Maxillofacial disorders

Lesson
12
By Esther Muriuki O.T/MSc sensory integration
Extraoral and intra oral classification
Defects in the maxillofacial region can be:
 intraoral involving the maxilla, soft palate
or mandible.
 or they can be extraoral, involving the
ear, orbit, nose, or a combination of all of
the above.
These defects can be due to developmental
anomalies, trauma, cancer or the sequelae of
ablative cancer surgeries.
Extraoral

 adjective
 ex·​tra·​oral -ˈȯr-əl, -ˈōr-əl, -ˈär-əl
 situated or occurring outside the mouth
an extraoral abscess an extraoral dental
appliance.
What is the meaning of extraoral?
 occurring outside the mouth
 situated or occurring outside the mouth
Extraoral
Intra-oral
 What is intra-oral?
 in·​tra·​oral -ˈōr-əl, -ˈȯr-, -ˈär- : situated, occurring, or performed within the mouth.
 The inside of the mouth, also known as the oral cavity, is made up of many parts that
work together to help with eating, speaking, and breathing:
 Teeth: The main structures of the mouth, teeth tear and grind food into smaller pieces
for digestion
 Gums: The gums, or gingivae, fit snugly around the teeth
 Palate: The roof of the mouth is divided into the hard palate, which is the bony front part,
and the soft palate, which is the muscular back part
 Tongue: The tongue is mostly in the oral cavity proper
 Salivary glands: The submandibular and sublingual salivary glands secrete fluid to keep
the mouth moist
 Oral mucosa: The mucous membrane that lines the mouth, ranging in color from reddish
pink to brown or black
 Uvula: A narrow muscular structure that hangs down from the soft palate and can be
seen when you say "Ahh"
 Buccal mucosa: The inner lining of the lips and cheeks
 Retromolar trigone: The area behind the wisdom teeth
 The mouth is also the entrance to the digestive and respiratory systems
Intra-oral
The retromolar trigone (RMT)
 The retromolar trigone (RMT) is a small
triangular subsite of the oral cavity. It is
the portion of mucosa that lies behind the
third molar tooth covering the anterior
ramus of the mandible.
 This anatomic area is critical from an
oncologic point of view due to its spatial
relationship with the surrounding
structures.
Imaging
 .
Intraoral images are taken inside the mouth.
Extraoral photos are taken outside the
mouth.
The well-trained and practiced dental
practitioner will become accomplished using
either a camera or an intraoral scanner. Still,
there is an obvious need to invest in the right
equipment.
Intraoral x-rays
 There are two main types of dental X-rays: intraoral (the x-ray film is
inside the mouth) and extraoral (the x-ray film is outside the mouth).
 Intraoral x-rays are the most common type of X-ray. There are several
types of intraoral x-rays. Each shows different aspects of teeth.
 Bitewing X-rays show details of the upper and lower teeth in one area of
the mouth. Each bite-wing shows a tooth from its crown (the exposed
surface) to the level of the supporting bone. Bite-wing x-rays detect decay
between teeth and changes in the thickness of bone caused by gum
disease. Bitewing X-rays can also help determine the proper fit of a crown
(a cap that completely encircles a tooth) or other restorations (eg,
bridges). It can also see any wear or breakdown of dental fillings.
 Periapical X-rays show the whole tooth ” from the crown, to beyond the
root where the tooth attaches into the jaw. Each periapical X-ray shows all
teeth in one portion of either the upper or lower jaw. Periapical x-rays
detect any unusual changes in the root and surrounding bone structures.
 Occlusal X-rays track the development and placement of an entire arch of
teeth in either the upper or lower jaw.
Extraoral Xrays
Extraoral Xrays are used to detect dental problems in the jaw and skull. There are
several types of extraoral x-rays.
 Panoramic X-rays show the entire mouth area -- all the teeth in both the upper
and lower jaws -- on a single x-ray. This x-ray detects the position of fully emerged
as well as emerging teeth, can see impacted teeth, and help diagnosis tumors.
 Tomograms show a particular layer or slice of the mouth and blur out other
layers. This X-ray examines structures that are difficult to clearly see because other
nearby structures are blocking the view.
 Cephalometric projections show an entire side of the head. This X-ray looks at
the teeth in relation to the jaw and profile of the individual. Orthodontists use this
X-ray to develop each patient's specific teeth realignment approach.
 Another test that uses X-rays is called a sialogram. This test uses a dye, which is
injected into the salivary glands so they can be seen on X-ray film (Salivary glands
are a soft tissue that would not be seen with an X-ray.) Dentists might order this
test to look for salivary gland problems, such as blockages, or Sjogren's syndrome (a
disorder with symptoms including dry mouth and eyes; this disorder can play a role
in tooth decay).
 Dental computed tomography (CT) is a type of imaging that looks at interior
structures in 3-D (three dimensions). This type of imaging is used to find problems
in the bones of the face such as cysts, tumors, and fractures.
 Cnt…
 Cone Beam CT is a type of X-ray that creates 3-D images of dental structures, soft tissue, nerves,
and bone. It helps guide tooth implant placement and evaluates cysts and tumors in the mouth
and face. It also can detect problems in the gums, roots of teeth, and jaws. Cone beam CT is
similar to regular dental CT in some ways. They both produce accurate and high-quality images.
However, the way images are taken is different. The cone-beam CT machine rotates around the
patient's head, capturing all data in one single rotation. The traditional CT scan collects flat slices
as the machine makes several revolutions around the patient's head. This method also exposes
patients to higher level of radiation. A unique advantage of cone beam CT is that it can be used in
a dentist's office. Dental computed CT equipment is only available in hospitals or imaging centers.
 Digital imaging is a 2-D type of dental imaging that allows images to be sent directly to a
computer. The images can be viewed on screen, stored, or printed out in a matter of seconds.
Digital imaging has several other advantages compared with traditional X-rays. The image taken of
a tooth, for example, can be enhanced and enlarged. This makes it easier for your dentist to see
the tiniest changes that can't be seen in an oral exam. Also, if necessary, images can be
sent electronically to another dentist or specialist for a second opinion or to a new dentist (eg, if
you move). Digital imaging also uses less radiation than X-rays.
 MRI imaging is an imaging method that takes a 3-D view of the oral cavity including jaw and teeth.
(This is ideal for soft tissue evaluation.)
 Intra &extra oral examinations
 A thorough intra-oral and extra-oral examination should be a routine part of any dental
assessment: checking and recording the presence or absence of any abnormalities. Faculty of
General Dental Practice (FGDP) protocols are available to guide dentists and dental care
professionals (DCPs) on how an extra and intra oral exam should be conducted, with no
differentiation made between an examination of an adult or a child.
 The importance of regular and thorough dental examinations has been emphasised within
literature and many case reports detail positive outcomes for patients as a result of an effective
examination.
 There has been a particular emphasis on a thorough dental examination due to dental
practitioners being one of the few health professionals who have frequent contact with patients
through routine examinations. They have the ability to detect possible oral cancers, skin cancers,
as well as manifestations of other systemic diseases such as Crohn's disease.
 Although the incidence of oral cancers is decreasing gradually, there has been an increase in the
number of patients diagnosed with oral cancer under the age of 40.
cnt
 Extra oral dental examinations can often be overlooked, even though they are a fundamental
aspect of oral cancer screening and possible manifestations of other systemic diseases. An extra
oral examination could result in the detection of enlarged lymph nodes, metastasis and skin
cancers, amongst various other diseases.
 Performing a thorough extra and intra oral examination could lead to patients questioning the
practitioner on the purpose of the examination.This gives the practitioner an opportunity to
educate the patient on sinister signs and symptoms to look out for. This could ultimately aid in
the early detection of lesions, which is so crucial, especially with oral cancers.
 Early detection and diagnosis of oral cancers have a direct impact on the patient's long-term
prognosis.It can result in simpler surgical procedures and a reduced need for radiotherapy and
chemotherapy.This often leads to a reduced risk of disfiguration and effect on eating or
swallowing which tends to occur in major head and neck surgeries and treatments, ultimately
granting the patient a better quality of life.
 The intra oral soft examination

The intra oral examination is divided into soft tissue and hard tissue examination. The soft
tissue examination will be focused on for the purpose of this article. Similarly to the extra
oral examination, the intra oral examination should be completed with every new
assessment and should be conducted in a systematic manner in order to minimise the
chances of an area not being assessed. With the development of technology, many clinicians
also find it useful to photograph any abnormal or unusual findings and include them within
the clinical record as it is often more useful than an illustration.
The areas assessed include:
1. Lips
a. Lips are normally smooth with a homogenous pink appearance and
the vermillion border is even and distinct. Symmetry, tissue
consistency, texture, colour, as well as any lumps should be noted.
b. Ensure to assess the commissures as this is a common site for
pathological conditions such as Candida albicans, angular cheilitis as
well as nutritional deficiencies.
The intra oral soft examination
2. Buccal and labial mucosa
 a. The buccal and labial mucosa should be moist and red in appearance. On
palpation it should be soft with no indurations or palpable lesions or
lumps. Stensen's or the parotid duct can also be identified on the buccal
mucosa adjacent to the upper molars. Linea alba and Fordyce spots or
granules are common findings on the buccal mucosa and should be noted,
but do not require treatment. [Images can be viewed
at https://healthproadvice.com/conditions/how-to-check-yourself-for-oral-
cancer.5] Linea alba can sometimes occur due to stress and as a result of
bruxism. It is a hyper-keratinised area in line with the occlusal plane.
 b. Findings such as cheek biting, burns and ulcers may be seen and should
be noted and reviewed at appropriate intervals, most commonly in two
weeks. Changes such as erythroplakia (red patch) and speckled leukoplakia
(red and white patch) can be indicative of neoplastic changes and therefore
should be noted in the clinical record and referred appropriately.
Ctn…
3. Floor of mouth
 a. The patient should be asked to raise their tongue to allow the
clinician to visualise the floor of mouth directly. Using the back
of a mirror may be useful to help see the most posterior
aspects of the floor of mouth. In most patients the tissues
should be moist in appearance and can be vascular.3 Normal
findings include the sublingual caruncle and folds, and the lingual
frenum.
 b. Abnormal findings include swelling, ulceration, mucoceles,
sialoliths and neoplastic changes similar to those mentioned
above amongst other findings.
Cnt..
4. Tongue
 a. The examination is particularly important when screening for oral cancer
as a common site for oral cancer to occur is the lateral border of the
tongue.
 b. To examine the dorsum of the tongue, ask the patient to stick their
tongue straight out. Then get the patient to move their tongue to the left
and the right to examine the lateral border of the tongue. Using a mirror
can sometimes be useful when trying to examine the most posterior
aspect of the lateral border of the tongue. The ventral aspect of the tongue
can be observed by asking the patient to curl their tongue up to the roof
of their mouth.
 c. The tongue should be pink in appearance and symmetrical in both shape
and function. There should be no palpable indurations or lumps. Common
findings include fissuring of the tongue as well as papillae including filiform,
fungiform and circumvallate papillae.
 d. Any abnormal findings such as geographic tongue,ulceration, leukoplakia
and erythrolakia should be noted in the clinical record and reviewed and
referred appropriately in accordance to local guidance.
Cnt..
5. Palate
 a. The palate should be examined visually with the aid of illumination. The
palate should be a pale pink colour and homogenous in appearance.
Normal structures that may be identified are the incisive papilla, raphe,
rugae, the maxillary tuberosities and the vibrating line.3
 b. The most common atypical findings on the palate are palatal tori and
ulceration.

6. Fauces
 a. The oropharyngeal assessment can be completed by depressing the
patient's tongue with a mirror. This allows visualisation of the pharyngeal
wall, tonsils and tonsillar crypt.
 b. Atypical findings can include asymmetry which could be as a result of
infection, tonsillectomy or due to the presence of a lesion.
 With over 6,500 new oral cancers and over 2,000 laryngeal cancers being
diagnosed every year, it is important to look out for any signs and
symptoms
The extra oral examination
The extra oral examination should be conducted routinely, and most
practitioners conduct it with each new assessment. This helps to reduce the
likelihood of missing any areas of concern. It is generally recommended to
complete the extra oral examination systematically and in the same order each
time. There is no set order and so the extra oral examination can be
conducted in the order that is preferable to the clinician. The extra oral
examination is made up of the face, head and neck and should assess the
following.
 1. Face
 a. The face should be assessed, and any abnormal findings noted in the
clinical records. These include swelling, discolouration and any asymmetry.
Asymmetry can occur due to swellings originating from both dental and
non-dental causes such as infection, neoplastic growths and hypertrophy.
 b. The clinical examination may also be altered as a result of a patient's
concern or history. For example, the patient may complain of altered
sensation following trauma or a gross swelling.These findings should also
be included in the extra oral examination clinical records.
Cnt…
 2. Head
 a. Similar to the examination of the face, the head should also be assessed
for any swellings, discolouration or asymmetry.Where a patient's scalp is
visible, this should be assessed visually as this can be a common site for
basal cell carcinomas and the patient may not be aware of them.
 b. The assessment of the patient's head should include the palpation of the
major lymph nodes. Findings such as enlargement, fixation and tenderness
of lymph nodes should be noted.This is particularly important as non-
tender and fixed lymph nodes can be indicative of malignancies whereas
tender lymph nodes can sometimes occur in conjunction to infections,
both of dental and non-dental origin.
 c. The temporomandibular joint (TMJ) is also assessed. This should be
assessed both at rest and when the patient is carrying out mandibular
movements.The patient can be asked to complete movements such as
opening and closing their jaw, moving it side to side as well as thrusting the
mandible forward in order to assess the TMJ.Any pain, clicking, limitation of
movement or opening, grating or tenderness as well as any deviation or
deflections should be noted.
Cnt…
3. Neck
 a. Similar to the assessment of the patient's head, the neck
should also be palpated to assess the major lymph nodes.
Again, any enlargement, fixation or tenderness of the lymph
nodes should be noted.
 b. Any lumps, swelling, tenderness or abnormalities should
also be noted.
 The extra oral examination is also an important assessment
when considering safeguarding. Any signs of non-accidental
injury such as lacerations or bruising should be noted
particularly in children and vulnerable adults.
 Findings such as cheek biting, burns and ulcers should be
noted and reviewed at appropriate levels intervals, most
commonly in two weeks.
Findings that could be concerning and their management

With over 6,500 new oral cancers and over 2,000 laryngeal
cancers being diagnosed every year within the UK, it is
important for dental professionals to look out for any signs or
symptoms that may be concerning.
Signs and symptoms commonly include:
 Persistent non-healing ulcers (present for longer than three
weeks with no obvious explanation for its presence)
 A mass or lump on the lip or within the oral cavity
 Abnormal bleeding
 A red (erythroplakia) or mixed red and white
(erythroleukoplakia) area
 An unexplained persistent sore throat
 Regional lymphadenopathy or unexplained neck lump
 Ctn…
 Unexplained pain on one side of the face or neck
lasting longer than four weeks
 Hoarseness that is persistent and unexplained.
If a patient presents with any of the above signs or
symptoms, then a referral on the suspected cancer
referral pathway is advised. These patients are then
typically seen within two weeks of the referral.
Clinicians are advised not to hesitate when referring
these patients as early diagnosis and treatment
significantly improves a patient's long-term prognosis.
 Classification activity

**place the given disorder

in the right classification
Open forum
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