Review of Anatomy, History taking, and Diagnosis

Dr. Rahaf Y. Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and

Maxillofacial Surgery

Anatomy Review

The trigeminal nerve is the largest of the cranial nerves. It has both motor and sensory components

Trigeminal Nerve

The ophthalmic nerve

carries sensory information from the:

Scalp and forehead,

The upper eyelid,

The conjunctiva and Cornea of the eye,

The nose (including the tip of the nose),

The nasal mucosa, and

The frontal sinuses.

The Maxillary Nerve

The maxillary nerve carries sensory

information from the :

Lower eyelid and cheek, Nares and upper lip,

The upper teeth and gums, The nasal mucosa,

The palate and roof of the pharynx,

The maxillary, ethmoid and sphenoidsinuses, and

parts of the meninges

The Maxillary Nerve

The maxillary nerve continues into the infraorbital canal as the infraorbital nerve.

The zygomatic nerve emerges and branches into its two major terminal branches, the zygomaticofacial and zygomaticotemporal nerves, which innervate the lateral cheek and side of the forehead, respectively.

As it projects anteriorly, the infraorbital nerve gives off the anterior and middle superior alveolar nerves, innervating the upper teeth.

It then exits the canal through the infraorbital foramen to innervate the upper lip, cheek and side of the nose.

Mandibular nerveThe mandibular nerve carries sensory information from the:

lower lip,

The lower teeth and gums,

The chin and jaw (except the angle of the jaw, which is supplied by C2-C3),

Parts of the external ear, and parts of the meninges.

Mandibular Nerve

The Buccal Nerve innervates the mucosa of the mouth and gums.

The Auriculotemporal Nerve innervates the external auditory meatus and portions of the external surface of the tympanic membrane.

The lingual Nerve provides general sensation to the anterior 2/3 of the tongue.

The Inferior Alveolar Nerve enters the mandibular canal through the mandibular foramen to innervate the lower teeth and gums.

Its Terminal branch exits the mental foramen as the mental nerve, innervating

the chin and lower lip.

Other several Branchial motor nerves .

History Taking and Diagnosis

Preoperative Health Status Evaluation

• Medical History

• Physical Examination

Medical History

An accurate medical history is the most usefulinformation a clinician can have to treat the patientsafely

The dentist should be able to predict how a medicalproblem will alter a patient’s response to plannedanesthetic agents and surgery

Standard Format for Recording Results of History of Physical Examination

1. Biographic Data2. Chief Complaint and its History3. Medical History4. Social and Family Medical Histories5. Review of Systems6. Physical Examination7. Laboratory and Radiographic/Imaging Examination

1- Biographic Date

• The most important information to obtain.

• Include patient’s full name, address, gender, and occupation, as well as the patient’s primary care physician.

• All together can be used to asses patient’s reliability.

• If patient is not reliable , alternative methods to obtain information should be found

2- Chief Complaint

• All patients should be asked about their CC.

• Can be accomplished on a form or transcribed into the dental record (verbally).

• Helps the dentist to establish priorities during treatment planning.

• Helps reveal the true reasons the patient is seeking care.

History of Chief Complaint

• Patient should be asked to describe the history of the CC

• First appearance, changes of events, effect of other factors

• Description of pain should include onset, intensity, duration, location, and radiation, as well as factors that affect the pain

• Other symptoms should also be inquired such as fever, chills, lethargy, anorexia, malaise, and weakness associated with the CC.

3- Medical History

• Health history forms are found to be an efficient mean of initial collection, that should be written in clear language

• Should inquire specific information about common medical problems (Table)

• Should ask specifically about allergies to local anesthetics, aspirin, and penicillin

• Female patients should also be asked about pregnancy if age appropriate.

Baseline Health History Database

1. Past hospitalization, operations, traumatic injuries, and serious illnesses

2. Recent minor illnesses or symptoms3. Medications currently or recently in use and allergies

(particularly drug allergies)4. Description of health-related habits or addictions, such as

the use of ethanol, tobacco, and illicit drugs and the amount and type of daily exercise

5. Date and result of last medical checkup or physician visit

4- Social and Family Medical Histories

5- Review of Systems

• It is a sequential, comprehensive method of eliciting patient symptoms on an organ system bases.

• For example, a review of the CVS in a patient with a history of ischemic heart disease include questions concerning chest pain (during exertion, eating, or at rest), palpitations, fainting, and ankle swelling.

• Such questions help the dentist decide wither to do the surgery at all or alter the treatment methods

Review of Systems

Routine Review of Head, Neck, and MaxillofacialRegions:Constitutional: fever, chills, sweats, weight loss, fatigue, malaise, loss of appetite.Head: headache, dizziness, fainting, insomnia.Ears: Decreased hearing, tinnitus, painEyes: Blurring, double vision, excessive tearing, dryness, painNose and Sinuses: Rhinorrhea, epistaxis, breathing problems, pain, change in sense of smell.TMJ: Pain, noise, limited movement.Oral: Dental pain and sensitivity, lip or mucosal sores, chewing or speaking problems, bad breath, loose restorations, sore throat, loud snoring.Neck: Difficulty swallowing, voice change, pain, stiffness.

Review of Systems

The need to review organ systems in addition to the maxillofacial region depends on clinical circumstances

(commonly the CVS and Respiratory system):CVS Review:Chest discomfort on excretion, when eating, or at rest;palpitations; fainting; ankle edema; shortness of breath(dyspnea) on excretion, dyspnea on assuming supine position;postural hypotension, fatigue, leg muscle cramping.

Respiratory Review:Dyspnea with exertion, wheezing, coughing, excessive sputumproduction, coughing blood (hemoptysis)

6- Physical Examination

• Focus on the oral cavity and to a lesser degree on the entire maxillofacial region

• All results should be recorded and should avoid jumping to diagnosis ( inner surface lip mucosal lesion 5mm in diameter, raised and firm, not painful to palpation) vs. “fibroma on lip”

• Should always start with measuring vital signs (BP,PR)• Physical evaluation is usually held through:• 1) Inspection, 2) Palpation, 3) Percussion, and 4) Auscultation.

Preoperative Physical Examination of the Oral and Maxillofacial Surgery Patient

Inspection:Head and Face: General shape, symmetry, hair distributionEar: Normal reaction to soundsEye: symmetry, size, reactivity of pupil, color of sclera and conjunctiva, movement, test of visionNose: Septum, mucosa, patency.Mouth: Teeth, mucosa, pharynx, lips, tonsilsNeck: Size of thyroid gland, jugular venous distention.

Palpation:TMJ: crepitus, tendernessParanasal: pain over sinuses.Mouth: Salivary glands, floor of mouth, lips, muscles of masticationNeck: Thyroid gland size, lymph nodes

Percussion: Paranasal: Resonance over sinus (difficult to asses)Mouth: Teeth

Auscultation:TMJ: Clicks, crepitusNeck: Carotid Bruits

Brief Maxillofacial Examination

While interviewing the patient, the dentist should visually examine the patient for general shape and symmetry of head and facial skeleton, eye movement, color of conjunctive, and sclera, and ability to hear. The clinician should listen to speech problems, TMJ sounds, and breathing ability.

Routine Examination:TMJ: • Palpate and auscultate joint• Measure range of motion of jaw and opening patternNose and paranasal Region:• Occlude nares individually to check for patency• Inspect anterior nasal mucosaMouth:• Take out all removable prosthesis• Inspect oral cavity for dental, oral, and para-pharyngeal mucosal lesions; look at

tonsils and uvula• Hold tongue out of mouth with dry gauze while inspecting lateral boarders• Palpate tongue, lips, floor of mouth, and salivary glands (saliva)• Palpate neck for lymph nodes and thyroid gland size, inspect jugular vein

7- Laboratory and Radiographic/Imaging Examination

The result of the medical evaluation are used to assign a physical status classification

The most commonly used classification is the American Society of Anesthesiologists (ASA)

American Society of Anesthesiologists (ASA)Classification of Physical Status

ASA I: Normal, Healthy patientASA II: A patient with mild systemic disease or significant health risk factorASA III: A patient with severe systemic disease that is not incapacitatingASA IV: A patient with severe systemic disease that is a constant threat to lifeASA V: A moribund patient who is not expected to survive without the operationASA VI: A declared brain dead patient whose organs are being removed for donor purposes.

Once the ASA physical status class has been determined, thedentist can then decide wither this patient can be safely treatedin the dental office

If the patient was not ASA I, or II:

1. Modifying routine treatment plans by anxiety-control techniques, more careful monitoring during treatment, or both

2. Obtain medical consultation for guidance in preparing patient for surgery (patient position)

3. Refuse to treat patient in an ambulatory setting4. Referring the patient to an oral and maxillofacial surgeon

Thank You

Reference: Contemporary Oral and Maxillofacial Surgery James R. Hupp, Edward Ellis III, Myron R. Tucker, 5th

EditionChapter 1 (page 3-9)