Oral and Maxillofacial Surgery, Medicine, and Pathology for the Clinician

Harry Dym, DDS, is Chairman of the Department of Dentistry and Oral and Maxillofacial Surgery at the Brooklyn Hospital Center and Clinical Professor of Oral and Maxillofacial Surgery at Columbia University College of Dental Medicine.

Leslie Halpern, M.P.H., D.D.S., M.A., M.PHIL., M.D., PH.D. is Adjunct Assistant Professor of Otolaryngology-Head and Neck Surgery at University of Utah School of Medicine in Salt Lake City, Utah, United States.

Orrett Ogle, DDS is an Oral & Maxillofacial Surgery Specialist in Brooklyn, New York, United States.

Contributors xix

Preface xxi

Part I Basics 1

1 Patient Evaluation and Management of Medical Problems in the Oral Surgery Patient 3

Risk

Assessment 3

Documentation

4

Management

of Patients with Medical Problems 5

Cardiovascular Disease 6

Hypertension 6

Angina Pectoris 7

Myocardial Infarction 8

Stroke/Cerebrovascular Accident 9

Cardiac Arrhythmias 9

Heart Failure 10

Treatment Guidelines 10

Endocrine Disorders 11

Diabetes Mellitus 11

Thyroid Disease 12

Adrenal Insufficiency 13

Hepatic Disease 13

Renal Disease 15

Dialyzed Patients 15

Pulmonary Disease 15

Asthma 15

Chronic Obstructive Pulmonary Disease 15

Pregnancy 16

Conclusion

18

References 18

2 Risk Reduction Strategies 21

Methods

of Risk Reduction 21

Faulty

Record Keeping 21

Informed

Consent 21

Conclusion

23

References 23

Contents

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3 Preparing the Dental Office for Medical Emergencies: 25

Staff

25

Equipment

26

Oxygen 26

Airway Adjuncts 26

Automated External Defibrillators (Figure 3.2) 26

Vitals Monitoring 27

Intravenous Kits 27

Emergency

Drug Kit 27

Oxygen 27

Aromatic Ammonia 27

Aspirin 28

Albuterol 28

Glucose 28

Nitroglycerin 28

Diphenhydramine 29

Epinephrine 29

Sedation-Specific Emergencies 29

Summary

29

References 29

4 Infection Control in Dental Practice 31

Why

is Infection Control Important in the Dental Office? 31

Hand

Hygiene 32

Potential

Infectious Diseases in the Dental Office 33

HBV

Vaccination 34

Preventing

Exposures to Blood and OPIM 34

General Recommendations 34

Engineering and Work Practice Controls 35

Postexposure Management and Prophylaxis 35

Handling of Biopsy Specimens 35

Handling of Extracted Teeth 35

Control

of 2009 H1N1 Influenza 35

Vaccination 35

Specific Recommendations for Dental Healthcare 35

Dental Healthcare Personnel 36

Transmission

Risk of Mycobacterium tuberculosis in Dentistry 36

Percutaneous

Injuries among Dental Healthcare Providers 36

Exposure

Prevention Strategies 36

Postexposure

Management 39

Disinfection

versus Sterilization 40

Decontamination

and Disinfection Methods 40

Manual Cleaning 40

Automated Cleaning 40

Sterilization

Methods 40

Instrument

Processing 41

Spore

Testing and Dual Monitoring Strips in Sterilization Bags 42

Proper

Disinfection of Handpieces, Impressions, Environmental Surfaces 42

Medical

Waste Management 43

Dental

Unit Waterlines 44

Infection

Control Program Plan and Goals 44

Conclusion

44

References 45

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Contents vii

Part II Dentoalveolar Surgery 47

5 Surgical Management of the Impacted Canine 49

Etiology

49

Diagnosis

49

Treatment

and Management of the Impacted Canine 51

Goals 51

Interceptive Treatment to Prevent Impactions 51

Surgical Management of the Impacted Canine 51

Open vs Closed Surgery 51

Palatal Maxillary Impactions 52

Labial Maxillary Impactions 52

Mandibular Impactions 53

Complications

53

References 54

6 Crown Lengthening 55

Biologic

Width 55

Indications

for Crown Lengthening [3] 55

Contraindications

for Crown Lengthening [1] 56

Procedures

Carried Out Prior to Crown Lengthening [4] 56

Bone

Sounding [2] 56

Sequence

of Treatment for Crown Lengthening 56

External Bevel Gingivectomy 56

Internal Bevel Gingivectomy 56

Flap Surgery with Osseous Surgery 57

Apically Positioned Flap With or Without Osseous Surgery 58

Combined with Orthodontic Extrusion 58

Classification

of Esthetic Crown Lengthening [2] 58

Postoperative

Care [3] 59

References 59

Part III Implantology 61

7 Bone-Grafting Techniques and Biomaterials for Alveolar Ridge Augmentation 63

Bone

Graft Materials and Healing Physiology 63

Introduction 63

Bone Graft and Tissue Engineering Materials – Outline 63

Autogenous (Natural) 63

Allograft (Natural) 63

Xenograft – Bovine, Porcine, Equine, Marine Coral, or Algal Sources 63

Alloplast 63

Other Synthetic Sources (Engineered) 64

Autologous Platelet Concentrate 64

Bone Graft and Tissue Engineering Materials 64

Autograft 64

Allograft 64

Mineralized Freeze-Dried Bone Allograft 65

Demineralized Freeze-Dried Bone Allograft 65

Particulate Cortical, Cancellous, and Corticocancellous Allograft 65

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Xenograft

65

Natural Hydroxyapatite 65

Bio-Oss – Bovine Derived 65

Natural Hydroxyapatite – Marine Coral Derived 65

Calcium Carbonate – Biocoral 65

Fluorohydroxyapatite (FHA) = Natural Sea Algae Derived 66

Alloplast (Synthetic Sources) 66

Hydroxyapatite Based (Synthetic HA) 66

Marine Coral Derived (Hydroxyapatite) 66

Coralline Porous Hydroxyapatite – Interpore (Synthetic HA) 66

Coralline Porous Hydroxyapatite – Pro Osteon (Synthetic HA) 66

Nanocrystalline Hydroxyapatite (Synthetic HA) 67

Tricalcium Phosphate (Synthetic) 67

Biphasic HA and B-TCP Material (Synthetic Combination) 67

Calcium Sulfate – Gypsum Based (Synthetic) 67

Calcium Sulfate – Nanocrystalline (Synthetic) 67

Biphasic Calcium Sulfate (Synthetic) 67

Bioactive Glass Ceramics (Synthetic) 68

Other Synthetic Sources – Recombinant Bone Morphogenetic Protein (rhBMP) 68

Autologous Platelet Concentrates (See Table 7.1 for Complete Formulations) 68

Platelet-Rich Plasma 68

Platelet-Rich Fibrin 68

Ridge

Preservation 70

Ridge Preservation Indications 70

Ridge Preservation Algorithm 70

Ridge Preservation Surgical Technique 71

Ridge Preservation Surgical Complications 73

Ridge Preservation Implant Survival and Success Rates 73

Ridge Preservation Conclusion (Box 7.4) 74

Guided

Bone Regeneration 75

Guided Bone Regeneration Indications 75

Nonabsorbable Membrane 75

Titanium Mesh 75

e-PTFE [51, 52] 75

Nonexpanded d-PTFE (Osteogenics Biomedical) [6, 49–51, 53] 75

Titanium-reinforced PTFE [51, 54] 76

Absorbable Membrane 77

Collagen Base (Bovine, Porcine, or Human Tendon, Dermis, Skin, or Pericardium) 77

Polymeric Membrane (Manufactured Synthetic Membrane) 77

Tuberosity Harvest Technique (Figures 7.9–7.11, Box 7.5) 78

Guided Bone Regeneration 78

Surgical Technique for Three Wall Defect (Figures 7.15–7.18) 78

Surgical Technique for Moderate-to-Severe Defect 78

Particulate Graft Resorption Post Grafting 80

Guided Bone Regeneration Complications 81

Guided Bone Regeneration Implant Survival and Success Rates 81

Guided Bone Regeneration Conclusion (Box 7.6) 81

Intraoral

Onlay Graft 82

Indications (Particulate and Block Graft) 82

Subperiosteal Tunneling Technique with Absorbable Membrane 83

Autogenous Onlay Corticocancellous Grafts Healing 84

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Contents ix

Surgical Harvest Technique: Intraoral Lateral Ramal Shelf and Symphysis (Figure 7.8) 84

Autogenous Intraoral Block Grafts – Surgical Complications 86

Allogeneic Block Bone (Cadaver Bone) 86

Block Graft Implant Survival and Success Rate 86

Block Graft Conclusion (Box 7.7) 86

Ridge

Split 87

Indications 87

Ridge Split Surgical Technique 87

Ridge Split Complications 87

Ridge Split Implant Survival and Success Rates 88

Ridge Split Conclusion (Box 7.8) 88

Interpositional

Bone Graft or “Sandwich Osteotomy” 89

Indications 89

Interpositional Bone Graft Surgical Technique 89

Interpositional Bone Graft Complications 90

Interpositional Bone Graft Implant Survival and Success Rates 90

Interpositional Bone Graft Conclusion (Box 7.9) 90

Distraction

Osteogenesis 91

Indications 91

Distraction Osteogenesis Surgical Technique 93

Distraction Osteogenesis Complications 93

Distraction Osteogenesis Implant Survival and Success Rates 93

Distraction Osteogenesis Conclusion (Box 7.10) 93

Postoperative

Instructions 93

Conclusion

94

Horizontal Augmentation Recap (Tables 7.5 and 7.6) 94

Horizontal Augmentation Complication Recap 94

Vertical

Augmentation Recap (Tables 7.5 and 7.6) 95

References 97

8 Maxillary Sinus Augmentation 101

Introduction

101

Maxillary

Sinus Anatomy 101

Indications,

Contraindications, Limitations 101

Lateral

Window Approach 102

Transalveolar

(Crestal) Approach 102

Bone-

Grafting Material 103

Complications

103

References 105

9 Technologic, Material, and Procedural Advancements in Dental Implant Surgery 107

Introduction

107

Three-

Dimensional Imaging 107

Computerized

Implant Planning Technology 108

Intraoral

Optical Impressions and Integration with CBCT, CAD/CAM, and Stereolithography 108

Surgical

Drilling Guide Integration and Fabrication 110

Guided

Navigation in Osteotomy Preparation and Implant Placement 110

Membranes

for Bone Grafting 111

BMP,

PRGF, and PRP 112

Implant-

Supported, Full-Arch, Fixed Prostheses with Immediate Loading and “All-on-Four” 113

Zygomatic

Implants 114

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Lasers

115

Conclusion

116

References 116

Part IV Trauma 117

10 Diagnosis and Management of Dentoalveolar Trauma 119

Introduction

119

Evaluation

119

History

119

Physical

Examination 119

Radiographic

Studies 120

Diagnosis

and Management of Dentoalveolar Injuries 120

Injuries

to the Dental Hard Tissue and Pulp 120

Crown Infraction 120

Crown Fracture 120

Crown-Root Fracture 121

Root Fracture 121

Injuries

to the Periodontal Tissues 121

Concussion 121

Subluxation 121

Intrusion 121

Extrusion 122

Lateral Luxation 122

Avulsion 122

Dentoalveolar

Injuries in the Primary Dentition 123

Splinting 124

Injuries

to the Gingiva or Oral Mucosa 124

Injuries

to Supporting Bone 124

Follow-

Up 125

Conclusion

125

References 125

Part V Pathology 129

11 Biopsy Technique: When, Where, and How? 131

Introduction

131

Patient

Evaluation: Health History, Medications 131

Lesion

History 132

Clinical

Examination 133

Indications

for Biopsies 136

Precancerous

Lesion: “Potentially Malignant Disorders” 136

Biopsy

Techniques 139

Incisional Biopsy 139

Excisional Biopsy 140

Punch Biopsy 140

Adjunctive

Techniques 140

Lugol’s Iodine 142

Toluidine Blue 142

Brush Biopsy/Cytology 144

References 144

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Contents xi

12 Recurrent Lesions of the Oral Mucosa: 147

Introduction

147

Aphthous

Lesions and Recurrent Aphthous Stomatitis 147

Presentation 147

Etiology 147

Diagnosis 148

Treatment 148

Herpetic

Lesions 149

Course of the Disease 149

Diagnosis 149

Treatment 149

Candidiasis

150

Clinical Presentation 150

Diagnosis 150

Treatment 150

Lichen

Planus 151

Clinical Presentation 151

Diagnosis 151

Treatment 151

Pemphigus

Vulgaris 152

Clinical Presentation 152

Etiology 152

Diagnosis 153

Treatment 153

Erythema

Multiforme 153

Clinical Presentation 153

Diagnosis 154

Treatment 154

Fixed

Drug Eruptions 154

Clinical Presentation 154

Etiology 154

Diagnosis 155

Treatment 155

References 155

13 Benign Pediatric Pathology: Diagnosis and Management 159

Introduction

159

Odontogenic

Cysts 159

Periapical Cyst 159

Buccal Bifurcation Cyst 159

Dentigerous Cyst 159

Eruption Cyst 160

Odontogenic Keratocyst 160

Odontogenic Tumors 161

Odontoma 161

Ameloblastoma 161

Ameloblastic Fibroma 162

Nonodontogenic

Cysts 162

Idiopathic Bone Cavity 162

Aneurysmal Bone Cyst 162

Nonodontogenic Tumors 163

Congenital Epulis 163

Melanotic Neuroectodermal Tumor of Infancy 163

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xii Contents

Juvenile Ossifying Fibroma 164

Fibrous Dysplasia 164

Giant Cell Lesion 164

Cherubism 166

Soft

Tissue Lesions 166

Fibroma 166

Pyogenic Granuloma 166

Branchial Cleft Cyst 166

Hemangioma 167

Vascular Malformation 167

Verrucous Vulgaris and Condyloma Acuminatum 168

Salivary

Gland Lesions 168

Mucocele 168

Ranula 168

Pleomorphic Adenoma 168

References 169

14 Diagnosis and Management of Salivary Gland Pathology 173

Introduction

173

Obstructive

Salivary Gland Disorders 173

Sialolithiasis (Salivary Gland Stones) 173

Etiology 173

Sialolithiasis Imaging 174

Management of Sialolithiasis 174

Bacterial Salivary Gland Infections 175

Viral

Diseases 176

Viral Sialadenitis 176

Granulomatous Disease of the Salivary Gland 176

Autoimmune

Diseases 177

Sjögren Syndrome 177

Salivary

Gland Tumors 177

Pleomorphic Adenoma 178

Warthin Tumor 178

Mucoepidermoid Carcinoma 179

Adenoid Cystic Carcinoma 179

Polymorphic Low-Grade Adenocarcinoma 179

Conclusion

179

References 179

15 Odontogenic Cysts and Odontogenic Tumors 183

Introduction

183

Basic

Embryology 183

Odontogenic

Cysts 183

Odontogenic Cysts of Inflammatory Origin 184

Radicular Cysts 184

Residual Cysts 184

Collateral Cysts 184

Developmental Odontogenic Cysts 184

Dentigerous Cysts 185

Odontogenic Keratocyst (Keratocystic Odontogenic Tumor) 185

Lateral Periodontal Cyst and Botryoid Odontogenic Cyst 187

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Contents xiii

Gingival Cyst 188

Glandular Odontogenic Cyst 188

Calcifying Odontogenic Cyst 188

Orthokeratinized Odontongenic Cyst 189

Odontogenic

Tumors 190

Ameloblastoma 190

Histologic Features 191

Treatment Considerations 191

Calcifying Epithelial Odontogenic Tumor 191

Clinical Presentation 191

Histologic Features 192

Treatment Considerations 192

Adenomatoid Odontogenic Tumor 192

Clinical Presentation 192

Histologic Features 192

Treatment Considerations 192

Squamous Odontogenic Tumor 193

Clinical Presentation 193

Histologic Features 193

Treatment Considerations 193

Odontogenic Fibroma 193

Clinical Presentation 193

Histologic Features 194

Treatment Considerations 194

Cementoblastoma 194

Clinical Presentation 194

Histologic Features 194

Treatment Considerations 194

Odontogenic Myxoma 194

Clinical Presentation 194

Histologic Features 194

Treatment Considerations 194

Odontoma 195

Clinical Presentation 195

Histologic Features 195

Treatment Considerations 196

References 196

16 Osteomyelitis of the Jaw 199

Classification

199

Demographic

Findings 199

Clinical

Presentation 199

Laboratory

Analysis 199

Radiologic

Evaluation 200

Microbiology

202

Histologic

Findings 203

Treatment

203

Case

Presentations 204

Osteomyelitis of the Maxilla 204

Osteomyelitis of the Mandible 205

References 208

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xiv Contents

17 Obstructive Sleep Apnea 209

Introduction

209

Etiology

209

Symptoms

210

Pathophysiology

and Related Health Issues 211

Diagnosis

and Classification 211

Treatment

212

Intraoral Devices 212

Surgical Procedures 212

Uvulopalatopharyngoplasty (UPPP) 212

Uvulopalatopharyngoplasty 213

Genial Tubercle Advancement 213

Maxillary-Mandibular Advancement 214

Distraction Osteogenesis 215

Conclusion

215

References 216

18 Temporomandibular Disorders: A Clinician’s Guide for Nonsurgical and Surgical Interventions 219

Introduction

219

Classification

and Diagnostic Evaluation 219

Classification 219

Diagnostic

Evaluation 221

History 222

Physical

Exam 222

Nonsurgical

Treatment Approaches 222

Methods of Therapy 223

Splint Therapy 224

Maxillary and Mandibular Full-Arch Splints 225

Other Reversible Therapeutic Options 225

Nonreversible General Dentistry Methods of Therapy 225

Surgical

Approaches 226

Case

Presentation 232

Conclusion

234

References 235

19 Postoperative Complications in Oral Surgery 237

Complications

Arising During the Procedure 237

Extraction of the Wrong Tooth 237

Teeth Splint Technique 237

Damage to Adjacent Tooth or Structures 238

Root Fracture and Displacement 238

Oroantral Communication 239

Aspiration of Teeth, Instruments, Restoration, or Dental Crowns 239

Nerve Injury 239

Complications

after Oral Surgery 240

Alveolar Osteitis (Dry Socket) 240

Infection 241

Pain, Swelling, and Trismus 242

Bleeding 242

Fracture of Bony Structures 242

References 243

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Contents xv

20 Odontogenic Infections: Anatomy, Etiology, and Treatment 245

Introduction

245

Definition

245

Microbiology

245

Clinical

Presentation 246

Clinical

Work-Up 246

Physical Examination 246

Radiographic Imaging 247

Procurement of Cultures 248

Pain

Control 248

Treatment

Techniques 249

Alveolar/Vestibular/Palatal Abscess 249

Method 249

Palatal Abscess 250

Method 250

Submandibular/Submental Abscess 250

Method 251

Sublingual Abscess 252

Method 252

Buccal and Midfacial Abscess 252

Method 253

Masticator Space 253

Submasseteric Space 254

Methods 254

Pterygomandibular Space 255

Method 255

Temporal Spaces 255

Method 255

Ludwig Angina 255

Treatment of Ludwig Angina 256

Pericoronitis

256

Antibiotic

Therapy 257

References 258

Part VI Pain Control 261

21 Approaches to the Management of Facial Pain 263

Introduction

263

Epidemiology

263

Neurophysiology

of Orofacial Pain 264

Diagnostic

Approach to Facial Pain Patients 264

Grouping

of Oral Facial Pain 266

Acute Facial Pain 266

Neuropathic Pain 266

Episodic Neuropathic Pain 267

Continuous NP 268

Neurovascular Pain 271

Topical

Medications for Orofacial Pain 271

Topical Anesthetics 271

Lidocaine Patches 271

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xvi Contents

Proparacaine 271

Streptomycin and Lidocaine 271

Vanilloid Compounds (Capsaicin) 271

Topical NSAIDs 272

Ketoprofen 272

Diclofenac 272

Antidepressants 272

Sympathomimetic

Agents 272

NMDA-

Blocking Agents 272

Botulinum

A Toxin 272

Surgical

Treatment Strategies for OFP 273

Injection Therapy 273

Complications of Injection Therapy 274

Summary

and Future Directions 275

References 275

22 Local Anesthesia: Agents and Techniques 279

Local

Anesthetics 279

Nerve

Block Techniques 280

Maxillary Nerve Blocks 280

Anatomy (Figure 22.1) 280

Greater Palatine Approach 281

High Tuberosity Approach 281

Sigmoid Notch Approach 282

Mandibular Nerve Block 282

Halstead Method 283

Akinosi Technique (Figure 22.6) 284

Gow-Gates Technique (Figure 22.7) 284

Auxilliary/

Supplemental Techniques 285

Intrasulcular Infusion 286

Intraosseous Injection 288

Trigger Point Injections 288

Nasal Spray 289

Reversal

of Local Anesthesia 289

References 290

23 Nitrous Oxide 293

History

293

Properties

293

Use

and Administration 293

Risks

and Concerns 294

Contraindications

294

Interactions

with Other Sedatives 295

Delivery

295

Safety

Mechanisms 295

Monitoring

296

Regulation

296

References 296