Oral Surgery Flashcards
when to refer non 3rd molars for XLA (6)
- unsuccessful initial attempt
- abnormal tooth morphology
- periapical radiolucency requiring histological assessment i.e. suspected cyst
- increased risk of damage to adjacent major anatomical structures
- reduced access to tx site
- medically compromised pt
when to refer 3rd molar XLA (7)
- 1 or more incidences of pericoronitis
- unrestorable caries in 3rdM or impaction causing caries in adjacent 2nd molar
- risk of caries in 3rdM or adjacent tooth
- anatomical position of tooth inhibiting OH & acting as risk factor for pericoronitis
- periapical pathology
- prior to orthognathic surgery
- prior to initiating radio or chemotherapy
when to refer to MOS (4)
- XLA / surgical exposure of impacted teeth
- closure of oroantral communication or fistula
- root in maxillary antrum removal
- pre prosthetic surgery as part of restorative txp
when to refer TMD (1)
failed initial conservatory management
when to refer oral cancer
- abnormal lesion in mouth suspected to be oral cancer
- oral cancer signs subject to urgent 2wk referral:
- non healing ulcer often painless or sore for >3wks
- lump or thickness in cheek or elsewhere in mouth
- persistent soreness of mouth / throat as well as difficulty chewing / swallowing
- numbness of tongue / other areas in mouth
- swelling of jaw
- unexplained loosening of teeth or pain around teeth / jaw
- voice changes
- lump or mass on back of neck
- unexplained weight loss
when to refer due to medical conditions (4)
- high MRONJ risk
- pt at risk of ORN
- unstable cardiovascular disease
- uncontrolled diabetes
medical considerations - high BP
risk of bleeding & MI risk
check how well controlled it is, asl for recent BP readings, consider postponing if >160/100mmHg, adrenaline containing LA is contraindicated
medical considerations - angina
risk of angina or MI during XLA
ensure GTN spray readily available & enquire re frequency of angina attacks
medical considerations - recent MI
risk of MI
no XLA within 3mths of MI, no GA within 6mths of MI (increases risk of repeat MI by 50%)
medical considerations - cardiac defects
e.g. valve replacement, previous endocarditis, hypertrophic cardiomyopathy
increased risk of infective endocarditis
ensure pt is aware of increased risk, explain symptoms, record discussion in notes, liaise with pt cardiologist, check guidelines, for high risk pt consider antibitoic prophylaxis, reinforce good OH
medical considerations - liver disease
risks - bleeding due to reduced produced of coagulation factors, splenomegaly causes reduced platelet numbers, cross infection risk due to hep B/C/D/E, reduced drug metabolism.
liaise with pt physician, consider coag screen & FBC, check BNF for appropriate drug prescription
medical considerations - kidney disease
risk - bleeding due to platelet dysfunction & immunocompromised
liaise with pt physician, consider renal profile & FBC, dialysis pt are best treated the day after dialysis for optimal renal function, check BNF for appropriate drug prescription
medical considerations - diabetes
risk - hypoglycaemic emergency, impaired wound healing
morning appt preferred as blood glucose more stable, pt safe to trear if blood glucose level is between 5-15mmol/L
medical considerations - epilepsy
risk - seizure due to stress
ensure pt has eaten prior to XLA, enquire re frequency & type of seizures, IV sedation may be recommended due to anticonvulsant effects
medical considerations - haemophilia A/B & VWB
risk - bleeding due to genetic deficiency of clotting factor VIII (A), IX (B) AND VW factor (VWB)
consider factor assay, between 50-75% factor VIII levels required for tx, DDAVP & tranexamic acid may be required, high bleeding risk XLA should be carried out in hospital setting, take all haemostatic measures & refer to SDCEP, book pt in early in day & week to allow space for emergency appt, consider referral
drug considerations - anticoagulant therapy
risk of bleeding:
1. warfarin - inhibits production of vit K dependent clotting factors
2. apixaban - factor Xa inhibitor
3. dabigatran - direct thrombin inhibitor
4. rivaroxaban - factor Xa inhibitor
liaise with pt physician, check INR (should be 2-4) of warfarin pt, take all haemostatic measures, refer to SDCEP, book early in day & week to allow for emergency appt, consider referral.
for high bleeding risk procedure:
1. warfarin - INR must be below 4 and ideally checked 24hrs prior to tx
2. apixaban & dabigatran - miss morning dose
3. rivaroxaban - delay daily dose to 4hrs post XLA
drug considerations - antiplatelet therapy
risk - bleeding due to inhibition of various stages required for platelet aggregation
liaise with pt physician, take all haemostatic measures & refer to SDCEP, book pt in early in day & week to allow space for emergency appt, check BNF for drug interactions, current evidence is to not interrupt single or dual antiplatelet therapy
drug considerations - radio / chemotherapy
risks:
- thrombocytopenia (decreased platelets)
- neutropenia (decreased neutrophils)
- MRONJ (if on anti-resorptive meds e.g. bisphosphonates)
- ORN due to reduced blood flow through irradiated region
- infection due to immunosuppression
thrombocytopenia - platelets >50 x10 9 / L is ok, avoid XLA if possible, atraumatic XLA, ensure pt is dentally stable prior to initiating radio/chemotherapy, ensure good OH prior to XLA, consider referral
drug considerations - bisphosphonates
risks - MRONJ as anti resorptive drugs half bone turn over by inhibiting RANKL
assess risk category:
HIGH RISK - on oral or IV BPs for >5yrs, concurrent course of systemic glucocorticoids irrespective of length of tx, pt being treated for cancer irrespective of length of tx, pt has previously had MRONJ
avoid XLA if possible, atraumatic technique (reduces chance of surgical), liaise with pt physician (consider drug holiday), consider referral, 8wk review
implications of tooth location when XLA
last standing upper teeth more difficult to xla as condylar translation over the articular eminence limits access upon mouth opening
long standing teeth more difficult to luxate & have greater # risk
implications of EO swelling when XLA
- limited mouth opening
- difficulty in anaesthetising
implications of adjacent structures when XLA
upper molar = risk of OAC / displacement of root into antrum
upper 3rd M = risk of tuberosity
lower 3rd M = risk of injury to IAN
raising lower flap = risk of damage to mental & lingual nerve
implication of planned tooth replacement following XLA
if traumatic, will result in increased bone resorption & subsequent gingival recession which is unideal for planned implants & bridges
radiographic analysis prior to XLA
- orientation & position of tooth
- crown - presence & extension or caries
- roots - no, length, curvature, presence of apical radiolucency / PDL widening
- bone height, width, density around tooth and in furcation area, absence of lamina dura (indicating possible ankylosis)
- follicular width (particularly unerupted 8s)
- impacted teeth around tooth in question
- relationship to important anatomical features i.e. IAN, tuberosity, sinus
- query any pathology i.e. cysts
what to include in risks when consenting pt for XLA
pain, swelling, bleeding, bruising, dry socket, jaw stiffness, infection, OAC/F if upper molar, root #, maxillary tuberosity #, temp or permanent altered sensation to lip side of tongue & cheek and chin, damage to adjacent teeth, root displacement into sinus, need for surgical intervention
types & use of elevators
- couplands - 1/2/3, flat tip will not break pdl, used to elevate teeth & xla of retained roots
- cryers - L & R, elevate teeth, xla retained roots, upper 3rdM elevation
- warwick james - L & R & straight, curved tip used for elevating upper 3rdM, straight used for elevating roots
luxator uses
rounded sharp tip used to break pdl fibres
lidocaine 2% HCl
vasoconstrictor - adrenaline 1:80,000
indications - infil, IDB, mental block, intra - ligamentary
max safe dose - 4.4mg/kg
duration - infil = 60mins, block = 90, soft tissues = 180-300
articaine 4% HCl
vasoconstrictor - adrenaline 1:1/2/400,000
indications - infil, IL, mental block
max safe dose - 7mg/kg
duration - infil 120mins, block N/A, soft tissues 180-300
prilocaine HCl 3%
vasoconstrictor - fely/octapresisn
indications - infil, IDB, mental block, IL
max safe dose - 6mg/kg
duration - infil = 30-45mins, block = 60, soft tissues = 180-360
DO NOT GIVE TO PREGNANT WOMAN AS INDUCES LABOUR
mepivicaine 3% plain
vasoconstrictor - NIL
indications - infil, block, metal block, IL
max safe dose - 3mg/kg
duration - infil = 20mins, block = 40, soft tissues = 120
local complications of LA
failure to achieve anaesthesia
prolonged anaesthesia
pain (during & after)
trismus
haematoma
temporary facial palsy
infection
soft tissue damage
needle stick injury
systemic complications of LA
allergy - mainly to preservatives
loss of consciousness
respiratory depression
circulatory collapse
octapressin induces labour in pregnant women
envelope flap design, +/- & indications
extended horizontal sulcular incision along multiple teeth
requires minimum 2 teeth for good vision
+ no relieving incision (minimises gingival recession)
+ easy re-approximation of flap
- can tear under pressure
- difficult reflection
- limited visualisation
indicated - aesthetic region, minimally invasive perio surgery, surgical xla
2 sided flap design, +/- & indications
envelope with 1 relieving incision (M or D for greater access)
acts as compromise between aesthetics & access
+ better access than envelope
+ adequate bloody supply
- gingival recession
- limited access to long roots
indication - aesthetic zone where greater access needed, minimal bone removal required, 3rdM xla, surgical xla, apicectomy, cyst removal
3 sided flap design, +/- & indications
envelope with 2 relieving incisions M & D
provides optimal access & vision
+ access & vision optimal
+ easy to reapproximate flap to original position
- prone to gingival recession
indication -3rdM xla, surgical xla when >1 tooth, apical repositioning flap, buccal advancement flap, bone graft, impacted tooth exposure, cyst removal, apicectomy
semilunar incision design +/- & indications
incision made across mucoperiosteum away from gingival margin
+ no gingival recession
+ pdl remains intact
- scarring
- difficult to replace flap
- limited access
- prone to tearing
- paraesthesia risk
flap principles
- gain max access with min trauma
- large flaps heal at same rate as smaller ones
- broader base to maintain blood supply
- for full thickness mucoperiosteal flap cut to bone using firm incision not feathered
- avoid sharp angles
- either include or exclude papilla entirely
- do not crush tissue & keep moist with saline
elevator principles
- elevator tip inserted between tooth & bone mesially
- do not level off adjacent teeth
- avoid excess force
- do not apply force towards major anatomical structure i.e. IAN
- support pt jaw & ridge
- use under direct vision only
- for upper xla take care not to push root into maxillary sinus
force movements when xla
conical roots = apical pressure, buccal & rotational movement
multiple roots = apical pressure, buccal expansion & figure of 8
consider atraumatic technique in certain cases e.g. planned implants
peri operative complications
