1. Oral and Maxillofacial Surgery25
Oral and Maxillofacial Surgery

2. Oral and Maxillofacial Surgery
Branch of dentistry that focuses on diagnosis and treatment of diseases, injuries, and malformations
This branch of dentistry involves surgery for both functional and aesthetic aspects of diseases, injuries, and malformations.
To become licensed as a maxillofacial surgeon a minimum of four years postgraduate education is required including studies of anatomy, anesthesia, pain control, and surgical procedures.

3. Oral and Maxillofacial Surgery Team
Surgeon
Receptionist and business staff
Dental assistant
Nurse anesthesiologist or anesthesiologist
Surgeon – patient examination, diagnosis, teeth extraction, cyst and tumor removal, TMJ treatment, biopsies, emergency reconstructive and implant surgeries.
Receptionist/business staff – same as a traditional general office with more responsibilities for communication and record keeping.
Dental assistant – vary by practice but may include sterilization and room prep, seating and dismissing patient, pre and postoperative care, and assisting surgeon during procedures.
Nurse anesthesiologist or anesthesiologist – administration of anesthesia, maintaining patient vitals during procedure, supervising post operative recovery, patient evaluation, and assisting with record keeping.

4. Scalpel Setup
Used to incise or excise soft tissues. Consist of a handle and blade. Blades come in a variety of sizes.

5. Retractors Tissue Cheek and lip Tongue
Retractors are used to keep tissues away from the surgical site.
This allows the surgeon to have an unobstructed view of the surgical site.
Tissue retractors move tissue away during the procedure.
Cheek and lip retractors move the cheeks and lips away from the site.
Tongue retractors move the tongue away from the surgical site.

6. Tissue Retractors

7. Tongue and Cheek Retractors

8. Mouth Prop
Mouth props are used to prevent the patient’s mouth from closing during the surgery.
There are a variety of types of mouth props.

9. Hemostats Multiple uses Retract tissue Remove small root tips
Clamp blood vessels
Grasp loose objects
A hemostat is a forcep with working ends that are not sharp but are long with serrated or grooved beaks.
They have locking handles and can be manipulated with one hand. They are available in various sizes.

10. Needle Holders Similar to hemostat Function similar to hemostat
The needle holder is a type of forcep with a straight beak that is shorter than that of a hemostat.
They are also available in various sizes.

11. Surgical Scissors
Surgical scissors are used to cut sutures and to trim soft tissue.
They come in various shapes and sizes.
They should only be used for surgical procedures to maintain the sharp edges.

12. Surgical Aspirating Tips
Surgical aspirating tips are long tapered tubes used to remove blood and debris from the surgical site through suction.

13. Surgical Curettes
Surgical curettes are used for curettage and debridement of the tooth socket of disease tissue. They come in various sizes.

14. Surgical Chisel and Mallet
Surgical chisels are used to remove or shape bone. They can be used alone or with a surgical mallet.

15. Surgical Bone File
The surgical bone files is used to smooth the edges of alveolar bone. They smooth and trim the bone after tooth extraction.

16. Rongeurs
Rongeurs are hinged forceps used to trim and shape the alveolar bone after extractions. They are available in a variety of sizes and shapes.

17. Periosteal Elevators
Periosteal elevators are often used to detach the periosteum and gingival tissues from around the tooth prior to the use of extraction forceps. They are also used to lift the mucoperiosteum form the bone.

18. Elevators Loosen and remove teeth, retained roots, and root fragments
Types
Apical
Root tip picks
Elevators have t-shaped handles allowing the surgeon to achieve a firm grip and exert the proper amount of force.
There are a variety of types and styles of elevators.

19. Extraction Elevators

20. Root Tip Picks

21. Extraction Forceps Used to remove teeth from alveolar bone
Hinged with various handles and beak styles
Specific forceps are designed to be used on specific teeth and on the right or left side of the oral cavity.

22. Asepsis in Oral Surgery
Infection control is critical
Increased risk of exposure to blood in surgery
Asepsis is critical in surgical dentistry.
The risk for exposure to blood and OPIMs is higher in surgery.
Extreme care should be taken with cleaning, disinfecting, and sterilizing equipment and the treatment rooms.
OSHA standards must be followed.

23. Patient Considerations
Review
Medical records
Dental records
Referring dentist notes
Radiographs
Treatment options
Patient consent
Financial arrangements
If a patient is a candidate for oral surgery it is important to carefully review a complete medical and dental history.
Factors may come up during this review that may impact decisions made about the surgery.
Radiographs may be taken or reviewed as well. These may be intraoral or extraoral radiographs.
Once all diagnostic data has been reviewed, treatment options are discussed with the patient.
The patient will determine what option he or she would like to pursue and will provide consent for the procedure.
A release form is signed indicating the patient understands the procedure and is aware of possible complications.
Insurance information should also be carefully considered and updates made.

24. Oral Surgery Procedures
Uncomplicated extractions
Removal of permanent or primary teeth that have erupted into the oral cavity
Also known as routine or simple extractions
This involves the removal of permanent or primary teeth that have erupted into the oral cavity.
The crown of the tooth to be extracted is generally intact allowing adequate surface area for forceps to grasp.
Sutures are not usually required and instrumentation is minimal.

25. Simple Extraction Setup

26. Oral Surgery Procedures
Multiple extractions and alveoplasty
Multiple extractions are performed to prepare patient for partial or dentures
Bone and soft tissue of the edentulous ridge is contoured and smoothed
Alveoplasty is when the soft edges or points of tissues are smoothed away from the alveolar ridge to assure comfort of the new removable prosthetic.
Roughness from bone is like a pebble in your shoe. It creates discomfort and may cause complications with tissue.
Edentulous ridge is contoured for partial or denture.

27. Multiple Extractions Setup

28. Oral Surgery Procedures
Extractions of impacted teeth
Tooth may be partially or fully covered by tissue or bone
Tooth has not erupted into the oral cavity
Extraction is difficult due to depth, position, or angulation of tooth in bone
This is one of the most common procedures performed by the oral surgeon.
This type of procedure typically involves the third molars or wisdom teeth.
Often the crown of the tooth is not visible and it is more difficult for the forceps to have something to grab onto.

29. Problems Caused by Impacted Wisdom Teeth
Three roots
Impacted
Two roots
Wisdom teeth (# 3 above) develop inside the bone. Crowns form first, then the roots.
If the jaw grows long enough, the wisdom teeth can erupt and be used.
If the jaws are not long enough by age 16, wisdom teeth stay trapped (impacted) inside the bone.

30. Problems Caused by Impacted Wisdom Teeth
Gum infected
Impacted wisdom teeth can cause:
(A) Infection of the gums over or around them
(B) Infection in the bone around them
(C) Destruction of the next tooth

31. Problems Caused by Impacted Wisdom Teeth
Looking down on the biting surfaces of the lower teeth
(E) Other teeth pushed out of line (arrows)
(D) Destruction of the bone by formation of a cyst

32. Removal of Boney Impaction
Handpieces and surgical burs required to gain access
(A)
(B)
(C)
Irrigation syringe
(D)
(E)
(F)

33. Oral Surgery Procedures
Biopsy procedures
Total or partial removal of tissue from suspicious areas for microscopic examination and diagnosis
Three types
Excisional, incisional, exfoliative
The dentist will examine every patient for abnormal tissue.
When found, a biopsy (removal of the suspect tissue) will be performed. The tissue will then be examined for malignancies.
Early detection can save lives.

34. Incisional Biopsy
Top view
Removal of small section of lesion and a small border of normal tissue
Used when lesions are larger than 1 cm
Normal tissue
Lesion
Incision
Side view
This procedure involves removal of a small section of abnormal tissue with an area of normal tissue.
This is the procedure of choice when total removal may impair patient appearance and function.
Lesion
Incision
Normal tissue

35. Excisional Biopsy
Top view
Complete removal of lesion including border of normal tissue
Performed on smaller lesions
Normal tissue
Lesion
Incision
Side view
This procedure involves the complete removal of the abnormal tissue with a border of normal tissue.
This is the procedure of choice for smaller lesions.
No interference of appearance and function will occur with this procedure.
Lesion
Incision
Normal tissue

36. Exfoliative Cytology Smear biopsy
Nonsurgical procedure
Removal of a layer of cells from surface of lesion
This procedure involves removal of a layer of abnormal cells.
The cells are spread on a glass slab for microscopic inspection.
This may be a first step before additional biopsy or removal techniques are performed.

37. Exfoliative Cytology
Cells spread on a glass slab for microscopic examination
Often done in addition to other forms of biopsies
This procedure involves removal of a layer of abnormal cells.
The cells are spread on a glass slab for microscopic inspection.
This may be a first step before additional biopsy or removal techniques are performed.

38. Oral Surgery Procedures
Dental implant surgery
Method for replacing missing teeth
Screw or framework placed into jaw bone
Tooth shaped restoration is screwed into framework
This is an increasingly popular procedure for individuals seeking to replace missing teeth.
It allows for a fixed or removable solution.
A metal screw of framework is placed within the bone and the bone fuses with the device.
A tooth shaped restoration is then fitted into the framework.
Patients must be in reasonably good health for this type of procedure to work properly.

39. Oral Surgery Procedures
Treatment sequence for implants
Patient meets with restorative dentist
Referral to oral surgeon
Diagnostic consultation
Decision on treatment plan
Stages of treatment depend on technique used
The decision for dental implants requires a collaborative team approach from the dental offices and a commitment of time and cooperation of the patient.
Thorough examinations and histories are reviewed.
A treatment plan is agreed upon and arrangements are made for consent and finances.

40. Dental Implant

41. Oral Surgery Procedures
Types of implants
Subperiosteal
Endosteal
Mini Implant
A subperiosteal implant is used for patients whose alveolar bone was worn away.
They are more commonly placed on the mandible.
Endosteal implants are placed in the bone surgically.
These implants are used to replace a single tooth.
The mini or transitional implant were originally used as a temporary placement until the real implant heals.
Due to ease of placement these are becoming more favored for specific types of restorations.

42. Postoperative Patient Care
Given verbally and written
Lists expectations, what to do, and what to avoid
Following surgery it is important for the patient to follow post op instructions.
The patient should have someone with them for 24 hours after the surgery in the event any complications may occur.
Discomfort, swelling, bleeding, difficulty opening the mouth, a sore throat, and earaches are common conditions to expect after surgery.
The patient should begin taking pain medication before the anesthetic wears off, apply an ice pack to ease swelling, apply pressure to control bleeding, eat only soft foods for 24 hours, take medications to prevent infection, brush and floss areas not involved in surgery, sleep with head elevated to reduce swelling, avoid vigorous exercise, and rest for several days following surgery.
The patient should avoid strenuous activity for 48 hours, sucking and spitting, smoking, chewing gum, driving, drinking alcohol, or operating machinery until after anesthetic wears for 24 hours.
Patient should not rinse vigorously for 48 hours.

43. Postsurgical Complications
Alveolar osteitis (dry socket)
Cause is loss of blood clot from extraction site
May be the result of insufficient blood supply, infection, or trauma
Occurs three to five days following surgery
This occurs when the extraction site fails to clot properly.
It is the most common complication following an extraction.
The signs of dry socket are extreme pain, foul breath, foul taste, and exposed bone.

44. Treatment of Dry Socket
Irrigate tissue with warm saline solution
Pack extraction site with iodoform gauze
Rx: analgesic and antibiotics
Procedure repeated every one to two days
Topical antiseptic to prevent infection.
Soothes nerve endings in the exposed bone.
Prevents food from becoming lodged in the wound.

45. Treatment for Alveolitis
Surgical scissors and curette.
Irrigating syringe with warm sterile saline solution and iodoform quaze or sponge.

46. Temporomandibular Joint Disease
Muscles, bones, and joints of mandible fail to function properly
Disorders of the TMJ can be caused by trauma, clenching or grinding of the teeth, or arthritis.

47. Temporomandibular Joint Disease
Signs and Symptoms
Pain around ear
Tenderness of the masticatory muscles
Popping and clicking noise when opening and closing the mouth
These are the most common symptoms of TMJ. They can be debilitating when severe.

48. Temporomandibular Joint Disease
Signs and Symptoms
Crepitus or tinnitus
Limited movement of mandible
Trismus
Headaches or neckaches

49. Temporomandibular Joint Disease
Diagnosing
Dental and medical history
Examination of joint
Radiographs
Dental study casts
There are a variety of methods used to diagnosis TMJ.
It is important to have both a medical and dental examination to correctly diagnosis TMJ.

50. Temporomandibular Joint Disease
Treatment
Application of ice and heat
Learning to rest jaw
Medications
Stress management
Physical therapy
Occlusal splinting
Orthodontics
Steroid injections
Arthrocentesis
Arthroscopic surgery
Open joint surgery
There are a variety of methods used to treat TMJ.
The treatment depends on severity of symptoms.
The first line of treatment is nonsurgical and includes activities such as the alternating application of heat and cold, resting the jaw, and stress management techniques.
Surgery may be required for more chronic or debilitating symptoms.

51. Hospital Dentistry Trauma High risk patients
Patients with mental or physical disabilities
Extensive surgeries
Some dental surgeries are best completed in a hospital.
These may include:
Traumatic injuries in which time is of the essence in saving or retaining function.
Patients with high risk conditions that must require monitoring of vital signs throughout the procedure.
Patients for whom complications requiring additional intervention are high.
Patients with disabilities, either physical or mental, that are best handled with the specialized equipment the hospital offers.
Patients who need extensive surgery and require additional monitoring throughout the procedure.

52. Advanced Chairside Functions
Suture removal
Hold tissue in original position
Prepare patient and equipment
Examine site
Consult with dentist
Remove with care to avoid trauma or infection
Sutures are used to hold tissue in place that has been displaced or incised.
The dental assistant should prepare the patient and equipment for the procedure.
Ask the patient if there have been any issues of concern regarding the sutures.
Examine the suture site for location of sutures, number of sutures, type of pattern the sutures were placed in, and the healing of the tissues around the sutures.
If there is any cause for concern consult with the dentist on the best approach to take.
When removing sutures, be sure to take care not to infect the site or to disturb the healing process.
Control any bleeding that may occur with pressure using a gauze pad.

53. Advanced Chairside Functions
Types of Sutures
Simple
Continuous simple
Sling
Continuous sling
Mattress
There are a variety of suture patterns that can be used to close an open wound site.
The simple suture is the most common and can be placed in most areas of the mouth.
The continuous simple is placed when there are multiple extractions.
The sling suture is used for interproximal suturing.
The continuous sling is placed where a large flap involving several teeth has been used.
The mattress suture is used when a flap is to be sutured.