Intro to Oral Surgery and Extractions Flashcards
MOPS
minor oral procedure surgery
what are the 2 indications for extractions
clinical
and/or (usually both)
radiographic
(in case of unusual anatomy)
10 reasons for unrestorable teeth that are indicated for extractions
Gross caries
Advanced periodontal disease
Tooth/root fracture
Severe tooth surface loss
Pulpal necrosis
Apical infection
Symptomatic partially erupted teeth
Traumatic position
- E.g. wisdom tooth biting into cheek
Orthodontic indications
- E.g. remove one of the premolars
Interference with construction of dentures
- Seems wrong as want more natural teeth, but if in detrimental odd anatomical position that would worsen the retention
straight upper anterior forceps
Totally flat unique
- Complete touching table surface
Cannot grab posterior teeth
- stretch cheek
Canine to canine on upper teeth
- Ideally upper central
upper universal forceps
Part of handle lifts of table
- Prevent stretching teeth
- Reach further back
Tip the same
Most single rooted teeth
- Canines, 1st and 2nd molars
- Not as good grip on molar
tips of straight upper anterior and upper universal forceps
have concave surface on either side
- Grab a root
used on Single rooted teeth
why is there a different design for upper molar forceps
3 roots
- 2 palatal and 1 buccal
Need either side
- Tips designed to engage roots regarding orientation
Point
- Designed to go into the furcation between 2 buccal roots
Triangle
- Beak to cheek
Smooth end on one side - concave like first ones
Grab single palatal root
point design of upper molar forceps
- Designed to go into the furcation between 2 buccal roots
Triangle
- Beak to cheek
Smooth end on one side - concave like first ones
Grab single palatal root
lower forceps design feature
90 degree bend for good approach and access
No need for lower right and left
- 2 roots (Mesial and distal)
Furcation on both sides
- Pointy beak engage with furcation on buccal and lingual side
lower universal forceps
90 degree bend for good approach and access
Concave on both sides
- engage root surface
Designed for lower 5 to 5 - one root
lower molar forceps
90 degree bend for good approach and access
Pointy beaks
- Buccal and lingual furcation on lower 6s (mesial and distal root)
‘cowhorn’ forceps
90 degree bend for good approach and access
Very pointy and sharp compared to others
Narrow ended
Highly polished - smooth
Used only 2 rooted lower molars
- Need radiographs
- Divergent/straight/separate roots
Put into furcation gap
Squeeze handle
Points go towards each other and lift the tooth up
- less pressure - good for children as bone softer in young
- less mobilising needed
- if not deep enough can crush crown
how to use ‘cowhorn forceps’
Put into furcation gap
Squeeze handle
Points go towards each other and lift the tooth up
- less pressure - good for children as bone softer in young
- less mobilising needed
- if not deep enough can crush crown
advantages of ‘cowhorn’ forceps
- less pressure - good for children as bone softer in young
- less mobilising needed
disadvantage of ‘cowhorn’ forcep
- if not deep enough can crush crown
3 general principles of extraction
Mobilise teeth with special instrument
Forceps on root
Various movements to expand bone socket to give ease of getting tooth out
bayonet forceps design
Easy to reach back with Z shape
- Bayonet pattern
- Don’t stretch cheek
why need for bayonet forceps
Hard to access upper wisdom teeth
Can use upper molar forceps or the top one
- Root pattern variable
- Don’t know where furcation’s are
- Assume one rooted
- Can be poor grip
upper bayonet third molar forceps
like universal with Z end
Part of handle lifts of table
- Prevent stretching teeth
- Reach further back
tip have concave surface on either side
- Grab a root
upper bayonet root forceps
Fine tip
- Removing little roots
- Fracture
- Not wisdom tooth - too narrow, no grip
where is right handed operator in extractions of lower right molars
standing behind the patient on left to pt
where is left handed operator in extraction of lower left molars
standing behind the patient on right of pt
when does the operator stand in front of the pt in extractions
All upper teeth
- Lower left if right handed
- Lower right if left handed
where does a right handed operator stand when standing in front of the pt
in front of the pt to the right
where does a left handed operator stand when standing in front of the pt
in front of the pt to the left (mind spittoon)
how should you change the pt positions for maxillary extractions
lie pt more flat
what does the correct extraction position allow
Non dominant hand cannot support jaw
- Retract cheek, hard palate, protect pt face
Let light in
purpose of elevators
Forceps good at extracting
- But straight to higher chance of breaking teeth
Minimise breaking teeth and get rid of excess easier use these
- Facilitate the extraction
Loosen tooth
- Roots are mobile - easier to get out
coupland’s elevators
Most popular
Different sizes
- 1 - narrowest
- 2
- 3 - widest (top)
Half universal forceps
- Bit sharper at end
Tear PDL
Elevate the tooth
Individually wrapped
Ends can wear with time
Cryer’s elevators
Sets of 2 in pack (R and L)
Pointy
Curved
Elevate broken fractured retained roots
how to differentiate right and left cryer’s elevators
Concave is pointing towards the ceiling - smile to the sky
Point to each other
One in right and left is left
And engraved usually
Warwick James elevators
Like fine Coupland
Sets of 3
- Distinguish left and right like Cryers
- then straight one
Curved is less pointy
Upper wisdom teeth
- Fit better in narrow space
3 elevators
Coupland’s
Cryer’s
James Warwick
non surgical extractions
Forceps and elevators
No flaps/incisions, no bone removal, no sectioning of teeth
surgical extractions
Incisions in gingivae/ mucoperiosteal flaps
Bone removal with drills or chizels
Tooth sectioning with drills
why would you remove gum in a surgical extraction
Expose as much as area as can
Preserve soft tissue
Pathology at root need to clean
Radiograph indicated
what is oral surgery reliant on
Entirely reliant on first stage of procedure - anaesthesia
Regional or block
- Number of nerves with 1 injection
Infiltration
- Underlying Anatomy hope to catch nerve desired
ID Block need to inject long buccal nerve too
regional or block LA
Number of nerves with 1 injection
infiltration LA
Underlying Anatomy hope to catch nerve desired
what is the first consideration prior to extraction
access
- access is success
corenectomy
Remove crown of tooth
Leave roots - Remove top of the tooth and leave roots near nerve to minimise damage - Smooth root down (when healthy) - 3mm bone around Should heal well
Can be used when roots are close to nerves, where surgical removal carries a higher risk of damage to the nerve
- e.g. lower third molars that are half through so can have bacterial invasion
- near ID nerve – bump can cause loss of sensation
Impacted canines and premolars treatment options
They can be uncovered (exposed to allow the orthodontist to bring them into alignment)
- Expose them and attach bracket to encourage them to come through into correct alignment
- Cut away gum, drill away bone and pass to ortho
Or they can be surgically removed if they are causing problems, cannot be orthodontically aligned or are in the way/ preventing orthodontic tooth movement
issues caused by impacted canines or premolars
Permanent Canines and premolars sometimes do not erupt
If left can cause problems to roots of other teeth
when should you palpate for erupting canines
9 years
Oro antral communication
acute communication between mouth and sinus
oro antral fistula
Chronic communication is an epithelial lined tract between mouth and sinus
what can cause an OAC/OAF
From canine to last molar in the upper arch – there can be a close relationship to the maxillary sinus
Extraction can result in a communication between the sinus and oral cavity
- As tooth roots have extended into air sinus space
- Granulated track tunnel from mouth to sinus
- Repeat infections
- Water runs out nose
what must happen if OAC or OAF doesn’t heal
they do not heal they need to be surgically closed
Need to remove tissue and tract to get closure
Can look small in soft tissue, but when remove soft tissue reveal a large hole
Move tissue buccally to palate and close off with sutures
excision
remove the whole lesion
scalpel needed
incision
take a sample of the lesion
scalpel needed
punch biosy
a core: punch a circle around the lesion (excision) or within the lesion (incision)
4mm or 6mm
Multiple layers of mucosa
3 types of soft tissue biopsy
excision
incision
punch biopsy
what is the point of soft tissue biopsies
Provide an answer to what is happening (pathological examination)
how can you give pathologist indication of orientation of soft tissue biopsy
May suture through biopsy to give pathologist context
Medical Hx needed
Mesial and distal or superior and inferior margin
biopsy for lesion that is suspected malignancy
do not remove whole lesion. Take a sample to identify it then produce a definitive treatment plan
- representative sample
lichehn planus/lichenoid reaction
6 different presentation (variable)
Increase risk of developing oral cancer over time
Over reaction of immune system
- Stimulus response - funny presentation
presentation of leukoplakia
White and red patches of unknown origin
White - thickened
Red - thinned
mucoceles
damaged minor salivary glands
- saliva trapped in
mucous extravastation cyst
saliva leaked into submucosal layer
minor salivary gland structure
tiny, grape like
saliva retention cyst
tube for saliva into mouth blocked so cannot escape
damage to minor salivary gland leads to
leak saliva where it shouldn’t be, body walls off and its stuck
- mucoceles
ranula
Damage to sublingual salivary gland (major salivary gland)
like a large mucocele in the floor of the mouth.
- frogs belly
Often marsupialised.
- If does not resolve requires more complex surgery for removal
what can cause mucoceles
trauma
what is the most common minor salivary gland problem
mucocele
what is the saliva like in mucocele
thicker, gluey consistency compared to saliva
appearance of mucocele
Soft bluish swelling fluid filled
- Purple/dark if blood
excision of mucocele
Not falsely inflate the size of the lesion
- Around site
Blunt dissection
- Push layers of tissue off round it
- Scissors in closed and then open up to remove tissue away
Ellipse
- Come together as straight line
Burst at top
cysts
Epithelial lined fluid filled cavities in bone or soft tissue
- Many different types
2 different ways of managing cysts
Enucleation
- removal of entire cyst
Marsupialisation
- removal of part of cyst lining and leaving it open.
- “De-roofing”
- Body can start laying bone down as compromised
enucleation of cysts
removal of entire cyst
Marsupialisation of cyst
- removal of part of cyst lining and leaving it open.
- “De-roofing”
- Body can start laying bone down as compromised
radicular cysts associated
radicular cysts are associated with non vital or dead tooth
periradicular surgery
Surgery around the root of the tooth
- Failed root canal treatment/ non-resolving infection/cyst
- Root fractures
- Post Crowned Teeth – post perforations
Can involve debridement (cleaning), sealing perforations, apicectomy (removal of root apex)
Can refer to endodontic team
- Root treatment is as successful
- Less invasive
- Less risk
preposthetic surgery
E.g. removal of denture induced hyperplasia
- Consistently rubbing on tissue - thicken and grow
- Lumps in the mouth, Not worrying
- But contribute to displacing denture
- Like atrophic ridge – hard to get to fit
Excision of Denture Hyperplasia
dentoalveolar infection treatment
incision and drainage
dentoalveolar infection
Localised collections of pus, patient not systemically unwell – Can be incised and drained in general practice under LA
dentoalveolar infection appearance
Bubble
- Not always like this
Can see sinus - dot
- Chronically draining pus
danager of dentoalveolar infection on palate
can spread infra-orbital and reach eye
painful - palate should be bound to bone, not got flex
how to tell if pt systemically unwell from dentoalveolar infection
Asymmetric
Assessed for heart rate and respiratory
- Sensitive markers of sepsis
Temperature
Bp
To OMFS
- Need more than removing source of infection of tooth and antibiotics
large risk for submandibular dentoalveolar infection
Cross midline – Ludwig’s angina
- Risk to airway
cannot see angle or lower border of mandible as lost anatomy
how to treat severe dentoalveolar infection
incision and drainage
IV antibiotics
- flush and wash out
what does an infection lead to at its site
inflammation - inc blood flow and fluid to area
cryosurgery/cryotherapy is
Liquid nitrogen/ Nitrous Oxide
- Freeze lesions
cryosurgery/cryotherapy on
Haemangiomas (vascular lesion)
- risk of bleeding if excised
malformed blood vessels
congenital or developed
Trigeminal neuralgia
- cryo the nerve involved e.g. infraorbital nerve, mental nerve
facial pain – freeze nerve so no feeling, constantly numbed
TMJ problems
Problems with jaw joint
Pain associated with muscles of mastication
Combination of muscle and joint pain
Often related to tooth grinding/clenching habits
- Parafunctional
TMJ problem treatment
be treated with conservative advice and analgesia, occlusal splints/bite raising appliances (hard/soft)
Modifying habits
- Can be difficult to manage
- Have to manage pt expectation
Habit breaking strategies
