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Oral Board Review Textbook > Dentoalveolar > Flashcards

Dentoalveolar Flashcards

1
Q

What is the classification system of third molars?

A

Pell and Gregory:
A-C (relation to second molar), 1-3 (relation to ascending ramus)
A: Third molar occlusal plan in line with 2nd molar
B: Third molar between occlusal plane and cervical junction
C: Below Cervical jntion
1: MD diameter anterior to ramus
2: Half lf crown covered by ramus
3: Tooth completely in ramus

Winter’s:
Based on angle between occlusal plane and longintudinal axis of third molar
Inverted: <0, very rare
Horizontal: 0-30 (10%)
Mesioangular: 31-60 (most common 45%)
Vertical: 61-90 (40%)
Distoangular: >90 (5%)

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2
Q

What are the indications of third molar removal?

A

Pericoronitis (most common reason)
Ortho, pericoronal pathology, caries, fracture, unexplained pain (5% removal helps), overlying prosthesis, periodontal disease

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3
Q

What is the anatomy of the IAN in relation to 3rd molar removal and the incidence of injury?

A

-1% injury incidence
-Generally nerve located buccal and apical

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4
Q

What is the anatomy of the lingual nerve in relation to 3rd molar removal and incidence of injury?

A

-0.6-2% incidence
-Average 2.8mm below crest and 2.5mm medial to lingual cortex
-4.6-21% of lingual nerves at or above crest of bone
-22% reported at lingual plate of bone
-Turns towards tongue at region of first/second molars

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5
Q

At what age does the risk of complications increase in 3rd molar removal?

A

25

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6
Q

What radiographic signs describe intamacy of IAN with roots of 3rd molar? (Rood’s Criteria)

A

-Darkening of root
-Deflection of root
-Narrowing of root
-Bifid root apex
-Diversion of canal
-Narrowing of canal
Interruption in white line of canal

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7
Q

What is alveolar osteitis?

A

-Incidence between 1-30% (subjective criteria)
-Seen at POD 3-7
-Theory: Fibrinolytic activity leads to break down of clot
-Risk factors: Tobacco smoke, increased age, pericoronitis, birth control, female gender, inexperienced surgeon, inadequate irrigation, increased medical co-morbidities

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8
Q

When can a root tip be left in place?

A

-Non-infected
-Small (<2mm)
-Risk of surgery outweighs benefit

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9
Q

What is the incidence of bleeding with 3rd molar surgery?

A

.2-5.8%
-Must rule out coagulopathies

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10
Q

How does gelfoam work?

A

-Absorbable gelatin spone
-Matrix for blood clot formation
-Gelatin made from purified porcine skin
-May cause excessive granuloma or fibrosis

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11
Q

How does Avitene work?

A

-Microfibrillar collagen
-Mechanically broken down bovine collagen
-Aggregates platelets onto fibrils and acts as a matrix for blood clot formation

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12
Q

How does HemCon/Chitoflex work?

A

-Chitosan dressing
-Polysaccharide from shellfish
-Positively charged to attract erythrocytes
-Acts as a scaffold for clotting
-Dissolves in 48h

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13
Q

How does thrombin work?

A

-Promotes clot formation through activated bovine prothrombin
-Activates factors IIA
-Acts as a serine protease converting fibrinogen to fibin

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14
Q

How does surgicel work?

A

-Oxidized regenerated methylcellulose
-Binds platelets
-Negative pH is bacteriostatic and precipitates fibrin
-More effective than gelatin sponge
-Aids in pressure hemostasis
-Causes prolonged healing,
-Can be neurotoxic (acidic environment)

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14
Q

How does a collaplug work?

A

-Cross-linked collagen
-Promotes platelet aggregation

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14
Q

How does a teabag help with hemostasis?

A

-Tanin serves as a vasoconstrictor

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15
Q

How does Amicar work (aminocaproic acid)?

A

-Stabilizes clot by inhibiting plasmin

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16
Q

How does TXA work (5% tranexamic acid)?

A

-Antifibrinolytic, inhibits conversion of plasminogen into plasmin

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17
Q

What is the management for displacement of a root into the sinus?

A

-Most commonly palatal root of maxillary 1st molar
-Take PA to verify position
-Attempt to suctioning into sinus to remove
-Pack sinus with xeroform gauze and pull out in one stroke
-Preform antral lavage
-Have patient block opposite nostril and blow nose
-Enlarge opening and explore

-fragments 3 mm or less that are not infected can be left in place (inform patient)

-Removal with Caldwell-Luc approach

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18
Q

How are OACs managed?

A

-3-6 mm: Place gel foam and close with figure-eight suture
->6mm: May require tension free primary closure, exicision of fistulous tract and inversion into the sinus. Consider buccal fat pad closure, buccal finger flap or tongue flap

-Sinus precautions 2 weeks, decongestants, antibiotics that cover sinus flora, no blowing nose

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19
Q

What is the management of displacing a root into the submandibular/sublingual space?

A

-Lingual cortex thins out in more posterior region
-Displacement often inferior to mylohyoid muscle

-First attempt to milk root back through cortical hole via manipulation
-Attempt at a lingual flap extended anterior to premolar with an incision to detach mylohyoid muscle
-Allow 6 weeks for fibrosis
-Get a CT scan to localize root
-May require transcutaneous approach via submandibular incision

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20
Q

What is the management for displacement of a root into the infratemporal space?

A

-Likely due to lack of retractor protection with excessive force/poor visualization
-Most likely lateral and inferior to pterygoid plate
-May attempt to manipulate tooth back manually
-Extend incision and retrieve with hemostat
-Allow 4-6 weeks to allow for fibrosis, obtain CT scan and use a spinal needle to identify, diessect along needle length
-Reported to preform a hemicoronal incision

-If no functional deficit and asymptomatic, may leave in place

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21
Q

What is the management for displacement of a root into the IAN canal?

A

-Retrieval attempts may lead to nerve damage
-Single attempt with suction should be attempted
-If root is not infected and no neurologic abnormality, consider leavign in place

-If sensory complication, must retrieve
-CT scan should be taken to ensure location
-Can approach by unroofing extraction site, lateral window intraoral or submandibular incision

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22
Q

What is the management for aspiration of a foreign object during dentoalveolar procedure?

A

-Heimlich maneuver may be attempted
-If under GA, deepen level of sedation and attempt visualization and removal with Magills

-If no respiratory distress, likely ingested
-Obtain abdominal and CXR to rule out

-Assume aspiration, place on right side and in trendelenburg, watch for signs of hypoxia and respiratory distress. ER for removal

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23
What is the incidence and typical patient demographics of impacted maxillary canines?
-2% incidence (0.4% mandibular canines) -2:1 female ratio -Canines normally erupt between 11 and 12 years of age -Labial impaction due to arch length discrepancies -Palatal impaction seen with peg or missing laterals -Genetic theory: Genetic disposition -Guidance theory: Max canine erupts along lateral incisors, malformation or lack of lateral leads to failure of canine
24
What are aspects of your clinical exam pertinent to impacted canines?
-Pay attention to bulging of area -Evaluate gingival health and quality (thick vs thin, presence of gingivitis, quantify amount of keratinized tissue (may affect approach) -Evaluate presence and position of lateral incisor -Examine tonsils and adenoids (sedation considerations) -Mobile teeth (aspiration risk) -Ortho treatment (Where will chain be secured, is there adequate space for a canine ~7.5 mm)
25
Describe your radiographic work-up of an impacted canine?
-CBCT -Clark's SLOB rule (same lingual, opposite buccal) -Pan: If horizontal/larger and out of focus likely palatal. Labial often vertical
26
What ortho considerations are needed pre-op prior to an expose and bond?
-Create room for canine before expose and bond -stabilize teeth with full thickness passive wire to allow anchorage -Need about 7.5 mm of space -The more perpendicular the canine is to the lateral, more likely tooth needs to be extracted instead of E&B
27
Describe the interceptive technique for impacted maxillary canine.
-Extract primary canine before age 11 if not palpable on buccal. 91% success. Success drops to 64% if crown is mesial to midline of lateral incisor
28
Describe the apically positioned flap technique for impacted maxillary canine.
-For labial impaction (and not displaced mesial or distal) -Maintains keratinized gingiva -Use if less than 3 mm of keratinized gingiva is expected after open window technique -Don't use for canines high in alveolus (thick palatal bone can push canine buccally and create dehiscence. Use closed technique -Flap is Mesial-distal width of tooth -Remove bone over surgical margin and remove follicular remnants -Reposition flap apically at cervical margin -Acid etch (30 seconds with 30% phosphoric acid), irrigate thoroughly with water -Know system you use (primer and bonding agent) -I use OrthoSource cuspid bond primer and adhesive (one drop of primer, adhesive over gold mesh and cure on tooth x40 seconds) -Suture keratinized tissue apically around CEJ of tooth
29
What is the open exposure technique for impacted canines? (Window technique)
-Crown is uncovered and left exposed -Ortho bracket may or may not be used -Window of overlying gingiva is removed or reflected -Tooth may spontaneously erupt or site can be packed with periodontal packing (left 2-3 weeks)
30
What is the closed technique for expose of impacted canines?
-Used when teeth are not in position to allow for repositioning of flap after crown exposed -For palatal impaction that is not close to the alveolar ridge -Local, full thickness flap, expose tooth crown to CEJ -Etch with 30% phosphoric acid 30s -Ensure hemostasis -Primer/bonding agent -Orthosouce primer and adhesive, apply 1 drop of primer and spread, apply adhesive to gold chain and light cure 40s -Test chain -Secure chain to bracket -Flap sutured back to place -Ortho traction after 1 week of tissue healing
31
How do you manage a situation in which an impacted tooth fails to erupt after an expose and bond?
-Re-explore area and check for ankylosis (percuss tooth and check for a high pitched sound) -Luxate tooth may aid in mobility -May consider segmental osteotomy or corticotomies -Consider extraction of tooth (leave space for dental implant, premolar substitution, autotransplantation
32
What are other complications of expose and bond?
-Resorption of tooth: Occurs from aggressive exposure, stop orthodontic movement and re-eval, consider extraction -Lack of attached gingiva: Occurs from poor quality of gingival mucosa, over-aggressive tissue removal and inappropriate treatment selection. May need a connective tissue graft -Bracket detachment: Occurs from ankylosis, disruption in path of guidance, over-aggressive movement, poor bonding. Re-exposure of tooth, check for ankylosis. Consider reattachment (consider polish with pumice or diamond burr to aide in bonding. Do not use ligature!)
33
What can happen if you remove bone past CEJ during expose and bond?
-Root resorption -Ankylosis -Perio disease
34
What is the correct terminology in describing nerve anatomy?
-Endoneurium: Connective tissue sheath that surrounds group of fibers forming a fascicle Perineurium: Connective tissue surround a bunch of fascicles within a nerve Epineurium: Outermost layer of a peripheral nerve, surrounding multiple fascicles and blood vessels
35
What is the incidence of IAN and lingual nerve injury from 3rd molar surgery?
-Lingual nerve: 0.04-0.6% -IAN: 0.1-1% -IAN more likely to self resolve -33% chance of persistent nerve impairment of IAN after 1 year s/p BSSO
36
What is the Seddon classification?
Based on histology -Neuropraxias: Focal segmental demyelination without disruption of axon continuity -Axonotmesis: Anatomical interruption of the axon with either none or partial interruption of connective tissue framework -Neurotmesis: Complete transection of a nerve
37
What is Sunderland's classification of nerve injuries?
Type 1: Neuropraxia. Temperary disturbance in nerve conduction. No treatment. Typically recovery spontaneously in up to 3 months Type 2: Axonotmesis. Loss of continuity. Endoneurium and perineurium intact. Surgery only if foreign body. Possible spontaneous recovery at 2-4 months Type 3: Axonotmesis. Endoneurium ad axonal loss of continuity, perineurium. Severe crush or chemical injury. Treat with microsurgery if no improvement for 3-4 months. Possible partial spontaneous recovery Type 4: Axonotmesis. Loss of endoneurium, perineurium. Epineurium intact. Extreme crush. Microsurgery if no improvement 3-4 months Type 5: Neurotmesis. Complete transection. Requires microsurgery Type 6: Neuroma. Requires microsurgery
38
What is the term for when you have pain from a non-painful stimulus?
Allodynia
39
What is the definition of anesthesia?
Absence of any sensation
40
What is anesthesia dolorosa?
Deafferentation pain is pain felt in an area, which is completely anesthetic to touch
41
What is hyperalgesia?
Increased response to stimulus that is normally painful
42
What is hyperpathia?
-Prolonged pain following a repetitive noxious stimulus that lingers beyond expected uration
43
What is hypoalgesia?
Diminished response to a normally painful stimulus
44
What is hypoesthesia?
Decreased sensitivity to stimulation
45
What is the definition of paresthesia?
Abnormal sensation (not unpleasent)
46
What is tinel sign?
Tingling or 'pins and needles' sensation. Elicited by tapping on distribution of the nerve
47
What is Wallerian degeneration?
Distal degeneration of the axon and its myelin sheath after injury, may result from passive wasting of the distal axonal fragment due to lack of nutrient supply
48
How is a nerve injury graded/evaluated?
Modified Medical Research Council Scale. S0-S4 S0: No sensation S1: Deep cutaneous pain S2: Some superficial pain and touch sensation S2+: Superficial pain and touch plus hyperesthesia S3: Superficial pain and touch w/o hyperesthesia, 2 point>15 mm S3+: Same as S3, 2 point 7-15 mm S4: 2 point 2-6 mm
49
What are the average two-point discrimination distances?
IAN generally 4 mm Lingual generally 3 mm Anything over 6.5 mm considered abnormal Lower lip mucosa: 3.5 mm (upper normal 6.5) Lower lip skin: 5 mm (upper normal 9) Chin: 9 mm (upper normal 18) Tongue tip: 3 mm (upper normal 4.5) Tongue dorsum: 5 mm (upper normal 12
50
What is the ideal timeframe for intervention of a nerve injury?
3 months critical for intervention. At 12 months, distal nerve tissue too damaged and recovery unlikely. Monitor every 2-4 weeks, at 3 months generally do not see further improvement
51
Describe your neurosensory testing.
Level A: Spatiotemporal perception. Aa & Ab fibers. -Cotton swab brush strokes. -2-point discrimination (4 mm normal, 6.5+ abnormal) -Stimulus localization with cotton stick (1-3 mm off considered normal) -If level A normal, no need to do further testing Level B: Static Light touch -A-b fibers -Touch skin with end of cotton tip applicator (should be able to feel w/o skin indentation), use Semmes-Weinstein monofilaments Level C: Nociception -A-delta and C fibers -27 gauge needle without indentation of skin should evoke pain response -Can delineate A-delta with heated gutta percha vs cold testing. Diagnostic Nerve blocks: If patient complains of altered sensation/pain, a block can be given to establish if pain is from peripheral nerve vs central. If central, very unlikely to help with surgery
52
What imaging can be completed prior to nerve injury repair?
-CBCT or panorex can help give insight on foreign body, retained root, hardware or bony damage. Does not give insight on nerve integrity
53
What are indications for nerve repair
-Observed nerve transection -Complete post-op anesthesia -Persistent anesthesia x1 month w/o improvement -Prescence or development of dysesthesia -Paresthesia w/o improvement x3 months -Foreign body in canal -Pt unable to tolerate hypoesthesia
54
Describe the steps of a nerve repair.
-External neurolysis (decompression): First step, exposing nerve from soft tisue bed without disrupting epineurium. May be only procedure if only mild disturbance and no neuroma -Neuroma excision: Resect 3 mm proximal and distal. Examine fascicles under magnification. Consider frozen sections -Direct neurorrhaphy: 4-6 circumferential epineural sutures with 7.0-9.0 nylon sutures. Lingual nerve gap of 1 cm and IAN gap of 5 mm possible for direct repair. Minimal tension -Nerve grafting: Need 25% longer graft than defect due to shrinkage. Sites include sural, greater auricular. May also use Processed allograft (axogen Avance, non-immunolgic alternative that provides scaffold) -Entubation: Polyglycolic acid conduit that breaks down in 3 months and resorbed by 9 months. Collagen type I tubes best <10 mm
55
What is the associated morbidity with a sural and greater auricular nerves?
-Sural: Anesthesia of heal and lateral foot, gait disturbance -Greater auricular: Anesthesia of lateral neck, posterior mandible and earlobe. Small diameter may require cable graft
56
What is the overall prognosis of nerve repairs?
-Overall success rate around 50% -70% of painful neuromas have improvement -All require sensory education after surgery -Hypoesthetic nerve injury better prognosis than hyperesthetic injuries -Delays >6 months have poorer outcomes
57
What is a coronectomy?
Partial tooth removal leaving roots behind to prevent inadvertent IAN damage
58
What are contraindications to coronectomy?
-Horizontal impaction with tooth along length of nerve, risk sectioning higher than complete removal -Inability to access or remove all enamel layer -Infection of roots -Plan for distalization of 2nd molar -Mobility of roots
59
What is the technique for coronectomy?
-Removal of all enamel and root remnant 3 mm below alveolar crest of bone -Post-op antibiotics and primary closure have little effect of success
60
What is the prognosis s/p coronectomy?
-Roots migrate 30% of time and can usually be appreciate within first 3 months

Oral Board Review Textbook (26 decks)

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