copyright 2003, elsevier science (usa). all rights reserved. lecture 1 history of surgical dentistry...

Copyright 2003, Elsevier Science (USA). All rights reserved.

LECTURE 1HISTORY OF SURGICAL DENTISTRY AND

MAXILLOFACIAL SURGERY, THEIR DEFINITION AND TASK. PREPARATION OF THE PATIENT FOR

SURGERY. DEFINITION OF PAIN; REACTION OF THE ORGANISM TO THE PAIN, THE OPERATING TRAUMA.

ANESTHESIA IN SURGICAL DENTISTRY.GENERAL ANESTHESIA. INDICATIONS AND

CONTRAINDICATIONS, PREANESTHETIC MEDICATION PRINCIPLES, NEUROLEPTANALGESIA. COMPLICATIONS OF GENERAL ANESTHESIA, THEIR TREATMENT AND PROPHYLAXIS. FUNDAMENTALS

OF CARDIOPULMONARY RESUSCITATION.

LECTURE 1HISTORY OF SURGICAL DENTISTRY AND

MAXILLOFACIAL SURGERY, THEIR DEFINITION AND TASK. PREPARATION OF THE PATIENT FOR

SURGERY. DEFINITION OF PAIN; REACTION OF THE ORGANISM TO THE PAIN, THE OPERATING TRAUMA.

ANESTHESIA IN SURGICAL DENTISTRY.GENERAL ANESTHESIA. INDICATIONS AND

CONTRAINDICATIONS, PREANESTHETIC MEDICATION PRINCIPLES, NEUROLEPTANALGESIA. COMPLICATIONS OF GENERAL ANESTHESIA, THEIR TREATMENT AND PROPHYLAXIS. FUNDAMENTALS

OF CARDIOPULMONARY RESUSCITATION.


Extractions of decayed teeth that cannot be restored

Surgical removal of impacted teeth Extraction of nonvital teeth Preprosthetic surgery to smooth and

contour the alveolar ridge Removal of teeth for orthodontic

treatment Removal of root fragments

Extractions of decayed teeth that cannot be restored

Surgical removal of impacted teeth Extraction of nonvital teeth Preprosthetic surgery to smooth and

contour the alveolar ridge Removal of teeth for orthodontic

treatment Removal of root fragments

Indications for Maxillofacial Surgery Indications for Maxillofacial Surgery


Removal of cysts and tumors Biopsy Treatment of fractures of the mandible

or maxilla Surgery to alter the size or shape of the

facial bones Surgery of the temporomandibular joint Reconstructive surgery

Removal of cysts and tumors Biopsy Treatment of fractures of the mandible

or maxilla Surgery to alter the size or shape of the

facial bones Surgery of the temporomandibular joint Reconstructive surgery

Indications for Maxillofacial Surgery cont’d Indications for Maxillofacial Surgery cont’d


Cleft lip and cleft palate repairs Salivary gland surgery Surgical implant procedures

Cleft lip and cleft palate repairs Salivary gland surgery Surgical implant procedures

Indications for Maxillofacial Surgery cont’d Indications for Maxillofacial Surgery cont’d


Must have advanced knowledge and skill in:• Patient assessment and monitoring• Specialized instruments• Surgical asepsis• Surgical procedures• Pain control techniques

Must have advanced knowledge and skill in:• Patient assessment and monitoring• Specialized instruments• Surgical asepsis• Surgical procedures• Pain control techniques

The Surgical Assistant The Surgical Assistant


Dental Operatory Surgical Suite Operating Room

Dental Operatory Surgical Suite Operating Room

The Surgical Setting The Surgical Setting


What is Surgical Dentistry /Oral Surgery?

The dental specialty of Surgical Dentistry / Oral Surgery is concerned with the diagnosis and surgical management of pathological processes and anomalies in the teeth or their supporting structures.

Most treatment can be completed on an out-patient basis using local anæsthesia, occasionally supplemented by sedation if necessary.


The Surgical Dentist / Oral Surgeon is trained in a number of surgical procedures including the following:the extraction of teeth and rootsthe treatment of ectopic and impacted teethsurgical endodonticsthe re-implantation of teethsurgical exposure of teeth (such as canines)minor soft tissue surgery (such as biopsy techniques)removal of intra-oral submandibular salivary calculimanagement of dental traumaclosure of holes between the mouth and sinusmanagement of cuts to the mouthdental implantologyminor orthodontic surgery (release of tongue-ties) and pain and anxiety control, local anæsthesia and sedation


The syllabus includes:•diagnosis and management of oral disease•surgical endodontics•minor soft-tissue surgery•management of dental trauma•surgical placement of dental implants•management of pain and anxiety by pharmacological and non-pharmacological means•control of cross-infection•medico-legal aspects of surgical dentistryMost Surgical Dentists / Oral Surgeons have trained in a hospital-setting and often work part-time in hospital Oral Surgery departments.


Oral and maxillofacial surgery is surgery to treat many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral (mouth) and maxillofacial (jaws and face) region. It is an internationally recognized surgical specialty. In some countries, including the United States, it is a recognized specialty of dentistry; in others, including the UK, it is recognized as a medical specialty.


Surgical proceduresTreatments may be performed on the craniomaxillofacial complex: mouth, jaws, face, neck, skull, and include:Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth extractions, extractions on medically compromised patients, bone grafting or preprosthetic surgery to provide better anatomy for the placement of implants, dentures, or other dental prostheses)Surgery to insert osseointegrated (bone fused) dental implants and Maxillofacial implants for attaching craniofacial prostheses and bone anchored hearing aids.Cosmetic surgery of the head and neck: (rhytidectomy/facelift, browlift, blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplasty, oculoplastics, neck liposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel etc.)Surgical treatment and/or splinting of sleep apnea, maxillomandibular advancement, genioplasty


Diagnosis and treatment of: benign pathology (cysts, tumors etc.)malignant pathology (oral & head and neck cancer) with (ablative and reconstructive surgery, microsurgery)cutaneous malignancy (skin cancer), lip reconstructioncongenital craniofacial malformations such as cleft lip and palate and cranial vault malformations such as craniosynostosis, (craniofacial surgery)chronic facial pain disorderstemporomandibular joint (TMJ) disordersDysgnathia (incorrect bite), and orthognathic (literally "straight bite") reconstructive surgery, orthognathic surgery, maxillomandibular advancement, surgical correction of facial asymmetry.soft and hard tissue trauma of the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures).


How does a patient prepare for oral surgery?Oral surgery can be a frightening experience, but proper preparation can go far in making the procedure easier to anticipate. The first step is to consult with the dentist or oral surgeon about the procedure to understand what will be involved. The dentist will give a brief description of how the procedure will be performed and the medications used before, during and afterward. Patients particularly nervous about the impending surgery may want to ask about sedation options available.The patient will be given a list of pre-operative instructions. It is imperative to follow the instructions very carefully to ensure the procedure will be safe and successful. Arrange for transportation to and from the surgery, since certain medications may make it impossible for the patient to drive himself. Take the necessary time off work as recommended by the doctor.


ObjectivesObjectives

Patient data Doctor – patient relationship Anesthetic plan Patient consent

Patient data Doctor – patient relationship Anesthetic plan Patient consent


1.Review of patient data 1.Review of patient data Medical record Interview history History of underlying disease,

medication, functional capacitance, previous anesthetic

history, family history,

smoking and alcoholic use, review of system, psychological support

Airway evaluationAirway evaluation

Medical record Interview history History of underlying disease,

medication, functional capacitance, previous anesthetic

history, family history,

smoking and alcoholic use, review of system, psychological support



1.Review of patient data1.Review of patient data

Surgical condition-Condition of disease, symptom of disease-Surgical procedure-Position of procedure

Surgical condition-Condition of disease, symptom of disease-Surgical procedure-Position of procedure


2. Physical examination2. Physical examination

Vital signs General appearance HEENT Respiratory system CVS system Abdomen Extremities and spine Neurologic system

Vital signs General appearance HEENT Respiratory system CVS system Abdomen Extremities and spine Neurologic system



History of difficult intubation Head and neck examination for airway

evaluation Face Oral cavity : mouth opening

mandibular space

tongue

teeth

Mallampati classification

History of difficult intubation Head and neck examination for airway

evaluation Face Oral cavity : mouth opening

mandibular space

tongue

teeth

Mallampati classification


Airway evaluationAirway evaluation Mentothyroid distance : normal 6 cm. Mentosternal distance : normal 15 cm Mentohyoid distance : normal 3 FB Neck movement: flexion and extension

of neck, history of radiation Nasal cavity

Mentothyroid distance : normal 6 cm. Mentosternal distance : normal 15 cm Mentohyoid distance : normal 3 FB Neck movement: flexion and extension

of neck, history of radiation Nasal cavity


Thyromental distance


Difficult intubationDifficult intubation Mouth opening less than 3 cm. Limitation of neck movement Micrognatia Macroglossia Protusion of teeth Short neck Morbid obesity

Mouth opening less than 3 cm. Limitation of neck movement Micrognatia Macroglossia Protusion of teeth Short neck Morbid obesity


3.Laboratory data3.Laboratory data

Value of testing Risk and costs benefits Preoperative testing: base on indication

Value of testing Risk and costs benefits Preoperative testing: base on indication


What is Pain? The answer to this question seems obvious - pain is pain, right? Pain is pain, but it's not all the same. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” However, pain is a symptom that cannot be objectively assessed. I can’t look at a patient and know precisely what hurts, how badly, and what the pain feels like. Pain, therefore, is whatever the person experiencing it says it is.


The practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain.

Methods of pain control• Anesthetic agents • Inhalation sedation• Antianxiety agents • Intravenous sedation • General anesthesia

The practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain.

Methods of pain control• Anesthetic agents • Inhalation sedation• Antianxiety agents • Intravenous sedation • General anesthesia

IntroductionIntroduction


The numbing of a specific site or area. Topical Anesthesia provides a

temporary numbing effect on nerve endings that are located on the surface of the oral mucosa.

Supplied as:• Ointments• Liquids• Sprays

The numbing of a specific site or area. Topical Anesthesia provides a

temporary numbing effect on nerve endings that are located on the surface of the oral mucosa.

Supplied as:• Ointments• Liquids• Sprays

Anesthetic AgentsAnesthetic Agents


Agents most frequently used for pain control in dentistry.

Criteria for use:• Be nonirritating to the tissues in the

area of the injection. • Produce minimal toxicity. • Be of rapid onset. • Provide profound anesthesia. • Be of sufficient duration. • Be completely reversible. • Be sterile.

Agents most frequently used for pain control in dentistry.

Criteria for use:• Be nonirritating to the tissues in the

area of the injection. • Produce minimal toxicity. • Be of rapid onset. • Provide profound anesthesia. • Be of sufficient duration. • Be completely reversible. • Be sterile.

Local AnesthesiaLocal Anesthesia


Local anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses.

Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment.

Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

Local anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses.

Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment.

Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

Method of ActionMethod of Action


Length of time from induction until the reversal process is complete.

Short-acting:• Local anesthetic agent lasts less than 30

minutes. Intermediate-acting:

• Local anesthetic agent lasts about 60 minutes.

Long-acting:• Local anesthetic agent lasts longer than

90 minutes.

Length of time from induction until the reversal process is complete.

Short-acting:• Local anesthetic agent lasts less than 30

minutes. Intermediate-acting:

• Local anesthetic agent lasts about 60 minutes.

Long-acting:• Local anesthetic agent lasts longer than

90 minutes.

DurationDuration


Criteria for use:• Prolongs the duration of an anesthetic

agent by decreasing the blood flow in the immediate area of the injection.

• Decreases bleeding in the area during surgical procedures.

Types:• Epinephrine • Levonordefrin • Norepinephrine

Criteria for use:• Prolongs the duration of an anesthetic

agent by decreasing the blood flow in the immediate area of the injection.

• Decreases bleeding in the area during surgical procedures.

Types:• Epinephrine • Levonordefrin • Norepinephrine

VasoconstrictorVasoconstrictor


Ratio of vasoconstrictor to anesthetic solution:

• 1:20,000• 1:50,000• 1:100,000• 1:200,000

Ratio of vasoconstrictor to anesthetic solution:

• 1:20,000• 1:50,000• 1:100,000• 1:200,000

Vasoconstrictor cont’dVasoconstrictor cont’d


Contraindications for the use of vasoconstrictors • Unstable angina. • Recent myocardial infarction. • Recent coronary artery bypass surgery. • Untreated or uncontrolled severe

hypertension. • Untreated or uncontrolled congestive

heart failure.

Contraindications for the use of vasoconstrictors • Unstable angina. • Recent myocardial infarction. • Recent coronary artery bypass surgery. • Untreated or uncontrolled severe

hypertension. • Untreated or uncontrolled congestive

heart failure.

Vasoconstrictor cont’dVasoconstrictor cont’d


Infiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure.• Most frequently used to anesthetize the

maxillary teeth. • Used as a secondary injection to block

gingival tissues surrounding the mandibular teeth.

Infiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure.• Most frequently used to anesthetize the

maxillary teeth. • Used as a secondary injection to block

gingival tissues surrounding the mandibular teeth.

Types of Local Anesthesia InjectionsTypes of Local Anesthesia Injections


Block anesthesia• The solution is injected near a major nerve,

and the entire area served by that nerve is numbed.

• Type of injection required for most mandibular teeth.

Inferior alveolar nerve block • Obtained by injecting the anesthetic

solution near the branch of the inferior alveolar nerve close to the mandibular foramen.

• Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

Block anesthesia• The solution is injected near a major nerve,

and the entire area served by that nerve is numbed.

• Type of injection required for most mandibular teeth.

Inferior alveolar nerve block • Obtained by injecting the anesthetic

solution near the branch of the inferior alveolar nerve close to the mandibular foramen.

• Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d


Incisive nerve block• Injection given at the site of the mental

foramen. • Used when the mandibular anterior

teeth or premolars require anesthesia. Periodontal ligament

• Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

Incisive nerve block• Injection given at the site of the mental

foramen. • Used when the mandibular anterior

teeth or premolars require anesthesia. Periodontal ligament

• Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

Types of Local Anesthesia Injections cont’dTypes of Local Anesthesia Injections cont’d


Table 37-2 Local Anesthesia Setup: Anesthetic SyringeTable 37-2 Local Anesthesia Setup: Anesthetic Syringe


Anesthetic carpule: Care and caution of use• Cartridges should be stored at room

temperature and protected from direct sunlight.

• Never use a cartridge that has been frozen. • Do not use a cartridge if it is cracked,

chipped, or damaged in any way. • Never use a solution that is discolored or

cloudy or has passed the expiration date. • Do not leave the syringe preloaded with

the needle attached for an extended period of time.

• Never save a cartridge for reuse.

Anesthetic carpule: Care and caution of use• Cartridges should be stored at room

temperature and protected from direct sunlight.

• Never use a cartridge that has been frozen. • Do not use a cartridge if it is cracked,

chipped, or damaged in any way. • Never use a solution that is discolored or

cloudy or has passed the expiration date. • Do not leave the syringe preloaded with

the needle attached for an extended period of time.

• Never save a cartridge for reuse.

Local Anesthesia SetupLocal Anesthesia Setup


Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia

Injection into a blood vessel Infected area Localized toxic reaction Systemic toxic reaction Temporary numbness Paresthesia

Local Anesthetic CautionsLocal Anesthetic Cautions


A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command. This controlled state in loss of consciousness, produces stage III general anesthesia.

A controlled state of unconsciousness in which there is a loss of protective reflexes, including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command. This controlled state in loss of consciousness, produces stage III general anesthesia.

General Anesthesia General Anesthesia


Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent, the patient can move into different levels of analgesia.

Stage I: Analgesia is the stage at which a patient is relaxed and fully conscious. The patient is able to keep his or her mouth open without assistance and is capable of following directions. The patient will have a sense of euphoria and a reduction in pain. Vital signs are normal. Depending on the agent, the patient can move into different levels of analgesia.

Four Stages of AnesthesiaFour Stages of Anesthesia


Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage.

Stage II: Excitement is the stage at which a patient is less aware of his or her immediate surroundings and can start to become unconscious. The patient can become excited and unmanageable. Nausea and vomiting can occur. This is an undesirable stage.

Four Stages of Anesthesia cont’dFour Stages of Anesthesia cont’d


Stage III: General anesthesia is the stage of anesthesia that begins when the patient becomes calm after stage II. The patient feels no pain or sensation. The patient will become unconscious. This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital.

Stage III: General anesthesia is the stage of anesthesia that begins when the patient becomes calm after stage II. The patient feels no pain or sensation. The patient will become unconscious. This stage of anesthesia can be met only under the guidance of an anesthesiologist in a controlled environment such as a hospital.



Stage IV: Respiratory failure or cardiac arrest is the stage at which the lungs and heart slow down or stop functioning. If this stage is not reversed quickly, the patient will die.

Stage IV: Respiratory failure or cardiac arrest is the stage at which the lungs and heart slow down or stop functioning. If this stage is not reversed quickly, the patient will die.



Patient preparation• Preoperative physical examination.• Laboratory tests.• Patient or legal guardian must sign a

consent form. Preoperative instructions

• Dentist will review the procedure, as well as the risks.

• Must not have anything to drink or eat 8 to 12 hours before receiving general anesthesia.

Patient preparation• Preoperative physical examination.• Laboratory tests.• Patient or legal guardian must sign a

consent form. Preoperative instructions

• Dentist will review the procedure, as well as the risks.

• Must not have anything to drink or eat 8 to 12 hours before receiving general anesthesia.

General Anesthesia cont’d General Anesthesia cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.54

Main stages of resuscitationA (Airway) – ensure open airway by preventing

the falling back of tongue, tracheal intubation if possible

B (Breathing) – start artificial ventilation of lungs

C (Circulation) – restore the circulation by external cardiac massage

D (Differentiation, Drugs, Defibrilation) – quickly perform differential diagnosis of cardiac arrest, use different medication and electric defibrillation in case of ventricular fibrillation


A (Airway) ensure open

airway


B (Breathing)

Tilt the head back and listen for. If not breathing normally, pinch nose and cover the mouth with yours and blow until you see the chest rise.


C. CirculationRestore the circulation, that is start external cardiac massage


ALGORITHM of Cardiopulmonary resuscitation

4 cycles: 15 compression and 2 breaths

10 cycles: 5 compression and 1 breath

check the pulse on carotid arteries (5 sec)

in case of absence of pulse continue resuscitation

2 breaths (duration 1 – 1.5 sec.)

palpation of pulse on carotid arteries (5 – 10 sec.)

in case of absence of pulse initiate external cardiac massage

1 person

compression rate 80 – 100/min.compression/breath = 15 : 2

compression rate 80 – 100/mincompression/breath = 5 : 1

2 breaths in 4 – 7 sec. breath during 1 – 1.5 sec. after each 5th compression

2 persons

a

a

a


Drugs used in CPR

• Atropine – can be injected bolus, max 3 mg to block vagal tone, which plays significant role in some cases of cardiac arrest

• Adrenaline – large doses have been withdrawn from the algorithm. The recommended dose is 1 mg in each 3-5 min.

• Vasopresine – in some cases 40 U can replace adrenaline

• Amiodarone - - should be included in algorithm

• Lidocaine – should be used only in ventricular fibrillation


Thank you for attention

Thank you for attention

copyright 2003, elsevier science (usa). all rights reserved. lecture 1 history of surgical dentistry...

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