Oral surgery Flashcards
What asepsis?
It is the exclusion of microorganisms from the wound. Through draping isolation and no touch technique as well regulation of host bacteria through topical prophylaxis using CHx.
What are the two sources of microrganisms in a wound?
Foreign or host
What are the techniques that are used in surgery to achieve asepsis?
1.No touch – do not touch the instruments that may go into the patients mouth
2.Sterilisation of instruments
When would we use GA?
1.Lengthy or difficult operations
2.Acute infection in the area that may denature LA
3.Young children or very nervous patients
What are the contraindications for GA?
1.Inadequate facilities
2.Medical issues such as respiratory disease
What are the 6 areas of concern that may occur in a medically compromised patient generally?
1.Stability – is their health easily made worse? - think coronary disease or asthma
2.Co-operation – think physical and behavioural co-operation – think epilepsy or pregnancy
3.Bleeding
4.Healing
5.Bacteremia – infective endocarditis
6.Drug interaction
How do we manage a patient with coronary disease?
1.Short appointments
2.Pain control
3.Maybe it is better to treatment with supervision of trained hospital staff or hospital
4.Be trained to resuscitate
What is the difference between angina and myocardial infarction?
Angina is a reversible condition, where the supply of blood to the heart muscles have been temporary effected.
Myocardial infarction is a sever restriction in supply of blood to the muscles of the heart, resulting in ischemic death of the heart muscles.
How do we manage a patient with asthma?
1.Know the type of asthma the patient might have
2.Know the triggers of their condition
3.Consider hospitalisation for general anaesthetic
How do we manage a patient with epilepsy?
1.Know their medication and frequency of attacks
2.Use mouth prop of rubber stopper
3.Remove all the instruments and support the patient while they having an epileptic attack
4.DO NOT ALLOW THEM TO LEAVE BEFORE THEY RECOVER put them in lateral recovery position
How do we manage patient who might be pregnant?
1.Posture – lying flat may cause interference of venus return through baby pressing on vena ceva.
2.Mid-trimester – best time for treatment - reduces the probability of teratology
3.Consider postponing treatment until the patient delivers a baby. The only time you can do it is in emergency.
What are the two major medical areas that may cause problems with bleeding?
1.Anticoagulats – INR – 4.5 or above is internal bleeding (send to GP) – 2-4 can perform surgery with local measures - less then 1 is sub-therapeutic amount of warfarin (send to GP) - remember aspirin still exist but it is not as potent, local measure are sufficient, for major surgery can stop aspirin for 10 days.
2.Liver disease – hepatitis – may lower the number of coagulation factors created by the liver
What are the two most common conditions that may impare healing?
1.Steroid use – Addisonian crisis – steroids naturally might not be generated thus need to increase the amount of steroids - diseases such as leukemia might cause a patient to be on steroids
2.Diabetes – determine what type they are and what is there BGL or HbA1C
What is the standard dose of antibiotic prophylaxis for infective endocarditis?
2mg Amoxycillin orally 1 hour preoperativley
Or
600 mg Clindamycin orally 1-2 hours preoperativley
What are the local haemostatic measure you can use for a patient with antithrombotic treatment or conditions effecting the coagulation and platelet aggregation?
1.Sutures
2.Minimising tissue trauma
3.Placing cellulose and collagen
4.Using tranexamic acid 4.8% but not with DOACs
5.Provision of post-operative instructions and materials
What is the managemnt of patient who use corticosteroids?
The possibility of Adesonia crisis is largely patient dependent. A large dose (above 5mg daily) for prologned period of time (2+ weeks) can be expected to cause an adesonia crisis in an event of severe stress.
Following management options:
- If non-invasive procedure like x-rays or examination – no additional dose needed
- If a procedure is invasive in outpatient setting for less than an hour (e.g. extractions or sub-gingival debridment of multiple quadrants) - additional dose may be required usually the day before and on the day of the procedure. Best to contact GP to create a dosing strategy or “action plan”
- If a procedure is invasive and longer than an hour or require sedation or fasting – better contact specialist as that will provide best patient care.
What are the stages of osteonecrosis of the jaw?
Stage 0 – symptomatic, evidence of radiographic changes and no bone exposure – require follow up monitoring but no treatment
Stage 1 – asymptomatic, bone exposure evident, no evidence of inflammation or infection – require follow up monitoring but no treatment
Stage 2 – symptomatic, evidence of bone exposure, adjacent soft tissue inflammation or secondary infection – requires treament
Stage 3 – symptomatic, full thickness of bone involvement, pathological fracture and extensive soft tissue infection and fistulae – requires treatment
What instrument are used in bone cutting?
1.Burs – slow speed
2.Chisels – not ideal because when a patient is over 40 may have bone that is brittle
3.Hand instruments such as roungers - used to remove bone between teeth
4.Bone files – good for removal of mandibular tori
5.High speed bone tutting instruments – different from a dental drill
What are the steps to risk management of medication-related osteonecrosis of the jaw?
1.Inform the patient of the risk
2.Advice not to get off the medication and delay treatment for denosumab closer to the repeat dose as possible (I.e 5 months after the dose ideal)
3.Do not use anti-biotic prophylaxis
4.Ensure optimal oral hygiene before and after procedure
5.Reduce plaque load
6.Minimise trauma
7.Monitor oral wound until it heals
8.Do not debride nonhealing wounds
9.Refer to a specialist if bone is still visible at 8 weeks
What are the principle of flaps?
1.Adequate access
2.Adequate blood supply to flap
3.Sharp incision at edges
4.Clean dissection
5.Edges of flap away from deeper operative site
6.Avoid vital structure and parallel muscles forces
What are the steps of the wound toilet?
1.Debridement – continually remove debri as you go and check at the end of the procedure and irrigate the wound
2.Drainage – ensure that puss can be drained and account for appropriate vascularisation – 1cm in diameter is appropriate as greater may result in necrosis or dead space
3.Repair – recheck the debri with scrub nurse and suture to control bleeding and promote healing
What are incisions created with?
With use of scalpel at right angle of the surface towards the operator in a single firm cut
What are the different types of dissection?
1.Sharp dissection – use to cut tissue
2.Blunt dissection – use to separate sittuse like muscles or mucoperiosteum seperated from the bone
When operating on muscles, what are the two effective technique to utilise?
1.Splitting prallel – splitting the muscle fibers – this is good for recovery
2.T shape cut – cut the muscle fibre at right angle to the extension of fibres – this is quite bad for recovery
What are methods used for bone cutting?
1.Shave surface of bone with gentle sweeps
2.Postage stam method – cut round holes joined by a flat fissure bur
What instrument are used in bone cutting?
1.Burs – slow speed like rosehead or fissure
2.Chisels – not ideal because when a patient is over 40 may have bone that is brittle. Mandibular grain is along the occlusal plain. start at 90 degrees to the grain.
3.Hand instruments such as roungers - used to remove bone between teeth
4.Bone files – good for removal of mandibular tori
5.High speed bone tutting instruments – different from a dental drill as it does not pushes lubricating oil or water into the wound or bacteria from poor sterilisation
- Osteomtom - dual cutting edge instrument
What is trigeminal neuralgia?
It is believed to be a condition where a demyelination of the nerve occurs. The demyelinated nerve is able to conduct electric signals down itself from other crossing nerves.
The result in the confusion of the PNS and manifest as pain in an area known as “trigger zone)
What are the treatment for trigeminal neuralgia?
First line - medications like carbamazepine or gabapentin
Second line - peripheral surgery such as cryoneurotomy
Third line - intracranial operation like Janetta procedure
What is the most common cause of TMJ pain localised to the joint only?
Intra-articular effusion (sprain).
Caused by:
- Direct trauma to the joint
- Repetition overload
- Internal derangement
- Arthritis
What are the indications for TMJ Arthrocentesis?
- Joint effusion - localised pain in joint and pain on movement
- Joint limitation - less then 20 mm opening
What is the Caldwell Luc procedure and where can we use it?
It is a procedure where the access to the maxillary sinus is made through the anterior wall of the maxilla.
It can be used fo investigation of sinus pathology, removal of foreign objects from the sinus (e.g. teeth) or fixing a large oro-antral fistulas.
When does taking of medical history occur?
Taking of the medical history occur upon patient presentation. Initial presentation is essential.
How can you take a medical history?
1.General conversation – requires skill
2.Using a questionnaire check list – a bit more suitable for starting dentist
Why do we ask for the name and phone number of medical doctor?
To identify at risk patients. Also, as another route of communication in gathering patient history in detail.
Where do you palpate the medial pterygoid muscle?
Inside the ramus of the mandible
Where do you palpate the lateral pterygoid muslce?
Behind the maxilla
How do you measure jaw opening?
Use a ruler
Normal movements: opening 45mm+, 6-8 mm laterally –
Abnormal jaw opening: 5mm very bad, 10mm difficult, 20mm problem with eating
How do you assess the TMJ?
Palpate on opening bilaterally.
Feel the rotation and translation.
Remember: when the jaw swings to the side (ipsilateral), the joint on the same side will rotate and contralateral side translates.
What is a good test to evaluate the source of orofacial pain?
Passive stretch test.
Make the patient open and push their lower jaw down with your finger.
They may feel discomfort allong their muscle (myofacial origin) or joint (TMD).
Also look at their neck muscles.
How do you determine the origin of salivary gland pathosis i.e. how do you examine each major salivary gland?
- Parotid - pathosis apparent just behind the jaw
- Sub-mandibular - palpate bi-manually intra and extra oraly at the angle of the mandible pushing the gland up and palpating intra-orally
- Sub-Lingual - too small
What are the three branches of lymph nodes present on the face?
- Submental
- Submandibular
- Facial - commonly inflamed. enlarged and tender after extraction of third molars
What is an improtant lymph node to palpate in oral cancer patients?
Jugulodiagastric with bi-manual technique on either side of the lymph nodes. Hard and painless - cancer
What are the cranial nerves?
Cranial nerve I – olfactory – function: smell – test: strong smelling object or CT scan or crubirform plate
Cranial nerve II – optic nerve – function: sight – test: reaction to light
Cranial nerve III - oculomotor nerve – function: binocular vision – test: move an object around them or close their eye lid
Cranial nerve IV – trochlear nerve - function: binocular vision - test: move an object around them
Cranial nerve V – trigeminal nerve – function: main censory nerve to the face – divisions: Opthalmic, maxillary and mandibular – there is also a motor branch to muscles of mastication
Cranial nerve VI – abducent nerve - function: binocular vision - test: move an object around them
Cranial nerve VII – facial nerve – function: motor functions of facial expression and taste through the cord of timpani – test: paulsy of muscles tested by movement and taste can be teste with sweet and salty food
Cranial nerve VIII auditory – function: auditory – whisper in their ear
Cranial nerve IX glassopharyneal nerve – function: sensory to tongue and other structure
Cranial nerve X vagus nerve – function: vagal stimulation to the heart and other
Cranial nerve XI accessory nerve – function: motor function to neck and shoulder – test: try to make the patient move their shoulder - may be effect by a tumour or neck dissection
Cnarnial nerve XII hypoglossal nerve – function: motor fucntion of the tongue – test: make the patient move their tongue
What are some of the sensory nerve testing?
1.Sharp or blunt testing using the syringe tip sheathed
2.2-point testing with tweezers
3.Directional sense using a sheathed syringe
4.Sensory loss using LA and a sheathed syringe
What are the key vital signs?
1.Blood pressure
2.Pulse
3.Respiration
4.Temperature
5.Consciousness
What measures blood pressure?
Sphygmomanometer
What are the normal values for blood pressure?
Systolic 120-140 - when heart beat begins on manual sphygmomanometers
Dyastolic 60-90 - when the head beat stops on manual sphygnomanometers
What is considered to be hyperventilation?
Above 20 shallow breaths per minute
What is considered to be a normal pulse?
60-80 beats per minute
Why should you not use an oral thermometer in a presence of oral infection/lesion?
An abnormally high reading will be the result. Concentration of inflammatory factors result sin higher local temperature and is not representative of systemic condition.
How do we assess the consciousness?
Normal responsiveness or twist their earlobe
What are two other useful basic assessments?
BMI and BGL
What is normal BGL?
3-8, 9-10 is prediabetic, 11+ is hyperglycemic
What are the signs of hyperventilation?
1.Blood pressure remains the same
2.Pulse decreases
3.Respiratory rate increases
4.Consciousness decreases
What are the sings of cardiac arrest?
1.Blood pressure drops
2.Pulse non-existent
3.Respiratory rate decreases
4.Consciousness decreases
What are the isntruments typically used in a soft tissue suturing?
1.Scalpel handle
2.Tissue holding forceps
3.Needle holder
4.Scissors
5.Periosteal elevator
6.Mailable retractor
7.Have curved needles with suture
What is the aim of suturting?
- Haemostasis acheivement
- Hold the tissue together to promote healing
How do you suture?
1.Place the suture in the right space
2.Put the knot as far away as possible to the tongue – buccal is a good spot or above the tongue
3.Grasp the tissue on one side of the wound
4.Pass the needle through it
5.Grasp the other side of the wound
6.Pass the needle through it
7.Tissue are now together
8.Wrap the string twice aroudn the needle holder and pass the loose string through ti
9.Wrap the string once aroudn the needle holder IN THE OTHER DIRECTION and pass the loose tring through it
10.Wrap the tring once around the needle holder IN THE ORIGINAL DIRACTION and pas the loose string through it
11.Cut 3-4 mm away from the knot
How to cute a 2 arms mucoperiosteal flap?
REMEMBER FINGER REST – MAIN OBJECTIVE IS TO SEPERATE THE SOFT AND HARD TISSUE
1.Cut the 2 arms of the flap – 1st between the teeth and gingiva in the periosteal membrane in the alveolar bone – 2nd go to the bottom of the attached gingiva toward your first cut
2.Use your periosteal elevator, round flat part toward bone and slide it along from your second cut – remember more coward the vestibule the tissue is softer
3.Remove any remanence of soft tissue
4.Remove raminance of bone
5.Smooth and shine tissue is the periosteum
6.Suture the flap starting at the corner of the flap at a bisecting angle using a sliding knot
7.Move on to suturing at the first bone – line up papilla to the tooth and pass the needle from the flap papilla to the papilla on the opposite side of the jaw to the flap I.e. if the flap is on the buccal pass it to the lignual papilla
How do you know you are supra-periostial during flap preperation?
Large amount of bleeding from the seperate tissues. This means you have not reached bone and need to go deeper.
Where would you put the sutures in a double arm flap?
- In the vertical aspect of the flap. 1-2 suture should be anough
- In the horizontal aspect through the interdental areas. Line up the papillas and suture together as it is a good guide.
What are the three acceptable flaps for the palate?
Main neurovascular supply to remember: Nasopalatine and greater palatine (this one gets damage most of the time by poor flap designs).
- SIngle midline incision. Suitable for small, superficial objects.
- Full palatal flap around the gingival margin
- No canine-to-canine flap. Similar to full palatal flap but does not include the nasopalatine area.
What are the main differences in the desing of surgical and dentine cutting burs?
- Surgical burs have larger flutes
- Surgical burs have more interspaces flutes
This is due to the fact that bone is different dexture then dentine thus a bur that is design to no clog is used.
What is a cryer elevator?
It is an elevator with an angled spear like appearance. Allows for rotation
What is a warwick james elevator?
It is a fine elevator that can be angled or straight
How do we assess the radiographs for third molar extractions?
1.Vertical and horizontal relations
2.Third molar relationship to mandibular canal
Real or imaginary drawing of line on radiograph: 1st line : occlusal line (along occlusal plain), 2nd line: long axis of the third molar, 3rd line: Front of vertical ramus (any third molar will be visible after raising the flap if above this line, below will barried in bone), 4th line if perpendicula from occlusal line to point of elevation (the longer it is, the more difficult extraction will get), 5th closeness to mandibular canal
What is the treatment for a mandbiular and condyle fracture?
- Direct epihpyseal fracture of the mandible, single, closed
- Indirect fracture of the RHD condular head
Treatment for 1 - exposure of the fracture at site at the mandible and placement of direct plating of the fracture (ORIF)
Treatment for 2 - intermaxillary fixation with use of arch bars to allow the condyle to heal if it is not displaced, comminuted or severely damage in other way. This will manage the occlusion. TMJ ficxation with direct bars may be possible.
Remember:
Soft food, and wire shut jaw for the next 3 months at least.
After the surgery, patient needs to be observed until reasching 12 hour stability.
Review 24 hours, a week, a month and 3 months after. If any complications occur, review.
Remove arch bars when the condyle is healed. A period of physiotherapy might be needed.
