Oral Surgery Flashcards
What is meant by “exodontia”?
The removal of teeth
Give the steps involved in a buccal infiltration
- The lip or cheek is reflected so that mucous membrane is under tension
- Needle inserted through taut mucosa with bevel towards bone
- Insert until bevel comes into contact with bone
What type of LA solution could be utilised for buccal infiltration in the mandible, particularly in order to anaesthetise premolar and molar teeth?
Articaine
What are the steps to carrying out a palatal infiltration?
- Needle inserted approx 10mm from free gingival margin
- Bevel of needle towards bone
- Insert slowly
why is only a small amount of LA solution required for palate infiltration?
Because of lack of potential volume in tightly bound tissue
Why should a palatal infiltration be the last injection given, if multiple infiltrations are being administered?
Because there is no submucosa in palate mucosa, so the bevel is easily blunted (never use a blunted bevel for injection!)
When give an IANB, what two occurrences would indicate that a modification to your technique is required before injecting any solution?
- If the bone is not reached when over 2/3rds of the needle has been inserted into tissue
- If the needle hits bone too quickly and seems very superficial
Following injection of LA solution to block the IDN, how would you block the lingual nerve?
Following injection of IDN, withdraw needle halfway and inject approx 1/2ml (remaining solution) to block the lingual nerve
When giving a buccal nerve block, where is the penetration site for injection?
Distal and buccal to the last molar(3rd molar region)
What does SBAR stand for?
Situation, background, assessment, recommendation
In oral surgery clinic, when checking patient dental history, what are the three most important questions to ask the patient?
- Have you has issues with post extraction haemorrhage?
- Do you have extraction problems? (E.g. LA phobia)
- What tooth is to be extracted today? (Check charting)
After LA is administered, what sensation should the patient expect to feel?
They will feel touch and deep pressure, they may even have a sensation of the tooth moving.
LA does not eradicate all sensation
When managing sharps, where should extracted teeth containing amalgam restorations be placed?
In the Tooth Box tub
How would you abbreviate in the notes, “haemostasis, post-operative instructions given; written and verbal”
H.P.O.I.G.w&v.
To carry out a lower extraction, what areas will need to be anaesthetised?
Buccal gum and lingual gum
To carry out an upper extraction, what areas will need to be anaesthetised?
Buccal gum and palatal gum
when extracting an upper tooth what position should the chair and patient be in regards to you (the operator)?
The chair should be between shoulder and elbow height, the patient should be lying back (45 degrees)
when extracting a lower tooth what position should the chair and patient be in regards to you (the operator)?
The chair should be low to the ground and the patient should be tilted slightly back
when extracting an upper tooth what position should you (the operator) be in regards to the patient?
In front of the patient, to the right side
when extracting an lower tooth what position should you (the operator) be in regards to the patient?
Right side teeth = behind patient to the right side
Left side teeth = in front of patient to the right side
As part of post-op instructions, What four things should a patient avoid doing after an extraction?
- Avoid rinsing mouth for 24 hours
- Avoid alcohol today
- Avoid smoking
- Avoid strenuous exercise
Why must a patient not smoke post extraction?
If they smoke they are more prone to dry socket, which can be very painful.
What is wrong site surgery?
A surgical intervention performed on the wrong patient to wrong site
What are the four key points to remember from the worst site surgery preventions protocol?
- Confirm “I see you are here for an extraction today, is that correct?”
- “Can you tell me which tooth it is”
- “Can you point to the tooth please”
- Check accuracy with clinical records
What forcep would you select for a badly broken down lower tooth?
Lower cow-horn forcep
Why is there only one lower molar forcep, instead of two for left and right?
Because the lower molars (both right and left) have the same tooth morphology
Which forcep can be used for any lower teeth?
The lower universal forcep
Which forcep is best for lower anterior teeth?
Lower universal forcep
Name the four different types of lower forceps
- Cow horn
- Lower molar
- Lower universal
- Lower narrow
Name the 5 types of upper forceps
- Upper universal
- Upper straight
- Upper molar (left and right)
- Upper narrow
- Upper crown horn/ eagle beak (left and right)
In an upper molar tooth, which beak of an upper molar forcep engages between the mesio-buccal and mesio-distal root, on the buccal side?
The pointed beak
In an upper molar tooth, which beak of an upper molar forcep engages on the single palatal root?
The rounded beak
which forcep should be selected for a very badly broken down upper tooth?
Upper cow-horn/eagle-beak forcep
when proceeding to carry out a lower right extraction (as a right-hand operator), how is your non-dominant hand going to be placed to support the mandible and retract the soft tissues?
- Three fingers under the chin supporting the mandible
- First finger in labial sulcus protecting the lips
- Thumb inside to protect the tongue
what is the first movement of an extraction?
To apply an apical push
Where should the beaks of a forcep be positioned?
In the furcation of the tooth
What movement is required to extract a tooth?
Buccaly and then back
By moving a tooth in a buccal direction, how is this aiding extraction of the tooth?
Because you are splaying out the buccal plate of the alveolus, severing PDL fibres.
why should the beaks of a forcep never be placed on a the crown of a tooth when extracting?
As this will cause crown to fracture
What position should the operator be in when extracting lower right molars- canines?
Behind the patient
What position should the operator be in when extracting lower left molars- canines and anterior teeth?
In front of patient
when proceeding to carry out a lower left or anterior extraction (as a right-hand operator), how is your non-dominant hand going to be placed to support the mandible and retract the soft tissues?
- Thumb supports under chin
- First finger retracts lip
- Middle finger restricts tongue
When carrying out an upper extraction where should the operator be positioned?
In front of patient
when proceeding to carry out an upper left extraction (as a right-hand operator), how is your non-dominant hand going to be placed to support the mandible and retract the soft tissues?
- Thumb on palate
- Finger on labial mucosa protecting lip
- Extra three fingers curled in
Name the three different types of elevators
- Couplands
- Warwick james’
- Cryers
what two functions do elevators have?
- Facilitate extractions by widening the neck of the socket
- Can be used individually to elevate teeth
What instrument is ONLY used to enlarge the neck of socket to allow for easier extraction?
A luxator
Why is a mandibular 3rd molar the most common tooth to elevate?
Because its the hardest to access with forceps
Which type of elevator is the best to access 3rd molars?
Cryers elevator
What are the 4 different categories of complications that can arise in oral surgery?
- Pre-operative
- Intra-operative
- Post-operative
- Special complications
What can disruption of the mental neurovascular bundle result in during extraction?
Altered sensation to the lower lip
What are the signs from the CNS of LA systemic toxicity?
- headache
- light headedness
- drowsiness
- blurred vision
- slurred speech
- tinnitus
- muscle tremors
- convulsions
What are signs from the CVS of LA systemic toxicity?
- reduced excitability/ Contractility of myocardium
- vasodilation
- CVS collapse due to hypoxaemia
Extraction of what tooth is most likely to result in fracture of the maximally tuberosity?
3rd molar
What factors will contribute to fracture of the crown/root during extraction?
Additional roots or bulbosity
Incorrect forcep location
Inappropriate tooth movement
No apical push
Poor forcep selection
What are the two largest patient factors that can make extraction difficult?
- anxiety
- Medical history
Why are individuals of a certain ethnic background, such as Afro-Caribbean and Asians at higher risk of difficult extractions?
Because these groups tend to have very dense alveolar bone
Why are lone standing molar teeth more difficult to extract?
- thickening of alveolar bone and PDL around the tooth
-pneumatisation of maxillary antrum (risk of OAC) - risk of fractured tuberosity
What term is used to describe a tooth that is prevented from achieving a functional occlusal position?
Impacted tooth
What are the 4 most common impacted teeth?
- Mandibular third molars
- Maxillary canines
- Maxillary incisors
- Second premolars
What is the term given to a small flap of gum that causes soft tissue impaction of a tooth?
Operculum
Why is access to maxillary third molars difficult with normal forceps?
As the mouth opens, the coronoid process moves into the space lateral to the maxillary third molars so there is little space to place forceps. Also these teeth are naturally buccaly inclined.
What specialised forceps can be used for maxillary third molar extraction?
Bayonet forceps
What are the three major reasons as to why impacted unerupted teeth are removed?
- Orthodontic reasons
- Restorative/aesthetic reasons
- Pathology
What teeth are most likely to become submerged?
Deciduous molars
What is most commonly the cause of deciduous molars becoming submerged?
When there is no permanent successor
Name 8 radiographic features that would indicate extraction will be difficult.
- Bulbous roots
- Dilacerated/divergent/convergent roots
- Fused roots
- Multi-rooted teeth
- Hypercementosis
- Ankylosis
- Lone-standing molars
- Deeply impacted 3rd molars
Why can deciduous molars be very difficult to extract?
Because their roots can be very divergent due to tooth bud of permannet successor sitting between the roots
What determines the path of withdrawal when extracting a tooth?
Curvature of the roots
When a tooth has more than one path of withdrawal, what is the only treatment option?
Surgical removal
What does curvature of molar roots on a radiograph indicate about the tooth’s proximity to the IAC?
It has a close relationship to the IAC
Name 6 osteoclytic lesions
- Cysts
- Odontogenic tumours
- Primary cancers
- Metastatic cancers
- Metabolic bone disorders
- Fibro-osseous lesions
What are the two types of root resorption?
- external
- internal
In what two areas can external root resorption occur?
Apically or coronally
Which type of root resorption makes extraction more difficult and why?
Internal root resorption, as tooth is more likely to fracture
Which type of root resorption makes extraction easier?
External root resorption
What is meant by ankylosis?
Tooth is fused to the bone
Give two examples of extrinsic obstacles during surgical extraction?
- Adjacent teeth to impacted tooth
- Proximity to IAC and maxillary antrum
Give two examples of intrinsic obstacles during surgical extraction?
- Bulbous roots
- Marked curvature in roots
Describe the removal of bone and sectioning during surgical extraction.
- Expose maximum bulbosity of crown to get access to the ACJ in order to section the tooth crown.
- This will allow access to furcation of multi-rooted teeth to section the roots before elevating.
Why is bone removal required during surgical extraction?
In order to engage an elevator with the tooth root for removal
What is necessary to carry out prior to bone removal during surgical extraction?
Cutting of flap
Why should you never use a normal high speed hand-piece to section roots?
Because it will cause surgical emphysema
What is surgical emphysema?
When air enters the subcutaneous tissues allowing bacterial ingress and potential infection/cellultis
What secondary care units would it be appropraite to refer difficult extraction cases to?
- oral surgery department
- Maxillofacial department
- oral surgery specialist
Describe the steps that lead to the formation and accumulation of pus which can become an abscess.
- Pulp necrosis
- Inflammation of PDL tissues
- Peri-apical periodontitis
- Accumulation of pus leading to abscess
What is “osteomyelitis”?
Infection of the medullary component of bone
Explain why antibiotics cannot primarily treat odontogenic infections?
A non-vital tooth wont have a vascular supply, so the antibiotics cant reach where the vast majority of the bacteria are harbouring (which is in the tooth). The antibiotic will only kill bacteria living in PDL space so will only help reduce symptoms not kill the source of infection.
Define, diffuse inflammation of the soft tissues which is not circumscribed or confined to one area but tends to spread through the tissue spaces along fascial planes.
Cellultis
Why is peri-orbital oedema a very worrying sign?
Because this indicates a potential route of infcetion for bacteria to reach the cavernous sinus, which could cause cavernous sinus thrombosis (potentially fatal condition)
What is the major risk of Ludwigs angina?
Asphyxiation
What effect can cavernous sinus thrombosis have on the eyes?
Build up of pressure results in proptosis and difficulties moving eyes
Define, a life-threatening organ dysfunction caused by a dysregulated host response to infection.
Sepsis
What are the main signs and symptoms of sepsis?
- slurred speech
- extreme shivering
- passed no urine in a day
- severe breathlessness
- skin mottled/discoloured
What clinical signs would indicate sepsis?
- temp >38 degrees Celsius or <36 degrees Celsius
- heart rate > 90
- respiratory rate >20
- White cell count >12 or <4
- BP systolic <100
Describe the management of sepsis?
- take blood cultures prior to antibiotics
- take serum lactate >2mmol/l
- give oxygen
- give empirical intravenous antibiotics
- give IV fluids
- monitor urine output
When should you review a patient who has been treated for odontogenic infection?
48-72 hours after
Define, a communication between the end of a tooth and the oral cavity which allows pus to discharge along a tract lined with granulation tissue.
Sinus
What type of infection is a sinus indicative of?
Chronic infection
Define, an epithelial lined tract connecting two body cavities.
Fistula
Infection from what teeth is most likely to cause a buccal space infection?
Maxillary molars
What is a common feature of a canine space infection?
Obliteration of nasolabial fold
What are the fascial spaces in which infection can spread around the head and neck?
- buccal space
- canine space
- infratemporal space
- submandibular/sublingual space
- cervical fascial spaces
Name the three cervical fascial spaces
- Lateral pharyngeal space
- Prevertebral space
- Retropharyngeal space
What part of a swelling is the most dependant point of abscess incision?
Fluctuant and most inferior part of the swelling
Describe the Hiltons method of drainage
- Incise through mucosa and periosteum with number 11 blade
- Blunt dissection to break down locales of pus
What type of bacteria is found in most dental abscesses?
Anaerobic
What is the usual choice of antibiotics for dental abscesses?
Metronidazole
How does crowding of teeth in crease difficulty of extraction?
Makes it difficult to put forceps on the tooth so you have to rely on elevators or luxators to mobilise the tooth
Why does a lone standing molar make extraction more difficult?
It often has stronger periodontal ligament and bone support and there is also risk of communication to the maxillary antrum or fractured tuberosity’s.
How do erosion/abrasion cavities cause extraction to be more difficult?
They increases the risk of crown fracture
Which drugs affect bone remodelling?
- Alendronate
- prednisolone
- denosumab
- diclofenac
Which of the following statements is not true of Bisphosphonates?
A. They are non-metabolised analogues of pyrophosphate that are capable of localising to bone and inhibiting osteoclastic function.
B. Bind avidly to exposed bone mineral and osteoblasts
C. Are not metabolised therefore these high concentrations are maintained within bone for long periods of time.
D. Are anti-angiogenic
E. There are two classes, nitrogen and non-nitrogen containing.
B, Bisphosphonates bind avidly to osteoclasts
