Oral surgery Flashcards
- Labial the maxillary and mandibular branches of the trigeminal nerves.
What foramen does the opthlamic nerve branch pass through?
Superior orbital fissure
What foramen does the maxillary branch pass through?
Foramen rotundum
What foramen does the mandibular branch pass through?
Foramen ovale
- What is the origin, insertion, innervation and function of the masseter?
o Origin – zygomatic arch
o Insertion – lateral surface and angle of mandible
o Action – elevates and deep fibres retrude mandible
o Testing – clench teeth together
o Innervation – masseteric branch of mandibular division of trigeminal nerve
What is the origin, insertion, innervation and function of the temporalis?
o Origin – floor of temporal fossa
o Insertion – coronoid process and anterior border of Ramus
o Action – elevates and retracts mandible
o Testing – clench teeth and palpate all fibres (anterior, middle and posterior)
o Innervation – anterior division of deep temporal nerve branches of mandibular division of trigeminal nerve
What is the origin, insertion, innervation and function of the medial pterygoid?
o Origin – deep head medial surface of lateral outer hood plate and superficial head to tuberosity of maxilla
o Insertion – medial surface of angle of mandible
o Action – elevates and assists in protrusion of mandible
o Testing – intra oral can be painful
o Innervation – nerve to medial pterygoid of the mandibular division of trigeminal
nerve
What is the origin, insertion, innervation and function of the lateral pterygoid
o Origin – lateral surface of lateral pterygoid plate
o Insertion – anterior border of Congolese and intra articulator disc via 2
independent heads – inferior to head of consult; superior to intra articulate disc o Testing – response to resisted movement by putting finger far back of maxilla
and move jaw side to side
o Innervation – anterior division nerve to lateral pterygoid branch of mandibular
division of trigeminal nerve
- Patient comes in with a right-body mandibular fracture
- Other than pain, bruising and swelling. List 6 other signs and symptoms associated with mandibular fractures
o Pain, swelling, limitation of function.
o Malocclusion
o Numbness of lower lip (due to possible damage to the IAN)
o Loose, mobile or fractured teeth
o swallowing, talking and mouth opening aggravate pain.
o Anterior open bite
o Facial asymmetry
o Deviation of the mandible to the opposite side
Name two radiographic views required for mandibular fractures
OPT and PA mandible
CBCT can also be used
What factors cause displacement of mandibular fractures? (6)
- Direction of the fracture line
- Opposing occlusion
- The magnitude of the force
- Mechanism of injury
- Intact soft tissue
- Other associated fractures
What does displacement of fragments depend on? (5)
- Pull of the attached muscles
- Angulation and direction of the fracture line
- Interfrity of the periosteum
- Extent of the communication
List 3 management strategies for mandibular fractures? Displaced and undisplaced (3)
For an undisplaced mandibular fracture - No tx (monitor)
Displaced may require are treated either closed (maxillomandibular fixation, splinting, modified diet) or open (plates and screws, interosseous wiring, lag screws).
- You have extracted tooth 26 but the bleeding won’t stop.
- List how you would manage the situation and gain haemostasis (4 ways)?
o Identify the cause if there is anything in their drug or medical history
o Apply firm Pressure by biting on damp packs of gauze or finger pressure
o Haemostasis agents – LA with vasoconstrictor
o Haemostasis aids – WHVP, bone wax, fibrin foam, surgicel
o Suture the socket
o Ligation of vessels with Diathermy
o Surgical haemostasis
What is a local risk factor for delayed onset of bleeding?(3)
How can the patient start bleeding after haemostasis has been achieved?
- Patient explores the socket with tongue or finger. which is traumatic to the socket
- LA vasocontrictor wears off increasing the blood flow to the area
- The sutures come loose
List 2 conditions for each of the following – congenital and acquired bleeding disorders (4)
Congenital = haemophilia A and B, Von willebrands’ disease
Acquired = vitamin K deficiency and End stage liver disease
What are apixaban and dabigatran classed as? and how would this effect your treatment if this patient was getting an extraction?
- Anti-coagulants DOAC’s
- Ask them to miss their morning dose for apixaban and dabigatran
and delay their morning dose till 4hrs post treatment for Rivaroxaban
What is Rivaroxaban classed as? and how would this effect your treatment if this patient was getting an extraction?
- Anticoagulant
- Delay their morning dose till 4hrs post treatment
What should an INR be for a patient on warfarin for oral surgery to be carried
out?
<4 treat without interrupting their anticoagulant medication
6) Patient attends with suspected dry socket
- What is the scientific term for a dry socket?
Alveolar/localised osteitis
It occurs when the blood clot at the site of the extraction fails to
develop, dislodges or dissolves before the wound have fully healed
How long should it take for a extraction to heal?
Inital healing and soft tissue healing
Intial healing 1-2 weeks
Soft tissues fully healed by 3-4 weeks
What are the predisposing risk factors for dry socket? (8)
o Molars more common – increased risk anterior to posterior o Mandible more common than the maxilla
o Smoking increases risk due to reduced blood supply
o More common in females than males
o Oral contraceptive pill can increase risk
o Excessive trauma during the extraction procedure
o Excessive mouth rinsing post extraction
o Family history or previous dry sockets
What are the treatment options for dry socket? (7)
Supportive and management
Supportive
- Reassure the pateint and give information leaflet of dry socket
- Recommend optimal systemic analgesics (P and I)
Management
- Give LA to releave some of the pain
- Keep it clean, irrigate the socket to wash out food or debris
- Curettage/debridement to encourage bleeding and a new clot to form
- Place Alvogyl (encourage new clot formation)
- Advise the patient on analgesics and hot salty mouthwash/CHX use
What are the risks related to extraction and how are they managed?
* Pain- give analgesics and warn patient this is to be expected but should subside within a few days/week
* Bleeding- place pressure on wound and/or use haemostatic agents, don’t discharge patient until bleeding has stopped and give them instructions on how to deal with any secondary bleeding (bite down on damp gauze for 20-30 minutes and if continued bleeding contact help)
* Bruising- warn patient this is normal but variable, instruct them to use ice pack (5 minutes on and 5 mins off)
* Swelling- use atraumatic technique and again warn patient variable & to use ice pack
* Soft tissue damage- careful technique
* Nerve damage risk- careful technique, evaluate risk with pre-op radiographs and use further imagining/avoid treatment if high risk and patient not willing to consent
* Infection- keep area as clean as possible (peri and post op)
* Limited mouth opening- atraumatic technique, warn patient is they happens will gradually get better over time and that heat packs can be used for muscle relaxation
* Fractured tooth or restoration- inform patient of risk before, ensure apply instruments in correct place and with the correct magnitude and direction of force
* OAC/tuberosity fracture/loss of tooth into antrum/ mandibular fracture/alveolar bone fracture- careful technique and warn patients at high risk beforehand
* Incorrect tooth- mark tooth, count teeth, check clinical situation against notes and radiograph and get colleague to check and confirm prior to removal
* Broken instrument- reduce pressure on fine instruments, only use instruments for intended use, check instruments for signs of damage or wear before use
* Dry socket- post-operatively avoid smoking, avoid traumatising or disturbing socket and excessive rinsing
You are planning an extraction for a patient who takes warfarin.
1. What is warfarin and how does it work?
Warfarin is an anti-coagulant
Warafarin is a vitamin K antagonist which means it blocks the bodys ability to make vitamin K dependent clotting factors 2,7,9 and 10
For a warfarin patient what do you need to do before extracting any tooth?
And when should you do it?
- Check the INR
- This should be done no more than 48hrs before but ideally 24hrs before is patient is uncontrolled
- INR should be <4 to proceed and local guidelines should be followed
For a warfarin patient do you manage the extraction any differently?
In terms of bleeding management
- Maximum of three teeth should be extracted from one quadrant at once
- Use atraumatic technique
- Suture socket closed
- Pack with surgicel or other absorbable haemostatic dressing/ agent to help with clot formation
- Oral tranexamic acid may be given
- Ensure haemostasis prior to discharging patient
- Stress postop instructions to patient (increased urgency for referral for help is bleeding restarts)
- When giving advice on post-op analgesia be aware ibuprofen contra-indicated and avoid re **use of paracetamol instead **
- Review the patient
- Consider extraction at the start of the day and week so any re-bleeding problems can be managed during the working day and week
- Take care with IAN block- administer slowly and always aspirate- and use infiltrations or mental block where possible
You are extracting a lower molar.
1. How would you achieve haemostasis after an extraction?
- Pressure on wound by biting on damp gauze or applying damp gauze with finger pressure
- Local anaesthetic with vasoconstrictor
- Suture socket
- Use of haemostatic agents such as surgicel or kaltostat (or bone wax if bleed from bone)
- Diathermy
- Ligatures or artery clips
What tissues could be responsible for the prolonged bleeding and how would you manage this?
- Veins
- Arteries; ligatures or haemostasis/artery forceps
- Arterioles
- Vessels in soft tissue including vessels in muscle; soft tissue haemostasis via pressure, suture, LA with vasoconstrictor, diathermy, artery forceps
- Vessels in bon; bone haemostasis via pressure (gauze or blunt probe), LA with vasoconstrictor injected into socket or on gauze, haemostasis agents such as surgicel, bone wax, packing with swabs and suturing
Give 4 risk factors for prolonged bleeding?
- Medical condition- haemophilia A, haemophilia B, Von Willebrand’s, Liver disease or cirrhosis
- Medications- Warfarin, Anticoagulants, Antiplatelets (e.g. aspirin)
- Lifestyle factors- Excessive alcohol consumption (alcoholic)
You are extracting a lower premolar.
1. What is your flap design?
- Two-sided flap with distal relieving incision or mesial relieving incision which is in line with canine (to avoid mental nerve)
You are extracting a pre-molar what vital structures are in the vicinity?
- Mental nerve (from mental foramen). Supplies sensation to the lower lip, skin on the chin and labial ginigiva of the mandible
Give 5 peri-operative complications of surgical extraction?
- Unplanned fracture of tooth or root
- Fracture of adjacent tooth or restoration
- Fracture of the lingual plate, loss of root or root into lingual space, fracture or alveolus or mandible (for an upper tooth would be a fracture of the maxillary tuberosity, oro-antral communication or loss of tooth or root into a maxillary sinus/pterygoid space)
- Direct trauma to IA neurovascular bundle
- Excessive bleeding
- Damage to soft tissue- crush, tear or laceration injuries
- Burns form handpiece resting on the lower lip
MRONJ-
You are planning on extracting a tooth for a patient on bisphosphonates.
1. What are bisphosphonates and what conditions are they used for?
- Class of drugs that are used to treat several conditions by helping to prevent and treat bone loss and increase bone density
- They work by reducing bony turnover by inhibiting osteoclast recruitment, function and formation
- Used for the treatment of- osteoporosis, Paget’s disease, osteogenesis imperfecta, malignant metastasis, multiple myeloma
For MRONJ to be diagnosed how many weeks must have pasted and the bone is still exposed?
8 weeks
How is MRONJ diagnosed?
- First, the patient must be on bisphosphonates (or any other anti0resorptive medication), anti-angiogenic drugs or RANK-L inhibitors and have no history of head or neck radiotherapy
- Diagnosis via bone exposure/ lack of extraction site healing after 8 weeks at review
How is a patient determined high or low risk for MRONJ?
Low risk, high risk and risk factors
- Low risk- treated for osteoporosis or other non-malignant diseases with either a) oral bisphosphonates, b) quarterly or yearly infusions of IV bisphosphonates or c) denosumab for less than 5 years and not concurrently being treated systemic glucocorticoids
- High risk- treated for osteoporosis other non-malignant diseases with either oral bisphosphonates, quarterly or yearly infusions of IV bisphosphonates or denosumab for either a) more than 5 years or b) any length of time with concurrent treatment with systemic glucocorticoids, treated with anti-resorptive or anti-angiogenic drugs (or both as part of the management of cancer , previous diagnosis of MRONJ
- Risk factors include dental Tx to be undertaken, dental implants, length of treatment, other concurrent medication and previous drug history
How do you manage the patient’s extraction in general practice if they are being treated with bisphosphanates?
- Assess the patient for their risk level and make the aware of the risks due to their medications
- Minimise trauma when extracting (atraumatic)
- As healing is the main concern, suture and use other haemostatic agents to encourage healing
- Stress post-op advice of keeping the area as clean as possible with salty water and no smoking
- Review and monitor
- Warn patient to looks for signs of MRONJ - bad taste and smell, swelling, puss, pain
- Patient attends with pericoronitis of the lower 8 - What is pericoronitis? (2)
o It is inflammation in the soft tissues around the crown of the tooth which only occurs when there is communication between the tooth and the oral cavity
o The tooth is normally partially erupted and visible but occasionally there may be very little evidence of communication and careful probing distal to the 2nd molar is required to show the small communication
o Food and debris gets trapped under the operculum resulting in inflammation or infection occurring
What are the signs and symptoms of pericoronitis?(5)
- Pain, swelling, ulceration of the operculum
- Bad taste in mouth (from pus)
- Halotosis
- Difficulty with eating, swollowing, trismus
- Systemic symtpoms of fever, malaise, lymphadenopathy
How is periocornitis treated? (5)
Start with simple treatments
- Give LA to relave some pain
- Irrigate and clean area (flush out any food or debris which may be causing irritation
More extreme cases - XLA of 8’s
- Incision and drainage of liasied pericoronal abscess washing underneath operculum with CHX or antiseptic Talbot’s iodine which is applied with tweezers underneath the operculum
- AB if there is systemic involvement (metronidazole), patient is immunocomprimised or severe E/O swelling.
- Consider MAXFAX referral if E/O swelling
How else can periocornitis be managed long term?
- Extraction or surgical extraction of affected tooth (after acute episode and resolution of inflammation)
- Extraction of upper opposing 8 if causing trauma to operculum
- Further imaging and possible coronectomy of lower 8 if radiographic investigation
What 6 radiographic signs show a close relationship of lower 8 with IAN? (6)
o Diversion/deflection of the inferior dental cana
o Interruption of the white lines/lamina dura of the canall
o Narrowing of the inferior dental canal
o Darkening of the root where crossed by the canal
o Deflection of the root
o Juxta apical area – well circumscribed Radiolucent area lateral to the root rather than at the apex
What imaging is requested when an 8 is close to IAN? (2)
OPT
or for better view CBCT
What risks should be explained to the patient with regards to damage to IAN of extracting the tooth?
Depending if the roots cross the IANC or not will effect the level of risk.
There is a chance of temporary or permenant pain, tingling or numbness (dysaesthesia, parathesia, anaesthesia) of the chin, lower lip and lateral border of the tongue.
If the nerve and tooth dont over lap the permenant risk is <1% and temporary risk if <5%. However if the roots of the tooth cross the nerve then P risk is 5% and temporary risk is 20%.
Altered taste or loss of taste
Give 1 type of nerve damage and 2 consequences?
- Axonotmesis- epithelial sheath damage
- Consequences- Anaesthesia (loss of sensation), paraesthesia (abnormal, tingling sensation) or dysesthesia (painful, uncomfortable, burning sensation) of lower lip and chin
What happens to the nerve during neurotmesis
Neurotmesis: In this serious nerve injury, your nerve is completely cut (severed).
Treatment option for XLA of lower 8’s with close proximity to the IAN? (1)
Coronectomy
Name 2 scenarios where there would be an increased risk of bleeding for a patient and 2 post operative methods of achieving haemostasis
Patient with a congenital bleeding disorder – Haemophilia A
- Pressure on socket
- Extra LA
- Sutures
- Haemostatic agents - surgicel
- Diathermy
- Atruamtic technique
- May require factor replacement therapy or oral tranexamic acid (consult the patients haemotologist)
Patient on warfarin – need to ensure INR <4
- Ensure INR <4 24 hours prior to appointment
- Pressure on socket
- Extra LA
- Sutures
- Haemostatic agents - surgicel
- Diathermy
- Atruamtic technique
Name a guideline for the removal of impacted molars?
SIGN (Scottish Intercollegiate Guidelines Network)
NICE (National Institute for health and care excellance)
Name 5 other post op complications apart from nerve damage?
- Pain
- Bleeding
- Swelling
- Bruising jaw stiffness of limited opening
- Damage to adjacent teeth or restoration
- Infection
What type of flap is used for removal of an impacted lower 8?
3 sided flap
Envelop flap
What nerve supplies the TMJ?
o Auriculotemporal and masseteric branches of mandibular branch of trigeminal nerve
Osteoradionecrosis
- What is osteoradionecrosis?
- The presense of non-vital necrotic bone in the area jaw after a patient has recieved radiotherapy to treat H&N cancer
- Endarteritis (reduced blood supply) occurs and turnover of any remaining viable bone is therefore slow while self repair is ineffective
Label this OPT
What is ludwig’s angina?
- Bilateral cellulitis infection and swelling of the sublingual and submandibular spaces which can compromise the airway
- Features include bilateral swelling in submandibular region raised tongue, dysphagia, drooling, redness and airway risk (difficulty breathing)
- Also get systemic SIRS response in form or increase HR, RR< temp and white cell count
- Patient should be quickly taken to hospital in an ambulance
