower jaw protrusion

• Worn down or broken teeth
  • These must be built up or restored before orthodontic treatment can start
• Lack of commitment
  • Adult patients may find it hard to commit to long term treatment, especially to wearing braces for long periods

 
6. Can an orthodontist help my painful jaw muscles and joints

• Your orthodontist or dentist will be able to diagnose the problem
• This problem can be caused by the grinding and clenching of teeth
• The action is unconscious and involuntary
• The technical name for it is "bruxism"
• Bruxism usually happens during sleep
• It wears down the teeth, and causes stress and trauma to the jaw muscles and the teeth
• The orthodontist will probably suggest a splint, bite plate or a nightguard to protect the teeth during sleep. This will also relax the muscles of the jaw
• These devices should relieve and prevent the results of tooth grinding
• The cause of the bruxism may be psychological, and may have to be treated by a suitable therapist

Nightguard

Nightguard in place

Periapical pathosis

Description: Well-delineated ovoid-shaped radiolucency at the apex of the lateral incisor.

Location: Periapical area of maxillary lateral incisor

هماتوم ساب دورال حاد

Acute Subdural Hematoma

Subacute subdural hematoma

سالم(شکل بیماری در پایین همین صفحه)

The brain is covered by a membrane (layer of tissue) called the dura.  If the veins located below the dura (subdural area) leak blood, then pressure in this area may build up and injure the brain.  Head injuries may injure these veins, causing them to be torn and leak.  This blood collects into a mass called a hematoma. Hence the name, Subdural Hematoma.  For an acute hematoma, symptoms generally occur in the first 24 hours, while for a subacute Hematoma, they occur in the first 2-10 days after a head injury.

Head injury (may be severe or a minor) Nausea Headache Personality changes Confusion Decreased level of consciousness Impaired vision Eye droop Speech difficulties Paralysis Numbness or decreased sensation in a limb  Seizures Coma Other neurological problems Symptoms may initially improve, but then dramatically worsen

Neurological exam by a physician Complete blood count, Chemistry panels, a PT, and a PTT should be performed CT scan of the head

Very young (infants) or the elderly Use of blood thinners such as aspirin or Coumadin  Alcoholism Diseases that increase the risk of falls such as Alzheimer's disease or narcolepsy.

Goal is to reduce pressure on the brain Circulation support (intravenous fluids and medications to maintain blood pressure) Respiratory support (oxygen and mechanical ventilation if necessary) Dexamethasone (a corticosteroid medication) may be used to decrease the inflammation of the brain Mannitol (a diuretic) may be used to decrease the swelling of the brain Dilantin (a seizure medication) may be used to prevent or control Seizures Reversal of blood thinning agents such as Coumadin or Heparin Emergency Surgery may be needed to drain the hematoma (blood clot), and relieve the pressure on the brain.  The hematoma is outside the brain, but still puts pressure on it.  Therefore, the surgery involves drilling small holes in the skull and evacuating the blood.  Occasionally, if the hematoma is very large or has solidified, a large opening in skull may be needed (this is called a craniotomy).

The individual needs immediate emergency medical treatment.  Untreated, this condition often leads to death.

Meningitis  Encephalitis  Subarachnoid Hemorrhage  Chronic Subdural Hematoma  Stroke

acute sinusitis

عکسی شماتیک و زیبا از سینوزیت حاد

توصیف بیماری

Sinuses are open cavities.  An infected sinus is known as sinusitis.  The maxillary and frontal sinuses are the two main sinuses that become infected.  The maxillary sinuses are located on the inside cheeks of both sides of the nose.  The maxillary sinuses drain through the nose.  In addition, the ears drain fluid into the maxillary sinuses by way of the eustachian tube. The eustachian tube may become blocked or inflamed from a sinus infection, resulting in pressure, pain, or fullness in the ears.  The frontal sinuses are located in the lower part of the forehead just above the bridge of nose. Sinusitis usually occurs either after a viral infection (cold/runny nose) or after allergy symptoms begin.  This occurs because of swelling in the nasal tract tissue, which drains the sinuses, causing them to become swollen.  The sinuses accumulate fluid and mucous, allowing bacteria to grow in the sinuses, which causes the sinusitis.

نشانه ها

Pain/pressure over the sinuses Occasional upper tooth pain Pain and tenderness over the forehead Ear pressure If symptoms do note resolve in three weeks, or do not respond to antibiotics, this may represent Chronic Sinusitis.  Please see the section on Chronic Sinusitis for more details.

عوامل مسبب

Streptococcus pneumoniae Hemophilus Influenza Moraxella catarrhalis Staphylococcus aureus

تشخیص ما چگونه باشد؟

Transilluminator may show a fluid collection Sinus X-Rays A CT scan of the sinuses is more accurate than an X-Ray Cultures are not helpful unless done by a needle placed into the sinuses (and this is not done unless the case is extreme)

درمان

Oral antibiotics are usually administered for 10 to 14 days.  Commonly used antibiotics include Ceftin, augmentin, or cipro. Older antibiotics, such as Amoxicillin and Erythromycin may be prescribed, but you should be aware that they do not provide the same scope of coverage that Ceftin, augmentin, or cipro.  They have poor coverage when dealing with Haemophilus Influenza as well. Oral Decongestants, such as Sudafed, and nasal sprays such as Afrin, for the first 3 days may be helpful (after 3 days a "rebound" may occur, and the decongestants may no longer be effective). Take a warm shower twice a day, and blow out your excessive mucous. Saline nasal sprays may be used multiple times during the day to loosen nasal secretions.

شرایط مساوی(similar condition)

Tooth  Abscess Mucormycosis Sinus cancer

متفرقه و گوناگونll

Predisposing Causes Viral Rhinitis (Cold) Allergies Dental problems nasal polyps