Oral Surgery Flashcards
management of acute OAC
inform patient
if small or sinus intact:
- encourage clot
- suture margins
- antibiotics?
- post-op instructions
management of chronic OAF
excise sinus tract
buccal advancement flap
OR
palatal flap
bone graft/collagen membrane
what are some peri-operative complications
haemorrhage
nerve/vessel damage
fractured root/tooth
abnormal resistance
dislocation of TMJ
Aims when retracting a flap
achieve maximal access w/ minimal trauma
protect soft tissues
no sharp angles
healing by primary intention to minimise scarring
wide based incision
factors influencing flap design
- base wider than flap
- trauma to interdental papilla should be minimal
- flap margins and sutures should lie on sound bone
- tissues should be kept moist
what instruments do you use to remove bone?
electrical straight handpiece w/ saline cooled bur (round or fissure/ tungsten carbibe)
motor driven - if turbine may lead to surgical emphysema
how to debride prior to a suture
- Physical
- bone file/handpiece to remove sharp bony edges
- mitchells/victoria currette to remove soft tissues - Irrigation
- sterile saline into socket and underflap - Suction
- aspirate under flap to remove debris
- check socket for retained apices
what much retained root can be safely left in aveolar bone?
3mm
what are predisposing factors to alveolar osteitis (dry socket)
lower extraction (molar)
smoker
female
oral contraceptive
LA w/ vasoconstrictor
what are the presenting signs and symptoms of dry socket
severe pain radiating to ear
c/o bad taste in mouth (+odour)
pt may think you’ve left tooth in
management of dry socket
- reassure pt & manage w/ pain relief
- give LA to help w/ pain relief & to allow you to carry out irrigation
-irrigate socket w/ warm saline (or sterile water) to wash out food/debris - encourage clot
- pack w/ antiseptic pack (BIP) OR alvogyl
- advise pt, salty mouthwashes
what are 3 nerve deficits
paraesthesia - tingly
dysaesthesia - unpleasnt/pain
hypo/hyperaesthesia
what are causes of nerve damage
- crushing injuries - from forceps
- cutting/shredding injuries - needle may hit nerve during LA
- transection injuries - nerve lacerated during incisions
flap design for a surgical extraction of 45
- distal relieving incision at 5 extending into attached gingivae
- cervicular incision extending form mesial of 4 to distal of 5
list haemostatic control
- use LA w/ vasoconstrictor
- pressure w/ finger OR damp gauze
- diathermy
- suture
- artery forceps
- bone wax
what can cause prolonged bleeding post XLA
- vasoconstricting effects of LA worn off
- sutures are loose
- Pt has traumatised area w/ tongue/finger/food
- Pt has bleeding disorder
what is surgicel?
a haemostatic agent.
it is an oxidised cellulose. it acts as a framework for clot formation
how would you management a maxillary tuberosity fracture?
If SMALL
- could potentially LEAVE IT
- remove fragement(s)
- reduce and stabilise
- close wound
- treat with ab
If LARGE
- stabilise mobile part(s) of bone w/ rigid fixation techniques e.g. splinting, arch bars for 4-6 weeks
- remove/treat pulp
- treat w/ ab
- remove tooth 8 weeks later
indications for extractions
gross caries
advanced perio
tooth/root fracture
severe tooth surface loss
pulpal necrosis
apical infection
symptomatic partially erupted
traumatic position
orthodontic purposes
interference with denture construction
what are the mechanical principles for tooth elevation. the 3 basic modes of action
wheel and axle
lever
wedge
what can cause difficult access during a XLA
- trismus
- reduced aperture of mouth (congenital/syndromes - microstomia; scarring)
- crowded/malpositioned teeth
what can cause abnormal resistance during XLA
- thick cortical bone
- shape/form of roots
- number of roots
- hypercementosis
- ankylosis
what are the most common places you can fracture of the alveolar bone
buccal plate
canine
molars
steps to follow, following a jaw fracture
inform pt
post-op radiograph
refer?
ensure analgesia
stabilise
if delay, antibiotic
what are risk factors of causing involvement of maxillary antrum during XLA
- extraction of upper molars/premolars
- close relationship of roots to sinus on radiograph
- last standing molars
- large bulbous roots
- older patient
- previous OAC
- recurrent sinusitis
what are the stages of surgery (generally)
anaesthesia
access
bone removal*
tooth division*
debridement
suture
achieve haemostasis
POI/POM
*as necessary
what are the main risks and complications when carrying out XLA
pain
bleeding
swelling
bruising
infection
dry socket
retained roots
OAC
further procedures
damage to adjacent teeth and structures
aims of suturing
position tissues cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention
types of sutures
non absorbable
absorbable
+
monofilament
polyfilament
when removing the 3rd molar what are nerves that can be damaged
lingual*
inferior alveolar*
mylohyoid
buccal
*most common
mechanistic action of ASPIRIN
inhibits cyclooxygenase - reduced production of prostaglandins
+
aspirin inhibits COX1 = inhibition reduces platelet aggregation
what groups of people do you NOT give aspirin to
peptic ulcer
haemophilia
children <16
hypersensitivity
what groups of people should you be cautious of giving ibuprofen to
previous active peptic ulceration
elderly
pregnancy/lactation
renal/cardiac/hepatic impairment
mechanistic action of paracetamol
blocks feedback mechanism - indirectly reduced PG synthesis
how do opiods act on the body
act on spinal cord - dorsal horn pathways - central regulation of pain
produced effects via specific receptors
reasons for teeth fracturing during XLAs
thick cortical bone
root shape
root number
hypercementosis (wide apex)
ankylosis
caries
alignment
define neuropraxia
focal segmental demyelination at the site of injury without disruption of axon continuity and its surrounding connective tissue
results in blockage of nerve conduction and transient weakness or paresthesia
define axonotmesis
nerves are stretched. the axon is disrupted in its myelin sheath.
define neurotmesis
complete loss of nerve continually/nerve transected
common post extraction complications XLA
pain/swelling/ecchymosis
trismus
haemorrhage
nerve damage - prolonged effects
dry socket
sequestrum
infected socket
chronic OAF/root in antrum
less common post-op complications
osteomyelitis
ORN
MRONJ
actinomycosis
bacteraemia/ infective endocarditis
management of post-op bleeding
pressure - finger/biting on damp pack
LA with vasoconstrictor
haemostatic aids e.g. Surgicel, bone wax in socket
suture socket
ligation of vessels/diathermy if available
what would you do if you cannot arrest haemorrhage?
URGENT REFERRAL
weekdays - dental hosp
weekends - A&E
why is it important to remove any sequestrum
it prevents/delays healing
what are predisposing factors to osteomyelitis
odontogenic infection and fractures of mandible
what causes involucrum
Involucrum formation typically indicates chronic osteomyelitis. this is an inflammatory reaction
it appears radiographically as an increase in radiodensity surrounding the radiolucent area
Treatment of Osteomyelitis
Antibiotics (if severe, may require hosp admission and IV Ab)
Surgical treatment:
- drain pus if possible
- remove any non vital teeth in area of infection
- in fractured mandible, remove any wires/plates/screw in the area
- corticotomy
- perforation of bony cortex
- excision of necrotic bone
ORN prevention
- scaling/chlorhexidine prior to extraction
- careful extraction technique
- Ab, chlorhexidine + review post op
- Hyperbaric Oz to increased local tissue oxygenation + vascular ingrowth to hypoxic areas before and after XLA
ORN treatment
- irrigation of necrotic debris
- Ab
- loose sequestra removed
- small wounds usually heal over course of weeks/months
- severe cases - resection of exposed bone, margin of unexposed bone and soft tissue closure
- hyperbaric oxygen
what is actinomycosis
rare bacterial infection
chronic
multiple skin sinuses and
