ShortNotes

🔹 Definition & Historical Note

• Ludwig’s Angina is a rapidly progressive, bilateral cellulitis of the submandibular, submental, and sublingual spaces, often without initial abscess formation.

• It is life-threatening due to potential airway obstruction and mediastinal spread.

• Named after Wilhelm Friedrich von Ludwig (German surgeon, 1790–1865).

🔹 Regional Anatomy Breakdown

🔸 Submental Space

• Boundaries:

  • Roof: Mylohyoid muscle

  • Floor: Deep cervical fascia, platysma, superficial fascia, skin

  • Lateral: Anterior belly of digastric

  • Posterior: Submandibular space

• Contents: Lymph nodes, anterior jugular vein

• Infection Source: Mandibular incisors

🔸 Sublingual Space

• Boundaries:

  • Superior: Mucosa of floor of mouth

  • Inferior: Mylohyoid muscle

  • Posterior: Hyoid bone

  • Anterior/Lateral: Inner mandibular body

  • Medial: Geniohyoid, genioglossus, styloglossus

• Infection Source: Mandibular premolars and first molars

🔸 Submandibular Space

• Boundaries:

  • Superior: Mylohyoid muscle, mandible

  • Inferior: Digastric muscle (anterior and posterior bellies)

  • Lateral: Platysma, deep cervical fascia, skin

  • Medial: Mylohyoid, hyoglossus, styloglossus

  • Posterior: Hyoid bone

  • Anterior: Submental space

• Infection Source: Mandibular second and third molars

🔹 Etiology

• Odontogenic (75–90%): Dental caries, extractions, poor hygiene

• Trauma: Lacerations, puncture wounds of floor of mouth

• Secondary infections: Oral malignancy, sialadenitis

• Systemic compromise:

  • Diabetes mellitus

  • HIV/AIDS

  • Chemotherapy

  • Transplant recipients

  • Aplastic anemia

  • Glomerulonephritis

🔹 Clinical Features

• Swelling:
  
  

  • Bilateral “wooden” induration in submandibular, submental, sublingual spaces

  • Skin is tense, pits and blanches on pressure

  • “Double chin” appearance

• Tongue displacement:
  
  

  • Elevation and posterior displacement

  • Leads to dysphagia, odynophagia, dysphonia, cyanosis

• Voice changes:
  
  

  • “Hot potato voice” due to laryngeal edema

• Systemic signs:
  
  

  • High-grade fever, malaise, leukocytosis, body aches

  • Septicemia risk

• Airway compromise:
  
  

  • Dyspnea in supine position

  • Thumb sign on lateral neck radiograph (epiglottic swelling)

• Spread:
  
  

  • Masticator space

  • Parapharyngeal space

  • Retropharyngeal and mediastinal spaces (late stages)

🔹 Investigations

Modality

Purpose

Panoramic X-ray (OPG)

Identifies odontogenic source

Lateral neck radiograph

Detects soft tissue swelling, tracheal deviation

Ultrasound

Differentiates cellulitis vs. abscess; no radiation

CT Scan

Gold standard for extent, staging, and airway evaluation

Blood tests

CBC, CRP, cultures

FNAC

Confirms abscess if suspected

🔹 Differential Diagnosis

• Angioneurotic edema

• Cellulitis

• Lingual carcinoma

• Lymphadenitis

• Peritonsillar abscess

• Salivary gland abscess

• Sublingual hematoma

🔹 Management Overview

🔸 Goals

• Secure airway

• Control infection

• Drain abscesses

• Support nutrition and hydration

🔹 Airway Management

Technique

Notes

Fibre-optic nasotracheal intubation

Preferred; less invasive

Tracheostomy

Gold standard; risks: mediastinal spread, tracheal stenosis

Cricothyroidotomy

Emergency alternative; lower mediastinal risk

Blind nasal intubation (BNI)

Discouraged due to trauma and low success

🔹 Medical Management

• IV access and fluid resuscitation

• Empirical IV antibiotics, tailored to cultures:

  • Penicillin + β-lactamase inhibitor

  • Cephalosporins (2nd–4th gen)

  • Metronidazole for anaerobes

• Steroids: May reduce edema

• Analgesics and antipyretics

🔹 Surgical Management

🔸 Incision & Drainage Principles (Topazian & Goldberg)

• Incise in healthy skin, not at fluctuance

• Use natural skin folds

• Place incisions in dependent positions

• Blunt dissection preferred

• Insert drains; remove when output is minimal

🔸 Incision Sites

• Bilateral submandibular incisions

• Midline submental incision

• ~3–4 cm below mandibular angle, parallel to inferior border

🔹 Postoperative Care

• Monitor airway and vitals

• Nasogastric feeding if needed

• Pain control and oral hygiene

• Follow-up imaging for complications

🔹 Prognosis

• Excellent with early diagnosis and intervention

• Delayed treatment → airway obstruction, mediastinitis, sepsis, death

🧠 Mnemonic: “LUDWIG’S”

• L – Laryngeal edema

• U – Unerupted molars

• D – Drooling

• W – Wooden swelling

• I – Infection (odontogenic)

• G – Glossal elevation

• S – Surgical drainage

🔹 Definition

• A benign but locally invasive tumor of odontogenic (tooth-forming) epithelial origin.

• Composed of proliferating odontogenic epithelium within a fibrous connective tissue stroma.

🔹 Etiology (Cause)

• Unknown, but possible contributing factors include:

  • Trauma or inflammation

  • Oral infections

  • Tooth extractions or jaw injuries

  • Irritation from erupting third molars

🔹 Origin

• Exact origin is uncertain; may arise from:

  • Epithelial rests of Serres or Malassez (remnants of tooth development)

  • Epithelial lining of odontogenic cysts, especially dentigerous cysts

  • Directly from oral epithelium

🔹 Types of Ameloblastoma

• Conventional solid or multicystic – 94% of cases

• Unicystic (mural) – 5%

• Peripheral (extraosseous) – 1%

🔹 Incidence

• Most common epithelial odontogenic tumor

• Accounts for 1% of all oral tumors

• Mandible is affected more than maxilla (85% vs. 15%)

  • In mandible:

    • 70% in molar–ramus area

    • 20% in premolar area

    • 10% in incisor region

  • In maxilla:

    • Usually in posterior region

• Age group: Most common in 4th and 5th decades, but can occur in children or elderly

🔹 Clinical Presentation

Early Stage:

• Slow-growing and asymptomatic

Advanced Stage:

• Expansion of cortical bone plates

• Thinning and erosion of bone (egg shell crackling)

• Invasion into soft tissues

• Visible swelling causing facial asymmetry

• May appear as solid, cystic, or mixed lesion

• Dental signs:

  • Loosening or tipping of teeth

  • Involvement of inferior alveolar nerve

  • Draining sinuses

  • Unhealed extraction sockets with granulation tissue

  • Bleeding, trismus (jaw stiffness), and other dental complaints

Maxillary Ameloblastoma:

• Nasal obstruction is often the first symptom

• Can be potentially lethal due to:

  • Thin bone structure

  • Proximity to nasal cavity, sinuses, orbit, pharynx, and skull base

• These factors also make complete surgical removal difficult

🔹 Radiographic Presentation

• Osteolytic lesion (bone-destroying)

• Appears as:

  • Unilocular (single cavity) or multilocular (multiple cavities) radiolucency

  • Honeycomb pattern: small loculations

  • Soap bubble pattern: large loculations

• May show:

  • Expansion or destruction of cortical bone

  • Associated unerupted tooth (resembles dentigerous cyst)

  • Root resorption of adjacent teeth

  • Maxillary lesions often appear as monocystic cavities

🔹 Histopathological Findings

Main Types:

• Follicular ameloblastoma:
  
  

  • Resembles enamel organ

  • Has peripheral tall columnar cells (ameloblast-like) and central stellate reticulum-like cells

• Plexiform ameloblastoma:
  
  

  • Epithelium forms a network of strands and cords

  • Same cell layers as follicular type

Variants of Follicular Type:

• Cystic

• Basal cell

• Acanthomatous

• Desmoplastic

🔹 Differential Diagnosis

• Other odontogenic tumors:
  
  

  • Ameloblastic fibroma

  • Odontogenic myxoma

• Non-odontogenic tumors:
  
  

  • Central giant cell granuloma

  • Aneurysmal bone cyst

• Odontogenic cysts:
  
  

  • Dentigerous cyst

  • Odontogenic keratocyst

🔹 Treatment Options

General Principles:

• Treatment depends on site, size, and nature of the tumor

• Ranges from conservative curettage to radical resection

Curettage:

• Scraping out the tumor

• Least preferred due to high recurrence

• Tumor cells often extend beyond visible margins

En-block Resection:

• Removal of tumor with a rim of healthy bone

• Maintains jaw continuity

• Effective for conventional ameloblastoma

• Tumor invades cancellous bone, but rarely the compact bone’s haversian system

Segmental Resection:

• Removal of a segment of jaw (e.g., hemimaxillectomy or hemimandibulectomy)

• Most effective with lowest recurrence rates

🔹 Unicystic (Mural) Ameloblastoma

• Arises from the wall of a dentigerous cyst

• Second most common pericoronal radiolucency

• Can occur in other locations, not always linked to teeth

• Represents 5% of all ameloblastomas

• Affects younger patients (2nd–3rd decades)

• Common in mandibular third molar region

• May be associated with other cysts (radicular, primordial, residual, globulomaxillary)

Clinical Features:

• Asymptomatic early on

• Detected via routine radiographs

• Slow enlargement, non-tender swelling

• Bone destruction may cause soft areas on palpation

Radiographic Signs:

• Haziness and thinning of radiopaque rim

• Tumor invades cyst capsule and bone trabeculae

Management:

• Before surgery, distinguish between unicystic and conventional types

• During surgery:

  • Enucleate cyst

  • If mural mass found, mark it for pathology

• If tumor has not penetrated basement membrane, no further surgery

• If penetration is confirmed, perform curettage or bone removal

• Regular follow-up is essential

🔹 Peripheral (Extraosseous) Ameloblastoma

• Originates from:

  • Basal layer of oral epithelium

  • Extraosseous epithelial rests of Serres

• Commonly affects gingiva and alveolar mucosa

• More frequent in mandible than maxilla

• Microscopically resembles acanthomatous basal cell carcinoma

• Management: Simple excision

• Behavior: Less aggressive than intraosseous types

🔹 OSSIFYING FIBROMA

Definition & Nature

• Also called cemento-ossifying fibroma or cementifying fibroma.

• A true neoplasm (tumor) with significant growth potential.

• Composed of highly cellular fibrous tissue with varying amounts of abnormal bone or cementum-like material.

• Previously classified separately based on dominant calcified material:

  • Bone-dominant: Ossifying fibroma.

  • Cementum-dominant: Cementifying fibroma.

• Now grouped under cemento-ossifying fibroma due to similar microscopic appearance.

Juvenile Ossifying Fibroma

• Aggressive variant occurring in the first two decades of life.

• Rapid growth and potential for significant deformity.

🔹 Clinical Features

• Affects a wide age range, most common in 3rd–4th decades.

• Female predilection.

• Mandible is more commonly affected than maxilla.

  • Most common site: premolar–molar region.

  • Maxillary lesions often involve the antrum (sinus area).

• Tooth displacement may be an early sign.

• Small lesions: Asymptomatic, found on radiographs.

• Large lesions: Painless jaw swelling, facial asymmetry, possible deformity.

• Pain and paraesthesia (numbness) are rare.

• Usually solitary, but multiple lesions may occur in rare cases or as part of hyperparathyroidism-jaw tumor syndrome.

🔹 Radiographic Features

Location

• Found exclusively in facial bones, most commonly:

  • Mandible: Below premolars/molars, above inferior alveolar canal.

  • Maxilla: Canine fossa and zygomatic arch.

Periphery

• Well-defined borders.

• May have a thin radiolucent line (fibrous capsule).

• Surrounding bone may show sclerotic border (dense bone reaction).

Internal Structure

• Mixed radiolucent–radiopaque appearance.

• Depends on type and amount of calcified material:

  • Bone-like: Wispy (cotton tuft) or flocculant (snowflake) pattern.

  • Cementum-like: Solid, amorphous radiopacities called cementicles.

• Some lesions may appear mostly radiolucent with minimal calcification.

Effect on Surrounding Structures

• Tooth displacement, inferior alveolar canal shift, and cortical bone expansion.

• Outer cortical plate is thinned but remains intact.

• Lamina dura (tooth socket lining) often missing.

• Root resorption may occur.

• In maxilla, lesion expands walls outward but maintains a bony partition between tumor and sinus.

🔹 Differential Diagnosis

• Fibrous dysplasia

• Periapical cemental dysplasia

• Calcifying odontogenic cyst

• Calcifying epithelial odontogenic tumor (Pindborg tumor)

• Adenomatoid odontogenic tumor

• Osteogenic sarcoma

🔹 Treatment

• Surgical enucleation or resection.

• Large lesions: May require bone grafting.

• Recurrence is uncommon after complete removal.

• Good prognosis, no known risk of malignancy.

🧠 Cemento-Osseous Dysplasia (COD)

🔹 General Features

• Most common fibro-osseous lesion.

• Occurs in tooth-bearing areas of the jaws.

• Not a neoplasm—considered a reactive or dysplastic process.

• Classified into three types based on location and extent:

  1. Focal

  2. Periapical

  3. Florid

🔹 1. Focal Cemento-Osseous Dysplasia

Clinical Features

• Involves a single site, usually posterior mandible.

• 90% of cases in females, mean age: 41 years.

• Most common in American Blacks, followed by East Asians and Whites.

• Asymptomatic, found on routine radiographs.

• Lesion size: <1.5 cm.

🔹 2. Periapical Cemento-Osseous Dysplasia

Clinical Features

• Affects periapical region of anterior mandible.

• May be solitary or multiple, often bilateral.

• Strong female predilection (10:1 to 14:1).

• 70% of cases in Black patients.

• Age range: 30–50 years.

• Associated teeth are vital (not infected or dead).

Radiographic Features

• Epicenter at tooth apex or apical third.

• Well-defined periphery, often with:

  • Radiolucent border

  • Surrounding sclerotic bone reaction

• Shape: Round, oval, or irregular.

Effect on Surrounding Structures

• Lamina dura is lost.

• Periodontal ligament (PDL) space may appear widened or unclear.

• Hypercementosis (excess cementum on roots) may occur.

• No jaw expansion in small lesions.

• Larger lesions may cause mild expansion with intact cortex.

Internal Structure – 3 Stages

1. Early Stage:
   
   

   • Bone replaced by fibrous tissue.

   • Appears as radiolucency at apex.

2. Mixed Stage:
   
   

   • Radiopaque material appears in radiolucent area.

   • Composed of cementum or abnormal bone.

   • May form cementicles (small calcified bodies).

3. Mature Stage:
   
   

   • Entire lesion becomes radiopaque.

   • Surrounded by a radiolucent margin.

   • May contain simple bone cysts.

🔹 Differential Diagnosis

• Periapical rarefying osteitis (early stage)

• Benign cementoblastoma (mixed/mature stage)

• Odontoma

🔹 Management

• Diagnosis based on clinical and radiographic features.

• No treatment required unless complications arise.

• Biopsy risk: Poor vascularity may lead to secondary infection.

• In cases of alveolar ridge atrophy, cementum may reach mucosa and cause ulceration under dentures.

• If exposed, cementum must be surgically removed to prevent osteomyelitis.

🔹 3. Florid Cemento-Osseous Dysplasia (FOD)

Clinical Features

• Multifocal involvement, not limited to anterior mandible.

• Affects Black females, typically middle-aged to older adults.

• Often bilateral and symmetrical.

• May involve all four quadrants.

• Usually asymptomatic, but may cause:

  • Dull pain

  • Sinus tract formation

  • Exposure of yellowish avascular bone

  • Jaw expansion

Radiographic Features

• Bilateral lesions in both jaws.

• Epicenter: Apical to teeth, usually posterior to cuspids.

• In mandible: Above inferior alveolar canal.

Periphery

• Well-defined, with sclerotic border.

• Soft tissue capsule may be absent in mature lesions.

Effect on Surrounding Structures

• Inferior alveolar canal may be displaced downward.

• Maxillary sinus floor may be pushed upward.

• Buccal and lingual cortical plates may expand.

• Hypercementosis may fuse tooth roots with lesion.

Internal Structure

• Varies from mixed radiolucent–radiopaque to fully radiopaque.

• May show:

  • Cotton wool appearance: Small, fluffy opacities.

  • Amorphous calcifications: Irregular dense areas.

  • Simple bone cysts: Radiolucent areas that may enlarge or fill with dysplastic tissue.

🔹 Differential Diagnosis

• Paget’s disease

• Chronic sclerosing osteomyelitis

• Secondary osteomyelitis

🔹 Management

• No treatment needed unless complications occur.

• Emphasize oral hygiene to prevent infection.

• Avoid odontogenic infections.

• If denture pressure causes mucosal breakdown, exposed cementum must be removed surgically.

• In severe cases, large areas of cementum may be removed, leaving minimal bone for prosthetics.

🔹 Definition & Terminology

• A developmental odontogenic cyst that forms around the crown of an unerupted or impacted tooth.

• Originates from fluid accumulation between the reduced enamel epithelium and the enamel surface.

• The cyst is attached at the cementoenamel junction (CEJ) and encloses the crown within its lumen.

• Also known as:

  • Follicular cyst

  • Pericoronal cyst

🔹 Epidemiology

• Second most common jaw cyst (after radicular cyst); accounts for ~20% of epithelial-lined jaw cysts.

• Most common developmental odontogenic cyst.

• Age: Typically seen between 10–30 years.

• Slight male predilection.

• More common in Whites than Blacks.

• Mandible (67%) more affected than maxilla (33%).

• Common sites:

  • Mandibular third molars

  • Maxillary canines

  • Maxillary third molars

  • Mandibular second premolars

• Rare in deciduous teeth, but may occur due to inflammation from non-vital primary teeth.

• May be associated with supernumerary teeth, odontomas, or syndromes like:

  • Cleidocranial dysplasia

  • Maroteaux-Lamy syndrome

🔹 Pathogenesis

Developmental Origin

• Pressure from erupting tooth → venous obstruction → serum transudation.

• Increased hydrostatic pressure separates the follicle from the crown.

Inflammatory Origin

• Periapical inflammation from a non-vital primary tooth may affect the underlying permanent tooth germ, leading to cyst formation.

🔹 Clinical Features

• Small cysts: Asymptomatic; discovered on routine radiographs or when investigating delayed eruption.

• Large cysts:

  • Painless jaw swelling

  • Facial asymmetry

  • Smooth, hard prominence

  • Eggshell crackling: Thin bone overlying cyst gives a brittle sound on palpation.

  • May interfere with dentures or cause ill-fitting prosthetics.

• Infected cysts:

  • Pain, swelling, pus discharge.

  • Infection may spread from adjacent periapical or periodontal lesions.

• Tooth displacement:

  • Teeth may be pushed into unusual positions (e.g., third molars into mandibular border or ramus; maxillary teeth into sinus or orbit floor).

🔹 Radiographic Features

• Unilocular radiolucency associated with crown of unerupted tooth.

• Well-defined, corticated borders unless infected.

• Types of cyst-to-crown relationships:

  • Central (coronal): Crown projects symmetrically into cyst.

  • Lateral: Cyst grows along one side of crown/root.

  • Circumferential: Cyst surrounds crown and extends along root.

• Root resorption of adjacent teeth may occur.

• Tooth displacement can be significant.

• Size criteria: Radiolucency >5 mm around crown suggests cyst; 3–4 mm may be a hyperplastic follicle.

• Radiographic mimics: OKC, ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma.

🔹 Histopathology

Non-inflamed Cyst

• Lining: 2–4 layers of non-keratinized stratified squamous epithelium.

• Flat epithelium-connective tissue interface.

• May resemble reduced enamel epithelium.

• Connective tissue: Loosely arranged, rich in glycosaminoglycans.

• May contain odontogenic epithelial rests.

Inflamed Cyst

• Thickened fibrous wall, infiltrated by chronic inflammatory cells.

• Epithelium may show:

  • Hyperplasia

  • Rete ridges

  • Squamous metaplasia

  • Keratinization (must be differentiated from OKC)

• May contain:

  • Mucous cells

  • Ciliated columnar cells

  • Sebaceous cells

  • These reflect the multipotential nature of odontogenic epithelium.

🔹 Investigations

• Radiological:

  • Orthopantomogram (OPG): First-line imaging.

  • CT scan: For large or complex lesions.

• Laboratory:

  • FNAC: May show straw-colored fluid.

  • Biopsy: For definitive diagnosis.

🔹 Differential Diagnosis

• Odontogenic keratocyst (OKC)

• Ameloblastoma

• Adenomatoid odontogenic tumor

• Ameloblastic fibroma

• Periapical cyst

• Osteoclastoma

• Hyperplastic dental follicle

🔹 Management

Small Cysts

• Aspiration + incisional biopsy

• Enucleation with or without tooth removal

• If tooth eruption is possible:

  • Leave tooth in place

  • Remove part of cyst wall

  • May require orthodontic assistance

• In children: Attempt to preserve tooth if root formation is complete

Large Cysts

• Marsupialization:

  • Creates a surgical window to decompress cyst

  • Reduces bone defect size

  • Allows tooth eruption or facilitates later enucleation

  • Preferred in children or when tooth preservation is desired

🔹 Prognosis

• Excellent with complete removal.

• Recurrence is rare.

• Tooth eruption may occur post-treatment, especially in younger patients.

⚠️ Complications

• Neoplastic transformation:

  • Ameloblastoma

  • Squamous cell carcinoma

  • Mucoepidermoid carcinoma (from mucous cells in cyst lining)

💡 Mnemonic for Complications

“A Silent Menace May Strike”

• A = Ameloblastoma

• S = Squamous cell carcinoma

• M = Mucoepidermoid carcinoma

• S = Secondary infection

• Histology: Double-layered ductal epithelium, oncocytic appearance, inflammatory infiltrate

• Treatment: Conservative excision

• Prognosis: Recurrence rare

🔷 6. Malignant Tumors – Detailed Profiles

🔺 Mucoepidermoid Carcinoma

• Most common salivary malignancy

• Sites: Parotid (60–90%), palate

• Clinical:

  • Low-grade: Painless, slow-growing

  • High-grade: Rapid growth, ulceration, facial palsy

• Pathology:

  • Low-grade: Mucinous fluid, encapsulated

  • High-grade: Solid, invasive; few mucinous cells

• Treatment:

  • Low-grade: Superficial parotidectomy

  • High-grade: Total parotidectomy ± nerve resection, neck dissection, radiation

• Prognosis:

  • Low-grade: 95% survival

  • High-grade: ~40% survival; 60% recurrence/metastasis

🔺 Acinic Cell Carcinoma

• Site: Parotid (90–95%), submandibular

• Age: 5th decade; more common in women

• Clinical: Slow-growing, sometimes painful; bilateral in 3%

• Pathology: Acinar-like cells + clear cells; lymphocytic infiltration

• Treatment: Superficial parotidectomy or gland removal

• Prognosis: 50% survival at 20 years

🔺 Adenoid Cystic Carcinoma

• Site: Submandibular + minor glands (50%)

• Age: 5th decade; M = F

• Clinical: Firm mass, pain, facial palsy, mucosal ulceration, bone invasion

• Pathology: Small cuboidal cells, pseudocystic spaces, dense chromatin

• Treatment: Wide excision ± radiation; chemotherapy limited

• Prognosis:

  • 5-year survival: ~70%

  • 15-year survival: ~10%

  • High recurrence (16–85%)

🔺 Polymorphous Low-Grade Adenocarcinoma

• Site: Minor glands (palate)

• Age: 50–70 years

• Clinical: Firm, non-ulcerated, painless swelling

• Pathology: Uniform cells, perineural invasion, trabecular cords

• Treatment: Wide excision; neck dissection if nodes involved

• Prognosis: Excellent; ~10% recurrence

🧮 Rule of 80s (Pleomorphic Adenoma)

• 80% of parotid tumors are benign

• 80% of those are pleomorphic adenomas

• 80% of pleomorphic adenomas occur in parotid

• 80% of parotid pleomorphic adenomas are in superficial lobe

• 80% of untreated pleomorphic adenomas remain benign