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Textbook of Oral and Maxillofacial Surgery
Neelima Anil Malik
SECTION ONE: PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY
1:
Introduction to Oral and Maxillofacial Surgery
Definition
Scope
Multidisciplinary Team Approach
Cleft Lip and Palate
Craniofacial Syndromes
Trauma Unit
Newer Advances
2:
Art of Diagnosis
History Taking
Art of History Taking
Steps in History Taking
1. Obtaining General Information
2. Chief Complaint/s
3. Past/Present Medical History
4. Personal and Family History
Clinical Examination
Extraoral Examination
Inspection
Palpation
Auscultation
Intraoral Examination
Inspection
Palpation
Clinical Diagnostic AIDS
Radiological Examination
Conventional Radiography
Intraoral Radiographs
Extraoral Radiographs
Specialized Imaging
1. Tomogram
2. Ultrasonography
3. Magnetic Resonance Imaging (MRI)
4. Radionuclide Imaging
5. Sialography
6. Arthrography
7. Angiography
8. Electrocardiogram (ECG)
Diagnostic Investigations
1. Routine Haematological Investigations
Haemoglobin (Hb)
Complete Blood Count (CBC)
2. Coagulation Tests
3. Biochemical Analysis
Renal Function Tests
Serum Electrolytes
Liver Function Tests
4. Specific Investigations
ELISA for HIV 1 and 2 Antibodies
Australia Antigen Test
Urine Analysis
5. Bacterial Culture and Antibiotic Sensitivity tests
6. Histopathological Evaluation
Exfoliative Cytology
FNAC
Biopsy
3:
Diagnostic Imaging
Fundamental Tenet of Imaging Modality
Diagnostic Imaging—ALARA Principle
Selection of Imaging Modality
Plain Conventional Radiography
Shortfalls
Magnetic Resonance Imaging—MRI (Figs 3.1 to 3.7)
Limitations of MRI
Radionuclide Bone/Skeletal Scan or Scintigraphy (Figs 3.8 to 3.14)
Indications of Scintigraphy
Clinical Applications
Advantages of Scintigraphy
Ultrasonography (USG) (Figs 3.15 to 3.20)
Advantages
Limitations
Ultrasonography Procedure
Application
Computed Tomographic Scan (CT Scan) (Figs 3.21 to 3.30)
About CT Scan
Techniques
Newer Advanced Softwares for CT Scans
Advantages
Disadvantages
Acquisition of Axial CT Scan
4:
Management of Medically Compromised Patients in Oral Surgery
Classification of Physical Status
Cardiac Diseases
Preoperative Investigations
Preoperative Medication
Intra and Postoperative Management
Hypertension
Preoperative Investigations
Preoperative Medication and Management
Intra and Postoperative Management
Respiratory Diseases
Preoperative Investigations
Intra and Postoperative Management
Renal Diseases
Preoperative Investigations
Intra and Postoperative Management
Hepatic Diseases
Preoperative Investigations
Intra and Postoperative Management
Diabetes Mellitus
Preoperative Investigations
Intra and Postoperative Management
Thyroid Disorders
Preoperative Investigations
Intra and Postoperative Management
Adrenal Diseases
Preoperative Investigations
Intra and Postoperative Management
Neurological Disorders
Preoperative Investigations
Intra and Postoperative Management
Disorders of the Haemopoetic System
Preoperative Investigations
Intra and Postoperative Management
Management of a Haemophiliac Patient
Immunocompromised Patients
Preoperative Investigations
Intra and Postoperative Management
Autoimmune Disorders
Pregnancy and Lactation
Conclusion
5:
Armamentarium Used in Oral and Maxillofacial Surgery
Instrument Used for Picking Up Sterile Instruments
Cheatle's Forceps (Fig. 5.1A)
Instrument Used for Preparing the Surgical Field
Swab Holder (Fig. 5.1B)
Uses
Instrument Used for Holding the Drapes
Towel Clips (Figs 5.1C and D)
Uses
Instruments Used for Incising the Tissues
Scalpel
Bard Parker Blade Handle (Fig. 5.2-I)
Blades (Figs 5.2-II to V)
Dissecting Scissors (Fig. 5.2-VI)
Instruments Used for Retracting Tissues
1. Langenbeck's Retractor (Figs 5.3A and 5.4A)
2. C-shaped Retractor
3. Austin's Retractor
4. Catpaw Retractor (Fig. 5.4C)
5. Seldin's Retractor
6. Obwegeser's Ramus Retractor (Figs 5.3B and C)
Uses
7. Condyle Retractors (Fig. 5.4B)
8. Weider's Retractor
9. Tongue Depressor (Fig. 5.4D)
Uses
Instruments Used for Reflecting the Mucoperiosteal Flap
Periosteal Elevators (Molt No. 9, Howarth's, Dial's) (Figs 5.5-II,III,V and VI)
Uses
Methods of Reflecting the Periosteum from the Flap
Moon's Probe (Fig. 5.5-I)
Uses
Cleft Palate Raspatory (Fig. 5.5 IV)
Haemostatic Forceps (Spencer Wells, Kelly's, Halstead)
Types of Haemostats (Fig. 5.6)
Uses
Instruments Used for Holding the Soft Tissues
Tissue Holding Forceps
1. Allis' Tissue Holding Forceps (Fig. 5.7A)
2. Lane's Tissue Holding Forceps (Fig. 5.7C)
3. Babcock's Tissue Holding Forceps (Fig. 5.7B)
4. Tissue Holding Forceps (Micro-Adson, Gillie's, Adson's) (Figs 5.13C and D)
Tongue Forceps
1. The Swab Holder Variety
2. Towel Clip Type
Gland Holding Forceps
1. Swab Holder Variety
2. Kocher's Variety
Instruments Used to Drain an Abscess
Lister's Sinus Forceps (Fig. 5.9A)
Haemostatic Forceps
Instruments Used to Keep the Mouth Open
Mouth Prop (Fig. 5.8-I)
Mouth Gag (Doyen's, Fergusson's) (Fig. 5.8-III)
Heister's Jaw Stretcher (Fig. 5.8-II)
Uses
Instruments Used to Remove Pathologic Tissue
Curette (Lucas) (Figs 5.9B and C)
Uses
Volkmann's Scoop (Fig. 5.9D)
Uses
Instruments Used to Cut or Remove Bone
Rongeurs Forceps (Blumenthal, Jensen Middleton) (Fig. 5.10C)
Uses
Miller and Colburn Bone File (Fig. 5.10D)
Bone Cutter
Uses
Chisel (Fig. 5.11-II, III, IV)
Uses
Osteotome (Fig. 5.11-I)
Uses
Mallet (Fig. 5.11-VII)
Bone Gouge (Fig. 5.11-V)
Uses
Hand Piece, Burs and Saws
Uses
Gigli's Saw (Fig. 5.12)
Instruments Used to Hold the Bone
Crocodile Bone Holding Forceps (Figs 5.10A and B) Fergusson's Lion Jaw Bone Holding Forceps
Uses
Kocher's Toothed Heavy Artery Forceps
Uses
Sequestrum Holding Forceps
Uses
Instruments Used to Suture the Tissues
Mayo Hegar Needle Holder (Fig. 5.13A)
Tissue Holding Forceps
Suture Cutting Scissors (Dean's) (Fig. 5.13B)
Instruments Used to Maintain a Clean Surgical Field
Suction Apparatus (Fig. 5.14A)
Suction Tubing (Fig. 5.14B-II)
Suction Tip (Frazier, Nuober) or Cannula (Fig. 5.14B-I)
Instruments Used for the Treatment of Fractures of the Jaw Bones
Rowe's Disimpaction Forceps (Fig. 5.15A-I)
Uses
Hayton William's Forceps
Walsham's Forceps
Asche's Forceps (Fig. 5.15A-II)
Erich's Arch Bar (Fig. 5.15B-VI)
Uses
Wire Holder (Hayton William) (Fig. 5.15B-I)
Wire (Fig. 5.15B-III)
Uses
Bone Plates (Fig. 5.15B-V)
Tracheostomy Set
Tracheostomy Tube
Blunt Hook
Sharp Hook
Tracheal Dilator
Miscellaneous Instruments
Skin Hook (Fig. 5.13E)
Uses
Nerve Hook
Uses
Aneurysmal Needle (Fig. 5.17)
Nasal Rasp (Fig. 5.11-VI)
Bone Spreader (Fig. 5.16)
Drains Used in Oral and Maxillofacial Surgery
Need for Establishing Drainage
Indications for Drainage
Functions
Types of Drains (Figs 5.18A and B)
Penrose Drain
Corrugated Rubber Drain (Fig. 5.18 B-II)
Infant Feeding Tube (Fig. 5.18 B-I)
Nasogastric Tube (Ryles Tube) (Figs 5.18A and B-IV)
Foley's Self Retaining Catheter (Fig. 5.18B-III)
Instruments Used for the Extraction of the Teeth and Root Remnants
Elevators
Work Principles of Elevation (Fig. 5.19)
Indications for the Use of Elevators
Rules to be Followed While Using the Elevators
Commonly Used Elevators
Straight Elevators (Coupland, London Hospital pattern) (Fig. 5.20D-I)
Cryer's Elevator
Winter's Elevator
Winter Cryer's Elevator (Fig. 5.20C-I)
Apexo Elevators (Fig. 5.20D-III)
Hockey Stick or London Hospital Elevator (Fig. 5.20D-II)
Extraction Forceps
Maxillary Extraction Forceps (Fig. 5.20A)
Maxillary Molars (Right and Left)
Mandibular Forceps (Fig. 5.20B)
Surgical Diathermy (Cautery, Electrocautery) (Fig. 5.21)
Monopolar Diathermy
Principles
Precautions
Bipolar Diathermy
Cryosurgery (Figs 5.22 (1 and 2))
6:
Suturing Materials and Techniques
Historical Background
Principles of Suture Material Selection
Biological Response of the Body to Suture Materials
Suture Needles
Needle Eye
Advantages of Eyeless Needles
Needle Body (Fig. 6.2)
Needle Point (Fig. 6.2)
Non-Absorbable Sutures
1. Perma-Hand Surgical Silk
2. Linen
3. Cotton
4. Polyamides
5. Polyesters
6. Polypropylene
7. Stainless Steel
Natural Absorbable Sutures
Surgical Gut
Synthetic Absorbable Sutures
Coated Vicryl - Polyglactin 910 Braided Suture Material
Principles of Suturing
Surgical Knot Tying
Secure/Square Knots
Surgeon's Knot (Fig. 6.3B)
Granny's Knot or Slip Knot (Fig. 6.3C)
Suturing Techniques
Interrupted Suture-Sling Suture (Fig. 6.4)
Advantages
Continuous Over and Over Suture (Fig. 6.5A)
Continuous Locking Suture (Fig. 6.5B)
Mattress Sutures
Horizontal Mattress Suture (Fig. 6.6)
Vertical Mattress Suture (Fig. 6.7)
Figure of 8 Suture (Fig. 6.8)
Subcuticular Sutures (Fig. 6.9)
Suture Removal
Mechanical Wound Closure Devices
Ligating Clips
Surgical Staples
Tissue Adhesives
Dermabond Topical Skin Adhesive
7:
Asepsis and Sterilization
Introduction
Definitions of Various Terminologies
Cleansing of Instruments
Cleansing Agents
Mechanism of Action
Drug Concentration and Therapeutic Index
Temperature and Duration of Contact
Methods of Sterilization
Principles
Moist/Steam Heat Sterilization: Autoclave (Figs 7.1A(1, 2, 3, 4)
Steam Sterilizers (Autoclave) with Pre and Post Vacuum Processes
Precautions
Packaging OR Wrapping Instruments for Autoclaving (Figs 7.10 and 7.11A)
Marking of Packs
Tests for Efficiency for Heat Sterilization
Storage of Sterile Goods
Dry Heat Sterilization
Hot Air Oven (Fig. 7.2)
Glass Beads Sterilizer (Fig. 7.3A)
Ethylene Oxide Gas Sterilization
Sterilization by Low-temperature Steam and Formaldehyde (LTSF) (Chemical Vapour Sterilization/Unsaturated Chemical Vapour Sterilization)
Irradiation
Ionizing Radiation
Non-ionizing Radiation
Ultraviolet Rays
Infrared
Boiling Water
Oil
Disinfection
Methods of Disinfection
Disinfection by Cleaning
Disinfection by Heat
Low Temperature Steam
Disinfection by Boiling Water
Disinfection by Chemical Agents (Figs 7.3B(1) and (2))
Disinfectants
Alcohols — Low Level Disinfectant
Aqueous Quarternary Ammonium Compounds
Phenolic Compounds- Intermediate Level, Broad Spectrum Disinfectant
Aldehyde Compounds—High Level Disinfectant
Formaldehyde
Glutaraldehyde
Antiseptics
Alcohols
Aqueous Quarternary Ammonium Compounds
Hexachlorophene Compounds
Iodophor Compounds — Intermediate level, Broad Spectrum
Chloride Compounds
Operating Room Procedures (Figs 7.4A and B and 7.5)
Relative Humidity (RH)
Temperature
Formaldehyde Levels in the Air in the Operation Theatre
Masks (Fig. 7.6A)
Eye Protection (Fig. 7.6B)
Hair/Beard Cover
Footwear
Antiseptic Environment
Hand Scrub Techniques
Hand Disinfection (Figs 7.7 and 7.8)
Gloving
Preparation of the Surgical Site (Fig. 7.9)
Other Precautions
Common Disinfectants
8:
Infection Control
Introduction
Objective
Infection
Infection Control
Cross-Infection
Routes of Transmission
Infectious Diseases of Concern in Dentistry
Bacterial Infections
Viral Infections
Revised Classification of HIV-associated Oral Lesions (1990)
Group I: Lesions Strongly Associated with HIV Infections
Group II: Lesions Less Commonly Associated with HIV Infection
Group III: Lesions Possibly Associated with HIV Infection
Signs and Symptoms of HIV Disease
Earlier Signs of HIV Infection
Late Signs of HIV Infection (AIDS)
Certain Tumours
General Principles
Universal Precautions
Handwashing and Care of Hands
Personal Protection: Protective Attire Barrier Technique
Prevent Environmental Contamination (Fig. 8.3)
Use of Sharp Instruments and Needles (Fig. 8.4)
Patient Management
Sterilization and Disinfection of Instruments
Disposal of Waste/Infected Materials (Fig. 8.5)
Handling Biopsy Specimens
Prosthodontics
Dental Radiography
Intraoral Techniques
Other Precautions
Rubber Dam Isolation
Minimizing Dental Aerosols and Splatter
Needle-Stick Injury
Measures for Prevention
Postaccidental Management—Chemoprophylaxis
HIV Infection Control
Measures at the Time of Surgery
Measures for Health Care Workers (HCWs)
Waste Disposal in a Health Care Setting
Classification
Aims of Waste Treatment
Segregation (Fig. 8.6)
Disposal of Hospital Waste (Table 8.4 and Fig. 8.7)
Disposal of Infected Waste
9:
Antimicrobial Therapy
Introduction
Classifications
Principles of Antibiotic Therapy
Selection of Antimicrobials
Antimicrobial Combinations
Antimicrobial Prophylaxis
Bacterial Resistance
Removal of Source of Infection
Principles of Antibiotic Administrations
Dosage
Duration
Route and Frequency of Administration
Use of Narrow Spectrum Antibiotic
Antibiotic Prophylaxis
Collaboration between Clinician and Bacteriologist
Beta-Lactam Antibiotics
Penicillins
Classification
Administrations
Oral Administration
Length of Course
Measurements of Penicillin (Units and Micrograms)
Toxic Effects
Anaphylaxis
Other Effects
Cephalosporins
Erythromycin
Preparation
Mode of Action
Pharmacology
Absorption
Excretion
Toxic Effects
Interactions
Use during Pregnancy and Lactation
Concomittant Use of Other Antibiotics
Sulfonamides and Trimethoprim
Absorption, Distribution and Excretion
Toxic Effects
Pregnancy and Lactation
Oral Contraceptives
Sulfadiazine
Cotrimoxazole (Combination of Sulfamethoxazole and Trimethoprim)
Quinolones
Mechanism of Action
Nalidixic Acid
Fluoroquinolones
Antiviral Antibiotics
Acyclovir (Cyclovir, Zovirax)
Valacyclovir and Famciclovir
Ganciclovir
Aminoglycosides
Gentamycin
Vancomycin
Antimycotic Agents
Polyenes
Amphotericin B
Nystatin
Azole Antifungal Agents
Clotrimazole
Miconazole
Ketoconazole
Fluconazole
Itraconazole
Metronidazole
Lincomycin and Clindamycin
Guidelines for Antibiotic Prophylaxis
10:
Minor Oral Surgical Procedures
Basic Purpose of Surgery
Principles of Oral Surgery
Developing a Surgical Diagnosis
Clinical Characteristics of the Lesion
History of the Lesion
Transalveolar Extraction (Open or Surgical Extraction)
Pre-extraction Radiological Evaluation (Fig. 10.1A)
Multiple Extractions
Order of Multiple Teeth Extractions
Difficult Extraction/Breakage of the Root
Surgical Extractions: (Complicated Extractions)
Postage Stamp Technique for Transalveolar Extraction (Fig. 10.1B)
Three Basic Principles
Basic Necessities for Surgery
Adequate Access
Patient
Equipment
Assistant
Surgeon's and Assistant's Preparation
Aseptic Technique
Planning of an Incision
Incisions in the Oral Cavity
Contraindications for Placement of Incision Lines
Types of Incisions
Flap Design
Main Complications of Flap Surgery
Principles of Flap Designing
Indications
Types of Flaps (Fig. 10.1D)
Envelope Flap (Fig. 10.1E)
Tissue Handling
Haemostasis
Haemostasis can be Achieved by
Dead Space Elimination
How To Avoid a Dead Space
Decontamination and Debridement
Suturing
Impacted Teeth
Causes of Impaction of Teeth
Inadequate Space in the Dental Arch for Eruption
Indications for Removal of Impacted Teeth
Risk of Nonintervention
Risk of Intervention
Benefits of Nonintervention
Benefits of Intervention
Classification of Impacted Teeth
Difficulty Index
Winter's Classification (Fig. 10.2A)
Pell and Gregory's Classification (Fig. 10.2C)
Maxillary Third Molars' Classification (Fig. 10.2D)
Classification of Impacted Maxillary Canines (Fig. 10.2E)
Classification for Impacted Mandibular Canine (Table 10.3)
Factors Responsible for Increasing the Difficulty Score for Removal of Impacted Teeth
Radiological Examination
Intraoral X-ray
Extraoral X-rays (Figs 10.2G 1, 2, 3)
Surgical Removal of Impacted Teeth
Isolation of Surgical Site
Local Anaesthesia
Incision (Flap Design)
For Mandibular Molars (Fig. 10.2J)
For Maxillary Molars (Fig. 10.2K)
For Maxillary Canines
For Mandibular Canines
Bone Removal
Aim
How much Bone is to be removed?
Two Ways of Bone Removal (Fig. 10.2L)
Lingual Split Bone Technique (Fig. 10.2M)
Tooth Sectioning, Elevation and Extraction
Horizontal Impaction (Fig. 10.2N-1)
Mesioangular Impaction (Fig. 10.2N-2)
Vertical Impaction (Fig. 10.2N-3)
Distoangular Impaction (Fig. 10.2N-4)
Elevation
Debridement and Smoothening of Bone Margins
Closure
Complications
Intraoperative Complications
During Incision
During Bone Removal
During Elevation
During Debridement
Postoperative Complications
Indications
Contraindications
Procedure (Figs 10.3A to E)
Steps
Retropreparation (Fig. 10.3F)
Complications
Intraoperative
Postoperative
SECTION TWO: GENERAL ANAESTHESIA AND SEDATION IN ORAL AND MAXILLOFACIAL SURGERY
11:
Introduction to General Anaesthesia and Sedation
Problems of Dental Anaesthesia
12:
Pre-anaesthetic Evaluation
Purpose of Preoperative Evaluation
Routine Preoperative Anaesthetic Evaluation
1. History
Physical Examination
Laboratory Tests
13:
Preoperative Preparation and Premedication
Basic Plan of Preoperative Preparation
Patient Counselling/Psychological Preparation
Procedure Done under Local Anaesthesia with or without Sedation
Hypersensitivity Reactions
Consent
Premedication
Premedicant Drugs (Table 13.3)
Other Sedative and Hypnotic Agents
Analgesic Agents
Anticholinergic Agents
Aspiration Prophylaxis
Premedication for Outpatient Dental Surgery
Premedication for Major Maxillofacial Surgery
Premedication for Children
Preoperative Instructions
Fasting Guidelines (Table 13.4)
Concurrent Medication or Pre-existing Drug Therapy (Table 13.5)
Concurrent Drug Therapy (Table 13.5)
Other Instructions
14:
Anaesthetic Equipment
Anaesthesia and Resuscitation Equipment
Anaesthesia Machine (Figs 14.1A and B)
Breathing System (Circuit) (Fig. 14.1)
Mask (Fig. 14.2)
Laryngoscope (Figs 14.3A and B )
Endotracheal Tubes (Figs 14.5A to E)
Airways
Oropharyngeal (Oral) Airway (Fig. 14.6A) (Placed from Lips to Pharynx)
Nasopharyngeal (Nasal) Airway (Figs 14.6B and C) (Placed from the Nose to the Pharynx)
Laryngeal Mask Airway (LMA) (Fig. 14.7)
Magill's Forceps (Fig. 14.8)
Mouth Prop (Bite Block) (Fig. 14.9)
Resuscitation Bag (Figs 14.10A and B).
Monitoring Equipment
Blood Pressure Monitor
Cardioscope (Fig. 14.11)
Pulse Oximeter (Fig. 14.12)
Capnometer/Capnographs (Fig. 14.13)
Respiratory Gas Monitor
Oxygen Therapy Equipment (Figs 14.14A and B)
Oxygen Cylinder
Oxygen Flowmeter
Oxygen Mask
Nasal Catheter/Prongs (Fig. 14.14B)
Intravenous (IV) Infusion Equipment
Scalp Needle
IV Cannula (Fig. 14.15)
Bivalve (Three Way) (Fig. 14.16)
Infusion Set
IV Fluids
15:
Pharmacology of Commonly Used Anaesthetic Drugs
IV Induction Agents
Inhalational Induction Agents
Minimum Alveolar Concentration (MAC)
Ideal Inhalational Agent
Ether (CH3CH2-O-CH2CH3)
Ethyl Chloride (C2H5Cl)
Halothane (Fluothane)
Nitrous Oxide
Muscle Relaxants
Reversal of Anaesthesia
16:
Sedation Techniques for Dentistry
Definitions
Conscious Sedation
Deep Sedation
Sedative Techniques
Intravenous Sedation
Advantages of Intravenous Sedation
Disadvantages of Intravenous Sedation
Drugs commonly Available for IV Sedation
Other Commonly Used Sedative Techniques
Inhalational Sedation
Indications
Contraindications
Advantages
Disadvantages
Techniques of Administration
Clinical Indicators of Oversedation
17:
Short Anaesthesia in a Dental Chair
Introduction
Definition of General Anaesthesia
History
Equipment
Anaesthetic Machine
Dental Chair
Breathing Circuits and Masks
Nasopharyngeal Airways
Mouth Props and Gags
Mouth Packs
Monitors and Resuscitation Equipment
Indications for General Anaesthesia
Day Stay Surgery
Position in Dental Chair: Horizontal/ Sitting
Preoperative Considerations
Induction of Anaesthesia
Maintenance of Anaesthesia
Endotracheal Anaesthesia
Recovery
Complications of Dental Anaesthesia
Hypoxia
Laryngospasm
Mouth Breathing
Contamination of Trachea
Apnoea
Hypotension
Cardiac Dysrhythmias
Nausea and Vomiting
18:
Tracheal Intubation for a Patient Undergoing Oral and Maxillofacial Surgery
Indications
Armamentarium Required for Intubations
Laryngoscope
Endotracheal Tubes (Fig. 18.1).
Procedure for Endotracheal Intubation
Ideal Position for Intubation (Fig. 18.2A)
Awake Intubation
Complications Associated with Tracheal Intubation
Complications at Endotracheal Intubation
Complications During Intubation
19:
Complications of General Anaesthesia
Anaesthetic Complications
Preoperative Period (Related to Prior Drug Therapy)
Common Complications During Maintenance of General Anaesthesia (GA)
Coughing
Hiccup
Wheezing
Cyanosis
Cardiac Arrhythmias
Fluctuations in Blood Pressure
Hypertension
Hypotension
Hypoxaemia
Carbon dioxide Status
Hypercarbia
Hypocarbia
Change of Body Temperature
Hypothermia
Hyperthermia
Malignant Hyperthermia
Laryngospasm
Signs
Life-threatening Upper Airway Obstruction
Pulmonary Aspiration in the Anaesthetized Patient
Cardiac Arrest during Anaesthesia (Absent Carotid Pulse)
Severe Drug Reactions
Complications due to Position
Nerve Injury
Air Embolism
Awareness during General Anaesthesia
Postoperative Complications
Postoperative Nausea and Vomiting
Predisposing Factors that Increase Nausea and Vomiting
Postoperative Hypertension
Postoperative Respiratory Inadequacy
Failure to Wake-up
Postoperative Infection
Postoperative Restlessness
Respiratory Obstruction
Postoperative Shivering
20:
Cardiopulmonary Resuscitation (CPR)
What is Cardiac Arrest?
Aetiology
Diagnosis
Treatment of Cardiac Arrest
Basic Life-support
Airway
Foreign Body Airway Obstruction
Mouth to Barrier Device
Mouth to Mask Breathing
Circulation Check
External Cardiac Compression (Fig. 20.4)
Advanced Cardiac Life-Support [ACLS]
Key Points
Drug Therapy
Other Drugs Used in CPR
Postcardiac Arrest Complications
Outcome of Resuscitation
SECTION THREE: TEMPOROMANDIBULAR JOINT DISORDERS
21:
Temporomandibular Joint: Afflictions and Management
Anatomy
Articulatory System
Mandibular (Glenoid) Fossa (Cranial Component) (Fig. 21.2A)
Mandibular Component
Mandibular Condyle
TMJ Capsule
Ligaments
Lateral or Temporomandibular Ligament (Fig. 21.3)
Accessory Ligaments (Fig. 21.4)
Articular Disc or Meniscus (Fig. 21.5)
Blood Supply
Nerve Supply
Movements (Fig. 21.7)
Temporomandibular Joint (TMJ) Disorders
Classification
Disorders due to Extrinsic Factors
Disorders due to Intrinsic Factors
Dislocation, Subluxation, Hypermobility of TM Joint
Causes of Acute Dislocation
Chronic Recurrent or Habitual Dislocation or Subluxation (Figs 21.12 and 21.13A and B)
Indications
Eminectomy (Figs 21.16 and 21.17A)
Surgical Approaches to Mandibular Condyle and Its Neck (Figs 21.18A and B) (Table 21.1)
Postauricular Approach
Endaural Approach (Fig. 21.19A)
Submandibular (Risdon) Approach (Fig. 21.19B)
Postramal (Hind) Approach (Fig. 21.20)
Preauricular Approach (Figs 21.21 to 21.23)
Preparation of the Surgical Site
Marking the Incision
Infiltration of Vasoconstrictor
Skin Incision
Dissection to the TMJ Capsule
Exposing the Interarticular Spaces
Closure
Modifications of Basic Preauricular Incision (Fig. 21.24)
A Surgical Approach Via Popowich Incision (Fig. 21.25)
Coronal Approach (Fig. 21.26)
22:
Ankylosis of the Temporomandibular Joint and its Management
Classification of Ankylosis
Aetiopathology
Pathogenesis
Diagnosis
Clinical Manifestations
Unilateral Ankylosis (Fig. 22.3)
Bilateral Ankylosis (Fig. 22.4)
Diagnosis
Radiographic Findings
Fibrous Ankylosis
Bony Ankylosis (Fig. 22.4)
Sequelae of Untreated Ankylosis
Management of TMJ Ankylosis
Aims and Objectives of Surgery
Surgical Techniques
Condylectomy (Fig. 22.7)
Gap Arthroplasty (Figs 22.8A, B and 22.9)
Interpositional Arthroplasty (Fig. 22.10)
Artificial Replacement of the Joint
The Internationally Accepted Protocols for the Management of TMJ Ankylosis
Lining of the Glenoid Fossa Side by Temporalis Myofascial Flap (Figs 22.13)
Interposition Arthroplasty Using Autogenous Costochondral Graft (Figs 22.14A and B)
Complications during TM Joint Ankylosis Surgery
During Anaesthesia
During Surgery
During Postoperative Follow-up
Frey's Syndrome (Fig. 22.17)
Treatment Options for Frey's Syndrome
Recurrence of TMJ Ankylosis
23:
Myofacial Pain Dysfunction Syndrome (MPDS)
History
Clinical Characteristics
Trigger Points
Pathophysiology [Aetiology]
Psychogenic Cause
Persistent Tension Relieving Oral Habits
Occlusal Disharmony
Symptoms
History of the Patient
Follow-7 R's for occlusal rehabilitation
Physical Examination
Articular or TMJ Function and Range of Motion
Muscular Examination
Dental/Occlusal Evaluation
Cervical Examination
Psychological Evaluation of a Patient
Psychological Symptoms
Internal Derangement of the TM Joint
Internal Derangements
Anterior Disc Displacement with Reduction (Fig. 23.8)
Anterior Disc Displacement without Reduction (Fig. 23.9)
Systemic Joint Diseases Causing Internal Derangement
Objectives of Treatment in MPDS
Technique for Auriculotemporal Nerve Block
Treatment of MPDS
Medications
Physiotherapeutic Modalities
Stress Management
Intra-articular Injections
Occlusal Splints (Fig. 23.12)
1. Stabilization splint
2. Relaxation Splints
Temporomandibular Joint Arthrocentesis (Fig. 23.14)
Arthrocentesis (Lavage or Irrigation of the Upper Joint Cavity)
Hypothesis
Postarthrocentesis Medication
Advantages
TMJ Arthroscopy
Arthroscopic Techniques
Arthroscopic Anatomy (Fig. 23.19)
Postoperative Care
Surgical Treatment of TMJ Dysfunction Disorders
SECTION FOUR: ORTHOGNATHIC SURGERY
24:
Introduction to Orthognathic Surgery, Diagnosis and Treatment Planning
Severe Skeletal Dentofacial Deformities and Associated Problems
Treatment
Growth Modification
Orthodontic Camouflage
Orthognathic Surgery
Problem List
Facial Esthetic Analysis
Frontal View Analysis (Fig. 24.14)
Profile or Lateral View Analysis (Fig. 24.15)
Oral Examination
Dental Model Analysis
Cephalometric Analysis
Soft Tissue Landmarks (Fig. 24.18)
Cephalometric Prediction Tracing (Figs 24.19A to C)
PA Cephalometric Analysis (Fig. 24.20)
A “Quick Ceph” Dentofacial Planner for Orthognathic Surgery
Natural Head Position (Fig. 24.16)
Case Evaluation
Treatment Plan
Conclusions
25:
Presurgical Orthodontic Phase
Meticulous Presurgical Orthodontics
Presurgical Orthodontics
Presurgical Intra-arch Objectives
Time Estimation
Presurgical Orthodontic Objectives for Antero-Posterior—- Sagittal Plane (AP)
Presurgical Orthodontic Objectives for Transverse Plane
Presurgical Orthodontic Objectives for Vertical Plane
To Relieve Arch Crowding by Presurgical Orthodontics
The Extraction Pattern for Presurgical Orthodontics
Selection of Orthodontic Appliance
Fixed Orthodontic Appliance System
Antero-posterior (Sagittal) Plane Presurgical Orthodontic Objectives
Presurgical Orthodontics Objectives for Transverse Plane
Presurgical Orthodontics Consideration for Vertical Plane
Skeletal Deep Anterior Overbite Pattern
Root Positioning at the Planned Osteotomy Sites and Retaining the Extraction Spaces
Completion of Presurgical Orthodontic Phase
Postsurgical Orthodontics Objectives
Model Surgery (Mock Surgery)
Aims of Model Surgery
Hand Articulation
Protocol for Mock Surgery
Marking Procedure for Models
26:
Orthognathic Surgery: Osteotomy Procedures
Historical Development of Orthognathic Surgery
Biological Basis for Orthognathic Surgery
Protocol for Osteotomies
Osteotomy Procedures
Soft Tissue Incisions for Osteotomies (Figs 26.2 to 26.6)
Mandibular Body Osteotomy
Anterior Body Osteotomy (Figs 26.7 and 26.8)
Posterior Body Osteotomy (Fig. 26.9)
Mid Symphysis Osteotomy (Fig. 26.10)
Segmental Subapical Mandibular Surgeries
Anterior Subapical Mandibular Osteotomy (Figs 26.11A to C)
Posterior Subapical Mandibular Osteotomy Procedure (Fig. 26.12)
Total Subapical Mandibular Osteotomy (Fig. 26.13)
Genioplasties
Augmentation Genioplasty (Figs 26.15 and 26.16)
Reduction Genioplasty (Fig. 26.18)
Straightening Genioplasty Procedure
Lengthening Genioplasty
Mandibular Ramus Osteotomies
Subcondylar Vertical Osteotomy
Intraoral Vertical Ramus Osteotomy (IVRO) and the Inverted L Osteotomy (Fig. 26.23)
Intraoral Modified Sagittal Split Osteotomy (Figs 26.24 to 26.29)
Maxillary Osteotomy Procedures
Segmental Maxillary Osteotomy: Surgical Procedures
Surgical Procedure—(followed at our institution) (Fig. 26.33)
Posterior Maxillary Osteotomy (Fig. 26.35)
Total Maxillary Surgery
The LeFort I Osteotomy (Figs 26.36 to 26.44)
Maxillary Advancement
Inferior Positioning of Maxilla (Fig. 26.37)
Leveling of Maxilla
Superior Repositioning of the Maxilla (Figs 26.38A to D)
Superior Positioning of Maxilla-leaving the Nasal Floor Intact. (Horseshoe-shaped Osteotomy) (Figs 26.41 and 26.42)
SECTION FIVE: MAXILLOFACIAL TRAUMA
27:
Basic Principles for the Management of Maxillofacial Injuries
General Care of the Injured Patient
General Considerations
Basic Principles of Treatment of a Severe Maxillofacial Injuries
Basic ABCs to be Followed for Preservation of Life
A: Maintenance of Patency of Airway
Clinical Signs and Symptoms of Respiratory Distress (Obstruction)
Causes of Respiratory Obstructions Related to Maxillofacial Injuries (Fig. 27.2)
A. Treatment for Airway Maintenance (Nonsurgical) (Figs 27.3 and 27.4)
Surgical Treatment
B: Bleeding or Haemorrhage Control
C: Consciousness Restoration/Circulation Maintenance
Soft Tissue Injuries
Wound Management
Types of Soft Tissue Wounds and Management (Figs 27.7 and 27.8)
Abrasions
Contusion
Haematomas
Lacerated Wounds
Incised Wounds
Penetrating and Punctured Wounds
Crushed Wounds
Gunshot Injuries (High Velocity Missile)
Treatment of Lacerated Wounds
Supportive Therapy
Factors Modifying Wound Healing Or Leading Towards Failure
28:
Injuries of the Maxillofacial Skeleton
Aetiology of Maxillofacial Injuries (Table 28.1)
Local Clinical Examination of Maxillofacial Injuries
Extraoral Examination
Inspection
Palpation (Fig. 28.1)
Intraoral Inspection
Intraoral Palpation
Fractures of the Jaw Bones
Classical Clinical Signs and Symptoms of Fracture of the Jaws
Basic Principles of Treatment of a Fracture
Different Types of Dental Wiring Techniques (Figs 28.4 to 28.8)
Armamentarium for Wiring
Essig's Wiring (Fig. 28.4)
Gilmer's Wiring (Fig. 28.5)
Risdon's Wiring (Fig. 28.6)
Ivy Eyelets Wiring (Fig. 28.7)
Col. Stout's Multiloop Wiring (Fig. 28.8)
Arch Bars (Fig. 28.9)
Custom made Splints
Acrylic Splints
Wiring Procedure
Peralveolar Wiring Procedure (Fig. 28.12)
Circumferential (Circummandibular) Wiring Procedure (Figs 28.13A and B)
Methods of Fixation
Treatment without Any Form of Fixation
Treatment with Intraoral Fixation Alone
External Fixation (Figs 28.15 to 28.17)
Internal Fixation
Construction of Plaster of Paris Headcap
Armamentarium
Procedure
Antral Approach
Internal Fixation by Means of Bone Plate Osteosynthesis
Bone Plate Osteosynthesis (Fig. 28.25)
AO System (Figs 28.26A to D)
Miniplate Osteosynthesis (Noncompression Monocortical Screw System)
Anatomy and Biomechanics of the Mandible
Champy's Ideal Osteosynthesis Lines (Figs 28.27 to 28.30)
29:
Fractures of the Middle Third of the Facial Skeleton
Middle Third of the Facial Skeleton
Bones Constituting the Middle Third of the Face (Fig. 29.1A)
Physical Characteristics of the Midfacial Skeleton
Applied Anatomy
Supporting Vertical and Horizontal Pillars of the Maxillary Skeleton (Fig. 29.3)
Horizontal Pillars
Nerve Supply
Important Blood Vessels
Surgical Anatomy
LeFort I Fracture (Low Level, Subzygomatic Fracture) (Fig. 29.5)
LeFort II (Pyramidal or Subzygomatic) Fracture (Fig. 29.6)
Clinical Signs and Symptoms of LeFort II Fracture
LeFort III Fracture (Transverse or Suprazygomatic) Fracture (Fig. 29.7A)
Midline Separation of the Maxilla (Figs 29.7B and 29.4A)
Modification of LeFort's Fracture Classification
Rowe and William's (1985) Classification
Fractures of the Zygomatic Complex
Applied Anatomy
Classification of the Zygomatic Complex Fracture (Rowe and Killey 1968) (Figs 29.8 and 29.9)
Signs and Symptoms
Diplopia
Monocular Diplopia
Binocular Diplopia
1. Physical Interference
2. Functional Interference
3. Neurological Causes
Testing the Motions of the Eye and Diplopia (Fig. 29.12)
Differentiating Points for Aetiology of Diplopia
Enophthalmos
Clinical Features of Enophthalmos
Blindness
30:
Principles of Treatment of Midfacial Fractures
Methods of Reduction
Manual Reduction
Reduction by Traction
Open Reduction (Figs 30.1C to F)
Fracture of the Floor of the Orbit (Blow-out Fracture)
Treatment of Fractures of the Zygomatic Bone
Operative Technique
Gillies Temporal Approach (Fig. 30.6)
Intraoral Procedure (Fig. 30.8)
Fractures of the Nasal Bone (Figs 30.16 to 30.19)
Diagnosis of Fractures of Nasal Bones
Radiographic Evaluation
Management
31:
Applied Surgical Anatomy of the Mandible and Classification of Mandibular Fractures
Anatomy of the Mandible (Fig. 31.1)
Areas of Weakness (Vulnerable for Fracture)
Blood Supply
Nerve Supply
Muscle Action
Factors Influencing Displacement of a Mandibular Fracture
Mandibular Fractures
Number of Fractures Per Mandible
Classification
Fracture Formula
32:
Management of Mandibular Fractures
Mandibular Fractures in Children
Conservative Therapy
Conservative Treatment with Splints
Open Reduction
Management of Mandibular Fractures in Adults (Table 32.1)
Closed Reduction
Indications
Advantages of Open Reduction and Direct Fixation
Indications for Open Reduction
Contraindications for Open Reduction
Surgical Approaches to the Mandible (Figs 32.3 to 32.9)
Intraoral Approach—Symphysis and Parasymphysis Region (Figs 32.3A and B)
Intraoral (Body, Angle, Ramus Region): Transbuccal Incision (Fig. 32.4)
Extraoral Submandibular Risdon's Incision (Fig. 32.5A)
Transosseous Wiring (Intraosseous Wiring)
Intraoral Transalveolar or Upper Border (Superior Border) Wiring (Fig. 32.8)
Extraoral Lower Border (Inferior Border) Transosseous Wiring (Figs 32.9A to C)
Bone Plating
Simple Noncompression Bone Plates
Miniplate Osteosynthesis
Compression Plates
Reconstruction Plates
33:
Fractures of the Condylar Process and Its Management
Classification of Condylar Fractures (Figs 33.1 to 33.10)
Aetiological Factors Leading to Condylar Fractures
Diagnostic Findings of Condylar Fractures
Treatment of Condylar Fractures
Nonsurgical Management of Condylar Fractures
Surgical Correction of Condylar Fractures
Absolute Indications for Open Surgery
Relative Indications (Figs 33.7 to 33.10)
Surgical Approach to the Condyle
Methods of Fixation of Condylar Fractures (Figs 33.11 and 33.12)
Malunion (Dysarthrosis or Meta-arthrosis) and Pseudoarthrosis
SECTION SIX: PREPROSTHETIC SURGERY
34:
Preprosthetic Surgery
Oral and Maxillofacial Prosthetics
Objective of the Preprosthetic Surgery
Denture Base Areas of Concern
Pathophysiology of Edentulous Bone Loss
Causes of Bone Loss
Rate of Resorption of Residual Alveolar Ridges Depends On
Patterns of Bone Loss
Characteristics of Ideal Denture Base Area
Aims of Preprosthetic Surgery
Treatment Planning and Examination
Facial Esthetic Examination
Intraoral Examination
Supporting Soft Tissue Examination
Preprosthetic Surgical Procedures
Alveolar Ridge Correction (Table 34.3)
Soft Tissue Surgeries for the Correction of Alveolar Ridge
Frenectomy
Lingual Frenectomy (Figs 34.11A and B)
Ridge Extension Procedure
Ridge Augmentation Procedures
SECTION SEVEN: CYSTS AND TUMOURS OF THE OROFACIAL REGION
35:
Cysts of the Jaws and Oral/Facial Soft Tissues
Cyst Formation
Cyst Initiation
Cyst Enlargement
Increase in the Volume of its Contents
Secretions
Epithelial Proliferation
Bone Resorption
Cyst Regression
Intraosseous Cysts
Odontogenic Epithelial Origin
Primordial Cyst (Keratocyst)
Dentigerous (Follicular) Cyst
Developmental Lateral Periodontal Cysts
Botryoid Odontogenic Cyst
Calcifying Epithelial Odontogenic Cyst (CEOC):Gorlin Cyst (Figs 35.9A to F)
Inflammatory (Periodontal) Radicular Cysts (Fig. 35.10)
Residual Cyst (Fig. 35.11)
Multiple Cystic Lesions of the Jaws
Basal Cell Nevus Syndrome (Gorlin's Syndrome)
Intraosseous Cyst of Non-Odontogenic Epithelial Origin
Developmental Fissural Cysts (Fig. 35.14)
Median Mandibular Cyst
Median Palatal Cyst
Globulomaxillary Cyst
Nasopalatine Duct Cyst
Nonodontogenic Nonepithelial Bone Cysts (Cyst-like Conditions)
Solitary Bone Cyst
Aneurysmal Bone Cyst
Stafne's Idiopathic Bone Cavity (Mandibular Salivary Gland Depression)
Cysts Associated with the Maxillary Antrum
Surgical Ciliated Cyst of the Maxilla
Benign Mucosal Cyst of the Maxillary Antrum
Soft Tissue Cysts
Odontogenic (Developmental) Cysts
Gingival Cysts
Gingival Cyst of the Adult
Gingival Cyst of Infants
Nonodontogenic Fissural Cysts
Anterior Median Lingual Cyst
Nasolabial Cyst
Retention (Salivary Glands) Cysts
Mucocele
Ranula
Nonodontogenic (Developmental) Cysts of the Soft Tissues
Dermoid and Epidermoid Cysts
Lymphoepithelial Cysts
Branchial Cleft Cyst (Cervical/Intraoral)
Thyroglossal Duct Cyst
Cystic Hygroma
Parasitic Cysts
Heterotopic Cysts
Oral Cysts with Gastric or Intestinal Epithelium
Cysts of the Oral Cavity
General Principles of Treatment
Reasons for Treatment of Benign Cysts of the Oral Cavity
Clinical Presentation (Summary of Signs/Symptoms)
Vitality of Teeth
Radiographic Examination
Radiopaque Dyes
Aspiration
Biopsy
Operative Procedures
Marsupialization (Decompression)
Modifications of Marsupialization
Marsupialization by Opening into Nose or Antrum
Enucleation
Enucleation with Primary Closure
36:
Benign Tumours of the Jaw Bones
Odontogenic Tumours
Classification of Benign Odontogenic Tumours
Non-odontogenic Tumours of the Jaw Bones
General Principles of Management of a Jaw Lesion
Recurrence
Habit
Clinical Examination of the Lesion
Principles of Surgical Management of Jaw Tumours
Odontogenic Tumours of Various Origins
Tumours Arising from Odontogenic Epithelium Without Odontogenic Ectomesenchyme
Ameloblastoma
Calcifying Epithelial Odontogenic Tumour (CEOT) (Pindborg Tumour)
Squamous Odontogenic Tumour
Clear Cell Odontogenic Tumour (CCOT)
Tumours Arising from Odontogenic Epithelium with Odontogenic Ectomesenchyme with or without Dental Hard Tissue Formation
Ameloblastic Fibroma
Ameloblastic Fibro-odontoma
Ameloblastic Fibrodentinoma
Adenomatoid Odontogenic Tumour (AOT) (Fig. 36.31)
Odontoma
Tumours Arising from Odontogenic Ectomesenchyme with or without Inclusion of Odontogenic Epithelium
Odontogenic Fibroma
Myxoma (Odontogenic Myxoma or Myxofibroma) (Figs 36.34A and B)
Benign Cementoblastoma (Cementoblastoma, True Cementoma) (Fig. 36.34C)
Non Odontogenic Lesions of the Jaws
Osteogenic Neoplasm
Ossifying Fibroma
Juvenile Aggressive Ossifying Fibroma
Osteoma (Figs 36.39 and 36.40)
Benign Osteoblastoma (Fig. 36.41)
Osteochondroma (Figs 36.42A to C)
Non-neoplastic Bone Lesions
SECTION EIGHT: SALIVARY GLAND DISORDERS
37:
Diseases of the Salivary Glands
Salivary Glands: Anatomy
Parotid Gland (Fig. 37.1)
Clinical Considerations
Sub-mandibular Gland (Fig. 37.2)
Clinical Considerations
Sublingual Gland (Fig. 37.3)
Minor Salivary Glands (Fig. 37.4)
Clinical Considerations
Salivary Glands – Physiology
Functions of Saliva
Classification of Salivary Gland Diseases
Salivary Gland Dysfunction
Sialorrhoea or Ptyalism
Suggested Surgical Treatment
Xerostomia
Sialolithiasis (Fig. 37.5)
Sialadenitis
Viral Infections
Bacterial Infection
Acute Bacterial Sialadenitis (Fig. 37.8 A)
Chronic Bacterial Sialadenitis (Figs 37.9A and B)
Cysts of the Salivary Glands
Mucocele
Types
Pathogenesis
Clinical Features (Fig. 37.10)
Differential Diagnosis
Treatment
Ranula (Figs 37.11A and B)
Treatment
Differential Diagnosis
Tumours of the Salivary Glands
Benign Tumours
Pleomorphic Adenoma
Warthin's Tumour (Papillary Cystadenoma Lymphomatosum)
Malignant Tumours
Mucoepidermoid Carcinoma
Adenoid Cystic Carcinoma
Other Malignant Tumours
Necrotizing Sialometaplasia
Sialadenosis (Fig. 37.15)
Sjögren's Syndrome
Clinical Features
Laboratory Findings
Diagnostic Imaging
Conventional Radiography
Sialography (Fig. 37.16A and B)
Indications
Contraindications
Phases of Sialography
Contrast Sialography
Technique
Radionuclide Salivary Imaging
Procedure
Phases of Radionuclide Salivary Imaging
Gallium Scanning
Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI)
Techniques of CT Examination (of Parotid and Submandibular Glands)
Ultrasound Evaluation of Major Salivary Glands
Salivary Analysis
Clinical Examination: Differential Diagnosis (Table 37.6)
History
Duration, Nature and Rate of Growth
Examination
Surgical Management
Parotid Gland: Superficial Parotidectomy (Fig. 37.17)
Indications
Approaches
Preventing Injury to the Facial Nerve
Complete Excision of Parotid Gland (Figs 37.19 and 37.20)
Incision and Dissection (Fig. 37.21)
Submandibular Salivary Gland (Figs 37.22 and 37.23)
Extra-oral Procedures
Complications of Surgery of Salivary Glands
Auriculotemporal Nerve or Frey's Syndrome (Fig. 22.17) Gustatory Sweating
Facial Nerve Paralysis
Salivary Fistulae and Sialoceles (Fig. 37.24)
SECTION NINE: OROFACIAL CLEFTS
38:
Cleft Lip and Cleft Palate Management
Introduction
Incidence
Aetiology
Hereditary
Environmental Influence
Embryological Aspects (Fig. 38.4)
Formation of the Clefts (Figs 38.5A and B)
Median Nasal Processes (MNP)
Lateral Nasal Processes (LNP)
Classification
Associated Deformities and Problems
Dental Problems
Feeding
Speech Problems
Aims and Objectives of Management of Cleft Lip and Palate
General Management Protocol for the Cleft Patient
Management of Cleft Lip
Timing of the Lip Surgery
Preoperative Evaluation
Feeding
Operative Procedure (Figs 38.8A, B and 38.9)
Unilateral Cleft Lip Repair: Millard's Rotation Advancement Principle
Primary Nasal Correction (Figs 38.10, 38.11A and B)
Suturing
Postoperative
Bilateral Cleft Lip
Principles and Objectives of the Surgical Correction
Repair Both Sides Simultaneously
Technique of Bilateral Lip Repair (Figs 38.12 to 38.16)
Columellar Lengthening
Cleft Palate
Basic Functions of Palate
Sucking
Swallowing
Speech
Repair of the Cleft Palate (Figs 38.17A and B)
Treatment Guidelines
Operative Procedure (Fig. 38.18)
Postoperative Management
Complete Cleft Lip and Palate Deformity
Orthodontics in Cleft Lip and Palate
SECTION TEN: MAXILLARY SINUS AND ITS IMPLICATIONS
39:
Maxillary Sinus and its Implications
General Considerations
Anatomy
Blood Supply
Nerve Supply
Embryology (Growth of Maxillary Sinus)
Physiology
Functions
Applied Surgical Anatomy
Relation of the Root Apices with the Floor of the Sinus
Low Incidence of Oroantral Fistula in Children under Fifteen Years
Circumstances with Increased Likelihood of Oroantral Fistula
Lining of Maxillary Sinus
Cracks and Fractures in the Bony Floor of Maxillary Sinus
Periapical Involvement
Pressure on the Nerves within the Antrum
Tumours Developing in Maxillary Antrum
Paraesthesia in Maxillary Teeth Following Surgical Procedures
Mucous Membrane Lining of Antrum Affected by Infection
Antral Puncture
Canine Fossa
Fractures of the Middle Third of Face
Foreign Bodies in the Sinus
Transillumination
Clinical Examination of Maxillary Sinus
Radiology of Maxillary Sinus
Extraoral Views
Occipitomental View (OM)
Lateral Skull
Submentovertex View
Occipitofrontal View
Tomography
Orthopantograph
Intraoral Views
Interpretations
Infections of Maxillary Sinus
Odontogenic Sinusitis
Definition
Aetiology
Spread of Infection to Maxillary Sinus, from Apical Abscess
Clinical Features
Diagnosis
Management
Acute Maxillary Sinusitis
Signs: Extraoral Examination
Intraoral Examination
Symptoms
Other Special Examinations
Management
Chronic Maxillary Sinusitis
Pathophysiology
Diagnosis
Management
Procedure for Surgical Drainage (Fig. 39.7)
Oroantral Communication and Fistula
Definition
Aetiology
Extractions
Symptoms: Fresh Oroantral Communication: Remember 5 Es
In late Stage, Symptoms of Established Oroantral Fistula—Remember 5 Ps
Fate of Clot
Persistence of Fistula
Physical Signs of Established Oroantral Fistula
Signs of Acute Sinusitis
Possible Sequelae
Management
Purpose
Treatment of Early Cases
Supportive Measures
Temporary Therapeutic Measures before Surgical Closure
Treatment of Delayed Cases
Management
Surgical Procedures Used in Closure of Oroantral Fistula
Buccal Flap Advancement Operation
Modified Rehrmann's Buccal Advancement Flap (Figs 39.11 and 39.12)
Intranasal Antrostomy
Surgical Procedure for Intranasal Antrostomy (Fig. 39.13)
Palatal Pedicled Flap: Rotational Advancement Flap Operation (Fig. 39.14)
Ashley's Operation
Combination of Buccal and Palatal Flaps (Fig. 39.15)
Caldwell-Luc Operation
Caldwell-Luc Surgical Procedure (Fig. 39.16)
Functional Endoscopic Sinus Surgery (FESS)
Purpose
Historical Background
Endoscopic Sinus Surgery
Indications
Diagnosis
Endoscopy of Maxillary Sinus
Types of Functional Endoscopic Sinus Surgery
Surgical Technique
Sphenoid Sinus
SECTION ELEVEN: OROFACIAL AND NECK INFECTIONS
40:
Orofacial and Neck Infections and their Management
Aetiology
Pathways of Odontogenic Infection (Fig. 40.1)
Odontogenic Infections
Acute Stage
Acute Infection (Fig. 40.2)
Chronic stage (Fig. 40.3A)
General Course of an Odontogenic Abscess
Acute Periapical Abscess
Acute Dentoalveolar Abscess
Acute Periodontal Abscess
Microbiology
Medical Therapy
Antibiotic Therapy
Choice of Antibiotic Therapy
Surgical Therapy
Surgical Technique for Incision and Drainage of an Abscess
Hilton's Method of Incision and Drainage (Fig. 40.3B)
Spread of Orofacial Infection
Routes of Spread
Factors Influencing Spread
General Factors
Local Factors
Pathways of Dental Infections (Fig. 40.4)
Anatomical Factors Influencing the Direction of Spread
Anatomical Considerations in Dentoalveolar Infections
Maxilla
Mandible
Evaluation of the Patient with Orofacial Infection
History Taking
Physical Examination
General Examination
Regional Examination
Clinical Features
Clinical Symptoms of Possible Life Threatening Infections
Toxicity—Signs and Symptoms
Central Nervous System Changes Associated with Infection
Radiological Examination
Conventional Radiography
Other Diagnostic Aids
CT View of Various Spaces (Figs 40.5A and B)
Submandibular Space
Sublingual Space
Masticatory Spaces
General Principles of Therapy for the Management of Acute Extensive Orofacial Infection
Antibiotic Therapy
Principles of Surgical Management
Potential Spaces
Organization of Cervical Fascia (Fig. 40.6)
The Space of Burns: The Suprasternal Space (see Fig. 40.6)
Classification of Fascial Spaces
Based on the Mode of Involvement
Based on Clinical Significance
Potential Primary Spaces Related to Upper Jaw
Upper Lip
Differential Diagnosis of Swellings of Upper Lip
Canine Fossa Involvement (Infraorbital Space)
Buccal Space Involvement (Fig. 40.12A and B)
Infratemporal Fossa Space (Fig. 40.14)
Potential Primary Spaces Related to Lower Jaw
Submental Space
Submandibular Space
Sublingual Space
Secondary Potential Fascial Spaces
Temporal Space (Fig. 40.26A)
Parotid Space (Figs 40.26C and D)
Masticatory Spaces (Figs 40.27 and 40.28)
Submasseteric Space
Pterygomandibular Space
Parapharyngeal Spaces
Lateral Pharyngeal Space: (Figs 40.30B and C)
Retropharyngeal Space: Prevertebral Space
Peritonsillar Abscess (Quinsy) (Fig. 40.30B)
Pericoronitis/Pericoronal Abscess
Possible Untoward or Life Threatening Complications of Orofacial Infection
Ludwig's Angina
Use of Cuffed Endotracheal Tube
Surgical Decompression
Antibiotic Therapy
A Simple Prototype Protocol is given below
Involvement of Carotid Sheath
Brain Abscess
Meningitis
Mediastinitis
Cavernous Sinus Thrombophlebitis: Intracranial Complication (Fig. 40.41A)
41:
Osteomyelitis and Osteoradionecrosis of the Jaw Bones
Osteomyelitis (OML) of the Jaw Bones
Definition
Predisposing Factors (Table 41.1)
Aetiology
Pathogenesis
Osteomyelitis in Maxilla
Microbiology
Classification and Staging
Acute Pyogenic OML: (Acute Suppurative OML)
Chronic Osteomyelitis
Types of Osteomyelitis
Infantile OML (OML Maxillaries Neonatorum, Maxillitis of Infancy)
Garre's Sclerosing OML
Chronic Sclerosing OML: (Focal and Diffuse)
Actinomycotic OML of Jaws
Tuberculous Osteomyelitis of the Jaw Bones
Aetiopathogenesis
Clinical Presentation of Tuberculous Osteomyelitis of the Jaw Bones
Closed Lesions (Lumpy Jaw) (Fig. 41.13)
Open Lesions (Fig. 41.14)
Diagnosis and Treatment
10-point Protocol Formulated for the Management of Tuberculous Osteomyelitis of the Jaw Bones (Figs 41.15 and 41.16)
Osteoradionecrosis (ORN) of the Facial Bones
Definition
Incidence
Aetiopathology (Pathological Changes)
Mechanism
Pathological Changes
Factors Involved in Reduction of ORN
Clinical Features
Radiological Features
Treatment
Staging and Treatment Algorithm
Prevention of ORN
Pre-irradiation Dental Care
Post-irradiation Dental Care
SECTION TWELVE: FACIAL NEUROPATHOLOGY
42:
The Trigeminal Nerve (V)
Functions
Attachment
Course
Divisions
Type of Fibres
Trigeminal Ganglion
Motor Root
Sensory Root
Ophthalmic Nerve (V1)
Functions
Origin, Course and Branches
Maxillary Nerve (V2)
Functions
Origin, Course and Branches
Branches
Within the Cranium: Middle Meningeal Nerve
In the Pterygopalatine Fossa
Branches in the Infraorbital Canal
Branches on the Face
Mandibular Nerve (V3)
Origin, Course and Branches
Branches
Branches from Undivided Nerve
Branches from Anterior Trunk
Branches of Posterior Trunk
Mylohyoid Nerve
43:
Orofacial Region Pain
Incidence
Definition
Basic Classification of Pain
Neurophysiology of Pain
Pain Perception
Pain Reaction
Noxious Stimuli Causing Pain
Transmission of Impulses in the CNS
Pain Pathways
44:
Trigeminal Neuralgia and its Management
Definition
Aetiology
General Characteristics
Clinical Characteristics
Diagnosis
Protocol for Diagnostic Nerve Blocks
Treatment
Medicinal Management
Medicinal Line of Treatment (Modification of the Paroxysmal Pain at Cortical Level)
Surgical Treatments (Fig. 44.3) (Peripheral Nerve Surgical Treatments)
Peripheral Injections
Peripheral Neurectomy (Nerve Avulsion)
Technique for Percutaneous Approach to the Gasserian Ganglion: Anaesthesia Protocol
Open Procedures (Intracranial Procedures)
Trigeminal root section
45:
Sensory Disturbances of Face and Jaws
Impaired Sensation
Aetiology
Incidence
Classification of Mechanical Nerve Injuries
Seddon's Classification (Table 45.1)
Tinel's Sign
Neuritis
Neuromas
Evaluation
Management
Surgical Approach
Nerve Regeneration-New Concept (Fig. 45.11)
Postoperative Management
Long-term Prognosis
46:
Facial Nerve and Motor Disturbances of Face and Jaws
Facial Nerve
Anatomical Course and Relationship (Fig. 46.2)
Branches of Distribution of the Facial Nerve
Ganglia
Applied Anatomy
Motor Control
Supranuclear Facial Paralysis
Nuclear Paralysis
Melkersson-Rosenthal Syndrome (Orofacial Granulomatosis)
Crocodile Tear Syndrome
Motor Disturbances of Face and Jaws
Aetiology Classification
Management
Evaluation of Facial Nerve Functions
Prognosis
House-Brackman (1985) Classification
Treatment
Neurorrhaphy Procedures
Factors Influencing the Results of Extracranial Facial Nerve Repair
Technique of Nerve Grafting
Bell's Palsy
Clinical features
SECTION THIRTEEN: ORAL MALIGNANCIES
47:
Oral Cancer
Incidence
Anatomical Subsites of Cancer in the Oral Cavity
Lip Mucosa
Buccal Mucosa
Lower Alveolar Ridge
Upper Alveolar Ridge
Retromolar Gingiva (Retromolar Trigone)
Floor of the Mouth
Hard Palate
Anterior Two-thirds of the Tongue
Aetiology
Tobacco
Alcohol
Tobacco and Alcohol Synergism
Viruses
Poor Dental Hygiene, Constant Chronic Trauma to Mucosa Due to Dental Cause
Spread of Squamous Cell Carcinomas of the Oral Cavity
Oral Precancer
Definitions (WHO 1972)
Premalignant Lesion
Precancerous Condition
Risk of Malignant Transformation of Oral Premalignant Lesions
Trismus can Present in One of the Following Four Groups
Malignant Transformation Rate of OSMF (Fig. 47.7)
Management of OSMF
Chemoprevention for Oral Premalignant Lesions
Diagnosis and Staging of Oral Cavity Cancer
Clinical Features (Fig. 47.8)
Biopsy
Imaging for Oral Cavity Cancers
Imaging for Assessing Mandibular Involvement (Table 47.2)
Imaging to Assess the Extent of Soft Tissue Spread
FNAC of Neck Nodes
TNM Staging (Table 47.4)
Management
Principles of Management of Early Stage Cancer
Advantages of Surgery
Disadvantages of Radiotherapy
Radiotherapy in Early Oral Cavity Cancer
Brachytherapy
Postoperative Radiation Therapy to the Neck is Indicated
Surgical Technique for Resection of Early Oral Cancers
Approaches to Oral Cavity
Marginal Mandibulectomy
Types and Indications for Marginal Mandibulectomy
Principles of Management of Locally Advanced Oral Cavity Cancers
Surgery for Locally Advanced Cancer
Types of Segmental Resections of the Mandible
Principles of Reconstruction (Table 47.7)
Mucosal Defects can be Delt with Following Modalities
Reconstruction of Mandibular Defects
Management of the Neck Lymph Nodes
Clinical Examination of Neck Lymph Nodes
Clinical Signs of Extracapsular Spread
Assessment of the Extend of Involvement of Clinically Negative Lymph Nodes
Lymph Node Levels (Fig. 47.17)
Nodal Metastasis
Classification of Neck Dissection (Fig. 47.20)
Radical Neck Dissection (RND)
Modified Radical Neck Dissection (MRND)
Selective Neck Dissection (SND)
Extended Neck Dissection
Adjuvant Treatment
Survival and Prognosis
Role of Dental Practitioner in Oral Cancer Management
Preoperative Dental Workup
SECTION FOURTEEN: IMPLANTOLOGY IN ORAL AND MAXILLOFACIAL SURGERY
48:
Dental Implants
Implant Materials
Titanium Implants
Classifications of Dental Implants (Fig. 48.2A)
1. Based on Shape and Form
2. Based on Surface Characteristics
3. Based on Implant Tissue Interface
4. Based on Foundation
5. Based on Mode of Retention of Prosthesis
6. Based on Various Systems
7. Immediate Implants
8. Transient Implants for Immediate Loading
Parts of Implant
Biologic Parameters for Implants Acceptance
a. Material Biocompatibility
b. Implant Design
c. Implant Surface
d. Host Site
Indications and Contraindications
Pre-surgical Investigations
Anaesthesia
Insertion of Implant
Surgical Steps
Incision
Drilling into Bone
Drilling
Drilling Speed
Insertion
Irrigation
Closing the Wound
Complications
Ailing v/s Failing Implant
Healing Period
Impressions for Loading
Clinical Photographs
SECTION FIFTEEN: HAEMORRHAGE AND SHOCK
49:
Haemorrhage and Shock: Its Management in Oral Surgery
Haemorrhage
Types of Haemorrhage
Depending on the Type of Blood Vessel Involved
Primary, Reactionary, Intermediate Bleeding and Secondary Bleeding
Internal or External Bleeding
Spontaneous Bleeding
Haemostasis
Clinical Evaluation of the Bleeding Patient
Laboratory Tests for Screening
Local Haemostatic Measures
Chemical Methods
Control of Haemorrhage from Major Arteries
Hereditary Coagulopathies
Acquired Coagulation Factor Disorders
Coagulopathy Associated with Liver Diseases
Concept of International Normalized Ratio and Management of a Patient on Oral Anticoagulants
SHOCK
Classification
Hypovolaemic Shock
Cardiogenic Shock
Septic Shock
Neurogenic Shock
SECTION SIXTEEN: MISCELLANEOUS
50:
HIV Disease—An Overview
History and Origin
Structure
Human Cells/Cell Lines and Tissue Susceptibility to HIV
Susceptibility
Global Scenario
Indian Scenario
Epidemiological Features
Agent Factors
Host Factors
Modes of HIV Transmission
Rate of Progression
Viral Transmission
Primary HIV Infection
Seroconversion
Early HIV Disease
Window Period of HIV Infection
Asymptomatic Infection
Oral Lesions and their Management
Fungal Lesions
Candidiasis
Clinical Features
Pseudomembranous Candidiasis (Thrush)
Erythematous Candidiasis
Angular Cheilitis
Hyperplastic Candidiasis
Differential Diagnosis
Diagnosis
Histoplasmosis
Cryptococcus Neoformans
Viral Lesions
Herpes Simplex
Clinical Features
Differential Diagnosis
Prognostic Significance
Herpes Zoster: (Shingles)
Clinical Features
Differential Diagnosis
Treatment
Human Papillomavirus Lesions
Clinical Features
Differential Diagnosis
Prognosis
Treatment
Cytomegalovirus (CMV) Lesions
Hairy Leukoplakia and Ebstein-Barr Virus
Hairy Leukoplakia and Progression of HIV Disease
Clinical Appearance and Manifestations
Differential Diagnosis
Diagnosis
Treatment
Bacterial Lesions
Periodontal Disease
Clinical Features
Differential Diagnosis
Treatment
Different Course in HIV Infection
Mycobacterium Avium-Intracellulare
Neoplastic Lesions
Kaposi's Sarcoma
Clinical Features
Differential Diagnosis
Treatment
Lymphoma
Clinical Features
Differential Diagnosis
Treatment
Other Lesions associated with HIV Disease
Oral Ulceration
Diagnosis
Treatment
Idiopathic Thrombocytopenic Purpura
Clinical Features
Differential Diagnosis
Salivary Gland Disease and Xerostomia
Management
Reporting of the Exposure
Determination of HIV Status Code (HIV SC)
Basic Regimen
Expanded Regimen
Testing and Counselling
Pregnancy and PEP
Side Effects of these Drugs
HIV Testing and Counselling
Different HIV Antibody Assays
Rapid Tests
Western Blot
Transfusion Safety
Diagnosis of HIV in the Newborn
Goals of HIV Pre-Test Counselling
Aims of Post-test Counselling
Reproductive Health Services
Protocol for HIV Positive Patients
A. Theatre
B. Personnel
C. Spillage
D. Instruments
Procedure for Anaesthetic Equipment
E. Sharps
F. Laboratory Specimens
Disinfectants
SECTION SEVENTEEN: APPENDICES
Appendix 1. Complications following minor oral surgical procedures
INDEX
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