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Library of School of Dentistry, TUMS

 For Personal Use Only
Library of School of Dentistry, TUMS

IN ORAL AND
WHEN, WHY AND WHERE

MAXILLOFACIAL SURGERY
 For Personal Use Only
Library of School of Dentistry, TUMS
 WHEN, WHY AND WHERE
IN ORAL AND
MAXILLOFACIAL SURGERY

PREP MANUAL FOR

UNDERGRADUATES AND POSTGRADUATES
Library of School of Dentistry, TUMS

PART I
For Personal Use Only

Prepared by
KC Gupta MDS
Professor and Head
Department of Oral and Maxillofacial Surgery
Modern Dental College and Research Center
Indore, Madhya Pradesh, India

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WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

© 2011, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication and should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the editor and the publisher.

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under Delhi jurisdiction only.

First Edition : 2011

ISBN 978-93-5025-356-4
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Library of School of Dentistry, TUMS

Dedicated to
My Parents
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Library of School of Dentistry, TUMS
 Preface

Teaching and learning is endless

There are several excellent textbooks available in oral

and maxillofacial surgery.
Last moment reading demands maximum information
within limited time. This handbook provides the basic
facts and principles of oral surgery which are necessary
for every student.
Library of School of Dentistry, TUMS
For Personal Use Only

KC Gupta
 For Personal Use Only
Library of School of Dentistry, TUMS
 Acknowledgments

I am deeply grateful to all my postgraduate students for

their untimely support and suggestions. I am also
thankful to my family members—my wife, Smt Sadhna;
my daughter, Jeenal; and my son, Kunal for their support
and encouragement.
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 For Personal Use Only
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 CONTENTS
1. AN OVERVIEW ....................................................................... 1
• Outline of Theory Topics—Oral Surgery- I ................... 1
• Outline of Theory Topics—Oral Surgery-II ................... 2
• Armamentarium for Basic Oral Surgery ...................... 5
• Chair Height ................................................................. 21
• Operator’s Position ....................................................... 21
• Basic Terms Used in Anatomy ................................... 21
• Basic Definitions .......................................................... 23
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• Basic Clinical Teaching ............................................... 28

• Answers—Basic Clinical Teaching ............................. 31
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2. BASIC FACTS IN ORAL SURGERY ......................................... 43

• The Craniocaudal Sequence of Cranial Nerves ......... 43
• Nerve Supply of Maxillary/Mandibular Teeth ........... 43
• Branches of Trigeminal Nerves .................................... 44
• Branches of Facial Nerve ............................................. 45
• Drugs Used in Emergency (Dental)—Outline ............ 46
• Composition of Blood ................................................... 46
• Blood Coagulation Factors .......................................... 47
• The Normal Oral Flora ................................................ 48

3. BASIC PRINCIPLES OF ORAL SURGERY ................................ 49

• Definition of Oral Surgery ............................................ 49
• Sterilization .................................................................. 49
• Principles of Skin Incision and Langer’s Line ............. 51
• Principles of Flap Design .............................................. 51
• Suture Material ............................................................. 51
• Principles of Suturing ................................................... 53
• Basic Principles of Incision and Drainage .................. 54
• Principles of Antibiotic Therapy .................................. 54
 • Different Common Pathological Tests ........................ 55
• Standard Pathological Values ..................................... 56
• Biochemical Profile with Normal Value ...................... 56

4. BASIC STUDY IN ORAL SURGERY ......................................... 57

• Bones of Skull ............................................................... 57
• Muscles of Mastication ................................................. 57
• Muscles of Facial Expression ...................................... 58
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Common Facial Expression Produced by Muscles ......... 59

• Description of an Instrument ....................................... 59
• Reading an X-ray ........................................................... 59
• Description of Drug ....................................................... 60

5. BASIC READING IN ORAL SURGERY ..................................... 61

• Shock ............................................................................. 61
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• Syncope ......................................................................... 65
• Allergy (Anaphylactic Reaction) ................................. 68
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• Hemorrhage .................................................................. 73
• Hemophilia ................................................................... 76
• AIDS (Acquired Immunodeficiency Syndrome) ........... 79
• Viral Hepatitis ............................................................. 81
• Exodontia ...................................................................... 83
• Dental Elevators .......................................................... 88
• Trismus ......................................................................... 90
• Pericoronitis .................................................................. 93
• Edema ............................................................................ 93
• Tetanus .......................................................................... 93
• Tetany ........................................................................... 94
• Oral Submucous Fibrosis—Precancerous Lesion .......... 94
• Dry Socket ..................................................................... 94
• Local Anesthesia .......................................................... 98
• Impaction ................................................................... 104
• Impacted Maxillary Canine ...................................... 108
• Acute and Chronic Infections of Jaw ........................ 110
• Fascial Spaces of Head and Neck Region ............... 112
xii • Ludwig’s Angina ........................................................ 114
 • Cavernous Sinus Thrombosis (CST) ........................ 116
• Apicoectomy ............................................................... 117
• Paranasal Sinus ........................................................ 120
• Oroantral Fistula ...................................................... 121
• Nerve Disorder ........................................................... 122
• Bell’s Palsy ................................................................ 124
• Facial Paralysis ........................................................ 125
• Cyst of Jaw and Oral Cavity .................................... 126
• Dentigerous Cyst ....................................................... 127
• Odontogenic Keratocyst ............................................ 127
• Radicular Cyst ........................................................... 128
• Retention Cyst ........................................................... 129
• Globulomaxillary Cyst .............................................. 129
• Odontogenic Tumor ................................................... 130
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• Nonodontogenic Tumor .............................................. 132

• Temporomandibular Joint ....................................... 133

CONTENTS
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• Special Note ............................................................... 134

• TMJ Disorder ............................................................. 134
• Fracture of Mandible ................................................ 138
• Maxilla Fracture ....................................................... 144
• Zygomatic Complex Fracture .................................... 145
• Orbital Fracture ........................................................ 147
• Diplopia ..................................................................... 148
• CSF Rhinorrhea ......................................................... 148
• Tracheostomy ............................................................ 149
• Salivary Gland Disease and Tumor ......................... 150
• Preprosthetic Surgery ............................................... 154
• Vestibuloplasty ........................................................ 156
• Biopsy ........................................................................ 158
• Precancerous Lesion .................................................. 159
• Oral Cancer ................................................................ 162
• Cleft Palate and Cleft Lip ........................................ 163
• Dental Implant .......................................................... 164
• Orthognathic Surgery ................................................ 166
• Premedication (Preanesthetic Medication) ............. 169 xiii
 • General Anesthesia ................................................... 170
• Distraction Osteogenesis or Callotasis ................... 171
• Cryosurgery ................................................................ 174
6. Role of Radiography in Oral and
Maxillofacial Surgery ................................................. 176
• Introduction ............................................................... 176
• Intraoral Radiographs .............................................. 176
• Extraoral Radiographs ............................................. 178
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Index ................................................................................ 183

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xiv
 CHAPTER

1 OVERV EW
AN OVERVIEW
OVERV

OUTLINE OF THEORY TOPICS—ORAL SURGERY- I

1. Exodontia
a. Definition, method, principles of tooth extraction.
b. Steps and forces exerted during tooth extraction.
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c. Indication and contraindication and complications

of the tooth extraction.
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d. Healing of extraction wound.

e. Causes of tooth/root breakage.
f. Extraction in medically compromised patient.
1. Epileptic patient 2. Diabetic patient
3. Cardiac status patient 4. Asthmatic patient
5. Hypertensive patient 6. Pregnant patient
7. Patient on steroid 8. Patient on
therapy anticoagulant therapy
g. Short account on dry socket and trismus.
2. Local anesthesia = LA (Local Anesthetic Agent)
a. Composition of local anesthetic agent.
b. Indication-contraindication and complication of
local anesthesia.
c. Classification of local anesthesia.
d. Ideal requisites of local anesthesia.
e. Mode of action of local anesthesia (mechanism of
local anesthesia action).
f. Toxicity of local anesthesia.
3. Technique for maxillary and mandibular nerve block
 4. Syncope and allergy
5. Shock
6. Sterilization
7. a. General account on hemorrhage.
b. Control of bleeding in normal patient.
8. a. General account on hemophilia.
b. Extraction in hemophilic patients.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

9. a. Hepatitis B.
b. AIDS.
10. a. Suture material.
b. Principles of suturing.

OUTLINE OF THEORY TOPICS—ORAL SURGERY-II

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1. Role of dental elevator in exodontia.

2. Impaction:
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a. Mandibular third molar.

b. Maxillary canine.
3. Acute and chronic infection of jaws:
a. Cellulitis.
b. Acute alveolar abscess.
c. Osteomyelitis.
d. Garre’s osteomyelitis.
e. Osteoradionecrosis.
f. Pericoronitis.
4. Apicoectomy (definition, indication, contraindication
and surgical procedures).
5. Fascial spaces infection and complication of fascial
space infection, e.g.
a. Ludwig’s angina.
b. Cavernous sinus thrombosis.
6. Maxillary sinus and disease:
a. Surgical anatomy of maxillary sinus.
b. Oroantral fistula.
2
c. Maxillary sinusitis.
 d. Methods used for removal of foreign body from
maxillary sinus.
7. Nerve disorders:
a. Trigeminal neuralgia.
b. Facial paralysis.
c. Bell’s palsy.
8. Odontogenic and non-odontogenic cyst short account
on:
a. Ranula.
b. Mucocele.
c. Globulomaxillary cyst.
9. Odontogenic tumor “Ameloblastoma” and “Odontoma”.

CHAPTER ONE: AN OVERVIEW

10. Preprosthetic surgery:
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a. Soft tissue preparation—tongue tie, vestibuloplasty.

b. Hard tissue preparation—alveoloplasty, torus
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palatinus, torus mandibularis.

11. Fracture:
a. Mandibular fracture.
b. Maxillary fracture.
c. Zygomatic complex fracture.
d. Orbital fracture (blow out and blow in fracture).
Short account on:
i. Tracheostomy.
ii. Diplopia.
iii. CSF rhinorrhea.
12. TMJ
a. Surgical anatomy
b. Ankylosis (Hypomobility)
c. MPDS
d. Hypermobility (subluxation)
e. Dislocation (luxation)
f. Arthritis
g. TMJ hyperplasia 3
 13. Salivary gland disease:
a. Sialadenitis.
b. Sialolithiasis.
c. Salivary gland tumor (pleomorphic adenoma).
d. Sialography.
e. Salivary fistula.
f. Frey syndrome.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

14. Biopsy (definition, indication, contraindication,

procedure, complication).
15. GA and premedication
a. Boyle’s apparatus
b. Laryngoscope
c. Ketamine
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16. Oral cancer (definition, causes, TNM classification,

management) and squamous cell carcinoma of tongue.
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17. Precancerous condition (oral submucous fibrosis and

leukoplakia)
18. Dentofacial deformities outline study orthognathic
surgery (definition, causes, classification) short
account on:
a. Mock preparation
b. Mandibular prognathism
c. Mandibular retrusion
d. Apertognathia (open bite)
e. Sagittal split osteotomy
f. Genioplasty
g. Rhinoplasty
19. Short account on:
a. Dental implant
b. Distraction osteogenesis
20. Short account on:
a. Cleft lip and cleft palate
4 b. Cryosurgery
 ARMAMENTARIUM FOR BASIC ORAL SURGERY

S. No. Name of the instruments/materials

1. Maxillary and mandibular tooth extraction forceps.
2. Universal tooth extraction forceps.
3. Dial/Molt periosteal elevator.
4. Miller’s apexo straight and angulated elevator
(wedge principle).
5. Straight elevator (hospital elevator) (lever and
fulcrum principle).
6. Coupland elevator (lever and fulcrum principle).
7. Warwick James elevator (lever and fulcrum

CHAPTER ONE: AN OVERVIEW

principle).
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8. Cryer elevator (M&D) (lever and fulcrum

principle).
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9. Cross bar elevator (M&D) (wheel and axle

principle).
10. Cheatle forcep
11. Swab holder
12. Towel clip (butter fly shape)
13. Suction tip
14. Eastman Chisel and Down’s stainless steel mallet.
15. Osteotome
16. Bard Parker scalpel handle no. 3 and 4.
17. Surgical blades no. 10, 11, 12, 15.
18. Allie’s soft tissue holding forcep.
19. Tissue dissecting forcep.
20. Dunhill straight artery forcep and artery forcep
(straight and curved).
21. Mayo needle holder.
22. Suture needle (curved-round and cutting body
half circle). 5
 23. Suture materials:
a. Braided black silk (000)
b. Catgut (plain and chromic).
24. Mayo tissue dissecting scissor.
25. McIndoe’s scissor (flat and round end).
26. Curettes (lucas /discoid/ spoon shaped).
27. Volkmann’s scoop
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

28. Bone rongeur

29. Jansen Middleton bone nibbler
30. Bone file
31. Austin’s flap retractor.
32. Ward’s double ended cheek retractor and tongue
depressor.
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33. Langen’s retractor (right angle retractor)

34. Stainless steel wire/ wire cutter
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35. Erich arch bar

36. Sinus dilator forcep
37. Bone wax
38. Ferguson mouth gascrew type/self-retaining
39. Hister’s jaw stretcher
40. Mouth prop:
a. McKesson rubber mouth prop
b. Mushin’s metal mouth prop
41. Corrugated rubber drain
42. Kocher forcep
43. Lion’s bone holding forcep
44. Rowe’s disimpaction forcep
45. Bristowe’s zygomatic arch elevator.

Armamentarium
Thorough knowledge of armamentarium can increase the
6
surgeons skill.
 Objectives
1. Optimal surgical field.
2. Optimal visibility.
3. Decreased strain of the surgeon.
Any instrument should be described as
a. Name of the instrument, e.g. tooth extraction forcep.
b. Instrument made up of, e.g. stainless steel.
c. Parts of the instrument mainly three parts: Beak, Hinge,
Handle.
d. Indications of the instruments, e.g. extraction of maxillary
anterior tooth.

CHAPTER ONE: AN OVERVIEW

Maxillary and Mandibular Tooth Extraction Forceps
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• Mainly made up of stainless steel.

• Three main components of dental extraction forceps
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are:
a. Beak: The beak is designed to adapt to the tooth at
the junction of crown and root. Beaks are kept
parallel to the long axis of tooth.
b. Hinge: For connecting the handle to the beak. The
hinge transfers and concentrates the force applied
to the handles to the beaks.
c. Handle: With the handle we can deliver sufficient
pressure to remove the require tooth. The handle
have a serrated surface to allow a positive grip and
prevent slippage.

Maxillary Anterior Teeth Forcep

• This forcep has beaks in approximation with each other.
• Handle is straight without curvature.

Maxillary Premolar Forcep

• Beaks are approximating each other which are placed
7
parallel to handle.
 • Handle is having concavity on one side and convexity
on other side (slight curvature).
• Rarely can be used for removal of upper root.

Maxillary Molar Forcep

• These are paired forcep. Having beaks which are
asymmetrical.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• One beak is pointed to engage the furcation point on

buccal side and other which is broader engage the
palatal root.
• Therefore, there are right and left sided forcep.

Maxillary Bayonet
• These forceps for removal of maxillary root.
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• Beaks are symmetrical and closely approximates each

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other.
• Handle is having angulations.

Maxillary Cow Horn Forcep

• Paired forceps same as maxillary molar forceps except
they are having beaks that appear as the horn of the
cow and called as cow horn forceps.
• They are used for maxillary molars which are badly
carious.
• Major disadvantage is that they crush alveolar bone
when used on intact teeth.

Maxillary Third Molar Forcep

• This forcep is especially designed for removal of
maxillary 3rd molar with small conical crown and little
abnormal in position.
• Forceps have beaks which engage the crown of 3rd
molar and having long handle to reach the most posterior
8
region in maxilla.
 Mandibular Anterior Forceps
• These forceps have beaks right angle to the handle.
• Beaks in approximation to each other.
• Mainly used for extraction of central incisor/ lateral
incisor/canine.
Mandibular Premolar Forcep
As anterior forcep except the space in between two beaks
to accommodate the crown of premolar which are having
larger diameter.
Mandibular Molar Forcep
• These are unpaired having beaks broader and stout.

CHAPTER ONE: AN OVERVIEW

• Beaks are at right angle to the handle.
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• The beaks are symmetrically pointed so that sharp

pointed tips can engage the bifurcation both at buccal
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and lingual surfaces.

Mandibular Cow Horn Forceps
• Shape of beaks like cow horn means tips are more
pointed and conical in shape.
• Mainly for extraction of mandibular molars.
Universal Tooth Extraction Forcep
• This forcep is having the beaks similar to the mandibular
molar forcep.
• Except that they are facing forward towards each other
at right angle to the handle.
• This is especially designed forcep mainly used for
extraction of 3rd molars.
Dial/Molt Periosteal Elevator
• Name of instrument is Molt periosteal elevator made
up of stainless steel. 9
• Double ended instrument.
 • To some extent—works on wedge principle to luxate
the tooth.
• One end broad, spatulated and slightly curved, used to
reflect the mucoperiosteal flap.
• Other end is narrow—tapering and ends in a tip that is
slightly curved, used to reflect interdental papilla and
attached gingival.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Millers’s Apexo Straight and Angulated Dental Elevator

• Made up of stainless steel
• Three main components:
a. Blade
b. Shank
c. Handle
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• Works on wedge principle

• In straight elevator—All three components are in same
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plane.
• In angulated elevator—Blade is angulated with shank.
Blade is narrow with a deep concavity on its working
side.
• Straight elevator is mainly used for luxation of
maxillary teeth and angulated used for fractured roots.
Hospital Pattern Straight Elevator
• Works on lever and fulcrum principle.
• It is used to luxate the tooth, prior to placing the forcep.
• The serrated flat side of the blade faces the tooth to be
extracted.
Coupland Elevator
• Works on lever and fulcrum principle.
• The blade is concave on its working surface.
• Used mainly to luxate and elevate maxillary and
10
mandibular posterior teeth. Also helpful in removing
impacted 3rd molar like mesioangular impaction.
 Warwick James Elevator
• Work on lever and fulcrum principle
• Straight and angulated types
• Mainly used to remove fractured root.
Cryer’s Elevator
• Paired instrument
• Work on lever and fulcrum principle
• Blade at right angle to shank and handle
• Mainly used to remove fractured root of posterior tooth.
Winter’s Cross Bar Elevator

CHAPTER ONE: AN OVERVIEW

• Paired instrument
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• Work on wheel and axle principle

• Blade is triangular in shape and right angle to shank
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and handle. Therefore, generate a large amount of force

• Should be used with caution
• Mainly for removal of fractured root mandibular
posterior teeth
• May be helpful in removal of mandibular 3rd molar
(buccoeversion and horizontal) with caution.
Cheatle Forceps
• Used for picking up sterile instruments from a tray or
sterile linen.
• It is a long angulated instrument which is stored in a
container with antiseptic solution.
Swab Holder
• It is an instrument with long blade, and forming an
oblong tip and blades have transverse serrations
• Uses—To hold a swab and clean the area of operation 11
and to hold the tongue and give anterior traction.
 Towel Clip
• May be of butterfly shape or can be of forceps type
• The working ends may have either curved sharp points
or blunt flat tips, that penetrated the towel or drapes
• Instrument has a locking handle and finger and thumb
rings
• Uses—Towel clips are used to maintain surgical towels
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

and draps in the correct position during an operation

• To stabilize suction tubes, motor cables and other
cables.
Suction Tip (Suction Cannula)
• This tip is used to suck out the blood/saliva during the
surgical procedure
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• This helps to clear out the surgical field

• One end is attached to the sterilized rubber tube, which
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in turn is attached to the suction machine.

Eastmann Chisel and Down’s Stainless Steel Mallet
• Chisel available is different size of cutting edge
• These are bone cutting instrument. For example, 3rd
molar surgery, preprosthetic surgery, hard surface
correction
• Chisel have a bevel on one side and flat surface on other
side
• If it is beveled on both sides, it is known as osteotome
to cut the bone on both sides in orthognathic surgery
• The bevel toward the surface of the bone that is to be
scarificed
• The chisel must be held at right angle to the bone
surface.
Osteotome
12 • Similar to a chisel but the edge of the working tip is
beveled.
 • It splits bone rather than cuts or chips the bone as
with the chisel.
• Uses:
i. Various osteotomy procedure.
ii. Biopsy of bony lesion.
iii. Removing or recontouring of the bone, e.g. lining
or granulation tissue which is to be removed.
iv. To remove small sequestra which may develop in
healing socket.
v. To remove proliferative or infected clot from the
extraction socket.
Bard Parker Handle

CHAPTER ONE: AN OVERVIEW

• It is used to fix different sizes and shapes of blades
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• It is held in a pen grasp to make an incision.

For Personal Use Only

Surgical Blade: Uses

• No.10—Shape like 15 no. But larger in size for making
skin incision
• No.15—Shape like 10 no. But smaller in size, for making
intraoral incision
• No.11—Sharp pointed tip. For making stab incision as
in case of draining sinus from an absecess cavity
• No.12—Sickle shape, crevicular incision, intraorally.
Allie’s Soft Tissue Holding Forceps
• These forceps have a locking handles
• The tips have teeth that grip the tissue firmly
• They can be used to retract tissue from surgical field
by locking
• They are moreover to be used on soft tissue.
Adson Tissue Holding Forceps
• It is used to hold the tissue while suturing is done 13
• They are toothed or nontoothed variety.
 Artery Forcep
• Available as straight (Dunhill’s) and curved (Halstead’s)
forcep
• Hemostat curved forcep also known as mosquito forcep
• Mainly to control bleeding
• Intraorally mainly used is curved artery forcep
• The hemostat must have tips that appose accurately
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• May be useful for removal of granulation tissue from

socket
• Also useful to pickup small root tip from tooth socket
• Having three lock system:
i. To catch
ii. To clamp
iii. To crush
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Mayo Needle Holder

For Personal Use Only

• Needle holding forcep

• The typical needle holder has two short, blunt, serrated
beaks with a distinct groove in each beak
• The grooves provide space for the placement and retention
of the needle
• At the end of handle, there is a locking device
• Used to hold needle during suturing.
Suture Needle
• Two shapes—Straight and curved
• Made up of stainless steel
• Round body and cutting body suture needle available
• Generally, intraorally half circle round body needle is
used
• Extraorally cutting body, half circle needle is used
• Curved needle may be swaged or eyed.
Suture Materials
• May be—Natural or synthetic; absorbable or non-
14
absorbable
 • Generally intraorally and extraorally—Three zero non-
absorbable braded black silk (natural) is used. Suture
should be removed after one week
• Absorbable suture material—Cat gut (natural) can be
used intraorally and extraorallly in the deep tissue
• As number increases—Suture material becomes finer.
Mayo Tissue Dissecting Scissors
• As name suggests dissecting scissors are used to
perform soft tissue dissection in the deeper layers
• The scissors have blunt ends for undermining the tissue
and a side cutting edge for cutting the tissue.

CHAPTER ONE: AN OVERVIEW

Suture Cutting Scissors
• The tips of these scissors are sharp, to facilitate its
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entry under the suture and cut it without causing pain

• Cutting edge with fine serrations.
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Curettes (Lucas Curette)

• Curer means to cleans
• Also known as periapical curette
• They are available in different size to be used in
different sized cavity
• They are also available as single ended or double ended
instrument
• These instruments are sharp, spoon shaped
• Used—To clear the lining out of the bony cavities as in
cyst enucleation, intraosseous tumors. Also used to
remove small amounts of granulation tissue debris from
the tooth socket
• The convex side should be toward the hard bony surface
and concave (depressed or spoon) towards the soft tissue.
Volkmann’s Scoop
• This instrument is used to scrape the contents of a 15
cavity
 • Similar to curette but the concavity of the working
edges is more pronounced. It may be used as spoon
• Uses:
i. To collect the contents from sinus tract, chronic
abscess cavity or a fistula.
ii. To scrape or curette bony cavities due to cystic/
tumorous lesion or osteomyelitic lesions.
iii. To scoop out the cancellous bone for grafting
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

procedure.

Bone Rongeur
• These instruments have a sharp side cutting blade and
curved handles with spring action that increase the
efficiency of the instrument
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• Commonly used to remove bone during alveoloplasty.

For Personal Use Only

Jansen Middleton Bone Nibblers

• Instrument have end cutting edge
• The tip has concave inner surface, curved handle with
spring action
• Mainly used to nibble out small sharp pieces of bone
after surgical procedure, e.g. alveoloplasty
• Instrument can be inserted into tooth socket for
removal of interradicular bone.

Bone File
• Double ended instrument with large and small end
• Mainly for smoothening the rough surface of bone as
in alveoloplasty or any other surgical procedure
• Work in one direction, only with a pull movement.

Austin Retractor
• This is a short right angled retractor, used for
16
retracting the cheek, tongue and mucoperiosteal flaps.
 Ward’s Double Ended Cheek Retractor and Tongue Depressor
• The tongue depressor is an “L” shaped instrument with
a broad smooth blade for depressor or retracting the
tongue
• Uses:
i. To depress the tongue for visualization of the tonsils
and the pharyngeal wall during inspection.
ii. To depress the tongue during endothelial intubation
and extubation.
iii. To retract the tongue during surgical procedure in
the oral cavity.
iv. To retract the cheek.

CHAPTER ONE: AN OVERVIEW

Langenbeck’s Retractor
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• It has a long handle and an “L” shaped blade

• It is available in different sizes and blade width
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• It is used to retract the soft tissues, incision edges, to

allow view of the deeper structure.
Stainless Steel Wire and Wire Cutter
• Generally 26 gauze wire is used, soft in nature
• In case of facial bone fracture for fixation of fractured
fragments by open method known as transosseous
wiring, by closed method–inter/intramaxillary
fixation and immobilization of jaws
• Wire cutter available with tungsten tip.
Erich Arch Bar
• Most commonly used for intra/intermaxillary fixation
and immobilization of jaw. Generally in case of closed
method
• There are ready made arch bar available. It has solid
hooks attached to the base wire
• It is easy to adapt, should be placed on middle third of
the tooth surface and accurately adapted to each tooth 17
• Indicated when there are not enough teeth in the arch.
 Lister’s Sinus Dilator Forcep
• These forceps are designed without a locking device
• With long, narrow blades. Tip is rounded and bulbous
• They are used–for probing and forcing into an abscess
cavity. Can also be used to open an abscess cavity, to
break the loculae, to dissect out sinus and fistulous tracts
in soft tissue.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Bone Wax
• Mainly used to control the bleeding from bony surface
• Should be used in limited quantity. Excess quantity may
cause bone wax granuloma
• Composition:
i. Beeswax – 7 part
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ii. Phenol – 1 part

iii. Olive oil – 2 part.
For Personal Use Only

Mouth Gag (Ferguson Mouth Gag)

• May be screw type and self-retaining.
• Mainly for postoperative gradual increasing mouth
opening in case of TMJ ankylosis, OSMF, trismus
• Mouth gag should be placed on posterior teeth should
be parallel to occlusal surface, gradually increase the
opening. The handle has a catch that is fixed at the
required opening
• The flat bladder have serrations that rest on the
occlusal surface of the maxillary and mandibular teeth.
Heister’s Jaw Stretcher
• This instrument has two flat blades that are applied
between the maxillary and mandibular posterior teeth
and are separated by turning a key that is positioned
between the two blades
• Uses—To force the mouth open when there is trismus
due to infection, muscle spasm, to give postoperative
18 active jaw physiotherapy after surgery for TMJ ankylosis/
OSMF
 • Precaution–care should be taken to prevent luxation
of the teeth and dislocation of TMJ.
Mouth Prop
• A mouth prop is a device for maintaining the jaw of a
dental patient in an open state. For example, epileptic
pt/ long duration dental surgery/surgery under GA
• It consists of a vertical block having a concave surface
on either of its ends to fit the maxillary and mandibular
teeth
• Blocks of different sizes are available attached to a chain
• Blocks made up of a rubber/metal
• Postoperative mouth exercise in case of oral submucous

CHAPTER ONE: AN OVERVIEW

fibrosis/TMJ ankylosis.
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Corrugated Rubber Drain

• It is a sheet of rubber with corrugations on its surface
For Personal Use Only

• It is usually used as a drain following abscess drainage

• The drain is inserted with one end in the cavity and
the other end is kept out of the skin or mucosa
• The drain secured by suture and is left in place for
three to five days.
Kocher Forcep
• This instrument is similar to a long heavy artery
forcep but it has toothed tip
• Uses:
i. To grasp heavy tissue or bone for stabilization of
the bony fragment.
ii. It may also be used as a clamp
iii. The instrument is especially designed to hold the
coronoid process during coronoidectomy procedure.
Lion’s Bone Holding Forcep
• Used to hold the mandibular fractured fragment in
19
normal anatomic position after reduction
• Sometime also helpful in reduction of fractured fragment
 • Forcep have 2 beaks which are toothed
• A catch is provided in the handle of the instrument to
stabilize it
• The beak looks like a lion so known as lion’s bone
holding forcep.
Rowe’s Disimpaction Forcep
• This instrument is used in pairs for reduction of maxilla
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

in Le Fort fracture, where maxilla is impacted

• It has two blades—Straight and curved one
• The straight one is unpadded blade which is passed up
a nostril
• The curved one is padded blade enters the mouth and
grip the palate
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• Rubber pad prevents the injury to palate during

For Personal Use Only

manipulation
• The operator stand behind the patient and grasp the
handles of each of the forceps and manipulates the
fragment into position
• Uses:
i. To disimpact the maxilla in fresh Le Fort fracture,
malunited fracture
ii. To check for free movement of the maxilla after
lefort osteotomy procedure.
Bristow’s Elevator
• Mainly used to elevate the depressed zygomatic arch
with the extraoral Gillies temporal approach
• Adjacent skull as a fulcrum to obtain the required
leverage to reduce the fracture
• It is necessary to place gauze under the instrument at
the point of fulcrum to avoid bruising of scalp
20 • This instrument should be used care as damage to the
cranium is possible.
 CHAIR HEIGHT
1. For maxillary teeth 8 cm (3 inch) below the shoulder
level of the operator.
2. For mandibular teeth 16 cm (6 inch) below the level of
the operators’s elbow.

OPERATOR’S POSITION
1. For maxillary teeth—Right front of the patient
2. For mandibular teeth
All left mandibular teeth—Right front of the patient
right side CI, LI, and canine = right front of the patient
1st and 2nd PM = just right of the patient
1st and 2nd M = exact right side of the patient

CHAPTER ONE: AN OVERVIEW

3rd M = just behind right side of the
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patient.
For Personal Use Only

BASIC TERMS USED IN ANATOMY

1. Anatomy: It is derived from a greek word “anatome”
meaning cutting up. The term dissection is a latin
equivalent of the greek anatome.
2. Surface anatomy (topographic anatomy): This
is the study of deeper parts of the body in relation to
the skin surface. It is helpful to clinical practice and
surgical operation.
3. Applied anatomy (clinical anatomy): Deals with
application of the anatomical knowledge to the medical
and surgical practice.
4. Supine position of the body: It is lying down
(recumbent) position with the face directed upward.
5. Muscle: Muscle is a contractile tissue which brings
about movements.
Belly: The fleshy and contractile part of a muscle.
Tendon: The fibrous, noncontractile and cord like part
of a muscle. 21
Aponeurosis: The flattened tendon.
 6. Arteries: These are distributing channels which carry
oxygenated blood away from the heart with the
exception of the pulmonary and umbilical arteries
which carry deoxygenated blood.
7. Veins: These are draining channel which carry
deoxygenated blood from different part of the body
back to the heart. Exception of the pulmonary and
umbilical vein which carry oxygenated blood.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

8. Capillaries: Capillaries are network of microscopic

endothelial interposed between arterioles and
vennules.
9. Symptom: Symptoms are subjective complaints of
the patient about his disease.
10. Signs (physical signs): Signs are objective finding
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of the doctor or the patient.

11. Diagnosis: Identification of a disease or determination
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of the nature of a disease.

12. Prognosis: Forecasting the probable course and
ultimate outcome of a disease.
13. Syndrome: A group of disease symptoms and signs
constituting together the picture of a disease.
14. Coma: Deep unconsciousness.
15. Benign: Mild (illness or growth) which does not
endanger life.
16. Malignant: Severe form of illness or growth which
is resistant to treatment and end in death.
17. Carcinoma: Malignant growth arising from the
epithelium (ecto- and endoderm).
18. Sarcoma: Malignant growth arising from the
connective tissue (mesoderm).
19. Bone: Bone is a connective tissue (1/3), impregnated
with calcium (2/3).
20. Joints: Joint is a junction between two or more bones
22 or cartilages. Ex. TM Joint type of synovial joint.
 21. Lymph: The tissue fluid enters the lymphatic vessels
is called lymph. It is a clear fluid. Lymph has the
constitution similar to the blood plasma. It contain
lymphocytes, large molecules of protein and particulate
matter absorbed from tissue fluid.
22. Lymph nodes: Lymph nodes are small nodules of
lymphoid tissue found in the course of smaller
lymphatics. The nodes are oval or reniform in shape.
23. Nerves: A nerve consists of large number of fibers
(axons) which are bound together by connective
tissue. Nerve is concerned with sending messages
(nerve impulses) from brain and spinal cord to the
peripheral part of the body (efferent) and also from

CHAPTER ONE: AN OVERVIEW

peripheral to the brain and spinal cord (afferent fiber).
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24. Fascia: Fascia is the name given to the collection of

connective tissue. Superficial fascia (subcutaneous
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tissue) is made up of the loose areolar connective

with the fat. Deep fascia is a dense inelastic connective
tissue membrane. It is made up of a regularly arranged
collagen fibers.
25. Ligaments: Ligaments are fibrous bands which
connect the adjacent bones forming integral parts of
the joints.
26. X-rays: X-rays are kind of electromagnetic waves
used for both diagnostic and therapeutic purpose. All
electromagnetic waves (X-rays, ultraviolet rays,
infrared rays, radiowaves) are produced by acceleration
of electrons.

BASIC DEFINITIONS
1. Blood: Blood may be described as specialized
connective tissue in which there is liquid intercellular
substance known as plasma and formed elements,
the RBC, the WBC, platelets suspended in the plasma. 23
 2. Pain: Pain is an ill defined, unpleasant sensation,
usually evoked by an external or internal noxious
stimulus.
3. Allergy: A hypersensitive state acquired through
exposure to a particular allergen (drug) re-exposure
to which produces a heightened capacity to react.
4. Idiosyncracy: It is genetically determined abnormal
reactivity to a chemical. These are uncharacteristic
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

or bizarre drug effect due to peculiarities of an

individuals.
5. Sterilization: It is process by which all microbial
forms are destroyed.
6. Syncope (fainting, black out): Refers to a sudden,
transient loss of consciousness, usually secondary to,
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cerebral ischemia with a resulting fall to the ground

if the person is unsupported.
For Personal Use Only

7. Shock: An acute generalized, inadequate perfusion

of critical organ, that is continued will produce serious
pathophysiological consequences. Hemodynamic,
endocrine and metabolic alterations and produce
clinical signs of shock.
8. Anaphylactic shock: Severe, allergic (hyper-
sensitivity) reaction resulting from injection of a
substance to which an individual or animal has
become sensitized.
9. Anaphylaxis: A rapidly developing immunologic
reaction occurring within minute after the combination
of an antigen with antibody bound to mast cells or
basophils in individuals or animals previously
sensitized to the antigen.
10. Hemorrhage: It is the escape of blood from the
vascular system.
11. Hemophilia: It is inherited sex linked anomaly of
24
clotting mechanism transmitted by female to male
 in which female do not suffer while male are affected
and characterized by a prolonged clotting time and
hemorrhagic tendencies.
12. Purpura: It is bleeding disorder characterized by
tendency to petechial hemorrhage under skin.
Bleeding time is prolonged but coagulation time
remains normal. There is diminuation of platelets in
blood.
13. Hematoma: Escape of blood in extravascular space.
14. Sepsis: It is the breakdown of the living tissue
by action of microorganism usually accompanied by
inflammation.
15. Asepsis: Medical asepsis attempt to keep patients,

CHAPTER ONE: AN OVERVIEW

health care staff and objects as free as possible of
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agents that cause infection. Surgical asepsis is attempt

to prevent microbes from gaining access to wounds.
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16. Antiseptic: A chemical that is applied to living tissues

such as skin, mucous membrane to reduce the number
of microorganism present through inhibition of their
activity or destruction.
17. Disinfectant: A chemical used on non-living object
to kill surface vegetative pathogenic organisms but
not necessarily spore forms or viruses.
18. Aerobic bacteria: A microorganism that is able to
live and grow in the presence of oxygen. Facultative
a microorganism which prefers oxygen free
environment but can grow in presence of oxygen.
Obligatory A microorganism that can live and grow
only in presence of oxygen.
19. Anaerobic bacteria: A microorganism that can live
and grow in the absence of oxygen. Facultative-
organism that prefers oxygen environment but is
capable of living and growing in its absence.
Obligatory—organism that can live and grow only in 25
absence of oxygen.
 20. Bacteremia: It is defined as presence of small number
of bacteria in the blood which does not multiply
significantly, not detected microscopically. Blood
culture is done for their detection. For example,
Salmonella typhi, E. coli, etc.
21. Septicemia means presence of rapidly multiplying
highly pathogenic bacteria in the blood. For example,
pyogenic cocci and bacilli.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

22. Pyemia: It is the dissemination of small septic thrombi

in the blood which cause their effects at the site where
they are lodged. This can result in pyemic abscess or
septic infarcts.
23. Toxemia: The condition resulting from the spread
of bacterial product by the bloodstream or condition
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resulting from metabolic disturbances.

24. Sinus: A blind tract (open at one end) lined by
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epithelium.
25. Fistula: A track open at both ends and lined by
epithelium.
26. Ulcer: A localized loss of surface continuity of the
skin or mucous membrane.
27. Inflammation: It is the local reaction of the tissue
to an injury or an abnormal stimulation caused
by a physical, chemical or biologic agent. It is
characterized by:
a. Swelling
b. Pain
c. Redness
d. Warmth or heat
e. Loss of function.“Dolor, Tumor, Rubor, Color,
Functiolesio”.
28. Vaccines are biological products which act by reinfor-
cing the immunological defense of the body against
26 foreign agencies (mostly infecting organisms or their
toxins).
 29. Tumor (Neoplasm): A circumscribed, noninflamm-
atory, abnormal growth arising from the body surface.
30. Cancer: A general term used to indicate any
malignant neoplasm which shows invasiveness and
resulting death of the patient.
31. Antibiotics: These are substances produced by
microorganisms, which suppress the growth of other
microorganisms (known as bacteriostatic antibiotic)
or kill the other microorganisms (known as
bactericidal antibiotic) at very low concentration.
32. Analgesic: A drug that selectively relieves pain
acting in the central nervous system or on peripheral
pain mechanisms without significantly altering

CHAPTER ONE: AN OVERVIEW

consciousness.
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33. Normal occlusion: It is a accepted relationship of

the teeth in the same jaw to each other and those to
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the opposing jaw, when teeth are approximated,

condyle are in centric position to glenoid fossa.
34. Malocclusion: A condition where deviation from the
normal relation of the teeth, to the other teeth in
the same arch and to the opposing arch.
35. Causalgia: It is a term to apply to serve pain which
arises after injury to or sectioning of peripheral
sensory nerve. It is usually followed by extraction of
a multirooted tooth particularly when extraction is
difficult or traumatic.
36. Dry socket: It is a postextraction complication in
which there is a loss of the blood clot from the socket
and characterized by:
a. Extreme pain
b. Foul smell
c. No suppuration, occasionally seen after a single
or multiple tooth extraction.
37. Trismus: Terms refers to tonic spasm of the muscles 27
of mastication or it is defined as a motor disturbance
 of the trigeminal nerve especially spasm of the
masticatory muscle with difficulty in opening the
mouth.
38. Biopsy: It is the removal of the tissue specimen either
totally or partial for microscopic examination and
diagnosis.
39. Cryosurgery: It is clinical application of extreme low
temperature to achieve tissue destruction.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

40. Laser surgery: Laser (Light amplification of

stimulated emission of radiation) CO2 laser—A laser
beam produced from the carbon dioxide source is used
for cutting both soft and hard tissues. Nd-Ae-YAg laser
is a contact laser. The recent advancement in laser
technology is Erbium Yag laser. I can cut through skull
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without damaging brain.

For Personal Use Only

BASIC CLINICAL TEACHING

1. Name of the cranial nerves.
2. Blood coagulation factors.
3. a. Branches of trigeminal nerve.
b. Branches of facial nerve.
c. Branches of maxillary artery.
4. Blood and nerve supply of upper and lower jaw.
5. a. Composition of blood.
b. Why blood not clot in vessels.
6. Definition of sterilization/antiseptic and disinfectant
sepsis and asepsis/sanitation.
7. a. Definition of bacteriostatic and bactericidal.
b. Definition of aerobic and anaerobic bacteria.
8. a. Definition of tooth extraction.
b. Methods for tooth extraction (intra and transalveolar).
c. Principles of tooth extraction.
28 d. Different steps for tooth extraction.
 e. Different forces exerted during tooth extraction.
f. Healing of extraction wound.
9. Indication/contraindication/complication to tooth
extraction.
10. Causes of root breakage.
11. a. Methods used for controlling the postextraction
bleeding.
b. Drugs may cause postextraction bleeding
c. Name of drugs used in hemophilic patient
12. Definition, causes, C/F management of syncope.
13. Definition, types, causes, C/F and management of shock.
14. Definition, types, causes, C/F and management

CHAPTER ONE: AN OVERVIEW

hemorrhage
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15. Definition, types, C/F of hemophilia. Dental treatment

in hemophilic patient.
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16. Definition of analgesia and anesthesia and causalgia/

local anesthesia and local anesthetic agent.
17. Composition of local anesthetic agent.
18. Classification of local anesthetic agent.
19. Indication/contraindication/types of local anesthesia.
20. Complication of local anesthetic agent.
21. Theories explaining the mode of action of LA.
22. Anatomical landmarks of :
a. Inferior alveolar nerve block.
b. Infraorbital nerve block.
c. Posterior superior alveolar nerve block.
23. Contents and boundaries of pterygomandibular space.
24. Define:
a. Hemophilia and purpura
b. Hematoma and ecchymosis
c. Thrombosis and emboli
d. Allergy and idiosyncracy
e. Sinus and fistula 29
f. Bacteremia and septicemia
 25. Different extra- and intraoral technique for maxillary
and mandibular nerve block.
26. Role of dental elevators in oral surgery.
27. Removal of root from maxillary sinus.
28. Anatomical landmarks of:
a. Gow Gates technique for mandibular nerve block.
b. Akinosi technique for mandibular nerve block.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

29. Extraction of tooth in:

a. Hemophilia
b. Hypertensive patient
c. Cardiac patient
d. Diabetic patient
e. Asthmatic patient
f. Epileptic patient
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30. a. Principles of suturing.

b. Different suture materials.
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31. a. Different surgical blades used in oral surgery.

b. Principles of flap designing.
c. Principles of skin incision.
d. Langer’s lines.
32. Definition of dental granuloma/abscess/cyst.
33. Definition, etiological factors of trismus, manage-
ment of postextraction trismus.
34. Definition, causes, clinical features and treatment of
dry socket.
35. a. Definition of biopsy and autopsy.
b. Types/indication/contraindications/procedures/
complications of biopsy.
36. Explain
a. Hepatitis B
b. AIDS
37. Pre-anesthetic medication.
38. Emergency drugs used in dental clinic.
30 39. Antihypertensive drugs.
 40. Classification of antibiotics.
41. Principles of antibiotic therapy.
42. Classification of analgesics, anti-inflammatory and
antipyretic drugs.
43. Drugs used as muscles relaxant.
44. Classification and role of corticosteroids in oral
surgery.
45. Definition, classification, stages of general anesthesia.
46. Muscles of mastication.
47. Classification of fascial spaces.
48. Different extraoral and intraoral radiographs and
indications of various. Radiographs used in oral surgery.

CHAPTER ONE: AN OVERVIEW

49. Composition of:
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a. Bone wax
b. White head varnish
For Personal Use Only

c. Carnoy’s solution
50. Blood and nerve supply:
a. Temporomandibular joint
b. Tongue.
51. Role in oral surgery:
a. Avil b. Adrenaline
c. Atropine d. Dexona
e. Aminophylline f. Calmpose
52. Role in oral surgery:
a. Aromatic spirit ammonia b. Normal saline
c. Hydrogen peroxide d. Surgical spirit
e. Carbolic acid.
53. Different position of the patient on the dental chair.
ANSWERS—BASIC CLINICAL TEACHING
Why blood does not clot in vessels?
1. Presence of natural anticoagulant known as heparin
in blood with cofactors. 31
2. Constant flow of the blood in the vessels.
 3. Smoothness of blood vessels wall known as endothelial
lining.

Methods Used for Controlling the Postextraction Bleeding

1. Compress the socket with finger pressure.
2. Pressure pack with wet gauze piece.
3. Use of vasoconstrictor in bleeding socket.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

In normal patient = Adrenaline (1:1000)

In cardiac patient = Sepguard, Hemlock.
4. Suture the bleeding socket.
5. Use of systemic hemostatic. For example, Inj/Tab.
Streptavidin/ Vit K/Chromostate.
• In case of bleeding from hard bony surface
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• Use bone wax— Directly apply bleeding point.

Drugs may Cause Postextraction Bleeding
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1. Alcohol 2. Aspirin
3. Anticoagulant 4. Antibiotic (Sulfonamide)
5. Antimalignant
Drugs Used as Systemic Administration in Hemophilic
Patient
1. Desmopressin
2. Amicar = Epsilon aminocaproic acid
3. Cyklokapron = Tranexamic acid
Anatomical Landmarks of Infraorbital Nerve Block
1. Infraorbital ridge 4. Infraorbital notch
2. Infraorbital depression 5. Anterior teeth
3. Supraorbital notch 6. Pupils of the eyes
Posterior Superior Alveolar Nerve Block
1. Mucobuccal fold and its concavity.
2. Zygomatic process of the maxilla.
32
3. Infratemporal surface of the maxilla.
 4. Anterior border and coronoid process of the ramus of
the mandible.
5. Tuberosity of the maxilla.
Inferior Alveolar Nerve Block
1. Mucobuccal fold.
2. Anterior border of the ramus of mandible.
3. External oblique ridge.
4. Retromolar triangle.
5. Internal oblique ridge.
6. Pterygomandibular raphe.
7. Buccal sucking pad.

CHAPTER ONE: AN OVERVIEW

8. Pterygomandibular space.
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Contents of Pterygomandibular Space

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1. Inferior alveolar nerve/artery/vein.

2. Mylohyoid nerve/vessels.
3. Auriculotemporal nerve.
4. Internal maxillary artery.
5. Lingual nerve.
6. Soft aerolar tissue.
Boundaries of Pterygomandibular Space
1. Anteriorly = Pterygomandibular raphe.
2. Posteriorly = Deep part of the parotid gland.
3. Laterally = Ramus of mandible.
4. Medially = Medial pterygoid muscle.
5. Superiorly = Lateral pterygoid muscle.

Define (Basic Differentiating Points)

1. Hemophilia and Purpura
Hemophilia = BT normal, CT increases
33
Purpura = BT increases, CT normal
 2. Hematoma and Ecchymosis
Hematoma = Collection of blood in extravascular
space
Ecchymosis = Collection of blood below the skin and
mucous membrane
3. Thrombosis and Embolism
Thrombosis = Intravascular coagulation of blood
known as thrombosis which is
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

attached with endothelial lining of

vessels known as thrombus.
Embolism = When attached clotted blood gets
detached from lining and circulate in
circulation, may cause obstruction,
condition is known as embolism and
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that detached blood clot known as

embolus.
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4. Allergy and Idiosyncracy

Allergy = A hypersensitive state acquired
through exposure to a particular
allergen
Idiosyncracy = Genetically determined uncharacter-
istic bizarre reaction
5. Sinus and Fistula
Sinus = A tract open at one end which is lined
by epithelium. For example, extra or
intraoral sinus.
Fistula = A tract open at both end which is
lined by epithelium. For example,
oroantral fistula—one end open in
the oral cavity, other end in the
maxillary sinus.
6. Bacteremia and Septicemia
Bacteremia = Presence of small number of bacteria
34 in the blood which does not multiply
significantly
 Septicemia = Presence of rapidly multiplying
highly pathogenic bacteria in the
Blood
Anatomical Landmarks
Gow Gates Technique for Mandibular Nerve Block (Open
Mouth Technique)
1. Anterior border of the ramus.
2. Tendon of temporal muscle.
3. Corner of the mouth.
4. Intertragic notch of the ear.
5. External ear.

CHAPTER ONE: AN OVERVIEW

Akinosi Technique for Mandibular Nerve Block (Closed Mouth
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Technique)
1. Occlusal plane of occluding teeth.
For Personal Use Only

2. Mucogingival junction of the maxillary molar teeth.

3. Anterior border of the ramus.
Different Surgical Blades Used in Oral Surgery
Blade No. 10 = Used for extraoral incision. Same shape
like No. 15 blade but larger in size than
No. 15 blade.
Blade No. 15 = Used for intraoral incision. Same shape
but smaller in size than No.10 blade.
Blade No. 11 = Used for drainage of abscess with the
stab incision.
Blade No. 12 = Sickle in shape. Mainly for intraoral
crevicular incision.
Definition of Dental Granuloma/Abscess/Cyst
• Dental granuloma: A granuloma is literally a tumor
made up of granulation tissue. The term dental
granuloma is used to designate the situation in the
periapical region in which an abscess or a localized area 35

of osteolysis is replaced by granulation tissue.

 • Abscess: Abscess is a localized collection of pus in a
cavity formed by the disintegration of tissues, usually
caused by Staphylococcus aureus.
• Cyst: A cyst is a cavity occurring in either hard or soft
tissue with a liquid, semisolid or air content. It is
surrounded by a definite connective tissue wall or
capsule and usually has an epithelial lining.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Antihypertensive Drugs—Commonly Used Drugs

a. Nifedipine, e.g. Tab Depin 5 to 10 mg (two to three
times a day).
b. Reserpine, e.g. Tab Adelphen 10 mg (three times a
day).
c. Alphamethyl DOPA, e.g. Tab Alphamethyl DOPA
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250 mg (two to three times a day).

d. Propranolol, e.g. Tab Ciplar 40 to 80 mg (two to three
For Personal Use Only

times a day).
e. Atenolol, e.g. Tab Aten 50 to 100 mg (once daily).

Classification of Antibiotics

On the Basis of their Spectra

1. Antibiotic mainly effective against gram-positive
bacteria:
a. Employed for systemic infection
i. Penicillin ii. Erythromycin
iii. Lincomycin iv. Vancomycin
v. Novobiocin vi. Fucidin
b. Those employed topically “Bacitracin”
2. Antibiotic mainly effective against gram-negative
bacteria:
a. Those mainly for systemic infection
i. Streptomycin ii. Colistin
iii. Gentamicin iv. Gentacin
36 b. Those used locally in intestine
i. Paromomycin
 3. Antibiotic effective against gram-negative and positive
bacteria:
a. Those employed for systemic infection
i. Ampicillin ii. Amoxicillin
iii. Cephalosporin iv. Rifamycin
b. Those employed topically:
i. Neomycin ii. Framycetin
4. Antibiotic effective against both gram-negative and
positive bacteria Rikettsiae and Chlamydia:
i. Tetracycline ii. Chloramphenical
5. Those effective against Acid-fast bacilli Mycobact-
erium tuberculosis

CHAPTER ONE: AN OVERVIEW

i. Streptomycin ii. Kanamycin
iii. Viomycin iv. Rifampicin
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v. Cycloserine
6. Antibiotic effective against Protozoa:
For Personal Use Only

i. Tetracycline ii. Paromomycin

iii. Fumagillin
7. Antibiotic effective against Fungi:
i. Nystatin
8. Antimalignancy antibiotic:
i. Actimycin ii. Mitomycin
iii. Bleomycin
Metronidazole (Metrogyl)
• Mainly effective against anaerobic protozoa (Ex- Blantidium
coli, T.vaginalis, E.histolytica), non-sporing anaerobic,
gram-negative bacilli (Bacteroides), Highly effective by
mouth and systemic Trichomonacide.

Classification of Analgesic/Antipyretic/Anti-inflammatory
1. Salicylates = Aspirin (Acetylsalicylic acid, sodium
salicylate)
37
2. Para-aminophenol derivatives = Paracetamol
3. Pyrazolone derivatives = Phenylbutazone
 4. Indole acetic acid derivatives = Indomethacin (Indocid)
5. Phenylacetic acid derivatives = Diclofenac sodium
(voveran)
6. Propionic acid derivatives = Ibuprofen
7. Fenamates = Mefanamic acid
8. Oxicams = Piroxicams (Dolonex)
9. Alpha arylacetic acid derivatives = Ketorolac
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Tromethazine “Ketanov”
Drugs Used as Muscles Relaxant: “Skeletal Muscles
Relaxation without Loss of Consciousness”
A. Drugs Acting Centrally
i. Diazepam (Benzodiazepines)
ii. Baclofen
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iii. Mephenesin
iv. Methocarbamol
For Personal Use Only

B. Drugs acting peripherally neuromuscular junction

i. Succinylcholine ii. D-Tubocurarine
C. Drugs acting directly on muscle
i. Dantrolene (Dantrium)
D. Drugs effective in Parkinsonism
i. “Levodopa”
Classification and Role of Corticosteroids
1. Short-acting
a. Cortisone b. Hydrocortisone
2. Intermediate acting
a. Prednisone b. Prednisolone
c. Methylprednisolone d. Triamcinolone
3. Long-acting
a. Dexamethasone b. Betamethasone
Role of Corticosteroid in Oral Surgery

38 1. As life-saving drugs (e.g. syncope, bradycardia): To

increase HR and BP
 2. Antiallergic
3. As anti-inflammatory drugs: To reduce postoperative
edema.
Different Extra- and Intraoral Radiographs Used on Oral
and Maxillofacial Region

Extraoral
1. Orthopantomograph (OPG)
2. Anteroposterior view (Town’s view)
3. Posteroanterior view
4. True lateral view of mandible with or without skull
(Left and Right)

CHAPTER ONE: AN OVERVIEW

5. Lateral oblique view of mandible with or without
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skull (Left and Right)

6. Paranasal (PNS): Water’s view
For Personal Use Only

7. Submentovertex (SMV) view: Jughandle view

8. View for TMJ
a. Transcranial view
b. Transorbital view
c. Transpharyngeal view
9. For salivary gland and their ductal system “Sialography”
Intraoral
1. Intraoral periapical view
2. Occlusal view
3. Bitewing view
Muscles of Mastication
1. Primary muscles = Masseter/Temporalis/Medial
pterygoid/Lateral pterygoid
2. Accessory muscle
a. Suprahyoid
i. Sternohyoid ii. Sternothyroid 39
iii. Thyrohyoid iv. Omohyoid
 b. Infrahyoid
i. Digastric ii. Mylohyoid
iii. Stylohyoid iv. Geniohyoid
3. Platysma muscle

Composition of White Head Varnish

i. Benzoin =10 part
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

ii. Iodoform = 10 part

iii. Storax = 7.5 part
iv. Balsam of Tolu = 5 Part
v. Ether (solvent) = 100 part
Indication: As antiseptic dressing, to check the bleeding
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Bone wax
i. Beeswax (yellow) = 7 part
For Personal Use Only

ii. Olive oil = 2 part

iii. Phenol = 1 part
Indication: To stop bleeding from hard bony surface
Carnoy’s solution
i. Alcohol = 6 ml
ii. Chloroform = 3 ml
iii. Glacial acetic acid = 1 ml
iv. Ferric chloride = 1 gm
Indication: As chemical cauterization (For example, OKC
and ameloblastoma.
Role of Drugs in Oral Surgery
1. Avil
a. Pharmacological name = Pheniramine maleate
b. Each ml of concentration = 22-75 mg/ml
c. Route of administration = IM/IV
40
d. Indication = Emergency drug, Antiallergic drug.
 2. Adrenaline
a. Pharmacological name = Adrenaline bitartrate
b. Each ml concentration = 1 mg/ml
c. Route of administration = SC/IM, intracardiac,
locally, inhalation, IV (rare).
d. Indication = Act as a vasoconstrictor in local
anesthesia. Act as a bronchodilator in asthma in
systemic administration. Act as a vasodilator in
systemic administration.
3. Atropine
a. Pharmacological name = Atropine sulfate
b. Each ml concentration = 0.5 mg/ml
c. Route of administration = IM/SC, orally, Ointment

CHAPTER ONE: AN OVERVIEW

d. Indication = Use as a premedication drug, As a
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antisialogue, prevents vasovagal attack

4. Dexamethasone (Dexona)
For Personal Use Only

a. Pharmacological name = Dexamethasone sodium

b. Each ml concentration = 4 mg/ml
c. Route of administration = IV/IM
d. Indication = Life-saving drug, in syncope, anti-
inflammatory drug-to reduce postoperative edema,
antiallergic drug.
5. Aminophylline
a. Pharmacological name = Aminophylline
b. Route of administration = IV very slowly with
dilution
c. Each ml concentration = 2.5 percent w/v
d. Indication = Antiasthmatic
6. Calmpose
a. Pharmacological name = Diazepam
b. Each ml concentration = 5 mg/ml
c. Route of administration = IV/IM
d. Indication = As a premedication drug, antianxiety
drug, as a muscle relaxant, antiepileptic anticon- 41
vulsive
 Role in Oral Surgery
1. Aromatic spirit ammonia: In case of syncope to
stimulate respiration by inhalation or by mouth with
equal dilution.
2. Normal saline: Replacement of fluid in case of dehy-
dration,loss of fluid from body, irrigation during
surgical procedure as cooling agent, dressing of wound.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

3. Hydrogen peroxide: Intraoral mouth wash, dressing

of wound in anaerobic infection.
4. Surgical spirit: As antiseptic and disinfectant,
extraoral preparation major and minor surgical
procedure and to sterilize instruments.
5. Carbolic acid: Use in periapical pathology as chemical
cauterization in poor accessible area. After application
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region should be cleaned with glycerine.

For Personal Use Only

Different Position of the Patient on the Dental Chair

1. Elevation (supine position)
2. Trendelenburg (Head down position)
3. Till table position (lateral position)
4. Table top turn position
5. Kidney surgery position
6. Neurosurgery position
7. Orthopedic position
8. Lithotomy position.

42
 CHAPTER

2 BASIC
BASII FACTS
BAS
ORAL
ORAL S
CTS
F CTS IN
I
SURGERY
SURGE
URGE
THE CRANIOCAUDAL SEQUENCE OF CRANIAL NERVES
S.No. Nerves Leaves Types
1. Olfactory Cribriform plate of ethmoid Special
bone sensory
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2. Optic Optic canal Special

sensory
For Personal Use Only

3. Oculomotor Superior orbital fissure Motor

4. Trochlear Superior orbital fissure Motor
5. Trigeminal
V1 Ophthalmic Superior orbital fissure Sensory
V2 Maxillary Foramen rotundum Sensory
V3 Mandibular Foramen ovale Mixed
6. Abducent Superior orbital fissure Motor
7. Facial Internal acoustic meatus Mixed
8. Auditory Internal acoustic meatus Sensory
9. Glossopharyngeal Jugular foramen Mixed
10. Vagus Jugular foramen Mixed
11. Accessory Jugular foramen Motor
12. Hypoglossal Hypoglossal canal Motor
13. Nervus intermedius Internal acoustic meatus Sensory

NERVE SUPPLY OF MAXILLARY/MANDIBULAR TEETH

Teeth Nerve
Maxi-CI, LI, canine — La = Anterior superior alveolar nerve
Pa = Nasopalatine nerve
Maxi-1st pm and 2nd pm— Ba = Middle superior alveolar nerve
Pa = Greater palatine nerve
Maxi-1st Molar — Ba = Middle superior alveolar nerve
(Mesiobuccal root of 1st maxillary
Contd..
 Contd...
molar) postsuperior alveolar nerve
(Distobuccal root of 1st maxillary molar)
Pa = Greater palatine nerve
Maxi-2nd and 3rd Molar — Ba = Posterior superior alveolar nerve
Pa = Greater palatine nerve
Mandi-ci, Li, Canine — La = Incisive nerve/Li = lingual nerve
Mandi-1st and 2nd pm — Inferior alveolar nerve/lingual nerve
Mandi -1st, 2nd and 3rd Molar — Inferior alveolar nerve/lingual nerve
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

and long buccal nerve

BRANCHES OF TRIGEMINAL NERVES

Three branches Types
V1 Ophthalmic nerve Sensory
V2 Maxillary nerve Sensory
V3 Mandibular nerve Mixed
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V1 Ophthalmic nerve
For Personal Use Only

1. Lacrimal nerve
2. Frontal nerve
a. Supraorbital nerve
b. Supratrochlear nerve
3. Nasociliary nerve
a. Branch arising in the orbit
b. Branch arising in the nasal cavity on the face

V2 Maxillary nerve
1. Branches within the cranium—Middle meningeal nerve
2. Branches within the pterygopalatine fossa
 Zygomatic nerve
– Zygomaticotemporal nerve
– Zygomaticofacial nerve
 Pterygopalatine nerve
– Orbital branches
– Nasal branches “nasopalatine nerve”
– Palatine branches
i. Greater (anterior) palatine nerve
ii. Lesser (middle and posterior) palatine nerve
– Pharyngeal branch
44  Posterior superior alveolar nerve

Contd..
 Contd..

3. Branches within the infraorbital canal

 Middle superior alveolar nerve
 Anterior superior alveolar nerve
4. Branches on the face
 Inferior palpebral branch
 External nasal branch
 Superior labial branch

V3 Mandibular nerve
1. Undivided nerve

CHAPTER TWO: BASIC FACTS IN ORAL SURGERY

 Nervous spinosus
 Nerve to medial pterygoid muscle (internal pterygoid muscle)
2. Divided nerve
 Anterior division  Posterior division
– Nerve to lateral pterygoid – Auriculotemporal nerve
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muscle
– Nerve to masseter muscle – Lingual nerve
For Personal Use Only

– Nerve to temporal muscle – Mylohyoid nerve

– Buccal nerve (long buccal nerve) – Inferior alveolar nerve
– Mental nerve
– Incisive nerve

BRANCHES OF FACIAL NERVE

1. Within the facial canal
i. Greater petrosal nerve
ii. Nerve to stapedius
iii. Chorda tympani
2. As it exit from the stylomastoid foramen
i. Posterior aurical nerve
ii. Digastrics, posterior belly
iii. Stylohyoid
3. Terminal branches within the parotid gland
i. Temporal nerve ii. Zygomatic nerve
iii. Buccal nerve iv. Marginal mandibularis
v. Cervical
4. Communicating branches with adjacent cranial and 45
spinal nerve
 DRUGS USED IN EMERGENCY (DENTAL)—OUTLINE
S.No. Drugs Emergency condition Dose
1. Aromatic spirit Syncope Inhalation/orally
of ammonia
2. Dexona Shock, anaphylaxis 4-20 mg/day I/V or I/M
(Dexamethasone)
3. Adrenaline1:1000 Anaphylactic shock, Lcc I/M 0.2 to 0.5 mg/
cardiac arrest C or I/M
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

4. Avil Allergic condition 20-50 mg orally or I/M

5. Sorbitrate angised Anginal pain 5 to10 mg sublingually
(nitroglycerine) 0.6 mg sublingually
6. Calmpose Anticonvulsant 0.2 to 0.5 mg/kg
7. Dopram Stimulates respiration 40-8 mg I/M or I/V
8. Atropin Vasovagal attack 0.6 mg I/M
9. Nifedipine Hypertension 10 mg Sl
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10. Dopamine Hypotensive shock 10 mg/Ml

11. Deriphyllin Bronchial asthma 2 cc I/M
12. Styptobion Bleeding 2-4 Ml I/M
For Personal Use Only

Adrenaline 1:1000 Local pack

13. Calcium gluconate Tetany 10% 10 cc I/V
14. Dextrose Hypoglycemic, coma 25% 10 cc I/V

COMPOSITION OF BLOOD
1. Cells
i. RBC (Erythrocytes) M = 4.6-5.2; F = 4.2-5.4
million/cumm
ii. WBC (Leukocytes) 5000 to 10,000/cumm
iii. Platelets (Thrombocytes) 150,000 to 400,000/cumm
2. Plasma = 35 to 50 cc plasma/kg body wt
i. Water 91 to 92 percent
ii. Solids 8 to 9 percent
a. Inorganic constituents 0.9 percent (Na, K, Ca,
Mg, P, Iron).
b. Organic constituents
– Protein 7.5 percent (serum albumin, serum
46 globulin, fibrinogen, prothrombin, etc.).
 – Nonprotein nitrogenous substance—urea,
uric acid, xanthine, hypoxanthine, creatine,
creatinine, ammonia, amino acid
– Fats
– Carbohydrates, glucose
– Other substance—Internal secretions,
antibodies. Enzymes-amylases, lipases,
phosphates, etc.
– Coloring matter—Yellow color of plasma is

CHAPTER TWO: BASIC FACTS IN ORAL SURGERY

due to bilirubin, carotene and xantho-
phylline.

BLOOD COAGULATION FACTORS

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S. No Clotting Synonyms
1. Factor-i Fibrinogen
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2. Factor-ii Prothrombin
3. Factor-iii Tissue thromboplastin
4. Factor-iv Calcium
5. Factor-v Proaccelerin, labile factor
6. Factor-vi Accelerin
7. Factor-vii Serum prothrombin, stable factor antihemo-
philic factor
8. Factor-viii Antihemophilic factor, Antihemophilic globulin,
Antihemophilic factor-a
9. Factor-ix Plasma thromboplastin component; christmas
factor, antihemophilic factor-b
10. Factor-x Stuart factor
11. Factor-xi Antihemophilic factor-c
12. Factor-xii Hageman factor
13. Factor-xiii Fibrin stabilizing factor
14. Prekallikrein Fletcher factor
15. High Molecular Fitzgerald factor weight kininogen
16. Platelets

47
 THE NORMAL ORAL FLORA

Regularly Present
Numerous In lesser number
Alpha-streptococci, coryne Gamma-streptococci
Bacteria, bacterinoma Beta-streptococci
Fusobacter, spirochetes Peptostreptococci, lactobacilli
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Veillonellas, anaerobic Micrococci, bacteroides, yeasts

Vibrios Actinomyces, norcoides
Pleuropneumonia like organisms

Often Present
In variable numbers Neisserias staphylococci
Probably transient Pneumococco coliforms haemophilus
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species, aerobic sport forming bacilli

For Personal Use Only

Occasionally Present
Mycobacteria, closteridia, Proteus and Pseudomonas species

48
 CHAPTER

3 BASIC
B S C PRINCIPLES
OFF O
PR
PR N I LES
ORAL
LES
AL SURGERY
SURG
SURG Y
DEFINITION OF ORAL SURGERY
Oral surgery is a branch of dentistry that deals with the
art of diagnosis and treatment of various diseases, injuries
and defects involving orofacial region.
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STERILIZATION
For Personal Use Only

Can be defined as the use of physical or chemical procedures

to destroy all forms of microorganisms including bacteria,
spores, fungi and viruses.

Various Methods of Sterilization

1. Physical methods
2. Chemical methods

Physical Methods
1. Heat sterilization:
a. Moist heat sterilization
i. Pressure steam sterilization (autoclave)
ii. Boiling water (100º C for 10 min)
iii. Oil (175º C for 15 min).
b. Dry heat sterilization (160º C for two hours)
2. Gas sterilization—Ethylene oxide gas
3. Irradiation:
a. Ionizing radiations (X-rays, gamma rays)
b. Nonionizing radiations (UV light).
 Chemical Methods
1. Cold or chemical sterilization (chemical disinfection)
for example, Cidex – 2 percent activated glutaraldehyde.
2. Chemical vapor sterilization (formaldehyde, alcohol).
Autoclaving
Key Points
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

1. It is the most effective and practical method in

form of saturated steam under pressure.
2. Autoclave—A airtight chamber includes a
pressure gauze and one or more vacuum pump.
Based on pressure cooker principle (steam
under pressure).
3. Normal cycle—121 degrees for 15 min, 15 pounds
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pressure.
4. Flash cycle—134 degrees for 3 min, 30 pounds
For Personal Use Only

pressure.

Disadvantages
1. It produces corrosion on very delicate instruments.
2. Unsuitable for greases, oils and powder.
• To avoid or minimize corrosive action on metal
recommends the addition of “ammonia or dicyclo-
hexylammonium nitrate or 2 percent sodium nitrate”.
Advantages
1. Known for destruction of all forms of microbial life.
2. Temperature is accurately controlled.
3. Heating and penetration is rapid.
4. Shortest sterilizing time.
5. Most economical.
• Used for rubber and plastic goods—gloves, cannulas,
syringe, needle, stainless steel instruments (except
50
sharp and cutting instruments).
 PRINCIPLES OF SKIN INCISION AND LANGER’S LINE
1. The incision can placed in a hidden area such as
within the hair line or in the shadow of the lower
border of mandible.
2. Incision can follow Langer’s line incision placed parallel
to these lines.
3. Incision should not be placed in a direction of muscles.
4. For skin incision—The best place in a skin crease.

CHAPTER THREE: BASIC PRINCIPLES OF ORAL SURGERY

(where there is a local excess of skin).
5. The wound should be closed carefully. Langer’s line—
It tend to run parallel with skin creases, which
generally are perpendicular to the action of the
underlying muscle.
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PRINCIPLES OF FLAP DESIGN

1. Incision must be clearcut and continuous.
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2. Flap must be designed to provide an adequate

exposure of the surgical area.
3. Flap must have a broad base and good vascular
supply.
4. Full thickness of tissue must be retracted.
5. Ultimately flap should rest on solid (healthy) bone
after surgery.

SUTURE MATERIAL
Purpose of suturing: The primary purpose for suturing is
to simply retain tissue layers and wound edges in passive
approximation.

Ideal Requisites of Suture Material

• Adequate strength
• Good knot holding and knot tying property
• Sterilizable
51
• Evoke little tissue reaction.
 Classification of Suture Material
1. Absorbable suture material
i. Catgut—plain catgut, chromic catgut
ii. Collagen
iii. Polyglycolic acid
iv. Polyglactin 910.
2. Nonabsorbable suture material
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

i. Silk ii. Nylon

iii. Cotton iv. Linen
v. Metal vi. Dacron polyester
vii. Polypropylene viii. Polyethylene
ix. Teflon coated dacron x. Silicon coated dacron
polyester polyester
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xi. Stainless steel xii. Tantalum.

For Personal Use Only

Different Suturing Technique

1. Interrupted suturing.
2. Continuous suture.
3. Continuous locked suture (blanket suture).
4. Vertical mattress suture.
5. Horizontal mattress suture.
6. Subcuticular suture.
7. Figure of eight suture.

Different Knot
1. Square knot or basic knot.
2. Surgeon’s knot.
3. Granny knot.

Suture Needle—“Key Point”

1. Suture needles are made up of either stainless steel
52
or carbon steel.
 2. Various types:
i. Straight needle ii. Curved needle (1/4, 3/8,
1/2, 3/4 circle)
iii. Round body needle iv. Cutting body needle
v. Reverse cutting vi. Traumatic needle
needle (needle having an eye).
vii. Atraumatic needle
(eyeless needle).

CHAPTER THREE: BASIC PRINCIPLES OF ORAL SURGERY

PRINCIPLES OF SUTURING
1. The needle should be grasped at approximately 1/3rd
from the distance from the eye and 2/3rd from the
point.
2. The needle should enter the tissues perpendicular to
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the tissue surface.

3. The needle should be passed through the tissues along
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its curve.
4. The suture should be grasped at an equal depth and
distance from the incision on both sides.
5. The needle always passes from the movable tissue to
the fixed tissue.
6. The needle always passes through the thinner tissue
to the thicker tissue.
7. The needle always passes from the deeper tissues to
the superficial tissue.
8. Tissues must never be closed under tension.
9. The knot should never lie on the incision line.
10. Suture should be placed at a greater depth than the
distance from the incision.
11. Dog ear suturing should be avoided.
12. Suture should be tied only for approximating tissue,
tissue not to be blanched.
13. Generally, intraorally needle should be passed in
anterior region labial to lingually or palatally and in 53
posterior region from buccally to lingually or palatally.
 14. Generally, intraorally knot should be placed on
labially or buccally.

BASIC PRINCIPLES OF INCISION AND DRAINAGE

1. Incision in healthy skin and mucosa.
2. Incision placed at the site of maximum fluctuance.
3. Place the incision in an esthetically acceptable area.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

4. When possible place the incision in a dependent

position to encourage drainage.
5. Dissect bluntly and explore all portions of the abscess
cavity thoroughly.
6. Extend the dissection to the root of the tooth
responsible for the infection.
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7. Place the drain and estabilize.

8. Use of through and through drain in bilateral
For Personal Use Only

submandibular space infection.

9. Do not leave drain in place for an overly extended
period.
10. Clean wound margin daily.

PRINCIPLES OF ANTIBIOTIC THERAPY

1. Antibiotic therapy is no substitute for surgery.
2. The antibiotic used should be appropriate to the
anticipated organism.
3. Where possible sample should be examined for the
infective organism. Pus/saliva/blood/urine exam-
ination.
4. As host defence mechanism—Bactericidal drugs are
not always essential.
5. Antibiotic should not be used as diagnostic agent in
the management of clinical problem.
54 6. Antibiotic should not be used blindly.
 7. Bacterial resistance may result from inadequate
antibiotic therapy.
8. Apart from right choice of drugs the appropriate
dosages mode and frequency of administrations are
important.
9. Two or more antibiotic should not be used simultan-
eously.
10. Patient is hypersensitive to drugs, alternative

CHAPTER THREE: BASIC PRINCIPLES OF ORAL SURGERY

antibiotic must be used.

DIFFERENT COMMON PATHOLOGICAL TESTS

1. AIDS (Acquired immunodeficiency syndrome)
a. ELISA Test (Enzyme linked immunosorbent assay):
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For HIV (human immunodeficiency virus) one and

two antibodies. If it is negative, AIDS is negative.
For Personal Use Only

If it is positive, next confirmation.

b. Western Blot test done.
c. Immunofluorescent test.
2. Hepatitis B—Australian antigen (HBsAg).
3. Syphilis—VDRL, TPI PTA, Kohn’s, Wassermann test.
4. Tuberculosis—Mantoux test.
5. Diphtheria—Schick test, Elek’s test.
6. Enteric fever—Widal test.
7. Herpes simplex, pemphigus—Tzanck test.
8. Infectious mononucleosis—Paul Bunnell test and
monospot test.
9. Acute rheumatic fever—ASO test (Antistreptolysin– O).
10. Salivary gland infection test (Sjögren’s syndrome)
a. Parotid flow test
b. Salivary gland biopsy
c. Salivary scintigraphy
d. Sialography. 55
 Vaccines
1. Hepatitis B—Engerix B (0-1-6 month interval, booster
dose every 10 years).
2. Tetanus—Tetanus toxoid, ATS, ATG.

STANDARD PATHOLOGICAL VALUES

RBC M = 4.6-5.2, F = 4.2-5.4 million/cumm
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Hemoglobin M = 14-18/100 ml, F = 12-16 gm/100 ml

WBC Total count-5000-10000/cumm
Neutrophils 54-62% (avg-4000)
Eosinophils 1-3% (avg-200)
Basophils 0.075% (avg-25)
Lymphocytes 25-33% (avg-2100)
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Monocytes 3-7 (avg-375)

Platelets 150,000-400,000/cumm
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Bleeding time 2-5 min (Duke’s method)

Clotting time 1-7 min (capillary tube)
Prothrombin time 11-16 sec (quick)

BIOCHEMICAL PROFILE WITH NORMAL VALUE

Whole blood volume 4.5 to 5 liter normal
Plasma 35 to 50 cc plasma/kg body wt
Blood: glucose fasting 70-100 m gm%
Postprandial/tandum 100-140 m gm%
Urea 20-40 m gm%
Serum protein 6-8 gm%
Serum a bumin 3.2-4.1 gm%
Serum globulin 2.5-3.5 gm%
Serum creatinine 0.5-1.3 m gm%
Serum bilirubin 0.2-1.0 m gm%
Serum cholesterol 120-260 mg/dl
• Normal blood pressure—120/80 mm Hg
• Normal pulse rate—72-80/min
• Normal respiratory rate—14-18/min
56
• Normal body temperature—98.4º F.
 CHAPTER

4 BASIC
BASI
B ASI STUDY
ORAL
S DY IIN
SURGERY
SURGE
ORAL S URGE
N

BONES OF SKULL
The skull consists of the 22 bones.
1. The calvaria or brain case is composed of 8 bones.
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Paired Unpaired
Parietal Frontal, occipital
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Temporal Sphenoid, ethmoid

2. The facial skeleton is composed of 14 bones.
Paired Unpaired
Maxilla, zygomatic Mandible
Nasal, lacrimal Vomer
Palatine, inferior nasal
Concha

MUSCLES OF MASTICATION
1. Primary Muscles:
i. Masseter ii. Temporalis
iii. Lateral pterygoid iv. Medial pterygoid
2. Accessory Muscles:
Suprahyoid Infrahyoid
Sternohyoid Digastric
Sternothyroid Mylohyoid
Thyrohyoid Stylohyoid
Omohyoid Geniohyoid
3. Platysma
 MUSCLES OF FACIAL EXPRESSION
a. They are subcutaneous
b. They develop from the mesoderm of the 2nd branchial
arch
c. They are supplied by the facial nerve
d. All of them are inserted into the skin.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

The Muscles are Grouped Under Six Headings

1. Muscles of the scalp: Occipitofrontalis.
2. Muscles of the auricle (situated around the ear):
a. Auricularis anterior.
b. Auricularis superior.
c. Auricularis posterior.
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3. Muscles of the eyelids:

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a. Orbicularis oculi.
b. Corrugator supercilii.
c. Levator palpebrae supercilii. (an extraocular muscle
supplied by oculomotor nerve).
4. Muscles of the nose:
a. Procerus
b. Compressor naris
c. Dilator naris, depressor septi
5. Muscles around the mouth:
a. Orbicularis oris.
b. Levator labii superioris alaeque nasi.
c. Zygomaticus major.
d. Zygomaticus minor.
e. Levator labii superioris.
f. Levator anguli oris.
g. Depressor anguli oris.
58 h. Depressor labii inferioris.
i. Mentalis.
 j. Risorius.
k. Buccinator.
6. Muscle of neck: Platysma

COMMON FACIAL EXPRESSION PRODUCED BY MUSCLES

1. Smiling and laughing—Zygomaticus major.
2. Sadness—Levator labii superioris, levator angulioris.
3. Grief—Depressor anguli oris.
4. Anger—Dilator naris and depressor septi.

CHAPTER FOUR: BASIC STUDY IN ORAL SURGERY

5. Frowning—Corrugator supercilii, procerus.
6. Horror, terror, fright: Platysma.
7. Surprize— Frontalis.
8. Doubt—Mentalis.
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9. Grinning—Risorius.
10. Contempt—Zygomaticus minor.
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11. Closing the mouth—Orbicularis oris.

12. Whistling—Buccinator, orbicularis oris.

DESCRIPTION OF AN INSTRUMENT
1. Name of the instrument.
2. Made up of the instrument.
3. Parts of the instrument.
4. Indications of the instrument.

READING AN X-RAY
An X-ray is described in the following way:
1. Name of the X-ray. Example: The name of the X-ray
is orthopantomograph.
2. Whether the X-ray is extraoral or intraoral. Example:
OPG is extraoral radiograph.
3. Abnormality seen in the X-ray. Example: In case of
fracture, radiographically fracture is defined as 59
radiolucent irregular margin on the bony surface.
 4. Discussion related to abnormality. Example, Fracture
(definition, type, classification, clinical features,
radiographic complications, etc.).

DESCRIPTION OF DRUG
1. Pharmacological name of the drug. Example: Avil
(pheniramine maleate).
2. Each ML concentration = 22.75 mg/ml.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

3. Route of administration = I/M and I/V.

4. Indication—As emergency drug or antiallergic drug.
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For Personal Use Only

60
 CHAPTER

5 BASIC
IIC
ORAL
CR
ORAL S
READING
I G IN
SURGERY
SURGE
URGE
I

SHOCK

Introduction
Shock is a complex clinical state which demands
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immediate care to avoid fatal outcome. Delay in treatment

leads to permanent cellular and organ damage leads to
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irreversible shock and death.

Definition
It can be defined as, “An acute, generalized, inadequate
perfusion of critical organs, that if continued will produce
serious pathophysiological consequences. Hemodynamic,
endocrine and metabolic alterations result and produce
the clinical signs of shock”.
Shock can be defined as “Failure of circulatory system
to deliver the chemical substances necessary for cellular
survival and remove the waste products of cellular
metabolism”.
Classification
On the Clinical Basis
1. Hypovolemic shock or oligemic shock
2. Cardiogenic shock
3. Obstructive shock
4. Distributive shock
 On the Basis of Pathophysiology Mechanism
1. Non-progressive shock
2. Progressive shock
3. Irreversible shock

Different Types
1. Vasovagal shock
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Neurogenic shock
3. Psychogenic shock
4. Hemorrhagic shock
5. Burn shock
6. Endotoxin shock
7. Bacteremic shock
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8. Histamine shock
9. Anaphylactic shock
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10. Shock due to dehydration/diarrhea/vomiting

11. Pleural, peritoneal, mediastinal and retroperitoneal
shock.

Clinical Features
1. Restlessness
2. Rapid thready pulse
3. Cool pale skin
4. Poor capillary fill
5. Low blood pressure
6. Thirst
7. Increased respiratory rate and depth
8. Nausea
9. Dyspnea with cardiopulmonary etiology
10. Vomiting
11. Hyperventilation
62 12. Decreased urinary output
13. Coma in later stage
 Hypovolemic Shock

Definition
Reduction in the amount of fluid pumped through the
vascular bed.

Causes
1. Hemorrhagic shock—Due to loss of intravascular
fluid.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

2. Non-hemorrhagic shock—Burn, vomiting, diarrhea,
crush injuries, surgical wound, ascites, pleural effusion,
peritonitis.
In hemorrhagic shock—Loss of blood may be:
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a. As external source—laceration
b. Internal source-ulcer, rupture of internal organ
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like liver, spleen, etc.

Principles of Management
1. Patient position—Trendelenburg position means “15
degree head down position”.
2. Assure oxygen exchange—100 percent oxygenation
also help to maintain body metabolism and body heat.
3. Ensure hemostasis—By pressure or direct ligation of
injured vessels.
4. Maintain body hear—Patient is covered with blankets
to maintain the body heat.
5. Restoration of vascular volume and extracellular fluid
volume:
a. One or two liters of Ringer’s lactate.
b. Fresh whole blood or components blood therapy.
c. Volume replacement with help of:
i. Colloidal plasma substitute, e.g. dextran.
ii. Crystalloid plasma substitute-normal saline, 63
chloride 0.9 percent, dextrose solution
 5 percent. Colloidal are superior to crystalloid
in maintaining blood in minimizing the shock
level.
6. To correct acid-base balance:
a. Metabolic acidosis—Hypovolemic shock usually
associated with metabolic acidosis. As tissue
hypoxia, increases the production of lactic acid.
Inj Sodium bicarbonate. I/V1 Amp (dose can be
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

repeated).
b. Metabolic alkalosis—Due to hypokalemia potassium
chloride (10-20 mg/hr). If alkalosis persists, Tab
Diamox (acetazolamide) 0.25 gm. Diamox reduce
the hydration of CO2.
7. Relief of symptoms, e.g. wound care, pain, anxiety. If
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no head injury and respiratory distress, small dose of

Inj Morphine (2.5 mg I/V, I/M 10 mg) or Inj Pethidine
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I/V 100 mg.

8. Drug therapy:
a. Inj vasopressor (mephentermine) increases BP.
b. Antibiotic—Broadspectrum I/V.
c. Steroids—Controversy still exists.
d. Inj Atropine sulfate—0.65 mg diluted in 5 ml of
distilled water, then 0.5 ml given slowly I/V.
Another 0.5 ml is repeated if radial pulse is not
clearly palpable.
e. Role of vasoconstrictors—Used with caution in case
of hemorrhage. Inj. Adrenaline (1:1000)—dilute in
10 ml distill water. Then 0.5 ml of this solution is
given very slowly followed by 1 drop/minute till a
good thrust is felt for radial pulse.
9. Monitoring the vital signs:
a. BP should remain stable.
b. Renal flow should be greater than 20 ml/hr
64 (preferably greater than 30 ml/hr otherwise chances
of early renal failure).
 10. Maintenance of sufficient PO2.
11. Maintenance of central venous pressure
12. Hematocrit—To estimate total original blood loss or
monitoring ongoing loss.

SYNCOPE

Synonym
Blackout/vasovagal syncope/fainting/vasopressor

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

syncope.

Introduction
Literally meaning-pause/ceasation/cutting short. Syncope
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is the most common untoward reaction seen in the dental

clinic.
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Definition
Syncope refers to the sudden, transient loss of consciousness,
usually secondary to cerebral ischemia with a resulting
fall to the ground if the person is unsupported.

Presyncope (Near Syncope/Faintness)

Referred to by the patient as “Feeling Faint”.

Etiology
Fear, pain, prolonged standing, lack of sleep, high humid
temperature, long hours of work, overheated poorly
ventilated room, blood loss, sharp blows, abrupt change
in posture.

Drugs may Cause Syncope

65
Antihypertensive, overdosage of insulin, diuretics,
procaine.
 Classification
Three broad groups depending on their cause:
a. Episodes occurring secondary to a decrease in the quantity
of blood reaching to brain.
b. Episodes arising from a change in the quality of blood
to the brain.
c. Episodes that occur secondary to disturbance within
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

the brain structure.

Types
• Vasovagal syncope
• Postural syncope
• Carotid sinus syncope
• Deglutition syncope
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• Cough syncope
• Effort syncope.
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Causes
• Severe fall in blood pressure
• Failure of cardiac output
• Depletion of circulating blood volume
• Orthostatic hypotension
• Prolonged coughing.

Clinical Features
• Patient feels and complains of black in front of eye or
darkness.
• Dizziness
• Weakness
• Nausea
• Cold, pale and sweating from skin.
Signs
• Restlessness
66
• Cold extremities
 • Low BP, slow thread pulse
• Shallow respiration.
Prevention
1. Proper history and examination of patient.
2. Check for contributing stimulate. For example,
malnutrition, emotional stress, hemorrhage, etc.
3. Past drug history. For example, antihypertensive drug,
etc.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

4. Patient should be adequately rested.
5. Patient should be placed in supine position with
comfortable head rest.
6. Relieve pain/fear/anxiety.
7. Vital signs of patient should be constantly monitored.
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Management
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1. Terminate all dental procedure.

2. Patient position on dental chair—Trendelenburg
(15º head down) position.
3. Tight clothes should be loosened.
4. Maintain patent airway.
5. Monitor BP and pulse.
6. Elevation of the feet straight up from a supine
position and rapidly help to restore adequate cerebral
circulation and oxygenation.
7. Foreign objects should be removed from the mouth.
8. Inhalation of aromatic spirit of ammonia to stimulate
respiration.
9. If there is any indication that patient is likely to
vomit, he should be turned laterally.
10. If patient is conscious, should instruct to take deep
breaths.
11. 100 percent oxygen should be administered.
12. If syncope is due to loss of blood—I/V dextrose 67
5 percent.
 13. If vital signs remains low and if there is bradycardia—
Inj atropine 0.4 mg IV.
14. Vasopressor—If hypotension persists, e.g. methoxime
HCL (vasoxyl) I/V 5 mg.

Complications
• Respiratory arrest
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Cardiac arrest.

ALLERGY (ANAPHYLACTIC REACTION)

Definition
Allergy is a hypersensitive state acquired through exposure
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to a particular allergen, re-exposure to which produces a

heightened capacity to react.
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Predisposing Factor
Hypersensitivity to ester type LA, e.g. procaine,
benzocaine.

Allergic Manifestation
Allergic manifestation of LA solution include:
• Allergic dermatitis
• Asthmatic attack
• Systemic anaphylaxis.
Prevention
• Medical history
• Medical consultation.
Clinical Complications (Clinical Features)
• Dermatologic reaction
68
• Respiratory reaction
 • Generalized anaphylaxis:
– Skin reaction
– Smooth muscle spasm
– Respiratory system
– Cardiovascular system
Dermatologic Reaction
i. Urticaria—Associated with wheals.
ii. Angioedema—Involves face, hands, feet, lip, tongue,

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

pharynx, larynx.
Respiratory Reaction
i. Bronchial asthma—Classic respiratory allergic
response. Effect of lower airway.
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Signs and Symptoms:

• Respiratory distress
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• Tachycardia
• Dyspnea
• Increased anxiety
• Wheezing
• Use of accessory muscles of respiration
• Flushing
• Perspiration
• Possible cyanosis.
ii. Laryngeal edema—Effect of allergy on the upper airway.
No exchange of air from lungs is possible.
Generalized Anaphylaxis (Anaphylactoid Reaction)
Most dramatic and acutely life-threatening. Can develop
within 5 to 30 minutes.

Signs and Symptoms

1. Skin reaction.
2. Smooth muscle spasm of the GIT and GUT and respiratory 69
smooth muscle.
 3. Respiratory distress.
4. Cardiovascular collapse.
1. Skin reaction
a. Early phase—Skin reaction
• Patient complains of a feeling of being sick
• Intense itching
• Flushing
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Urticaria—Over face and upper chest

• Nausea and vomiting
• Conjunctivitis
• Vasomotor rhinitis—inflammation of mucous
membrane of nose
• Pilomotor erection—feeling of hair standing on
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end.
2. GIT and GUT Disturbance Related to Smooth Muscle
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Spasm
• Severe abdominal cramps
• Nausea and vomiting
• Diarrhea.
3. Respiratory Symptoms
• Feeling of substernal tightness or pain in chest
• Cough may develop
• Wheezing
• Dyspnea
• In case of severe condition—cyanosis of mucous
membrane and nail beds
• Possible laryngeal edema.
4. Cardiovascular System
• Pallor
• Cardiac arrhythmias
• Palpitation
• Unconsciousness
70
• Tachycardia
• Cardiac arrest
 • Hypotension
• With prompt and appropriate therapy the entire
reaction may be terminated rapidly
• Hypotension and laryngeal edema can persist for
hours to days.
• Death may occur at any time, usually caused by an
upper airway obstruction produced by laryngeal
edema.
Management

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Skin Reaction
1. Delayed Skin Reaction—develop 60 min or more
Step i = I/M (antihistamine) diphenhydramine HCL
and Cap. diphenhydramine, 6 hourly/
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3 to 4 days.
Step ii = Medical consultation.
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2. Immediate Skin Reaction—within 60 min.

Step i = I/M epinephrine (adrenaline 1:1000) 0.3 ml
Step ii = I/M (antihistamine) diphenhydramine 50 mg
Step iii = Medical consultation
Step iv = Observe patient for 60 min for evidence of
recurrence
Step v = Cap diphenhydramine (benadryl) 6 hourly
Step vi = Fully evaluate reaction
Respiratory Reaction
1. Bronchial Asthma
Step i = Terminate dental therapy
Step ii = Semierect patient position
Step iii = Administer oxygen via full face mask
Step iv = I/M epinephrine (1:1000) 0.3 ml
Step v = Observe patient for 60 min prior to discharge.
71
If relapse occurs, I/M epinephrine (1:1000)
adrenaline 0.3 ml
 Step vi = I/M diphenhydramine 50 mg (to minimize
relapse)
Step vii = Medical consultation
Step viii = Cap benadryl (diphenhydramine) 6 hourly
2. Laryngeal Edema
Step i = Patient position, in supine position
Step ii = I/M or I/V epinephrine (1:1000 adrenaline)
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

0.3 ml
Step iii = Airway maintenance
Step iv = Administration of oxygen
Step v = I/M diphenhydramine HCL (antihistamine)
50 mg
Step vi = I/M hydrocortisone sodium succinate
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100 mg to reduce edema

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Step vii = Cricothyrotomy—in case of emergency, to

maintain airway.
Generalized Anaphylaxis—in case of unconsciousness
Step i = Patient in supine position
Step ii = Basic life support
A = Airway
B = Breathing
C = Circulation
D = Drugs
Step iii = I/M or I/V epinephrine (1:1000 adrenaline)
0.3 ml
Step iv = Medical consultation
Step v = Monitor vital signs
Step vi = Additional drug therapy (improves BP
increases, bronchospasm). For example,
I/M or I/V (antihistamine) diphenhydramine
50 mg, I/M or I/V corticosteroid 100 mg.
72
 HEMORRHAGE

Introduction
Most common complication of disease in oral cavity and
vital concern to every dental practitioner.
Definition
Hemorrhage is the escape of blood from the vascular
system.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Classification
Three main categories:
Arterial Hemorrhage
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1. Will be bright red in color

2. Distinguished by its pulsating character
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3. Vigor of the flow.

Venous Hemorrhage
1. Will be dark red in color
2. May not have the pulsating quality
3. The flow will be less rapid.
Capillary Hemorrhage
1. An intermediate red in color
2. Nonpulsating in character
3. Capillary blood will be oozing
4. Capillary bleeding may be quite aggressive in O and
MF region as a result of the strong arterial pulse on
one side of the capillaries.
Types of Hemorrhage
1. Primary hemorrhage
2. Reactionary (intermediate) hemorrhage
73
 3. Secondary hemorrhage
4. External hemorrhage
5. Internal hemorrhage
6. Petechial hemorrhage
7. Ecchymosis
8. Hematoma
Causes of Hemorrhage
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Divided into four different categories:

Hemorrhage due to Local Cause

a. Infection—e.g. primary herpes simplex
b. Local irritants—e.g. malposed tooth, calculus.
c. Postsurgical or post-traumatic
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d. Cheek biting.
e. Congenital malformation.
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Hemorrhage due to Clotting Factors

a. Deficiencies
i. Hereditary—Hemophilia A, hemophilia B
ii. Anticoagulant therapy
iii. Liver disease
iv. Factors II, VII, IX, X deficiencies
b. Dysfunction—multiple myeloma.

Hemorrhage due to Platelets

a. Deficiencies
• Idiopathic thrombocytopenic purpura
• Secondary thrombocytopenic purpura
• Leukemia
• Aplastic anemia.
b. Excess thrombocytosis
74
c. Dysfunction—thrombocytopathia
 Hemorrhage due to Systemic Disease
a. Viral infection
b. Scurvy
c. Allergy
Clinical Features of Acute Blood Loss
1. Increasing pallor
2. Increasing pulse rate
3. Restlessness

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

4. Air hunger (deep respiration)
5. Cold clammy skin
6. Empty veins, thirst
7. Tinnitus
8. Blindness
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9. BP—It must be remembered that falling of BP is nor

a sign of acute blood loss. A normal or slightly raised
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BP can be recorded. Reliance on the reading can lead

to a false sense of security. Collapse and death can
occur suddenly.
10. Urinary output—Can be reduced in case of acute blood
loss.
11. Hemoglobin level—Not immediately changed but may
fall after some hours.
Management of Hemorrhage during the Operation
1. Planning of the incision to avoid large blood vessels.
2. Securing the blood vessels with hemostat.
3. Hemostasis through the application of pressure with
swabs.
4. The use of hemostatic agents.
5. Hypotensive anesthesia.
6. Use of vasoconstrictor.

Control of Bleeding in Case of Tooth Extraction

75
“Exodontia”— Primary Hemorrhage
 Five Basic Steps
1. To compress the bleeding socket with finger pressure.
2. To pack the bleeding socket with wet gauze piece “pressure
pack”.
3. Pack the bleeding socket with the help of local hemostat,
e.g. Adrenaline (1:1000) pack in case of normal patient.
In case of cardiac status patient: pack with hemolock
or sepguard or revicee.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

4. Suturing the socket.

5. Use of systemic hemostatic INJ/Tab/Vit/K, chromostate,
streptobion, etc.

Control of Secondary Hemorrhage

1. If bleeding from sutured area—remove the suture,
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clean the area, remove any foreign body from socket.

2. If bleeding from bony surface—use Bonewax.
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3. If bleeding is generalized from alveolar/soft tissue—

packing the socket with gelatin sponge gauze and again
suture little under pressure with pressure pack.
4. If patient is dehydrated—I/V DNS 5 percent.
5. Evaluate systemic condition if bleeding still continues.

HEMOPHILIA

Synonym
The disease of Kings/the disease of Hapsburgs/the
Bleeder’s disease.
Definition
Hemophilia is a congenital hereditary disorder of clotting
mechanism. It is characterized by a prolonged coagulation
time and hemorrhagic tendencies but bleeding time
normal.
Hemophilia is a sex linked anomally transmitted
76
by female to male in which female do not suffer, while
 males are affected. Female acts as carrier, transmits the
50 percent to their sons.
Types of Hemophilia
Type Deficient factor
Hemophilia A (true hemophilia) Antihemophilic globulin (factor VIII
AHG)
Hemophilia B (christmas disease) Plasma thromboplastin components
(factor IX)
Hemophilia C Factor XI, plasma thromboplastin

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

antecedent

Hemophilia—A

Synonym
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True hemophilia/classic hemophilia.

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Definition
A deficiency of AHG (factor VIII) in plasma, results in the
occurrence of hemophilia A.

Clinical Features
1. Characteristic feature of bleeding—stop immediately
after injury.
2. Persistent intracapillary oozing or start rapid blood
loss. Even after tooth extraction.
3. Bleeding into large joint.
4. Hemorrhage into the subcutaneous tissue/organ/
joint.
5. Intra-abdominal hemorrhage.
6. Intracranial bleeding.
7. Bleeding in muscle.
77
8. Bleeding in bladder.
 9. Recurrent bleeding into the joint “Hemarthrosis”.
10. Oral manifestations—gingival hemorrhage—massive
prolonged, mandibular pseudotumor of hemophilus.

Lab Findings
1. Increase clotting time.
2. Prothrombin increased.
3. Platelets aggregation.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

4. Bleeding time normal.

5. Thrombin clotting time normal.
6. Activated partial/thromboplastin time normal.
7. Deficiency of clot promoting factor.

Extraction in Hemophilic Patient

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1. Anesthesia
• Local anesthesia is preferable.
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• Periodontal membrane—ligamentary injection.

• Mandibular block is contraindicated.
• GA is not preferable—may cause bleeding in back
of throat and glottis region.
2. Use of local hemostatic agent—oxidized cellulose with
mechanical device to protect the clot.
3. Use of mechanical splints—splint should be used
without applying under pressure.
4. Use of suture is controversial. On one hand, it may
protect the clot, smallest in size and minimum in
number. On the other hand, it should not be sutured,
needle can cause wound to bleed, blood can go into
facial plane of the neck. If not sutured blood can flow
into the mouth, can be seen and treated.
5. Postoperative instructions and medications:
i. Absolute bedrest.
ii. Nursed in sitting position
78
iii. To prevent breakdown of clot—immobilize the
mandible.
 iv. Liquid diet.
v. Minimum talking and avoid drinking.
vi. Patient should be sedated.
vii. Tab aspirin absolutely contraindicated.
viii. Additional booster dose of Factor VIII use of factor
VIII replacement:
a. Fresh plasma
b. Fresh whole blood and plasma.
c. Cryoprecipitate prepared from human plasma.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

ix. Drugs used as systemic administration in hemophilic
patient:
a. Epsilon aminocaproic acid (EACA)—“AMIKAR”
an antifibrinolytic substance—to increase the
stability of clot.
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b. Tranexamic acid-cyklokapron—to reduce

plasminogen activity. Tab 0.5 gm, 3 times/day
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c. Desmopressin (DDAVP)—I/V 0.3 microgram/kg.

AIDS (ACQUIRED IMMUNODEFICIENCY SYNDROME)

Introduction
AIDS was first recognized as a new serious medical
problem in USA at the end of 1980.

Explanation
• It affects heterosexual individual.
• This syndrome caused by a retrovirus—human
immunodeficiency virus HIV—type I and type II.
• Homosexual and bisexual men form the largest group
of patient’s with IV drugs addicts next in frequency.
• Recipients of multiple blood transfusion or infusion of
blood products are at a higher risk.
Mechanism
• Depletion of T-helper cells
79
• Also show profound B-cell dysfunction
 Clinical Complications
• AIDS patient’s are subjected to many life-threatening
infection
• It is possible that soon recover completely
• Some develop the persistent generalized lymphadeno-
pathy (PGL) syndrome.
Patient later suffer from:
– Low degree of malaise, night sweats
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

– Weight loss
– Hepatomegaly
– Symmetrical enlargement of group of lymphnode,
some develop lymphomas
– Pneumocystic carinii pneumonia (PCP)
– Non-productive cough, shortness of breadth
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– Fever, then becomes markedly hypoxic and die

unless treatment given.
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Diagnosis
• Not simple, requires bronchial lavage
• Transbronchial biopsy
• Multiflagella protozoa is seen in stained specimens.

Treatment
IV high doses of cotrimoxazole for three weeks.

AIDS Patients with Dentist

AIDS patient’s may present to the dentist with:
• Oral Kaposi’s sarcoma
• Widespread oral and pharyngeal candidiasis
• Severe ulcerating herpes simplex infection
• Kaposi’s sarcoma tumors are reddish or purplish in color
and either raised or flat. They are often multiple,
affecting the skin, GIT and oral mucosa.
80
• Epulis or fibroepithelial polyps of unusual appearance.
 • Leukoplakia of oral mucosa affecting young individual
is also suspicious particularly hairy leukoplakia
affecting the side of the tongue.

Test for Diagnosis

1. Enzyme linked immunosorbent assay “ELISA”.
2. Western Blot test.

Prognosis

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• Poor. Some may survive 2 or 3 years.

Mode of Transmission
• Via semen and mucosal abrasion
• Blade, razor, tooth brush, hypodermic needle.
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Prevention
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• Well fitting gloves

• Avoid puncture of skin accidently, water proof dressing
should be used.

Management
• Interferon
• Thymic replacement therapy
• Lympokines and cytokines
• Bone marrow transplantation
• Monoclonal antibiotic therapy
• Antiviral
• IV immunoglobulin therapy.

VIRAL HEPATITIS

Introduction
The two most common cause of viral hepatitis are the 81
hepatitis A (HAV) and hepatitis B (HBV) virus.
 Types of Hepatitis
Hepatitis A/B/C/D/E/F/G.
Hepatitis A
• Incubation period 30 to 35 days
• Virus shed in the saliva, feces, and urine
• Mortality rate is low.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Hepatitis B
• Infection via mucous membrane
• Incubation period is about 3 months
• Arthralgia and urticaria may proceed the jaundice
• Variable degree of malaise with episodes of toxemia
• The liver is enlarged, tender and there is a gastro-
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intestinal disturbance
• Route of transmission—contamination of cuts and
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infected blood and saliva mixed with blood

• Sources of infection:
a. Patient’s with acute hepatitis type “B”
b. Carriers–drug addicts, homosexual male, who have
multiple blood transfusion, inadequately sterilized
instruments.
c. Patient’s with liver chronic disease
d. Patient’s from north America and Australia.
• Recognition of Australian antigen positive patient
is always associated with risk of transmission of
hepatitis B.
Precautions to Control Cross Infection
• Should be control by routine autoclaving of all instruments
• Avoid the contamination of blood with saliva
• Use disposable gloves
• Infected patient’s should be treated in a single chair
82
surgery
 • Turbine handpiece should not be used for surgical
operation
• Operator should wear gown and gloves
• Disinfection should be used to clean the floor and OT
• Hepatitis B vaccine available. Series of three. I/M
doses 0-1-6 months and booster dose after 5 years.

EXODONTIA

Definition of Exodontia

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Exodontia is a branch of oral surgery which deals with
extraction of teeth.
Definition of Tooth Extraction
The ideal tooth extraction is the painless removal of
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the whole tooth or tooth root with minimal trauma to

the investing tissue so that the wound heals uneventfully
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and no prosthetic problem is created.

Principles of Tooth Extraction
1. Expansion of the bony socket.
2. The use of a lever and fulcrum.
3. The insertion of a wedge between the tooth root and
the bony socket.
Methods of Tooth Extraction

Intra-alveolar Extraction (Forcep Extraction or Closed Method):

Consists of Removing the Tooth or Root by the Use of Forcep
or Elevator or Both
The steps of intra-alveolar tooth extraction:
1. Reflection of mucoperiosteum flap with the help of
periosteal elevator.
2. Luxation of tooth with the help of tooth extraction
forceps or dental elevator up to grade I mobility (up to
83
1 mm).
 3. Further luxation of tooth with the help of tooth
extraction forceps or dental elevator up to grade
II mobility (up to 2 mm).
4. Deliver the tooth from socket with the help of tooth
extraction forceps.
5. Compress the socket with finger pressure.
Transalveolar Extraction (Surgical Extraction or Open
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Method): Consists of Reflection of an Adequate

Mucoperiosteal Flap and the Removal of Bone followed
Tooth Removal
The following sequence is followed during open extraction:
a. Anesthesia
b. Elevation of mucoperiosteal flap.
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c. Removal of bone.
d. Division of bone if required.
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e. Removal of tooth and roots.

f. Control of bleeding.
g. Alveoloplasty if required.
h. Toilet of the alveolar socket.
i. Suture of flap.
Causes of Root Breakage
Root breakage due to: Operator fault, patient fault, nature
fault.
1. Wrong forces used for luxating the tooth.
2. Improper application of forceps.
3. When wrong types of instruments are used.
4. Teeth with very large filling.
5. When the tooth has gone brittle because of non-vitality.
6. When there are unfavorable condition like dilacer-
ations of root, hypercementosis, additional roots.
7. When there are locked, flaring, bulbous or very thin
84
roots.
 8. When the surrounding bone is excessively dense.
9. Brittleness due to age.
10. Root canal filling indicate the possibility of root
fracture.
Forces Exerted during Tooth Extraction
Maxillary Teeth
CI, LI = Labiopalatal pressure with mesial
rotation (3:1).

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Canine = Rotatory or screw like movement
(mesiodistal movement) followed by
traction force.
1st PM,
2nd PM
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1st Molar
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2nd Molar
3rd Molar = Buccopalatal (3:1).
Mandibular Teeth
CI, LI, Canine = Labiolingual (3:1). 1st PM, 2nd PM,
1st Molar, 2nd Molar,
3rd Molar = Buccolingual (3:1).
Followed by traction force to deliver the tooth from the
socket.
Indications of Tooth Extraction
1. Periodontal disease.
2. Dental caries.
3. Nonvital teeth.
4. Teeth with infected pulp.
5. Teeth mechanically interfering.
6. Over retained deciduous teeth.
7. Orthodontic reason.
8. Malposed teeth. 85
9. Serial extraction.
 10. Retention of impacted/unerupted teeth.
11. Supernumerary teeth.
12. Teeth in the line of fracture.
13. Teeth with fracture root.
14. Potentially infected root.
15. Teeth cause trauma to soft tissue.
16. Teeth causing bony pathology.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

17. Tooth involved in cyst formation.

18. Tooth which is decayed causing obstruction to
eruption of adjacent teeth.
19. Patient with oral malignancy.
20. Teeth responsible for focal sepsis.
Contraindications of Tooth Extraction
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Local Factors
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1. Acute infections.
2. Acute pericoronitis.
3. Acute infections like gingivitis and stomatitis.
4. Maxillary sinusitis
5. Tooth embedded in malignant growth.
6. Irradiated jaw.

Systemic Factor
1. Uncontrolled diabetic mellitus.
2. Cardiac problem.
3. Pregnancy.
4. Bleeding disorder.
5. Patient on steroid therapy.
6. Renal failure.
7. Psychosis and neurosis.
8. Patients on anticoagulant therapy.
9. Patient with liver disorder.
86
10. Patient with toxic goiter.
 Complications of Tooth Extraction
Operative Complications
1. Fracture of tooth.
2. Alveolar bone fracture.
3. Maxillary tuberosity fracture.
4. Mucosal tear.
5. Oroantral opening.
6. Tooth pushed into spaces of neck.
7. Neural injuries.

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8. Injury to soft tissues.
9. Hemorrhage.
10. Injuries to the adjacent teeth.
11. Failure to secure anesthesia and removal of tooth.
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12. TMJ dislocation.

13. Fracture of jaws.
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Postoperative Complications
1. Postoperative hemorrhage (secondary hemorrhage).
2. Pain and swelling.
3. Dry socket.
4. Osteomyelitis.
5. Bacteremia.
6. Precipitation of systemic problem.
Other Complications
1. Syncope.
2. Respiratory arrest.
3. Cardiac arrest.
4. Anesthetic emergencies.
Sequence of Healing of Extraction Wound
1. Hemorrhage and clot formation.
2. Organization of the clot by granulation tissue.
3. Replacement of granulation tissue by connective 87
tissue and epithelization of the wound.
 4. Replacement of the connective tissue by course fibrillar
bone.
5. Reconstruction of the alveolar process and
replacement of the immature bone by mature bone
tissue.
DENTAL ELEVATORS
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Definition
These instruments are used to luxate the teeth from the
surrounding bone and elevate the tooth from the socket.
These are single blade instrument and they are applied
to the cementum on the tooth surface on the mesial,
distal, buccal surface at the point of application.
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Part of the Dental Elevator

Mainly three parts:
For Personal Use Only

(i) Blade (ii) Shank (iii) Handle

Design
Basically two design:
(i) Straight (ii) Angulated
Classification of Dental Elevators
A. According to form
i. Straight ii. Angular
ii. Crossbar (pair)
B. According to use
i. Elevators designed to remove the entire tooth.
ii. Elevators designed to remove root broken off at the
gingival line.
iii. Elevators designed to remove roots broken off
halfway to the apex.
iv. Elevators designed to remove the apical third of the
88 root.
v. Elevators designed to reflect the mucoperiosteum.
 Types of Elevators
a. Straight type
b. Triangle type
c. Pick type (crane pick).
Indications of Dental Elevator
1. To reflect mucoperiosteal membrane.
2. To luxate and remove tooth which cannot be engaged
by beak of forceps. Example, impactions and malposed

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

teeth.
3. To remove roots.
4. To loosen teeth prior to application of forceps.
5. To remove intraradicular bone.
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6. In case of crowding where impossible to apply the

forceps. Example, lingually, buccally, palatally, labially
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placed tooth.
Dangers in the Use of Elevators
1. Damaging or even of extracting adjacent teeth.
2. Fracturing the maxilla or mandible.
3. Fracturing of alveolar bone.
4. Slipping and plunging the point of the instrument into
the soft tissue.
5. Possible perforation of vessels and nerve.
6. Penetrating the maxillary antrum in case of maxillary
posterior teeth.
7. Forcing a root or tooth into the maxillary antrum
(maxillary post teeth).
8. Forcing a apical third root of mandibular third molar
into mandibular canal.
9. Forcing a apical third of root of third molar into the 89
pterygomandibular space.
 Rules (Precautions) when Using the Elevators
1. Be certain that forces applied by elevator are under
control.
2. Exerting pressure should be in correct direction.
3. Never use an adjacent as a fulcrum unless that tooth
is to be extracts also.
4. Never use the buccal plate at the gingival line as a fulcrum.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

5. Never use the lingual plate at the gingival line as a fulcrum.

6. Always use finger guards to protect the patient in case
the elevator slips.
7. Take care not to engage the root of adjacent tooth.
Work Principles in Use of Dental Elevators
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1. Wedge Principle: Example

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a. Periosteal elevator
b. Straight Miller’s apexo elevator
c. Angulated (paired) Miller’s apexo elevator.
2. Lever and fulcrum principle: Example
a. Heavy duty hospital pattern straight elevator.
b. Cryer elevator (paired).
c. Coupland elevator.
d. Warwick James elevator.
e. Apical fragment ejector.
3. Wheel and axle principle
Example: Winter’s crossbar elevator (paired).

TRISMUS

Introduction
Trismus is the one of the local complication of tooth
90
extraction and local anesthetic agent.
 Definition
It is defined as a motor disturbance of the trigeminal
nerve, especially spasm of the masticatory muscles with
difficulty in opening the mouth.
Etiology of Trismus
Inflammatory Conditions
• Pericoronitis
• Dentoalveolar abscess

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• Odontogenic infection
• TMJ arthritis
• TMJ dislocation
• Acute tonsillitis
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• Parotitis
• Otitis externa
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• Quinsy.
Traumatic Conditions
• Infection after 3rd molar surgery
• Post-injection sequelae
• Fracture of mandible condyle/Angle
• Fracture of zygomatic arch
• Fibrous ankylosis
• Edema from surgical insult
• Myositis ossification.
Neoplastic Conditions
• Submucous fibrosis
• Carcinoma of oral cavity.
Neurogenic Conditions
• Tetanus (bacterial infection)
• Tetany (hypocalcemia)
91
• Hysteria.
 Trismus due to Tooth Extraction
• This is result of inflammation involving the muscle of
mastication
• The trismus may be result of multiple injection of local
anesthesia, especially if the injection have penetrated
muscle
• Most likely involved muscle is “Medial pterygoid
muscle” during inferior alveolar nerve block
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Surgical removal of impacted mandibular third molars

frequently result in trismus because the inflammatory
reaction involve several muscles of mastication
• Usually trismus is not severe.
Treatment
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• If there is infection: Needs to be treated with antibiotic.

• Advice: Analgesic, Anti-inflammatory, Muscle relaxation
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(chlorzoxazone)
• Ask the patient to maintain the oral hygiene, gargle
after every meal.
• Avoid spicy, hot, hard food
• In severe cases: Diazepam 5 mg, three times a day,
for a week with mouth gag under sedation.
Trismus due to Needle Injury
Causes
• Trauma to muscle or blood vessels in the infratem-
poral space is the most common cause
• Local cartridges into which alcohol or other cold
sterilizing solution produce irritation of tissues leading
to trismus
• Due to trauma hematoma formation may cause
trismus.
Treatment
• Most heat may be applied to the region, next day which
92
acts as analgesic and vasodilators.
 PERICORONITIS
Due to inflammatory reaction and involvement of muscles
of mastication.
Treatment
Symptomatic with operculectomy is done to expose the
tooth for complete eruption of tooth.
Infection
Contamination of needles or solution may lead to low

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grade infection which result in trismus.
Treatment
Moist heat, analgesic, muscle relaxant, physiotherapy.
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EDEMA
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Causes
• Trauma during injection
• Infection
• Allergy to LA
• Hemorrhage into soft tissues
• Edema result in pain and dysfunction of region which
lead to nerve trismus
• This can be managed by antibiotic, analgesic.
TETANUS
• Gram + anaerobic organism Clostridium tetani which
is found in soil will invade any wound
• It multiples and produces a powerful toxin in wound
• Exotoxin also travels along the nerve to the CNS and
causes widespread reflex spasm of muscles in response
to sensory stimuli.
Treatment
Human antitetanus globulin is given. I/M 250 to 500 units. 93
Sedation and muscles relaxants.
 TETANY
Followed by parathyroidectomy.
• After thyroidectomy there is steady decrease in
extracellular calcium, the result is hypocalcemic tetany
which is due to increased activity of the motor nerve
fiber
• This condition is characterized by extensive spasm of
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

skeletal muscle causing severe trismus.

ORAL SUBMUCOUS FIBROSIS—PRECANCEROUS LESION
• Most common in 20 to 40 years of age
• Mucosa becomes blanched and opaque
• Fibrotic bands will appear cause severe trismus
• Local application of corticosteroid
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• Supplementary vit E, B complex and C

• Intralesion injection of corticosteroid
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• Surgical—excision of the fibrotic tissue.

DRY SOCKET

Synonym
A vascular socket/postexodontic alveolar osteitis/post
extraction osteomyelitis/ focal osteomyelitis/ alveolagia/
acute alveolar osteitis/ alveolitis sicca dolorosa.
Introduction
Dry socket is one of very unpleasant painful local
complication of extraction of teeth or surgical removal of
teeth. Most common cause of delayed postoperative pain.
Definition
A. Dry socket is a condition in which there is a loss of
the blood clot from the socket.
B. Dry socket is a term applied to a socket, with a faulty
healing, with pain, occasionally seen after a single tooth
94
extraction. Or multiple tooth extraction.
 It is basically the focal osteomyelitis caused due to
dislodging of blood clot. Characterized by:
• Extreme pain (throbbing pain)
• Foul smell (necrotic odor)
• No suppuration (no pus formation).
Explanation
• Two or three days after removal of the tooth, disintegr-
ation of the normal blood clot occurs.
• Initially the clot has a dirty gray appearance then it

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disintegrates, ultimately leaving a gray or grayish
yellow bony socket bare of granulation tissue.
• When first seen, however the socket may not always
be completely empty, it may still contain a partially
necrotic blood clot and confirmed by gently passing a
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small probe into the extraction wound, bone is

encountered which is extremely sensitive.
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• The name dry socket is given due to the fact that the
blood clot forms and gets disintegrates leaving the
walls of the socket exposed and giving dry appearance.
Causative Organism
Streptococci, staphylococci mixed infection, but the presence
of a large number of fusiform bacilli and vincent’s
spirochetes may point to a low grade putrifaction process.
Etiology
Two main group:
General Factors
• The importance of the general factors in a develop-
ment of dry socket is highly doubtful.
• Decreased resistance due to general disease like heart
disease, liver disorder, syphilis, hemorrhagic
diathesis.
• Nutritional disturbance like protein deficiencies, vit 95
A,B,C and D deficiency, Ca, P deficiencies.
 Local Factors
• Insufficient blood supply to the alveolus.
• Pre-existing infection
• The use of too large amount of LA
• Postoperative bleeding
• Trauma to the alveolar bone during extraction
• Infection during or after infection
• Root or bone fragment or foreign body left into alveolus
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Excessive irrigation or curettage after extraction

• Ankylosis
• Hypercementosis
• Contamination of socket by saliva.
Clinical Features
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• The symptoms generally start on the 3rd to 5th day

after extraction of tooth
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• Severe pain extreme intensity and radiating character

of pain
• Suppuration is generally absent
• Foul odor is present
• The gingival margin of the socket is usually swollen
and dusky red
• The socket itself contains a brown, friable sometime,
foamy clot which is easily washed out
• Food debris may accumulated in the socket with
disintegrating clot produce a foul taste
• Socket wall may be extremely sensitive when touched
• The regional lymph nodes may be tender and can be
enlarged
• May be there is pyrexia present.
Preventive Measures
1. Preoperatively—To improve oral hygiene with mouth
wash, scaling, atraumatic extraction.
2. Immediate after extraction—Five days antibiotic
96
course with metronidazole 400 mg/1 tds
 Management
The treatment of dry socket is directed primarily toward
the relief of pain because the patient may is suffering
from severe pain, prompt treatment is required.
Accomplished in two ways: Local therapy consists of:
• Irrigation of the socket with a normal saline or dilute
solution of the hydrogen peroxide to remove the
necrotic material and other debris.

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• Followed by the application of either—An obtudent
(eugenol) or A topical anesthetic (Benzocaine). The drug
may be applied on a piece of sterile gauze.
• In addition to local therapy, medication prescribed are
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a. Antipyretic.
b. Analgesic depends on severity of pain (tab voveran
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–D 1 tds or Brufen 400 to 600 mg, 1 tds)

• The patient is re-examined in 24 hours—if the pain
has stopped, the medication in the socket need not be
replaced.
• If pain persists—the irrigation and dressing of socket
should be repeated as necessary.
• Curettage should never be employed in the treatment
of dry socket—This procedure not only predisposes the
patient to spread of infection but also destroys any
previous attempt at normal healing.
• The routine use of antibiotic in the treatment of dry
socket is not recommended because the major problem
is one of pain control rather than of unlimited infection.
• Certainly the use of antibiotic alone is an ineffective
method for relief of the patient’s pain.
• In rare instances where suppuration does exist, the
antibiotic should be used systemically rather than
97
topically in the socket.
 LOCAL ANESTHESIA

Definition
• Local anesthesia: It is a local state of loss of sensation,
without loss of consciousness, in a circumscribed area of
the body due to a depression of, excitation in nerve
endings or an inhibition of the conduction process in
peripheral nerves.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

• Local anesthetic agent: Local anesthetic are drugs

which when applied directly to peripheral nervous
tissue block nerve conduction and abolish all sensation
in the part supplied by the nerve. They are generally
applied to somatic nerves and are capable of acting on
axons, cell body, dendrites and synapses.
• General anesthesia: General anesthetics are the agent
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which bring about loss of all modalities of sensation

particularly pain along with a reversible loss of
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consciousness.

Ideal Requisites/or Ideal Properties of LA Agent

1. It should not be irritating to the tissue to which it is
applied.
2. It should not cause any permanent damage to the
nerve structure.
3. Its systemic toxicity should be low.
4. It must be effective either it is injected into the tissue
or applied locally to mucous membrane.
5. The time of onset of anesthesia should be as short as
possible.
6. Duration of action must be long enough to permit
completion of procedure.
7. It should have a potency sufficient to give complete
anesthesia without the use of harmful concentrated
solution.
8. It should be stable in solution.
98 9. It should be relatively free from producing allergic
reaction.
 10. It should be readily undergo biotransformation in the
body.
11. It should be capable of being sterilized by heat without
deterioration.
12. Its action must be reversible.
13. It should have sufficient penetrating properties.
Classification of Local Anesthesia Agent
Esters

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i. Esters of benzoic acid
• Butacaine • Benzocaine
• Cocaine • Tetracaine
• Hexylcaine • Piperocaine
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ii. Esters of para-aminobenzoic acid (PABA)

• Procaine
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• Chloroprocaine
Amide
• Lidocaine (xylocaine, lignocaine)
• Etidocaine
• Mepivacaine, bupivacaine
Composition of Local Anesthetic Agent
1. Local anesthetic agents (lignocaine HCL) 2% (20 mg/ml)
2. Adrenaline HCL (As vasoconstrictor) 1:80,000 (0.012 mg)
3. Sodium metabisulphite (as preservative of 0.5 mg
vasoconstrictor as reducing agent)
4. Methylparaben (preservative and 0.1% (1mg)
bacteriostatic) or (caprylohydroxamic acid
which includes in xylotox)
5. Sodium chloride (as isotonic solution) 6 mg
6. Sodium hydroxide To adjust PH
7. Thymol Fungicidal
8. Ringer’s solution As vehicle (to
minimize discomfort
during injection) 99
9. Distilled water For dilution
 Indications of Local Anesthesia
1. Extraction of teeth.
2. Surgical removal of teeth.
3. Alveoloplasty.
4. Alveolectomy.
5. Incision and drainage of abscesses.
6. Cavity preparation especially in deeper painful
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

cavities.
7. Pulp procedures like pulpotomy and pulpectomy.
8. Cyst enucleation or marsupialization.
9. Removal of residual infection.
10. Removal of small neoplastic growths.
11. Removal of salivary stones.
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12. For relief from sore spots of dentures.

13. Treatment of trismus.
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14. Diagnostic test of trigeminal neuralgia.

15. As a treatment therapy of trigeminal neuralgia.
16. In radiography when the patient is gagging due to
placement of film in the mouth.
17. For anesthesia of oral cavity and jaws bones like
routine surgical procedure like treatment of fracture,
growth, etc.
Contraindications of Local Anesthesia
1. Fearful and apprehensive patient.
2. Allergy to local anesthetic solution.
3. Acute infection.
4. Mentally retarded patient.
5. Anatomic anomalies.
6. Hyperthyroidism.
7. Liver disorder.
8. Renal disorder.
9. Patient with cardiac problem.
100
10. Patient with diabetic mellitus.
 11. Patient with any internal hemorrhage.
12. Major oral surgical procedure
Advantages of Local Anesthesia
1. Patient is awake and cooperative during operation.
2. There is little distortion of normal physiology.
3. It can be used in poor and sick patients.
4. There is very low incidence of untoward reaction.
5. Patient may leave the office without guard.
6. No additional trained person is required.

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7. The techniques are not difficult.
8. The chances of failure is rare.
9. There is no additional expenses to patient.
10. Patient is need not omit the previous meal.
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Disadvantages of Local Anesthesia

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There is no true valid disadvantage to the use of regional

anesthesia. When the patient is mentally prepared for it
and when there is no contraindication.
Methods of Local Anesthesia
1. Nerve block.
2. Field block.
3. Local infiltration.
4. Topical anesthesia (surface anesthesia).
5. Intraligamentary technique.
Theories Explaining the Mode of Action of Local
Anesthesia
1. Surface charge theory (electrical potential theory).
2. Membrane expansion theory.
3. Specific receptor hypothesis (most accepted theory).
4. Acetylcholine theory.
5. Reversible coagulation theory.
6. Ca displacement theory. 101
7. Interference with nerve metabolism.
 Complication of Local Anesthesia

Local Complications
1. Needle breakage.
2. Pain on injection.
3. Burning on injection.
4. Persistent anesthesia (paresthesia).
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

5. Trismus.
6. Hematoma.
7. Infection.
8. Edema.
9. Slugging of tissue.
10. Soft tissue injury (lip, cheek, tongue, palate).
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11. Facial nerve paralysis.

12. Postoperative intraoral lesions.
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a. Recurrent aphthous stomatitis.

b. Herpes simplex.
13. Visual disturbance
14. Intravascular injection
15. Failure to obtain anesthesia.

Systemic Complications
1. Toxicity due to overdose.
2. Allergy.
3. Idiosyncracy.
4. Syncope.
5. Drug interaction.
6. Serum hepatitis.
7. Occupational dermatitis.
8. Respiratory arrest.
9. Cardiac arrest.
102 10. Hyperventilation.
 Techniques for Maxillary Nerve Blocks

Intraoral Techniques
1. Local infiltration of nerve endings.
2. Block of the terminal branches.
3. Infraorbital nerve block (Anterior and middle superior
alveolar nerve block).
4. Posterior superior alveolar nerve block (zygomatic
block).
5. Nasopalatine nerve block.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

6. Greater palatine nerve block (anterior palatine nerve
block).
7. Maxillary nerve block.
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Extraoral Techniques
1. Infraorbital nerve block.
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2. Maxillary nerve block.

Techniques for Mandibular Nerve Blocks

Intraoral Techniques
1. Classical inferior nerve block.
2. Akinosi closed mouth approach.
3. Gow-Gates (high condylar technique).
4. Lingual nerve block.
5. Long buccal nerve block.
6. Mental nerve block.
7. Incisive nerve block.
8. Block of terminal branches.
9. Local infiltration.

Extraoral Techniques
1. Mandibular nerve block.
2. Mental nerve block.
3. Incisive nerve block.
103
4. Local infiltration.
 IMPACTION

Definition
1. Impacted mandibular third molar: If a tooth cannot
assume its normal position in the oral cavity due to
any mechanical obstruction, tooth is known as
impacted tooth.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Malposed tooth: A tooth unerupted or erupted which

is in an abnormal position in the maxilla or mandible.
3. Unerupted tooth: A tooth not having perforated the
oral mucosa.
Order of Frequency
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Maxillary 3rd molar, mandibular 3rd molar, maxillary

canine, mandibular premolar, mandibular canine,
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maxillary premolars, maxillary central incisors, maxillary

lateral incisors.
Etiology—Theories Explaining the Etiology of Impaction
1. Physiologic theory.
2. Mendelian theory.
3. Endocrine theory.
4. Pathologic theory.
5. Orthodontic theory.
Local Causes
1. Irregularity in position of tooth.
2. Increased density of the overlying or surrounding bone.
3. Increased density of overlying mucosa.
4. Problems of space in the jaws.
5. Early extraction of deciduous teeth.
6. Over retention of deciduous teeth.
104 7. Infection of jaws.
 Systemic Causes
1. Hereditary.
2. Systemic condition example anemia, TB, syphilis,
rickets, etc.
3. Rare condition—cleidocranial dysostosis.
4. Cleft lip and cleft palate.
Indications
1. Prevention of periodontal disease.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

2. Prevention of dental caries.
3. Prevention of pericoronitis.
4. Prevention of root resorption of adjacent teeth.
5. Prevention of odontogenic cyst.
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6. Prevention of pain of unexplained origin.

7. Prevention of fracture of jaw.
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8. Prevention of odontogenic tumor.

9. For dental prosthesis.
10. Facilitation of orthodontic treatment.
11. As a prophylactic measure.
12. Ophthalmic complication.
13. Ear complication.
14. Throat complication.
Contraindications
1. Extreme age.
2. Compromise medical state.
3. Proable excessive damage of adjacent structure.
Classification of Impacted Mandibular Third Molar
Mainly three classification:
1. Pell and gregory classification
A. Relation of the tooth to the ramus of mandible and
2nd molar
105
Class I Class II Class III
 B. Relative depth of the third molar in the bone
Position A Position B Position C
2. Winter’s classification: On the basis of the position of
the long axis of the impacted third molar, in relation
of the long axis of the second molar:
a. Vertical b. Horizontal c. Mesioangular
d. Distoangular e. Buccoversion f. Linguoversion
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

g. Inverted (torsoversion).
3. Combined ADA and AAOMS classification
07220 = Soft tissue impaction
07230 = Partial bony impaction
07240 = Complete bony impaction
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07241 = Complete bony impaction with unusual

surgical complication.
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Surgical Procedure for Removal of Impacted Mandibular

Third Molar
Following points should be considered:
A. Preoperative consideration
B. Preoperative preparation
C. Techniques
I. Standard surgical set.
II. Preoperative assessment:
1. Access
2. Position and depth—depends on “three George
Winter’s imaginary lines”
a. White line b. Amber line c. Red line
3. Root pattern of impacted mandibular third
molar.
4. Shape of crown of impacted mandibular third
molar.
106 5. Texture of investing bone.
 6. Position and root pattern of mandibular second
molar.
7. Inferior dental canal relationship with mandibular
third molar.
III. Basic step by step technique
1. Reflecting adequate flap for accessibility.
2. Removal of overlying bone.
3. Sectioning of tooth (if required).
4. Delivery of tooth from socket.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

5. Debridement of wound.
6. Wound closure.
D. Postoperative care.
E. Postoperative instruction.
F. Postoperative medication.
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Complications of Surgical Procedure

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A. During surgical procedure.

B. Immediate after surgical procedure.
C. Late postoperative complication.
Example:
1. Fracture of tooth, mandible, alveolar process.
2. Exposure of inferior alveolar canal.
3. Compression of nerve.
4. Disruption of blood supply.
5. Dislodgment of adjacent teeth.
6. Injury to lip, cheek, tongue, oral mucosa.
7. Forcing an apex into lingual space.
8. Pain.
9. Loss of large section of alveolar section.
10. Secondary hemorrhage.
11. Ecchymosis.
12. Edema.
13. Trismus.
14. Infection. 107
 IMPACTED MAXILLARY CANINE

Introduction
Maxillary canine are usually more commonly impacted
than mandibular canine. Maxillary canine 20 times more
impacted than mandibular canine.
Definition—As mandibular third molar.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Order of frequency—As mandibular third molar.

Etiology
1. The bone of hard palate offers more resistance.
2. Mucoperiosteal tissue of the palate is very thick, dense
and firm. Such offers more resistance to eruption of
canine.
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3. The greater the distance is supposed to travel, greater

will be possibility of its misdirection and its impaction.
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4. Crown of permanent canine lie very close to primary

canine so, any change in the primary canine may cause
deviation in the position of permanent canine.
5. Delayed resorption of primary canine (unduly retention)
6. Early shedding of the primary canine.
7. Permanent canine erupt between teeth those are
already in occlusion so more mesiodistal diameter may
cause impaction.
Classification
1. Field and Ackerman, 1935
a. Labial position
b. Palatal position
c. Intermediate position
d. Unusual position, e.g. in nasal/antrum infraorbital
region
108
 2. 2nd Classification
Class I: Impacted cuspid located in palate
a. Horizontal b. Vertical c. Semivertical
Class II: Impacted cuspid located in labial/buccal
surface of maxilla
a. Horizontal b.Vertical c. Semivertical
Class III: Impacted cuspid located in both palatal
process and labial or buccal surface
Class IV: Impacted cuspid located in alveolar

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process, usually vertical between incisor
and 1st bicuspid.
Class V: Impacted cuspid located in edentulous
maxilla. Impacted cuspid located in.
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Diagnosis
A. Patients history
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B. Clinical examination
C. Radiographs (Slob Tech)
Surgical Procedure
A. Preoperative assessment/consideration
B. Preoperative preparation—Extra/intraoral preparation
and drapping
C. Armamentarium (standard surgical set)
D. Anesthesia under LA/GA (Nasal or oral intubation)
E. Step by step surgical technique:
1. Reflection of mucoperiosteum flap with the help of
different incision (labial position) semilunar
incision, angulated/trapezoidal/crevicular incision.
Palatal position-flap reflected from around the neck
of teeth.
2. Removal of overlying bone.
3. Sectioning of tooth (if required).
109
 4. Delivery of tooth from the socket.
5. Debridement of wound.
6. Wound closure.
F. Postoperative instructions, medication and care.
Complications
1. During surgical procedure
2. Immediate after surgical procedure
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

3. Late complication
4. Due to local anesthesia, e.g. tooth can be push into
nasal cavity/antrum, paresthesia infraorbital nerve.

ACUTE AND CHRONIC INFECTIONS OF JAW

1. Acute alveolar abscess: It is defined as localized acute
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inflammation and suppurative condition around the

teeth. It may occur almost immediately after injury
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to pulp and tissue.

Abscess is circumscribed collection of pus in a
pathological tissue space. A true abscess is a thick
wall cavity containing pus which require immediate
drainage.
2. Acute periapical abscess: An odontogenic abscess
usually arise and remain in the confines of alveolar
bone. This is referred to as acute periapical abscess.
3. Acute cellulitis: Cellulitis is spreading infection of
loose connective tissue.
It is diffused erythematous mucosal or cutaneous
infection. It is characteristically result of streptococcal
infection and does not normally result in large
accumulation of pus.
4. Pericoronitis (acute pericoronal infection): Define as
inflammation of soft tissue around the crown of tooth
or can be defined as inflammation of gingiva in relation
to crown of an incomplete erupted tooth commonly
110 impacted 38, 48 region.
 5. Granuloma: A granuloma is literally a tumor made
up of granulation tissue. The term dental granuloma
is used to designate the situation in periapical region
in which an abscess or a localized area of osteolysis
is replaced by granulation tissue.
6. Chronic alveolar abscess: An abscess by definition is
a localized collection of pus in a cavity formed by the
disintegration of tissue the chronic alveolar abscess
may be after a month of an acute periapical infection
or it may be produced by a chronic periapical infection.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

The periapical cyst is an epithelium lined sac
containing liquid or semisolid inflammatory exudates
and necrotic tissue.
7. Osteomyelitis: Osteomyelitis is an extensive inflam-
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mation of bone. It involves the cancellous portion,

bone marrow, cortex and periosteum may be acute
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osteomyelitis, chronic osteomyelitis, chronic

osteomyelitis associated with systemic disease, focal
osteomyelitis.
8. Garre’s osteomyelitis: Also called periostitis ossificans,
clinically characterized by a localized hard, nontender
bony swelling of the lateral and inferior aspect of
mandible generally seen in children commonly
associated with carious first molar.
9. Osteoradionecrosis: Shaffer’s defined as that
pathological process which sometime follows heavy
radiation of bone and is characterized by:
a. Chronic painful infections.
b. Necrosis.
c. Accompanied by late sequestrum or sometime
permanent deformities. Marx—defined it is a
chronic nonhealing wound that is caused by
hypoxia/hypocellularity/hypovascularity of radiated
bone. Mayer—outlined the classical triad of ORN
as: Radiation-trauma-infection. 111
 Treatment
Nonsurgical
I. Change in lifestyle.
II. Tropical treatment:
a. Maintain oral hygiene with mouthwash.
b. BIPP—bismuth and iodoform paste.
c. All infected teeth and nonvital teeth should be
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

extracted.
d. Scaling.
e. Fluoride therapy.
f. No radiation therapy should be attempted for
7 to 10 days following tooth extraction.
g. Teeth with caries should be extracted. If teeth in
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irradiated area should be extracted.

III. Systemic antibiotic
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IV. Hyperbaric oxygen HBO

Surgical
I. Ingress of granulation tissue.
II. Sequestrectomy.
III. Resection-intraoral or extraoral.

FASCIAL SPACES OF HEAD AND NECK REGION

Definition with Explanation

Fascial space is a portion of anatomy that is partially or
completely walled by fascial membrane. Fascial area are
potential areas between layers of fascia.
These areas are normally filled with loose connective
tissue which readily break down when invaded by
infection.
These fascia of the head and neck may be divided into:
a. Superficial fascia
112
b. Deep cervical fascia.
 Classification of Fascial Spaces—(Total 16 in Number)
On the Face
1. Canine space
2. Buccal space
3. Masticatory spaces
i. Masseteric space
ii. Pterygomandibular space
iii. Temporal space (zygomaticotemporal space)
4. Parotid space

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

5. Infratemporal space.
Suprahyoid Fascial Space
1. Sublingual space
2. Submental space
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3. Submandibular space
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4. Lateral pharyngeal space

5. Peritonsillar space
Infrahyoid Space
1. Pretracheal space
Spaces of the Total Neck Region
1. Retropharyngeal space
2. Danger space
3. Space of the carotid sheath.
Boundaries of Pterygomandibular Space
Anteriorly : Pterygomandibular raphe
Posteriorly: Deep part of parotid gland
Laterally : Ramus of mandible (medial surface)
Medially : Medial pterygoid muscle
Superiorly : Lateral pterygoid muscle.
Contents of Pterygomandibular Space
a. Inferior alveolar nerve/artery/vein 113
b. Myeloid nerve and vessel
 c. Maxillary artery
d. Lingual nerve
e. Auriculotemporal nerve
f. Soft areolar tissue
Boundaries of Submandibular Space
Laterally : Submandibular skin, superficial fascia,
platysma muscle, superficial layer of deep
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

cervical fascia, lower border of mandible.

Medially : Mylohyoid muscle, hypoglossal muscle,
styloglossal muscle.
Inferiorly : Anterior and posterior bellies of digastrics
Posteriorly: Hyoid bone.
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Contents of Submandibular Space

a. Submandibular gland and duct
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b. Submandibular nodes
c. Facial artery
d. Lingual nerve
e. Hypoglossal nerve.

Complication of Fascial Space Infection

a. Ludwig’s angina
b. Cavernous sinus thrombosis
c. Meningitis
d. Brain abscess.

LUDWIG’S ANGINA

Definition
Ludwig’s angina is a bilateral swelling of the sublingual,
submandibular, and submental spaces.
Ludwig’s angina is a firm, acute, toxic, cellulitis of
submandibular and sublingual spaces bilaterally and
114 submental space.
 Bacteriology of Ludwig’s Angina
• Streptococci E. coli
• Staphylococci Pseudomonas
• Peptostreptococcus Bacteroides—anaerobes
(B. oralis, B. corrodens)
Management (Aims/Object/Goal)
1. Early diagnosis of incipient cases.
2. Maintenance of patent airway.

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3. Intense and prolonged antibiotic therapy.
4. Extraction of offending teeth.
5. Parenteral hydration.
6. Early surgical drainage.
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Treatment
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Nonsurgical Treatment
i. Aerobic and anaerobic antibiotic
ii. For hydration—IV DNS or NS, 5 to 10 percent
iii. As supportive—multivitamin.

Surgical Treatment
• Incision and drainage (extra or intraoral).
Complications of Ludwig’s Angina
1. Reinfection.
2. Scar formation.
3. Stenosis of Wharton’s duct.
4. Cavernous sinus thrombosis.
5. Aspiration pneumonia.
6. Mediastinitis.
7. Suffocation and death may occur. 115
 CAVERNOUS SINUS THROMBOSIS (CST)
Key Points
1. CST is neurological complication of odontogenic
infection.
2. CST is one of the major complication of
odontogenic infection of maxillofacial region.
3. CST may develop from sinusitis, abscess
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

cellulitis of the orbit, upper lip, nose, maxilla

or maxillary anterior teeth.
4. Greatest importance is the communication of
the facial vein with the ophthalmic vein which
enter cranial cavity to empty into the cavernous
sinus.
5. The classic danger area of the face is one of the
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common site for CST. Danger area is triangular

in shape with upper lip as its base and root of
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the nose at its apex.

6. Venous drainage from the area of the face is by
the veins that empty into the cavernous sinus.
Infection usually involves only one sinus at
onset but quickly extend through the circular
sinus to the opposite sinus.
7. Infection is usually staphylococcal.
8. Two path of propagation: One from facial vein
into superior ophthalmic vein or inferior
ophthalmic vein. Second from deep facial vein
into pterygoid venous plexus. Infection from the
face can spread in retrograde direction and cause
thrombosis of cavernous sinus.
9. Retrograde infection spread due to presence of
valve less vein (e.g. facial vein, ophthalmic vein,
deep facial vein, superior ophthalmic vein,
pterygoid venous plexus, etc.).
116
 Diagnosis
According to Eagleton
1. A known site of infection.
2. Evidence of bloodstream infection.
3. Early signs of venous obstruction in the retina,
conjunctivitis or eyelid.
4. Paresis of the oculomotor (3rd), Trochlear (4th),
Abducent (6th) cranial nerve resulting from inflamm-
atory edema.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

5. Abscess formation in the neighboring soft tissue.
6. Evidence of meningeal irritation.
Diagnostic Lab Test in Case of CST
1. Increase CSF protein.
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2. Normal CSF glucose.

3. Increase CSF pressure.
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4. Tobey Ayer test: This is performed by compressing the

internal jugular vein with the finger on the side of the
thrombosis, there will be no rise in CSF pressure which
is measured by lumbar puncture otherwise on normal
side increases CSF pressure or internal jugular vein
compression.
Treatment
1. Antibiotic: Choice of drug is (because it crosses blood
brain barrier). Chloramphenicol and sulfonamide.
2. Anticoagulant therapy.
3. Surgical: In case of abscess formation incision and
drainage.

APICOECTOMY

Synonym
Apical surgery, root resection, endodontic surgery, root
117
amputation.
 Definition
It is the cutting off, of the apical portion of the root and
curettage of the periapical necrotic, granulomatous,
inflammatory or cystic lesion.
If periapical lesion are not resolved then periapical
surgery is undertaken.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Indications
1. Apical anomaly of root tip-dilacerations, intracanal
calcification.
2. Presence of lateral/accessory canal/apical region
perforations.
3. Roots with broken instruments.
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4. Root with overfilling.

5. Fracture of apical third of root.
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6. Formation of periapical granuloma and cyst.

7. Draining sinus tract.
8. Nonresponsive to RCT.
9. Extension of root canal cement.
10. Extension of RC filling beyond the apex.
11. Teeth with ceramic crowns.
12. When patient with chronic periapical infection.
13. Teeth with apical resorption.
Contraindications
1. Medically compromised patients.
2. Teeth with deep periodontal pocket and excessive
mobility.
3. Teeth with poor accessibility.
4. When there is extensive involvement of bone.
5. Danger of involvement of anatomical structure.
118
 Surgical Procedures
A. Preoperative assessment.
B. Preoperative consideration.
C. Preoperative preparation (intraoral and extraoral).
D. Armamentarium (standard surgical set).
E. Anesthesia (LA, nasal intubation).
F. Step by step surgical technique:
1. The design of mucoperiosteal flap.
2. Reflection of mucoperiosteal flap.

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3. Exposure of periapical pathology and root tip.
4. Removal of periapical pathology.
5. Resection of root apex (apical 1/3rd).
6. Sealing of the apex.
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7. Toilet of the wound.

8. Smoothing of the bony margin.
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9. Control of bleeding.
10. Closure of the surgical wound.
G. Postoperative instruction, medication and care.
Complications
1. Flare up of infection.
2. Cellulitis.
3. Ludwig’s angina.
4. Fracture of adjacent root.
5. Fracture of maxilla and mandible.
6. Soft tissue injury.
7. Opening of maxillary sinus.
8. Secondary hemorrrhage.
9. Nonvitality of adjacent teeth.
10. Nerve injury.
11. Luxation of adjacent teeth.
119
 PARANASAL SINUS
These are four paired cavities lined with respiratory
mucous membrane, they communicate with nasal cavity
through aperture. They are known as paranasal sinuses.
They are:
i. Maxillary sinus.
ii. Ethmoid sinus (they are behind lateral wall of nose).
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

iii. Frontal sinus.

iv. Sphenoidal sinus (about at midline).

Maxillary Sinus

Gross Anatomy
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The maxillary sinus is the largest of paranasal sinus and

is a cavity, in the body of maxilla which is pyramidal in
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shape. Size and shape vary in each individual.

• Synonym : Antrum of Highmore, maxillary antrum
• Number : 2
• Shape : Pyramidal shape, largest of all paranasal
sinus
• Situation : In the body of the maxilla
• Capacity : 30 ml

Key Points
Lined by pseudostratified columnar ciliated
epithelium.
1. Height : Opposite 1st molar, 3.5 cm
2. Depth : 3.2 cm
3. Breadth : 2.5 cm
4. Arterial supply : The major arterial supply
is internal maxillary artery
small arteries derived
from facial and maxillary,
120
Contd...
 Contd...

infraorbital and greater

palatine artery.
5. Venous drainage : Through the anterior facial
vein and angular vein.
6. Lymphatic drainage: Towards the subman-
dibular lymph nodes.
7. Nerve supply : Infraorbital nerve.

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Functions of Maxillary Sinus
1. They lighten the facial bone.
2. They help in maintaining the temperature.
3. They help in voice production.
4. Serve as insulator to prevent incoming cold air.
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Methods Used for Removal of Foreign Body (Root/Tooth)

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from the Maxillary Sinus

1. Unanesthetized patient to blow forcibly with the
nostrils close.
2. Sucked out with sucker nozzle.
3. Pair of small curved artery forceps can be used.
4. Gentle irrigation of the sinus with sterile normal saline
may effect delivery.
5. A ribbon gauze mixed with iodine packed in the
maxillary sinus, then sudden withdrawal from sinus.
Surgical Approach
1. Through bony socket wall.
2. Through Caldwell-Luc operation—canine fossa
approach (classical approach).

OROANTRAL FISTULA
Oroantral communication: After immediate perforation
of maxillary sinus. 121
 Oroantral fistula: It is a unnatural persistent epithelialized
communication between the alveolar process and
maxillary sinus.
Management

Aims of Treatment
1. Prevent the escape of fluid.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Prevent the entry of other mouth contents into

the antrum.
3. To protect the sinus from oral bacteria.
Surgical Repair of Oroantral Fistula

Local Flap
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a. Buccal flap: Von-Rhermann’s buccal advancement flap,

sliding flap, bipedicled flap.
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b. Palatal flap: Ashley rotational advancement flap.

Bipedicled advancement flap, iceland flap.
c. Combined flap.

Distant Flap
a. Tongue flap (anterior-based, posterior-based)
b. Graft procedure (bone, alloplastic material).

NERVE DISORDER

Trigeminal Neuralgia
Synonym : Tic douloureux
Definition : Neuralgia may be defined as paroxysmal
intense, intermittent pain that is usually
confined to specific nerve branch of the head
and neck.
Trigeminal neuralgia characterized by—
122 paroxysms pain in the distribution of the
trigeminal nerve without any major weakness
 or demonstrable sensory loss (paroxysmal—
intense—intermittent—pain).
White and Sweet Five Diagnostic Features
1. Pain is characteristically paroxysmal.
2. Majority of patient will have one or more of trigger
points.
3. The pain is confined to the area of the cutaneous
innervations of the trigeminal nerve.
4. The pain affects only one side of the face at a time.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

5. Characteristically the neurologic examination is
normal between the attack.
Differential Diagnosis
1. Atypical trigeminal neuralgia.
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2. Eagle syndrome.
3. Fry’s syndrome.
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4. Paratrigeminal syndrome of Reader’s.

5. Post-therapeutic neuralgia.
6. Vagoglossopharyngeal neuralgia.
7. Ramsay Hunt syndrome.
8. Aneurysm of the ICA.
9. Fifth seven CN syndrome.
10. Traumatic neuroma.
11. Troture syndrome.
12. Migraine.
Treatment
Nonsurgical Management (Medical Management)
A. Physiologic therapy
B. Pharmacologic therapy
1. Local anesthetic—paraneural block
2. Anti-inflammatory:
a. Adrenocorticosteroid: Dexamethasone
b. Nonsteroidal anti-inflammatory drug: Aspirin 123
(1200 mg–2000 mg/day)
 3. Topical application: Capsaicin
4. Antidepressant agent: Amitriptyline at night.
5. Narcotic agent: Morphine sulfate—100 mg SC or
IM, 2.5 mg IV
6. Anticonvulsant: Phenytoin (Dillantine)—200 mg
twice a day carbamezapine (Tegritol)—Initially 100
mg twice daily, 1200 mg maximum. Baclofen 50 to 60
mg/day, benzodiazepines, alprazolam
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

7. Antisympathetic agent— Clonidine 0.1 to 0.3 mg.

C. Behavioral therapy.

Surgical Treatment
1. Anterior fossa surgery: Peripheral injection, neurec-
tomy
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2. Middle fossa surgery: Gasserian ganglion injection,

compression and decompression procedure, trigeminal
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rhizotomy, thermocoagulation.
3. Posterior fossa surgery: Trigeminal rhizotomy, bulbar
trigeminal tractotomy.
Complication of Surgery
1. Coronal ulceration.
2. Blindness.
3. Dysesthesia.
4. Anesthesia dolorosa.
5. Herpes simplex.
BELL’S PALSY

Definition
Bell’s palsy is an isolated facial paralysis of sudden onset
caused by a neuritis of the 7th nerve within the facial canal.
On examination paralysis of frontal belly of occipito-
frontalis muscle, orbicularis oris, orbicularis oculi,
buccinator, platysma, zygomatic major and minor.
124
 Treatment
1. In early stage of Belly’s palsy, inflammation may
suppress by using systemic cortisone (prednisolone,
1mg/kg/day with tapered dose).
2. Supportive therapy—B complex.
3. Cornea protect from use of lubricant.
4. Surgical decompression of the facial canal.
5. Galvanic stimulation of facial muscle.
6. Redirection of the accessory nerve into the degenerated

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7th cranial nerve.
7. Active and passive myotherapy.
8. Bedrest.
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FACIAL PARALYSIS
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Definition

It is defined as paralysis of facial musculature, result in

functional and cosmatic deformity on the affected side,
particularly those supplied by 7th cranial nerve due to
injury, infection, tumor, etc.

Management
1. Medical therapy—betamethasone (0.5 mg), multivitamin
2. Physiotherapy
3. Surgical treatment—nerve decompression, anastomosis,
grafting
4. Nerve grafting
5. Facial cramp
6. Reanimation procedure
7. Repair of facial paralysis by buccal sulcus support
8. Repair of facial drooping.
125
 CYST OF JAW AND ORAL CAVITY

Definition
Killey and Kay: Cyst is a pathologic cavity, occurring in
hard and soft tissue, with a liquid or semi-liquid or air
content. It is surrounded by a definitive connective tissue
wall or capsule and usually has an epithelial lining.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Classification
WHO classification “Shear – 1983”.

Epithelial Cyst
Odontogenic cyst Nonodontogenic cyst
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Developmental cyst Fissural cyst

i. Gingival cyst of infants i. Nasopalatine duct cyst
(incisive canal cyst)
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ii. Gingival cyst of adults ii. Median palatine cyst

iii. Lateral periodontal cyst iii. Median mandibular cyst
iv. Dentigerous cyst iv. Nasolabial cyst
(follicular cyst) (nasoalveolar cyst)
v. Odontogenic keratocyst v. Globulomaxillary cyst
(Nevoid basal cell
carcinoma syndrome)
vi. Calcifying odontogenic
cyst (Gorlin cyst)
vii. Eruption cyst
Inflammatory cyst Retention cyst
i. Radicular cyst i. Mucocele
ii. Residual cyst ii. Ranula
iii. Inflammatory lateral
Periodontal cyst
iv. Paradental cyst

Nonepithelial Cyst
i. Aneurysm bone cyst (ABC)
ii. Traumatic bone cyst
• Simple
126 • Solitary
• Hemorrhagic bone cyst
 DENTIGEROUS CYST

Synonym
Follicular cyst, pericoronal cyst.
Definition
A cyst that produces an enlargement of the follicular space,
about the whole or part of the crown of the tooth (may
contains the crown of an unerupted tooth which may be

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either normal or supernumerary tooth) may grow to a
large size before clinical diagnosis. They often do not cause
pain unless they become infected.
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Types of Dentigerous Cyst

1. Central type
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2. Lateral type
3. Circumferential type
4. Multiple type
5. A dentigerous cyst containing a crown of unerupted
tooth.
Treatment
1. Marsupialization
2. Cyst enucleation

ODONTOGENIC KERATOCYST

Synonym
Nevoid basal cell carcinoma syndrome.
Definition
• WHO has defined as a cyst arising from tooth bearing
areas of the jaws having thin fibrous capsule and a
lining of keratinized squamous epithelium. 127
 • The cell lining rarely exceeds five cell thickness and
has no rete pegs. Keratocyst contain “creamy white
suspension of keratin that appear like pus without an
offensive smell”.
Key Points
OKC is known for its:
1. High recurrence rate.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Aggressive in nature.
3. Occasionally associated with the basal cell nevus
syndrome or bifid rib syndrome.
4. These cyst are also known to carry satellite
daughter cyst.
5. OKC are known to change to malignant lesion.
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Treatment
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1. Cyst enucleation:
a. With primary closure.
b. With packing of white head varnish.
c. With chemical fixation, Carnoy’s solution.
d. Cryosurgery.
e. Irrigation with 1:5000 perchloride of Hg in Na2CO3.
f. Radical enucleation and packing with cancellous
bone chip.
2. Marsupialization (Partsch’s operation) followed by
enucleation.
3. Resection with bone grafting hemimandibulectomy.

RADICULAR CYST
Synonym
Periodontal cyst, dental cyst, dental root end cyst.
Definition
A radicular cyst is one which arise from the epithelial
128 residues in the periodontal ligament as a result of
inflammation.
 Radicular cyst may be:
a. Periapical periodontal cyst.
b. Lateral periodontal cyst.
c. Residual periodontal cyst.

RETENTION CYST

Mucocele
It is the “mucous extravasation cyst” which occurs because

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

of the pooling of mucous. It does not have any epithelial
lining and is surrounded by compressed connective tissue
cells, in some cases only granulation tissue is present.
Ranula
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Ranula is a term used to describe a thin walled, bluish,

transparent, cyst occurring in the floor of the mouth,
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below the tongue, resembling to a Frog’s belly, because

of this it has been termed as ranula.
GLOBULOMAXILLARY CYST
Nonodontogenic developmental cyst.
The term globulomaxillary is really no longer
appropriate.
• Cyst forms at the junction of the globular portion of
the medial nasal process with maxillary process
between lateral incisor and canine in maxillary region.
• Cyst develops from residual epithelium in the area of
contact of globular process of the frontonasal bone with
the adjacent maxillary process of palatine bone.
Treatment
Cyst enucleation followed by primary closure.
Management of Cystic Lesion
129
1. Marsupialization: Marsupialization of cyst consists of,
surgically producing a window, by removing a generous
 section of the overlying mucoperiosteum and adjacent
cyst wall, to decrease intracystic tension.
2. Cyst enucleation: It is a process in which a complete
removal of a cyst desired.
Possible Various Operative Procedures
1. Enucleation of the cyst and primary closure.
2. Enucleation and open packing.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

a. With removal of the tooth.

b. With tooth conservation.
c. Combined with Caldwell- Luc operation.
d. Combined with fixation of the pathological fracture.
3. Marsupialization or Partsch’s operation and healing
by secondary intention.
4. Combination procedure: Marsupialization followed by
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enucleation after the cavity shrinks.

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ODONTOGENIC TUMOR

Definition
Odontogenic tumors are uncommon lesion that are
derived from the specialized dental tissue.
Ameloblastoma

Synonym
Adamantinoma, adamantoblastoma, multilocular cyst,
neoplastic cyst.
Definition
Ameloblastoma is a true neoplasm of the enamel organ
type tissue which does not undergo differentiation to the
point of enamel formation.
Ameloblastoma is defined as unicentric, nonfunctional,
intermittent in growth, anatomically benign, clinically
130
persistent.
 Ameloblastoma is a tumor arising from embryonal
cells of developing teeth.
Types of Ameloblastoma
a. Intraosseous ameloblastoma (commonest)
b. Extraosseous ameloblastoma (peripheral)
c. Extraoral ameloblastoma.
Histological types of ameloblastoma:
a. Follicular type b. Plexiform type

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c. Acanthomatous type d. Granular cell type
e. Basal cell type
Management: Various treatment modalities are as follows:
1. Curettage involves eradication of the macroscopically
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visible mass of tumor by scraping procedure.

2. Chemical cauterization (Carnoy’s solution, carbolic
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acid).
3. Electrocauterization with electrodesication.
4. En bloc excision (marginal mandibular resection): It
helps in maintaining the continuity of bone at level of
lower border of mandible.
5. Jaw resection (hemimandibulectomy or hemima-
xillectomy).
6. Jaw resection with or without reconstruction.
Odontoma
Definition
These are malformation of the dental tissue of develop-
mental origin. Once they fully calcify, they do not develop
further, produced by the aberrant development of the
dental lamina.
Types of Odontoma
a. Compound composite odontomes has at least superficial
anatomic similarity to normal teeth. The denticles are 131
only smaller than typical teeth inside.
 b. Complex compound odontomes: In this case, calcified
dental tissues are simply an irregular mass bearing
no morphological similarity to normal teeth.
Histological Features
Ghost cells are seen, single roothed denticles, normal
calcified tissues of tooth are seen.
Radiographic Features
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Situated between roots of teeth, appear either as an

irregular mass of calcified material surrounded by a
narrow radiolucent mass with smooth outer periphery
or a variable number of tooth like structure.
Treatment
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Because capsule provides a clear line of separation, thus

is easily enucleated.
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NONODONTOGENIC TUMOR

Osteoma
Osteomas are nonodontogenic beningn tumor which
consists of mature, compact, cancellous bone. Not clear
some appear as true neoplasm of bone while other show
response to trauma or infection.
May be peripheral osteoma and endosteal osteoma.
Treatment

Conservative surgical excision.

Lipoma
The lipoma is a slow growing beningn tumor of adipose
tissue developing anywhere in the oral cavity where fat
tissue is present.
Treatment
132
Surgical excision.
 TEMPOROMANDIBULAR JOINT

Synonym
Jaw joint, mandibular joint, craniomandibular syndrome.
Types of Joint
Condylar variety of synovial joint, atypical synovial joint.
Definition

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Articulation between the mandible and cranium. The TMJ
is the diarthrodial freely movable articulation between
the condyle of the mandible and squamous part of the
temporal bone.
(Diarthrodial joint means joint that are freely movable.
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For example, Arms, Legs, Finger joint).

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Surgical Anatomy

Articulating Surfaces
a. The articulating surfaces of glenoid fossa largely oval.
b. The articular eminence-strongly convex
c. Condyle—four types:
i. Convex condyle ii. Flat condyle
iii. Pointed condyle iv. Bulbous condyle
Ligamentous Structure
a. Articular disk, articular meniscus (interarticular fibro-
cartilage)
b. Articular capsule (capsular ligament)
c. Synovial membrane
d. TM ligament (lateral ligament)
e. Sphenomandibular ligament (Internal ligament)
f. Stylomandibular ligament 133
g. Mandibulo-malleolar ligament (Pinto ligament).
 Blood Supply
• Arterial supply: Blood supply to the joint is through
the internal maxillary artery. Branch of external
carotid artery, principally via its deep auricular artery.
• Venous drainage: Veins of the joint drain to—superficial
temporal vein, maxillary vein, pterygoid plexus of vein.
• Lymphatic drainage: From lateral and anterior surface
drain into—preauricular nodes and parotid nodes. From
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

posterior and medial surface drain into submandibular

nodes.
• Nerve supply: Hilton’s law states that a nerve supplied
a joint also supplies the muscles moving the joint and
skin over the insertions of the same muscles. Anterior
surface supplied by—Masseteric nerve (anterior
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midportion), posterior deep temporal nerve (anterior

lateral portion), posterior surface supplied by—
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Auriculotemporal nerve.

SPECIAL NOTE
Articular cartilage and central portion of the disk— “Does
not have any nerve and blood supply”.

TMJ DISORDER

TMJ Ankylosis
Abnormal immobility and consolidation of joint.
Definition
Intracapsular adhesion or ossification between disk
and temporal articular surface which attach disk condyle
complex to articular eminence is termed ankylosis of TMJ.

Classification of TMJ Ankylosis

a. False (pseudo/fibrous/extra-articular) ankylosis is a
134
chronic condition in which the TM joint is fixed,
 immobilized by flexible soft tissue that may include
the joint capsule, ligaments, tendons, muscles, oral
mucosa and contiguous tissue.
b. True (bony/intracapsular) ankylosis is defined
as immobilization by bony or fibro-osseous union
(consolidation) between the mandible and skull.
Usually between the condyle and glenoid fossa of the
TM joint. Frequently fusion may be between coronoid
process of mandible and the zygoma, mandible and
the maxillary tuberosity.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Types of Ankylosis
a. i. Partial ii. Complete
b. i. Fibrous ii. Bony
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c. i. Intracapsular ii. Extracapsular

d. i. Unilateral ii. Bilateral
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Management of TMJ ankylosis:

a. Aims of treatment: To provide freely movable joint.
b. Concept of surgery: In children—separation of condyle
from glenoid fossa and interpositioning material are
used. In adults—condylectomy and sectioning of the
ramus is preferred.
c. Age for surgery: As early as possible.
d. Different surgical procedure:
i. False ankylosis: Coronoidectomy.
ii. True ankylosis: Condylectomy, menisectomy,
arthroplasty (gap and interpositional), costoch-
ondral grafting in children with temporalis muscle
flap, ear cartilage, etc.
e. Different approach:
i. Preauricular incision.
ii. Alkayat and Bramley incision.
iii. Risdon incision. 135
iv. Postramal incision.
 v. Intraoral retromolar incision.
vi. Bicoronal flap incision.
vii. Inverted hockey stick incision, etc.
f. Structure avoid to damage and care during surgery—
Protection of parotid gland, auriculotemporal nerve,
facial nerve (main trunk), medially maxillary artery.
Myofascial Pain Dysfunction Syndrome (MPDS)
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

MPDS Name given by Laskin

The spasm of the muscles of mastication, joint and face
pain, due to occlusal imbalance. In most cases the
precipitation is either overwork or overstimulation.
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Symptomatology
There are four findings. One or more of which are always
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present.
1. Pain (unilateral).
2. Joint sound (clicking sound).
3. Limitation of jaw movement and deviation of mandible
on opening.
4. Tenderness of masticatory muscle.
Management
Nonsurgical
1. Counseling
2. Occlusal splint
3. Physical therapy
4. Therapeutic exercise
5. Injection therapy (corticosteroid)
6. Denervation procedure (Inj sclerosant—3 percent Na
tetradecylsulfate)
136 7. Medication NSAIDs (Ibuprofen), muscles relaxant
narcotic analgesics (morphine), antidepressant.
 Surgical
High condylectomy, condylotomy, lateral pterygoid muscle
myotomy.
Hypermobility (Subluxation) of TMJ
Definition is characterized by excessive anterior movement
of the codyle, at maximum mouth opening without strain
or symptoms. Moreover, great mobility of the condyle in
all direction.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Treatment
Every efforts must be made to keep the patient jaw at
rest. Advice short-term IMF (10-21 days). Or advice limited
jaw movement. Surgical capsule tightening procedure,
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creation of a mechanical obstacle.

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TMJ Dislocation (TMJ Luxation)

Definition
Forward movement of the condyle in front of the articular
eminence.
Defined as dislocation is complete separation of the
articular surfaces (head of the condyle and glenoid fossa)
with fixation in an abnormal position.
Types
a. Drug associated dislocation.
b. Psychogenic dislocation.
Management
Nonsurgical: Acute dislocation—Relocation of condyle.
Recurrent dislocation:
a. Physical therapy.
b. Symptomatic.
c. Occlusal correction.
Surgical: Anchoring procedure, discectomy condylotomy, 137
condylectomy, myotomy.
 FRACTURE OF MANDIBLE

Definition
Defined as discontinuity on hard bony surface. Radio-
graphically irregular, radiolucent margin on the hard bony
surface.
Etiology
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Traumatic cause violence, RTA, fall on the ground, gun

shoot wound. Pathologic cause—cyst, tumor, infection,
osteoradionecrosis, bone atrophy, etc.
Types of Mandible Fracture
1. Closed or simple fracture.
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2. Compound or open fracture.

3. Comminuted fracture.
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4. Complex or complicated fracture.

5. Multiple fracture.
6. Impacted fracture.
7. Atropic fracture.
8. Pathologic fracture.
9. Green stick fracture.
10. Indirect fracture.
Classification
On the basis of anatomic region (Dingman)
1. Midline: Fracture between central incisors.
2. Parasymphysis: Fracture between distal central incisor
to distal canine.
3. Symphysis: Fracture between distal canine to opposite
distal canine.
4. Body: Distal to canine to distal to third molar (teeth
bearing area).
5. Angle: Distal to 3rd molar region to triangular angle
138 region.
 6. Ramus: Fracture in ramus region (superior to angle
to apex of sigmoid notch).
7. Condylar process: Area of condylar process (superior
to ramus region).
8. Coronoid process: Include the coronoid process
(superior to ramus region).
9. Dentoalveolar process: Region that would normally
contain teeth.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Common Clinical Features of Mandible Fracture
1. Change in occlusion.
2. Anesthesia (paresthesia).
3. Abnormal mandibular movement.
4. Change in facial contour and mandibular arch shape.
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5. Laceration on the chin region.

6. Hematoma formation.
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7. Ecchymosis.
8. Loose teeth.
9. Crepitation on palpation (step deformity).
10. All signs of inflammation present (pain, swelling,
redness, heat, loss of function).

Angle Fracture of Mandible

Key Points
1. The fracture usually result from a blow over
the same side of mandible between the canine
and 2nd molar region.
2. Secondly result from violence to the chin on the
opposite side.
3. Fracture at the angle of mandible are influenced
by medial pterygoid masseter sling. Medial
pterygoid muscle is strongest component.
139
 Classification
Mainly four categories:
1. Vertically favorable angle fracture.
2. Vertically unfavorable angle fracture.
3. Horizontally favorable angle fracture.
4. Horizontally unfavorable angle fracture.
Specific Clinical Features
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

1. Extraoral swelling is present at the angle region.

2. There may be deformity. Intraorally step deformity
behind the last molar.
3. Undisplaced fracture are usually revealed by presence
of Tell—Tale hematoma.
4. Anesthesia or paresthesia of the lower lip on the same
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side.
5. The occlusion is often deranged.
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Condylar Fracture of Mandible

Classification
Proposed by Lindahl
Group 1 Fracture level:
a. Condylar head.
b. Condylar neck.
c. Subcondylar.
Relationship of condylar fragment to the
Group 2
mandible:
i. Undisplaced.
ii. Deviated.
iii. Displaced with medially.
iv. Displacement with laterally.
v. Without contact between the fragment.
Group 3 Relationship of condylar head to fossa:
i. No displacement.
140 ii. Displacement.
iii. Dislocation.
 Key Points
1. Fracture of condyle due to in most cases trauma
to the TMJ region.
2. Occlusal disturbance in most cases.
3. Internal derangement of the TMJ.
4. Most of the cases condylar fracture results in
restricted mouth opening.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Diagnosis of Mandible Fracture
Basically diagnosis based on:
1. History of injury—How injury occurred.
2. Clinical examination (clinical feature—symptoms and
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signs)
a. Extraoral: Local examination (inspection and
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palpation)
b. Intraoral: Local examination (inspection and
palpation).
3. Radiographic examination—Intraoral – IOPA, occlusal
view. Extraoral—Orthopantomograph (OPG), left and
right lateral oblique view of mandible. True lateral
view of mandible, PA view of mandible, CT scan.
Management of Mandible Fracture

Object
i. To avoid infection.
ii. Provide immobilization.
iii. Maintain oral hygiene.
Goal
i. Symmetrical face (normal facial contour).
141
ii. Normal functional activity.
 Treatment is considered in four following headings:
1. First aid treatment:
a. Maintenance of airway.
b. Arrest of hemorrhage.
c. Prevention of shock.
d. Relief of pain and anxiety.
e. Temporary immobilization (barrel bandage,
fourtailed bandage).
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Preliminary treatment at hospital.

a. General care of the patient.
b. Administration of Inj ATS (750–1500 unit).
c. Prevention of dehydration (oral fluid or intravenous)
d. Tracheostomy.
e. Clean the wound thoroughly and dressing.
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f. Temporary immobilization with the help of

periodontal spring.
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g. Control of infection.
3. Final or definite treatment.
a. Reduction of fracture fragment in normal anatomical
position.
b. Fixation of fracture fragment in normal
anatomical position
c. Immobilization of jaw (if required)
i. Reduction of fracture fragment: Reduction is
the process of bringing the fracture fragment
into an alignment.
• Closed reduction: This is a procedure by
which we bring the fracture fragment into
an alignment without exposing the fractured
bone ends.
• Open reduction: This is a procedure we expose
the fractured bone ends and bring them into
an alignment under direct vision. Fracture
142 fragment can be exposed through a lacerated
wound or by planned surgical approach.
 • Different incision (extraorally) for exposure
of the fractured fragment:
– Symphysis region (midline and parasym-
physis) = Submental incision.
– Body and angle of mandible = Submandi-
bular incision.
– Condylar fracture = Preauricular incision
ii. Fixation of fractured fragment:
Indirect skeletal fixation Direct skeletal fixation

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1. Direct interdental wiring 1. Direct wiring or osteosynthesis
2. Indirect interdental wiring 2. Bone plating
(transosseous wiring)
(IVY loop or eyelet wiring)
3. Continuous or multiple loop 3. Intramedullary pinning
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4. Arch bars (Erich, Risdon) 4. Titanium mesh

5. Cap splint 5. Circumferential straps
6. Gunning type splint 6. Bone clamps
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7. Pin fixation 7. Bone staple

8. Bone screw (lag screw)
iii. Immobilization of jaw: The period of immobili-
zation young adult with fracture of angle in
which tooth removed from fracture line = 3
weeks
Tooth retained in fracture line = 3 +1 week
Age 40 years or over = 3+1 (2) week
Fracture at symphysis = 3 + 1 week
Children and adolescent = 3 – 1 week
4. Rehabilitation: Medical, oral and maxillofacial.
To Retrain the Patient for Normal Function
Postoperative complication
i. Infection. ii. Paresthesia.
iii. Nonunion. iv. Malunion.
v. Delayed union. vi. Nerve damage.
vii. Exposure of bone viii. Non-vitality of teeth.
plate /wire. 143
ix. Sequestration of bone. x. Scar formation.
 MAXILLA FRACTURE

Definition of Middle Third of Face

It is defined as an area bounded superiorly by a line drawn
across the skull from zygomaticofrontal suture across the
frontonasal and frontomaxillary to the zygoma ticofrontal
suture of the opposite side and inferiorly by occlusal plane
of the upper teeth. If the patient is edentulous, upper
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

alveolar ridge.
Course of Le-Fort I Fracture (Low Level, Horizontal,
Guerin’s Fracture)
a. Floor of the nose maxilla
b. Lower 3rd of patient pterygoid plate
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c. Palate
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Course of Le-Fort II Fracture (Pyramidal Fracture)

Fracture line traverses from thin portion of frontal process
and extend laterally through lacrimal bone and floor of
the orbit, zygomaticomaxillary suture. Infraorbital
foramen and continue through lateral wall of maxilla
through pterygoid plate into pterygomaxillary fossa.
Course of Le-Fort III (Suprazygomatic, High Level
Fracture, Craniofacial Disjunction)
These essentially runs parallel to the base of the skull—
Nasofrontal suture, floor of the orbit, zygomaticofrontal
suture, zygomatic arch.
Le-Fort IV Fracture
Pure frontal bone fracture.
Treatment
Main four stages of treatment.
1. First aid and resuscitation.
144
2. Initial assessment.
 3. Definite treatment.
4. Rehabilitation.
Definite Treatment
Four main essentials to decide before operative procedure:
1. Type of fixation required (internal/external)
2. Need for open reduction.
3. Type of IMF required.
4. The need for tracheostomy.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Operative Procedure
Logical sequence as follows:
1. Tracheostomy.
2. Facial laceration.
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3. Reduction of associated mandibular fracture.

4. The occlusion.
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5. Zygomatic fracture.
6. Disimpaction and reduction of the maxilla.
7. Open reduction.
8. Skeletal fixation.
9. Temporary intermaxillary fixation.
10. Nasal fracture.
11. Definitive IMF.

ZYGOMATIC COMPLEX FRACTURE

The high incidence is due to zygomas prominent position.
Gross Anatomy
Two Surfaces
a. Outer surface (convex) towards cheek.
b. Inner surface (concave).
Four Processes
1. Frontal. 2. Temporal.
145
3. Orbital. 4. Maxillary process.
 Articulate with Four Bones
1. Frontal. 2. Temporal.
3. Sphenoid. 4. Maxillary bone.
Zygomatic Complex Fracture
Zygoma (molar bone), zygomatic arch.
Three Suture Lines
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Frontozygomatic, zygomaticomaxillary, zygomati-

cotemporal.
Clinical Complication
Asymmetrical face, diplopia, partial trismus, periorbital
ecchymosis, edema and hematoma.
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Radiograph
PNS view, submentovertex view (jug handle view mainly
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for zygomatic arch fracture), PA view of skull.

Management of Zygomatic Complex Fracture
Purpose or Aims of Treatment
1. To restore the normal contour of the face for cosmetic
reason.
2. To restablish the skeletal protection for the globe of
the eye.
3. To correct diplopia.
4. To remove any interference with the range of
movement of the mandible.
Definitive Treatment
1. Reduction of fracture fragment in normal anatomical
structure.
a. By extraoral Gillie’s temporal approach.
b. By intraoral buccal sulcus approach.
146 c. Technique of lateral coronoid approach.
d. Elevation from eyebrow approach.
 e. Percutaneous technique.
f. Intrasinus approach.
2. Fixation of fracture fragment—if required.
a. Internal fixation by bone plate.
b. Internal fixation by wire osteosynthesis.
c. Internal fixation by—transfacial, transnasal, oblique
K wire technique.
d. External fixation either by wire or pin (Toller pin).
Different Incision for Zygomatic Complex Fracture

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a. Periorbital incision—infraorbital incision, lower lid
incision, supraorbital incision.
b. Alkayat and bramley incision.
c. Coronal incision (Bifrontal flap).
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Complication of Zygomatic Complex and Arch Fracture

a. Functional ophthalmic disturbances.
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b. Esthetic or cosmetic deformities.

c. Neurosensory deficiencies.
d. Masticatory compromise.

ORBITAL FRACTURE
Orbital fracture can be discussed as:
a. Fracture of orbital rim.
b. Fracture of orbital wall.
c. Blowout fracture.
d. Blow-in fracture.
• Blowout fracture: Fracture of orbital floor into the
maxillary antrum without the involvement of the orbital
rim is called as pure orbital blowout fracture.
If orbital rim is involved known as impure orbital
blowout fracture.
• Blow-in fracture: If the posterior section of the orbital
wall which consists of comparatively thinner lateral
wall, roof and floor. These are prone to fracture inwardly, 147
known as blow-in fracture.
 • Treatment: The treatment of blowout fracture has
much controversy. The surgical intervention should
be undertaken if both radiographic and forced duction
test indicate a blowout fracture with entrapment.
Treatment of blow-in fracture is immediate
decompression and reconstruction is necessary for a
blow-in fracture. In case of minimum displacement,
no treatment is required.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

DIPLOPIA
• Synonym: Double vision, binocular polyopia, amblyopia
• Definition: The perception of two images of a single
object.
• Diagnostic test: Checked by forced duction test with
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the help of tooth dissecting forcep (inferior rectal

muscle mainly involved).
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Types of Diplopia
• Monocular: It is unusual and traumatic origin
possibility of retinal detachment.
• Binocular: Due to decrease or imbalance of extraocular
muscle function.
• Incidence of diplopia: May be seen in Le-Fort II and
Le-Fort III fractures, zygomaticocomplex fracture,
blowout fracture, naso-orbital ethmoidal fracture, floor
and medial surface of orbital fracture.
• Management: If condition due to edema and hemo-
rrhage resolve within a week spontaneously, otherwise
surgical intervention required.

CSF RHINORRHEA

Definition
Discharge of CSF through the nose due to skeletal
148 disruption in the base of the anterior cranial fossa, produce
CSF rhinorrhea.
 Discharge of CSF through the ear due to skeletal
disruption in the base of middle and posterior cranial
fossa produce CSF otorrhea.
• Incidence: Le-Fort II fracture, Le-Fort III fracture,
nasal fracture, nasoethmoidal complex fracture.
• Clinical features: Clear fluid leaks from nose, anosmia,
loss of light touch on face, supraorbital paresthesia,
local damage to the skull, scalp and ear, deafness,
tinnitus, vertigo, facial palsy.

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• Diagnosis: With the help of handkerchief test—if the
fluid collected on the handkerchief is truly CSF in
origin, there will be a homogeneous ring and no
stiffening of material. If the leakage is serous or mucous
secretion there will be several rings or stiffening of clot.
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• Treatment: Prophylactic antibiotic (sulphonamide can

cross blood-brain barrier). Surgical repair of traumatic
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region.

TRACHEOSTOMY

Definition
Tracheostomy is a surgical opening made in the anterior
wall of the trachea. It is often performed as a lifesaving
procedure. Usually performed at the level of 2nd, 3rd,
4th tracheal ring. Tracheostomy is performed
immediately below the isthmus of the thyroid gland
appears to be the most satisfactory.
Classification of Tracheostomy
A. i. Emergency tracheostomy.
ii. Elective tracheostomy.
B. i. Temporary tracheostomy.
ii. Permanent tracheostomy.
C. i. High tracheostomy.
ii. Mid tracheostomy. 149
iii. Low tracheostomy.
 Function of Tracheostomy
1. Reduce the anatomical dead space by 30 to 50 percent
2. Relieves upper airway obstruction.
3. Reduces airflow resistance.
4. Provide access for toilet of tracheobronchial tree.
5. Protects against aspiration.
6. Allows positive pressure ventilation.
7. Relieves alveolar hypoventilation in pulmonary
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

disease.
8. Provides pathway to deliver medication or humi-
dification.
Indication
1. Laryngeal indication—congenital, traumatic,
inflammatory, neoplasm, neurological, laryngeal
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edema, laryngeal stenosis, extrinsic obstruction.

2. Tracheobronchial indication—tracheobronchial toilet,
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foreign body.
3. Pulmonary causes.
Complication
1. Immediate: Bleeding, damage to the esophagus, dome
of pleura, anesthetic complication (cardiac and
respiratory arrest), failure to establish respiration.
2. Delayed complication: Bleeding, delayed tracheoeso-
phageal fistula, pneumothorax, surgical emphysema,
tracheobronchial infection, dysphagia.
3. Late complication: Laryngeal and tracheal stenosis,
difficulty in decannulation.
SALIVARY GLAND DISEASE AND TUMOR
Saliva is the fluid released into the oral cavity by the
salivary duct and it is the result of secretion and excretion.
Sialadenitis
150 Any acute inflammation of salivary gland is termed as
acute sialadenitis.
 Any of the acute salivary gland infection may become
chronic, most frequently, it occurs behind and obstruction
that has produced long period of stasis is termed as
chronic sialadenitis
Sialolithiasis
Sialolithiasis: It denotes the presence of stone in a salivary
gland. This is generally due to accretion of mineral salt
in an around a soft plug of mucous and bacteria.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Pleomorphic Adenoma (Bizzare Tumor)
Salivary gland tumor.
Definition
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Tumor of salivary glands constitute a heterogeneous

group of lesions of great morphologic variation.
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Its morphologic complexity is the result of the differen-

tiation of the tumor cells and the fibrous, hyalinized and
myxoid, chondroid and even osseous are the result of
metaplasia.
Characterizes closely the unusual histologic pattern
of the lesion and derived from more than one primary
tissue.
Diagnostic Aids in Salivary Gland Tumor
1. Sialography
2. CT scanning
3. Ultrasonogram
4. Radionuclide images
5. Fine needle aspiration
6. Frozen section
7. Open biopsy
8. Classic biopsy (superficial)
151
9. Incisional intraoral biopsy.
 Management
Surgical procedure known as parotidectomy with the help
of Gutiérrez incision.
Complications of Surgical Procedure
a. Facial palsy
b. Frey’s syndrome (sweating of the face)
c. Salivary fistula
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

d. Numbness of preauricular tissue

e. Active hemorrhage
f. Devascularization
Frey’s Syndrome
Synonym
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Gustatory sweating, auriculotemporal syndrome.

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Definition
Syndrome is a complex of symptoms that include localized
facial sweating of the upper cheek, temporal, forehead
and flushing during mastication of food.
Diagnosis
The area of gustatory can be objectively documented by
performing the minor starch iodine test. This involves
painting the skin on the face with a solution of 3 gm of
iodine, 20 gm of castor oil and 200 ml of absolute alcohol.
Once this solution dries the painted area, is dusted
with starch powder. The patient is asked to chew a lemon
slice for 2 minutes to produce a salivary response. The
affected area produce dark, blue, black spots.
Treatment
The most promising approach is to use of glycopyrrolate
prepared as 1 percent Rolon’s solution. Surgical—
tympanic neurectomy, subdermal insertion of fascia lata
152
graft, rotation of sternocleidomastoid muscle.
 Salivary Fistula
Fistula is rare postoperative complication defined as an
abnormal pathway through which saliva exits to the skin
or mucosal surface.
Types of Fistula
i. External fistula: Present as draining tract on the skin
surface.
ii. Internal fistula: Discharge of the saliva into the oral

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

cavity.
Treatment
Salivary fistula close spontaneously in 10 to 14 days. Big
fistula requires repair of capsule of the gland.
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In case of fistula persist partial removal of gland may

require suture with vicryl. A method of eliminating the
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source of salivary drainage. In case of infection antibiotic

advised. Atropine in small repeated doses advised.
Sialography
Sialography is a valuable aid in the diagnosis and
management of the disease of the salivary gland.
Definition
Sialography is a roentgenographic visualization of the
ductal system of the two of the paired, major salivary
gland, parotid and submandibular gland (because
multiductal anatomy of sublingual gland does not well to
this examination).
Indications
1. Detection of calculus and foreign body.
2. Detection of fistula.
3. Detection and diagnosis of recurrent swelling. 153
4. Detection of residual stone.
 5. Determination of tumor.
6. Determination of cyst.
7. Determination of extent of destruction of gland.
Contraindications
1. Patient is known sensitive to iodine compound.
2. During the period of acute inflammation of salivary
system.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Contrast Media
Two types of contrast:
i. Water soluble contrast media. For example, Hypaque,
sinograph, isopaque.
ii. Fat soluble or oil based. For example, Ethiodol,
Pantopaque.
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Procedure
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Mainly three phases:

1. Primary film evaluation.
2. The injection or filling phase.
3. The parenchymal phase (in water soluble media) or
evacution phase in fat soluble media.
Sialography in different condition
a. Sjögren’s syndrome: Cherry blossom appearance
(uniform collection).
b. In case of sialocholecystis: Pruned tree appearance-
strings of sausage.
c. In case of sialosis: Ball in hand configuration.
d. Post-traumatic lesion: Fistulas communication.

PREPROSTHETIC SURGERY

Definition
It is the surgical procedures in the making the alveolar
154
process suitable to receive prosthesis.
 Aims of Surgery
Aims to restore the functional, esthetic portion that have
being lost or completely absent.
a. To eliminate disease.
b. To conserve the oral structure.
c. To provide the best residual tissues to withstand
masticatory stresses.
d. To maintain function.
e. To retain esthetics for the denture patient.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Surgical Procedures
1. Augmentation
a. Onlay
b. Interpositional.
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2. Vestibuloplasties.
3. Implants.
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4. Any combination of augmentation, vestibuloplasties

and implants.

Corrective Surgical Procedures

Primary preparation
a. Soft tissue deformity: For example, ankyloglossia,
double lip, labial frenectomy, etc.
b. Hard tissue deformity: For example, alveoloplasty,
torus palatines, exostosis.
Alveoloplasty (Alveolectomy)
Definition
Defined as excision of a portion of the alveolar process.
Goal
The immediate goal in performing alveoloplasty is to
provide optimal ridge contour quickly, permitting early
155
construction of a well fitting and comfortable denture.
 Types of Alveoloplasty
1. Alveolar compression.
2. Simple alveoloplasty.
3. Labial and buccal cortical alveoloplasty.
4. Intercortical “Interseptal” alveoloplasty.
5. Reduction of the knife edge ridge.
6. Reduction of the mylohyoid ridge.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

7. Reduction of lingual alveolar crest.

8. Elimination of labial mandibular undercut.

VESTIBULOPLASTY

Synonym
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Ridge extension/sulcoplasty/sulcus extension.

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Definition
Vestibuloplasty is the surgical procedure where by oral
vestibule is deepened by changing the soft tissue
attachment. Vestibuloplasty is a relative ridge augmentation.
Purpose
Its purpose is to make more of the residual ridge, available
for use of a denture bearing surface.
Classification
A. By extent:
a. Total (full ridge).
b. Partial (segment of ridge).
B. By dissection:
a. Open (supraperiosteal).
b. Closed (supraperiosteal).
C. By healing:
a. Secondary re-epithelization.
156
b. Covering graft.
 D. Modification:
a. Lowering floor of mouth.
b. Buccal inlay technique.
E. By stability of result :
a. Split thickness skin graft.
b. Free mucosal graft.
c. Pedicaled mucosal graft.
d. Secondary re-epithelization.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Contraindications
• Absolute: Pregnancy, untreatable granulocytopenia
• Relative: Hemophilia, leukemia, malignancy, Marfan’s
syndrome, etc.
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Ankyloglossia (Tongue Tie)

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One of the soft tissue corrective surgical procedure. In

this condition patient (most often in children) unable to
move the tip of the tongue adequately.
The lingual frenum may consist of a fold of mucous
membrane or it may contain a dense fibrous septum that
binds the tip of the tongue to the alveolus process that
restricts movement of the tongue.

Treatment
Lingual frenectomy is indicated.
Torus Palatinus
Definition
Non-odontogenic benign tumor. The torus palatinus is a
slowly growing flat based bony protuberance which occurs
in midline of the hard palate or palatal torus is a sessile,
nodular mass of bone that presents along the midline of 157
the hard palate.
 Treatment
It is benign, which never becomes malignant, surgical
removal is indicated in case of big size and shape.
Torus Mandibularis
Composed of dense cortical bone, minimal medullary core,
mainly mandibular canine-premolar region bilaterally,
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

body, alveolar process.

Treatment
Removal of tori.

BIOPSY
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Definition
• Biopsy is the removal of a living tissue specimen either
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totally or partially for microscopic examination and

diagnosis.
• Autopsy is the termed used to indicate removal of
tissue from a dead body.
Types of Biopsy
1. Soft tissue biopsy.
2. Hard tissue biopsy.
3. Open tissue biopsy.
4. Oral cytology.
Types of Soft and Hard Tissue Biopsy
1. Excisional biopsy: It is indicated for smaller lesion (less
than 1 cm in size). It is removal of entire lesion. Lesion
appears to be benign.
2. Incisional biopsy: It is indicated in case of extensive
size (more than 1 cm in size).
3. Exploratory biopsy.
158
4. Punch biopsy.
 5. Needle biopsy.
6. Curettage biopsy.
7. Unplanned biopsy.
8. Open tissue biopsy.
Indication for Biopsy
1. Any lesion that persists for more than 2 weeks.
2. Any inflammatory lesion that does not respond to local
treatment.
3. Persistent hyperkeratotic changes in surface tissue.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

4. Any persistent tissue is either visible or palpable below
the normal tissue.
5. Inflammatory changes of unknown cause that persist
for long time.
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6. Lesion that interferes with local function.

7. Bone lesion is not identified by clinical and radiographic
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finding.
8. Any lesion that has characterstic of malignancy.
Contraindications
1. Normal anatomic variation. Example, linea alba.
2. Lesion caused by recent trauma.
3. Acute /subacute inflammatory lesion.
4. Vascular lesion. Example, hemangioma.
5. Radiolucent lesion without initial aspiration.
Complications
1. Spreading of tumor cell.
2. May cause infection and hemorrhage.
3. Complication due to LA.

PRECANCEROUS LESION

Definition
Defined as morphologically altered in which cancer is
more likely to occur than in its apparently normal 159
counterpart.
 Types
1. Oral submucous fibrosis (OSMF).
2. Leukoplakia.
3. Erosive lichen planus.
4. Erythroplakia.
5. Leukoedema.
6. Syphilitic glossitis.
7. Oral hairy leukoplakia.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Oral Submucous Fibrosis (Atropia Idiopathic

Mucosa Oris)
OSMF is a chronic, insidious, disabling disease involving
oral mucosa, oropharynx and larynx. The disease is
characterized by blanching and stiffness of the oral
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mucosa, trismus, a burning sensation of the mouth,

hypomobility of the soft palate and tongue, loss of
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gustatory sensation, mild hearing impairment.

The pinborg defined the disease: An insidious, chronic
disease affecting the any part of the oral cavity and some
times oropharynx. OSMF is a slowly progressive disease
in which fibrous bands form in the oral mucosa.
OSMF is always associated with a—Juxtaepithelial
inflammatory reaction followed by a fibroelastic change of
the lamina propia with epithelia atropia leading to stiffness
of the oral mucosa and causing trismus and inability to
eat.
The mucosa becomes blanched, opaque, leather like
showing typical fibrous which extends from the pharynx
to retromolar area and pterygomandibular area even
extending to the lips involving the palate.
Etiology
1. Strong irritating spice. 2. Chillies.
3. Tobacco. 4. Vitamin B deficiency.
160 5. Protein deficiency. 6. Betel nut and areca nut.
7. Malnutrition.
 Classification
On the basis of clinical grading of severity:
1. Grade I: Incipient—Very early stage.
2. Grade II: Mild—Early stage.
3. Grade III: Moderate—Moderately advanced stage.
4. Grade IV: Severe—Advanced stage.
Common Sites
Buccal mucosa, soft palate, lips, tongue.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Treatment
1. Restriction of habit.
2. Local injection of fibrinolytic agent (hyaluranidase).
3. Corticosteroid.
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4. High dose of vitamins A, D and iodides.

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Surgical
1. Excision of fibrous bands followed by buccal pad of fat.
2. Nasolabial flap. 3. Skin grafting.
4. Placental graft. 5. Lingual pedicled flap.
6. Local injection of dexona.
Leukoplakia (Idiopathic Leukokeratosis)
The term leukoplakia is indicated by a keratotic patch or
plug occurring on the surface of mucous membrane which
will not rub or strip off.
Etiology
1. Tobacco. 2. Alcohol.
3. Vitamin deficiency. 4. Oral sepsis.
5. Syphilis, etc.
Site
1. Buccal mucosa. 2. Retromolar area.
3. Palate. 4. Lip. 161
5. Cheek. 6. Tongue.
 Treatment
Administration of vitamin A,B complex, topical
chemotherapy.
Surgical
Excision, skin grafting, cryosurgery.

ORAL CANCER
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Most common carcinoma is squamous cell carcinoma.

Ninety percent of all oral malignancy.
This is malignant tumor of ecto- or endodermal origin,
commonly as oral cancer.
Etiology
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1. Dental factor: Poor oral hygiene, faulty restoration,

ill fitting denture.
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2. Other factor: Tobacco, alcohol, trauma, sepsis,

constant irritation, etc.
Common Site
1. Lip.
2. Buccal mucosa.
3. Gingiva.
4. Alveolar ridge.
5. Floor of mouth.
Staging of Oral Cancer
(TNM) (T = Tumor, N = Nodes, M = Metastasis)
Stage I T1 N0, N1a, N2a M0
Stage II T2 N0, N1a, N2a M0
Stage III T3 N0, N1a, N2a M0
Stage IV Any T N1b, Any N2b, N3, Any N M1

Diagnosis
1. Extraoral and intraoral inspection and palpation.
162 2. Invasive—Biopsy.
 3. Noninvasive—X-ray.
4. Lab finding.
Treatment Modalities
1. Surgical excision. 2. Radiation therapy.
3. Chemotherapy. 4. Cryosurgery.
5. Laser excision. 6. Immunotherapy.
Surgical Management
1. Excision of small localized superficial lesion using a

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electrocautery followed by primary closure.
2. Wide excision followed by skin grafting.
3. Partial or total glossectomy in case of wide involve-
ment of tongue.
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4. Marginal, segmental or complete resection of mandible.

5. Regional lymph node dissection of neck, radical neck
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dissection or—commando operation.

CLEFT PALATE AND CLEFT LIP

The meaning of a cleft is a fissure or split or gap. Cleft
lip and cleft palate are congenital deformities that are
manifested at birth.
Etiology
1. Hereditary on the genetic basis.
2. Environmental influences: For example, viral
infection, exposure to radiation, influence of drugs,
deficiency of vitamins A and B, anemia, stress,
maternal age, anorexia, etc.
Classification
Davis and Ritchie divided into three groups:
1. Prealveolar cleft (uni/bilateral).
2. Post alveolar cleft.
3. Complete alveolar cleft (uni/bilateral). 163
 Professor Balkrishnan has modified and his classification
is as follows:
Cleft of lip alone (complete, incomplete,
Group 1
subsurface, unilateral, bilateral).
Cleft of palate alone (hard and soft palate only,
Group 2
submucous cleft).
Group 3 Cleft of lip, alveolus and palate (uni/bilateral).
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Treatment
Goal
Increase survival rate, improved overall function, improve
esthetic, better social acceptance and social acceptance.
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Aims and Object

1. To correct the birth defect.
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2. To correct the dentition.

3. To allow normal function and esthetic.
Repair of Cleft Lip
The two most popular methods are:
1. Milliard’s rotation advancement principle.
2. Triangular flap repair of tension by Balkrishnan.
Repair of Cleft Palate
The two main popular techniques are:
1. Von Langenbeck technique.
2. Veau Wardill Kilner palatoplasty.

DENTAL IMPLANT

Definition
Dental implantology involves insertion of prosthesis into
164
jaw as a replacement to natural teeth. It is expected to
behave similar to natural teeth.
 Classification
1. According to the relationship to bone
a. Endosteal implant.
b. Subperiosteal implant.
c. Transosteal implant.
2. According to implant tissue interface
a. Direct interface implant.
b. Indirect interface implant.

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3. According to functional performance of implant
a. Retentive implant.
b. Supportive implant.
Indication of Implant
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1. Single missing tooth replacement.

2. Multiple missing teeth replacement.
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3. Partially edentulous patient.

4. Completely edentulous patient.
5. As a replacement for a one edentulous jaw.
6. Patient who refuse to wear removable prosthesis.
7. Poor neuromuscular coordination.
8. Hyperactive gaggin reflex.
Contraindications
1. Patient with all systemic problem.
2. Patient with hypersensitivity to implant component.
3. Lack of maintenance of good oral hygiene.
Criteria for Successful Implant
1. Implant should be immobilized.
2. No evidence of any peri-implant radiolucency.
3. The mean vertical bone loss should be less than
0.2 mm annually after the first year of service.
4. There should be no persistent pain, discomfort and 165
infection.
 Complication
1. Morbidity of the implant due to faulty insertion
technique.
2. Mucosal perforation.
3. Exposure of implant.

ORTHOGNATHIC SURGERY
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Orthognathic (Ortho = straight, Gnathic = Jaw) surgery

includes to change the deform face from distortion to
proportion and disharmony to harmony.
Definition
The surgical correction of the deformities of the jaw, that
present malocclusion of the jaw and associated facial
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disfigurement constitute orthognathic surgery.

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Developmental jaw deformities are:

1. Mandibular prognathism: Forwardly placed mandible.
2. Retrognathism: Retruded jaw (micrognathism).
3. Hypoplasia (small jaw).
4. Laterognathism (either unilateral mandibular hyper-
or hypoplasia).
5. Hemihyperplasia.
6. Microgenia (small retruded chin).
7. Macrogenia (large protruded chin).
8. Condylar hypoplasia.
9. Condylar hyperplasia.
10. Benign masseteric hypertropic.

Mandibular Prognathism

Definition
The lower jaw projecting too far forward when mouth is
shut which is attended with inconvenience in disfiguring
166
the face.
 Treatment
Mainly three surgical sites:
1. Osteotomy in the condylar neck.
2. Osteotomy in the body of the mandible.
3. Osteotomy of the ramus. (horizontal, vertical, vertical
oblique).
4. Vertical sagittal split osteotomy.
Mandibular Retrusion (Retrognathism)

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Definition: One of the skeletal dentofacial deformities. In
such deformities, deficiency of mandibular growth occurs.
Treatment
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Sagittal split osteotomy.

Apertognathia (Open Bite)
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Definition: Condition in which space remains between the

maxillary and mandibular teeth when some teeth are in
contact at one or more point.

Cephalometric analysis for open bite:

1. Jaraback’s analysis.
2. The delaire analysis.
3. Soft tissue analysis.
Treatment
Goal of Treatment
The improvement of the:
a. Occlusion b. Appearance
c. Tongue function d. Speech
Modalities are:
1. Orthodontic treatment.
2. Anterior segmental dentoalveolar osteotomy of the 167
mandible.
 3. Ramus osteotomy.
4. Anterior segmental dentoalveolar osteotomy of the
maxilla.
5. Posterior segmental osteotomy of the maxilla.
6. Total maxillary osteotomy.
7. Tongue reduction.
8. Genioplasty.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

9. Bimaxillary operation.
10. Le-Fort II osteotomy.

Genioplasty
Definition: A surgical procedure designed to reshape the
contour of the chin usually by augmentation or reduction.
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Types of Genioplasty
1. Sliding genioplasty.
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2. Reduction genioplasty.
3. Jumping genioplasty.
4. Genioplasty with interpositioning bone graft.
5. Centering genioplasty.
6. Two tired genioplasty.

Sagittal Split Osteotomy (a surgical procedure)

Obwegeser and Turner (1957) developed this procedure.
This is a very popular most versatile performed on the
mandibular ramus and body, which can be employed for
the correction of retrognathism and prognathism.
It avoids an external scar and injury to the marginal
mandibular nerve.
Postoperative care: Edema may be expected, usually
Resolves within a two weeks times. Intraoperatively
administration of corticosteroid helps to control the post-
operative edema.
168
 PREMEDICATION (PREANESTHETIC MEDICATION)

Definition
It can be defined as preliminary medication, drug with specific
pharmacological action administered preoperatively with
specific goals to achieve.
Objective of Premedication
1. Relieve of anxiety.

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2. Sedation.
3. Analgesia.
4. Amnesia of perioperative events.
5. Reduction of stomach acidity and volume.
6. Antisialogogue effect.
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7. Prevention of nausea and vomiting.

8. Facilitation of anesthetic induction.
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9. Prophylaxis against allergies.

10. Vasolytic action.
Route of Administration
Oral, rectal, intranasal, sublingual, intramuscular and
intravenous administration.
1. As sedative and hypnotic agent:
i. Benzodiazepine (diazepam, midazolam).
ii. Barbiturates (secobarbitol, pantobarbitol).
2. Antiemetic, sedative and antisialogogue: Phenergan.
3. Sedative and antiemetic: Vellargan.
4. Antihistamine: Diphenhydramine (benadryl).
5. Analgesic: Morphine, pethidine.
6. Vagolytic effect and antisialgogue: Atropine, glycopyr-
olate.
7. Sedative and amnesia: Scopolamine.
8. Antacid, antiemetic, aspiration prophylaxis-ranitidine. 169
 GENERAL ANESTHESIA

Definition
The term anesthesia means loss of sensation. General
anesthetic are the agents which brings about loss of all
modalities of sensation particularly pain, along with a
reversible loss of consciousness.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Classification
Inhalation general anesthetic:
1. Volatile liquid 2. Gases
a. Chloroform. a. Cyclopropane.
b. Diethyl ether. b. Nitrous oxide.
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c. Ethyl chloride.
d. Trichloroethylene.
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e. Halothane.
Nonvolatile general anesthetics (intravenous anesthetics)
1. Ultra short acting 2. Nonbarbiturates
barbiturates
a. Thiopental sodium a. Ketamine
(methohexital) b. Propanidide
Stages of General Anesthesia
1. Stage of analgesia.
2. Stage of delerium or excitement.
3. Stage of surgical anesthesia (plane I, plane II,
plane III, plane IV).
4. Stage of respiratory paralysis.
Methods of Administration of General Anesthetic Agent
A. Open method (open drop procedure).
B. Semi open method.
170
C. Semi closed method.
D. Closed method.
 Complication of General Anesthesia
1. Complication associated with IV injection—hematoma,
extravenous injection, venous thrombosis, intra-arterial
injection, nerve damage.
2. Complication associated with endrotracheal intubation—
for example, trauma to the teeth and soft tissue,
bleeding, inhalation of gastric contents, intubation of
the right bronchus, postoperative sore throat, muscle
pain.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

3. Cardiovascular complication—for example, hypotension
(due to posture, vasovagal attack, pre-existing medical
disease) cardiac arrhythmias, cardiac arrest.
4. Respiratory complication for example, respiratory
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depression (due to inadequate cerebral perfusion)

respiratory obstruction (due to tongue falling back,
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presence of enlarged tonsil) laryngeal edema (due to

hypoxemia or irritation of larynx, foreign material),
aspiration of foreign material into the tracheobronchial
tract).
5. Neurological complication—for example, delayed
recovery, convulsion.
6. Allergic responses—These are characterized by:
“Hypotension, bronchoconstriction, blochy cyanosis”.

DISTRACTION OSTEOGENESIS OR CALLOTASIS

Introduction
Distraction osteogenesis is a slow application of force to
the bone cut thereby widening the gap resulting in
production of new bone as well as soft tissue.
A Russian scientist designed a scientific protocol on
human bone lengthening and gave the principles of
171
“ Law of tension stress”.
 Definition with Explanation
This is a simple technique in which a corticotomy and
osteotomy is created in the deficient part of bone and a
distractor is then applied.
The distractor is then activated daily, advancing the
bone segment 1 mm, to induce the formation of new bone
and soft tissue.
The newly created bone is formed in the distracted
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

gap which is then allowed to ossify.

Merits of Distraction Osteogenesis
1. Relatively simple operative technique.
2. Lengthening of bone and soft tissue.
3. Good long-term stability.
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4. Potential for growth in children.

5. Avoidance of bone graft.
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6. Expanded bone is of high quality.

7. Multidimensional distraction.
8. Results are apparently early.
Drawbacks of Distraction Osteogenesis
1. Skin scars with extraoral devices.
2. Damage to facial nerve.
3. Damage to inferior alveolar nerve.
4. Damage to tooth germ.
5. Transient changes to TMJ.
6. Infection.
7. Nonunion / inadequate bone formation.
8. Device failure.
Classification of Treatment Modalities
1. To lengthen the mandible.
2. To advance midface/maxilla.
3. Bone segment transportation (bifocal distraction
172 treatment).
 4. Trifocal distraction treatment.
5. Distraction for alveolar augmentation procedure.
6. Distraction implantology.
Basic Principles of Distraction Osteogenesis
1. Preservation of blood supply.
2. Close apposition of cut bone surfaces to allow early
bridge formation.
3. Gradual distraction at regular rhythm.

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Selection of Patient for Distraction Osteogenesis
1. Age of the patient.
2. Severity of anatomical malformation.
3. Potential for bone growth depending on the etiology.
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4. Functional and esthetic effect.

5. Psychological consideration.
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Types of Distraction
Can be classified as:
a. Extraoral distractor devices.
b. Intraoral distractor devices.
c. Subcutaneous internal buried devices (for cranial /mid
face distractor).
Surgical Technique
1. Anesthesia.
2. Incision and exposure.
3. Planning of osteotomy.
4. Device positioning.
5. Corticotomy/osteotomy (buccal aspect).
6. Corticotomy/osteotomy (lingual aspect).
7. Device fixation.
8. Device inspection.
9. Device closure.
10. Incision closure. 173
 CRYOSURGERY

Definition
It is the clinical application of extreme low temperature
(at least—15°C) to achieve tissue destruction.
Advantages
1. Cryosurgery is simple procedure.
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

2. Inexpensive procedure.
3. Carried out without special procedure.
4. Healing is excellent.
5. Minimal scarring.
Disadvantages
1. In pharyngeal cancer, death may be due to aspiration.
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2. Carefully in aged patients.

3. Limited vision.
For Personal Use Only

4. Pain, edema and inflammation.

5. Neuropathy.
Indications
1. In treatment of malignant soft tissue lesions of oral
cavity.
a. Oral tumor
i. Carcinoma in situ.
ii. Leukoplakia.
b. Oral cancer—At primary stage.
2. Pharyngeal cancer.
3. In treatment of tumor of face and scalp, e.g. tumor of
nose, eyelid, ear.
4. In treatment of brain tumor.
5. Vascular anomalies—Hemangioma.
6. Ameloblastoma.
7. Giant cell lesion.
174 8. Aneurysmal bone cyst.
9. Benign neoplasm of bone.
 10. Pyogenic granuloma.
11. Cataract and other ocular problem.
12. Lymphangioma.
13. Odontogenic keratocyst.
14. In chronic lip fibroma.
15. In case of chronic facial pain.
16. In case of idiopathic trigeminal neuralgia.
Technique

CHAPTER FIVE: BASIC READING IN ORAL SURGERY

Two basic techniques:
1. Closed system with probes for application to the tissues
(-80ºC).
2. By spraying liquid nitrogen directly on the tissues
(-196ºC).
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Conclusion
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Cryosurgery has the greatest application and versality

in oral and maxillofacial surgery.

175
 CHAPTER
RO LE OF RADIOGRAPHY
ROLE RA I RA PH
RAPH
6 IN
I ORAL
RALLAND MAXILLO-
RA
FFACIAL
AXILLO-
AX
CIAL SURGERY
S RGE
RGERR
ILLO-

INTRODUCTION
Roentgenography is one of the noninvasive, single most
important diagnostic aid on which the treatment plan is
based (helpful in accurate evaluation of a variety of
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problems pertaining to oral surgery).

For Personal Use Only

INTRAORAL RADIOGRAPHS
1. Intraoral periapical view
2. Occlusal view
3. Bitewing film.

Intraoral Periapical (IOPA) View

Helps to visualize individual teeth and the tissue around
apices.
Indications
1. Studying impacted third molar.
2. Understanding periapical infection.
3. Relation of maxillary sinus to teeth.
4. Localizing fracture or remanent root piece.
5. Differentiating between cystic or tumorous lesions.
6. Evaluation of dentoalveolar trauma.
7. Implantology.
8. During endodontic and periapical surgery.
 9. Localizing foreign bodies in interdental and periodontal
region.
Advantages
Excellent view of teeth and periapical region with minimal

CHAPTER SIX: ROLE OF RADIOGRAPHY IN ORAL AND MAXILLOFACIAL SURGERY

distortion.
Disadvantages
1. It cannot be used in case of reduced mouth opening.
2. It is not useful in case of extensive lesion.

Occlusal View
Areas best appreciated in occlusal view of mandible are:
1. Floor of mouth.
2. Lingual aspect of mandible.
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3. Lower arch contour and continuity.

Areas best appreciated in occlusal view of maxilla are:
For Personal Use Only

1. Hard palate.
2. Contour and continuity of upper arch.
Indications in Oral Surgery
1. Localized foreign bodies.
2. To evaluate unerupted tooth or impacted tooth.
3. To evaluate residual root.
4. To evaluate salivary stone.
5. To evaluate implants.
6. Determine the extent of tumor and cyst.
7. To determine extent of alveolar cleft.
8. Check for buccal/palatal cortical plate expansion.
9. To study hard palate and its lesions like palatine tori,
palatal tumors.
Advantages
1. The only view that gives excellent visualization of the
hard palate and floor of mouth.
2. Help to give an idea of buccopalatal or buccolingual 177
position.
 Bitewing Film
Include the crown of maxillary and mandibular teeth and
the alveolar crest on the same film.
Indications
1. Useful in evaluating periodontal condition of tooth.
2. Evaluating the calculus deposits in the interproximal
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

areas.
3. Evaluate the changes in alveolar bone crest and height.
Disadvantages
1. Does not provide information related to sectional
anatomy of jaw.
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2. It does not shows all the regions of jaw.

For Personal Use Only

EXTRAORAL RADIOGRAPHS
1. Orthopantomograph (OPG).
2. Posteroanterior view (PA view) of mandible.
3. PA view skull.
4. Anteroposterior view (AP view), Town’s view.
5. Reverse Town’s view.
6. True lateral view of mandible with or without skull.
7. Lateral oblique view of mandible—left and right.
8. Lateral oblique view of skull.
9. Paranasal sinus view (PNS view)/water’s view.
10. Submentovertex view/jug handle view.
11. Projections for TMJ.
a. Transpharyngeal projection.
b. Transorbital projection.
c. Transcranial projection.
12. For salivary glands and ductal system “ Sialography”.
178 13. Lateral cephalogram view.
14. Chest X-ray (PA view).
 Common Indications for Extraoral Radiographs
1. Any abnormalities related to dentition for example,
impaction, ankylosis, gomphosis, dilacerated teeth,
hypercementosis, supernumerary tooth.

CHAPTER SIX: ROLE OF RADIOGRAPHY IN ORAL AND MAXILLOFACIAL SURGERY

2. Any jaw pathology, for example, cystic lesion, tumor
3. Traumatic condition, for example, fracture of jaw, facial
bone fracture.
4. TMJ abnormalities.
5. Infections of jaw, for example, osteomyelitis (sequestrum
formation).

Orthopantomograph (OPG)
It covers a relatively large areas of jaws.
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Technique
The position of object is fixed whereas the X-ray tube as
For Personal Use Only

well as film moves in a semicircular fashion.

Indication
As common indications.
Advantages
1. We can see both jaws abnormalities, abnormal dentition
on a single film at a glance. We can compare abnormal-
ities from normal structures.
2. Minimal radiation hazard because minimum X-rays
required.
3. Economical.

Posteroanterior View of Mandible

Technique
Interpupillary line horizontal parallel to film. Central
beam is tilted 10 degrees upwards. 179
 Indications
1. Body of mandible.
2. Inferior border, anterior border of ramus.
3. Condylar neck.
4. Nasal cavity .

Anteroposterior View (30 degrees)/Town’s View

WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Technique
Interpupillary line is parallel to film. The central X-ray
beam is tilted 30 degree downwards.
Indications
1. To show posterior fossa of skull.
2. Zygomatic arches.
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3. Ascending rami of mandible on each side.

For Personal Use Only

Paranasal Sinus View/Water’s View/Occipitomental

View/ “Hanging Drop Appearance”
Introduction
This view was described by Water and Waldron in 1915.
Technique
Central beam is perpendicular to the image receptor and
centered in the areas of maxillary sinuses.
Indications
1. Any abnormalities related to maxillary sinus, e.g.
impacted tooth, cysts.
2. Trauma/fracture of orbital rim, supraorbital,
infraorbital, lateral wall fracture.
3. Fracture of zygomatic complex (except zygomatic arch)
includes frontozygomatic suture, zygomaticomaxillary
suture, zygomaticotemporal suture.
180 4. Zygoma (malar) bone fracture.
 5. Bony disease, e.g. fibrous dysplasia, Paget’s disease.
6. To detect oroantral fistula.
7. Infections such as sinusitis.

Submentovertex/Jug Handle View/Full Axial View

CHAPTER SIX: ROLE OF RADIOGRAPHY IN ORAL AND MAXILLOFACIAL SURGERY

Technique
Central X-ray beam is tilted up 5 degree and centered to
midline behind chin.
Indications
1. Mainly for zygomatic arch fracture.
2. Base of skull for orthognathic surgery.
3. Foramina at the base of skull.
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4. May help in visualizing posterior walls of maxillary

sinus.
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5. Lateral wall of maxillary sinus.

6. Sphenoidal air sinus.
7. Medial and lateral pterygoid plates.
Contraindications
In case of spinal injury.

Projection for TMJ

Transorbital View
Best area appreciated is mandibular condylar neck.
Helpful in diagnosis of subcondylar fracture.
Transcranial View
Best area appreciated are glenoid fossa, articular
eminence, condylar head.
Transpharyngeal View
For TMJ projection.
181
 Index
A Angle fracture of mandible 139
Accessory muscle 39 Ankyloglossia 157
Acquired immunodeficiency Ankylosis 3
syndrome 55, 79 Antibiotics 27
Actimycin 37 Antimalignancy antibiotic 37
Acute Antiseptic 25
alveolar abscess 2, 110 Antistreptolysin 55
and chronic infections of Apertognathia 4, 167
jaw 2, 110 Apicoectomy 117
blood loss 75 Armamentarium for basic oral
cellulitis 110 surgery 5
periapical abscess 110 Arterial hemorrhage 73
Arteries 22
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pericoronal infection 110

rheumatic fever 55 Arthritis 3
tonsillitis 91 Asepsis 25
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Adrenaline 41 Asthmatic attack 68

Advantages of local anesthesia Atropia idiopathic mucosa 160
Atropine 41
101
Atypical trigeminal neuralgia
Aerobic bacteria 25
123
Alcohol 40
Auriculotemporal nerve 114
Allergic dermatitis 68
Austin’s
Allergy 2, 24, 68
flap retractor 6
Allie’s soft tissue holding forcep
retractor 16
5, 13
Autoclaving 50
Alveolectomy 155
Avil 40
Alveoloplasty 155
Ameloblastoma 130 B
Aminophylline 41 Bacitracin 36
Amoxicillin 37 Baclofen 38
Ampicillin 37 Bacteremia 26, 87
Anaerobic bacteria 25 Bacteriology of Ludwig’s angina
Anaphylactic 115
reaction 68 Bard Parker
shock 24, 62 handle 13
Anaphylaxis 24 scalpel handle no. 3 and 4 5
Aneurysm of ICA 123 Basic
Angioedema 69 facts in oral surgery 43
 principles of C
distraction osteogenesis Calmpose 41
173 Cancer 27
incision and drainage 54 Capillary hemorrhage 73
oral surgery 49 Carcinoma 22
reading in oral surgery 61 of oral cavity 91
study in oral surgery 57
Cardiac
terms used in anatomy 21
arrest 68, 70, 87
Basophils 56
arrhythmias 70
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Beeswax 40
Cardiogenic shock 61
Bell’s palsy 3, 124
Benzodiazepines 38 Carnoy’s solution 31, 40
Benzoin 40 Carotid sinus syncope 66
Biopsy 28, 158 Causalgia 27
Bitewing film 178 Causes of
Bizzare tumor 150 hemorrhage 74
Bleeding time 56 root breakage 84
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Bleomycin 37 tooth/root breakage 1

Blindness 124 Cavernous sinus thrombosis 2,
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Blood 23 114, 115

and nerve supply 31 Cellulitis 2, 119
coagulation factors 47 Cephalosporin 37
Blow Chair height 21
in fracture 147 Cheatle forceps 11
out fracture 147 Chloramphenicol 37
Bone 22 Chloroform 40
file 6, 16 Chorda tympani 45
rongeur 6, 16
Chronic
wax 6, 18, 31
alveolar abscess 111
Bones of skull 57
painful infections 111
Boyle’s apparatus 4
Classification of
Braided black silk 6
Brain abscess 114 antibiotics 31, 36
Branches of dental elevators 88
facial nerve 45 fascial spaces 113
trigeminal nerves 44 impacted mandibular third
Bristow’s molar 105
elevator 20 local anesthesia agent 99
zygomatic arch elevator 6 suture material 52
Bronchial asthma 69, 71 TMJ ankylosis 134
Burn shock 62 tracheostomy 149
184
Butter fly shape 5 treatment modalities 172
 Cleft Definition of
lip 4, 163 dental granuloma/abscess/
palate 4, 163 cyst 35
Clotting time 56 exodontia 83
Cold extremities 66 middle third of face 144
Colistin 36 oral surgery 49
Complication of tooth extraction 83
general anesthesia 171 Deglutition syncope 66
local anesthesia 102 Dental
Ludwig’s angina 115 elevators 88
tooth extraction 87 implant 4, 164
Composition of Dentigerous cyst 127
blood 46 Dentoalveolar abscess 91
local anesthetic agent 99 Dexamethasone 41
white head varnish 40 Dexona 41
Condylar fracture of mandible Diazepam 38
140 Diclofenac sodium 38
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Contraindications of Different suturing technique 52

local anesthesia 100 Diplopia 3, 148
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tooth extraction 86 Diphtheria 55

INDEX
Control of secondary Distraction osteogenesis 4, 171
hemorrhage 76 Distributive shock 61
Corner of mouth 35 Dolonex 38
Coronal ulceration 124 Drawbacks of distraction
Corrective surgical procedures osteogenesis 172
155 Dry socket 27, 87, 94
Corrugated rubber drain 6, 19 Dunhill’s straight artery forcep
Cough syncope 66 and artery forcep 5
Coupland’s elevator 5, 10 Dysesthesia 124
Course of Le-Fort Dyspnea 62, 69
I fracture 144
E
II fracture 144
Eagle syndrome 123
Cross bar elevator 5
Eastman Chisel and Down’s
Cryosurgery 4, 28
stainless steel mallet 5, 12
CSF rhinorrhea 3, 148
Effort syncope 66
Curettes 6, 15
Endotoxin shock 62
Cycloserine 37
Enteric fever 55
Cyst of jaw and oral cavity 126
Enzyme linked immunosorbent
D assay 55, 81
Dangers in use of elevators 89 Eosinophils 56
Dantrium 38 Epithelial cyst 126 185
Dantrolene 38 Erich arch bar 6, 17
 Erythromycin 36 H
Ether 40 Healing of extraction wound 1
Etiology of trismus 91 Heat sterilization 49
Exodontia 1, 83 Hematoma 25, 74
External Hemoglobin 56
ear 35 Hemophilia 24, 76
hemorrhage 74 Hemorrhage 24, 74, 75
Extraoral radiographs 178 Hemorrhagic shock 62, 63
Hepatitis
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

F A 82
Facial B 2, 30, 55, 56, 82
artery 114 Herpes simplex 124
paralysis 3, 125 Histamine shock 62
Fascia 23 Hyoid bone 114
Fascial spaces of head and neck Hyperventilation 62
region 112 Hypoglossal nerve 114
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Fenamates 38 Hypotension 71
Ferguson mouth gag 18 Hypovolemic shock 61, 63
Ferric chloride 40
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Hysteria 91
Fibrous ankylosis 91
Fifth seven CN syndrome 123 I
Fistula 26 Ibuprofen 38
Fracture of Idiopathic leukokeratosis 161
adjacent root 119 Idiosyncracy 24
mandible 138 Immunofluorescent test 55
maxilla and mandible 119 Impacted maxillary canine 108
zygomatic arch 91 Impaction 2, 104
Framycetin 37 Indications of
Frey’s syndrome 4, 152 dental elevator 89
Fucidin 36 local anesthesia 100
Fumagillin 37 tooth extraction 85
Function of tracheostomy 150 Indole acetic acid derivatives 38
Indomethacin 38
G Infectious mononucleosis 55
Garre’s osteomyelitis 2, 111 Inferior alveolar nerve/artery/
Geniohyoid 40 vein 113
Genioplasty 4, 168 Internal hemorrhage 74
Gentamicin 36 Intertragic notch of ear 35
Glacial acetic acid 40 Intraoral radiographs 176
Globulomaxillary cyst 3, 129 Iodoform 40
186
Granuloma 111 Irreversible shock 62
 J fracture 3
Jansen Middleton bone nibblers molar forcep 9
6, 16 premolar forcep 9
Joints 22 prognathism 4, 166
retrusion 4, 167
K third molar 2
Kanamycin 37 Maxilla fracture 144
Kaposi’s sarcoma 80 Maxillary
Ketamine 4 anterior teeth forcep 7
Kocher forcep 6, 19 artery 114
L bayonet 8
Langenbeck’s retractor 17 canine 2
Laryngeal edema 72 cow horn forcep 8
Laryngoscope 4 fracture 3
Laser surgery 28 molar forcep 8
Le-Fort IV fracture 144 premolar forcep 7
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Leukoplakia 160 sinus and disease 2

Lever and fulcrum principle 5 sinusitis 2
third molar forcep 8
For Personal Use Only

Levodopa 38

INDEX
Ligamentous structure 133 Mayo
Lincomycin 36 needle holder 5, 14
Lingual nerve 114 tissue dissecting scissors 15
Lion’s bone holding forcep 6, 19 McIndoe’s scissor 6
Lipoma 132 McKesson rubber mouth prop
Lister’s sinus dilator forcep 18 6
Local anesthesia 98 Mefanamic acid 38
Lucas curette 15 Meningitis 114
Ludwig’s angina 2, 114, 115 Merits of distraction
Luxation of adjacent teeth 119 osteogenesis 172
Lymph 23 Methods of
Lymphocytes 56 local anesthesia 101
tooth extraction 83
M Metrogyl 37
Management of Metronidazole 37
TMJ ankylosis 135 Migraine 123
zygomatic complex fracture Mitomycin 37
145 Moist heat sterilization 49
Mandible fracture 138 Monocytes 56
Mandibular Mouth gag 18
anterior forceps 9 Mucocele 3 187
cow horn forceps 9 Muscle 21
 Muscles of Opening of maxillary sinus 119
facial expression 58 Oral
mastication 57 cancer 4, 162
Mushin’s metal mouth prop 6 Kaposi’s sarcoma 80
Myeloid nerve and vessel 113 submucous fibrosis 4, 160
Myofascial pain dysfunction Orbital fracture 3, 147
syndrome 136 Oroantral
Myositis ossification 91 communication 121
fistula 2, 121
N
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

Orthognathic surgery 166

Nausea 62, 66 Orthopantomograph 39, 178
Necrosis 111 Osteoradionecrosis 2
Needle injury 92 Osteoma 132
Neomycin 37 Osteomyelitis 2, 87, 111
Nerve Osteoradionecrosis 111
disorders 3, 122 Osteotome 5, 12
injury 119 Otitis externa 91
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supply of maxillary/ Oxicams 38

mandibular teeth 43
Neurogenic shock 62 P
For Personal Use Only

Neutrophils 56 Pain 24
Nonepithelial cyst 126 Palpitation 70
Non-hemorrhagic shock 63 Para-aminophenol derivatives
Nonodontogenic tumor 132 37
Non-progressive shock 62 Paracetamol 37
Nonvitality of adjacent teeth Paranasal sinus 120
119 Paratrigeminal syndrome 123
Normal Paromomycin 36, 37
occlusion 27 Parotid flow test 55
oral flora 48 Parotitis 91
Novobiocin 36 Part of dental elevator 88
Nystatin 37 Paul Bunnell test 55
Penicillin 36
O Pericoronitis 2, 91, 110
Obstructive shock 61 Petechial hemorrhage 74
Odontogenic Phenol 40
infection 91 Phenylacetic acid derivatives
keratocyst 127 38
tumor 3, 130 Phenylbutazone 37
Odontoma 131 Piroxicams 38
Oligenic shock 61 Platelets 56
Olive oil 40 Platysma muscle 40
188 Omohyoid 39 Pleomorphic adenoma 4, 151
 Pneumocystic carinii Role of dental elevator in
pneumonia 80 exodontia 2
Post-injection sequelae 91 Rowe’s disimpaction forcep 6, 20
Postural syncope 66
S
Primary hemorrhage 73
Sagittal split osteotomy 4, 167
Principles of Salicylates 37
antibiotic therapy 54 Salivary
flap design 51 fistula 4, 153
skin incision and Langer’s gland
line 51 biopsy 55
suturing 53 disease 4
tooth extraction 83 infection test 55
Progressive shock 62 tumor 4
Propionic acid derivatives 38 scintigraphy 55
Prothrombin time 56 Sarcoma 22
Psychogenic shock 62 Secondary hemorrhage 74, 119
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Pterygopalatine nerve 44 Sepsis 25

Purpose of suturing 51 Septicemia 26
Shock 2, 24, 61
For Personal Use Only

Purpura 25

INDEX
Sialadenitis 4, 150
Pyemia 26
Sialography 4, 55, 153
Pyramidal fracture 144
Sialolithiasis 151
Pyrazolone derivatives 37 Sinus dilator forcep 6
Q Sjögren’s syndrome 55
Quinsy 91 Soft
areolar tissue 114
R tissue injury 119
Radicular cyst 128 Stainless steel wire and wire
Ramsay Hunt syndrome 123 cutter 6, 17
Ranula 3 Standard pathological values 56
RBC 56 Sterilization 2, 24
Reactionary hemorrhage 73 Storax 40
Streptomycin 36, 37
Respiratory
Stylohyoid 45
distress 69
Submandibular
arrest 68, 87
gland and duct 114
reaction 68 nodes 114
Retention cyst 129 Submucous fibrosis 91
Retrognathism 166 Succinylcholine 38
Rhinoplasty 4 Suction
Rifampicin 37 cannula 12 189
Right angle retractor 6 tip 5, 12
 Supine position of body 21 Transalveolar extraction 84
Suture Transbronchial biopsy 80
cutting scissors 15 Traumatic neuroma 123
materials 2, 14, 51 Trigeminal neuralgia 3, 122
needle 5, 14, 52 Trismus 27, 90
Swab holder 5, 11 Torture syndrome 123
Syncope 65, 87 Tuberculosis 55
Syphilis 55 Types of
Systemic anaphylaxis 68 ameloblastoma 131
WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

ankylosis 135
T biopsy 158
Tachycardia 69, 70 dentigerous cyst 127
Techniques for diplopia 148
mandibular nerve blocks elevators 89
103
fistula 153
maxillary
hemophilia 77
and mandibular nerve
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hemorrhage 73
block 1
hepatitis 82
nerve blocks 103
For Personal Use Only

joint 133
Temporomandibular joint 31,
mandible fracture 138
133
soft and hard tissue biopsy
Tendon of temporal muscle 35
158
Tetanus toxoid 56
Tetracycline 37 U
Tissue dissecting forcep 5 Ulcer 26
TMJ Unconsciousness 70
ankylosis 134 Universal tooth extraction
arthritis 91 forceps 5, 9
dislocation 91, 137 Urticaria 69
disorder 134
hyperplasia 3 V
luxation 137 Vaccines 26, 56
Tobey Ayer test 117 Vagoglossopharyngeal
Tongue 31 neuralgia 122
tie 157 Vancomycin 36
Torus Various methods of sterilization
mandibularis 158 49
palatinus 157 Vasovagal
Towel clip 5, 12 shock 62
Toxemia 26 syncope 66
190 Tracheostomy 3, 149 Veins 22
 Venous hemorrhage 73 Western Blot test 55, 81
Vestibuloplasty 156 Wheezing 69
Viral hepatitis 81 White head varnish 31
Volkmann’s scoop 6, 15 Winter’s cross bar elevator 11
Vomiting 62
Z
W Zygomatic
Warwick Jame’s elevator 5, 11 complex fracture 145, 146
WBC 56 nerve 44
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For Personal Use Only

INDEX

191