Final Flashcards
What is considered severe over jet?
7-10mm
What is considered severe reverse over jet (class 3)
-3 - -4mm
What is considered severe open bite?
-3 - -4mm
Most facial deformities in the U.S are what type?
Mandibular deficiency
Vertically maxillary excess
Or both
(This makes up 2% of the population)
What percent of the population has asymmetry in their face?
0.1%
What are some causes of dentofacial deformities?
Inherited tendencies
Prenatal problems
Systemic conditions during growth
Trauma
Environmental influences
Multifactorial nature of facial development ___ prediction of inherited pattern
Precludes
What does fetal alcohol syndrome cause in regards to congential facial abnormalities?
Midfacial hypoplasia
What are three environmental influences that may influence facial growth?
Respiratory difficulty
Mouth breathing
Tongue position
What are some things that trauma can cause in regards to facial growth?
TMJ ankylosis
Assymetric mandibular growth
True or false… any non-restorable teeth should be extracted before surgical intervention
True
When malocclusion involves ____, treating with Orthodontics alone may result in adequate ____ but poor facial or dental esthetics or poor long term prognosis for post-treatment retention (over-compensation).
Skeletal discrepancy
Occlusion
True or false.. it is typically better to delay surgery until growth complete in pts with problem of excess growth. However, surgery can be considered earlier for patients with growth deficiencies
True
What is compensatory response?
Undesirable angulation of anterior teeth
What is decompensation?
Aim of presurgical orthodontics to align the teeth in proper proportion to the arches. Magnifies the appearance of the defect
How long does presurgical orthodontics typically take?
12-18 months
What is the advantage of a vertical ramus osteomoty?
You arent involving the nerve
What is the advantage of rigid fixation (vertical ramus osteotomy)?
You dont have to wire the teeth shut
Is the bilateral saggital split osteotomy used for mandibular excess or deficiency?
Deficiency
What surgery would you do if it is a class 2 dental relationship but the A-P position of the chin is ok?
Total subapical osteotomy
What allows the adequate collateral circulation for mobilization of total maxilla in regards to maxillary excess?
Palatal and buccal gingival Pedicles
In maxillary excess, you may find what classes of occlusion?
1 2 3 Open bite Transverse discrepancy
Vertical maxillary excess is often associated with apertognathia. What is that?
Anterior open bite
Results from excess downward growth of maxilla
Causes downward rotation of mandible
Result of premature contact of posterior teeth
Corrected by superior repositioning of maxilla in one or several pieces. Le fort osteotomy with or without segmentalization
What class of occlusion do you often see in maxillary/mid-face deficiency?
Class 3 with reverse anterior over jet
What surgical procedure do you do for maxillary horizontal deficiency?
Le fort 1 advancement
In severe midface deficiency you can do a lefort ___ advancement
2 or 3
What is the most common serious congenital anomaly in the orofacial region? It occurs 1 out of ___ births in the US
Cleft lip and palate
700
Who is cleft lip/palate more often seen in?
Less frequent in blacks, more frequent in Asians
Boys more often than girls
True or false… most cases of cleft lip are bilateral
False. 3/4 are unilateral (left>right)
True or false.. you can be genetically predisposed for cleft lip/palate
True
True or false… supernumerary teeth may be involved in cleft palates
True
What type of occlusion is seen in cleft palate?
Class 3 (pseudo-prognathism)
What are the hearing problems involved with cleft palate?
Levator veli and tensor veli palatini muscles unattached, make middle ear a closed space.
Requires myrinogotomy or leads to hearing loss
What is an alteration in a pts speech that persists after surgical correction of cleft palate?
Hyper-nasality
When is the usual time to correct cleft lip and cleft palate?
Cleft lip - rule of 10s (10wks)
Palate - usually 8-18 months
What are some advantages and disadvantages of early surgical repair of cleft lip/palate?
Advantages: proper muscle development, ease of breast feeding, development of phonation skills, better auditory function, better hygiene, psychological
Disadvantages: more difficult surgery on small structures. Scar formation causes maxillary growth restriction
True or false… in a palatorrhaphy, the hard palate is closed with soft tissues only.
True. The 3 layers include nasal mucosa, muscle, and oral mucosa
How does the maxillary sinus communicate with the environment?
Middle nasal meatus and nasal vestibule
What four arteries supply the maxillary sinus?
Facial artery
Maxillary artery
Infra-orbital artery
Greater palatine artery
The pterygoid plexus drains into the ___ vein. It also communicates with the cavernous sinus by ___
Facial
Emissary veins
What is the nerve supply to the maxillary sinus?
ASA MSA PSA IO Greater palatine
How thick is the bone in front of the maxillary sinus?
1mm
This is why palpation works well. When you palpate the superior alveolar nerves are stimulated
What are three types of developmental anomalies seen with the maxillary sinus?
Agenesis (completely absent)
Aplasia/hypoplasia (seen with cleft palate, Chonal atresia, high palate, septal deformity, mandibular dysostosis, malformation of external nose)
Supernumerary (two completely separated sinuses on same side)
Hypoplasia of the sinus is seen with what conditions?
Cleft plate
Choanal atresia (back of nasal passage is blocked)
High palate
Septal deformities
Mandibular dysostosis
Malformation of external nose
What is the most common symptom of acute sinusitis?
Headache
What should you do if a pt fails to respond to the initial tx within 72 hours?
Culture and sensitivity tests should be carried out
What are some similarities between pulpal pain and sinusitis pain?
Tenderness on percussion
Sensitive to cold
Pain on mastication
What are some things that distinguish sinusitis pain from pulpal pain?
Cannot locate pain (unlike pulpal pain)
Radiating pain/headache (may also be present in pulpal pain)
Fever (may also be present in pulpal pain)
Viral infection
Pain of changing position
Nasal discharge
Foul taste, blood, pus, tinged mucous
When can sinus lift procedures contribute to acute maxillary sinusitis?
When the sinus membrane is severely lacerated or avulsed
When the sinus is overfilled
*significant disruption of the sinus membrane allows exposure of the graft material to the open sinus and possible contamination by nasal bacteria. (This is why you must place a membrane cover befor you place bone graft)
True or false… fistula are ALWAYS lined by stratified squamous epithelium and the patency of the tract is preserved until epithelial cells are removed
True
True or false… fistulas are associated with acute sinusitis
False. Chronic sinusitis
True or false… oro-antral fistulas are often iatrogenically created
True
True or false… you should be conservative with the A-P dimension of the palatal flap by making it short to avoid the artery
False. You want to be anterior enough so you contain the artery within the flap. Make it anterior enough so you dont cut the artery.
What is the difference between a pseudocyst and retention cyst?
The serum under the lining.
Pseudocyst = accumulation of serum (not mucus)
Retention cyst = accumulation of mucin forming a true cystic lesion
True or false.. you cannot distinguish between a pseudocyst and a retention cyst radiographically
True. You’d have to biopsy
What are the causes of pseudocysts and retention cysts?
Pseudocyst = cause is not clear but may be replanted to inflammation of the sinus lining
Retention cyst = blockage of ducts within the mucus-secreting glands within the sinus
Which antral pathology can become expansile and erode the walls of sinus?
Mucocele
This is why you must differentiate through removal and biopsy
Why are nasal cavity and sinus tumors so dangerous?
They are extremely close to vital organs
Sino-nasal malignancies are rare in the US but common in ___ and ___
Africa and Asia
Among the sino-nasal tumors, __ - ___% are maxillary sinus tumors
60-70%
Other than the two most common malignancies of the sinus (SCCA, adenoid cystic carcinoma) what are other types of malignant tumors of the maxillary sinus?
Malignant melanoma
Lymphoma
Salivary type neoplasm
Sarcomas
Metastatic tumors
What are some etiologies that can lead to cancer of the maxillary sinus?
Viral infections (EBV and HPV)
Exposure to wood dust
Nickel and chrome industries
Leather industries
Iatrogenic causes (irradiation)
What are the clinical features of a maxillary tumor?
Nasal obstruction
Recurrent sinusitis
Cranial neuropathy
Sinus pain
Facial parashteia
Propotosis
Diplopia
The treatment of maxillary tumors depends on the extent and histological type. What are some treatments?
Surgery - maxillectomy
Radiotherapy - total 6500 rads in 5 weeks
Chemotherapy - cisplatin and 5 flurouracil
Combined management
Should the chair be lower for the extraction of maxillary or mandibular teeth?
Mandibular
True or false.. in the first step of an extraction, you use the periosteal elevator to sever the PDL
False.. just separate the soft tissue attachements.
What is very important before extraction?
Proper oral hygiene
An un-obstructed pathway is a requirement for ideal extraction. What can you use to ensure an unobstructed pathway?
Use a bite block. This is because pts usually close their jaw to compensate for the pressure
When are tractional forces used for tooth extraction?
The final removal of tooth from socket. They should always be small forces because teeth are never “pulled”
What is the initial movement during the extraction of the lower second and third molars?
Lingual (this is also the direction that these teeth should be finally withdrawn)
All other teeth (expect those with conical roots) the initial movement should be buccal
What is the initial movement used in upper central incisor and lower second premolars?
Primary rotary movement
Why should the final withdrawing movement of teeth be outward?
To avoid traumatizing the opposing tooth
When would you use the wheel and axel technique?
When one root of a multiple-rooted tooth is left in the alveolar process
__% of the population have sought TMD treatment
16%
What is the dividing line between neck vs. jaw in muscle ligamentous?
Jaw is in front of the ear canal
What kind of a splint do you want for muscle ligamentous?
Hard maxillary splint that opens the bite to a flat bite… ? (Not sure what he meant by this)
What is the most common TMD?
Muscle-ligament problems
You should always look for complicating disorders associated with internal derangements such as…
Ehlers-danlos
Prescription medication
Psycholigical
Abuse
Habits
Rheumatoid arthritis develop intra-articular __ formations. Can involve ___
Pannus
Bone loss
True or false.. the treatment varies between youth and aged for TMJ arthritis
True
What are some treatments for TMJ arthritis?
Physical therapy
Bite splint?
Prosthetic joint
Injection of platelet rich plasma and stem cell
Injection of hyaluronic acid (need to inject both spaces)
TMJ arthritis can cause mild to substantial bony changes, bone spurs and ___
Sub-condylar cyst formation
True or false.. TMJ arthritis bone changes always occur slowly
False. They may occur rapidly
What does it mean to not treat an X ray. “It it moves and doesn’t hurt it is a joint”
If its asymptomatic and functional, there is no reason to correct it
What does the sound sound like in TMJ arthritis?
Bone on bone fibrillar “bony” sounds
Pain is variable more deep sense constant
…this guy’s slides dont make any sense… smh..
True or false.. arthrocenesis is very helpful for TMJ arthritis. Steroids and physical therapy are also useful
True
True or false… splints are useful treating TMJ ankylosis
False
True or false.. fibrous TMJ ankylosis may continue to bony ankylosis
True.
Bony ankylosis doesn’t move, unlike fibrous ankylosis
True or false… steroid injections are useful for TMJ ankylosis
True
What is a medical condition that can lead to TMJ ankylosis?
Ankylosing spondylitis
Muscle calcifications
Is TMJ arthroscopy effective for rheumatoid arthritis?
No. Just osteoarthritis
What is TMJ arthrocentesis?
Injection of cannula and lavage of fluid in joint.
What is the biggest risk with TMJ arthrocentesis?
Its close to the ear canal (2mm away)
You can puncture the ear drum and even dislocate the ossicles
Although TMJ tumors (and malignancies) are rare. List the most common to least common TMJ neoplasms.
Osteo-chondroma
Osteoma
Chondroma
Facial planes in face can cause death from tooth infection within __ days (if spreads to specific facial planes)
5
Pus is present in __
Abscesses
What are the two ways in which odontogenic infections are spread?
Periapical spread
Periodontal spread
6% of bacteria in odontogenic infections are ___.
44% are ___.
50% are ____.
Aerobic bacteria: 6%
Anaerobic bacteria: 44%
Aerobic + anaerobic bacteria: 50%
When should you do culture/sensitivity testing of bacteria?
Infection is spreading
Rapid progression
Antibiotics are not working
Compromised host defenses (diabetes/ HIV)
Give it 72 hours
Should you use narrow spectrum or broad spectrum antibiotics in an acute infection?
Narrow
What should you look for in an intraoral examination?
Caries
Swellings of oral vestibule
Periodontal disease
Tooth mobility
Pericornitis
Swellings
*always be thinking about the airway
What does it look like when there is pharyngeal swelling?
Difficulty swallowing
Uvula shifted away
What does it look like if there is swelling in the retropharyngeal space?
Sniffing position
What does it look like if there is swelling in the lateral pharyngeal space?
Head deviated to opposite side
True or false.. when there is cellulitis in the facial planes it can lead to difficulty sleeping in the supine position
True
What happens to the voice with epiglottitis?
Muffled voice
What happens to the voice with swelling in the retropharyngeal/lateral pharyngeal space?
Distant quality to voice
What happens when there is swelling in the sublingual space?
Elevated tongue
Trismus is when opening is less than __mm.
30mm
This can mean they would be difficult to incubate
Inflammation in which spaces will lead to trismus?
Inflammation of muscles of mastication
Masticator space (severe trismus) (Specifically, Pterygomandibular space and temporal space)
Anterior compartment of lateral pharyngeal space (not posterior compartment)
Infection usually goes through cortical or medullary bone?
Medullary bone. (Routes of spread of odontogenic orofacial infections along planes of least resistance)
In infections, the bacteria that first appear are ___, then ___. Cellulitis is typically ___
Aerobes
Anaerobes
Mixed
Can end up in an abscess
True or false… spread of infection through medullary bone is considered cellulitis
False.. cellulitis is inflammation through soft tissue or organ
True or false… cellulitis develops swelling rapidly and often involves a high fever
True
How long does it take to form ludwigs angina?
It can form within 4 hours
Clinical examination of cellulitis underestimate extent in __% of cases
70%
Where is the best place to evaluate the cellulitis?
Site of origin
What antibiotics do you give a pt who is allergic to penicillin?
Clindamycin (great bone penetration)
Azithromycin
Clarithromycin
True or false.. pus is a reason to put someone on antibiotics
True. Pain and swelling may also be reasons.
What drug should you first give someone with an odontogenic infection?
Pen V (its narrow spectrum against gram positive and streptococcus species are highly prevalent)
True or false… gangrenous gas is worse than pus
True
What does infection in the vestibular space look like?
Diffuse facial swelling
Elevation of the oral vestibule
Draining sinus
True or false… in a vestibular space infection you should take out the causing tooth.
False. You dont necessarily have to extract the tooth but you need to open up the area to change the oxygen environment. (Not sure about this one, my notes are unclear)
In a sup-periosteal space infection, the dental infection perforated the __ but not the ___
Cortical layer but not periosteum
A buccal space infection is a ___ space infection. It connects to what three spaces?
Subcutaneous
Infraorbital space
Periorbital tissues
Superficial temporal space
In children, buccal abscesses are hardly ever due to a problem with a tooth, it is mostly ___
Sinusitis or idiopathic spread of an upper respiratory tract infection (hemophilus influenzae cellulitis)
What is your workup if you are suspecting a facial plane infection?
CT (if you can)
Radiograph
Trismus evaluation
Examine dentition (try to find the potential location for the origin of spread)
What happens if you get cellulitis in bilateral submandibular spaces and submental/sublingual space?
Ludwig’s angina
What has a submandibular “woody” swelling, elevated tongue, and pt is in sniffing position, mouth pain, drooling, dysphagia.
Ludwig’s angina
True or false… trismus is involved in ludwigs angina
False
True or false.. lymph nodes are involved in ludwigs angina
False
What are two dangerous things about Ludwig’s angina?
Rapid spread to lateral pharyngeal and retropharyngeal space and beyond
*rapidly obstructs upper airway (number one issue) ( may need to do tracheotomy)
How do get a submental space infection?
Secondary spread from submandilbar space (its part of the sublingual and submylohyoid spaces)
You can get a submental space infection from mandibuar molars.
True or false.. it is possible to get a submental space infection from a mandibular third molar
True
True or false… a simple swelling can end up in the mediastinum, no matter where you start.
True. All odontogenic infections from any location have the potential to spread anywhere
What are the most likely teeth to cause buccal space abscesses?
Maxillary molars and premolars because of the thin bone
Which is safer of the two compartments of the lateral pharyngeal space… anterior or posterior?
Anterior is safer
What is found in the anterior compartment of the lateral pharyngeal space?
Muscles
CT
What is found in the posterior compartment of the lateral pharyngeal space?
Carotid sheath
9-12 cranial nerves
Sympathetic trunk
(This is considered the neuromuscular compartment)
Where are peritonsillar abscesses found?
Lateral pharyngeal space
What are the signs/symptoms of an infection in the anterior compartment?
Dysphasia
Trismus
Pain
What are the signs/symptoms in the posterior compartment>
No trismus
Neurological/vascular problems… such as issues with the VAGUS nerve and other cranial nerve palsies
Edema of epiglottis and larynx
Horner’ syndrome (involves eye)
Superlative jugular thrombophlebitis (lemierre syndrome)
Carotid artery erosion
True or false.. an infection in both the anterior and posterior comparment of the lateral pharyngeal space can cause trismus.
False. Anterior compartment can but the posterior compartment does not result in trismus
The retropharyngeal space is delineated by ___ layers of deep cervical fascia. Most important to remember is the __ fascia
3
Alar
The retropharyngeal space starts at __ and ends at ___. It results in ___ spread, affecting __ and ___ tissues
C7
T1
Mediastinal
Pleural
Pericardial
The dangerspace continues from the base of skull to diaphragm
What is preseptal cellulitis?
Cellulitis around orbital space
Subperiosteal abscess can affect the ___
Orbital wall
Orbital cellulitis/abscess can cause what?
Optic nerve damage due to cavernous sinus thrombosis
True or false… an orbital space infection can spread directly into the brain
True
Infection in the masticator space can result in severe trismus because it surround the muscles of mastication. Name the three spaces that come together in the masticator space.
Pterygo-mandibular space (in back of third molar)
Superficial/deep temporal space (Side of head by temporalis)
Masseteric space (head of mandible under the masseter and above the ramus)
What two things can an infection in the temporal space lead to?
Trismus
Cavernous sinus thrombosis
___ is necessary for the diagnosis of the bugs involved in the infection. Always culture with facial plane infections. What kind of testing should you do first?
Pus
Gram stain
What is the surgical treatment for odontogenic infections?
Gravity dependent surgical drainage
Antibiotics secondary
Tooth extraction
In an odontogenic infection, initially the bugs are ___, (treat with __), then ___ (treat with __)
Aerobic streptococci
Treat with penicillin
Anaerobic bacteria (antibiotics that will kill penicillin resistant microbes)
Later, it is a mixed synergistic interaction of bugs that is predominantly anaerobic in nature
___% of odontogenic infectious bugs are penicillin resistant
30-50%
What is the treatment for mediastinitis?
Airway security
Contrast CT
Open thoracotomy
Broad spectrum antibiotics
Cavernous sinus thrombosis is due to ascending septic thrombophlebitis. Its anterior route is ___, its posterior route is ___.
Angular vein (infraorbital space)
Facial vein (buccal space, temporal space can also go this route!)
Cavernous sinus thrombosis causes…
Congestion of retinal veins
CN 6 paresis
Opthalmoplegia
Blindness
Severe orbital/periorbital/infraorbital swelling
What is the treatment for cavernous sinus thrombosis (4 things)
Tooth extraction/RCT
Drainage deep spaces
High dose IV antibiotics
Anticoagulation
What are the 5 suspects for soft and hard tissue lesions?
Developmental
Neoplasm
Reactive/inflammatory
Trauma related
Metabolic/systemic
What is the difference between an ulcer an erosion of the soft tissue?
Ulcer: a defect or break in continuity of the mucosa that creates a punched-out area similar to a crater
Erosion of the soft tissue: a shallow defect in the mucosa caused by mechanical trauma
True or false… leukoplakia very often precedes the development of a malignant tumor
True
What is the difference between minor RAU and minor RAU?
Minor: episodes fewer than 6 times a year. Lesions usually heal within 7-10 days. Smaller lesions
Major: outbreaks of larger, deeper ulcers that take longer to heal
True or false.. there is no histological connotation associated with erythroplakia
True? But on the same slide it says…
Most can histologically be diagnosed as epithelial dysplasia or worse
Areas of erythroplakia have an increased rate of progression to carcinoma
What are the three types of erythroplakia?
Homogenous form
Erythroleukoplakia
Specialized erythroplakia
What is the differential breakdown for a 35 year old female who says there is a red area on FOM?
Physical trauma
Chemical burns
Infectious or non-infectious mucositis
Epithelial dysplasia (erythroplakia)
Carcinoma in-situ
SCCA
Does midazolam have analgesia?
No
Its used for anxiolysis, short half life, amnestic qualities, status epilepticus
What are the top two medical emergencies in the dental office?
Syncope
Allergic reaction
What is the reversal for midazolam?
Flumazenil
True or false.. a dentist will encounter an average of 4-7 emergencies in their first 5 years of practice
False
True or false.. a bronchospasm is a protective reflex
False.. a laryngospasm is however
What are the most common causes of symptomatic orthostatic hypotension?
A drop in the systolic BP of 10mm and diastolic BP of 10mm when repositioning the pt
Impaired autonomic reflex mechanisms
Not hypovolemia
What pt population do you need to take extra percautions with administration of opioid and sedation medications?
Elderly and pediactric pts
True or false… arterial pulsations cause a source of mismeasurment in pulse oximetry readings
False. Venous pulsations can cause errors. As well as bilirubin, color interferences, and body movements
True or false… pts who are sedated, once awoken and can tell you their name, DOB, and location can be disconnected from the physical monitoring and discharged with an escort.
False
In otherwise healthy pts, the duration of NPO for clear liquids is at least __ hours
6
In the case of re-implanted or significantly displaced teeth with closed foramina, RCT should be instituted when?
2 weeks after initial stabilization
What is the recommended minimum stabilization period for dentoalveoalr injuries with tooth displacement?
2-3 weeks
In evaluation of pts with significant facial trauma, what should the first consideration be?
Airway
In treating severe facial injuries involving maxillary, orbital, nasal, zygomatic, and mandibular fractures, the treatment begins with…
The mandibular arch and condyles to establish a vertical dimension then the occlusion
True or false… the first rule of pt care is to do no harm unless the practitioner feels it is necessary to do harm to save a life
True
What is the most common cause of end stage renal disease?
Diabetes
True or false.. oral surgical procedures are planned the same day as dialysis to avoid too much clotting
False
True or false… adjustment in dosing is needed when giving an opioid when they are also on benzodiazepines
True
True or false… benzodiazepines in moderate sedation should always be reversed by flumazenil
True
All of the following are examples of pre-prosthetic surgical intervention except…
A: tuberosity reduciton of mandibular lingual ridge
B: palatal torus reduciton
C: maxillary tuberosity reduction
D: maxillary frenulum trimmming
A
What are three characteristics of sympotmollogy of a mandibular fracture?
Cranial nerve 5 division neurosensory deficit of the lip and chin
Ecchymosis in FOM
Discontinuity of fracture segments
