Oral Sugery p323 Flashcards
Stages of surgery
- anaesthesia
- access
- bone removal as necessary
- tooth division as necessary
- debridement
- suture
- achieve haemostasis
- post-operative instructions
- post-operative medication
- surgical access
surgical access principles
- wide-based incision to aid circulation
- use scalpel in one firm continuous stroke
- no sharp angles
- adequately sized flap
- flap retraction should be down to bone and done cleanly
- minimise trauma to interdental papillae
- no crushing
- keep tissue moist
- ensure flap margins nd sutures will lie on sound bone
- make sure wounds not closed under tension
- aim for healing by primary intention to minimise scarring
2 reasons for soft tissue retraction
access to operative field
protection of soft tissues
how to retract soft tissue
flap design facilitates retraction
Howarth’s periosteal elevator or rake retractor
should be done with care
Bone removal and tooth division is done by using….
electrical straight handpiece with saline cooled bur
(air driven handpiences may lead to surgical emphysema)
round or fissure tungsten carbide burs
REMEMBER PROTECTION OF SOFT TISSUES
priniciples of use for elevators
- mechanical advantage
- avoid excessive force
- support instrument to avoid injury to pt if it slps
- ensure applied force away from major structures e.g. antrum, ID canal, mental nerve
- always use elevators under direct visison
3 different types of elevators movement
wheel and axle
wedge
lever
3 classes of surgical debridement
physical
irrigation
sucation
how to perform physcial surgical debridement
bone file or handpiece to remove sharp bony edges
mitchell’s trimmer or Victoria currette to remove soft tissue debris
how to perform irrigation surgical debridement
sterile saline into socket under flap
how to perform suction derbridement
aspirate under flap to remove debris
check socket for retained apices etc
5 aims of suturing
- reposition tissues
- cover bone
- prevent wound breakdown
- achieve haemostasis
- encourage healing by primary intention
2 types of suture material
monofilament
polyfilament
monofilament sutures characteristics
single stranded
pass easily through tissue
resistant to bacterial colonisation
polyfilament sutures characteristics
several filament twisted together
easier handling
prone to wicking and colonisation
how to achieve haemostasis peri-operatively
- LA with vasoconstrictor
- artery forceps
- diathermy
- bone wax
how to achieve haemostasis post-operatively
pressure
LA infiltration
diathermy
WHVP
surgical
sutures
possible causes of teeth fracture
- thick cortical bone
- root shape and number
- hypercementosis
- caries
- ankylosis
- alignment
18 possible perioperative complications
- difficult access
- abnormal resistance
- # tooth
- # root
- # alveolar plate
- # maxillary tuberosity
- # manible/maxilla
- oro antral communication
- soft tissue danage
- damaged to nerves/vessels
- continuity/nerve transected
- haemorrhage
- dislocation of TMJ
- damage to adjacent teeth/restorations
- extraction of permanent tooth germ
- broken instruments
- wrong tooth
possible causes of difficult access for oral surgery
microstomia
scarring
congenital reasons
tooth crowding
trismus
causes of abnormal resistance during oral surgery
thick cortical bone
shape/form/no. roots
hypercementosis
ankylosis
most common place for alveolar plate to #
usually buccal plate
3’s and 6-8’s
aetiological reasons for # maxillary tuberoisity
single standing molar
unknown unerupted molar wisdom tooth
pathological gemination
extracting in wrong order
inadequate alveolar support
treatement of # maxillary tuberoisty
- remove/treat pulp
- ensure occlusion free
- antibiotic and antisepsis
- instruction post op
- remove tooth 8 weeks later
mandible/maxilla causes
- impacted wisdom tooth
- large cyst/atrophic mandible
- radiographs essential
- forceful application
how to dx oroantral communcation
- size of tooth
- radiographic position of roots in relation to antrum
- bone at trifurcation of roots
- bubbling of blood
- nose holding test (careful as can create an OAF)
- direct visison
- good lighting and suction - echo
- blunt probe 9take care not to create an OAF)
management of oro-antral communication
- encourage clot
- suture margins
- antibiotic
- post-op instructions
loss of tooth management in oral surgery
- where?
- STOP
- suction
- radiograph
possible damage to nerves/vessels in oral surgery
- crush injuries
- cutting/shredding injuries
- transection
- damage from surgery or damage from LA
may not know at the time
neurapraxia
contusion of nerve
continuity of epineural sheath and axons maintained
axonotmesis
continuity of axons but not epineural sheath (disrupted)
neurotmeisis
complete loss of nerve
anaesthesia
numbness
paraesthesia
tingling
dysaesthesia
unpleasant sensation/pain
hypoaesthesia
reduced sensation
hyperaesthesia
increased/heightened sensation
possible haemorrhages in oral surgery
- veins (+++)
- arteries - spurts/haemorrhage (+++)
- arterioles -spurts/pulsating (+++)
- vessels in muscle
- vessels in bone
how to deal with dislocations of the TMJ
relocate immediately (analgesia and advice on supported yawning)
if unable to relocate try local
anaesthetic into masseter intraorally
if still unable to relocate - immediate referral
possible damages to adjacent teeth/restorations
hit opposing teeth with forceps
crack/fracture/move adjacent teeth with elevators
crac/fracture/remove restorations/crowns/bridges adj
teeth
how may accidentally extract permanent tooth germ
e.g. when removing deciduous molar extraction or damage too developing permanent premolars
how to manage if instruments breaks during oral surgery
stop
radiograph
retrieve
common post operative complications
- pain/swelling/ecchymosis
- trismus
- hamorrhage
- prolonged effects to nerve damage
- dry socket
- sequestrum
- infected socket
- chronic OAF/root in antrum
sequestrum
a piece of dead bone tissue formed within a diseases or injured bone
possible haemorrhage timings
intraoperative
immediate post op (within 48hrs after vasoconstrictor wears off)
secondary bleeding 3-7 days later due to infection
dry socket characteristics
- often starts 3-4 days after extraction
- takes 7-14 days to resolve
- localised osteitis -inflammation affecting lamina dura
- some say clot does not form others say clot breaks down
- smoking/female/contraceptives/LA vasconstrictor can all predispose
- hamaetagenous bacteria in socket, excessive rinsing
management of dry socket
- warm saline
- analgesia
- alvogel (LA and antiseptic mix)
symptoms of dry socket
- dull aching pain - moderate to severe
- ususally throbs/can radiate to patient’s ear/often awake at night
- exposed bone is senstive and is the source of the pain
- characterist bad smell and taste
uncommon post operative complications
- osteomyelitis
- osteoradionecrosis
- MRONJ
- actinomycosis
- infective endocarditis
infective endocarditits
caused by rheumatic fever, heart valve replacment and anthing dental - but very rare
was hypothesised that post extraction microorgamisms would form vegetations on the heart valve leading to IE
NICE guidelines “AB prophylaxis for IE is not recommended routinely” - Risk assess pt
actinomycosis
rare bacterial infection
(Actinomyces israelli/A.naeslundii/A.viscosus)
- the bacteria have low virulence and must be inoculated into an area of injur or susceptibility
- e.g. recent extraction/severely carious teeeth/bone fracture/ minor oral trauma
- it erodes through tissues rather than follow typical fascial planes and spaces pattern of progression
presentation and treatment of actinomycosis
fairly chronic
- multiple skin sinuses and swelling
- thick tenacious pus
- bacterial colonies look like sulphur granulus on histology
responds to antibiotic therapy but returns when therapy stopped
- have to remain on antibiotics for a long time - penicillins, doxycycline or clindamycin
refer
what is osteomyleitits
invasion of bacteria into cancellous bone causes soft tissue inflammation and oedema in the closed bony marrow spaces
effect of osteomyletitis
- oedema in an enclosed space leads to increased tissue hydrostatic pressure
- higher than blood pressure feeding arterial vessels
- compromised blood supply results in soft tissue necrosis
- involved area becomes ischaemic and necrotic
- bateria proliferate because normal blood borne defences do not reach the tissue
osteomyelitis spreads until arrested by antibiotic and surgical therapy
where is the most common site for osteomyelitis
mandible
- only main vessle is the inferior alveolar artery which also has deep overlying cortical bone which limits penetration of periosteal blood vessels
= poorer blood supple and more likely to be infected
appearance of osteomyleitis
bone takes on a patchy/moth eaten appearance when seen radiographically
main organisms involved in osteomyelitis
- streptococci
- anaerobic cocci - Peprostreptococcus
- anaerobic gram -ve rodes - Fusobacterium and Prevotella
changes between early, acute suppurative and chronic osteomyelitis
early osteomyelitis
- difficult to distinguish from dry socket/localised infection
acute suppurative osteomyelitis
- little to no radiographic change
chronic osteomyelitis
- pus/no pus, with bony destruction in area of infection
osteoradionecrosis
seen in patients who have received radiotherapy of the head and neck to treat cancer
bone within radiation beam becomes virtually non-vital
- endarteritis = reduced blood supply
- turnover of any remaining viable bone is slow
- self-repair ineffective
- worse with time
mandible most commonly affected (poor blood supply)
care of osteoradionecrosis
differing opinions on whether careful routine extraction ir surgical is best
Antibiotics, CHX and review
provide hyperbaric oxygen to increase local tissue ocygenation before and after surgery
bisphosphonates
class of drugs used to treat osteoporisis, Paget’s disease and malignant bone metastases
inhibit osteoclast activity and so inhibit bone resorption and therefore bone renewal
can remain in body for years
aetiology of MRONJ
- occurs post extraction
- trauma/spontaneous
- exclusive to jaws
- both mandible and maxilla
- risk higher in patients receiving IV bisphosphonates but still occurs in patients on oral bisphosphonates
- ranges from small asymptomatic areas of exposed bone to extensive bone exposure/dehiscence/pus/pain
- drug dose/diabetes/steroids/chemo/smoking are risk factors
what to do if pt has MRONJ
avoid extraction if at all possible
if a must -> refer
medications that can cause MRONJ
- bisphosphonates
- RANKL inhibitor + monoclonal antibody - Denosumab
- antiangiogenic drugs - Bevacuzimab (block growth factor) and Sunitinib nad Sorafenib (bind to tyrosine kinase receptor)
spread of infection
submandiblular space
Molar teeth roots below the mylohyoid line
Signs and symptoms of a submandibular space infection:
- trismus (difficulty opening the mouth),
- inability to palpate the inferior border of the mandible
- swelling of the face over the submandibular region.
If the space contains pus, the usual treatment is by incision and drainage
- The site of the incision is extra-oral, and usually made 2-3cm below, and parallel to, the inferior border of the mandible
spread of infection
submental space
located between mylohyoid line superiorly and the platysma inferiorly
This space may be created by pathology, such as the spread of pus in an infection
- Odontogenic infection of the mandibular anterior teeth may erode through the lingual cortical plate of the mandible.
If the level at which the infection breaks out of the mandible is below the attachment of the mylohyoid, then it will spread into the submental space
- However, it is more usual for odontogenic infections to spread into the submental space via first involving the submandibular space.
Cutaneous infections or symphyseal/parasymphyseal mandibular fractures may also give rise to a submental space infection.
Signs and symptoms of a severe submental abscess include
- a firm swelling below the chin
- dysphagia (difficulty swallowing).
Treatment is by surgical incision and drainage, with the incision running transversely in a skin crease behind the chin.
spread of infection
sublingual space
fascial space of the head and neck
It is a potential space located below the mouth and above the mylohyoid muscle, and is part of the suprahyoid group of fascial spaces.
- This space may be created by pathology, such as the spread of pus in an infection, e.g. odontogenic infections.
A periapical abscess may spread into the sublingual space if the apex of the tooth is above the level of attachment of mylohyoid, and the infection erodes through the lingual cortical plate of the mandible.
Signs and symptoms of a sublingual space infection might
- a firm, painful swelling in the anterior part of the floor of the mouth.
- A sublingual abscess may elevate the tongue and cause drooling or dysphagia (difficulty swallowing).
- usually little swelling visible on the face outside the mouth.
Comes with a risk
➡ Ranula can form if sublingual plica incised
➡ wharton’s duct and sublingual vasculature is located
here
sublingual infection tx risk
Comes with a risk
➡ Ranula can form if sublingual plica incised
➡ wharton’s duct and sublingual vasculature is located
here
cause and singns of sublingual infection
A periapical abscess may spread into the sublingual space if the apex of the tooth is above the level of attachment of mylohyoid, and the infection erodes through the lingual cortical plate of the mandible.
Signs and symptoms of a sublingual space infection might
- a firm, painful swelling in the anterior part of the floor of the mouth.
- A sublingual abscess may elevate the tongue and cause drooling or dysphagia (difficulty swallowing).
- usually little swelling visible on the face outside the mouth.
casue and signs of submental infection
Odontogenic infection of the mandibular anterior teeth may erode through the lingual cortical plate of the mandible.
If the level at which the infection breaks out of the mandible is below the attachment of the mylohyoid, then it will spread into the submental space
- However, it is more usual for odontogenic infections to spread into the submental space via first involving the submandibular space.
Cutaneous infections or symphyseal/parasymphyseal mandibular fractures may also give rise to a submental space infection.
Signs and symptoms of a severe submental abscess include
- a firm swelling below the chin
- dysphagia (difficulty swallowing).
signs of submandibular infection
Signs and symptoms of a submandibular space infection:
- trismus (difficulty opening the mouth),
- inability to palpate the inferior border of the mandible
- swelling of the face over the submandibular region.
spread of infection
mental space
a fascial space of the head and neck
It is a potential space, bilaterally located in the chin,
between the mentalis muscle superiorly and the platysma muscle inferiorly.
Commonly the origin of the infection is an anterior mandibular tooth with associated periapical abscess which erodes through the buccal cortical plate of the mandibular at a level below the attachment of the mentalis muscle
mental space infection cause
Commonly the origin of the infection is an anterior mandibular tooth with associated periapical abscess which erodes through the buccal cortical plate of the mandibular at a level below the attachment of the mentalis muscle
spread of infection
buccal space
lies between the Buccinator muscle and overlying skin and superficial fascia
Commonly the origin of the infection is an anterior mandibular tooth with associated periapical abscess which erodes through the buccal cortical plate of the mandibular at a level below the attachment of the mentalis muscle.
- A hematoma may create the buccal space, e.g. due to hemorrhage following wisdom teeth surgery.
Buccal space abscesses typically cause a facial swelling over the cheek that may extend from the zygomatic arch above to the inferior border of the mandible below, and from the anterior border the masseter muscle posteriorly to the angle of the mouth anteriorly.
Long standing buccal abscesses tend to spontaneously drain via a cutaneous sinus at the inferior of the space, near the inferior border of the mandible and the angle of the mouth.
An untreated cutaneous sinus can cause disfiguring soft tissue fibrosis, and the tract can become epithelial lined.
signs of buccal space infection
typically cause a facial swelling over the cheek that may extend from the zygomatic arch above to the inferior border of the mandible below, and from the anterior border the masseter muscle posteriorly to the angle of the mouth anteriorly.
buccal space healing complication
Long standing buccal abscesses tend to spontaneously drain via a cutaneous sinus at the inferior of the space, near the inferior border of the mandible and the angle of the mouth.
An untreated cutaneous sinus can cause disfiguring soft tissue fibrosis, and the tract can become epithelial lined
spread of infection
infraorbital/canine space
It is located between the levator anguli oris muscle inferiorly and the levator labii superioris muscle superiorly.
Canine space infections may occur by spread of infection
from the buccal space
Signs and symptoms of a caninen space abscess include
- swelling that obliterates the nasolabial fold.
If left untreated, infections of this space will eventually spontaneously drain via the medial or lateral canthus of the eye, as this is the path of least resistance.
Treatment is usually by surgical incision and drainage, and
the incision is placed inside the mouth to avoid a facial scar.
Odontogenic infections may spread to involve the canine
space.
- most likely causative tooth is the maxillary canine or maxillary first premolar.
This occurs when pus (e.g. from a periapical abscess), perforates the buccal cortical plate of the maxilla above the level of attachment of the levator anguli oris muscle.
- more likely if the tooth root is long (the maxillary canine has the longest root of all the teeth), and its apex lies at a level above the muscle attachment.
causes of infraorbital space infection
Odontogenic infections may spread to involve the canine
space.
- most likely causative tooth is the maxillary canine or maxillary first premolar.
This occurs when pus (e.g. from a periapical abscess), perforates the buccal cortical plate of the maxilla above the level of attachment of the levator anguli oris muscle.
- more likely if the tooth root is long (the maxillary canine has the longest root of all the teeth), and its apex lies at a level above the muscle attachment.
OR
by spread of infection from the buccal space
signs of canine space infection
swelling that obliterates the nasolabial fold
tx of infraorbital/canine space infection
Treatment is usually by surgical incision and drainage, and
the incision is placed inside the mouth to avoid a facial scar
if left untreated, infections of this space will
eventually spontaneously drain via the medial or lateral
canthus of the eye, as this is the path of least resistance.
