Surgical Techniques in Oral and Maxillofacial Surgery

Drainage of Abscess

• Hilton's method is used to drain pus from an abscess: a sinus forceps is introduced closed and then opened.
• Submandibular abscess: skin incision is made parallel to the lower border of the mandible, 1.5 inches below and in front of the angle of the mandible, to avoid injury to the mandibular branch of the facial nerve.

Chronic Sialadenitis

• Etiology:
  • Chronic calculous sialadenitis: infection, stasis (sepsis, stricture, or foreign body)
  • Chronic non-calculous sialadenitis: poor oral hygiene, obstruction of salivary duct by food particles or foreign body, imperfect drainage of acute sialoadenitis
• Pathology:
  • Chronic calculous sialadenitis: stones lie in the gland or duct, most common in the submandibular gland (50:1 ratio to parotid gland)
  • Chronic non-calculous sialadenitis: chronic inflammation of the gland and duct
• Complications:
  • Chronic calculous sialadenitis: obstruction, infection, abscess, fistula, migration, malignancy
  • Chronic non-calculous sialadenitis: recurrent acute attacks, stone formation, sialectasis

Clinical Features and Investigations

• Clinical features: painful gland swelling while eating, calculus may cause acute or recurrent attacks of sialadenitis
• Investigations: plain occlusal view radiograph (80% radio-opaque), ultrasound (can show almost all stones)

Treatment of Salivary Stones

• Treatment is surgical
• Stones in the duct: removal through the mouth
• Stones in the gland: removal with the submandibular or parotid gland
• Parotidectomy for calcular disease requires high experience due to the difficulty of identifying the facial nerve

Sialectasis

• Definition: abnormal dilatation of the small branches of the salivary ducts and alveoli
• Cause: unknown, but childhood type is known to be a familial disease
• Presentation: recurrent attacks of sialadenitis
• Investigation: sialography

Differential Diagnosis

• Enlarged submandibular salivary gland vs. enlarged submandibular lymph node
  • Multiple vs. single swelling
  • -ve lemon test vs. +ve lemon test
  • Can be rolled around mandible vs. cannot be rolled around mandible
  • Bidigital examination: palpated from outside vs. palpated from inside

Treatment of Chronic Sialadenitis

• Submandibular gland:
  • Stone in the duct: removal under local anesthesia
  • Stone in the gland: submandibular sialadenectomy
• Parotid gland:
  • Stone in the duct: removal intraorally
  • Stone in the gland: total conservative parotidectomy

Submandibular Sialadenectomy

• Incision: parallel to the lower border of the mandible
• Complications:
  • Injury of mandibular branch of facial nerve
  • Injury of hypoglossal nerve
  • Injury of lingual nerve
  • Injury of the pharynx