Oral Surgery Flashcards
What is exodontia?
Tooth extraction
What are the principles of exodontia?
Expansion of bony socket
Separation of attachment of PDL
Separation of gingival soft tissues
What are the average bone losses in the first 1-6 months post exodontia in mm?
Horizontal loss 3.8mm
Vertical height reduction 1.24mm
Which plate (buccal/lingual) exhibits the most resorption post exodontia?
Buccal plate
What is the healing cascade post exodontia?
Clot formation fibrin mesh work. 24-48h
Epithelial migration over socket & clot becomes granular. 7 Days
granulation tissue become collagen &early bone. 20 Days
Bone marrow occupies socket replacing woven bone. 8 weeks
How is the clot formed post exodontia?
Haemorrhage
Bleeding
Platelet aggregation
Clot formation (platelets and leukocytes in fibrin gel).
2-3 days inflammatory cell clean site prior to new tissue formation.
What is a periotome?
Like a sharp flat plastic used to sever PDL
Not used in LDI (expensive)
How is a periotome used?
Long axis of blade Inserted into socket along medial and distal sides
Not used in facial plate because it’s thin and easily damaged
Wait 10-20 seconds with instrument in situ
Then used as a lever
Slow pressure otherwise tip will break
What are luxators?
Thin and sharp sever PDL
Effective
Bone preserving
Separate tooth and bone before extraction
How is a luxator used?
Chops a size matching root diameter
Apply apical pressure
Gently rock to sever PDL
Vacuum broken remove tooth with forceps
What is an elevator?
Rotate around a fulcrum to lever tooth out of socket
What are the three ways to use an elevator?
Lever
Wedge - similar to a luxator
Wheels and axel - between teeth and rotated
What are the three types of elevator?
Couplands straight ones
Warwick James straight and left and right hockey stick
Cryers left and right and mega sharp
What are the 5 pairs of sinuses in the maxilla?
Frontal sinus Ethmoid sinus Sphenoid sinus Nasal cavity Maxillary sinus
What is the average volume of the maxillary sinus?
10.5-18 cm3
What is the ostium?
This is where the maxillary sinus drains into middle meatus of the nasal cavity
What are vascular canals in the sinus?
This are tuberositys wishing the bone lining the sinus where vessels run
Important when carrying out sinus surgery.
(Infra Osseous artery’s)
What are the four functions of the maxillary sinus?
Vocal resonance
Olfactory function (smell)
Warming & humidifying air
Decreasing the weight if the scull
What is pneumatisation?
This is where the sinus drops down between roots.
This is poorly understood
This increases with age and tooth loss.
What is the schneiderian membrane?
This is the membrane that lines the maxillary sinus.
What is the thickness of the schneiderian membrane and how does the alter with gender?
0.34-3.11mm
Males usually thicker
Related to biotype
What is a septa?
These are thin bony projections between walls of the sinuses.
What is the relevance of the maxillary sinus?
Exodontia
Endodontics
Implants
What are complications involving the maxilla related to exodontia?
Oro-antral communication (OAC)
Oro-antral Fistula (OAF)
Displacement if teeth/roots
Maxillary tuberosity fracture
What is an Oro-antral communication (OAC) ?
This is a non epithelialised passage between the oral cavity and the maxillary antrum which can be as a result of exodontia
What is an oro-antral fistula (OAF)?
A pathological epithelial lined passage between the oral cavity and maxillary antrum
How is an OAF formed?
From an OAF that’s untreated, it’s a chronic version.
What cause an Oro-antral communication?
Roots close to the sinus Thin alveolar bone Peri apical pathology Root morphology Lone standing molars Traumatic extractions
What are the signs and symptoms of an OAC?
Signs - visible
-resonant
Symptoms- Bubbling into nose/mouth Discharge Congestion and pain Sinus symptoms Air escaping into mouth
What must you not do if a patient may have a suspected OAC?
Don’t get them to blow nose because if OAC isn’t present it may cause one
What are signs and symptoms of a fistula?
Signs - soft tissue perforations
Prolapse of sinus lining
Discharge
Symptoms-
Bubbling
Air escaping
What are the options for an OAC (5options)?
If tiny, spontaneous healing may occur
Buccal advancement flap
Palatial advancement flap
Buccal fat pad
Playlet rich fibrin (PRF) membrane closure
What is a buccal advancement flap?
This is where the buccal tissue is pulled over to close.
Works best in first attempt
Reduces sulcus depth (denture counter indication)
Tissue is thin so can perforate
Sharp bone must be removed first
Not good for large OAC
What is a palatial advancement flap?
This is where skin from the palate is rotated around to cover OAC
This has a good blood supply
More tissue with less tension
Thi her tissue and preserves sulcus depth
Granulating palate bone (sore) will regrow tissue to
Ensure that it is cut long enough so it will rotate and cover OAC otherwise it’s useless
What is a buccal fat pad?
This is taking tissue from the buccal fat pad to fill OAC
It’s used in conjunction with buccal advancement flap or palatial advancement flap
It’s for larger OAC’s
What’s is playlet rich fibrin?
Patients blood is taken and centrifuged
Playlet rich fibrin with healing cells gel is removed and sutured in place
(Favoured option)
Not available on NHS
What is important about suturing over an OAC?
Has to be watertight otherwise it will break down
What are treatment options for a displaced root?
Gentle suction
Leave
Refer for lateral window removal
What are the 6 places a fractured tooth root be?
Socket Mucoperiosteum Antrum Swallowed Inhaled Suctioned
What is antral regime?
This is what’s used to care for an OAC after it’s been managed conservatively
What are the 6 components of an antral regime?
Analgesia No nose blowing Sneeze like a horse (let it out) No straws Decongestants Consider broad spectrum antibiotics
What are tuberosity fractures?
Fracture of bone.
How do you manage a tuberosity fracture?
If it’s attached and small leave it
Splint if moving
Refer
If significant bleeding out the bone back in get them to bite on gauze and emergency referral
How do you know if it’s a dental sinus infection?
It’s almost always unilateral
What are the dental causes of acutely odontogenic maxillary sinusitis?
Periapical infection
Periodontitis
Peri-implantitis
Post extraction infection
Trauma
Odontogenic cyst
Osteomyelitis
Displacement into sinus
What Bacteria cause non odontogenic acute sinusitis?
Predominantly aerobic bacteria
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhails
Staphylococcus aureus
What bacteria cause odontogenic acute sinusitis?
Commonly anaerobes
Viridans streptococci Fusobacterium Prevotealla Peptostreptoccus Porphyromonas
What bacteria cause odontogenic chronic sinusitis?
Polymocrobrial, viridans streptococci and anaerobes
Similar to acute but reduced number of bacteria
What are signs and symptoms of sinusitis?
Pain and feeling unwell
Throbbing pain worse when leaning forward
Congestion
What happens if sinusitis spreads?
Orbital cellulitis
Cavernous sinus thrombosis
Meningitis
Inter-cranial abscess
What is the STOP Mnemonic?
Site (tissue present)?
Translucency/opaque?
Outline (margins)?
Previous imaging?
What are some big red flags?
Loss of symmetry and tissue masses
Distorted anatomy and displaced teeth
Bone erosions
Teeth floating
What to do if odontogenic cause is excluded?
GP/ENT referral
What to do if odontogenic cause is confirmed (acute &chronic)?
Acute
Antimocrobrial therapy
Early and aggressive
Analgesia
Decongestants - ephedrine nasal drops
Chronic
Eliminate source of infection
Antimicrobrials
What do I need to know about a sinus cyst?
Radio graphic changes (1/3 have mucosal thickening)
Radiological analysis
If in doubt CBCT
If it’s well circumscribed and asymptomatic it’s not likely to be sinister
Remember red flags
If you suspect cancer what are some things you should ask?
Are you experiencing any unexplained weight loss
And vision disturbance
Any tiredness
What are symptoms of neoplasia in a sinus?
Neoplasia erode tissue and bone They may cause bleeding or nasal discharge Have radiological features Cause mobile teeth Ocular symptoms and neorogical signs
What is impaction?
Obstruction in the eruption pathway of
What is the average eruption completion of the third molar?
Early 20s
What are the three types of impaction of a third molar?
Partially covered by soft tissue
Completely covered by soft tissues
Completely covered by bone
What are the four classifications if impaction?
Mesioangular - tilts mesialy
Horizontal - lies horizontally
Vertical - good path but won’t erupt
Distoangular - most difficult to treat
What impaction classification is most common?
Vertical
Mesioangular
Horizontal
Distoangular
What are the statistics about third molars?
Quarter of population have impacted ones
Higher in females
One of most common procedures on NHS
Most common OMFS procedure
What are the most common issues with mesioangular impaction?
Pericoronitis
Caries
Perio
Distal caries in second molar
What is a simptom and a sign?
Symptom - something patient notices
Pain swelling
Sign - observed by professional
Palpitation lumps
BOP
What is pericoronitis
Partially erupted teeth with operculum covering it causes food packing and infection
What is an operculum?
Flap of gingival tissue overlying 8s
What are symptoms of pericoronitis ?
Pain Halitosis Swelling Erythema Bad taste
What happens when pericoronitis progresses?
Tiramus Purexia Lymphadenopathy Malaise Dysphagia
What is trismus?
Limited mouth opening
What is pyrexia?
Fever
What is lymphadenopathy?
Swelling of lymph nodes and glands
What is malaise?
General unwellness
What is Dysphagia?
Difficulty swallowing
Where can swellings appear?
Submandibular
Sublingual
Buccal space
What are issues with submandibular and sublingual swellings?
If they are bilateral then this can obstruct the airway
What symptoms can mimic pericoronitis?
Quinsy
Peritonsilar abscess
Tonsillitis
(Non are our issue)
How do we treat pericoronitis?
If no systemic involvement
Irrigate with warm saline give pt syringe to take home
Take paracetamol ibuprofen etc
Don’t use chlorohexadone given anaphylaxis systemically found from treating dry sockets.
What are the treatment options for pericoronitis with systemic involvement?
Metronidazole 400mg 3 times a day three days (anaerobic)
Amoxicillin 500mg 3 times a day for 3 days
What happens if pericoronitis does not improve with antibiotics?
Removal of molar tooth
May have wrong antibiotic
May have non compliant patient
What are the indications for third molar removal?
Any good reason
Including caries in the 7
Is there any evidence with third molars and crowding?
These don’t cause crowding
What impact successful surgery?
Social and medical history
What impact does high bMI have on third molar surgery?
Worse healing
Short necks
Small mouths
What is different for ginger people?
Bleed more
Require more analgesia because of lower pain tolerance
What radiographs are indicated for third molars?
Periapicals and OPTs CBCT
What is the CBCT indication?
OPT doesn’t give enough info
Might change treatment plan
What nerves can be affected when thinking about third molars?
Lingual nerve
Mylohyoid nerve
Inferior alveolar nerve
Long buccal nerve
What are the indications that suggest a risky third molar surgery?
Superimposed IAN Diversion of INA at apex Darkening of root where INA crosses it Interruption of white lines of canal Darkening of roots associated with widening canal Juxta apical area
What are the indications for tooth roots & how does this make the extraction?
Underdeveloped roots Conical roots - favourable Roots with widened PDL - favourable Splayed roots - challenging might leave roots in. Relationship to second molar
What are the indications around bone and age in third molar surgery?
18 and younger bone very soft less needs to be removed, less dens so will cut and expand better. Better healing.
35 and over much more dense not as flexible more bone removal required worse healing
What are the predictors of difficulty for third molar removal?
Alveolar bone level
Tooth position
Application depth
Doing of elevation
Are there any neurological issues with treating maxillary third molars?
No
What sedation options are there for third molar removal?
LA
LA&IV/Inhilation sedation
LA&GA
What are the warnings to all patients undergoing any kind of oral surgery?
Pain Swelling Bleeding Bruising Infection Dry socket Difficulty opening Damage to adjacent teeth
What do you need to warn patients about with third molar surgery?
Damage to chorda timpani supplying slight taste
IA Nerve
lingual nerve
So lower lip, skin of the chin, side of the tongue, gingivae of lower teeth, lower teeth and taste
This can be pins and needles, pain or complete loss of sensation temporarily or permanently
Will be bruised, time off work and swelling rarely leading to hospitalisation
When is the lingual nerve at risk
Anything too lingual when carrying out a procedure
Or kebabing when suturing
What happens to the long buccal nerve in third molar surgery?
Gets sacrificed only supplies small amount of buccal tissue
What is risk of maxillary third molar surgery?
Fractured tuberosity
OAC
Damage to adjacent teeth
What is critical for third molar exodontia?
Good anaesthesia
What anaesthetics and nerves would you numb before molar extraction?
Lower - lidocaine IA block
Articaine long buccal nerve
Upper -
Articaine buccal and palatial
What is an operculectomy?
Removes soft tissue flap over third molar
What is the periosteum?
Part of bone containing cells for remodelling
What pre-op meds could be given to a straight forward third molar case?
Ibuprofen
What is given post op after third molar removal?
Ibuprofen and paracetamol
What can be given in addition for complex third molar surgeries?
Steroids dexamethasone
What are the indications for air generating turbines in surgery?
No air at all can cause surgical emphysema which is medical negligence
Non air generating rotors
What is a coronectomy?
Removing just the crown of the tooth when the molars are high risk
What happens if roots move in coronectomy?
Roots have to be removed as well.
What is an apicectomy/root end surgery
Removing the apex of a tooth
What is a hemisection
This is premolarisation of a tooth- cutting it in half
What is decompression
When there is a large anterior lesion and a surgical drain is put in to encourage healing before apicectomy
What is special about MTA
Osteoinductive and very biocompatible
What are the indexation for endodontic surgery
To eliminate/reduce infection when’re this isn’t possible non surgically
How is endodontic surgery carried out?
Raise a flap Remove bone to reach apex Clear granulation tissue Remove apical 3mm roots at 90 degree angle Remove 3mm GP and fill with MTA Done
What are counter indications that need to be considered in endo surgery
Tooth Supporting bone Flap design Crowns Veneers Issues of recession Depth of sulcus Size and site of lesion
3 types of flap design
Standard rectangular- includes papilla
Sub marginal - 3mm from gingival margin saves papilla and negates recession
Papilla base - leaves papilla but it to the gingival margin let’s you see more but negates recession abit more.
What factors affect endodontic surgery outcome
Age Sex Health Tooth location Clinical signs and symptoms Lesion size Bone loss Coronal restoration Resurgerey Level of resection Root filling material Haemostatic agent Bone grafting
Why do root canals fail
Presence of bacteria in the root canal. Or biofilm outside if the canal.
How do you do an endodontic retreat don’t restorability assessment
Make sure no cracks
Good amount of dentine
This will only be found out when restoration removed so make pt aware
What could be suggested by a halo or J shaped bone los pattern surrounding a whole root on a radiograph.
Root fracture
What can surgical endo be carried out?
After endo non surgical retreat meant and failure because this improves endo surgery outcome
How is GP removed
Hand files one large mass
Use of rotary instruments
Braiding technique-push 2-3 files down around GP and twist to pull out like a claw
Solvent as last resort
What files are used to remove GP
Headstrom files engage and help pull it out
What are solvents used to remove root filling.
Endosolv - will dissolve rubber dam, one drip needed
What mechanised rotary instruments are available for specific retreatment of a root canal
Pro taper D1-3
Very stiff and can easily extrude a canal
Reciprocating files :
Wave one gold - middle and apical third removal
Reciproc file good for whole removal
What are the two types of healing
Primary - like a cut where there is no tissue loss etc
Secondary - tissue lost distance between margins heal is with a scar
What are the four stages of healing
Haemostasis
Inflammatory phase
Proliferation phase
Remodelling phase
What happens in the inflammatory phase of healing
Cellularisation
Vascularisation
Vasodilation
(Redness heat swelling)
What happens in proliferation phase
Fibrin strands form structure
Fibroblasts lay ground substance and tropocollagen
Capillary formation and collagen formation
What happens in the Re-modelling phase
Collagen fibres destroyed and replaced with better orientated collagen fibres
Wound strength increases
Vascularity and erythema decreases
Wound contracts
What are considerations that need to be made relating to factors that influence healing
Foreign material
Necrotic tissue
Ischaemia
Wound tension
Which does necrotic tissue impact healing
Acts as a barrier to ingrowth of reparative cells and can feed the bacteria
How does ischaemia impact healing
Reduction in blood supply Tissue necrosis Reduction in delivery of antibiotics Antibodies Nutrients
Patient factors that influence healing
Age Heart disease Diabetics Anticoagulants Steroids Bisphosphonates Immunosuppressants BMI (airway, access, medical)
What are the key surgical primciples
Adequate access
Adequate light
Surgical field free of excess blood / saliva
What are key principles of preservative surgery
Sufficient access Preserve vital structures Protect soft tissue Preserve blood supply Closure on sound bone
