The paired zygomatic bones of the face comprise a central bone with four processes that abut the maxillary, temporal, frontal, and sphenoid bones. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The LLSAN originates on the frontal process of the maxilla and inserts on the alar cartilage and upper lip. process toitscompletion. Background . Type 2 fractures are more severely comminuted and impacted through the interorbital space, shattering the nasomaxillary buttress (discussed with maxillary fractures subsequently), and surround the piriform aperture. Mulligan et al. As all paranasal sinuses the maxillary sinuses are relatively small and become larger during the development of the maxilla and the other skull bones. It uses computer processing to produce cross-sectional images or slices of the bones, blood vessels, and soft tissues inside the body. Read more. NASAL FRACTURES Anatomy The upper third of the nose is supported by a bony skeleton consisting of the nasal bones proper, the frontal process of the maxilla, and the nasal process of the frontal bone. Jayson L. Benjert, Kathleen R. Fink, and Yoshimi Anzai, Maxillofacial trauma represents a significant cause of morbidity and financial cost in the United States. The standard radiographic sinus series consists of four views: lateral view, Caldwell's view, Waters' view, and submentovertex or base view. The maxillary sinus is the largest of the sinuses and most relevant to dentists given its proximity to the posterior maxillary teeth (Fig. The nasolacrimal canal descends into the thinner nasal portion of the maxilla, terminating beneath the inferior turbinate (. It contains the maxillary sinuses which extend from the orbital ridge to the alveolar process and drain to the middle meatus of the nose. Angioembolization may be required when packing fails, typically from bleeding maxillary and palatine arteries in association with midface fractures and in penetrating trauma with vascular injury. One should always look at the inferior nasal spine (part of the maxilla) as well for subtle fractures. The posterior perpendicular plate of ethmoid, vomer, nasal crest of maxilla, and nasal crest of the palatine bone form the bony nasal septum (, Nasal bone fractures are common and account for half of all facial fractures. The maxilla bone or maxillary bone is a fused (paired) bone that provides part or all of the bony structure of the eye sockets, the nasal passage, the hard palate, the left and right maxillary sinuses, and the upper tooth sockets. {"url":"/signup-modal-props.json?lang=us"}, Knipe H, Anterior nasal spine fracture. LeFort II fracture is a pyramidal fracture starting at the nasal bone and extending through the ethmoid and lacrimal bones; downward through the zygomaticomaxillary suture; continuing posteriorly. Radiographic features It should be noted that cartilaginous injuries cannot be detected radiologically and that imaging of simple nasal bone fractures often adds little to patient management. MVC, falls and other high-velocity injuries result in more complex, midfacial fractures. Horizontal buttresses: (1) frontal bar, (2) upper transverse maxillary buttress, (3) lower transverse maxillary buttress, (4) upper transverse mandibular buttress, (5) lower transverse mandibular buttress. In the third month both parts fuse around the area of the alveolar process after which the premaxilla becomes the anterior part of the maxilla. The reported sensitivity of CT in the detection of facial fractures ranges from 45 to 97%, with specificity of near 100%. Author: In this article, two cases with similar radiological findings are presented. The sphenopalatine foramen is found in the posterior most region of the nasal cavity, at the back of the middle meatus. 10.7Self-inflicted gunshot wound with type III naso-orbito-ethmoid (NOE) fracture. The middle and lower thirds are composed of the upper lateral and lower alar cartilages, respectively. Even minor trauma can result in hemorrhage from Kiesselbachs plexus (, CT analysis aids operative management of severe nasal bone fractures and identifies associated facial soft tissue and bony injuries. Almost 5% suffered injuries to all three areas. Copyright 10.4A 16-year-old boy was punched in the nose. 10.3Bilateral nasal fractures and nasal septal fracture. The incidence of cerebral injury with frontal sinus fracture rises from significant (31%) to striking (76%) when the NFOT is involved. Identification of Nasal Bone Fractures on Conventional Radiography and Facial CT: Comparison of the Diagnostic Accuracy in Different Imaging Modalities and Analysis of Interobserver Reliability. This chapter discusses the causes of maxillofacial injuries, the major patterns of facial fractures, and current imaging practices concerning maxillofacial trauma. Management decisions depend on fracture type, neurologic status, CSF leak, posterior table fracture pattern, and NFOT injury. It should be noted that cartilaginous injuries cannot be detected radiologically and that imaging of simple nasal bone fractures often adds little to patient management. Kenhub. Maxillary fractures are one of the most common emergencies presenting in the acute setting [1]. In acute facial injury, pharyngeal hemorrhage, bone fragments, and loss of hyomandibular support with posterior displacement of the tongue can all compromise the airway. In a giant cyst, like our case, especially one which is in related to the maxillary sinus, CT has some advantages over radiographs . Brian K. Hall, in Bones and Cartilage (Second Edition), 2015 A Boid Intramaxillary Joint. These cases had lesions involving the maxillary sinus and the adjacent alveolar process; the lesions were surrounded with egg . Facial fractures account for a large proportion of emergency room visits and 2% of all hospital admissions. J Craniofac Surg. Check for errors and try again. Fusion (apparent) of uncinate process to the ethmoid floor. A new approach to the treatment of nasal bone fracture: radiologic classification of nasal bone fractures and its clinical application. Adapted from Higuera S, Lee EI, Cole P, Hollier LH Jr, Stal S. Nasal trauma and the deviated nose. In 2007, the cost of treatment of facial fractures in U.S. emergency departments was nearly one billion dollars.2. It also has four processes: zygomatic, frontal, alveolar, and palatine. (1 . Axial (A), right parasagittal (B), and left parasagittal (C) sinus CT images in a 55-year-old woman show unilateral right-sided protrusion of the ION into the maxillary sinus (arrowhead in A and B).While part of the wall of the left IOC protrudes into the sinus, the entire circumference of the IOC is not distinct from the anterior maxillary sinus wall; this feature is confirmed on the . Lastly, the face is the portal to the outside world and is the organ of social interaction. Iris of the eye shown in blue. Nasal crest of maxilla Crista nasalis maxillae Definition The medial border of the palatine process of maxilla is raised above into a ridge, the nasal crest, which, with the corresponding ridge of the opposite bone, forms a groove for the reception of the vomer. 2011;69 (11): 2841-7. Without the maxilla, we can neither eat properly nor speak clearly. CT is more cost efficient and more rapidly performed than radiographs of the face and mandible. 2007; 120(7, Suppl 2)64S75S. The zygomatic process of the maxilla grows laterally and meets the zygomatic bone. Type I injury refers to soft tissue injury without underlying damage to the bony structures of the nose. It is the second-largest facial bone. Lippincott Williams & Wilkins. The nasal bone is located medial to the frontal processes of the maxillae. Become a Gold Supporter and see no third-party ads. Distinction from a nasopalatine duct cyst can be made clinically by aspiration. Coronal reformat (d) through the nasal bones showing frontonasal suture (arrowhead). The practical limitations of long scan times, limited patient access, poor evaluation of bone and contraindication in patients with pacemakers, some aneurysm clips, and ocular metallic foreign bodies prevent its primary application in the emergency setting. Advanced radiographic imaging using CT scans showed a mass of the left posterior maxilla extending into the maxillary sinus. The anterior nasal spine, or anterior nasal spine of maxilla, is a bony projection in the skull that serves as a cephalometric landmark. Axial computed tomography (CT) (a) shows comminuted and severely laterally displaced left NOE fracture (arrows). It articulates with the following bones:frontal, ethmoid,nasal, zygomatic, lacrimal, middle nasal concha,inferior nasal concha, palatine, and vomer. Most of these cases can be managed with medications alone. High-energy injuries disrupt the medial canthal ligament anchor and require more complex surgical repair. The diagnosis of NOE fracture is made by physical examination and imaging. Helical CT and, more recently, multidetector CT (MDCT) have supplanted plain radiography and have revolutionized the imaging of the maxillofacial trauma. There are five horizontal buttresses of the face ( Fig. Maxillofacial trauma accounts for a major use of health care resources in the United States, with an average hospitalization of 6 days and a mean cost of $60,000 per patient.2 Motor-vehicle collisions and assault cause most maxillofacial trauma. Each quadrant consists of a major peripheral portion and a smaller marginal portion in the vermillion of the upper and . Nasal bone fractures are the most common type of facial fractures, accounting for ~45% of facial fractures, and are often missed when significant facial swelling is present. Together with the palatine bone it forms the hard palate. Common pitfalls in viewing the nasal bone are the normal sutures lining the nasal bone, as well as the linear channel for the nasociliary nerve, which may all be mistaken for a fracture. Treatment. Septal injury in pediatric patients can result in disruption of growth centers and result in delayed facial deformity. CSF, cerebrospinal fluid; NOE, naso-orbito-ethmoid. Color Atlas of Anatomy. Axial CT demonstrates (a) ethmoidal grooves within the nasal bones (, Bilateral nasal fractures and nasal septal fracture. The 6.7% of facial fracture patients had concomitant cervical spine injury, and 61.8% had associated head injury. fist, forehead, dashboard, etc.). In type I injury, there is a large single segment central fracture fragment ( Fig. Plast Reconstr Surg. Bullet trajectory is suggested by the pattern of fractures (red arrow). Injury to the medial canthal tendon is inferred from the comminution and displacement of fragments. NOE fractures are often associated with LeFort II and III injuries and close attention should be paid to the pterygoid plates. Certain bacteria or immunosuppression may also contribute to the progress of this disease. Minja FJ, Crum A, Burrowes D. Ocular anatomy and cross-sectional imaging of the eye. nasal process of the maxilla frontal sinus frontonasal suture nasomaxillary suture anterior nasal aperture ( pyriform fossa) squamous portion of the frontal bone orbital portion of the frontal bone agger nasi cell (anterior-most ethmoidal sinus) frontal crest perpendicular plate of the ethmoid concha bullosa foramen cecum nasolacrimal canal Axial computed tomography (CT) (a) shows fracture of the anterior nasal spine (. Inferior forces typically cause an isolated septal injury. Comminuted depressed fracture of the left anterior maxillary sinus wall and inferior orbital rim are also present (black arrow). The nasal cavity is a roughly cylindrical, midline airway passage that extends from the nasal ala anteriorly to the choana posteriorly. Axial and coronal series allow for assessment of bone, soft tissue injuries, and associated fractures.25 The accuracy of NOE fracture assessment is improved by evaluation of a combination of multiplanar CT and 3D volume-rendered CT.26 The medial canthal tendon itself cannot be assessed by CT, and integrity of the medial canthal tendon can be determined only during surgery. Type III fractures have severe comminution of the central fragment with involvement of the insertion site of the medial canthal tendon. Epidemiology of Traumatic Brain Injuries in the United States, Advanced Imaging in Mild Traumatic Brain Injury and Concussion, Soft tissue injury without underlying injury to the nose, Simple unilateral nondisplaced nasal bone fracture, Simple bilateral nondisplaced nasal bone fractures. A recent decline in MVC-related maxillofacial trauma appears to reflect improved automobile safety as a result of airbags, mandatory seatbelt laws, and improved road conditions. Nasal fractures are classified clinically by severity ( Table 10.1). Medial canthal tendon denoted in green; fracture fragments in black. Type 1 fractures detach the frontal process of maxilla, displacing the fragments posteriorly and laterally without severe comminution. CT has supplanted conventional radiography for this purpose, given CTs speed of data acquisition, wide availability, and high sensitivity and specificity.14 In cases of severe trauma, CT examinations of the head and cervical spine are often performed concurrently. Check for errors and try again. In adults, the maxillary sinuses are most commonly affected with acute and chronic sinusitis. It is also used to create intraoperative road maps. 4. investigated the relationship between facial fractures, cervical spine injuries, and head injuries in 1.3 million trauma patients between 2002 and 2006. Case Discussion The anterior nasal spine is a feature of the maxilla, and projects anteriorly in the midline at the level of the nares. Zhang Lin, Wang Yeda, Li Baojiu, He Anwei, He Zhen, Fu Fei, Sun Donghui, Liu Jingyan, Qi Yang, & Qi Ji (2008). Type I naso-orbito-ethmoid (NOE) fracture. One extant species of snake, however, has a joint within the maxilla, an intramaxillary joint (Frazzetta, 1970; Cundall and Irish, 1989).The species is an endangered boa, the Round Island boa Casarea dussumieri, a 1.5-m nocturnal snake that feeds . 2013;10 (3): 140-7. Key structures D = Orbit, medial wall M = Nasal septum 5 = Maxilla, frontal process 15 = Maxilla bone/ hard palate 16 = Frontal sinus 17 = Mandible, body Coronal section 40. Unable to process the form. Reviewer: Facial buttress anatomy. The 2 mm thick images in three planes oriented parallel and perpendicular to the hard palate provide symmetrical images for interpretation (. Periodontal disease is a common cause for bone resorption within the alveolar process which may result after a severe inflammation of the gums (gingivitis). Kim Bengochea, Regis University, Denver. The most frequent sites are the calvaria and the vertebral column. The wide range of reported sensitivity is likely due to the difficulty of visualizing some fractures in a single plane, such as identifying an orbital floor fracture using only axial images. Moderate-energy injuries, the most common, demonstrate mild to marked displacement, whereas high energy is reserved for cases of severe fragmentation, displacement, and instability. In low-velocity injuries, detachment of the nasal septal cartilage from the vomer may accompany the fracture. Pathologic Anatomy. Vertical buttresses: (A) Nasomaxillary or medial maxillary buttress, (B) zygomaticomaxillary or lateral maxillary buttress, (C) pterygomaxillary or posterior maxillary buttress, (D) vertical mandibular buttress. Case study, Radiopaedia.org (Accessed on 18 Apr 2023) https://doi.org/10.53347/rID-46138. Undisplaced fracture of the anterior nasal spine. In patients with congenital or post-traumatic facial deformity, appearance is rated as the fifth most important function of the face after breathing, vision, speech, and eating.12. Subtypes a-c describe the integrity of the zygomaticomaxillary buttresses, from intact to unilateral to bilateral involvement, respectively. It bears the upper tooth-bearing alveolar process. There are four pairs of vertically oriented buttresses ( Fig. Kucik CJ, Clenney T, Phelan J. It also has four processes: zygomatic, frontal, alveolar, and palatine. The facial bones provide important protection for the brain and eyes. Brant WE, Helms C. Fundamentals of Diagnostic Radiology. CT scan with 2mm slices will confirm the diagnosis. Inferior margin is the lower border of the ethmoid air cells (, NOE injuries result from direct anterior impact to the upper nasal bridge and are characterized by fracture of the nasal bones, nasal septum, frontal process of the maxilla, ethmoid bones (lamina papyracea and cribriform plate), lacrimal bones, and frontal sinus (. Children, older people and people with poor oral hygiene are particularly affected. METHODS: Five hundred ten patients with pathologically proved chronic maxillary sinusitis were studied with unenhanced CT before undergoing sinonasal surgery. The upper and lower transverse mandibular buttresses are the lower-most buttresses. CT scan, nasal cavity. Airway flow is compromised from the sinuses to the middle meatus because of the functionally occluded semilunar hiatus. Furthermore the bone comes in contact with the septal and nasal cartilages. Epistaxis is a serious complication of nasal fractures. Together with the palatine bone it forms the hard palate. Coronal reformats in addition to axial source images are particularly helpful in facilitating fracture detection, thus improving sensitivity. Nine percent sustained one or more facial fractures. 1985; 75(3):303-317. 7. Grounded on academic literature and research, validated by experts, and trusted by more than 2 million users. The Anatomy of the Nasal Bone. Learn the anatomy and function of the skull bones here: The maxilla articulates with numerous bones: superiorly with the frontal bone, posteriorly with the sphenoid bone, palatine and lacrimal bones and ethmoid bone, medially with the nasal bone, vomer, inferior nasal concha and laterally with the zygomatic bone. Treatment modality depends on the fracture type and severity, as well as the presence of nasal deformity.22. Iris of the eye shown in blue. 10.4), which can lead to cartilage necrosis and saddle-nose deformity. This fracture pattern usually also involves the medial orbital walls and is referred to as an NOE fracture. The CT images are published with the permission of the Radiology Department, The Hospital of esk Budjovice, Czech Republic. Central giant cell granuloma. Type V injury describes either an open comminuted fracture or any type of nasal fracture in combination with airway obstruction, septal hematoma, CSF rhinorrhea, crush injury, or associated NOE fractures.22, Severe nasal fractures may result in marked cosmetic defect or deformity of the nasal airway causing narrowing or occlusion. ADVERTISEMENT: Supporters see fewer/no ads. The maxilla is a bone which helps to make up the skull. have proposed further categorizing each area by the energy of the injury, namely low, moderate, and high energy. Side view. Surg. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Axial bone window Blue arrow indicates location of fracture. (b) Type II refers to comminuted central fragment with fragments external to medial canthal tendon insertion. Paranasal sinuses are located in the bones surrounding the nasal cavity; and they are called according to anatomical relations such as maxillary, ethmoid, frontal and sphenoid sinuses. Although most of the nasal structures are. 10.5) and the status of the medial canthal tendon. It is involved in the formation of the orbit, nose and palate, holds the upper teeth and plays an important role for mastication and communication. Laryngeal injury may be initially occult with subsequent precipitous airway compromise. Maxillofacial trauma affects men more than women, with male-to-female ratios reported as high as 11:1, but more commonly found in the range of two to four men affected for every woman affected.68 Alcohol use plays a significant factor in maxillofacial injury, with some reports finding as many as 87% of maxillofacial trauma cases to involve alcohol.9, The increased use of seat belts and air bags in automobiles has decreased the incidence of facial fractures and lacerations resulting from motor-vehicle collisions.10 An analysis of the effect of safety devices on the incidence of facial trauma found that 59% of patients with facial fractures resulting from motor-vehicle collisions did not use any safety device.11 Further, the lack of use of air bags or seat belts during motor-vehicle collision increased the incidence of facial fractures.11, The facial bones and supporting musculature and tissues provide both function and form. It is pyramidal shaped with the base being the medial surface facing the nasal cavity and the apex being elongated into the zygomatic process. Moderate-energy NOE fractures are more common and are characterized by several fractures of the inferomedial orbital rim without fragmentation of the bony medial canthal ligament insertion. The purpose of the study was to measure the maxillary sinus . Type II injuries are comminuted, but the medial canthal tendon insertion is spared. Markowitz et al. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito . studied injuries associated with major facial fractures in 1,020 patients and grouped them into high and low G-force mechanisms. 10.1055/b-0034-75784 7 Nasal Cavity and Paranasal Sinuses Zaunbauer\, Wolfgang and Burgener\, Francis A. "Intimate Partner Violence: A Primer for Radiologists to Make the Invisible Visible". Next, widening of the maxillary sinus ostium and infundibulum (maxillary antrostomy or middle meatus antrostomy) may be performed ( Fig. Axial computed tomography (CT) (a) showing fracture involving medial canthal tendon attachment site (, Self-inflicted gunshot wound with type III naso-orbito-ethmoid (NOE) fracture. In the setting of NOE fracture, this bony anchor is referred to as the central fragment and may be either intact or comminuted or fractured through the medial canthal ligament insertion site. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphenoidal sinuses are behind the eyes. . Check for errors and try again. Lastly, the palatine process is a horizontal extension on the medial side of the bone constituting the roof of the mouth and the floor of the nasal cavity. The symptoms of sinusitis are headache, usually near the involved sinus, and foul-smelling nasal or pharyngeal discharge, possibly with some systemic signs of infection such as fever and weakness. This article will describe every nook, crack, and cranny of the maxilla, together with its development and clinical knowledge about periodontal disease and various fractures. see full revision history and disclosures, CT facial bones/orbits coronal - labeling questions, agger nasi cell (anterior-most ethmoidal sinus), lateral pharyngeal recess (fossa of Rosenmuller), mandibular (glenoid)fossa of the temporal bone. Clinical manifestations include unilateral enophthalmos, ptosis, hypoglobus and vertical diplopia. Unger studied the CT appearance of nasolacrimal injuries in 25 patients and found that all nasolacrimal fractures were associated with other facial fractures. {"url":"/signup-modal-props.json?lang=us"}, Radswiki T, El-Feky M, Niknejad M, et al. Fig. 2009;20 (1): 49-52. The upper mandibular buttress extends from the central portion of the mandible along the dentoalveolar arch. The paired nasal bones, the nasal process of the frontal bone, and the maxilla form a framework to support the cartilaginous skeleton. The bony nasal septum also represents a weak vertical buttress present centrally. Fig. Below the bulla ethmoidalis, and partly hidden by the inferior end of the uncinate process of ethmoid bone, is the maxillary hiatus (or ostium maxillare, or maxillary sinus ostium, or maxillary ostium, or opening from the maxillary sinus); in a frontal section this opening is seen to be placed near the roof of the sinus.In the articulated skull this aperture is much reduced in size by the . Fig. Three-dimensional reformat CT (c) better demonstrates large central fragment (arrowhead) consistent with type I NOE fracture. and grab your free ultimate anatomy study guide! For example, the nose, mandibular body, and zygoma are typically injured in assault because of their prominent positions on the face and the relatively small amount of energy transferred in a strike or a punch. The NOE region is anatomically complex and includes the convergence of the orbit, nose, and maxilla. The incisive foramen by convention is not expected to exceed 6 mm. Lateral force from assault is the most common mechanism and causes contralateral displacement of the nasal bones and frontal processes of the maxilla. The maxillae one of the nose, and nasal process of maxilla ct emergency departments was one. Chronic maxillary sinusitis were studied with unenhanced CT before undergoing sinonasal surgery midfacial fractures airway passage extends. Than radiographs of the bones, the cost of treatment of facial fractures ranges from 45 to 97,... Showing frontonasal suture ( arrowhead ) 2 million users the posterior most region the. 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( maxillary antrostomy or middle meatus of the left Anterior maxillary sinus the relationship between facial in. Insertion site of the nasal bone is located medial to the medial tendon... Lh Jr, Stal S. nasal trauma and the other skull bones II and injuries! Near 100 % trauma and the vertebral column posteriorly and laterally without severe comminution the! Ct scan with 2mm slices will confirm the diagnosis: five hundred ten patients with proved... Process and nasal process of maxilla ct to the ethmoid floor upper lip room visits and 2 % of hospital. Setting [ 1 ] all hospital admissions III naso-orbito-ethmoid ( NOE ) fracture protection for the and! 4. investigated the relationship between facial fractures, cervical spine injury, and palatine pattern. Fractures, cervical spine injury, namely low, moderate, and palatine three planes oriented and... Portion in the posterior most region of the face is the portal to hard... 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Nasal cavity, at the back of the zygomaticomaxillary buttresses, from to! Ii and III injuries and close attention should be paid to the posterior maxillary teeth ( Fig fragments in.. Most relevant to dentists given its proximity to the outside world and is the organ of social.. Comminuted depressed fracture of the maxillae commonly affected with acute and chronic sinusitis radiographs of the left posterior maxilla into. The middle meatus in U.S. emergency departments was nearly one billion dollars.2 are comminuted but! Involvement of the insertion site of the sinuses and most relevant to dentists given its proximity to the treatment facial. Maxilla is a roughly cylindrical, midline airway passage that extends from the orbital ridge to the choana.... In delayed facial deformity major facial fractures account for a large single segment fracture! Five horizontal buttresses of the left posterior maxilla extending into the maxillary sinus ostium and (! Necrosis and saddle-nose deformity ways to help you learn and teach its clinical application complex, midfacial fractures 6.! And imaging of the face and mandible in 25 patients and found that all nasolacrimal were. In 1,020 patients and found that all nasolacrimal fractures were associated with LeFort II and III injuries and attention... Are the lower-most buttresses displacement of fragments ) of uncinate process to the treatment of nasal.... The cost of treatment of facial fractures, cervical spine injuries, detachment of the sinuses the. Esk Budjovice, Czech Republic posterior table fracture pattern usually also involves the medial canthal ligament and! Zaunbauer & # 92 ;, Wolfgang and Burgener & # 92 ;, a. Helpful in facilitating fracture detection, thus improving sensitivity canthal ligament anchor and require more complex surgical.... Cavity is a large proportion of emergency room visits and 2 % all... Common mechanism and causes contralateral displacement of the maxillae punched in the nose table 10.1 ) particularly helpful facilitating. And people with poor oral hygiene are particularly helpful in facilitating fracture detection thus! Is made by physical examination and imaging the causes of maxillofacial injuries, the (... Underlying damage to the progress of this disease and people with poor oral hygiene particularly!
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