WISDOM OF THE MOUTH:
ANGLED AND HORIZONTAL LIE
Professor Ambrose Emeka Obiechina
University of Ibadan,
18th December, 2003
The Vice Chancellor,
Deputy Vice Chancellor (Administration),
Deputy Vice Chancellor (Academic),
Registrar,
Bursar,
Librarian,
Provost of the College of Medicine,
Acting Dean, Faculty of Dentistry,
Deans of other Faculties, Postgraduate School and Students,
Directors of Institutes,
Heads of Departments,
Colleagues,
Distinguished ladies and gentlemen.
It is indeed a great honour to be nominated to deliver this inaugural lecture, the 9th in the
2002/2003 series on behalf of the Faculty of Dentistry. Professor J.O. Daramola, an oral and
maxillofacial surgeon, on behalf of the Faculty of Clinical Sciences and Dentistry on January 28,
1988, delivered the first inaugural lecture from Dentistry. That was 15 years ago when I was still
a postgraduate student under him. I never conceived the idea then that I would give the next
lecture after him. It is therefore with immense pleasure that I give this inaugural lecture, the first
from the Faculty of Dentistry.
During this lecture, it is my intention to take you a little down the memory lane, tell a bit of my
story, bring to light my profession of oral and maxillofacial surgery, and highlight a few of my
works. I do not consider it of great importance to chronicle my achievements in academic
research. It could have been necessary if I were from another tertiary institution. I would have
been compelled to prove my worth to the audience of this great institution. This institution has a
“Trademark and Tradition”, which has stood the test of time and has consistently proved its
worth. I wear this “Trademark” with great pride and humility. I am a professor of oral and
maxillofacial surgery of Nigeria’s Premier University; The University of Ibadan. This alone
speaks for itself.
By the end of this lecture, I hope therefore, that you would pick one or two useful information
that may be helpful to other people and maybe, yourself too.
1
MY STORY
The Bachelor of Dental Surgery (BDS) degree program was established in the University of
Ibadan in 1975. The first set comprised of 13 students who passed into clinical Dentistry in 1977,
and graduated as the 1st set of Bachelor of Dental Surgery students of the University of Ibadan in
1980.
My admission into the Dentistry program of the University of Ibadan was neither planned nor
premeditated on my own part. I was among the last batch of University of Ibadan, students at the
Jos campus, who refused to be conscripted into the newly established University of Jos. We
marched in protest to our University, the University of Ibadan, refusing the enticements offered
us by the University of Jos. We argued that our contract to acquire higher education was with
the University of Ibadan and not the University of Jos. We refused to leave the Ibadan campus
until we were assured that our contract with the University of Ibadan still subsists. We
mobilized the solidarity of our colleagues on this campus. The then Vice Chancellor Professor
Tekena Tamuno addressed us and benevolently assured us that we remain bonafide students and
were free to continue at University of Ibadan, the following session. His speech was greeted
with great ovation.
On arrival at the campus on October 1976, accommodation for students was tight because of the
influx from Jos. This perhaps marked the beginning of population explosion in the University.
While at Jos I had applied to do Medicine after my preliminary course. I was in the Botany
laboratory one afternoon when my friend informed me that the list for admission into medicine
was out. Behold our names were not included yet I performed better than most of my successful
peers. Our forms never got to the Dean of Medicine. I produced my result and protested to the
Sub-Dean. He regretted that admission into medicine was concluded and to show his concern,
he asked if we would like to study Dentistry. I knew next to nothing about Dentistry and I
looked at my friend who was a Lagosian and he nodded in approval. So we were admitted into
the 2nd set of Bachelor of Dental Surgery students of the University in 1976.
When I asked to know more about Dentistry, my friend was quick to tell me that I would be
addressed as a doctor. We felt good. When I got back I proudly announced to my peers that I
had been offered a place to study Dentistry. Several of my peers looked at me with disdain and
asked; “what does that mean?” Are you going to spend 6 years in the University studying 32
teeth in the mouth? My enthusiasm began to dampen. “How will I spend the rest of my life
counting teeth and pulling them out?”, I wondered. That would bore me stiff.
Had I made a wrong choice or was the offer of Dentistry of Divine providence? This question
has since been answered which explains why I am giving the 1st inaugural lecture in the Faculty
of Dentistry, of the University of Ibadan.
I have since found the study of Dentistry very demanding, exciting, and fulfilling.
2
MY CONTRIBUTIONS
When I completed my postgraduate training I was offered appointment in the University just
before the dawn of “brain drain”. I was still a young lecturer when my teachers left in search of
greener pastures. It was peculiar in that
(i) Dentistry was left with 4 departments and 2 young lecturers to run the
programme.
(ii) My teachers left the tropics to search for greener pastures in the desert!
This was the darkest night in the history of Dentistry in the University of Ibadan. I was in love
with my profession and I considered it a challenge and a sacred duty to my students, the
University and to God to ensure that the Dentistry program survived the dark nights to embrace
the light of the day.
Teaching and Staff Development
It is on record that during this period, 4 out of 5 (80%) successful candidates in the Part 1
fellowship examinations of Faculty of Dental Surgery of the West African College of Surgeons
in April 1992 were my students. In May 1992, 50% of the successful candidates in the Part 1
examination in the Faculty of Dental Surgery of the National Postgraduate Medical College of
Nigeria were also my students.
At undergraduate level, the pass rate was over 80%. This performance is yet to be rivaled in the
history of Dentistry in this institution.
Since 1991, the academic staff in the Faculty has increased from 2 to 20. Of this number 75% of
them passed through my active tutelage at Postgraduate level. In my department, the department
of Oral & Maxillofacial Surgery, I trained and supervised the postgraduate dissertations of 3 of
the four lecturers, the 4th being myself. Of the 3 lecturers I am delighted that 2 are Senior
Lecturers at the brink of crossing over to the Professorial cadre, while the one who was
appointed recently is still being groomed in the art of research, surgical skills and teaching. I
have no doubt that she will soon justify our efforts.
The evolution of the Faculty of Dentistry
When the Bachelor of Dental Surgery Degree program was established in 1975, the founding
fathers recognized the need for the program to evolve into a full-fledged faculty, hence it was
placed under the Faculty of Clinical Sciences and Dentistry. The then Provost College of
Medicine and the current Vice Chancellor, Professor A.O. Falase presented a special package in
this regard. Try as he could his special package for the establishment of the Faculty of Dentistry
could not sail through. It was hit and wrecked by the storm of “Brain drain”. Was that initiative
wasted to go unheralded?
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Under the dynamic and focused leadership of the last Provost College of Medicine Professor
M.T. Shokunbi, the issue of establishing the Faculty of Dentistry was again presented by me, the
Sub-Dean Dentistry to my Dean, the current Provost, College of Medicine, Professor I.F.
Adewole who took up the matter with the Provost. I was assigned the duty of retrieving the
wreckage of the special package that was wrecked by the storm of brain drain. It was an onerous
duty that I did “struggling and smiling”. I commend the goodwill and hardwork of my friends at
the senate secretariat.
The wreckage was rescued, repacked, represented and given a clean bill and had a smooth sail.
The original initiator of the establishment of the Faculty of Dentistry, the Vice Chancellor,
Professor A.O Falase received his reward. He was befittingly honoured. He inaugurated the
Faculty of Dentistry on April 22, 2002 – A dream come true.
THE SCOPE OF ORAL & MAXILLOFACIAL SURGERY
The discipline of Oral and Maxillofacial Surgery deals with diseases and disorders of the jaws,
teeth, mouth, associated structures and the face. The mouth, teeth and tongue are essential tools
for mastication (chewing).
People usually become more receptive and radiant after a hearty meal. Food is lubricated with
saliva, chewed with the teeth, moulded with the tongue and cheeks and swallowed with the aid of
the tongue. Need I remind us of what we often do during the course of having an appetizing
meal?
Eager to savour and devour the whole lot, we often forget that the food had graciously lubricated
our lips to aid eating. We would mould our tongue and lick the lips to ensure that no morsel
escapes. Still not satisfied, we would reach for a glass of water, support it with the lips, gaggle
and wash down whatever morsel that was lurking in the mouth. This is followed by belching,
signaling satisfactions. To the beloved, the belch after a good meal is a loaded speech.
Your spouse is saying, darling, my heart is now open, talk to me and ask for whatever you desire
now. It is the heart speaking; the wisdom of the heart. I hope the ladies are listening. The oral
and maxillofacial surgeon is therefore a custodian of the gateway to the heart.
The oral and maxillofacial surgeon fixes disorders of the jaws and teeth so that smile is not
unduly reserved and restores the lips and cheeks in healthy states. For the ladies, he ensures that
these organs are well positioned to accept lipsticks and make-ups. The oral and maxillofacial
surgeon therefore enhances esthetics and face value.
The discipline of oral and maxillofacial surgery transverses most of the surgical specialities.
Thus like the orthopaedic surgeon, the oral and maxillofacial surgeon fixes broken jaw bones;
like the urologist, he ensures that the flow of water (saliva) through the pipes (salivary duct) is
maintained and repaired when damaged; like the plastic surgeon he restores esthetics of the face.
With the Ear, Nose and Throat surgeon we have several areas of overlap. The Anaesthetist? Yes.
A dentist, Horace Well discovered the use of nitrous oxide for anaesthesia in 1844. Another
dentist, William Thomas Green Morton in 1846 administered ether for tooth extraction.
4
Experience has shown that none administers anaesthesia of the head and neck region better than
the oral and maxillofacial surgeon. I stand to be challenged.
Of gynaecology, the oral and maxillofacial surgeon works upstairs, the gynaecologist works
downstairs. Both gateways lead to the heart. Thus the oral and maxillofacial surgeon is the first
custodian of the gateway to the heart, the gynaecologist comes after the oral and maxillofacial
surgeon.
Wisdom of the mouth
The mouth as an organ for speech and phonation plays a vital role in communication. Speech is
often impaired if the components of the mouth essential to speaking is missing or defective. This
often manifests in diseases of the tongue, missing anterior teeth or inability of the lips to come
together. The important point however is that the mouth is the organ through which words of
wisdom are spoken.
There was this little boy who lost a tooth while eating chocolates. His parents had told him that if
he saved the missing tooth, tooth fairy would replace it with money.
“I am going to put it under my pillow”, he announced to his parents that night. Since he was 8
years old his mother figured it was time to tell him the facts of life. Trying to find out how much
he knew, she asked, “Do you really think it is necessary anymore?”
“I don’t know,” he said.
“Who do you think the tooth fairy is?” his mother asked.
He thought for a minute and said “You and Dad.” It was a wild guess but he had suspected it for
a while now.
“That’s right” the mother said.
“What about Easter bunny and Santa Claus”?
“That’s us too”, the mother admitted.
Now that he knew the truth, the boy was anxious about the presents he cherished, so he asked.
“But will I still be getting my Easter presents?”
“You will my dear”, she assured him.
Then she cautioned him “But don’t go telling the younger kids in the neigbourhood about this?”
The boy started to leave the room. Suddenly he stopped and shouted, “Oh no!”
Turning to his mother with a worried look on his face, he asked, “Are you God, too?”
5
What the parents told their child was a myth. It had no iota of truth. It was
Wisdom of the Mouth; Horizontal Lie
Parents like to think they are doing children a favour by telling them these stories. But the day of
illusion always comes. Faith is lost not only in the trail of myths in which their faith is based but
their parents as well. Suddenly the kids learn that the people they admired the most have been
lying to them.
There was a Proprietor on a campaign trail, and he kept telling his audience that education would
be free. Come the elections; he won and declared that education was free in fulfillment of his
promise.
When the Principal went to him for money to implement free education, he was told to generate
funds.
“How do I do it sir” the principal asked.
“Sell what you have, make money” he replied.
The Principal knew that the pricey commodity was knowledge. After deliberating with members
of the management staff, they decided to sell what they have; all be it, at a cheap price in keeping
with the advice of the proprietor and trying to avoid the wrath of the students and their sponsors.
They placed price on their commodity. Hell was let loose. Students demonstrated and called
them thieves. Sponsors queried their authority. The proprietor reiterated that education was still
free. In truth, education has never been free. Someone somewhere has to pay for it. What the
politician told his people was less than half-truth. It was
Wisdom of the mouth: Angled lie.
The administrators lost confidence in the proprietor. There were at a loss as to what to believe
whenever the proprietor made a promise.
Wisdom in the mouth
When I was in secondary school I counted my teeth. They were 28 in number. During one the
lectures on dental anatomy in this University, we were told that between the ages of 16 to 21
years, it was common in black Africans to have a set of 32 teeth, unlike the Caucasians who
often have a set of 28 teeth only, because their jaws were too small to accommodate 32. I
counted my teeth. There were 32. I was excited. “I was a true African”. I said to myself.
But what about these 4 “extra” teeth? Do we really need them or was nature just being generous
to the black race? After all, those with 28 chew normally. But the “extra 4” we were told, are
the “Wisdom Teeth”? Does it mean that these teeth impart wisdom?
6
If that is so, the black race, particularly Nigeria must be the bastion of wisdom, having the
highest population among the black races of the world. Perhaps this may explain why Nigerians
acquired the wisdom of “Suffering and Smiling” and were therefore acclaimed to be the
“happiest people in the world”. A case of the more you look, the less you see. Should I attribute
this to the wisdom teeth or to Fela Anikulapo-Kuti for aptly describing the situation, or to both.
Again we are taught that all the teeth are numbered. The wisdom teeth are numbered 18, 28, 38
and 48. The figure 8 was ascribed to all the wisdom teeth. What about figure 8 and wisdom?” I
wondered. Perhaps the secret is in the application of wisdom to figure 8, or the application of
figure 8 to wisdom.
Indeed the Black race has more wisdom teeth in the mouth than other races, and maybe
Nigerians applied this wisdom to describe unique and alluring feature peculiar to us. The figure
of the typical African woman is characterized by a “fore” and “hind” bump. “Maybe” , I thought,
“the figure 8 was used to describe another feature peculiar to the Black race.” Any wonder then
that a typical beautiful black woman in Nigeria is simply described as “figure 8”.
Again figure 8 is applied to wisdom in the mouth. Those in the Red Cross and Scout movement
know that figure 8 is a knot, that is supposedly easy to untie if one knows how. The wisdom in
the mouth, the wisdom teeth, often present knots that every oral and maxillofacial surgeon must
untie, and that is to:
Extract Impacted Wisdom Teeth.
The wisdom tooth is the most frequently displaced tooth in the mouth.
When displaced, the wisdom teeth often lie in angled or horizontal positions.
7
Figure 1.1: Mesioangular impaction
Figure 1.2: Distoangular impaction
8
Figure 1.3: Horizontal impaction
The foregoing explains the title of my lecture.
WISDOM OF THE MOUTH: ANGLED OR HORIZONTAL LIE.
This wisdom, whether in the mouth or of the mouth have a common factor. They are responsible
for a host of problems and complications. The problems and complications of impacted wisdom
teeth include pain, infections, disorders of the temporomandibular joint, abnormal transformation
of tooth germ to tumour and surgical reconstruction.
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IMPACTED THIRD MOLAR (WISDOM) TEETH.
Figure 1.4: Mesioangular impaction Extracted
The wisdom or third molar teeth are the last teeth to erupt and do so between the ages of 16-21
years. Sometimes these teeth fail to erupt into occlusion and may need to be extracted. Reasons
for failure to erupt include, insufficient space in the jaw to accommodate the erupting tooth,
abnormal or pathological change.
Pattern and Symptoms of Impactions
Excision of impacted wisdom teeth is the most frequently performed minor oral surgical
procedure except routine forceps extraction and accounts for 79% of minor oral surgical
procedures performed at the University College Hospital, Ibadan.
We studied 338 patients, aged 16- 54 years, mean 24.4 ± 6.1 years consisting of 181 (53.55%)
males and 157 (46.45%) females with 473 impacted molars. The study showed that 69.73% of
impacted wisdom teeth were either angular or horizontal and occurred most frequently in the age
group of 21-25 years, followed by the age group of 16-20 years.
Table 1.1. Age distribution of types of impaction.
Age (years) 16-20 21-25 26-30 31-35 36-40 41> Total
Mesioangular 77 74 41 16 10 10 228
(48.20)
Vertical 36 88 16 3 0 0 143
(30.23)
Horizontal 21 27 16 2 6 2 74
(15.64)
Distoangular 7 10 6 0 3 0 26
5.50)
Inverted 0 1 0 1 0 0 2
(0.42)
Total 141 200 79 22 19 12 473
% (29.81) (42.28) (16.71) (4.65) (4.02) (2.54) (100)
Obiechina AE, Arotiba JT, Fasola AO. 2001.
10
Impacted wisdom teeth often present with disturbing symptom of pain. The study showed that
68.29% of impactions presented with pain which was the reason for coming to see the dentist.
Pain was most common with distoangular impactions. Some unerupted impactions presented
with pain, which appeared to be of doubtful origin. Thus there is the need for radiological
evaluation of unerupted third molars in cases of pain of doubtful origin in the head and neck
region.
Another study showed that while pericoronitis and caries were common among the younger age
groups (16-29 years), cysts, odontomes and squamous cell carcinoma occurred in the older age
groups (30 years and above) (Obiechina . 1991)
Figure 1.5: Impacted Wisdom Tooth with Odontome
Extraction of impacted third molar teeth
367 impactions were extracted under local anaesthesia. The complication recorded was
paraesthesia (Numbness or altered sensation) of the lower lip representing 1.36% (Obiechina
1991). This complication was found to be comparatively low and all the patients had complete
recovery within 6 months.
11
Figure 1.6: Paraesthesia of the Lower Lip after Third Molar Extraction
Among Caucasians it is generally accepted that impacted mandibular third molars with a depth
of 4mm and above be extracted under general anaesthesia. This is cost intensive; furthermore
there are more serious conditions that require surgery under general anaesthesia, such that theatre
space is often inadequate. In this study, we extracted 717 impacted mandibular third molars
from 517 patients (297 males; 220 females) in 3 centres.
69.1% of the extractions were in patients aged 25 years and below while 30.9% were in older
patients. The depth of impaction and type of anaesthesia are presented on Table 1.2.
Table 1.2: Distribution of type of anaesthesia and depth of impaction.
Type of anaesthesia Depth of impaction
No. of Local General Range Mean
extractions Anaesthesia anaesthesia (mm) (mm)
109 (15.2%) 86 (12.0%) 23 (3.2%) 0.5-0.8 0.53
282 (39.3%) 277 (38.6%) 5 (0.7%) 0.2-0.4 0.27
326 (45.5%) 326 (45.5%) 0 0-0.1 0.002
717 (100%) 689 (96.1%) 28 (3.9%)
3.9% of the extractions were done under general anaesthesia.
The reasons for having extractions done under general anaesthesia were;
i) deep and aberrant impactions 8 (1.1%)
ii) bilateral impactions 11 (1.5%)
iii) patient’s preference for general anaesthesia 9 (1.3%)
This study showed that impaction of depth of up to 5.5mm could be extracted under local
anaesthesia suggesting that over 96% of impactions can be extracted under local anaesthesia.
Complication was at 2.2% which was considered quite low.
12
The significance of this study is that patients do not have to be kept waiting for availability of
theatre space because preference will always be given to major surgical cases. The cost of
removal of impacted third molar teeth will be within the reach of more patients. It will aid in
budgeting and planning. (Obiechina, Oji, Fasola. 2001 )
OROFACIAL INFECTIONS
Infections in the oral and facial region often arise from tooth and tooth related structures.
2. Cancrum Oris (Noma)
Cancrum oris is a rapidly spreading gangrene of the soft and hard tissues of the mouth and face.
It occurs mainly the debilitated and malnourished children especially between the ages of 2 –7
years. Cancrum oris is a grave disfiguring and disabling condition that leaves in its wake serious
complications such as ankylosis of the mandible, impairment of speech and mastication, facial
deformity and psychological disability. This grave situation was highlighted, analyzed, and the
need for preventive measures were stressed (Obiechina 1991).
Figure 2.1: A 5 year old girl with perforation of the cheek ankylosis of the mandible.
Note inability to open the mouth.
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Figure 2.2: Note loss of the lower lip, cheek and exposure of the mandible.
The role of the oral and maxillofacial surgeon include control of infection in acute cases, release
of ankylosis of the mandible and facial reconstruction.
The causative factors of Cancrum Oris were identified as a triad of malnutrition debilitating
disease and poor hygiene. The disease also has been attributed to poverty.
Aware of the fact that educational status to a large extent mirrors the level of ignorance and
ignorance could lead to the desire for large families and malnutrition, we conducted
a study to determine the educational status, occupation of parents and the number of children of
parents whose children presented with Cancrum oris.
We analyzed 173 cases.
Table 2.1. Educational Level of Parents.
No. Percent
No formal education 148 85.5%
Primary education 21 12.1%
Secondary education 3 1.7%
Tertiary education 1 0.6%
Total 173 99.9%
It is of significance that 97.6% of the parents had either primary school or no formal education.
There was only one case in which a parent had tertiary education. The child was left at the care
of her illiterate grandmother, while her parents were abroad.
One hundred and twenty-one (69.9%) were from monogamous family while 52 (30.1%) were
from polygamous family. The mean of the total number of children from both family types is
presented in Table 2.2.
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Table 2.2: Analysis of family types
Family Type Frequency % Total no. Mean Standard
of children deviation
Monogamous 121 69.9 571 4.7 1.4
Polygamous 52 30.1 635 12.2 3.2
Monogamous 173 100 1206 7.0 4.0
&
Polygamous
Low income earners constituted 170 (98.3%), while medium income earners were 3 (1.8%) only.
This study buttressed the impact of poverty in cancrum oris. Of interest is the mean of 7.0
children per family which is well above the recommended norm of 2.0 children that has been
achieved in most developed countries where cancrum oris has been totally eradicated. The
average number of children per family in this study suggests that the families have more children
than they can cater for, thus giving rise to malnutrition and its attendant consequences, such as
cancrum oris. It also points to the relevance of birth control in the prevention of cancrum oris.
This study revealed a highly significant correlation between the level of education, occupation
and income status. In Nigeria, empirical evidence shows that there is a steady decrease in the
percentage of the poor, as the level of education increases. It is therefore evident that meaningful
education is a veritable tool for eradicating poverty and malnutrition, more so because education
enhances the acquisition of knowledge and skills, and promotes birth control.
This study suggests that apart from poverty, large family units and low educational status of
parents are contributing factors in the aetiology of cancrum oris (Obiechina, Arotiba, Fasola
2000).
3. Fascial Space Infections
Most infections in the mouth and facial region are of odontogenic (tooth related) origin. These
infections often arise from caries (tooth decay) or periodontal disease (disease of the gums) and
if untreated, spread through the jawbones to the face, neck and chest. Majority of these infections
arise from the molar teeth. Many people do not believe that tooth decay and gum disease can
easily lead to death. This year we have recorded 2 deaths which we regarded as avoidable deaths.
15
Figure 3.1:Spread of infection from wisdom tooth.
16
Figure 3.2: Full recovery after treatment.
In some cases the spread of infection is very rapid resulting in necrosis of the skin of the over the
jaw, the neck and chest with copious discharge of pus and offensive odour. Such cases are called
necrotising fasciitis.
4. Necrotising fasciitis of odontogenic origin.
A study was conducted on 8 patients (3 females 5 males) aged between 46-72 years (mean 58
years) who presented with of necrotising fasciitis.
The aetiology showed that 5 of the patients had caries (Tooth decay) while 3 had periodontal
disease. We made the following observations.
Infection started from the molar teeth, particularly the 3rd molars that is the wisdom teeth.
All patients were feverish with temperatures not exceeding 38.50C. The swelling was initially
fairly demarcated, warm, tense, and shiny, giving a deceptive impression of odontogenic or
periodontal abscess. Incision and drainage at this stage yielded little pus.
17
Figure 4.1: Rapid spread of infection extending from the eyes to the chest
Figure 4.2: Note change in skin colour and serosanguinous exudates
18
The next stage was rapid spread of the infection along the superficial fascial planes. The skin
remained tense, smooth, and shiny, and was unusually reddish for a dark skin. The extent of the
swelling became poorly demarcated, and was followed by the formation of bullae. Incision and
drainage in the area of rapid spread of the infection yielded serosanguinous exudate. Within 48
hours, the skin which had been reddish turned black, signaling the onset of necrosis. The exudate
became purulent. The necrotic skin crumpled and sloughed creating pus-filled pockets and
necrotic fascia.
Figure 4.3: Crumpled skin and purulent necrotic slough in the submental and anterior part
of the neck four days after incision and drainage.
The underlying muscles were exposed.
Infection was controlled by antimicrobial treatment and debridement, which resulted in lowering
of the temperature, and reduction of the swelling and purulent discharge.
In all cases the area of necrosis was less than the extent of infection. In three of the patients in
whom infection started in the maxilla, it spread to the submandibular and neck region.
Irrespective of whether the infection started in the maxilla or the mandible, necrosis invariably
started in the submandibular region and progressed downwards.
All infections were polymicrobial and were caused by bacteria that commonly inhabit the oral
cavity.
All the patients had symptoms of toothache or pain of periodontal origin, and the duration varied
from 28 to 42 days (mean 34) before they sought treatment at the peripheral clinics. The patients
delayed before attending the clinic as a result of ignorance.
19
The time interval before referral to our clinic ranged from 3-13 days (mean 6), and the delay
before referral was because some clinicians failed to recognise the gravity of the condition.
Treatment
Initial treatment with antimicrobials was empirical. Any change in antimicrobials was dictated
by the result of sensitivity tests, which favoured pefloxacin.
Necrotic tissues were excised. Wound was irrigated with 2% hydrogen peroxide. At eight-hourly
intervals the wounds were dressed with gauze soaked in hydrogen peroxide of the same
concentration. All the teeth involved were extracted.
Debridement and fasciotomy improved healing and depending on the extent of skin loss, the
wound was closed with a split thickness skin graft or local flap.
One of the eight patients died of overwhelming infection and septicaemia.
Figure 4.4: Improved healing six days after debridement and fasciotomy.
Significant findings in this study include:
The disease takes the usual path of spread of odontogenic infection, which invades deep tissue
planes in the early stages. It is only when the infective process gets to the superficial fascia that
the spread becomes rapid and the typical features of necrotising fasciitis begin to show. This
mode of presentation can be misleading to the unsuspecting clinician and makes diagnosing the
early stage of the disease difficult. It is therefore imperative that all cases of odontogenic
infection should be observed closely.
The unusual reddish colour on a dark skin that accompanies the rapid spread of infection can be
ascribed to early involvement of the deep fascia, muscles, and transient hyperaemia of the
20
overlying superficial fascia and skin. It should be regarded as a warning sign. We were the first
to report this clinical sign in medical literature.
There was a direct relationship between morbidity, mortality, and the time lapse before the start
of appropriate treatment. Early treatment reduced the incidence of disfigurement and death
(Obiechina, Arotiba, Fasola 2001).
DISORDERS OF THE MANDIBULAR JOINT.
5. Ankylosis Of The Mandible
Ankylosis of the mandible is immobility and consolidation of the mandible resulting in inability
to open the mouth. In the temporomandibular joint (TMJ), there are several etiological factors of
ankylosis. Trauma as a cause of ankylosis frequently include road traffic accidents, falls and
fights. Injury capable of causing bleeding into the joint can induce ankylosis if adequate
treatment is not administered.
Though rare, trauma as a cause of ankylosis of the mandible may be from forceps delivery as
reported below.
Figure 5.1: Asymmetry of the mandible, with fullness
of the right and flatness of the left cheek.
Figure 5.2: Posterior crossbite on the right and
mandibular midline shifted to the same side.
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Figure 5.3: Bony fusion at the medial and lateral margins of the condyles
and diminished joint space.
This healthy looking two and half years old female presented in the clinic with inability to open
the mouth. Her mother reported that shortly after birth, she noticed that she could not put a spoon
into her baby’s mouth while feeding her.
Gradual decrease in mouth-opening in the absence of fever should be reported to the oral and
maxillofacial surgeon immediately.
About the age of 6 months, there was asymmetry of the lower jaw. There was no history of a fall
or trauma to the mandible or TMJ area since birth, and no severe neonatal fevers or oral
infection. She however disclosed that she had a difficult labour and was delivered of her baby by
use of obstetrics forceps (Obiechina, Arotiba , Fasola 1999).
We conducted further studies.
The aim was to determine the relationship between the etiological factors, duration of ankylosis,
the type of ankylosis and to evaluate the different treatment modalities.
Out of 36 cases studied, 19 were males and 17 females representing an approximate ratio of 1:1.
The results showed that TMJ ankylosis predominantly affected children aged 15 years and
below. Seventy-five percent of the cases were not more than 10 years of age. The youngest was 6
months old and the oldest was 39 years (Mean 8.2 years). Our records revealed that 26 (72.2%)
of the patients or their parents were of low socio-economic class
.
22
Table 5.1: Aetiological factors
Aetiology Male Female Total %
Cancrum oris 7 8 15 41.7
Trauma 5 3 8 22.2
Otitis media 3 3 6 16.6
Osteomyelitis 1 2 3 8.3
Forceps delivery 1 1 2 5.6
Unknown 2 0 2 5.6
Total 19 17 36 100
Aetiology can be divided into two categories namely, infection and trauma representing 66.6%
and 27.8% respectively.
Infection comprises cancrum oris, otitis media and osteomyelitis while trauma includes falls,
road traffic accidents and forceps delivery. Unknown factor was recorded when no obvious cause
of ankylosis was observed and the patient could not associate the condition with any cause.
Ankylosis due to cancrum oris and osteomyelitis were mainly extracapsular . The only case of
intracapsular ankylosis arising from osteomylitis was in a sickle cell patient. Otitis media, trauma
and forceps delivery resulted in intracapsular ankylosis. Bony and mixed fibrous and bony
ankylosis recorded 61% and 16.7% respectively, and were seen in cancrum oris. Ankylosis with
bony component totalled 77.7%.
A significant relationship was established between infection and trauma as aetiologocal factors
and types of ankylosis according to anatomic site (p0.05).
Table 5.2. Time interval between onset of ankylosis and treatment.
Months ≤ 6 6+ - 12 12+ - 18 18+ - 24 > 24 Total
Cancrum oris 0 2 0 1 12 15
Trauma 1 2 0 0 5 8
Otitis media 0 2 0 0 4 6
Osteomyelitis 0 0 0 0 3 3
Forceps delivery 0 0 0 0 2 2
Unknown 2 0 0 0 0 2
Total 3 6 0 1 26 36
% 8.3 16.7 0 2.8 72.2 100
Time of onset of ankylosis was recorded as the time the patient or parent observed limitation of
mouth opening. Only 25% of cases came for treatment within 12 months of onset of ankylosis,
while 72.2% reported after 24 months. In fact 13 (36.1%) patients reported for treatment after 10
years of onset. The high percentage of cases reporting after twenty-four months of onset (72.2%)
23
correlates significantly to ankylosis that has bony components (77.7%). The same similarity was
noted between cases seen within 12 months of onset (25%) and fibrous ankylosis (22.3%).
Treatment Outcome
Treatment outcome was regarded as satisfactory if patient can masticate, close the jaws into
centric occlusion and has mouth opening of not less than 2.5cm. Follow up was for a period of
18 months. Of the 36 patients, 7 (19.4%) were lost to follow up. Ankylosis recurred in 11
(30.6%) and 18 (50%) had satisfactory results.
Figure 5.4: Ankylosis of the Mandible; Before Surgery
Figure 5.5: Ankylosis of the Mandible; After Surgery.
24
Table 6.3. Summary of Treatment, Type of Ankylosis and Outcome.
Treatment Type of ankylosis No. of cases Outcome
Jaw exercise only Fibrous/intra- 3 Satisfactory-3
capsular
Fibrous/extra- 2 Satisfactory-2
capsular
Condylectomy Fibrous/intra- 3 Satisfactory-3
capsular
Gap arthroplasty Bony/intra- 9 Lost to follow up –2
capsular Recurred -4
Satisfactory -3
Bony/extra- 5 Lost to follow up –1
capsular Recurred -3
Satisfactory -1
Mixed/extra- 6 Lost to follow up -3
capsular Recurred -3
Interpositional Bony/extra- 6 Recurred -1
arthroplasty capsular Satisfactory -5
Bony/intra- 2 Satisfactory -2
capsular
From our experience, majority of the cases are from poor socio-economic class and this should
be regarded as very crucial to the treatment method of choice for the patient. Those of low socio-
economic class cannot afford expensive interpositional materials, long stay in hospital or
additional surgery for whatever reason. The technique adopted should be simple. It should
achieve adequate mouth opening and closure into centric occlusion. It should be both functional
and satisfactory to the patient.
Based on this study we adopted a treatment protocol which has become popular in this country
and some developing countries with similar problems. This includes the use of acrylic screw,
condylectomy, gap arthroplasty and interpositional arthroplasty.
Use of acrylic screw: i) Ankylosis must be of less than six months duration. ii) It must of the
fibrous variety, confirmed by radiographs and/or computed tomography scan. iii) Ankylosed
mandible must have mouth opening enough to admit at least the second groove on the mouth-
screw. iv) The patient must be adequately motivated. Where significant mouth opening was not
achieved within a week, the method should be abandoned and an appropriate surgical technique
was adopted.
Condylectomy: Condylectomy should be performed on patients who present with unilateral
fibrous intracapsular ankylosis and disarticulation of the condyle does not pose any problem that
could lead to perforation of the roof of the gleniod fossa.
Gap Arthroplasty: Our experience with gap arthroplasty was less than satisfactory. The rather
high rate of recurrence could be attributed to the high potential for new bone formation within
25
the age group. Without an interposing medium the gap can be readily bridged through
osteogenesis. We use gap arthroplasty for the elderly.
Interpositional Arthroplasty: The bulk of the masseter muscle, the temporalis or temporalis
muscle was sufficient to maintain the ramus height while acting as a barrier to prevent
reankylosis. We preferred this method because it is free from donor site morbidity and produced
satisfactory results (Obiechina, Arotiba , Fasola 1999).
MAXILLOFACIAL RECONSTRUCTION
Distortion of the maxillofacial region may be due to congenital causes, trauma, or tumour.
7. Trauma – Gunshot injuries
A study was conducted on 22 cases (3 females; 19 males) of gunshot injuries to the
maxillofacial region. The age range was 10- 60 years (mean 35.4, SD 11.8 years).
Table 7.1: Distribution of aetiology by age group
AETIOLOGY AGE GROUP
10-20 21-30 31-40 41-50 51-60 TOTAL (%)
Accidental discharge 2 1 1 0 0 4 (18.18%)
Attempted suicide 0 0 3 0 0 3 (13.64%)
Armed robbers 0 3 3 3 1 10 (45.45%)
Unknown assailant 1 0 1 0 1 3 (13.64%)
Communal conflict 0 1 0 0 0 1 (4.55%)
Student gangs 0 1 0 0 0 1 (4.55%)
Total 3 6 8 3 2 22
(%) 13.64 27.27 36.36 13.64 9.09 100
We observed that the commonest cause was attack by armed robbers (45.45%), next was
accidental discharge (18.18%). (Please take note of how Policemen carry their guns.)
48.5% constitute injuries that are comminuted with avulsion of soft tissue. The nature of the
injuries and late presentation pose problems of reconstruction. (Obiechina, Fasola 2001)
26
Figure 7.1: Nightguard with avulsion and comminuted gunshot injuries.
Figure 7.2: Nightguard: First stage reconstruction
27
Figure 7.3: Nightguard: Second stage reconstruction.
Patient said he was overwhelmed and satisfied with the outcome of surgery, and that further
reconstruction was not necessary. Try as I could to convince him, he remained adamant and
discharged himself.
8. Tumours
Tumours of the jaw are notoriously known to destroy the jaw bones.
Figure 8.1: Large swelling on the floor of the mouth (congenital sublingual dermoid) of a 4-
year old boy.
28
Figure 8.2: The 4-year old boy after surgery
Figure 8.3: Tumour of the maxilla in 18-year old boy
29
Figure 8.4: The 18-year old boy after surgery
Figure 8.5: Tumour of the maxilla in 18-year old female
30
Figure 8.6: The 18-year old female after surgery
9. Mandibular reconstruction with iliac crest (Hip Bone)
There are several materials and methods for mandibular reconstruction. These include the use of
alloplasts and autogenous bonegrafts. Alloplast materials in use include stainless steel, titanium,
dacron urathane , hydroxyapatite and silastic. Free nonvascularised graft for mandibular
reconstruction include ribs, frozen autogenous bone and iliac crest. Although iliac crest is more
readily vascularised than the rib, its use has often been limited to the reconstruction of relatively
short segments of the mandible. Often, split- thickness ilac bone is used.
We conducted a study. The aim was to determine the efficacy of full-thickness iliac crest bone in
immediate reconstruction of segments of the mandible.
Twenty mandibular resections with immediate reconstruction were done. In 5 patients where the
lesion extended from the symphyseal region to the ascending ramus compromising the condyle,
hemimandibulectomy was done. In 15 patients, 1 to 3 segments of the mandible were resected
and the iliac crest was sufficient to span the defect.
31
Figure 9.1: Before Surgery
Figure 9.2: Iliac bone grafted to the mandible
Figure 9.3: After Surgery
Full thickness graft (cortico-medullary) of the ilium was the graft of choice, thus taking
advantage of its properties. With its generous cancellous component sandwiched by compact
bone, the iliac crest has both rigidity and strength, while the cancellous part enhanced the take of
the graft. In 4 patients who were followed up for two years, resorption was minimal. This could
be attributed to the quick integration of the graft and resistance to resorption of the compact parts
of the bone. The iliac crest thus provided adequate base for denture support and the bulk of the
32
graft seemed sufficient to support osteointegrated implant. Although dental implant was not
placed in any of the grafts, the suitability of the iliac crest in securing osteointegrated implants
have been reported
Figure 9.4: Reconstruction of the Hemi-mandible with Iliac Bone
Figure 9.5: Reconstruction of the Hemi-mandible with Iliac Bone
Patient after surgery.
Unlike most cases where the iliac crest was used to bridge continuity defect of one to two
contiguous segments, we were able to bridge as much as four contiguous segments, from the
33
sypmhysis to the ascending ramus in patients where hemimandibulectomy was done. (Obiechina
et al 2003).
The surgery was very cost-effective. Surgery was performed once. The patient at no additional
financial cost provided the raw material. . With this graft, patients can have their teeth back,
even when half of the mandible have been removed.
10. Combined Acrylic and Stainless Steel Implant in Mandibular Reconstruction
Here is the case of a 23-year old male undergraduate who presented with a painless facial
swelling of one-year duration.
Figure 10.1: A 23-year old male undergraduate with a painless facial swelling of one-year
duration.
Investigation showed complete destruction of the mandible.
We were racing against time and something had to be done urgently to save the patient. The
sponsor could not afford expensive titanium mandibular reconstruction implant. Even if the
sponsor could, it may be too late by the time the material would arrive.
In the dental laboratory at the Faculty of Dentistry, we fabricated a Combined Acrylic and
Stainless Steel Implant.
34
Figure 10.2: Combined Acrylic and Stainless Steel Implant
We used this material to reconstruct the mandible.
Figure10.3: During Surgery
35
Figure 10.4: 8 weeks after Surgery.
This material can be readily fabricated and is being used by some oral and maxillofacial
surgeons in the country. (Obiechina et al)
Some of these cases that I did that were featured on NTA Network and other TV stations in the
country.
CONCLUSION
The training of oral and maxillofacial surgeon is cost intensive and exceeds what it takes to train
a medical counterpart. Financial resources are meager and this has adverse effect on the quality
of graduates. Therefore training and research should focus on needs relevant to Nigerian
situation. The Nigerian trained oral and maxillofacial surgeon should be able to manage orofacial
diseases and disorders that are common in our society with available resources. Research should
be tailored to find solutions to our problems through affordable materials and techniques.
The need to educate the populace on the diseases and disorders of oral and maxillofacial region
is imperative. On this note I add; never take toothache for granted. Seek immediate appropriate
treatment. Consult your dentist or oral and maxillofacial surgeon.
ACKNOWLEDGEMENTS
I wish to express my profound gratitude to my parents of blessed memory who had no formal
education. Yet they cherished academic excellence and labored so hard to ensure that all their
children including I, the fourth among my six other siblings were well educated. My siblings and
their families have generously showered me with love, financial and moral support. To Chris,
John, Paul, Evelyn and Joe, I am extremely grateful for your selfless contributions.
For my academic achievements, I wish to thank all my teachers, particularly those in Dentistry.
Professor JO. Daramola and Professor HA. Ajagbe have been and still are my academic masters
who brought me up in the field of Oral and Maxillofacial Surgery. I wish to pay special tribute to
Professor HA. Ajagbe who has been a role model to me. He has consistently identified himself
with the growth and progress of Dentistry in this University and has always been there for us,
36
any day, anytime. He is infact the Father of Dentistry in this University. If it were not for him, I
probably would not be here today. When I completed my postgraduate training, there was only
one vacancy in the department and that position went to a foreigner. Professor Ajagbe insisted
that I was one of their own, an alumnus. He borrowed and secured a place for me. But he had not
finished yet. He made sure he cloned a professor of Oral and Maxillofacial Surgery before he
quit active service, and that clone is delivering this lecture. Professor Ajagbe has a twin brother
so cherished and so caring and always by his side, that they virtually share everything. I therefore
wish to express my profound gratitude to you and “Brother Janet”.
I wish to sincerely appreciate the Acting Dean Dr. JO. Lawoyin, staff of the departments in
Dentistry and members of the faculty for their contributions and sacrifices to ensure the success
of this occasion.
Mr. Vice Chancellor Sir, it is indeed a privilege to acquire education and work in this institution
and I most grateful to the University of Ibadan to have provided me this opportunity. I wish to
show my appreciation to the Vice Chancellor, Professor A.O. Falase, Sir, for inspiring me to my
success. This may come as a surprise to you sir, but its true. Right from the era of brain drain,
each time we met, and I greeted you, you responded by calling me the Chief of Dentistry. I often
wondered: Me!, Chief of Dentistry! But later I caught it, and worked towards it. And here it has
come to be. His response was wisdom of the Heart. The heart knows what the head does not
know. Don’t ask if he still calls me Chief of Dentistry! Because he still does.
I appreciate the contributions of Professors Akinkugbe, Nwoku, Osuagwuh, Asuzu, Ijaduola.
There are so many people who have contributed in no small measure to my upliftment and
success but time constrains me from listing their names individually. Please know that my heart
is filled with gratitude and appreciation for all you have done for me. And a big thanks to Bayo
for his assistance in this presentation. My sincere gratitude to my inlaws and friends for their
support, especially those of them that are present today.
To a large extent, my immediate family is the bedrock of my success. They have provided
conducive atmosphere, support and love that have given me the strength and motivation to
achieve my goal. Ogo, Zim and Chidinma constitute members of this very happy family and they
have each played their role enviably well. I love you with all my heart.
Finally, I have derived a lot of satisfaction and fulfillment from the lessons of life as the
Almighty God would dish to me. My profound gratitude to a friend so dear, my Spiritual Master
and Teacher, Sri Harold Klemp, the Spiritual Leader of ECKANKAR who is teaching me the
way of life, the secret of love and the wisdom of the heart.
Mr. Vice Chancellor sir, distinguished ladies and gentlemen, accept my gratitude for your time
and patience.
THANK YOU FOR LISTENING.
37
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39