Past Cases

1. Oral/Maxillofacial
Surgery Scope
Dr Christos Michaelides
DDS,MD
Gen.Surgeon/Oral-Maxillofacial Surgeon
YGIA Private Hospital
Limassol

2. Diagnos7c approach and treatment of Oral Cavity Surgical
pathology to include:
Odontogenic Cyst Fibroma/
Premalignant changes
• Benign and malignant disease of the
oral mucosa, tongue and jaws
• Non neoplasLc changes due to
chronic trauma or irritaLon eg
hyperplasia induced by dentures
• Inflammatory, InfecLous,
autoimmune or neoplasLc disease
• Pre-malignant lesions (leucoplakia,
erythroplakia, pigmented lesions,
lichen planus)
• Odontogenic or non-Odontogenic
CysLc lesions
• Odontogenic or non-odontogenic
tumors

3. Oral Cancer
DiagnosLc approach
Biopsy-surgical excision in wide
margins
ReconstrucLon with local or
free flaps
SelecLve Neck dissecLon (removal of
interfascial faRy Lssue along with lymph nodes)
Referral to Oncologist for
radiotherapy/chemotherapy or
adjuvant therapy
Follow-up
1. Ca lip 2. Ca (R) buccal mucosa 3.Ca (L) tongue a;er
excision and reconstruc>on with forearm free-flap

4. Ca lower lip/reconstruc7on aim to
acceptable cosme7c and func7onal
result
Excision lower lip cancer and
reconstruc>on with local flaps Pa>ent 1/52 post-op

5. Ca buccal mucosa
• Malignant ulceraLon R
buccal mucosa
• SelecLve Neck
DissecLon (Clearance of
lymph nodes chain along IJV)
• ReconstrucLon aUer
wide excision with
Alloderm
• PaLent 2/52 post-op

6. Skin carcinomas Head/Neck
• BCC L Temple
• Excision and reconstrucLon with
• Full thickness skin graU harvested
from the posterior aspect of the
auricle
• BCC L auricle local
excision

7. Dento-alveolar Surgery
• Removal of impacted teeth
• Dental implantology
• Sinus li; opera>on/bone
gra;ing
• Pre-prosthe>c surgery (prepare
the mouth to receive new
prostheLc appliances or dentures
in coordinaLon with the paLent’s
DenLst) to include:
• Surgical removal of hyperplasLc
changes
• VesLbuloplasty
• Lowering of floor of the mouth
• AugmentaLon of alveolar ridge

8. Diagnosis and treatment of benign or malignant
pathology of the Head/Neck soE 7ssues
2.Thyroglossal duct cyst 3. Branchial cyst • Removal of congenital cysLc
lesions in the neck
(thyroglossal duct cyst or
branchial cysts etc)
• Benign or malignant tumors
• Skin lesions and
reconstrucLon with flaps
4.Reconstruc>on with bilobed flap
1. Removal meta-Ca supraclavicular and
reconstruc>on with Major pectoralis
flap( axial myocutaneous)

9. L infraorbital haemangioma
Digital angiography- the
vascular tumor occupying
part of the L lower eyelid
Catheteriza>on of the nasolacrimal
duct pre-op / Reconstruc>on with
nasolabial island flap to avoid
ectropion post-op

10. Ruptured L frontal mucocele in
the orbit Painful Exopthalmus
L eye proptosis - Pre-op CT
scan
Abla>on of the frontal sinus-oblitera>on
with faSy >ssue-closure of the bony
window and fixa>on with mini-plate on
urgent basis

11. Thyroglossal duct cyst
Incision – CT scan neck “Sistrunk” approach

12. Surgical removal of 2nd cleE R
Branchial cyst

13. R Superficial Paroditectomy for benign
pathology (no7ce the full func7on of R facial nerve)

14. Management of Cervico-Facial
Infec7ons
• Admission and iv
anLbioLcs and
monitoring of the
airway and
temperature
• Incision-Drainage of the
abscess
• Pus culture
• ConLnue with per os
anLbioLcs

15. Diagnosis and treatment of Paranasal Sinuses surgical
pathology to include benign/malignant tumors, mucocele etc
• Cancer maxillary sinus
• Poor prognosis due to atypical signs at
iniLal stages and late diagnosis
• 1.CT scan: Tumor R maxillary sinus
invading the orbit (eye socket) and cheek
• 2. Radical surgery and reconstrucLon
• Mucocele shows slow growth and gradually
• cause erosion to the surrounding bony
walls
• of the sinus. Shows atypical symptoms at
• iniLal stages
• 1.Approach via coronal flap L frontal sinus
mucocele
• 2.AblaLon of the sinus and obliteraLon with
faRy Lssue harvested from the abdomen

16. Osteotomies to include par7al or total maxillectomies for the
removal of locally aggressive lesions or malignancies involving the bony
7ssue and reconstruc7on with bone graEs/ free composite flaps/
obturator
Par>al maxillectomy-
Obturator (denture like
prosthesis)
Reconstruc>on with a free
flap is the preferable op>on

17. Diagnosis and treatment of Salivary glands
Surgical pathology to include : Benign or malignant
tumors of minor or major Salivary glands as well as treatment
of sialolithiasis (salivary duct stone) and ranula
SUPERFICIAL PAROTIDECTOMY DissecLon along the facial n. branches

18. Diagnosis and treatment of
Salivary glands Surgical pathology
Advanced stage L submandibular gland
carcinoma along with Neck lymph nodes
metastases
Apart from the tumor excision ipsilateral
Modified Radical Neck DissecLon is mandatory

19. Sialolithiasis-Mucocele
• R floor of the mouth Ranula (mucocele
formaLon due to Wharton’s duct blockade)
• Mucocele L lower lip
Treatment of sialolithiasis:
• intraoral approach if calculus near the opening of salivary
duct,
• extracorporeal short-wave lithotripsy and sialendoscopy for
minor calculi
• Submandibular gland excision

20. Diagnosis and treatment of TMJ pathology and Facial Pain
Differen>al diagnosis and
treatment of Headache and
Facial pain:
• Psychogenic tension headache
• Post-concussion headache, raised
intracranial pressure headache
• Migraine, trigeminal neuralgia,
glossopharyngeal neuralgia
• Temporal arteriLs
• Atypical facial pain
• Referred pain (radiaLng towards the face
from different origin eg cervical spine)
• TMJ related pain
TMJ disorder: Consider occlusal
splint and physiotherapy with
U/S and Laser

21. Orthognathic Surgery
• Who needs orthognathic surgery?
• PaLents with skeletal disharmony between the middle and lower
face that lead to malocclusion and unacceptable facial profile
• Cases that the orthodonLcs alone cannot achieve the desirable
result
• Goals:
Ø Achievement of a beRer facial cosmeLc result
Ø Improvement of basic funcLonal disturbance: masLcaLon or speech
Ø In specific cases for the improvement of breathing

22. Orthognathic Surgery
• Which facial skeletal problems might be
corrected with orthognathic surgery?
• Though there is a broad spectrum of skeletal
• anomalies the most common are
• the following:
v Prognathism upper or lower jaw
v Retrognathism upper or lower jaw
v Malar-maxillary hypoplasia
v Facial asymmetry (skeletal)
v Weak or prominent chin
v Gummy smile
v Open bite

23. The Orthognathic Surgery is based on
osteotomies
• The osteotomies mostly
used are:
1. Le Fort I
osteotomy(upper jaw)
2. SagiRal split
osteotomy(lower jaw)
3. Genioplasty
(advancement/reducLon chin)

24. Congenital malformaLons affec7ng the
Head/Neck region
• CleU lip and Palate
• Craniofacial Syndromes
to include:
• Crouzon’s syndrome
• Apert’s syndrome
• Pfeiffer’s syndrome
• Treacher-Collin’s
syndrome
• Pierre-Robin sequence
Pfeiffer syndrome: premature craniosynostosis
causing secondary facial deformity, syndactyly

25. Orthognathic Surgery
Cle; lip and palate:
1:1000 Caucasian live births
Management:
3/12 Primary closure of cleU lip.
6/12-18/12 primary closure of hard
palate.
8y-10y Alveolar bone graUing
16y-18y Orthognathic Surgery

26. Orthognathic Surgery
Cle; lip and palate pa>ents
need revision surgery over >me
That could affect the midface growth
Orthognathic interven>on is needed when the growth is
considered completed

27. Distrac4on Osteogenesis
q Is the surgically induced
osteogenesis-elongaLon
of bone by
postosteotomy
applicaLon of internal or
external specific devices
(distractors)
q It is an aRracLve method
used for the correcLon of
specific cranio-facial
disproporLons

28. Distrac(on Osteogenesis
• CROUZON’S SYNDROME
(Craniofacial dysostosis)
• Craniosynostosis
• Hypoplas4c middle third of
the face
• Exopthalmus
• Upper airway obstruc4on-
Needs correc4on at early
stage – Distrac4on
osteogenesis
Pre-op.
Post-op.

29. ObstrucLve Sleep Apnea
-Introduc7on
• The obstruc>ve sleep
apnea-hypopnea is a sleep
disorder that involves:
• Recurrent episodes of
upper airway collapse
during sleep along with
• cessaLon or significant
decrease in airflow in the
presence of breathing effort
• as well as recurrent
oxyhemoglobin
desaturaLons and arousals
from sleep
• O.S.A.S is a rather common but
potenLally severe disorder that
affects approximately 2%-9% of
the adult populaLon.
• 10% of men and 5% of women
are habitual snorers in the 3rd
decade with an increase to 20%
and 15% respecLvely, during the
5th decade.
• However, O.S.A affects 2% of
children aged 2-8 years and its
consequences may include
hypertension, nocturnal enuresis,
growth retardaLon, cogniLve
impairment and hyperacLvity

30. O.S.A.S-Clinical manifesta7ons /
Therapeu7c op7ons
• Snoring
• Restless sleep
• Excessive dayLme somnolence
(especially if RDI>20/h)
• Morning headaches
• Depression, memory impairment
• Decreased libido
• Increased risk for accidents
• Sleep related arrhythmias
• Systemic and pulmonary
hypertension
• CongesLve heart failure
• Control of risks factors
(weight loss, quit
alcohol and smoking,
avoid sedaLves)
• C-PAP or Oral
appliances
• Surgery

31. Non surgical management
• C-PAP venLlator
(conLnuous posiLve
airway pressure during
sleep-Follow up by
Specialist
Pneumonologist)
• Intra-oral appliances
during sleep (for snoring
and mild cases of O.S.A-
Follow-up by DenLst)

32. The role of the relevant muscles
on airway patency during sleep
• Genioglossus m.
• Geniohyoid m.
• Tensor palaL m.
• Stylopharyngeus m.
The role of the above
muscles on respiraLon is
crucial not only due to their
anatomical locaLon but
also because their funcLon
is regulated by respiratory
sLmuli (hypercapnia -
hypoxemia) (Shepard
1991,Powell 1995)

33. Advancement procedures
Advancement genioplasty
§ Apart from the advancement of
genioglossus the aRachments of the
anterior bellies of digastrics and geniohyoid
muscles are also advanced.
§ Therefore, simultaneous anterior movement
of the tongue and more favourable hyoid
bone posiLon is achieved
Maxillo-mandibular advancement (MMA)
§ Rather major operaLon that should be
considered when paLent’s anatomy
suggests that other methods are not likely
to achieve significant improvement

34. Maxillo-Mandibular advancement
(MMA)
Opens the airway by pulling forward the
anterior pharyngeal Lssues especially the
tongue

35. Facial CosmeLc Surgery
• Surgical or non- surgical
techniques to include:
• Blepharoplasty-Incision (1)
• Rhinoplasty- Open rhinoplasty (2)
• Otoplasty – approach for “Bat”
ears correcLon (3)
• Revision facial scar
• “wrinkle” removal
• FaceliU- LiposucLon
• Dermabrasion
• Facial rejuvenaLon (Botox, fillers,
laser) - Botox
injecLon (4)

36. Maxillofacial Surgery-Head/Neck Trauma
The frontal bone fractures are mainly the result of a great impact
and usually coexist with intracranial injury- Coronal approach
and fixation with mini-plates or titanium mesh

37. Zygoma fracture
Fracture line of R zygoma
fracture
Post-op 2/52 / Post-op X-ray
L Zygoma fracture

38. Maxillofacial Trauma
Zygoma>c complex and
Orbital fractures
Floor of the orbit fracture (eye
socket) reconstruc>on- Fixa>on
R supraorbital fracture

39. Mandibular fractures
• Can cause occlusion disturbance
• FixaLon-Osteosynthesis with mini-plates
and screws
• Intermaxillary fixaLon ( I.M.F) with
splints and elasLcs

40. Involved in RTA - Deep lacera7on R face
Explora7on R Facial n. branches- Reconstruc7on

41. SoE 7ssue trauma and
reconstruc7on
Nasal >ssue loss due to
dog bite
Reconstruc>on with local
flaps 10 days post-op

42. SoE 7ssue trauma and
reconstruc7on
Dog bite L cheek Post-op 1/52

43. Reconstruc7on full thickness
lacera7on lower lip

44. R zygoma7c complex/orbital floor
fracture with periorbital skin
degloving
Fixa>on R zygoma fracture and
explora>on/reconstruc>on orbital
floor and catheteriza>on of naso-
lacrimal duct
Full eye-globe movement post-op

45. Nasal comminuted fracture
Pre-op CT scan Close reduc>on-post-op 2/52

46. Comminuted mandibular fracture/ facial
lacera7ons/ loss of teeth
sustained aEer “horse-kick”
• CT-scan facial bones on admission
• Pre-op tracheostomy due to gross neck swelling
• open reduc>on osteosynthesis with mini-plates
• IMF for 1/12
Post-op 1/12 and 6/12 (Good
cosme>c and func>onal result -
dental implants)

47. RTA- comminuted fracture
L Frontal sinus and
intracranial hematoma
CT scan brain on admission
Coronal incision-Removal
intracranial hematoma and
reconstrucLon-osteosynthesis