Professional Documents
Culture Documents
A
A
A
C and B fibres
Lloyd 1943
6 20 m. diameter
6 20 m.
1 6 m.
smaller diameter fibres
Samii 1980
Type II
Type III
2nd degree
3rd degree
4th degree
5th degree
6th degree
Controversies
Complete loss any stimulus detection and perception including mechanoreceptors and nociceptor
stimuli.
Alteration in sensibility with abnormal or normal stimulus detection and perception which may be
perceived as unpleasant but not painful.
Alteration in sensibility with abnormal stimulus detection and perception which may be perceived
as unpleasant and painful.
Types : Allodynia, Hyperpathia.
(Controversies
Location
Prognosis
Epifascicular epineurium
Good prognosis
B
Interfascicular epineurium
Prognosis depends on
original damage
Endoneurium
Poor.
In a Sunderland class IV
injury, the epineural
connective tissue that
maintains continuity can be
infiltrated by neuroma.
Poor
S
Continuity in class IV injury
maintained only by scar
tissue.
Poor.
Grade A, B & C are used in combination with Sunderlands classification : I A & I B; II A & II B and III A, III B &
III C.
Grade C fibrosis occurs only with class III injury.
Mackinnon
S0
S1
S2
S 2+
S3
No recovery
Recovery of deep cutaneous pain
Return of some superficial pain / tactile sensation
Return of some superficial pain / tactile sensation with over-reaction
Return of some superficial pain / tactile sensation without over-reaction and the presence of static two-point
discrimination (2pd) >15 mm
S 3+
As per S 3, with good localisation of stimulus (2pd) = 7-15 mm
S4
As per S 3+, (2pd) =2-6 mm
Sensory score equal to or greater than S 3 is defined as useful sensory requirement
Description
Motor Recovery
No contraction
Return of perceptible contraction in proximal muscles.
Return of perceptible contraction in both proximal and distal muscles.
Return of function in both proximal and distal muscles of a degree that all important
muscles are sufficiently powerful to act against resistance
Return of function as in stage 3 with addition that all synergetic and independent movements are possible.
Complete recovery.
Sensory Recovery
Absence of sensibility in the autonomous area.
Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve.
Recovery of some superficial cutaneous pain and tactile sensibility within the autonomous area of the
nerve.
Recovery of superficial cutaneous pain and tactile sensibility throughout the autonomous area with
disappearance of any previous over response.
Recovery of sensibility as in S 3 with the addition of some recovery of two-point discrimination within the
autonomous area.
Complete recovery.
Pain
Pain classification
Burket
Page 327
Categorises pain into various parameters.
Axis I
Regions ( the body region or site of the reported pain ).
Axis II
Systems ( the body system whose abnormal function produces pain
Axis III
Temporal ( temporal characteristics of pain and the pattern of occurrence. )
Axis IV
Patients statement. ( time since onset and intensity of pain).
Axis V
Aetiology. ( the presumed aetiology of the pain problem ).
Ronald C. King et al
Anatomic types
Median dermoid
Lateral sublingual
True lateral
Cysts
Numerous classifications have been published of cysts of the jaws. Most of them are perfectly satisfactory
in clinical evaluation and practise.
Robinsons classification (1945)
Developmental cysts
A) from odontogenic tissue
1. Periodontal cyst
(a) radicular or root apex type
(b) lateral type
(c) residual type
2. Dentigerous cyst
3. Primordial cyst
B) from non-dental type of tissue
1. Median cyst (median palatal cyst)
2. Incisive canal cyst
3. Globulomaxillary cyst
Krugers classification (1964)
A) Congenital cyst
1. Thyroglossal
2. Branchiogenic
3. Dermoid
B) Developmental cyst
1. non-dental origin
a) fissural type
i.
ii.
iii.
iv.
Naso-alveolar
Median
Incisive canal cyst (Naso-palatine)
Globulomaxillary
2.
b) retention type
i.
ii.
dental origin
a) periodontal
i.
ii.
iii.
b) primordial
c) dentigerous
mucocoele
ranula
periapical
lateral
residual
3.
WHO classification published in Histologic typing of odontogenic tumours (Kramer, Pindborg, Shear
1992)
I. Cysts of the jaws
A) Epithelial
1. developmental
a) odontogenic
i.
gingival cysts of infants
ii.
odontogenic keratocyst (primordial cyst)
iii.
dentigerous (follicular) cyst
iv.
eruption cyst
v.
lateral periodontal cyst
vi.
gingival cyst of the adults
vii.
botryoid odontogenic cysts
viii.
glandular odontogenic (sialo-odontogenic / mucoepidermoidodontogenic) cyst
ix.
calcifying odontogenic cyst
b) non-odontogenic
i.
naso-palatine duct (incisive canal) cyst
ii.
naso-labial (naso-alveolar) cyst
iii.
midpalatine raphae cyst of infants
iv.
median palatine, median alveolar and median mandibular cysts
v.
globulomaxillary cyst
2. inflammatory
i.
radicular cyst (apical / lateral)
ii.
residual cyst
iii.
paradental (mandibular infected buccal) cyst
iv.
inflammatory collateral cyst
B) Non-epithelial
i.
solitary (traumatic/simple/haemorrhagic) bone cyst
ii.
aneurysmal bone cyst
II. Cysts associated with the maxillary antrum
a)
benign mucosal cyst of the maxillary antrum
b)
post-operative maxillary cyst (surgical ciliated cyst of the maxilla)
III.Cysts of the soft tissues of the mouth, face and neck
a)
dermoid and epidermoid cyst
b)
lymphoepithelial (branchial cleft) cyst
c)
thyroglossal duct cyst
d)
anterior median lingual cyst (intralingual cyst of fore-gut origin)
e)
oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)
f)
cystic hygroma
g)
naso-pharyngeal cysts
h)
thymic cysts
i)
cysts of the salivary glands
i.
mucous extravasation cyst
ii.
mucous retention cyst
iii.
ranula
iv.
polycystic (degenerative) disease of parotid
j)
parasitic cysts
i.
hydatid cyst
ii.
cysticerus cellulosae
iii.
trichinosis
Fibro-osseous lesions
1.
Fibrous dysplasia
a
2.
b
c
d
3.
e
f
a. Polyostotic
b. Monostotic.
Fibro-osseous (Cemental ) lesions. Reactive (dysplastic ) lesion arising in the tooth bearing area. They are
presumably arising from periodontal ligament. They are divided into three types based on their radiologic
features although they represent the same pathologic process.
a. Periapical cemental (Cemento-osseous )dysplasia.
b. Focal (local) cemento-osseous lesions (dysplasia). probably reactive in nature.
c. Florid cemento-osseous dysplasia (gigantiform cementoma).
Fibro-osseous neoplasms. They are of uncertain or debatable relationship to those arising in the periodontal
ligament. They are widely designated as cementifying fibroma, ossifying fibroma or cemento-ossifying
fibroma.
a. Cementoblatoma, Osteoblastoma and Osteoid osteoma.
b. Juvenile active ossifying fibroma and other so called aggressive, active ossifying / cementifying
fibromas.
TNM classification
The TNM system is used to describe the anatomical extent of a malignant disease. It is based on the
assessment of three components
T the extent of primary tumour
T primary tumour
N the absence or presence and extent of regional lymph node metastasis
M the absence or presence of distant metastases.
T0
Tis
T1
T2
T3
T4
Lip: Tumour invades adjacent structures, e.g. through cortical bone, tongue, skin of neck.
Oral cavity: Tumour invades adjacent structures, e.g. through cortical bone, into deep (extrinsic) muscles
of tongue, maxillary sinus, skin
Pharynx (oropharynx)
Tx
T0
Tis
- Carcinoma in situ
T1
T2
T3
T4
- Tumour invades adjacent structures, e.g. through cortical bone, soft tissues of neck, deep
muscles of tongue
Pharynx (nasopharynx)
Tx
T0
(extrinsic)
Tis
- Carcinoma in situ
T1
T2
T3
T4
Maxillary sinus
Tx
T0
Tis
- Carcinoma in situ
T1
T2
- Tumour with erosion or destruction of the infrastructure including the hard palate and/or the middle
meatus.
T3
- Tumour invades any of the following: skin of cheek, posterior wall of the maxillary sinus, floor or medial
wall of the orbit, anterior ethmoid sinus
T4
- Tumour invades the orbital contents and/or any of the following: cribriform plate, posterior ethmoid or
sphenoid sinuses, nasopharynx, soft palate, pterygomaxillary or temporal fossae, base of skull
Salivary glands
Tx
T0
T1
T2
T3
T4
N0
N1
N2
- Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension, or in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, or in bilateral
or contralateral lymph nodes, none more than 6cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N3
- Metastasis in a lymph node more than 6 cm in greatest dimension
N 3 ba Clinically positive ipsilateral node(s), one more than6 cm in diameter.
N 3b Bilateral clinically positive nodes( in this situation, each side of the neck should be staged separately)
N 3c contralateral clinically positive node(s) only.
M0
- No distant metastasis
M1
- Distant metastasis
Other tumours
Osteosarcoma
T Primary tumour
Tx
T0
T1
T2
- Tumour invades beyond the cortex
The classification applies to all primary malignant bone tumours except multiple myeloma, juxtacortical
osteosarcoma and juxtacortical chondrosarcoma
Soft tissue sarcomas
T Primary tumour
Tx
T0
T1
T2
Skin tumours
T Primary tumour
Tx
T0
Tis
- Carcinoma in situ
T1
T2
T3
T4
- Tumour invades deep extradermal structures, i.e. cartilage, skeletal muscle or bone
Note: In the case of multiple simultaneous tumours, the tumour with the highest T category will be classified and the
number of separate tumours will be indicated in parenthesis e.g. T2 (5)
Melanoma
T Primary tumour
The extent of tumour is classified after excision. This is a pathological tumour classification.
Tx
T0
Tis
- Melanoma in situ (Clarks level I) (atypical melanocytic hyperplasia, severe melanocytic dysplasia, not
an invasive malignant lesion)
T1
- Tumour 0.75 mm or less in thickness and invading the papillary dermis (Clarks level II)
T2
- Tumour more than 0.75 mm but not more than 1.5 mm in thickness and/or invading the papillaryreticular dermal interface (Clarks level III)
T3
- Tumour more than 1.5 mm but not more than 4.0 mm in thickness and/or invading the reticular dermis
(Clarks level IV)
T3a Tumour more than 1.5 mm but not more than 3.0 mm in thickness
T3b Tumour more than 3.0 mm but not more than 4.0 mm in thickness
T4
- Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue (Clarks level V) and/or
satellites within 2cm of the primary tumour.
T4a Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue
N0
N1
N2
- Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s) and/or in-transit
metastasis
N2a - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s)
N2b - In-transit metastasis
N2c Both
Note: In-transit metastasis involves skin or subcutaneous tissue more than 2cm from the primary tumour but beyond the regional lymph nodes
M Distant metastasis
Mx
M0
- No distant metastasis
M1
- Distant metastasis
M1 a
- Metastasis in skin or subcutaneous tissue or lymph node(s) beyond the regional lymph nodes
M1 b
- Visceral metastasis
Classification of sialadenitis
(I)
(II)
Sialadenitis, infection of salivary gland tissue is a relatively common tissue. It may be classified as
Bacterial and viral
a) Mumps (viral parotitis)
b) Bacterial parotitis (sialadenitis)i. Acute
ii. chronic
c) Recurrent parotitis of childhood
Obstructive sialadenitis
a) Sialolithiasis
b) Mucous plugs
(III)
c) Stricture stenosis
d) Foreign body
Systemic granulomatous diseases
a) Tuberculosis
b) Actinomycosis
c) Fungal infection
d) Uveoparotid fever
II.
Various classifications systems have been proposed, but only a few have found wide acceptance.
In the classification of David and Ritchie (1922), congenital clefts were divided into three groups
according to the position of the clefts in relation to the alveolar process.
Group I Pre-alveolar clefts unilateral (right or left), bilateral or median
Group II Post-alveolar clefts involving soft palate only
involving soft and hard palates
submucous cleft
Group III Alveolar clefts unilateral (right or left), bilateral or median.
Veau (1931) suggested a classification that divides cleft palates into four groups.
Group I Cleft of soft palate only.
Group II Cleft of hard and soft palate extending no further than incisive foramen, thus involving
secondary palate alone.
Group III Complete unilateral cleft, extending from the uvula to the incisive foramen in the midline, then
deviating to one side and usually extending through the alveolus at the position of the future
lateral incisor tooth.
Group IV Complete bilateral cleft, resembling Group III with two clefts extending forwards from the
incisive foramen through the alveolus.
III.
Kernahan and Stark (1958) recognised the need for a classification based on embryology rather than
morphology.
A.
Incomplete cleft of secondary palate
B.
Complete cleft of secondary palate
C.
Incomplete cleft of primary and secondary palates
D.
Unilateral complete cleft of primary and secondary palates
E.
Bilateral complete cleft of primary and secondary palates
IV.
Kernahan (1971) subsequently proposed a striped Y classification. The incisive foramen, which is the
dividing line between primary and secondary palate, is taken as the reference, and forms the junction of the Y.
With stippling of the involved portion of the Y, the system provides rapid graphic representation of the
original pathologic condition and renders itself to computer-graphic presentation.
V.
VII.
Preprosthetic surgery
Alveolar ridge classification
Class I
Class II
Class III
Class IV
Class V
Dentate
Immediate post extraction
Convex ridge form with adequate height and width
Knife edge ridge form, inadequate height and width
Loss of basal bone that may be extensive and follows no predictable pattern.
AJOMS 1997
Tucker 1997
Carl E. Misch
Page 94
Division
Dimension
Treatment options
2.5 5 mm width
> 10 13 mm height
> 12mm length
< 20 degree angulation
Crown / implant ratio < 1
Osteoplasty
Division A root form.
Augumentation
Demanding aesthetics.
Great force factors
Narrow Implants
Division B root form
Plate form.
Unfavourable in :
Width
Misch 1988
Carl E. Misch
Page 113
Bone
D1
D2
Density
Dense cortical bone.
( Anterior mandible)
Thick dense to porous cortical bone on crest and coarse trabecular bone within
( Anterior maxilla)
D3
Thin porous cortical bone on crest and fine trabecular bone within
( Anterior Maxilla & Posterior mandible)
D4
Fine trabecular bone
( Posterior maxilla)
D5
Immature, nonmineralized bone.
D1 bone is similar to drilling into Oak or maple wood, D2 bone is similar to the tactile sensation
of drilling into white pine or spruce, D3 bone is similar to drilling into balsa wood, D4 bone is imilar to
drilling into styrofoam.
CT determination of bone density
Contemporary implant dentistry
D1
> 1250 Hounsfield units
D2
850 1250 Hounsfield units
D3
350 850 Hounsfield units
D4
150 350 Hounsfield units
D5
< 150 Hounsfield units
Carl E. Misch
Carl E. Misch
Misch
Carl E. Misch
Misch
Carl E. Misch
Page 114
Page 163-74
Page 199
Page 184
Carl E. Misch
Misch 1989
Page 235
FP3
RP4
RP5
Fixed prosthesis, replaces missing crowns and gingival colour and portion of the edentulous site, prosthesis
most often uses denture teeth and acrylic gingiva, but may be porcelain to metal.
Removable prosathesis, overdenture supported completely by implant.
Removable prosthesis, overdenture supported by both soft tissue and by implant.
Misch 1993
Carl E. Misch
Page 29
Trauma
Trauma score & Basics
Classification of operative wounds in relation to contamination and increasing risk of infection.
Altemeier, Burke and Pruitt
AJOMS 1997
Class I
Clean (non-traumatic, uninfected, GIT & Resp. tract not involved
Class II
Clean contaminated (involving GIT and RT under controlled conditions)
Class III Contaminated (gross spillage from GIT, genito-urinary tract involvement with infected urine and bile.
Class IV Dirty and infected (traumatic wound with devitalised tissue, foreign bodies, faecal contamination or from
a dirty source
Classification of hemorrhagic shock by American College of surgeons committee on trauma 1984
Peterson Principles of oral & Maxillofacial surgery. Page 290.
Class I
Acute blood loss 15 % of total blood volume. Pulse & respiration increased. BP not significantly
affected.
Class II
Acute blood loss of 20 25 % of total blood volume. Increased pulse & respiration. Decreased BP.
No decrease in urine output.
Class III
Blood loss of 30 40 % of total blood volume. Increased pulse & respiration. Decreased BP &
Urine output.
Class IV
40 50 % loss of total blood volume. Lack of vital signs. Decreased urine output. Obtunded mental
status.
For 70 kg man (Peterson, Principles of Oral & Maxillofacial surgery) Page 291
Class I
Class II
Class III
Class IV
Blood Loss
750 ml
750 - 1500
1500 - 2000
2000 or more
% loss
15 %
15 30 %
30 40 %
40 % or more
Pulse rate
< 100
> 100
> 120
140 or higher
BP
Normal
normal
decreased
Decreased
Normal or
increased
decreased
decreased
decreased
Normal
positive
positive
positive
Respiratory rate
14 20
20 30
30 - 40
> 35
30 or more
20- 30
5 - 15
Negligible
Slightly anxious
Mild anxious
Crystalloid
crystalloid
Anxious and
confused
Crystalloid +
blood
Confused &
lethargic
Crystalloid +
blood
Page 272
Code
4
3
2
1
0
Score
A:
_____
B:
_____
C:
_____
D:
______
E:
______
Respiratory effort
Reactive
Normal
Reactive / none
1
0
90
70 89
50 69
0 - 49
0
4
3
2
1
0
No carotid pulse.
Capillary refill
Normal - forehead / lip mucosa colour refill in 2 secs.
Normal
Delayed
None
2
1
0
5
4
3
2
1
Trauma score = A + B + C + D + E
Classification of open fractures based on extent of soft tissue injury. Gustilo & Anderson 1976
Grade I
Grade II
Grade III
Grade III A
Grade III B
Grade III C
Midface fractures
Classification of midface fractures
Rn Le Fort
1901
Killey fractures of middle third of face
Page 11
Le Fort I
Low-level fracture
Le Fort II
Pyramidal or Subzygomatic Fracture
Le Fort III
High Traverse or Suprazygomatic Fracture
Classification of midface fractures
Wassmund 1927
Krger & Schilli. Page 107 - 113.
Wassmund I
Pyramidal fracture of maxilla without involvement of nasal bones
Wassmund II
Pyramidal fracture of maxilla with involvement of nasal bones
Wassmund III
Total displacement of midface from cranial base without involvement of nose.
Wassmund IV Total displacement of midface (visecrocranium) from cranial base with involvement of nose.
Classification of midface fractures
Schwenzer 1967
Krger & Schilli. Page 107.
1. Central midface fractures ( from root of nose to alveolar process without involvement of cheek bones)
a) Alveolar process fracture
b) Transverse (horizontal) fracture of maxilla (Le Fort I)
c) Sagittal fracture of maxilla (median or paramedian)
d) Pyramidal fracture with separation of entire maxilla with involvement of nasal bones (Le Fort II)
e) Fracture of nasal bones and naso-ethmoid complex.
2. Centrolateral midface (separation of entire facial skeleton from base of skull)
a) Total displacement of visecrocranium with involvement of nasal bones (Le Fort III / Wassmund IV)
b) Total displacement without involvement of nasal bones (Wassmund III)
c) Combination fractures characterised by central and centrolateral fractures with atypical fractures.
3. Lateral midface
a) Fractures of Zygoma
b) Fractures of zygomatic arch
c) Zygomatico-maxillary fracture
d) Zygomatico-mandibular fracture
e) Fracture of the floor of the orbit (Blow out fracture).
1987
Paul N. Manson et al
PSR 1998
a. No significant displacement
b. Partial medial displacement
c. Total medial displacement
d. Dorsal displacement
e. Inferior displacement
f. Comminuted fractures
2. Fractures of Zygomatic arch
3. Complex fractures
a. Centrolateral midface fractures
b. Zygomatico-maxillary fractures
c. Zygomatico-mandibular fractures.
1985
Type II
Type III
fractured large fragments, medial canthal tendon attached to the fractured segment.
fracture involving the central fragment of bone where the medial canthus attaches.
Condylar fractures
Classification of injuries to the TMJ region
Helmut Schle 1986
Oral & Maxillofacial traumatology Vol 2 . Kruger & schilli. Page 45 47.
1.1.1
1.1.2
1.1.2.1
1.1.2.2
1.1.2.3
1.1.3
1.1.4
1.1.5
1.1.6
Int.JOMS 1999
Mandibular fractures
Classification of mandibular fractures
Kazangia and Converse
Clinics in plastic surgery 1992, advances in craniofacial management. Page62.
Class I
Teeth present on both sides fracture line
Class II
Teeth present on only one side.
Class III
fracture occurs in an area without dentition
Classification of mandibular fractures based on type of fracture
Peterson. (Principles of Oral & Maxillofacial surgery, Vol. I. Page 409).
Simple fracture
Single fracture line that does not communicate with the exterior.
Compound fracture
These fractures have communication with the external environment, usually by
periodontal ligament of a tooth or
Greenstick fracture
This type frequently occurs in children with incomplete loss of continuity of bone.
Usually one cortex is fractured and the other is bent, leading to distortion without
complete section. There is no mobility between distal and proximal segment.
Comminuted fractures
Multiple fragmentation of bone at one fracture site. Usually as a result of greater force.
Complex or complicated Damage to adjacent structures of bone like vessels, nerves or joint structures.
Telescoped or impacted one bone is driven into another. Rare in mandible.
Direct fractures
Fractures at the site of impact
Indirect fracture
Fractures at a point away from site of impact.
Pathological fracture
occurring as a result normal force or minimal trauma as a result of bone weakened by
pathology.
Classification of mandibular fractures based on site of fracture
Kelly & Harrigan1975
Peterson. (Principles of Oral & Maxillofacial surgery, Vol. I. Page 410).
Condylar process
Ascending ramus
Angle fracture
Body fracture
Symphysis fracture
1.
2.
3.
E.g. F1L2O3S2A1
Categories of fractures. ( F ).
F1 :
Single fracture.
F2 :
Multiple Fractures ( segmental fractures).
F3 :
Comminuted Fracture.
F4 :
Fracture with bone defect.
Categories of localisation ( L )
L1 :
Precanine.
L2 :
Canine.
L3 :
Postcanine
L4 :
Angular
L5 :
Supra angular
L6 :
Processus articularis
L7 :
Processus muscularis
L8 :
Alveolar process
Categories of Occlusion ( O ).
O0 : No malocclusion.
O1 : Malocclusion.
O2 : Nonexistent occlusion ( edentulous mandible )
Categories of soft tissue involvement ( S )
S0 : Closed.
S1 : Open intraorally.
S2 : Open extraorally.
S3 : Open intraextraorally.
S4 : Soft tissue defect.
Categories of associated fracture ( A )
A
None
A1 : Fracture and / or loss of tooth.
A2 : Nasal bone.
A3 : Zygoma.
A4 : Le Fort I
A5 : Le Fort II
A6 : Le Fort III
Grade of severity ( I - V )
Grade of severity
Soft tissue formula
I A
I B
F0S0
F1S0
II A
II B
F2S0
F3S0
III A
Clinical presentation
Closed fracture
III B
IV A
IV B
F3S1 / F3S2
F3S3
VA
VB
F4S4
Linear
Displaced
Linear
Displaced
Open fracture
Infection
ORN
Marx 1983
AJOMS
Type I Develops shortly after radiation; is due to synergistic effects of surgical trauma and radiation injury
Type II Develops years after radiation and follows a traumatic event; rarely occurs before 2 years after treatment;
most commonly occurs after 6 years; due to progressive endarteritis and vascular effusion.
Type III Occurs spontaneously without a preceding traumatic event; usually occurs between 6 months and 3 years
after radiation. ; due to immediate cellular damage and death due to radiation treatment.
Osteonecrosis
1.
2.
3.
Epstein et al
1987
AJOMS
Orbital cellulitis
(Chandler 1970)
Osteomyelitis
Hudson
1993
Trauma.
2.
Surgery.
3.
Odontogenic infection
B. Progressive
1.
Burns.
2.
Sinusitis.
3.
Vascular insufficiency.
C. Hematogenous (metastatic)
1.
2. Developing dentition
II)
2.
B) Garrs osteomyelitis
1.
2.
C) Suppurative or nonsuppurative.
1.
2.
3.
D) Sclerosing
1.
2.
Diffuse
a.
Fastidious micro-organisms.
b.
Focal
a.
Predominantly odontogenic
b.
1985
Stage 1: Medullary osteomyelitis involved medullar bone without cortical involvement, usually
hematogenous.
Stage 2: Superficial osteomyelitis less than 2-cm bony defect without cancellous bone.
Stage 3: Localised osteomyelitis less than 2-cm bony defect on radiograph, which does not appear
to involve both cortices.
Stage 4: Diffuse osteomyelitis defect larger than 2 cm, pathologic fracture, infection, nonunion.
II) Physiologic class
III) Systemic or local factors that affect immune surveillance, metabolism and local vascularity
Temporomandibular Joint
TMJ disorders classifications
Moore
Page 566
Structural disorders
Inflammation
Acute
Chronic
Infection
Ankylosis
True
False
Trauma
Neoplasia
Developmental
Degenerative
Functional
Pain dysfunction syndrome
Chondromalacia : Grading
Grade I
Grade II
Grade III
Grade IV
Outerbridge RE
Milgram 1977
I Early Stage
A) Clinical : No significant mechanical symptoms other than opening reciprocal clicking, no pain or limitation of
motion.
B) Radiologic : Slight forward displacement, good anatomic contour of the disk, negative tomograms.
C) Anatomic/ pathologic : Excellent anatomic form, slight anterior displacement, passive incoordination
demonstrable.
II Early Intermediate stage
A) Clinical : One or more episodes of pain, beginning major mechanical problems consisting of mid to late opening
loud clicking, transient catching and locking.
B) Radiologic : Slight forward displacement, beginning disk deformity of slight thickening of posterior edge,
negative tomograms.
C) Anatomic/ pathologic : Anterior disk displacement, early anatomic disk deformity, good central articulating
area.
III Intermediate Stage.
A) Clinical : Multiple episodes of pain, major mechanical symptoms consisting of locking (intermittent or fully
closed ), restriction of motion, and difficulty with function.
B) Radiologic : Anterior disk displacement with significant deformity or prolapse of disk ( increased thickening of
posterior edge), negative tomograms.
C) Anatomic/ Pathologic : Marked anatomic disk deformity with anterior disk displacement, no hard tissue
changes.
IV Late Intermediate stage.
A) Clinical : Slight increase in severity over intermediate stage
B) Radiologic : Increase in severity over intermediate stage, positive tomograms showing early to moderate
degenerative changes flattening of eminence, deformed condylar head, sclerosis
C) Anatomic/ Pathologic : Increase in severity over intermediate stage, Hard tissue degenerative remodelling of
both bearing surfaces (osteophytosis), multiple adhesions in anterior and posterior recesses, no perforation of
disk or attachments
V Late Stage.
A) Clinical : Characterised by crepitus, variable and episodic pain, chronic restriction of motion and difficulty with
function
C) Radiologic : Disk or attachment perforation, filling defects, gross anatomic deformity of disk and hard tissues,
positive tomograms with essentially degenerative arthritic changes
C) Anatomic/ Pathologic : Gross degenerative changes of disk and hard tissues, perforation of posterior
attachment, multiple adhesions, osteophytosis, flattening of condyle and eminence, subcortical cyst formation.
TMJ ankylosis
Kazanjian 1938
Moore
True ankylosis
False ankylosis
False ankylosis
Miller et al 1975
Moore
Myogenic
Neurogenic
Psychogenic
Bone impingement
Fibrous adhesions
Tumours
Short / Long
Intracapsular / Extracapsular
Histologic variations
Fibrous
Fibro-osseous
Osseous
Osteocartilaginous
TMJ ankylosis
Raveh et al
TMJ ankylosis
Topazian 1966
Type I
Type II
Type III
TMJ ankylosis
Sawhney 1986
Dowson et al
1997 / 1996
Type 2
Laster et al
2000 / 2001
General
American Society of Anaesthesiologist physical status classification system
Schiender 1983
Schobinger
Blush/ stain, warmth and AV shunting by continuos Doppler or 20 MHz colour Doppler
Same as stage I + enlargement, tortuous tense veins, pulsation, thrill and bruit.
Same as stage II + either dystrophic changes, ulceration, bleeding, persistent pain or destruction
Same as stage II + cardiac failure.
Carl E. Misch
Page 46
Impacted teeth
Winters classification 1926.
Based on the relation of long axis of impacted tooth to the 2nd molar.
Vertical
Mesioangular
Distoangular
Horizontal
Inverted
Buccoangular
Linguoangular
Difficulty index for removal of impacted mandibular 3rd molar Pedersen G W 1988
Oral surgery
Pedersen G W
This index is based on Pell & Gregory classification and aids in assessing difficulty in surgical removal of
third molar
Classification
Value
Spatial relationship
Mesioangular
1
Horizontal / Transverse
2
Vertical
3
Distoangular
4
Depth
Level A
1
Level B
2
Level C
3
Ramus relationship / Space available
Class I
1
Class II
2
Class III
3
Total score out of 10.
Difficulty index:
Very difficult
7 10.
Moderately difficult
5 7.
Minimal difficult
3 4.
Page 73
Category
Score
Winters classification
Vertical
0
Mesioangular
1
Distoangular
2
____________________________________Horizontal
2
Height of mandible
35 39 mm
0
31 34 mm
1
1 30 mm
2
Angulation of third molars
1o 50o
0
51o 69o
1
70o 79o
2
80o 89o
3
90o +
4
Root shape
Conical
1
Favourable curvature
2
Unfavourable curvature 3
Follicles
Enlarged
0
Possibly enlarged
1
Normal
2
Path of Exit
Space available
0
Mesial cusp covered
1
Distal cusp covered
2
Both covered
3
_______________
Total score for out of 33
Higher score indicates difficult extraction
Canine impactions
1935
Archer
Page 325
Conical
Composite odontoma
1. Complex
2. Compound
Tuberculate
Supplemental
2.
Multiple
Non-Syndrome
1.
Tuberculate
2.
Supplemental
Syndrome
1.
Cleft Lip/Palate
2.
Cleidocranial Dysplasia
3.
Gardner Syndrome
Archer
Page 311
Vertical
Horizontal
Mesioangular
Distoangular
Inverted
Buccoangular
Linguoangular
C
Based on the relationship of impacted third molar and maxillary sinus.
SA (Sinus approximation):
No bone or thin portion of bone between the maxillary third molar and the
maxillary sinus.
NSA (No sinus approximation):
2mm or more thickness of bone between the impacted maxillary third molar and
the maxillary sinus.
Medicaments
Carnoys solution
Killey & Kay part II page.
Absolute alcohol
Chloroform
Glacial acetic acid
6 parts
3 parts
1 part
7 parts by weight
2 parts
1part
Whiteheads varnish
Killey & Kay part II page. 41.
Benzoin
Storax
Balsam of Tolu
Iodoform
Solvent ether
10 parts
7.5 parts
5 parts
10 parts
to make 100 parts.
Bonneys blue
McGregor principles of Plastic Surgery. Page
Gentian violet
10 g
Brilliant green 10 g
Alcohol 95%
950 ml
Water
to make 2000 ml.
Eusol
Local anaesthetic
Anaesthetic
Vasoconstrictor
Tumescent solution
Grab & Smith
Allogenic bone
Os purum
Killey & Kay part II page. 186.
Bone in which some of the organic elements have been removed
Anorganic bone
This is prepared by boiling bone in ethylenediamine for several days. This can be stored without
refrigeration. This can be trimmed with scalpel and cut into chips.
Kiel bone
Bovine bone treated with hydrogen peroxide and a de-fattening agent.
Boplant bone
Bovine bone treated with propiolactone to sterilise it and de-fattening is by detergents and organic
solvents.
AAA bone (antigen
Nerves
Classification of axons conduction speed
A
A
A
A
B
C
A
A
A
C and B fibres
Lloyd 1943
6 20 m. diameter
6 20 m.
1 6 m.
smaller diameter fibres
Samii 1980
Type II
Type III
2nd degree
3rd degree
4th degree
5th degree
6th degree
Controversies
Complete loss any stimulus detection and perception including mechanoreceptors and nociceptor
stimuli.
Alteration in sensibility with abnormal or normal stimulus detection and perception which may be
perceived as unpleasant but not painful.
Alteration in sensibility with abnormal stimulus detection and perception which may be perceived
as unpleasant and painful.
Types : Allodynia, Hyperpathia.
(Controversies
Location
Prognosis
Epifascicular epineurium
Good prognosis
B
Interfascicular epineurium
Endoneurium
Poor.
Poor
Poor.
Grade A, B & C are used in combination with Sunderlands classification : I A & I B; II A & II B and III
A, III B & III C.
Grade C fibrosis occurs only with class III injury.
Mackinnon
S0
S1
S2
S 2+
S3
No recovery
Recovery of deep cutaneous pain
Return of some superficial pain / tactile sensation
Return of some superficial pain / tactile sensation with over-reaction
Return of some superficial pain / tactile sensation without over-reaction and the presence of static
two-point discrimination (2pd) >15 mm
S 3+
As per S 3, with good localisation of stimulus (2pd) = 7-15 mm
S4
As per S 3+, (2pd) =2-6 mm
Sensory score equal to or greater than S 3 is defined as useful sensory requirement
Description
Motor Recovery
No contraction
Return of perceptible contraction in proximal muscles.
Return of perceptible contraction in both proximal and distal muscles.
M3
M4
M5
S0
S1
S2
S3
S3+
S4
Return of function in both proximal and distal muscles of a degree that all
important muscles are sufficiently powerful to act against resistance
Return of function as in stage 3 with addition that all synergetic and independent movements are
possible.
Complete recovery.
Sensory Recovery
Absence of sensibility in the autonomous area.
Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve.
Recovery of some superficial cutaneous pain and tactile sensibility within the autonomous area of
the nerve.
Recovery of superficial cutaneous pain and tactile sensibility throughout the autonomous area with
disappearance of any previous over response.
Recovery of sensibility as in S 3 with the addition of some recovery of two-point discrimination
within the autonomous area.
Complete recovery.
Pain
Pain classification
Burket
Page 327
Categorises pain into various parameters.
Axis I
Regions ( the body region or site of the reported pain ).
Axis II
Systems ( the body system whose abnormal function produces pain
Axis III
Temporal ( temporal characteristics of pain and the pattern of occurrence. )
Axis IV
Patients statement. ( time since onset and intensity of pain).
Axis V
Aetiology. ( the presumed aetiology of the pain problem ).
78: 5.
OOO 1994,
Anatomic types
Median dermoid
Lateral sublingual
True lateral
Cysts
Numerous classifications have been published of cysts of the jaws. Most of them are perfectly
satisfactory in clinical evaluation and practise.
Robinsons classification (1945)
Developmental cysts
C) from odontogenic tissue
4. Periodontal cyst
(d) radicular or root apex type
(e) lateral type
(f) residual type
5. Dentigerous cyst
6. Primordial cyst
D) from non-dental type of tissue
4. Median cyst (median palatal cyst)
5. Incisive canal cyst
6. Globulomaxillary cyst
Krugers classification (1964)
C) Congenital cyst
4. Thyroglossal
5. Branchiogenic
6. Dermoid
D) Developmental cyst
3. non-dental origin
c) fissural type
v.
vi.
vii.
viii.
d) retention type
iii.
Naso-alveolar
Median
Incisive canal cyst (Naso-palatine)
Globulomaxillary
mucocoele
4.
iv.
ranula
iv.
v.
vi.
periapical
lateral
residual
dental origin
d) periodontal
e)
f)
primordial
dentigerous
Fibro-osseous lesions
4.
g
5.
h
i
j
6.
k
l
Fibrous dysplasia
a. Polyostotic
b. Monostotic.
Fibro-osseous (Cemental ) lesions. Reactive (dysplastic ) lesion arising in the tooth bearing area. They
are presumably arising from periodontal ligament. They are divided into three types based on their
radiologic features although they represent the same pathologic process.
a. Periapical cemental (Cemento-osseous )dysplasia.
b. Focal (local) cemento-osseous lesions (dysplasia). probably reactive in nature.
c. Florid cemento-osseous dysplasia (gigantiform cementoma).
Fibro-osseous neoplasms. They are of uncertain or debatable relationship to those arising in the
periodontal ligament. They are widely designated as cementifying fibroma, ossifying fibroma or
cemento-ossifying fibroma.
a. Cementoblatoma, Osteoblastoma and Osteoid osteoma.
b. Juvenile active ossifying fibroma and other so called aggressive, active ossifying /
cementifying fibromas.
TNM classification
The TNM system is used to describe the anatomical extent of a malignant disease. It is based on
the assessment of three components
T the extent of primary tumour
T primary tumour
N the absence or presence and extent of regional lymph node metastasis
M the absence or presence of distant metastases.
T0
Tis
T1
T2
T3
T4
Lip: Tumour invades adjacent structures, e.g. through cortical bone, tongue, skin of neck.
Oral cavity: Tumour invades adjacent structures, e.g. through cortical bone, into deep (extrinsic)
muscles of tongue, maxillary sinus, skin
Pharynx (oropharynx)
Tx
T0
Tis
- Carcinoma in situ
T1
T2
T3
T4
- Tumour invades adjacent structures, e.g. through cortical bone, soft tissues of neck, deep
(extrinsic) muscles of tongue
Pharynx (nasopharynx)
Tx
T0
Tis
- Carcinoma in situ
T1
T2
T3
T4
Maxillary sinus
Tx
T0
Tis
- Carcinoma in situ
T1
T2
- Tumour with erosion or destruction of the infrastructure including the hard palate and/or the
middle meatus.
T3
- Tumour invades any of the following: skin of cheek, posterior wall of the maxillary sinus, floor
or medial wall of the orbit, anterior ethmoid sinus
T4
- Tumour invades the orbital contents and/or any of the following: cribriform plate, posterior
ethmoid or sphenoid sinuses, nasopharynx, soft palate, pterygomaxillary or temporal fossae, base
of skull
Salivary glands
Tx
T0
T1
T2
T3
T4
N0
N1
N2 - Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension, or in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, or in
bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N3
- Metastasis in a lymph node more than 6 cm in greatest dimension
N 3 ba Clinically positive ipsilateral node(s), one more than6 cm in diameter.
N 3b Bilateral clinically positive nodes( in this situation, each side of the neck should be staged
separately)
N 3c contralateral clinically positive node(s) only.
Note: Midline nodes are considered ipsilateral nodes.
M Distant metastasis
Metastasis in any lymph node other than regional is classified as distant metastasis. The definition
of M-Distant Metastasis is the same for all types of cancer.
Mx
M0
- No distant metastasis
M1
- Distant metastasis
Other tumours
Osteosarcoma
T Primary tumour
Tx
T0
T1
T2
- Tumour invades beyond the cortex
The classification applies to all primary malignant bone tumours except multiple myeloma, juxtacortical
osteosarcoma and juxtacortical chondrosarcoma
Soft tissue sarcomas
T Primary tumour
Tx
T0
T1
T2
Skin tumours
T Primary tumour
Tx
T0
Tis
- Carcinoma in situ
T1
T2
T3
T4
- Tumour invades deep extradermal structures, i.e. cartilage, skeletal muscle or bone
Note: In the case of multiple simultaneous tumours, the tumour with the highest T category will be
classified and the number of separate tumours will be indicated in parenthesis e.g. T2 (5)
Melanoma
T Primary tumour
The extent of tumour is classified after excision. This is a pathological tumour classification.
Tx - Primary tumour cannot be assessed
T0 - No evidence of primary tumour
Tis - Melanoma in situ (Clarks level I) (atypical melanocytic hyperplasia, severe melanocytic dysplasia,
not an invasive malignant lesion)
T1 - Tumour 0.75 mm or less in thickness and invading the papillary dermis (Clarks level II)
T2 - Tumour more than 0.75 mm but not more than 1.5 mm in thickness and/or invading the papillaryreticular dermal interface (Clarks level III)
T3 - Tumour more than 1.5 mm but not more than 4.0 mm in thickness and/or invading the reticular dermis
(Clarks level IV)
T3a Tumour more than 1.5 mm but not more than 3.0 mm in thickness
T3b Tumour more than 3.0 mm but not more than 4.0 mm in thickness
T4 - Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue (Clarks level V) and/or
satellites within 2cm of the primary tumour.
T4a Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue
T4b Satellites within 2cm of the primary tumour
Note: In case of discrepancy between tumour thickness and level, the T category is based on the less favourable
finding.
N Regional lymph nodes
Nx
N0
N1
N2
- Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s) and/or
in-transit metastasis
N2a - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s)
N2b - In-transit metastasis
N2c Both
Note: In-transit metastasis involves skin or subcutaneous tissue more than 2cm from the primary tumour but beyond the regional
lymph nodes
M Distant metastasis
Mx
M0
- No distant metastasis
M1
- Distant metastasis
M1 a
nodes
- Metastasis in skin or subcutaneous tissue or lymph node(s) beyond the regional lymph
M1 b
- Visceral metastasis
Stage III
Stage IV
involvement of more than two separate masses, or disease on both sides of the
diaphragm
pleural effusion, ascites, or involvement of the central nervous system (malignant cells in
the cerebrospinal fluid) or bone marrow.
Definition
Normal
Mild; slight irregular dilation of the main duct, often with areas of local stenosis. No disease within the
gland
Moderate; more ductal changes than in the mild disease with dilated branching ducts and some punctate
sialectasis
Severe; more widespread changes than in moderate disease, spreading to most of the ducts with complete
sialectasis and formation of cavities.
Score
Definition
5. Normal
6. Slight focal and periductal lymphocytic infiltration and slight increase in the diameter of the duct
7. Moderate periductal inflammation and formation of lymphoid follicles; interstitial fibrosis; localised
destruction of acini and moderated changes to ductal epithelium.
8. Reduced lymphocytic infiltration; formation of periductal and interlobular lymphoid follicles;
periductal hyalinisation; reduced ductal metaplastic changes and acinar destruction
Classification of sialadenitis
(IV)
(V)
(VI)
Sialadenitis, infection of salivary gland tissue is a relatively common tissue. It may be classified as
Bacterial and viral
c) Mumps (viral parotitis)
d) Bacterial parotitis (sialadenitis)i. Acute
ii. chronic
c) Recurrent parotitis of childhood
Obstructive sialadenitis
e) Sialolithiasis
f) Mucous plugs
g) Stricture stenosis
h) Foreign body
Systemic granulomatous diseases
e)
f)
g)
h)
Tuberculosis
Actinomycosis
Fungal infection
Uveoparotid fever
X.
XI.
Veau (1931) suggested a classification that divides cleft palates into four groups.
Group I Cleft of soft palate only.
Group II Cleft of hard and soft palate extending no further than incisive foramen, thus involving
secondary palate alone.
Group III Complete unilateral cleft, extending from the uvula to the incisive foramen in the
midline, then deviating to one side and usually extending through the alveolus at the
position of the future lateral incisor tooth.
Group IV Complete bilateral cleft, resembling Group III with two clefts extending forwards
from the incisive foramen through the alveolus.
Kernahan and Stark (1958) recognised the need for a classification based on embryology rather
than morphology.
F.
Incomplete cleft of secondary palate
G.
Complete cleft of secondary palate
H.
Incomplete cleft of primary and secondary palates
I.
Unilateral complete cleft of primary and secondary palates
J.
Bilateral complete cleft of primary and secondary palates
Kernahan (1971) subsequently proposed a striped Y classification. The incisive foramen, which
is the dividing line between primary and secondary palate, is taken as the reference, and forms the
junction of the Y. With stippling of the involved portion of the Y, the system provides rapid graphic
representation of the original pathologic condition and renders itself to computer-graphic presentation.
XII.
American Association of Cleft Palate Rehabilitation Classification (AACPR). The
classification suggested by Harkins and associates (1962) and endorsed by the American Association
of Cleft Palate Rehabilitation Classification (AACPR) is based on the same principles used by
Kernahan and Stark.
VII.
Cleft of primary palate
a) Cleft lip unilateral, bilateral, median, prolabium, congenital scar
b) Alveolar cleft unilateral, bilateral, median
VIII.
Cleft of palate proper
a) Involving soft palate
b) Involving hard palate
IX.
Mandibular process cleft
(i) Mandibular cleft lip
(ii) Mandibular cleft
(iii) Lower lip pits
X.
Naso-ocular cleft extending from narial region to the medial canthal region
XI.
Oro-ocular cleft extending from the angle of the mouth towards the palpebral
fissure
XII.
Oro-aural cleft extending from the angle of the mouth towards the ear.
XIII.
XIV.
Tessier (1973) introduced a classification system for the more complex orbito-facial clefts.
Detailed descriptions of the classification were subsequently published by Tessier (1976) and
Kawamoto (1976). The classification successfully integrates the clinical examination findings with
direct observations of the underlying skeletal deformity at the time of reconstructive surgery.
The system classifies the clefts in circumferential manner around the orbit with cranial extensions.
The clefts are numbered from 0 to 14 and follow constant lines, or axes, through the eyebrows or
eyelid, the maxilla, the nose and the lip. All components of an individual cleft combination add up to
14. The orbit is regarded as the reference landmark, since it is common to both the cranium and the
face. The common cleft lip is part of clefts 2 and 3.
Median clefts of the lower lip and mandible coincide with the caudal extension of number 0 cleft,
but Tessier has labelled them number 30 clefts.
Preprosthetic surgery
Alveolar ridge classification
Class I
Class II
Class III
Class IV
Class V
Dentate
Immediate post extraction
Convex ridge form with adequate height and width
Knife edge ridge form, inadequate height and width
Loss of basal bone that may be extensive and follows no predictable pattern.
AJOMS 1997
Tucker 1997
Carl E. Misch
Page 94
Division
Dimension
Treatment options
2.5 5 mm width
> 10 13 mm height
> 12mm length
< 20 degree angulation
Crown / implant ratio < 1
Osteoplasty
Division A root form.
Augumentation
Demanding aesthetics.
Great force factors
Narrow Implants
Division B root form
Plate form.
Unfavourable in :
Width
Misch 1988
Carl E. Misch
Page 113
Bone
D1
D2
Density
Dense cortical bone.
( Anterior mandible)
Thick dense to porous cortical bone on crest and coarse trabecular bone within
( Anterior maxilla)
D3
Thin porous cortical bone on crest and fine trabecular bone within
( Anterior Maxilla & Posterior mandible)
D4
Fine trabecular bone
( Posterior maxilla)
D5
Immature, nonmineralized bone.
D1 bone is similar to drilling into Oak or maple wood, D2 bone is similar to the tactile
sensation of drilling into white pine or spruce, D3 bone is similar to drilling into balsa wood, D4
bone is imilar to drilling into styrofoam.
CT determination of bone density
Contemporary implant dentistry
D1
> 1250 Hounsfield units
D2
850 1250 Hounsfield units
D3
350 850 Hounsfield units
D4
150 350 Hounsfield units
D5
< 150 Hounsfield units
Carl E. Misch
Page 114
Page 163-74
Page 199
Misch
Carl E. Misch
Misch
Carl E. Misch
Page 184
Carl E. Misch
Page 235
Misch 1989
Misch 1993
Carl E. Misch
Page 29
Trauma
Trauma score & Basics
Classification of operative wounds in relation to contamination and increasing risk of infection.
Altemeier, Burke and Pruitt
AJOMS 1997
Class I
Clean (non-traumatic, uninfected, GIT & Resp. tract not involved
Class II
Clean contaminated (involving GIT and RT under controlled conditions)
Class III Contaminated (gross spillage from GIT, genito-urinary tract involvement with infected urine
and bile.
Class IV Dirty and infected (traumatic wound with devitalised tissue, foreign bodies, faecal contamination
or from a dirty source
Classification of hemorrhagic shock by American College of surgeons committee on trauma 1984
Peterson Principles of oral & Maxillofacial surgery. Page 290.
Class I
Acute blood loss 15 % of total blood volume. Pulse & respiration increased. BP not
significantly affected.
Class II
Acute blood loss of 20 25 % of total blood volume. Increased pulse & respiration.
Decreased BP. No decrease in urine output.
Class III
Blood loss of 30 40 % of total blood volume. Increased pulse & respiration. Decreased
BP & Urine output.
Class IV
40 50 % loss of total blood volume. Lack of vital signs. Decreased urine output.
Obtunded mental status.
For 70 kg man (Peterson, Principles of Oral & Maxillofacial surgery) Page 291
Class I
Class II
Class III
Class IV
Blood Loss
750 ml
750 - 1500
1500 - 2000
2000 or more
% loss
15 %
15 30 %
30 40 %
40 % or more
Pulse rate
< 100
> 100
> 120
140 or higher
BP
Normal
normal
decreased
Decreased
Normal or
increased
decreased
decreased
decreased
Normal
positive
positive
positive
Respiratory rate
14 20
20 30
30 - 40
> 35
30 or more
20- 30
5 - 15
Negligible
Slightly anxious
Mild anxious
Crystalloid
crystalloid
Anxious and
confused
Crystalloid +
blood
Confused &
lethargic
Crystalloid +
blood
Page 272
Code
4
3
2
1
0
Score
A:
_____
B:
_____
C:
_____
D:
______
E:
______
Respiratory effort
Reactive
Normal
Reactive / none
1
0
90
70 89
50 69
0 - 49
7
4
3
2
1
0
No carotid pulse.
Capillary refill
Normal - forehead / lip mucosa colour refill in 2 secs.
Normal
Delayed
None
2
1
0
5
4
3
2
1
Trauma score = A + B + C + D + E
Classification of open fractures based on extent of soft tissue injury. Gustilo & Anderson
1976
Grade I
Grade II
Grade III
Grade III A
Grade III B
Grade III C
Midface fractures
Classification of midface fractures
Rn Le Fort
1901
Killey fractures of middle third of face
Page 11
Le Fort I
Low-level fracture
Le Fort II
Pyramidal or Subzygomatic Fracture
Le Fort III
High Traverse or Suprazygomatic Fracture
Classification of midface fractures
Wassmund 1927
Krger & Schilli. Page 107 - 113.
Wassmund I
Pyramidal fracture of maxilla without involvement of nasal bones
Wassmund II
Pyramidal fracture of maxilla with involvement of nasal bones
Wassmund III
Total displacement of midface from cranial base without involvement of nose.
Wassmund IV Total displacement of midface (visecrocranium) from cranial base with involvement of nose.
Classification of midface fractures
Schwenzer 1967
Krger & Schilli. Page 107.
1. Central midface fractures ( from root of nose to alveolar process without involvement of cheek bones)
a) Alveolar process fracture
b) Transverse (horizontal) fracture of maxilla (Le Fort I)
c) Sagittal fracture of maxilla (median or paramedian)
d) Pyramidal fracture with separation of entire maxilla with involvement of nasal bones (Le Fort II)
e) Fracture of nasal bones and naso-ethmoid complex.
2. Centrolateral midface (separation of entire facial skeleton from base of skull)
a) Total displacement of visecrocranium with involvement of nasal bones (Le Fort III / Wassmund IV)
b) Total displacement without involvement of nasal bones (Wassmund III)
c) Combination fractures characterised by central and centrolateral fractures with atypical fractures.
3. Lateral midface
a) Fractures of Zygoma
b) Fractures of zygomatic arch
c) Zygomatico-maxillary fracture
d) Zygomatico-mandibular fracture
e) Fracture of the floor of the orbit (Blow out fracture).
1987
Paul N. Manson et al
PSR 1998
1. Fractures of Zygoma
a. No significant displacement
b. Partial medial displacement
c. Total medial displacement
d. Dorsal displacement
e. Inferior displacement
f. Comminuted fractures
2. Fractures of Zygomatic arch
3. Complex fractures
a. Centrolateral midface fractures
b. Zygomatico-maxillary fractures
c. Zygomatico-mandibular fractures.
1985
Type II
Type III
fractured large fragments, medial canthal tendon attached to the fractured segment.
fracture involving the central fragment of bone where the medial canthus attaches.
Variants of types I. II and III fractures may occur on one side or the other in conjunction with each
other. If such is the case, the type of injury and its severity guides the treatment.
Condylar fractures
Classification of injuries to the TMJ region
Helmut Schle 1986
Oral & Maxillofacial traumatology Vol 2 . Kruger & schilli. Page 45 47.
1.1.1
2.1.2
2.1.2.1
2.1.2.2
2.1.2.3
2.1.3
2.1.4
2.1.5
2.1.6
Subcondylar
Relationship of condylar segment to mandibular fragment.
Nondisplaced
Deviated
Displacement with medial or lateral overlap
Displacement with anterior or posterior overlap
No contact between fractured segments
Relationship between condylar head & Glenoid fossa
Nondisplaced
Displacement
Dislocation
Mandibular fractures
Classification of mandibular fractures
Kazangia and Converse
Clinics in plastic surgery 1992, advances in craniofacial management. Page62.
Class I
Teeth present on both sides fracture line
Class II
Teeth present on only one side.
Class III
fracture occurs in an area without dentition
Classification of mandibular fractures based on type of fracture
Peterson. (Principles of Oral & Maxillofacial surgery, Vol. I. Page 409).
Simple fracture
Single fracture line that does not communicate with the exterior.
Compound fracture
These fractures have communication with the external environment, usually
by periodontal ligament of a tooth or
Greenstick fracture
This type frequently occurs in children with incomplete loss of continuity of
bone. Usually one cortex is fractured and the other is bent, leading to
distortion without complete section. There is no mobility between distal
and proximal segment.
Comminuted fractures
Multiple fragmentation of bone at one fracture site. Usually as a result of
greater force.
Complex or complicated Damage to adjacent structures of bone like vessels, nerves or joint structures.
Telescoped or impacted one bone is driven into another. Rare in mandible.
Direct fractures
Fractures at the site of impact
Indirect fracture
Fractures at a point away from site of impact.
Pathological fracture
occurring as a result normal force or minimal trauma as a result of bone
weakened by pathology.
Classification of mandibular fractures based on site of fracture
Kelly & Harrigan1975
Peterson. (Principles of Oral & Maxillofacial surgery, Vol. I. Page 410).
Condylar process
Ascending ramus
Angle fracture
Body fracture
Symphysis fracture
F0S0
Clinical presentation
I B
F1S0
II A
II B
F2S0
F3S0
III A
III B
IV A
IV B
F3S1 / F3S2
F3S3
VA
VB
F4S4
Closed fracture
Linear
Displaced
Linear
Displaced
Open fracture
Infection
ORN
Type I
Type II
Type III
Marx 1983
Osteonecrosis
4.
AJOMS
Develops shortly after radiation; is due to synergistic effects of surgical trauma and radiation
injury
Develops years after radiation and follows a traumatic event; rarely occurs before 2 years after
treatment; most commonly occurs after 6 years; due to progressive endarteritis and
vascular effusion.
Occurs spontaneously without a preceding traumatic event; usually occurs between 6 months
and 3 years after radiation. ; due to immediate cellular damage and death due to radiation
treatment.
Epstein et al
1987
AJOMS
5.
6.
Orbital cellulitis
Group 1
Group 2
Group 3
Group 4
Group 5
Osteomyelitis
III)
IV)
(Chandler 1970)
Hudson
1993
4.
Focal
c.
d.
Predominantly odontogenic
Chronic localised injury.
1985
Temporomandibular Joint
TMJ disorders classifications Moore
Page 566
Structural disorders
Inflammation
Acute
Chronic
Infection
Ankylosis
True
False
Trauma
Neoplasia
Developmental
Degenerative
Functional
Pain dysfunction syndrome
Chondromalacia : Grading
Grade I
Grade II
Grade III
Grade IV
Outerbridge RE
Milgram 1977
I Early Stage
A) Clinical : No significant mechanical symptoms other than opening reciprocal clicking, no pain or
limitation of motion.
C) Radiologic : Slight forward displacement, good anatomic contour of the disk, negative tomograms.
C) Anatomic/ pathologic : Excellent anatomic form, slight anterior displacement, passive incoordination
demonstrable.
II Early Intermediate stage
A) Clinical : One or more episodes of pain, beginning major mechanical problems consisting of mid to late
opening loud clicking, transient catching and locking.
C) Radiologic : Slight forward displacement, beginning disk deformity of slight thickening of posterior
edge, negative tomograms.
C) Anatomic/ pathologic : Anterior disk displacement, early anatomic disk deformity, good central
articulating area.
III Intermediate Stage.
A) Clinical : Multiple episodes of pain, major mechanical symptoms consisting of locking (intermittent or
fully closed ), restriction of motion, and difficulty with function.
C) Radiologic : Anterior disk displacement with significant deformity or prolapse of disk ( increased
thickening of posterior edge), negative tomograms.
C) Anatomic/ Pathologic : Marked anatomic disk deformity with anterior disk displacement, no hard
tissue changes.
IV Late Intermediate stage.
A) Clinical : Slight increase in severity over intermediate stage
D) Radiologic : Increase in severity over intermediate stage, positive tomograms showing early to
moderate degenerative changes flattening of eminence, deformed condylar head, sclerosis
C) Anatomic/ Pathologic : Increase in severity over intermediate stage, Hard tissue degenerative
remodelling of both bearing surfaces (osteophytosis), multiple adhesions in anterior and posterior
recesses, no perforation of disk or attachments
V Late Stage.
A) Clinical : Characterised by crepitus, variable and episodic pain, chronic restriction of motion and
difficulty with function
E) Radiologic : Disk or attachment perforation, filling defects, gross anatomic deformity of disk and hard
tissues, positive tomograms with essentially degenerative arthritic changes
C) Anatomic/ Pathologic : Gross degenerative changes of disk and hard tissues, perforation of posterior
attachment, multiple adhesions, osteophytosis, flattening of condyle and eminence, subcortical cyst
formation.
TMJ ankylosis
Kazanjian 1938
True ankylosis
False ankylosis
(Moore)
False ankylosis
Myogenic
Neurogenic
Psychogenic
Bone impingement
Fibrous adhesions
Tumours
Short / Long
Intracapsular / Extracapsular
Histologic variations
Fibrous
Fibro-osseous
Osseous
Osteocartilaginous
TMJ ankylosis
Raveh et al
TMJ ankylosis
Topazian 1966
Type I
Type II
Type III
TMJ ankylosis
Sawhney 1986
Type 1a Simple anterior syngnathia -- Bony fusion of alveolar ridges only without other congenital
deformities
Type 1b Complex anterior syngnathia -- Bony fusion of alveolar ridges only, associated with other
congenital deformities
Type 2
Zygomatico-mandibular syngnathia
Type 2a
Simple Zygomatico-mandibular syngnathia Bony fusion of mandible
to zygomatic complex causing mandibular micrognathia.
Type 2b
Complex Zygomatico-mandibular syngnathia Bony fusion of
mandible to zygomatic complex associated with clefts or TMJ
ankylosis.
General
American Society of Anaesthesiologist physical status classification system
Schiender 1983
Schobinger
Carl E. Misch
Page 46
Impacted teeth
Winters classification 1926.
Based on the relation of long axis of impacted tooth to the 2nd molar.
Vertical
Mesioangular
Distoangular
Horizontal
Inverted
Buccoangular
Linguoangular
Difficulty index for removal of impacted mandibular 3rd molar Pedersen G W 1988
Oral surgery
Pedersen G W
This index is based on Pell & Gregory classification and aids in assessing difficulty in surgical
removal of third molar
Classification
Value
Spatial relationship
Mesioangular
1
Horizontal / Transverse
2
Vertical
3
Distoangular
4
Depth
Level A
1
Level B
2
Level C
3
Ramus relationship / Space available
Class I
1
Class II
2
Class III
3
Total score out of 10.
Difficulty index:
Very difficult
7 10.
Moderately difficult
5 7.
Minimal difficult
3 4.
Page 73
Category
Score
Winters classification
Vertical
0
Mesioangular
1
Distoangular
2
____________________________________Horizontal
2
Height of mandible
35 39 mm
0
31 34 mm
1
1 30 mm
2
Angulation of third molars
1o 50o
0
51o 69o
1
70o 79o
2
80o 89o
3
90o +
4
Root shape
Conical
1
Favourable curvature
2
Unfavourable curvature 3
Follicles
Enlarged
0
Possibly enlarged
1
Normal
2
Path of Exit
Space available
0
Mesial cusp covered
1
Distal cusp covered
2
Both covered
3
_______________
Total score for out of 33
Higher score indicates difficult extraction
Canine impactions
1935
Archer
Page 325
Conical
Composite odontoma
3. Complex
4. Compound
Tuberculate
Supplemental
4.
Multiple
Non-Syndrome
3.
Tuberculate
4.
Supplemental
Syndrome
4.
Cleft Lip/Palate
5.
Cleidocranial Dysplasia
6.
Gardner Syndrome
Archer
Page 311
Vertical
Horizontal
Mesioangular
Distoangular
Inverted
Buccoangular
Linguoangular
C
Based on the relationship of impacted third molar and maxillary sinus.
SA (Sinus approximation):
No bone or thin portion of bone between the maxillary third molar and
the maxillary sinus.
NSA (No sinus approximation):
2mm or more thickness of bone between the impacted maxillary third
molar and the maxillary sinus.
Medicaments
Carnoys solution
Killey & Kay part II page.
Absolute alcohol
Chloroform
Glacial acetic acid
6 parts
3 parts
1 part
7 parts by weight
2 parts
1part
Whiteheads varnish
Killey & Kay part II page. 41.
Benzoin
Storax
Balsam of Tolu
Iodoform
Solvent ether
10 parts
7.5 parts
5 parts
10 parts
to make 100 parts.
Bonneys blue
McGregor principles of Plastic Surgery. Page
Gentian violet
10 g
Brilliant green 10 g
Alcohol 95%
950 ml
Water
to make 2000 ml.
Talbots solution
Iodine
12 g (183 gr)
Zinc iodide
7 g (110 gr)
Water
4.5 ml (82 minims)
Glycerin to make 28.4 ml (1 fl oz)
Eusol
Local anaesthetic
Anaesthetic
Vasoconstrictor
Tumescent solution
Grab & Smith
page 673
2% lignocaine
25 ml
1:1000 epinephrine
1 ml
Lactated Ringers solution
1000 ml
------------------------------------------------------0.05% lignocaine with 1:1,000,000 epinephrine
1026 ml
Allogenic bone
Os purum
Killey & Kay part II page. 186.
Bone in which some of the organic elements have been removed
Anorganic bone
This is prepared by boiling bone in ethylenediamine for several days. This can be stored without
refrigeration. This can be trimmed with scalpel and cut into chips.
Kiel bone
Bovine bone treated with hydrogen peroxide and a de-fattening agent.
Boplant bone
Bovine bone treated with propiolactone to sterilise it and de-fattening is by detergents and
organic solvents.
AAA bone (antigen extracted autolysed allogenic bone)
Cadaver bone is harvested & treated so that the stainable intralacunar bone is enzymatically
digested. Then freeze dried.