Textbook of Oral and Maxillofacial Surgery Neelima Anil Malik
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1Principles of Oral and Maxillofacial Surgery
  • 1. Introduction to Oral and Maxillofacial Surgery
  • 2. Art of Diagnosis and Diagnostic Imaging
  • 3. Management of Medically Compromised Patients in Oral Surgery
  • 4. Armamentarium Used in Oral and Maxillofacial Surgery
  • 5. Suturing Materials and Techniques
  • 6. Asepsis and Sterilization
  • 7. Infection Control
  • 8. Antimicrobial Therapy2

Introduction to Oral and Maxillofacial SurgeryCHAPTER 1

Oral and Maxillofacial Surgery is one of the branches of health sciences. It is an internationally recognized surgical specialty. In India, it is one of the nine specialties of dentistry and recognized branch for post graduate studies in the subject, by Dental Council Of India.
The field of oral and maxillofacial surgery has evolved through the ages. From extracting teeth by tying a thread around the tooth to refined techniques of today, the field has come a long way. Andre Fouchard is considered to be the Father of Dental Surgery. Pioneers like Lister in the practice of asepsis, Wells in the introduction of anesthetic techniques, Bell in the field of orthognathic surgery, Gillie and Champy in the treatment of fractures have established a scientific basis to oral and maxillofacial surgical procedures. It is to them, we owe the modern day practice of oral and maxillofacial surgery.
Oral and maxillofacial surgery is a surgical branch, to correct wide spectrum of diseases, injuries and defects in the head, neck, face, jaws region and the hard and soft tissues of the oral and maxillofacial region (Association of Oral and Maxillofacial Surgeons of India-AOMSI). It deals with the art of diagnosis and treatment of various diseases, injuries and defects involving the orofacial region.
Other Accepted International Definition
Oral and maxillofacial surgery is a surgical specialty, which involves the diagnosis, surgery and an adjunctive treatment of diseases, injuries and deformities/defects (congenital/acquired), involving both the functional and esthetic aspects of the hard and soft tissues of the oral (mouth) and maxillofacial (jaws, face and associated structures) region. This specialty is often seen as the bridge between medicine and dentistry.
Other specialties dealing with the cranio-oromaxillofacial region include the plastic surgery, neurosurgery, ENT surgery and ophthalmology, etc. Although, there is a considerable overlapping between these branches, in the past few years a definite delineation has been made among each of these specialties. The oral and maxillofacial surgeon has carved a special niche in the multidisciplinary approach to craniofacial pathologies.
In some countries around the world, including USA, Canada and Australia, it is a recognized specialty of dentistry. In others, such as the UK and most of the Europe, it is recognized as a specialty, both of medicine and dentistry and a dual degree in medicine and dentistry is compulsory for treating conditions that require expertise from both the backgrounds, such as head and neck cancers, salivary gland diseases, facial disproportions, facial pain, temporomandibular joint disorders, etc.
  • The scope of oral and maxillofacial surgery depends on the qualifications and capabilities of the dentist. There is a definite distinction in the case selection for an undergraduate, trained in oral surgery, and a postgraduate, trained in oral and maxillofacial surgery and for cases that require multidisciplinary approach.
    • An undergraduate student trained in oral surgery: He/she is expected to deal with simple exodontia, complications arising from routine extractions like tooth/root fractures, tissue laceration, postextraction bleeding, minor post-extraction infections, immediate management of medical emergencies in the dental office and minor surgical procedures like apicoectomy and alveoloplasty, etc.
  • 4Oral and maxillofacial surgeon requires to undergo three years of further formal university training after obtaining BDS degree.
    • A postgraduate student in oral and maxillofacial surgery: He/she is expected to deal with both the outpatient department cases as well as the patients admitted in the indoor ward. Beginning with complicated exodontia, the postgraduate program gradually trains the student to become a full-fledged oral and maxillofacial surgeon, capable of handling the various problems or pathologies of the face and the jaw bones.
  • Further fellowship programs or further specialized training can be acquired depending on area of interest, after formal MDS degree in oral and maxillofacial surgery.
    • Head and Neck Oncology Fellowship
    • Cleft lip and Palate Fellowship
    • Cosmetic Facial Surgery Fellowship
    • Craniofacial Surgery and Pediatric Maxillofacial Surgery Fellowship
    • Cranio-maxillo-facial Trauma Fellowship.
Various treatments performed by oral and maxillofacial surgeons include:
  • Dentoalveolar surgery: Surgery to remove difficult tooth extractions/impacted teeth surgical extractions, dental extractions or any minor/major oral surgical procedures in medically compromised patients, bone grafting or preprosthetic surgery to provide better, adequate anatomical foundation for the placement of implants, dentures, or other dental prostheses.
    • Preprosthetic surgical procedures including implantology.
    • Surgery to insert osseointegrated (bone fused) dental implants and maxillofacial implants for attaching craniofacial prostheses and bone-anchored hearing aids.
  • Diagnosis and treatment of problems in oral cavity, head, face, neck region
    • Benign pathology—cysts, tumors, etc. Treatment of cysts and tumors of both odontogenic and nonodontogenic origin, involving the jaw bones.
Premalignant lesions and conditions—early detection and treatment of lesions and conditions, such as, oral submucous fibrosis and leukoplakia.
  • Malignant pathology—oral cavity, head, face, neck region cancer:
    • ▸ Detection and management of oral cancer, with ablative and followed by postreconstructive surgery. Microvascular reconstructive surgery.
    • ▸ Cutaneous malignancy—skin cancers on the facial region, lip reconstruction, etc.
  • Management of disorders of maxillary sinuses
  • Congenital craniofacial malformations
    • Such as cleft lip and palate and cranial vault malformations such as craniosynostosis (cranio-facial surgery)
  • Soft and hard tissue trauma of the oral and maxillofacial region
    • Initial and definitive management of traumatic injuries of soft and hard tissues of orofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures). Post-traumatic reconstruction.
  • Chronic orofacial pain disorders management
  • Temporomandibular joint (TMJ) disorders
    • Temporomandibular joint disorders including internal derangement and ankylosis.
  • Salivary gland diseases and their management.
  • Corrective jaw surgery—Orhognathic surgery
    • Dysgnathia—incorrect bite and orthognathic is straight bite
    • Diagnosis and management of dentofacial deformities, either acquired, developmental or congenital (including clefts of the lip and palate).
    • Corrective surgery for jaw bones along with dentition-maxillo-mandibular advancement, setback, genioplasty, correction of facial asymmetry, correction of sleep apnea, etc.
  • Management of orofacial infections involving the soft and hard tissues and handling life-threatening emergencies due to acute infections.
  • Detection and management of facial neurological disorders
  • Trigeminal neuralgia, Bell's palsy, Frey's syndrome, etc.
  • Reconstruction of missing portion of jaw bones with bone graft/distraction osteogenesis.
  • Surgical management of the complex airway, snoring and sleep apnea.
Cosmetic Surgery
Cosmetic surgery limited to the head and neck (rhytidectomy/facelift, browlift/blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplasty, neck liposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel, hair transplant, etc.)
Goals of the Undergraduate Training Program in Oral and Maxillofacial Surgery
The training program is designed to train undergraduate students to competence in handling exodontias and minor oral surgical procedures under local anesthesia. Basically, it is a vertical integration of linking theoretical ideas with clinical practice. It is targeted to provide the students with a broad academic background in the biomedical sciences and surgical principles, in the diagnosis and management of basic oral and maxillofacial surgery, including the management of medically compromised patients, and the fundamental knowledge, principles and surgical skills in the treatment of minor oral and maxillofacial surgical problems.
It is structured to achieve the following objectives:
  • Knowledge:
    • To acquire basic understanding of the etiology and pathophysiology, treatment planning of various common oral and maxillofacial minor surgical problems.
    • To understand the basic general minor surgical principles, along with pre- and postsurgical pain management.
    • To understand basic sciences relevant to practice of oral surgery.
    • Essential knowledge of personal hygiene and infection control, prevention of cross-infection and safe disposal of waste management, keeping in view, the high prevalence of hepatitis and HIV.
  • Skills: To develop skills to perform simple extractions and to carry out minor dentoalveolar surgical procedures under local anesthesia.
  • Attitude: To develop ethical attitude in all aspects of minor dentoalveolar surgeries. To also develop compassion, empathy, warmth and honesty for the welfare of the patients.
  • Communicative skills and ability: With patients, professional colleagues and develop attitude to seek opinion from an allied medical/dental specialists, as and when required.
  • Research and updated brief knowledge in recent advances in the subject.
  • To develop within the students a foundation of professional knowledge coupled with the surgical skills to enable them to recognize and select those cases for operation which lie within the limit of their ability, and to refer other surgical problems wisely. Develop a sense of confidence in the students’ surgical skills and clinical judgment, and to encourage a desire for continued professional development and self-improvement through continuing education courses, postgraduate courses or graduate training for a teaching career or specialty practice.
  • To teach the students a standard pattern of intelligent history taking, examination, critical analysis of case findings, and full utilization of appropriate diagnostic aids all directed toward a sound diagnosis for an oral surgical problem. To develop within the student a foundation of professional knowledge coupled with minimum surgical skills to enable him/her to competently diagnose and operate upon oral surgery problems related to the practice of general dentistry.
  • The dentist assumes an ethical and legal responsibility too when he/she accepts a patient for oral surgery. When faced with a problem for which he/she is not qualified to treat, it is his/her professional responsibility to appropriately refer the patient for treatment.
  • Undergraduate student in the subject of oral and maxillofacial surgery should be trained in following clinical procedures:
    • Use basic surgical instruments
    • Perform extraction of normally erupted teeth.
    • Remove fractured roots resulting from the extraction of normally erupted teeth.
    • Prepare the oral cavity for the reception of prostheses. This includes the surgical management of alveolar bone and soft tissues without mutilation for the requirements of prosthetic foundation.
    • Remove surgically uncomplicated periapical granulomas and cysts of dental etiology.
    • Incise and drain intraoral subperiosteal abscesses and other localized infectious processes of dental origin.
    • Control hemorrhage from bone and soft tissues.
    • Detect prodromal signs, prevent and treat reactions of syncope, shock or other untoward reactions to anesthesia or surgery, which may require resuscitative measures.
    • Provide general and specific postoperative care to all extraction problems.
    • Biopsy or refer for biopsy lesions of the mouth and jaws requiring this diagnostic aid.
    • Reduce and immobilize simple fractures of the alveolus
    • Understand operating room technique, hospital procedure, and patient care through hospital experience.
    • 6Brief knowledge of the broad-spectrum of oral and maxillofacial surgery as a dental specialty, in the management of complicated facial fractures, orthognathic surgery, vestibuloplasty, bone and soft tissue grafting, dental implant surgery, tumor surgery, and other maxillofacial surgical procedures.
Cleft Lip and Palate
The oral and maxillofacial surgeon forms an important part of the cleft lip and palate management team, that comprises of the plastic surgeon, the pediatric surgeon, the orthodontist, the pedodontist, and the speech therapist. The oral and maxillofacial surgeon plays an important role in the primary as well as secondary closure of the lip and palate, as well as in the correction of residual deformities of the maxilla and the mandible at a later stage.
Craniofacial Syndromes
The oral and maxillofacial surgeon also forms a part of the core group, consisting of neurosurgeon, plastic surgeon and ENT surgeon involved in treating craniofacial abnormalities, especially syndromal, like Crouzon's syndrome or Goldenhar syndrome, etc.
Trauma Unit
  • The oral and maxillofacial surgeon is also involved in the polytrauma unit along with orthopedic surgeon, general surgeon and plastic surgeon.
  • The oral and maxillofacial surgeon, thus, forms an important link between the various specialties in the treatment of craniofacial pathologies.
The field of oral and maxillofacial surgery is constantly evolving and adapting newer techniques, to refine the surgical procedures, and to achieve precision with minimally invasive techniques. One such technique that has revolutionized the treatment of facial deformities is distraction osteogenesis. The technique deals with the elongation of the bone by gradual callus distraction.
It is extremely difficult to outline the scope of a subject, where there is a constant adaptation with the introduction of research-based technology and techniques. It is our aim to impart the knowledge with every new edition of this textbook. The students are advised to keep themselves updated with new literature on the subject.