ORAL & MAXILLOFACIAL

SURGERY
Priciples of oral surgery
Assessment
1. History taking Operative
2. Examination 1. Incision ( full thickness)
3. Investigations 2. Retraction (blunt
4. Diagnosis instrument)
5. Ttt plan 3. Bone removal (drill or
chisel) + irrigation
Preparation 4. Removal of a tooth or a R.R
1. Asepsis & antiseptic 5. Debridement
2. Analgesics & anaesthesia 6. Suturing & haemostasis
3. Anatomy & pathology 7. Postoperative edema
4. Access (intra/extraoral)

Full thickness flap = mucoperiosteal flap

Split flap = mucogingival flap
Trapezoidal full thickness flap (wider base )
1. Better blood supply
2. Better accessibility & visibility
3. Less traumatic surgery

Complications of surgery
 Access : due to
1. Small mouth
2. Crowded arch & malpositioned teeth.
3. Space infection & trismus
 Pain : due to
1. Failed local anaesthesia
2. Acute infection at site of infection
 Inability to move of a tooth ( solid tooth ) : due to
1. Bulbous , diverging , very long roots
2. Ankylosis or sclerotic bone
 Breaking the tooth : common complication
- If < 3mm R.R →antibiotics , tell the pt , review
- If > 3mm R.R → transalveolar surgery

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  Fracture of alveolar &/or basal bone :
- If # alveolus of the extracted tooth (common)→ remove
- If # alveolus of other teeth (uncommon)→remove the tooth by
transalveolar extraction & splint other teeth
- If # basal bone (rare) → ORIF
 Loss of a tooth: stop & look where it escaped?
- In the mouth
- Under the mucoperiosteum
- In tissue space & lingual pouch
- In suction apparatus
- In the antrum ( maxillary sinus)
- Inhaled or swallowed ( chest x ray is a must)
 Damage to other teeth / tissues & extraction of the wrong tooth:
Confirm with the pt before you start, & tell the pt if you made a
mistake.
 Dislocated jaw : reduce it at once
 Pain, swelling & trismus: are common sequele , prescribe steroids
or NSAIDs postoperatively.
 Bleeding
 Bisphosphonate-related osteonecrosis.

Postoperative bleeding
Postoperative bleeding is described as:
A. Immediate: when haemostasis is not achieved at completion of
surgery.
B. Reactionary: within 48hrs due to rupture of small bl vs. in
hypertensive pt.
C. Secondary: within 7 days due to infecion that destroy blood clot &
ulceration of bl. Vs.
Bleeding after extraction is common, the pt often anxious & nauseated due
to smell, sight,taste of blood & blood in stomach which is irritant.

How to manage of postoperative bleeding?

1. Pt. reassurance, remove entourage, reassess medical & drug history.
2. A cotton pack is rolled to fit the area of bleeding.
3. Clean pt`s face & mouth.
4. Identify source of bleeding in good light ( gingival capillaries –
vessels of bone socket – large vessel under the flap or in bone )

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 Source of bleeding manegment
gingival capillaries LA and suturing
vessels in the bone of the socket Bone wax
large vessel Ligation

from the depths of the socket, and the clot may need to be removed
supported by a resorbable mesh
(oxidized cellulose)
Use BIPP or Whitehead’s varnish
packs.

If all else fails, all the earlier mentioned measures plus a pressure pack,
analgesia &a sedative antiemetic, a night in a hospital bed will do the
trick.

MRONG
(Medication Related Osteonecrosis Guidelines)
What are these medications?
They are group of medications that inhibit function of octeoclasts
1. Bisphosphonates

Indications of their use:

1. Prevent fractures in osteoporosis
2. Stabilizze Paget`s disease.
3. ↓↓bone pain & fractures in bone metastases.
4. Ttt of hypercalcaemia of carcinomatosis.

Side effect of their use:

Necrosis of jaw bone usually associated with extraction & dento-alveolar
surgery.

Management of pt. who is to start Bisphosphonates:

Make sure to avoid future need for extraction
1. Maintain good oral hygiene
2. Healthy diet
3. Stop smoking
4. Limited alcohol intake
5. Regular dental check-up.
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Management of pt. taking Bisphosphonates:
 Avoid implant – surgical extraction – periodontal surgery –
apicectomy
 While Endo ttt & coronectomy can be suitable.
 Warn the pt. of risk of BRON development ( 1% for low grade as in
osteoporosis & 30 % in myeloma ).
 Use antibiotic prophylaxis, chlorohexidine mw, traumatic extraction,
alveolar septoplasty (to provide good vascularization of mucosa &
prevent superinfection of bone.
 Written informed consent about MRON is a must.
 Review after 4 w to insure good healing.

Management of already established MRON:

No agreed effective ttt till now, but..
Sequestrectomy + some form of bone coverage + supplemental drug
therapy may be effective.

Spreading of infection
Dento-facial infections

Microbiology of dento-facial infections

= Bacteroids (anaerobes) sensitive to Metronidazole
+ Streptococci (aerobes +anaerobes) sensitive to penicillin

Signs & symptoms:

Pain, swelling, temperature, discharge, fatigue, malaise, dehydration,
spread beyond site of infection

Origin of infection:
 Apical abscess : I&D + AB ( Amoxicillin 500mg tds for5-7 days ,
Metronidazole 400mg tds for 5-7days)

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  Periodontal abscess :I&D +eliminate the pocket +AB
 Periocoronitis : extract up8 + irrigation with saline or CHX+ AB +
extract low8
 Dry socket : clean –irrigation – pack – analgesic – chx mw
 Actinomycosis : drainage + Amoxicillin 500mg tds or Doxycyclin
100mg od
 Staphylococcal lymphadenitis : children – drainage & flucloxacillin
 Atypical mycobacteria: cold nodes – excicion of nodes &
clarithromycin.
 Necrotizing fasciitis: rare & life threatening, incision of necrotic
tissue & IV antibiotics.
 Cellulitis: warm, diffuse,erythematous ,indurated &painful swelling of
tissue in an infected area.
 Ludwig`s angina : infection of submandibular +sublingual space
bilaterally

Factors that control spread of odontogenic bacteria:

1. Thickness of bone adjacent to offending tooth.
2. Position of muscle attachment in relation to root tip
3. Virulence of bacteria
4. Host response

What are primary fascial spaces?

The spaces directly adjacent to the origin of odontogenic infection
1. Buccal (Max. PM&M, Mand PM )
2. Canine (infection mostly from canine)
3. Sublingual (Mand. PM & 1st molar)
4. Submandibular (Mand 2nd&3rd molars )
5. Submental (Mand incisors & canine)
6. Vestibular
Also Max. Lateral & max. 1st molar can cause localized infection in palate.

What are the secondary fascial spaces?

1. Pterygomandibular ( from sublingual & submandibular space )
2. Temporal spaces (from masseteric & pterygomand spaces, max. &
mand. Molars)
3. Masseteric ( from buccal space )
4. Lateral pharyngeal ( submand . space & pterygomand. Space, max. &
mand. Molars)
5. Retropharyngeal ( from lateral pharyngeal ,pterygomand.,submand.,
sublingual spaces )
6. Prevertebral ( from retropharngeal space )

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 Management of trauma
Primary line of management of trauma:
1. ABCDE (ATLS)
2. Temporary immobilization
3. Tetanus prophylaxis
4. Antibiotics (especially for CSF leakage)
5. Analgesics
6. Nutrition

Secondary line of management of trauma:

1. X ray
2. Reduction & fixation
3. Immobilization
4. Rehabilitation
5. Conservative ttt
- Soft & liquid diet
- Medication
- Functional restriction
- Avoid more trauma to site of infection

Primary line of management of trauma

ATLS (Advanced Trauma Life Support)
It is one system or resuscitation of a trauma victim.
The core concept behind ATLS is the primary survey with simultaneous
resuscitation, followed by a secondary survey leading to a definitive care.

Assessed by … How to save..?

Airway & If conscious pt . → It will 1. Chin lift
cervical spine be potent. 2. Jaw thrust
control If unconscious pt.→ look, 3. Oral suction & oral airway
listen & feel. 4. Nasopharyngeal tube
5. Endotracheal intubation
6. Cricothyroidectomy
7. Surgical airway
intervention(trachestom)

+ immobilization of
cervical spine by rigid
collar

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 Or two sand bags & tape.
Breathing 1. inspection ,palpation, 1. provide Oxygen 100%
percussion,auscultation 2. chest decompression
-
2. count R.R
N= 14-16 cycle/min
Circulation 1. Level of consciousness 1. Pressure packs over
2. Skin color wound.
3. BP & pulse rate 2. Ligation of large vessels.
4. Capillary refill time 3. Anterior nasal pack
N= 1-2 sec 4. Posterior nasal pack
(Foely catheter)
5. Establish 2 large venous
cannules for fluid
replacement.
6. Establish urinary catheter.
7. Tranexemic acid IV in 1st 3
hours.
8. Oro or nasogastric tube.
Disability 1. Glassgow coma scale Prevent hypovolemia &
(eye , motor response, hypoxia ( provide all
verbal response) previous methods to get
2. Visual acuity. potent airway & preserved
3. Pupillary response to circulation)
light.
4. Cranial n. Assessment
5. CT scan
Exposure Remove all clothing to 1. Ensure monitoring RR ,BP
allow full assessment of , pulse rate ,Temperature ,
injury arterial blood gases ,ECG.
2. Prevent hypothermia.

Secondary line of management for trauma

Hard Tissue Injuries
Dentoalveolar Fractures
I. Mandibular Fractures
II. Mid Face Fractures
III. Zygomatic/Orbital Fractures
IV. Zygomaticomaxillary complex
V. Nasal Bone Fractures

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 I. Mandibular Fractures

Major etiologic factors vary based on geographic location:

1. motor vehicle accidents
2. assaults

Location of mandibular fractures:

- The body (29%) - The symphyses (17%)

- Condyle (26%) - Ramus (4%)
- Angle (25%) - Coronoid process (1%)
Number of fractures per mandible in patients with mandible fractures,
53% of patients had unilateral fractures
37% of the patients had bilateral
Classification of mandibular fracture
- Simple or closed : Fracture that does not produce a wound open to the
external environment,
- Compound or open - Fracture in which an external wound, involving
skin, mucosa, or periodontal membrane, communicates with the break
in the bone
- Comminuted - Fracture in which the bone is splintered or crushed
- Greenstick - Fracture in which one cortex of the bone is broken and the
other cortex is bent(children)
- Pathologic - Fracture occurring from mild injury because of preexisting
bone disease
- Multiple - Variety in which two or more lines of fracture on the same
bone are not communicating with one another
- Atrophic - Fracture resulting from severe atrophy of the bone, as in
edentulous mandibles
- Indirect - Fracture at a point distant from the site of injury
Sign and symptoms:
- Facial lacerations, swellings, hematomas, pain, tenderness.
- Step deformity
- Paresthesia ,dysesthesia, or anesthesia
- Numbness in this region is almost pathognomonic of a fracture distal
to the mandibular foramen.
- Deviation on opening of the mouth. Classically, deviation on opening
is toward the side of the mandibular condyle fracture.
- Limited opening and trismus that may be a result of reflex muscle
spasm, temporomandibular effusion
- Occlusion derangement

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Mandibular Fracture Radiographic Signs
- OPG
- PA Mandible
- Lateral Oblique
- Mandibular Occlusal
- CT Scan

Management:
- open reduction & rigid internal fixation (ORIF)
- closed reduction (CR) & external fixation
ORIF CR
- Displaced unfavorable fractures - Non displaced favorable fractures
- Severely atrophic edentulous - Grossly comminuted fractures
mandibles - Fractures in children involving
- Complex facial fractures the developing dentition
- Timing for ORIF : - Contraindications :
Traditional teaching has been that 1. Patients with poorly
mandible fractures should be controlled seizure history
reduced within 24 hours of injury. 2. Patients with compromised
Recent studies have shown no pulmonary function (ie,
increase in complications with a moderate-to-severe asthma,
delay of repair beyond 24 hours. chronic obstructive
pulmonary disease)
3. Patients with psychiatric or
neurologic problems
4. Patients with eating or GI
disorders

 Gunning splints were used (edentlous patient). This technique has

been superseded by the use of bone plates in virtually all cases.

Management of condylar fractures

- Management depends on age and type of injury.
- They can be treated with closed reduction for a period of 2-3 weeks to
allow for initial fibrous union of the fracture segments.
- If the condylar fracture is in association with another fracture of the
mandible, treat the noncondylar fracture with ORIF, and treat the
condylar fracture with closed reduction
- The condyle is the growth center of the mandible, and trauma to this
area can retard growth and cause facial asymmetry.
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- Early mobilization (7-10 d of intermaxillary fixation) of the condyle is
important.
- <12yrs: analgesia, soft diet, and intermaxillary elastic guidance (if
needed) produces optimal results.
- >12yrs: pain-free, pre-injury occlusion should be established (by elastic
traction if need be), and the patient reassessed at 7 days. If spontaneous
pain-free occlusion not possible at this stage: ORIF.

Guardman fracture:
Also referred to as parade ground fracture, is one of the common forms of
mandibular fracture which is caused by a fall on the midpoint of the chin
resulting in fracture of the symphysis as well as both condyles.
It is usually seen in epileptics, elderly patients and occasionally in soldiers
(fall forwards due to syncope) and is known as guardsman fracture.

II. Maxillary Fractures

(Midface fracture)

 The maxillae bones are the largest bones of the face

The Le Fort I (transverse maxillary)
Fracture is a horizontal fracture above the roots of the teeth and
extends from the piriform sinus of the nose to the pterygomaxillary
fissure, separating the maxillary tuberosity from the pterygoid plates
Signs and symptoms
 swelling of upper lip and cheek
 ecchymosis
 nasal block
 no ocular sign

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The Le Fort II (pyramidal)
Fracture courses upward through the infraorbital rim, through the medial
orbit and the nasal bones. Since the fragment forms a triangular shape, this
is often called a pyramidal fracture.
Signs and symptoms
 gross edema ballooning (moon face)
 bridge nose depressed
 anterior open bite
 step deformity
 parathesia over the check
 epistaxis

The Le Fort III (craniofacial dysjunction):

Fracture crosses the maxilla, nasoethmoid complex, and the zygoma
Signs and symptoms
 Spinal fluid leakage is common.
 Mobility of the whole skeleton as one block
 Racoon eye
 Subconjunctival haemorrhage
 Enophthalmas
 Diplopia

Management
 Internal fixation.Interosseous plating using Kirschner wires.
 External fixation. E.g. Levant frame, box frame, which fix the mid-face
to the cranium.

IV. Zygomatic Fractures

Because the zygoma is a thick bone, it is rare to have an isolated fracture of
the zygoma.

V. Zygomaticomaxillary complex
Fracture (tripod or malar fracture) results from a direct blow to the cheek.
Signs
 Severe facial edema
 Diplopia may be reported by the patient.
 Depression of the inferior orbital rim or parathesia in the
distribution of the infraorbital nerve suggests extension into the orbit
or maxilla.
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managment
 Closed tech Are elevated by a temporal approach (Gillies approach)
 Open tech
 Bone hook
 Screw and traction
 Caroll-Girard screw enlarge (Threaded reduction tool)

Facial soft tissue injuries

The face is highly visible & once cut no one can make the scar disappear.
Assessment:
1. ABCs, past medical history, allergies.
2. Tetanus & rabies prophylaxis
3. Wounds should be closed within 24 hrs.

Examination:
Type of pt, type of wound, anatomy, eye, eye lid, parotid, lacrimal duct.

Types of soft tissue wounds:

1. Abrasion→cleaned & heal spontaneously+chloramphenicol ointment
2. Simple laceration → remove sutures in 6 days
3. Crush laceration → remove sutures in 3-4 days
4. Slicing /shelving laceration
5. Avulsion → repositioning or skin graft
6. Penetrating injuries
7. Bites → clean very carefully & use coamoxiclav.
8. Burns → need specialist referral
9. Tissue loss → as nasal tip , ear pinna ,skin graft or local flap
10. Gunshot wounds (composite tissue loss)→ hard & soft tissue
injury , so management of both according to degree of tissue loss.

Investigation: X. ray to detect foreign bodies.

Critical anatomical sites :

Eyelid, pinna, eyebrow, vermillion border require precise matching &
test pre-anaesthetic for facial & trigeminal nerve function.

Wound closure:
In layers, mucosa & muscle → resorbable 3/0 -4/0
Skin → monofilament 4/0 -6/0

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 Suturing
Suture materials may be
 Resorbable (Dexon ® , Vicryl ®, Monocryl®)
 Nonresorbable (silk , nylon , prolene , Novafil®)
Monofilament suture(nylon) cause less tissue response than braided (silk)

- Skin is best sutured by nonresorbable material & removed at 4-6

days.
- Mucosa, vessles & deep tissue best sutured by resorbable materials.
- Suture strength is described as 0 (thickest), to 4/0 (commenest
intraorally) & 11/0 (thinnest for microvascular work).

BIOPSY
Types of biopsy
Excisional biopsy
Incisional biopsy , which are divided into
1. Fine needle aspiration (cytology)
2. Punch biopsy
3. True –cut needle biopsy
4. Elliptical biopsy ( the commonest type)

What should be biopsied?

All red lesions of oral mucosa + most white patches.

Specimen is best preserved in 10 times of tissue volume 10 % formalin

Impacted 3rd molar

Indication for extraction of impacted 3rd molar:

Surgical removal of impacted third molars should be limited to patients
with evidence of pathology. Such pathology includes:
1. Unrestorable caries, non-treatable pulpal and/or periapical
pathology, cellulitis, abcess and osteomyelitis of the tooth or adjacent
teeth.
2. Internal/external resorption of the tooth or adjacent teeth.
3. Fracture of tooth.
4. Disease of follicle including cyst/tumour.
5. Tooth/teeth impeding surgery or reconstructive jaw surgery.
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 6. Tooth is involved in or within
the field of tumour resection.
7. One severe attack or two
moderate attacks of
pericoronitis /year.

There is no reliable research

evidence to support a health
benefit to patients from the
prophylactic removal of pathology-
free impacted third molar teeth.
No prophylactic extraction, not for
ortho, not for TMJ vague pain.

Assessment of difficulty of extraction

Clinically: Pell & Gregory classification
Based on
 The amount of tooth covered by anterior border of the ramus (1, 2 ,
3)
 The depth of impaction relative to adjacent tooth (A,B,C)

Radiographically: Winter`s lines (WAR

lines)
To apply Winter`s lines, 3 imaginary
lines are drawn on the radiographic
image (periapical x ray)
1. White line → runs along the
occlusal plane.
2. Amber line → along the upper
bone surface through the
interdental bone crests.
3. Red line → passess vertically at right angle to the white line (the
application point for an elevator ) ,
If red line >5 mm, so GA is recommended.
If red line >9 mm, so extensive bone removal will be required.

Disadv.of Winter`s lines technique?

1. The length of red line is useless for distoangular impaction.
2. It ignores the possibility of tooth sectioning which makes the
extraction easier.
3. It is applied on periapical x ray with paralling technique, it is less
accurate with panorama & lateral oblique.
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Complications of surgical removal of impacted 3rd molar:
1. Postsurgical pain , haemorrhage,trismus ,swelling ,ecchymosis
2. Alveolar osteitis (dry socket) 5%
3. Temporary 8 %& permanent 3% nerve damage.
4. Acute TMJ pain / dysfunction.
5. Iatrogenic fracture.
6. Acute/chronic postoperative infection.
7. Oroantral fistula
8. Injury to adjacent structure including teeth & periodontium.
9. Introduction of a tooth or tooth fragment into tissue space.
10. Unpredictable death by GA. (1-2 :400 000)

Radiographic signs of ↑ risk of nerve damage :

1. Proximity to nerve canal
2. Narrowing of nerve canal.
3. Diversion of nerve canal.
4. Darkening of root.
5. Interrupting white lines of canal.
6. Interruption of lamina dura.

Dentoalveolar surgery

Removal of roots
Indications :
- Large remaining roots
- Associated with pulpal or periapical pathology
- Symtomatic
- Affects denture construction
- Immunocompromised pt. to prevent future development of infection.
- If nonsurgical methods fails to remove R.R, so surgical removal is
indicated.

Hints on technique:
- Removal of R.R are approached by buccal flap
- If edentulous arch → crestal incision
- If dentate → incise in the gingival margin (simple envelop)
- You can extend the simple envelop flap (gingival incision ) to two
sided flap (triangular) or 3 sided flap (trapezoidal ) to get better
access by relieving incisions.
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 Removal of unerupted (impacted) teeth
Most common unerupted (impacted) teeth are third molars → maxillary
canines & premolars→ supernumeraries’ → mandibular canines & PM.

Hints on Technique:
- Buccal impactions are approached via a buccal flap.
- Palatal impactions are approached via a palatal flap.
- Cross or within arch impactions need a combination of two.
- For maxillary canine :
 Palatal flaps involve the reflection full thickness of
mucoperiosteum of anterior hard palate.
 The incision running in the gingival crevice from upper 6 to
upper 6 for bilateral impacted canines.
 The incision running in gingival cervice from upper 6 to the
contralateral canine for single impaction.
 The neurovascular bundle emerging from incisive foramen is
often sacrificed.
- For mandibular canine : buccal flap
- For maxillar premolars : palatal flap unless within arch do buccal flap
- Foar mandibular premolars : often angled lingually but extended
buccal flap is raised ( triangular or trapezoidal)
- For mandibular third molar :
 If vertical impaction → a buccal flap is incised along the
external oblique ridge over the crest of the ridge (if unerupted)
or in gingival margin (if partially erupted), extend to the distal
aspect of 7 & down into the buccal sulcus.
 If horizontal or mesioangular impaction → extend the incision
to the mesial border of 7 (beaware of buccal br. Of facial a)
- For maxillary third molar :
 A flap similar to mand. Third molar, (slash incision) extends
from distopalatally on the tuberosity to disto buccally at the
second molar & into buccal sulcus.
 Care is taken to prevent displacement into pterygoid space.
 Slash incision may need no suturing.

Dentoalveolar surgery + Endodontics

1) Apicectomy
2) Root hemisection
3) Removal of extruded paste

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 Apicectomy
Indications:
1. Impossible to repare & fill apical 1/3 of root (pulpal calcification ,
curved apex ,open apex)
2. Irretrievable broken instrument in the canal
3. Post crown on tooth with apical pathology
4. Root perforation
5. Fractured & infected apical 1/3
6. Persistent infection due to cyst or other pathology require biopsy.

Technique:
1. L.a
2. Raise a flap
 Maxillary anteriors → semilunar
 Maxillary PM & 1st molar → 2 sided or 3 sided
 Mandibular incisors → 3 sided flap
 Mandibular PM → extended 2 sided flap
 Apicectomy for multirooted teeth has lower success rate.
3. Reflect, retract, bone removal as a window over the apex.
4. Exicise apical 1-2 mm & curette out cystic & granulation t.
5. Pack the cavity with bone wax.
6. Prepare the canal , seal with MTA
7. Close with interrupted suture or vertical mattress.

Dentoalveolar surgery + Orthodontics

Fraenectomy
This is of value in closing a median diastema only if gentle traction on
the upper lip and fraenum produces blanching in a palatal insertion
around the incisive papilla.
The excision of the fraenum must include those fibrous insertions,
which leaves a raw area of alveolus after excision—this can be dressed
with Surgicel®, BIPP, or a periodontal pack.
Pericision
Is simply incising supra-alveolar periodontal fibres to prevent relapse
when derotating teeth?
Tooth exposure Orthodontic traction
 The treatment of choice for malpositioned, unerupted canines and
incisors if the apices are in good position for eruption.
 Bonding an eyelet and gold chain or other bracket technique has a
lower incidence of reoperation

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Tooth repositioning (transplantation)
 Although there are claims of success rates as high as 93%, few people
match this and most would transplant only when exposure and
orthodontic movement were rejected.
 The most commonly transplanted tooth is the maxillary canine.
Distrcation osteogenesis
Growing bone bu osteotomizing & gradually moving bone apart (1-2
mm/day)

Cysts management
• Enucleation with primary closure
Is commonest and generally the Rx of choice. It consists of removing the
cyst lining from the bony walls of the cavity and repositioning the access
flap. Any relevant dental pathology is treated at the same time, e.g. by
apicectomy
• Enucleation with packing and delayed closure
Is used when badly infected cysts, particularly very large ones, are
unsuitable for primary closure. Pack with Whitehead’s varnish or BIPP.
• Enucleation with bone grafting. Rarely useful.
• Marsupialization. This is the opening of the cyst to allow continuity
with the oral mucosa;

inflammatorydental cysts Rx: enucleation plus endodontics or

extraction. Eruption cysts See E Eruption cyst, p. 64.
Dentigerous cysts Rx: marsupialization or enucleation, depending on
position and desired fate of the tooth.
‘Keratinizing odontogenic tumour’
It is important to identify these cysts, as outpouching walls and
‘daughter’ or ‘satellite’ cysts make them more liable to recur.
Rx: careful enucleation, &/or cryotherapy &/or Carnoy’s solution, or
aggressive curettage of the cavity
Aneurysmal bone
areexpansile lesions full of vascular spongy bone.
 Small ones can be carefully enucleated, but
 Large one cysts need excision and possible reconstruction since they
will recur if incompletely excised
. Fissural cysts.. Rx: enucleation

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 Maxillart sinus
I. Chronic maxillary sinusitis
II. Acute maxillary sinusitis
III. Antral response to inflammation of dental origin.
IV. Displacement of a root into the sinus
V. Oroantral communication
VI. Fracture of maxillary tuberosity

I. Chronic maxillary sinusitis

Chronic inflammation of mucosa lining the sinus mostly due to pollution,
smoking, allergies.
No signs or symptoms unless acute exacerbations of inflammation.

II. Acute maxillary sinusitis

Acute inflammation of mucosa lining the sinus mostly associated with
common cold & influenza.
S&S:
1. nasal discharge or stuffiness
2. tenderness over the cheeks
3. Pain worse on moving the head.
Occipito-mental x-rays may reveal antral opacity
Odontogenic causes must be excluded.

III. Antral response to inflammation of dental origin

Where the lamina dura of posterior maxillary tooth is lost, the cortical bone
of antral floor, periapical inflammation of dental origin may provoke
inflammation of antral lining.
S&S:
As periapical periodontitis
X ray: a round radio-opacity immediately above the affected tooth (antral
halo)

IV.Displacement of roots into the sinus

1. Take a periapical radiograph of the socket or oblique occlusal or
panorama if p.a is unappropriate to discover the root.
2. If the root is beneath the antral lining, it may be retrieved by raising
buccal mucoperiosteal flap & carefully remove buccal bone to remove
it.
3. If the root is beneath the antral lining, it is retrieved by Caldwell-Luc
approach (antrostomy) ,.

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 V. Oroantral communication
OAC → Communication between the oral cavity and the antrum
OAF →Epithelization of the communication after 14 days
Diagnosis:
1. Post-extraction reflux of fluids into the nose or minor nose bleeds
2. Getting patient to attempt to blow out against a closed nose; air
bubbles through the fistula.
3. Occasionally antral mucosa prolapses through the socket.
4. Echo sound (wind tunnel sound) when using the suction in the socket

Management (surgery+antral regime):

- Many small fistulae are asymptomatic and close spontaneously.
- Closure if ∆ is made at time of extraction:
- Close the socket by resorbable suture (if <4 mm) or buccal
advancement flap (if >4mm)
- give antibiotics and decongestants
- Erythromycin 500mg PO qds or doxycycline 100mg PO OD.
Decongestants, e.g. oxymetazoline or xylometazoline spray
- Never to blow nose for 48 hrs at least.
- No straws

1- Buccal advancement flap

- Excise fistula to prepare a line of closure over bone and raise a broad-
based buccal flap.
- Incise periosteum to allow mucosa to stretch over the socket
- Close, over bone,with vertical mattress sutures.
- Disadvantages: thin tissue may break down; reduces sulcus depth.
2- Palatal rotation flap
- Excise fistula as for buccal advancement flap.
- Dissect a palatal mucoperiosteal flap based on palatine artery, rotate
over socket, and suture
Disadvantages:
- bare bone left to granulate
- Difficult flap to rotate without distortion.
3- Buccal fat pad
4- Sinus lift operation
VI. Fracture of maxillary tuberosity
1. periapical or panoramic radiograph
2. assess continuity of antral lining
3. if the fractured segement is small & mobile , dissect it & remove ,
surgical closure & antral regime.

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 4. If the fractured segement is large & still attached, stop extraction, do
pulp extirpation, splinting of bone for 6 weeks, and then extract the
tooth by dentoalveolar surgery.

TMJ disorders
 Ankylosis  Anterior displacement
 Trauma without reduction
 TPDS  Condylar hyperplasia
 Dislocation  Tumors
 Anterior displacement with  Osteoartheritis
reduction  TMJ degenerative diseases

Ankylosis
Restriction of TMJ movement by bony or fibrous union due to:
 Intracapsular causes (true ankylosis) → infection or trauma
 Extracapsular causes (false ankylosis)→ ms trismus

Causes:
1. Surgical extraction of mandibular molars
2. Post-anaesthetic injections
3. Direct trauma: Fractured mandible Other facial fractures
4. Facial laceration Recent dental restorative procedures
5. Radiation therapy
6. Infection
7. TMD: Chronic complaints usually seen in young females. They do not
need any urgent attention.
8. Conditions that affect the central nervous system such as
meningitis/encephalitis, brain tumour/abscess and epilepsy should be
ruled out.
9. Drug history
10. Tumours/oral cancers:. One should not forget oral submucous
fibrosis in differential diagnosis.
11. Psychogenic causes, such as hysterical trismus.

Management: exercise – surgery – joint replacement

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 Trauma
As condylar & coronoid trauma.

MPDS
The most common TMJ disorder
S&S:
- Headche
- Deviation of jaw opening
- Joint sounds
- Pain on palpatation on TMJ & associated ms.

Dislocation
The condyle is abnormally positioned outside the mandibular fossa but still
within the joint capsule.
S&S:
- Inability to close the jaw
- Pain
- Ms spasm
Management: manual manipulation to reduce the dislocation

Disc displacement with reduction

A displaced disc reduces into normal position on opening, but reverts to
abnormal position on closing.
S&S:
- Clicking on opening
- Clicking on closing
- Normal opening not limited
- Transient jaw deviation on opening & closing.
Management: reassurance – occlusal splint (anterior repositioning splint) –
physiotherapy

Disc displacement without reduction

A displaced disc remains in a displaced position on opening & closing.
S&S:
- No clicking
- Limited mouth opening
- Pain in front of the ear
Management:
Reassurance – ms relaxant & physiotherapy –– TMJ surgery

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 Implant

Osseointegration : it is functional & structural connection between bone &

implant with no connective tissue inbetween .
It is a process whereby clinically asymptomatic rigid fixation of alloplastic
materials is achieved & maintained in bone during functional loading.

Categories of dental implant:

 Subperiosteal
 Endosteal
 Transosseous (transmandibular)

Material of implant:
1. Pure Titanium or Ti alloy with different surface attachments
2. Bioceramic (less common)

Indications:
1. Edentulous mouth unable to retain dentures.
2. Partially dentate for bridge abutments.
3. Single anterior tooth replacement.
4. Maxillofacial prosthesis post cancer surgery or trauma.

Contraindications (relatively):
1. Smoking
2. Immunocompromised pt. (bleeding ,diabetic , …)

Advantages:
Successful long term prothesis mand > max. Due to bone quality.

Disadventages :
1. Cost
2. Time
3. Surgery
4. Need for temporary restoration

Components:
1. The implant (fixture): the portion that osseointegrate to bone.
2. Abutment: the portion attached to the implant by abutment screw.
3. Crown: porcelain or PFM.

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Criteria of success:
1. No mobility
2. No bone loss (should be less than 0.2mm/year )
3. No peri-implantitis

Steps:
Assessment → implant placement →abutment loading → final prosthesis

Assessment:
1. Age ( not less than 18y)
2. Clinical examination of (ridge ,pdl,oral hygiene ,occlusion ,dentition
,mouth opening )
3. Medical status ( diabetes ,smoking ,bisphosphonates , …)
4. Bone disease ,bone pathology
5. Quality &quantity of bone (x ray)
6. Relation to adjacent structures.

The most common reasons for endosseous dental implant removal:

1. Lack of integration
2. Lake of bone support
3. Surgical malposition
4. Psychiatric reasons

How to avoid failure of implant?

1. Good assessment
2. Copious irrigation
3. Surgical stent
4. Enough healing time & loading time
5. Slow speed drill
6. Sterile technique

Complications of implant placement:

1. Infection
2. Perforation of maxillary sinus or nasal cavity
3. Loss of implant
4. Bone resorption , peri-implantitis
5. Nerve injury & numbness
6. Fracture of mandible.

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