Chapter 5: Oral Surgery Introduction



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Introduction


To a surgeon, having good access to the surgical field often means reflecting a flap. A properly developed flap will afford you optimum access to the field. A flap will heal much better and faster than a torn, traumatized area of tissue.

Caution: Care and dexterity should be used in reflecting flaps, as it is extremely important that soft tissue not be traumatized.

Indications for Mucoperiosteal Flaps


Mucoperiosteal flaps are indicated in the following situations:

Requirements for Mucoperiosteal Flaps


The following requirements should be met prior to reflecting a flap:

  • The incision should be large enough to permit access.

Note: A 4 cm incision heals just as fast as a 1 cm incision.

  • The base should be wider than the free margin.

  • The incision should be for the full thickness (i.e., you should go down to the bone with the incision).

  • The margins should not be over a bony defect.

Treating TMJ Disorders

Introduction


Pain or dysfunction of the temporomandibular joint can be a difficult disorder to manage. The most common causes are either

  • derangements of the joint itself

  • myofascial pain dysfunction syndrome

Treatment Options


The majority of these conditions are generally well managed with a variety of nonsurgical treatment modalities. Detailed management is beyond the scope of this manual; however, a number of excellent surgical textbooks and recent literature provide detailed descriptions of management techniques.

Phases of TMJ Management Protocol

The table below describes some of the events that may occur during each phase of the TMJ Management Protocol Process.

Phase

Events

1

Patient contact

2

Medical and Dental Histories

Clinical Examination

Radiographs

Study Models

Counseling

Consultations



3

Splints

Medications

Manipulation

Injections

Diet

Exercises



Arthroscopy (closed lock)

4

Orthosis

5

Equilibration

Occlusal Reconstruction

Orthodontia

Orthognathic Surgery



6

Physiotherapy

Psychotherapy

Splint Adjustment


7

Detailed imaging studies

8

Response

9

Arthroscopy or arthrocentesis (1st) Arthrotomy

10

Physiotherapy

Psychotherapy

Occlusal Management

Treating Odontogenic Infections

Introduction


Pulpal and periapical infections account for the majority of oral odontogenic infections. Most of the infections of the pulp and periapical regions are of a mixed variety and include both aerobic and anaerobic bacteria. Many microbiologists now believe that in periapical infections, more than 50 percent of all organisms are anaerobic.

Symptoms


Periodontal infections usually occur after a period of chronic periodontitis. The gingival tissue may become red, swollen, and painful.

Diagnosing Odontogenic Infections


Pain upon percussion and soft tissue swelling adjacent to the involved tooth can often pinpoint the cause of the infection. Radiographic evidence of a periapical radiolucency indicates extension of infection into the bone.

Common Treatment Regimens


  • The following treatment regimens are recommended for the specific conditions described:

  • If without further extension of the infection, start endodontic treatment or extraction along with appropriate surgical drainage and antibiotic therapy.

  • If bone destruction is extensive, extract the involved tooth.

  • If at any time there is purulence, perform culture and sensitivity tests. Select the antibiotic therapy according to the results.

  • If fluctuance occurs in the soft tissue, make an incision and begin drainage.

  • If infections extensively involve the soft tissue areas of the face and neck region, you must decide whether to admit the patient for aggressive management.

Treatment of a Pericoronal Infection of a Partially Erupted
Mandibular Third Molar

Warning: Pericoronal infection of the partially erupted mandibular third molar presents a potentially life threatening situation.

Because of the anatomic location of the mandibular third molar, an infection may result in rapid soft tissue extension of the infection. This infection may spread into most of the fascial planes and also posteriorly and inferiorly into the mediastinum.



If an erupted maxillary third molar is irritating the soft tissue overlying the partially erupted mandibular third molar, the maxillary molar should be removed.

Antibiotics


The following antibiotics are appropriate in treating odontogenic infections:

  • penicillin (if not allergic to it). (This is still the first drug of choice for oral infections.)

  • V-Cillin K (or Pen VK) 500 mg dispense tab #28 Sig 1 tab po QID

Antibiotics (Anaerobic Organisms)


The following antibiotics are appropriate in treating odontogenic infections when anaerobic organisms are suspected:

  • V-Cillin K (or Pen VK) 500 mg dispense tab #28 Sig 1 tab po QID and
    Metronidazole 500 mg dispense tab #28 Sig 1 tab po QID

  • the Metronidazole may be added to the penicillin, but should never be used alone

Alternative Antibiotics (Penicillin Allergy)


Patients with an allergy to penicillin may require an alternative antibiotic:

  • Clindamycin 300 mg dispense tab #28 Sig 1 tab po QID

  • Keflex 500 mg dispense tab #28 Sig 1 tab po QID

Other Alternative Antibiotics


When failure occurs with the above mentioned antibiotics, or if a beta lactamase producing bacteria is suspected, the following is a logical alternative: Augmentin 500 mg dispense tab #21 Sig 1 tab po TID

Indications for Hospitalization


The following is a list of indications for hospitalizing a patient with a severe oralfacial infection:

Signs of severity:

  • fever

  • dehydration

  • rapid progression of swelling

  • trismus

  • marked pain

  • elevation of tongue

  • swelling of soft palate

    • submandibular swelling (possibility of Ludwig’s angina if bilateral)

Symptoms of severity:

  • marked pain

  • malaise

  • chills

  • difficulty swallowing

  • difficulty breathing

Laboratory test:

  • elevated temperature (over 101F)

  • elevated white blood count (WBC) (over 11,000)

  • shift to the left on differential count (increase in immature leukocytes)

Medical problems:

  • diabetes mellitus

  • patient taking steroids or other immunosuppressive drugs

  • prosthetic valves or other prosthesis

Hospitalization may provide the following services:

  • intravenous antibiotic dosage not possible with oral medication

  • adequate hydration

  • relief of severe pain

  • extraoral surgical drainage under general anesthesia

  • monitoring of life-threatening symptoms

Serious Facial Infections


When a determination is made that a patient should be admitted for a serious facial infection, an oral and maxillofacial surgeon should be consulted. The oral and maxillofacial surgeon is very familiar with the proper management of such cases. Rapid and aggressive management of a serious infection may save someone’s life.
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