ORAL AND MAXILLOFACIAL SURGERY

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Contents

Associated Links

GRADE SHEETS

CLINIC FORMS

Referral Form to the Department of Oral & Maxillofacial Surgery

Syllabi

DMD Oral Surgery Protocol (This video is not accessible from the clinic computers. The file is 2.74 GB in size and requires about 90 seconds to download from a hardwire connection. Because of the file size, the movie may not run from a wireless connection.)


Introduction

A. Definition: Oral and Maxillofacial Surgery is the specialty of dentistry that includes the diagnosis, surgical, and adjunctive treatment of diseases, injuries, and defects, including both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial regions.

B. Scope of Care: Oral and maxillofacial surgical procedures are performed in both inpatient and outpatient ambulatory treatment facilities. The scope of care includes, but is not limited to, the following categories.

  1. Odontogenic Procedures. Includes routine tooth removal; impacted tooth removal; and tooth implantation, replantation, transplantation; and surgical exposure.
  2. Repair Procedures. Includes repair of single and complex traumatic oral and facial wounds of skin, mucosa, and other soft tissue; repair of congenital clefts of lip and palate; oroantral and oronasal fistula repair, skin or mucosal grafts; and bone grafts.
  3. Preposthetic Surgery. Surgical contouring and alternation of soft or hard tissues to aid prosthodontic rehabilitation, including alveoloplasty, simple and complex stomatoplasty, and oral implantology.
  4. Surgical Excision of Pathologic Lesions. Includes salivary gland surgery, soft tissue lesions, benign tumors, odontogenic and nonodontogenic cysts of tumors, destruction of lesions by physical methods, removal of exostoses, partial or radical resection of maxilla or mandible and sequestrectomy.
  5. Surgical Incision. Includes incision and drainage, biopsy, foreign body removal, maxillary sinusotomy, cricothyrotomy, tracheostomy, and therapeutic and surgical management of odontogenic infection.
  6. Treatment of Fractures. Includes closed and open reduction of maxillary and mandibular fractures, alveolar process fractures, and fractures of other facial bones.
  7. Orthognathic Surgery. Correction of craniofacial disharmonies by surgical repositioning of maxilla, mandible, and other facial bones and segments.
  8. Temporomandibular Joint (TMJ) Dysfunction. Surgical and nonsurgical management of TMJ dysfunction.
  9. Anesthesia. Includes local anesthesia, inhalation sedation, IV sedation, and general anesthesia.
  10. Diagnostic Procedures. Includes oral examination, physical examination, radiographic and other imaging studies, and use of laboratory tests.

C. General Standards Applicable to All Criteria Sets: Following are general criteria that are applicable to all surgical cases. Exception – in case of imminent life-threatening emergency, immediate treatment of the patient may preclude obtaining the applicable history, performing a complete examination, or obtaining informed consent.

  1. Applicable History.
  2. Examination. The purpose of the clinical examination is to observe and record pertinent information regarding the physical condition of the patient preliminary to development of a rational diagnosis and effective treatment plan. All significant findings should be properly documented in the patient’s records.
  3. Diagnosis. Preoperative diagnosis or needs assessment based on the subjective data and objective data should be established and documented.
  4. Treatment Plan: A comprehensive treatment plan must be completed at the time of examination and must be recorded in the patient’s record.
  5. Infection Control. An appropriate level of asepsis must be attained.
  6. Pathology Evaluation. All tissue removed should be identified macroscopically or microscopically.
  7. Antibiotic Prophylaxis. Appropriate antibiotic prophylaxis must be prescribed when indicated for prevention of bacterial endocarditis.

D. Level of Care Required: Oral and maxillofacial surgical procedures should be accomplished in the hospital setting rather than in the outpatient clinic when:

  1. Historical evidence of complex systemic disease requiring extensive medical management is evident.
  2. Control of pain and apprehension in the unduly fearful patient (i.e., patient under psychiatric care, previous attempt made to treat in ambulatory setting, nonresponsive to ambulatory outpatient management) is needed.
  3. Cervicofacial infection is present that may require extraoral drainage.
  4. A patient requires inpatient anesthesia management.
  5. Complexity of surgical procedure, or the patient, requires special diagnostic and therapeutic equipment only available in the hospital.
  6. Postoperative supportive nursing care will be required.


How To Refer A Patient

  1. Working with your preceptor or other Department of Comprehensive Care faculty:
    1. Determine the need for a specific oral surgery procedure
    2. Decide if a consult to determine what procedure, if any, is appropriate
    3. Find out if implant surgery will be performed by the Department of Oral & Maxillofacial Surgery
  2. Complete the Referrals to the Department of Oral & Maxillofacial Surgery form
  3. Call or visit the Department of Oral & Maxillofacial Surgery to set up an appointment. (DMD students must be present at the time of surgery)
  4. Periodically check the status of your patient's appointment. (Patients get bumped by trauma surgeries).
  5. DMD students must be present at the time of surgery.

Oral and Maxillofacial Surgical Procedures

Tooth Extraction – Forceps

  1. Procedure. The nonsurgical removal of an erupted tooth using forceps. Indications for the procedure are derived from an evaluation which includes one or more of the following:
    • History of evidence of oral functional impairment, pain, swelling, etc.
    • Radiologic evidence of decay: coronal, periapical or periodontal pathosis; or bone destruction.
    • Clinical evidence of decay, swelling, tooth fracture, abnormal pulp tests, missing crown, excessive mobility.
    • Insufficient tooth structure for operative restoration or root canal treatment.
    • Refusal or failure of root canal treatment.
    • Part of orthodontic treatment.
    • Nonfunctional teeth.
  2. Postoperative Criteria
    • No sepsis (e.g., wound infection, abscess, bacteremia, septic phlebitis).
    • No hemorrhage.
    • No alveolar ostetitis.
    • No anesthesia, paresthesia, or dysesthesia of mandibular, mental, or other nerve distribution.
    • No extraction of the wrong tooth.
    • No fracture of the jaw.
    • No oroantral fistula.
    • No damage to adjacent teeth.
    • No airway problems.
    • Should not require intravenous fluid administration to maintain appropriate hydration level.
    • No portion of tooth or root unremoved without informing patient and noting in record.

Surgical Removal of Teeth

  1. Procedure. Surgical removal is a method for extracting complicated erupted teeth and impacted teeth. The procedure requires reflection of mucoperiosteal flaps for access and/or bone removal or sectioning of teeth with surgical drills or chisel technique. Indications for the surgical procedure are derived from an evaluation which includes one or more of the following:
    • When the possible need for excessive force to extract a tooth is perceived.
    • When initial attempts at forceps extraction have failed.
    • History or evidence of oral functional impairment, pain, swelling, etc.
    • Radiologic evidence of decay, coronal, periapical or periodontal pathosis; bone destruction, or impaction.
    • Clinical evidence of decay, swelling, tooth fracture, abnormal pulp tests, malocclusion.
    • Unerupted tooth, inaccessible to operative repair or root canal treatment.
    • Refusal or failure of root canal treatment.
    • Part of orthodontic treatment plan.
    • Clinically indicated removal of nonfunctional teeth.
  2. Postoperative Criteria
    • No sepsis (e.g., wound infection, abscess, bacteremia, septic phlebitis).
    • No hemorrhage.
    • No alveolar osteitis.
    • No anesthesia, paresthesia, dysesthesia of mandibular, mental, or other nerve distribution.
    • No extraction of the wrong tooth.
    • No fracture of the jaw.
    • No oroantral fistula.
    • No damage to adjacent teeth.
    • No airway problems.
    • Should not require intravenous fluid administration to maintain appropriate hydration level.
    • No portion of tooth or root unremoved without informing patient and noting in record.


Alveoloplasty

  1. Procedure. Alveoloplasty is the surgical recontouring of the bony alveolar ridge using surgical drills, rongeur, chisels, and bone files. Indications for the procedure include:
    • Bony exostosis.
    • Clinical evidence of oral functional impairment (inability to tolerate prosthesis, masticatory problems).
    • Post tooth extraction alveolar bone projections or defects requiring alveolar ridge smoothing and modification.
    • Radiologic and clinical evidence of defective alveolar ridge.
  2. Postoperative Criteria
    • Adequate bony support has been established for subsequent placement of the prosthetic appliance(s).
    • No sepsis (e.g., wound infection, abscess, bacteremia, or septic phlebitis).
    • No hemorrhage.
    • No anesthesia, paresthesia, dysesthesia of mandibular, mental, or other nerve distribution.
    • No fracture of the jaw.
    • No oroantral fistula.
    • No airway problems.
    • Should not require intravenous fluid administration to maintain appropriate hydration level.


Oral Biopsy Procedure

Incisional or excisional biopsy of lesions of the oral tissues including mucosa, gingival, lips, cheeks, tongue, maxilla, mandible, hard and soft palate, and floor of mouth.

  1. Indications for Surgical Procedure
    • Lesions of oral tissue with question of malignancy (e.g., white lesions of mucosa, leukoplakia, red lesions, speckled lesions, deeply pigmented or melanotic lesions.
    • Lesions of oral tissue to establish histologic diagnosis.
    • Lesions of oral tissue subject to malignant change through chronic irritation.
  2. Postoperative Criteria
    • No sepsis (e.g., wound infection, abscess, bacteremia, or septic phlebitis).
    • No hemorrhage.
    • No neurosensory deficit.


Open or Closed Reduction of Facial Fracture

  1. Procedure. Closed reduction using splints, intermaxillary fixation, and various archbar or dental wiring techniques of facial fractures for management of maxillary and mandibular fractures. Open reduction of facial fractures is a procedure which may use the preceding plus surgical exposure of the fracture and placement of internal fixation. Indications for the operation are derived from the following suggested evaluation:
    • Physical evidence of facial bone fracture, with instability or displacement.
    • Radiologic evidence of facial bone fracture with displacement.
  2. Postoperative Criteria
    • No sepsis (e.g., wound infection, abscess, bacteremia, or septic phlebitis).
    • No hemorrhage.
    • No airway obstruction.
    • No cranial nerve deficit.
    • No instability, malunion, or nonunion.
    • No malocclusion.
    • No visual disturbance.
    • No cosmetic deformity.
    • No cerebrospinal fluid leak.


Excision of Salivary Glands, Partial or Total

  1. Procedure. Surgical excision of minor or major salivary glands via the oral cavity or extraoral approach. The indications for the procedure include:
    • Mucous retention phenomenon (muccocele or ranula).
    • Tumor of salivary gland.
    • Persistent or recurrent sialoadenitis, with or without calculus.
  2. Postoperative Criteria
    • No sepsis (e.g., wound infection, abscess, bacteremia, or septic phlebitis).
    • No hemorrhage.
    • No cranial nerve deficit.
    • No salivary cutaneous fistula.


Other Procedures

The standards of care for surgical procedures usually performed within a hospital (i.e., orthognathic surgery, TJM surgery, preprosthetic surgery, and anesthesia procedures) should conform to the parameters of care published by the American Association of Oral and Maxillofacial Surgeons.

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