Oral surgery Flashcards
1
Q
- Labial the maxillary and mandibular branches of the trigeminal nerves.
A
2
Q
What foramen does the opthlamic nerve branch pass through?
A
Superior orbital fissure
3
Q
What foramen does the maxillary branch pass through?
A
Foramen rotundum
4
Q
What foramen does the mandibular branch pass through?
A
Foramen ovale
5
Q
- What is the origin, insertion, innervation and function of the masseter?
A
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
6
Q
What is the origin, insertion, innervation and function of the temporalis?
A
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
7
Q
What is the origin, insertion, innervation and function of the medial pterygoid?
A
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
8
Q
What is the origin, insertion, innervation and function of the lateral pterygoid
A
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
9
Q
- 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
A
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
10
Q
Name two radiographic views required for mandibular fractures
A
OPT and PA mandible
CBCT can also be used
11
Q
What factors cause displacement of mandibular fractures? (6)
A
- Direction of the fracture line
- Opposing occlusion
- The magnitude of the force
- Mechanism of injury
- Intact soft tissue
- Other associated fractures
12
Q
What does displacement of fragments depend on? (5)
A
- Pull of the attached muscles
- Angulation and direction of the fracture line
- Interfrity of the periosteum
- Extent of the communication
13
Q
List 3 management strategies for mandibular fractures? Displaced and undisplaced (3)
A
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).
14
Q
- You have extracted tooth 26 but the bleeding won’t stop.
- List how you would manage the situation and gain haemostasis (4 ways)?
A
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
15
Q
What is a local risk factor for delayed onset of bleeding?(3)
How can the patient start bleeding after haemostasis has been achieved?
A
- 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
16
Q
List 2 conditions for each of the following – congenital and acquired bleeding disorders (4)
A
Congenital = haemophilia A and B, Von willebrands’ disease
Acquired = vitamin K deficiency and End stage liver disease
17
Q
What are apixaban and dabigatran classed as? and how would this effect your treatment if this patient was getting an extraction?
A
- 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
18
Q
What is Rivaroxaban classed as? and how would this effect your treatment if this patient was getting an extraction?
A
- Anticoagulant
- Delay their morning dose till 4hrs post treatment
19
Q
What should an INR be for a patient on warfarin for oral surgery to be carried
out?
A
<4 treat without interrupting their anticoagulant medication
20
Q
6) Patient attends with suspected dry socket
- What is the scientific term for a dry socket?
A
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
21
Q
How long should it take for a extraction to heal?
Inital healing and soft tissue healing
A
Intial healing 1-2 weeks
Soft tissues fully healed by 3-4 weeks
22
Q
What are the predisposing risk factors for dry socket? (8)
A
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
23
Q
What are the treatment options for dry socket? (7)
Supportive and management
A
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
24
Q
What are the risks related to extraction and how are they managed?
A
* 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
25
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
26
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
27
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
28
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
29
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
30
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)
31
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)
32
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
33
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
34
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
35
For MRONJ to be diagnosed how many weeks must have pasted and the bone is still exposed?
8 weeks
36
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
37
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
38
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
39
7. 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
40
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
41
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
42
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
43
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
44
What imaging is requested when an 8 is close to IAN? (2)
OPT
or for better view CBCT
45
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
46
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
47
What happens to the nerve during neurotmesis
Neurotmesis: In this serious nerve injury, your nerve is completely cut (severed).
48
Treatment option for XLA of lower 8's with close proximity to the IAN? (1)
Coronectomy
49
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
50
Name a guideline for the removal of impacted molars?
SIGN (Scottish Intercollegiate Guidelines Network)
NICE (National Institute for health and care excellance)
51
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
52
25-Year-Old patient attends with impacted lower 8’s.
1. What are the SIGN guidelines strong recommendations for removal of wisdom teeth?
- Episodes. one or more episodes of infection. Such as pericornitis, cellulitis, abscess formation or untreatable pulpal/periapical patholgy.
- Caries. Caries in the third molar which is unlikely to be resotred
- Caries in the adjacent tooth which cannot be treated without removal of 8
- Periodontal disease due to position of 8
- Case of dentigerous cyst or other related oral pathology
- External root resorption of the 6 or 7 as a result of the 8
53
What are the SIGN guidelines recommendations for when removal of wisdom teeth is advisable?
* Patients who are/have experiences significant infection associated with uninterrupted or impacted 8
* Patient with predisposing risk factors who’s occupation/lifestyle precludes ready access to dental care
* Patient with a medical condition when risk of retention outweighs potential complications with removal (e.g. prior to radiotherapy, cardiac surgery or starting bisphosphonate therapy)
* Patients who have agreed to tooth transplantation, orthognathic surgery or other local procedure which removal of 8 will help with
* In case of GA for removal of one third molar consider removing opposing or contralateral 8’s where risks of retention and further GA outweigh risks associated with their removal
54
What are the SIGN guidelines other indications for removal of wisdom tooth?
* For autogenous transplantation into socket of 6
* Fracture of mandible in region or 8 or involved in tumour resection
* Unerupted third molar in atrophic mandible
* Prophylactic removable of PE in certain specific medical conditions
* (NB. Atypical pain from unerupted 8 is uncommon and always rule out TMJ or muscle dysfunction before considering removal)
* Partially erupted or unerupted 8, close to alveolar surface prior to denture construction or close to planned implant
* Extraction of opposing maxillary third molar due deal with acute exacerbation of symptoms while patient is on waiting list for surgery
55
What are the SIGN guidelines for not advising removal of wisdom teeth?
- Medical contraindication, where the risk of removal exceeds the benefit
- 8's that are judged to have erupted successfully and have a function role in the dentition
- Deeply impacted 8's with no history or evidence of perminant local or systemic pathology
- Patients where risk of surgical complicatinos is judged to be unacceptably high
- Simultaneous extraction of asymptomatic contralateral third molars where surgical removal of one third molar is planned under LA
56
What is assessed during radiological assessment when removing 3rd molars?
- Apices is there signs of PAP
- Bone levels (including depth and density at point of elevation
- Caries
- Type and orientation or impaction (mesial,distal, vertical etc)
- Access to the tooth
- Crown shape, size and condition (caries)
- Root number and pathology (including presence of apical hooks)
- Follicular width
- Periodontal status
- Realtion or proximity of upper maxilary antrum to roots and relation o f lower 8's to IANC
- Assocaited pathology or loss of bone distal to crown due to pericoronal infection
## Footnote
Same as all radiographs ABC then specific to 8's
* M (easure follicular width) O (orientation) L (loss of bone & recurring infection) A (adjacent tooth & position of sinus + alveolar bone levels) R (roots + relationship to anatomical structures) S (size of crown)
57
What is the incidence of a) temporary and b) permanent loss of sensation in extraction of wisdom teeth when the roots are not overlapping the IANC radiographically?
a) Temporary- 5%
b) Permanent- <1%
58
What type of flap is used for removal of an impacted lower 8?
3 sided flap
Envelop flap
59
Give 4 other post-operative complications for lower 8 removal?
* Pain
* Swelling
* Bruising
* Bleeding
* Jaw stiffness or limited jaw opening
* Infection
* Dry socket (alveolar osteitis) (delayed healing)
* Dysesthesia (painful, uncomfortable sensation) or paraesthesia (altered, tingling sensation) of the lower lip, chin and tongue (temporary or permanent nerve damage to lingual or IAN possible)
* Altered taste
60
Briefly describe the surgical removal of an impacted lower 8?
* Anaesthesia achieved- LA, IV or inhalation sedation or GA
* Access to the area by raising a buccal mucoperiosteal flap +/- lingual flap
* Bone removal as necessary using electrical straight on buccal aspect of the tooth and onto the distal impact of the impaction; create deep narrow (buccal) gutter around the tooth)
* Tooth division as necessary; horizontal sectioning of crown from roots and possible subsequent vertical sectioning of roots
* Elevation and removal of all segments of tooth (crown and roots) with elevators forceps etc.
* Debridement of the area through physical removal of debris, irrigation with saline and suction under flap (includes curettage of follicular or granulation tissue)
* Suture to approximate tissue and encourage healing by primary intention (anaomtical repositioning
* Achieve haemostasis
* Post-operative instruction and relevant medications given/prescribed
61
What is the use of iodine following extraction of lower 8?
* Iodine is found in Whitehead’s varnish pack which is used to manage dry sockets following extraction
* It has antiseptic properties and is proposed to act as a dressing material to keep soft tissue or bony cavities free from infection postoperatively (reducing post op pain and infection)
62
Name three types of nerve damage?
* Neurapraxia- contusion of nerve but continuity of epineural sheath and axons maintained; local myelin damage usually secondary to compression
* Axonotmesis- continuity of axons maintained but epineural sheath disrupted -
* Neurotmesis- complete loss of nerve continuity or nerve transaction
63
What are the peri-operative complications of impacted third molar extraction?
* Risk of restoration fracture
* Risk of jaw fracture- increased in edentulous patients, atrophic mandible, aberrant lower 8’s close to the lower border of the lower border of the mandible or where there is a large cystic lesion associated with 3rd molars
* Risk of damage to adjacent structure
* Risk of nerve damage
* Fracture or root or tooth
* Wrong tooth
* Broken instruments
* Soft tissue damage
* Nerve damage
64
Flap Design-
Design a flap for surgical removal of a lower 5?
2 sided flap
65
What are the principles of flap design? (11)
- Wide based incision (to allow adequate own blood supply)
- USe scalpel in one firm continuous stroke
- No sharp angles
- Adequately size flap
- Flap reflection should be down to bone and done cleanly
- Minimise trauam to the dental papillae
- No crushing
- keep moist
- Ensure that flap margins and sutures lie on solid bone
- Make sure wounds are not closed under tension
- AIm for healing by primary intention to minimise scaring
66
What are the aims of suturing?
- Approximate/reposition the tissues
- Compress blood vessels and achieve good haemostasis
- cover bone
- Prevent wound breakdown
- Encourage healing by primary intention
67
Name 4 types of suture and give examples?
* Resorbable monofilament- Monocryl
* Resorbable multifilament- Vicryl Rapide
* Non-Resorbable Monofilament- Prolene
* Non-Resorbable Multifilament- Mersilk
68
Patient has a swelling around unerupted lower 8, slight facial swelling and feeling slightly unwell.
1. What 6 things from the history and investigation should you note before looking at the region in the mouth?
* Pain history
* Duration of swelling- has it gotten bigger or smaller and how quickly? This indicates how serious the situation is and if a referral to MAXFAX is required.
* Previous or recent dental treatment in the area
* Temperature
* BR
* HR
* Medical history- any pertinent factors (e.g. immunosuppression)
* Any signs of airway being compromised
How does the patient look in general
## Footnote
SEPSIS is always at the front of your mind.
69
Patient has a swelling around unerupted lower 8, slight facial swelling and feeling slightly unwell.
- Outline your initial management. (5)
- Anaesthetise patient with IDB
- Incise and drain localised pericoronal abscess
- Irrigate with blunt needle under the operculum. Getting rid of any food or debris around the area.
- Give patient instruction on how to use syringe and warm salty water to keep the area clean (every time they eat) and prevent flare ups
- Analgesics and instruction on keeping fluids up
- Consider AB prescription as E/O swelling and patient is systemically unwell.
- Review patient
- Generally wait until acute episode has been dealt with then extract the lower 8.
70
What 2 nerves are at risk of damage during extraction of lower 8 and what tissues do they supply?
IAN - lower lip, skin on the chin, teethand labial mucosa
Lingual nerve - lateral border of the tongue, lingual mucosa
71
8. Patient attends with suspected OAF - How would you diagnose a OAF?
o Direct visual assessment if you can visualise a communication
o Nose holding test – nose pinched between thumb and index finger and air will rush out of the socket (be careful with this as can make the communication worse)
o Bubbling of blood from extraction site. This is a sign of air transfer which is indicative of OAC
o Searching for an echo when suctioning with good light
o Using a blunt probe
72
What symptoms would a patient be complaining of with OAF?
o Problems with fluid consumption (fluid coming from the nose) o Problems with speech or singing (nasal sounding)
o Problems playing wind instruments
o Problems smoking or using a straw
o Bad taste/odour/halitosis/pus discharge
o Pain and sinusitis type symptoms (unilateral brown nasal discharge)
73
What treatment is used for OAF?
o Excise the sinus tract/fistula
o Perform a buccal advancement flap +/- buccal fat pad or palatal flap (parallel incisions, score the mucoperiosteum to aid stretch and mattress sutures)
o May require bone graft or collagen membrane
o Antral washout (lots of saline)
- Prescribe AB
- Give post-op instructions
* Leave it alone
* Don’t vigorously rinse today- start gentle rinsing from tomorrow
* Brush teeth as normal but spit don’t rinse toothpaste
* Try not to use straws, avoid use of wind instruments and try not to suck air into the area
* Try to avoid nose blowing (as will create air movement and keep communication open)
* Try closed/stifled sneeze (hold mouth) if necessary
74
What is the difference between an OAF and OAC
An OAF is a chronic epithelial lined tract between the maxillary sinus and oral cavity whereas an OAC is an acute communication which is nit epithelial lined.
75
What are post-op instructions for OAC/OAF
* Leave it alone
* Don’t vigorously rinse today- start gentle rinsing from tomorrow
* Brush teeth as normal but spit don’t rinse toothpaste
* Try not to use straws, avoid use of wind instruments and try not to suck air into the area
* Try to avoid nose blowing (as will create air movement and keep communication open)
* Try closed/stifled sneeze (hold mouth) if necessary
Review in 6-8weeks
76
Patient experiences dripping from nose after upper molar extraction.
1. What is your clinical diagnosis? (1)
* Oral antral communication (OAC)
## Footnote
When there is an opening between the sinus and tooth socket, blood from the tooth socket may enter the sinus. The sinus will clear this blood, and it will be discharged either down the throat or from your nose. This will often be a dark-colored discharge
77
What are 5 presenting signs and symptoms that there is an OAC? (5)
* Bubbling of blood from extraction site
* Bone at trifurcation of the roots after extraction
* Direct vision shows communication
* Air rushing out of socket on nose holding test
* Blunt palpation allows detection of communication
78
How would you surgically close an OAC?
* Inform patient what has happened
* If small encourage bleeding and suture margins with non-resorbable sutures
* If large (>2mm) or lining torn close with buccal advancement flap using non resorbable sutures
* Prescribe 7-day course of antibiotics
* Give following post-operative instructions; refrain from forceable nose blowing, don’t stifle sneeze, avoid use of straw, refrain from smoking and wind instrument playing, use steam or menthol inhalation (as opposed to blowing nose)
79
What is the difference between and OAF and OAC?
* OAC is acute presentation when communication between mouth and antrum originally occurs (no epithelial lined tract)
* After this has persisted for a while it will become lined by an epithelial tract at which point it is in its chronic form known as OAF
80
9. TMD
- What are 6 signs and symptoms of TMD?
o Intermittent pain of several months or years in duration
o Pain on opening
o Limited mouth opening
o Muscle/joint/ear pain particularly on wakening
o Trismus and locking are commonly associated
o Clicking and popping joint noises
o Associated headaches
o Crepitus (late degenerative changes)
o Signs of wear – Linea Alba, wear facets, tongue scalloping
o Facial asymmetry
81
What 2 muscles should be palpated when querying TMD?
o Masseter
o Temporalis
82
What are the common causes of TMD?
o Inflammation of the muscles of mastication or TMJ secondary to parafunctional habits
o Trauma either directly or indirectly to the joint
o Stress
o Psychogenic
o Occlusal abnormalities
o Degenerative disease – localised (osteoarthritis); systemic (RA)
o Disc displacement – anterior +/- reduction
o Neoplasia
o Infections
83
What nerve supplies the TMJ?
o Auriculotemporal and masseteric branches of mandibular branch of trigeminal nerve
84
What conservative advice is given to manage this patient's TMD?
- Reassure this patient about the conditon. Validate their feelings
- Heat packs combined with NSAID's
- Medications to relax the muscles, botox, tricylic anti-depressants, steroids, muscle relaxants
- Excercises to relax muscle, massage and relaxation techniques
- Soft diet. muscles dont need to work as hard.
- Supported mouth opening and yawning
- Reduce stress levels
- Treat parafunction habit (grinding and clenching)
- Splints and bite raising appliances (soft, hybrid and hard)
85
What are the mechanisms of a bite splint?(2)
- Stabilise the occlusion which improves the function of the masticatory muscles, decreasing stress on them
- Protect the teeth and act as a habit breaker
86
What is arthrocentesis?
Arthrocentesis is when the TMJ is flushed out with saline and anti-inflammatory steroids. When flushing the joint it breaks up fibrous adhesion and flushes awat inflammatory exudate.
87
Give 2 possible surgical options for TMD?
- Disc repositioning/repair and removal
- Arthroscopy (key hole surgery of the joint)
88
Dawn is a final year uni student who presents with difficulty opening her mouth widely, facial pain and jaw clicking when chewing food. You suspect TMD.
- What information could be elicited from your clinical examination in relation to the suspected diagnosis? (5)
- E/O range of movement
- On opening does the TMJ deviate
- Does the TMJ click and pop as she opens and closes.
- Is there signs of crepitus (this is a signof joint degeneration)
- Is the joint tender itself
- Feel the muscles of MOM, SCM and trapezius if they are tender
- Skeletal occlusal classification
I/O
- Are there signs of parafunction. Wear facers, scalloped tongue, linea alba, cheek biting
- Lack of posterior suppport
- Dental occlusion upset
## Footnote
Think about what you would do in your clinical examination. Start with the stuff E/O and then I/O
89
2. What factors could predispose to temporomandibular dysfunction? (2)
- Stress
- Parafunctional habits with secondary inflammation like grinding and clenching
- Trauma
- More common in female s
- More common between ages of 18-30
90
Dawn is a final year uni student who presents with difficulty opening her mouth widely, facial pain and jaw clicking when chewing food. You suspect TMD.
- Are there any other conditions that might present with similar signs/symptoms are how might you exclude there? (5)
## Footnote
Think systemically to rule out other possible causes.
* Dental pain
* Sinusitis
* Atypical facial pain/myofascial pain syndrome
* Salivary gland pathology
* Trigeminal neuralgia
* Thorough history is required to rule out any of these other conditions
* The following factors may allow differentiation-
* Most if not all are not normally associated with jaw click, deviation on opening, tenderness of TMJ itself, or hypertrophy of the muscles of mastication
* For dental pain cause check existing radiographs and preform thorough clinical examine to check for teeth with extensive caries or infection which could be causative, the pain is also much likely to have a more recent and short lived onset while TMJ is characterised by gradual worsening of symptoms over months or years
* Sinusitis is usually precipitated by the effects of a viral infection, it won’t affect mouth opening or cause tenderness of muscles of mastication and may also be uncomfortable on palpation of infraorbital region plus the patient may feel congested
* Salivary gland pathology is also often associated with change in volume or viscosity of saliva in the mouth and onset of meal-times symptoms which can be enquired about
* Trigeminal neuralgia more characteristically has acute spasms of sharp shooting pain while TMD is a dull ache and trigeminal neuralgia is normally unilateral as opposed to TMF which is more commonly bilateral
* If there is great uncertainty about the nature of the pain can consider doing imaging of the salivary glands, sinuses and teeth to confirm or rule out any other differential diagnoses
91
Having conducted your examination, you confirm the diagnosis of temporomandibular dysfunction. What would your first line management be? (5)
Conservative management first.
- Educate and inform the patient
- Jaw excercises
- NSAID's and heat packs on face reduces the inflammation
- Medication
- Soft diet, 2-4 weeks. cut up food into smaller pieces
- No chewing gum
- Supportive yawning
- Reduce stress in their life, give relaxation techniques
- Get patient to be aware if they have a parafunctional habit that they try to not clench (teeth should only be in contact 20mins a day).
- Make they a splint for at night, soft, hybrid and hard.
- Regular analgesics
- Replace any posterior teeth that are missing to increase the support
## Footnote
Remember TMD is either a muscular or joint problem. If muscular, use the gym analogy. Need to give their muscles a rest. Eg relax them, massage, soft deit etc
92
You decide to construct a stabilisation splint. As your technician, is unsure what this is, describe how you would like your splint made?
*** Please construct a hard-acrylic splint with full occlusal coverage which extends to cover all teeth**
* Upper and lower alginates and a face bow registration will be provided
* After construction requires to be ground both in the lab and clinically to achieve maximum bilateral intercuspation
* Should include canine guidance plane (and wear facets)
* Splint should cover occlusal surface, incisal edges and into the palate and should be built up to include even contact with opposing teeth without indentations on the posterior but with and incisal ramp to allow contact with opposing incisors and canine guidance ramps
* Multiple even contacts on posterior teeth with lighter contacts on anterior teeth
* Ideally have anterior guidance ramp providing canine guidance and disocclusion of the posterior teeth in lateral and protrusive excursions
* Heat cured acrylic is preferable
* NB. Maxillary- Michigan splint & Mandibular- Tanner appliance
93
ZOC
- What are 6 signs and symptoms of ZOC fractures involving orbit floor?
- Sub congunctival haemorrhage (bleeding of the clear part of your eye)
- excess watering of the eye
- Changes to vision
- Facial asymmetry (swelling followed by flattening)
- Alteration in sensation
- numb cheek
- Pain and brusing
94
What imaging would you take to confirm ZOC fracture diagnosis?
o Occipitomental (OM) views 15/30o (facial views)
o CT scan for complex fractures or blow outs
o Use Campbell’s lines to interpret facial injuries on radiographs
95
What are the management options for ZOC fractures?
o None:
§ leave and monitor
o Exposure and repair of fracture:
§ Or ORIF (open, reduction and internal fixation)
o Closed reduction:
§ Gillies loft – arch lifted out for realignment
§ Malar hook or buttress plate for F-Z displacement
o Post-op Instructions:
§ Avoid nose blowing
§ Post op steroids – dexamethasone 4-8mg
§ Eye observation overnight – retrobulbar haemorrhage § Pain management
96
11. Implants
- What are 2 local and 2 general factors for implant placement
Local - Alveolar bone levels and suitable space to place the implant (need 7mm)
General - Smoking status and bisphosphonate use, age
97
What factors does an implantologist consider before placing an implant?
## Footnote
Start with general things outside the mouth before then factors inside the mouth
- Medical and drug history
- Smoking history
- Age
- patient on bisphosphonates
- Patient motivation and compliance
- Level of alveolar bone levels (7mm+) and quality
- Occlusion
- Oral hygiene and periodontal status
98
What bone dimensions are required and how are they best measured? For implants.
PT are access with CBCT
Need to have 1.5mm of horizontal bone around the implant
3mm between implants
>5mm space for the papilla between bone crest and contact points
7mm spacing between crowns
2mm clear from adjacent structures. Such as the IAN and maxillary sinus
99
Give 3 alternative treatment options instead of an implant?
Accept the space
Bridge
RPD
100
12. A patient attends your surgery for provision of a complete upper with extraction of 17 required
- Name 3 possible complications associated with extraction of lone standing upper molars
## Footnote
Think structures close to the area of this tooth
- Maxillary tuberosity fracture
- OAC
- Loss of roots/tooth into the maxillary antrum
101
Describe how you would diagnose a OAC?
- Look for bubbling of blood in the socket
- Nose holding test - get the patient to pinch their nose and then air will rush out of the socket (be careful not to create an OAC here). Whilstling sound of air
- DIrect visual assessment can use a blunt probe gently to inspect
- Searching for echo with good light and suction
- Pre and post operative radiographs
102
Describe how you would diagnose a maxillary tuburosity fracture?
- Firstly would feel and hear the noise of the fracture
- Then would see the facture, either by visual tear of the palate or notice the mobility of the bone in the area
103
Describe how you would diagnose the loss of tooth or root into the maxillary antrum?
Post op radiographs (OPT, occlusal or PA)
Visual assessment (Put ribbon gauze into sinus and hope when you pull it out the roots come with it)
104
What flap design is used for OAC?
Buccal advancement flap
105
Outline your management of the possible complications for OAC?
## Footnote
Treatment differs depending on the size of the OAC
No matter the size inform the patient and explain an OAC
Small OAC is < 2mm
- Encourage clot formation and suture. WIll heal with normal clot and routine mucosa healing
- AB prophylactic
Large or the lining is torn
- Close the area with a buccal advancement flap
- AB amoxicillin 500mg for 7 days 3x daily and nose blowing instructions.
- CHX mouthwash rinuse
- Analgesics
Conservative advice
- no forceful blowing of nose or stifling sneeze
- Steam and menthol inhalation is advantageous
- Avoid straws, smoking and alcohol
106
Outline your management of the possible complications of maxillary tuberosity fracture.
- Dissect out and close the wound, reduce and stabilise with fingers or forceps
- Fix the bone in place with an orthodontic buccal archwire or soft splint
Always check.
- Occlusion
- AB and antiseptic use
- Remove and treat involved pulp, POI
- Remove the tooth 8 weeks later, as need the bone to heal first
107
Outline your management of the possible complications for root in antrum
Surgical:
* Caldwell-luc approach – buccal sulcus/window cut in the bone
* Open fenestration with care
* Efficient suction and narrow bore
* Use small curettes and irrigate or use ribbon gauze to remove all
fragments
* Close with buccal advancement flap
ENT involvement – endoscopic retrieval
| Ribbon Gauze is a sterile wound dressing that binds bacteria and fungi
108
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
109
What are the risk factors for ORN?
- Dose of radiation, higher risk where the dose is greater than 60 gray
- Mandible is more commonly effected due to the poorer blood supply
- Poor OH
- patient not dentally fit berfore cancer treatment and then requiring more traumatic procedures
- Post radiotherapy damage, trauma, biopsy or irritation
110
How can you reduce the chances of ORN
## Footnote
Think of the risk factors and how you would combat them
- Good OH to prevent the need for extractions
- If extracting teeth try minimise trauma to the bone. Surgical may be better as reduces amount of pressure
- Patient should be dentally fit before their cancer treatment, this reduces the chances of treatment needed after
- CHX mouthwash used before and after extraction
- Hyperbaric oxygen before and after to increase local tissue oxygenation and vascular ingrowth to hypoxic areas.
111
If a patient does have ORN how would you maange them?
- Surgical debridment - irrigation of necrotic debris (may be all that is required if the lesion is small), removal of necrotic and infected tissue and removal of loose, sharp necrotic bone (sequestrum- (as this will prevent healing)
- In severe cases may be referrred to hospital for resection of exposed bone( to margin of unexposed bone and then attempt soft tissue closure)
- Surgical microvascular reconstructive surgery - to restore blood flow to the area
- Bone and soft tissue grafts
- Hyperbaric oxygen
112
Forceps
- Give 8 different forceps and their uses?
* Straight upper anterior- maxillary 3-3
* Upper universal- maxillary 3-3, root and premolars
* Upper molars; left and right- maxillary molars left and right (beak to cheeky)
* Lower universal forceps- mandibular anteriors and premolars
* Lower molar forceps- mandibular molars
* Cowhorn forceps- mandibular molars (or to split teeth in half (dissect) or in teeth with two divergent roots)
* Upper bayonet third molar- maxillary 8’s
* Upper bayonet roots- broken roots
113
Name 3 types of elevator?
* Coupland’s- multiple sizes 2,3,
* Cryer’s- pairs left and right
* Warwick James- set of 3 straight, right and left
114
What movement are used for elevation?
* Wheel and axel AKA rotation
* Lever
* Wedge
115
What are the uses for elevators?
- Provide a point of application for the forceps
- Loosen the tooth before placement of forceps
- Ex tooth completely
- Removal of multiple root stumps, retined root or root apices
116
What is the function of a luxator?
* Break/sever/tear the PDL and in turn loosen the tooth (to aid with elevator and forceps use)
117
Label this OPT
118
Osteomyelitis
- What is osteomyelitis?
Osteomyelitis is a bacterial infection of the bone which results in inflammation of the bone marrow. Increasing tissue pressure (due to oedema), comprimises blood supply and possible subsequent ischemia and necrosis.
119
What are the risk factors for osteomyelitis?
- Mandible due to blood supply
- Odontogenic infections and fractures of the mandible
- Any medical condition where the host is immunocomprimised. (diabetes, alcoholism, IV drug use, malnutrition, myeloproliferative disease (e.g leukemia, sickle cell and chemotherapy))
120
How is osteomyelitis managed?
- Refer patients
- Requires aggressive antibiotic and surgical intervention
* Clindamycin or penicillin antibiotics treatment as first line generally for 6-8 weeks (up to a maximum of a few months during which patient will be regularly reviewed); these antibiotics are effective against odontogenic infections and good bone penetration (other antibiotics may be used depending on findings of pus sample)
* Surgical treatment is utilised is there are bony sequestrum, if no improvement from antibiotics along or if marked area of infection; drain pus, remove non-vital teeth in infected area, remove loose sequestrum, remove any wires or plates in case of fractured mandible
* Corticotomy (removal of bony cortex) or perforation of bony cortex followed by excision of necrotic bone until reach actively bleeding healthy bone
* Severe acute osteomyelitis may require hospital admission and IV antibiotics if systemic symptoms
121
Patient presents with a large extra-oral swelling.
1. What information is required when taking a history and investigating a patient with swelling before looking in the mouth?
## Footnote
Think sepsis
- How does the patient look in general, do they look unwell? Colour of them.
- Thorough history, pain history
- Specifically when did the swelling start and how quickly has it gotten? Do they have any systemic symptoms? is the airway comprimised?
- Have they had any recent dental treatment
- Medical history
- What is there temperature
- BR
- HR
- BP
122
What things would you note about a facial swelling?
- Location
- Size
- is airway comprimised
- How quickly is it progressing
- Is the tongue raised (this suggests its spread to FOM and airway could be comprimsied soon)
- Palpation is the swelling fixed or mobile
- Pus present/sinus tract
- Heat from the area
- Colour
- Diffuse borders
- Systemic symptoms
123
What are the critical perimetres for SIRS?
2 or more positive SIRS factors +/- suspected or comfirmed infection (if infectiion comfirmed then sepsis)
- HR >90bpm at rest
- BR > 20 bpm
- WCC >1,200/mm3
- Temperature <36 or >38
124
What is the breathing criteria for SIRS?
- >20 bpm
125
What is the HR criteria for SIRS?
- >90bpm
126
What is the temperatire criteria for SIRS?
-<36 or >38
127
You suspect sepsis. What do you do?
- urgent referral to A&E or MAXFAX
128
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
129
Name 4 maxillary and mandibular spaces?
Maxillary
- Infra-orbital space
- Buccal space
- Palatal space
- Infra-temperoral space
- Labial space
mandibular space
- Sub-lingual
- Sub-mandibular
- sub-mental
- Buccal space
- Sub-messeteric
- lateral pharyngeal space
