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INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
• Painless surgery
• Asepsis & sterilization
• Adequate access
• Arrest of haemorrhage...
Principles of Maxillofacial Surgery
Painless Surgery
• Pre-medication
• Anaesthetic considerations
• Local
• Local and sed...
Principles of Maxillofacial Surgery
Goals of Pre medication
• Sedation
• Amnesia
• Analgesia
• Drying of airway secretions...
Principles of maxillofacial surgery
Selection of appropriate drugs
Considerations • Psychological condition
• Physical sta...
Common Pre-operative Drugs
Drug
Route
Diazepam
Oral
Midazolam
I.M.
Pentobarbitol
Oral, I.M.
Morphine
I.M.
Meperedine
I.M.
...
Principles of maxillofacial surgery
Painless surgery
Local Anaesthesia Majority of the minor oral surgical procedures
are ...
Principles of maxillofacial surgery
Painless surgery
Local anaesthesia with sedation In apprehensive patients minor surgic...
Principles of maxillofacial surgery
Indications for general anaesthesia
• Acute infections (Ludwig’s Angina)
• Surgery in ...
Principles of maxillofacial surgery
Asepsis & sterilisation
Asepsis
Method of surgery designed to prevent introduction
of ...
Principles of maxillofacial surgery
Sources of infection during surgery
• Patient himself
• Operator
• Instruments & mater...
Principles of maxillofacial surgery
Minimising infection from the patient
• Attention to oral hygiene
• Oral prophylaxis
•...
Principles of maxillofacial surgery
Minimising infection from the operator
• Wearing mask & head cap
• Keeping finger nail...
Principles of maxillofacial surgery
Are gloves really safe??
Study to access the risk of glove puncture during
oral surger...
Principles of maxillofacial surgery
Accidental injury / prick
What to do??
• Stop the procedure
• Check for depth of penet...
Principles of maxillofacial surgery
Risk of cross infection
HIV
• Percutaneous exposure – 0.4 %
• Start on Zidovudine with...
Principles of maxillofacial surgery
Preventing infection from instruments
• Using only sterilised instruments and material...
Principles of maxillofacial surgery
Methods of sterilisation
• Moist heat

-

autoclave

• Dry heat

-

hot air oven

-

G...
Principles of maxillofacial surgery
What is the reliable method of Sterilisation?
Moist heat (autoclave)
Types

-

high va...
Principles of maxillofacial surgery
Hot air oven sterilisation
• Temperature

-

160 to 183° c

• Time

-

1 hour

• Mode ...
Principles of maxillofacial surgery
Minimising iatrogenic infection
• Clean environment
 Daily & meticulous cleansing of ...
Principles of maxillofacial surgery

Access
• Oral cavity - Mucoperiosteal flaps
• Face

- Skin incisions

www.indiandenta...
Principles of maxillofacial surgery
Access - intra oral
Principles of muco periosteal flaps
• Visibility
• Vascularity
• H...
Principles of maxillofacial surgery
Access – intra oral
Muco periosteal flap
• Flap consisting mucosa and periosteum

Desi...
Principles of Maxillofacial Surgery
Armamentarium

Minor Surgery Tray

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Access – intra oral

• Base wider than free end
• Include papilla in the flap
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Access – intra oral

Labial Approach

Palatal Approach

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Degloving incision for maxilla

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Degloving incision for mandible

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

www....
Principles of maxillofacial surgery
Access
Instruments for bone removal
1. Chisel
2. Osteotome
3. Gouge
4. Ronguers
5. Bon...
Principles of maxillofacial surgery
Access
Removal of bone using burs
• Ideally micromotor is used with either rosehead or...
Principles of maxillofacial surgery
Methods to arrest haemorrhage
Soft tissue –
• Digital pressure
• Pressure packs
• Use ...
Principles of maxillofacial surgery
Debridement of wound
Removal of
• Devitalised tissue
• Granulation tissue
• Bone piece...
Principles of maxillofacial surgery
Drainage of wounds to prevent
haematoma
Drains :
• Corrugated rubber
• Polythene tube
...
Principles of maxillofacial surgery
Closure of wounds - reasons for suturing
• To get close approximation of wound margins...
Principles of maxillofacial surgery
Closure of wounds -types of sutures
Interrupted suture
• Most commonly used to close
m...
Principles of maxillofacial surgery
Closure of wounds
Mattress suture - horizontal
• Tissues under tension
• To get slight...
Principles of maxillofacial surgery
Closure of wounds
Mattress suture - Vertical
• Tension in tissues
• Eversion of wound ...
Principles of maxillofacial surgery
Closure of
wounds

Sub cuticular

• To prevent dead space and for
cosmetic reasons

Co...
Principles of maxillofacial surgery
Closure of wounds
Suture materials - Requirements
• Adequate tensile strength
• Knot r...
Principles of maxillofacial surgery
Post Operative care
• Pain
• Infection
• Bleeding
• Diet
• Sutures
• Review
www.indian...
Principles of maxillofacial surgery
Post operative pain
Pain Mechanisms
• Peripheral tissue injury
• Transmission through ...
Principles of maxillofacial surgery
Post operative pain
Target areas for pain control
• Blockade of Prostaglandin synthesi...
Principles of maxillofacial surgery
Post operative pain
Strategies • Mild pain - Pre and post operative NSAIDS,
Regular LA...
Principles of maxillofacial surgery
Antibiotic Prophylaxis
Who needs it?
• Patients with impaired host defense.
• Patients...
Principles of maxillofacial surgery
Use of antibiotics
Guidelines
• No routine use of post operative antibiotics
• Acute i...
Principles of maxillofacial surgery
Antibiotic prophylaxis
What should be the duration of administration?
A study conducte...
Principles of maxillofacial surgery
Antibiotic prophylaxis
Has timing any influence?
Administration of antibiotic immediat...
Principles of maxillofacial surgery
Antibiotic combinations
Advantages
• Broad Spectrum coverage
• Poly microbial infectio...
Principles of maxillofacial surgery
Antibiotic combinations
Disadvantages
• Antagonism
• Increased colonization with resis...
Principles of maxillofacial surgery
Antibiotic prophylaxis

www.indiandentalacademy.com
Principles of maxillofacial surgery
Antibiotic prophylaxis

www.indiandentalacademy.com
Antibiotic prophylaxis

www.indiandentalacademy.com
Principles of maxillofacial surgery
Antibiotic resistance
• Unresponsiveness of a micro-organism to an
antimicrobial agent...
www.indiandentalacademy.com
Principles of maxillofacial surgery
Prevention of drug resistance
• No indiscriminate & inadequate or unduly
prolonged or ...
Principles of maxillofacial surgery
Swelling or Oedema
Physiology of cold and heat
• Cold application immediately - Preven...
Principles of maxillofacial surgery
Postoperative care
• Proper oral hygiene instructions
• Regular warm saline gargles mo...
Principles of Maxillofacial Surgery
Common Minor Surgical Procedures

Impacted lower third molar
www.indiandentalacademy.c...
Principles of Maxillofacial Surgery
Mesioangular

Vertical

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
Distoangular

Horizontal

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
Maxillary third molar

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
Preprosthetic Surgery
“ Making of satisfactory artificial dentures
starts with the ext...
Principles of Maxillofacial Surgery
SIMPLE ALVEOLOPLASTY

www.indiandentalacademy.com
Excision of
flabby tissue

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
HIGH LABIAL FRENAL ATTACHMENT

www.indiandentalacademy.com
LINGUAL
FRENECTOMY

• L.A. / G.A.
• Excision and closure
• Avoid damage to
 Wharton’s duct
 Sublingual vein
 Geniogloss...
Principles of Maxillofacial Surgery
CLOSURE OF OROANTRAL FISTULA

www.indiandentalacademy.com
Incisions for Caldwell-Luc operations

www.indiandentalacademy.com
Principles of Maxillofacial Surgery
IN A NUTSHELL..
• Proper diagnosis and systematic approach
• Investigate thoroughly if...
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Principles of surgery (nx power lite) /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Principles of surgery (nx power lite) /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Principles of Maxillofacial Surgery • Painless surgery • Asepsis & sterilization • Adequate access • Arrest of haemorrhage • Debridement & drainage • Closure of wounds • Post operative care www.indiandentalacademy.com
  3. 3. Principles of Maxillofacial Surgery Painless Surgery • Pre-medication • Anaesthetic considerations • Local • Local and sedation • General www.indiandentalacademy.com
  4. 4. Principles of Maxillofacial Surgery 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 www.indiandentalacademy.com
  5. 5. 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 www.indiandentalacademy.com
  6. 6. 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) www.indiandentalacademy.com 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.
  7. 7. Principles of maxillofacial surgery Painless surgery Local Anaesthesia Majority of the minor oral surgical procedures are carried out under local anaesthesia www.indiandentalacademy.com
  8. 8. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  9. 9. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  10. 10. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  11. 11. Principles of maxillofacial surgery Sources of infection during surgery • Patient himself • Operator • Instruments & materials used • Operating area www.indiandentalacademy.com
  12. 12. Principles of maxillofacial surgery Minimising infection from the patient • Attention to oral hygiene • Oral prophylaxis • Chlorhexidine / betadine mouth washes • Preparation of the mouth prior to surgery www.indiandentalacademy.com
  13. 13. Principles of maxillofacial 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 www.indiandentalacademy.com
  14. 14. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  15. 15. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  16. 16. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  17. 17. Principles of maxillofacial surgery Preventing infection from instruments • Using only sterilised instruments and materials during surgery • Avoiding contamination & minimizing extraoral contact www.indiandentalacademy.com
  18. 18. Principles of maxillofacial surgery Methods of sterilisation • Moist heat - autoclave • Dry heat - hot air oven - Glutaraldehyde - Ethylene oxide • Boiling water • Chemicals • Gamma rad. • Gases www.indiandentalacademy.com
  19. 19. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  20. 20. Principles of maxillofacial surgery Hot air oven sterilisation • Temperature - 160 to 183° c • Time - 1 hour • Mode of action - Oxidation www.indiandentalacademy.com
  21. 21. Principles of maxillofacial surgery Minimising iatrogenic infection • Clean environment  Daily & meticulous cleansing of surfaces  Fumigation • Regular microbiological monitoring of facilities  Swabs from different areas - CST www.indiandentalacademy.com
  22. 22. Principles of maxillofacial surgery Access • Oral cavity - Mucoperiosteal flaps • Face - Skin incisions www.indiandentalacademy.com
  23. 23. Principles of maxillofacial surgery Access - intra oral Principles of muco periosteal flaps • Visibility • Vascularity • Healing www.indiandentalacademy.com
  24. 24. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  25. 25. Principles of Maxillofacial Surgery Armamentarium Minor Surgery Tray www.indiandentalacademy.com
  26. 26. Access – intra oral • Base wider than free end • Include papilla in the flap www.indiandentalacademy.com
  27. 27. Access – intra oral Labial Approach Palatal Approach www.indiandentalacademy.com
  28. 28. Degloving incision for maxilla www.indiandentalacademy.com
  29. 29. Degloving incision for mandible www.indiandentalacademy.com
  30. 30. Principles of maxillofacial surgery Access Removal of bone • Bone is removed either by using surgical burs or chisel www.indiandentalacademy.com
  31. 31. Principles of maxillofacial surgery Access Instruments for bone removal 1. Chisel 2. Osteotome 3. Gouge 4. Ronguers 5. Bone file www.indiandentalacademy.com
  32. 32. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  33. 33. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  34. 34. Principles of maxillofacial surgery Debridement of wound Removal of • Devitalised tissue • Granulation tissue • Bone pieces • Hanging bone margins Trimming of flap margins Proper irrigation www.indiandentalacademy.com
  35. 35. Principles of maxillofacial surgery Drainage of wounds to prevent haematoma Drains : • Corrugated rubber • Polythene tube Kept till drainage subsides (48hrs) Daily irrigation with antiseptic solution www.indiandentalacademy.com
  36. 36. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  37. 37. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  38. 38. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  39. 39. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  40. 40. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  41. 41. Principles of maxillofacial surgery Closure of wounds Suture materials - Requirements • Adequate tensile strength • Knot retension • No tissue reaction • Absorbability • Ease of handling www.indiandentalacademy.com
  42. 42. Principles of maxillofacial surgery Post Operative care • Pain • Infection • Bleeding • Diet • Sutures • Review www.indiandentalacademy.com
  43. 43. Principles of maxillofacial surgery Post operative pain Pain Mechanisms • Peripheral tissue injury • Transmission through the nerves • Perception within the brain www.indiandentalacademy.com
  44. 44. Principles of maxillofacial surgery Post operative pain Target areas for pain control • Blockade of Prostaglandin synthesis • Intervening peripheral nerve conduction • Suppression of higher sites in CNS www.indiandentalacademy.com
  45. 45. Principles of maxillofacial surgery 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) www.indiandentalacademy.com
  46. 46. Principles of maxillofacial surgery 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. www.indiandentalacademy.com
  47. 47. Principles of maxillofacial surgery Use of antibiotics Guidelines • No routine use of post operative antibiotics • Acute infections - Penicillin group • Subacute infection - Penicillin and Metronidazole • Chronic infection - Metronidazole www.indiandentalacademy.com
  48. 48. Principles of maxillofacial surgery 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. www.indiandentalacademy.com
  49. 49. Principles of maxillofacial surgery Antibiotic prophylaxis Has timing any influence? Administration of antibiotic immediately prior to surgical incision should be effective prophylaxis for surgical wound infections. www.indiandentalacademy.com
  50. 50. Principles of maxillofacial surgery Antibiotic combinations Advantages • Broad Spectrum coverage • Poly microbial infections • Enhancement of antimicrobial effect • Decreased emergence of resistant strains www.indiandentalacademy.com
  51. 51. Principles of maxillofacial surgery Antibiotic combinations Disadvantages • Antagonism • Increased colonization with resistant organisms • Increased toxicity • Increased cost www.indiandentalacademy.com
  52. 52. Principles of maxillofacial surgery Antibiotic prophylaxis www.indiandentalacademy.com
  53. 53. Principles of maxillofacial surgery Antibiotic prophylaxis www.indiandentalacademy.com
  54. 54. Antibiotic prophylaxis www.indiandentalacademy.com
  55. 55. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  56. 56. www.indiandentalacademy.com
  57. 57. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  58. 58. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  59. 59. Principles of maxillofacial surgery 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 www.indiandentalacademy.com
  60. 60. Principles of Maxillofacial Surgery Common Minor Surgical Procedures Impacted lower third molar www.indiandentalacademy.com
  61. 61. Principles of Maxillofacial Surgery Mesioangular Vertical www.indiandentalacademy.com
  62. 62. Principles of Maxillofacial Surgery Distoangular Horizontal www.indiandentalacademy.com
  63. 63. Principles of Maxillofacial Surgery Maxillary third molar www.indiandentalacademy.com
  64. 64. Principles of Maxillofacial Surgery Preprosthetic Surgery “ Making of satisfactory artificial dentures starts with the extraction of the teeth ” - Willard (1853) www.indiandentalacademy.com
  65. 65. Principles of Maxillofacial Surgery SIMPLE ALVEOLOPLASTY www.indiandentalacademy.com
  66. 66. Excision of flabby tissue www.indiandentalacademy.com
  67. 67. Principles of Maxillofacial Surgery HIGH LABIAL FRENAL ATTACHMENT www.indiandentalacademy.com
  68. 68. LINGUAL FRENECTOMY • L.A. / G.A. • Excision and closure • Avoid damage to  Wharton’s duct  Sublingual vein  Genioglossus • Resorbable sutures • Speech therapy www.indiandentalacademy.com
  69. 69. Principles of Maxillofacial Surgery CLOSURE OF OROANTRAL FISTULA www.indiandentalacademy.com
  70. 70. Incisions for Caldwell-Luc operations www.indiandentalacademy.com
  71. 71. Principles of Maxillofacial Surgery 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 www.indiandentalacademy.com
  72. 72. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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