Oral Surgery Flashcards
What are the signs and symptoms of mandibular fracture?
Nerve damage- numbness in lower lip
Step deformity
Bleeding
Asymmetry
Mobile teeth
Lack of function
AOB
What are 2 radiographic views for mandibular fracture?
PA mandible
OPT
What factors could cause a fracture to be displaced?
ST damage
Force
Opposing occlusion
Direction of fracture line
Presence of other fractures
How are mandibular fractures managed?
Undisplaced- Do nothing
Displaced:
Open reduction and internal fixation
Closed reduction with inter maxillary fixation
What are the signs and symptoms of TMD?
- Limited opening
- Clicking
- Crepitus
- Headache
- Earache
- Locking of jaw- fixed or patient may be able to manipulate back in (subluxation)
- Wear facets/micro-cracks
- Lost fillings
- Linea Alba on buccal surface- keratin layer (protective)
- Radiographically Flattening of bones in joint, Widened PDLs (also seen in high fillings)
What muscles do you palpate in a TMD exam?
Masseter
Temporalis
What advice can you give for conservative management of TMD?
Soft diet
Masticate bilaterally
No wide opening
No chewing gum
Don’t incise foods
Cut food into small pieces
Stop parafunctional habits e.g. nail biting, grinding
Support mouth on opening e.g. yawning
BRAs
Meds- NSAIDs, muscle relaxants, TCAs
How does a bite splint work?
Stabilise the occlusion
Improve the function of the masticatory muscles,
-> Decrease abnormal activity
Protect the teeth in cases of tooth grinding
Reduced loading on TMJ
What is athrocentesis?
Injecting medicaments (steroids, hyaluronic acid, ringer lactate solution) into joint to improve lubrication and reduce inflammation (flushing effect)
How do you manage bleeding after an extraction that won’t stop?
Oxidised cellulose
LA with vasoconstrictor
Suture
Diathermy
Pressure with damp gauze
What are the causes of delayed onset bleeding?
Restarting blood thinners
Infection
LA with vasoconstrictor wears off
Loosening of suture
Patient traumatises region with finger, tongue, food
What are conditions associated with congenital bleeding?
VWD
Haemophilia A
Haemophilia B
What are the acquired causes of bleeding disorder?
Anticoagulants- warfarin
Antiplatelets- aspirin
Patient is on a NOAC when should you check INR?
What are 4 criteria for SIRS (systemic inflammatory response syndrome)?
Temperature- >38/<36
Raised HR- >90bpm
Raised respiratory rate- >20 breaths per min
WCC- >12000 per ml/ <4000 per ml
How many signs need to be positive to make diagnosis of SIRS?
2
Why is written consent gained prior to third molar extraction prior to sedation process?
As patient cannot consent while sedated
What drug is most commonly used for IV sedation in the UK? What is the preparation?
Midazolam- 5mg/5ml
What are 3 vital signs you monitor- before, during and after sedation?
HR
Blood pressure
Oxygen saturation
What drug is used to reverse effect of midazolam?
Flumazenil
What advice should you give to patient after IV sedation?
Do not drive that day
No signing of legal documents
Don’t go back to work
What are the indication for inhalation sedation?
Gagging issues
Mild to moderate anxiety
Needle phobia
Unaccompanied adult
Unpleasant/traumatic procedure
Medical conditions aggravated by stress like asthma
What are the advantages of IS over IV?
Rapid onset
Rapid recovery
Flexible duration
No cannulation
Less side effects
No chaperone needed for adults
What are the contraindications for IS?
Cold/blocked nose
First trimester of pregnancy
Patients under 7
Severe COPD
Tonsillar enlargement
What are the safety features of the quantiflex machine?
Pin index system- prevents wrong cylinder being attached
Diameter index system- prevents cross connection of piping
Min oxygen delivery of 30%
Oxygen fail safe
Oxygen monitor
Oxygen flush
Reservoir bag
Colour coding- Black O2, Blue NO
When may referral for treatment under GA be made?
Medical conditions that make sedation unsafe
Uncooperative children
Severe anxiety
Long/complex procedures
Procedure requires complete stillness
What are the stages of General Anaesthesia?
- Induction
- Excitement
- Surgical anaesthesia
- Overdoses
What must be included in referral letter for GA?
Patient name
Patient address
Patient/ Parent contact numbers- landline and mobile
Patient medical history
Patient GP details
Parental responsibility
Justification for GA
Proposed treatment plan
Previous treatment details
What the definition of conscious sedation?
Use of drug or drugs which produce state of depression within the CNS enabling treatment to be carried out but communication can be maintained, patient can respond to command and retain protective reflexes
-> involves a margin of safety wide enough to make unintended loss of consciousness unlikely
What is GABA and its function?
Gamma-aminobutryic acid
Inhibitory neurotransmitter in cerebral cortex and motor circuits
-> prolongs time for receptor repolarisation
What is the half life of midazolam?
90-150 mins
What are the contraindications for IV sedation?
Obesity
Allergy
No chaperone
Pregnancy/lactation
COPD
Severe systemic diseases
Severe special needs
What should you assess before carrying out IV sedation?
ASA class
Weight
Vitals- HR, BP, SaO2
MH- drugs
Cooperation level
Level of anxiety
What are the different ASA classes? American Society of Anaesthetist
ASA I: Normal healthy patient-non-smoker, minimal alcohol
ASA II: Mild systemic disease
ASA III: Severe systemic disease; limits activity (but not incapacitating)
ASA IV: Severe systemic disease (constant threat to life)
ASA V: Moribund; not expected to live > 24 hrs.
ASA VI: Patient who is brain dead for organ donation
A patient attends with pain on biting, 9mm suppurating pocket with vertical bony defect. What are the possible diagnoses?
Symptomatic peri-apical periodontitis
Periodontal abscess
Periapical abscess
What special investigation would help you ascertain whether it was SPP, PerioA or PA abscess?
Check if TTP
Use EPT
What initial treatment would you carry out for a tooth
Drainage of Pus
RCT or extraction
What are the ways an extracted tooth can be replaced?
Implant
Bridge
Partial denture
What local factors must be checked when determining suitability of a patient for an implant?
Bone levels- 10mm
Space between teeth- 7mm
What are the generalised factors you would check when determining suitability of patient for an implant?
Smoking status
MH- bisphosphonates
How would you investigate and manage an OAC?
Investigate:
-> Look for blood bubbling
-> nose holding test
-> radiographs
Manage:
-> Encourage clot, suture margins, give AB, no nose blowing, encourage steam inhalation
-> If large close with BAF
How would you investigate and manage root in the antrum?
Investigate- take PA/occlusal radiograph OR OPT
Manage:
Use suction, curettage, irrigation, ribbon gauze, close as for OAC
How would you investigate and manage tuberosity fracture?
Investigate:
Look for signs- noise, tear on palate, mobility of more than one tooth
Manage:
-> Dissect out and close wound
-> Reduce and stabilise with wire/splint
-> Remove or treat pulp
-> Give AB
-> remove tooth 8 weeks later
When are impacted 3rd molars not advisable to be removed?
Caries free/no pathology associated
Predicted to erupt naturally
Medical History precludes XLA
Risk of mandibular fracture
When should impacted 3rd molars be removed?
Unrestorable caries
Non-treatable pulpal/PA pathology
If cyst present
If fractured
If abscess
Osteomyelitis
Recurrent pericoronitis
What are the therapeutic indications for 8 removal?
Infection (caries, pericoronitis, periodontal disease or local bone infection) – most common
Cysts
Tumours
External resorption of 7 or 8
What are the surgical indications for 8 removal?
Within surgical field (orthognathic, fractured mandible, in resection of diseased tissue)
High risk of disease
Medical indications eg awaiting cardiac surgery, immunosuppressed or to prevent osteonecrosis
Accessibility- limited access
Patient age- complications and recovery time increase with age
Autotransplantation- to position of 6
General Anaesthetic for other treatment
What flap is used for removal of impacted 8?
3 sided buccal mucoperiosteal flap starting around gingival margin of 7 (mesial and distal relieving incisions)
What flap is used for surgical removal of lower 5?
2 sided with distal relieving incision
What are the principles of flap design?
Wide based incision
Reflect down to bone
Cut in one continuous stroke
Avoid ID papilla
No sharp angles
Keep tissues moist
Do not close under tension
Margins of flap should lie on sound bone
What should be checked on radiograph before removing an 8?
Presence or absence of disease
Anatomy- size, shape, root formation
Depth of impaction
Orientation of impaction
Follicular width
Periodontal Status
Proximity to antrum or IDC
Describe the removal of an impacted lower 8?
Anaesthesia (LA used even if patient sedated)
Access- flap
Bone removal as necessary
Tooth division as necessary
Debridement
Suture
Achieve haemostasis
Post-operative instructions
What is the use of iodine in extraction of lower 8
What are 3 types of nerve damage that can occur?
Neuropraxia- contusion but no damage to sheath/axon
Axonotmesis- damage to axon but not sheath
Neurotmesis- transection
What is the risks of temporary and permanent nerve damage?
Temporary- 10-20%
Permanent- <1%
What is the clinical term for when a patient has dripping from the nose following upper molar extraction?
Oro-antral communication
What are presenting symptoms of an OAC?
Salty metallic taste
Sinusitis
Pain in teeth in both sides
Difficulty creating oral seal
What are the signs of an OAC?
Splayed roots and trifurcations
Bubbling of blood from socket
Black hole on direct vision
Echo on suction
Prolapsed lining coming through socket
Felt on nose holding test
How are OAC closed?
If smaller than 2mm
-> encourage clot and suture margins
If larger
-> Buccal advancement flap
Give POI and AB
What are the radiographic signs that indicate roots of 8s are close to Inferior dental canal?
Interruption of tramlines by tooth
Diversion and deflection of canal
Deflection of root
Narrowing of canal- goes back to normal width
Narrowing of root as it crosses canal
Dark bifid root
Juxta-apical area
What is an alternative treatment to extraction of an 8 which may avoid interference with the canal?
Coronectomy
What images can be used to look at relationship of 8 and IDC?
OPT- half?
CBCT
What aspects of history would you want to know when a patient has swelling around lower 8, feels unwell and has facial swelling?
Pain history
Temperature
Breathing rate
HR
How long has swelling been present
What nerves are at risk of damage in XLA of an 8, what do they supply?
Lingual nerve- sensation to tongue, lingual gingivae
IAN- sensation to chin, lip and gingivae on that side
Nerve to mylohyoid
Long buccal
What may a patient complain of if they have a sialolith?
Bad taste
Thick saliva
Dry mouth
Prandial pain and swelling
Which gland and duct is most commonly affected by salivary stones and why?
Submandibular gland- duct goes up the way to reach oriface (also has long and curved course)
What investigations can be done for salivary gland stones?
Ultrasound
Sialography
Plain radiographs- lower occlusal
How are sialoliths managed?
Removal via surgery
What is dry socket if it is not an infection?
Alveolar osteitis- exposed and inflamed lamina dura due to loss of clot
What are the risk factors for dry socket?
Extraction of molars
Extraction in mandible
Smoking
Female
OCP
Previous dry socket
LA w ADR
How is dry socket treated?
Analgesia
LA w ADR
Irrigate w saline
Antiseptic packs- BIP/alvogyl
Curettage and debridement
What are the risk factors for an OAC?
Lone standing molars
Extraction of maxillary molar
Splayed roots
Large maxillary antrum
Close proximity of apex and antrum
Ankylosis
What are the post-op complications that can occur on extraction of impacted 3rd molar
Jaw fracture
Pain
Bleeding
Swelling
Stiffness
Infection
Damage to adjacent teeth
What guidelines exist for removal of impacted 3rd molars?
NICE
SIGN
FDS
How are risks related to extractions managed?
Pain- analgesia as for headache (pre-emptive), do not exceed dose
Swelling- cold compresses
Bleeding- haemostat agents, bite on damp gauze, avoid increases in BP, avoid exploring clot
Dry socket- avoid smoking
Infection- keep area clean, salty mouth rinses
What is a juxta-apical area
Well defined and corticated radiolucent area lateral to root rather than apex
What are the potential outcomes of nerve damage?
Anaesthesia- numbness
Paraestheisa- tingling
Dysaethesia- painful sensation
Hypo/hyper
What is warfarin and how does it work?
Coumarin based anticoagulant
-> inhibits vitamin K dependent clotting factors 2, 7, 9, 10 and protein C/S
What would you need to check before completing an extraction with a patient on warfarin?
Check INR- should be less than 4
-> INR must be from last 48 hours ideally last 24
-> 72 hours if well controlled
Do you manage extraction differently for patients on warfarin?
Try to make extraction as atraumatic as possible
Use enhanced haemostatic aids
-> WHVP
-> Oxidised cellulose
-> Sutures
-> Oral transexamic acid
Extract no more than 3 roots
What are bisphosphinates and what conditions are they used for?
Inhibit osteoclasts and bone resorption (and bone renewal)
Used for- Paget’s, OP, osteogenesis imperfecta, metastatic cancers, multiple myeloma
How is MRONJ diagnosed?
Ascertain if patient on bisphosponates (or RANKL inhibitors/anti-angiogenics)
Ask about history of head and neck cancer
Look for areas of exposed bone (may have pus, pain, dehiscence)
What is considered low risk for MRONJ?
Patient has taken densomumab in last 9 months
Patient has taken or took bisphosponate for less than 5 years
What is considered high risk for MRONJ?
Patients on anti-resorptive/angiogenic drugs for cancer
Patient who has taken or took bisphospohantes for more than 5 years
-> or less than 5 years with systemic glucocorticoid
How would you manage a patient who required extraction and was at risk of MRONJ due to medical history?
Advise patient of the risks
Encourage good OH
Avoid extraction if possible
Atraumatic XLA technique
Primary closure
Extensive POI
Review- in 8 weeks
*seek advice from OS/special care team
What is pericoronitis? What teeth are usually affected?
Inflammation around the crown of a partially erupted tooth- there may be formation of an operculum (flap of gingivae sitting over tooth)
-> usually occurs impacted lower 8s
What are the signs and symptoms of pericoronitis?
Pain
Swelling
Bad taste
Pus discharge
Ulceration of operculum
Cheek biting
Pyrexia/malaise
Limited opening
How do you manage an acute episode of pericoronitis?
Incision of localised pericoronal abscess under LA
Irrigation with Saline/CHX
-> under operculum with blunt needle
Analgesia
AB if systemic symptoms or immunocompromised
How is pericoronitis managed long term?
Extract opposing 8 if traumatising operculum
Extract tooth- once it has resolved
What POI are given following extraction?
Pre-emptive analgesia- paracetamol and ibuprofen
No rinsing for 24 hours- then regular salty mouthrinses
Bleeding prevention
- Avoid overly hard or hot foods
- Avoid increases in BP for 24 hours- limit exercise/no drinking
- Avoid exploring clot
- Be careful around area when cleaning
Do not smoke- dry socket risk (hold off for as long as possible)
Bleeding- bite on damp gauze for 30 mins, try twice, if not contact GDP/NHS24
What procedure may be performed for partial erupted tooth that is not an extraction?
Coronectomy
What are the potential complications of extracting a lone standing upper molar?
Jaw fracture
OAC
Fractured tuberosity
Root in antrum
What are the means for achieving haemostasis?
Pressure with damp gauze
LA w ADR
Diathermy
Ligatures
Haemostatic forceps
Surgical
WHVP
What tissues may be responsible for prolonged bleeding?
Soft tissue
Bone
BV- veins, arteries, arterioles
What are the risk factors for prolonged bleeding?
NSAIDs- anti-platelets
Anticoagulants- warfarin
Liverdisease
Alcoholism
Haemophilia
Fracture
Mucoperiosteal tear
What would you want to consider if a patient presented with facial swelling?
Size
Presence of pus
Rate of progression
Colour
Airway- is it compromised
If you suspect sepsis, what should you do?
Urgently refer for treatment in hospital environment
-> likely given IV AB
What is Ludwig’s angina?
Bilateral swelling of submandibular, submental and sublingual spaces
-> medical emergency
-> requires intubation and EO drains
Name the maxillary spaces?
Buccal space
Palatal space
Infraorbital space
Infratemporal space
Name the mandibular spaces?
Sub-lingual space
Submandibular space
Lateral pharyngeal space
Retropharyngeal space
Submental space
What is osteoradionecrosis?
Bone in head and neck within the radiotherapy beam becomes non-vital (endarteritis)
-> results in slower bone turnover and lack of self repair
What are the risk factors for ORN?
Radiotherapy
Extraction in mandible
How can ORN be prevented?
Scaling and CHX in lead up to extraction
Careful extraction technique
Extract teeth at least 10 days before start of radiotherapy
AB and CHX given after
Hyperbaric oxygen before and after
Vit E- 1000IU per day
Pentoxyfilline- 800mg per day
How is ORN managed?
Irrigate necrotic debris
Sequestrae removal
Resection of exposed bone
Hyperbaric oxygen
What vital structure may cause need for altered flap design when removing a lower premolar?
Mental foramen housing the mental nerve
What is the function of the mental nerve?
Supplies sensation to lower lip, skin on chin and gingivae
What are some examples of peri-operative complications of extraction?
Limited opening- trismus
Swelling
Jaw fracture
Extracting wrong tooth
OAC
Root in antrum
Fracture tuberosity
Bleeding
Nerve damage
What are the aims of suturing?
Cover bone
Aid haemostasis
Compression of BVs
Reposition tissues
Healing by primary intention
Protection of clot
What are the different types of sutures, give examples?
NA:
Monofilament- Prolene
Polyfilament- Silk
A:
Monofilament- monocryl
Poly- Vicryl
What are examples of different forceps and their uses?
Upper straight- extract 3-3
Upper universal- extraction of 3, 4, 5
Upper molar L/R- extract maxillary molars
Upper/lower roots- extract roots
Lower universal- 5-5
Cowhorns- lower 6s
Lower molars- mandibular molars
Name 3 types of elevator?
Couplands
Warwick James
Cryer’s
What are the different techniques for elevation?
Lever
Wheel and axle
Wedge
What is the use of a luxator?
Sever PDL
What is osteomyelitis?
Bacterial infection of bone:
Invasion of bacteria into the cancellous bone causing inflammation and oedema in marrow spaces
-> blood supply becomes compromised and ischaemia and necrosis occur
-> Due to lack of blood supply bacteria proliferate and spread
What are the risk factors for OM?
Poor blood supply in mandible
Fracture of mandible
Odontogenic infection
Immunocompromised
Alcoholism
Diabetes
IV drug use
Myeloproliferative diseases- leukaemia, sickle cell
How is OM managed?
Long course AB- clindamycin and penicillin
Drain pus
Remove non-vital teeth in area of infection
Remove loose bone
Excision of necrotic bone until healthy bleeding bone tissue is reached
What treatment can GDPs carry out in bleeding disorder patient?
LA
BPE
Supragingival PMPR
Restorations with supra gingival margins
Endo
Pros/impressions
Ortho?
