Indications for Maxillofacial Surgery

1. LECTURE 1HISTORY OF SURGICAL DENTISTRY AND MAXILLOFACIAL SURGERY, THEIR DEFINITION AND TASK. PREPARATION OF THE PATIENT FOR SURGERY. DEFINITION OF PAIN; REACTION OF THE ORGANISM TO THE PAIN, THE OPERATING TRAUMA. ANESTHESIA IN SURGICAL DENTISTRY.GENERAL ANESTHESIA. INDICATIONS AND CONTRAINDICATIONS, PREANESTHETIC MEDICATION PRINCIPLES, NEUROLEPTANALGESIA. COMPLICATIONS OF GENERAL ANESTHESIA, THEIR TREATMENT AND PROPHYLAXIS. FUNDAMENTALS OF CARDIOPULMONARY RESUSCITATION.

3. 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

4. Indications for Maxillofacial Surgery- cont’d • Removal of cysts and tumors • Biopsy • 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

5. Indications for Maxillofacial Surgery- cont’d • Cleft lip and cleft palate repairs • Salivary gland surgery • Surgical implant procedures

6. The Surgical Assistant • Must have advanced knowledge and skill in: • Patient assessment and monitoring • Specialized instruments • Surgical asepsis • Surgical procedures • Pain control techniques

7. The Surgical Setting • Dental Operatory • Surgical Suite • Operating Room

8. What is Surgical Dentistry /Oral Surgery? The dental specialty of Surgical Dentistry / Oral Surgeryis concerned with the diagnosis and surgical management of pathological processes and anomalies in the teeth or their supporting structures. Most treatment can be completed on an out-patient basis using local anæsthesia, occasionally supplemented by sedation if necessary.

10. The Surgical Dentist / Oral Surgeon is trained in a number of surgical procedures including the following: the extraction of teeth and rootsthe treatment of ectopic and impacted teethsurgical endodonticsthe re-implantation of teethsurgical exposure of teeth (such as canines)minor soft tissue surgery (such as biopsy techniques)removal of intra-oral submandibular salivary calculimanagement of dental traumaclosure of holes between the mouth and sinusmanagement of cuts to the mouthdental implantologyminor orthodontic surgery (release of tongue-ties) and pain and anxiety control, local anæsthesia and sedation

11. The syllabus includes: • diagnosis and management of oral disease • surgical endodontics • minor soft-tissue surgery • management of dental trauma • surgical placement of dental implants • management of pain and anxiety by pharmacological and non-pharmacological means • control of cross-infection • medico-legal aspects of surgical dentistryMost Surgical Dentists / Oral Surgeons have trained in a hospital-setting and often work part-time in hospital Oral Surgery departments.

12. Oral and maxillofacial surgery is surgery to treat many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral (mouth) and maxillofacial (jaws and face) region. It is an internationally recognized surgical specialty. In some countries, including the United States, it is a recognized specialty of dentistry; in others, including the UK, it is recognized as a medical specialty.

13. Surgical procedures Treatments may be performed on the craniomaxillofacial complex: mouth, jaws, face, neck, skull, and include: Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth extractions, extractions on medically compromised patients, bone grafting or preprosthetic surgery to provide better anatomy for the placement of implants, dentures, or other dental prostheses) Surgery to insert osseointegrated (bone fused) dental implants and Maxillofacial implants for attaching craniofacial prostheses and bone anchored hearing aids. Cosmetic surgery of the head and neck: (rhytidectomy/facelift, browlift, blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplasty, oculoplastics, neck liposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel etc.) Surgical treatment and/or splinting of sleep apnea, maxillomandibular advancement, genioplasty

14. Diagnosis and treatment of: benignpathology (cysts, tumors etc.) malignant pathology (oral & head and neck cancer) with (ablative and reconstructive surgery, microsurgery) cutaneous malignancy (skin cancer), lip reconstruction congenitalcraniofacial malformations such as cleft lip and palate and cranial vault malformations such as craniosynostosis, (craniofacial surgery) chronic facial pain disorders temporomandibular joint (TMJ) disorders Dysgnathia (incorrect bite), and orthognathic (literally "straight bite") reconstructive surgery, orthognathic surgery, maxillomandibular advancement, surgical correction of facial asymmetry. soft and hard tissue trauma of the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures).

15. How does a patient prepare for oral surgery? Oral surgery can be a frightening experience, but proper preparation can go far in making the procedure easier to anticipate. The first step is to consult with the dentist or oral surgeon about the procedure to understand what will be involved. The dentist will give a brief description of how the procedure will be performed and the medications used before, during and afterward. Patients particularly nervous about the impending surgery may want to ask about sedation options available. The patient will be given a list of pre-operative instructions. It is imperative to follow the instructions very carefully to ensure the procedure will be safe and successful. Arrange for transportation to and from the surgery, since certain medications may make it impossible for the patient to drive himself. Take the necessary time off work as recommended by the doctor.

16. Objectives • Patient data • Doctor – patient relationship • Anesthetic plan • Patient consent

17. 1.Review of patient data • Medical record • Interview history History of underlying disease, medication, functional capacitance, previous anesthetic history, family history, smoking and alcoholic use, review of system, psychological support Airway evaluation

18. 1.Review of patient data • Surgical condition -Condition of disease, symptom of disease -Surgical procedure -Position of procedure

19. 2. Physical examination • Vital signs • General appearance • HEENT • Respiratory system • CVS system • Abdomen • Extremities and spine • Neurologic system

20. Airway evaluation • History of difficult intubation • Head and neck examination for airway evaluation • Face • Oral cavity : mouth opening mandibular space tongue teeth Mallampati classification

22. Airway evaluation • Mentothyroid distance : normal 6 cm. • Mentosternal distance : normal 15 cm • Mentohyoid distance : normal 3 FB • Neck movement: flexion and extension of neck, history of radiation • Nasal cavity

23. Thyromental distance

26. Difficult intubation • Mouth opening less than 3 cm. • Limitation of neck movement • Micrognatia • Macroglossia • Protusion of teeth • Short neck • Morbid obesity

30. 3.Laboratory data • Value of testing • Risk and costs benefits • Preoperative testing: base on indication

31. What is Pain? The answer to this question seems obvious - pain is pain, right? Pain is pain, but it's not all the same. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” However, pain is a symptom that cannot be objectively assessed. I can’t look at a patient and know precisely what hurts, how badly, and what the pain feels like. Pain, therefore, is whatever the person experiencing it says it is.

33. Introduction • The practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain. • Methods of pain control • Anesthetic agents • Inhalation sedation • Antianxiety agents • Intravenous sedation • General anesthesia

34. Anesthetic Agents • The numbing of a specific site or area. • Topical Anesthesia provides a temporary numbing effect on nerve endings that are located on the surface of the oral mucosa. • Supplied as: • Ointments • Liquids • Sprays

35. Local Anesthesia • Agents most frequently used for pain control in dentistry. • Criteria for use: • Be nonirritating to the tissues in the area of the injection. • Produce minimal toxicity. • Be of rapid onset. • Provide profound anesthesia. • Be of sufficient duration. • Be completely reversible. • Be sterile.

36. Method of Action • Local anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses. • Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment. • Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

37. Duration • Length of time from induction until the reversal process is complete. • Short-acting: • Local anesthetic agent lasts less than 30 minutes. • Intermediate-acting: • Local anesthetic agent lasts about 60 minutes. • Long-acting: • Local anesthetic agent lasts longer than 90 minutes.

38. Vasoconstrictor • Criteria for use: • Prolongs the duration of an anesthetic agent by decreasing the blood flow in the immediate area of the injection. • Decreases bleeding in the area during surgical procedures. • Types: • Epinephrine • Levonordefrin • Norepinephrine

39. Vasoconstrictor- cont’d • Ratio of vasoconstrictor to anesthetic solution: • 1:20,000 • 1:50,000 • 1:100,000 • 1:200,000

40. Vasoconstrictor- cont’d • Contraindications for the use of vasoconstrictors • Unstable angina. • Recent myocardial infarction. • Recent coronary artery bypass surgery. • Untreated or uncontrolled severe hypertension. • Untreated or uncontrolled congestive heart failure.

41. Types of Local Anesthesia Injections • Infiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure. • Most frequently used to anesthetize the maxillary teeth. • Used as a secondary injection to block gingival tissues surrounding the mandibular teeth.

42. Types of Local Anesthesia Injections- cont’d • Block anesthesia • The solution is injected near a major nerve, and the entire area served by that nerve is numbed. • Type of injection required for most mandibular teeth. • Inferior alveolar nerve block • Obtained by injecting the anesthetic solution near the branch of the inferior alveolar nerve close to the mandibular foramen. • Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

43. Types of Local Anesthesia Injections- cont’d • Incisive nerve block • Injection given at the site of the mental foramen. • Used when the mandibular anterior teeth or premolars require anesthesia. • Periodontal ligament • Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

44. Table 37-2 Local Anesthesia Setup: Anesthetic Syringe

45. Local Anesthesia Setup • Anesthetic carpule: Care and caution of use • Cartridges should be stored at room temperature and protected from direct sunlight. • Never use a cartridge that has been frozen. • Do not use a cartridge if it is cracked, chipped, or damaged in any way. • Never use a solution that is discolored or cloudy or has passed the expiration date. • Do not leave the syringe preloaded with the needle attached for an extended period of time. • Never save a cartridge for reuse.

46. Local Anesthetic Cautions • Injection into a blood vessel • Infected area • Localized toxic reaction • Systemic toxic reaction • Temporary numbness • Paresthesia

47. General Anesthesia • A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command. This controlled state in loss of consciousness, produces stage III general anesthesia.

49. Four Stages of Anesthesia • Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent, the patient can move into different levels of analgesia.

50. Four Stages of Anesthesia- cont’d • Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage.