Final Flashcards
There are different types of nerve fibers. Which of the myelinated nerve is responsible for Proprioception and which one is for Fine touch… Know your Myelinated nerve on Table 41-2
- Proprioception: a-beta
- Fine touch: a-alpha
When patient has nerve injury, what are the Level A, B, C testing? Example, what’s tests are included in Level A, B, C?
* A:
o Level A test: used to determine the response of the slowly adapting larger myelinated fibers (A-alpha)
o Two point discrimination test: patient’s eyes closed with 2 points of the caliper essential touching so that the patient is able to discriminate only one point. The distance between the 2 points are increased in 2 mm increments until the patient is able to discriminate between two distinct points at 6 mm – which is then considered normal
o Brush stroke directional discrimination: the test is used to determine the response of the slowly adapting larger myelinated fibers (A-alpha) and A-beta myelinated axons. The sensory modalities for these receptors are vibration, touch, and flutter. The brush is stroked gently across the area of involvement at a constant rate, and the patient is asked to indicate the direction of the movement and the correct number of patient statements out of 10 is recorded.
- B:
o Contact detection
o Von Frey filaments
- C:
o Thermal discrimination
o Pinprick nociception
Surgical Nerve Repair.. How you do it? How you put the segmented nerve back together?
- Surgical exploration of the nerve, identification and removal of pathology is present, and identification and repair of severed nerve endings in a tension free manner (epineural neurorrhaphy)
- Nerve repair is completed under general anesthesia in an OR setting, magnification using 3.5x loupes or operating microscope with fiberoptic lighting, and repair using 8-0 nylon suture in epineural fashion
When perform nerve graft, which nerve(s) in our body provides the best answer?
- Sural nerve: preferred since it most appropriately matches the nerve diameter and the fascicular number and pattern of the trigeminal nerve
- Greater auricular nerve
Nerve injury classification. Know Sunderland and Seddon and how they correlate and which nerve injury is more severe. Yes, there is a blue table in your slide under “Sunderland’s Classification”
* Most severe:
Neurotmesis
What’s in the incident of Inferior alveolar nerve injury vs Lingual nerve injury (Know the average?)
* Inferior alveolar never injury:
* Lingual nerve injury:
1.2%
0.9%
How do you injury inferior alveolar nerve and Lingual nerve? In another word, what procedure or movement you have to do to CUT and mess it up? Dude, you are the one with the 15 blade so don’t tell me “I don’t know what happened”.
* Inferior alveolar nerve:
o During extraction of lower third molars, during administration of LA injection, during placement of endosseous dental implants/plates/screws, during RCT, due to pathology, due to infections.
How do you injury inferior alveolar nerve and Lingual nerve? In another word, what procedure or movement you have to do to CUT and mess it up? Dude, you are the one with the 15 blade so don’t tell me “I don’t know what happened”.
* Lingual nerve:
o Third molar extraction is most common etiology for iatrogenic trauma to the lingual nerve.
o Extraction of lower third molars, placement of dental implants through lingual cortex, pathology, LA injection
There are several criteria need to meet before performing Secondary Alveolar Bone grafting. (Slide 89/93) Example: Done before eruption of the permanent canine, usually when the root of the canine is 1/3 to 2/3 formed…… yes, that slide
* Secondary alveolar bone grafting:
o Done before eruption of the permanent canine
o Usually when the root of the canine is 1/3-2/3 formed
o Usually between the ages of 9-11 years
o In CLP dental age is usually behind chronological age
o 3 layered closure (nasal layer, bone graft, oral layer)
o Provide bone for the eruption and/or orthodontic repositioning of teeth
o Closure of oro-nasal fistulas
o Support and elevation of the alar base
o Stabilization of the pre-maxilla in bilateral cases
o Provide continuity of the alveolar ridge
VPI Velopharyngeal Incompetence. What is it? Why do you need to do Pharyngoplasty procedure? (Slide 83/93)
* Velopharyngeal incompetence (VPI)
o The velopharyngeal mechanism is incapable of separating the oral and nasal cavities during swallowing and speech. In this situation, a pharyngoplasty procedure is necessary.
- Indications for Pharyngoplasty:
o Pharyngeal flap surgery may be recommended to resolve velopharyngeal incompetence after patients prove unable to achieve significant speech improvements through speech therapy alone.
o Other requirements to qualify for the surgery include a short wand immobile or easily fatigued palate
What’s special about Palatoplasty? There are layered closure. What are the layers?
(3)
- Nasal layer
- Muscle
- Oral layer
There is a General question that you need to think about CLP patient. CLP patient usually have restricted grow of which part of the maxillofacial region? What does not mean to the patient in term of esthetic? What you may like to do to take care of that? (That’s All I can tell you… I want you to think about it and understand what the overall picture of the CLP patient is)
Slide 53/93. It should be about “Management of Cleft Lip and Palate, Sequence of Interventions”
What is the most commonly used surgical technique to close a cleft lip….
Millar’s Rotation Advancement Flap (unilateral cleft lip and palate)
Cleft lip develops when there is a failure of fusion of what fetal structures?
- Maxillary processes with the lateral and medial nasal prominences (4-7 weeks of gestation)
Anatomical classification of the CLP is based on?
(3)
- Location
- Completeness (incomplete/complete)
- Extent
Incidence of CLP in USA according to different ethnic groups are?
- Native north Americans have the highest incidence rates followed by Asians, Caucasians, Africans
What are the 3 major glands and what do they secrete?
(3)
- Parotid (largest): serous
- Submandibular: serious>mucous
- Sublingual: mucous
Faial nerve is associated with what gland?
- Parotid
o The facial nerve is embedded within the superficial and deep lobes of the parotid gland
Wharton’s duct and Stenson’s duct, what are they and who do they work for?
* Wharton’s duct
o SUBMANDIBULAR
o Excretory duct, exits on the sides of the lingual frenum
o Adjacent to the lingual nerve and drains into punctum within the sublingual caruncles on either side of the lingual frenum. Punctum prevents retrograde flow of fluid
Wharton’s duct and Stenson’s duct, what are they and who do they work for?
* Stenson’s duct
o PAROTID
o Excretory duct emerges anteriorly from gland and is superficial to the masseter muscle, pierces the buccinator muscle
Name the 3 benign salivary gland tumor and which one is more commonly seen?
(3)
- Pleomorphic adenoma – most common
- Warthin’s tumor (Adenolymphoma)
- Canalicular adenoma
What are the 4 common Malignant Salivary gland tumors?
- Mucoepidermoid tumor – most common
- Adenoid cystic carcinoma
- Acinic cell tumor
- Squamous cell carcinoma
How to treat Sialadenitis? (Know the various treatments)
- Sialadenitis is an inflammation of a gland or duct. Inflammation of the salivary glands can arise from various infectious and non-infectious causes
- Treatment:
o Acute sialadenitis is treated by antibiotic therapy and rehydration (fluids), heat, salivary stimulants to stimulate salivary flow
o Surgical drainage may be required if abscesses occur, culture pus
o Management of chronic sialadenitis depends upon the severity and duration of the condition
o Significant inflammatory destruction of the salivary gland (chronic sialadenitis) can occur requiring its surgical removal
Mucocele is usually found at..?
- Lower lip (70%) and buccal mucosa
What is Ranula and know its characteristics.
- Presents as a translucent blue, dome shaped, fluctuant swelling in the tissues of the floor of the mouth
o Mucocele that occurs on the floor of the mouth
o Lateral to the midline
o Plunging or cervical ranulas dissect through the mylohyoid muscle to produce swelling in the neck - Obstruction disorder usually involves the sublingual gland
- Consists of mucin from ruptured salivary gland
- Etiology: usually trauma to duct or gland
- Common in children
- Usually asymptomatic with exception to elevation in the floor or the mouth
What may cause or things associated with Sialorrhea? (increase in salivary flow)
(5)
- Psychosis
- Mental retardation
- Certain neurological diseases
- Rabies
- Mercury poisoning
Treatment for smaller Sialolith includes?
- Small sialoliths can sometimes be removed by gentle massage, sialagogues, moist heat, or increased fluid intake
Most common cause of Mandible fracture?
- Vehicular accidents – 43%
- Assaults – 34%
Types of Mandibular Fracture?
(4)
- Greenstick fracture
o Incomplete fracture, periosteum intact (children) - Simple fracture
o Do not violate mucosa or skin - Comminuted fracture
o Involving multiple fragments of bone which are independently dislocated - Compound fracture
o Associated with bone exposure through tissue avulsions
Common sites for mandible fracture? Hint… SITES.
(3)
- Third molar area, socket of the canine tooth, and the condyle
What muscles attaches to mandible?
(7)
- Masseter
- Temporalis
- Lateral Pterygoid
- Anterior belly of digastric
- Medial pterygoid
- Mylohyoid
- Geniohyoid and genioglossus
Clinical Examination of occlusion while evaluating mandible fracture patient (slide 27/64)
(3)
- Anterior open bite is suggestive of bilateral condylar fractures
- Posterior open bite is common with anterior alveolar process or parasymphyseal fractures
- Unilateral condylar neck fx’s are associated with open bite on the opposite side and deviation of chin towards the side of the fx during mouth opening
Intraoral Examination of mandibular fracture patient (slide 26/64)
(6)
- Anesthesia of the lower lip
- Abnormal mandibular movement
o Unable to close
o Trismus - Lacerations, hematomas, ecchymosis
- Loose teeth
- Palpation for step defects
- Bleeding
Secondary Bone Healing, What area the stages of healing? (Slide 34/64)
(4)
- Hematoma/inflammation
- Soft callus
- Hard callus
- Remodeling
What’s Primary Bone Healing? (Slide 35/64)
(3)
- Involves a direct attempt by the cortex to re-establish itself after interruption without the formation of a fracture callus (open reduction and internal fixation (ORIF))
- Primary healing only works when the fracture edges are touching exactly
- The principle is used for rigid surgical fixation as in ORIF or in green-stick fractures
Main Objective of surgical Treatment of Mandibular Fracture are (Slide 38/64)
What is it?
o — is key
o — of fragments in good position
o — until bony union occurs (IMF = OR – internal fixation with plates and screws)
o — repair
- Restoration of functional alignment of the bone fragments in anatomically precise position utilizing the present teeth for guidance
Normal occlusion
Anatomical reduction
Immobilization
Soft tissue
Study the muscles involved in favorable vs unfavorable fracture (Slide 14-18 / 64)
What are the common indications to perform Orthognathic Surgery?
(5)
- Dentofacial deformities
- Growth disturbances
- Malocclusion from skeletal disharmonies
- Orthodontic problems not amenable to orthodontic treatment alone (transverse maxillary deficiency)
- Obstructive sleep apnea
Pre-Surgical Growth Assessment includes? (Slide 35/98)
(4)
- History (shoe size changes, secondary sex characteristics)
- Hand/wrist films
- Serial lateral cephalograms
- Technetium bone scans (to assess condylar activity)
Principles of Orthognathic Surgery (Slide 31/98)
* Main goal of orthognathic surgery is to —
* Correction of dento-facial deformities using combined orthodontic and surgical treatment can provide dramatic changes in both…
* The key to a successful outcome is correct diagnosis of both …
* Dental compensation can often mask an underlying …
restore form and function
cosmetic and functional aspects of the face
dental and skeletal abnormalities
skeletal deformity
Know the occlusion class with respect to Molar and CANINE (Slide 48-49/98)
LeFort I osteotomy can be used to ….. ( 5 things) (Slide 75/98) I need you guys to understand what hard tissue is cut for LeFort I and think about that structure that you have move about. In this case, you are only freeing up maxilla right?
- To cut and separate the maxilla a the Le Fort 1 fracture lines
- Can be used to:
o Advance the maxilla (max retrognathia)
o Set back maxilla (max prognathia)
o Correct maxillary occlusal canting or tilt (facial asymmetry)
o Superiorly reposition maxilla (vertical maxillary excess)
o Inferiorly reposition maxilla (vertical maxillary deficiency)
Bilateral Sagittal Split Osteotomy Indications (Slide 84/98)
(3)
- Mandibular advancement
- Mandibular set-back
- Mandibular rotation
Components of Nasal Complex (Slide 7/65)
* The — forms the midline support structure of the nose
* The bony portion of the nasal septum consists of the …
* The posterior cartilage portion articulates with the …
* The … bones form the bony floor of the nasal cavity
nasal septum
perpendicular plate of the ethmoid bone posterosuperior and the vomer posteroinferiorly
ethmoid and the vomer
maxilla and the palatine
Anatomy of the Orbit, Bones forming the orbit (Slide 12/65)
* Bones forming the orbit:
(7)
o Frontal
o Zygomatic
o Ethmoid
o Lacrimal
o Maxilla
o Palatal
o Sphenoid
Anatomy of the Orbit, Bones forming the orbit (Slide 12/65)
* Anatomy:
o Floor slopes into the — wall
o The floor is made of — bone and part of the — bounded laterally by the inferior orbital fissure and small part of the ethmoid bone
o — enters the orbit superior-medially to the true apex
o There’s no clear anatomical separation between the …
medial
maxillary,zygoma
Optic nerve (CN 2)
floor and the medial wall of the orbit
Epidemiology of midface Fracture (Slide 23/65)
* Males: females
* Predominately in
* Cause:
* Site:
* In altercations — zygoma fractured more often
4:!
20/30s
MVA>altercation>fall
nasal>zygoma>other
left
During physical examination of midface fracture, what are the common clinical findings? (Slide 27/65)
(7)
- Facial asymmetry
- Peri-orbital ecchymosis
- Subconjunctival hemorrhage and chemosis
- Widened intercanthal distance
- Crepitation and step deformity
- Maxillary mobility and malocclusion
- Rule of Battle’s sign (mastoid ecchymosis – skull base fracture)
Pattern of Fractures of Mid-Facial Skeleton (Slide 30/65)
(4)
- Le fort fracture (maxillary fractures)
- Orbital wall fractures
- Zygomatic complex fracture
- Naso-orbital-ethmoid fracture
LeFort I, II, III fracture patterns. How are they different? Which bone that all LeFort Fractures have in common? (Slide 32-35/65)
- PTERYGOID PLATE
- Lefort 1
o Horizontal fracture through the maxilla above the level of the nasal floor and alveolar process
- Lefort 2 (pyramidal)
o Separation of NF suture, medial orbital walls
(lacrimal bone), inferior orbital floor and rum (adjacent to infraorbital canal and foramen), anterior maxilla below zygomatic buttress and pterygoid plates
o Separation of the block from the base of the skull is completed via the nasal septum and may involve the floor of the anterior cranial fossa
- Lefort 3 (craniofacial dysfunction)
o Separation of NF suture, medial orbital walls (involve the depth of the ethmoid bone and cribiform plate, pass below optic foramen and cross the inferior orbital fissure), inferior orbital floor, lateral orbital wall, ZF suture, zygomatic arch, root of pterygoid plate
3 types of NOE fractures. What’s the difference? (Hint, notice the red accented wordings) (Slide 44/65)
* Type 1
* Type 2
* Type 3
o Involve a single, non-comminuted, central fragment without medial canthal tendon disruption
o Involve comminution of the central fragment without medial canthal tendon disruption
o Result in severe central fragment comminution with medial canthal tendon avulsion
