Oral Surgery 1

Oral Surgery
Many case-based question on the INDBE will be surgical cases that require the integration of pathology,
anatomy, and medicine. These notes cover the high yield material to succeed on any question relating to
oral surgery diagnosis, treatment, techniques, and best practices.

1 Armamentarium for Oral Surgery Yankauer Suction

• Only used for soft tissue (no hard tissue
The following is a list of the most common options)
instruments used in Oral Surgery. For the
INDBE, you will need to be able to recognize
these instruments and understand how, when,
and why to use them.

Bite Block
Bite blocks are soft, rubber devices that allow
the patient to rest their jaw while keeping their
mouth open. These blocks help maintain a
good eld of vision for the operator while Frazier Suction
maintaining patient comfort. In addition, the
bite block helps to stabilize the mandible,
which can facilitate an easier surgery.
Figure 1.02 Yankauer suction
• Can be used for soft and hard tissue
• If using on hard tissue, cover the hole on
top to increase suctioning power
• If using on soft tissue, keep hole on top
open
• Can be used to pick up tooth fragments
when the hole is covered

Figure 1.01 Bite block

Suction Tips
There are two different suctions used for oral Figure 1.03 Frazier Suction
surgeries: the Yankauer and Frazier suction.
Be familiar with both types and their utility
during surgery.

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Towel Clip
The main purpose of towel clips is to stabilize
drapes around the patient during surgery.
These clips function like hemostats. To use, clip
the drapes placed on the patient while taking
Figure 1.06 Mayo scissors
care not to pinch the patient. In addition, you
can stabilize any suction tube with these clips
to prevent them from falling on the ground. Blades
Blades are the primary instrument used to cut
into soft tissue for oral surgery. After assembly
with the blade handle, the instrument should
be held with a pen grasp to allow for maximal
control. For the INDBE, there are four different

Figure 1.04 Towel clip Blade Use Image

Used for
Scissors 10 large incision
For oral surgery, there are two types of scissors into skin
that are commonly used: Dean and Mayo
scissors. For stab
incisions,
which are
Dean Scissors 11
used for
• Main function of these scissors is to cut
drainage
sutures
• The blades are angled upward to help in
cutting sutures Primarily for
mucogingiva
l surgery.
Access to
12 sulcus is
made easy
with curved
blade
Figure 1.05 Dean scissors

Most
Mayo Scissors common
These scissors are speci cally for cutting fascia blade for
15
and soft tissue intraoral
surgery

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 Oral Surgery 3

Blade Handle Weider

The blade/knife/scalpel handle is assembled • Used to protect and retract the tongue
with the surgical blade to puncture and • Broad heart shape allows for tongue
separate soft tissue. The blade handle holds protection
the blade. • Used in mandibular lingual surgery

Figure 1.09 Weider tissue retractor

Figure 1.07 Blade handle

Seldin
• Used for elevating tissue in the oor and
the mouth
Tissue Retractors • Long and at shape
Tissue retractors are used to move and control • Used in mandibular tori removal
soft tissue to allow for better access and
visibility to the surgical site. Finger retraction is
unreliable and should never be used as it only
allows for retraction of the cheek, tongue, or
ap. Tissue retractors can retract the cheek,
tongue, and ap at the same time. Below are
Figure 1.10 Seldin tissue retractor
the four most common tissue retractors.

Austin Dental Elevators

• Speci cally for small aps Elevators are a key instrument for oral surgery
• Bend is a right angle procedures. They provide various functions like
Minnesota disrupting PDL bers, luxating teeth, and
• Most used tissue retractor expanding alveolar bone.
• Used for cheek & ap retraction All elevators have three components:
• Curve is offset and broad 1. Blade
2. Shank
3. Handle

Elevators should be gripped with a palm grip

with the pointer nger resting near the
blade. This technique allows for the operator
Figure 1.08 Minnesota tissue retractor to obtain adequate leverage and control for
ideal use.

Before understanding each type of dental

elevator, let’s look at the three functionalities
of elevators.
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 Oral Surgery 4

Wheel & Axle

This type of elevator applies force in a
rotational manner to elevate the tooth.
Elevators that apply this kind of force aim to
remove hard to access root tips from the bone.
Utilizing wheel & axle force application is more
aggressive than the other two. Improper
application of a wheel & axle elevator can lead
to mandible fracture.

Figure 1.11 Dental elevator

Levers
Elevators that work as a lever have three
components: Fulcrum, Effort, and Load.
These three components act as a class I lever
Figure 1.13 Wheel & axle
where the fulcrum is between the load and
effort. The elevator is the effort that allows the
blade (working end) to apply load onto the Straight Elevator (#301)
tooth with the fulcrum being the crest of the • Most used elevator
alveolar bone. • Acts as a lever; can be used as a wedge
but is mostly used as a lever
• Technique: Place the concave part of the
blade towards the tooth that is being
elevated

Figure 1.12 Lever

Figure 1.14 Straight elevator

Wedges
Wedges are placed between two objects with
the goal of expansion, splitting, or Triangular Elevator (Cryer)
displacement. Elevators that are wedges are • Second most used elevator
typically placed between the root and bone • Function is to extract roots left inside a
parallel to the long axis of the tooth. Force is socket
applied the elevator to split, expand, or • Acts as a wheel & axle
displace the tooth from the socket to allow for • Left & right variants
a lever to remove the tooth from the socket.

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 Oral Surgery 5

Woodson Periosteal
• Smaller of the two periosteal elevators
• Sharp end is used to lift a ap
• Broad, round end is used to elevate and
re ect a ap

Figure 1.15 Triangular elevator

Pick Elevator
• Two Versions:
‣ Crane Pick = heavy version
‣ Root Tip = delicate version
• Function is to remove retained/broken/
isolated root tips → this is accomplished Figure 1.17 Woodson periosteal
by placing elevator between a retained
root tip and the buccal plate in the PDL
#9 Molt Periosteal
space. • Larger periosteal elevator
• Wedge
• Sharp end used to re ect the papilla and
lift a ap
• Broad end used for general re ection of
mucoperiosteum from the bone

Figure 1.16 Pick elevator

INBDE Pro Tip:

Straight Elevator = Lever (+/- Wedge)
Triangular Elevator = Wheel & Axle
Pick Elevator = Wedge
Figure 1.18 Molt periosteal

Periosteal Elevators Extraction Forceps

Periosteal elevators are separate from dental
elevators. They have a much thinner body and
are typically used at the beginning of an
extraction. Their function is to re ect the
mucoperiosteum from underlying bone to
clear the gingiva from the working area. There
are two periosteal elevators to be familiar with
for the INDBE.
Extraction forceps are used to obtain a strong
grip on the tooth for nal removal. These
forceps are comprised of a beak, hinge, and
handle There are six extraction forceps to be
familiar with for the INDBE.

Figure 1.19 #150 forceps

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 Oral Surgery 6

#150 #74 Ash Forceps

• Universal forceps designed for upper teeth • Used speci cally for mandibular premolars
• Mainly for molars, but 2 variants for other
teeth
‣ A = Mainly premolars, also used for
canines, incisors
‣ S = Primary Teeth
#151
Figure 1.22 Ash forceps
• Universal forceps designed for lower teeth
• Beaks pointed more down to improve
access #65 Upper Root Forceps
• Mainly for molars, but 2 variants for other • These forceps help facilitate access of
teeth maxillary roots
‣ A = Premolars, canines, incisors
‣ S = Primary Teeth

#23 Lower Cowhorn Forceps

• These extraction forceps are for lower
molars

Figure 1.23 Upper root forceps

Non-Extraction Forceps
Non-extraction forceps are not equipped to
help with extractions directly, but rather to
manipulate other objects/tissues. There are
Figure 1.20 Lower cowhorn forceps
two important non-extraction forceps to be
familiar with.
• They possess two sharp beaks to engage in
bifurcations of mandibular molars Adson Tissue Forceps
#88R/L Upper Cowhorn Forceps • Used for handling soft tissue
• These cowhorn forceps are used for upper • Two types
molars ‣ Toothed:
• There are right & left variants - Speci cally for periosteum, muscle,
aponeurosis
‣ Non-tooth:
- Speci cally for fascia, mucosa,
pathological tissue for biopsy

Figure 1.21 Upper cowhorn forceps

Figure 1.24 Adson tissue forceps

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 Oral Surgery
Utility Forceps
• Used for handling items on the surgical tray
• Used to prepare packing materials
• Do NOT use for hard or soft tissue
manipulation
Figure 1.25 Utility forceps
Irrigation
Irrigation is the process of applying a stream of
sterile saline or water with a Monoject syringe.
Irrigation is done when using a surgical bur or
when cleaning a surgical site. It is crucial to
irrigate while using a surgical bur to increase
ef ciency of drilling and to prevent heat
damage to the bone. A syringe can also be
given to the patient to rinse the extraction site
with warm salt water at home.
Figure 1.26 Irrigation
Curettes
Curettes are used to mechanically clean
surgical sites of all remaining soft tissue. The
ends are spoon-shaped to better scrape away
soft tissue at the base of sockets. It is crucial to
always curette a socket once a tooth is
removed; this step can never be skipped as it
allows for better clotting and wound healing.
Figure 1.27 Curettes
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Rongeurs
Rongeurs are double spring pliers that are
used to trim small amounts of bone. It is
particularly good for removing interradicular
bone left after a tooth has been extracted.
Clinicians will sometimes use these as
extraction forceps; however, this is not the
intended purpose of this instrument.
Figure 1.28 Rongeurs
Osteotome
The osteotome, aka bone chisel, is used in
conjunction with a mallet to remove bone. The
wedge-like end is placed on bone and the
surgical mallet is used to tap on the at end.
At the end of the instrument there is an angled
sloped called a bevel. Osteotomes can be
mono-beveled or bi-beveled. Mono-bevels
are used to remove tori while bi-bevels are
used to section teeth.
Figure 1.29 Osteotome
Bone File
Bone les are used with a pull stroke to
smooth out bone before suturing. If any sharp
edges of bone remain around the extraction
site, a bone le is used to smoothen the area.
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 Oral Surgery 8

Nonabsorbable:
• Silk: caution is needed with silk sutures as
they possess a wicking property that
allows for saliva and bacteria to travel
through the thread into the surgical site by
Figure 1.30 Bone le capillary action and cause infection
• Nylon
Surgical Handpiece • Polypropylene (Prolene)
Surgical handpieces are used to remove larger • Mersilene (Dacron)
amounts of bone or section teeth during a
surgical extraction. It is important to never use Types of Suture Techniques
an air-driven handpiece (restorative • Simple interrupted
handpiece). Air-driven handpieces can push air • Simple continuous
into the socket and cause subcutaneous • Mattress (horizontal or vertical)
emphysema (air emphysema). There are two • Figure “8”
types of burs used with surgical handpieces in • Continuous locking
oral surgery: • Subcuticular
• Straight Fissure Bur: used to section teeth
INBDE Pro Tip:
• Round Bur: used to remove bone
Simple Interrupted is the most common suture
technique.
INBDE Pro Tip:
A potential complication of using an air-driven
handpiece is subcutaneous emphysema Needle Holder
The needle holder is like the hemostat except
it is only for holding the needle end of a
Sutures
suture. To aid in stability, the face of the beak
Sutures are the needle & thread used to
is crosshatched to allow for positive grasp of
immobilize aps and facilitate healing. The
the needle.
diameter of sutures is denoted in # of 0’s (10-0,
9-0, etc.), and the greater the number of 0’s,
Hemostat
the smaller the diameter. For the INDBE, be
Hemostats are instruments that can be locked
able to recognize different suture materials,
in place to hold or clamp different objects.
know the different suture techniques, and be
There are curved or straight beak hemostats
able to compare the diameters of different
both with serrated ends to aid in grip strength.
suture.
Below are two common uses of the hemostat:
Suture Materials
Absorbable: 1. Clamping blood vessels closed before
• Gut: plain or chromic suturing or cauterizing
• Vicryl 2. Dissection of soft tissue in incision &
• Polydioxanone (PDS) drainage (I&D) procedures
‣ Using a hemostat in I&D procedures
involves entering an incision while closed
and then opening it to separate the soft
tissue inside.
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 Oral Surgery 9

2 Extractions Medical Indications: Head & Neck Radiation:

- Pre-radiation Hyperbaric oxygen pre &
therapy post-op can help mitigate
Indications & Contraindications
- Pre-cardiac surgery against osteonecrosis of
Below is a table of common indications and
- Pre-transplant the jaw for these patients
contraindications for tooth extraction. Keep in surgery
mind, these contraindications are relative and - Pre-bisphosphonate
should be used as markers to refer to an Oral therapy
Surgeon. Be sure to recognize each of these
clinical conditions as they will likely show up on Non-restorable Leukemia & Lymphoma:
case-based scenarios. In addition, any bulleted tooth / non- - High risk of infection (low
points are high yield material. restorable fracture WBC)
- Contraindications
Indications Contraindications includes Hodgkinson’s &
Non-Hodgkinson’s
Non-restorable teeth Uncontrolled diabetes:
Lymphoma
High risk of infection

Pulpal necrosis; RCT End-stage renal disease INBDE Pro Tip:

failure Acute infection is NOT a contraindication for
extractions. However, an infection can interfere
Compromised Uncontrolled cardiac
with local anesthesia ef ciency. The low pH
periodontium disease (HTN; Unstable
environment can inactivate the speci c
angina; MI)
molecules that facilitate anesthesia.
Orthodontics Increased bleeding risk
- Hemophilia; Complications of Extractions
thrombocytopenia Below are the most common and highly tested
- Anticoagulant drugs complications that could arise during an
extraction procedure. Be sure to understand
Cracked Tooth IV Bisphosphonates:
how each of the complications may occur, how
increases the risk of
to prevent them pre-operatively, and how to
osteonecrosis of the jaw
treat them if they occur.
Pathology (cancer, Chemotherapeutic agents
cysts, etc..) Subperiosteal Abscess
A subperiosteal abscess occurs when pus
Tooth malposition/ Pregnancy:
eruption disturbances - Although dental work can
collects under the periosteum after surgery.
be done at any time during Necrotic tissue or other debris left under a ap
pregnancy, best time to following extraction could cause an infection
perform elective dental that leaks pus subperiosteally. The risk for
procedures is during the development of a subperiosteal abscess is
second trimester highest when elevating a mucoperiosteal
ap.
Supernumerary Pericoronitis:
Teeth: - If severe, treat with
Prevention: ensure the extraction socket is
Most common = antibiotics
mesiodens (extra - If not severe, treat local,
clean through curettage and irrigation
tooth) causative factors Treatment: Surgical drainage +/- Antibiotics

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 Oral Surgery 10

Oro-Antral Communication (OAC) Alveolar Osteitis (Dry Socket)

This complication occurs when an exposure is This complication occurs 3-5 days post-
created between the sinus and oral cavity operatively when a blood clot dislodges or
during surgery, aka sinus exposure. This dissolves before the wound heals. Without
complication clinically presents as a black hole the clot in the socket, the bone and nerves are
connecting the oral cavity to the sinus. If exposed, which causes intense throbbing pain
observed, caution is needed with irrigation as (possibly radiating) for the patient. This
liquid can enter the sinus and potentially into complication is most common after the
patient's nose. The teeth where OAC is most extraction of mandibular molars.
likely to occur are the maxillary 1st molars.
Prevention:
Prevention: A good pre-op radiograph should • Post-Op instructions & compliance
be used to assess the distance between the ‣ No negative pressure (straws)
root and sinus and excessive apical pressure ‣ No smoking
should be avoided during surgery. • Stimulate hemostasis after surgery via
curettage
Treatment: • Place collagen plug or gel foam into
Treatment for OACs is dependent on the extraction site
diameter of opening between the sinus and Treatment:
oral cavity. The following are the different • Thorough irrigation of extraction site with
standards of care for various diameters: sterile saline to ush out debris
• Medicative dressing composed of Eugenol
< 2mm diameter: ‣ Change every 48 hours till patient is
• No surgical treatment needed asymptomatic
• Optional suture for closure • Local pain control with:
• Monitor with post-op visits ‣ OTC pain medication (Acetaminophen/
• Pt instructions: Ibuprofen)
‣ Do not blow nose ‣ Prescription pain medications (opioids)
‣ Do not poke • Antibiotics are generally NOT indicated
‣ Mouth open when sneezing or coughing Instructions After Treating Dry Socket:
‣ No negative pressure (straws) • Cold pack compressed on surgical site
‣ No smoking • Warm salt-water rinse

2-6mm diameter: Nerve Injury

• Use gure 8 suture to promote hemostasis This complication occurs when a nerve is
• 4A's: damaged during surgery. The nerve most often
‣ Antibiotics damaged is the IAN during mandibular 3rd
‣ Antihistamines molar extraction. The lingual nerve can also
‣ Analgesic be damaged as it travels very close to the
‣ Afrin Nasal Spray bid: lingual cortex. Injury to a nerve can manifest as
- Vasoconstrictor paresthesia in areas associated with the
- Relieves sinus pressure damaged nerve. General Dentists should refer
- Px: 2x/day cases with high probability of nerve damage
> 6mm diameter: Flap Closure Surgery (tooth near a nerve) to an oral surgeon.

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Prevention: Treatment:
• Preliminary panoramic radiograph to • Suction/tease out root fragment if possible
assess proximity to IAN • If small (<3 mm), non-infected root
• Order CBCT to determine true relationship fragment displaced into high risk area
of tooth to IAN in 3D space when (close to sinus, IAN): do not remove
necessary fragment, inform patient, and monitor
Treatment: closely in the future
• Medrol Dosepak (methylprednisolone) - • If large root fragment is displaced into the
steroid) prescription to treat in ammation maxillary sinus: Caldwell-Luc approach to
• Monitor closely with periodic neurosensory remove the fragment
testing/mapping of affected area until
resolution Aspiration/Ingestion of Foreign Object
• Refer patients for micro-neurosurgery Aspiration of foreign objects or teeth into the
consultation if numbness lasts for more airway is a serious and dangerous complication
than 4 weeks. that must be acted on immediately. An awake
patient will violently cough and gag to remove
Tooth Displacement the foreign object. A sedated patient might
During surgery, it is possible for a tooth, tooth show less severe cough and gag re exes.
roots, or fractions of a tooth, to be displaced.
This is a rare but serious complication that Prevention:
must be considered when planning and • Place pharyngeal curtain in sedated patient
executing an extraction. Below are common • Full attention and eyes should always be on
locations of displacement for several teeth. the extraction site throughout the
This material is highly tested on the INDBE. procedure
Treatment for aspiration:
• Maxillary 1st/2nd Molar = Maxillary Sinus • If laryngeal obstruction and patient unable
‣ Palatal root of maxillary first molar is the to breath: perform Heimlich maneuver,
most likely to be displaced into maxillary Advanced Cardiovascular Life Support
sinus • If unsuccessful removal: emergency
• Maxillary 3rd Molar = Infratemporal fossa cricothyrotomy
• Mandibular 3rd Molars = Submandibular • Referral to ER for chest X-ray and possible
space bronchoscopy
Treatment for ingestion:
Prevention: • An awake patient will know if they ingested
• Good pre-op radiograph to identify risk the teeth vs. aspirated the teeth
level • Reassure patient that the tooth will
• Surgical extraction from onset eventually be excreted out of the body
• Avoid excessive apical vertical forces on • Refer patient to ER for chest X-ray to
teeth & fractured segments con rm ingestion

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Other Complications
The following are other important
complications of oral surgery.
• Root Fracture – most common
complication
• Bleeding
• Infection
• TMD
• Jaw fracture Figure 2.01 Horizontal partial
• Maxillary tuberosity fracture bony impaction
• Air emphysema
• Soft tissue injuries 1) Nature of overlying Tissue
• Damage to adjacent teeth This system uses the amount and nature of
tissue overlying the impacted tooth as the
Impacted Teeth criteria for classi cation. While any impacted
A tooth is considered impacted if it fails to tooth can be classi ed with this system, it is
erupt into the dental arch within the primarily for impacted 3rd molars. There are
expected time. The primary cause for an two classi cations:
impacted tooth is inadequate arch length. 1. Soft Tissue Impaction
‣ A tooth falls into this category if its
A common test question on the INDBE is to impaction is limited to soft tissue without
identify the tooth that is most likely to be bone involvement. In other words, the
impacted. The three most likely teeth to be gingiva is covering the tooth fully or
impacted are the mandibular 3rd molars, partially without bone atop the occlusal
maxillary 3rd molars, and maxillary canines. surface. This is the easiest type of
These teeth are ranked below from most to impacted tooth to extract.
least likely to be impacted. Be sure to 2. Hard Tissue Impaction
memorize this order as this is a highly tested ‣ This type of impacted tooth has bone
fact on the INDBE. overlying its crown and is more dif cult to
• Mandibular 3rd molars > Maxillary 3rd extract than soft tissue impactions.
molars > Maxillary Canines There are 2 subclassi cations within this
category:
Classi cations of Impacted Teeth 1. Partial Bony Impaction
While the concept of impacted teeth is simple, ‣ If the bone incompletely covers the tooth
there are several classi cation systems to crown, it is a partial bony impaction. The
categorize the diverse presentations of level of dif culty of extraction is in the
impacted teeth. These systems are important middle compared to full bony impaction
to understand as they dictate diagnosis and and soft tissue impaction.
treatment. The three classi cation systems 2. Full Bony Impaction
tested on the INDBE are: ‣ These impacted teeth are fully
1. Nature of Overlying Tissue surrounded by bone. Because these teeth
2. Winter’s Classi cation are under hard tissue, they are the
3. Pell & Gregory Classi cation hardest to extract.

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 Oral Surgery 13

Figure 2.02 Types of bony

impaction

Figure 2.03 Winter’s classi cation

INBDE Pro Tip:
Memorize the order of extraction dif culty for
the Nature of Underlying Tissue Classi cation. INBDE Pro Tip:
Fully Bony > Partial Bony > Soft Tissue A general rule to assess how dif cult a
mandibular 3rd molar extraction is:
The further away from the ramus, the easier
2) Winter’s Classi cation the extraction.
This classi cation system is only for impacted
3rd molars and is based on the relative
3) Pell & Gregory Classi cation
position of the long axis of the 3rd molar
This classi cation system is only for impacted
compared to the long axis of the 2nd molar.
lower 3rd molars. A complete Pell & Gregory
The following are the speci c classi cations:
Classi cation involves two different categories:
• Vertical = Crown of the impacted tooth is
Impaction Depth & Ramus Relationship.
parallel to the adjacent tooth.
Impaction depth classi es the relative height of
• Mesioangular = Crown of the impacted
the 3rd molar to the adjacent molar's height.
tooth is tilted towards the adjacent tooth.
The Ramus Relationship measures the depth of
‣ Least dif cult to remove for impacted
the 3rd molar inside the ramus.
mandibular molars
Impaction Depth
‣ Most dif cult to remove for impacted • Class A = The impacted tooth’s crown is on
maxillary molars
the same plane as the adjacent molar
• Horizontal = Crown of the impacted tooth
• Class B = The impacted tooth’s crown is in
and occlusal surface is perpendicular to the
between the occlusal plane and the cervical
adjacent tooth.
line of the adjacent molar
• Distoangular = Crown of the impacted
• Class C = The impacted tooth’s crown is
tooth is tilted away the adjacent tooth.
below the cervical line of the 2nd molar
‣ Most dif cult to remove for impacted
Ramus Relationship
mandibular molar
• Class I = The impacted tooth’s crown is
‣ Least dif cult to remove for impacted
anterior to the ramus
maxillary molars)
• Class II = The impacted tooth’s crown is
• Transverse = Crown of the impacted tooth
partially inside ramus
is perpendicular to the adjacent tooth.
• Class III = The impacted tooth’s crown is
Occlusal plane does not face the adjacent
completely inside the ramus
tooth. (Aka Buccolingual)
‣ A major complication for class III
• Inverted = Crown of the impacted tooth is
extractions is nerve damage to the IAN.
upside down relative to the adjacent too.

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 Oral Surgery 14

INBDE Pro Tip: • Long and/or divergent roots

Class C impaction depth and Class III ramus • Root dilacerations
relationships are the hardest to extract. • Dense bone & hypercementosis
• Root fracture
• Endo-treated tooth
• Proximity to the oor of the sinus or IAN
• Gross caries
• Bruxism causes a stronger PDL
• Severe crowding
• Exostoses or tori
• Limited opening

Figure 2.04 Pell & Gregory classi cation

Simple Extractions
A simple extraction is when the tooth is
removed with dental forceps, it typically
Simple vs. Surgical Extractions does not require an incision or sutures,
There are two types of extractions: Simple & although a small number of each could be
Surgical. While both involve the removal teeth, used. A surgical handpiece is never used,
each require unique considerations before, and a ap is not necessary. Below are the
during, and after the procedure. Before diving general steps of a simple extraction.
into speci cs, there is a common list of 1. Severe Soft tissue Attachment
preparatory steps that must be taken: ‣ The purpose of this step is to sever the
gingival and PDL bers attached to the
Steps to Prepare for Any Extraction tooth to prevent soft tissue tear during
• Pre-Op BP extraction
• Ensure correct tooth is being extracted
‣ Use a Woodson or #9 periosteal elevator
• Check tooth condition
‣ Provides space for apical placement of
• Check radiograph forceps
• Obtain informed consent 2. Luxate Tooth with an Elevator
• Ensure patient is seated comfortably
‣ Luxate = To Dislocate
• Suf cient anesthesia has been achieved
‣ Using a lever-type elevator, place the
• Bite Block & Throat Screen blade against the tooth to be extracted
and the back of the blade against the
Factors Predicting Dif cult Extractions alveolar crest – avoid damaging the
Below is a list of conditions that indicate a adjacent teeth
surgical extraction is necessary vs a simple ‣ Find a Purchase Point
extraction. Be able to recognize these clinical - Purchase Point = point between bone
scenarios. & tooth where you can feel resistance
as you slowly twist elevator, so the
blade turns occlusally (clockwise or
counter clockwise) in a slow &
controlled manner
‣ Socket wall should expand and PDL
should tear at this stage
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3. Deliver Tooth with Forceps Considerations for Different Teeth

‣ Slow and deliberate force should be Understanding the general steps of a simple
used instead of quick, jolting actions extraction is important: however, there are
‣ Care should be taken to expand the speci c considerations for each type of tooth.
socket and loosen the tooth before The following list outlines the speci c details
removal is attempted on simple extractions for speci c teeth.
‣ There are ve different directions of
pressure that can be applied at this stage Upper Incisors & Canines
to help release the tooth • Forceps need to be seated as far apically as
- Outward (Buccal/Labial) possible for the best grip on the tooth
✦Initial movement for most permanent • Initial luxation with labial force and hold
teeth for a couple of seconds
- Inward (Lingual/palatal) • Then, apply force lingually and hold
✦Initial movement of most primary • Rotational forces may be used
teeth • Tooth is removed to the labial-incisal with
- Rotational tractional force
✦Initial movement in straight, single- • Canine’s longer roots and the canine
rooted teeth eminence make them more dif cult to
- Apical extract than incisors
✦Applied to every tooth initially to Upper First Premolars
grab the tooth as apically as possible • Apply pressure buccally rst and then
✦Avoid excessive apical pressure in lingual pressure
maxillary molars → risk of • Do not use any rotary force to remove
displacement into maxillary sinus tooth because these teeth typically have
- Tractional two roots
✦This is a straight pulling force that • Rotary movement risks root fracture with
delivers the tooth from the socket teeth that have two or more roots.
Upper 2nd Premolars
4. Post-Extraction Hygiene • Apply pressure buccally rst and then
‣ It is important to bend the bone back in lingually
place unless orthodontics or implants are • You can use rotary force since they typically
in the treatment plan. This facilitates have only one root
better healing since the bone was Upper Molars
expanded during luxation. • Apply pressure buccally rst and then
‣ “CSI” Protocol: lingually
- Curettage socket to remove all soft • For upper molars, pressure applied should
tissue favor the buccal direction as the palatal
- Smooth bone with bone le or rongeur root may be forced into the sinus with
- Irrigate with sterile saline excessive palatal pressure

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 Oral Surgery 16

Lower Incisors & Canines • The blade should be placed at 90 degrees

• Care needs to be taken while extracting to the soft tissue and incisions should be
these teeth as the bone is thin labially and made with a single, rm, continuous stroke
lingually and can fracture easily • The base of the ap needs to be wider
• Roots are less conical and circular, which than the neck to ensure proper blood
require more buccal/lingual pressure and supply and prevent ap ischemia and
less rotary force necrosis
• Crowding is common in this area, which • Incisions should always be over intact
makes access dif cult bone, never over bony defects, or
Lower Premolars eminences
• Conical and single roots of lower premolars • Avoid vital structures (nerves, arteries,
make them easy to extract papilla, etc)
• Rotational force can be used when • Place ap margins 1-2mm away from the
appropriate tooth being working on
Lower Molars
• Multi-rooted and often possess divergent Mucoperiosteal (Full thickness) Flap
roots, which make them the hardest to A mucoperiosteal ap involves the incision and
extract re ection of both the mucosa and underlying
• Use buccal to lingual pressure and no periosteum, exposing the bone. There are
rotary pressure three different types of mucoperiosteal aps.
• Enveloped = 0 vertical releases, only
INBDE Pro Tip: sulcular incision
Rotational force should only be used with single ‣ Dif cult to re ect, minimum exposure,
rooted teeth with conical root shapes. prone to tear due to increased tension
• Three-Cornered (Triangular/L-shaped) = 1
vertical release with sulcular incision
Surgical Extractions
Surgical extractions are more invasive than ‣ Easier to re ect, good exposure, not
prone to tear due to decreased tension
simple extractions, involving soft tissue aps
• Trapezoidal = 2 vertical releases with
and bone removal. This section will review ap
sulcular incision
design, types of aps, surgical handpieces,
factors predicting dif culty of extraction, and ‣ Easiest to re ect, best exposure, not
prone to tear due to no tension
tips for removing root tips.

Flaps Semilunar Incision

The purpose of a ap during a surgical This type of ap is placed apical to the
extraction is to gain better access and visibility mucogingival junction and is speci cally for
at the surgical site. When creating a ap, there apicoectomies. This cannot be done on the
are several guiding principles that must be maxillary palatal soft tissue as it is attached to
followed: underlying bone, preventing ap release.

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 Oral Surgery 17

Double “Y” Incision Important Miscellaneous Facts

This incision creates a ap for palatal torus The following are highly tested facts related to
removal. An incision is made down the midline oral surgery. Be sure to learn and understand
of the hard palate and two “Y” shaped vertical these concepts.
releases are made at each end. • To assess the position of tooth
radiographically using SLOB (Same Lingual
Opposite Buccal) or BAMA (Buccal Always
Using a Surgical Handpiece Moves Away) rule.
The use of a surgical handpiece is a telltale • Wait to perform elective extractions until 6
sign of a surgical extraction. If a surgical months after Coronary Artery Bypass
handpiece is used, the extraction is Surgery
automatically surgical. In general, there are • If a tooth is swallowed or lost in the
three utilities of a surgical handpiece for oropharynx, refer to ER for chest and
extractions abdominal x-rays.
• Removal of buccal bone • Teeth within the line of a jaw fracture can
‣ Makes elevator placement easier through be salvaged. However, it cannot interfere
creating a trough between the tooth and with reduction of the fractured bone
cortical bone – be aware this can create a segments
de ciency especially in the aesthetic zone • Osteoradionecrosis can occur when
• Removal of interradicular bone performing an extraction on an area
‣ Makes tooth removal easier by moving previously exposed to Radiation Therapy
the center of resistance apically • Recommended order for extractions
• Sectioning teeth ‣ Maxillary → Mandibular Posteriors →
‣ Sectioning Lower Molars Mandibular Anteriors
- Surgical bur splits tooth in half
- Insert the elevator to complete the 3 Implants
break
- Remove each half separately
Indications & Contraindications
‣ Sectioning Upper Molars
The following is a list of indications and
- Split the tooth into three sections with
contraindications for implants. Keep in mind,
surgical burr
these contraindications are relative and should
- Extract each piece separately
serve as markers for referral to an oral surgeon.
You will notice that many of the
Removing Root Tips
contraindications for implants and extractions
A common occurrence during a surgical
are the same.
extraction is fracture of the tooth that leaves a
root tip in the socket. Below are techniques to
remove retained root tips. Do not forget to
carry out the “CSI” protocol after removing the
root tip.
• Use a root tip pick to pry out the root tip
• Ostectomy of buccal bone to allow for
facial elevation
• Create a bone window apically and push
the root out
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 Oral Surgery
Indications Contraindications
Replace a Uncontrolled diabetes: high risk
single missing of infection
tooth
Abutment for IV Bisphosphonates:
a bridge Increases the risk of osteonecrosis
of the jaw
Implant Head & Neck Radiation
supported Hyperbaric oxygen pre & post-op
dentures can help mitigate against
osteonecrosis of the jaw
Immunocompromised patients:
high risk of infection
Bruxism
Smoking: poor healing and
osteointegration
Cleft palate
Low bone volume and/or height
Adolescences: patient not done
growing, so the implant can
migrate as bone grows
Recent heart attack or stroke
(within the past 6 months)
Pregnancy: delay implant
placement until post delivery
INBDE Pro Tip:
Old age is NOT a contraindication for implants.
While special considerations should be taken
with older patients, they can still receive strong,
effective implants.
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Types of Implants
Subperiosteal
Subperiosteal implants are not placed inside
bone. Rather, they are anchored directly
underneath the periosteum. Only brous
integration occurs and no osteointegration
occurs. Generally, these implants are weak and
have poor outcomes. Hence, they are rarely
used today.
Transosteal
Placement of transosteal implants occurs extra-
orally and are therefore only used to restore
mandibular anteriors. To place this type of
implant, the operator must drill through the
inferior boarder of the mandible and into the
oral mucosa. Due to a low success rate and
invasive nature, transosteal implants are rarely
used.
• Primary indication = atrophic mandible
Endosteal
Endosteal implants are the most used implant
today. They are placed inside the bone and are
delivered intraorally. The following information
about implants is primarily applicable to
endosteal implants.
Implant Components
Endosteal implants are comprised of four main
components: Implant Body, Abutment,
Abutment Screw, and Implant Crown. Below
are the high yield details for each component
for the INDBE.
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 Oral Surgery 19

Implant Body Abutment & Screw

This part of the implant is also called the The abutment is the part of the implant that is
implant or xture. It is the component that is placed into the body. Just like an abutment for
placed into bone and acts as the foundation a xed partial denture, this component is
for the entire apparatus. Implant surgery is where the restoration is placed. There are two
required to place the implant body into bone, types of abutments: One-Piece & Two-Piece
which involves drilling subsequently larger One Piece
holes into the bone until the body tightly ts. • Abutment screw and the abutment are a
This sequential technique provides three main single unit
bene ts: • There is no anti-rotational component
• Heat control Two-Piece
• Create appropriate axis for free hand • Abutment screw and abutment are
placement separate
• Allow for angle adjustments as needed • Has an anti-rotational component
Typically, threading is created in the bone • More commonly used
during this drilling process for the implant The Anti-Rotational Component of an implant
body to screw in. These are called Tapped serves to prevent rotation of the abutment and
Holes. Some implant bodies are Self-Tapping, provides stabilization. There are two types of
which mean they drill threads into the bone anti-rotational components: internal and
while being placed. external hex. Only two-piece abutments have
anti-rotational components.
Implant Crown
This is the restoration that is place on the
abutment. Below are the various types of
implant crowns.

Screw Retained
• A screw is place through the implant and
crown, making it a two-piece abutment
• Con: presence of a screw access hole
‣ Usually located in the central fossa for
posteriors and cingulum in anteriors
‣ Can pose an aesthetic problem if poor
Figure 3.01 Body of implant implant angulation resulting in buccally
inclined implant in aesthetic zone
• Pro:
INBDE Pro Tip:
‣ Can be removed for cleaning or
Know the difference between self-tapping and
non-self-tapping implant bodies.
replacement without sectioning
‣ No cement

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 Oral Surgery
Cement Retained
• The abutment is attached to the implant via
cement
• Better for aesthetics zones since there is no
screw access hole
• Must be sectioned to be removed
• Cement cannot be left sub-gingivally as this
could lead to peri-implantitis
INBDE Pro Tip:
For cement retained implant crowns, take a
periapical radiograph after cementation to
detect any cement that may have been left
behind
Integration & Stability
Implant success is highly dependent on
integration and stability. Integration refers to
the implant binding to soft or hard tissue.
Stability refers to how well the implant can
resist movement.
Integration
Osseointegration is the ideal form of
integration to maximize implant success.
Osteointegration occurs when surface of the
implant is directly connected to the living bone
and this is con rmed histologically.
Fibrous integration occurs when the surface of
the implant is in direct contact with connective
tissue and not bone. The presence of brous
integration means osseointegration has
failed, and the probability of implant failure is
higher.
Stability
Just as with integration, there are two types of
stability: primary & secondary stability. The
overall stability of the implant is determined by
the sum of the primary and secondary stability.
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Primary Stability
Primary stability refers to how the implant stays
in the bone immediately after surgery. This
form of stability is mechanical and is
dependent on the quality of threading from
bone tapping. Primary stability is essential for
limiting implant movement and achieving
osseointegration. If poor primary stability is
observed after implant placement, a two-stage
implant surgery is indicated. Primary stability
peaks at implant placement and decreases
during the following weeks as some level of
bone necrosis & osteoclastic activity occur due
to trauma by implant placement.
Secondary Stability
Secondary stability occurs when there is
osseointegration of the implant to the bone.
The quality of this type of stability predicts the
long-term health and success of the implant.
Secondary stability becomes the main
stabilizing force as primary stability decreases
over time
INBDE Pro Tip:
Secondary stability can only occur with
osseointegration. Fibrous integration can never
result in secondary stability
Bone Quality
Bone quality is an important factor to consider
when planning for an implant. Placing an
implant in weak bone will severely hinder
implant success. Below are the four
classi cations of bone and their respective
locations in the Oro-facial complex.
• Type I
‣ Dense cortical bone - Hardest & densest
type of bone
‣ Great cortical anchorage but Less
vasculature, which results in longer
healing timelines (5 months)
‣ Location: Anterior Mandible
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 Oral Surgery 21

• Type II • Buccal & Lingual Plate = 1mm

‣ Core of dense trabecular bone • Maxillary sinus = 1mm
surrounded by thick cortical bone • Nasal cavity = 1mm
‣ Softer than type I • Inferior Border of the Mandible = 1mm
‣ Shorter healing timeline than type I (4 • IAN = 2mm
months) • Adjacent Implant = 3mm
‣ Location: Posterior Mandible
• Adjacent teeth = 1.5mm
• Type III • Mental Nerve = 5mm
‣ Core of trabecular bone surrounded by
This information will be tested with in the
think cortical bone
context of a case. For example, a question may
‣ 6 months of healing time
asked, “if you were If you were placing a 3mm
‣ Location: Anterior Maxilla
diameter implant in the posterior mandible,
• Type IV
what is the minimum buccal-lingual space
‣ Low density trabecular bone with needed to place the implant.”
surrounded by almost no cortical bone • Answer: 3mm of implant + 1mm for
‣ 8 months of healing time buccal plate + 1mm for lingual plate =
‣ Location: Posterior Maxilla 5mm needed total

Socket Preservation
Socket preservation typically occurs after an
extraction to maintain the height and width of
the alveolar ridge for future implant
placement. The main requirement for this
procedure is an atraumatic extraction, i.e. no
Figure 3.02 Types of bone quality breakage of the buccal plate and trauma is
limited to the extraction area. The following
are the steps of pocket preservation:
INBDE Pro Tip: • Irrigate extraction site
Know that for placing implants, Type II bone is • Remove granulation tissue
the best.
• Place graft
• Cover with resorbable collagen membrane
Implant Placement • Primary closure is not needed
The entirety of this section is important and Remember, disease control always comes
will be on the INDBE. The amount of bone rst. If a periodontitis patient presents with a
available needs to be measured to ensure hopeless teeth & resorbed buccal bone & soft
proper space and support for the implant tissue recession, treatment is extraction
before placement. There are minimum without socket preservation as often there is
amounts of bone needed in between the no socket to preserve. If the same patient
implant and a certain landmarks. Below are the desires for an implant, let the extraction site
speci c minimum bone requirements. heal and plan for ridge augmentation or
guided bone regeneration.

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 Oral Surgery
Biologic Width of Implant
In the periodontal notes, you learned about
biological width. Implants possess a biological
width that differs from a normal tooth. First, it
is important to remember that cementum and
PDL is not present because the implant directly
attaches to bone. However, some gingival
bers do connect to the implant cuff and are
oriented parallel to that cuff. Finally, the part
of the implant that interfaces with bone is
rough to allow for better osteointegration, but
the surface that interfaces with soft tissue is
smooth.
Figure 3.03 Biological width of implant
Surgical Stents
Surgical stents are devices used to help guide
implant surgery for proper placement. Often,
the radiographic stent can be modi ed into
the surgical stent. There are three dimensions
these stents can aid with: Location,
Angulation, and Depth.
INBDE Pro Tip:
Use the acronym “LAD” to help remember
Location, Angulation, and Depth as the
dimension’s surgical stents aid.
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One vs Two-Stage Surgery
Implant surgery can take place in either one or
two stages. The following are high yield
information for each stage.
One Stage
• Only one surgery is needed to place the
implant
• The implant and healing abutment is
placed in one visit
• The healing abutment is not covered by
soft tissue and is exposed to the oral cavity
• The restoration can be place at the next
visit once the healing abutment is removed
Two Stage
• Two surgeries are needed for two stage
implants
• During the rst surgery, the implant is
placed with a cover screw and covered with
soft tissue
• At the second surgery, the implant is re-
exposed, and the healing abutment is
placed
• The following are reasons to do a two-
stage surgery over a one stage
‣ If the implant has poor primary stability,
covering the implant from occlusal forces
could preserve it until it gains secondary
stability
‣ Required if placing a graft
‣ Primary closure is best for medically
comprised patients to decrease risk of
infection
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 Oral Surgery 23

Implant Success vs. Failure Peri-implantitis

There are several conditions that are clear In ammatory reaction involving soft and hard
indications of success or failure for implants. tissues resulting in loss of alveolar bone
Understand these conditions and be able to surrounding the implant
recognize them for the INDBE. Risk factors
Success: • History of periodontitis
• Immobility • Poor plaque control and lack of regular
• No peri-implant radiolucency maintenance
• Less than 0.2mm vertical bone loss annually Diagnosis
following the rst year of implant function • Presence of BOP or suppuration on
• No pain post-surgery probing
Failure: • PD increased compared to previous exam
• Absence of all the above conditions for OR ≥6mm if no previous record
success • Further bone loss after initial bone
• Large concentration of gram-negative remodeling OR bone level ≥3mm apical of
anaerobic rods & laments most coronal portion of implant if no
• Inappropriate temperatures previous record
‣ Exposing the implant to 47C for 1 minute Treatment:
or 40C for 7 minutes is enough to • Remove the failed implant, debride socket
compromise osseointegration +/- bone graft with a resorbable membrane

Peri-implant Mucositis INBDE Pro Tip:

Reversible soft tissue in ammation surrounding Understand the difference between Peri-implant
implant mucositis & Peri-implantitis
Risk factors
• Plaque
• Smoking
Treatment
- Professional mechanical debridement
- Subgingival CHX irrigation
- Self-performed OH (toothbrush +
toothpaste for mechanical plaque control)
with CHX rinse

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 Oral Surgery 24

4 Trauma & Orthognathic Surgery 1. Condylar: This is the most common

location for fracture due to its small size
Trauma Surgery and location in the glenoid fossa. A
Be familiar with the following types of trauma condylar fracture is characterized by a
surgeries: shortened ramus on the affected side, This
• Reduction = Fracture fragments are will cause deviation of the mandible to the
returned to their normal position affected side
• Opened Reduction = Surgical dissection of 2. Angle
tissues to expose fracture fragments 3. Symphysis
• Closed Reduction = Manipulation of
fracture fragments without surgical
INBDE Pro Tip:
exposure
Trauma to the parasymphyseal region of the
• Internal Fixation = Use of titanium bone
mandible can cause a fracture on the
plates to hold bone together contralateral side, particularly the subcondylar
• Inter-Maxillary Fixation/ region.
Maxillomandibular Fixation = Wiring jaws
closed, arch-bars, and elastics The following are ve different classi cations of
mandibular fractures to learn.
Maxillofacial Fractures • Simple = Fracture is closed to oral cavity
There are two important types of fractures to • Compound = Fracture communicates with
be familiar with for the INDBE: Mandibular & the external environment. Infection is a
Midface fractures. common complication.
• Greenstick = Fracture goes part way
Mandibular Fracture through the bone, with the other side bent.
Fractures of the mandible are most frequently Most often seen in children
caused by trauma to the jaw and should be • Comminuted = Fracture of bone into
evaluated with a panoramic radiograph. The multiple pieces
following regions of the jaw are listed from • Pathologic = Fracture at a site weakened
most to least likely to be fractured. Be sure to due to previous disease
memorize this order!

Figure 4.01 Mandibular fractures Figure 4.02 Five classi cations

of mandibular fractures

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 Oral Surgery 25

Treatment In addition to Le Fort fractures, it is important

• Closed reduction/maxillomandibular to understand Zygomaticomaxillary Complex
xation (MMF) Fractures. These were formerly known as a
• External xation tripod fracture and are caused by trauma to
• Open reduction and internal xation the malar eminence. A distinctive feature of
this fracture is bleeding under conjunctiva.
INBDE Pro Tip: The three regions involved with this fracture
Mandibular fractures are ideally treated with are:
open reduction and internal xation (ORIF). • Lateral orbit
• Zygoma
• Maxilla
Midface Fracture
These fractures are much more serious than
mandibular fractures and require CBCT
radiographs for proper evaluation. Midface Orthognathic Surgery
fractures are classi ed via the Le Fort The purpose of orthognathic surgery is to
classi cation system, which differentiates these correct severe skeletal discrepancies by
fractures into three groups: manipulating the upper and/or lower jaw.
• Le Fort I = Horizontal fracture across the
midface Skeletal Discrepancies
‣ Maxilla is mobile with intact nasofrontal The follow are skeletal discrepancy terms you
complex should be familiar with for the INDBE:
• Le Fort II = Pyramidal Fracture • Retrognathic mandible = Class II
• Prognathic mandible = Class III
‣ Maxilla is mobile with mobile nasofrontal
• Apertognatic = Anterior open bite
complex
• Le Fort III = Complete craniofacial • Vertical Maxillary Excess = Maxilla is too
disjunction long with the presentation of a gummy
‣ Maxilla is mobile with mobile nasofrontal smile
• Horizontal Transverse Discrepancy =
complex and malar processes
posterior crossbite
• Macrogenia = enlarged chin
• Microgenia = small chin

Treatment
For orthognathic surgery treatment planning,
lateral cephalometric radiographs are the
standard radiographical record. Below are the
types of surgeries that would be completed to
achieve the following goals:
• Move maxilla → Le Fort I Osteotomy
Figure 4.03 Midface fractures
• Move Mandible → BSSO
• Move the chin → Genioplasty

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Oral Surgery 26

Le Fort I Osteotomy • Phase I = Osteotomy is completed

A Le Fort I fracture is created to advance the • Phase II = Latency period where appliance
maxilla forward. It is particularly useful to x a is mounted to bone on both sides of the
retrusive maxilla or vertical maxillary excess. cut. Appliance is not activated for 1 week.
• Phase III = Distraction phase where the
Bilateral Sagittal Split Osteotomy (BSSO) appliance is activated to separate the bone
A cut is made on each side of the mandible at the osteotomy site. Bone lls in the gap
above the IAN to allow for manipulation of the
mandible without disruption to condyle
position. This surgery is useful for correcting
retrusive or protrusive mandibles. The most
common post-op complication is nerve
damage to the IAN.

Figure 4.05 Distraction osteogenesis

Figure 4.04 BSSO

INBDE Pro Tip:

Correcting class III malocclusions surgically
involve different surgeries depending on the
presentation:
• Retrusive Maxilla = Le Fort I
• Protrusive Mandible = BSSO
• Both = BSSO & Le Fort I

Distraction Osteogenesis (DO)

This surgery done to lengthen bone through
creating an arti cial suture to allow for bone
deposition. The arti cial suture is gradually
separated, allowing bone to ll in with each
extension. It is important to note this
procedure only lengthens bone, no width is
gained. There are three phases to DO

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5 Orofacial Pain

Biopsychosocial Model of Pain

This model of pain is comprised of two parts:

Axis I Axis II

“Bio” part of “Psychosocial” part of

biopsychosocial biopsychosocial

Involves nociceptive Involves the interaction

input form somatic between the thalamus,
tissue cortex, and limbic
structures

Responsible for acute Responsible for chronic

pain pain
Figure 5.01 Pain pathway

Pain Pathway
This pathway is the way nociceptive stimuli There are four types of pain that can
travel from the site of detection to conscious transmitted through this pain pathway:
perception. Each step is listed in sequential • Somatic pain
order. • Neuropathic pain
1. Transduction = Pain information travels • Psychogenic pain
from PNS to CNS • Atypical pain.
2. Transmission = Information travels from
CNS to higher cortical centers and Painful stimulus is carried to the brain by either
thalamus Aδ bers or C bers
3. Modulation = Altering the ow of the • Aδ bers – sense mechanoreceptive pain,
pain. Mostly limitation of pain. localized, fast (due to myelination); intense,
4. Perception = Subjective experience of acute pain
pain that is an amalgamation of the above • C bers – sense nociceptive pain, larger
physiological processes with psychological area, slow (no myelination); throbbing,
factors. chronic pain

Somatic Pain
Somatic pain is any kind of pain derived from
the activation of pain receptors in tissues. This
is the type of pain is involved with day-to-day
dental pain. In general, as you increase the
stimulus causing the pain, the pain also
increases, aka stimulus-dependent pain. For
the orofacial complex, you can have somatic
pain of musculoskeletal or visceral origins.

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 Oral Surgery 28

• Musculoskeletal = TMJ, periodontal Postherpetic Neuralgia (PN)

tissues, muscles This type of pain often presents as a burning,
• Visceral = Salivary glands, pulpal tissues aching, or shocking sensation. Commonly, PN
results from herpes zoster infection resulting
Myofascial Pain Syndrome (MPS) in shingles. However, it is important to note
MPS is a chronic muscular pain disorder. It is that this pain does NOT result from herpes
somatic in nature and is the most common simplex virus. Treatment involves
cause of masticatory pain. Typically, the pain anticonvulsants, antidepressants, or
is diffuse through the preauricular region with sympathetic blockers
the muscles of mastication being particularly
sensitive. MPS is thought to be a stress-related Burning Mouth Syndrome (BMS)
disorder with pain can be exacerbated by BMS presents as it is named, a burning pain in
parafunctional habits and muscle hyperactivity. the mouth often accompanied by dryness and
Treatments include physical therapy, stress potentially altered taste. It is more common in
management, splint therapy, and medication. post-menopausal women and associated with
type II diabetes, malnutrition, and xerostomia.
There are two types:
Neuropathic Pain • Primary BMS = Idiopathic burning
Neuropathic pain is pain independent of sensation of oral mucosa; some research
stimuli, aka stimuli-independent pain. suggest it is the result of damage to nerves
Therefore, perception of pain does not that regulate pain and taste
correlate to modulation of stimuli associated ‣ Treatment is largely supportive (sucking
with the pain. There are several speci c cases ice chips, drinking cold water);
of neuropathic pain that are common to see ‣ can refer to MD for prescription of topical
clinically and important to know for the INDBE. clonazepam or systemic anticonvulsant &
antidepressant medications used in
Trigeminal Neuralgia (TN) neuropathic pain management
TN, aka tic douloureux, involves pain along any
branch of the trigeminal nerve (CN V). The • Secondary BMS = Caused by an
quality of pain can be described as electric, underlying medical condition
sharp, and/or shooting. Typically, TN pain is
unilateral and episodic with periods of Chronic Headache (CH)
refraction. Treatment of TN can involve CH’s, aka neurovascular pain, have two types
anticonvulsants like carbamazepine, tricyclic of presentations: migraines or tension type
antidepressants like amitriptyline and/or headaches.
surgery for destruction of the sensory neuron. • Migraines:
‣ Presents as unilateral and pulsating
Atypical Odontalgia (AO) headaches
Directly translating to “not typical tooth pain,” ‣ Episodic
AO involves pain at a site where part of the ‣ Accompanied by nausea and vomiting,
neural pathway was removed (i.e., RCT or both of which are exacerbated by light
extraction). This type of pain can be thought of and sound (photophobia &
as a “phantom toothache.” phonophobia)
‣ Tx: SSRIs (Triptan)

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 Oral Surgery 29

• Tension Type:
‣ Bilateral and non-pulsating in nature
‣ No aggravated by light, sound, or other
routine activities
‣ Cluster = Intense pain near one eye

Psychogenic Pain
Pain associated with psychological
disturbances. For example, strong emotions
could prolong or exacerbate pain.

Atypical Pain
Facial pain of unknown cause and without a Figure 6.01 Bony anatomy of TMJ
de nitive diagnosis.
Muscular Anatomy
6 Temporomandibular Disorder (TMD) Muscles of the TMJ move the mandible. Be
sure to learn each muscle and the speci c
TMD is a group of musculoskeletal & movement they are responsible for.
neuromuscular conditions involving TMJ, • Lateral Pterygoid → Anterior translation of
masticatory muscles, and associated tissue. mandible to prepare for opening
This section will discuss various presentations • Masseter, Temporalis, Medial Pterygoid
of TMD and outline important anatomical → Closing the mouth
information about the temporomandibular
joint (TMJ).

TMJ Anatomical Structures

Bony Anatomy
• Condyle
• Mandibular/Glenoid Fossa
• Articular Eminence
• Articular Disc
Figure 6.02 Muscular anatomy of TMJ
‣ Lower Joint Space: responsible for
rotation
‣ Upper Joint Space: responsible for
translation

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Ligaments • De ection = The mandible is stuck to one

The function of ligaments in the TMJ is to limit side at maximum opening
the movement of the mandible. The following ‣ The mandible de ects towards the side
are the important ligaments to learn and their that is stuck
speci c functions. - This is because the mandible can only
• Capsular Ligament rotate on that side and not translate
‣ This ligament covers the TMJ space and - For example, if the right condyle is
protects the TMJ stuck in place, opening will move to
‣ If you were to surgically access the upper the right
joint space, you would need to puncture • Deviation = During opening, the mandible
this ligament deviates to a side but returns to the
• Discal/collateral Ligament midline at maximum opening
‣ Attaches to the medial and lateral poles ‣ Deviation is a variation of normal
of the condyles and keeps the disc ‣ Sometimes presents with TMD, but not
attached to the condyle during always
movement ‣ Clinically, pain and tenderness present on
• Posterior Ligament the side where the deviation is located
‣ Attaches to both the articular disc and upon palpation
the back of the condyle
‣ Function is to prevent anterior disc
displacement
• Lateral Ligament
‣ Wraps around condyle and attaches to
articular disc
‣ Prevents posterior and inferior disc
displacement

Blood Supply Figure 6.03 two types of opening patterns

The TMJ is supplied by several arteries. An
acronym to remember these arteries is MADS.
• M = Maxillary Artery INBDE Pro Tip:
• A = Ascending Pharyngeal Artery There is no scienti c evidence to suggest that
• D = Deep Auricular Artery occlusion is the etiology of TMJ disorders
• S = Super cial Temporal Artery

Opening Patterns
There are two types of opening patterns to be
familiar with for the INDBE: De ection &
Deviation.

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 Oral Surgery
Disc Displacements
Disc displacement refers to when the articular
disc is not in its anatomically normal position.
There are two types of displacement: with and
without reduction.
• Displacement With Reduction
‣ Patients will present with a clicking noise
upon opening
‣ The clicking occurs because the condyle
pops anteriorly over the displaced disc
and pops when it returns to the fossa
(reciprocal clicking)
‣ The condyle can still move
• Displacement Without Reduction
‣ The condyle is locked in place behind
the articular disc
‣ Patient presents with a limited range of
motion and ipsilateral movement upon
opening
‣ The ipsilateral movement will occur
towards the side with disc displacement
Figure 6.05 Disc displacement
Recurrent Dislocation
This form of dislocation occurs when the
condyle translates anterior to the articular
eminence. When this occurs, direct
manipulation of the jaw downwards and
backwards is required to put the condyle back
in it proper anatomical place. Treatment for
this condition includes Botox injections of the
lateral pterygoid or surgery if it is chronic.
31
TMJ Clinical Exam
Below are the important steps for performing a
TMJ clinical exam.
• Evaluate tenderness to palpation
• Palpate the lateral aspect of the joint while
the patient opens and closes their mouth
• Palpate the posterior aspect of the
mandibular condyle by palpating the
anterior wall of the external auditory
meatus
• Measure mandibular range of motion
including vertical, lateral, and protrusive
movements
• Assess clicking and crepitus for both joints
INBDE Pro Tip:
Clicking and crepitus does not always signal
pathology, especially without pain.
Ankylosis
Ankylosis within the context of TMD occurs
when the condyle and the skull are fused at the
level of bone or ligament, severely limiting the
mandible’s range of motion. The most
common cause of this condition is trauma, but
other causes include local or systemic
infection, systemic disease, surgery, and
radiation therapy. Treatment for this condition
is mostly surgical.
Bruxism
Bruxism is a condition involving severe
clenching and grinding of the teeth. There are
two types of bruxism, sleep & awake bruxism.
Both types can present together. The primary
cause of this condition is thought to be stress.
The main treatment includes an occlusal guard
to relax muscles and better distribute
masticatory forces.
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TMD Therapy Indications

Non-surgical Therapy • When conservative treatment fails to
Generally, there are ve types of non-surgical reduce symptoms
therapies available in the treatment of TMD. • Intra-articular pathology is causing
Each are listed below in order from most symptoms
conservative to most aggressive: • Symptoms severely lower quality of life
• Counseling: the goal of counseling is to
stop any parafunctional habits that could INBDE Pro Tip:
be exacerbating TMD symptomology The nerve most likely to be damaged during
‣ Ex: Grinding teeth, biting nails, stress, TMJ surgery is the facial nerve.
etc.
• Medication: medications commonly
7 Biopsy Techniques
prescribed to treat TMD include
‣ NSAIDS
‣ Steroids Biopsy Techniques
‣ Analgesics Cytology/Brush Biopsy
‣ Antidepressants This technique involves scraping cells off a
‣ Muscle Relaxants lesion with a kit brush. Cells removed are
• Physical Therapy (PT): forms of PT for smeared on a glass slide to be xed and
TMD include electrical nerve stimulation, analyzed. Ideally, cells are obtained from all
massage, and thermal treatment epithelial layers (basal, intermediate, and
• Occlusal Splint: used to unload the joint super cial cells). Particularly useful for large
• Arthrocentesis: emptying the superior joint white patch on buccal mucosa that wipes off.
space with needles This technique is non-invasive and able to be
performed by hygienists. However, there is a
Surgical Therapy high false positive rate.
For the INDBE, be familiar with following ve
surgical therapies for TMD. Again, these are Indications
listed from most conservative to most • Monitoring large areas of mucosal change
aggressive. for dysplastic changes (ex. herpes or
• Arthroscopy = Instrumentation of the pemphigus).
superior joint space with two cannulas
‣ Allows for direct visualization of TMJ and
injection of steroids
• Arthroplasty = Repositioning of the disc
surgically
‣ Indicated for chronic, painful clicking and
closed lock
• Discectomy = Repairing or removing a Figure 7.01 Cytology/Brush biopsy
severely damaged disc
• Condylotomy = Osteotomy of the vertical
ramus to allow for soft tissue to reposition
the condyle and disc into a more favorable
position

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Aspiration (Fine Needle Aspiration)

For aspiration, a needle and syringe are used
to extract contents of a lesion and ascertain
the identity of that uid. This is often used to
explore radiolucent intraosseous lesions (ex:
odontogenic cyst, ameloblastoma) to
determine malignancy and uid lled lesions
Figure 7.03 Incisional biopsy
(except mucocele). It is great for
distinguishing benign and malignant bone
lesions. Cannot be used for rm, calcifying Good Practices
lesions. • Block anesthesia is preferred over local
in ltration as local can distort the lesion,
Excisional making biopsy more dif cult
This biopsy technique involves complete ‣ If local in ltration is necessary, mark the
removal of a small (<1cm) lesion. Normal boarders of the lesion with a sharpie
tissue should be included in the margins, before administration of anesthetic and
speci cally 2-3mm margins of normal tissue in inject the anaesthetic at least 1cm away
an elliptical shape. from the lesion
• Avoid handling biopsies directly as the cells
can be crushed. Use tractional suture
through the specimen or handle gently
with ne tissue forceps.
• Samples are generally stored in 10%
formalin solution that is 20x the volume of
the surgical specimen for delivery to an oral
pathologist
Figure 7.02 Excisional biopsy
Biopsy Indications
• Any lesion that persists for more than 2
Incisional
weeks with no apparent etiology
This biopsy technique is indicated for large
• Any lesion with signs of malignancy
(>1cm) lesions that are suspected to be
‣ Rapidly changing or growing
malignant or lesions in hazardous locations.
• Brown or black pigmented lesions
Only part of the lesion is removed for analysis.
To complete, a deep, narrow wedged incision • Lesion with associated tissue paresthesia
is created down to healthy tissue and a
representative portion of the lesion is removed INBDE Pro Tip:
with some normal tissue around it. It is vital to Biopsies are indicated after 2 weeks of
avoid necrotic tissue. monitoring a lesion that does not go away.

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 Oral Surgery 34

8 Medical Emergencies Angina

Angina is most simply understood as chest
This section covers various medical pain caused by ischemia without necrosis.
emergencies seen in a dental setting. Be sure Only assume dx of angina for chest pain if
to understand each condition and how to there is previous history of angina, assume
manage a patient undergoing an emergency in myocardial infarction if no history of angina
the dental chair. present. This chest pain occurs when the
coronary arteries are unable to provide
Cardiovascular Emergencies enough blood to cardiac tissue. There are two
Anticoagulation types of anginas: stable & unstable.
• Stable Angina = Angina caused by a
Medical emergencies surrounding
anticoagulation events, aka excessive stimulus like exercise. There is a repeatable
bleeding, can be avoid through a through pattern of onset.
• Unstable Angina = Chest pain that occurs
medical history. In the medical history, be sure
to note any blood disorders, any at rest without a stimulus.
anticoagulants that are being taken, and why.
INBDE Pro Tip:
It is imperative to know these facts about a
MI’s involve ischemia WITH necrosis; angina
patient because the relevant coagulation test involves ischemia WITHOUT necrosis
to assess the probably of an anticoagulation
event is dependent on speci c conditions and/
or medications. Treatment: check ABCs, Administration of
• Complete Blood Count (CBC) → Anemia, 100% oxygen, nitroglycerin (NTG), and aspirin
leukopenia, thrombocytopenia if no resolution
• Bleeding time → Improper platelet • NTG (0.4mg sublingual tablet)
function administration protocol
• Prothrombin Time (PT) → Anticoagulant ‣ NTG → 5-minute wait → NTG → 5-
medications, liver damage, vitamin K minute wait → NTG
de ciency - If no resolution → call 911 →
‣ Tests the extrinsic clotting pathway - 160-325mg Aspirin chewed
• INR → Patient on Warfarin/Coumadin ‣ NTG is contraindicated when systolic BP
‣ This is a standardized PT value calculated < 90mmHg or patient has recently used
by normalizing PT results across all types 5-PDE inhibitor (ex. Viagara)
of PT tests
‣ Normal clotting = 1; < 1 = Increased INBDE Pro Tip:
clotting; > 1 = Increased bleeding Avoid NSAID & narcotics with asthma attacks.
• Partial Thromboplastin Time → Heparin,
renal dialysis, hemophilia
‣ Tests the intrinsic clotting pathway

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 Oral Surgery 35

Myocardial Infarction Treatment: Sit patient upright and give a

MI’s, aka heart attacks, occur when there is a brown paper bag to breath into and inhale
sudden block of a major coronary vessel. from to increase CO2 concentrations in their
Typically, the vessel blocked is the left anterior blood.
descending artery. MI are classi ed as
ischemia with necrosis and are therefore more Airway Obstruction
serious than episodes of angina. The common sign of an airway obstruction is
hands wrapped around the throat. If a patient
Key Signs and Symptoms: has an airway obstruction, the goal is to clear
• Chest pain with tightness & pressure the pharynx of any obstruction.
• Levine’s sign
• Radiating pain to the neck and left arm. How to Handle:
• Check for breathing
Treatment: Check ABCs → call 911 → ASA • Tilt the chin upward to extend the neck
160mg or 325mg → nitroglycerin (if systolic • Open airway by protruding the mandible
BP >90 & no 5-PDE inhibitor used recently) → and tongue
analgesic with morphine (2mg IV or 5mg IM) or • Encourage coughing, Heimlich maneuver
50% Nitrous oxide • If patient becomes unresponsive, perform
• Only administer 100% oxygen if indication CPR
present - pale, grey, or cyanotic patient
INBDE Pro Tip:
Respiratory Emergencies DO NOT place a pregnant woman in the
Asthma Trendelenburg position as the fetus can
Generally, asthma is caused by the constriction compress their inferior vena cava. Instead, lay
and/or in ammation of the bronchioles. The them on their left side.
classic sign for asthma is a high-pitched
wheeze on exhalation.
Anaphylactic Shock
Treatment: Administer emergency inhaler, This medical emergency is a severe allergic
typically albuterol (2 puffs, repeat prn) which reaction. The best way to prevent this
relaxes the smooth muscle around the emergency is to take a through medical history
bronchioles. If no resolution, give Epi before administering any treatment.
(0.3-0.5mg, 1:1000) IM, repeat q5min
Treatment
Hyperventilation • Check ABCs, call 911, 100% O2
Hyperventilation occurs when a patient has too • Epi (0.3-0.5mg, 1:1000) IM repeat q5min
much oxygen and not enough CO2, causing • Diphenhydramine 50mg IM
quick and erratic breathing. Signs include light- • Hydrocortisone 100mg IM (if available)
headedness, dizziness, and weakness. Because
of the physiologic state that causes this, never
give oxygen to a hyperventilating patient.

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 Oral Surgery 36

Neurological Emergencies Stroke

Syncope Strokes occur when brain tissue does not
Syncope, aka fainting, is the most common receive an adequate amount of blood. Signs of
medical emergency in the dental chair. There a stroke are facial droops, arm drifts, and
are two types of syncope to be familiar with: slurred speech. One cause of stroke to know
Vasovagal Syncope & Orthostatic Hypotension. for the INDBE is hyponatremia. Also be
• Vasovagal Syncope familiar with the difference between transient
‣ Fainting due to needle anxiety ischemic accidents (TIA) and cerebrovascular
‣ Most common form of syncope in the accidents (CVAs). TIAs involve temporary
dental chair presentation of stroke signs and symptoms,
• Orthostatic Hypotension aka a mini-stoke, while CVAs are full strokes.
‣ Fainting due to blood pressure falling
after standing up quickly Treatment: Administer oxygen and call 911
‣ Caused by a failure of the baroreceptor
re ex to mediate peripheral vascular Epinephrine Overdose
resistance This emergency is rare and occurs when local
‣ Second most common cause of syncope anesthetic with epinephrine is injected rapidly
into vasculature. Signs include a rise in heart
Treatment: Place patient in a supine position rate and blood pressure with a noticeably
with the patient’s feet above their head, called strong heartbeat.
the Trendelenburg position, give 100%
oxygen. How to Avoid:
• Inject slowly
Seizures • Aspirate before injection to ensure you are
Seizures are uncontrollable electrical not injecting directly into a blood vessel
disturbances of the brain that can cause erratic • Calculate the appropriate amount of
movements. In general, the goal of seizure epinephrine for each patient
management in the dental of ce is to protect
from injury without restraint. There are two Diabetes/Hypoglycemia Hypoglycemia is
general types of seizures to be familiar with: another common medical condition to be
Gran Mal & Status Epilepticus. aware of, especially for diabetic patients.
• Grand Mal Seizure Symptoms for hypoglycemia include:
‣ Most common type of seizure with a • Sweating
tonic-clonic presentation • Pale appearance
‣ Treatment = Dilantin (Phenytoin) • Irritability
• Status Epilepticus • Sleepiness
‣ Seizure that lasts more than ve minutes • Hunger
‣ Treatment = Valium (Diazepam)
Treatment: Treatment depends on if the
hypoglycemic patient is conscious or
unconscious.
• Conscious = Give glucose tab or juice
• Unconscious = IV dextrose or intramuscular
glucagon (1mg)

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Figure 8.01 Symptoms of Hypoglycemia

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