Ministry of Health of Ukraine Danylo llalytsky Lviv National Medical University Department of Surgical Dentistry and Maxillofacial Surgery

Methodical Guide for Practical Training in Surgical Dentistry for the 3-th year Students of the Dentistry Faculty according to the European Credit Transger System ( Module II) ( compiled on the basis of educational plan sample of 2011 )

Lviv- 2014 Methodigical guide was approved at the meeting of the Methodical Commision of Dentistry of the Danylo Halytsky Lviv National Medical University ( proceedings No ).

Methodigical guide has been compiled by: Ya.E. Vares, Professor of the Department of Surgical Dentistry and Maxillofacial Surgery, N.M. Krupnyk, Associate Professor of the Department of Surgical Dentistry and Maxillofacial Surgery, Yu.O.Medvid, Assistant Professor, PhD, M.D. Kh. R. Pohranychna, Assistant Professor, PhD, M.D. A. V. Filipskiy, Assistant Professor, PhD, M.D.

Reviewers: O.S.Isayeva, Associate Professor of the Department of Foreign Languages of Danylo Halytsky Lviv National Medical University O. R. Ripetska, Associate Professor of the Department of Therapeutic Dentistry of Danylo Halytsky Lviv National Medical University O. Ya. Matviychuk, Associate Professor of the Department of Prosthetic Dentistry of Danylo Halytsky Lviv National Medical University

Responsible for the publication: Head of the Department of Surgical Dentistry and Maxillofacial Surgery, Professor Ya. E. Vares. Introduction

The main task of the Departments of Surgical Dentistry and Maxillofacial Surgery cal educational establishments of the III - IV levels of accreditation in the process of training the future doctors - dentists their mastering the bases of theory and practice in all divisions of surgical dentistry and maxillofacial surgery. Organization of the academic work for the 3-d year students of Dentistry Faculty is conducted with due regards for the credit-module system in accordance with the requirements of the Bologna process . The basic knowledge level of students who study at the Department should also include the profound knowledge of anatomy, histology, physiology, pathological anatomy, microbiology, pharmacology, general surgery, propedeutics of internal diseases. They must have special training at the departments of general-medical and general-clinical profile as well as propedeutics of surgical dentistry. Considerable attention given to providing the students with cducational-and-methodical Reference. For this purpose the professorial-and-teaching staff of the Department of Surgical Dentistry and Maxillofacial surgery of Danylo Iiaiytsky LNMU has compiled the methodical guide for students in their preparation to practical classes in surgical dentistry ( part " Inflammatory processes of maxillofacial area"(Module - 3). It will help the students to focus their attention on obligatory questions, pertaining to every theme of practical classes that they are to study , it wile allow them to be well-orientated in the structure and content of situation- oriented tasks which will be offered for the written inquiry. We hope that it will encourage the students-dentists to prepare thoroughly for their final module control.

1 Reference structure of test credit

Independent Individual Practical Theme Lecture student’s independent classes work student’s work

Module II. Inflammatory Processes o f Maxillofacial area Theme 1 Inflammatory processes of the 2 3,5 3 2 maxillofacial area: etiology, pathogenesis, types ol clinical reactions, paculiarities of odontogenic infections. The role of the immune, endocrine, reticulo-endothelial systems. Classification. Theme 2. Diseases of the teeth erruption. 3,5 Retention and dystopiya of the teeth. Perecoronaritis: clinical signs, diagnoses, treatment, complications. Theme 3. Periodontitis. Classification. Acute 3,5 2 periodontitis: clinical signs, diagnoses, surgical treatment, methods of prevention. Chronic periodontitis: classification, clinical signs, diagnoses, surgical treatment, methods of prevention. Odontogenic granuloma of the face: clinical signs, diagnoses, treatment. Theme 4. Odontogenic periostitis of the jaws (acute and chronic): clinical signs, diagnoses, - 3,5 - • treatment, complications, physiotherapy Theme 5. Acute odontogenic osteomyelitis of the jaws: etiology, pathogenesis, classification. Modem theories of its origin Acute and subacute odontogenic osteomyelitis of the jaws: clinical 2 3,5 - - flow, diagnoses, methods of treatment anc prevention. Complications Theme №6. Chronic odontogenic osteomyelitis 3,5 of the jaws: classification, clinical signs, diagnoses, methods of treatment. Features of osteomyelitis course in patients with drug dependence.

Theme №7. Acute and chronic odontogenic 2 3,5 2 sinusitis: etiology, pathogenesis, classification clinical signs, diagnoses, methods of treatment, complications. Plastic closure of oro-antral communication Theme №8. Odontogenic phlegmons and abscesses 2 3,5 2 of the maxillofacial area: etiology, pathogenesis, classification, clinical flow, diagnoses, treatment, complications Phlegmons ofsuperfical and deep fascial spaces: differences in their clinical manifestations

2 Theme №9. Lymphadenitis, adenophlegmons ofthe 3,5 3 maxillofacial area: etiology, pathogenesis, diagnoses, clinical signs, treatment, preventive methods. Inflammatory cellulitis of the maxillofacial area Theme №10. Palatal abscesses Phlegmons and 3,5 2 abscesses of infraorbital, zygomatic and buccal areas. Clinical signs, methods of treatment. Complications and their prevention Theme №11. Phlegmons and abscesses of 3,5 pterygopalatine and subtemporal fossa Clinical signs, methods of treatment. Complications and their prevention. Theme№12. Phlegmons and abscesses of the 3,5 temporal area: Clinical signs, methods of treatment. Complications and their prevention. Phlegmons of orbit: peculiarities of origin, clinical flow and surgical methods of treatment. Theme №13. Phlegmons and abscesses of buccal, 3,5 masseteric, pterygomandibular, retromandibular, parotide spaces. Clinical signs, methods and peculiarities of treatment Theme №14. Phlegmons and abscesses of 3,5 3 submental and submandimular spaces. Clinical signs, methods and peculiarities of treatment. Theme 15. Phlegmons and abscesses 3,5 parapharyngeal space: etiology, pathogenesis, clinical signs, diagnoses, methods of treatment. Theme 16. Phlegmons and abscesses of the tongue. 3,5 Abscesses of sublingual fascial spaces. Clinical signs, methods and peculiarities of treatment. Theme 17. Oral cavity bottom phlegmon. Zhansul - 3,5 Ludwig angina. Etiology, pathogenesis, clinical signs, methods of diagnostics and peculiarities of treatment. Possible complications. Theme 18. Uncommon infections of maxillofacial 2 3,5 3 area: actinomycosis , tuberculosis and candidosis. Clinical signs, diagnostic and treatment. HIV- infection/ AIDS. Manifistations in the maxillofacial area. Theme 19. Erysipelas ofthe face, nome. 3,5 3 haemodymamic necrosis Manifistations in the oral cavity. Etiology, pathogenesis, clinical signs, diagnoses, methods of treatment Theme 20. Furuncles and carbuncles of the face 3,5 2 etiology, pathogenesis, clinical signs, diagnoses methods of treatment, complications.

3 Theme 21.. Complications of the phlegmons associated 3,5 2 with the lower jaw: phlegmons of the neck, mediastinitis. Sepsis, infectious-toxic shock. Pathogenesis, clinical flow, diagnoses, treatment, prognosis. Theme 22. Complications of the phlegmons associated 2 3,5 3 with the upper jaw: sepsis, brain abscess, cavernous sinus thrombosis Theme 23. Artritis and artrosis of the tempo- 3,5 6 mandibular joint (TMf): classification, clinical sings, diagnostics, treatment, complications, prevention. Pain TMI dysfunction syndrome. Theme 24. Acute sialadenitis: etiology, 3,5 3 pathogenesis, classification, clinical signs, diagnoses treatment Theme 25. Chronic sialadenitis, etiology, 2 3,5 3 pathogenesis, classification, clinical signs, diagnostics, treatment. Sialosis. Necrotizing sialometaplasia. Sjogren's syndrome. Theme 26. Calculary sialoadenitis: etiology, 3,5 3 2 pathogenesis, clinical features, differential diagnostics, treatment, complications.

Modul control №2. “ 3,5

Total hours: 139,5 12 94,5 33 16 Credits ECTS- 5,05

Theme №1. Inflammatory processes of the maxillofacial area: etiology, pathogenesis, types of clinical reactions, paculiarities of odontogenic infections. The role of the immune, endocrine, reticulo-endothelial systems. Classification.

Actuality of the theme: The incidence, severity, morbidity, and mortality of odontogenic infections have declined dramatically over the past 60 years. Dentistry has made great progress in the prevention and early diagnostic of odontogenic infections. Oral and maxillofacial surgeons, have made great strides in managing and preventing mortality in severe odontogenic infections. These accomplishments, however, impose upon the oral and maxillofacial surgeon the obligation to remain intellectually prepared for the always unscheduled occurrence of severe odontogenic infections by keeping one’s knowledge of the relevant anatomy and surgery fresh, and by remaining abreast of current developments in the microbiology and antibiotic therapy of odontogenic infections in patients with inflammatory processes of maxillofacial Aim _To study the main classifications of inflammatory processes of maxillofacial area, the main etiological factors of inflammatory processes of MFA, pathogenesis theories. To learn the types of clinical reactions, clinical features and role of immune, endocrine and vascular systems in their development.

Basic knowledge level. 1. Pathogenic microorganisms: aerobic and anaerobic bacteria, bacteroides, fusobacterias 2. Specific and non-specific protective properties

4 3. Mechanism of allergic reactions. 4. Inflammation: mechanisms, phases, features. 5. Immune system. 6. Endocrine system. 7. Vascular system.

Test questions: 1. The role of microorganisms in inflammatory processes of MFA. 2. Odontogenic infection extension. 3. The modem classifications of inflammatory processes of MFA by: - etiology; - the phase of the disease; - the localization . 4. The types of reactions and features of inflammatory processes, clinical signs in MFA. 5. The role of the dynamic balance disturbance between macro- and microorganism in acute odontogenic inflammatory processes. 6. Odontogenic chronic sepsis.

The professional abilities and practical skills the student should to study during practical lesson. 1 To teach the methods of examination in patients with inflammatory processes of MFA 2. To acquire the methodology of aspiration biopsy of inflammatory focus for morphological research 3. Be able to differentiate acute and chronic inflammatory processes of MFA

Situation tasks. 1. What diseases are most often in clinic of Maxillofacial surgery? A. Tumors B. Tumor like processes C. Inflamatory D. Traumatic injures E. Cleft Lip and Palate 2. What bacterias are the agents of purulent inflammatory processes of maxillofacial areas? A. Aerobe, facultative, anaerobe B. Aerobe C. Facultative D. Aerobe and facultative E. Anaerobe 3. What microorganisms are more frequent cause the purulent inflammatory processes in lymphatic nodes ? A. Monoculture of streptococcus В Monoculture of staphylococcus C. Collibacillus D Protey E. Association of staphylococcus, streptococcus and collibacillus 4. What are the most reliable reason of organism allergization from data of maxillofacial surgery? A. Carious teeth, periodontitis, tonzilitis В Tonzilitis C. Stomatitis D Gingivities E. Inflamation focus of other localizations

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 141-144

5 Theme №2. The Diseases of the teeth erruption. Impaction and dystopiya of the teeth. Perecoronaritis: clinical signs, diagnosis, treatment, complications.

Actuality of the theme: The management of impacted teeth is a basic component of most oral and maxillofacial surgery practices. Although the majority of impacted teeth are third molars, any other tooth may be impacted. The usual care for impacted teeth is removal; however, the care for impacted teeth other than third molars may include exposure (with or without attachment of an orthodontic bracket), uprighting, transplantation, or removal.These teeth often pose challenges in treatment planning and surgical care. It is confirmed, that insufficient chewing loading on the maxilla and breathing through the mouth stipulate the jaw underdevelopment and corresponding abnormalities of teeth and jaws, particularly, the disorders of teeth eruption That is why a well-timed clinical and roentgenological diagnostics in such cases is very necessary and aimed to chose an adequate treatment plan in different clinical situations Aim._To study the main clinical signs of teeth uneruption, methods of diagnostics and surgical treatment of impacted teeth.

Basic knowledge level. 1. Anatomical and physiological structure of upper and lower jaw 2. Anatomical structure of the teeth. 3. Methodology of the extraction of different groups of teeth ( adequate anaesthesia, design of surgical instruments, patient’s and surgeon’s position, etc ) Test questions: 1. A definition of “uneruption” and “impaction” terms. 2. The main reasons of teeth uneruption. 3. Indications for removal of impacted teeth 4. Contraindications for removal of impacted teeth. 5. Classification systems of impacted teeth. 6. Methodology of impacted teeth extraction. 7. Postoperative patient management. 8. Pericoronaritis: clinical signs, diagnostic, treatment, complications.

Practical manipulations the student must to learn during practical lesson. 1. To work the patient inspection ( extraoral and intraoral) on phantom. 2. To work methodology of the upper and lower “ impaction ’’teeth extraction on a phantom. 3. The X-ray examination of the patients with impacted teeth 1. Assisting during operation of impacted tooth extraction

Situation tasks. 1. A 26-years-old man appealed with complaints about periodic pain in the area of a 38 tooth during 3 years. Objectively: A mouth opens in full. The 38 tooth is partly errupted with the distal tubers, the surrounding mucous is bloodshot, swelling, painful during palpation. On the panoramic x-ray the medial tubers of the 38 tooth touch the neck of the 37 tooth What method of treatment is the most optimal? A. Antiinflammatory therapy B. Extraction of the 37 tooth C. Atypical extraction of the 38 tooth D. Irrigation with anaesthetic solution E. Cutting off the mucosa above the 38 tooth

2. Tooth impaction is of: A. Delayed eruption terms normally prevailing permanent tooth. В Incomplete eruption of the tooth through the bone of the jaw or mucosa C. Improper position in the tooth row cut his teeth or abnormal location in the jaw

6 3. Dystopia - is: A. Delayed eruption terms normally prevailing permanent tooth. B. Incomplete eruption of the tooth through the bone of the jaw or mucosa. C. Improper position in the dentition or abnormal tooth cut its location in the jaw

Litrature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 113-126

Theme №3. Periodontitis. Classification. Acute periodontitis: clinical signs, diagnoses, surgical treatment, methods of prevention. Chronic periodontitis: classification, clinical signs, diagnoses, surgical treatment, methods of prevention. Odontogenic granuloma of the face: clinical signs, diagnoses, treatment

Actuality of the theme: Mostly odontogenic infection affects the periapical tissues . The main cause of periapical inflammation is complicated caries. Distinct types of periodontitis: 1. Acute periodontitisf serous and purulent) 2. Chronic periodontitis: ( granulation, granulomatous, fibrous ) 3. Chronic periodontitis in exacerbation stage. Each clinical type characterized by a special clinical and X - Ray features. Periapical inflammation in most cases are the first steps of inflammatory processes of maxillofacial area: osteomyelitis of jaws, abscesses and phlegmons, sinusitis, etc. Aim. To learn the classification, etiology, clinical features, diagnostic methods and surgical treatment of periapical inflammatory processes and hypodermic face granuloma.

Basic knowledge level: 1. Anatomical structure of periapical tissues. 2. Ways of odontogenic infection extension. 3. Pathogenesis of acute and chronic periapical inflammation. 4. Modem schemas of periodontitis medicamentous treatment.

Test questions: 1. Periapical inflammation is: 2. Periapical inflammatory processes clasification. 3. Etiology, pathogenesis, clinical features of periodontitis. 4. X -R ay features of periapical inflammatory processes. 5. Methods of surgical treatment. 6. The main clinical features of hypodermic face granuloma. 7. Surgical treatment of hypodermic face granuloma.

The professional abilities and practical skills the student should to study during practical lesson. 1. Be able to diagnose a sharp and chronic periodontitis. 2. To reveal on X-rav the signs of chronic periodontitis. 3. To compile the plan of surgical treatment of the patients with periodontitis .

Situation tasks. 1. The patient of 42 years old appealed to the dental clinic with complaints about periodic pain in the area of a 36 tooth Painfull percussion of 36 tooth is educed during examination. After X-Ray examination a diagnose chronic granulomatous periodontitis of 36 tooth was set. Describe the roentgenologic picture of this disease. A Near the root apex an area of bone destruction , rounded form , with even limits. B. Near the root apex an area of bone destruction, rounded irregular-shaped , with unequal limits C. Duty of areas of narrowing and expansion of periodontitis crack. D. Even narrowing of periodontitis crack. E. Specific roentgenologic signs are absent

7 2. A patient 28 years old appealed to the dentist with complaints of carious cavity in 44 tooth. A deep carious cavity that is reported with a pulp chamber is educed in 44 tooth. Explorering of cavity is painless. Percusion of 44 tooth is painless. After a X-Ray examination a diagnosis is proposed: chronic fibrous periodontitis of 44 tooth. Describe the roentgenologic picture of this disease A. Duty of narrowing and expansion areas of periodontitis crack. B. Near the root apex an area of bone destruction , rounded form , with even limits. C. Near the root apex an area of bone destruction, rounded irregular-shaped , with unequal limits . D. Even narrowing of periodontitis crack. E. Specific roentgenologic signs are absent. 3. In a patient, 64 yers old, a chronic granulation periodontitis of 47 tooth . A tooth does not have a functional and aesthetic value. On skin in the area of projection of 47 root apex fistula with festering excretions was diagnose. What should be the patient’s treatment? A. Tooth extraction, carving of scar on a skin after fistula scarring . B. Tooth extraction. C Tooth treatment. D. Tooth extraction and fistula carving with the next inseaming of wound on face.

Litrature: Oral and Maxillofacial Surgery - Edited by Prof. V. Malanchuk, 2011,- P 144-151

Theme № 4. Odontogenic periostitis of the jaws (acute and chronic): clinical signs, diagnoses, treatment, complications, physical therapy treatment.

Actuality of the theme: Odontogenic periostitis is a serious problem in dentistry and maxillofacial surgery. In recent years in maxillofacial hospitals marked increase in the number of patients with this pathology . There is a tendency to heavy flow periostitis of jaws. Acute odontogenic jaw periostitis often leads to dangerous inflammatory complications such as MFA and neck abscesses and phlegmon, osteomyelitis mediastenit, etc.

Aim: to teach students the classification, etiology, pathogenesis, clinical signs , diagnosis and treatment of periostitis of the upper and lower jaws . Develop clinical thinking .

Basic knowledge level: 1. Opportunistic and pathogenic microorganisms . 2. Ways of pathogenic microorganisms spreading - into the tooth cavity, periodont, bone tissues of jaws and surrounding tissues. 3. Specific and nonspecific resistance factors . 4. The mechanism of allergic reactions. 5. Inflammation : the mechanism of, phase characteristics. 6. Principles of anti inflammatory and antibionic therapy

Test questions: I Microorganisms that causes inflammatory processes in maxillofacial area 2. Pathophysiologic characteristic of inflammatory processes of maxillofacial area bones 3. Types of reactions and clinical course of inflammatory diseases of the maxillofacial area 4. The etiology and pathogenesis, classification jaw abscess . 5 Clinical signs of acute jaw periostitis 6. Diagnosis of acute jaw periostitis 7. Decide on the setting of care: treat surgically or support medically. 8. Principles of surgical treatment of acute jaw periostitis. 9 Choose and prescribe antibiotic therapy 10 Prognosis and complication of acute jaw periostitis I I Chronic periostitis of jaws , classification, clinical features, treatment principles The professional abilities and practical skills the student should to study during practical lesson. 1. To teach the methods of examination in patients with acute and chronic jaw periostitis 2. Be able to diagnose an acute and chronic jaw periostitis. 3. To be able to differentiate the acute and chronic jaw periostitisfrom other inflammatory processes of MFA. 4 To compile the plan of surgical treatment of the patients acute jaw periostitis.

Situation tasks. 1. The most common cause of periostitis are: A. Soft tissues contusion B. Exacerbation of chronic sinusitis C. Exacerbation of chronic periodontitis D. Exacerbation of chronic pulpitis E. Tooth fracture 2. After the periosteum incision the drainage of the wound is carried out: A. On the 2 day B. On the 3 day C. On the 4 day D. After the incision E. After tooth treatment 3. A man , 35 years old , complaints about painful swelling in the left maxilla space. The body temperature is 37.5 C. There was 26 tooth ache two days ago . Then the swelling and pain in the left upper jaw were appeared Objectively: face asymmetiy by swelling in the left cheek and infraorbital spaces, swelling and yperemiah of the mucous membrane of the alveolar process and transitional fold within 25 - 27 teeth. The teeth are not mobility. During palpation on a transitional fold fluctuation appears Percussion of 26 tooth - slightly painful. The crown of 26 tooth is destroyed completely. Set the diagnosis: A. Acute odontogenic periostitis B Acute osteomielitis C. Acute periodontitis D. Acute sinusitis E. Odontogenic cyst 4. In men the subperiostal palate abscess was diagnosed. What is the most properly incision for abscess drainage ? A. Cut section of mueo- periosteum flap. B. Line parallel incision to the palate suture C. Line perpendicular incision to the palate suture D. Puncture of abscess E. extraction of causative tooth

Literature: Oral and Maxillofacial Surgery Edited by Prof. V. Malanchuk, 2011,- P. 151-155

Theme № 5. Acute odontogenic osteomyelitis of the jaws: etiology, pathogenesis, classification. Modern theories of its origin . Acute and subacute odontogenic osteomyelitis of the jaws: clinical flow, diagnoses, methods of treatment and prevention. Complications

Actuality of the theme: Patient with purulent and inflammatory processes of maxillofacial region make up a considerable percentage from the general amount of dental surgical patients There’s a tendency to growth. Among inflammatory diseases of maxillofacial region the frequency of odontogenic osteomyelitis of jaws is 15 - 33%. Despite usage of contemporary methods of treatment the probability of different complications is rather high. Among them the transmition of acute phase to chronic is the most frequent During osteomyelitis this occurs in 13-25% cases Diffuse chronic purulent-destructive process during osteomyelitis can cause long-term violation of jaws function and

9 considerable bone necrosis. In some cases after removal of large sequesters a big bone defects remain. This requires a plastic intervention, long-term hospital treatment of patients. Consequently, early detection, on time and effective treatment of patients with disease of periodont and parodont tissues and it’s complications with the aim of prophylactic of acute odontogenic osteomyelitis are very important. Aim: To consider the concept of "odontogenic osteomyelitis of jaws", it’s classification, pathogenesis, pathomorphology, clinic, diagnostic and treatment.

Basic knowledge level:

1. What is virulence of microorganisms and it’s pathogenicity. 2. Anatomical and physiological peculiarities of maxillofacial area: a/ anatomy of maxilla and mandible, histology of bone tissues, b/ innervation and vascularization of aforementioned areas, c/ anatomy of head and neck lymphatic system; d/ lymph outflow from upper and lower teeth. 3. Factors of oral cavity resistency. (specific and nonspecific). 4. Mechanism of allergic reaction: what is allergen, antibody, sensibilisation. 5. What are the types of allergic reactions? Phases . 6. Clinical manifestation of allergy. 7. Etiology of inflammation. 8. Mechanism of inflammation, phases. 9. Pathomorfologic clinical manifestations of chronic inflammation. 10. What are the infection that can induce inflammatory process in maxillofacial area bones. 11. Which microorganisms can caused the purulent inflammatory processes of maxillofacial area? 12. What are the ways of odontogenic infection spreading in jaws? 13. Definition of inflammatory infiltrate (cellulitis), lymphadenitis, furuncle, anthrax, abscess, phlegmon, periodontitis, periostitis, osteomyelitis, maxillary sinusitis, sialoadenitis. 14. Contemporary classifications of inflammatory processes of maxillofacial region.

Test questions: What is osteomyelitis? 1. Ostemielitis theories. 2. Etiology of acute osteomyelitis of jaws. 3. Spreading ways of odontogenic infection in jaws. 4. Pathogenesis of osteomyelitis process. 5. Pathomorphological changes in bone tissue during osteomielitis. 6. Classification of chronic odontogenic osteomyelitis of jaws. 7. Clinical symptoms of acute odontogenic osteomyelitis of jaws. 8. Peculiarities of acute odontogenic osteomyelitis of maxilla. 9. Peculiarities of acute odontogenic osteomyelitis of mandible. 10. Blood and urine analyzes during acute odontogenic osteomyelitis of jaws. 11. Differential diagnosis of acute odontogenic osteomyelitis of jaws with acute periodontitis and periostitis. 12. Surgical methods of acute odontogenic osteomyelitis of jaws treatment 13. Indications for causal tooth removal. 14. Which stages does the operation of periostotomy and intraosseous lavage consist of? 15. General ethiotropic, pathogenetic, symptomatictreatment of acute osteomielitis. 16. Complications of acute osteomielitis, thei prevention

The professional abilities and practical skills the student should to study during practical lesson. 1 To teach the methods of examination in patients with acute osteomielitis 2 Be able to reveal the clinical signs of acute osteomielitis 3. To be able to differentiate the acute osteomielitis from other pathological processes.

10 4 Be able to reveal the special clinical symptoms of this disease. 6. To be able to reveal the results of blood, urine analysis, thermometry and other additional methods. 7. To compile the plan of complex treatment of the patients with acute odontogenic osteomyelitis of jaws. 8 To select the correct methods of anaesthesia . To define ways of mucous incision for periostotomy and intraosseous lavage 9. To able to reveal the general and local complications of acute osteomyelitis of jaws.

Situation tasks. 1. To the diagnosis of “acute odontogenic osteomyelitis of mandible” we don’t need to provide following: A. Blood analysis on ESR and leukocytes. B. Radiological assessment. C. Determination of C- reactive protein. D. EOD E. Body temperature measurement. 2. Patient, 42 years old, entered the maxillofacial surgery department with complaints on acute pain in the area of mandible, teeth mobility, high body temperature. Patient was feeling ill during two days. After clinical examination surgeon defined the diagnosis: acute osteomyelitis of mandible. What should be the tactic of doctor concerning movable teeth? A. Removal only casual tooth. B Removal of all movable teeth. C. Conservative treatment of movable tooth. D. Conservative treatment of all movable teeth. E. Extraction of casual tooth, trepanation and treatment of all movable teeth. 3. Child, 16 years old complaints on strong pain in the area of right mandible, increased body temperature to 39°C, general weakness. Objectively: asymmetrical face because of edema of right mandible region, regional lymphadenitis, complicated mouth opening and unpleasant scent from oral cavity. While intraoral examination: 46 tooth is destroyed, was painful before, but patient didn’t visit the doctor. Percussion is sharply painful, there’s mobility present. In the area of 44, 45, 46 and 47 teeth - hyperemic mucous, edematous both sides of alveolar process. What is the most probable diagnosis? A. Acute purulent periostitis. B. Chronic periodontitis from tooth # 46 in the stage of aggravation. C. Chronic osteomyelitis of mandible. D. Acute odontogenic osteomyelitis of mandible. E. Submandibular phlegmon. 4. 39 years old patient has had a bad general state since three days when the 47tooth was extracted. The patient is pale, body temperature is 38,1°C, mandible from the left is both sides thikness, adjacent soft tissues are swollen, complicated opening of the mouth is revealed. Buccal fold in the area of 48, 47, 46 teeth is swollen, mucous is hyperemic, from the socket of 47 tooth comes a purulent content. The percussion of the 48,46,45 teeth is painful. In the area of lower lip paresthesia is revealed. What is the most probable diagnosis? A. Acute osteomyelitis of alveolar process. B Phlegmon of submandibular triangle. C Acute osteomyelitis of corpus of mandible D Acute periostitis of alveolar process E. Acute periostitis of corpus of mandible. 5. 39 years old patient has had a bad general condition after extraction of the 47 tooth three days ago. Patient is pale, body temperature is 38,l°C, left mandible is thickened from both sides, soft tissues are swollen, complicated mouth opening is observed There’s a paresthesia in the area of lower lip What symptom was diagnosed? A Kemig’s symptom. B Dyupyuitren’s symptom. C Ravich-Shcherba’s symptom.

11 D. Vensan’s symptom. E. Bella’s symptom.

Literature: Oral and Maxillofacial Surgery Edited by Prof. V. Malanchuk, 2011.- P. 155-163

Theme №6. Chronic Odontogenic Osteomyelities of the Jaws. Classification. Clinics and Diagnostic.

Actuality of the theme: Because of incorrect management of acute odontogenic osteomyelitis the prognosis becomes poor. Owing to it. considerable bone destruction with the leading sequestration of the involved area is to be anticipated. This condition may cause pathologic fracture of the mandible, non-union (false joint) formation, jaws deformation, temporomandibular joint dysfunction and ankylosis. These complications need prolonged full-time department treatmen and usually cause invalidity.

Aim: to study the main clinical diagnostic principles of chronic odontogenic osteomyelitis of the jaws. Teach students to compose treatment plan in patients with chronic odontogenic osteomielitis.

Basic knowledge level: 1. Anatomical and physiological peculiarities of maxillofacial area: a/ anatomy of maxilla and mandible, histology of bone tissues, b/ innervation and vascularization of aforementioned areas, d anatomy of head and neck lymphatic system; d/ lymph outflow from upper and lower teeth. 2. Pathophysiologic characteristic of inflammatory processes of maxillofacial area bones. 4. Ways of pathogenic microorganisms spreading - into the tooth cavity, periodont, bone tissues of jaws and surrounding tissues. 5. Factors of oral cavity resistency. (specific and nonspecific).

Test questions: 1. Mechanism of allergic reaction: what is allergen, antibody, sensibilisation. 2. What are the types of allergic reactions? Phases 4. Clinical manifestation of allergy. 5. Etiology of inflammation. 6. Mechanism of inflammation, phases. 8. Pathomorfologic clinical manifestations of chronic inflammation. 9. General and local changes in organism in patients with chronic osteomielitis. 10. General and local complication during chronic inflammatory process. 11. What are the ways of odontogenic infection spreading in jaws? 12. What is odontogenic osteomyelitis of jaws? (in clinical and morphological aspects). 13. Causes of development and mechanisms of acute odontogenic osteomyelitis transition into chronic stage. 14. Clinical symptoms of chronic odontogenic osteomyelitis of jaws. 15. Peculiarities of chronic odontogenic osteomyelitis of maxilla. 16. Peculiarities of chronic odontogenic osteomyelitis of mandible. 17. Specificity of chronic osteomyelitis flow in children and elderly persons 18. Contemporary methods of diagnostic used to reveal chronic osteomyelitis. 19 What additional diagnostics methods are revealed in patients with chronic osteomielitis of jaws? 20. Blood and urine analyzes changes in patients with chronic odontogenic osteomyelitis of jaws 21. Differential diagnosis of chronic odontogenic osteomyelitis of jaws.

The professional abilities and practical skills the student should to study during practical lesson. 1 To master the technique of examination of patients with the chronic odontogenic

12 osteomyelitis of jaws (asymmetry of the face, skin changes above inflammatory infiltrate - fistulas, scars). 2. To master the technique of palpation of jaw bones, revealing thickening of periosteum, movement of intact teeth . 3. To master the technique of fistulas probe 4. To select the additional methods of research and interpret them correctly. 5. Be able to reveal the characteristic clinical symptoms of chronic odontogenic osteomyelitis of jaws. 6. To compile the plan of complex treatment of patients with the chronic odontogenic osteomyelitis of jaws. 7. Be able to assist during surgical treatment of chronic osteomyelitis of jaws.

Situation tasks: 1. Patient, 44 years old, has a chronic odontogenic osteomyelitis of mandible from 47 tooth. There was revealed a naked rough movable area of bone while probing of the fistula. Radiographically - area of destruction in the middle of which - 1 x 1,5 cm shadow, separated from healthy bone tissue. What is the method of patient’s treatment? A. Antibiotic. B. Stimulation. C. Sanitation. D. Sequestrectomy of mandible. E. Sequestrectomy with tooth 47 removal. 2. 39 year old patient has movable 44, 46, 47 teeth. Pus discharge were revealed from alveolar socket of removal 45 toott and from buccal fold incision that were provided two months ago. There’s a dense, slightly painless infiltrate in the right buccal area and enlarged submanidular lymphatic nodes. There’s a bluish, pasty, mucous adjacent to the 44, 46,47 teeth. There’s a fistula with granulation and purulent discharges on buccal fold near extracted 45 tooth. What is the most probable diagnosis? A. Chronic localized osteomyelitis . B. Localized osteomyelitis because of the 45 tooth. C. Hyperplastic chronic osteomyelitis. D. Chronic mandible periostitis because of the 45 tooth. E. Chronic alveolitis. 3. 35-year-old patient has movable 38, 37, 36 teeth and fistula in the area of removed 35 tooth . All these signs are proceeding for 3 months. Naked, rough, movable bone is revealed while probing. Radiologically - area of 0,5x3 cm bone destruction. What is the diagnosis? A. Actinomycosis of mandible. B. Acute osteomyelitis of mandible . C. Aggravation of chronic osteomyelitis. D. Chronic periostitis of mandible E. Chronic osteomyelitis of mandible . 4. Patient, 43 years, has a fistula with pus on the mucosa mandibular alveolar process. There is revealed an inflammatory swelling of lower part of right cheek and submandibular area There’s a fracture line between 45 and 46 teeth where shadows of sequesters of different sizes are revealed Set a correct diagnosis A. Chronic posttraumatic osteomyelitis of mandible. B. Abscess of submandibular area. C. Acute posttraumatic osteomyelitis of mandible D Bone wound purulence E. Chronic odontogenic osteomyelitis of mandible. 5 Patient has a posttraumatic osteomyelitis of mandible in the region of the 46 tooth Injury took place 1,5 months ago There’s a shadow of sequester in the line of fracture and fistula with purulent discharge on the skin What is the management of the patient? A. There’s no need in treatment. B. Excision of the fistula, scquestrectomia, antibiotic therapy. C Osteosynthesis of mandible, local enzyme therapy

13 D. Physiotherapy. E. Excision of the fistula, antibiotic therapy.

Literature:Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P. 163-172.

Theme№ 7. Acute and chronic odontogenic sinusitis: etiology, pathogenesis, classification, clinical signs, diagnoses, methods of treatment, complications. Plastic closure of oro-antral communication.

Actuality of the theme: In the clinical practice of dental surgeon during operation of upper premolars and molars removal occurs perforation of maxillary sinus, which should be fixed. Dental surgeon should know clinical manifestations of odontogenic maxillary sinusitis, provide qualified aid for such a patients.

Aim: On the basis of knowledge of anatomy, physiology, propaedeutic of surgical dentistry study the main clinical signs of odontogenic maxillary sinusitis, diagnostic methods and treatment.

Basic knowledge level: I Anatomy and Physiology of the Nose and Paranasal Sinuses. 2. Methods of the clinical examination of patient's with maxillary sinusitis. 3. Additional methods of maxillary sinusitis diagnostic. Roles of Endoscopy and CT.

Test questions: 1. Maxillary sinus anatomy. 2. Odontogenic maxillary sinusitis etiology and pathogenesis. 3. Maxillary sinusitis classification. 4. Acute odontogenic maxillary sinusitis clinic, diagnostic and treatment. 5. Chronic odontogenic maxillary sinusitis clinic, diagnostic and treatment. 6. The principle of odontogenic sinusitis therapy ( antibiotic selection) 7. Indications for maxillary sinusitis surgical treatment. 8. Frontal sinus trephination surgery . The Caldwell-Luc operation 9. Complications of odontogenic maxillary sinusitis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To teach the methods of examination in patients with odontogenic maxillary sinusitis 2. To be able to differentiate odontogenic and not odontogenic maxillary sinusitis. 3. To reveal on X-rays the signs of odontogenic maxillary sinusitis. 4 To be able to differentiate the maxillary odontogenic sinusitis from other pathological processes of MFA. 5. To compile the plan of treatment of the patients with odontogenic maxillary sinusitis

Situation tasks: 1. Dental surgeon after extraction of the 26 tooth noticed air bubbles allocated from alveolar socket. A slightly bleeding appeared from left nostril Patient couldn’t inflate his cheeks. On X-Ray - maxillary sinuses are without any changes. What is the optimal method of treatment? A. Antrostomy plasty. B. Pressing the edge of the socket. C. Tamponade of socket with the haemostatic sponge. D. Production of protective plate. E. Antibiotic therapy. 2. An operation of antrostomy plasty is planned. Which of surgical methods is the most usually used? A. Plasty by the trapezoid muco-periosteal flap from the vestibular site of alveolar process B. Plasty by the tongue-like flap from the palate.

14 C Plasty by the tongue-like flap from buccal fold. D. Bridge - like flap plasty bythe muco-periosteal flap from a distal part of alveolar process. E. Tamponade by the iodoform gauze. 3. Patient K., 29 years old, entered to a clinic of oral surgery with complaints on periodic feeling of difficulty in the head, catarrh and efficiency violation. Objectively: fistula in the area of the extracted two months ago 25lh tooth . On X-Ray - a polyp in the maxillary sinus . Which of the surgical methods treatment should be used in this case? A. Caldwel-Luke operation. B. Plasty by the trapezoid muco-periosteal flap. C. Plasty by the tongue-like flap from the palate 1. D. Tamponade by the iodoform gauze.. E. Antibiotic therapy. 4. After hypothermia patient K ., 34 years old, complaints on headache in the left forehead area, under left eye and under left cheek. Objectively: face asymmetry , complicated breath through left nostril, slight pain during pressure on the left suborbital area. Painful palpation of the transitional fold near 24,25 teeth. Percussion of 24th and 25lh teeth is painful. There’s a filling in the 2 4 111 tooth. On X-Ray - reduction of maxillary sinus pneumatization. What is the diagnosis? A. Excebration of chronic periodontitis of the 24 tooth. B. Acute periodontitis of the 24 tooth. C. Excebration of chronic odontogenic maxillary sinusitis D. Acute localized osteomyelitis . E. Acute serous periostitis.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof V. Malanchuk, 2011,- P. 204-209.

Theme №8. Odontogenic phlegmons and abscesses of the maxillofacial area : etiology, pathogenesis, classification, clinical flow, diagnoses, treatment, complications. Phlegmons of superficial and deep spaces: differences in their clinical manifestations.

Actuality of the theme: abscesses and phlegmons is the most common pathology in the maxillofacial surgery. Among all inflammatory processes of MFA abscesses and phlegmons occupy 52,2 %. The incidence, severity, morbidity, and mortality of odontogenic infections have declined dramatically over the past 60 years. The knowledge of classifacation, etiology, pathogenesis, clinical signs and treatment of these inflammatory processes allows in-time diagnostic, correct management, conduct prevention’s work with patients and even prevent lethal consequences which sometimes arise because of late diagnostic and incorrect treatment methods . Three major factors must be considered in determining the severity' of an infection of the head and neck: anatomic location, rate of progression, and airway compromise.

Aim: to study classifacation, etiology, pathogenesis, clinical features, principles of surgical treatment of abscesses and phlegmons of MFA.

Basic knowledge level: 1 Borders of the Spaces of the Head and Neck 2. Pathogenesis of inflammatory processes 3 Relations of Spaces and Infection

Test questions: 1. Etiology and pathogenesis of abscesses and phlegmons of Head and Neck. 2. Pathogenesis of abscesses and phlegmons of MFA. 3. Ways of infection spreading. 4. Classifacation of abscesses and phlegmons of MFA 5. Clinical signs of MFA abscesses and phlegmons ( general and local).

15 6. Patient’clinical examination. 7. Additional examination methods . 8. The main principles of abscesses and phlegmons of MFA treatment. 9. Determine the severity of infection. 10. Indications of Choose and Prescribe of Antibiotic Therapy. 11. Timing of Abscesses and Phlegmons Incision and Drainage. 12. Incision placement for intraoral and extraoral drainage. 13. Complication of Odontogenic Abscesses and Phlegmons of MFA.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with Odontogenic Abscesses and Phlegmons of MFA. 2. Be able to reveal the characteristic clinical symptoms of Odontogenic Abscesses and Phlegmons of MFA. 3. Be able to choose the proper antibiotic therapy in patients with Odontogenic Abscesses and Phlegmons of MFA. 4. To select the additional examination methods and interpret them correctly. 5. To choose the proper incision placement depending to the Abscesses or Phlegmons space localization.

Situation tasks: 1. Patient, 50 years old , complaints on acute pain, hyperemia in the right infraorbital area, swelling of lower eyelid. Orbital opening is narrowed. Bad general condition, body temperature - 38,5 "C. An acute pain dense infiltrate, dense skin are revealed while palpation. Intraoral examination - mucus near the 13 tooth is edematous, hyperemic. The crown of the 13 tooth destroyed, percussion is painful. Set the diagnosis. A. Infraorbital phlegmon. B. Acute odontogenic osteomyelitis. C. Excebration of chronic periodontitis. D. Acute odontogenic maxillary sinusitis. E. Acute odontogenic periostitis. 2. Patient, 42 years old, complains on swelling, pain in submandibular space. These symptoms are enlarged while speaking and eating. There are general weakness and heightened body temperature up to 38,5’C . The 46 tooth was periodically painftil. The crown of the 46 tooth is destroyed, there’s a painful percusion. The skin above the swelling is hyperemic, dense. Set the diagnosis. A. Right submandibular phlegmon. B. Acute submandibular sialoadenitis in a right C. Acute purulent periostitis in a right. D. Acute osteomyelitis of mandible in a right. E. Acute submandibular lymphadenitis. 3. Patient entered department of dentistry with complaints on pain and swelling in submental area, limited mouth opening In anamnesis 31 tooth endodonticaly treatment. There’s an acute painful and dense infiltrate of submental area. The mucous is hyperemic, buccal fold is edematous. Set the diagnosis. A. Odontogenic phlegmon of submental space. B Acute purulent lymphadenitis of submental area C. Purulent dermoid cyst of submental area D. Odontogenic cyst of the bottom of the mouth. E. Furuncle of mental area. 4. Patient complains on pain during swallowing, speaking, limited mouth opening. Patient was treated because of 38 tooth complicated eruption . The treatment was not effective. The general state of the patient is bad. Objectively: symmetric face, pterygomandibular fold - hyperemic, dense, painful while palpation Palpation of mandibular angle is acute painful Set the diagnosis A. Odontogenic phlegmon of the left pterygomandibular space.

16 B. Odontogenic phlegmon of the submasseterical space. C. Odontogenic adenophlegmon of the left submandibular space. D Odontogenic phlegmon of left pharyngeal space. E. Acute periostitis of the mandible in a left.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P. 172-177.

ThcmeJV« 9. Lymphadenitis, adenophlegmon of the maxillofacial area: etiology, pathogenesis, diagnoses, clinical signs, treatment, preventive methods. Inflammatory cellulitis of the maxillofacial area.

Actuality of the theme: Lymphadenitis of maxillofacial region is widespread pathology in the department of surgical dentistry. As a physiological tissue drainage lymphatic nodes actively react on a wide spectrum of such an inflammatory diseases like furuncle, carbuncle, periostitis, periodontitis and so on . But not in time diagnosed lymphadenitis can lead to diffuse purulent inflammation of adjacent anatomical spaces of the face which can cause much more complicated treatment and rehabilitation of such a patients. Inflammatory cellulitis is the first stage of located and diffuse inflammation of soft tissues jaws. In-time diagnostic of lymphadenitis and its adequate therapy can prevent transformation of inflammatory cellulitis into stage of serous or purulent inflammation and can be limited only with therapeutic treatment.

Aim: To study the main diagnose features of lymphadenitis and inflammatory cellulitis of maxillofacial area. Learn principles of differential diagnostic of lymphadenitis and other inflammatory diseases of maxillofacial area Learn to make treatment plan of patient with lymphatic nodes inflamation. Surgical treatment methods of patients with purulent lymphadenitis of maxillofacial area

Basic knowledge level: 1 Anatomy of MFA lymphatic system. 2. Pathogenesis and clinical features of inflammation stages. 3. Principles of therapeutic treatment of inflammatory processes.

Test questions: 1. Etiology and pathogenesis of lymphadenitis and inflammatory infiltrate of maxillofacial region. 2. Ways of infection spreading in maxillofacial area. 3. Clinical examination and additional diagnostic methods in patient with lymphadenitis and inflammatory cellulitis of maxillofacial area. 4. Clinical examination and additional diagnostic methods in patient with adenophlegmon. 4. Diagnostic and differential diagnostic principles of lymphadenitis and inflammatory cellulitis of maxillofacial area. 5 Diagnostic , differential diagnostic and surgical treatment in patients with adenophlegmon 6 Indications to surgical and therapeutic treatment of lymphadenitis and inflammatory cellulitis. 7.Complications of lymphadenitis and adenophlegmon.

The professional abilities and practical skills the student should to study during practical lesson. 1 To master the technique of examination of patients with inflammatory diseases of lymphatic nodes of MFA. 2 Be able to reveal the characterized clinical symptoms of the inflammatory diseases of lymphatic nodes of MFA : lymphadenitis, inflammatory cellulitis, adenophlegmon 3. To select proper additional methods of research in patients with inflammatory diseases of lymphatic nodes of MFA interpret them correctly 4. To choose the plan of treatment of patients with the inflammatory diseases of lymphatic nodes of MFA : lymphadenitis, inflammatory cellulitis, adenophlegmon 5. Be able to choose the proper incision placement for adenophlegmon drainage

17 Situation tasks: 1. Patient M., 25 years old, entered oral surgery department with complaints on a high temperature, pain and swelling in the left submandibular area. Objectively: there’s a swelling in the left submandibular area, the skin above the swelling is hyperemic, edematous, symptoms of fluctuation is present. Set the diagnosis. A. Acute purulent lymphadenitis. B. Acute serous lymphadenitis. C. Chronic hyperplastic lymphadenitis. D. Abscesses of submandibular space E. Tuberculosis of lymphatic nodes. 2. Child, 5 years old, has a diagnosis of acute serous lymphadenitis. Choose the main clinical features of the disease: A. Lymphatic node is enlarged, dense, painful B. Pain in the area of lymphatic node. C. Hyperemic, tense skin. D. Fluctuation symptom E. Body temperature 38°C and higher. 3. Patient, 14 year old entered oral surgery department with diagnosis of acute purulent lymphadenitis of the right submandibular area. Dental surgeon provided an aspiration biopsy of the lymphatic node. Which will be the content of the exudate? A. Neutrophils, lymphocytes, monocytes, macrophages, eosinophil and plasmatic cells. B. Only lymphocytes. C. Only degenerative changed neutrophils. D. Monocytes, neutrophils, macrophages, eosinophil and plasmatic cells. E. Lymphocytes, macrophages and plasmatic cells. 4. Patient, 8 years old, complaints on painful swelling of the right auricular area, which appeared three days ago after purulent medium otitis. While examination^ right auricular area swelling and skin hyperemic. A rounded infiltrate with limited contours is palpated. The diameter of this infiltrate is approximately 3 sm, dense, painful, not connected with adjacent soft tissues. Oral cavity is health. Set the diagnosis. A. Acute purulent nonodontogenic lymphadenitis of the right auricular area. B. Acute serous nonodontogenic lymphadenitis of the right auricular area. C. Acute serous odontogenic lymphadenitis of the right auricular area. D. Acute nonepidemic patotitis. E. Acute epidemic parotitis.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P 195-201.

Theme № 10. Palatal abscesses. Phlegmons and abscesses of infraorbital, zygomatic and buccal areas. Clinical signs, methods of treatment. Complications and their prevention.

Actuality of the theme: Among the inflammatory processes of soft tissues of maxillofacial area those that deserve attention are phlegmons and abscesses of infraorbital and zygomatic regions. The amount of patients with such localisation abscesses and phlegmons for the last 20 years increased in almost 12%. The peculiarities of the maxillofacial area is rapid spread of inflammatory process by anatomical spaces, and appearance of cosmetic defects on face It results in severe complications, such as mediastinitis, sepsis, thrombosis of facial veins and sinuses

Aim: to study the etiology, pathogenesis of abscesses and phlegmons of infraorbital and zygomatic spaces, the palate abscesses: to teach the main clinical signs of abscesses and phlegmons of indicated anatomical spaces

18 Basic knowledge level: 1 Anatomy of the soft and hard palate. 2. Borders of zygomatic, infraorbital, buccal spaces. 3. Innervation and vascularisation of the soft and hard palate, zygomatic, infraorbital, buccal spaces. 4. Methods of soft and hard palate anaesthesing. 5. Methods of zygomatic, infraorbital, buccal spaces anaesthesing.

Test questions: 1. Likely causes of the palatal abscesses, zygomatic, infraorbital and buccal spaces abscesses and phlegmons. 2. The mam complaints in patients with palatal abscesses. 3. The main complaints in patients with zygomatic, infraorbital, buccal spaces abscesses and phlegmons 4. Clinical signs of palatal abscesses. 5. Clinical signs of zygomatic, infraorbital, buccal abscesses and phlegmons 6. Proper design of incision for palatal abscesses drainage. 7. Proper incisions for zygomatic, infraorbital, buccal abscesses and phlegmons drainage. 8. Post operative wound observation. 9. The proper antibiotic therapy in patients with palatal abscesses, zygomatic, infraorbital, buccal spaces abscesses and phlegmons. 10. Medical supportive care for the patient with the palatal abscesses, zygomatic, infraorbital, buccal abscesses and phlegmons. 11. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with palatal abscesse, zygomatic, infraorbital, buccal abscesses and phlegmons. 2. Be able to reveal the characterized clinical symptoms of the palatal abscesse, zygomatic, infraorbital, buccal abscesses and phlegmons. 3. To select proper additional methods of research in patients with palatal abscesse, zygomatic, infraorbital, buccal abscesses and phlegmons, interpret them correctly. 4. To choose the surgical treatment methods in patients with the palatal abscesse, zygomatic, infraorbital, buccal abscesses and phlegmons. 5. Be able to choose the proper incision placement for palatal abscesse, zygomatic, infraorbital, buccal abscesses and phlegmons, drainage.

Situation tasks: l. The most possible ways of the infection spread in patients with infraorbital phlegmon are: A. Cellular tissue of pterygopalatal fissure B. Cellular tissue of eye socket C. Cellular tissue of submasseteric space D. Cellular tissue of cheek and eye socket E. Cellular tissue of zygomatic region 2. What are the borders of infraorbital space? A. Anterior is the nasal cartilages, posterior- the buccal space, superior- the quadratus labii superioris m., inferior- oral mucosa, superficial - quadratus labii, deep- levator anguli oris m. B. Anterior - corner of mouth , posterior - masseter m . pterygomandibular space, superior - maxilla, infraorbital space . inferior - mandible, tissue and skin, superficial - subcutaneous, deep - buccinator m. C Anterior - buccal space, posterior - parotid gland, superior - zygomatic arch . inferior -inf. border of mandible, superficial - ascending ramus of mandible , deep - masseter m. 3. Likely cayses of infraorbital abscesses and phlegmons are. A. Maxillary incisors, canines, premolars

19 B. Maxillary incisors, canines, premolars and molars C. Premolars and molars of the upper jaw 3. Patient N. had a toothache of the 13 tooth for 3 days After upper lip and infraorbital space on the right swollen accompanied by pain. During clinical examination hyperemia and swelling of the upper lip, infraorbital space are marked. Swelling of the right eyelids. Intraoral examination: hyperemia and slight swelling of the transitional fold within 12, 13, 14, 15 teeth. Percussion of the tooth 13 is painful. What is the disease? A. Odontogenic infraorbital phlegmon on the right B Acute odontogenic maxillary periostitis on the right C. Buccal phlegmon on the right D. Zygomatic phlegmon on the right 4. A patient M. was diagnosed infraorbital odontogenic abscess on the right . Introral examination: the crown of the 12 tooth is destroyed to the gums. Percussion of the tooth is slightly painful. There is hyperemia and swelling of transitional fold in the within the 11, 12, 13 teeth. The X-ray revealed lateral root granuloma of the 12 tooth. What treatment should be used? A. Incision of the abscess and extraction of the tooth 12 B. Endodontic treatment of the tooth 12 with delayed root canal treatment C. Incision of the abscess, endodontic treatment of the tooth 12 with delayed root canal treatment D Incision of the abscess, endodontic treatment of the tooth 12 with momentary root canal treatment E. Incision of the abscess 5. Choose the correct incision to drainage the infraorbital abscess: A. Incision in the transitional fold within the maxillary incisors B. Incision parallel to the infraorbital edge

Literature:Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 172-177.

Theme № 11. Abscesses and phlegmons of the pterygopalatine and subtemporal fossa. Clinical signs, methods of treatment. Complications and their prevention.

Actuality of the theme: Clinical experience suggests that pyoinflammatory processes in the deep cellular tissue spaces adjacent to the maxilla often become a life-threatening condition for a patient. These processes include abscesses and phlegmons of infratemporal and pterygopalatine fossae. It is well known that pterygoid venous plexus is located in the infratemporal fossa. Infection spreading from pterygoid plexus to ophthalmic veins can lead to the phlegmon of the orbit, cavernous sinus thrombosis, meningitis Therefore, timely diagnosis, surgery and active post-operative therapy of abscesses and phlegmons of pterygopalatine and infratemporal fossae are crucial

Aim: To study etiology and main clinical manifestations of abscesses and phlegmons of subtemporal and pterygopalatine fossae, possible complications and their prevention; to be able to plan the complex treatment of abscesses and phlegmons of the given localization.

Basic knowledge level: 1. Borders of the subtemporal and pterygopalatine spaces. 2. Innervation and vascularisation of the subtemporal and pterygopalatine spaces. 3. Methods of subtemporal and pterygopalatine spaces anaesthesing 4 Stages of Intimation.

Test questions: 1 Likely causes of the subtemporal and pterygopalatine spaces abscesses and phlegmons 2. The main complaints in patients with subtemporal and pterygopalatine abscesses and phlegmons. 3. Clinical signs of subtemporal abscess and phlegmon 5. Clinical signs of pterygopalatine abscess and phlegmon 6 Proper design of incision for subtemporal abscess and phlegmon drainage

20 7. Proper incisions for pterygopalatine abscess and phlegmon drainage. 8. Post operative wound observation. 9. The proper antibiotic therapy in patients with subtemporal and pterygopalatine abscesses and phlegmons. 10. Medical supportive care for the patient with subtemporal and pterygopalatine abscesses and phlegmons. 11. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with subtemporal and pterygopalatine abscesses and phlegmons. 2. Be able to reveal the characterized clinical symptoms of the subtemporal and pterygopalatine abscesses and phlegmons. 3. To select proper additional methods of research in patients with subtemporal and pterygopalatine abscesses and phlegmons, interpret them correctly. 4. To choose the surgical treatment methods in patients with the subtemporal and pterygopalatine abscesses and phlegmons. 5. Be able to choose the proper incision placement for subtemporal and pterygopalatine abscesses and phlegmons, drainage

Situation tasks: 1. Likely causes of subtemporal and pterygopalatineabscesses are: A. Maxillary incisors and canines B. Maxillary premolars C. Maxillary molars D. Mandibular molars E. Nasolabial lymph node 2. What kind of anesthesia can caused the inflammation in the pterygopalatine fossa? A. Infraorbital B. Mandibular C. Incisal D. Posterior superior alveolar nerve block E. Infiltration in the area of maxillary incisors 3. Male, 45 years old, entered surgical dentistry department 5 days after the extraction of the 28 tooth. Tuberal and palatal anaesthesia were conducted for 28 tooth extraction . Complains of pain and swelling in the left buccal area, fever, limited moth opening Objectively: body temperature 38°C, the general condition is poor, slight asymmetry due to swelling of temporal and subparotid area. Contracture of the III degree. Intraoral examination - swelling of the mucous membrane in the transitional fold to the left wuthun maxillary molars Palpation over maxillary tuber is acute painful. What is the most likely diagnosis? A. Phlcgmon of the left subtemporal and pterygopalatine fossae B. Phlegmon of the left temporal region C. Acute suppurative maxillary periostitis on the left D. Phlegmon of the posterior region of the maxilla to the left E. Left maxillary acute osteomyelitis 4 Incision for pterygopalatine abscesses drainage is through the transitional fold within teeth: A. 18, 17,16 or 26, 27, 28 B. 46, 45, 44 or 34,35, 36 C 13, 12, 11 or 21, 22, 23 D 48, 47, 46 or 36, 37, 38 E. 43,42,41 or 33,32,31

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V Malanchuk, 2011- P 172-177.

21 Theme № 12. Phlegmons and abscesses of the temporal space: Clinical signs, methods of treatment. Complications and their prevention. Phlegmons of orbit: peculiarities of origin, clinical flow and surgical methods of treatment.

Actuality of the theme: If abscesses and phlegmons are localized in the temporal space infection can spread ascending to the orbit or through the foramina in the skull base bones into its cavity with subsequent complications: phlegmons of the orbit, thrombosis of cerebral sinuses, meningitis. These pathological conditions can be life-threatening Therefore, prompt detection of these diseases is crucial relying on knowledge of typical clinical symptoms. It is also important to be able to provide a comprehensive treatment that will prevent the complications.

Aim: To learn the basic clinical manifestations and diagnostic methods of temporal spaces abscesses and phlegmons, phlegmons of the orbit and retrobulbar spaces. To teach students to plan a comprehensive treatment of such pathologies.

Basic knowledge level: 1. Borders of the temporal and retrobulbar spaces 2. Innervation and vascularisation of the temporal and retrobulbar spaces. 3. Methods of temporal and retrobulbar spaces anaesthesing. 4. Stages of Intimation. 5. Role of pathogenic microorganisms in the development of inflammatory processes of the maxillofacial area.

Test questions: 1. Likely causes of the temporal and retrobulbar spaces abscesses and phlegmons. 2. The main complaints in patients with temporal retrobulbar spaces abscesses and phlegmons. 3. Clinical signs of temporal space abscess and phlegmon. 5. Clinical signs of retrobulbar space abscess and phlegmon. 6. Proper design of incision for temporal abscess and phlegmon drainage. 7. Proper incisions for retrobulbar abscess and phlegmon drainage. 8. Post operative wound observation. 9. The proper antibiotic therapy in patients with temporal and retrobulbar spaces abscesses and phlegmons. 10. Medical supportive care for the patient with temporal and retrobulbar spaces abscesses and phlegmons 11. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with temporal and retrobulbar spaces abscesses and phlegmons 2. Be able to reveal the characterized clinical symptoms of the temporal and retrobulbar spaces abscesses and phlegmons 3. To select proper additional methods of research in patients with temporal and retrobulbar spaces abscesses and phlegmons , interpret them correctly 4. To choose the surgical treatment methods in patients with the temporal and retrobulbar spaces abscesses and phlegmons 5. Be able to choose the proper incision placement for temporal and retrobulbar spaces abscesses and phlegmons drainage

Situation tasks: 1 44-year-old patient experiences pulsating pain in the eye, limited mouth opening, which is presumably connected with extraction of the 18 tooth He is sick for 5 days with body temperature of 38.7°C, swelling of eyelids, conjunctiva, the eyeball palpation is painful, its mobility is limited. What is the diagnosis?

22 A. Abscess of retrobulbar space. B. Infraorbital abscess. C. Abscess of subtemporal region. D. Phlegmon of subtemporal area. E. Acute odontogenic maxillary sinusitis. 2. Which incision is the most effective in case of the phlegmon of the orbit?: A. Along the bottom edge of the orbit. B. Near the lateral comer of the eye. C. Intraoral incision along the transitional fold. D. Near the inner comer of the orbit. E. Submandibular incision . 3. What kind of drainage should be used after incising the phlegmon during the first 2-3 days: A. Cotton gauze soaked in hypertonic solution of sodium chloride B. Rubber strips C. Smooth rubber tubes E. The wound does not need any drainage 4. Patient N., 36 years old with moderate severity of general condition and body temperature 38.5°C entered the oral surgery department Objectively: face asymmetry due to the soft tissue swelling in buccal, zygomatic and temporal spacess. Infiltrate looks like an hourglass in the side of zygomatic arch Palpation of infiltrate is painful and dence Limited mouth opening. What is the diagnosis? A. Phlegmon of the temporal space. B Phlegmon of the pterygomaxillary fossa. C. Phlegmon of the buccal space. D. Phlegmon of the zygomatic space. E. Phlegmon of the subtemporal space.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk. 2011- P. 172-177.

Theme №13. Phlegmons and abscesses of buccal, masseteric, pterygomandibular, retromandibular spaces. Clinical signs, methods and peculiarities of treatment.

Actuality of the theme: Among the inflammatory processes of soft tissues of maxillofacial area phlegmons and abscesses are most frequently encountered. The number of patients with such pathologies has increased by almost 16% for the past 20 years. One of the peculiarities of the maxillofacial area is rapid spread of inflammatory process by anatomical spaces. Phlegmons cause such severe complications as mediastinitis, sepsis, thrombosis of facial veins and sinuses of the brain.

Aim: To study etiology , anatomical localization and peculiarities of clinical signs of phlegmons in the buccal, masseteric, pterygomandibular and retromandibular spaces To learn the conduction of general and local examination of patients with phlegmons To survey some basic methods of conservative treatment and surgical approaches, sequence of postoperative management of patients. To learn the conduction of differential diagnostics of phlegmons with other inflammatory processes of maxillofacial area.

Basic knowledge level: 1. Borders of the buccal, masseteric, pterygomandibular and retromandibular spaces. 2. Innervation and vascularisation of the buccal, masseteric, pterygomandibular and retromandibular spaces. 3. Methods of the buccal, masseteric, pterygomandibular and retromandibular spaces anaesthesing 4 Stages of Inflmation 5. Role of pathogenic microorganisms in the development of inflammatory processes of the maxillofacial area.

23 Test questions: 1. Likely causes of the buccal, masseteric, pterygomandibular and retromandibular spaces abscesses and phlegmons. 2. The main complaints in patients with the buccal, masseteric, pterygomandibular and retromandibular spaces 3. Clinical signs of buccal abscess and phlegmon. 5. Clinical signs of masseteric abscess and phlegmon. 6. Clinical signs of pterygomandibular abscess and phlegmon 7. Clinical signs of retromandibular abscess and phlegmon. 8. Proper incision for buccal abscess and phlegmon drainage. 9. Proper incisions for masseteric abscess and phlegmon drainage 10. Proper incisions for pterygomandibular abscess and phlegmon drainage 11. Proper incisions for retromandibular abscess and phlegmon drainage 12. Post operative wound observation. 13. The proper antibiotic therapy in patients with temporal and retrobulbar spaces abscesses and phlegmons. 14. Medical supportive care for the patient with temporal and retrobulbar spaces abscesses and phlegmons 15. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with with buccal, masseteric, pterygomandibular and retromandibular abscesses and phlegmons. 2. Be able to reveal the characterized clinical symptoms of the with buccal, masseteric, pterygomandibular and retromandibular abscesses and phlegmons. 3. To select proper additional methods of research in patients with buccal, masseteric, pterygomandibular and retromandibular abscesses and phlegmons, interpret them correctly. 4. To choose the surgical treatment methods in patients with the buccal, masseteric, pterygomandibular and retromandibular abscesses and phlegmons. 5. Be able to choose the proper incision placement for buccal, masseteric, pterygomandibular and retromandibular abscesses and phlegmons drainage.

Situation tasks: 1. A patient with the masseteric phlegmon was admitted to the department of surgical dentistry. What incising placement should be conducted for phlegmon drainage? A. Intraoral incision along transitional fold. B. Midsection. C. Triangle incision D. Extraoral incision. E. Incision circumflexing the mandibular angle 2 Patient 26 years old complains of difficult mouth opening limited to 1cm, pain, weakness, general sickness, body temperature 38.0°C. Objectively: swelling in the mandibular angle space to the left, skin does not fold due to hyperemia with sharp painful palpation, limited mouth opening to 1cm. On the radiograph there is half-erupted wisdom tooth. What is the diagnosis? A. Phlegmon of maseteric space. B Buccal phlegmon. C. Submental phlegmon . D. Phlegmon of submandibular space E. Phlegmon of pterygomandibular space. 3 A man 40 years old entered a dentist with complains of a swelling in the left buccal area, throbbing pain, chilly sensation The examination revealed asymmetry of the face due to the swelling in the maxillary region to the left. Limited mouth opening to 1 5cm Pam radiates to the temporal space and eye. In oral examinations: 27 tooth is destroyed with hyperemic and tenderness of mucosa in the buccal area What is the correct diagnose?

24 A. Buccal phlegmon. B. Phlegmon of the temporal space. C. Phlegmon of subtemporal and pterygopalatine fossae. D. Phlegmon of the parapharyngeal space. E. Phlegmon of the pterygomandibular space. 4. A patient 33 years old complains of uncorrect feeling , pain in swallowing. Throat ache was appeared week ago. Objectively: the patient is pale with body temperature - 38.5°C. There is a slight swelling of soft tissues in the right retromandibular space. On palpation there is dense painful infiltration. Skin is tight and it does not fold. What is the most probably diagnose ? A. Odontogenic phlegmon of the retromandibular space. B. Sublingual fold abscesses. C. Odontogenic parapharyngeal space phlegmon. D. Peritonsillar abscess. E. Odontogenic pterygomandibular phlegmon. 5. What design of incision should be conducted for the retromandibular phlegmon drainage? A. Along the margin of the mandible ramus. B. Incision circumflexing the mandibule angle. C. Midsection. D. Horizontal incision 7-8cm long in the submandibular space 2cm lower than the edge of the mandible. E. Collar-type section.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P. 172-177.

Theme №14. Phlegmons and abscesses of submental and submandibular spaces. Clinical signs, methods and peculiarities of treatment.

Actuality of the theme: Among the inflammatory processes of soft tissues of maxillofacial area phlegmons and abscesses are most frequently encountered. The number of patients with such pathologies has increased by almost 16% for the past 20 years. One of the peculiarities of the maxillofacial area is rapid spread of inflammatory process by the anatomical spaces. Phlegmons cause such severe complications as mediastinitis, sepsis, thrombosis of facial veins and sinuses of the brain.

Aim: To teach students diagnostic techniques and treatment of phlegmons of submental and submandibular spaces. To practice surgical treatment of phlegmons and abscesses.

Basic knowledge level: 1 Borders of submental and submandibular spaces. 2. Innervation and vascularisation of the submandibular and submental spaces. 3. Methods of the submandibular and submental spaces anaesthesing 4. Stages of Intimation 5. Role of pathogenic microorganisms in the development of inflammatory processes of the maxillofacial area.

Test questions: 1. Likely causes of the submandibular and submental abscesses and phlegmons. 2. The main complaints in patients with the submandibular and submental abscesses and phlegmons spaces. 3 Clinical signs of submental abscess and phlegmon 5. Clinical signs of the submandibular abscess and phlegmon. 6 Proper incision for the submental abscess and phlegmon drainage. 7. Proper incisions for the submandibular abscess and phlegmon drainage. 8 Post operative wound observation.

25 9. The proper antibiotic therapy in patients with submental and submandibular abscesses and phlegmons. 10. Medical supportive care for the patient with submentall and submandibular abscesses and phlegmons 11. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with submental and submandibular abscesses and phlegmons. 2. Be able to reveal the characterized clinical symptoms of the submental and submandibular abscesses and phlegmons. 3. To select proper additional methods of research in patients with submental and submandibular abscesses and phlegmons, interpret them correctly. 4. To choose the surgical treatment methods in patients with the submental and submandibular abscesses and phlegmons 5. Be able to choose the proper incision placement for submental and submandibular abscesses and phlegmons drainage.

Situation tasks: 1. Patient 45 years old was admitted to the maxillofacial department complaining 37.6°C fever , swelling of soft tissues in the submental area. From the anamnesis: the 34 tooth was painful for five days. Objectively: face is disproportionate due to dense, painful infiltration in the submental space, skin does not fold due to hyperemia, it’s also painful and swollen, the fluctuation symptom is marked Limited mouth opening to 3cm; there is hyperemia and swelling of oral mucosa around 34 tooth. The crown of 34 tooth is destroyed on 2/3. What is the diagnosis A. Submental phlegmon. B .Submandibular phlegmon. C Phlegmon of the pterygopalatinum space. D. Sublingual fold abscess E. Acute suppurative periostitis of the jaw. 2. Patient E. 31 years old was admitted to the maxillofacial department diagnosed with odontogenic submandibular phlegmon on the left. There were no complications during the postoperative period When should we remove the drainage? A. On the 5th day. B. On the 3rd day. C. On the 6th day. D. On the 7th day. E. On the 8th day. 3. A female, 23 years old complains on a slight limitation of mouth opening, pain in the left submandibular space. The body temperature is 37.9°C. Objectively: asymmetry of the face, skin in the left submandibular space does not fold due to hyperemia. Palpation is painful, mouth opening is limited to 2 cm. Oral examination revealed edema and hyperemia of the mucosa in the area of the 36 tooth. What is the diagnosis? A Phlegmon of the submandibular space. B. Phlegmon of the submental space. C. Pterygomaxillary phlegmon D Sublingual fold abscess E. Abscess of the submandibular space 4. The diagnosis of submental phlegmon of the area. What type of incision should be conducted for phlegmon drainage? A. Intra-oral incision in the transitional fold in the region of the teeth 36-38. B. External incision of tissues under the mandibular angle along its edge. C External midsection of tissues. D Intra-oral incision in the internal surface of the mandible.

26 H. External incision of tissues along the mandibular edge 5. What is the most appropriate design of incision of submandibular phlegmon drainage? A. The horizontal 7-8cm long incision and 2cm from the mandibule edge. B. 5-6cm long incision circumflexing the mandibular angle C. Intraoral incision along the transitional fold at the level of molars. D. 5-6cm long incision along the upper cervical fold.

Literature: Oral and Maxillofacial Surgery Edited by Prof. V Malanchuk, 2011- P. 172-177.

Theme №15. Phlegmon and abscess of parapharyngeal space: etiology, pathogenesis, clinical signs, diagnoses, methods of treatment.

Actuality of the theme: inflammatory processes of the jaw bones may extend to adjacent soft tissues, with localization of pathological foci in the deep spaces of the face, particularly parapharyngeal and pterygomandibular. Severe clinical flow, the inadequacy of local manifestations of the general condition of patients with specified pathology promotes frequent development of complications that can lead to fatal consequences.

Aim: to learn basic principles of clinical manifestations and diagnosis of parapharyngeal phlegmon. To teach students to draft a comprehensive treatment of the disease

Basic knowledge level: 1 Borders of the parapharengeal space. 3. Indications for choosing the proper anaesthesia in patients with inflammatory processes of MFA. 4. Stages of Odontogenic Infection passing. 5. Role of pathogenic microorganisms in the development of inflammatory processes of the maxillofacial area

Test questions: 1. Likely causes of the parapharengeal abscess and phlegmon. 2. The main complaints in patients with the parapharengeal abscess and phlegmon. 3. Clinical signs of the parapharengeal abscess and phlegmon. 4. Proper incision for the parapharengeal abscess and phlegmon drainage. 5. Post operative wound observation. 6. The proper antibiotic therapy in patients with parapharengeal abscess and phlegmon . 7. Medical supportive care for the patient with parapharengeal abscess and phlegmon. 8. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1 To master the technique of examination of patients with parapharengeal abscess and phlegmon 2. Be able to reveal the characterized clinical symptoms of the parapharengeal abscess and phlegmon 3. To select proper additional methods of research in patients with parapharengeal abscess and phlegmon, interpret them correctly. 4. To choose the surgical treatment methods in patients with the parapharengeal abscess and phlegmon. 5. Be able to choose the proper incision placement for parapharengeal abscess and phlegmon drainage

Situation tasks: 1 A 36-years-old patient complains of painful and labored swallowing, malaise Body temperature - 38,5 0 C. Left submandibular space is swollen, painful during deep palpation, mouth opening is limited up to 2 cm, percussion of the 38 tooth is painful. The left lateral wall of the pharynx is swollen, hyperemic. Put diagnosis

27 A. Odontogenic parapharengial phlegmon B. Adenophlegmon of the submandibular area. C Paratonsilar sbscess D. Angina E. Submandibular lymphadenitis 2. A 42-years-old patientcomplains of health worsening, fever, complicated swallowing and breathing. The general condition of the patient is middle The body temperature -39° C. During examination, asymmetry of face due to the swelling of the soft tissue in the left submandibular area is revealed. The skin over the swelling is of normal color. The mouth opening is labored difficult. During the inspection of the oral cavity - redness, swelling of the palatal arches and tongue, protrusion of the left lateral wall of the pharynx to the middle line, and the tongue to te right. What is the most likely diagnosis: A. Phlegmon of the parapharengeal space. B. Phlegmon of the pterigomandibular space. C. Phlegmon of the submandibular space. D. Phlegmon of the ratromandibulasr spaces. E. Abscess of the mandibular-hyoid groove. 3. A 28-years-old patient appealed to the department of maxillofacial surgery where the diagnosis of odontogenic parapharengeal phlegmon was set. What treatment should be taken: A. Extraoral submandibular access. B. Collar incision. C. Puncture of the pharynx space, physiotherapy. D. Incision in the bottom of oral cavity. E. Incision in the tonsil space 4. Patients with diabetes mellitus type 1, 39-years-old, underwent operation of the parapharengeal phlegmon disclosure, then the patient's condition improved, but after 3 days the body temperature rose to 39 ° C, appeared difficult breathing, pain when swallowing and coughing. Symptoms became severe in the supine position. What complications can be suspected? A. Sepsis. B. Purulent thrombophlebitis of the angular vein. C. Phlegmon of the bottom of oral cavity. D. Thrombosis of the cavernous sinus. E. Mediastinitis. 5. A 51-year-old patient complains of the sickness, fever, complicated swallowing and eating. In the right submandibular area a slight painful swelling is revealed, mouth opening is limited to 0.5 cm, percussion of the 48 tooth is painful. Put diagnosis. A. Angina. B. Adenophlegmon of the submandibular area. C. Phlegnon of the pterygo-mandibular area. D Odontogenic parapharengial phlemone E. Submandibular lymphadenitis

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 172-177.

Theme № 16. Phlegmon and abscess of the tongue. Abscess of sublingual spaces. Clinical signs, methods and peculiarities of treatment

Actuality of the theme: anatomy of the tongue and surrounding tissues, blood and lymphatic vessels often lead to the infection spreading and to the development of diffuse purulent inflammation of the spaces that form the bottom of oral cavity. Phlegmons of such location are one of the most dangerous diseases often with terrible consequences

28 Aim: to learn the basic principles of clinical manifestations and diagnosis of sublingual groove abscesses, abscesses and phlegmon of the tongue. Teach the students to draft a comprehensive treatment of the disease.

Basic knowledge level: 1. Borders of the sublingual space. 2. Anatomy of the bottom of oral cavity. 3. Indications for choosing the proper anaesthesia in patients with tongue abscess and phlegmon and sublingual space 4. Stages of Odontogenic Infection passing. 5. Role of pathogenic microorganisms in the development of inflammatory processes of the maxillofacial area

Test questions: 1. Likely causes of the tongue abscess and phlegmon and sublingual abscess. 2. The main complaints in patients with the tongue abscess and phlegmon and sublingual abscess. 3. Clinical signs of the tongue abscess and phlegmon. 4. Clinical signs of the sublingual abscess. 5. Proper incision for the tongue abscess and phlegmon drainage. 6. Proper incision for the sublingual abscess drainage. 5. Post operative wound observation. 6. The proper antibiotic therapy in patients with tongue abscess and phlegmon and sublingual abscess. 7. Medical supportive care for the patient with tongue abscess and phlegmon and sublingual abscess. 8. Diseases prognosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with tongue abscess and phlegmon and sublingual abscess. 2. Be able to reveal the characterized clinical symptoms of the tongue abscess and phlegmon and sublingual abscess 3. To select proper additional methods of research in patients with tongue abscess and phlegmon and sublingual abscess, interpret them correctly. 4. To choose the surgical treatment methods in patients with the tongue abscess and phlegmon and sublingual abscess. 5. Be able to choose the proper incision placement for tongue abscess and phlegmon and sublingual abscess drainage.

Situation tasks: 1. A 62-years-old patient appealed to the dental surgeon complaining of severe constant, pulsated pain under the tongue to the left, with irradiation into the ear and temple, pain when chewing, complicated mouth opening, the overall poor condition. He considers himself sick for a week, since there was pain in the tooth on the lower jaw on the left. After 2 days the body temperature rose to 38.9 C.Objectively: crown of the 37 tooth is destroyed by 2/3, II degree of tooth mobility, percussion painless. In the area of the sublingual groove at the area of 36, 37 defined infiltration, mucous membrane over it hyperemic, edematous, palpation - fluctuations. Congestion of the mucous membrane covers the anterior part of the palatal brace. Formulate a clinical diagnosis. A. Abscess of the jaw-lingual groove on the left B Acute odontogenic abscess of the alveolar process of the mandible on the left C. Exacerbation of chronic periodontitis 37 D. Phlegmon of the pterygo-mandibular space on the left E. Abscess of the pterygo-mandibular space on the left 2 A 30-years-old patient, turned to the dentist complaining of excruciating pain in the tongue, swelling in the area of the chin. Clinically: The skin on the chin is not changed in color, makes a fold. Opening of mouth is free. Tongue is increased, dense, evenly marked swelling of tongue, palpation of the

29 midline painful. Choose the operating access? A. Incision in submental area on the midline in the direction of the chin to the hyoid bone. B. Incision in submental area, section parallel to the lower edge of the mandible. C. Dissection of the oral cavity in the middle projection of hyoid area. D. Incision in the lateral surface of the tongue. E. Incision in the submandibulars area, 1.5-2 cm from the edge of the mandible. 3. A 31-years-old patient, turned to the dentist complaining of excruciating pain in the tongue, sharply painful swallowing, swelling in the area of the chin. Clinically: the skin on the chin in color is not changed, going to fold. Mouth opening is free. Tongue is enlarged, dense, evenly marked swelling of tongue, palpation of the midline painful. Set the diagnosis? A. Abscess of the tongue B. Phlegmon of the bottom of oral cavity C. Abscess of the sublingual platen D. Phlegmon the chin space E. Abscess of the mandibular-lingual groove 4. In the maxillofacial clinic entered a 45-years-old patient in serious condition with complains of a sharp pain when swallowing and tongue movements. From history we know that 7 days ago 34 tooth become pain. Objectively: mouth halfopen, considerable salivation, mouth opening is limited. Tongue is enlerged, dry, covered with bloom. Mucosa in the sublingual area is hyperemic, edematous. Which disease characterized this clinical picture? A. Phlegmon of the submental area. B. Abscess of mandibular-lingual groove C. Phlegmon of a tongue. D. Phlegmon of the pterygomandibular space. E. Phlegmon of the bottom of oral cavity.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk. 2011,- P. 172-177.

Theme №17: Oral cavity bottom phlegmon. Zhansul - Ludwig angina. Etiology, pathogenesis, clinical signs, methods of diagnostics and peculiarities of treatment. Possible complications

Actuality of the theme: topographicand anatomy complexity locations of maxillofacial area , syntopic proximity of face and neck vital structures , a significant microbial contamination of the oral cavity causing rapid spread of inflammation pathological focus in the deep spaces of the face, especially on the bottom of the oral cavity. Multimicrobial spectrum of pathogens that are of high virulence and antibiotic resistance , causing especially severe putrid clinical course phlegmon of the bottom of the oral cavity - Zhansul - Ludwig necrotic angina, accompanied by severe endogenous body intoxication occurrence of complications such as inediastinitis, meningitis , thrombophlebitis , sepsis and so on.

Aim: to focus the students attention on the basic principles of clinical manifestations and diagnosis of the putrid phlegmon of the oral cavity bottom - Zhansul - Ludwig necrotic angina. To teach students to make up a complex treatment plan of the pathology.

Basic knowledge level: 1. The mandible anatomy and topography. 2. Vascularisation and innervation of head and neck 3. The role of pathogenic microorganisms in MFA inflamation determination. 4. Pathomorphology of inflammatory processes. 5 Modem antyinphlammatory pharmacology.

Test questions: 1. Etiology and pathogenesisof the putrid phlegmon of the oral cavity bottom - Zhansul - Ludwig necrotic angina

30 2. Ways of infection spreading in the oral cavity bottom 3. Clinical signs of Zhansul - Ludwig necrotic angina. 4. The main diagnostic and differential diagnostic of Zhansul - Ludwig necrotic angina. 5. The treatment of of Zhansul - Ludwig necrotic angina. 6 Complications of Zhansul - Ludwig necrotic angina and their prevention.

The professional abilities and practical skills the student should to study during practical lesson. 1 To master the technique of examination of patients with oral cavity bottom phlegmon. Zhansul - Ludwig angina.. 2. Be able to reveal the characterized clinical symptoms of the oral cavity bottom phlegmon. Zhansul - Ludwig angina. 3. To select proper additional methods of research in patients with oral cavity bottom phlegmon. Zhansul - Ludwig angina. 4. To choose the complex treatment methods in patients with the oral cavity bottom phlegmon. Zhansul - Ludwig angina. 5. To acquire the methodology of incision to drainage the inflammatory focus in patients with oral cavity bottom phlegmon. Zhansul - Ludwig angina.

Situation tasks: 1. In patient N., 56 years old severe general condition. Body temperature 39,9 ° C . Objectively: face asymetry because of submental and both submandibular spaces infiltration It is difficult speech because of tongue upward displacement, painful swallowing . Sublingual rolls considerably swollen, hyperemic . Set diagnosis: A. Submandibular phlegmon. B. Submental phlegmon. C. Tongue abscess D. Oral bottom phlegmon 2. What incision is most effective for oral bottom phlegmon drainage? A. Both side submandibular B. Collar zone incision. C. Intraoral incision. D Midline incision. E Submandibular incision. 3. 45 years old patient was delivered to the oral surgery clinic in severe condition with a diagnosis of cellulitis of the oral cavity bottom with the spread of purulent process in to the neck cellular spaces . The consciousness of the patient is unclear. Skin cyanotic. BP 70/40 mm Pulse 140 beats per minute. Breathing liquid , surface . What somatic condition develops in a patient ? A. Septic shock. B. Collaps. C Anaphylactic shock. D Quinck edema. E. Syncop 4 Patient B , 40 years old , sitting in a forced position with the head tilted back , his mouth half open Face is graish . In the submandibular , submental spaces and on the front of the neck tight painful infiltration, marked crepitus , skin over infiltrate purple spots. Set preliminary diagnosis ? A. Submandibular phlegmon B Tongue abscess. C. Zhansul - Ludwig necrotic angina D Submental phlegmon. E. Neck phlegmon. 5. The patient was hospitalized in the maxillofacial department with a diagnosis of odontogenic abscess of oral cavity bottom . The general condition of the patient is difficult, forced position in bed , sitting with his head tilted to the front He complains of chest pain that is worse when you try to tilt the head backward , cough, shortness of breath What complication has developed in this patient

31 A. Neck phlegmon. B. Parapharyngeal phlegmon. C. Mediastenit. D. Tongue abscess. E. Oral bottom phlegmon.

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 172-177.

Theme №18: Uncommon infections of maxillofacial area: actinomycosis , tuberculosis and candidosis. Clinical signs, diagnostic and treatment. HIV-infection. AIDS. Manifistations in the maxillofacial area.

Actuality of the theme: Actinomycosis - a chronic inflammation of the soft tissues and bones of the maxillofacial area that is caused by luminous fungi (actinomycetes). Different types of actinomycetes constantly exist as in a human oral cavity (especially in the plaque, caries cavities of the teeth, pathological gingival pockets), but also in the environment (ears com, various herbs). Patients with actinomycosis are 6-8% of all infections of the maxillofacial area. Tuberculosis - a chronic infection with the appearance of specific granules in tissues and polymorphic clinical picture. In 92% of cases it caused by Mycobacterium tuberculosis (tubercle bacillus). Predominantly affects the lungs, and then aerogenic lymphogenous or by contact may involve soft or hard tissue schld of the maxillofacial area. There is alimentary way of infection - drinking milk of cows sick with tuberculosis. Syphilis - a chronic infection caused by a pale treponema. Increasing number of sexually transmitted diseases in recent years determines the necessity of dentist knowledge in main clinical manifestations of syphilis in the mouth and the ability to perform differential diagnosis of this disease. AIDS - an infectious viral disease that is caused by multiplication in human cells lymphotropic retroviruses and the death of these cells, leading to loss of functionality of the immune system. The vims destroys T-helper cells, the patient is exposed to conditionally pathogenic microflora and once it becomes infected. AIDS is transmitted sexually, through medical instruments, blood products, from mother to child during pregnancy, childbirth, breastfeeding.

Aim: study the etiology, clinical symptoms of uncommon infections of the maxillofacial area and neck, to be able to use additional methods of examination for diagnosis; able to assign specific treatment of uncommon infections of the maxillofacial area and to distinguish these diseases.

Basic knowledge level: 1. Anatomical and physiological structure of the maxillofacial area 2. Microbiological properties of pathogens that cause uncommon infections of the maxillofacial area. 3. X-ray picture of uncommon infections of the maxillofacial area. 4. Current medicines that are used to treat these diseases.

Test questions: 1. Etiopathogenesis and classification of actinomycosis of the maxillofacial area 2. Ways of actinomycetes penetration into the maxillofacial area. 3. Clinical features in various forms of actinomycosis 4 Surgical treatment of actinomycosis. 5. Specific immunotherapy for actinomycosis. 6 Antibiotic therapy actinomycosis accompanying microflora. 7 X-Ray therapy of actinomycosis. 8 Consequences and complications of actinomycosis. 9. Etiopathogenesis of syphilis 10. Clinical features in primary, secondary and tertiary syphilis. 11. Differential diagnosis and principles of treatment of syphilis.

32 12. Etiopathogenesis of tuberculosis of the maxillofacial area. 13. The clinical signs of various forms of tuberculosis: - Tuberculous lymphadenitis; - Primary tuberculosis of the skin; - Tuberculous lupus; - Skrofuloderma; - Verrucous tuberculosis; - Miliary tuberculosis, ulcerative; - Dessiminated miliary tuberculosis of the face; -Papules and necrotic tuberculosis; - Tuberculosis of the salivary glands; - Tuberculosis of the jaws. 14. Differential diagnosis and principles of treatment of tuberculosis. 15. Complications and consequences of the disease. 16. Stages of HIV infection flow in humans. 17. Manifestations of AIDS in the maxillofacial area. 18. Current methods of HI V infection treatment. 19. Prevention of tuberculosis, actinomycosis, syphilis and AIDS in the maxillofacial area.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with uncommon infection of MFA. 2. Be able to reveal the characterized clinical symptoms of the uncommon infection of MFA. 3. To select proper additional methods of research in patients with uncommon infection of MFA, interpret them correctly. 4. To choose the complex treatment methods in patients with the uncommon infection of MFA. 5. To acquire the methodology of biopsy of inflammatory focus in patients with uncommon infection of MFA.

Situation tasks: 1 In a 40 years old patient a painful ulcer on the mucous membrane of the oral cavity is revealed, size 1.5x2 cm, covered with yellowish coating with soft edges and pale red rim inflammation. Bottom of the ulcer is rough and gray. Who is the most likely factor of the disease? A. Pale treponema C. Bacillus anthracis C. Actinomycetes human D. Mikobakteriya tuberculosis E. Pyogenic streptococcus 2. Histological examination of the soft tissues of pathological foci detected xantom cells. What disease is characterized with these cells?: A. Actinomycosis B. Odontogenic granuloma of the face. C. Chronic osteomyelitis of the jaws. D. Tuberculous E. Pyogenic granuloma. 3. In a patient in the submandibular space large lymph nodes that do not decrease during 5 months. In lymph node biopsies - epithelioid and giant cells Pirogov - Lanhhansa, areas of cheesy necrosis What is it? A. Syphilis B. Tuberculosis C. Actinomycosis D. Acute serous lymphadenitis E. Chronic hyperplastic lymphadenitis 4. In a 28-years-old patient, ulcers on the tongue, dense infiltration, red erosion with smooth shiny bottom diameter of about 1.5 cm, sharp-edged, painless. Put the most likely diagnosis?

33 A. Secondary syphilis B. Tuberculosis, miliary ulcer-form S. AIDS D. Actinomycosis E. Diphtheria

Literature: Oral and Maxillofacial Surgery Edited by Prof V. Malanchuk, 2011P. 201-204.

Theme №19: Erysipelas of the face, nome, haemodymamic necrosis. Manifistations in the oral cavity. Etiology, pathogenesis, clinical signs, diagnoses, methods of treatment.

Actuality of the theme: Erysipelas - bacterial infectious and allergic skin disease or (rarely) oral mucosa, which is caused by beta-hemolytic Gram-positive streptococcus group A. Ways of transmission - contact and airborne. Erysipelas of the face takes about 45% of all cases of primary disease. Disease is caused on a background of possibilities of general and local immunity, the presence of sensitization. More common in children and older people. Noma (synonyms: water cancer, oral cancer, idiopathic gangrenous stomatitis) - infectious disease that occurs in a rapidly progressive moist gangrene of the facial tissues with a sharp decrease in defense of the organism. The etiology is not completely understood. Often from the areas of necrosis fuzospirohety, putrefactive bacteria, Bac Rerfringens are revealed. Sick mostly children, weakened by nutritional starvation, infectious diseases (especially measles and dysentery) and adults - on the background of cardiovascular disease. Wegener's disease (synonyms: progressive lethal granulomatous ulceration of the nose and face; Stewart malignant nonspecific granuloma; infectious necrotizing granulomatosis) - a rare form of collagenosis, type nodular periarteritis, accompanied by the appearance of the mouth and nose foci of necrosis and ulcers. Affected not only the arteries but also veins and capillaries. More common in adults (men and women), aged 20-50 years, rarely - children and the elderly. Diphtheria - an acute infectious disease transmitted by airborne - droplets, which caused wand Leffler. Most often affects the nasopharynx, soft and hard palate, gums and tongue sometimes. The resultant white and gray filmy coating that is hard to be removed, and under it - painful bleeding wound. Aim: learn basic causes and related factors of noma, Wegener's disease, erysipelas, diphtheria. Identify the main clinical symptoms of the disease manifestations in the mouth and on the face, principles of treatment and prevention. To be able to conduct their differential diagnosis.

Basic knowledge level: 1. Anatomical and physiological structure of the maxillofacial area. 2. Microbiological properties of pathogens that cause erysipelas, nome, Wegener's disease and diphtheria.

Test questions: 1. Causes and the role of co-factors in the occurrence of noma face. 2. Clinical signs of noma in the oral cavity (gingivitis, ulcerative-necrotic stomatitis - their features). 3. Clinical stages of noma flow. 4. Complications arising during and after undergoing noma, their prevention and treatment. 5. Principles of coplex treatment of noma of the maxillofacial area 6. Possible pathways of infection into the skin. 7. Mechanism of erysipelatous inflammation, the role of sensitization of the organism in the development of this pathology. 8. Classification of erysipelatous inflammationio 9. Differential diagnosis of erysipelatous inflammation with polymorphic exudative erythema, herpes zoster, systemic lupus red, anthrax, syphilis, microbial eczema and dermatitis. 10. Complications that can occur when erysipelas: lymphedema, sepsis, meningitis - clinical signs, treatment guidelines.

34 ■

11. Principles of erysipelatous inflammation treatment. 12. The causes and related factors contributing to the Wegener disease. 13. The main clinical manifestations of the Wegener disease in oral cavity. 14. Typical performance of laboratory studies of blood in patients with Wegener disease. 15. Differential diagnosis of Wegener's disease with cancer, syphilis, tuberculosis. 16. Principles of treatment and prevention of Wegener disease. 17. The etiology of diphtheria. 18. Clinical features and diagnosis of diphtheria. 19. Differential diagnosis of diphtheria with infectious mononucleosis, scarlet fever, leukemia, angina. 20. The principles of local and general treatment of diphtheria. 21. Prevention of diphtheria.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with erysipelas of the face, nome, Wegener disease and diphtheria 2. Be able to reveal the characterized clinical symptoms of the erysipelas of the face, nome , Wegener disease and diphtheria 3. To select proper additional methods of research in patients with erysipelas of the face, nome, Wegener disease and diphtheria, interpret them correctly. 4. To choose the complex treatment methods in patients with the erysipelas of Ihe lace, nome, Wegener disease and diphtheria 5. To acquire the methodology of biopsy of inflammatory focus in patients with erysipelas of the lace, nome, Wegener disease and diphtheria

Situation tasks: 1. A boy, 14 years old, at throat and palate mucosa white-gray film coating is detected that is poorly removed. In a place of plaque removing bleeding and painful wound is found, submandibular lymph nodes are enlarged Put the most likely diagnosis? A. Tuberculous ulcer B. Diphtheria C. Infectious mononucleosis D. Scarlet fever E. Decubital ulcer 2. In a 42-year old woman complains of itching, burning and swelling of the upper and lower lips, body temperature - 39, 5Q C. Skin lip slightly raised; symmetrical redness in the form of a butterfly. What are the probable cause of this disease? A. Haemolytica pyogenic streptococcus B. Epidermal aureus C. Sybirkova bacillus D Pathogen Plague E. Pseudomonas aeruginosa 3. In youth, 15 years old, swelling of the right cheek. Patient three days was before treated of dysentery. Swelling covers the entire thickness of the soft tissues of the right cheek, in the center of the skin spots dark blue, the skin around the pathological focus is pale waxy color with a pearlescent hue, and on the periphery of glassy appearance, no congestion In the mucosa of the cheek stain dark blue, and the phenomenon of ulcer stomatitis. What is the most likely diagnosis? A. Actinomycosis B Anthrax C. Erysipelas D. Carbuncle of the cheeks E. Noma 4. During microscopy biopsy revealed mucoid swelling of blood vessel walls, their fibrinous changes: polymorphic cells necrotizing granulomas. What disease is characterized by this histological picture? A Tuberculosis

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. B. Cancer C. Noma D. Wegener's Disease E. Syphilis 5. What disease is quite effective treatment with sulfanilamide preparations ? A. Erysipelas B. Syphilis C. Actinomycosis D. Nome E. Wegener's Disease

Literature: Oral and Maxillofacial Surgery Edited by Prof. V. Malanchuk, 2011- P. 209-210.

Theme 20. Furuncles and carbuncles of the face. Etiology, pathogenesis, clinical signs, diagnoses, methods of treatment, complications.

Actuality of the theme: Furuncles and carbuncles of the face occupy one of the leading places among nonodontogenic inflammatory diseases of the maxillofacial area. The most dangerous for the patient's life are their complications, orbital venous thrombophlebitis, cavernous sinus thrombosis, orbital abscess, etc. The key to a favorable prognosis is timely diagnosis and appropriate treatment.

Aim: To study the clinical signs, etiology, methods of diagnosis, treatment, and factors that contribute to the development and recurrence of furuncles and carbuncles of the face. To teach to diagnose the development of dangerous complications and make treatment algorithm

Basic knowledge level: 1. Topographical anatomy of the face and head. 2. Pathogenesis of inflammatory processes in soft tissues of maxillofacial area. 3. Pathways of infection in maxillofacial area. 4. Therapeutic treatment of inflammatory processes treatment.

Test questions: 1. Etiology of face furuncle and carbuncle. 2. Classification of furuncles and carbuncles. 5 The main clinical signs of face furuncles and carbuncles 6. Indication for surgical treatment. 7. Therapeutic treatment of face furuncle and carbuncle. 8. Local complications of face furuncle and carbuncle and their prevention and treatment. 9. Common complications of face furuncle and carbuncle and their prevention and treatment.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with face furuncle and carbuncle. 2. Be able to reveal the characterized clinical symptoms of the face furuncle and carbuncle 3. To choose the complex treatment methods in patients with the face furuncle and carbuncle . 4. To acquire the methodology of surgical treatment of the facial furuncle and carbuncle.

Situation tasks: 1 On the skin of the chin of a 60 years old man appeared pustule that rapidly developed to solid sharply painful infiltration 3x3 cm in size. Skin over it is cyanotic. In the epicenter of injury there are three areas of necrosis around the hair follicles. Lymph nodes of the chin are enlarged, painful. T - 38,5 C. Put a diagnose. A . Allergic dermatitis of the chin B Erysipelas of the chin.

36 C. Furuncle of the chin. D. Atheroma that inflamated E. Carbuncle of the chin. 2In the patient's upper lip there is a sharply painful, limited infiltration, towering above the healthy skin, conical in shape with a necrotic core in the center. T of body 39 C. Patient feels sick for 5 days. Put the diagnosis A. Furuncle B. Carbuncle C. Osteofollikulitis D. Deep folliculitis E. Siberia-ulcerative carbuncle 3. Patient C., 30 years old, complained of increased body temperature up to 39 C, general weakness, presence of rounded infiltration on the upper lip Patient feels sick for 3 days. Objectively: in the area of the upper lip on the left there is a beet color infiltrate aprox. 2.5 cm in diameter above the skin with necrotic core in the center. The upper lip is hyperemic, edematous. Put a diagnose. A. Retention cysts of the upper lip B. Carbuncle of the upper lip C. Furuncle of the upper lip D. Acute periostitis of the upper jaw E. Acute suppurative lymphadenitis

Literature: l .Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P. 177-178.

ThemeJV* 21. Complications of the phlegmons associated with the upper jaw: sepsis, brain abscess, cavernous sinus thrombosis.

Actuality of the theme: The incidence, severity, morbidity, and mortality of odontogenic infections have declined dramatically over the past 60 years. Dentistry has made great progress in the prevention and early intervention of odontogenic infections. Oral and maxillofacial surgeons have made great strides in managing and preventing mortality in severe odontogenic infections. These accomplishments, however, impose upon the oral and maxillofacial surgeon the obligation to remain intellectually prepared for the always unscheduled occurrence of severe odontogenic infections by keeping one’s knowledge of the relevant anatomy and surgery fresh, and by remaining abreast of current developments in the microbiology and antibiotic therapy of odontogenic infections. Inflammatory' processes of upper jaw may extend to adjacent soft tissues, with localization of pathological foci in superficial and deep spaces of the face and occurrence of many complications Disregard of the main principles of complex surgical and therapeutic treatment of severe odontogenic inflammatory processes of MFA can provoke the determination of different complications such as sepsis, brain abscess and cavernous sinus thrombosis, which can lead to fatal consequences Aim: To study the basic principles of clinical manifestations and diagnostics of sepsis, brain abscess and cavernous sinus thrombosis. Teach to make a plan of complex treatment of listed diseases.

Basic knowledge level: 1. Role of pathogenic microorganisms in the development of MFA inflammatory diseases complications 3. Pathogenesis of inflammatory processes. 4. Relations of Spaces and Infection. 5 Modem schemas of antibiotic and anti inflammatory , de toxic therapy

Test questions: 1.Phases of sepsis. Clinical signs, diagnostics principles. 2 Differential diagnosis of sepsis

37 3. Complex treatment principles of odontogenic sepsis. 4. Clinical signs and diagnostics principles of brain abscess. 5. Treatment principles and prevention of brain abscess. 6-Etiology and pathogenesis of the cavernous sinus thrombosis. 7 The clinical features of cavernous sinus thrombosis. 8. Treatment and prognosis of the cavernous sinus thrombosis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with sepsis, brain abscess, cavernous sinus thrombosis. 2. Be able to reveal the characterized clinical symptoms of sepsis, brain abscess, cavernous sinus thrombosis. 3. To select proper additional methods of research in patients with sepsis, brain abscess, cavernous sinus thrombosis, interpret them correctly. 4. To choose the surgical complex treatment methods in patients with the sepsis, brain abscess, cavernous sinus thrombosis. 5. Be able to choose the proper medical supportive care for the patient with the sepsis, brain abscess, cavernous sinus thrombosis.

Situation tasks: 1. Function of which cranial nerve are stored at the cavernous sinus thrombosis? A. n.oculomotorius B. n.throhlearis C. n.abducens D. n. facial is E. n. trigeminus 2 Brain abscess can often develop in case of... A . Periostitis of the upper jaw B. Exacerbation of chronic periodontitis C. Acute sinusitis D. Phlegmon of pterygopalatine shace E. Radicular cyst

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P. 210-230.

Theme №22. Complications of the phlegmons associated with the lower jaw: neck phlegmons , mcdiastinitis , sepsis, toxic shock. Pathogenesis, clinical signs, diagnoses, treatment, prognosis

Actuality of the theme: Severe odontogenic infections can be the most challenging cases that an oral and maxillofacial surgeon will be called on to treat. Often the patient with a severe odontogenic infection has significant systemic or immune compromise, and the constant threat of airway obstruction due to infections in the maxillofacial region raises the risk of such cases incalculably. Furthermore, the increasing rarity of these cases and the ever-changing worlds of microbiology and antibiotic therapy make staying abreast of this field difficult for the busy surgeon Therefore, the main steps in the treatment of severe odontogenic infections, remain the fundamental guiding principles that oral and maxillofacial surgeons must use in successful management of these cases. Inflammatory processes of lower jaw may extend to adjacent soft tissues, with localization of pathological foci in superficial and deep spaces of the neck and can causing particularly severe clinical course of phlegmons with occurrence of many complications, such as sepsis, mediastenitis and neck phlegmon, which can lead to fatal consequences.

Aim: To study the basic principles of clinical manifestations and diagnostics of sepsis, mediastenitis and neck phlegmons. Teach to make a plan of complex treatment of listed diseases

38 Basic knowledge level: 1 Anatomy of submandibular space and neck. 2. Role of pathogenic microorganisms in the development of MFA inflammatory diseases complications. 3. Pathogenesis of inflammatory processes. 4. Relations of Spaces and Infection. 5 Modem schemas of antibiotic and anti inflammatory , de toxic therapy

Test questions: 1. Etiology, pathogenesis of odontogenic sepsis. 2. Phases of sepsis. 3 .Criteria of pathogenic infection generalization . 5. The clinic, diagnosis, differential diagnosis and treatment: a) purulent resorptive fever b) initial form of sepsis, c) septicemia, d) pyosepticemia e) septic shock. 6. Etiology, pathogenesis of odontogenic mediastenitis. 7. Pathways of spread of odontogenic infection to the mediastinum. 8. Classification of mediastenitis: a) by origin; b) by the type of inflammation; c) by the localization; d) by the clinical course. 9. The clinic, diagnosis, differential diagnosis and treatment of mediastenitis. 10. Etiology, pathogenesis, route of infection, symptoms, diagnosis, differential diagnosis and complex treatment of phlegmons:

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the technique of examination of patients with neck phlegmons , mediastinitis . sepsis, toxic shock. 2. Be able to reveal the characterized clinical symptoms of the neck phlegmons , mediastinitis , sepsis, toxic shock. 3. To select proper additional methods of research in patients with neck phlegmons , mediastinitis , sepsis, toxic shock, interpret them correctly. 4 To choose the surgical treatment methods in patients with the neck phlegmons , mediastinitis , sepsis, toxic shock. 5. Be able to choose the proper medical supportive care for the patient with the neck phlegmons , mediastinitis , sepsis, toxic shock.

Situation tasks: 1. In a patient there is a necrotic phlegmon of oral cavity bottom, sepsis syndrome, multi-organ failure. What phase of sepsis occurred in a patient? A. Pyosepticemia B. Septicemia C The initial phase of sepsis D. Purulent resorptive fever E. Eoxemia 2. A. The patient was hospitalized in the department of oral and maxillofacial surgery with the odontogenic phlegmon of the floor of the mouth. At hospitalization the general condition of the patient heavy, position in the bed - forced sitting with head tilted to the front. Complaints of chest pain that is worse when bending head to rump, cough, shortness of breath What complication has developed in this patient? A. Mcdiastenitis B. Phlegmon of retropharyngeal space C Phlegmon of the neck

39 D. Phlegmon of the tongue E. Phlegmon parapharyngeal space 3. The patient complains of pain and swelling in the front of the neck above the breastbone. Clinical examination and palpation marked hyperemic tense skin, soft tissue swelling, painful infiltration with signs of fluctuations. For what phlegmon is such clinical signs are characteristic ? Л.Phlegmon of suprasternalis cellular space B. Phlegmon of subcutaneous layer of the anterior part of hyoid space C. Phlegmon ofpretraheal space D Phlegmon of the neck

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 210-230.

Theme №23. Arthritis and arthrosis of the temporomandibular joint (TMJ): classification, clinical signs, diagnostic methods, treatment, complications, prevention. Pain TMJ dysfunction syndrome.

Actuality of the theme: Currently, the level of incidence of temporal mandible joint (TMJ) diseases significantly increased. The demand for treatment of temporomandibular joint is well known. Most studies estimate the prevalence of clinically significant TMJ related jaw pain to be at least 5% of the general population. Majority TMJ inflammatory diseases are arthritis and arthrosis. Infections of the TMJ are not common. Prompt diagnostic and therapeutic interventionis required when an infection of the TMJ is suspected because joint distention is usually painful and permanent changes in joint function can occur. The bacteria causing an infected joint are usually spread through a hematogenous route Following the resolution of an TMJ inflamation. a treatment program must be startedto minimize joint disability and to monitor for recurrence of inflamation The primary goal in treatment of TMJ inflammatory diseases is to alleviate pain and/or mandibular dysfunction. Pain and alterations in function ( mastication and speech) can become quite debilitating, greatly affecting oral health care and diminishing the quality of life for these individuals.

Aim: to teach basic clinical features of TMJ disorders, diagnostics methods to provides basic guidelines for main principles of inflammatory TMJ diseases treatment and complications prevention.

Basic knowledge level: 1. Anatomy and Pathophysiology of the Temporomandibular: - bony structures; - cartilage and synovium; - the articular disk and retrodiskal tissue; - ligaments; - vascular supply and innervation; - musculature ( supramandibular muscle group, inframandibular muscle group) 2. Biomechanics of temporomandibular joint movement.

Test questions: 1 The main etiological factors of arthritis. 2. Pathway of infection spreading in TMJ space. 3. Imaging diagnostic methods in patients with TMJ diseases ( panoramic X-Ray, CT, arthroscopy ). 3. Classification of arthritis and arthrosis 4. Clinical features of arthritis. 5. The main clinical features of arthrosis. 6. The main clinical symptom of TMJ pain disorders 7. Nonsurgical treatment of TMJ diseases:

40 - diet; - pharmacotherapy (analgesics, anti-inflammatory medications, corticosteroids, muscle relaxants, local anesthetics); - physical therapy; - stress-reduction techniques; - occlusal appliance therapy; 8. TMJ surgery (open joint surgery and arthroscopic surgery ) 9. Complications of TMJ diseases and their prevention

The professional abilities and practical skills the student should to study during practical lesson. l .To master the technique of examination of patients with the inflammatory diseases of TMJ. 2. To master the technique of palpation of TMJ. 3. To select the additional methods of research and interpret them correctly. 5. Be able to reveal the characteristic clinical symptoms of inflammatory diseases of TMJ 6. To compile the plan of complex treatment of patients with the inflammatory diseases of TMJ. 7. Be able to assist during surgical treatment inflammatory diseases of TMJ.

Situation tasks: 1. The patient complains moderate intensity pain in the right half of the face, which increases with mouth opening, dryness and bum of oral mucosa. General condition unchanged. When opening the mouth there is the S-like diviation of the mandible, a spasm of masticatory muscle is revealed by palpation right. X-Ray examination: changes in bone elements of TMJ absent. Please put a diagnosis A. Pain dysfunction Syndrome of the right TMJ B. Purulent arthritis of the right TMJ C. Ancylosis of the right TMJ D. Trigeminal neuralgia E. Scar contracture 2. The patient fell from the bike and hit the chin . He entered the doctor with complaints of pain in the lower jaw, a painful mouth opening, inability of mastication. Objectively: scratches on the chin skin , half-opened mouth, jaw movements cause pain. Swelling in the TMJ, condylar are in joint sockets, TMJ movements are saved. X-Ray: the bones in the joints are not erupted. What diagnosis can be predicted? A. Acute traumatic arthritis of TMJ B. Articular fracture germ left C. Complete dislocation D. Closed bilateral fracture of coronal processes of mandible E. Contusion of the mandible 3. The patient is 55 years old, complained of permanent, nagging headache, extending to the lower jaw and neck. Suffering for three years. At the examination a partial secondary aedentia (I class by Kennedy) and deep bite were revealed. Radiologicaly a slight shift of TMJ heads upwards and backwards revealed. Violations of bone structures are absent. Set preliminary diagnosis. A. TMJ, occlusion, articulation syndrome B. Osteoarthritis C. Biogenic osteoarthritis D. Neuromuscular TMJ syndrome E. Posterior dislocation of the TMJ

Literature: Oral and Maxillofacial Surgery .- Edited by Prof V Malanchuk, 2011- P. 188-195

41 Theme №24. Aeute sialadenitis: etiology, pathogenesis, classification, clinical signs, diagnoses, treatment.

Actuality of the theme: The salivary glands consist of three major paired glands (the parotid, submandibular, and sublingual) as well as numerous minor salivary glands. In the oral cavity 700 to 900 minor salivary glands are found, the majority of which are located at the junction of the hard and soft palates. The salivary glands are affected by many different disease processes, some of which are surgical in nature while others have a medical basis. Acute sialoadenitis are common diseases in the clinic of maxillofacial surgery. Their causes and clinical manifestations are quite varied requiring the dentist to know the characteristics of acute sialoadenitis and be able to provide skilled care to patients with these diseases

Aim: to teach the etiology, related development factors of acute sialoadenitis; to study the main clinical signs of diseases and appoint appropriate diagnostic and treatment.

Basic knowledge level: 1 Anatomy and Pathophysiology of the Salivary glands. 2. Saliva secretion.

Test questions: 1. The principles of examination in patients with acute sialadenitis. 2. Additional diagnostic methods ( ultrasound and contrast X-Ray diagnostics ). 3. Classification of acute sialoadenitis. 4. Epidemic parotitis: etiology and pathogenesis of disease. 5. Epidemic parotitis: clinical signs, diagnosis, differential diagnosis, treatment and prevention. 6. Acute viral sialoadenitis (caused by the cytomegalovirus, herpes, Epstein -Barr virus etc ): etiology, pathogenesis, clinical symptoms, diagnosis, differential diagnosis, treatment and prevention. 7. Acute bacterial sialoadenit: etiology and pathogenesis of the disease, main clinical sings< treatment. 8. Necrotic parotitis: etiology, clinical signs, diagnosis, differential diagnosis and treatment. 9. Lymphogenous parotitis ( Hertsenbeg parotitis): etiology, pathogenesis, clinical symptoms, diagnosis, differential diagnosis and treatment. 10. Acute contact sialoadenitis: etiology, pathogenesis, clinical signs, diagnosis, differential diagnosis and treatment principles.

The professional abilities and practical skills the student should to study during practical lesson. 1. To teach the methods of examination in patients with acute sialadenitis. 2. To be able to differentiate epidemic and non epidemic acute sialadenitis. 3 . To reveal the main signs of acute sialadenitis. 4. To be able to differentiate the acute sialadenitis from other similar inflammatory diseases of MFA. 5. To compile the plan of treatment of the patients with acute sialadenitis 6. To select the proper schemas of pharmacotherapy of the acute sialadenitis

Situation tasks: 1 Patient A , 45 years old, appealed with complaints about the presence of a painful swelling of the soft tissues of the left parotid area, the body temperature 37 8 C The pain appeared 3 days ago Objectively: facial asymmetry due to infiltration. Skin’s color is not changed, taken in the fold. Palpation of the left parotid salivary gland sharply painful Opening of the mouth is free, oral mucosa of pale pink color, without visible changes. The opening of the duct of the left parotid salivary gland is hyperemic, swollen. At palpation the left parotid salivary gland the muddy saliva is secreted. Set a diagnose. A.Acute serous parotitis B Epidemic parotitis C Acute serous lymphadenitis

42 D. Chronic lymphadenitis E. Chronic parotitis 2. Patient K., 12 years old, two days ago, increased body temperature to 38.0 C on the second day appeared swelling in the parotid region on both sides. The skin over the swelling is tense, has normal color. Palpation reveals mild painful increasing of parotid saliva glands, violations of ducts of parotid salivary glands, openings of ducts are hyperemic. Pain during palpation in thespace of the angle of the mandible, the mastoid apex, anterior to the ear tragus. Put a diagnosis. A. Epidemic parotitis B. Hercenberg’s parotitis. C. Acute bacterial parotitis. D. Purulent - necrotizing parotitis E. Sjogren's syndrome. 3. Parents of boy O , 5 years old, which attends kindergarten complain of soft tissue swelling in both parotid-masticatory regions, raising the temperature to 38,0 ° C. Objectively: parotid salivary gland enlarged, palpation soft and painful. Skin tight, pale and oily. From the duct of parotid salivary gland a small amount of clear saliva is secreted. What is the most likely diagnosis? A. Epidemic parotitis B. Abscess of the masseteric space C. Lymphadenitis of parotid space D. Bacterial parotitis E. Adenoma of salivary gland

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011- P. 181-188.

Theme №25. Chronic sialadenitis, etiology, pathogenesis, classification, clinical signs, diagnostics, treatment. Sacroidosis. Necrotizing sialometaplasia. Sjogren's syndrome.

Actuality of the theme: The salivary glands are affected by many different disease , some of which are surgical in nature while others have a medical basis. The large variety of the diseases that occur in the salivary glands make the importance the fundamentals of their diagnostics and treatment management. This necessitates knowledge of the clinical signs of these tumours and their ability to diagnose them and to choose the right methods of treatment. So the skills of a dentist to diagnose these diseases are important.

Aim: to teach etiology, basic clinical features of chronic sialadenitis and collagen diseases, diagnostic methods to provides basic guidelines for main principles of their treatment and complications prevention.

Basic knowledge level: 1. Anatomy and Pathophysiology of the Salivary glands. 2. Innervation and vascularization of the salivary glands. 3. The function of the salivary glands. 4 Connective tissue histological structure .

Test questions: 1 Etiology and pathogenesis of chronic sialadenitis and collagen diseases. 2. Pathogenesis of chronic sialadenitis and collagen diseases. 3. Classifacation of chronic sialadenitis. 4 Clinical and additional examination of patients with chronic sialadenitis and collagen diseases 5. Parenchymatous parotitis: etiology and pathogenesis , factors that contribute the occurrence. 6. Parenchymatous parotitis: clinical signs depending on the stage of the disease. 7. The main principles of patient’s with parenchymatous parotitis treatment. 8 Sclerosing submaxylitis:etiology , pathogenesis, main clinical features and treatment.

43 9. What is sialosis? Sialosis classification. Stages of sialosis. 10. The main clinical signs and principles of treatment. 11. Sjogren's syndrome: main clinical symptoms and treatment. 12. Mikulich disease: etiology, pathjgenesis< clinical signs and treatment principles. 13. Determine the severity of the chronic sialadenitis and collagen diseases. 14.0utcome and complication of chronic sialadenitis and collagen diseases.

The professional abilities and practical skills the student should to study during practical lesson. 1 To teach the methods of examination in patients with chronic sialadenitis and collagen diseases. 2. To be able to differentiate forms of chronic sialadenitis and collagen diseases. 3. To study to identify characteristic clinical symptoms of chronic sialadenitis and collagen diseases 4. Master the method of bouginage of the salivary glands ducts. 5. To be able to differentiate the collagen diseases 6. To compile the plan of treatment of the patients with chronic sialadenitis and collagen diseases. 7. To select the proper schemas of pharmacotherapy of the mentionad diseases .

Situation tasks: 1. The patient, 53 years old. Swollen cheeks, dry mouth and eyes, the feeling of getting sand in the eyes, pain in the joints. Parotid salivary gland enlarged, thick, uneven, slightly painful on palpation. Opening of the mouth is free. The mucous membrane of the mouth is dry. During the massage glands no saliva obtained. Multiple cavities, kerato-conjunctivitis. Put a diagnosis. A. Sjogren's syndrome B. Viral parotitis C. Sarcoidosis of the salivary glands D. Mikulic’s disease E. Actinomycosis of parotid salivary glands 2. The patient, 38 years of age. There is triad of symptoms: xerostomia, xerophthalmia and rheumatoid arthritis. What disease is characterized by these symptoms? A. Sjogren's syndrome B. Epidemic parotitis C. Fibrous dysplasia D. Mikulic’s disease E. Benign lympho-epithelial lesions 3. The man pain and swelling in the right parotid region, poor sleep, loss of appetite. Sick year. Pain increases during eating and then disappears. Preliminary diagnosis: chronic sialoadenitis What additional diagnostic needs to confirm the diagnosis? A.Radiography of salivary gland B .Radiography of the mandible from the affected side C. Puncture of the parotid salivary gland D. Computed tomography E. Electroodontodiagnostics

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V. Malanchuk, 2011,- P.181-188

Theme №26. Calculary sialadenitis: etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications.

Actuality of the theme: calculary sialadenitis - a disease with the formation of calculi (stones) in the salivary glands and their excretory ducts. It belongs to the most common diseases of the salivary glands. Statistics show that over the last ten years calculary sialadenitis is about 30% of total non- tumorous diseases of the salivary glands and 54.5% of all cases of chronic sialadenitis. This

44 necessitates knowledge of the clinical features of these diseases and their ability to diagnose and select appropriate treatment.

Aim: to study the frequency, etiology, pathogenesis, clinical signs, diagnosis, differential diagnosis and treatment of calculary sialadenitis.

The basic knowledge level : I Anatomy of the salivary glands 2. Morphological structure of the salivary glands 3. Differential diagnosis of acute and chronic diseases. 4 Methods of salivary glands diagnosis

Test questions: I Etiology and pathogenesis of calculary sialadenitis. 2. The clinical examination of patients with calculary sialadenitis. 3. Additional examination of patients with calculary sialadenitis 4. CIinical signs depending to the stages of the calculary sialadenitis. 5. Indications to surgical treatment of calculary sialadenitis.

The professional abilities and practical skills the student should to study during practical lesson. 1. To master the method of examination of the patients with calculary sialadenitis. 2. To study to identify characteristics of the stages of the calculary sialadenitis. 3. To select additional methods. Correctly interpret the results of instrumental studies. 4. To compile a plan of comprehensive treatment of patients with calculary sialadenitis 5. Be able to assist during calculary sialadenitis surgical treatment.

Situation tasks: 1. Patient M., 47 years old, complained of pain and pain that irradiates to the right submandibular salivary gland,filling of fullness that occurs during meals. At bimanual palpation along the duct of the submandibular salivary gland a dence structure is defined. The mucous membrane of the mouth in the area of the opening of the salivary gland duct with no signs of inflammation. Body temperature within normal limits. Put a diagnosis. A Parenchymatous parotitis B. Sialosis C. The initial stage of sialolitiasis D. Contact sialadenitis E. Stage of clinically significant inflammation at the salivary stone disease 2. In a patient was diagnosed calculary sialadenitis of the left parotid gland. In which section parotid salivary gland duct is localized the stone if it is easily palpated in the mouth? A.Submucosal В Cheek C.Premaseterical D Maseterical E. Submaseterical 3. То Patient A. the extirpation of the submandibular salivary gland is planned due to the calculous submaxylitis (late stage). What period after such surgery pressing bandage should be applied for? A.For 1-2 days В At least for 2-3 days C. At least for 3-4 days D. At least for 5-6 days E. For 1-2 weeks

Literature: Oral and Maxillofacial Surgery .- Edited by Prof. V Malanchuk, 2011 - P. 181-188

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