Oral and Maxillofacial Surgery Chapter 56 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

Chapter 56 Lesson 56.1 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

Learning Objectives Pronounce, define, and spell the Key Terms. Describe the specialty of oral and maxillofacial surgery. Discuss the role of an oral surgery assistant. Identify specialized instruments used for basic surgical procedures. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

Learning Objectives (Cont’d) Discuss the importance of the chain of asepsis during a surgical procedure. Prepare a sterile field. Perform a surgical scrub. Perform sterile gloving. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

Introduction Oral and maxillofacial surgery is the specialty of dentistry involving the diagnosis and surgical treatment of diseases, injuries, and defects. An oral and maxillofacial surgeon is a dentist with 4 to 6 additional years of postgraduate training. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

Indications for Maxillofacial Surgery Extractions of decayed teeth that cannot be restored Surgical removal of impacted teeth Extraction of nonvital teeth Preprosthetic surgery to smooth and contour the alveolar ridge Removal of teeth for orthodontic treatment Removal of root fragments Removal of cysts and tumors Biopsy (Cont’d) Some general dentists are competent to perform these procedures in their offices. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

Indications for Maxillofacial Surgery (Cont’d) Treatment of fractures of the mandible or maxilla Surgery to alter the size or shape of the facial bones Surgery of the temporomandibular joint Reconstructive surgery Cleft-lip and cleft-palate repairs Salivary gland surgery Surgical implant procedures Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

The Surgical Assistant Must have advanced knowledge and skills in: Patient assessment and monitoring Specialized instruments Surgical asepsis Surgical procedures Pain-control techniques What should be monitored in a patient during a surgical procedure? Assistants can attend the Oral and Maxillofacial Anesthesia Assisting Program, or OMAAP. The program includes 4 to 6 months of study with a board-certified oral and maxillofacial surgeon and a test. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

The Surgical Setting Dental operatory Surgical suite Operating room A dental operatory is an in-office operatory. A surgical suite is generally located in the office and has specialized equipment used for certain procedures. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

Dental Instruments It is critical for the surgical assistant to have a working knowledge and understanding of surgical instruments. Each instrument has a specific purpose. How are these instruments disinfected or sterilized? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Elevators Used to apply leverage against the tooth to loosen it from the periodontal ligament and ease extraction. Types Periosteal elevator Straight elevator Root-tip pick Bulbous handle. Single-ended. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Fig. 56-2 Periosteal elevator. (Courtesy of Miltex, Inc, York, Pa.) Double-ended. What is this instrument used to reflect? First instrument used in a surgical procedure. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

Fig. 56-3 Straight elevator. (Courtesy of Miltex, Inc, York, Pa.) Note the bulbous handle. Single-ended. What is this instrument used for? The working end resembles a spoon. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

Fig. 56-4 Root-tip picks. (Courtesy of Miltex, Inc, York, Pa.) Single-ended. May have a bulbous or a slim handle. Smaller working end. What is this instrument used for? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

Fig. 56-5 Commonly Used Forceps. (Courtesy of Miltex, Inc, York, Pa.) The working ends are available in a variety of shapes and sizes. Some handles are curved to fit into the palm of the dentist’s hand. What is this instrument used for? What does a universal forceps mean? Photographs are of maxillary forceps. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Surgical Instruments Surgical curette Rongeur Bone file Used to clean and scrape the interior of the tooth socket to remove diseased tissue Rongeur Used to trim alveolar bone Bone file Used to smooth rough margins of the alveolus (Cont’d) These instruments are commonly used after the tooth has been removed from the socket. Rongeur: hinged instrument similar to a fingernail clipper. During a procedure sharp edges must be kept clean with gauze squares. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

Fig. 56-6 Surgical curettes. (Courtesy of Miltex, Inc, York, Pa.) The double-ended type is the most commonly used. Smaller working end. What instrument does it resemble? What is it used for? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

Fig. 56-8 Bone file. (Courtesy of Miltex, Inc, York, Pa.) Used in a push-pull motion. Grated. What is the use of this instrument? Be careful about the terminology you use in the patient’s presence. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

Surgical Instruments Scalpel Hemostat Needle holder (Cont’d) Scalpel Surgical knife used to make precise incisions into soft tissue Hemostat Used to grasp and hold things Needle holder Used to firmly grasp a suture needle Depending on the treatment plan, these instruments may not be needed. Sutures are not placed on all extraction sites. What type of extraction would require an incision to be made? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

Fig. 56-9 Scalpel handle and blade. (Courtesy of Miltex, Inc, York, Pa Different sizes of blades are available. Commonly referred to as a Bard Parker. The scalpel may be one piece (blade and handle together, one-time use, disposed of). How is the used blade disposed of? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

Fig. 56-10 Hemostat. (Courtesy of Miltex, Inc, York, Pa.) Locking handle. Curved and straight beaks available. Serrated edges. What is the use of a hemostat in a surgical procedure? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

Fig. 56-11 Needle holders. (Courtesy of Miltex, Inc, York, Pa.) What instrument does a needle holder resemble? How would a dental assistant transfer this instrument? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

Surgical Instruments Surgical scissors Suture scissors Retractors (Cont’d) Surgical scissors Used to trimm soft tissue Suture scissors Used to cutt suture material Retractors Used to hold or retract tissue during surgery These are accessory instruments. Retractors: tissue and tongue. Tissue retractor: forklike prongs. Tongue retractor: larger, curved instrument. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

Surgical Instruments Mouth prop Chisel (Cont’d) Mouth prop Also known as a bite-block; allows the patient to rest and relax the jaw muscles during surgery Chisel Either in a single-bevel or bi-bevel design; single-bevel type used for removing bone, bi-bevel for splitting teeth Be careful in your choice of terminology in the patient’s presence. A patient may become anxious if he or she hears the word “chisel.” A chisel is used with a mallet. When would a mouth prop be used? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

Surgical Instruments Mallet Surgical burs (Cont’d) Mallet Source of pressure used on the chisel handle Surgical burs Used to remove bone or to cut or split the crowns or roots of teeth A mallet is like a hammer and is used with a chisel. A high-speed handpiece or surgical handpiece can be used for surgical burs. Surgical burs are disposed of in the sharps container after each use. What item must be used when a surgical bur is used? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

Surgical Asepsis Because surgical procedures invade open tissue, the surgical team must follow sterile technique. What does the term “asepsis” mean? (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

Surgical Asepsis Sterile field Surgical scrub Sterile gloving (Cont’d) Sterile field Site where surgical instruments and accessory items are placed during the surgery Surgical scrub Type of hand wash used to lessen the chance of infection Sterile gloving Required for assistance in an invasive procedure Who are we protecting by maintaining the chain of asepsis? How is a sterile field prepared? How is a surgical scrub different from a nonsurgical scrub? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

Preparing for Surgery Advance preparation Have all patient records and radiographs in order. Have consent forms signed and available. Information requested from the patient’s physician must have been received. Check for laboratory cases. Ensure that surgical setups have been prepared and sterilized. Provide preoperative instructions for any premedication. (Cont’d) What type of radiographs are used in a surgical procedure? Why should consent forms be completed before a surgical procedure is started? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28

Preparing for Surgery Treatment-room preparation (Cont’d) Treatment-room preparation Place protective barriers. Keep surgical instruments in their sterile wraps until they are to be used. Have the appropriate pain-control medications set out and ready for administration. Have the postoperative instructions ready to provide to the patient. Where are protective barriers placed? When should we give a patient postoperative instructions? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29

Preparing for Surgery Patient preparation (Cont’d) Patient preparation Update the medical history and laboratory reports. Confirm with the patient that any prescribed premedication was taken as directed. Place the radiographs on a view box. Take vital signs for a baseline. Seat and drape the patient. Position the chair. What type of premedication could the patient take before a surgical procedure? What vital signs must be obtained before the procedure is started? What is the correct positioning of the patient? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30

Preparing for Surgery During surgery Maintain the chain of asepsis. (Cont’d) During surgery Maintain the chain of asepsis. Transfer and receive instruments. Provide aspiration and retraction as needed. Maintain a clear operating field with light. Monitor the patient’s vital signs. Steady the patient’s head and mandible if necessary. Observe the patient’s condition and anticipate the surgeon’s needs. A surgical tip should be used for the high-volume extractor (smaller head to fit into the socket). How would the assistant support the patient’s head during a surgical procedure? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31

Preparing for Surgery After surgery Stay with the patient. (Cont’d) After surgery Stay with the patient. Give verbal and written postoperative instructions. Schedule a postoperative visit. Update the patient’s treatment records. Return the patient’s records to the business assistant. Break down and disinfect the treatment area. Why is it important to stay with the patient? Why would we give postoperative instructions before the surgical procedure? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

Chapter 56 Lesson 56.2 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33

Learning Objectives Describe surgical procedures typically performed in a general practice. Assist in a simple extraction. Assist in a multiple-extraction procedure with alveoplasty. Assist in the removal of an impacted tooth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34

Forceps Extraction Forceps extraction is the surgical removal of a tooth that is fully erupted and has a solid, intact crown that can be grasped firmly with the forceps. Does not require sutures to be placed. Commonly referred to as a simple or routine extraction. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35

Multiple Extractions and Alveoloplasty Multiple extraction procedure involving the contouring and smoothing of the alveolar crest of the surgical site. Most commonly done when a partial or denture is being constructed. Can be multiple extractions in different arches; would not need alveoplasty. Same procedure as a forceps extraction. Why would the alveolar bone need to be contoured and smoothed? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36

Removal of Impacted Teeth A complex extraction of a tooth that has not erupted Soft-tissue impaction Hard-tissue impaction Sutures are placed. Surgical burs may be required to gain access to the tooth below the bone level. A scalpel would be used to make an incision to gain access. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37

Biopsy The surgical removal and examination of lesions in the oral cavity Incisional biopsy Excisional biopsy Exfoliative cytology What is a malignancy? An incisional biopsy is performed on lesions larger than 1 cm; a wedge of lesion is cut along with normal tissue. Exfoliative cytology is also known as a smear biopsy; the lesion is brushed and spread on a slide. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38

Chapter 56 Lesson 56.3 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39

Learning Objectives Assist in suture placement. Perform suture removal. Describe the postoperative care given to a patient after a surgical procedure. Discuss the possible complications of surgery. Assist in the treatment of alveolitis (dry socket). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40

Sutures Sutures are the stitches placed to control bleeding and promote healing. Sutures, which are not placed for all procedures, are an important part of the healing process. When would sutures need to be placed? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41

Types of Sutures Absorbable Nonabsorbable Plain catgut provides the fastest healing for mucous membranes and subcutaneous tissues. Chromic catgut provides a much slower healing, allowing the internal tissues to heal first. Vicryl is a synthetic absorbable material. Nonabsorbable Silk is used for its strength and ease of use. Polyester fiber is one of the strongest sutures. Nylon is used for its strength and elasticity. Dentist preference determines the type of suture material used. Suture material is usually supplied with the needle already attached. What does the term absorbable mean? What does the term nonabsorbable mean? What will need to be done for nonabsorbable sutures? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42

Suture Removal When nonabsorbable sutures are placed, the patient is scheduled to return to have them removed in approximately 5 to 7 days. What instruments are needed for a suture-removal procedure? Who is allowed to remove sutures? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43

Postoperative Care Control of bleeding A 2 × 2-inch piece of gauze is folded and placed to control bleeding and encourage clot formation and healing. Keep gauze in place for 30 minutes. If bleeding does not stop, call the dental office. Do not disturb the clot with your tongue or by rinsing your mouth vigorously. Strenuous work or physical activity is restricted that day. (Cont’d) Frequently remind the patient of how to care for the extraction sites. Advise the patient to keep his or her head elevated and to sleep with an extra pillow. Should a patient be given postoperative instructions even though he or she received the instructions before surgery? Are postoperative instructions given orally or written? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44

Postoperative Care Control of swelling (Cont’d) Control of swelling Ibuprofen is used before and after surgery. During the first 24 hours, a cold pack is placed in a cycle of 20 minutes on/20 minutes off. After the first 24 hours, external heat is applied to the area of the face in question to increase circulation in the tissues and to promote healing. After the first 24 hours, the patient may begin gently rinsing the oral cavity with warm saline solution. Advice for patient: Eat/drink cool, smooth things (e.g., ice cream, pudding, yogurt). No spicy food. No straws. No sucking motions. No smoking or chewing tobacco. No alcohol. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45

Postsurgical Complications Alveolitis (dry socket) Causative factors Inadequate blood supply to the socket Trauma to the socket Infection within the socket Dislodgment of the clot from the socket How can the clot become dislodged from the socket? What is the purpose of the medicated dressing or squares? Will the patient need to return for evaluation? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46