OMFS case discussions

[DREDAY]

I ran into this interesting case on youtube.

http://www.youtube.com/watch?v=VeWEII9E7pM&feature=related


and a pretty cool panfacial one:

http://www.youtube.com/watch?v=K9_RNopUZRk&feature=related


any comments?

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[Trench Mouth]

I gotta say Dre, these cases make me happy to be going to an ortho program. I'll let you wake up in the middle of the night thinking of these patients!

 

[WhiteBrickRoad]

Any suggestions on the best current OMFS textbook?


Also,
Dreday... after watching those videos, I'm not sure whether I'm horrified or amazed.
.

 

[Bifid Uvula]

Any suggestions on the best current OMFS textbook?


Also,
Dreday... after watching those videos, I'm not sure whether I'm horrified or amazed.
.

My favorites in no specific order...
Petersons 2 Volume
Fonseca 2 Volume Trauma
Fonseca 3 Volume Series
Baker... Flaps
Marx... Pathology
Ellis.... Approaches to the Facial Skeleton
Booth... Maxillofacial Trauma and Esthetic Facial Reconstruction
Booth... 2 Volume Maxillofacial Surgery
Sclar... Soft Tissue and Esthetic Considerations in Implant Therapy
Block... Color Atlas of Implant Surgery

 

[WhiteBrickRoad]

My favorites in no specific order...
Petersons 2 Volume
Fonseca 2 Volume Trauma
Fonseca 3 Volume Series
Baker... Flaps
Marx... Pathology
Ellis.... Approaches to the Facial Skeleton
Booth... Maxillofacial Trauma and Esthetic Facial Reconstruction
Booth... 2 Volume Maxillofacial Surgery
Sclar... Soft Tissue and Esthetic Considerations in Implant Therapy
Block... Color Atlas of Implant Surgery

Thanks Bifid!

 

[godbless]

A 56 year old patient with a grossly carious #5, long standing abcess, no history of pain,when treated endodontically had slight bleeding during the rct. and minutes later patient shows unilateral swelling on the cheek which is fluctuant and not painful. few hours later the swelling doubles in size and towards the end of the day swelling has spread till below the eye and the chin, all fluctuant and very soft.on the second day the swelling or the lump moves from left to right when patient shakes his head.patient is already on antibiotics and no pain. the dentist pulled out the tooth, few hours later the swelling is gone from the cheek and moved to the chin,soft and fluctuant, no pain and mvoes freely from left and right.any idea whats going on??please reply...

 

[armorshell]

When you say it moves right to left, do you mean it, say, crosses the midline? Or just moves a few mm? cm?

 

[toofache32]

A 56 year old patient with a grossly carious #5, long standing abcess, no history of pain,when treated endodontically had slight bleeding during the rct. and minutes later patient shows unilateral swelling on the cheek which is fluctuant and not painful. few hours later the swelling doubles in size and towards the end of the day swelling has spread till below the eye and the chin, all fluctuant and very soft.on the second day the swelling or the lump moves from left to right when patient shakes his head.patient is already on antibiotics and no pain. the dentist pulled out the tooth, few hours later the swelling is gone from the cheek and moved to the chin,soft and fluctuant, no pain and mvoes freely from left and right.any idea whats going on??please reply...

Edema/inflammation. Which caustic substances were used to irrigate the canal? I would guess that something got pushed past the apex....either the infected contents of the tooth, or that battery acid they irrigate with.

 

[Count Orlok]

Sounds like a hypochlorite incident to me due to the fast swelling right after RCT.

 

[armorshell]

Sounds like a hypochlorite incident to me due to the fast swelling right after RCT.

You usually get bruising from hypochlorite though, right?

 

[Count Orlok]

You usually get bruising from hypochlorite though, right?

Yeah, and i thought there was significant amount of pain associated with it too, but honestly I can't imagine anything else that would come on that fast after a RCT.

 

[butter143]

hello everyone. i have a case i feel might be of benefit to us all, any general advice would be helpful.

A 6 year old patient presented with an obvious facial asymmetry(discovered on waking up) and complaining of pain from the right cheek. there's an obvious swelling involving the right buccal fascial space, there's limited mouth opening. there's also a high fever. 39-40c range.

the informant (kid's grandma), said there was no history of a toothache, recent trauma, though the child was treated for an unknown ailment 9 months ago involving a fever and requiring admission in a hospital. the child also said there was a history of pain on salivation.

under light, i was able to get a slight opening and was able to do an examination, my findings were:

no sign of caries, no mobile or tender tooth.

there's inflammation of the marginal gingiva of the upper teeth.

inflammation of the buccal vestibule and the stenson's duct.

an attempt to express pus didn't yield anything. although i took a swab for mcs, results aren't ready.

nothing significant was seen on radiographs (took PA, oblique lateral views)

so far, i instituted iv antibiotics, crystalline penicillin, metronidazole, paracetamol. she started them yesterday.

at this point, I'm thinking of:

buccal space infection ?cause
?bacterial sialadentis involving the parotid gland
?mumps

I'm wondering what could be responsible for the swelling,

will there be a need to drain?, if so, is there an intraoral approach to draining the buccal space?
any other related info would be helpful.

thanks.

 

[OMSKooK]

Good differential, here's my two cents,

Mumps I would think would be a long shot since most children get MMR or MMRV vaccine unless you know this child never received said vaccine. No drainage indicated if this is the case, Tylenol and just let the virus run its course with supportive measures if necessary.

Buccal space infection is a tough push without some sort of identifiable etiology (carious tooth that would reach this space, recent deep tissue masticatory trauma? - r/o with detailed history?) Also, these types of infections are pretty rare as is and in a child this young, I would think even more rare as there are not likely any odontogenic sources that can reach below/above the buccinator muscle attachment at the age of 6 (1st molar roots are not likely fully developed), but I have seen it.... if this continues to be high in the differential, you can drain intraorally but be mindful of the anatomy and make sure you know what you are draining.

Acute sialadenitis of the parotid is probably what I would bet on with the reported symptom of pain on salivation and clinical picture. This could be on account of masticatory trauma to stenson's duct with scarring and fibrosis that leads to decrease in salivary flow and eventual bacterial influx. I would imaging pen covering this fine since this is early on, if I had my pick, amp or unasyn but cost becomes an issue, flagyl is a nice way to augment the pen, but I would not think this acute 1 day cellulitis to be grossly anaerobic at this point. Some would argue surgical drainage is the way to go, but if this were my child, I would wait to see how he fairs on the IV abx and drain only if there is a suspected abscess consolidation and get a CT to guide you/or who ever this gets referred to. Remember the facial n. branches within the substance of the parotid and damaging that in a child (or anyone) would be a serious bummer...

I have a feeling there is more to this story with the previous mysterious admission, make sure to r/o any existing medical conditions (autoimmune?, immunocompromised? possible salivary gland neoplasm that is not otherwise clinically significant at this time?). I would not expect the mcs to be very informative, will likely return oral flora which you are already empirically treating.

This is a good case to discuss, thanks. I am sure I haven't covered everything and have missed something, but that's all I got for now.

 

[GoGatorsDMD]

You didn't get pus, but was saliva easily expressed?

Is the kid an immigrant that makes you think mumps? Other symptoms besides the fever?

When I get stuff like this I think of those "old-school" sialograms and wonder if they would be more helpful than a CT w contrast.

 

[butter143]

Good differential, here's my two cents,

Mumps I would think would be a long shot since most children get MMR or MMRV vaccine unless you know this child never received said vaccine. No drainage indicated if this is the case, Tylenol and just let the virus run its course with supportive measures if necessary.

Buccal space infection is a tough push without some sort of identifiable etiology (carious tooth that would reach this space, recent deep tissue masticatory trauma? - r/o with detailed history?) Also, these types of infections are pretty rare as is and in a child this young, I would think even more rare as there are not likely any odontogenic sources that can reach below/above the buccinator muscle attachment at the age of 6 (1st molar roots are not likely fully developed), but I have seen it.... if this continues to be high in the differential, you can drain intraorally but be mindful of the anatomy and make sure you know what you are draining.

Acute sialadenitis of the parotid is probably what I would bet on with the reported symptom of pain on salivation and clinical picture. This could be on account of masticatory trauma to stenson's duct with scarring and fibrosis that leads to decrease in salivary flow and eventual bacterial influx. I would imaging pen covering this fine since this is early on, if I had my pick, amp or unasyn but cost becomes an issue, flagyl is a nice way to augment the pen, but I would not think this acute 1 day cellulitis to be grossly anaerobic at this point. Some would argue surgical drainage is the way to go, but if this were my child, I would wait to see how he fairs on the IV abx and drain only if there is a suspected abscess consolidation and get a CT to guide you/or who ever this gets referred to. Remember the facial n. branches within the substance of the parotid and damaging that in a child (or anyone) would be a serious bummer...

I have a feeling there is more to this story with the previous mysterious admission, make sure to r/o any existing medical conditions (autoimmune?, immunocompromised? possible salivary gland neoplasm that is not otherwise clinically significant at this time?). I would not expect the mcs to be very informative, will likely return oral flora which you are already empirically treating.

This is a good case to discuss, thanks. I am sure I haven't covered everything and have missed something, but that's all I got for now.

thanks for the quick reply.

you were right about the mcs. at this point i'm inclined to agree with you that acute sialdenitis would be likely. as of now, her mouth opening is begining to improve, albeit slightly. though the fever still remains.

as for the previous admission, i'm up against a wall sort of, all the granny will tell me is she was admitted and treated for an illness she doesn't know/or is it wouldn't disclose. i do agree with you there's more to the story. learnt that her mum is deceased.

i'll keep an eye on this for a few days and refer to an omfs if there's no improvement.