Classification of dentoalveolar injuries

Injuries to dental hard tissues and pulp

• Enamel infraction – incomplete crack of enamel, no loss of tooth structure
• Enamel fracture – loss of tooth structure involving enamel only
• Enamel dentine fracture – loss of enamel and dentine, pulp not involved
• Complicated crown fracture – crown fracture involving pulp
• Complicated crown root fracture – enamel, dentine, cementum involved and pulp exposed
• Uncomplicated crown root fracture – pulp not exposed

Injuries to periodontal tissues

• Concussion – injury to tooth supporting structure. Pain on percussion and no bleeding or displacement
• Subluxation – increased tooth mobility due to traumatic injury to PDL tissues, no displacement
• Extrusive luxation – partial displacement from socket
• Intrusive luxation – intrusion into socket with socket fracture
• Lateral luxation – displacement in horizontal plane with fracture of alveolar socket
• Avulsion – complete displacement of tooth from socket

Injuries to alveolar bone

• Comminution of alveolar socket wall
• Fracture of alveolar socket wall – fracture confined to lingual/palatal or facial socket wall
• Fracture of alveolar process ± alveolar socket
• Fracture of basal mandibular or maxillary bone ± alveolar socket

Other injuries

• Soft tissue injuries – laceration, imbedding foreign body in lips
• Swallowing/inhaling avulsed tooth
• Iatrogenic injury:
  • During extraction damage to adjacent teeth, fracture of associated jaw
  • Perforate root apex or side of root during endodontic treatment

Radiographic investigation

• Two x-rays perpendicular or in different angles in vertical plane (IOPA, USO)
• OPG
• CBCT
• Chest/abdomen x-ray if tooth aspirated/swallowed
• Reproducible views for follow up evaluation

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Classification of mandibular fractures

Anatomical site of fracture and associated radiographic investigation

1. Condylar neck:

• OPG/oblique lateral
• PA jaws – low neck
• Reverse Townes – high neck

NB: Intracapsular fracture of bone → Bleeding within joint cavity (hemarthrosis)→ Bone fragments with high osteogenic potential → Organization of hematoma within joint → Conversion to fibrous tissue → Then to bone (Ankylosis)

2. Coronoid process:

• OPG/oblique lateral
• 0° Occipitomental

3. Ramus:

• OPG/oblique lateral
• PA jaws

4. Angle

• OPG/oblique lateral
• PA jaws

5. Body:

• OPG/oblique lateral
• PA jaws
• IOPA of involved teeth
• Lower 90° occlusal

6. Canine region:

• OPG/oblique lateral
• IOPA of involved teeth
• True lateral skull

7. Symphysis:

• Lower 45° occlusal
• Lower 90° occlusal

Nature and complexity of fracture

• Simple fracture – no communication with external environment, not breached overlying skin/mucosa
• Compound fracture – communication with external environment, due to break in overlying skin and mucosa
• Comminuted fracture – several broken bone fragments
• Complex fracture – involves injury of vital structure eg. nerve, major blood vessel, joint
• Greenstick fracture – in children, one side of cortex is broken and opposite side is spared

Etiological agent

• Trauma
• Iatrogenic – during extraction or enucleation of large cyst
• Pathologic – neoplasm, cyst, osteomyelitis
• Contrecoup fracture – fracture due to indirect force

Effect of action of muscles of mastication:

• Favourable/unfavourable
• Horizontal/vertical

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Midfacial fractures

Le Fort I

• Horizontal force delivered above the level of teeth (to the maxilla)
• Bilateral detachment of alveolar process and palate
• Involves pterygoid process of sphenoid bone
• ± Nasal septum
• Unilateral or bilateral
• The fracture separates the maxilla from pterygoid plates and nasal and zygomatic structures

• Clinical:
  • Extraoral:
    • Swelling of upper lip
    • Soft tissue laceration
    • Open mouth due to displaced dentoalveolar portion epistaxis
  • Intraoral:
    • Malocclusion
    • Mobile dentoalveolar portion
    • Dull sound on percussion
    • Ecchymosis of maxillary buccal sulcus

Le Fort II

• Pyramidal subzygomatic fracture of the maxilla
• Separation of maxilla and attached nasal complex from the orbital and zygomatic structures

• Clinical:
  • Extraoral:
    • Ballooning of face
    • Lengthening of face
    • Circumorbital ecchymosis
    • Subconjunctival hemorrhage
    • Epistaxis
    • Diplopia
    • Enophthalmos
    • CSF rhinorrhea
    • Step deformity in lower border of orbit
    • Intact zygomatic bone and arch
  • Intraoral:
    • Malocclusion
    • Anterior open bite
    • Mobility of the maxilla
    • Ecchymosis of sulcus

Le Fort III

• High level suprazygomatic fracture of central and lateral parts of face
• Most severe
• Extensive soft tissue injury
• “Floating” component is almost entire face

• Clinical:
  • Extraoral:
    • Ballooning of face
    • Lengthening of face
    • Bilateral circumorbital ecchymosis – “racoon eyes”
    • Bilateral subconjunctival hemorrhage
    • Flattening of cheeks
    • Epistaxis
    • Diplopia – due to edema, hematoma, restrictive motility disorder (mechanical), cranial nerve injury
    • Enophthalmos
    • CSF rhinorrhea
  • Intraoral:
    • Malocclusion
    • Anterior open bite
    • Mobility of the maxilla, mandibular interference
    • Ecchymosis of sulcus
    • Obstructed airway – soft palate rests on posterior dorsum of tongue

• Radiology for Le Fort fractures
  • 0° occipitomental
  • 30° occipitomental
  • True lateral skull (brow up)
  • CBCT

Zygomatic complex fractures

• 4 principle fracture lines:
  • Lateral orbital rim
  • Zygomatic arch
  • Zygomaticomaxillary buttress
  • Inferior orbital rim
• Radiology:
  • 0° occipitomental
  • 30° occipitomental
  • Submentovertex
  • CBCT

Naso-orbito-ethmoid (NOE) complex fractures

• Classification:
  • Type I: Single segment central fracture
  • Type II: Comminuted central fracture with fractures external to the medial canthal tendon insertion
  • Type III: Comminuted central fracture with fractures extending into bone bearing the medial canthal tendon insertion

• Signs and symptoms:
  • Occular injury
    • Enophthalmos
    • Diplopia
    • Loss of globe integrity
  • Epiphora
  • Saddle nasal deformity – pushed between the eyes
    • Reduced nasal projection and height
    • Flattened nasal dorsum
    • Septal deviation/dislocation
  • Cerebrospinal fistula
  • Airway obstruction
  • Epistaxis
  • Frontal sinus involvement
  • Telecanthus – Increased distance between inner corners of the eyelids (medial canthi), while interpupillary distance is normal. Occurs due to displacement of bone fragments

• Examination:
  • Airway
  • Anosmia (loss of smell)
    • CSF rhinorrhea
    • Loss of dorsal support
  • Ocular examination
    • Visual acuity
    • Pupillary response
    • Diplopia
    • Canthal position – “Bow string” or lid traction test
  • Ophthalmology consultation
  • Intercanthal distance: Rule of thirds: intercanthal distance equal palpebral fissure width
    • Female: 32-33mm
    • Male: 33-34mm

• Radiology:
  • 0° occipitomental
  • 30° occipitomental
  • True lateral skull (brow up)
  • CBCT
  • PA
  • Soft tissue lateral view of nose

• Complications of NOE fractures:
  • Facial deformity
  • Telecanthus
  • Epiphora
  • Anosomia
  • Meningitis

• Management:
  • Reattatchment and repositioning of the medial canthal tendon is key. Restore intercanthal distance
  • Nasolacrimal duct repair
  • Plating bone pieces
  • Transnasal wiring
  • Primary bone grafting for dorsal nasal support
  • Soft tissue adaptation
  • CSF leak – chemoprophylaxis to prevent disease

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Objectives of fractures

• Establish occlusion
• Anatomic reduction
• Ensure continuity with bone
• Esthetic

Dermoid cyst:

• Etiology: Epithelial tissue implanted into another structure
• Commonly: Face, inside skull, lower back, ovaries
• Clinical: Mature skin with sweat glands, hair follicle, sebum, blood, fat, bone, cartilage, nails, teeth
• Benign, solitary, expand slowly due to accumulation of epithelial debris and glandular secretion
• Non tender
• Can rupture

Picture

Epidermoid cyst: Lined with stratified squamous epithelium, no skin appendages, don’t rupture

Picture

Branchial (lymphoepithelial) cyst:

• Rare
• Upper lateral neck, anterior border of sternocleidomastoid muscle
• Etiology: Developmental
• Clinical: Asymptomatic, soft, 1-10cm, fluctuant swelling
• Lab: Histopathology
• Management: Surgical removal
• Differentials: Dermoid cyst, lymphadenopathy, sialadenitis, salivary gland tumor

Picture

Thyroglossal duct cyst:

• Central neck
• Moves when swallowing
• Between hyoid and thyroid
• Management:
  • Thyroid function test incase absent thyroid gland – thyroid scintigraphy
  • Surgical removal – Sistrunk operation
  • High recurrence rate

Picture

Cystic hygroma/ lymphangioma:

• Anterior and posterior triangle of neck
• Etiology: Developmental
• Clinical: Birth to 3 years, large cystic spaces, large soft swelling of neck
• Management: Surgical removal for esthetic and respiratory problems
• Differentials: Branchial cyst, lymphadenopathy, parotitis, submandibular sialadenitis

Picture

Thymic cyst

Calcification is soft tissues i.e. heterotopic ossification

1. Dystrophic calcification

• Degenerated, diseased, dead tissue
• Normal calcium and phosphate levels
• Localized to site of injury (trauma, infection, inflammation) eg. cysticercosis parasite

a. Chronically inflamed cysts – eg. Residual cyst

b. Calcified lymph nodes

• Cervical tuberculosis adenitis
• Sarcoidosis
• Cat scratch disease
• Rheumatoid arthritis
• Systemic sclerosis
• Fungal infection
• Metastasis from calcifying neoplasm
• Lymphoma treatment with radiology

c. Tonsillar calculi (tonsilloliths)

• Repeated inflammation enlarges tonsillar crypts
• Incomplete resolution of organic debris (bacteria, pus, epithelial cells, food) – nidus for calcification

Picture

d. Arterial calcifications: Arteriosclerosis – calcium deposits (atheromatous plaque) in medial coat of vessel

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2. Idiopathic calcification (calcinosis)

• Deposit calcium in normal tissues
• Normal calcium and phosphate levels

a. Chondrocalcinosis: Calcium phosphate crystals build up in joints – irritation – inflammation – cartilage damage

b. Sialoliths

c. Phleboliths – intravascular thrombi form due to venous stagnation – mineralize

d. Rhinoliths

e. Antroliths

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3. Metastatic calcification

• Minerals precipitate into normal tissues due to higher than normal calcium levels
• Bilateral and symmetrical

a. Ossification of stylohyoid ligament

• Classic eagle syndrome – cranial nerve impingement
• Carotid artery syndrome – impingement of carotid vessels

b. Osteoma cutis: In skin, acne of long duration, in a scar, chronic inflammatory dermatosis

c. Myositis ossificans

• Fibrous tissue and heterotrophic bone form in muscles interstitial tissues, tendons and ligaments
  • 1. Localized MO – acute/chronic trauma, heavy muscular strain, in occupation or sports, muscle injury from multiple injections (dental LA)
  • 2. Progressive MO – AD, rare, early infancy, males
• High calcium levels: Hyperparathyroidism, hypercalcemia, malignancy
• High phosphate levels: Chronic liver failure

1. Inflammatory

a. Retention cyst – Mucosal gland blocked

NB: Antral cysts

• From mucous glands:
  • Asymptomatic
  • Disappear spontaneously
• Odontogenic cysts:
  • Radicular, residual, fissural cysts may extend into maxilla

Picture

b. Mucocele

• Sinus opening in nasal passage blocked (allergy/cold)
• Sinus filled with thick viscous fluid
• Radiology: Clouding/opacification of whole sinus, sclerotic border still intact
• If bacterial infection – destroy sclerotic wall

Picture

c. Sinusitis

• Acute x chronic x hypersensitive
• Rhinogenic x odontogenic
• Periapical inflammation of premolar or molar
• Long oroantral communication
• Pain + percussion sensitivity
• Histology:
  • Respiratory epithelium → squamous metaplasia
  • Thickened basal membrane
  • Infiltrate:
    • Acute – neutrophils
    • Chronic – lymphocytes + plasma cells
    • Hypersensitive – eosinophils
• Radiology
  • Mucosa lining thickened – opaque thickening on sclerotic border
  • Long standing – forms polyps (sessile/pedunculated) within sinus
  • Picture

Picture

d. Pneumatization

• Sinus enlarges :
  • Edentulous
  • Chronic recurrent sinusitis
• Roots may look like are in sinus
• Enlarging sinus develops compartments

Picture

e. Fungal infection

• Aspergillus/mucor
• Grow in nasal passage and sinus of immune compromised
• Bone destruction, sclerotic border disappear
• Differential diagnosis: Sinus carcinoma

Picture

f. Mucositis

• Sinus mucosa thickens due to long standing periapical infection/unsuccessful RCT

Picture

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2. Foreign bodies in sinus

• Displaced root fragments in antrum after unsuccessful extraction + form oroantral fistula
• External objects inhaled into sinus
• Foreign bodies may calcify – laminated opacities in sinus (anthrolith) or nasal passage (rhinolith)

Oroantral communication

• After extraction of premolar or molar
• Nose blowing test
• Root or tooth in sinus
• Prolapse of antral mucosa

Picture

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3. Sinus fracture

• Le Fort fracture of lateral sinus wall
• Blow out fracture of ventral orbital wall:
  • Trap door sign – fracture wall bone fragments project down from roof of sinus
  • Fluid level in sinus
  • Polyp like mass hanging from roof of sinus

Picture

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4. Sinus neoplasia

a. Sinus osteoma – Well circumscribed opacity in sinus

b. Giant cemento-ossifying fibroma – enlarges and obliterated sinus

c. Sinus carcinoma – destroy sinus wall, opacification of sinus

d. Others:

• Squamous cell carcinoma
• Advanced stage – local spread
• Nose obstruction, nose bleeding
• Paresthesia of infraorbital nerve
• Visual disturbances
• Poor prognosis

Picture

Radiolucent lesions

A. Periapical radiolucency

• Apical periodontitis – widened PDL at root apex
• Bone cyst – UL/ML – round at periapex or scalloped between PM and M roots
• Periapical abscess or granuloma
• Periapical COD – early
• Radicular cyst
• Scar – dense fibrous tissue in RCT treated tooth

B. Pericoronal radiolucency (impacted teeth)

• AOT
• Ameloblastoma – UL/ML – resorbed roots
• Ameloblastic fibroma – UL/ML – well circumscribed sclerotic margin, maxilla
• CCOT
• CEOT
• Dentigerous cyst – from neck of crown CEJ, resorbs adjacent roots
• KCOT – UL/ML – Anterior posterior direction, radiopaque margin, no roots resorbed

C. Unilocular radiolucency

• Dentigerous cyst – UL/ML – from neck of crown CEJ, resorbs adjacent roots
• Eruption cyst
• Hemangioma
• Histiocytosis X – well defined, non corticated, punched out no jaw expansion, no root resorption, therefore floating teeth
• Lateral periodontal cyst – usually between canine and premolar
• Nasopalatine duct cyst – heart shaped, midline, symmetrical, sclerotic border, >8mm in diameter
• Paradental cyst – distal to partially impacted mandibular 8s
• Periapical abscess or granuloma
• Pleomorphic adenoma – “ball in hand”
• Radicular cyst – root divergence, resorption
• Scar – dense fibrous tissue in RCT treated tooth

D. Unilocular radiolucency with ragged and poorly defined borders

• Burkitt’s lymphoma
• Chronic dentoalveolar abscess
• Chronic osteitis
• Chronic osteomyelitis – moth eaten appearance
• Ewing’s sarcoma – onion skin periosteal reaction. Biopsy to differentiate from Garre’s osteomyelitis
• Fibrous dysplasia – early, loss of lamina dura, ground glass, expands bone
• MNTI
• Metastatic tumors of the jaw – moth eaten
• Osteogenic sarcoma – osteolytic type
• Primary lymphoma of bone – do biopsy
• Squamous cell carcinoma

E. Multilocular lesions

• Aneurysmal bone cyst – empty intrabony cavity, expands between roots of teeth
• Ameloblastoma – UL/ML – resorbed roots
• Ameloblastic fibroma – UL/ML– well circumscribed sclerotic margin, maxilla
• Ameloblastic carcinoma
• Central hemangioma of bone
• Cherubism – soap bubble appearance, bilateral
• Dentigerous cyst – UL/ML – from neck of crown CEJ, resorbs adjacent roots
• Giant cell granuloma – wispy trabeculae
• Giant cell lesion of hyperparathyroidism – pepper pot skull, Brown’s tumor
• KCOT – UL/ML – Anterior posterior direction, radiopaque margin, no roots resorbed
• Odontogenic myxoma – tennis racket appearance

F. Multiple separate radiolucency

• COD – early
• Histiocytosis X – well defined, non corticated, punched out no jaw expansion, no root resorption, therefore floating teeth
• KCOT – UL/ML – Anterior posterior direction, radiopaque margin, no roots resorbed
• Metastatic tumors of the jaw – moth eaten
• Multiple myeloma – punched out, non corticated radiolucency

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Mixed Radiopaque radiolucent lesions

• Ameloblastic fibro-odontoma
• AOT – small radiopaque foci in radiolucent lesion, anterior maxilla
• CCOT – “salt and pepper” appearance, anterior maxilla
• Cementoblastoma – well defined, “golf ball” at apex, 2-3 cm, radiolucent halo
• CEOT – “driven snow” appearance, multifocal
• COD
• Ossifying fibroma – well circumscribed
• Osteomyelitis

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Radiopaque lesions

A. Periapical radiopacity

• Cementoblastoma – well defined, “golf ball” at apex, 2-3 cm, radiolucent halo
• COD – late, multifocal
• Condensing osteitis/focal sclerosing osteitis – in long standing periapical inflammation
• Odontoma
• Hypercementosis

B. Discrete and diffuse multifocal radiopacities

• COD
• Diffuse sclerosing osteomyelitis
• Garre’s osteomyelitis – onion skin appearance
• Idiopathic osteosclerosis
• Odontoma
• Ossifying fibroma
• Ossifying subperiosteal hematoma
• Osteosarcoma – sunburst appearance
• Peripheral osteomas – circumscribed sclerotic mass
• Retained roots
• Sjogren’s syndrome – “cherry blossom” appearance
• Socket sclerosis
• Unerupted, impacted, supernumerary teeth

C. Generalized radiopacity

• Florid COD – cottonwool appearance only in 4 quadrants of the jaws
• Osteopetrosis – cottonwool appearance
• Paget’s disease – cottonwool appearance, bone deformity
• Albright syndrome
• Gardener’s syndrome

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Distinctive radiological features

• AOT – small radiopaque foci in radiolucent lesion
• CCOT – “salt and pepper” appearance
• Cementoblastoma – well defined, “golf ball” at apex, 2-3 cm, radiolucent halo
• CEOT – “driven snow” appearance
• COD – early radiolucent, late cottonwool appearance
• Cherubism – soap bubble appearance, bilateral
• Chronic osteomyelitis – moth eaten appearance
• Ewing’s sarcoma – onion skin periosteal reaction
• Fibrous dysplasia – early radiolucent, ground glass, late cottonwool appearance, loss of lamina dura, expands bone
• Florid COD – cottonwool appearance only in 4 quadrants of the jaws
• Garre’s osteomyelitis – onion skin appearance
• Giant cell lesion of hyperparathyroidism – pepper pot skull, Brown’s tumor
• Multiple myeloma – punched out, non corticated radiolucency
• Osteopetrosis – cottonwool appearance
• Odontogenic myxoma – tennis racket appearance
• Osteosarcoma – sunburst appearance
• Paget’s disease – cottonwool appearance, bone deformity
• Pleomorphic adenoma – “ball in hand”
• Sjogren’s syndrome – “cherry blossom” appearance

Cottonwool appearance:

• FCOD
• Fibrous dysplasia
• Osteopetrosis
• Paget’s disease

Moth eaten appearance:

• Ewing’s sarcoma
• Metastatic tumors of the jaw
• OSCC
• Osteomyelitis
• Osteosarcoma

Exostosis

• Overgrowth of mature bone from periosteal surface extending outwards

Picture

Enostosis

• Overgrowth of bone from endosteal surface extending into marrow space

Picture

Tori

• Bony overgrowths, not a neoplasm

Picture

PAIN is an unpleasant sensory/emotional experience associated with actual or potential tissue damage or described in terms of such damage

It is described by duration, site, distribution, type

1. Acute pain – sudden onset, obvious cause, identifiable pathology, responds to analgesics, and treatment of the pathology, associated with the emotions of fear and apprehension.

2. Chronic pain – insidious onset, no evident cause or readily identifiable pathology, responds poorly to analgesics, patient depressed

Physiology of pain:

• Nociceptive stimuli (inflammation, infection, trauma, chemicals, thermal stimulus, biochemical stimulus)
• Acts on peripheral pain receptors (non myelinated nerve fibres).
• The impulse transmitted in form of a chemical transmitter substance across the synaptic cleft & an electric potential along the neuron.
• Pain is perceived centrally causing peripheral release of endorphins (endogenous morphines)
• From small interneurons that block the presynaptic release of the chemical pain transmitter (substance P) = tolerance

Gate control theory of pain:

• Spinal gates at dorsal horn – at each segment of spinal cord
• Heat, touch and pain impulse compete for the gate – therefore non painful stimulus blocks transmission of noxious stimulus
• Modulated by substantia gelatinosa (SG) in the dorsal horn
• Which then influences the first central transmission cells (T cells)
• SG – modulating gate – permits only one type of impulse to pass through
• Larger nerves eg. touch receptors carry impulse to brain quicker and get through gate, blocking nociceptors
• Therefore use massage and heat therapy to inhibit pain sensation

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Causes of facial pain and headaches

1. Local causes:

• Dental or oral disease
• Referred pain
• Upper respiratory tract lesions
• Neck lesions
• Ocular lesions/ defective vision
• Trauma

2. Neurologic causes:

• Trigeminal neuralgia
• Glossopharyngeal neuralgia
• Herpetic neuralgia
• Intracranial disease

3. Psychogenic causes:

• Tension headaches
• Atypical facial pain
• Temporomandibular pain dysfunction syndrome

4. Vascular causes:

• Migraine
• Migranous neuralgia
• Temporal arteritis

5. Systemic causes:

• Severe hypertension
• Drugs (vinca alkaloids etc)

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Diagnostic features of conditions presenting with orofacial pain

Common diseases in this list need to be ruled out before diagnosis of rare conditions

1. Acute osteomyelitis:

• Causative lesion – carious tooth/PDL disease, and bone swelling
• Moth eaten appearance only manifests when approx 30% of bone undergoes osteolysis

2. Acute pulpitis:

• Sensitivity to temperature extremes and sugary foods
• ↑ pain at night or when lying down.
• Vitalometry – indicates that the pulp is still vital
• Percussion sensitivity – indicates apical spread

3. Apical abscess:

• Non vital tooth with fistula, parulis or extra oral drainage tracts
• This may be acute (with febrile presentation) or chronic

4. Cracked tooth syndrome:

• Apico-occlusal crack which does not show up on x-ray
• Pain on mastication
• Lateral pressure on the inclines of the cusp causes pain

5. Cluster headaches:

• Seasonal headaches with acute episodes in the evenings + ipsilateral conjunctival
  reddening and nasal discharge

6. Internal derangement of TMJ meniscus/ capsule adhesions

7. Myalgia of masticatory muscles:

• Pain and spasm of muscles of mastication – marked by a trigger point on one or more of these muscles (masseter, medial and lateral pterygoids, temporalis)
• Usually found in patients with a history of jaw clenching on anxiety

8. Otitis media:

• Unilateral hearing impairment and bulging, perforated, red or purulent tympanic membrane

9. PDL abscess:

• Expression of pus from the PDL pocket of a vital tooth
• Characterized by presence of calculus and alveolar bone damage
• If the tooth is non vital, it’s a perio-endo lesion

10. TMJ capsulitis/ synovitis/ arthritis:

• Pain over the joint
• Limited mouth opening or deviation on opening
• Crepitus on palpation of the TMJ – indicates bone erosions – secondary to arthritis

11. Neuralgia (Trigeminal, Glossopharyngeal or Postherpetic):

• Pain of neural origin, paroxysmal pain
• Distinct trigger zone on skin/ in mouth
• Middle aged or old patients, female patients
• Trigeminal neuralgia is called ‘Tic Doloureux’ when it is accompanied by spasms of the muscles of facial expression

Classical trigeminal neuralgia:

• Sudden unilateral, severe, brief, stabbing, recurrent pains in the distribution of trigeminal nerve branches
• Pain is paroxymal
• Provoked by light touch
• Confined to trigeminal distribution
• Unilateral
• Lasts from few seconds to 2 minutes
• Etiology: Intracranial compression of nerve by vasculature/foramina (osteopetrosis)
• Diagnosis: History, CT scan, MRI, LA during an attack attenuates the pain instantly
• Management: Carbamazepine, cryotherapy, vascular decompression

12. Atypical facial pain:

• No known organic cause (diagnosis of exclusion)
• Described by the patient in vague terms, treated as a symptom of depressive illness
• It is also called psychogenic pain

13. Myofascial pain dysfunction syndrome (MPDS)

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The diagnostic protocol for acute facial pain

Is the contributing lesion clinically visible (intra- and extra-oral examination for caries, PDL
disease, swellings, erosions, joint sounds, radiographic changes)?

If YES:
− Is it accompanied by fever (a sign of acute disease)?

If YES:
− Pulp or PDL: Abscess or osteomyelitis
− Mucosal lesions: Viral vesiculo-ulceration
− Facial swelling: Cellulitis or space infection
− Salivary swelling: Mumps or obstructive sialadenitis
− TMJ or mid ear: Infectious capsulitis or otitis media

If NO:

1. Dull or episodic aches:

2. Constant ache:

• Teeth or jaws:
  − Atypical facial pain
  − Myalgia of muscles of mastication
• TMJ: Temporomandibular myalgia

3. Acute episodic ache:

• Short term (seconds): Trigeminal neuralgia
• Long term (minutes): Cluster headaches

NB: Manage pain and re-evaluate in 1 wk to eliminate an organic source eg cracked tooth

4. Chronic episodic ache:

• Teeth or jaws:
  − Atypical facial pain
  − Myalgia of muscles of mastication
  − Cardiogenic (one of the signs of hypertension)
  − Vasogenic (migraine)
• TMJ: Myalgia

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Facial paralysis

UMN lesion: Lesion of the neural pathway above the anterior horn cell of spinal cord, or motor nuclei of the cranial nerves

LMN lesion: Affects nerve fibers traveling from anterior horn of spinal cord or cranial motor nuclei to the relevant muscles

1. Bell’s palsy: Picture

• LMN paralysis of the face – due to inflammation in the stylomastoid canal
• Reversible in 80% of cases
• Management: Corticosteroid therapy

2. Ramsay Hunt syndrome:

• Severe facial palsy – due to herpes zoster infection of the geniculate ganglion of the facial nerve
• In hereditary craniofacial malformation

3. Tardive dyskinesia: Picture

• Complication of longterm treatment with phenothiazines or butyrophenones
• Clinical: Involuntary facial movements

4. Horner’s syndrome: Picture

• A series of signs and symptoms – secondary to trauma to the cervical sympathetic trunk
• Clinical: Miosis (papillary constriction), ptosis (drooping eyelids), facial anhidrosis (loss of sweating) and occasionally enophthalmos

5. Adie’s pupil: Unilateral dilatation + very slow light reflex – due to syphilis. Picture

6. Argyll-Robertson pupil: Picture

• Failure of light reflex, but dilation for accommodation.
• Also seen in neurosyphillis + other conditions affecting the Edinger Westphal nucleus eg diabetes mellitus, sarcoidosis, encephalopathies, midbrain tumors, trauma and amyloidosis

Affects men, positive correlation to smoking

Histology: Encapsulated tumor with numerous cystic spaces – containing papillae – lined by
oncocytes (columnar eosinophilic cells) – and overlie a layer of cuboidal cells – which
overlie lymphoid tissue – complete with germinal centers

Picture

Rare tumors: arise from the intralobular duct epithelium particularly the striated
ducts

Histology:

• Well encapsulated tumor
• Bilayers of oncocytes – large cells with granular eosinophilic cytoplasm rich in mitochondria.
• +ve for phosphotungstic acid haematoxylin (PTAH) – specific for mitochondria

Picture