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 Table of Contents  
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 397-400

Guidelines for maxillofacial surgeon concerning emergency operative procedures in COVID-19 outbreak

Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission19-Dec-2020
Date of Decision10-Feb-2021
Date of Acceptance30-Mar-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Saurabh Sunil Simre
DMIMS Campus, Raghobhaji PG Boys Hostel Room No. 17, Second Floor, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha - 442 004, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_454_20

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The COVID-19 pandemic is now a global problem that has significantly impacted the safe practice of Maxillofacial Surgery. It is important to compile information and experiences that have been gained worldwide and define a set of guidelines for best practice for staff performing these procedures and for patients undergoing maxillofacial surgery procedures. As such, these recommendations should be treated as “expert opinion” and are based mostly on personal communication, guidelines put forth by various national and international societies, and peer-reviewed data when possible. Surgical procedures involving the nasal–oral–endotracheal mucosal region are high risk due to aerosolization of the virus, which is known to be in high concentration in these areas when compared to swabs from the lower respiratory tract1. Further, it appears that if viral particles become aerosolized, they stay in the air for at least 3 h, if not longer. Based on experience in Wuhan, China, and Northern Italy, N95 masks were not enough to control this spread of the disease and it was not until powered air-purifying respirators were introduced that transmission of the virus was controlled among medical personnel. The current paper focuses on setting basic guidelines for dental operating surgeons in taking up an emergency operative procedure.

Keywords: COVID 19, Maxillofacial Surgery, severe acute respiratory syndrome

How to cite this article:
Simre SS, Kambala R, Jadhav A, Bhola N. Guidelines for maxillofacial surgeon concerning emergency operative procedures in COVID-19 outbreak. J Datta Meghe Inst Med Sci Univ 2021;16:397-400

How to cite this URL:
Simre SS, Kambala R, Jadhav A, Bhola N. Guidelines for maxillofacial surgeon concerning emergency operative procedures in COVID-19 outbreak. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2023 Oct 4];16:397-400. Available from: https://journals.lww.com/dmms/pages/default.aspx/text.asp?2021/16/2/397/328476

  Introduction Top

The COVID-19 pandemic is a worldwide issue which has affected the safe practice of dentistry. The oral health-care providers are at risk in their workplace. It is essential to know about this global problem that has been faced and set some specific guidelines or recommendations regarding undertaking the operative procedures for a nontested patient. These recommendations must include opinion from personal communication, overview from guidelines implemented by other national and international organizations.

In surgical procedures in and out of the oral cavity or near maxillofacial region such as throat, nose, and oral cavity, there is high risk of aerosolization of virus as compared to other surgical procedures as it is very common for the virus to reside in throat and nasal secretions. Further, if these viruses get aerosolized at the time of operative procedures, they stay in air for a minimum of 3 h, if not longer. As it was reported in Wuhan, China, and Northern Italy that N95 masks are not sufficient to restrict the spread of disease, until powered air-purifying respirators (PAPRs) were introduced. PAPRs are said to have control over transmission of virus between health professionals. Based on the report, around 14 staff members in operating room got infected, resulting in death in Wuhan when performing an endoscopic transsphenoidal pituitary procedure. There was significant mortality of otolaryngologists and ophthalmologists evidenced in Wuhan which can be correlated to the fact that the aerosolized virus was transmitted through exposure of nasooral pathways.

It is important to direct treatment recommendations to those who are at stake. The OPD should be limited to those patients in need of emergency medical/dental operative procedure or postoperative visit. It is recommended to wear protective eyewear with N95 or PAPR for personal protection in OPDs. Nonemergency procedures can be handled on telephonic conversations or videoconference, if resources are available and can be replaced by a postdated appointment. Emergency procedures such as emergent airway maintenance, epistaxis, surgical management of maxillofacial fractures that will need open reduction and internal fixation, and oncologic procedures in which a delay in management could affect the ultimate outcome shall be considered for treatment but with proper personnel protection and handling of patients and instruments.

It must be kept in mind that any patient can be infected so, assume all patients to be positive and treat accordingly with all safety measures and personnel protective gear, until the patients have had 2 consecutive RTPCR reports negative with a minimum time interval of 24 h between the two reports as there can be chance of false negative results. Hence, it is important to wait till the proper reporting is being done before initiating any procedure or undertaking any major operation. If it still becomes essential to treat an infected patient, it is mandatory to follow the guidelines and protocols for the protection of personal and surrounding health-care professionals. In most regions, testing of asymptomatic patients is not possible and some road traffic accident patients will not be able to provide a history to risk stratify the patient.

It is important to limit the contact with the patients above 60 years of age having systemic comorbidities or pulmonary disorders or immunocompromised states. They should be given consideration and should be avoided as far as possible. The number of residents and assisting nursing staff should be restricted as much as possible. Proper PPE donning and doughing and training for all members of the team is essential.

  Specific Recommendations Top

These recommendations are to denote for all the procedures that are at level of high risk for everyone, as there can be aerosolization of virus in treating environment. Important suggestions and considerations are provided to attempt to alleviate this risk as much as possible, however realize they remain high risk. PPE recommended for all procedures below are minimum requirement N95 (FFP2) mask with face shield (or mask/with attached shield over N95), gloves, nonporous gown, and disposable hat. Scrubs worn during the procedure should be changed immediately afterward. It is worldwide accepted that FPP3 or PAPR provides better protection and should be used in place of N95 mask if available. We realize that PAPRs may not be widely available, and other systems or strategies such as the Stryker Flute system with a FFP3 mask or and FFP2 or FFP3 mask combined with eye protective wear and a disposable cap can be an alternative.

Maxillofacial fractures

Procedures should be performed by an experienced surgeon, with a minimum assistance possible. In general, closed procedures, if internal fixation is not required for stability of the reduction, are favored. Specific recommendations should be followed based on the anatomical region.

Lower face/mandible fractures

  • Consider closed reduction using MMF screws
  • Consider surgical knife over cautery for incisions
  • Consider using bipolar for hemostasis on lowest power setting
  • Consider self-drilling screws for monocortical screw fixation
  • While drilling, restrict or eliminate excessive irrigant
  • For drilling, consider a battery powered low power drill
  • If a fracture requires open reduction and internal fixation, consider placing MMF screws intraorally, then place a barrier in form of biodressing over the mouth, and use a transcutaneous approach rather than an extended intraoral approach
  • If osteotomy is required, consider use of osteotome instead of electric saw.

Midface fractures

  • Opt for closed reduction alone if fracture is stable after reduction
  • Consider using Carroll-Girard screw for reduction, and avoid intraoral incision, if two-point fixation (rim and ZF) is sufficient for stabilization in ZMC fractures
  • Consider surgical blade over cautery for incisions
  • Restrict repeated suctioning/irrigation
  • Consider using bipolar for hemostasis on lowest power setting
  • Consider self-drilling screws for monocortical screw fixation
  • If osteotomy is required, consider osteotome instead of electric saw or high-speed drill.

Upper face fractures/frontal sinus procedures

  • Consider delay of nonfunctional frontal bone/sinus fractures
  • Avoid endoscopy procedures, and the associated instrumentation as there is a very high risk of aerosolization
  • When performing a frontal sinus obliteration or cranialization, consider performing the mucosal stripping manually, and not using a burr or power equipment
  • While drilling, restrict or eliminate excessive irrigant
  • Consider bipolar cautery for hemostasis on lowest power setting
  • Consider self-drilling screws for monocortical screw fixation
  • If osteotomy is required, consider osteotome instead of electric saw or high-speed drill.

Emergency airway management

Intubation should be performed by the most experienced member of the team. As the procedure should be done once with perfection, it must be carried in single attempt, without exercising excess attempts to beginners. Paralysis should be considered to limit coughing. Restrict the ventilation using Ambu bag/mask before intubating the patient and avoid jet ventilation, suctioning as much as is absolutely necessary to mitigate aerosolization. Intubation is preferred over placement of LMA.

Oncologic care

Consider nonsurgical therapy if it is equivalent to surgery in combination to radiation. Consider various other approaches such as chemoradiotherapy or induction chemotherapy to treat tumors if it is equivalent to surgical procedure.

  • Patients with poor prognosis and outcome if surgery is postponed more than 6 weeks, i.e., cases of SCC of the oral cavity, oropharynx, larynx, and hypopharynx
  • Carcinomas compromising the airway maintenance can be taken for surgery
  • Papillary thyroid cancer with compromised airway, rapidly growing, bulky tumor – opt for surgery
  • High-grade end-stage salivary cancer where surgery is the option
  • High-grade T3/T4 melanoma
  • Rapidly progressing cutaneous SCC with regional disease
  • Salvage surgery for recurrent/persistent carcinomas
  • High-grade sinonasal malignancy without equally efficacious nonsurgical options

Dental procedures

  • Emergency and urgent care should be taken in an environment appropriate to the patient's condition and with appropriate PPE and protection of health-care personnel. Recall that any procedure involving the oral cavity is considered high risk
  • Asymptomatic patients requesting removal of disease-free teeth with no risk of impairment of the patient's condition or pending treatment should deferred treatment to a later appointment
  • Asymptomatic patients, patients under investigation, and patients tested positive for COVID-19, who have acute oral and maxillofacial infections, active oral and maxillofacial disease, should be treated in facilities where all appropriate PPE, including N-95 masks, are available
  • Patients with conditions in which a delay in surgical treatment could result in impairment of their condition or impairment of pending treatment (e.g., impairment of the restoration of diseased tooth when another tooth that is indicated for removal prevents access to the diseased tooth) should be treated in a timely manner if possible.


  • Surgical procedures involving the nasal–oral mucosal regions are high risk for infection of medical personnel due to aerosolization of the COVID-19 virus
  • Asymptomatic patients may be infected with COVID-19 virus
  • Elective procedures and routine ambulatory visits should be canceled
  • Appropriate PPE should be worn during surgical procedures and urgent ambulatory visits, which includes N95/full face shield or PAPR
  • Intraoperative measures which limit the generation of aerosolized virus are recommended
  • Oncologic cases in which a worse outcome is expected if surgery is delayed more than 6 weeks should be performed with appropriate PPE.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18]

  Conclusion Top

COVID-19 pandemic is a constantly evolving situation and these recommendations are based on the best available information at this time. These are general recommendations and the ultimate decision of treating the patients still lies in the hands of treating health-care personnel. The primary goal is to provide safe yet effective means of treatment to patients with minimal risk to practitioner as possible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: Retrospective case series. BMJ 2020;368:368-72.  Back to cited text no. 7
Cao JL, Hu XR, Cheng W, Yu L, Tu WJ, Liu Q. Clinical features and short-term outcomes of 18 patients with corona virus disease 2019 in intensive care unit. Intensive Care Med 2020;46:851-3.  Back to cited text no. 8
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus – Infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 9
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Yang M, Zhao J, Zhang Z. More than pneumonia, the potential occurrence of multiple organ failure in 2019 novel coronavirus infection. Digital scientific journal INSPILIP 2020;47:334-3345. [doi: 10.2139/ssrn. 3532272].  Back to cited text no. 12
Oudit GY, Kassiri Z, Jiang C, Liu PP, Poutanen SM, Penninger JM, et al. SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS. Eur J Clin Invest 2009;39:618-25.  Back to cited text no. 13
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