Procedures in Oral Surgery

Procedures in Oral Surgery

Tara Renton

Introduction

Oral surgery is a dental speciality dealing with conditions of the face, jaws, neck and mouth. It provides diagnosis and treatment for conditions affecting these areas. The patient may be fit and well or have significant comorbidity including social and medical complexities, or have difficulty managing their anxiety and fear during the procedure. This chapter is divided into the following parts:

  • Part 1: Medical complexities and their appropriate management, and the assessment of the patient for management by means of local anaesthesia (LA), conscious sedation or general anaesthesia (GA). Management of anxiolysis, both non‐medical and medical, is covered in separate chapters. The additional clinical tests which may be required, depending on the condition of the patient, are summarised and the importance of valid consent is emphasized.
  • Part 2: Dentoalveolar surgery, which may involve routine exodontias, or the surgical removal of one or more teeth.
  • Part 3: Surgery indicated for impacted teeth or fractured roots. Surgical access is most commonly indicated for third molar (wisdom tooth) removal or coronectomy, where there is a high risk of nerve injury.
  • Part 4: Management of acute and chronic orofacial infections using medical and surgical techniques.
  • Part 5: Management of temporomandibular joint (TMJ) disorders, including dysfunction, arthritides and myalgia.
  • Part 6: Prevention and management of complications related to surgery including pain, infection, nerve injury and other less common complications.

Oral surgery procedures may be routine and simple in uncomplicated patients, or complex, involving extended surgery in an exceedingly compromised (psychologically, socially or medically) patient with a high risk of complications.

Other procedures to be covered in related chapters include:

  • Management of patients presenting with acute and chronic orofacial pain using medical, surgical and affective techniques (Chapter 9).
  • Surgical management of patients requiring implant dentistry, as part of a multidisciplinary team approach to rehabilitation (Chapter 12).
  • Management of anxiolysis by means of behavioural interventions (Chapter 4), and pharmacological techniques (Chapter 10).
  • Management of antral pathology and grafting of the antral space, when required for implant placement (Chapter 12), and in the management of dentoalveolar fractures.
  • Surgical procedures in acute dental traumatology and in the management of dentoalveolar fractures.
  • Surgical management of periapical pathology as part of endodontic therapy (Chapter 16).

Procedures which are considered to fall out with the scope of this manual, include:

  • Management of orofacial trauma.
  • TMJ surgery.
  • Surgical management of salivary gland disease.
  • Management of benign cystic and solid lesions of the soft and hard tissues of the mouth and jaws requiring advanced surgical management.
  • Maxillary antral procedures.
  • Preprosthetic surgery.
  • Complex dental implant surgery.
  • Oral surgery for the orthodontic patient.
  • Surgical management of neoplasia.

Part 1: Examination, Medical Complexities and Considerations, and Consent

To provide each patient with the most suitable treatment plan to address individual need, it is essential to discover and record as much information as possible about each patient’s past experiences, attitudes, expectations, general and oral health, and wellbeing. Procedures for patient examination and assessment are considered in detail in Chapter 6. For oral surgery, the standard history and examination should be augmented by examinations (Table 15.1) and special tests (Table 15.2) of particular relevance to oral surgery and the medical condition of the patient categorised, according to the scheme of the American Society of Anaesthesiologists (Table 15.3). Decisions must be made about the management of medically compromised patients (Table 15.4). In addition, a decision needs to be made about the selection of the anaesthesia most appropriate for the proposed procedures (Figure 15.1).

Table 15.1 Examinations of particular relevance to oral surgery.

Extraoral examination
  • Palpation and evaluation of TMJ and movements.
Jaw movement is important in relation to mouth opening (access for surgery) and in assessments of TMJ disorders (clicks, crepitus, deviations on opening, tenderness of joints and muscles).
  • Palpation of lymph nodes.
Enlargement of lymph nodes may be related to infection or neoplasm.
  • Assessment of the symmetry of the face.
Pathology (congenital, growth deformity, infection or neoplasm), trauma and neuropathy may be indicated by asymmetry of the face or mouth.
  • Cranial nerve evaluation.
Cranial nerve evaluation is important in any patient presenting with neoplasia, pain or neuropathy.
  • Palpation of the salivary glands.
In patients presenting with xerostomia or recurrent meal time syndrome the evaluation of salivary gland enlargement and possible obstructions is important.
Intraoral examination
  • Examination of the oral mucosa.
Conditions of the oral mucosa, which may present as some form of ulceration or changes in appearance and texture, may be local or indicative of an underlying systemic problem. The examination must include screening for oral cancer.
  • Palpation of the alveolus.
If the alveolus or edentulous ridge is tender to digital palpation, this may infer localised infection or trauma. A swelling may be related to an unerupted tooth, cystic lesion or neoplasia.
  • Bimanual palpation of salivary glands and any soft tissue mass to assess mobility, blanching and fluctuance.
Condition of the dentition

  • Occlusion – Class I, II or III with or without an open or cross bite?
  • Unerupted or partially erupted teeth.
  • Heavily restored teeth.
  • Oral hygiene, presence of calculus, gingivitis and periodontitis.
  • Tooth wear – attrition, abrasion and erosion.
  • Evidence of parafunction.
  • Evidence of trauma.

TMJ, temporomandibular joint.

Table 15.2 Specific tests of particular relevance to oral surgery procedures.

Procedure Additional clinical examination Haematological examination Radiographic tests
Routine dental extraction Only with relevant medical history. Long cone periapical (Figure 15.2).
M3M extraction Only with relevant medical history.
  • Long cone periapical, if possible, or sectional dental panoramic tomogram (Figure 15.3).
  • If high risk M3M use cone beam CT scan.
Removal or exposure of an impacted tooth Only with relevant medical history.
  • Parallax views for impacted canines.
  • Low‐dose cone beam CT scan may be indicated.
Management of infection
  • Assess for spread of infections to local spaces.
  • Temperature to assess for pyrexia.
  • Culture and sensitivity testing of pus exudates to assist with selection of antibiotics.
To check for spreading infection (leukocytosis, bacteraemia).
  • LCPA or sectional DPT to evaluate the presence of an abscess and or sequestrate.
  • Rarely PET scans are indicated when presented with difficult to diagnose chronic bone infections.
TMJ examination Three‐minute examination (Table 15.12). If arthritides suspected or chronic pain.
  • Sectional DPT.
  • Occasionally, MRI may be indicated if open or closed locking associated with disc displacement or rarely CT for condylar or base of skull pathology.
Evaluation of neuropathy, facial weakness or sensory neuropathy Cranial nerve examination. If systemic cause for neuropathy is suspected, for example diabetes.
Salivary gland examination Salivary pooling, evaluation of Wharton’s and Stenson’s ducts for clear salivary exudates and lack of pus. Palpation of glands (often bimanual with fingers intra‐ and extraorally). Routine in patients presenting with dry mouth to exclude connective tissue disorders and Sjogren’s syndrome. Sialogram may be indicated if obstructive salivary gland disease is suspected.
Soft tissue lesion/mass examination
  • Duration.
  • Site, size, shape, surface.
  • Consistency, contour, colour.
  • Mobility, tenderness, exudates.
  • Fine needle aspiration or core biopsy.
Only with relevant medical history. Radiological guided fine needle aspiration may be indicated for deeper salivary or lymph node lesions.
Hard tissue lesion/mass examination Aspiration of a cystic lesions to:

  • Elucidate any malignant cells with cytology.
  • Exclude a haemangiomatous lesion prior to surgical excision.
  • Assist in diagnosis of a lesion, for example, odontogenic keratocyst or ameloblastoma.
Only with relevant medical history.
If lesion may be related to systemic disease including Paget’s disease, fibrous dysplasia, giant cell lesions.
LCPA or sectional DPT depending on the size of the lesion.
Additional cone beam CT or MRI scans may be required if lesion is large, expansive and involving soft tissues.

CT, computed tomography; DPT, dental panoramic tomogram; LCPA, long cone periapical radiograph; M3M, mandibular third molar; MRI, magnetic resonance imaging; PET, positron emission tomography.

Table 15.3 American Society of Anesthesiologists Health Categorisation.

Category

  • 1. Fit and well patients requiring straightforward surgery who are expected to make a complete and uneventful recovery.
  • 2. Patients with a medical condition which may complicate the delivery of care but is unlikely to affect outcome (e.g. hepatitis, coagulopathies, history of endocarditis, steroids, epilepsy, mental handicap).
  • 3. Patients with medical condition(s), or past surgery, which may additionally compromise outcome (complicated surgery, uncontrolled diabetes, immunosuppression).
  • 4. Patients in whom the complications of surgery may be severe with marked local or systemic complications (inherited clotting disorders, uncontrolled local or systemic disease) and/or require contemporaneous specialised medical therapy (severe immunosuppression, haemophillia).
  • 5/6. Not relevant to surgical dentistry.

Table 15.4 Management of medically compromised patients.

Medical condition Issue related to oral surgery Recommendations
Cardiovascular problems Hypertension:

  • Bleeding.
  • Risk of myocardial infarction (MI) and stroke.

Angina:

  • Angina attack.
  • Risk of MI.

Recent MI

Hypertension:

  • <160/100 treat as normal.
  • >160/100 haemostatic agent postoperatively; IV sedation is preferable

Angina:

  • Instruct patient to use nitrolingual spray preoperatively and ensure oxygen available

MI:

  • Within 3 months – no elective treatment.
  • Within 6 months – no general anaesthesia – 50% increased risk of repeat MI.
Cardiac defects/ valve replacements/previous endocarditis/hypertrophic cardiomyopathy Need for antibiotic cover.
  • No antibiotic cover.
  • Maintain good oral hygiene.
  • Warn patient of risk of repeat infective endocarditis.
Liver disease
  • Bleeding problems.
  • Impaired drug metabolism.
  • Cross‐infection risk – hepatitis B, C,D,E.
  • May be immunocompromised.
Preoperatively:

  • Liaise with physician.
  • Liver profile, coagulation screen, FBC, APTT.
  • Caution with administration of local anaesthetic and sedation.
  • Drug prescription – check British National Formulary (BNF) Appendix 2 on liver disease.

Postoperatively:

  • Haemostatic agent in socket.
  • Hepatitis B immunity, caution with hepatitis C patient cross‐infection measures in place.
Kidney disease
  • Bleeding tendency.
  • Drug prescription.
  • Dialysis patients.
  • May be immunocompromised.
Preoperatively:

  • Liaise with physician.
  • Renal profile, FBC, coagulation screen.
  • Check BNF Appendix 3 on renal impairment for caution with drug prescription.
  • Dialysed patients to be treated the day after dialysis
  • May require antibiotic cover.

Postoperatively:

  • Haemostatic measures.
Diabetes
  • Hypoglycaemic emergency.
  • Delayed healing and immunocompromised.
  • HbA1c prior to implant placement.
Preoperative:

  • Measure blood sugar level (<5.0 mmol – administer glucose orally).
  • Morning appointment.
  • HbA1c <6%

Postoperative:

  • Antibiotics if poorly controlled or difficult surgical procedure.
Epilepsy
  • Increased stress may cause seizure.
  • Check frequency and presentation of seizures.
  • Intravenous sedation recommended due to anticonvulsant effects.
Disorders of haemostasis
  • Increased risk of bleeding postoperatively.
Haemophilia A and B, Von Willebrand’s disease:

  • Liaise with haematology physician/haemophilia centre.
  • Factor VIII levels between 50 and 75% required prior to treatment.
  • Desmopressin, tranexamic acid may be needed.
  • Treat in hospital – may require inpatient management.
  • Avoid inferior dental blocks whenever possible.

Thrombocytopenia:
Preoperative:

  • Liaise with haematology physician.
  • Platelet levels >80 × 109/ l treatment in a hospital setting.
  • <80 × 109/l platelet levels will require platelet transfusion.

Postoperative:

  • Local haemostatic measures.
  • Platelets may be needed.
  • Desmopressin, tranexamic acid.
  • Avoid NSAIDs.
Anticoagulant therapy
  • Increased risk of bleeding for patients – INR should be <4.
  • Increased risk of thromboembolic event.
  • Warfarin effect altered by antibiotics and NSAIDs.
Preoperative:

  • If INR >4 refer back to haematology clinic.
  • Dual antiplatelet therapy patients – refer for treatment in hospital.

Postoperative:

  • Local haemostatic measures.
  • No NSAIDs.
HIV
  • Viral load.
  • CD4 count – >200 cells/mm blood suitable for treatment.
  • Be aware of common oral manifestations: cervical lymphadenopathy, candidosis, hairy leukoplakia, herpes virus, papilloma virus, apthous ulcers, Kaposi’s sarcoma and lymphoma. May require biopsy.
  • Neutropenia.
  • Bleeding tendency due to risk of thrombocytopenia.
  • IV sedation – benzodiazepine activity may be enhanced with HAART.
  • ART is treatment of people infected with HIV using anti‐HIV drugs. The standard treatment consists of a combination of at least three drugs (often called ‘highly active ART’ or HAART) that suppress HIV replication.
Preoperative:

  • Viral load – <50 viral RNA copies/mm blood, low infectivity suitable for treatment.
  • CD4 count – >200 cells/mm blood suitable for treatment.
  • FBC, liver profile, coagulation screen.
  • Antibiotics if neutropenic and at risk of infection.

Postoperative:

  • Antibiotics may be required if neutropenic.
  • Cross‐infection risk low, but postexposure prophylaxis may be required for up to 4 weeks if exposure occurs.
Malignancy
  • Malignant spread from organs may manifest in the head and neck region.
  • Haematological malignancy causes thrombocytopenia (decreased platelets), neutropenia (decreased neutrophils) and anaemia causing increased risk of bleeding and infection.
  • Patients with metastases from breast, prostate and multiple myeloma may be on oral or IV bisphosphonates.
Preoperative:

  • FBC, coagulation screen.
  • If platelets <80 × 109/l may need platelet transfusion.

Postoperative:

  • Haemostatic measures.
  • Antibiotic therapy.
Chemotherapy
  • Risk of bleeding due to thrombocytopenia.
  • Risk of infection due to neutropenia and immunosuppression.
  • Anaemia.
  • Patients on high dose steroids – dexamethasone, are at risk of adrenal crisis.
Preoperative:

  • If platelet <80 × 109/l, platelet transfusion required.
  • If neutrophils <1.5 × 109/l, antibiotic prophylaxis required.
  • If erythrocytes <8 × 109/l, special care with general anaesthesia and IV sedation.
  • Steroid cover – 25 mg IV hydrocortisone, if on high dose steroids.
Steroids
  • Risk of Addisonian crisis.
  • May cause delayed healing.
Preoperative:

  • >7.5 mg prednisolone, or equivalent steroid cover required.

Prior to procedures under local anaesthetic or IV sedation:

  • 25 mg hydrocortisone IV, or double dose of steroids on the day of surgery.

For procedures under general anaesthesia:

  • Preoperative: 25–50 mg hydrocortisone IV.
  • Postoperative: 25–50 mg hydrocortisone IM every 6  h for 24  h. Antibiotics may be required.
Sedation
  • Contraindicated in pregnancy and in patients with severe chronic obstructive pulmonary disease and allergy to benzodiazepines.
  • With caution in extremes of age and in patients with sickle cell disease, liver and renal disease, myasthenia gravis and psychiatric disease.
  • Elderly – administer sedation slowly There is a correlation between age and midazolam dose, which decreases with increasing age. The initial bolus should be reduced in patients over 70 years (0.3 mg not 2 mg).
  • In patients with sickle cell disease, administration of sedation reduces oxygen levels and may result in a sickle crisis.

APTT, activated partial thromboplastin time; ART, antiretroviral therapy; FBC, full blood count; HAART, highly active antiretroviral therapy; HIV, human immunodeficiency virus; IM, intramuscular; INR, international normalised ratio; IV, intravenous; NSAIDs, non‐steroidal anti‐inflammatory drugs.

Block diagram illustrating the selection of appropriate anaesthesia for oral surgery, with boxes labeled “patient requires surgery? LA first choice”, “dental anxiety and noncompliant”, etc.

Figure 15.1 Algorithm for the selection of appropriate anaesthesia for oral surgery. ASA, American Society of Anesthesiologists. GA, general anaesthesia. IV, intravenous. LA, local anaesthesia.

Image described by caption.

Figure 15.2 Dental panoramic tomogram of high‐risk M3M showing roots crossing the inferior dental canal.

Consent

The consent process as considered in Chapter 5 is a requirement prior to any surgical intervention. Consent, which should involve joint decision making with the patient, is a process whereby the patient is made aware of the risk–benefit of undertaking the surgical procedure. It is the surgeon’s responsibility to ensure that the patient understands the alternative treatment options and their consequences. This two‐way discussion and agreement also allows the surgeon to ensure that the patient’s expectations are managed appropriately and to recognise if the patient has unrealistic expectations which may prevent surgery.

Part 2: Dentoalveolar Surgery – Routine Dental Extraction

Dental extraction or exodontia is the surgical process of removing teeth from the jaws. Erupted teeth can usually be extracted routinely without additional soft tissue or bone surgery, unlike partially erupted or impacted teeth (Tables 15.5 and 15.6).

Table 15.5 Preoperative requirements for routine dental extractions.

Treatment plan Check that preparatory treatment has been completed.
Signed consent Confirm valid consent.
Radiographs To provide information on available bone height, width of periodontium, root morphology, restorative condition of adjacent teeth, relationship of important anatomical structures, position and angulation of adjacent tooth roots.
Sterile surgical kit Basic surgical kit to elevate mucoperiosteal flaps and close wound with sutures.
Sterile irrigation system To keep drills irrigated during drilling procedures and avoid overheating of bone.
Sterile drapes To maintain appropriate surgical environment, covering the patient’s clothing and hair.
Chlorhexidine mouthwash A preoperative rinse with 0.2% chlorhexidine for 1 min to reduce bacteria in mouth. Some clinicians also use 0.2% chlorhexidine as a circumoral skin disinfection. More stringent barrier methods, such as adhesive film dressings and covering of nose are used in some countries.
Local anaesthesia Usually obtained using local anaesthetic solution containing adrenaline to produce more profound anaesthesia and haemostasis. Lignocaine commonly used. Articaine infiltration may be more effective in mandibular sites, but do not use for inferior dental blocks.

Table 15.6 Surgical procedure for routine dental extractions.

Position the patient appropriately Once positioned appropriately (Figure 15.4), the patient should be given and asked to put on protective eye wear.
Use Luxator or elevator to mobilise tooth Firm grip of an elevator or Luxator is required with forefinger protruding up the shaft to ensure minimal damage occurring, should the instrument dislodge and slip.
Once tooth is mobilised elevation of single rooted teeth may be possible with Warwick James or Couplands elevators
Multiple‐rooted teeth will require specific forceps application
The key in application of forceps to a tooth during dental extraction is a very firm grip of the tooth in the forcep beaks, once pressure has been applied down the root length to gain a grip below the enamel–dentine junction. Once this grip is established, firm support to the patient’s jaw is required to prevent discomfort and assist in providing resistance to the action of the active extracting hand (Figure 15.5) Application of forceps beaks to teeth, upper straights for upper incisors and canines, upper curved roots for premolars. Upper molar forceps for upper molars (beak to cheek).
Lower straight roots for incisors and canines, lower molars forceps for molars. Modified forceps such as cow horns may be used for lower molars.
A strong downward pressure should be applied to expand the periodontal membrane. Various mobilisation techniques may be used:

  • Vertical axis rotation for single‐rooted teeth.
  • Buccal/lingual–palatal rocking for single‐ and multiple‐rooted teeth. Some operators advocate a ‘figure of 8’ movement for multiple‐rooted molar teeth. Once mobility is gained the extraction can be completed with a slow, but firm buccal inclination of the tooth. Any resistance may be related to poor technique, adverse root morphology or dense bone. If this difficulty persists, or results in root fracture, further elevation with elevators, root sectioning or surgical access may be required.
Irrigation of the site To remove any loose tissue tags and loose bone fragments.
Check socket To check that no pieces of soft tissue or tooth bone fragments are retained and to inspect for continued haemorrhage.
Compression with damp gauze To ensure good flap adaptation and haemostasis.
Give postoperative instructions, verbally and in writing These include taking analgesics every 4–6 h for next 24/48 h, use of chlorhexidine mouth rinse –10 ml of 0.2% chlorhexidine mouthwash for 1 min twice daily, application of ice packs within next few hours to reduce swelling, and instructions to use firm pressure with sterile gauze if bleeding is encountered. Patient should be provided with contact details (name and phone number of the individual) to contact in the event of difficulties.
Homecheck:
the patient should agree preoperatively to provide the practitioner with a contact telephone number, so that the practitioner can phone and speak to the patient 4–6  h postoperatively, when the local anaesthetic has worn off, or failing that the next day
Routine homecheck questions include:

  • Is analgesia required?
  • Any excessive pain or swelling?
  • Any paraesthesia?
  • Any continued or fresh bleeding?

This provides an excellent assessment of the quality of service and audit data.
An early follow‐up appointment should be arranged if the patient is feeling compromised.

Review appointment Review the patient approximately 1 week postoperatively to remove sutures, check healing and deal with any concerns the patient may have.

Part 3: Surgery Indicated for Impacted Teeth or Fractured Roots

Surgical access is most commonly indicated for wisdom tooth–third molar removal, or coronectomy in situations in which there is a high risk of nerve injury. Surgical access may also be required for other impacted tooth removal, or exposure and orthodontic bonding (Tables 15.7, 15.8 and 15.9).

Table 15.7 Preoperative requirements for surgical removal of impacted teeth and retained and fractured roots.

Only gold members can continue reading. Log In or Register to continue

Treatment plan To check that preparatory treatment has been completed.
Signed consent To confirm valid consent.
Radiographs To provide information on available bone height, width of periodontium, root morphology, restorative condition of adjacent teeth, relationship of important anatomical structures, position and angulation of adjacent tooth roots.
Surgical guide disinfected in chlorhexidine solution Surgical guides help in establishing mesiodistal and buccolingual positioning, angulation and vertical level of retained roots.
Sterile surgical dental extraction instruments Complete set of instruments compatible with planned procedure (Figure 15.6).
Sterile surgical kit Basic surgical kit to elevate mucoperiosteal flaps and close wound with sutures.
Sterile irrigation system To keep drills irrigated during drilling procedures and avoid overheating of bone.
Sterile drapes To maintain appropriate surgical environment covering patient’s clothing and hair.
Antibiotics
Jan 22, 2018 | Posted by in General Dentistry | Comments Off on Procedures in Oral Surgery
Premium Wordpress Themes by UFO Themes