LOSS OF SUBSTANCE OF THE MAXILLA
PLAN
- INTRODUCTION
- ETIOLOGY
3 – CLASSIFICATION
4 – CLINICAL STUDY
4 – 1 – Mandibular substance losses 4 – 1- 1- Partial substance losses
4 – 1- 2- Total or interruptive substance losses
- Median or Anterior PDS
- PDS extending to horizontal branches
- PDS of the horizontal branch
- Lateral or posterior PDS 4 – 1- 3- Skin lesions
4 – 1- 4 CONSEQUENCES
Pathophysiological consequences Functional consequences Morphological consequences
. Psychological consequences 4 – 1 – 5 – TREATMENT
Immediate treatment Definitive treatment
Prevention of facial asymmetry
4 – 2 – LOSS OF MAXILLARY SUBSTANCES
4 – 2 – 1 – CLASSIFICATION by Benoit 1978 according to PDS size
- Small PDS
* Large PDS
4 – 2 – 2 – CLINICAL FORMS
The Little PDS
- Etiology
- Clinical
The great loss of substance
- Etiology
* Clinic
4 – 2 – 3 Pathophysiological consequences
- Functional consequences
- Morphological consequences
- Psychological consequences
4 – 2 – 4 Treatment
4 – 3 – CHILD SUBSTANCE LOSSES
5 – CONCLUSION
6 – Bibliography
1 – INTRODUCTION
Maxillary substance losses essentially represent acquired substance losses (ASL).
Acquired PDS is bone destruction resulting in a permanent disruption of bone tissue in the mandible or maxilla. The malformations leading to PDS are congenital PDS.
Depending on their location and extent, loss of substance (PDS) can have consequences on all functions of the masticatory system.
The PDS of the mandible affect the mandibular kinetics (occur on a mobile bone) unlike the middle level of the face where the bony elements are fixed, hollowed out with cavities, the PDS cause speech and eating disorders.
2 – ETIOLOGY
The causes of PDS can be traumatic, pathological or surgical.
- The traumatic origin can be:
- More damaging ballistic trauma is often associated with integumentary PDS.
- Work or domestic accidents following explosions, rupture of rotating instruments, attempted self-dissection using hunting weapons.
- Road accidents and violent trauma causing dislocations of the facial muscles.
- Pathological causes: infectious origin (osteitis) of local or diffuse dental origin, toxic osteitis (arsenic, osteoradionecrosis (ORN), osteochemonecrosis of the jaws (ONJ).
*Surgical causes secondary to the excision of a sequestrum or malignant or benign tumors; require interruptive bone resection: such as surgery for an ameloblastoma, squamous cell carcinoma or sarcoma.
- Causes, hematogenous or specific: syphilis, tuberculosis, actinomycosis, osteitis on an osteopathic ground.
3 – CLASSIFICATION
In the mandible, we distinguish between partial PDS and total or interruptive PDS. PDS can affect the mandible and the maxilla. In the mandible:
- The symphysis, the horizontal branch, groups together the anterior or median PDS;
- The angle and the ascending branch group the lateral PDS. In the maxilla, we distinguish the small PDS and the large PDS.
4 – CLINICAL STUDY
4 – 1 – Mandibular substance losses
4 – 1 – 1- Partial loss of substance: They do not interrupt bone continuity. They are often caused by trauma. They affect the basilar or alveolar edge, the incisor-canine block is the most affected.
In the event of trauma, the teeth are dislocated, accompanied by alveolar fracture. Sometimes the mucosa is detached with rupture of the vascular supply, leading to bone necrosis.
Figure 1: Non-interrupting mandibular PDS of the horizontal branch
4 – 1 – 2 – Total or interrupting substance losses
Characterized by the disappearance of a bone segment.
- Median or Anterior PDS : Gives birth to 2 fragments.
In the incisor-canine block, the PDS may be limited to the incisor-canine region (figure 2- plate 1-C) but may extend towards the premolars and the horizontal branch.
The dental arch takes the form of a V with an anterior tip. In occlusion, we note the inward inclination of the molars, the mobility of the fragments on palpation, displacement of the lateral fragments upwards and inwards under the action of the elevators. The extent of the displacement depends on the presence or absence of teeth (anterior open bite – molar contact).
- PDS extending to the horizontal branches: Characterized by the disappearance of the chin protrusion, the lips and upper incisors protrude, giving the appearance of a pro-alveolus.
In the presence of teeth, the articulation is disturbed; in the absence of teeth, the movements are significant. The cheek lesions are significant.
- PDS of the horizontal branch (figures 3 – 4) : The fragments are asymmetrical, one large and one small fragment. The functions are disturbed, the teeth are embedded in the palate, the latero-deviation is marked on the side of the lesion, the aesthetics are altered, the soft parts are damaged (lips are more affected).
- Lateral or posterior PDS: the fragments are asymmetrical (plate 1 – HL),
The clinical appearance depends on the location of the PDS. The displacement follows the muscular physiology (small fragment pulled upwards, the large fragment displaced downwards and backwards).
- At the level of the ascending branch (figure 5) : The clinical appearance is not modified with the mouth closed.
At mouth opening: the laterodeviation is marked, the static occlusion is not disturbed in the presence of teeth. Normal opening may be limited by the presence of scar bands.
- Loss of the hemimandible : The remaining hemimandible is pulled downward and backward by the action of the depressor muscles. The remaining mandibular fragment moves to the side of the resection.
4 – 1- 3- Skin lesions : Mainly affecting the skin of the cheek, scar retraction occurs laterally and causes facial asymmetry.
Figure 2 Figure 3 Figure 4 Figure 5
Plate 1: Total mandibular substance losses:
C: Anterior PDS with symmetrical fragment (may extend to the horizontal branch +/- symmetrical L: Lateral PDS extending from the symphysis to the ascending branch with respect to the ATM
H: PDS of a hemi-mandible
4 – 1- 4 CONSEQUENCES
Pathophysiological consequences :
Intermaxillary PDS will cause an osteomaxillary imbalance, responsible for deformations resulting in functional, aesthetic and psychological repercussions.
Functional consequences :
- Respiratory: Loss of the anterior attachments of the genioglossals causes glossoptosis, which is life-threatening due to obstruction of the pharyngolaryngeal passages.
- masticatory function: The consequences on chewing are significant due to displacement of bone segments, the presence of scar tissue; Difficulty swallowing, when opening and closing the mouth.
- Phonation Disorder: Secondary to the disorder of lingual competence, the loss of lingual supports.
Morphological consequences:
- Anterior PDS causes the bird profile due to the absence of bony support, the approximation of fragments and the scar bands
- Lateral P. DS causes facial asymmetry, loss of angular relief, homolateral lowering of the labial commissure.
Psychological consequences
The functional and aesthetic after-effects have a serious impact on morphology and represent a major handicap for social and professional reintegration.
4 – 1 – 5 – TREATMENT
Immediate treatment: Emergency treatment is to give priority to lesions that are of vital importance. Primary treatment carried out before 48 hours by immobilization of the fragments by osteosynthesis in the edentulous subject, and BIM by IVY ligatures while waiting for definitive treatment (by surgery, graft, or maxillofacial prosthesis)
Soft tissue injuries: after removing bone fragments and foreign bodies, sutures are performed while avoiding any tension. Skin deficiency will be treated secondarily with grafts.
Definitive treatment: Will only be undertaken when all traces of infection have disappeared (at least for 3 months).
Provide support if the dental condition allows it (BIM, gutter). Bone grafting using an iliac or costal graft.
A restoration by maxillofacial prosthesis.
The prosthetic means used are endoprostheses (figures 6 – 7).
Prevention of facial asymmetry by using guide devices (Cernéa-Benoist)
(plate 2).
It is a rehabilitation device. It will guide the remaining mandibular portion using a device interposed between the two maxillae, placed in the mouth as early as possible. This guide intervenes during the opening and closing movements; it opposes the latero-deviation of the mandible. It is worn continuously. It is placed on the side opposite to the loss of substance.
Figure 6 Figure 7
4 – 2 – LOSS OF MAXILLARY SUBSTANCES
4 – 2 – 1 – CLASSIFICATION by Benoit 1978 according to PDS size
- Small PDS : when the size of the communication does not exceed a quarter of the palatine vault
* Large PDS : when the size exceeds a quarter of the palatal vault
At the upper max level, the PDS are differentiated by their volume.
4 – 2 – 2 – CLINICAL FORMS
Small PDS: Are CBS or CBN. They are located at the level of the palatine vault, the alveolar processes, rarely vestibular (plate 3 abc).
- Etiology:
Traumatic: a fall on a sharp object in the open mouth, suction necrosis of a total prosthesis;
Infectious: osteitis of dental or specific origin, following infection of a radiculodtary cyst with palatal (lateral) development;
Surgical and Iatrogenic: following extraction: traumatic, extraction of impacted teeth (DDS, palatal canine). Excision of small tumors and pseudotumors (benign tumor, cysts).
- Clinical: Clinical signs vary depending on the location. Functional signs are more marked in palatal perforations.
The major losses of substance (plate 4 (abcd)
They are extensive, affecting a significant segment of the palatine vault, the sinuses, the nasal cavities, the floor or orbital cavities; sometimes accompanied by skin perforation.
The physiological and therapeutic consequences are important.
- The etiology is essentially surgical
Large PDS, caused by cancer surgery
Trauma, namely ballistic injuries (suicide attempts, war) and road accidents are strongly incriminated.
These PDS are rarely isolated, they are accompanied by destructive lesions of the mandible, facial organs or the skull .
* Clinic : Varies depending on location and extent; Large oro-sinuso-nasal communications are characterized by air leakage, speech disturbances, food reflux
and liquid through the nose.
4 – 2 – 3 Pathophysiological consequences
- Functional consequences: Chewing disorders due to missing teeth, Chronic sinusitis Ophthalmological problems: disturbances in eye statics and vision.
- Morphological consequences: Sagging of unsupported integuments. Modification of facial morphology.
- Psychological consequences: The psychological impact is significant
Plate 4 (abcd) Major maxillary substance losses
4 – 2 – 4 Treatment
Goals : Aesthetics: To obtain a restoration of the forms.
Physiological: Correct functional disorders by ensuring nutrition, phonation, and blocking communications.
Psychological: Allow the patient to reintegrate into society.
The treatment includes primary treatment, which is essentially emergency treatment. Secondary treatment includes physiological means (physiotherapy), surgical means and prosthetic means represented by maxillofacial prosthesis.
- Primary surgical treatment
Is essentially an emergency treatment.
Traumatic PDS: perform wound debridement and sutures plus antibiotic coverage. In front of a CBS: Avoid any maneuver likely to enlarge the PDS (wicks, curettage to be avoided). Promote the clot and protect it with a flexible gutter (figure 8), plus medical treatment with antibiotics. Avoid pressurized mouthwashes.
- Secondary surgical treatment:
The obturation of the PDS is done by mucosal autoplasty by sliding or by pedicled flap (figure 9).
If there is a contraindication or postponement of surgery, an obturator prosthesis will be made (figure 10).
Fig 8 Protective gutter Fig 9 Mucosal autoplasty surgery Fig 10 Obturator prosthesis
CHILD SUBSTANCE LOSS
The major problem is the existence of growth zones . The destruction of growth zones causes very serious after-effects. Treatment must be early.
It consists of: primary treatment by adequate reduction and containment;
secondary treatment and prevention of after-effects, through the use of guide devices; orthodontic treatment to correct dental movements.
CONCLUSION
Acquired PDS is essentially a therapeutic problem with a view to good functional and aesthetic restoration.
The care of these patients in distress is provided through a care contract for a decent life; because good care will depend on the resumption of eating, the possibility of reestablishing communication with loved ones, but also of reintegrating a quasi-normal social and/or professional life.
Losses of facial or maxillary substance that cannot be surgically reconstructed benefit from treatment with a maxillofacial prosthesis. The effectiveness of the maxillofacial prosthesis is inversely proportional to the size of the gap it closes.
Bibliography
- – Benoist M. Loss of substance of the jaws EMC stomatology 22087. E 10 12- 1975
- – Boutault F, Paoli JR, Lauwers F. Surgical reconstruction of maxillary substance losses. EMC – Stomatol. 2005 Sep;1(3):231–53.
- – Candelle C. Bio-psycho-social approach to the patient in maxillofacial prosthesis. [University of Toulouse III – Paul Sabatier]; 2013.
- – Gleizal A, Merrot O, Bouletreau P. Velopalatine disorders. EMC – Stomatol. 2005 June; 1(2):141–61.
- – Herve V. Maxillofacial trauma and its implications in dental practice: Benefits of a multidisciplinary approach. Nancy Poincaré University; 2011.
- – Rouvier B, Lenoir B, Rigal S. Ballistic Trauma. 1997.
LOSS OF SUBSTANCE OF THE MAXILLA
Wisdom teeth can cause infections if not removed in time.
Dental crowns protect teeth weakened by cavities or fractures.
Inflamed gums can be a sign of gingivitis or periodontitis.
Clear aligners discreetly and comfortably correct teeth.
Modern dental fillings use biocompatible and aesthetic materials.
Interdental brushes remove food debris between teeth.
Adequate hydration helps maintain healthy saliva, which is essential for dental health.