Maxillectomy

Maxillectomy is a surgical procedure involving the resection of the maxilla (upper jaw) and is typically performed to remove tumors, treat severe infections, or address other pathological conditions affecting the maxillary region. The procedure requires careful planning and execution to ensure adequate access, removal of the affected tissue, and preservation of surrounding structures for optimal functional and aesthetic outcomes.

Surgical Access and Incision

1. Weber-Fergusson Incision:

   • The classic approach to access the maxilla is through the Weber-Fergusson incision. This incision provides good visibility and access to the maxillary region.
   • Temporary Tarsorrhaphy: The eyelids are temporarily closed using tarsorrhaphy sutures to protect the eye during the procedure.

2. Tattooing for Aesthetic Alignment:

   • To achieve better cosmetic results, it is recommended to tattoo the vermilion border and other key points on both sides of the incision with methylene blue. These points serve as guides for alignment during closure.

3. Incision Design:

   • The incision typically splits the midline of the upper lip but can be modified for better cosmetic outcomes by incising along the philtral ridges and offsetting the incision at the vermilion border.
   • The incision is turned 2 mm from the medial canthus of the eye. Intraorally, the incision continues through the gingival margin and connects with a horizontal incision at the depth of the labiobuccal vestibule, extending back to the maxillary tuberosity.

4. Continuation of the Incision:

   • From the maxillary tuberosity, the incision turns medially across the posterior edge of the hard palate and then turns 90 degrees anteriorly, several millimeters to the proximal side of the midline, crossing the gingival margin again if possible.

5. Incision to Bone:

   • The incision is carried down to the bone, except beneath the lower eyelid, where the orbicularis oculi muscle is preserved. The cheek flap is then reflected back to the tuberosity.

Surgical Procedure

1. Extraction and Elevation:

   • The central incisor on the involved side is extracted, and the gingival and palatal mucosa are elevated back to the midline.

2. Deepening the Incision:

   • The incision extending around the nose is deepened into the nasal cavity. The palatal bone is divided near the midline using a saw blade or bur.

3. Separation of Bone:

   • The basal bone is separated from the frontal process of the maxilla using an osteotome. The orbicularis oculi muscle is retracted superiorly, and the bone cut is extended across the maxilla, just below the infraorbital rim, into the zygoma.

4. Maxillary Sinus:

   • If the posterior wall of the maxillary sinus has not been invaded by the tumor, it is separated from the pterygoid plates using a pterygoid chisel.

5. Specimen Removal:

   • The entire specimen is removed by severing the remaining attachments with large curved scissors placed behind the maxilla.

Postoperative Considerations

• Wound Care: Proper care of the surgical site is essential to prevent infection and promote healing.
• Rehabilitation: Patients may require rehabilitation to address functional issues related to speech, swallowing, and facial aesthetics.
• Follow-Up: Regular follow-up appointments are necessary to monitor healing and assess for any complications or recurrence of disease.

Glasgow Coma Scale (GCS): Best Verbal Response

The Glasgow Coma Scale (GCS) is a clinical scale used to assess a patient's level of consciousness and neurological function, particularly after a head injury. It evaluates three aspects: eye opening, verbal response, and motor response. The best verbal response (V) is one of the components of the GCS and is scored as follows:

Best Verbal Response (V)

• 5 - Appropriate and Oriented:

  • The patient is fully awake and can respond appropriately to questions, demonstrating awareness of their surroundings, time, and identity.

• 4 - Confused Conversation:

  • The patient is able to speak but is confused and disoriented. They may answer questions but with some level of confusion or incorrect information.

• 3 - Inappropriate Words:

  • The patient uses words but they are inappropriate or irrelevant to the context. The responses do not make sense in relation to the questions asked.

• 2 - Incomprehensible Sounds:

  • The patient makes sounds that are not recognizable as words. This may include moaning or groaning but does not involve coherent speech.

• 1 - No Sounds:

  • The patient does not make any verbal sounds or responses.

Mandibular Tori

Mandibular tori are bony growths that occur on the mandible, typically on the lingual aspect of the alveolar ridge. While they are often asymptomatic, there are specific indications for their removal, particularly when they interfere with oral function or prosthetic rehabilitation.

Indications for Removal

1. Interference with Denture Construction:

   • Mandibular tori may obstruct the proper fitting of full or partial dentures, necessitating their removal to ensure adequate retention and comfort.

2. Ulceration and Slow Healing:

   • If the mucosal covering over the torus ulcerates and the wound exhibits extremely slow healing, surgical intervention may be required to promote healing and prevent further complications.

3. Interference with Speech and Deglutition:

   • Large tori that impede normal speech or swallowing may warrant removal to improve the patient's quality of life and functional abilities.

Surgical Technique

1. Incision Placement:

   • The incision should be made on the crest of the ridge if the patient is edentulous (without teeth). This approach allows for better access to the torus while minimizing trauma to surrounding tissues.
   • If there are teeth present in the area, the incision should be made along the gingival margin. This helps to preserve the integrity of the gingival tissue and maintain aesthetics.

2. Avoiding Direct Incision Over the Torus:

   • It is crucial not to make the incision directly over the torus. Incising over the torus can lead to:
     • Status Line: Leaving a visible line on the traumatized bone, which can affect aesthetics and function.
     • Thin Mucosa: The mucosa over the torus is generally very thin, and an incision through it can result in dehiscence (wound separation) and exposure of the underlying bone, complicating healing.

3. Surgical Procedure:

   • After making the appropriate incision, the mucosal flap is elevated to expose the underlying bone.
   • The torus is then carefully removed using appropriate surgical instruments, ensuring minimal trauma to surrounding tissues.
   • Hemostasis is achieved, and the mucosal flap is repositioned and sutured back into place.

4. Postoperative Care:

   • Patients may experience discomfort and swelling following the procedure, which can be managed with analgesics.
   • Instructions for oral hygiene and dietary modifications may be provided to promote healing and prevent complications.

5. Follow-Up:

   • Regular follow-up appointments are necessary to monitor healing and assess for any potential complications, such as infection or delayed healing.

Submasseteric Space Infection

Submasseteric space infection refers to an infection that occurs in the submasseteric space, which is located beneath the masseter muscle. This space is clinically significant in the context of dental infections, particularly those arising from the lower third molars (wisdom teeth) or other odontogenic sources. Understanding the anatomy and potential spread of infections in this area is crucial for effective diagnosis and management.

Anatomy of the Submasseteric Space

1. Location:

   • The submasseteric space is situated beneath the masseter muscle, which is a major muscle involved in mastication (chewing).
   • This space is bordered superiorly by the masseter muscle and inferiorly by the lower border of the ramus of the mandible.

2. Boundaries:

   • Inferior Boundary: The extension of an abscess or infection inferiorly is limited by the firm attachment of the masseter muscle to the lower border of the ramus of the mandible. This attachment creates a barrier that can restrict the spread of infection downward.
   • Anterior Boundary: The forward spread of infection beyond the anterior border of the ramus is restricted by the anterior tail of the tendon of the temporalis muscle, which inserts into the anterior border of the ramus. This anatomical feature helps to contain infections within the submasseteric space.

3. Posterior Boundary: The posterior limit of the submasseteric space is generally defined by the posterior border of the ramus of the mandible.

Clinical Implications

1. Sources of Infection:

   • Infections in the submasseteric space often arise from odontogenic sources, such as:
     • Pericoronitis associated with impacted lower third molars.
     • Dental abscesses from other teeth in the mandible.
     • Periodontal infections.

2. Symptoms:

   • Patients with submasseteric space infections may present with:
     • Swelling and tenderness in the area of the masseter muscle.
     • Limited mouth opening (trismus) due to muscle spasm or swelling.
     • Pain that may radiate to the ear or temporomandibular joint (TMJ).
     • Fever and systemic signs of infection in more severe cases.

3. Diagnosis:

   • Diagnosis is typically made through clinical examination and imaging studies, such as panoramic radiographs or CT scans, to assess the extent of the infection and its relationship to surrounding structures.

4. Management:

   • Treatment of submasseteric space infections usually involves:
     • Antibiotic Therapy: Broad-spectrum antibiotics are often initiated to control the infection.
     • Surgical Intervention: Drainage of the abscess may be necessary, especially if there is significant swelling or if the patient is not responding to conservative management. Incision and drainage can be performed intraorally or extraorally, depending on the extent of the infection.
     • Management of the Source: Addressing the underlying dental issue, such as extraction of an impacted tooth or treatment of a dental abscess, is essential to prevent recurrence.

Extraction Patterns for Presurgical Orthodontics

In orthodontics, the extraction pattern chosen can significantly influence treatment outcomes, especially in presurgical orthodontics. The extraction decisions differ based on the type of skeletal malocclusion, specifically Class II and Class III malocclusions. Here’s an overview of the extraction patterns for each type:

Skeletal Class II Malocclusion

• General Approach:
  • In skeletal Class II malocclusion, the goal is to prepare the dental arches for surgical correction, typically involving mandibular advancement.
• Extraction Recommendations:
  • No Maxillary Tooth Extraction: Avoid extracting maxillary teeth, particularly the upper first premolars or any maxillary teeth, to prevent over-retraction of the maxillary anterior teeth. Over-retraction can compromise the planned mandibular advancement.
  • Lower First Premolar Extraction: Extraction of the lower first premolars is recommended. This helps:
    • Level the arch.
    • Correct the proclination of the lower anterior teeth, allowing for better alignment and preparation for surgery.

Skeletal Class III Malocclusion

• General Approach:

  • In skeletal Class III malocclusion, the extraction pattern is reversed to facilitate the surgical correction, often involving maxillary advancement or mandibular setback.

• Extraction Recommendations:

  • Upper First Premolar Extraction: Extracting the upper first premolars is done to:
    • Correct the proclination of the upper anterior teeth, which is essential for achieving proper alignment and aesthetics.
  • Lower Second Premolar Extraction: If additional space is needed in the lower arch, the extraction of lower second premolars is recommended. This helps:
    • Prevent over-retraction of the lower anterior teeth, maintaining their position while allowing for necessary adjustments in the arch.

Lines in Third Molar Assessment

In the context of third molar (wisdom tooth) assessment and extraction, several lines are used to evaluate the position and inclination of the tooth, as well as the amount of bone that may need to be removed during extraction. These lines provide valuable information for planning the surgical approach and predicting the difficulty of the extraction.

1. White Line

• Description: The white line is a visual marker that runs over the occlusal surfaces of the first, second, and third molars.
• Purpose: This line serves as an indicator of the axial inclination of the third molar. By assessing the position of the white line, clinicians can determine the orientation of the third molar in relation to the adjacent teeth and the overall dental arch.
• Clinical Relevance: The inclination of the third molar can influence the complexity of the extraction procedure, as well as the potential for complications.

2. Amber Line

• Description: The amber line is drawn from the bone distal to the third molar towards the interceptal bone between the first and second molars.
• Purpose: This line helps to delineate which parts of the third molar are covered by bone and which parts are not. Specifically:
  • Above the Amber Line: Any part of the tooth above this line is not covered by bone.
  • Below the Amber Line: Any part of the tooth below this line is covered by bone.
• Clinical Relevance: The amber line is particularly useful in the Pell and Gregory classification, which categorizes the position of the third molar based on its relationship to the surrounding structures and the amount of bone covering it.

3. Red Line (George Winter's Third Line)

• Description: The red line is a perpendicular line drawn from the amber line to an imaginary line of application of an elevator. This imaginary line is positioned at the cement-enamel junction (CEJ) on the mesial aspect of the tooth, except in cases of disto-angular impaction, where it is at the distal CEJ.
• Purpose: The red line indicates the amount of bone that must be removed before the elevation of the tooth can occur. It effectively represents the depth of the tooth in the bone.
• Clinical Relevance: The length of the red line correlates with the difficulty of the extraction:
  • Longer Red Line: Indicates that more bone needs to be removed, suggesting a more difficult extraction.
  • Shorter Red Line: Suggests that less bone removal is necessary, indicating an easier extraction.