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Oral Surgery - All Chapters Explained

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Chapter 1: Medical History & Patient Assessment

• Patients on anticoagulants may need INR checks before extraction; tranexamic acid mouthwash is used post-operatively in hemophiliacs.
• Patients with prosthetic heart valves historically received antibiotic prophylaxis (amoxicillin 2g pre-op), though current guidelines have narrowed these indications.
• Diabetic patients require glucose control, as impaired wound healing and infection risk are elevated.
• Allergic reactions to local anesthetics (true IgE-mediated allergy is rare; most reactions are vasovagal or toxic) must be distinguished.

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Chapter 2: Radiology in Oral Surgery

• Periapical (PA) X-rays - Show individual tooth roots, periapical pathology, bone levels, root morphology. The most commonly used.
• Panoramic (OPG/OPT) - Full-mouth survey; shows all teeth, both jaws, sinuses, TMJ, and the inferior alveolar nerve canal. Essential before third molar surgery.
• Bitewing radiographs - Primarily for interproximal caries, also show crestal bone levels.
• Occlusal radiographs - Good for floor of mouth, palate, and stone detection in submandibular duct.
• Lateral cephalometric radiographs - Used in orthognathic surgery planning.
• CT / CBCT (Cone Beam CT) - Three-dimensional imaging; now standard for implant planning, complex impactions, jaw pathology, and trauma. CBCT delivers lower radiation than conventional CT.
• Vertical transversal tomography - Cross-sectional jaw views for ridge assessment.

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Chapter 3: Principles of Surgery (Surgical Fundamentals)

3.1 Sterilization and Infection Control

• Autoclaving (steam under pressure, 134°C/3 min or 121°C/15 min) is the gold standard for metal instruments.
• Chemical disinfection for heat-sensitive items.
• Single-use items: needles, scalpels, sutures.
• Operating room protocols: PPE (mask, gloves, gown, eye protection), instrument packaging, biological indicators.

3.2 Patient and Surgeon Preparation

• Patient positioned supine or semi-reclined in dental chair.
• Surgeon scrubs hands; sterile draping of operative field.

3.3 Surgical Incisions and Flap Design

• Envelope (sulcular) flap - Horizontal incision along the gingival margin; no vertical releasing incision. Simple, good blood supply.
• Triangular flap - One vertical releasing incision + horizontal. Good access for anterior teeth.
• Trapezoidal flap - Two vertical releasing incisions + horizontal. Maximum exposure for large lesions or multiple teeth.
• Semilunar flap - Curved incision in attached gingiva; used for apicoectomy.

1. Base must be wider than free margin (to preserve blood supply)
2. Avoid incisions over bony defects
3. Include adequate attached gingiva
4. Vertical incisions should be in embrasures, not over roots

3.4 Suturing

• Interrupted sutures - Most common; each stitch independent.
• Continuous sutures - Faster; used for long wounds.
• Mattress sutures (horizontal/vertical) - Better wound eversion.
• Figure-of-eight - Common for post-extraction socket closure.
• Materials: resorbable (Vicryl, chromic gut - dissolve in 1-4 weeks) vs. non-resorbable (silk, nylon - require removal at 7 days).

3.5 Hemostasis

• Local - Pressure, vasoconstrictors (epinephrine in local anesthetic), bone wax, oxidized cellulose (Surgicel), tranexamic acid.
• Systemic - Correction of coagulopathy, desmopressin for mild hemophilia A.

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Chapter 4: Instruments in Oral Surgery

Extraction Instruments

• Elevators (luxators/periotomes) - Used to expand the socket and luxate the tooth before forceps application. Types: straight, curved (Cryer), cross-bar (T-bar), apical (Warwick-James).
• Extraction forceps - Specific to each tooth (upper straight forceps, lower molar forceps with beaks straddling bifurcation, cowhorn forceps for lower molars).

Surgical Instruments

• Scalpels - Handle No. 3 with blade No. 15 most common in oral surgery; No. 11 for stab incisions.
• Periosteal elevators - Howarth, Molt; used to raise mucoperiosteal flaps.
• Surgical burs - Round burs for bone removal, fissure burs for tooth sectioning. Used with surgical handpiece under copious irrigation.
• Retractors - Minnesota, Austin; protect soft tissues and improve visibility.
• Rongeur forceps - Bone nibbling; alveoloplasty.
• Bone files - Smooth sharp bone edges.
• Chisel and mallet - Bone splitting, tooth division (now less used; burs preferred).
• Curettes - Remove granulation tissue, periapical pathology.
• Hemostats (artery forceps) - Clamping blood vessels.
• Needle holders - Suturing.
• Scissors - Tissue scissors (Dean's, iris) and suture scissors (straight).
• Bite blocks/mouth props - Maintain mouth opening.
• Surgical suction - Frazier tip, Yankauer; essential for visibility and airway protection.

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Chapter 5: Local Anesthesia in Oral Surgery

Pharmacology

• Lidocaine (lignocaine) 2% with 1:80,000 or 1:100,000 adrenaline - Gold standard. Duration ~1.5-2 hours pulpal, 3-5 hours soft tissue.
• Articaine 4% with 1:100,000 adrenaline - Better bone penetration; preferred in some European practices. Risk of nerve paresthesia slightly higher with lingual injection.
• Bupivacaine 0.5% - Long-acting (8+ hours); useful for post-operative pain control.
• Mepivacaine 3% - No vasoconstrictor; useful in patients where epinephrine is contraindicated.
• Prilocaine 3% - With felypressin; alternative vasoconstrictor in cardiovascular disease.

Injection Techniques

• Inferior Alveolar Nerve Block (IANB) - Anesthetizes all mandibular teeth on that side, buccal mucosa anterior to first molar, lower lip, chin. Needle directed toward mandibular foramen (pterygomandibular space).
• Buccal (long buccal) nerve block - Anesthetizes buccal gingiva of lower molars.
• Mental nerve block - At mental foramen; anesthetizes premolars, canine, incisors, lower lip.
• Lingual nerve block - Usually co-blocked during IANB.
• Maxillary nerve block - Posterior superior alveolar (PSA), middle superior alveolar (MSA), anterior superior alveolar (ASA) - block upper molars, premolars, anterior teeth respectively.
• Infraorbital nerve block - Anesthetizes upper anterior teeth, premolars, lower eyelid, upper lip.
• Greater palatine / nasopalatine blocks - Palatal soft tissue anesthesia.
• Intraligamentary (PDL) injection - Supplemental; single-tooth anesthesia.
• Intraseptal/intraosseous - Supplemental for hot teeth.

Complications of LA

• Intravascular injection (cardiovascular toxicity, CNS excitation then depression)
• Hematoma (PSA block most common due to pterygoid plexus)
• Trismus (from multiple injections or muscle trauma)
• Paresthesia (nerve injury - articaine lingual blocks)
• Facial nerve palsy (parotid infiltration with IANB)
• Infection, broken needle

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Chapter 6: Exodontia (Tooth Extraction)

Indications

• Severe caries (unrestorable)
• Advanced periodontal disease
• Impaction (no space to erupt)
• Orthodontic extraction (space creation)
• Pre-radiation extraction (teeth in field of irradiation)
• Periapical disease unresponsive to root canal treatment
• Fractured teeth
• Supernumerary or retained deciduous teeth

Contraindications

• Local - Active acute infection without antibiotic coverage, vascular lesions (hemangioma), malignant tumors in the area
• Systemic - Recent MI (within 6 months), uncontrolled hypertension/diabetes, severe coagulopathy, bisphosphonate therapy (MRONJ risk), recent radiation to jaw

Technique

1. Adequate anesthesia confirmation
2. Separation of gingival attachment with periosteal elevator
3. Luxation with elevator - expands socket, severs PDL
4. Forceps application - beaks on cementum (not crown), apical pressure
5. Controlled movements: rotation (round-rooted teeth), figure-of-eight, labio-lingual
6. Controlled extraction without excessive force
7. Socket curettage - remove granulation tissue, check for retained root tips
8. Compression of socket walls
9. Hemostasis - gauze pressure 30 minutes

Post-operative Instructions

• Bite on gauze for 30-60 min
• No smoking, hot liquids, vigorous rinsing for 24 hours
• Soft diet
• Salt water rinses from day 2
• Analgesics (ibuprofen + paracetamol)

Complications

• Intra-operative: Fracture of crown/root, displacement of root into sinus or infratemporal fossa, mandible fracture, soft tissue laceration, nerve injury, hemorrhage, jaw dislocation
• Post-operative: Alveolar osteitis (dry socket), hemorrhage, infection, trismus, oro-antral communication

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Chapter 7: Surgical (Complicated) Extractions and Impacted Teeth

Indications for Surgical Extraction

• Fractured or retained roots
• Hypercementosis
• Ankylosis (fused to bone)
• Dilacerated roots
• Impacted teeth

Impacted Teeth - Definition and Classification

• Class I, II, III - relationship to ascending ramus
• Position A, B, C - depth relative to occlusal plane

• Vertical, horizontal, mesioangular (most common), distoangular (most difficult), inverted, buccoangular, linguoangular

• Recurrent pericoronitis
• Caries in third or second molar
• Cyst or tumor formation
• Orthodontic indication
• Nerve compression pain

1. Envelope or triangular flap
2. Bone removal with surgical bur (buccal bone guttering)
3. Tooth sectioning (crown from root, or crown into sections)
4. Delivery in pieces
5. Socket toilet
6. Wound closure (3-0 Vicryl)

• IAN damage (temporary paresthesia 5-10%, permanent <1%)
• Lingual nerve damage
• Dry socket (highest risk tooth)
• Oro-antral communication (upper thirds)
• Postoperative swelling and trismus (peaks day 2-3)

Impacted Canines

• Upper canines are the second most commonly impacted tooth (after lower third molars)
• Palatal impaction more common than buccal
• Managed with exposure and orthodontic traction, or extraction if non-restorable position
• Surgical approach: palatal flap for palatally impacted; tunneling technique preserves attached gingiva

Impacted Premolars and Supernumeraries

• Usually managed in context of orthodontic treatment
• Mesiodens (midline supernumerary) can prevent central incisor eruption

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Chapter 8: Complications of Exodontia

Alveolar Osteitis (Dry Socket)

• Most common post-extraction complication (2-5% overall, up to 25% for mandibular third molars)
• Premature loss of blood clot exposing bare bone
• Onset day 2-4 post-extraction
• Severe throbbing pain radiating to ear, halitosis, exposed white bone
• Risk factors: Smoking (nicotine causes vasoconstriction, sucking disrupts clot), oral contraceptives, difficult extraction, poor oral hygiene, mandibular location
• Treatment: Gentle irrigation with warm saline, alvogyl (iodoform + eugenol-based dressing) into socket, systemic NSAIDs, chlorhexidine. Heals in 1-3 weeks.

Post-Extraction Hemorrhage

• Primary: During procedure - inadequate hemostasis
• Reactionary: Within hours - vasoconstriction wears off
• Secondary: Days later - infection erodes clot
• Management: LA with vasoconstrictor, local pressure, suturing, oxidized cellulose, electrocautery, correct underlying coagulopathy

Oro-Antral Communication (OAC)

• Communication between oral cavity and maxillary sinus
• Most common after upper molar/premolar extraction
• Symptoms: Air/fluid passing through socket, nose bleed, nasal voice
• Diagnosis: Valsalva test (air bubbles from socket on nose-blowing)
• Small OAC (<2mm): close spontaneously with good clot formation + Schneiderian membrane precautions (no nose-blowing, decongestants, antibiotics)
• Large OAC: formal closure with buccal advancement flap (Rehrmann flap) or palatal rotation flap

Oro-Antral Fistula

• Persistent OAC epithelialized after weeks
• Requires formal surgical closure with flap reconstruction

Root Displacement into Maxillary Sinus

• During upper molar surgery
• Do not attempt blind retrieval
• Refer for FESS (functional endoscopic sinus surgery) or Caldwell-Luc

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Chapter 9: Dentoalveolar Infections and Abscesses

Pathways of Odontogenic Infection

• Buccal space (most common)
• Palatal abscess
• Canine (infraorbital) space
• Pterygomandibular space

• Sublingual space (anterior spread from lower anteriors/premolars)
• Submandibular space (posterior spread - molars)
• Parapharyngeal/lateral pharyngeal space

Ludwig's Angina

• Bilateral submandibular and sublingual cellulitis
• Life-threatening - airway can be compromised rapidly
• Signs: "woody" boardlike floor of mouth, elevation of tongue, dysphagia, drooling, stridor
• Management: Airway first (awake fibreoptic intubation or surgical airway), IV antibiotics (penicillin + metronidazole or ampicillin-sulbactam), urgent surgical drainage

Classification of Abscesses

• Periapical abscess - Acute infection at root apex; causes severe throbbing pain, tooth tender to percussion
• Periodontal/lateral abscess - From periodontal pocket
• Pericoronal abscess (pericoronitis) - Around crown of partially erupted tooth (especially lower third molar); operculum traps food
• Subperiosteal abscess - Pus beneath periosteum; indurated swelling
• Submucous abscess - Pus beneath mucosa; fluctuant
• Chronic dentoalveolar abscess - Low-grade, draining sinus (parulis)

Treatment Principles

1. Eliminate the cause - Extraction or root canal treatment of offending tooth
2. Establish drainage - Incision and drainage (I&D) of fluctuant abscess
3. Antibiotics - Amoxicillin 500mg TDS, or amoxicillin-clavulanate; add metronidazole for anaerobes; clindamycin if penicillin-allergic
4. Supportive care - Analgesics, hydration, warm saline rinses

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Chapter 10: Preprosthetic Surgery

Hard Tissue Procedures

• Alveoloplasty - Recontouring of the alveolar ridge after multiple extractions. Removes sharp bony spicules and undercuts that would interfere with denture seating. Intraseptal alveoloplasty (Dean's technique) preserves ridge height while reducing width.
• Torus removal:
  • Torus palatinus - Midline palatal bony exostosis; often lobulated; interferes with upper complete denture. Removed with chisel or bur through midline palatal incision.
  • Torus mandibularis - Bony protuberance on lingual aspect of mandible near premolars; bilateral in 80%. Removed through lingual incision.
  • Multiple buccal exostoses - External bony prominences; undermining technique used.

Soft Tissue Procedures

• Frenectomy/Frenotomy: Labial frenum (high attachment) causes diastema, pulls denture, or restricts lip movement. Simple excision or Z-plasty. Lingual frenum (ankyloglossia) limits tongue mobility and speech.
• Vestibuloplasty - Deepens the vestibule to increase ridge height for denture retention. Techniques: submucosal, secondary epithelialization (Edlan-Mejchar), skin grafting.
• Redundant tissue removal - Hyperplastic fronds (epulis fissuratum) from ill-fitting dentures; excised.
• Tuberosity reduction - Enlarged maxillary tuberosities reduced (hard or soft tissue excess).

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Chapter 11: Periapical Surgery (Endodontic Surgery)

Indications

• Failed root canal treatment with persistent periapical pathology
• Calcified/blocked canal inaccessible to instruments
• Perforated root
• Instrument fractured in canal
• Periapical cyst requiring enucleation
• Diagnostic biopsy of periapical lesion

Contraindications

• Tooth with <50% bone support
• Poor crown-to-root ratio
• Inadequate access due to anatomy

Surgical Techniques

1. Mucoperiosteal flap (semilunar or rectangular)
2. Osteotomy - bone window over apex
3. Curettage of periapical granuloma or cyst lining
4. Root-end resection (3mm) at 0-10° bevel (modern: perpendicular cut to reduce exposed dentinal tubules)
5. Root-end preparation (Class I cavity 3mm deep with ultrasonic tips)
6. Root-end filling (MTA - mineral trioxide aggregate, or IRM)
7. Flap replacement and suturing

• Root resection - Removal of one root of a multi-rooted tooth
• Hemisection - Division of lower molar through furcation; one half retained
• Bicuspidization - Both halves retained as separate teeth

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Chapter 12: Cysts of the Jaws

Classification

• Radicular (periapical) cyst - Most common jaw cyst (65%); arises from periapical granuloma after pulp necrosis; Malassez epithelial rests activated by inflammation
• Dentigerous (follicular) cyst - Surrounds crown of unerupted tooth; second most common; associated with impacted third molars and upper canines
• Odontogenic keratocyst (OKC) - Now called keratocystic odontogenic tumor; high recurrence rate (30%); lining has parakeratinized epithelium; associated with Gorlin-Goltz syndrome (nevoid basal cell carcinoma syndrome)
• Lateral periodontal cyst - Lateral to root; from rests of dental lamina
• Gingival cyst of adults - Soft tissue cyst of attached gingiva

• Nasopalatine duct cyst - Most common non-odontogenic jaw cyst; midline anterior maxilla; from remnants of nasopalatine duct
• Nasolabial cyst - Soft tissue; alar base region
• Globulomaxillary cyst - Between upper lateral incisor and canine (some consider odontogenic)

• Simple bone cyst (traumatic/hemorrhagic) - Empty or fluid-filled cavity; scallops between roots; self-limiting
• Aneurysmal bone cyst - Blood-filled spaces; locally destructive
• Stafne bone cavity - Depression at angle of mandible; contains salivary gland tissue; no treatment needed

Clinical Features

• Most jaw cysts are asymptomatic; discovered on routine X-ray
• Large cysts: jaw expansion, tooth displacement, pathological fracture
• Infected cysts: painful swelling
• OKC: multilocular appearance, grows along medullary cavity with minimal expansion

Treatment

• Small (<1cm): root canal treatment alone may suffice
• Large: Enucleation (surgical removal of entire lining) ± root canal treatment
• Very large: Marsupialization first (Partsch I) to decompress, then enucleation

• Enucleation + extraction of associated impacted tooth
• If associated tooth can erupt: marsupialization allows eruption

• Enucleation + peripheral ostectomy + Carnoy's solution to fix residual epithelium
• High recurrence requires long-term radiographic follow-up (5-10 years)

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Chapter 13: Apicoectomy (Revisited/Advanced Techniques)

• Microsurgical apicoectomy - Use of surgical loupes or microscope; ultrasonic root-end preparation; significantly improves success rates (>90% vs 60% for conventional)
• Guided tissue regeneration - Membrane barriers to promote periapical bone regeneration
• Management of perforations - MTA repair; prognosis depends on location and chronicity

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Chapter 14: Odontogenic Tumors and Benign Jaw Tumors

Benign Odontogenic Tumors

• Most significant benign odontogenic tumor; locally aggressive
• Most common in posterior mandible
• Radiograph: multilocular "soap-bubble" or "honeycomb" appearance
• Histology: follicular, plexiform, acanthomatous patterns
• Treatment: radical resection with 1-1.5cm margins (high recurrence with curettage alone); reconstruction with fibula free flap

• Most common odontogenic tumor overall
• Compound odontoma (tooth-like structures) vs. complex odontoma (disorganized calcified mass)
• Benign, treated by simple excision

Non-Odontogenic Benign Jaw Lesions

• Giant cell granuloma - Central (intraosseous) or peripheral (gingival); curettage; recurrence common in central
• Ossifying fibroma - Gradual replacement of bone by fibrous tissue with bone/cementum; mandible; enucleation
• Osteoma - Dense bone outgrowth; if multiple osteomas, consider Gardner's syndrome
• Fibrous dysplasia - Replacement of medullary bone by fibrous tissue; "ground glass" appearance on X-ray; monostotic (McCune-Albright) or polyostotic

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Chapter 15: Oral Cancer and Malignant Tumors

Epidemiology

• Oral cancer accounts for ~3% of all cancers worldwide
• Squamous cell carcinoma (SCC) = 90% of oral malignancies
• Most common sites: lateral tongue, floor of mouth, lower lip
• Peak age: 6th-7th decade; M > F (though gap closing)

Risk Factors

• Tobacco - Smoked (cigarettes, bidi, cigars) and smokeless (gutka, snuff)
• Alcohol - Synergistic effect with tobacco (multiplicative, not additive)
• HPV 16 and 18 - Especially oropharyngeal SCC (tonsillar, base of tongue)
• Betel quid/areca nut - Major risk factor in South/Southeast Asia (oral submucous fibrosis)
• Chronic sun exposure - Lower lip carcinoma
• Chronic trauma - Ill-fitting dentures, sharp tooth

Premalignant Conditions

• Leukoplakia - White patch that cannot be rubbed off; cannot be classified as any other lesion. Malignant transformation: 1-17%. Speckled (erythroleukoplakia) highest risk.
• Erythroplakia - Red velvety patch; malignant transformation up to 51% (highest risk).
• Oral submucous fibrosis - Fibrosis of submucosa causing progressive trismus; 7-13% transformation.
• Oral lichen planus - Erosive type has low transformation risk (~1%).

Staging - TNM

• T1 (<2cm), T2 (2-4cm), T3 (>4cm), T4a (adjacent structures), T4b (masticator space, pterygoid plates, skull base, carotid)
• N0-N3 (cervical lymph nodes)
• M0/M1 (distant metastasis)

Treatment

• Surgery - Primary treatment for most resectable oral cancers; wide local excision with 1cm margins; neck dissection for N+ disease or elective dissection for T3/T4
• Radiation - Post-operative (adjuvant) for positive margins, perineural invasion, lymphovascular invasion, multiple positive nodes, extracapsular spread
• Chemotherapy - Concurrent cisplatin with radiation for high-risk features
• Reconstruction - Radial forearm free flap (thin, pliable - tongue/floor), fibula free flap (mandible), anterolateral thigh flap (large defects)

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Chapter 16: Facial Trauma and Maxillofacial Fractures

Soft Tissue Injuries

• Abrasions, lacerations, avulsions, burns
• Principles: thorough irrigation, layer-by-layer closure, minimal debridement (excellent blood supply)
• Facial nerve identification and repair

Dentoalveolar Trauma (Tooth Injuries - Andreasen Classification)

• Concussion - No mobility, no displacement, tender to percussion
• Subluxation - Increased mobility, no displacement
• Extrusive luxation - Partial displacement out of socket (axially)
• Lateral luxation - Displacement with alveolar bone fracture
• Intrusive luxation - Driven into socket; worst prognosis
• Avulsion - Complete displacement; replant within 30-60 minutes (store in milk, saliva, or saline)
• Root fracture - Management depends on location

Facial Bone Fractures

• Most common facial fracture (due to prominence and mobility)
• Common sites: condyle > angle > body > symphysis/parasymphysis > ramus > coronoid
• Signs: malocclusion, step deformity, trismus, paresthesia of lower lip (IAN), bruising (floor of mouth)
• Classification: by location, type (favorable/unfavorable - muscle pull direction), displacement
• Management:
  • Closed (intermaxillary fixation / IMF) - for favorable, minimally displaced
  • Open reduction internal fixation (ORIF) with titanium miniplates (Champy technique for mandible body)

• Le Fort I - Horizontal fracture separating tooth-bearing maxilla from upper facial skeleton. "Floating palate."
• Le Fort II - Pyramidal fracture through nasal bones, lacrimal bones, orbital floor, lateral maxillary walls. "Floating maxilla."
• Le Fort III - Craniofacial dysjunction - entire midface separates from skull base. Through orbits, zygomatic arches, nasofrontal suture.
• In practice, Le Fort fractures are rarely symmetric; mixed patterns common.
• Treatment: ORIF with plates at buttresses (zygomaticofrontal, nasofrontal, infraorbital rim, Le Fort I level)

• "Tripod" or "trimalar" fracture - zygomaticofrontal suture, infraorbital rim, and zygomatic arch
• Signs: flattening of cheek, infraorbital paresthesia, subconjunctival hemorrhage, trismus
• Treatment: Gillies temporal approach (hook through temporal fascia) for arch; fixation of ZF suture if unstable

• Pure blow-out: orbital floor fractures inward with contents herniation into maxillary sinus
• Signs: enophthalmos, diplopia (inferior rectus entrapment), infraorbital paresthesia
• CT orbital with coronal cuts for diagnosis
• Surgery: floor repair with titanium mesh or PDS sheet

• Complex fractures of nasal bones, ethmoids, lacrimal bones
• Signs: telecanthus (widening of intercanthal distance), CSF leak (rhinorrhea)
• Require careful medial canthal ligament reattachment

• Anterior wall only: ORIF
• Posterior wall + CSF leak: neurosurgical involvement; possible obliteration or cranialization

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Chapter 17: Temporomandibular Joint (TMJ)

Anatomy

• The TMJ is a synovial joint with articular disc (meniscus) separating the superior (translation) and inferior (rotation) joint spaces.
• Unique: bilateral joint functioning as one unit.

TMJ Dysfunction (TMJD / TMD)

1. Muscle disorders (myofascial pain) - Most common; pain from masticatory muscles; no structural joint pathology
2. Disc displacement - Disc displaced anteromedially
   • With reduction: click on opening (disc recaptures)
   • Without reduction ("closed lock"): limited opening, no click
3. Degenerative joint disease (osteoarthritis) - Crepitus, radiographic changes

• Conservative first (80-90% respond): occlusal splint, physiotherapy, NSAIDs, lifestyle modification
• Arthrocentesis (joint lavage) - First-line surgical; needle irrigation of superior joint space
• Arthroscopy - Visualization, lavage, lysis of adhesions
• Open arthroplasty - Discectomy, disc repositioning, disc replacement
• Total joint replacement (TMJ prosthesis) - For end-stage disease, ankylosis

TMJ Ankylosis

• Fibrous or bony fusion of joint; most often following condylar fracture in childhood or infection
• Complete trismus
• In children: impairs mandibular growth, severe facial asymmetry
• Treatment: gap arthroplasty with interposition material, followed by early physiotherapy to prevent recurrence; total joint replacement in adults

TMJ Dislocation

• Condyle displaced anterior to articular eminence and cannot self-reduce
• Reduction: Hippocratic technique (thumbs on molars, downward then posterior pressure)
• Recurrent dislocation: eminectomy (reduces the barrier)

Orthognathic Surgery (Jaw Deformity Correction)

• Surgical correction of skeletal jaw discrepancies not correctable by orthodontics alone
• Mandibular procedures:
  • Bilateral sagittal split osteotomy (BSSO) - Advancement or setback; most versatile
  • Vertical ramus osteotomy - Setback only
• Maxillary procedures:
  • Le Fort I osteotomy - Advancement, impaction, expansion
• Combined - Bimaxillary surgery for complex deformities
• Treatment planning: cephalometric analysis, model surgery, surgical wafers, computer planning (VSP)

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Chapter 18: Salivary Gland Surgery

Major Salivary Glands

• Parotid (largest; purely serous; Stensen's duct opens opposite upper second molar)
• Submandibular (mixed; Wharton's duct opens at sublingual papilla)
• Sublingual (mucous; multiple short ducts - ducts of Rivinus)

Salivary Gland Pathology

• 80% in submandibular gland (thick mucous secretion, uphill duct flow, tortuous duct)
• Symptoms: mealtime pain and swelling ("mealtime syndrome"), intermittent
• Diagnosis: bimanual palpation, floor of mouth X-ray (80% calcified), ultrasound, sialography, CBCT
• Treatment: anterior duct stones - transoral removal; posterior gland stones - submandibular gland excision; sialendoscopy is now preferred minimally invasive option

• Acute bacterial: mostly parotid; Staphylococcus aureus; dehydrated/post-operative patients
• Chronic sialadenitis: recurrent; duct stenosis; managed with gland excision
• Viral (mumps parotitis): bilateral parotid swelling; viral; self-limiting

• Mucocele - Mucous extravasation or retention cyst; most common in lower lip; blue, fluctuant; excised with associated minor salivary gland
• Ranula - Floor of mouth mucocele from sublingual gland; plunging ranula extends through mylohyoid into neck; treated by marsupialization or sublingual gland excision

• Parotid tumors: 80% benign, 20% malignant
• Submandibular: 50/50
• Minor salivary glands: majority malignant

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Chapter 19: Implantology (Dental Implants)

Principles of Osseointegration (Branemark)

• Titanium forms a direct structural and functional bond with living bone (no fibrous tissue interface)
• Requires initial implant stability, bone quality/quantity, sterile technique, and loading protocol

Patient Assessment

• Medical fitness, bone volume (CBCT assessment), oral hygiene, smoking status (doubles failure risk), diabetes (impairs osseointegration)
• Contraindications: active cancer treatment, recent bisphosphonate use, uncontrolled diabetes, insufficient bone

Implant Components

• Fixture (root portion in bone) - various lengths (8-16mm) and diameters (3-6mm)
• Abutment - connects fixture to crown
• Prosthetic crown/denture

Surgical Protocol

1. Flap reflection
2. Sequential drilling (pilot → twist drills in increasing diameter)
3. Implant placement at bone crest level
4. Cover screw placement
5. Flap closure
6. Healing period (osseointegration): 3 months in mandible, 6 months in maxilla
7. Second stage: abutment connection
8. Prosthetic restoration

Bone Grafting Techniques (when bone is insufficient)

• Guided bone regeneration (GBR) - Resorbable/non-resorbable membrane + bone graft particles
• Socket preservation - Immediate grafting after extraction to prevent ridge resorption
• Sinus lift - Lateral window or transcrestal approach; to augment maxillary posterior ridge
• Block bone graft - From chin (symphysis) or ramus; for localized defects
• Distraction osteogenesis - Gradual bone transport
• Free fibula flap - For major jaw reconstruction before implant placement

Complications

• Early failure: infection, failure of osseointegration, nerve injury, sinus perforation
• Late: peri-implantitis (bone loss around implant; analogous to periodontitis; biofilm-driven), implant fracture, abutment loosening

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Chapter 20: Bleeding Disorders and Hemostasis in Oral Surgery

Normal Hemostasis Review

1. Vasoconstriction
2. Primary hemostasis (platelet plug)
3. Secondary hemostasis (coagulation cascade)
4. Fibrinolysis

Common Bleeding Disorders Encountered

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Chapter 21: Anesthesia and Sedation for Oral Surgery

Levels of Sedation

• Minimal sedation (anxiolysis) - Oral benzodiazepines; patient fully conscious
• Moderate sedation ("conscious sedation") - Intravenous midazolam ± fentanyl; responds to verbal commands; most common in oral surgery
• Deep sedation - Depressed consciousness; not easily roused
• General anesthesia - Complete loss of consciousness; dedicated anesthesiologist; endotracheal tube (nasal RAE tube for oral surgery access) or LMA

Common IV Sedation Agents

• Midazolam - Benzodiazepine; 1-5mg IV titrated; anterograde amnesia; reversible with flumazenil
• Propofol - For deep sedation/GA; short-acting
• Nitrous oxide (N₂O)/oxygen - Inhalation sedation; ideal for anxious children and mild phobia; rapid recovery; contraindicated in pregnancy, B12 deficiency, COPD

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Chapter 22: Cleft Lip and Palate

Embryology

• Upper lip and primary palate form from fusion of medial nasal processes with maxillary processes (weeks 5-7)
• Secondary palate fuses in midline (weeks 8-12)
• Failure of fusion: cleft lip ± cleft palate

Classification

• Unilateral/bilateral; complete (through entire lip to nose) / incomplete
• Cleft palate: primary (anterior to incisive foramen), secondary (posterior), or both

Treatment Timeline (Protocol)

• 0-3 months: Pre-surgical orthopaedics (Nasoalveolar Moulding, NAM)
• 3 months: Cleft lip repair (Millard rotation-advancement technique)
• 9-18 months: Cleft palate repair (Veau-Wardill-Kilner pushback or intravelar veloplasty)
• 8-10 years: Alveolar bone grafting (iliac crest cancellous bone) before permanent canine eruption
• 16-18 years: Orthognathic surgery if midface hypoplasia present
• Ongoing: Speech therapy, orthodontics, rhinoplasty

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Chapter 23: Nerve Injuries and Paresthesia

Sunderland Classification (nerve injury)

IAN and Lingual Nerve Injury in Oral Surgery

• Causes: Third molar surgery, implant placement, inferior alveolar nerve blocks
• Symptoms: Numbness, tingling, burning (dysesthesia), allodynia
• Management: Monitoring for 3 months; if no recovery - microsurgical repair (neurorraphy, nerve graft)

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Summary: The Core Chapters at a Glance