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Medical Forum / General / Dentistry / May 2005Talk about bad luck
A patient came in for a consultation this week for jaw pain. He tells me he was punched in the jaw about 10 days ago and the pain keeps getting worse in the area of his left angle and his bite is off. He had a mild swelling in the area and an open bite on the left side. I am figuring atleast an angle fracture so I get the panorex expecting maybe a subcondylar to go with it. Fortunately, its only broken on the left side but it probably wouldnt have broken at all if a cyst associated with #17 didnt go from the distal of #18 to half way up the ramus! #17 is pushed down to the inferior border. A post-traumatic pathologic fracture. He never had a problem nor knew he had something growing until now. So, Tuesday is his lucky day. I will post the films when I get the chance. Look forward to seeing them. You should keep them on hand for the next "Why should I get my wisdoms extracted if I'm not having a problem?" type question.  SignatureRoy rem NADA to reply | A patient came in for a consultation this week for jaw pain. He tells | me he was punched in the jaw about 10 days ago and the pain keeps [quoted text clipped - 11 lines] | So, Tuesday is his lucky day. I will post the films when I get the | chance. > Look forward to seeing them. You should keep them on hand for the next "Why > should I get my wisdoms extracted if I'm not having a problem?" type question. REPLY Or at least, "a panoramic film and two bite wings are the absolute minimum REQUIRED to avoid lawsuits for failure to diagnose ......" > -- > Roy [quoted text clipped - 15 lines] > | So, Tuesday is his lucky day. I will post the films when I get the > | chance. Keep us updated. Another argument for getting rid of impacted third molars at an early age. Signature~+--~+--~+--~+--~+-- Stephen Mancuso, D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > > A patient came in for a consultation this week for jaw pain. He tells [quoted text clipped - 12 lines] > So, Tuesday is his lucky day. I will post the films when I get the > chance. >A patient came in for a consultation this week for jaw pain. He tells >me he was punched in the jaw about 10 days ago and the pain keeps [quoted text clipped - 11 lines] >So, Tuesday is his lucky day. I will post the films when I get the >chance. Here is the link http://www.deomfs.com/cyst_fx.htm I outlined the lingual fracture on the bottom image. This fracture is minimally displaced but mobile clinically. The fun part is going to be attempting rigid fixation after I remove the cyst and tooth. >>A patient came in for a consultation this week for jaw pain. He tells >>me he was punched in the jaw about 10 days ago and the pain keeps [quoted text clipped - 18 lines] > minimally displaced but mobile clinically. The fun part is going to be > attempting rigid fixation after I remove the cyst and tooth. Oh, man! Has there been a biopsy yet? Based on clinical signs, do you suspect odontogenic tumor? Steve SignatureCut the nonsense to reply >>>A patient came in for a consultation this week for jaw pain. He tells >>>me he was punched in the jaw about 10 days ago and the pain keeps [quoted text clipped - 23 lines] > >Steve I plan to address the cyst/tumor & fracture on Tuesday. I will send the specimen to get a diagnosis. Tricky case. I dont expect much bone on the cortices, which can compromise fixation. mainly because the bigger the plate needed to get to areas of sound bone, the harder it is to do intraorally. the screws ideally engage both the lingual and buccal cortices. He really doesnt want me to go through a skin crease in his neck, which is the best and easier way to deal with that kind of problem. Wider access to better bone stock. That intra/extraoral approach to this can lead to a higher rate of infection but I gotta do what I gotta do. he is already complaining about being wired shut for 6 weeks if I dont place any plates (closed reduction). Closed reduction may also be tricky if minimal bone is there, leading to a non-union. My bet is on needing a big, honkin plate. > That intra/extraoral approach to this can lead to a higher rate of > infection but I gotta do what I gotta do. he is already complaining > about being wired shut for 6 weeks if I dont place any plates (closed > reduction). Closed reduction may also be tricky if minimal bone is > there, leading to a non-union. My bet is on needing a big, honkin > plate. I saw one of those extraoral fixation cases when I was in the year of multidisciplinary rotation. IIRC, it was an ameloblastoma case. The fixation worked out quite well, but the guy was a real philosopher, and accepted it quite well. Don't remember what that extraoral bar was made of, but it wasn't metal. SP SignatureFinally: take out the TRASHH >> That intra/extraoral approach to this can lead to a higher rate of >> infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 9 lines] >of, but it wasn't metal. >SP I was referring more to an actual plate placed on the bone. Your referring to a 'Joe Hall Morris' external fixator. These are actually great options, especially in this case, if the patient is willing to walk around with half a punters facemask on one side of their face. I have placed many of these but not recently and this fella declined it. The bar is made from cold-cure acrylic. You place atleast two pins proximal and distal to the fracture. An endotracheal tube is placed, connecting all the pins together. You then fill er' up with the acrylic by injecting it into one end of the breathing tube/matrix and let it harden. Works like a champ. Many companies have newer designs, all metal, that look like erector sets. The old fashion way is cheaper and works just as well. > I was referring more to an actual plate placed on the bone. Your > referring to a 'Joe Hall Morris' external fixator. These are actually > great options, especially in this case, if the patient is willing to > walk around with half a punters facemask on one side of their face. Very good analogy... > I have placed many of these but not recently and this fella declined > it. The bar is made from cold-cure acrylic. Too bad the guy can't see his way through to having the best treatment and to hell with esthetics, temprorarily, at least. > You place atleast two pins proximal and distal to the fracture. An > endotracheal tube is placed, connecting all the pins together. You > then fill er' up with the acrylic by injecting it into one end of the > breathing tube/matrix and let it harden. Works like a champ. Many > companies have newer designs, all metal, that look like erector sets. Well, at least he could walk around sayin': .... I'LL BE BACK...... in an Austrian robot's accent. > The old fashion way is cheaper and works just as well. Not to mention that you can start doing it THE MOMENT the patient decides 'Yes'. Thanks for the background. SP SignatureFinally: take out the TRASHH > That intra/extraoral approach to this can lead to a higher rate of >infection but I gotta do what I gotta do. he is already complaining >about being wired shut for 6 weeks if I dont place any plates (closed >reduction). Closed reduction may also be tricky if minimal bone is >there, leading to a non-union. My bet is on needing a big, honkin >plate. What about marsupializing the cyst ? Just an idea. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > > That intra/extraoral approach to this can lead to a higher rate of > >infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 4 lines] > > What about marsupializing the cyst ? REPLY The Kangaroo did not agree.. Joel > Just an idea. > -- > > W_B > Take out the G'RBAGE > wubbabubbazG@RBAGEyahoo.com >> That intra/extraoral approach to this can lead to a higher rate of >>infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 6 lines] > >Just an idea. Thats what I gotta do first followed by management of the fracture. >>> That intra/extraoral approach to this can lead to a higher rate of >>>infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 8 lines] > >Thats what I gotta do first followed by management of the fracture. You would think that the patient would want the best outcome. He's complaining already, before treatment has started ? I don't envy your position on this case. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com >>>> That intra/extraoral approach to this can lead to a higher rate of >>>>infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 13 lines] > >I don't envy your position on this case. Well, I seldom meet someone that didnt deserve that punch ;) This is tricky and I hope the path report comes back saying 'dentigerous cyst' and not something else that warrants resection. >>>>> That intra/extraoral approach to this can lead to a higher rate of >>>>>infection but I gotta do what I gotta do. he is already complaining [quoted text clipped - 18 lines] >This is tricky and I hope the path report comes back saying >'dentigerous cyst' and not something else that warrants resection. Just a follow up.... Scooped out the tumor and the fracture reduced well. Simply wired him together. Path report came back as OKC (odontogenic keratocyst). In other words, he has a chance of recurrence but the fracture reduction was perfect. I will post pics of post-op films next week. I am glad we didnt need anything more. >>This is tricky and I hope the path report comes back saying >>'dentigerous cyst' and not something else that warrants resection. [quoted text clipped - 5 lines] >was perfect. I will post pics of post-op films next week. I am glad we >didnt need anything more. Good news indeed, looking forward to the pix. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > >>You would think that the patient would want the best outcome. > >>He's complaining already, before treatment has started ? [quoted text clipped - 12 lines] > was perfect. I will post pics of post-op films next week. I am glad we > didnt need anything more. Good for him (I think); but from what you stated above, he will STILL complain about the inconvenience. I have only seen one keratocyst in my life (OMFS rotation in 4th year Dental School). That was in an edentulous space occupying the place of the lower left molars. The The Barbers biopsied it using a rather large needle attached to a glass syringe. I think that needle was a 20 guage or something like that. They just shoved it into the lesion and aspirated. The stuff came out as brownish viscous fluid. They looked at it: 'Keratocyst...' Visual confirmation made, they sent him up for an appointment to remove it. Now, _that_ was impressive. The thing was, there was no pain at all as the needle went in. So there was no anesthesia. I wonder if they removed it under general or local anesthesia, and what happened after that. But, of course, I was not privy to all that; I was only there two weeks. I don't think there is a Generalist alive who is not impressed by the Barber's bag of tricks and what they do. One question: is the Mandibular vascular bundle preserved here or does it get resected out as well? Thanks SP SignatureFinally: take out the TRASHH >> >>You would think that the patient would want the best outcome. >> >>He's complaining already, before treatment has started ? [quoted text clipped - 34 lines] >Thanks >SP Link for the post-op panorex. Like that right subcondylar fracture? I found it on another film we took in the Wilmington Hospital OMFS clinic prior to the OR that morning. Didnt see it too well on the previous and he had no discomfort on that side. Oh well, better late than never. A perfect example of why this is the most common misdiagnosed facial injury. http://www.deomfs.com/cyst_fx2.htm When I enucleated the cyst, the nerve was laterally positioned, as expected, but completely removed from any canal. I left it intact but he is still tingling at the lip two weeks out. OKC lack the cytokines for perineural invasion so even if he gets a large recurrence that warrants resection, techniquely you can leave the nerve. Recurrence is from leaving teeth behind or the trabeculation of the bone, hiding cells for further growth and more common in multilocular OKC's. Lionel Gold, a retired OMFS surgeon and pathologist in the Philly area has argued that OKC's do in fact invade the perineurium. Robert Marx disagrees. I am waiting for a recurrence. Dave Surgical approach was buccal or lingual? Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>> >>You would think that the patient would want the best outcome. [quoted text clipped - 56 lines] > > Dave >Surgical approach was buccal or lingual? Long buccal incision from mid ramus, along retromolar area and into the vestibule to around the first molar. The gingival sulcus wasnt used. I started with wide access for easy visualization, easier enucleation and just incase I placed a plate. Seeing is a luxury. The third molar popped right out. >>Surgical approach was buccal or lingual? > [quoted text clipped - 3 lines] >enucleation and just incase I placed a plate. Seeing is a luxury. The >third molar popped right out. I was wondering about the long buccal nerve. You just stayed below it? .. Stephen Mancuso, D.D.S. Troy, Michigan, USA I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. >>>Surgical approach was buccal or lingual? >> [quoted text clipped - 6 lines] >I was wondering about the long buccal nerve. You just stayed below >it? Probably above it but a somewhat variable course means I dont get too excited. That is a nerve that I have never seen not regain function. >.. >Stephen Mancuso, D.D.S. >Troy, Michigan, USA > >I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting. > >I was wondering about the long buccal nerve. You just stayed below > >it? > > Probably above it but a somewhat variable course means I dont get too > excited. That is a nerve that I have never seen not regain function. If I may ask: how long does that take? 6 weeks? months? years? Thanks SP SignatureFinally: take out the TRASHH >> >I was wondering about the long buccal nerve. You just stayed below >> >it? [quoted text clipped - 5 lines] >Thanks >SP That all depends. I cant remember the last time I had someone claiming of a numb cheek, regardless of the procedure. Predictably not too much to worry about. Dave > >> >I was wondering about the long buccal nerve. You just stayed below > >> >it? [quoted text clipped - 11 lines] > > Dave Danke SP SignatureFinally: take out the TRASHH Thanks Dave. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>>>Surgical approach was buccal or lingual? [quoted text clipped - 17 lines] >>I am writing on a Tablet-PC,so forgive me if the PC misreads my >>handwriting. > Link for the post-op panorex. Like that right subcondylar fracture? I > found it on another film we took in the Wilmington Hospital OMFS [quoted text clipped - 3 lines] > misdiagnosed facial injury. > http://www.deomfs.com/cyst_fx2.htm Nice photo. I also kinda seems like the condyle bone is rarified on that side. Surprising that such a fracture didn't affect the neruovascular bundle on that side, ' cause it sure seems to be interfering at the spine of Spix. > When I enucleated the cyst, the nerve was laterally positioned, as > expected, but completely removed from any canal. I left it intact but > he is still tingling at the lip two weeks out. If he had asked me, I would have told him that this becomes less and less noticable as time wears on. >OKC lack the cytokines > for perineural invasion so even if he gets a large recurrence that > warrants resection, techniquely you can leave the nerve. That is what I wanted to knwo; thanks >Recurrence is > from leaving teeth behind or the trabeculation of the bone, hiding [quoted text clipped - 4 lines] > > Dave Too bad you couldn't do a really high resolution CT scan and blow it up to histopathological magnification. You could check your resection margins and evaluate the site periodically. Thanks for the info SP SignatureFinally: take out the TRASHH |
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