Ebook Contemporary oral and maxillofacial surgery: Part 2

(BQ) Part 2 book “Contemporary oral and maxillofacial surgery” has contents: Infections, management of oral pathologic lesions, temporomandibular and other facial pain disorders, oral and maxillofacial trauma, management of hospital patients, dentofacial deformities.

Part IV Infections Odontogenic infections are generally caused by bacteria that have a propensity to cause abscess formation In addition, the roots of the teeth provide a pathway for infecting bacteria to enter the deep tissues of the periodontium and periapical regions Therefore, odontogenic infections cause deep-seated abscesses, and they almost always require some form of surgical therapy Treatments range from endodontic therapy and gingival curettage to extraction, incision, and drainage of the deep fascial spaces of the head and neck Antibiotic therapy is an adjunctive treatment to the required surgery Prophylactic antibiotic therapy may prevent distant infections caused by bacteremias arising from oral-maxillofacial surgical procedures, and such therapy may also prevent some postoperative wound infections This section presents the principles of management and prevention of infections in dental patients Chapter 16 describes the basic management techniques, including surgery and antibiotic administration, in the treatment of odontogenic infections This chapter also discusses the principles of antibiotic prophylaxis for the prevention of wound infection and distant metastatic infection such as infectious endocarditis Chapter 17 presents an overview of complex odontogenic infections that involve the deep fascial spaces, which may necessitate hospitalization of the patient Osteomyelitis and other unusual infections are also discussed Chapter 18 presents the indications, rationale, and technical aspects of surgical endodontics Although periapical surgery is occasionally necessary for successful endodontic management, it is necessary for the clinician to choose this treatment modality wisely Therefore, the discussion of the indications and contraindications for endodontic surgery is extensive, and the technical aspects of surgical endodontics are well illustrated Chapter 19 presents information about patients at risk for infection and other problems that are caused by compromise of the patient’s host defense as a result of radiotherapy or cancer chemotherapy These patients are susceptible to a variety of problems, and the prevention and management of these problems are discussed Chapter 20 describes maxillary sinus problems that arise from odontogenic infections and other problems Although general practitioners rarely see patients with these problems, they may have to provide diagnoses before referring these patients to the appropriate health care professional for definitive care Finally, Chapter 21 discusses salivary gland diseases, primarily the obstructive and infectious types The major diagnostic and therapeutic modalities used in managing these problems are discussed 295 Chapter 16  Principles of Management and Prevention of Odontogenic Infections Thomas R Flynn CHAPTER OUTLINE MICROBIOLOGY OF ODONTOGENIC INFECTIONS  297 NATURAL HISTORY OF PROGRESSION OF ODONTOGENIC INFECTIONS  298 PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS  299 Principle 1: Determine Severity of Infection  300 Complete History  300 Physical Examination  300 Principle 2: Evaluate State of Patient’s Host Defense Mechanisms  302 Medical Conditions That Compromise Host Defenses  302 Principle 2: Choose Correct Antibiotic  313 Principle 3: Antibiotic Plasma Level Must Be High  313 Principle 4: Time Antibiotic Administration Correctly  313 Principle 5: Use Shortest Antibiotic Exposure That Is Effective  313 Summary  313 PRINCIPLES OF PROPHYLAXIS AGAINST METASTATIC INFECTION  314 Prophylaxis Against Infectious Endocarditis  314 Prophylaxis in Patients with Other Cardiovascular Conditions  316 Prophylaxis Against Total Joint Replacement Infection  316 Pharmaceuticals That Compromise Host Defenses  302 Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral-Maxillofacial Surgeon  303 Principle 4: Treat Infection Surgically  304 Principle 5: Support Patient Medically  306 Principle 6: Choose and Prescribe Appropriate Antibiotic(s)  306 Determine the Need for Antibiotic Administration  306 Use Empirical Therapy Routinely  307 Use the Narrowest-Spectrum Antibiotic  308 Use the Antibiotic with the Lowest Incidence of Toxicity and Side Effects  308 Use a Bactericidal Antibiotic, if Possible  309 Be Aware of the Cost of Antibiotics  309 Summary  309 Principle 7: Administer Antibiotic Properly  310 Principle 8: Evaluate Patient Frequently  311 PRINCIPLES OF PREVENTION OF INFECTION  311 PRINCIPLES OF PROPHYLAXIS OF WOUND INFECTION  312 Principle 1: Procedure Should Have Significant Risk of Infection  312 296 In dentistry, one of the most difficult problems to manage is an odontogenic infection Odontogenic infections arise from teeth and have a characteristic flora Caries, periodontal disease, and pulpitis are the initiating infections, that can spread beyond teeth to the alveolar process and to the deeper tissues of the face, oral cavity, head, and neck These infections may range from low-grade, well-localized infections that require only minimal treatment to severe, lifethreatening deep fascial space infections Although the overwhelming majority of odontogenic infections are readily managed by minor surgical procedures and supportive medical therapy that includes antibiotic administration, the practitioner must constantly bear in mind that these infections occasionally become severe and life threatening within a short time This chapter is divided into several sections The first section discusses the typical microbiologic organisms involved in odontogenic infections Appropriate therapy of odontogenic infections depends on a clear understanding of the causative bacteria The second section discusses the natural history of odontogenic infections When infections occur, they may erode through bone and into the adjacent soft tissue Knowledge of the usual pathway of infection from the teeth and surrounding tissues through bone and into the overlying soft tissue planes is essential when planning appropriate therapy The third section of this chapter deals with the principles of management of odontogenic infections A series of principles are discussed, with consideration of the microbiology and typical pathways of infection Principles of Management and Prevention of Odontogenic Infections The chapter concludes with a section on the prophylaxis of wound infection and of metastatic infection MICROBIOLOGY OF ODONTOGENIC INFECTIONS The bacteria that cause infection are most commonly part of the indigenous bacteria that normally live on or in the host Odontogenic infections are no exception because the bacteria that cause odontogenic infections are part of the normal oral flora: those that comprise the bacteria of plaque, those found on mucosal surfaces, and those found in the gingival sulcus These bacteria are primarily aerobic gram-positive cocci, anaerobic gram-positive cocci, and anaerobic gram-negative rods These bacteria cause a variety of common diseases such as dental caries, gingivitis, and periodontitis When these bacteria gain access to deeper underlying tissues, as through a necrotic dental pulp or through a deep periodontal pocket, they cause odontogenic infections As the infection progresses more deeply, different members of the infecting flora can find better growth conditions and begin to outnumber the previously dominant species Many carefully performed microbiologic studies of odontogenic infections have demonstrated the microbiologic composition of these infections Several important factors must be noted First, almost all odontogenic infections are caused by multiple bacteria The polymicrobial nature of these infections makes it important that the clinician understand the variety of bacteria that are likely to cause infection In most odontogenic infections, the laboratory can identify an average of five species of bacteria It is not unusual to identify as many as eight different species in a given infection On rare occasions, a single species may be isolated New molecular methods, which identify the infecting species by their genetic makeup, have allowed scientists to identify greater numbers and a whole new range of species, including unculturable pathogens, not previously associated with these infections In the future, these methods may lead to a completely new understanding of the pathogenesis of odontogenic infections A second important factor is the oxygen tolerance of the bacteria that cause odontogenic infections Because the mouth flora is a combination of aerobic and anaerobic bacteria, it is not surprising to find that most odontogenic infections are caused by anaerobic and aerobic bacteria Infections caused by aerobic bacteria alone account for 6% of all odontogenic infections Anaerobic bacteria alone are found in 44% of odontogenic infections Infections caused by mixed anaerobic and aerobic bacteria comprise 50% of all odontogenic infections (Table 16-1) The predominant aerobic bacteria in odontogenic infections (found in about 65% of cases) are the Streptococcus milleri group, which consists of three members of the S viridans group of bacteria: Table 16-1  Role of Anaerobic Bacteria in Odontogenic Infections Percentage Anaerobic only 50 Mixed anaerobic and aerobic 44 Aerobic only Data from Brook I, Frazier EH, Gher ME: Aerobic and anaerobic microbiology of periapical abscess Oral Microbiol Immunol 6:123–125, 1991 Chapter | 16 | S anginosus, S intermedius, and S constellatus These facultative organisms, which can grow in the presence or the absence of oxygen, may initiate the process of spreading into deeper tissue (Table 16-2) Miscellaneous bacteria contribute 5% or less of the aerobic species found in these infections Rarely found bacteria include staphylococci, group D Streptococcus organisms, other streptococci, Neisseria spp., Corynebacterium spp., and Haemophilus spp The anaerobic bacteria found in odontogenic infections include an even greater variety of species (see Table 16-2) Two main groups, however, predominate The anaerobic gram-positive cocci are found in about 65% of cases These cocci are anaerobic Streptococcus and Peptostreptococcus Oral gram-negative anaerobic rods are cultured in about three quarters of the infections The Prevotella and Porphyro­ monas spp are found in about 75% of these, and Fusobacterium organisms are present in more than 50% Of the anaerobic bacteria, several gram-positive cocci (i.e., anaerobic Streptococcus and Peptostreptococcus spp.) and gram-negative rods (i.e., Prevotella and Fusobacterium spp.) play a more important pathogenic role The anaerobic gram-negative cocci and the anaerobic gram-positive rods appear to have little or no role in the cause of odontogenic infections; instead, they appear to be opportunistic organisms The method by which mixed aerobic and anaerobic bacteria cause infections is known with some certainty After initial inoculation into deeper tissues, the facultative S milleri group organisms can synthesize hyaluronidase, which allows the infecting organisms to spread through connective tissues, initiating the cellulitis stage of infection Metabolic byproducts from the streptococci create a favorable environment for the growth of anaerobes: the release of essential nutrients, lowered pH in the tissues, and consumption of local oxygen supplies The anaerobic bacteria are then able to grow, and as the local oxidation–reduction potential is lowered further, the anaerobic bacteria predominate and cause liquefaction necrosis of tissues by Table 16-2  Major Pathogens in Odontogenic Infections PERCENT OF CASES Microorganism Sakamoto et al.* (1998) Heimdahl et al.† (1985) Streptococcus milleri group 65 31 Peptostreptococcus species 65 31 Other anaerobic streptococci 38 Prevotella species (e.g., P oralis and P buccae) 74 35 Porphyromonas species (e.g., P gingivalis) 17 – Fusobacterium species 52 45 *Data from Sakamoto H, Kato H, Sato T, Sasaki J: Semiquantitative bacteriology of closed odontogenic abscesses Bull Tokyo Dent Coll 39:103–107, 1998 † Heimdahl A, Von Konow L, Satoh T, et al: Clinical appearance of orofacial infections of odontogenic origin in relation to microbiological findings J Clin Microbiol 22:299, 1985 297 Part | IV | Infections their synthesis of collagenases As collagen is broken down and invading white blood cells necrose and lyse, microabscesses form and may coalesce into a clinically recognizable abscess In the abscess stage, anaerobic bacteria predominate and may eventually become the only organisms found in culture Early infections appearing initially as a cellulitis may be characterized as predominantly aerobic streptococcal infections, and late, chronic abscesses may be characterized as anaerobic infections Clinically, this progression of the infecting flora from aerobic to anaerobic seems to correlate with the type of swelling that can be found in the infected region Thus, odontogenic infections seem to pass through four stages In the first days of symptoms, a soft, mildly tender, doughy swelling represents the inoculation stage, in which the invading streptococci are just beginning to colonize the host After to days, the swelling becomes hard, red, and acutely tender as the infecting mixed flora stimulates the intense inflammatory response of the cellulitis stage At to days after the onset of swelling, the anaerobes begin to predominate, causing a liquefied abscess in the center of the swollen area This is the abscess stage Finally, when the abscess drains spontaneously through skin or mucosa, or it is surgically drained, the resolution stage begins as the immune system destroys the infecting bacteria, and the processes of healing and repair ensue The clinical and microbiologic characteristics of edema, cellulitis, and abscess are summarized and compared in Table 16-3 Table 16-3  Comparison of Edema, Cellulitis, and Abscess Characteristic Edema (Inoculation) Cellulitis Abscess Duration 0–3 days 1–5 days 4–10 days Pain, borders Mild, diffuse Diffuse Localized Size Variable Large Smaller Color Normal Red Shiny center Consistency Jelly-like Boardlike Soft center Progression Increasing Increasing Decreasing Pus Absent Absent Present Bacteria Aerobic Mixed Anaerobic Seriousness Low Greater Less A NATURAL HISTORY OF PROGRESSION OF ODONTOGENIC INFECTIONS Odontogenic infections have two major origins: (1) periapical, as a result of pulpal necrosis and subsequent bacterial invasion into the periapical tissue, and (2) periodontal, as a result of a deep periodontal pocket that allows inoculation of bacteria into the underlying soft tissues Of these two, the periapical origin is the most common in odontogenic infections Necrosis of the dental pulp as a result of deep caries allows a pathway for bacteria to enter the periapical tissues Once this tissue has become inoculated with bacteria and an active infection is established, the infection spreads equally in all directions, but preferentially along the lines of least resistance The infection spreads through the cancellous bone until it encounters a cortical plate If this cortical plate is thin, the infection erodes through the bone and enters the surrounding soft tissues Treatment of the necrotic pulp by standard endodontic therapy or extraction of the tooth should resolve the infection Antibiotics alone may arrest, but not cure, the infection because the infection is likely to recur when antibiotic therapy has ended without treatment of the underlying dental cause Thus, the primary treatment of pulpal infections is endodontic therapy or tooth extraction, as opposed to antibiotics When the infection erodes through the cortical plate of the alveolar process, it spreads into predictable anatomic locations The location of the infection arising from a specific tooth is determined by the following two major factors: (1) the thickness of the bone overlying the apex of the tooth and (2) the relationship of the site of perforation of bone to muscle attachments of the maxilla and mandible Figure 16-1 demonstrates how infections perforate through bone into the overlying soft tissue In Figure 16-1, A, the labial bone overlying the apex of the tooth is thin compared with the bone on the palatal aspect of the tooth Therefore, as the infectious process spreads, it goes into the labial soft tissues In Figure 16-1, B, the tooth is severely proclined, which results in thicker labial bone and a relatively thinner palatal bone In this situation, as the infection spreads through bone into the soft tissue, the infection is seen as a palatal abscess Once the infection has eroded through bone, the precise location of the soft tissue infection is determined by the position of the perforation relative to the muscle attachments In Figure 16-2, A, the infection has eroded through to the facial aspect of the alveolar process and inferior to the attachment of the buccinator muscle, which results in an infection that appears as a vestibular abscess In B Figure 16-1  When infection erodes through bone, it will enter soft tissue through thinnest bone A, Tooth apex is near thin labial bone, so infection erodes labially B, Right apex is near palatal aspect, so palatal bone will be perforated 298 Principles of Management and Prevention of Odontogenic Infections A Chapter | 16 | B Figure 16-2  Relationship of point of bone perforation to muscle attachment determines fascial space involved A, When tooth apex is lower than muscle attachment, vestibular abscess results B, If apex is higher than muscle attachment, the adjacent fascial space is involved Figure 16-3  Palatal abscess arising from the palatal root of a maxillary first premolar Figure 16-2, B, the infection has eroded through the bone superior to the attachment of the buccinator muscle and is expressed as an infection of the buccal space because the buccinator muscle separates the buccal and vestibular spaces Infections from most of the maxillary teeth erode through the facial cortical plate These infections also erode through the bone below the attachment of the muscles that attach to the maxilla, which means that most maxillary dental abscesses appear initially as vestibular abscesses Occasionally, a palatal abscess arises from the apex of a severely inclined lateral incisor or the palatal root of a maxillary first molar or premolar (Fig 16-3) More commonly, the maxillary molars cause infections that erode through the bone superior to the insertion of the buccinator muscle, which results in a buccal space infection Likewise, on occasion a long maxillary canine root allows infection to erode through the bone superior to the insertion of the levator anguli oris muscle and causes an infraorbital (canine) space infection In the mandible, infections of incisors, canines, and premolars usually erode through the facial cortical plate superior to the attachment of the muscles of the lower lip, resulting in vestibular abscesses Mandibular molar infections erode through the lingual cortical bone more frequently than in the case of the anterior teeth First molar infections may drain buccally or lingually Infections of the second molar can perforate buccally or lingually (but usually lingually), and third molar infections almost always erode through the lingual cortical plate The mylohyoid muscle determines whether infections that Figure 16-4  Vestibular abscess arising from maxillary incisor Overlying mucosa is thin because pus is near the surface (From Flynn TR: Anatomy of oral and maxillofacial infections In Topazian RG, Goldberg MH, Hupp JR, editors: Oral and maxillofacial infections, ed 4, Philadelphia, PA, 2002, WB Saunders.) drain lingually go superior to that muscle into the sublingual space or below it into the submandibular space The most common odontogenic deep fascial space infection is a vestibular space abscess (Fig 16-4) Occasionally, patients not seek treatment for these infections, and the process ruptures spontaneously and drains, resulting in resolution or chronicity of the infection The infection recurs if the site of spontaneous drainage closes Sometimes, the abscess establishes a chronic sinus tract that drains to the oral cavity or to skin (Fig 16-5) As long as the sinus tract continues to drain, the patient experiences no pain Antibiotic administration usually stops the drainage of infected material temporarily, but when the antibiotic course is over, the drainage recurs Definitive treatment of a chronic sinus tract requires treatment of the original causative problem, which is usually a necrotic pulp In such a case, the necessary treatment is endodontic surgery or extraction of the infected tooth PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS This section discusses the management of odontogenic infections A series of principles are useful in treating patients who come to the dentist with infections related to teeth and the gingiva The clinician must keep in mind the information in the preceding two sections of 299 Part | IV | Infections A Figure 16-6  Patient with severe infection and elevated temperature, pulse rate, and respiratory rate The patient feels sick and tired; he has a “toxic appearance.” (From Flynn TR: Surgical management of orofacial infections Atlas Oral Maxillofac Surg Clin North Am 8:79, 2000.) B Figure 16-5  Chronic drainage sinus tracts that result from low-grade infections may drain intraorally (A) or extraorally (B) (A, Courtesy of Sasha B Ross, DMD B, From Flynn TR, Topazian RG: Infections of the oral cavity In Waite D, editor: Textbook of practical oral and maxillofacial surgery, Philadelphia, PA, 1987, Lea & Febiger.) this chapter to understand these principles By following these principles in a stepwise fashion, the clinician will certainly have met the standard of care, even though the expected result may not always be achieved The first three principles are perhaps the most important in determining the outcome, yet they can be accomplished by the experienced practitioner within the first few minutes of the initial patient encounter Principle 1: Determine Severity of Infection Most odontogenic infections are mild and require only minor surgical therapy When the patient comes for treatment, the initial goal is to assess the severity of the infection This determination is based on a complete history of the current infectious illness and a physical examination Complete history.  The history of the patient’s infection follows the same general guidelines as those for any history The initial purpose is to find out the patient’s chief complaint Typical chief complaints of patients with infections are “I have a toothache,” “My jaw is swollen,” or “I have a gum boil in my mouth.” The complaint should be recorded in the patient’s own words The next step in history taking is determining how long the infection has been present First, the dentist should inquire as to time of onset of the infection How long ago did the patient first have symptoms of pain, swelling, or drainage, which indicated the beginning of the infection? The course of the infection is then discussed Have the symptoms of the infection been constant, have they waxed and waned, or has the patient’s condition steadily grown worse since the 300 symptoms were first noted? Finally, the practitioner should determine the rapidity of progress of the infection Has the infection process progressed rapidly over a few hours, or has it gradually increased in severity over several days to a week? The next step is eliciting information about the patient’s symptoms Infections are actually a severe inflammatory response, and the cardinal signs of inflammation are clinically easy to discern These signs and symptoms are, in Latin terms, dolor (pain), tumor (swelling), calor (warmth), rubor (erythema, redness), and functio laesa (loss of function) The most common complaint is pain The patient should be asked where the pain actually started and how the pain has spread since it was first noted The second sign is tumor (swelling), which is a physical finding that is sometimes subtle and not obvious to the practitioner, although it is obvious to the patient It is important that the dentist ask the patient to describe any area of swelling With regard to the third characteristic of infection, calor (warmth), the patient should be asked whether the area has felt warm to the touch Redness of the overlying area is the next characteristic to be evaluated The patient should be asked if there has been or is any change in color, especially redness, over the area of the infection Functio laesa (loss of function) should then be checked When inquiring about this characteristic, the dentist should ask about trismus (difficulty opening the mouth widely) and any difficulty chewing, swallowing (dysphagia), or breathing (dyspnea) Finally, the dentist should ask how the patient feels in general Patients who feel fatigued, feverish, weak, and sick are said to have malaise Malaise usually indicates a generalized reaction to a moderateto-severe infection (Fig 16-6) In the next step, the dentist discusses treatment The dentist should find out about previous professional treatment and selftreatment Many patients treat themselves with leftover antibiotics, hot soaks, and a variety of other home or herbal remedies Occasionally, a dentist may see a patient who had received treatment in an emergency room or days earlier and was referred to a dentist by the emergency room physician The patient might have neglected to follow the emergency room physician’s advice until the infection became severe Sometimes, the patient may not have taken the prescribed antibiotic because he or she could not afford to purchase it The patient’s complete medical history should be obtained in the usual manner through an interview or a self-administered questionnaire with verbal follow-up of any relevant findings Physical examination.  The first step in the physical examination is to obtain the patient’s vital signs, including temperature, blood pressure, pulse rate, and respiratory rate The need for evaluation of Principles of Management and Prevention of Odontogenic Infections temperature is obvious Patients who have systemic involvement of infection usually have elevated temperatures Patients with severe infections have temperatures elevated to 101°F or higher (greater than 38.3°C) The patient’s pulse rate increases as the patient’s temperature increases Pulse rates of up to 100 beats per minute (beats/min) are not uncommon in patients with infections If pulse rates increase to greater than 100 beats/min, the patient may have a severe infection and should be treated more aggressively The vital sign that varies the least with infection is the patient’s blood pressure Only if the patient has significant pain and anxiety will an elevation occur in systolic blood pressure However, septic shock results in hypotension Finally, the patient’s respiratory rate should be closely observed One of the major considerations in odontogenic infections is the potential for partial or complete upper airway obstruction as a result of extension of the infection into the deep fascial spaces of the neck As respirations are monitored, the dentist should carefully check to ensure that the upper airway is clear and that the patient is able to breathe without difficulty The normal respiratory rate is 14 to 16 breaths per minute (breaths/min) Patients with mild to moderate infections may have elevated respiratory rates greater than 18 breaths/min Patients who have normal vital signs with only a mild temperature elevation usually have a mild infection that can be readily treated Patients who have abnormal vital signs with elevation of temperature, pulse rate, and respiratory rate are more likely to have serious infection and require more intensive therapy and evaluation by an oral-maxillofacial surgeon Once vital signs have been taken, attention should be turned to the physical examination of the patient The initial portion of the physical examination should be inspection of the patient’s general appearance Patients who have more than a minor, localized infection have an appearance of fatigue, feverishness, and malaise This is referred to as a “toxic appearance” (see Fig 16-6) The patient’s head and neck should be carefully examined for the cardinal signs of infection (as discussed earlier), and the patient should be inspected for any evidence of swelling and overlying erythema The patient should be asked to open the mouth widely, swallow, and take deep breaths so that the dentist can check for trismus, dysphagia, or dyspnea These are ominous signs of a severe infection, and the patient should be referred immediately to an oralmaxillofacial surgeon or to the emergency room A recent study of severe odontogenic infections requiring hospitalization found trismus (maximum interincisal opening less than 20 mm) in 73% of cases, dysphagia in 78%, and dyspnea in 14% Areas of swelling must be examined by palpation The dentist should gently touch the area of swelling to check for tenderness, amount of local warmth or heat, and the consistency of the swelling The consistency of the swelling may vary from very soft and almost normal to a firmer, fleshy swelling (described as “doughy”) to an even firmer or hard swelling (described as “indurated”) An indurated swelling has similar firmness to a tightened muscle Another characteristic consistency is fluctuance Fluctuance feels like a fluid-filled balloon Fluctuant swelling almost always indicates an accumulation of liquid pus in the center of an indurated area The dentist then performs an intraoral examination to try to find the specific cause of the infection Severely carious teeth, an obvious periodontal abscess, severe periodontal disease, combinations of caries and periodontal disease, or an infected fracture of a tooth or the entire jaw may be present The dentist should look and feel for areas of gingival swelling and fluctuance and for localized vestibular swellings or draining sinus tracts The next step is to perform a radiographic examination This usually consists of the indicated periapical radiographs Occasionally, Chapter | 16 | Figure 16-7  Cellulitis involving the submental and submandibular region The cellulitis is indurated on palpation, and the patient is sick (From Flynn TR: Surgical management of orofacial infections Atlas Oral Maxillofac Surg Clin North Am 8:79, 2000.) Figure 16-8  Well-localized abscess with fluctuance in the center and induration at its periphery (Courtesy of Richard G Topazian, DDS.) however, extraoral radiographs such as a panoramic radiograph may be necessary because of limited mouth opening, tenderness, or other extenuating circumstances After the physical examination, the practitioner should begin to have a sense of the stage of the presenting infection Very soft, mildly tender, edematous swellings indicate the inoculation stage, whereas an indurated swelling indicates the cellulitis stage (Fig 16-7), and central fluctuance indicates an abscess (Fig 16-8) Soft tissue infections in the inoculation stage may be cured by removal of the odontogenic cause, with or without supportive antibiotics; infections in the cellulitis or abscess stages require removal of the dental cause of infection plus incision and drainage and antibiotics Distinctions between the inoculation, cellulitis, and abscess stages are typically related to duration, pain, size, peripheral definition and consistency on palpation, presence of purulence, infecting bacteria, and potential danger (see Table 16-3) The duration of cellulitis is usually thought to be acute and is the most severe presentation of infection An abscess, however, is a sign of increasing host resistance to infection Cellulitis is usually described as being more painful than 301 Part | IV | Infections an abscess, which may be the result of its acute onset and tissue distention Edema, the hallmark of the inoculation stage, is typically diffuse and jelly-like, with minimal tenderness to palpation The size of a cellulitis is typically larger and more widespread than that of an abscess or edema The periphery of a cellulitis is usually indistinct, with a diffuse border that makes it difficult to determine where the swelling begins or where it ends The abscess usually has distinct and well-defined borders Consistency to palpation is one of the primary distinctions among the stages of infection When palpated, edema can be very soft or doughy; a severe cellulitis is almost always described as indurated or even as being “boardlike.” The severity of the cellulitis increases as its firmness to palpation increases On palpation, an abscess feels fluctuant because it is a pus-filled tissue cavity Thus, an infection may appear innocuous in its early stages and extremely dangerous in its more advanced, indurated, rapidly spreading stages A localized abscess is typically less dangerous because it is more chronic and less aggressive The presence of pus usually indicates that the body has locally walled off the infection and that the local host resistance mechanisms are bringing the infection under control In many clinical situations, the distinction between severe cellulitis and abscess may be difficult to make, especially if an abscess lies deeply within the soft tissue In some patients, an indurated cellulitis may have areas of abscess formation within it (see Chapter 17) Severe infections occupying multiple deep fascial spaces may be in an early stage in one anatomic space, and in a more severe, rapidly progressive stage in another fascial space A severe, deeply invading infection may pass through ever deeper anatomic spaces in a predictable fashion, similar to a house fire, where smoke may be present in one room, intense heat in another, and open flames near the source of the fire The goal of therapy in such infections is to abort the spread of the infection in all involved anatomic spaces These infections are discussed in detail in Chapter 17 In summary, edema represents the earliest inoculation stage of infection which is most easily treated Cellulitis is an acute, painful infection with more swelling and diffuse borders Cellulitis has a hard consistency on palpation and contains no visible pus Cellulitis may be a rapidly spreading process in serious infections An acute abscess is a more mature infection with more localized pain, less swelling, and well-circumscribed borders The abscess is fluctuant on palpation because it is a pus-filled tissue cavity A chronic abscess is usually slow growing and less serious than cellulitis, especially if the abscess has drained spontaneously to the external environment Principle 2: Evaluate State of Patient’s Host Defense Mechanisms Part of the evaluation of the patient’s medical history is designed to estimate the patient’s ability to defend against infection Several disease states and several types of drug use may compromise this ability Immunocompromised patients are more likely to have infections, and these infections often become serious more rapidly Therefore, to manage their infections more effectively, it is important to be able to identify those patients who may have compromised host defenses Medical conditions that compromise host defenses.  Delineation of those medical conditions that may result in decreased host defenses is important These compromises allow more bacteria to enter the tissues or to be more active, or they prevent the humoral or cellular defenses from exerting their full effect Several specific conditions may compromise patients’ defenses (Box 16-1) Uncontrolled metabolic diseases—such as uncontrolled diabetes, end-stage renal disease with uremia, and severe alcoholism with 302 Box 16-1  Compromised Host Defenses Uncontrolled Metabolic Diseases • • • • Poorly controlled diabetes Alcoholism Malnutrition End-stage renal disease Immune System–Suppressing Diseases • Human immunodeficiency virus/acquired immunodeficiency syndrome • Lymphomas and leukemias • Other malignancies • Congenital and acquired immunologic diseases Immunosuppressive Therapies • Cancer chemotherapy • Corticosteroids • Organ transplantation malnutrition—result in decreased function of leukocytes, including decreased chemotaxis, phagocytosis, and bacterial killing Of these metabolic diseases, poorly controlled type (insulin-dependent) and type (non–insulin-dependent) diabetes are the most common immunocompromising diseases, and worsening control of hyperglycemia correlates directly with lowered resistance to all types of infections The second major group of immunocompromising diseases includes those that interfere with host defense mechanisms, for example, leukemias, lymphomas, and many types of cancer These diseases result in decreased white cell function and decreased antibody synthesis and production Human immunodeficiency virus (HIV) infection attacks T lymphocytes, affecting a person’s resistance to viruses and other intracellular pathogens Fortunately, odontogenic infections are caused largely by extracellular pathogens (bacteria) Therefore, HIVseropositive individuals are able to combat odontogenic infections fairly well until acquired immunodeficiency syndrome (AIDS) has progressed to advanced stages, when B lymphocytes are also severely impaired Nonetheless, care for the HIV-seropositive patient with an odontogenic infection is usually more intensive than for the otherwise healthy patient Pharmaceuticals that compromise host defenses.  Patients taking certain drugs are also immunologically compromised Cancer chemotherapeutic agents can decrease circulating white cell counts to low levels, commonly less than 1000 cells per milliliter (cells/mL) When this occurs, patients are unable to defend themselves effectively against bacterial invasion Patients receiving immunosuppressive therapy, usually for organ transplantation or autoimmune diseases, are compromised The common drugs in these categories are cyclosporine, corticosteroids, tacrolimus (Prograf), and azathioprine (Imuran) These drugs decrease the function of T and B lymphocytes and immunoglobulin production Thus, patients taking these medications are more likely to have severe infections The immunosuppressive effects of some cancer chemotherapeutic agents can last for up to a year after therapy ends In summary, when evaluating a patient whose chief complaint may be an infection, the patient’s medical history should be carefully reviewed for the presence of diabetes, severe renal disease, alcoholism with malnutrition, leukemias and lymphomas, cancer chemotherapy, and immunosuppressive therapy of any kind When the patient’s history includes any of these, the patient with an infection must be treated much more vigorously because the infection may spread more Principles of Management and Prevention of Odontogenic Infections Box 16-2  Criteria for Referral to an Oral-Maxillofacial Surgeon • • • • • • • • • • Difficulty breathing Difficulty swallowing Dehydration Moderate to severe trismus (interincisal opening less than 20 mm) Swelling extending beyond the alveolar process Elevated temperature (greater than 101°F) Severe malaise and toxic appearance Compromised host defenses Need for general anesthesia Failed prior treatment rapidly Referral to an oral-maxillofacial surgeon for early and aggressive surgery to remove the cause and initiate parenteral antibiotic therapy must be considered Additionally, when a patient with a history of one of these problems is seen for routine oral surgical procedures, it may be necessary to provide the patient with prophylactic antibiotic therapy to decrease the risk of postoperative wound infection Use of the guidelines and regimens for prevention of endocarditis published by the American Heart Association (AHA) and American Dental Association (ADA) is a practical way to manage this problem Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral-Maxillofacial Surgeon Most odontogenic infections seen by the dentist can be managed with the expectation of rapid resolution Odontogenic infections, when treated with minor surgical procedures and antibiotics, if indicated, almost always respond rapidly However, some odontogenic infections are potentially life threatening and require aggressive medical and surgical management In these special situations, early recognition of the potential severity is essential, and these patients should be referred to an oral-maxillofacial surgeon for definitive management As the specialist with the best training and experience in the management of severe odontogenic infections, the oralmaxillofacial surgeon can optimize the outcomes and minimize the complications of these infections For some patients, hospitalization is required, whereas others can be managed as outpatients When a patient with an odontogenic infection comes for treatment, the dentist must have a set of criteria by which to judge the seriousness of the infection (Box 16-2) If some or all of these criteria are met, immediate referral must be considered Three main criteria indicate immediate referral to a hospital emergency room because of an impending threat to the airway The first criterion is a history of a rapidly progressing infection This means that the infection began or days before the interview and is growing rapidly worse, with increasing swelling, pain, and other associated signs and symptoms This type of odontogenic infection may cause swelling in deep fascial spaces of the neck, which can compress and deviate the airway The second criterion is difficulty breathing (dyspnea) Patients who have severe swelling of the soft tissue of the upper airway as the result of infection may have difficulty maintaining a patent airway In these situations, the patient often will refuse to lie down, have muffled or distorted speech, and be obviously distressed by breathing difficulties This patient should be referred directly to an emergency room because immediate surgical attention may be necessary to maintain an intact airway The third Chapter | 16 | urgent criterion is difficulty swallowing (dysphagia) Patients with acutely progressive deep fascial space infections may also have difficulty swallowing their saliva Drooling is an ominous sign because the inability to control one’s secretions frequently indicates a narrowing of the oropharynx and the potential for acute airway obstruction This patient should also be transported to the hospital emergency room immediately because surgical intervention or intubation may be required for airway maintenance Definitive treatment of the infection can follow once the airway is secure Several other criteria should indicate referral to an oralmaxillofacial surgeon Patients who have extraoral swellings such as buccal space infections or submandibular space infections may require extraoral surgical incision and drainage (I&D) as well as hospitalization Next, although infection frequently causes an elevated temperature, a temperature higher than 101°F indicates a greater likelihood of severe infection, and this patient should be referred to the hospital Another important sign is trismus, the inability to open the mouth widely In odontogenic infections, trismus results from the involvement of the muscles of mastication by the inflammatory process Mild trismus can be defined as a maximum interincisal opening between 20 and 30 mm; moderate trismus is an interincisal opening between 10 and 20 mm; and severe trismus is an interincisal opening of less than 10 mm Moderate or severe trismus may be an indication of the spread of the infection into the masticator space (surrounding the muscles of mastication) or, worse, either or both the lateral pharyngeal space and the retropharyngeal space surrounding the pharynx and the trachea In this situation, referral to a specialist is necessary for evaluation of upper airway patency In addition, systemic involvement of an odontogenic infection is an indication for referral Patients with systemic involvement have a typical toxic facial appearance: glazed eyes, open mouth, and a dehydrated, sick appearance When this is seen, the patient is usually fatigued, has a substantial amount of pain, has an elevated temperature, and is dehydrated Finally, if the patient has compromised host defenses, he or she may have to be hospitalized An oral-maxillofacial surgeon is qualified to admit the patient expeditiously to the hospital for definitive care In summary, within the first few minutes of the initial patient encounter, the three principles mentioned above allow the dentist to assess the severity of the infection, evaluate host defenses, and expeditiously decide on the best setting for the patient’s care In doubtful situations, it is always best to err on the side of caution and refer the patient for a higher level of care Appropriate decision making at this stage can prevent serious morbidity and the occasional mortality that still occur because of odontogenic infections Principle 4: Treat Infection Surgically The primary principle of management of odontogenic infections is to perform surgical drainage and to remove the cause of the infection Surgical treatment may range from something as straightforward as an endodontic access opening and extirpation of the necrotic tooth pulp to treatment as complex as the wide incision of the soft tissue in the submandibular and neck regions for a severe infection or even open drainage of the mediastinum The primary goal in surgical management of infection is to remove the cause of the infection, which is most commonly a necrotic pulp or deep periodontal pocket A secondary goal is to provide drainage of accumulated pus and necrotic debris When a patient has a typical odontogenic infection, the most likely appearance is a carious tooth with a periapical radiolucency and a small vestibular abscess With this presentation, the dentist has the following surgical options: endodontic treatment or extraction, with or without I&D If the tooth is not to be extracted, it should be opened and its pulp removed, which results in elimination of the 303 Part | IV | Infections cause and limited drainage through the apical foramen of the tooth If the tooth cannot be salvaged or is not restorable, it should be extracted as soon as possible Extraction provides removal of the cause of the infection and drainage of the accumulated periapical pus and debris In addition to the endodontic procedure or extraction of the tooth, an I&D procedure may be required for an infection that has spread beyond the periapical region Incision of the abscess or cellulitis allows removal of the accumulated pus and bacteria from the underlying tissue Evacuation of the abscess cavity dramatically decreases the load of bacteria and necrotic debris Evacuation also reduces the hydrostatic pressure in the region by decompressing tissues, which improves the local blood supply and increases the delivery of host defenses and antibiotics to the infected area I&D of a cellulitis serves to abort the spread of the infection into deeper anatomic spaces The I&D procedure includes the insertion of a drain to prevent premature closure of the mucosal incision, which could allow the abscess cavity to re-form It is important to remember that the surgical goal is to achieve adequate drainage If endodontic opening of the tooth does not provide adequate drainage of the abscess, it is essential to perform an I&D The technique for I&D of a vestibular abscess or cellulitis is straightforward (Fig 16-9) The preferred site for intraoral incision is directly over the site of maximum swelling and inflammation However, it is important to avoid incising across a frenum or the path of the mental nerve in the lower premolar region When I&D procedures are performed extraorally, a more complex set of criteria must be met when selecting a site for the incision Once the area of incision has been selected, a method of pain control must be used Regional nerve block anesthesia is preferred when it can be achieved by injecting in an area away from the site of infection Alternatively, infiltration of local A anesthetic solution into and around the area to be drained can be performed Once the local anesthetic needle has been used in an infected site, it should not be reused in an uninfected area Before the actual incision of the abscess is performed, obtaining a specimen for culture and sensitivity (C&S) testing must be considered If the decision is made to perform a culture, it is carried out as the initial portion of the surgery (Box 16-3) After the site of surgery has been anesthetized, the surface mucosa is disinfected with a solution such as povidone-iodine (Betadine) and dried with sterile gauze A large-gauge needle, usually 18 gauge, is used for specimen collection A small syringe, usually 3 mL, is adequate The needle is then inserted into the abscess or cellulitis, and or 2 mL of pus or tissue fluid is aspirated The specimen may contain only tissue fluid and blood instead of pus, yet it commonly provides sufficient bacteria for an accurate culture The specimen is then inoculated directly into aerobic and anaerobic culturettes, which are sterile tubes containing a swab and bacterial transport medium Culturettes and specimen bottles that are appropriate for both aerobes and anaerobes are also available All Box 16-3  Indications for Culture and Antibiotic Sensitivity Testing • • • • • • C B D Infection spreading beyond the alveolar process Rapidly progressive infection Previous, multiple antibiotic therapy Nonresponsive infection (after more than 48 hours) Recurrent infection Compromised host defenses E Figure 16-9  A, Periapical infection of lower premolar extends through buccal plate and creates sizable vestibular abscess B, Abscess is incised with No 11 blade C, Beaks of hemostat are inserted through incision and opened so that beaks spread to break up any loculations of pus that may exist in abscessed tissue D, A small drain is inserted to depths of abscess cavity with a hemostat E, The drain is sutured into place with a single black silk suture Note that pus usually flows out along, rather than through, a tubular drain 304 Index Consultations (Continued) inpatient, 654 request for, 654 Contact inhibition, in wound healing, 43–44 Continuing education, in medical emergency management, 20, 20b Controlled substances, Drug Enforcement Administration Schedule of Drugs, Contusion, treatment of, 471, 471f Coronary artery bypass grafting (CABG), 10, 316 Corticosteroids adrenal insufficiency from, 14, 35 COPD and, 11 for edema control, 41–42 equivalency of, 35t in impacted tooth removal, 166 for temporomandibular disorders, 638 Cosmetic surgery, facial See Facial cosmetic surgery Costochondral bone grafts, in temporomandibular joint surgery, 645 Cotton forceps, 69, 70f Cover screw, 254 Cowhorn forceps, 81–83, 85f Crane pick, 78, 78f as lever, 101, 102f in single-rooted tooth extraction, 131–132, 133f Cranial nerve examination, 625, 625t Cranial neuralgias, miscellaneous, 622 Craniofacial separation, 499, 499f Crestal incision in alveoloplasty, 204, 206f mid-, 246, 247f Cricothyrotomy, 492, 492f Crown condition of, tooth extraction and, 93, 93f–94f craze or crack in, 478, 479f fractures of, 474, 478–479, 479f Crown-root fractures, 480, 480f–481f Crown-root ratio, poor, periapical surgery and, 346 Crown-to-implant ratio, 241 Crusts, 426b Cryer elevator, in multirooted tooth extraction, 134–136, 135f–136f Crystalloids, postoperative, 673 Culture and sensitivity testing in maxillary sinusitis, 388 in odontogenic infections, 304–305, 304b, 307–308 Curettage of jaw cysts, 458 of jaw tumors, 460 in periapical surgery, 351, 352f Curette, for soft tissue removal from bony cavities, 69f, 72 Cutting needles, 72–73, 73f Cyclooxygenase-2 (COX-2) inhibitors, for temporomandibular disorders, 637 Cyclosporine A, gingival hyperplasia and, 12 Cyst(s) definition of, 449 enucleation of, 445f of jaws causes of, 449, 449f classification of, 449 radiographic appearance of, 449, 449f–450f surgical management of, 449–458 enucleation in, 450–452, 451f–453f, 457–458 enucleation with curettage in, 458 marsupialization in, 454–457, 454f–457f Cystadenoma lymphomatosum, papillary, 417, 417f D Damages, in malpractice claims, 189 Danger space, infections of, 331, 333f Database, health history, 3, 3b Dead space management, 41, 41f Deafferentation pain definition of, 620b oral, 619–621, 621b 690 Dean scissors, 74 Dean’s alveoloplasty technique, 204–205, 208f Débridement, wound, 41, 472 Decontamination, definition of, 57 Deep cervical fascia borders and relations of, 323t–324t spaces of, infections of, 320b, 330–331 superficial or investing layer of, 329 Deep temporal space infections of, 330 relations of, 324t, 329 Deformities, dentofacial See Dentofacial deformities Degeneration, in nerve healing, 51f, 52–53 Degenerative disease, of temporomandibular joint, 633–634, 634f Dehiscence flap, 39 wound, 185–186, 186b Demyelination, segmental, in nerve healing, 51f, 52 Dental elevators See Elevator(s) Dental implants See Implant(s) Dental medications lactation and, 17t, 18 pregnancy and, 17b, 18 Dental procedures, endocarditis antibiotic prophylaxis in, 314–316, 314b–315b, 315t Dentist-patient relationship, 189–190 termination of, 192 Dentoalveolar abscess, 307 tooth extraction and, 92 Dentoalveolar injuries, 473–489 classification of, 476–477, 477b clinical examination in, 474–475 history in, 473–474, 475f management of, 473 radiography in, 475–476, 476f–478f stabilization of, duration of, 484, 486t treatment of, 477–489 alveolar fractures, 474, 487–488, 488f avulsion, 483–487, 486t, 487f crown craze or crack, 478, 479f crown fractures, 478–479, 479f crown-root fractures, 480, 480f–481f extrusion, 483, 484f horizontal root fractures, 480, 482f intrusion, 481–482, 482f–483f lateral displacement, 483, 485f–486f mobility, 481 pulp damage, 488–489, 489f sensitivity, 480–481 Dentofacial deformities, 520–563 causes of, 521 distraction osteogenesis for, 538–556, 557f–561f evaluation of, 522–524, 524f, 525t, 526f facial growth and, 521, 522f genetic and environmental influences on, 521–522, 522f–523f perioperative care in, 556–557, 562f postsurgical treatment of, 557 dental and periodontal, 557 orthodontic, 557 restorative and prosthetic, 557 presurgical treatment of, 524–530 final treatment planning in, 526–530 conventional, 526–529, 528f–529f three-dimensional computerized, 530, 530f orthodontic, 525–526, 527f–528f periodontal, 524–525, 526f restorative, 525 prevalence of, 520, 521t surgical treatment of, 530–538 for combination deformities and asymmetries, 538, 548f–555f for mandibular deficiency, 532–535, 536f–539f for mandibular excess, 530–532, 531f–535f for maxillary and midface deficiency, 535–538, 544f–547f for maxillary excess, 535, 540f–543f Denture(s) See also Overdenture fixed partial, 257, 259f immediate, after extraction of teeth, 223–224, 225f–226f postirradiation wearing of, 369 Denture fibrosis, 217, 219f Deposition for malpractice, 194 Dermabrasion, 569 Dermal fillers, in facial cosmetic practice, 567, 569f Dermal graft, in temporomandibular joint surgery, 642–644, 643f Dermatochalasis, 571–572 Dexamethasone, in impacted tooth removal, 166 Dextrose, for hypoglycemia, 34 Diabetes mellitus, 13–14, 13t, 14b dental treatment for patients with, 312–313, 313t emergency management of, 33–34, 34b, 34f Diagnose, failure to, 193 Diagnosis differential See Oral lesions, differential diagnosis of surgical, development of, 37 Diagnostic casts, in implant therapy, 239–240 Dialysis, 11–12, 12b antibiotic prophylaxis in patients receiving, 316 Diazepam, for seizure, 33 Dicloxacillin, 11 Diet, postoperative, 171 Digital subtraction sialography, 400–401, 401f Diphenhydramine hydrochloride, for allergic reactions, 24 Disabilities, Americans with Disabilities Act and, 196–197 Discharge note, 664, 664b, 671f Discharge summary, 664, 665b, 672f Disinfection chemical, 59, 59t–60t definition of, 57 operatory, 61 Disk repair or removal, for temporomandibular disorders, 642–644, 643f–644f Disk-repositioning surgery, for temporomandibular disorders, 641–642, 643f Dislocation condylar, 635, 635f temporomandibular joint, chronic recurrent, 635, 635f Disposable materials, 59–61 Distoangular impaction, 150–152, 152f, 158, 158f, 163–164, 165f Distraction, alveolar ridge, 271–274, 274f Distraction histogenesis, 538 alveolar ridge, 271–274, 274f Distraction osteogenesis advantages and disadvantages of, 543–545 for alveolar ridge, 271–274, 274f for dentofacial deformities, 538–556, 557f–561f phases of, 543 for temporomandibular disorders, 645–647, 647f Ditching, in impacted tooth removal, 161–162 Divalproex, for trigeminal neuralgia, 621t Documentation, 191 Doxepin, for trigeminal neuralgia, 621t Doxycycline cost of, 310t for tooth preservation, 484 Drain, for dead space management, 41, 41f Drapes, instrumentation for holding, 76, 76f Dressing, pressure, for dead space management, 41 Drug(s) breastfeeding and, 17t, 18 in dental office emergency kit, 21, 21t–22t pregnancy and, 17b, 18 prescription, examples of, Drug Enforcement Administration Schedule of Drugs, Dry eyes, in Sjögren’s syndrome, 414–415, 414f–415f Dry-heat sterilization, 57, 58t–59t Dry mouth radiation-induced, 364–365, 365f–366f in Sjögren’s syndrome, 414, 414f treatment of, 364–365 Index Dry socket, 186–187, 307 Duty, in malpractice claims, 189 Dysesthesia definition of, 620b orofacial, 619–620 after segmental demyelination, 52 Dysplasia, 426b Dyspnea, paroxysmal nocturnal, 10 Dysrhythmias, 10 E Ear problems, in cleft lip and palate, 592 Ear surgery, corrective, 577–578, 578f Ebner glands, 395, 395t Ecchymosis periorbital, 492, 492f postoperative, 172, 172f Edema after impacted tooth removal, 166 lower extremity, 10–11 odontogenic infections and, 298, 298t, 302 postoperative, 41–42, 171, 171f in wound healing, 44, 44f Edentulous patients mandibular fracture treatment in, 502 partially implants for, 257–262, 259f–262f segmental alveolar surgery in, 229–232, 231f postirradiation denture wear in, 369 totally implants for, 256–257 all-implant-supported overdenture, 256–257, 258f complete implant-supported fixed prosthesis, 257, 259f fixed partial denture, 257, 259f hybrid prosthesis, 257, 259f implant- and tissue-supported overdenture, 256, 257f skeletal abnormalities in, correction of, 232 Education continuing, in medical emergency management, 20, 20b patient, for temporomandibular disorders, 636–637 Electrolytes, postoperative, 669–673 Electronic records, 191–192 HITECH regulations related to, 196 Elevator(s) apex, 78, 78f components of, 76–77, 77f Cryer, in multirooted tooth extraction, 134–136, 135f–136f delivery of sectioned tooth with, 164, 166f periosteal, 68, 68f straight, 77, 77f delivery of sectioned tooth with, 164, 166f in root fragment removal, 138, 138f in single-rooted tooth extraction, 131, 131f–132f in tooth extraction as levers, 101, 102f luxation with, 101f, 106, 106f principles of, 102–105 as wedge, 101, 103f as wheel and axle, 101, 103f triangular, 77–78, 77f, 101, 103f types of, 77–78, 77f–78f Elliptical incision, in maxillary tuberosity reduction, 215, 216f–217f Embolism, cerebrovascular compromise from, 36 Emergencies, medical See Medical emergency(ies) Emergency Medical Treatment and Active Labor Act (EMTALA), 197 Emergency room consultations, 654 Emergency supplies and equipment, 21–22, 21f–22f, 21t–22t Endocarditis heart abnormalities predisposing to, 10 prophylaxis against, 314–316, 314b–315b, 315t Endocrine disorders, 13–15, 14b–15b Endodontic surgery abscess drainage in, 340 adjuncts to, 360–361, 360f algorithm for, 340, 341f biopsy with, 359–360, 360b bone augmentation in, 361 categories of, 340b corrective, 355–357 contraindications to, 355, 360b indications for, 355, 355b, 356f–357f procedure for, 357, 358f prognosis for, 357 repair material for, 356–357 surgical approach to, 356 definition of, 339 difficulties with, 361 for fractured teeth, 358, 359f guided tissue regeneration in, 361 healing after, 358 light and magnification devices in, 360–361, 360f periapical, 340–354 See also Periapical surgery principles of, 339–362 recall evaluations after, 358–359, 360f referrals in, 361 tooth extraction after, 95, 97f training and experience for, 361 Endoscopy in endodontic surgery, 361 in maxillary sinusitis, 388, 389f salivary gland, 403–404, 405f English style of forceps, 79, 80f Enucleation of cysts, 445f of jaw cysts, 450–452, 451f–453f with curettage, 458 after marsupialization, 457–458 of jaw tumors, 460 Envelope flap, 120f, 121 in impacted tooth removal, 160, 162f Envelope incision, 121 in impacted tooth removal, 160–161, 161f Environment, dentofacial deformities and, 521–522, 522f–523f Epinephrine for allergic reactions, 24 angina pectoris and, for asthma, 26 dysrhythmias and, 10 for hemostasis, 41 for hypoglycemia, 34 Epithelialization secondary, vestibuloplasty with, in labial frenectomy, 221, 222f in wound healing, 43–44 Epithelium, proliferation of, wound healing by, 43 Epulis fissurata, 217, 219f Erosion, 426b Erythematous candidiasis, 336–337, 337f Erythromycin cost of, 310t overview of, 11 Esthetic surgery, facial See Facial cosmetic surgery Ethanol withdrawal, seizures in, 32 Ethanolism, 16 Ethylene oxide, sterilization with, 59 Etidocaine, maximum dose of, 33t, 90t Etidronate, 376t Excisional biopsy, 434, 435f Exfoliative cytologic examination, 431–432 Exodontia See Extraction of teeth Exostosis buccal, alveolar ridge recontouring for, 206, 210f–211f palatal, lateral, alveolar ridge recontouring for, 206–207, 211f Extraction forceps, 78–83 adaptation of, in closed technique, 106–107, 107f–108f apical pressure by, 103–104, 103f–104f beaks of, 79 Extraction forceps (Continued) buccal pressure by, 104, 104f components of, 78–79, 79f–80f English style of, 79, 80f lingual or palatal pressure by, 104, 104f luxation with, 107 mandibular, 79–83, 79f No 17, 81, 85f No 87 (cowhorn), 81–83, 85f No 151, 80–81, 83, 84f, 86f No 151A, 81, 84f No 151S, 83, 86f vertical-hinge, 81, 84f maxillary, 79–80, 79f No 1, 80, 81f No 53, 80, 82f No 65 (root-tip), 80, 83f No 88, 80, 82f No 150, 80, 80f No 150A, 80, 81f No 150S, 80, 83f No 210S, 80, 83f principles of, 102–105 rotational pressure by, 104, 105f tractional forces of, 104–105, 105f as wedge, 101, 103f Extraction of teeth, 88–118 alveolar ridge preservation in, 224–225, 226f anxiety control in, 90 chair position for, 98–100 clinical evaluation for, 92–93 access to tooth in, 92 condition of crown in, 93, 93f–94f mobility of tooth in, 92–93, 98f closed adaptation of forceps in, 106–107, 107f–108f disadvantages of, 128, 129f loosening of soft tissue in, 105–106, 105f luxation with elevator in, 101f, 106, 106f luxation with forceps in, 107 procedure for, 105–108 removal from bone in, 107 role of assistant during, 108 role of opposite hand during, 107–108 complications of, 176–178 root displacement, 176–177, 176b, 177f root fracture, 176, 176b tooth lost into pharynx, 177–178 consent for, 9f contraindications to, 91–92 elevators in See Elevator(s), in tooth extraction for fascial space infections, 332 forceps in, 78–83 See also Extraction forceps immediate dentures after, 223–224, 225f–226f indications for, 91 instrumentation for, 76–83 local anesthesia for, 89–90, 89t–90t mandibular, 112–116, 114f anterior teeth, 112, 114f chair position for, 98–99, 99f–101f molars, 115–116, 116f–117f premolars, 112–115, 115f maxillary, 108–112, 108f canines, 110, 110f chair position for, 98, 98f–99f, 101f incisors, 109, 109f molars, 111–112, 113f premolars first, 110–111, 111f second, 111, 112f mechanical principles involved in, 100–101, 102f–103f multiple, 139–142 sequencing in, 139–140 technique for, 140–142, 141f–142f treatment planning for, 139 open, 128–139 See also Extraction of teeth, surgical advantages of, 128, 129f bruxism and, 128, 129f hypercementosis and, 129, 129f indications for, 128–130, 129f–130f 691 Index Extraction of teeth (Continued) for multirooted tooth, 132–137 mandibular molars, 133, 133f–135f maxillary molars, 136, 136f–137f for single-rooted tooth, 130–132, 132f bone removal in, 130–131, 131f–132f Crane pick in, 131–132, 133f purchase point in, 131–132, 132f pain control in, 89–90, 89t–90t, 169–171, 170t patient preparation for, 96–97, 97f periotomes in, 78, 78f preoperative medical assessment for, 89 primary teeth, modifications for, 116 radiographic evaluation for, 93–96, 94f relationship to vital structures in, 94, 94f–95f root configuration in, 94–95, 95f–97f surrounding bone condition in, 96, 97f radiotherapy and impacted third molar, 368 postirradiation, 368 pre-irradiation, 368 root displacement in, 176–177, 176b, 177f root fracture in, 176, 176b root fragments and tips in justification for leaving, 138–139 removal of, 137–138, 138f–140f sedation for, 90 socket care after, 116–118, 117f–118f surgeon preparation for, 96–97, 97f surgical, 119–142 flaps in, 119–128 design of, 119–121, 120f–121f mucoperiosteal, 121–122 See also Mucoperiosteal flaps suturing principles for, 123–128 See also Suture(s) removal of tooth in See Extraction of teeth, open tray system for, 1t, 83, 86f tooth lost into pharynx in, 177–178 tray systems for, 1t, 83–87, 86f–87f Extraction sockets care of, 116–118, 117f–118f healing of, 47 Extraoral implants, 275, 277f Extrusion of teeth, traumatic, 483, 484f Eye(s) dry, in Sjögren’s syndrome, 414–415, 414f–415f lateral hooding over, 571–572, 573f Eye protection, 61f, 64 F Face and neck lift, 578–580, 579f–581f Facial aging, 565–566, 565f–566f Facial asymmetry, surgical correction of, 538, 554f–555f Facial cosmetic practice botulinum toxin injection in, 567–570 dermal fillers in, 567, 569f facial resurfacing in, 568–584, 571f skin care in, 566–567 Facial cosmetic surgery, 564–584 facial aging and, 565–566, 565f–566f facial analysis in, 566, 566f–568f historical perspective on, 564–565 lower third, 578–584 genioplasty, 580, 581f lip augmentation or reduction, 580–583, 582f lower face and neck lift, 578–580, 579f–581f neck liposuction, 583–584, 583f middle third, 572–574 blepharoplasty (lower lid), 572–574, 574f midfacial implants, 574–578, 575f otoplasty, 577–578, 578f rhinoplasty, 575–576, 576f–577f procedures for, 570–584 upper third, 570–572 blepharoplasty (upper lid), 571–572, 573f–574f brow and forehead lift, 570–571, 572f–573f 692 Facial fractures, 491–518 See also Facial trauma causes of, 496 evaluation of, 491–496 mandibular See Mandibular fracture midface See Midface fracture treatment of, 500–516 buttresses in, 500–501, 500f mandibular, 501–508 midface, 508–510 timing of, 500 Facial growth, principles of, 521, 522f Facial lacerations, 516, 516f–517f Facial liposuction, 583–584, 583f Facial nerve laceration, 415 Facial neuralgia, 622 Facial neuropathology, 618–626 headache as, 622–624 See also Headache neuropathic facial pain as, 619–622 See also Neuropathic facial pain orofacial pain classification and, 619, 620b pain neurophysiology and, 618, 619f, 619t patient evaluation in, 624–626, 625t temporal arteritis as, 624 Facial pain neuropathic, 619–622 See also Neuropathic facial pain of unknown cause, 619 Facial proportions, normal, 522–523, 524f Facial resurfacing, 568–584, 571f Facial trauma causes of, 496 classification of, 496–499 evaluation of, 491–496 history in, 492–493 immediate assessment in, 491–492, 492f physical examination in, 492–493, 492f–494f radiographic examination in, 493–496, 495f–497f Factor deficiencies, 15 Family history, 3–6, 6b Fascial space borders and relations, 323t–324t Fascial space infections, 319–333 anatomic spaces involved in, 319–320, 320b, 320f arising from any tooth, 320, 320b buccal, 321, 325f cavernous sinus, 321–325, 326f–327f danger space, 331, 333f deep, antibiotics for, 307 deep cervical, 320b, 330–331 infraorbital, 320, 323f infratemporal, 321, 326f lateral pharyngeal, 326, 330–331, 331f–332f management of, 331–333, 332b, 336f mandibular body, 325, 328f mandibular teeth–related, 320b, 325–330 masticator space, 329, 329f maxillary sinus, 321–322, 327f maxillary teeth–related, 320–325, 320b pericoronitis and, 146 prevertebral, 331 pterygomandibular, 329–330, 330f retropharyngeal, 331, 331f, 333f–334f severity of, classification based on, 320, 321b, 321f–322f sublingual, 325, 328f submandibular, 325–326, 328f submasseteric, 329, 330f submaxillary (perimandibular), 325, 328f submental, 326, 328f superficial and deep temporal, 330 Fasciitis, necrotizing, 331, 335f Fat, autologous, as dermal filler, 567 Feeding problems, in cleft lip and palate, 591–592 Fetus, risk reduction strategies for, 16–18, 17b Fever, in postoperative patients, 669 Fiberoptics, in endodontic surgery, 361 Fibrinolysis, 45, 45f Fibronectin, 45 Fibroplastic stage of bone healing, 47, 48f–49f of wound healing, 45, 45f–46f Figure-of-eight sutures, 124, 124f in oroantral communication, 183, 183f Financial issues, tooth extraction related to, 91 Fine needle aspiration biopsy, 434 of salivary gland tumors, 404–405, 405f Fistula, oroantral, 43–44 delayed treatment of, 391, 391f–393f postoperative, 182 Fitzpatrick skin classification scale, 566, 568f Fixation maxillomandibular (MMF) or intermaxillary (IMF), 501–502, 501f–502f, 504 rigid internal, for mandibular fracture, 504–508, 506f–508f with wiring techniques, for mandibular fracture, 504, 505f Flap(s), 119–128 buccal, for oroantral communication, 183, 389f, 390–391, 391f definition of, 119 dehiscence of, 39 design of, 38–39, 39f–40f, 119–121, 120f in periapical surgery, 346–347 vertical-releasing incisions in, 121, 121f–122f vital structure issues in, 120–121 envelope, 120f, 121 in impacted tooth removal, 160, 162f four-cornered, 121, 122f for implant site exposure, 245–246, 247f in implant uncovering, 251, 252f mucoperiosteal, 121–122 See also Mucoperiosteal flaps necrosis of, 38, 39f palatal, for oroantral communication, 391, 392f pharyngeal, in cleft lip and palate, 598, 603f reflection of, in impacted tooth removal, 160–161, 161f–162f replacement and suturing of, in periapical surgery, 354, 355f suturing principles for, 123–128 See also Suture(s) tearing of, 39, 40f three-cornered, 121, 121f, 125–127, 128f Flapless surgery, for implant site exposure, 245, 247f Flesh-eating bacteria infection, 331, 335f Floor-of-mouth lowering procedure buccal vestibuloplasty and, 226–228 labial vestibuloplasty and, 226–228, 228f–229f Floor-of-mouth swelling, differential diagnosis of, 410 Fluconazole for candidiasis, 376 overview of, 12 Fluctuant, definition of, 427 Fluid(s), postoperative, 669–673 Fluid-free surgical field, 38 Fluoroquinolones, 12 Follicular sac size, impacted tooth removal and, 155, 155f Forceps chalazion, 436, 437f–438f extraction, 78–83 See also Extraction forceps prices of, 1t rongeur, 70, 71f tissue, 39–40, 40f, 69–70, 70f Forehead and brow lift, 570–571, 572f–573f Foreign body aspiration of, emergency management of, 27–28, 28b, 28f–29f intraoral, radiography of, 476, 478f in maxillary sinus, 383–384, 385f, 389 Foreign material, impaired wound healing and, 46 Formaldehyde, biocidal activity of, 60t Fracture(s) alveolar, 179–181, 180b, 180f–181f, 474, 487–488, 488f comminuted, 497–498, 498f compound, 497–498, 498f crown, 474, 478–479, 479f crown-root, 480, 480f–481f facial, 491–518 See also Facial fractures favorable vs unfavorable, 498, 498f Index Fracture(s) (Continued) greenstick, 47–48, 497–498, 498f jaw, 474 prevention of, impacted tooth removal for, 147, 149f teeth involved in, extraction of, 91 Le Fort, 499, 499f mandibular See Mandibular fracture maxillary tuberosity, 181, 181f midface See Midface fracture orbital complex, 492–493, 493f orbital floor, blow-out, 499, 500f root, 176, 176b, 475, 476f horizontal, 343, 344f, 480, 482f vertical, endodontic surgery for, 358, 359f simple, 497–498, 498f tooth, endodontic surgery for, 358, 359f zygomatic arch, 509 zygomatic complex, 492, 492f, 499, 499f, 508, 508f Fraser suction, 76, 76f Frenectomy labial, 217–222, 220f–223f lingual, 222–223, 223f–224f Friction massage, for temporomandibular disorders, 639 Fusobacterium spp., in odontogenic infections, 297, 297t G Gabapentin, for trigeminal neuralgia, 621t Gas sterilization, 59 Gastric contents aspiration, 28–29, 29b, 30f Gauze pad medicated, for dry socket, 187 postextraction, 118, 118f Gelatin sponge for oroantral communication, 183 for postoperative bleeding, 184, 185f Genial tubercle, reduction of, 208 Genioplasty, 580, 581f Giant cell arteritis, 624 Gingival hyperplasia, cyclosporine A and, 12 Glossopharyngeal neuralgia, 622 Gloving preoperative, 661, 664f self-, sterile, 62f, 64 Glucagon, for hypoglycemia, 34 Glucocorticoids, equivalency of, 35t Glutaraldehyde, biocidal activity of, 60t Gowning, preoperative, 661, 663f Graft(s) bone See Bone grafts combinations of, 610, 611f definition of, 605 dermal, in temporomandibular joint surgery, 642–644, 643f types of, 606–610, 607f–609f, 611f Graft substitutes, for implant placement, 267–268, 267f, 269f–270f Grafting augmentation, for implant placement mandibular, 268, 271f maxillary, 268–270, 272f–273f bypass, coronary artery, 10, 316 tissue, maxillary vestibuloplasty with, 229, 231f Granulation tissue, postextraction, 118 Greenstick fracture, 47–48, 497–498, 498f Gut suture, 73–74 H Hand scrub for office-based surgery, 61–64, 61f–62f preoperative, 661, 662f Hanks solution, for tooth preservation, 483–484 Hard palate, closure of, 594–596, 595f, 597f–598f Harelip, definition of, 585 Head and neck deep fascial spaces of, borders and relations of, 323t–324t review of, 6b Headache cluster, 623–624, 624b, 625t differential diagnosis of, 625t hypnic, 624 indomethacin-responsive, 624 migraine, 622–623, 623b, 625t tension-type, 623, 623b, 625t Healing bone, 47–48, 48f–49f after endodontic surgery, 358 of extraction sockets, 47 wound See Wound healing Healing abutment, 254–255, 255f Healing screw, 254 Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), 196 Health status evaluation, preoperative See Preoperative health status evaluation Healthcare Insurance Portability and Accountability Act (HIPPA), 195–196 Hearing impaired patients, 197 Hearing loss, in cleft lip and palate, 592 Heart abnormalities of, endocarditis and, 10 disorders of, endocarditis risk associated with, 314, 314b Heart failure, congestive, 10–11, 11b Heat for hemostasis, 41 sterilization with, 57–59, 58f, 58t–59t Heimlich maneuvers, 27–28, 28f Hematologic disorders, 15–16, 15b–16b Hematoma, 40 Hematopoietic system, chemotherapy effects on, 375 Hemicrania, chronic paroxysmal, 624 Hemodialysis, 11–12, 12b antibiotic prophylaxis in patients receiving, 316 Hemophilia, 15 Hemorrhage cerebral, 36 control of instrumentation for, 70, 71f postoperative, 168–169, 169f postoperative, 183–185, 183b, 184f–186f subconjunctival, 492, 492f Hemostasis after impacted tooth removal, 165 in lacerations, 472 postextraction, 118, 118f in soft tissue biopsy, 436 during surgery, 40–41, 41f wound, promotion of, 40–41, 41f Hemostat, 70, 71f Heparin, 16, 16b Hepatic disorders, 12–13, 13b Hepatitis viruses, 55–56, 56b Herpes zoster, postherpetic neuralgia after, 621–622 Heterografts, 609 Hexachlorophene, 64 HIPPA (Healthcare Insurance Portability and Accountability Act), 195–196 Histogenesis, distraction, 538 alveolar ridge, 271–274, 274f History, medical See Medical history HITECH (Health Information Technology for Economic and Clinical Health Act of 2009), 196 HIV/AIDS, 56 dentist-patient relationship and, 193 odontogenic infections in, 302 Horizontal impaction, 150, 151f, 162–163, 163f Horizontal root fracture, 343, 344f, 480, 482f Hospital(s) administrative organization of, 652–653, 653f consultations in, 654, 654b, 655f–657f day surgery facilities in, 657–658 Hospital(s) (Continued) medical staff membership in, 653–654 operating room protocols in, 658, 661f Hospitalized patients, 652–673 care of, 658–664 consultations for, 654 discharge note for, 664, 664b, 671f discharge summary for, 664, 665b, 672f operating room protocols for, 658, 661f postoperative orders for, 661–663, 663b, 666f postoperative problems in, 665–673 airway-related, 665 atelectasis, 669 blood transfusion for, 673 fever, 669 fluid and electrolyte imbalance, 669–673 nausea and vomiting, 665–669 postoperative responsibilities in, 661–664 preoperative evaluation for, 658, 659f–660f preoperative orders for, 658, 659f progress notes for, 663–664, 670f rationale for dental care in, 654–658 surgery on gloving for, 661, 664f gowning for, 661, 663f hand and arm scrub for, 661, 662f operative note for, 663, 663b, 667f–669f surgeon and assistant preparation for, 658–661, 662f–665f Host defense mechanisms, in odontogenic infections, 302–303, 302b Human immunodeficiency virus See HIV/AIDS Hybrid prosthesis, 257, 259f Hydrocephaly, antibiotic prophylaxis and, 316 Hydrocodone, for postextraction pain, 170, 170t Hydrocortisone sodium succinate, for adrenal insufficiency, 36 Hydroquinone, in facial cosmetic practice, 566–567 Hygiene, oral, postoperative, 171 Hyperalgesia, definition of, 620b Hyperbaric oxygen (HBO) in jaw reconstruction, 610–611 in radiation-related tooth extraction, 368 Hypercementosis, 95, 96f tooth extraction and, 129, 129f Hyperesthesia definition of, 620b after segmental demyelination, 52 Hyperglycemia, 13–14 Hyperkeratosis, 426b Hyperplasia, 426b Hypersensitivity reactions, emergency management of, 22–24, 23t Hypertension, 12, 13b Hyperthyroidism, 14, 15b exacerbation of, 34–35, 35b Hypertrophy, 426b Hyperventilation syndrome, emergency management of, 26, 26b–27b Hypnic headache, 624 Hypoalgesia, definition of, 620b Hypoesthesia definition of, 620b after segmental demyelination, 52 Hypoglycemia, 13–14 emergency management of, 33–34, 34b, 34f Hypotension during allergic reactions, 24 orthostatic, emergency management of, 30, 30b Hypothyroidism, 14–15 Hypovolemia, postoperative, 669–673 I Ibandronate, 376t Ibuprofen, for postextraction pain, 170, 170t 693 Index Ice for edema control, 41–42 after impacted tooth removal, 166 for postoperative edema, 171 Imipramine, for trigeminal neuralgia, 621t Immune response, in bone reconstruction, 606 Immunocompromised patients, odontogenic infections in, 302 Immunosuppressive therapy, odontogenic infections and, 302 Impacted tooth removal, 143–167 classification systems for angulation, 150–152, 151f–152f, 158, 158f mandibular third molar, 150–153 maxillary third molar, 158–159, 158f nature of overlying tissue, 156–157, 157f relationship to anterior border of ramus, 152–153, 152f–153f relationship to occlusal plane, 153, 153f summary, 153, 154f contraindications to, 149–150 age, 149, 149f damage to adjacent structures, 150 medical status, 149 factors influencing, 157, 157b contact with mandibular second molar, 156 follicular sac size, 155, 155f nature of overlying tissue, 156–157, 157f relationship to inferior alveolar nerve, 156, 156f root morphology, 153–157, 154f–155f surrounding bone density, 155–156 indications for, 91, 144–149 caries prevention, 144, 145f jaw fracture prevention, 147, 149f odontogenic cyst/tumor prevention, 146–147, 148f–149f orthodontic treatment facilitation, 147 pain of unexplained origin, 147 pericoronitis prevention, 144–146, 145f periodontal disease prevention, 144, 144f–145f periodontal healing facilitation, 147–149 root resorption prevention, 146, 147f timing of, 144 tooth under dental prosthesis, 146, 148f maxillary canines, 159, 160f perioperative management in, 165–166 premolars, 159 procedure for, 159–165 bone removal in, 161–162, 162f delivery of sectioned tooth in, 164, 166f flap reflection in, 160–161, 161f–162f sectioning in, 162–164, 163f–165f wound closure in, 165 after radiotherapy, 368 supernumerary teeth, 159 Implant(s), 234–263 alveolar ridge distraction for, 271–274, 274f angulation of, 236–237, 237f anterior-posterior (A-P) spread of, 242, 243f augmentation grafting for mandibular, 268, 271f maxillary, 268–270, 272f–273f biomechanical considerations in, 236–238, 237f–238f bone grafting and graft substitutes for, 266–268, 267f, 269f–270f complex cases involving, 275–293, 277f–293f complications of, 252–253 litigation related to, 193 prosthetic, 262 components of, 253–256 cover or healing screw, 254 healing or interim abutment, 254–255, 255f implant abutment, 255–256 implant analog or replica, 255–256 implant body or fixture, 253–254, 253f–254f impression coping, 255, 256f prosthesis-retaining screw, 256 contraindications to, 238–239 diagnostic imaging for, 274–275, 275f–276f extraoral, 275, 277f 694 Implant(s) (Continued) failure of, litigation related to, 193 hard tissue interface in, 235, 235f–236f midfacial, 574–578, 575f multidisciplinary approach to, 235 one-stage, 254, 254f osseointegration of, 48–50, 50f biologic considerations for, 235, 235f–236f for partially edentulous patients, 257–262, 259f–262f pharyngeal wall, in cleft lip and palate, 598, 603f placement of flap reflection in, 248, 248f flap suturing in, 251 immediate postextraction, 264–266, 265f–266f implant insertion in, 248–251, 249f–250f osteotomy preparation in, 248, 249f–250f site exposure for, 245–246, 247f surgical armamentarium for, 245, 246f surgical preparation for, 245–251, 247f postoperative management of, 251 preoperative medical evaluation for, 238–245 diagnostic casts and photographs in, 239–240 intraoral examination in, 239 radiographic evaluation in, 240, 240f–241f after radiotherapy, 369, 370f–371f soft tissue interface in, 236, 237f spacing of, 241, 243f stability of, 251 surgery for one-stage, 235, 236f techniques in, 245 two-stage, 235, 236f for totally edentulous patients, 256–257 all-implant-supported overdenture, 256–257, 258f complete implant-supported fixed prosthesis, 257, 259f fixed partial denture, 257, 259f hybrid prosthesis, 257, 259f implant- and tissue-supported overdenture, 256, 257f treatment planning for anterior mandible, 243–244, 244f anterior maxilla, 245 computer-assisted virtual, 274–275, 276f final, 245, 246f posterior mandible, 244, 244f posterior maxilla, 244–245 prosthetic considerations in, 240–243, 242f–243f surgical, 243–245, 244f surgical guide template in, 245, 246f two-stage, 254, 254f uncovering of, 251, 252f zygomatic, 275, 277f Implant abutment, 255–256 Implant analog or replica, 255–256 Implant body or fixture, 253–254, 253f–254f Impression coping, 255, 256f Incision(s) crestal in alveoloplasty, 204, 206f mid-, 246, 247f elliptical, in maxillary tuberosity reduction, 215, 216f–217f envelope, 121 in impacted tooth removal, 160–161, 161f for implant site exposure, 245–246, 247f instrumentation for, 66–67, 67f in periapical surgery full mucoperiosteal, 348–350, 350f and reflection, 350, 351f semi-lunar, 347, 350f submarginal, 347–348, 350f releasing, in impacted tooth removal, 161, 161f semi-lunar, 121, 122f, 347, 350f in soft tissue biopsy, 436, 439f sulcular, 120f, 121 surgical, principles of, 38, 38f vertical-releasing, 121, 121f–122f for implant site exposure, 246, 247f “Y”, 121, 122f Incision and drainage for fascial space infections, 332–333, 336f for odontogenic infections, 303–306, 304f Incisional biopsy, 432–434, 435f Indomethacin-responsive headache, 624 Infection bone, 333–335, 336f diabetes mellitus and, 14 metastatic See Metastatic infections microbiology of, 297–298, 297t–298t odontogenic, 296–318 See also Odontogenic infections postoperative, 185 antibiotic prophylaxis of, 312–314, 312b, 313t prevention and recognition of, 171–172 prevention of, principles of, 311 pulpal, 298 recurrent, 311 salivary gland, 410–415, 413f secondary, 311 soft tissue, 298, 298f temporomandibular joint, 636 Infection control, 54–64 communicable pathogenic organisms and, 54–56, 55t, 56b concepts in, 57, 57b instrument disinfection in, 59, 59t–60t instrument sterilization in, 57, 58f, 58t–60t operatory disinfection in, 61 sterility maintenance in, 59–61, 61f surgical staff preparation in, 61–64, 61f–63f terminology in, 56–57 Infectious endocarditis, prophylaxis against, 314–316, 314b–315b, 315t Inferior alveolar canal, 94, 95f Inferior alveolar nerve, 89t impacted tooth relationship to, 156, 156f injury to, 50 surgery-related, 182 Inferior border osteotomy, in mandibular deficiency correction, 535, 539f Inflammation, signs of, 44–45, 300 Inflammatory fibrous hyperplasia, of alveolar ridge, 217, 219f Inflammatory stage of wound healing, 44–45, 44f–45f Informed consent, 190–191 in differential diagnosis of oral lesions, 431 for extractions and anesthesia, 9f Infraorbital space borders and relations of, 323t–324t infections of, 320, 323f Infratemporal space infections of, 321, 326f relations of, 324t root fragment displaced into, 177 Inspection, 6, 7b, 8f Instrument tie, 124, 126f–127f Instrumentation, 66–87 basic tray, 1t for biopsy, 432b for bone removal, 70–71, 71f–72f disinfection of, 59, 59t–60t for extraction of teeth, 76–83 See also Extraction forceps for hemorrhage control, 70, 71f for holding mouth open, 74–75, 75f for holding towels and drapes, 76, 76f for irrigation, 76, 76f for mucoperiosteal elevation, 68, 68f prices of, 1t for soft tissue grasping, 69–70, 70f for soft tissue removal from bony cavities, 69f, 72 for soft tissue retraction, 68–69, 68f–69f for soft tissue suturing, 72–74 See also Suture(s) sterilization of, 57, 58f, 58t–60t for suctioning, 75–76, 76f for tissue incision, 66–67, 67f tray systems for, 1t, 83–87, 86f–87f Insulin, types of, 13–14, 13t Interarch distance, 202, 202f, 241 Index Interim abutment, 254–255, 255f Intermaxillary fixation, 501–502, 501f–502f, 504 Intermaxillary segment, 587, 589f Internet, medicolegal considerations related to, 195 Intraoral examination, in implant therapy, 239 Intraosseous biopsy, 440–444 follow-up for, 444 instruments for, 432b osseous window in, 442, 445f precautionary aspiration in, 442, 446f specimen management in, 442–444 through mucoperiosteal flap, 442, 445f Intraseptal alveoloplasty, 204–205, 208f Intrusion of teeth, traumatic, 481–482, 482f–483f Involucrum, 334 Iodophors, 61, 64 biocidal activity of, 60t Iris scissors, 74, 74f Irrigation for decontamination, 41 for dry socket, 187 instrumentation for, 76, 76f in periapical surgery, 354 Irrigation-suction technique, for removal of root fragments and tips, 137 Ischemia impaired wound healing and, 46–47 wound edge, 38, 38f Ischemic heart disease, 8–10, 9b–10b Itraconazole, 12 J Jaw See also Mandible; Maxilla bisphosphonate-induced osteonecrosis of, 376–379 See also Bisphosphonate-induced osteonecrosis of jaws (BOJ) cysts of causes of, 449, 449f classification of, 449 radiographic appearance of, 449, 449f–450f surgical management of, 449–458 enucleation after marsupialization in, 457–458 enucleation in, 450–452, 451f–453f enucleation with curettage in, 458 marsupialization in, 454–457, 454f–457f defects of patient assessment in of associated problems, 611–612 of hard tissue defect, 610 of soft tissue defect, 610–611 surgical reconstruction of, 605–616 alveolar bone height restoration in, 612 biologic basis of, 605–606 bone grafts in, 606–610, 607f–609f, 611f continuity restoration in, 612 goals in, 612 immune response in, 606 maxillofacial bone grafts in, 612–613, 613f–615f osseous bulk restoration in, 612 patient assessment for, 610–612 after tumor removal, 465–467, 466f fractures of, 474 prevention of, impacted tooth removal for, 147, 149f teeth involved in, extraction of, 91 osteomyelitis of, 333–335, 336f sensory innervation of, 89, 89t tumors of intraosseous vs extraosseous, 460 maxillary vs mandibular, 460 proximity to adjacent vital structures and, 460 size of, 460 surgical management of, 458–460 curettage in, 460 enucleation in, 460 lesion aggressiveness and, 460 lesion duration and, 460 lesion location and, 460 Jaw (Continued) marginal or partial resection in, 459f, 459t, 460, 461f–463f procedures for, 459b, 459t reconstruction after, 460, 465–467, 466f Keratoconjunctivitis sicca, in Sjögren’s syndrome, 414–415, 414f–415f Keratosis, 426b Ketoconazole, for candidiasis, 376 Local anesthetics (Continued) for temporomandibular disorders, 638 toxicity from, emergency management of, 32–33, 33t Long buccal nerve, 89t Lower extremity edema, 10–11 Ludwig’s angina, 326 Luxation, in tooth extraction with elevator, 101f, 106, 106f with forceps, 107 Lymph nodes, regional, examination of, 427–429, 427f–428f Lymphoma, uncontrolled, as contraindication to tooth extraction, 92 L M Labial bone, fracture of, 110 Labial frenectomy, 217–222, 220f–223f Labial glands, 395, 395t Labial vestibuloplasty, and floor-of-mouth lowering procedure, 226–228, 228f–229f Laboratory coats, 61f, 64 Laboratory tests, in differential diagnosis of oral lesions, 429 Lacerations, 471–473, 472f–473f facial, 516, 516f–517f Lactation, 17t, 18 Lag stage of wound healing, 45, 45f Lamotrigine, for trigeminal neuralgia, 621t Language proficiency, Title VI and, 196 Laser excision, in labial frenectomy, 221–222, 223f Laser resurfacing, ablative, 569–570 Lateral nasal osteotomy, 576f Lateral palatal exostosis, alveolar ridge recontouring for, 206–207, 211f Lateral palatal soft tissue excess, removal of, 215, 218f Lateral pharyngeal space borders and relations of, 323t–324t infections of, 326, 330–331, 331f–332f Le Fort fractures, 499, 499f Le Fort I osteotomy, in maxillary deficiency correction, 535–538, 544f–545f Le Fort III osteotomy, in midface deficiency correction, 538, 547f Lead apron shield, during pregnancy, 17f, 18 Lesions, oral See Oral lesions Leukemia, uncontrolled, as contraindication to tooth extraction, 92 Leukoplakia, 426b Levofloxacin, 12 Liability, legal concepts influencing, 188–189 Lidocaine, maximum dose of, 33t, 90t Light, during surgery, 38 Light and magnification devices, in endodontic surgery, 360–361, 360f Light-enhanced adjuncts for clinical screening, 429 Limited English proficiency (LEP), Title VI and, 196 Linezolid, cost of, 310t Lingual frenectomy, 222–223, 223f–224f Lingual glands, 395, 395t Lingual nerve in flap design, 120 injury to, 50 surgery-related, 182 Lingual undercut, 244, 244f Lip(s) augmentation or reduction of, 580–583, 582f biopsy of, 440f carcinoma of, excision of, 464, 464f–465f cleft See Cleft lip and palate laceration of, 473, 473f mucoceles of, 408–409, 410f–411f Lip switch, 226, 227f Liposuction, neck, 583–584, 583f Liver clots, 184–185 Local anesthetics for extraction of teeth, 89–90, 89t–90t for impacted tooth removal, 165–166 Macrolides, overview of, 11 Macule, 426b Magnetic resonance imaging (MRI) in salivary gland disorders, 403 in temporomandibular disorders, 631, 631f Malaise, 300 Malignant, definition of, 426b Malingering, 619 Mallet and chisel, for bone removal, 71, 71f Malocclusion See also Dentofacial deformities in cleft lip and palate, 590–591, 591f Malpractice See also Medicolegal considerations definition of, 188–189 deposition for, 194 Malpractice claims common areas associated with, 193–194 legal concepts influencing, 188–189 patient threats about filing, 194 Managed care, medicolegal considerations related to, 194–195 Mandible See also Jaw anterior, implant placement in, 243–244, 244f augmentation of, 268, 271f condyle of See Condyle defects of, surgical reconstruction for, 605–616 See also Jaw, defects of, surgical reconstruction of growth of, 521, 522f mobility of, radiation effects on, 364 odontogenic infections arising in, 299 osteomyelitis of, 333–335, 336f osteoradionecrosis of, 365, 366f–367f, 371–375, 372f–374f posterior, implant placement in, 244, 244f range of motion of assessment of, 629, 629f exercises for, 638, 638f reconstruction of, for jaw defects, 605–616 See also Jaw, defects of, surgical reconstruction of ridge extension of, 226–228, 227f–229f stabilization of, in facial trauma, 491, 492f tumors of, 460 Mandibular advancement distractor appliance for, 557f plus maxillary advancement, 538, 550f–551f plus superior maxillary repositioning, 538, 552f–553f Mandibular body, space of, infections of, 325, 328f Mandibular deficiency distraction osteogenesis for, 547–556, 559f–560f narrow or collapsed airway from, 555f–556f surgical correction of, 532–535, 536f–539f Mandibular excess, surgical correction of, 530–532, 531f–535f Mandibular fracture airway obstruction in, stabilization for, 491, 492f classification of, 497–498, 498f during extraction, 187 physical examination in, 493, 493f radiographic examination in, 494, 495f treatment of, 501–508 closed reduction, 501–502, 501f–502f in edentulous patients, 502 MMF or IMF, 501–502, 501f–502f, 504 open reduction, 502–504, 505f K 695 Index Mandibular fracture (Continued) rigid internal fixation, 504–508, 506f–508f splinting, 502, 504f wiring techniques, 504, 505f Mandibular molars extraction of, 115–116, 116f–117f multirooted, open extraction of, 133, 133f–135f Mandibular premolars, extraction of, 112–115, 115f Mandibular retromolar pad, reduction of, 215 Mandibular setback, plus maxillary advancement, 538, 548f–549f Mandibular space, borders and relations of, 323t–324t Mandibular symphysis, bone graft from, 267, 267f Mandibular teeth extraction of See Extraction of teeth, mandibular fascial space infections associated with, 320b, 325–330 Mandibular tori, removal of, 210, 213f–215f Marsupialization of jaw cysts, 454–457, 454f–457f enucleation after, 457–458 of ranula, 410, 412f Massage, for temporomandibular disorders, 639 Masticator space, infections of, 329, 329f Masticatory muscles, examination of, 628, 628f Masticatory myofascial pain, 623 Maxilla See also Jaw anterior, implant placement in, 245 augmentation of, 268–270, 272f–273f edentulous, prosthetic options for, 241–242, 243f growth of, 521, 522f mobility of, 493, 494f odontogenic infections arising in, 299, 299f posterior implant placement in, 244–245 tuberosity fracture of, impacted tooth removal and, 159 ridge extension of, preprosthetic surgery for, 228–229, 230f–231f tumors of, 460 Maxillary advancement in cleft lip and palate, 596–598 plus mandibular advancement, 538, 550f–551f plus mandibular setback, 538, 548f–549f Maxillary canines extraction of, 110, 110f impacted, 159, 160f Maxillary deficiency in cleft lip and palate, 590, 591f distraction osteogenesis for, 545–547, 556, 558f, 561f plus midface deficiency, surgical correction of, 535–538, 544f–547f Maxillary excess, surgical correction of, 535, 540f–543f Maxillary molars extraction of, 111–112, 113f root displacement during, 176–177, 177f multirooted, open extraction of, 136, 136f–137f Maxillary osteotomy, in maxillary excess correction, 535, 540f–543f Maxillary premolars, extraction of first, 110–111, 111f second, 111, 112f Maxillary sinus, 382–393 anatomy of, 382–383, 383f clinical examination of, 383, 383f embryology of, 382–383 foreign body in, 383–384, 385f, 389 impacted tooth removal and, 159 infections of, 321–322, 327f nonodontogenic, 385–387 odontogenic, 387, 387f radiographic examination of, 384–385, 386f lifting of, 268–270, 272f–273f oral cavity and, communication between, 182–183, 182b, 183f oral surgery involving complications of, 389–391 delayed, 391, 391f–393f immediate, 389–391, 390f 696 Maxillary sinus (Continued) perforation of, 389 during alveolar ridge recontouring, 206 pseudocysts of, 388–389 radiographic examination of, 383–385 CT, 384, 386f interpretation of, 384–385, 386f standard views, 383, 384f Waters’ and lateral views, 384, 385f root fragment displaced into, 176–177, 177f Maxillary sinusitis acute, 386, 388 chronic, 387–388, 388f–389f nonodontogenic, 385–387 odontogenic, 387, 387f postoperative, 182 radiographic examination of, 384, 385f–386f Maxillary teeth extraction of See Extraction of teeth, maxillary fascial space infections associated with, 320–325, 320b Maxillary tori, removal of, 209–210, 212f–213f Maxillary tuberosity fracture of, 181, 181f reduction of hard tissue, 205–206, 209f soft tissue, 215, 216f–217f Maxillary vestibuloplasty, with tissue grafting, 229, 231f Maxillofacial bone grafting, surgical principles of, 612–613, 613f–615f Maxillofacial region examination of, 8, 8b review of, 6b skin flora of, 55, 55t Maxillomandibular fixation, 501–502, 501f–502f, 504 Mediastinitis, 331 Medical asepsis, 57 Medical emergency(ies), 19–36 in adrenal insufficiency, 35–36, 35b–36b, 35t altered consciousness as, 29–36 anxiety-induced, 20, 20b in asthma, 26, 26b, 27f in cerebrovascular compromise, 36, 36b chest discomfort as, 24–26, 24b–25b, 25f in chronic obstructive pulmonary disease, 27 in diabetes mellitus, 33–34, 34b, 34f in foreign body aspiration, 27–28, 28b, 28f–29f frequency of, 19 in gastric contents aspiration, 28–29, 29b, 30f hypersensitivity reactions as, 22–24, 23t in hyperventilation syndrome, 26, 26b–27b in local anesthetic toxicity, 32–33, 33t management of access to help in, 20–21 continuing education in, 20, 20b office staff training in, 20 supplies and equipment for, 21–22, 21f–22f, 21t–22t in orthostatic hypotension, 30, 30b preparation for, 20–22, 20b prevention of, 19–20 respiratory, 26–29 in seizure, 30–32, 32f in thyroid dysfunction, 34–35, 35b types of, 22–36 in vasovagal syncope, 29–30, 31f Medical history biographic data in, chief complaint in, in differential diagnosis of oral lesions, 422–423 format for, 3, 3b health history in, 3–6, 3b, 4f–5f, 6b history of chief complaint in, review of systems in, 6, 6b Medical records, 191 Medicolegal considerations, 188–198 common areas of litigation, 193–194 complications-related, 192 informed consent, 190–191 Medicolegal considerations (Continued) legal liability concepts, 188–189 managed care issues, 194–195 patient management problems, 192–193 patient threatening to sue, 194 records and documentation, 191 referral to general dentist or specialist, 192 risk reduction, 189–190 rules and regulations, 195–197 ADA, 196–197 EMTALA, 197 HIPPA, 195–196 HITECH, 196 Title VI, limited English proficiency, 196 telemedicine and Internet, 195 Membrane-assisted closure, of oroantral communication, 391, 393f Mental foramen, 94, 95f Mental nerve in flap design, 120 injury to, surgery-related, 181–182 Mepivacaine, maximum dose of, 33t, 90t Mesioangular impaction, 150, 151f, 158, 158f, 162, 163f Metabolic disease, uncontrolled as contraindication to tooth extraction, 92 odontogenic infections and, 302 Metastatic infections antibiotic prophylaxis for, 314–317, 314b against endocarditis, 314–316, 314b–315b, 315t in other cardiovascular conditions, 316 against prosthetic joint infection, 316–317 definition of, 314 factors necessary for, 314, 314b Methicillin, 11 Metronidazole, 307, 309–310 cost of, 310t overview of, 11 toxicity and side effects of, 309 Metzenbaum scissors, 74, 74f Microplate/microscrew stabilization in dentofacial deformity correction, 557, 562f of midface fractures, 510, 510f–514f Microscope, surgical, in endodontic surgery, 360–361, 360f Microsurgery, for bone grafting, 606, 609f Midazolam, for hyperventilation syndrome, 26 Middle superior alveolar nerve, 89t Midface deficiency, plus maxillary deficiency, surgical correction of, 535–538, 544f–547f Midface fracture classification of, 498–499, 499f–500f physical examination in, 493, 494f radiographic examination in, 496, 496f–497f treatment of, 508–510 advanced technologies in, 510, 515f bone plate systems in, 510, 510f–514f NOE, 509, 509f resorbable plate and screw systems in, 510, 514f suspension wiring in, 510, 510f zygoma, 508, 508f zygomatic arch, 509 Midfacial implants, 574–578, 575f Migraine headache, 622–623, 623b, 625t Milk, for tooth preservation, 483–484 Millard cheilorrhaphy, 595f Mineral trioxide aggregate (MTA) in corrective surgery, 356–357 in periapical surgery, 353–354 Minnesota retractor, 1t, 68, 68f Mirror, mouth, for tongue retraction, 68 Model surgery, for dentofacial deformity correction, 526, 528f Moist-heat sterilization, 57–59, 58t–59t Molars mandibular extraction of, 115–116, 116f–117f multirooted, open extraction of, 133, 133f–135f Index Molars (Continued) maxillary extraction of, 111–112, 113f root displacement during, 176–177, 177f multirooted, open extraction of, 136, 136f–137f third, impacted See Impacted tooth removal Molt mouth prop, 1t, 75, 75f Molt periosteal elevator, No 9, 68, 68f Monitoring postbiopsy, 431 prebiopsy, 430 Monofilament suture, 74 Morphine sulfate, for chest pain, 26 Mounted study models, in implant therapy, 239–240 Mouth dry radiation-induced, 364–365, 365f–366f in Sjögren’s syndrome, 414, 414f treatment of, 364–365 open, instrumentation for holding, 74–75, 75f Mouth mirror, for tongue retraction, 68 Mouth prop, 75, 75f Moxifloxacin, 309–310 cost of, 310t overview of, 12 toxicity and side effects of, 309 Mucoceles salivary gland, 408–409, 410f–411f sinus, 388–389 Mucoepidermoid carcinoma, salivary gland, 418, 418f Mucoperiosteal elevation, instrumentation for, 68, 68f Mucoperiosteal flaps in alveoloplasty, 204 biopsy through, 442, 445f development of, 121–122, 122f–123f tear of, surgery-related, 175, 175f types of, 121, 122f Mucoperiosteal incisions, full, in periapical surgery, 348–350, 350f Mucosal signs, in hypersensitivity reactions, 22, 23t Mucositis, radiation-induced, 364 Mumps, 412 Muscle relaxants, for temporomandibular disorders, 637 Mycobacteria, 56 Mycobacterium tuberculosis, 56 Myelosuppression, chemotherapy-induced, 375 Mylohyoid line, 325, 328f Mylohyoid ridge, reduction of, 207–208, 212f Myocardial infarction, 9–10, 10b Myocardial ischemia/infarction, chest pain associated with, 24–25, 24b See also Angina pectoris Myofascial pain masticatory, 623 in temporomandibular disorders, 632 N Nasal cavity, flora of, 55, 55t Nasal deformity, in cleft lip and palate, 587f, 591 Nasal surgery, corrective, 575–576, 576f–577f Naso-orbital-ethmoid (NOE) injuries, 509, 509f evaluation of, 493, 494f Nasomaxillary buttress, 500–501, 500f Nasopalatine nerve, 89t injury to, surgery-related, 181 Nausea, in postoperative patients, 665–669 Navigation system, intraoperative, for midface fracture treatment, 510, 515f Neck deep fascia of, superficial or investing layer of, 329 deep fascial spaces of borders and relations of, 323t–324t infections of, 320b, 330–331 masses in, differential diagnosis of, 410 Neck and face lift, 578–580, 579f–581f Neck liposuction, 583–584, 583f Necrosis, flap, 38, 39f Necrotic tissue, impaired wound healing and, 46 Necrotizing fasciitis, 331, 335f Necrotizing sialometaplasia, 412–414, 414f Needle(s), suture, 72–73, 73f, 124, 124f Needle holder in scalpel blade loading, 66, 67f in suturing, 72, 72f–73f Neoplasms See Tumors Nerve healing, 51f–52f, 52–53 Nerve injury classification of, 50–52, 51f maxillofacial, traumatic, 50–53 surgery-related, 181–182, 182b, 193 Neuralgia cranial, miscellaneous, 622 definition of, 620b postherpetic, 621–622 pretrigeminal, 620–621, 621b trigeminal, 620, 620b, 621t Neurapraxia, 51f, 52 Neurologic disorders, 16, 16b Neuroma, 53, 622 Neuropathic facial pain, 619–622 burning mouth syndrome as, 622 miscellaneous cranial neuralgias as, 622 neuroma as, 622 odontalgia from deafferentation as, 621, 621b postherpetic neuralgia as, 621–622 pretrigeminal neuralgia as, 620–621, 621b trigeminal neuralgia as, 620, 620b, 621t Neuropathology, facial See Facial neuropathology Neuropathy, definition of, 620b Neurophysiology, pain, 618, 619f, 619t Neurotmesis, 51f, 52 Nitroglycerin, for chest pain, 25 Nitrous oxide angina pectoris and, for extraction of teeth, 90 in pregnant patients, 18 Nociception, 618, 619f, 619t Nodule, 426b Noncompliance, patient, 192 Nonsteroidal antiinflammatory drugs (NSAIDs) asthma and, 11 in pregnant patients, 17b for temporomandibular disorders, 637 Nortriptyline, for trigeminal neuralgia, 621t Nose-blowing test, for oroantral communication, 182 Nystatin for candidiasis, 337, 376 overview of, 12 O Obstructive sleep apnea, orthognathic surgery for, 538, 555f–556f Occlusal plane, impacted tooth classification relationship to, 153, 153f Occlusal splints, for temporomandibular disorders, 639–640, 639f–640f Occlusion, permanent modification of, for temporomandibular disorders, 640 Odontalgia from deafferentation, 621, 621b Odontogenic cyst/tumor, prevention of, impacted tooth removal for, 146–147, 148f–149f Odontogenic infections, 296–318 actinomycosis and, 335–336, 336f candidiasis and, 336–337, 337f complex, 308, 308b, 319–338 fascial space, 319–333 See also Fascial space infections history in, 300, 300f host defense mechanism evaluation in, 302–303, 302b metastatic infections and, 314–317, 314b See also Metastatic infections osteomyelitis and, 333–335, 336f physical examination in, 300–302, 300f–301f progression of, natural history of, 298–299, 298f–300f severity of, determination of, 300–302, 300f–301f Odontogenic infections (Continued) simple, 308, 308b treatment of algorithm for, 305–306, 305f antibiotics in, 306–310 See also Antibiotics culture and sensitivity testing in, 304–305, 304b, 307–308 medical support in, 306 principles of, 299–311 referrals in, 303, 303b, 306 surgical, 303–306, 304f Office staff training, in medical emergency management, 20 Onlay bone grafting, for maxillary augmentation, 268, 272f Open-window technique, for removal of root fragments and tips, 138, 140f Operating room protocols, 658, 661f Operative note for hospital record, 663, 663b, 667f–669f for office record, 3, 172–173, 172b Operatory disinfection, 61 Opioids, for postextraction pain, 170, 170t Oral brush biopsy, 432, 434f Oral candidiasis, 336–337, 337f Oral cavity benign lesions in, surgical management of, 464–465 malignant tumors of, 463–464 treatment of, 463–464 chemotherapy in, 464 radiotherapy in, 463–464 surgical, 464, 464f–465f Oral flora, 54–55, 55t chemotherapy effects on, 375 radiation effects on, 365 Oral hygiene, postoperative, 171 Oral lesions differential diagnosis of, 422–447 biopsy in See Biopsy clinical examination in, 424–429, 425f–428f, 426b borders and mobility, 426–427 coloration, 426 consistency to palpation, 427 location, 424 lymph nodes, 427–429, 427f–428f physical characteristics, 424–426, 426b pulsation, 427 single vs multiple, 426 size, shape, and growth presentation, 426 surface appearance, 426 follow-up in, 430–431 history of specific lesion in, 423–424 informed consent and shared risk in, 431 laboratory tests in, 429 light-enhanced adjuncts in, 429 medical history in, 422–423 monitoring in postbiopsy, 431 prebiopsy, 430 presumptive clinical, 429–430 principles of, 422–431 radiography in, 429, 430f referral in, 430–431 pathologic surgical management of, 448–467 for benign lesions in oral soft tissues, 464–465 for cysts and cyst-like lesions of jaw, 449–458 eradication in, 448–449 functional rehabilitation in, 449 goals in, 448–449 for malignant tumors of oral cavity, 463–464 reconstruction in, 465–467, 466f for tumors of jaw, 458–460 terminology for, 426b Oral mucosa chemotherapy effects on, 375 radiation effects on, 364 Orbital complex fracture, 492–493, 493f Orbital floor, blow-out fracture of, 499, 500f Organ transplantation, 12, 12b 697 Index Oroantral communications, 182–183, 182b, 183f treatment of delayed, 391, 391f–393f immediate, 389–391, 390f Oroantral fistula, 43–44 postoperative, 182 Orofacial actinomycosis, 335–336, 336f Orofacial clefts, 585–604 See also Cleft lip and palate areas affected by, 586, 586f–587f causes of, 587–588 dental needs in patients with, 598–604, 604f embryology of, 586–587, 588f–589f epidemiology of, 585 syndromes associated with, 587–588 Orofacial pain classification of, 619, 620b evaluation of, 624–626, 625t neuropathic See Neuropathic facial pain neurophysiology of, 618, 619f, 619t Orthodontics in dentofacial deformity correction, 525–526, 527f–528f, 557 for eruption of intruded tooth, 482, 483f facilitation of, impacted tooth removal for, 147 tooth extraction related to, 91 Orthognathic surgery cephalometric analysis for, 523–524, 524f, 525t for cleft lip and palate, 596–598 for dentofacial deformities, 530–538 See also Dentofacial deformities, surgical treatment of for obstructive sleep apnea, 538, 555f–556f perioperative care in, 556–557, 562f Orthopnea, 10–11 Orthostatic hypotension, emergency management of, 30, 30b Osseointegration, biologic considerations for, 235, 235f–236f Osseous bulk, restoration of, 612 Osseous window, in intraosseous biopsy, 442, 445f Ostectomy, body, in mandibular excess correction, 530–531, 531f Osteoarthritis, temporomandibular joint, 633–634, 634f Osteogenesis distraction See Distraction osteogenesis two-phase theory of, 605–606 Osteonecrosis, bisphosphonate-induced, 376–379 See also Bisphosphonate-induced osteonecrosis of jaws (BOJ) Osteoradionecrosis, 365, 366f–367f management of, 371–375, 372f–374f Osteotomy bilateral sagittal split in mandibular deficiency correction, 535, 536f–537f in mandibular excess correction, 532, 535f for implant placement, 248, 249f–250f inferior border, in mandibular deficiency correction, 535, 539f lateral nasal, 576f Le Fort I, in maxillary deficiency correction, 535–538, 544f–545f Le Fort III, in midface deficiency correction, 538, 547f maxillary, in maxillary excess correction, 535, 540f–543f segmental, in partially edentulous patients, 229–232, 231f subapical in mandibular deficiency correction, 535, 538f in mandibular excess correction, 530, 531f vertical ramus, in mandibular excess correction, 531, 532f–534f Otitis media, in cleft lip and palate, 592 Otoplasty, 577–578, 578f Overdenture all-implant-supported, 256–257, 258f implant- and tissue-supported, 256, 257f surgery for, 225–226 Oxcarbazepine, for trigeminal neuralgia, 621t 698 Oxycodone, for postextraction pain, 170, 170t Oxygen hyperbaric in jaw reconstruction, 610–611 in radiation-related tooth extraction, 368 supplementation of COPD and, 11 equipment for, 21–22, 21t P Pacemakers, 10 transvenous, antibiotic prophylaxis in patients with, 316 Packing, for dead space management, 41 Pain chest acute-onset, differential diagnosis of, 24–25, 25b myocardial ischemia/infarction–induced, 24–25, 24b control of in extraction of teeth, 89–90, 89t–90t postoperative, 169–171, 170t deafferentation definition of, 620b oral, 619–621, 621b facial neuropathic, 619–622 See also Neuropathic facial pain of unknown cause, 619 mandibular, of unexplained origin, impacted tooth removal for, 147 myofascial masticatory, 623 in temporomandibular disorders, 632 neuropathic, 619 See also Neuropathic facial pain neurophysiology of, 618, 619f, 619t orofacial classification of, 619, 620b evaluation of, 624–626, 625t psychological, 619 somatic, 619 temporomandibular, evaluation of, 627–631, 629f terminology for, 620b Palatal exostosis, lateral, alveolar ridge recontouring for, 206–207, 211f Palatal flap, for oroantral communication, 391, 392f Palatal soft tissue excess, lateral, removal of, 215, 218f Palate abscess of, 298–299, 298f–299f adenoid cystic carcinoma of, 419f cleft See Cleft lip and palate hard, closure of, 594–596, 595f, 597f–598f pleomorphic adenoma of, 416, 417f soft, closure of, 596, 599f–600f Palatine glands, 395, 395t Palatorrhaphy, 594–596, 595f, 597f–600f Palpation, 6, 7b Pamidronate, 376t Panoramic radiography in implant therapy, 240, 240f–241f in temporomandibular disorders, 629, 630f Pansinusitis, 386 Papillary cystadenoma lymphomatosum, 417, 417f Papule, 426b Paranasal sinus, flora of, 55, 55t Paresthesia definition of, 620b orofacial, 619–620 after segmental demyelination, 52 Parotid gland anatomy and physiology of, 395, 396f, 397b, 397t, 398f innervation of, 398, 398f pleomorphic adenoma of, 416, 417f sialadenitis of, 410, 413f Warthin tumor of, 417, 417f Parotideomasseteric fascia, 329 Parotitis, viral, 412 Paroxysmal nocturnal dyspnea, 10 Particulate marrow graft, 606 Passavant’s ridge, in cleft lip and palate, 592–593 Pathogenic organisms communicable, 54–56, 55t, 56b control of See Infection control in odontogenic infections, 297–298, 297t Patient abandonment of, 192–193 noncompliance of, 192 Patient-dentist relationship, 189–190 termination of, 192 Patient education, for temporomandibular disorders, 636–637 Patient positioning, for edema control, 41–42 Pedicled bone graft, 606 Pell and Gregory classification of impacted teeth classes 1, 2, and 3, 152–153, 152f–153f classes A, B, and C, 153, 153f Pen grasp, 121, 122f for scalpel, 66–67, 67f Penicillin, 309 allergy to, 309 cost of, 310t for odontogenic infection prophylaxis, 313 overview of, 11 in periapical surgery, 346 preoperative, in implant placement, 245 prescription for, example of, 7f Penrose drain, 41f Peptostreptococcus spp., in odontogenic infections, 297, 297t Percussion, 6–7, 7b of tooth, 474 Perforations, corrective surgery for, 355, 355b, 356f–357f Periapical cysts, enucleation of, 450, 451f–453f Periapical exposure, 350–351, 351f Periapical radiolucencies, 96, 97f Periapical surgery, 340–354 algorithm for, 340, 341f contraindications to, 344–346, 344b anatomic considerations, 346, 348f–349f conventional endodontic treatment is possible, 344, 348f medical complications, 346 poor crown-root ratio, 346 simultaneous root canal treatment and apical surgery, 344–346 unidentified cause of treatment failure, 344 indications for, 342–344, 342b, 342f–343f anatomic problems, 342–343, 343f horizontal root fracture, 343, 344f irretrievable material in canal, 343, 345f large, unresolved lesions after root canal treatment, 344, 348f procedural error, 343, 346f–347f restorative considerations, 343, 344f procedure for, 346–354 anesthesia in, 350 antibiotics in, 346 curettage in, 351, 352f flap design in, 346–347 flap replacement and suturing in, 354, 355f incisions in full mucoperiosteal, 348–350, 350f and reflection, 350, 351f semi-lunar, 347, 350f submarginal, 347–348, 350f irrigation in, 354 periapical exposure in, 350–351, 351f postoperative instructions in, 354 radiographic verification in, 354 root end-filling materials in, 353–354, 354f root end preparation and restoration in, 352–353, 353f root end resection in, 351–352, 352f suture removal and evaluation in, 354 Index Pericoronitis antibiotics for, 307 impacted tooth removal and, 144–146, 145f tooth extraction and, 92 Perimandibular space, infections of, 325, 328f Periodontal considerations, in dentofacial deformity correction, 524–525, 526f, 557 Periodontal disease prevention of, impacted tooth removal for, 144, 144f–145f tooth extraction for, 91 Periodontal healing, facilitation of, impacted tooth removal for, 147–149 Periodontal ligament injection, in extraction of teeth, 89 Periodontal ligament space, impacted tooth removal and, 155, 155f Periodontal tissue, peri-implant soft tissue vs., 236, 237f Periorbital ecchymosis, 492, 492f Periosteal elevators, 68, 68f Periotomes, 78, 78f Peripheral nerve fibers, 618, 619t Peripheral nerve injury, 50–53 See also Nerve injury Personnel asepsis, 61–64, 61f–63f Pharyngeal flap, in cleft lip and palate, 598, 603f Pharyngeal space, lateral borders and relations of, 323t–324t infections of, 326, 330–331, 331f–332f Pharyngeal wall implant, in cleft lip and palate, 598, 603f Pharynx, tooth lost into, 177–178 Phenytoin, for trigeminal neuralgia, 621t Photographs, preoperative, in implant therapy, 239–240 Physical examination ASA physical status classification in, 7, 8b format for, 3b methods in, 6–7, 7b–8b, 7f–8f Physical therapy, for temporomandibular disorders, 638–639, 638f Pick Crane, 78, 78f root-tip, 78, 78f Pilocarpine, for xerostomia, 364–365 Plaque, 426b Plate and screw systems, resorbable, in midface fracture treatment, 510, 514f Plate stabilization in dentofacial deformity correction, 557, 562f in maxillofacial bone grafting, 612, 614f–615f of midface fractures, 508–510, 508f–514f Platelet-inhibiting drugs, 16, 16b Platelet problems, 15 Pleomorphic adenoma, salivary gland, 416, 417f Polyfilament suture, 74 Polymyalgia rheumatica, 624 Porphyromonas spp., in odontogenic infections, 297, 297t Portal hypertension, 13 Posterosuperior alveolar nerve, 89t Postextraction socket care, 116–118, 117f–118f Postherpetic neuralgia, 621–622 Postoperative management, 168–173 diet in, 171 ecchymosis in, 172, 172f edema in, 171, 171f follow-up in, 172 hemorrhage control in, 168–169, 169f in hospitalized patients See under Hospitalized patients infection in, 171–172 operative note in, 3, 172–173, 172b oral hygiene in, 171 pain control in, 169–171, 170t trismus in, 172 Postoperative orders, 661–663, 663b, 666f Postoperative tray, 1t, 83–87, 87f Postpartum patients, 17t, 18 Postsurgical asepsis, 63f, 64 Postural hypotension, emergency management of, 30, 30b Povidone-iodine, 61 Precautions, universal, 56 Pregnancy dental medications to avoid during, 17b, 18 patient management during, 16–18, 17b radiography during, lead apron shield for, 17f, 18 tooth extraction during, 92 Premolars impacted, 159 mandibular, extraction of, 112–115, 115f maxillary, extraction of first, 110–111, 111f second, 111, 112f Preoperative health status evaluation, 2–18, 42 compromising medical conditions and, 8–16 for extraction of teeth, 89 for hospitalized patients, 658, 659f–660f for implant therapy, 238–245 medical history in, 2–6, 3b, 4f–5f, 6b physical examination in, 6–7, 7b–8b, 7f–8f postpartum, 17t, 18 during pregnancy, 16–18 Preoperative orders, 658, 659f Preprosthetic surgery, 200–233 for abnormal ridge relationships, 229–232, 231f alveolar ridge distraction in, 271–274, 274f in alveolar ridge preservation, 224–225, 226f alveolar ridge recontouring in, 204–208 See also Alveolar ridge, recontouring of augmentation grafting in mandibular, 268, 271f maxillary, 268–270, 272f–273f bone grafting and graft substitutes in, 266–268, 267f, 269f–270f immediate dentures and, 223–224, 225f–226f lingual frenectomy in, 222–223, 223f–224f for mandibular ridge extension, 226–228, 227f–229f for maxillary ridge extension, 228–229, 230f–231f objectives of, 200–226, 201f overdenture surgery and, 225–226 patient evaluation for of bony tissue, 202–203, 202f–203f principles of, 202–204 of soft tissue, 203, 203f for soft tissue abnormalities, 210–223 See also Soft tissue, abnormalities of tori removal in, 209–210 mandibular, 210, 213f–215f maxillary, 209–210, 212f–213f treatment planning in, 203–204 Prescriptions, useful, examples of, Pressure dressing, for dead space management, 41 Pressure massage, for temporomandibular disorders, 639 Pretracheal space, borders of, 323t Pretrigeminal neuralgia, 620–621, 621b Prevotella spp., in odontogenic infections, 297, 297t Prilocaine, maximum dose of, 33t, 90t Primary intention bone healing by, 47–48 wound healing by, 47 Primary teeth, extraction of, modifications for, 116 Privacy regulations, HIPPA, 195–196 Procoagulants, for hemostasis, 41 Progress notes, 663–664, 670f Prosthesis complete implant-supported fixed, 257, 259f in dentofacial deformity correction, 557 hybrid, 257, 259f impacted tooth under, 146, 148f temporomandibular joint, 644–645, 645f–646f Prosthesis-retaining screw, 256 Prosthetic joint infection, antibiotic prophylaxis against, 316–317 Prosthetic speech aid appliance, in cleft lip and palate, 600–604, 604f Prosthetic valve endocarditis, 316 Pseudocysts, antral, 388–389 Pseudomembranous candidiasis, 336–337, 337f Psychological evaluation, in temporomandibular disorders, 631 Psychological pain, 618–619 Pterygomandibular space borders and relations of, 323t–324t, 329 infections of, 329–330, 330f Pterygomaxillary buttress, 500–501, 500f Pulmonary disorders, 11, 11b–12b Pulp infection of, 298 necrosis of, tooth extraction for, 91 testing of, 475 treatment of, 488–489, 489f Pulpotomy, 479, 479f Pulse rate, measurement of, 6, 7f Puncture wound, surgery-related, 175, 176f Purchase point, in single-rooted tooth extraction, 131–132, 132f Pustule, 426b Q Questionnaire, health history, 3, 4f–5f R Radiofrequency analysis of implant stability, 251 Radiography cephalometric in dentofacial deformities, 523–524, 524f, 525t in preprosthetic surgery, 202, 203f in dentoalveolar injuries, 475–476, 476f–478f in differential diagnosis of oral lesions, 429, 430f in facial trauma, 493–496, 495f–497f of jaw cysts, 449, 449f–450f of maxillary sinus, 383–385 See also Maxillary sinus, radiographic examination of in odontogenic infections, 301 panoramic in implant therapy, 240, 240f–241f in temporomandibular disorders, 629, 630f in periapical surgery, 354 during pregnancy, lead apron shield for, 17f, 18 in preprosthetic surgery, 202, 203f in salivary gland disorders, 398–399, 399b, 399f–400f in temporomandibular disorders, 629–631 in tooth extraction, 93–96, 94f relationship to vital structures in, 94, 94f–95f root configuration in, 94–95, 95f–97f surrounding bone condition in, 96, 97f Radiotherapy, 363–375 bone effects of, 365, 366f–367f management of, 371–375, 372f–374f caries management after, 368 dental evaluation before, 365–366 dental implants after, 369, 370f–371f dental maintenance after, 367 dental preparation for, 367–368 denture wear in edentulous patients after, 369 mandibular mobility effects of, 364 oral flora effects of, 365 oral mucosa effects of, 364 for oral tumors, 463–464 salivary gland effects of, 364–365, 365f–366f tooth extraction and, 91–92 impacted third molar, 368 postirradiation, 368 pre-irradiation, 368 Ramsay Hunt syndrome, 622 Ramus, anterior border of, impacted tooth classification relationship to, 152–153, 152f–153f Ramus osteotomy, vertical, in mandibular excess correction, 531, 532f–534f Ranula, 409–410, 411f–413f Re-epithelialization, 44 Recall evaluations, after endodontic surgery, 358–359, 360f Referrals biopsy vs., 431 in differential diagnosis of oral lesions, 430–431 in endodontic surgery, 361 699 Index Referrals (Continued) failure to provide, 193–194 as medicolegal consideration, 192 in odontogenic infections, 303, 303b, 306 Regeneration bone guided, for implant placement, 268, 270f two-phase theory of, 605–606 in nerve healing, 52f, 53 tissue, guided, 50 in endodontic surgery, 361 Relaxation training, for temporomandibular disorders, 638 Releasing incisions in impacted tooth removal, 161, 161f vertical, 121, 121f–122f for implant site exposure, 246, 247f Remodeling stage of bone healing, 47, 49f of wound healing, 45–46, 46f Renal disorders, 11–12, 12b–13b Renal failure, 11–12, 12b Renal transplantation, 12, 12b Replantation of avulsed tooth, 483–484, 486–487 Resin composite, in periapical surgery, 353–354 Resorptive perforations, corrective surgery for, 355, 357f Respiratory problems in asthma, 26, 26b, 27f in chronic obstructive pulmonary disease, 27 emergency management of, 26–29 in foreign body aspiration, 27–28, 28b, 28f–29f in gastric contents aspiration, 28–29, 29b, 30f in hyperventilation syndrome, 26, 26b–27b Respiratory system hypersensitivity reaction effects on, 22–23, 23t review of, 6b Restorations in dentofacial deformity correction, 525, 557 in periapical surgery, 343, 344f Retention cysts, in maxillary sinus, 389 Retraction suture, 436, 437f–438f Retractors, 68–69, 68f–69f Retromolar gland, 395, 395t Retromolar pad, mandibular, reduction of, 215 Retropharyngeal space borders of, 323t infections of, 331, 331f, 333f–334f Review of systems, 6, 6b Rheumatoid arthritis, temporomandibular joint, 634–635, 635f Rhinoplasty, 575–576, 576f–577f Risedronate, 376t Risk reduction, 189–190 Rongeurs in alveoloplasty, 204, 205f for bone removal, 70, 71f Root ankylosis of, tooth extraction and, 92–93, 93f caries extending into, 95, 96f configuration of, in radiographic evaluation for tooth extraction, 94–95, 95f–97f curvature of, periapical surgery for, 343f dilacerated, 129, 130f displacement of, 176–177, 176b, 177f divergent, 129, 130f, 148f, 154 hypercementosis of, 129, 129f morphology of, impacted tooth removal and, 153–158, 154f–155f, 158f resorption of, 95, 96f prevention of, impacted tooth removal for, 146, 147f Root canal, irretrievable material in, 343, 345f Root canal treatment and apical surgery, simultaneous, periapical surgery as contraindication to, 344–346 failure of, determining causes of, 361 large, unresolved lesions after, 344, 348f Root end filling materials for, in periapical surgery, 353–354, 354f 700 Root end (Continued) preparation and restoration of, in periapical surgery, 352–353, 353f resection of, in periapical surgery, 351–352, 352f Root form implants, 253, 253f Root fracture, 176, 176b, 475, 476f horizontal, 343, 344f, 480, 482f vertical, endodontic surgery for, 358, 359f Root fragments justification for leaving in, 138–139 removal of, 137–138, 138f–140f Root-tip forceps, 80, 83f Root-tip pick, 78, 78f, 137–138, 138f S Saline therapy, postoperative, 673 Saliva examination of, 397t, 404 functions of, 397–398, 397b, 397t, 398f neurosecretory control of, 398, 398f–399f Salivary gland(s) anatomy and physiology of, 394–398, 395f–399f, 395t biopsy of, 405, 406f embryology of, 394–398, 395f infections of, 410–415, 413f mucoceles of, 408–409, 410f–411f radiation effects on, 364–365, 365f–366f ranula of, 409–410, 411f–413f stones in See Sialolithiasis tumors of, 415–419 benign, 416–417, 417f biopsy of, 404–405, 405f distribution of, 416t malignant, 418–419, 418f–419f Salivary gland disorders, 394–420 diagnosis of, 398–405 biopsy in, 405, 406f clinical examination in, 398 computed tomography in, 401–403, 404f endoscopy in, 403–404, 405f fine needle aspiration biopsy in, 404–405, 405f history in, 398 magnetic resonance imaging in, 403 plain-film radiographs in, 398–399, 399b, 399f–400f scintigraphy in, 403 sialochemistry in, 397t, 404 sialography in, 399–401 See also Sialography ultrasonography in, 403 infectious, 410–415, 413f mucus retention and extravasation phenomena as, 408–410 necrotizing sialometaplasia as, 412–414, 414f neoplastic, 415–419 obstructive, 405–408 See also Sialolithiasis in Sjögren’s syndrome, 414–415, 414f–415f traumatic, 415, 415f–416f Salt water rinse, postoperative, 171 Sanitization, definition of, 57 Scale, 426b Scalpel blade, 38, 38f, 66–67, 67f in flap development, 121, 122f Scalpel handle, 66, 67f Schirer test for dry eyes, 415, 415f Scintigraphy in salivary gland disorders, 403 in temporomandibular disorders, 631, 632f Scissors, in suturing, 74, 74f Screw healing, 254 prosthesis-retaining, 256 Second molar, mandibular, contact with, impacted tooth removal and, 156 Second premolar granuloma of, 184f maxillary, extraction of, 111, 112f Secondary intention bone healing by, 47 wound healing by, 47 Sectioning, in impacted tooth removal, 162–164, 163f–165f Security regulations, HIPPA, 195–196 Sedation for extraction of teeth, 90 for hyperventilation syndrome, 26 for impacted tooth removal, 165 in pregnant patients, 18 Segmental demyelination, in nerve healing, 51f, 52 Segmental osteotomy, in partially edentulous patients, 229–232, 231f Seizure emergency management of, 30–32, 32f in vasovagal syncope, 29 Seizure disorders, 16, 16b Seldin retractor, 68, 69f Self-gloving, sterile, 62f, 64 Semi-lunar incision, 121, 122f, 347, 350f Sensitivity, tooth, 480–481 Sepsis, definition of, 57 Septoplasty, 575–576, 577f Sharps management, 63f, 64 Shingles, postherpetic neuralgia after, 621–622 Shunts arteriovenous, antibiotic prophylaxis and, 316 ventriculoatrial, antibiotic prophylaxis and, 316 Sialadenitis, 401, 402f–403f, 410–415, 413f Sialochemistry, 397t, 404 Sialodochitis, 401, 402f Sialodochoplasty, 407–408, 409f Sialodochotomy, 408f Sialoendoscopy, 403–404, 405f Sialography, 399–401 digital subtraction, 400–401, 401f phases of, 400, 400f–401f in sialadenitis, 401, 402f–403f in sialodochitis, 401, 402f technique for, 400, 400f Sialolithectomy, 408f Sialolithiasis, 398–399, 399b, 399f–400f, 405–408 in children, 407 clinical manifestations of, 407, 407b, 407f incidence of, 406–407, 406b management of, 407–408, 407b, 407f–409f Sialometaplasia, necrotizing, 412–414, 414f Side-action mouth prop, 75, 75f Silicone oil, as dermal filler, 567 Silk suture, 74 Simple excision technique, in labial frenectomy, 219, 220f Single photon emission computed tomography, in temporomandibular disorders, 631, 632f Sinus maxillary, 382–393 See also Maxillary sinus paranasal, flora of, 55, 55t Sinus lift for maxillary augmentation, 268–270, 272f–273f in maxillary sinusitis, 388 Sinus tract, chronic, 299, 300f Sinusitis definition of, 386 maxillary See Maxillary sinusitis Sjögren’s syndrome, 414–415, 414f–415f salivary gland biopsy in, 405, 406f Skin care of, in facial cosmetic practice, 566–567 facial, analysis of, 566, 568f hypersensitivity reaction effects on, 22, 23t maxillofacial, flora of, 55, 55t protective barriers of, 55 Skin hook, 39–40, 40f Sleep apnea, obstructive, orthognathic surgery for, 538, 555f–556f Smoking, wound healing and, 168–169 Index Socket dry, 186–187, 307 extraction care of, 116–118, 117f–118f healing of, 47 Soft palate, closure of, 596, 599f–600f Soft tissue abnormalities of, 210–223 inflammatory fibrous hyperplasia as, 217, 219f labial frenectomy for, 217–222, 220f–223f lateral palatal soft tissue excess removal for, 215, 218f mandibular retromolar pad reduction for, 215 maxillary tuberosity reduction for, 215, 216f–217f unsupported hypermobile tissue removal for, 215–217, 218f in bony cavities, removal of, 69f, 72 grasping of, instrumentation for, 69–70, 70f infection of, 298, 298f injury to, 470–473 abrasion as, 470–471, 471f contusion as, 471, 471f with dentoalveolar injuries, 474 laceration as, 471–473, 472f–473f surgery-related, 175–176, 175b, 175f–176f loosening of, in closed tooth extraction, 105–106, 105f periodontal vs peri-implant, 236, 237f retraction of, instrumentation for, 68–69, 68f–69f surgical handling of, 39–40, 40f suturing of, instrumentation for, 72–74 Soft tissue biopsy, 434 anesthesia in, 434–436 examples of, 440f–441f hemostasis in, 436 incisions in, 436, 439f instruments for, 432b specimen care in, 438–439, 442f–444f specimen submission in, 439–440, 444f tissue stabilization in, 436, 437f–438f wound closure in, 436–438, 439f Soft tissue flaps See Flap(s) Soft tissue hook, 39–40, 40f Soft tissue scissors, 74, 74f Somatic pain, 619 Specimen management in intraosseous biopsy, 442–444 in soft tissue biopsy, 438–439, 442f–444f Specimen submission, 439–440, 444f Speech aid appliance, prosthetic, in cleft lip and palate, 600–604, 604f Speech problems, in cleft lip and palate, 592–593, 592f Spinal pain, pathways of, 619f Splint(s) acrylic for alveolar fracture, 487–488 in dentofacial deformity correction, 557, 562f for mandibular fracture, 502, 504f occlusal, for temporomandibular disorders, 639–640, 639f–640f Sponge, for hemostasis, 40–41, 41f Spray and stretch, for temporomandibular disorders, 639 Squamous cell carcinoma, of oral cavity, 366 Stabilization of alveolar fractures, 487–488 of avulsed tooth, 484, 487f of dentoalveolar injuries, duration of, 484, 486t of mandible, in facial trauma, 491, 492f plate in dentofacial deformity correction, 557, 562f in maxillofacial bone grafting, 612, 614f–615f of midface fractures, 508–510, 508f–514f tissue, in soft tissue biopsy, 436, 437f–438f Standards of care, 189 Status epilepticus, 31–32 Statute of limitations, 189 Steam sterilization, 57–59, 58t–60t Stensen duct, 395, 396f repair of, 415, 415f–416f Sterile technique, for office-based surgery, 64 Sterility definition of, 57 maintenance of, 59–61, 61f Sterilization with gas, 59 with heat, 57–59, 58f, 58t–59t instrument, techniques of, 57, 58f, 58t–60t Steroids See Corticosteroids Stillies forceps, 69, 70f Stomatitis, 426b Straight elevator, 77, 77f delivery of sectioned tooth with, 164, 166f in root fragment removal, 138, 138f in single-rooted tooth extraction, 131, 131f–132f Streptococcus milleri, in odontogenic infections, 297, 297t Stridor, during allergic reactions, 24 Stroke, 8–10 Subapical osteotomy in mandibular deficiency correction, 535, 538f in mandibular excess correction, 530–531, 531f Subciliary blepharoplasty, 574, 574f Subconjunctival hemorrhage, 492, 492f Sublingual gland anatomy and physiology of, 397, 397b, 397f innervation of, 398, 399f ranula of, 409–410, 411f–413f Sublingual space borders and relations of, 323t–324t infections of, 325, 328f Submandibular gland anatomy and physiology of, 395, 396f, 397b, 397t, 398f innervation of, 398, 399f Submandibular space borders and relations of, 323t–324t infections of, 325–326, 328f root fragment displaced into, 177 Submarginal incisions, in periapical surgery, 347–348, 350f Submasseteric space borders and relations of, 323t–324t, 329 infections of, 329, 330f Submaxillary space, infections of, 325, 328f Submental space borders and relations of, 323t–324t infections of, 326, 328f Submucosal vestibuloplasty, 228–229, 230f–231f Substance abuse, Drug Enforcement Administration Schedule of Drugs related to, Suctioning instrumentation for, 75–76, 76f irrigation, for removal of root fragments and tips, 137 Sulcular incision, 120f, 121 Sun exposure, facial aging and, 565–566 Superficial temporal space infections of, 330 relations of, 324t, 329 Supernumerary teeth in cleft lip and palate, 590, 590f extraction of, 91 impacted, 159 Surgery aseptic techniques for, 38, 54–64 See also Infection control basic necessities for, 37–38 complications of See Surgical complications edema control after, 41–42 flap design in, 38–39, 39f–40f See also Flap(s) hemostasis during, 40–41, 41f incisions for, 38, 38f See also Incision(s) patient general health before, 42 principles of, 37–42 tissue handling during, 39–40, 40f Surgical asepsis, 57 Surgical complications, 174–187 adjacent tooth–related, 178–179, 178b fracture or displacement, 178, 178f luxation, 178–179, 179f wrong tooth extraction, 179, 179b Surgical complications (Continued) bone injuries, 179–181 alveolar process fracture, 179–181, 180b, 180f–181f maxillary tuberosity fracture, 181, 181f delayed wound healing, 185–187 dry socket, 186–187 extracted tooth–related, 176–178 root displacement, 176–177, 176b, 177f root fracture, 176, 176b tooth lost into pharynx, 177–178 infections, 185 mandibular fracture, 187 nerve injuries, 181–182, 182b oroantral communications, 182–183, 182b, 183f postoperative bleeding, 183–185, 183b, 184f–186f prevention of, 174–175 soft tissue injuries, 175–176, 175b, 175f–176f temporomandibular joint injuries, 182, 182b wound dehiscence, 185–186, 186b Surgical diagnosis, development of, 37 Surgical field, sterility maintenance for, 61 Surgical microscope, in endodontic surgery, 360–361, 360f Surgical scrub protocol, 64 Surgical staff, aseptic preparation of, 61–64, 61f–63f Surgical suction, 75, 76f Suspension wiring, in midface fracture treatment, 510, 510f Suture(s), 72–74 continuous, 127–128, 129f figure-of-eight, 124, 124f in oroantral communication, 183, 183f horizontal mattress, 127, 128f materials for, 73–74 needle holder for, 72, 72f–73f, 124, 124f needles for, 72–73, 73f, 124, 124f principles of, 123–128 removal and evaluation of, in periapical surgery, 354 resorbability of, 73–74 retraction, 436, 437f–438f scissors for, 74, 74f simple interrupted, 127 size of, 73 sling, in periapical surgery, 354, 355f technique for, 124, 125f–126f tying of, 124, 126f–127f Suture ligation, for hemostasis, 41 Suture scissors, 74, 74f, 125 Suture tagging of specimens, 439, 443f–444f Syringe, for irrigation, 76, 76f T Taste buds, 395, 395t radiation effects on, 364 Teeth See Tooth (teeth) Telemedicine, medicolegal considerations related to, 195 Telithromycin, cost of, 310t Temporal arteritis, 624, 625t Temporal space infections of, 330 relations of, 324t, 329 Temporalis fascia, 329 Temporalis muscle flap, in temporomandibular joint surgery, 644, 644f Temporomandibular disorders, 627–649 ankylosis in, 635–636, 636f classification of, 632–636 degenerative joint disease in, 633–634, 634f dislocation in, 635, 635f infections in, 636 internal derangements in, 632–633, 632f–634f, 633b litigation related to, 194 myofascial pain in, 632, 637 neoplasia in, 636 patient history in, 627–628 701 Index Temporomandibular disorders (Continued) physical examination in, 628–629, 628f–629f psychological evaluation of, 631 radiographic evaluation of, 629–631 arthrographic, 630, 630f CBCT, 630–631, 631f CT, 630, 630f MRI, 631, 631f nuclear, 631, 632f panoramic, 629, 630f tomographic, 629 systemic arthritic conditions in, 634–635, 635f treatment of distraction osteogenesis in, 645–647, 647f patient education in, 636–637 permanent occlusion modification in, 640 pharmacotherapy in, 637–638, 638f physical therapy in, 638–639, 638f reversible, 636–640 splint therapy in, 639–640, 639f–640f surgical, 640–645 See also Temporomandibular joint surgery Temporomandibular joint ankylosis of, 635–636 extracapsular, 636, 636f intracapsular, 635–636, 636f anterior displacement of with reduction, 632–633, 633f without reduction, 633, 634f, 636, 637f chronic recurrent dislocation of, 635, 635f degenerative disease of, 633–634, 634f infections in, 636 injury to growth abnormalities after, 521–522, 523f surgery-related, 182, 182b internal derangement of, 632–633, 632f–634f, 633b neoplasms in, 636 normal disk and condyle relationship in, 632, 632f systemic arthritic conditions of, 634–635, 635f Temporomandibular joint surgery, 640–645 arthrocentesis, 641, 641f arthroscopy, 641, 642f condylotomy, 644, 644f disk repair or removal, 642–644, 643f–644f disk-repositioning surgery, 641–642, 643f total joint replacement, 644–645, 645f–646f Temporomandibular pain, evaluation of, 627–631, 629f Tension, impaired wound healing and, 47 Tension-type headache, 623, 623b, 625t Tetracyclines overview of, 11–12 toxicity and side effects of, 309 Therapeutic privilege, 191 Thermal coagulation, for hemostasis, 41 Third molars, impacted See Impacted tooth removal Thrill, 427 Thrombi, cerebrovascular, 36 Thrombin, topical, for postoperative bleeding, 184 Thyroid dysfunction, emergency management of, 34–35, 35b Thyroid hormone, abnormalities of, 14–15, 15b Thyroid storm, 34–35, 35b Thyrotoxicosis, 14 Tic douloureux, 620, 620b, 621t Tiludronate, 376t Tinel sign, in neuroma, 622 Tissue guided regeneration of, 50 in endodontic surgery, 361 incision of, instrumentation for, 66–67, 67f soft See Soft tissue stabilization of, in soft tissue biopsy, 436, 437f–438f surgical handling of, 39–40, 40f Tissue forceps, 39–40, 40f, 69–70, 70f Tissue grafting, maxillary vestibuloplasty with, 229, 231f Tissue punch method of implant uncovering, 251, 252f Titanium, for implants, 235 Title VI of Civil Rights Act of 1964, 196 Tomograms, in temporomandibular disorders, 629 702 Tongue asymmetry of, 521–522, 522f biopsy of, 441f candidiasis of, 337f Tongue retractor, 68, 69f Tonsillar glands, 395, 395t Tooth (teeth) See also specific teeth, e.g., Molars access to, tooth extraction and, 92 adjacent, injuries to, 178–179, 178b fracture or displacement, 178, 178f luxation, 178–179, 179f wrong tooth extraction, 179, 179b avulsion of, 483–487, 486t, 487f cracked, extraction of, 91 crown of See Crown displacement of, 474 lateral, 483, 485f–486f examination of, in temporomandibular disorders, 629 extrusion of, 483, 484f fractured, endodontic surgery for, 358, 359f impacted See Impacted tooth removal intrusion of, 481–482, 482f–483f jaw fracture–associated, extraction of, 91 malposed, extraction of, 91 missing in cleft lip and palate, 590, 590f in dentoalveolar injuries, 474, 475f mobility of, 474, 481 tooth extraction and, 92–93, 98f pathologic lesion–associated, extraction of, 91 percussion of, 474 pulp testing of, 475 sensitivity of, 480–481 sensory innervation of, 89, 89t socket of See Socket supernumerary in cleft lip and palate, 590, 590f extraction of, 91 impacted, 159 traumatic injuries to, 476–477, 477b See also Dentoalveolar injuries wrong, extraction of, 179, 179b, 193 Tooth-preserving system, 483–484 Topiramate, for trigeminal neuralgia, 621t Tori removal, 209–210 mandibular, 210, 213f–215f maxillary, 209–210, 212f–213f Total joint replacement infection after, antibiotic prophylaxis against, 316–317 for temporomandibular disorders, 644–645, 645f–646f Towel clip, 76, 76f for tongue retraction, 68–69 Towels, instrumentation for holding, 76, 76f Toxic appearance, 300f, 301 Tracheostomy, 492, 492f Training, office staff, in medical emergency management, 20 Transconjunctival blepharoplasty, 574, 574f Transcutaneous electrical nerve stimulation (TENS), for temporomandibular disorders, 639 Transfusion, blood, for postoperative patients, 673 Transient ischemic attack, 36 Transillumination of maxillary sinus, 383, 383f Transplantation, organ, 12, 12b Transpositional flap vestibuloplasty, 226, 227f Transverse impaction, 152 Trauma dentoalveolar See Dentoalveolar injuries facial See Facial trauma soft tissue See Soft tissue, injury to Trauma team, 492 Tray systems, instrument, 1t, 83–87, 86f–87f Treatment, discontinuation of, 192 Tretinoin, in facial cosmetic practice, 566–567 Triangular elevator, 77–78, 77f, 101, 103f Tricyclic antidepressants for temporomandibular disorders, 637 for trigeminal neuralgia, 621t Trigeminal neuralgia, 620, 620b, 621t Trigeminal pain, pathways of, 619f Trimethoprim-sulfamethoxazole, cost of, 310t Trismus after impacted tooth removal, 166 in odontogenic infections, 303 postirradiation, 364, 368 postoperative, 172 Tuberculosis, 56 Tuberosity, maxillary fracture of, 181, 181f reduction of hard tissue, 205–206, 209f soft tissue, 215, 216f–217f Tumors of jaw See Jaw, tumors of odontogenic, prevention of, impacted tooth removal for, 146–147, 148f–149f of oral cavity, malignant, 463–464 of salivary glands, 415–419 benign, 416–417, 417f biopsy of, 404–405, 405f distribution of, 416t malignant, 418–419, 418f–419f in temporomandibular joint, 636 tooth extraction in area of, 92 U Ulcer, definition of, 426b Ultrasonic tissue heating, for temporomandibular disorders, 638–639 Ultrasonography, in salivary gland disorders, 403 Ultraviolet protection, in facial cosmetic practice, 566–567 Undercuts excessive, alveolar ridge recontouring for, 206, 210f–211f lingual, 244, 244f Unerupted teeth, 143 See also Impacted tooth removal Universal precautions, 56 Upper respiratory tract, bacteria in, 54–55, 55t Uvula, bifid, 586, 587f V Vagal neuralgia, 622 Vancomycin, cost of, 310t Vasoconstriction, in wound healing, 44, 44f Vasoconstrictors, for hemostasis, 41 Vasodilation, in wound healing, 44, 44f Vasovagal syncope, emergency management of, 29–30, 31f Velopharyngeal mechanism, in cleft lip and palate, 592 VELscope, 429 Vertical-hinge forceps, 81, 84f Vertical impaction, 150, 151f, 158, 158f, 163, 164f Vertical ramus osteotomy, in mandibular excess correction, 531, 532f–534f Vertical-releasing incisions, 121, 121f–122f for implant site exposure, 246, 247f Vertical root fracture, endodontic surgery for, 358, 359f Vesicle, 426b Vestibular abscess, 298–299, 299f incision and drainage for, 304, 304f Vestibuloplasty labial, and floor-of-mouth lowering procedure, 226–228, 228f–229f maxillary, with tissue grafting, 229, 231f with secondary epithelialization, in labial frenectomy, 221, 222f submucosal, 228–229, 230f–231f transpositional flap, 226, 227f Viral parotitis, 412 Virus(es), 55–56, 56b Visibility, for surgery, 37 Index Vital signs in odontogenic infections, 300–301 in physical examination, 6, 7f Vitamin C, in facial cosmetic practice, 566–567 ViziLite system, 429 Volume loss, facial aging and, 565–566, 565f Vomer flap technique, 596, 598f Vomiting in gastric contents aspiration, 28–29, 29b, 30f in postoperative patients, 665–669 Von Langenbeck operation for closure of hard palate, 595f Von Willebrand’s disease, 15 Voriconazole, 12 W Wallerian degeneration, in nerve healing, 51f, 52–53 Wardill procedure for closure of soft palate, 596, 600f Warfarin, 16, 16b Warthin tumor, 417, 417f Waters’ view, of maxillary sinus, 384, 385f Weber glands, 395, 395t Weider tongue retractor, 68, 69f Wharton duct, 396–397, 397f Wheezing, during allergic reactions, 24 Wilkes staging classification for internal derangement of temporomandibular joint, 633b Wiring in mandibular fracture management, 504, 505f suspension, in midface fracture treatment, 510, 510f Wound closure in impacted tooth removal, 165 in lacerations, 472–473, 473f in soft tissue biopsy, 436–438, 439f Wound contraction, 46 Wound débridement, 41, 472 Wound dehiscence, 185–186, 186b Wound edge ischemia, 38, 38f Wound healing, 43–53 around implants, 48–50, 50f See also Implant(s), osseointegration of of bone, 47–48, 48f–49f delayed/impaired foreign material and, 46 ischemia and, 46–47 necrotic tissue and, 46 postoperative, 185–187 tension and, 47 epithelialization in, 43–44 of extraction sockets, 47 factors influencing, 42, 46–47 of nerve, 50–53 See also Nerve injury by primary intention, 47 by secondary intention, 47 smoking and, 168–169 stage(s) of, 44–46 fibroplastic, 45, 45f–46f inflammatory, 44–45, 44f–45f remodeling, 45–46, 46f by tertiary intention, 47 Wound hemostasis, promotion of, 40–41, 41f Wound infections postsurgical asepsis and, 64 prevention of, antibiotics in, 312–314, 312b, 313t Wound repair See Wound healing X Xenografts, 609 for implant placement, 267 Xerostomia radiation-induced, 364–365, 365f–366f in Sjögren’s syndrome, 414, 414f treatment, 364–365 Y “Y” incision, 121, 122f Z Z-plasty technique, in labial frenectomy, 219–221, 221f Zoledronate, 376t Zygomatic arch fracture, 509 Zygomatic buttress, 500–501, 500f Zygomatic complex fracture, 492, 492f, 499, 499f, 508, 508f Zygomatic implants, 275, 277f 703 This page intentionally left blank ~StormRG~ ... editors: Oral and maxillofacial infections, ed 4, Philadelphia, PA, 20 02, Saunders B, From Topazian RG, Goldberg MH, Hupp JR, editors: Oral and maxillofacial infections, ed 4, Philadelphia, PA, 20 02, ... 6 hr $74.59 6. 12 Metronidazole 500 mg 6 hr $29 .99 2. 46 Trimethoprim/Sulfamethoprim 160/800 12 hr $11.99 0.98 Vancomycin 125  mg 6 hr $878.99 72. 11 Ciprofloxacin 500 mg 12 hr $24 .99 2. 05 Moxifloxacin... temporal Parotid Peritonsillar Intraoral-extraoral Masseteric artery and vein Buccal Intraoral Pterygomandibular Superficial temporal Parotid Intraoral-extraoral Pterygomandibular Submasseteric Lower