Oral Surgery Flashcards
A 25 year olf patient presents with an impacted lower wisdom tooth. Name a set of published guidelines for the removal of wisdom teeth.
SIGN
NICE
What complications could arise in a patient requiring the extraction of an unerupted premolar if they wear a -/f and the mandibular denture bearing area is very resorbed and the patient has osteoarthritis?
Pain, swelling, bleeding, bruising, infection, dry socket (alveolar osteitis), mandibular fracture (atrophic mandible), MRONJ, immunosurpressed and elderly = increased infection risk, nerve damage
When working through a surgical sieve to reach a diagnosis, what does VITAMIN D stand for?
Vascular, Infective/Inflammatory, Traumatic, Autoimmune, Metabolic, Idiopathic, Neoplastic, Degenerative
List three reasons for the removal of impacted lower wisdom teeth
Pericoronitis
Caries
Systemic symptoms
Pathology
Periodontal disease
What is the incidence of i) temporary and ii) permanent loss of sensation following the removal of wisdom teeth?
i) 10% (anywhere from 5-30% accepted)
ii) less than 1%
List four post op complications of removing wisdom teeth
Pain
Bruising
Swelling
Limited mouth opening/trismus
Other than pain, bruising and swelling, list 6 signs and symptoms of a body of madible fracture
* Bleeding
* Limitation of function
* Mobile teeth
* Lower lip numbness
* Occlusal derangement/step deformity
* Facial asymmetry
What 2 radiographic views would you want to assess a mandibular fracture?
OPT and PA mandible
What factors would cause a mandibular fracture to be displaced?
Pull of attached muscle (unfavourable)
Angulation of fracture line
Magnitude of force
Opposing occlusion
List 3 management options for a mandibular fracture?
Do nothing
ORIF
IMF (inter maxillary fixation)
How does a bite splint for TMD work?
Acts as a habit breaker to reduce parafunctional habits.
Reduces load on TMJ
Decreases abnormal activity
Stabilises occlusion
What is artherocentesis and mechanism of action?
Sterile saline injected into TM joint space. Breaks fibrous adhesions and flushes away inflammatory exudate
Bleeding wont stop following an extraction. How do you manage this?
Take a quick history. Apply pressure. Give LA with vasocontrictor. Suture. Diathermy. If doesnt stop, refer to A&E
What are some local risk factors for delayed onset of bleeding?
LA with vasoconstrictor wears off.
Loosening of sutures
Patient traumatises area with tongue, finger, food
Name 2 congenital conditions that cause prolonged bleeding
Haemophilia A
Haemophilia B
Name 2 aquired conditions that can cause prolonged bleeding?
Warfarin
Aspirin
SIRS (systemic inflammatory response syndrome), 4 criteria with parameters
Temperature equal or greater than 38 degrees, or equal or lower than 36 degrees
Heart rate equal or more than 90 BPM
Respiratory rate equal or greater than 20 breaths per minute
WBC count equal or greater than 12,000 mL, or equal to or less than 4,000 mL. 10% immature nutrophils
How many criteria must be met to get a diagnosis of SIRS?
2 out of 4
List 4 things to take note of with a facial swelling
* Airway compromise
* Fever
* Malaise
* Duration
* Colour
* Size
* Location
*Palpation (firm/mobile)
* Pus
* Heat
Why is written consent gained prior to sedation process?
Patient doesnt have capacity to consent during procedure
What drug is commonly used for IV sedation and what preparation would this drug be?
Midazolam 5mg/5ml IV
What 3 vital signs would you monitor before, during and after sedation?
Oxygen saturation.
Heart rate
Respiratory rate
What drug is used to reverse the effect of midazalam?
Flumazenil
Give 3 pieces of advice you would give to a patient following sedation?
No driving.
Avoid the internet
Dont sign any legal documents
What are the indications for inhalation sedation?
Conditions aggrevated by stress; epilepsy, hypertension, asthma, ischemic heart disease.
Social; anxiety, gagging
Dental; unpleasant or traumatic procedures
What are the advantages of inhalation sedation vs midazolam?
Quicker onset. Quicker recovery. Recovery time independent of dose. No needles. No amnesia. Nitrous oxide not metabolised so very safe. No chaperone required for adults. Less side effects
What are the contraindications of inhalation sedation?
Unable to nose breathe; mouth breather/poor cooperation, cold, tonsilitis.
First trimester of pregnancy
Severe COPD
List the safety features of the quantiflex machine.
* Oxygen flush buttong.
* Reservoir bag.
* Scavenger system.
* Coloured cylinders (black o2, blue NO)
* Pin index so the gases cant be mixed
* Minimum O2 set at 30%
* NO stops if O2 stops
O2 fail safe at 40 psi
* O2 monitor
* One way expiratory valve
When might a referral for GA be made?
When a patient is uncooperative.
When a patient is anxious/phobic
Complex or long procedures
Multiple extractions
Benefits must outweigh risks
Procedure/dentist requires complete stillness
MH contraindicates sedation
What are the 4 stages of anaesthesia?
- Induction
- Excitement
3 Surgical anaesthesia
4 Overdose
What needs to be included in a referral for GA?
Patient name, DOB, address and contact details.
Medica history
GMP details
Justification for GA
Radiographs
Treatment plan
GDP name and contact details
What is the definition of conscius sedation?
Use of drugs to depress the CNS to allow treatment.
The patient must be able to maintain verbal contact, remain conscious, retain protective reflexes and is able to understand and respond to verbal commands
Margin of safety is wide enough so that unintended loss of consciousness is unlikely
What is GABA?
Gamma-aminobutiyric acid
What is the function of GABA?
Inhibitory neurotransmitter in the CNS
What is the half life of midazolam?
90-150 minutes
What are the contraindications for IV sedation
Severe systemic disease.
Severe special needs.
Severe psychiatric problems
COPD
Pregnancy/breastfeeding
Taking erythromycin.
Uncooperative pt
No chaperone
Under 12 yo or elderly
Give 6 things you assess a patient for before IV sedation
ASA class
Heart rate
Blood pressure
Weight
MH any drugs?
Cooperation level
What is the ASA classification?
- Fit and well
- Mild systemic disease
- Severe systemic disease
- Severe systemic disease with threat to life
- Moribund
6 Braindead
What do you monitor in a sedated patietn?
Hb level -> O2 saturation. Heart rate
Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.
Give 3 differential diagnosis
Symptomatic periapical periodontitis
Periodontal abscess
Periapical abscess
Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.
What special investigations would you carry out to help determine diagnosis?
Sensibility testing. EPT. TTP
Pt attends practice c/o pain on biting. o/e 9mm suppurating pocket with vertical body defect radiographically tooth 15.
Explain one suitable initial treatment you would carry out
Draining of pus
Removing the source of infection; RCT or extraction
What two local factors would you check for suitability for an implant?
Alveolar bone levels.
Space available, need 7mm between two crowns
What two general factors woul dyou check for suitability for an implant?
If there are any medical contraindications such as bisphosphonates. Patients smoking status
As per SIGN guidelines, when are impacted 3rd molars not advisable to be removed?
8’s predicted to erupt healthily.
MH precludes extraction.
Deeply impacted with no pathology.
High risk of surgical complications
Risk of madibular fracture
As per SIGN guidelines, when is it advisable to remove and impacted 3rd molar?
Pt is experiencing significant infection associated with unerupted 8.
In patients with predisposing risk factors where occupation/lifestyle make accessing dental care difficult.
Patients whose medical history carries more risk from retention than possible complications of removal ie radiotherapy, cardiac surgery.
In patients who have agreed to a tooth transplant procedure, orthognathic surgery or other relevant local surgical procedure.
When patient is having GA for removal of 8, consideration should be given to removing the others
What are some stong indications for the extraction of a lower 8?
Previous episodes of infection such as pericoronitis, cellulitis, abscess formation, or untreatable pulpal/periapical pathology
Caries in the 8 with little chance of useful restoration
Caries present in adjacent 7 that cannot be restored without removal of 8
Perio disease due to position of 8
Dentigerous cyst formation or other pathology
External resorption of 8 or 7, where it appears to be caused by the 8
what are the principles of a flap design?
Wide based incision with own blood supply
Cut in a continuous stroke
Reflect flap down to bone
Avoid interdental papilla
Keep moist
No sharp angles
Margins on sound bone
Do not crush tissues
Do not close under tension
Aim for healing by primary intention
What are some other indications for the extraction of a lower 8?
Autogenous transplantation into a 6 socket
Cases of fracture in the mandible in the 8 region, or for a tooth involved in tumour resection
UE 8 in atrophic mandile
Prophylactic removal of PE 8, where specific medical conditions are present
Acute exacerbation of symptoms such as operculitis while patient is on waiting list, extraction of upper 8 to relieve symptoms
PE or UE 8 close to alveolar ridge when patient is having denture constructed or is close to a planned implant
What is assessed on a radiograph before removing an 8?
Type and orientation of impaction and access to the tooth - working distance
Crown size and condition (caries, size, shape)
Root number and morphology, presence of any apical hooks
Alveolar bone level, including depth and the point of elevation and density
Follicular width
Perio status along with that of the adjacent tooth
Relationship or proximity of upper 8s to maxillary sinus, lower 8s to IAC
Briefly describe the surgical removal of a lower 8
LA (+/- Inhalation/IV sedation/GA)
Gain access - flaps/bone removal as necessary
Tooth division as necessary
Tooth removal
Debridement
Suture
Achieve haemostasis
Post op instructions and medication
What is the use of iodine in extractions?
Found in alvogyl, used in the management of dry sockets
Name 3 types of nerve damage
Neurapraxia
Axonotmesis
Neurotmesis
What are 5 presenting symptoms of an OAC?
Bubbling from tooth socket when patient breathes
Bone at trifurcation of roots
Direct vision
Blunt probe
Nose holding test
Nasal voice
Describe the surgical closure of an OAC
Buccal advancement flap
If smaller than 2mm, encourage bleeding of the socket and close with suture
ABs
Post op instructions
Use of steam inhalation, avoid anything that forms pressure; sneeze/cough etiquitte
Give 4 signs indicating tooth proxiity to IAC
Defleciton of IAC
Darkening of root crossing canal
Deflection of root
Narrowing of IAC
Pt has swelling around UE lower 8, facial swelling and is feeling unwell. 6 things from history and investigation to note before looking at region in mouth
Pain history
Temperature
Breathing rate
Heart rate
How long has swelling been present
How quickly has it increased in size?
Pt has swelling around UE 8, facial swelling and feels unwell, what is your initial management?
LA
Irrigate under operculum
Incise and drain
Can extract upper 8 if irritating operculum
Extract lower 8
What two nerves are at risk of damage when ext lower 8s and what tissues do the supply
Lingual nerve - tongue
IAN - chin and lip
What might a patient c/o if they have a sialolith?
Fluctuant swelling at meal times
Pain
Dry mouth
Bad taste
Thick saliva
What gland/duct is most commonly affected by sialolith and why?
Submandibular gland
Duct has a tortuous and uphill path
If you suspect a sialolith, what investigations can be done?
Palpation of gland and duct
Lower occlusal radiograph
Sialography
How can a sialolith be managed?
Surgical removal - LA, secure gland and stone, make an incision and remove, suture, POIG
Sialoendoscopic removal by basket retrieval
Shockwave lithotripsy
What are the risk factors for an OAC?
Roots in antrum
Maxillary molars
Cyst
Hypercementosis
Large maxillary antrum
Ankylosis
Divergent roots
What is the juxta apical area?
A well circumscribed radiolucent area lateral to the root rather than the apex
What is warfarin and how does it work?
An anticoagulant
A vitamin K agonist
Inhibits clotting factors 2, 7, 9, 10
A patient is taking warfarin, do you manage the extraction differently?
Check INR no more than 48 hours before ext, ideally less than 24 esp if uncontrolled
INR must be below 4. Check local guidelines
Atraumatic technique
Suture socket
Can use oral tranexamic acid
Ensure HA
Emphasise post op instructions; verbal and written
Review
Pt has swelling around unerupted lower 8, facial swelling and feeling slightly unwell. What 6 things from history and investigation should be noted before looking at the mouth?
Pain history
Temperature
Breathing rate
Heart rate
How long swelling has been present/how quickly it has increased in size
You are planning to extract a tooth from a patient on bisphosphonates. What are they and what conditions are they used for?
Reduce bony turnover by inhibiting osteoclast recruitment, function and formation. Used for osteoperosis, Pagets disease, osteogenesis imperfecta, malignant metastasis
How is MRONJ diagnosed?
Must be on bisphosphonates or similar ie anti angeogenesis drugs, RANKL inhibitors
No history of head and neck radiotherapy
Exposed bone for more than 8 weeks
Following a recent extraction, a patient attends with a dry socket. What is this?
Alveolar osteitis.
Not an infection
Exposed and inflammed lamina dura usually due to loss of clot following extraction
When should an extraction site have healed?
Within 2 to 3 weeks
Name four types of sutures and give examples
Monofilament resorbable - monocryl
Polyfilament resorbable - Vicryl
Monofilament non resorbable - Prolene
Polyfilament non resorbable - Mersilk
What is osteomyelitis?
Bilateral infection of bone. Results in inlammation causing necrosis
What are the risk factors for osteomyelitis?
Immunocompromised patients
Mandible more than maxilla
Mandibular fracture
What is haemophillia A?
Clotting factor VIII deficiency
What is haemophillia B?
Clotting factor IX deficiency
What is Von Willebrand disease?
Affects Factor VIII
How is haem A/B and Von Willebrands managed>
Factor replacement
Desmopressin
Tranexamic acid
What are the steps that should be followed when carrying out oral surgery
Gain consent
Surgical pause/safety checklist
Anaesthesia
Access
Bone removal as necessary
Tooth division as necessary
Debridement/wound management
Suture
Achieve haemostasis
Post op instructions
Post op medication
Follow up
Identify this flap design
3 sided flap design
Identify this flap design
Envelope
What are the aims of suturing?
Reposition the tissues
Cover bone
Prevent wound breakdown
Achieve hamostasis
Encourage healing by primary intention
