Department of Oral and Maxillofacial Surgery

The Department of Oral and maxillofacial surgery at Sri Balaji Dental College is a speciality department, well equipped with state of the art facilities. It caters to a broad spectrum of patients ranging from newborns with clefts and craniofacial deformities, to patients who have different kinds of cysts and tumors, and also facial trauma surgeries which form the crucial cases as we are also associated with a hospital which is located on a major highway.

The department has a very well equipped Minor oral surgery unit capable of dealing with emergencies. Impactions, surgical excisions of small cysts, handling of space infections and biopsies are meticulously done with all precautions following the highest standards of sterilization and asepsis so that even the under graduates are aware of the protocols that should follow once they step into the operation theatres.

We also have an excellent backing from the department of Orthodontics and Dentofacial Orthopedics at Sri Balaji Dental College and in constant consultation and discussions with them we formulate a treatment plan for all the patients who might also require surgical interventions. They are identified early and before the treatment starts a panel discussion takes place to make sure that the treatment plan is thoroughly discussed and the patient is explained about the need of any such procedure going forwards.

Bhaskara medical college is a sister institute to which we are affiliated and they have an emergency unit which keeps us posted about the facial trauma cases that come in their unit. In consultation with the surgeons and the radiologists a proper treatment plan is formulated for all these patients. Primary assessment is done by our interns under the guidance of a staff who is always posted in the emergency unit.

The Radilology department also has a state of the art MRI and CT work station which makes it easier for us to assess the nature of injury that these patients step in with.

The Department currently imparts UG curriculum for III BDS, IV BDS students along with Interns and PG curriculum for MDS students as prescribed by KNR University of Health Sciences, Telangana, in keeping with the norms laid down by the Dental Council of India.

The overall goal of this course is to introduce basic surgical principles and techniques using a didactic curriculum and clinical experiences in the field of oral and maxillofacial surgery with special emphasis on pain and anxiety management, management of medical emergencies and management of such medically compromised patients. The student will also be able to understand basic principles of wound healing, preoperative assessment, in -patient management and post-operative management of the patients.

Throughout this course, the students will be able to develop clinical skills in patient communication, evaluation, review of different systems of the body, physical examination, and perform oral surgical procedures.

OBJECTIVES:

a) Knowledge & Understanding: At the end of the course and the clinical training the graduate is expected to

1. Apply the knowledge gained in the related medical subjects like pathology, microbiology and general medicine in the management of patients with oral surgical problem.
2. Diagnose, manage and treat (understand the principles of treatment of) patients with oral surgical problems.
3. Knowledge of range of surgical treatments.
4. Decide the requirement of a patient to have oral surgical specialist opinion or treatment.
5. Understand the principles of in-patient management.
6. Understanding of the management of major oral surgical procedures and principles involved in patient management.
7. Should know ethical issues and communication ability

b) Skills:

1. A graduate should have acquired the skill to examine any patient with an oral surgical problem in an orderly manner. Be able to understand the requisition of various clinical and laboratory investigations and is capable of formulating differential diagnosis.
2. Should be competent in the extraction of teeth under both local and general anaesthesia.
3. Should be able to carry out certain minor oral surgical procedures under L.A. like frenectomy, alveolar procedures & biopsy etc.
4. Ability to assess, prevent and manage various complications during and after surgery.
5. Able to provide primary care and manage medical emergencies in the dental office.
6. Understanding of the management of major oral surgical problems and principles involved in in-patient management.

1. Introduction, definition, scope, aims and objectives.
2. Diagnosis in oral surgery: (a) History taking (b) Clinical examination (c) Investigation.
3. Principles of infection control and cross-infection control with particular reference to HIV / AIDS and Hepatitis.
4. Principles of Oral Surgery:-

a) Asepsis: Definition, measures to prevent introduction of infection during surgery.

• Preparation of the patient
• Measures to be taken by operator
• Sterilisation of instruments – various methods of sterilization etc.
• Surgery set up.

b) Painless Surgery:

• Pre-anaesthetic considerations. Pre-medication: purpose, drugs used
• Anaesthetic considerations – a) Local b) Local with IV sedations
• Use of general anaesthetic

c) Access:

• Inter-oral: Mucoperiosteal flaps, principles, commonly used intra oral incisions.
• Bone Removal: Methods of bone removal
• Use of Burs: Advantages & precautions
• Bone cutting instruments: Principles of using chisel & osteotome.
• Extra-oral: Skin incisions – principles, various extra-oral incision to expose
• facial skeleton: Submandibular, Pre auricular, Incision to expose maxilla & orbit, Bicoronal incision.

d) Control of haemorrhage during surgery

• Normal Haemostasis
• Local measures available to control bleeding
• Hypotensive anaesthesia etc.

e) Drainage & Debridement

• Purpose of drainage in surgical wounds
• Types of drains used
• Debridement: purpose, soft tissue & bone debridement.

f) Closure of wounds:

• Suturing: Principles, suture materal, classification, body response to various materials etc.

g) Post Operative care

• Post operative instructions
• Physiology of cold and heat
• Control of pain – analgesics
• Control of infection – antibiotics
• Control of swelling – anti-inflammatory drugs
• Long term post operative follow up – significance.

5. Exodontia:

General considerations

• Ideal Extraction.
• Indications for extraction of teeth
• Extractions in medically compromised patients.
• Methods of extraction
• Forceps or intra-alveolar or closed method. Principles, types of movement, force etc.
• Trains alveolar, surgical or open method, indications, surgical procedure
• Dental elevators: Uses, classification, principles in the use of elevators, commonly used elevators.
• Complications of Exodontia
• Complications during exodontias; Common to both maxilla and mandible
• Post-operative complications
• Prevention and management of complications.

6. Impacted teeth: Incidence, definition, aetiology.

(a) Impacted mandibular third molar.

• Classification, reasons for removal,
• Assessment – both clinical & radiological
• Surgical procedures for removal.
• Complications during and after removal,
• Prevention and management.

(b) Maxillary third molar,

• Indications for removal, classification,
• Surgical procedure for removal.

(c) Impacted maxillary canine

• Reasons for canine impaction,
• Localization, indications for removal,
• Methods of management, labial and palatal approach
• Surgical exposure, transplantation, removal etc.

7. Pre-prosthetic Surgery: Definition, classification of procedures

(a) Corrective procedures: Alveoloplasty, Reduction of maxillary tuberosities Frenectomies and removal of tori.

(b) Ridge extension or Sulcus extension procedures Indication and various surgical procedures

(c) Ridge augmentation and reconstruction

• Indication, use of bone grafts, Hydroxyapatite implant
• Concept of osseo integration
• Knowledge of various types of implants and surgical procedure to place implants.

8. Diseases of the maxillary sinus

• Surgical anatomy of the sinus
• Sinusitis, both acute and chronic
• Surgical approach of sinus – Caldwell-Luc procedure
• Removal of root from the sinus.
• Oro-antral fistula aetiology, clinical features and various surgical methods for closure.

9. Disorders of T.M. Joint

• Applied surgical anatomy of the joint.
• Dislocation – Types, aetiology, clinical features and management.
• Ankylosis – Definition, aetiology, clinical features and management
• Myo-facial pain dysfunction syndrome, aetiology, clinical features, management – Non surgical and surgical.
• Internal derangement of the joint.
• Arthritis of T.M. Joint.

10. Infections of the Oral cavity Introduction, factors responsible for infection, course of odontogenic Infection, spread of odontogenic infections through various facial spaces.

• Dento-alveolar abscess – aetiology, clinical features and management.
• Osteomyelitis of the jaws – definition, aetiology, pre-disposing factors, Classification, clinical features and management
• Ludwigs angina – definition, aetiology, clinical features, management and complications.

11. Benign cystic lesions of the jaws Definition, classification, pathogenesis.
Diagnosis – Clinical features, radiological, aspiration biopsy, use of contrast media and histopathology. Management – Types of surgical procedures, rationale of the techniques, indications, procedures, complications etc.
12. Tumours of the Oral cavity General considerations

• Non odontogenetic benign tumours occurring in oral cavity – fibroma, papilloma, lipoma, ossifying fibroma, myoma etc.
• Ameloblastoma – Clinical features, radiological appearance and methods of management. Carcinoma of the oral cavity Biopsy – types TNM classification.
• Outline of management of squamous; cell carcinoma: Surgery, radiation and chemotherapy. Role of dental surgeons in the prevention and early detection of oral cancer.

13. Fractures of the jaws:-

• General considerations, types of factures, aetiology, clinical features and general principles of management.
• Mandibular fractures – Applied anatomy, classification. Diagnosis – Clinical and radiological Management – Reduction closed and open Fixation and immobilization methods Outline of rigid and semi-rigid internal fixation
• Fractures of the condyle – aetiology, classification, clinical features, principles of management.
• Fractures of the middle third of the face. Definition of the mid face, applied surgical anatomy, classification, clinical features and outline of management.
• Alveolar fractures – methods of management.
• Fractures of the Zygomatic complex: Classification, clinical features, indications for treatment, various methods of reduction and fixation.
• Complications of fractures – delayed union, non-union and malunion.

14. Salivary gland diseases: –

• Diagnosis of salivary gland diseases
• Sialography, contrast media, procedure
• Infections of the salivary glands
• Sialolithiasis – Sub mandibular duct and gland and parotid duct. Clinical features, management.
• Salivary fistulae
• Common tumours of salivary glands like Pleomorphic adenoma including minor salivary glands.

15. Jaw deformities – Basic forms – Prognathism, Retrognathism and open bite.
Reasons for correction. Outline of surgical methods carried out on mandible and maxilla.
16. Neurological disorders – Trigeminal neuralgia – definition, aetiology, clinical features and methods of management including surgical. Facial paralysis – Aetiology, clinical features. Nerve injuries – Classification, neurorrhaphy etc.
17. Cleft Lip and Palate – Aetiology of the clefts, incidence, classification, role of dental surgeon in the management of cleft patients. Outline of the closure procedures.
18. Medical Emergencies in dental practice – Primary care of medical emergencies in dental practice particularly –

(a) Cardio vascular

(b) Respiratory

(c) Endocrine

(d) Anaphylactic reaction

(e) Epilepsy

19. Emergency drugs & Intra muscular I.V. Injections – Applied anatomy, Ideal location for giving these injections, techniques etc.
20. Oral Implantology:

• History of implants, their design & surface characteristics and oseointegration.
• Scope of oral & maxillofacial implantology & terminologies
• A brief introduction to various implant systems in practice.
• Bone biology, Morphology, Classification of bone and its relevance to implant treatment and bone augmentation materials.
• Soft tissue consideration in implant dentistry
• Diagnosis & treatment planning in implant dentistry. Case history taking / Examination / Medical evaluation / Orofacial evaluation/ Radiogaphic evaluation / Diagnostic evaluation / Diagnosis and treatment planning / treatment alternatives / Estimation of treatment costs / patient education and motivation.
• Pre surgical preparation of patient.
• Implant installation & armamentarium for the Branemark system as a role model.
• First stage surgery – Mandible – Maxilla
• Healing period & second stage surgery
• Management of surgical complications & failures
• General considerations in prosthodontic reconstruction & Bio mechanics
• Prosthodontic components of the Branemark system as a role model
• Impression procedures & Preparation of master cast
• Jaw relation records and construction of suprastructure with special emphasis on occlusion for osseointegrated prosthesis
• Management of prosthodontic complications & failures.
• Recall & maintenance phase.

21. Ethics

Protocols to be followed:

1. Students must adhere strictly to the clinical timings.
2. Attendance of 75% in theory & 80% in clinical is essential for appearing in university exam.
3. Quota of work to be completed for eligibility for appearing in university exam is a total of 60 extractions (3rd and 4th year combined)
4. Micro seminars by each student maximum for 15 minutes. Topics to be taken from the UG in charge of the department one week in advance of their clinical posting.
5. Every student must present at least one topic each in 3rd year and 4th year
6. In addition to the presenter, all other students must prepare notes of all micro seminars a day in advance and getting them duly approved by the moderator of the day.
7. End posting exam will be conducted on the last two days of clinical posting by the UG in charge of the department along with the other faculty both in 3 rd & 4th year
8. Case allotment will be done based on the student roll number. A student who is absent from the clinical postings will not disturb the case distribution sequence and will have to wait for his/her turn.
9. Upon case allotment, student must take a brief surgical history, record vitals of the patient and discuss their findings with the staff before commencing with the procedure.
10. Following extractions, the students must keep the patient under observation for 15 min on the recovery chairs.
11. Patients must be discharged with prescription as needed and recalled the immediate next day for follow up/further treatment.
12. Hands on training a. 3 rd years – Suturing on sponge (interrupted sutures, figure 8 suture and simple continuous suturing) Wiring technique (arch bar fixation on a single cast) b. 4 th years – Suturing on sponge (all suturing techniques) Wiring techniques ( all techniques, arch bar fixation and IMF)
13. Completion of record books by the end of 4th year clinical posting.
14. Assisting minor surgeries (minimum 2 – for 4th years only)
15. Observation of major surgeries (minimum 2 – for 4th years only)
16. No leave permitted prior permission considered as ABSENT.

1. Interns must adhere strictly to clinical timings.
2. Working lunch break for interns is between 1pm -2pm (divided in 2 batches)
3. Interns must aid in clearing the OP on a rotation basis along with the 1st year PG under the guidance of the faculty
4. Micro seminars by each student maximum for 15 minutes. Topics to be taken from the UG in charge of the department one week in advance of their clinical posting.
5. Hands on training – Suturing on sponge (all suturing techniques) , Wiring techniques (all techniques, arch bar fixation and IMF)
6. Administration of IM and IV drugs to patients under the guidance of staff following BLS training.
7. Demonstration of minor surgical procedures by staff
8. Assisting minor oral surgery cases – 5
9. Performing minor oral surgery cases under guidance – 3
10. Observing major cases in the OT – 4
11. Interested interns can do night duties with PG to familiarize with ICU protocol and in-patient management.
12. Completion of record books by the end of clinical posting.
13. Students are free to work post working hours till 5 pm to complete their quota in the presence of the faculty.
14. Casualty posting on roaster basis

The faculty is devoted to training and mentoring the next generation of oral and maxillofacial surgeons who can practice and teach the discipline. The course is designed as per the guidelines of the Dental Council of India with an aim to provide a balanced approach to patient care, didactic curriculum and research experience.
The postgraduate trainees are extensively trained in various aspects of Oral and Maxillofacial Surgery and includes clinical rotations within various branches of medicine (general medicine, general surgery, anesthesia, plastic surgery, ENT, neurosurgery, orthopedics) at Bhaskara medical college and also postings at various sub specialties of the branch (centers for oral oncology, cleft lip- cleft palate).

The department also has MoUs with GSR Institute of Craniomaxillofacial and Facial Plastic Surgery, Hyderabad, Telangana and MNJ cancer institute, Hyderabad, Telangana where training and research are carried out.

The program outlines address both the knowledge needed in Oral and Maxillofacial Surgery and allied medical specialties in its scope. A minimum of three years of formal training through a graded system of education as specified will equip the trainee with skill and knowledge at its completion to be able to practice basic oral and Maxillofacial surgeon competently and have the ability to intelligently pursue further apprenticeship towards advanced Maxillofacial surgery.

General Medicine:
General assessment of patients including children with special emphasis on cardiovascular, endocrinal, metabolic, respiratory, blood dyscrasias and renal diseases. The candidates are expected to gain competency in managing medical emergencies.
General Surgery:
Principals of general surgery, exposure to common general surgical procedures with special on perioperative care of the surgical patients. The candidates are expected to gain competency in management of surgical emergencies and trauma.
Neuro – Surgery:
Evaluation of the patient with Head injury, exposure to various Neurosurgical procedures, diagnosis and management of neurologic disorders with special emphasis on stroke.
ENT/Ophthalmology:
Examination of Ear Nose and Throat, exposure to common ENT surgical procedures, ophthalmic examination and evaluation, exposure to ophthalmic surgical procedures.
Orthopaedics:
Basic principles of orthopaedic surgery and bone diseases with special emphasis on trauma management. Exposure to various Orthopaedic surgical procedures.
Interpretation of radiographs, CT, MRI and Ultrasound.
Anaesthesia & Critical Care:
Evaluation of GA techniques and management of emergencies, various IV sedation techniques and management of Difficult Airway. Principles of management of patients on ventilator.

Principles of Surgery:
Medical Emergencies:

1. Examination and Diagnosis
2. Exodontia
3. Impaction
4. Surgical Aids to Eruption of Teeth.
5. Transplantation of Teeth
6. Surgical Endodontics.
7. Procedures to improve alveolar soft tissues.
8. Infection of Head and Neck.
9. Chronic Infections of the Jaws.
10. Maxillary Sinus.
11. Cysts of the Orofacial region.
12. Neurological Disorders of the maxillofacial region.
13. Implantology.
14. Anesthesia.
    • Local Anesthesia.
    • General Anesthesia.
15. Trauma.
16. Surgical Anatomy of head and neck.
17. Etiology of injury.
18. Basic principles of treatment.
19. Primary Care.
20. Diagnosis.
21. Soft tissue injury of face and scalp.
22. Dentoalveolar Fractures.
23. Mandibular Fractures.
24. Fracture of Zygomatic Complex.
25. Orbital Fractures.
26. Nasal Fractures.
27. Fractures of Middle third of the facial skeleton.
28. Ophthalmic injuries.
29. Traumatic Injuries to Frontal sinus.
30. Maxillofacial injuries in Geriatric and pediatric patients.
31. Gun shot wounds and war injuries.
32. Osseointegration in Maxillofacial Reconstruction.
33. Metabolic response to trauma.
34. Healing of traumatic injuries.
35. Nutritional consideration following trauma.
36. Tracheostomy.

Salivary gland:

• Sialography
• Salivary fistula and management
• Diseases of salivary gland – developmental disturbances, cysts, inflammation and sialolithiasis.
• Mucocele and Ranula
• Tumors of salivary gland and their management
• Staging of salivary gland tumors
• Parotidectomy

Temporomandibular Joint:

• Etiology, history signs, symptoms, examination and diagnosis of temporomandibular joint disorders.
• Ankylosis and management of the same with different treatment modalines.
• MPDS and management.
• Condylectomy – different procedures
• Various approaches to TMJ
• Recurrent dislocations – Etiology and Management.

Oncology:

• Management of pre-malignant tumors of head and neck region.
• Benign and Malignant tumors of Head and Neck region.
• Staging of oral cancer and tumor markers
• Management of oral cancer
• Radial neck dissection
• Diagnosis and management of tumors of nasal, paranasal, neck, tongue, cheek, maxilla and mandible.
• Radiation therapy in maxillofacial regions.
• Lateral neck swellings.

Orthognathic surgery:

• Diagnosis and treatment planning
• Cephalometric analysis
• Model surgery
• Maxillary and mandibular repositioning procedures
• Segmental osteotomies
• Management of apertognathia
• Genioplasty
• Distraction osteogenesis
• Cysts and tumor of oro facial region
• Odontogenic and Non-Odontogenic tumors and their management.
• Fibro osseous lesions of jawbone.
• Cysts of jaw.

Laser surgery:

• The application of laser technology in surgical treatment of lesions cryosurgery.
• Principles, applications of cryosurgery in surgical management.
• Cleft lip and palate surgery.
• Detailed knowledge of the development of the face, head and neck.
• Diagnosis and treatment planning.
• Current concepts in the management of cleft lip and palate deformity.
• Knowledge of nasal endoscopy and other diagnostic techniques in the evaluation of speech and hearing.
• Concept of multidisciplinary team management.

Aesthetic facial surgery:

• Detailed knowledge of the structures of the face and neck including skin and underlying soft tissue.
• Diagnosis and treatment planning of deformities and conditions affecting facial skin.
• Underlying facial muscles, bone. Eyelids external ear.
• Surgical management of post acne scarring, facelift, bhlepharoplasty, otoplasty, facial bone recontouring etc.

Craniofacial surgery:

• Basic knowledge of developmental anomalies of the face, head and neck.
• Basic concepts in the diagnosis and planning of various head and neck anomalies including facial clefts, craniosynostosis, syndromes, etc.,
• Current concept in the management of Craniofacial anomalies.

1st Year:
Dissection, basic sciences, basic computer sciences, exodontias seminars on basic topics, selection of dissertation topic, library assignment topic, attending O.T. and ward rounds, preparation of synopses and its submission within the six months after admission to the university as per calendar of events.

Examination of basic sciences – one paper of three hours duration to be conducted by the college.
II Year:

• Minor oral surgery and higher surgical training
• Submission of library assignment by the end of first term
• Examination on minor oral surgical procedures – one paper of three hours duration to be conducted by the college.
• Second term (rotation and postings in other department):
• Oncology → 1 Month
• Cleft Lip & Palate → 1 Month
• General Medicine → 15 Days
• General Surgery → 15 Days
• Anesthesia → 15 Days
• Ophthalmology → 15 Days
• Neurology → 15 Days
• ENT → 15 Days
• Radiology → 15 Days
• Orthopedic → 15 Day

III Year:
Maxillofacial surgery, submission of dissertation in the first term, Eg: Six months before the final examination to the university.

Examination of three hours duration three months before the final examination to be conducted by the college. It is desirable to enter general surgical skills and operative procedure that are observed, assisted or performed in the log book in the format as given by KNRUHS in the revised ordinance governing MDS degree course.