Indian Dental Academy Principles of Maxillofacial Surgery

INDIAN DENTAL ACADEMY
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Principles of Maxillofacial Surgery
• Painless surgery
• Asepsis & sterilization
• Adequate access
• Arrest of haemorrhage
• Debridement & drainage
• Closure of wounds
• Post operative care

Painless Surgery
• Pre-medication
• Anaesthetic considerations
• Local
• Local and sedation
• General

Goals of Pre medication
• Sedation
• Amnesia
• Analgesia
• Drying of airway secretions
• Prevention of autonomic reflex responses
• Reduction of gastric secretions
• Antiemetic effects
• Reduction of anaesthetic requirements
• Facilitation of smooth induction of anaesthesia

Principles of maxillofacial surgery
Selection of appropriate drugs
Considerations • Psychological condition
• Physical status
• Age
• Surgical procedures & its duration
• Out patient or in patient procedure
• Elective or emergency

Common Pre-operative Drugs
Drug
Route
Diazepam
Oral
Midazolam
I.M.
Pentobarbitol
Oral, I.M.
Morphine
I.M.
Meperedine
I.M.
Atropine
I.M., I.V.
(Anticholinergic)
Scopolamine
I.M.,I.V.
Metoclopramide Oral, I.M.,I.V.
(Antiemetic)

Dose
5 to 20 mg.
3 to 7 mg.
50 to 200 mg.
5 to 15 mg.
5 to 15 mg.
0.3 to 0.6 mg
0.3 to 0.6 mg
5 to 20 mg.

Painless surgery
Local Anaesthesia Majority of the minor oral surgical procedures
are carried out under local anaesthesia


Painless surgery
Local anaesthesia with sedation In apprehensive patients minor surgical procedures
are carried out under local anaesthesia combined
with intra-venous sedation using • Diazepam 5 to 20 mg
• Midazolam 3 to 7 mg

Indications for general anaesthesia
• Acute infections (Ludwig’s Angina)
• Surgery in several parts of the mouth
• Prolonged surgery
• Technically difficult surgery
• Extremes of age
• Very nervous patients

Asepsis & sterilisation
Asepsis
Method of surgery designed to prevent introduction
of infection into a wound at the time of operation
Sterilisation
Removal or disinfection of all micro-organisms
including bacterial spores and virus

Sources of infection during surgery
• Patient himself
• Operator
• Instruments & materials used
• Operating area


Minimising infection from the patient
• Attention to oral hygiene
• Oral prophylaxis
• Chlorhexidine / betadine mouth washes
• Preparation of the mouth prior to surgery


Minimising infection from the operator
• Wearing mask & head cap
• Keeping finger nails short & clean
• Removing rings, watches, bangles
• Scrubbing the hands
• Wearing sterile gloves
• Aseptic procedure

Are gloves really safe??
Study to access the risk of glove puncture during
oral surgery (Burke et al 1996)
• Incidence of 16%
• More in the left hand glove
• Highest incidence during surgical extraction
• Avoid – Double gloving, non-perforated gloves

Accidental injury / prick
What to do??
• Stop the procedure
• Check for depth of penetration / injury
• Check pt’s status – investigate for HIV & HbSAg
• Apply pressure over the area to avoid spread
• Promote bleeding and wash with soap under tap water
• If pt. seropositive then start on antivirals / immunoglobulin

Risk of cross infection
HIV
• Percutaneous exposure – 0.4 %
• Start on Zidovudine within 4 hours
HbSAg
• Percutaneous exposure – 20 %
• Conc. of virus in blood more than HIV
HbSAg – 1012 particles / ml , HIV – 104 particles / ml

Preventing infection from instruments
• Using only sterilised instruments and materials
during surgery
• Avoiding contamination & minimizing extraoral
contact


Methods of sterilisation
• Moist heat

-

autoclave

• Dry heat

-

hot air oven

-

Glutaraldehyde

-

Ethylene oxide

• Boiling water
• Chemicals
• Gamma rad.
• Gases


What is the reliable method of Sterilisation?
Moist heat (autoclave)
Types

-

high vaccum

-

Downward displacement

Temperature required - 121° c
Pressure

- 15 to 20 pounds

Time

- 15 to 20 mts.

Mode of action - coagulation of proteins

Hot air oven sterilisation
• Temperature

-

160 to 183° c

• Time

-

1 hour

• Mode of action -

Oxidation


Minimising iatrogenic infection
• Clean environment
 Daily & meticulous cleansing of surfaces
 Fumigation
• Regular microbiological monitoring of facilities
 Swabs from different areas - CST



Access
• Oral cavity - Mucoperiosteal flaps
• Face

- Skin incisions


Access - intra oral
Principles of muco periosteal flaps
• Visibility
• Vascularity
• Healing


Access – intra oral
Muco periosteal flap
• Flap consisting mucosa and periosteum

Design
Visibility
• Large enough to provide adequate access
Viability
• Broad base with narrow margin to provide
proper blood supply
Healing
• Line of incision should be placed on sound bone

Armamentarium

Minor Surgery Tray



• Base wider than free end
• Include papilla in the flap


Labial Approach

Palatal Approach


Degloving incision for maxilla


Degloving incision for mandible


Access
Removal of bone
• Bone is removed either by using surgical burs or
chisel


Access
Instruments for bone removal
1. Chisel
2. Osteotome
3. Gouge
4. Ronguers
5. Bone file

Access
Removal of bone using burs
• Ideally micromotor is used with either rosehead or
straight fissure burs
• Copious saline irrigation during use to prevent
thermal necrosis of bone
• Avoid airotor due to risk of surgical emphysema

Methods to arrest haemorrhage
Soft tissue –
• Digital pressure
• Pressure packs
• Use of haemostat
• Ligation of blood vessels
• Electro cautery

Bone –

• Burnishing
• Hot pack
• Use of bone wax
• Absorbable haemostatic agents

Debridement of wound
Removal of
• Devitalised tissue
• Granulation tissue
• Bone pieces
• Hanging bone margins

Trimming of flap margins
Proper irrigation


Drainage of wounds to prevent
haematoma
Drains :
• Corrugated rubber
• Polythene tube
Kept till drainage subsides (48hrs)
Daily irrigation with antiseptic solution

Closure of wounds - reasons for suturing
• To get close approximation of wound margins
• To ensure healing by primary intension
• To minimise wound contamination
• To control post-operative haemorrhage

Closure of wounds -types of sutures
Interrupted suture
• Most commonly used to close
mucoperiosteal flaps and skin

Advantages
• Better in mobile areas
• Alternate sutures can be removed

Closure of wounds
Mattress suture - horizontal
• Tissues under tension
• To get slight eversion of wound margins
• To prevent scar contraction
• To control post extraction bleeding
• Does not cut through tissues
• Used for sectioned muscles

Closure of wounds
Mattress suture - Vertical
• Tension in tissues
• Eversion of wound margins
• Better adaptation
• Where healing is expected to be delayed
• Control of haemorrhage

Closure of
wounds

Sub cuticular

• To prevent dead space and for
cosmetic reasons

Continuous suture
• Closing subcutaneous tissues
• Long mucosal & skin incisions
• Sectioned muscle
Disadvantage - only two knots if
one knot breaks failure of suturing

Closure of wounds
Suture materials - Requirements
• Adequate tensile strength
• Knot retension
• No tissue reaction
• Absorbability
• Ease of handling

Post Operative care
• Pain
• Infection
• Bleeding
• Diet
• Sutures
• Review

Post operative pain
Pain Mechanisms
• Peripheral tissue injury
• Transmission through the nerves
• Perception within the brain

Post operative pain
Target areas for pain control
• Blockade of Prostaglandin synthesis
• Intervening peripheral nerve conduction
• Suppression of higher sites in CNS


Post operative pain
Strategies • Mild pain - Pre and post operative NSAIDS,
Regular LA agent
• Moderate pain – Pre and post operative NSAIDS
Long acting LA agent.
• Severe pain – Pre and post operative NSAIDS
Long acting LA agent
Centrally acting analgesics (codiene)

Antibiotic Prophylaxis
Who needs it?
• Patients with impaired host defense.
• Patients undergoing surgical procedures where the
risk of infection is small but consequences are very
serious e.g., infective endocarditis.
• Patients undergoing surgical procedures which have
a high rate of infections (normal host defense mechanisms),
but the nature of surgery renders the patient vulnerable
to infection.


Use of antibiotics
Guidelines
• No routine use of post operative antibiotics
• Acute infections

- Penicillin group

• Subacute infection - Penicillin and Metronidazole
• Chronic infection - Metronidazole


Antibiotic prophylaxis
What should be the duration of administration?
A study conducted using three different antibiotic
regimens suggested that a single dose of preoperative
antibiotic is sufficient for prophylaxis when surgery is
completed within 3 hours. Antibiotic coverage should
extend for operations of longer duration. No value of
antibiotic after the operation.

Has timing any influence?
Administration of antibiotic immediately prior
to surgical incision should be effective prophylaxis
for surgical wound infections.


Antibiotic combinations
Advantages
• Broad Spectrum coverage
• Poly microbial infections
• Enhancement of antimicrobial effect
• Decreased emergence of resistant strains


Antibiotic combinations
Disadvantages
• Antagonism
• Increased colonization with resistant organisms
• Increased toxicity
• Increased cost


Antibiotic resistance
• Unresponsiveness of a micro-organism to an
antimicrobial agent
• Either natural or acquired (mutation / gene transfer)
• Reasons:
 Increased virulence of micro-organisms
 Decreased host resistance
 Altered biological activity of the drug

Indiscriminate use by the clinician

Prevention of drug resistance
• No indiscriminate & inadequate or unduly
prolonged or sub therapeutic doses be
administered.
• Prefer rapidly acting & narrow spectrum when
ever possible.
• Use combination of antimicrobial agents when
prolonged therapy is undertaken

Swelling or Oedema
Physiology of cold and heat
• Cold application immediately - Prevents oedema
after Surgery
• Warmth after oedema
has occured

- Resolves oedema

• Use of anti-inflammatory agents

Postoperative care
• Proper oral hygiene instructions
• Regular warm saline gargles more so in case sutures are
placed
• Dietary advice – adequate intake (proteins)
• Sutures to be removed after 7 days unless absorbable used
• Review to assess the outcome of surgery
• Manage any complications / refer if necessary

Common Minor Surgical Procedures

Impacted lower third molar

Mesioangular

Vertical


Distoangular

Horizontal


Maxillary third molar


Preprosthetic Surgery
“ Making of satisfactory artificial dentures
starts with the extraction of the teeth ”
- Willard (1853)


SIMPLE ALVEOLOPLASTY


Excision of
flabby tissue


HIGH LABIAL FRENAL ATTACHMENT


LINGUAL
FRENECTOMY

• L.A. / G.A.
• Excision and closure
• Avoid damage to
 Wharton’s duct
 Sublingual vein
 Genioglossus
• Resorbable sutures
• Speech therapy

CLOSURE OF OROANTRAL FISTULA


Incisions for Caldwell-Luc operations


IN A NUTSHELL..
• Proper diagnosis and systematic approach
• Investigate thoroughly if in doubt
• Medical status alters treatment outcome
• Aseptic procedure with appropriate instruments
• Adherence to principles at every step
• Appropriate medications postoperatively
• Follow up and rehabilitation


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Indian Dental Academy Principles of Maxillofacial Surgery

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