Oral and maxillofacial surgery

Introduction

Oral and maxillofacial surgery: is a branch of dentistry, that deals with the art of diagnosis and treatment of various diseases, injuries and defects involving the orofacial region.

The first dentist was an Egyptian, Hesi Re (3100- 2181 BC). Due to lack of advanced tools, extraction was the first choice for the dentist.In 1764 dentist in American colonies used key to extract teeth.In 1796 Josiah Flagg, used the first chair specifically for the dentist.In the 18th century, dental instruments were seen more as objects of art and were made of ivory, gold, silver.Forceps are probably the oldest of all instrument.

Principle of surgery:Painless surgery, Asepsis, Minimal damage, Adequate access, Arrest of haemorrhage, Debridement (toilet of wound), Drainage, Repair of wounds, Control and prevention of infection of wound, Support to the patient.

The oral and maxillofacial include the following:

  1. Simple and complicated extractions of teeth and related management.
  2. Treatment of cysts and tumours of both odontogenic and non odontogenic origin, involving the jaw bones.
  3. Management of disorders of maxillary sinuses.
  4. Intial and definitive management of traumatic injuries of soft and hard tissues of orofacial region.
  5. Temporomandibular joint disorders including internal derangement and ankylosis.
  6. Salivary gland diseases and their management.
  7. Diagnosis and management of dentofacial deformities, either acquired developmental or congenital (including clefts of the lip and palate).
  8. Management of orofacial infections involving the soft and hard tissues.
  9. Pre-prosthetic surgical procedures including implantology.
  10. Precancerous lesions such as, oral submucousfibrosis and leukoplakia.
  11. Detection and management of oral cancer.
  12. Management of orofacial pain.
  13. Reconstruction of missing portion of jaw bones with bone graft/ distraction osteogenesis.
  14. Detection and management of facial neuropathy.

The management include the following:

  1. History taking
  2. clinical examination
  3. radiological analysis
  4. laboratory investigations
  5. interpretation and final diagnosis

The preparation the patient for surgery must include:

  1. the choice of anaesthesia.
  2. Whether the patient can withstand the trauma of surgery.
  3. Whether the patient can withstand general anaesthesia.
  4. Any abnormalities in the patients general health, that need to be taken care of, prior to surgery.
  5. Choice of premedication.
  6. Treatment plan that will suit/ benefit the patient the most.

History taking: The aim of history taking is to obtain a correct account of the patient' problems, taking into consideration his/ her symptoms, general condition, lifestyle, and socioeconomic background.Importance of case history:

  1. For making correct diagnosis and treatment plan.
  2. Assessment of patient's mental and behavioral status.
  3. Awareness of any systemic diseases.
  4. To know the exact nature of medication patient is taking.
  5. For research purposes.

personal details: The first step in history taking is to obtain general information about the patient regarding the name, age, sex, marital status, address, race, occupation, telephone No. and the patient's primary care physician.

Chief complaint/s: The chief complaint ascertains the principal reason as to why the patient is seeking medical attention. Most common chief complaint:Pain, Swelling, Bleeding, Loose teeth, Delayed tooth eruption, Recent occlusal problems, Burning sensation, Bad taste, Halitosis, Xerostomia, Parasthesia and anaesthesia .

History of chief complain: The following details are recorded:

  1. All the symptoms, chromologically, in the patient's own words.
  2. The onset, duration and progress of each of these symptoms.
  3. Any treatment taken earlier for the condition, and the patient's response to the same.
  4. A previous history of similar symptoms and treatment taken for the same, along with the outcome.
  5. If the patient gives a history of trauma, additional history regarding unconsciousness, vomiting, bleeding from mouth, ear, nose, or throat, retro/ anterograde amnesia is obtained.

Past/ present medical history: A detailed picture of the general medical status of the patient is obtained, which may or may not bear relevance to the chief complaint, the management of the patient and outcome of the treatment.

  • Cardiovascular disorders like myocardial infarction, ischemic heart disease, rheumatic heart disease, angina, valvular septal defect, hypertension and congestive cardiac failure. All th medications taken by the patient are listed including details about anticoagulants, antihypertensive drug therapy.
  • Diseases of the respiratory system such as chronic obstructive pulmonary disease, bronchial asthma, pneumonia, pleuritis, bronchitis, upper respiratory tract infections. These patients may be on bronchodilators, antihistaminics or steroid therapy. Any disease of the respiratory system significantly affects the anaesthetic management of the patient. A history of sleep apnea may be obtained from the relatives. This condition is commonly seen in patients with severe Mandibular retrusion secondary to bilateral tempromandibular joint ankylosis.
  • Neurologic conditions like epilepsy, hemiparaplegia and past history of head injury and medications taken for the same. If the patient is an epileptic, then the last seizure episode of seizure and the frequency of seizure episode are recorded. fits, faints, limb weakness, paraesthesia, visual problems, hearing problems.
  • Diseases of the endocrine system including thyroid disorders (heat or cold intolerance, lethargy, voice change), diabetes, adrenal pheochromocytoma, and multiple endocrine neoplasia and medications taken for the same. If the patient is a diabetic, care must be taken to mention his/ her latest blood sugar values and the route of administration of the antidiabetic therapy, i.e., oral drugs or insulin injections.
  • Haematological disorders like anaemias, leukaemia, haemophilia, platelet count abnormalities.
  • Infectious diseases like tuberculosis, syphilis, viral hepatitis, herpes, and other sexually transmitted diseases.
  • Reproductive system pregnancy, lactation, last menstrual cycle, No. of children, abortions and use of oral contraceptives. Many common antibiotics are known to have interaction with oral contraceptives rendering them ineffective.
  • Gastric disorders like peptic ulcer, acidity problems, vomiting, and diarrhea.
  • Renal pathologies like glomerulonephritis, nephritic syndrome, renal failure, and patients on dialysis.
  • Disorders of the liver like cirrhosis, alcoholic liver disease, hepatitis.
  • Autoimmune disorders like systemic lupus erythematosus, scleroderma, requiring long-term corticosteroid therapy.
  • Psychiatric ailments stress, depression, sleep disturbance, anxiety and treatment taken for the same.
  • Digestive system loss of appetite, loss of weight, polydipsia, polyuria.
  • Musculoskeletal: Joint pain, stiffness, swelling.
  • Dermatology: rash, itching, bruising, discoloration.
  • Allergy to any drug.
  • Childhood illness/ birth trauma.
  • Details of previous hospitalization, blood transfusions and surgeries.
  • Past/ present history of radiation therapy.
  • Current/ past medications taken, e.g. NASIDs for chronic inflammatory lesions, aspirin, anticoagulant therapy, steroid therapy for autoimmune disorders.

Past dental history: It is the component of the patient's history that is particularly pertinent in the education of the dental patient significant items that should be recorded.

  1. The frequency of past treatment, previous restorative, periodontic, endodontic, or oral surgical treatment.
  2. Reasons for loss of teeth towards complication of dental treatment.
  3. Attitude towards previous dental treatment.
  4. Experience with orthodontic appliance and dental prosthesis.
  5. Fluoride history including supplement and the use of well water.
  6. Radiation or other treatment for facial or oral lesion.

Personal and family history: The personal habits and social history of the patient. It gives an overview of the patient's lifestyle as fallow:

  1. Habits like chewing tobacco, chronic alcoholism, chronic smoking, drug abuse.
  2. Diet: Vegetarian or non-vegetarian.
  3. A detailed history of the immediate family of the patient, with their age, general health status, medical ailments, cause and age at the time of death of any deceased member is recorded. A family history of epilepsy, cardiac disorders, diabetes, bleeding disorders, and tuberculosis is particular importance.

Clinical examination: include the following:

  1. Temperature: a patient normal temperature is 37o axillary temperature is about 1o less than oral temperature.
  2. The pulse: the pulse should be felt in both wrists. The normal adult pulse-rate is usually 72 per minute.
  3. Blood pressure: the blood pressure is measured with a sphygmomanometer. The average blood pressure in healthy adult as 120/80.
  4. respiratory rate: The normal respiratory rate is 16-20 per minute.
  5. Body weight

Extraoral examination can be divide into frontal and profile examination. The following structures are examined:

  1. Face
  2. Skin and soft tissue
  3. Skull
  4. Bony skeleton of the face
  5. Temporomandibular joints
  6. Lymphatic systems
  7. Salivary glands
  8. Eyes

Intraoral examination can be divided:

  1. Lips
  2. Labial mucosa
  3. Buccal mucosa
  4. The vestibule
  5. The upper and lower teeth
  6. The gingival
  7. The roof of mouth
  8. The floor of mouth
  9. Tongue
  10. Oropharynx
  11. Saliva salivary glands

Looking: inspection

  1. Head and face: general shape, symmetry, hair distribution.
  2. Ear: normal reaction to sounds.
  3. Eye: symmetry, size, reactivity of pupl, color of sclera and conjunctiva, movement, and vision.
  4. Nose: septum, mucosa, patency.
  5. Mouth: teeth, mucosa, pharynx, lips, and tonsils.
  6. Neck: size of thyroid gland, jugular venous distention.

touching: palpation

  1. Tempromandibular joint: crepitus, tenderness.
  2. Paranasal sinus: pain over sinuses
  3. Mouth: salivary glands, floor of mouth, lips, muscles of mastication.
  4. Neck: thyroid gland size, lymph nods.

Tapping: percussion

  1. Paranasal sinus:resonance over sinuses.
  2. Mouth: teeth

listening: Auscultation

  1. Tempromandibular joint: clicks, crepitus.
  2. Neck: carotid bruits

Investigation: investigations are used an aid to diagnosis. Pre-operative assessment, and post-operative management. The investigations should be ordered after adequate clinical history taking and examination. Special investigation should be requested to answer specific questions, or provide information essential for diagnosis and treatment planning.

Radiological examination:

  1. Conventional radiography
  2. Specialized imaging

Intraoral radiographs:

  1. Periapical view
  2. Occlusal view of the maxilla and the mandible
  3. Bitewing view

Extraoral radiographs:

  1. Orthopantomogram (OPG)
  2. Lateral oblique view right and left mandible
  3. Occipitomental projection (Water's postion)
  4. Posteroanterior view of the mandible
  5. Transorbital view
  6. Transcranial view
  7. Lateral cephalogram view
  8. Postero-anterior view of skull
  9. Lateral skull view
  10. Submentovertex view
  11. Chest X-ray postero-anterior view

Specialized imaging:

  1. Tomogram
  2. Conventional tomography
  3. Computed tomography (CT)
  4. Ultrasonography
  5. Magnetic resonance imaging (MRI)
  6. Radionuclide imaging
  7. Sialography
  8. Arthrography
  9. Angiography

Routine haematological investigation:

  1. Haemoglobin (Hb) normal value 12-16 gm% for female, 14-18 gm% for male
  2. Complete blood count (CBC) normal value of RBC 4.5-5.5 million per cu mm for female, 4.5-6.2 million per cu mm for male. WBC normal value 5000-10000 cell per gu mm. differential WBC count polymorphnuclear leukocytes (Neutrophils 50-70%, Lymphocytes 25-40%, Monocytes 3-8%, Eosinophils 1-8%, Basophils 0-1%), platelate count normal value 150000-400000 cells per cu mm.
  3. Erythrocyte sedimentation rate (ESR) normale value 0-20 mm/ hour for female, 0-10 mm/ hour for male by Wintrob's method.
  4. Blood film
  5. Blood group and cross-match.

coagulation tests

  1. Bleeding time 3-5 minutes by Ducke's method.
  2. Clotting time 4-10 minutes by Lee-White method.
  3. Prothrombin time 12-14 seconds.
  4. Partial thromboplastin time 25-45 seconds.
  5. Thromboplastin generation time 12 seconds or less.

The urine test: the normal daily urinary output in a healthy adult is about 1500 ml and the range between 400-3000 ml, the general urine examination include:

  1. Colour normal light yellow, early morning urine is dark.
  2. Odure light aromatic odour.
  3. Reaction slight acidic pH 4.5-6
  4. Specific gravity: varies between 1024 and 1032.
  5. Proteinuria: must be nail.
  6. Cells in urine: must be nail.
  7. Blood in urine: must be nail.
  8. Glycousuria: must be nail.

Liver function tests: include tests for some of the functions of the liver, such as bilirubin and albumin, and tests for liver cell integrity, liver enzymes such as alkaline phophatease, plasma aspartate, alanine transaminass.

Random blood glucose (RBG) = 80-150 mg % and fasting blood glucose (FBG) = 60-100 mg %.

Biopsy indicates the removal of tissue from a living subject for histological evaluation and analysis.

  1. Punch biopsy
  2. Incisional biopsy
  3. Exicional biopsy
  4. Fine needle aspirating biopsy
  5. Brush biopsy
  6. Exfoliative cytology

Microbiological investigations: These are test for the mico-organisms as bacteria, fungi, virus, protozoa, etc.. Blood, sputum, serum, and other specimen are collactrf and examined for microbiology.

Differential diagnosis: which involves the consideration and comparison initially of groups of diseases but ultimately of perhaps two or three individual all of which share various clinical and pathological features in common.

Diagnosis: which involves the recognition of a specific pattern in the available data. Even with straightforward cases alternative possibilities should be considered. This way any item of data which may be inconsistent with the obvious solution and which suggests the possibility of some alternative explanation will not be disregarded.

Treatment plane: There are several choices of treatment, or even a decision not to treat at all, which depend on:

  1. the patient's age
  2. general health
  3. family and work responsibility
  4. the distance to the surgery
  5. Possible complications
  6. the degree of temporary disability, and discomfort

the chances of a successful and satisfactory outcome must all be weighed where the proposed treatment involves an operation.