This document provides an overview of the scope of oral and maxillofacial surgery performed by Dr. Christos Michaelides. It describes diagnostic approaches and treatments for various pathologies including cysts, tumors, infections, trauma, sleep apnea and orthognathic/cosmetic procedures. Surgical techniques involve biopsies, excisions, reconstruction with grafts or flaps, osteotomies and other approaches to treat conditions of the oral cavity, salivary glands, sinus, jaws and facial bones. Non-surgical management of sleep apnea includes CPAP and oral appliances.

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

2. Diagnostic 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 neoplastic changes due to
chronic trauma or irritation eg
hyperplasia induced by dentures
• Inflammatory, Infectious,
autoimmune or neoplastic disease
• Pre-malignant lesions (leucoplakia,
erythroplakia, pigmented lesions,
lichen planus)
• Odontogenic or non-Odontogenic
Cystic lesions
• Odontogenic or non-odontogenic
tumors

3. Oral Cancer
Diagnostic approach
Biopsy-surgical excision in wide
margins
Reconstruction with local or
free flaps
Selective Neck dissection (removal of
interfascial fatty tissue 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 after
excision and reconstruction with forearm free-flap

4. Ca lower lip/reconstruction aim to
acceptable cosmetic and functional
result
Excision lower lip cancer and
reconstruction with local flaps Patient 1/52 post-op

5. Dento-alveolar Surgery
• Removal of impacted teeth
• Dental implantology
• Sinus lift operation/bone
grafting
• Pre-prosthetic surgery (prepare
the mouth to receive new
prosthetic appliances or dentures
in coordination with the patient’s
Dentist) to include:
• Surgical removal of hyperplastic
changes
• Vestibuloplasty
• Lowering of floor of the mouth
• Augmentation of alveolar ridge

6. Diagnosis and treatment of benign or malignant
pathology of the Head/Neck soft tissues
2.Thyroglossal duct cyst 3. Branchial cyst• Removal of congenital cystic
lesions in the neck
(thyroglossal duct cyst or
branchial cysts etc)
• Benign or malignant tumors
• Skin lesions and
reconstruction with flaps
4.Reconstruction with bilobed flap
1. Removal meta-Ca supraclavicular and
reconstruction with Major pectoralis
flap( axial myocutaneous)

7. Management of Cervico-Facial
Infections
• Admission and iv
antibiotics and
monitoring of the
airway and
temperature
• Incision-Drainage of the
abscess
• Pus culture
• Continue with per os
antibiotics

8. 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
initial stages and late diagnosis
• 1.CT scan: Tumor R maxillary sinus
invading the orbit (eye socket) and cheek
• 2. Radical surgery and reconstruction
• Mucocele shows slow growth and gradually
• cause erosion to the surrounding bony walls
• of the sinus. Shows atypical symptoms at
• initial stages
• 1.Approach via coronal flap L frontal sinus
mucocele
• 2.Ablation of the sinus and obliteration with
fatty tissue harvested from the abdomen

9. Osteotomies to include partial or total maxillectomies for the
removal of locally aggressive lesions or malignancies involving the bony
tissue and reconstruction with bone grafts/ free composite
flaps/obturator
Partial maxillectomy- Obturator
(denture like prosthesis)
Reconstruction with a free
flap is the preferable option

10. 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 Dissection along the facial n. branches

11. 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 Dissection is mandatory

12. Sialolithiasis-Mucocele
• R floor of the mouth Ranula (mucocele
formation 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

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

14. Orthognathic Surgery
• Who needs orthognathic surgery?
• Patients with skeletal disharmony between the middle and lower
face that lead to malocclusion and unacceptable facial profile
• Cases that the orthodontics alone cannot achieve the desirable
result
• Goals:
 Achievement of a better facial cosmetic result
 Improvement of basic functional disturbance: mastication or speech
 In specific cases for the improvement of breathing

15. 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:
 Prognathism upper or lower jaw
 Retrognathism upper or lower jaw
 Malar-maxillary hypoplasia
 Facial asymmetry (skeletal)
 Weak or prominent chin
 Gummy smile
 Open bite

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

17. Congenital malformations affecting the
Head/Neck region
• Cleft 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

18. Orthognathic Surgery
Cleft lip and palate:
1:1000 Caucasian live births
Management:
3/12 Primary closure of cleft lip.
6/12-18/12 primary closure of hard
palate.
8y-10y Alveolar bone grafting
16y-18y Orthognathic Surgery

19. Orthognathic Surgery
Cleft lip and palate patients
need revision surgery over time
That could affect the midface growth
Orthognathic intervention is needed when the growth is
considered completed

20. Distraction Osteogenesis
 Is the surgically induced
osteogenesis-elongation
of bone by
postosteotomy
application of internal or
external specific devices
(distractors)
It is an attractive method
used for the correction of
specific cranio-facial
disproportions

21. Distraction Osteogenesis
• CROUZON’S SYNDROME
(Craniofacial dysostosis)
• Craniosynostosis
• Hypoplastic middle third of
the face
• Exopthalmus
• Upper airway obstruction-
Needs correction at early
stage – Distraction
osteogenesis
Pre-op.
Post-op.

22. Obstructive Sleep Apnea
-Introduction
• The obstructive sleep
apnea-hypopnea is a sleep
disorder that involves:
• Recurrent episodes of
upper airway collapse
during sleep along with
• cessation or significant
decrease in airflow in the
presence of breathing effort
• as well as recurrent
oxyhemoglobin
desaturations and arousals
from sleep
• O.S.A.S is a rather common but
potentially severe disorder that
affects approximately 2%-9% of
the adult population.
• 10% of men and 5% of women
are habitual snorers in the 3rd
decade with an increase to 20%
and 15% respectively, 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 retardation, cognitive
impairment and hyperactivity

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

24. Non surgical management
• C-PAP ventilator
(continuous positive
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 Dentist)

25. The role of the relevant muscles
on airway patency during sleep
• Genioglossus m.
• Geniohyoid m.
• Tensor palati m.
• Stylopharyngeus m.
The role of the above
muscles on respiration is
crucial not only due to their
anatomical location but
also because their function
is regulated by respiratory
stimuli (hypercapnia -
hypoxemia) (Shepard
1991,Powell 1995)

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

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

28. Facial Cosmetic Surgery
• Surgical or non- surgical
techniques to include:
• Blepharoplasty-Incision (1)
• Rhinoplasty- Open rhinoplasty (2)
• Otoplasty – approach for “Bat”
ears correction (3)
• Revision facial scar
• “wrinkle” removal
• Facelift- Liposuction
• Dermabrasion
• Facial rejuvenation (Botox, fillers,
laser) - Botox
injection (4)

29. 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

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

31. Maxillofacial Trauma
Zygomatic complex and
Orbital fractures
Floor of the orbit fracture (eye
socket) reconstruction- Fixation
R supraorbital fracture

32. Mandibular fractures
• Can cause occlusion disturbance
• Fixation-Osteosynthesis with mini-plates
and screws
• Intermaxillary fixation ( I.M.F) with
splints and elastics

33. Involved in RTA - Deep laceration R face
Exploration R Facial n. branches- Reconstruction