Oral Surgery Flashcards
When removing epulis, what is the ideal tissue forceps to be used?
Allis tissue forceps
principles of oral surgery
asepsis
atraumatic surgery
maintain patient airway
good anes/pain control
control of infection
CD4 serial extraction is proposed by
Bunon & Dewel
D4C - Tweed (siya din yung tweed’s triangle na IMPA, FMA, FMAI)
best time for exo for patients with ESRD End-stage renal disease
1-2 days after dialysis
universal sign of ischemic chest pain
Levine’s sign
Angina (stable, unstable, variant or prinzmetal)
management of pericoronitis
abx
irrigation
consider removing upper 3rds (trauma to operculum)
EXO of 3rd
mucosal defects if not resting on solid bone
dehiscence, fenestration
sizes of blades and indication
No. 11 - incision and draining procedures (precise or sharply angled incision)
No. 12 - sickle-shaped - maxillary tuberosity area and impacted teeth
No. 15 - intra-oral No. 15 C - thin blade for implants (smaller #10)
No. 10 - skin incisions (extraoral)
blade handle
bard-parker handle no. 3
flap that provides best access
trapezoidal flap (2 vertical incisions)
convex area of semilunar flap is directed towards ____
occlusal
submarginal incsion flap or modified trapezoidal semilunar flap aka
Luebke-Ochsenbein
tx and flap options for oro-antral communication
1-2mm - no tx
2-6mm - figure of 8 suture
>6mm - water tight closure with flap:
Pedicle flap
Berger flap (buccal advancement flap)
pedicled buccal fat pad
most commonly displaced root into the maxillary sinus
palatal root of 1st molar
used to remove infected tissue, mucosa, foreign objects from maxillary sinus
caldwell-luc technique
*at the maxi premolar area above the roots (other sources: sa canine ata)
best suture needle for OS
material: carbon steel > stainless steel
shape: 1/2 > 1/4, 3/8
configuration: reverse cutting > round, conventional cutting
attachment: swaged > eye
best part of suture needle to grasp
2/3 or 3/4 from the tip
Most fragile part: swaged end/eye of needle
most common absorbable suture material
chromic gut (7-10days) with chromium salts to prolong absorption
absorbable suture materials
I. Natural: gut (sheep/cow; 4-5days), chromium gut (7-10days), collagen (bone grafting)
II. Synthetic: absorbs after 2-3 weeks; Polyglycolic acid (Dexon), Polyglactin (Vicryl)
non absorbable suture material
silk (Dacron polyester) - most popular, cheapest, easiest to use
Nylon - has memory
ideal size for intraoral suture material
3-0 & 4-0
5-0 or 6-0 = cosmetic procedure
7-0 to 10-0 = microsurgery
principle of suturing: needle passage
from free to fixed
from thinner to thicker
from deeper towards the elevated side
suture should be ___ away from the margin and ___ from the next suture
2-3mm from the margin and 3-4mm from next suture
suture technique for everted wound edges (maxillary torus removal)
horizontal mattress - for suturing two adjacent papillae with one suture
suture technique good for controlling bleeding because of tight closure at the deeper part
vertical mattress
suture technique used to close open sockets and prevent clot displacement
figure of 8 - used din sa 2-6mm oro antral communication
if maxillary tuberosity fracture during exo, you should ___
if more thatn 2/3 - remove suture slightly
if less than 2/3 and attached to periosteum - reposition, suture lightly
if small and detached - remove and suture tightly
barrier membrane material used for guided tissue regeneration
gore-tex / PTFE (polytetrafluoroethylene)
durable, excellent knot tying characteristics, flexible
common space/fossa for maxillary third molar to be displaced into
infratemporal space/fossa
tx: retrieve after 2 weeks to allow fibrosis to take place, make it more stable and para di ma-push further
- if too lateral incision, tooth may be displaced into what space
- if lingual plate is fractured, tooth may be displaced into..
- buccal space
- submandibular space
non healing or delayed healing extraction socket with radiating pain (2-4 days)
foul odor and foul taste in mouth
dry socket
alveolar osteitis
fibrinolytic alveolitis
tx: gentle curettage, copious irrigation, eugenol dressing in the socket for obtundent effect
Wound healing first phase
Inflammatory phase / initial lag phase (immediate 2-5 days)
Hemostatiss - vasoconstriction, platelet aggregation, thromboplastin for clot
inflammation - vasodilation, phagocytosis
second phase of wound healing
proliferative phase (fibroblastic phase 2 days to 3 weeks)
Granulation - fibroblasts lay bed of collagen (Reticular first type III - allows for angiogenesis)
fills defect and produces new capillaries
Reepithelialization - epithelial healing
3rd phase of wound healing (when??)
remodeling phase (maturation phase: 3 weeks to 2 years)
new collagen type I forms
scar tissue
wound healing by primary intention vs secondary vs tertiary
primary - stabilized in essentially the same anatomic position prior to injury, minimal scar tissue (suturing??)
secondary - gap is left bet wound edges after repair (tooth socket), requires granulation tissue
tertiary /delayed closure - would is initially left open for a period of observation before closure, tissue grafts and implants, burn patients
type of hemorrhage seen in bleeding due to wound sepsis a few days after exo
secondary hemorrhage
types of hemorrhage
primary - during surgery
secondary - post op bleeding up to 14 days due to infection/sepsos
tertiary - post op bleeding 2-3 hours after surgery due to movement or disruption of surgical site or anes wears off
healing response characterized by restitution of new tissue, structurally and functionally indistinguishable from old tissue is:
regeneration
what makes bone healing “privileged”?
regeneration
cause of necrotizing sialometaplasia
death of minor salivary gland in the palate after infiltration
gelfoam / gelatin-based sponge used to control hemorrhage is absorbed in ___ (how long?)
4-6 weeks
collacone and surgicell are __
extraction socket packing materials
how does electrocautery or electrosurgery control hemorrhage
coagulation tip will precipitate the protein and stop bleeding by closing blood vessel opening
local measures to control hemorrhage
ice or old compress
tannic acid/tannins (tea bag)
suture
local pressure
gel foam
extraction socket packing material
electrocautery or electrosurgery
hydrogen peroxide (diluted)
tranexamic solution
primary lesions
flat, non palpable lesions
macules (<10mm)
patch (>10mm)
elevated leions
papules (<10mm)
plaques (>10mm)
nodules - firm lesions that extend to dermis or subq
clear, fluid filled blisters
vesicles (<10mm)
bullae (>10mm)
pustules - vesiccles that contain pus
erosion vs ulcer
erosion - shallow, superficial opening that shows loss of part or all of the epidermis
ulcer - crater like lesion with loss of epidermis and part of dermis
linear, often painful deep breaks within the skin surface
fissure - result of excessive xerosis (Dryness of skin)
linear erosion caused by scratching, rubbing, or picking
excoriation
consists of dried serum, blood, or pus over damaged layers of skin
crusts (scabs)
occurs in inflammatory or infectious skin diseases (eg impetigo)
thin, compressed superficial accumulation of horny epithelium
scale
permanent fibrotic skin changes that develop as a consequence of tissue injury
scar
necrotic tissue discarded from the surface of the skin following injury or disease
eschar (seen in burn patients or gangrene)
rate of nerve regeneration
1 - 1.5mm / day
recovery of neuropraxia
spontaneous and complete within 3 to 4 weeks
primary vs secondary primary degeneration
primary - immediately proximal to injury
secondary or wallerian degeneration - distal to the site of injury degenerate (within 78 hours, phagocytosis by adjacent schwann cells and by macrophage)
schwann cell outgrowths from portion of axon distal to site of injury in an attempt to connect the proximal and distal nerve stumps
Bungner’s band - if hindi continous can cause axonal outgrowths or Neuroma
axonal outgrowths randomly aligning with fibrin clot
neuroma
based on root development, when is it ideal to remove a lower 3rd molar
2/3 of root developed
1/3 - difficult to luxate and crown will roll around socket
classification of impacted lower 3rd molar depending on the inclination of 3rd molar to 2nd molar
WINTER’S
Mesioangular - easiest, most common
distoangular - hardest
vertical
horizontal - 2nd easiest
buccoverted - you can see cusp tips
linguoverted - cannot see cusp tips
different winter’s lines
white line - occlusal plane, helps assess the axial inclination of the impacted tooth
amber line - alveolar crest, shows amount of overlying bone
red - vertical line from amber line to CEJ on mesial side; measures depth of impaction - if 5mm or longer, is indicative that the tooth should be removed under GA
classification of impacted lower 3rd m according to anterior border of the ramus
PELL & GREGORY
Class 1 - there is sufficient space for the widest part of the tooth
Class 2 - insufficient space
class 3 - there is no space
classification of impacted lower 3rd m according to depth of impaction
PELL & GREGORY
Position A - Higher than the occlusal of 2nd molar
Position B - between occlusal and cervical of 2nd molar
Position C - below CEJ of 2nd molar
hardest impacted 3rd molar to exo based on winter’s classification
Mandi:
mesioangular - easiest
distoangular - hardest
Maxi:
mesioangular - hardest
distoangular - easiest
classification of impacted canines
ARCHER’S
Class 1 - palatal (vertical, horizontal, semivertical)
class 2 - labial (v, h, sv)
class 3 - crown is labial and the root is palatal
class 4 - at the alveolar bone above the apices of the teeth, neither labial or palatal
class 5 - inside palate of edentulous maxilla
bur used for odontectomy
round bur (#6, #8)
tapering fissure bur (#557 and #703)
types of fracture
simple fracture - bone is broken, skin or mucosa is not broken
compound fracture - both bone and skin are broken (PDL space provides communication with external environment)
complicated fracture - 1 bone, more than 1 fracture line
comminuted fracture - shattered/several pieces (can be simple or compound)
greenstick fracture - one sided fracture/ di umabot sa buong bone
maxillary fractures (other names) and pathognomonic signs
Le Fort I / Horizontal / Guerin’s / Low maxillary / transmaxillary - floating jaw
Le Fort II / Pyramidal Fracture - Battle’s sign or Post-auricular ecchymosis or mastoid ecchymosis and Raccoon eye (Base: dentition, apex: nasofrontal suture)
Le Fort III /Transverse Fracture / Cranio Dysjunction - Dish face, Cerebrospinal rhinorrhea due to basilar fracture usually cribriform plate of ethmoid bone
most common part of mandible involved in a fracture
condyle, angle, symphysis
least common: coronoid
Mandibular fracture
Guardsman fracture - bilateral condyle + symphysis
Bucket-Handle fracture - bilateral mandibular body fracture in edentulous patients, proximal segment is pulled anteriorly and superiorly (masseter), anterior segment is pulled inferiorly (genioglossus, geniohyoid)
inferiorly and posteriorly?? - digastric and mylohyoid??
aka as tripod fracture, nerve usually involved in paresthesia
zygomaticomaxillary complex fracture; paresthesia is common: infraorbital nerve
muscle imblances (ocular m. and masseter)
maxillary sinus hematoma
articulations of zygoma
superiorly - zygomaticofrontal
anteriorly - zygomaticomaxillary
posteriorly - zygomatico-temporal
contributes to orbit
medially borders the mandible
radiographs used
panoramic radiograph (OPG) - both arches
water’s view - maxi sinus, frontal, ethmoid sinus
reverse towne view (tingin sa baba?) - condylar neck fractures; like posteror anterior view
submentoverter view (SMV) (from baba) or Jug-Handle - zygomatic arch, sphenoid sinus
treatment of fractures
- debridement
- reduction (open or closed)
- fixation (interdental wiring technique, interosseous wiring technique, circumferential wiring (edentulous mandible), titanium plates with screws, intermaxillary fixation (ERICH ARCH BAR)
- immobilization (3-6 weeks) and functional rehabilitation
best treament for greenstick fracture of mandible
interdental wiring to restore normal occlusion
condylar neck fracture displaces the condyle due to?
lateral pterygoid muscle to medially and forward
radiographs useful in confirming mandibular fracture
lateral oblique / PA ceph -coronoid? Tmj??
panoramic radio -entire md
intraoral radio
towne’s projection
basic principles in treating mandibular fractures
reduction of fracture
fixation of fracture
restoration of occlusion
fracture at md condyle jaw deviates where
towards same side (ipsilateral)
most serious complication from facial abscess secondary to infected maxillary canine
cavernous sinus thrombosis / thrombophlebitis - PHOTOPHOBIA, headache, nausea, fever
needle aspiration of central bone lesion rationale
to rule out if vascular lesion –> bleeding if incised kasi
3rd molar infection directly spreads to
submandibular, pterygomandibular, parapharyngeal
intraoral drainage for infection in pterygomandibular space is through ___
buccinator muscle
sequestrum vs involucrum
sequestrum - necrotic bone separated from healthy bone
involucrum - sclerotic bone that shields healthy bone from necrotic bone – radiopaque and not removed
gap in the cortex of a bone affected by chronic osteomyelitis that allows the drainage of pus or other material from the bone into the adjacent tissues
CLOACA
surgical removal of necrotic bone to prevent the spread of infection and minimize tooth mobility and bone loss
sequestrectomy
- better to delay until involucrum is fully formed
- light curettage
- SAUCERIZATION - removal of overlying bone to access
- DECORTICATION - removal of undermined and infected cortical plates of bone
needle used in fine needle aspiration biopsy
18G needle
biopsy used in radical neck dissection
frozen-section biopsy - malignant lymph nodes of the neck are removed, frozen and immediately examined until 2 consecutive nodes are determined to be benign
Carnoy’s solution is…
- it is a cauterizing and fixating agent that penetrates cancellous spaces in the bone at 1.5 - 2mm –> prevents recurrence after excision etc
- 1 g ferric chloride + 10 mL solution (60% absolute alcohol, 30% chloroform, 10% glacial acetic acid)
3-5mins is sufficient because more than can possibly damage vital structures
types of resection
- marginal resection - without disruption of the continuity of bone
- partial resection - partial removal of a full-thickness segment of the bone thereby disrupting continuity
- total resection - complete removal of the entire bone
- composite resection - resection of a tumor with bone, adjacent soft tissues, and contiguous lymph node channels
types of implants
- endosseous (root form or blade form)
- subperiosteal - rides on bone, underneath the mucoperiosteum
- transosseous - penetrate the entire jaw
bone repair
osteogenesis - formation of new bone (spontaneous vs transplanted)
osteoconduction - passive framework or scaffold to guide formation of new bone
osteoinduction - illicit bone formation by bone morphogenic proteins (BMP)
classification of grafts
- autogenous / autograft - same individual, best (ostegenic, osteoconductive, osteoinductive)
- allogenic / allograft - same species, NOT related (
a. Fresh frozen (high rate of infection), b. freeze dried (osteoconductive), c. demineralized freeze dried (exposes BMPs which are osteoinductive, also osteoconductive but lower mech strength) - Isogenic / isograft - same species, RELATED
- Xenogenic / xenograft / heterograft - another species
- alloplast - synthetic graft, intert
heating bone above 47 degree C can lead to bone necrosis. how to avoid?
use copious irrigation
implant distance minimum
bet implant and natural tooth or vital structure - min 1.5mm
bet 2 implants - min. 3mm
effect of bone density to implant stability? best bone density type?
more cortical bone, higher implant stability but lower blood supply
BEST would be D2 bone type = thich cortical bone with coarse trabecular bone underneath - anterior and post mandible - high implant stability with EXCELLENT blood supply
d1 - anterior mandible
d2 - anterior and post mandible
d3 - posterior mandible, anterior and posterior maxilla (porous - low implant stability)
d4 - posterior maxilaa (MOSTLY fine trabecular, most challenging)
three methods to reflect tissue
prying or twisting - pointed end to elevate soft tissue
push stroke - broad end separates mucoperiosteum
pull/ scrap stroke - tends to shred periosteum if not careful
