Oral Surgery Flashcards
What is the flow chart of the end result of caries
Caries
—> Pulp Hyperaemia
<-> Chronic Pulpitis or
—> Acute Apical Periodontitis
—> Acute Apical Abscess
(<—> Chronic Sinus)* some cases
<-> Chronic Apical Infection (granuloma)
—> Apical Cyst (Radicular)
<-> Infected Apical Radicular Cyst
Can jump Acute apical periodontitis —> Chronic apical infection (granuloma)
What are the four clinical features of pulp hyperaemia?
Pain lasting for seconds
Pain stimulated by hot/cold or sweet foods
Pain resolves after stimulus
Caries approaching pulp, but tooth can still be restored without treating pulp
What are the clinical features of acute pulpitis?
Constant severe pain
Reacts to thermal stimulus
Poorly localised pain
Referral of pain
No (or minimal) response to analgesics
Open symptoms, less severe
What are the factors that contribute towards the diagnosis of Acute Pulpitis?
History
Visual Examination
Negative tenderness to percussion (usuallly)
Pulp testing is equivocal
Radiographs
Diagnostic Local anaesthetic
Removal of restorations
What are the factors of an acute apical periodontitis diagnosis?
Tenderness to percussion
Tooth is non-vital (unless traumatic)
Slight increase in mobility
Radiographs
What is the radiographic presentation of acute apical periodontitis?
Loss of clarity of lamina dura
Radiolucent shadow
Delay in changes at the apex of the tooth
Widening of apical periodontal space
What are the causes of traumatic periodontitis?
Parafunction; tooth clenching or grinding
What are the features of diagnosis of traumatic periodontitis?
Clinical examination of the occlusion: functional positioning, posturing
Tender to percussion
Normal vitality
Radiographs; generalised pdl space widening
What are the treatment options for traumatic periodontitis?
Occlusal adjustment
Therapy for parafunction
What is the most common pus producing infection?
Acute apical abscess
What are the four pus producing infections?
Acute apical abscess
Periodontal abscess
Pericoronitis
Sialadenitis
What are two examples of organisms associated with dental abscesses?
Polymicrobial
Anaerobes
What are two unusual infections associated with dental abscesses?
Staphylococcal lymphadenitis of childhood
Cervico-facial actinomycosis
What are the symptoms of acute apical abscess?
Severe unremitting pain
Acute tenderness in function
Acute tenderness on percussion
No swelling, redness or heat
What are the five cardinal signs of inflammation?
Heat
Redness
Swelling
Pain
Loss of function
What are the symptoms of an abscess that has perforated bone?
Pain often remits
Swelling, redness and heat in the soft tissues
As swelling increases, pain returns
Initial reduction in tenderness to percussion of the tooth as pus escapes into soft tissues
What does the site of swelling of an acute apical abscess depend on?
The position of the tooth in the arch
Root length
Muscle attachments
Potential spaces in proximity to lesion
What are some examples of potential spaces in proximity to an acute apical abscess lesion?
Submental space
Sublingual space
Submandibular space
Buccal space
Infraortbital space
Lateral pharyngeal space
Palate
What are the treatment options for an acute apical abscess?
Provide drainage
Provide antibiotics
What are the methods used to provide drainage of an acute apical abscess?
Soft tissue incision intraorally
Soft tissue incision extraorally
Remove source/cause; extract tooth, pulp extirpation, Periradicular surgery
What is the need for antibiotics determined by?
Severity
Absence of adequate drainage
Patient’s medical condition
What are the local factors considered in the assessment of antibiotic need?
Toxicity
Airway compression
Dysphagia
Trismus
Lymphadenitis
Location
What are the systemic factors in assessment for need of antibiotics?
Immunocompromised (acquired, drug induced, blood disorders)
Diabetes
Extremes of age
What is an example of acquired immunocompromisation?
HIV
What are causes of drug induced immunocompromisation?
Steroids
Cytostatics
What are the causes of blood disorder associated immunocompromisation?
Leukaemia
How would you describe a periapical granuloma (chronic apical periodontitis)
Mass of chronically inflamed granulation tissue at apex of tooth
Which cells are in a periapical granuloma/ chronic apical periodontitis?
plasma cells, lymphocytes, histiocytes, fibroblasts and capillaries)
Why is a periapical granuloma not a true granuloma?
It is not granulomatous inflammation
What type of cells are present in granulomatous inflammation?
Epithelloid histocytes
Lymphocytes
Giant cells
What is the aetiology of an apical (radicular) cyst?
Caries
Trauma
Periodontal disease
Pulp necrosis
Apical bone inflammation
Dental granuloma
Stimulation of epithelial rests of malassez
Epithelial proliferation
Periapical cyst formation
Why is a maxillary abscess more likely to spread buccally opposed to palatally?
The palate is more dense
What happens when a sublingual abscess travels above the mylohyoid muscle?
It will become a sublingual abscess
What happens if a mandibular abscess travels below the mylohyoid muscle?
It will become a submandibular abscess
Where can an infection in the upper anterior teeth spread to?
Lip
Nasolabial region
Lower eyelid
From which tooth can infection spread to the palate?
Upper lateral incisor
Where can infection in upper premolars and molars spread to?
Cheek
Infra-temporal region
Maxillary antrum
Palate
Where can infection in lower anterior spread to?
Mental and submental space
Where can infection in lower premolars and molars spread to?
Buccal space
Submasseteric space
Sublingual space
Submandibular space
Lateral pterygoid space
What are the three management options for infections?
Establishment of drainage
Removal of source of infection
Antibiotic therapy
What is Ludwigs Angina?
Bilateral cellulitis of the sublingual and submandibular spaces
What are the intraoral features of Ludwig’s Angina?
Raised tongue
Difficulty breathing
Difficulty swallowing
Drooling
What are the extra oral features of Ludwigs Angina?
Diffuse redness and swelling bilaterally in the submandibular region
What are the systemic features of ludwigs angina?
Increased heart rate
Increased respiratory rate
Increased temperature
Increased white cell count
What techniques can be used to stop a bleeding socket?
Direct pressure
Vasoconstrictor (LA)
Diathermy
Surgicel
Bone wax
What techniques can be used to stop bleeding soft tissue?
Suturing
Cauterising
Direct pressure
Haemostatic clips
Ligatures
What are the 5 types of sensory changes?
Anaesthesisa
Paraesthesia
Dysaesthesia
Hypoaesthesia
Hyperaesthesia
What are the four causes of nerve damage?
LA damage
Transection
Crush injuries
Cutting/shredding injuries
What are the three types of nerve damage?
Neurapraxia
Axonotmesis
Neurotmesis
What is neurapraxia?
Contusion
Epineural sheath intact
Axons intact
What is axonotmesis?
Epineural sheath not intact
Axons intact
What is neurotmesis?
Nerve transected
What are 4 causes of abnormal resistance?
Hypercementosis
Ankylosis
Long/divergent/increased number of roots
Thick cortical bone
What are post extraction complications?
Dry socket
Prolonged bleeding
Infection
OAF
Bruising
Swelling
Pain
Trismus
ORN
MRONJ
How is OAC diagnosed?
Visual
Air bubbling
Blunt probe
How is a small OAC managed?
Bone cutterage
Encourage new clot
Alvogyl
How is a large OAC managed?
Buccal advancement flap
What are the causes of post extraction pain/swelling/bruising?
Poor technique
Rough tissue handling
Torn periosteum
What are the two types of post Xla haemorrhage?
Immediate
Secondary
What does an immediate post Xla haemorrhage consist of?
Reactionary and rebound bleeding within 48 hours post op
What is immediate post Xla haemorrhage associated with?
Vessels opening up as the vasoconstrictive effect of local anaesthetic wears off
Sutures become loose
Socket is traumatised
What is secondary post Xla haemorrhage associated with?
Infection
Occurs 3-7 days after Xla
What are examples of haemostatic agents?
Surgical oxidised cellulose
Gelation sponges
WHVP
Bone wax
Thrombin liquid/powder
Fibrin foam
What does Whitehead’s Varnish Pack (WHVP) consist of?
Iodoform
Gum benzoin
Storax
Balsam tolu
Ethyl ester
What are the surgical aids for haemostasis?
Suturing the socket
Ligation of vessels
Diathermy
What are the aims of suturing?
To approximate and reposition tissues
To compress the blood vessels
To cover the bone
To achieve haemostasis
To encourage healing by primary intention
What are the two types of suture?
Resorbable
Non-resorbable
What are examples of resorbable monofilament sutures?
Monocryl: poliglecaprone 25
What are examples of multifilament/polyfilament sutures?
Vicryl rapide: polyglactin 910
What are the features of vicryl rapide?
Holds tissue edges together temporarily
Vicryl breaks down via water absorption
What are examples of non-resorbable monofilament sutures?
Prolene: polypropylene
What are examples of non-resorbable multifilament/polyfilament sutures?
Mersilk: black silk
What are the features of mersilk sutures?
Used when extensive periods of retention are required
Must be removed post-op
Used for closure of the OAF/exposure of a canine
What are the ten principles of flap design?
Maximal access, minimal trauma
Wide based incision for circulation
Scalpel used in one firm motion
No sharp angles
Minimise trauma to dental papilla
Flap resection down to bone
No crushing of tissues
Keep tissues moist
Ensure flap margins lie on sound bone
Aim for healing by primary intention to minimise scarring
What hand piece is used during surgical extractions?
Straight electric with saline cooled round or tissue tungsten carbide bur
Why should air turbine handpieces be avoided in oral surgery?
Risk of surgical emphysema
Why should air turbine handpieces be avoided in oral surgery?
Risk of surgical emphysema
What is flap design influenced by?
The procedure
Surrounding nerves
Required access
Personal preference
What are the methods for debridement?
Physical
Aspiration
Irrigation
What is the official name for dry socket?
Localised osteitis
What are the predisposing factors for dry socket?
Female
Contraceptive
Mandible
Previous experience
Smoking
Family history
Excessive trauma
Excessive rinsing
What are the treatment options for dry socket?
Irrigate with warm saline
Currette or debridement to encourage bleeding
Use an antiseptic pack
What instructions should be given to a DOAC patient before a single tooth extraction?
Miss morning dose: apixaban, dabigatran
Delay morning dose: rivaroxiban
What are reasons for fractures?
Thick cortical bone
Root shape
Root number
Hypercementosis
Ankylosis
Caries
Alignment
What are post-op complications of extractions?
Pain
Stiffness
Swelling
Bleeding
Bruising
Dry socket
Infection
Nerve damage
How are large OACs managed?
Buccal advancement flap
Antibiotics
Nose blowing instructions
How are small OACs managed?
Encourage clot
Suture margins
Antibiotics
Post op instructions
How is a tuberosity fracture diagnosed?
Noise
Movement noted- visually or with fingers
Tear on palate
What are examples of soft tissue excisional pre-prosthetic surgery?
Frenectomy/frenoplasty (labial, buccal or lingual)
Papillary hyperplasia
Flabby ridges
Denture induced hypoplasia (epulis fissuratum)
Maxillary tuberosity reduction
Retromolar pad reduction
What are examples of pre-prosthetic ridge extension procedures?
Vestibuloplasty- maxillary or mandibular
What are examples of pre-prosthetic augmentation procedures?
Soft tissue grafting
What are examples of hard tissue excisional pre-prosthodontic surgery?
Removal of retained teeth/root/pathology
Ridge defect correction (alveoplasty)
Mandibular tori
Maxillary tori
Maxillary tuberosity
Exostoses
Undercuts
Genial tubercle reduction
Mylohyoid ridge reduction
What are examples of hard tissue augmentation procedures in pre-prosthodontic surgery?
Autografts
Allografts
Xenografts
Synthetic grafts
What are some other examples of hard tissue pre-prosthodontic surgeries?
Implants
Inferior alveolar nerve relocation
What are examples of autographs?
Iliac crest bone
Rib
What is an allograft?
Bone from other humans
What is a xenograft?
From animals e.g. Bio-oss
What is a xenograft?
From animals e.g. Bio-OSS
What is an example of a synthetic graft?
Tri calcium phosphate
At what age do third molars usually erupt?
18-24 years
When does the crown calcification of third molars begin?
7-10 years
When does the crown calcification of third molars end?
18 years
When does the root calcification of third molars complete?
18-25 years
What percentage of adults have at least 1 third molar missing?
25%
Which arch is ageneis of third molars most common?
Maxilla
What gender is agenesis of third molars most common?
Females
At what age should third molars be radiographically present?
14
What does impacted mean?
Tooth eruption is blocked
What is the most common reason that third molars fail to erupt?
Impaction
What are third molars usually impacted against?
Adjacent tooth
Alveolar bone
Surrounding mucosal soft tissue
Combination
What does partially erupted mean?
Some of the tooth has erupted into the oral cavity
What does unerupted mean?
The tooth is completely buried
What is the incidence of impacted lower third molars?
36-59%
What are the consequences of third molar impaction?
Caries
Pericoronitis
Cyst formation
What nerves are at risk during third molar surgery?
Inferior alveolar nerve
Lingual nerve
Nerve to mylohyoid
Long buccal nerve
How medial to the mandible is the lingual nerve?
0-3.5mm
In what % of cases is the lingual nerve at or above the level of the lingual plate?
15-18%
What guidelines are associated with third molar surgery?
NICE: Guidance on Extraction of Wisdom Teeth, 2000
SIGN Publication Number 43- Management of Unerupted and Impacted Third Molar Teeth, 2000
FDS, RCS 2020- Parameters of Care for patients undergoing mandibular third molar sugery
What are the Therapeutic indications for third molar extraction?
Infection (caries, pericoronitis, periodontal disease, local bone infection)
Cysts
Tumours
External resorption of 7 or 8
High risk of disease
Medical indications (awaiting cardiac surgery, immunosuppressed or to prevent osteonecrosis)
Patient age- complications and recovery time increase with age
Autotransplantation
GA
What are the surgical indications for third molar extraction?
Orthognathic
Fractured mandible
In resection of diseased tissue
What can pericoronitis result in?
Food and debris gets trapped under the operculum resulting in inflammation or infection
What is pericoronitis?
Inflammation around the crown of a partially erupted tooth
What is the second most common reason for third molar extraction?
Pericoronitis
What anaerobic microbes are associated with pericoronitis?
Streptococci
Actinomyces
Propionibacterium
A Beta Lactase producing prevotella
Bacteroides
Fusobacterium
Capnocytophaga
Staphlococci
What are the signs and symptoms of pericoronitis?
Pain
Swelling- intra or extra
Bad taste
Pus discharge
Occlusal trauma to operculum
Ulceration of operculum
Cheek biting
Foetor oris
Limited mouth opening
Dysphagia
Pyrexia
Malaise
Regional lymphadenopathy
What is the treatment of pericoronitis?
Incision of localised pericoronitis abscess if required
+/- local anaesthetic (depends on pain/patient)
Irrigation with warm saline or chlorhexidine mouthwash (10-20ml syringe with blunt needle- under the operculum)
Extraction of third molar if traumatising the operculum
Patient instructed on frequent warm saline or chlorhexidine mouthwashes
Advice regarding analgesia
Keep fluid levels up and eating soft
When should antibiotics be prescribed to a pericoronitis patient?
Severe
Systemically unwell
Extra oral swelling
Immunocompromised
When should you refer a patient with pericoronitis to A&E/maxillofacial unit?
Extra oral swelling
Systemically unwell
Trismus
Dysphagia
What are the predisposing factors to pericoronitis?
Partial eruption and vertical or distoangular impaction
Opposing maxillary molar causing mechanical trauma contributing to recurrent infection
Upper respiratory tract infections including stress and fatigue pericoronitis
Poor oral hygiene
Insufficient space between the ascending ramus of the lower jaw and the distal aspect of the 2nd molar
White race
Full dentition
What are the causes of temporomandibular dysfunction?
Myofascial pain
Disc displacement
Degenerative disease
What are the two types of disc displacement?
Anterior with reduction
Anterior without reduction
What is a localised degenerative disease associated with temporomandibular dysfunction?
Osteoarthritis
What is a generalised/systemic degenerative disease associated with temporomandibular dysfunction?
Rheumatoid arthritis
What are the causes of TMD?
Chronic recurrent dislocation
Ankylosis
Hyperplasia
Neoplasia (osteochrondroma, osteoma or sarcoma)
Infection
What is the pathogenesis of TMD?
Inflammation of muscles of mastication or TMJ secondary to parafunctional habits
Trauma, either directly to the joint or indirectly (sustained opening during treatment)
Stress
Psychogenic
Occlusal abnormalities
What features of a pain history should be taken for a patient with TMD?
Location, nature, duration, exacerbating/relieving factors, severity, frequency, time of occurrence
Associated pain in neck/shoulders
What does TMD pain in the morning indicate?
Bruxism
What does TMD pain in during the day indicate?
Habits
What features of a social history are relevant for a patient with TMD?
Occupation
Stress
Home circumstance
Sleeping pattern
Recent bereavement
Relationships
Habits
Hobbies
What features of an E/O exam are relevant for a patient with TMD?
Muscles of Mastication
Joints- clicks (early/late), crepitus
Jaw movements
Facial asymmetry
What features of an I/O exam are relevant for a patient with TMD?
Interincisal mouth opening
Signs of parafunctional habits
Musicels of mastication
What are intra oral signs of parafunctional habits?
Cheek biting
Linea alba
Tongue scalloping
Occlusal non-carious tooth surface loss
What special investigations can be carried out for a TMD patient?
Radiographs
What gender is TMD most common in?
Females
What age is TMD most common in?
18-30 years
What are the clinical features of TMD?
Intermittent pain of several months or years duration
Muscle/joint/ear pain particularly on wakening
Trismus/locking
Clicking/popping joint noises
Headaches
Crepitus indicates degenerative changes
What may have a similar presentation to TMD?
Dental pain
Sinusitis
Ear pathology
Salivary gland pathology
Referred neck pain
Headache
Atypical facial pain
Trigeminal neuralgia
Angina
Condylar fracture
Temporal arteritis
What are the reversible treatments for TMD?
Patient education
Medication
Reassurance
Physical therapy
Splint
What does patient education for TMD contain?
Counselling
Electromyographic recording
Jaw exercises (physiotherapy)
What medications can be offered for TMD?
NSAIDs
Muscle relaxants
Tricyclic antidepressants
Botox
Steroids
What reassurance can be given to a TMD patient?
Soft diet
Masticate bilaterally
No wide opening
No chewing gum
Don’t incise foods
Cut food into small pieces
Stop parafunctional habits (e.g. nail biting, grinding)
Support mouth on opening e.g. yawning
What physical therapy can be provided to a TMD patient?
Physiotherapy
Massage/heat
Acupuncture
Relaxation
Ultrasound therapy
TENS (Transcutaneous Electronic Nerve Stimulation)
Hypnotherapy
What splints can be given to a TMD patient?
Bite raising appliances (Lucia jig, hard acrylic)
Anterior repositioning splint (wenvac or Michigan)
What is the theory behind bite raising appliances?
Stabilise the occlusion and improve the function of the masticatory muscles thereby decreasing abnormal activity
They protect the teeth in grinding cases
May need to be worn for several weeks before effect is seen
What are the irreversible treatments of TMD?
Occlusal adjustment
TMJ surgery
What are the TMJ surgeries that can be done for TMD patients?
Arthrocentesis
Arthroscopy
Disc-repositioning surgery
Disc repair/removal
High condylar shave
Total joint replacement
What is the cause of painful clicking in the TMJ
Lack of coordinated movement between the condyle and the articular disc
The condyle has to overcome the mechanical obstruction before full joint movement can be achieved
Discuss anterior disc replacement with reduction?
Disc is initially displaced anteriorly by the condyle during opening until disc reduction occurs
What are the signs/symptoms of anterior disc replacement?
Jaw tightness/locking
The mandible may initially deviate to the affected side before returning to the midline
What can untreated anterior disc displacement lead to?
Osteoarthritis
What is the treatment for disc displacement with reduction?
Counselling: limit mouth opening, bite raising appliance, surgery may be considered
If painless: reassurance
What are minor traumatic events that can cause trismus?
IDB
Prolonged dental treatment
Infection
What happens if there is no resolution to trismus after acute phase?
Physiotherapy
Therabite
Jaw screw
What is therabite?
Jaw motion rehabilitation system
What are the common treatment options for third molars?
Referral
Clinical review
Removal of M3M
Extraction of maxillary third molar
Corenectomy
What are the less common treatment options for third molars?
Operculectomy
Surgical exposure
Pre-surgical orthodontics
Simple reimplantation/autotransplantation
What factors play a role in decision making when treatment planning for a third molar?
Patient involvement
Good note keeping
Current status of the patient and the M3M
Risk of complications
Patient access to treatment
What are the anaesthetic options when managing M3M?
Local anaesthetic
Conscious sedation
General anaesthetic
What % of people require conscious sedation for routine dental treatment?
7%
What type of anaesthetic requires written consent?
GA and IV
(LA if there is high risks associated with the tx)
What should feature in the consent for a M3M extraction?
Explain procedure to patient
If tooth is likely to need sectioned; explain this
Give the patient an idea of what to expect during the procedure
Explain minor surgical procedure, flap, possible drilling, sutures
If there is a large 2nd molar restoration explain risk of restoration fracture
If risk of jaw fracture- aberrant lower 8 to lower border of mandible, large cynic lesion associated with wisdom tooth
What are the components of an assessment for M3M?
History
Clinical
Radiographic
What features should be noted when taking a history for a third molar?
General appearance
Presenting complaint e.g. recurrent pericoronitis
History of presenting complaint: how long, how many episodes, how often, severity, requirement for Ab
Medical history : systemic enquiry, medications, allergies, previous hospitalisations
Dental history: history of extractions, dental anxiety, dental experience, regular oral hygiene
Social history: smoking, alcohol, occupation, carer, support
What should be noted in an extra-oral examination for a third molar?
TMJ
Limited mouth opening
Lymphadenopathy
Facial asymmetry
Muscles of Mastication
What should be noted in an intra-oral examination for a third molar?
Soft tissue examination
Dentition
M2M
Eruption status of the M3Ms
Condition of the remaining dentition
Occlusion
Caries status
Periodontal status
What should be noted in a radiographic assessment for a third molar if surgical intervention is being considered?
Presence or absence of disease
Anatomy of 3M (crown size, shape, condition, root formation)
Depth of impaction
Working distance (distal of lower 7 to ramus of mandible)
Folicular width
Periodontal status
The relationship or proximity of upper third molars to the maxillary antrum and of lower third molars to the inferior dental canal
Any other associated pathology
What features are associated with risky relationship between the roots and the ID canal?
Interruption of the white lines/lamina dura of the canal
Darkening of the root where crossed by the canal
Diversion/deflection of the inferior dental canal
Deflection of the root
Narrowing of the inferior dental canal
Narrowing of the root
Dark and bifid root
Juxta apical area
What parts of a radiographic assessment are associated with a significantly increased risk of nerve damage during third molar surgery?
Diversion of the inferior dental canal
Darkening of the root where crossed by the canal
Interruption of the white lines of the canal
What can be used if the proximity of the roots is close to the ID canal?
CBCT
What % of lower 8’s have a vertical impaction?
30-37%
What % of lower 8’s have a medial impaction?
40%
What % of lower 8’s have a distal impaction?
6-15%
What % of lower 8’s have a horizontal impaction?
3-15%
What is the angulation/orientation of third molars measured against?
Curve of Spee
What does depth of third molars give an indication about?
The amount of bone removal required
What does a superficial depth indicate?
Crown of 8 related to crown of 7
What does a moderate depth indicate?
Crown of 8 related to crown and root of 7
What does a deep depth indicate?
Crown of 8 related to root of 7
What is the management of asymptomatic diseased/high risk disease development?
If high risk surgical intervention should be considered
Active surveillance is recommended until symptoms develop
When are therapeutic extractions indicated?
Single severe acute or recurrent subacute pericoronitis
Unrestorable caries of the M3M or to assist restoration the adjacent tooth
Periodontal disease compromising the M3M and/or adjacent tooth
Resorption of the M3M and/or adjacent tooth
Fractured M3M
M3M periapical abscess, irreversible pulpitis, or acute spreading infection
Surrounding pathology (cysts or tumours) associated with the M3M
What is the treatment for symptomatic diseased/high risk disease development?
Therapeutic removal of M3M (coronectomy)
Removal of upper third molar
What are the medical considerations for prophylactic removal?
Patients undergoing planned medical treatment/therapy that may complicate the likely surgery of M3M including:
Pharmaceutical therapy (bisphosphonates, antiangiogenics, chemotherapy)
Radiotherapy of head and neck
Immunosuppressant therapy
What are the surgical considerations for prophylactic removal of third molars?
The third molar lies within the perimeter of a surgical field:
Mandibular fractures
Orthographic surgery
Resection of disease (benign and malignant lesions)
What can you do to manage the pain in the region of third molars?
Temporomandibular disorders
Parotid disease
Skin lesions
Migraines or other primary headaches
Referred pain from angina, cervical spine
Oropharyngeal oncology
What post operative complications are associated with third molar extractions?
Pain
Swelling
Bruising
Jaw stiffness/limited mouth opening
Bleeding
Infection
Dry socket (localised osteitis)
What % of patients have temporary numbness to lower lip/chin in IDB?
10-20%
What % of patients have temporary numbness to the tongue after a lingual infiltration?
0.25-23%
What % of patients have permanent numbness to the lip/chin in IDB?
<1%
What % of patients have permanent numbness to the tongue after a lingual infiltration?
0.14-2%
How long can temporary numbness last?
18-24 months
What should a referral include?
Situation
Background
Assessment
Recommendation
What are examples of TMJ diseases?
TMJ dysfunction
Jaw dislocation
Osteo-arthritis
Rheumatoid arthritis
Chondromatosis
Foreign body granuloma
Infection
Traumatic damage
Radiation damage
Ankylosis
Tumours
What are the components of TMJ dysfunction?
Muscular ‘initiation’
Mechanical ‘TMJ dysfunction’
Psychological ‘underlying cause’
Trauma ‘aetiology’
What are the components of TMJ dysfunction?
Muscular ‘initiation’
Mechanical ‘TMJ dysfunction’
Psychological ‘underlying cause’
Trauma ‘aetiology’
What are examples of aetiological factors associated with TMJ dysfunction?
Macrotrauma
Microtrauma
Occlusal factors
Anatomical factors
What are examples of microtrauma associated with TMJ disorder?
Chronic joint overloading secondary to stress related repetitive clenching or bruxism
What are examples of occlusal factors associated with TMJ dysfunction?
Deep bite
Occlusal disharmony (high filling)
Lack of teeth
What are examples of anatomical factors associated with TMJ dysfunction?
Class II jaw relation
What are the symptoms of TMJ dysfunction?
Pain
Reduced mobility
TMJ clicking and locking
What types of pain is associated with TMJ dysfunction?
Muscular
Capsular
Intra-capsular ‘disc’
What are the anatomical considerations associated with TMJ dysfunction?
Glenoid fossa
Condylar head
Articular disc
Lateral ligament
Internal surface of capsule
Synovial membrane
What type of joint is the TMJ?
Fibro-cartilage discs
What movement takes place in the upper compartment of the TMJ?
Translocation
What movements take place in the lower compartment of the TMJ?
Rotation
What aspect of the TMJ helps to resist load?
Cartilage
Synovial fluid
Joint shape
Muscles
Ligaments
What does articular cartilage consist of?
Chondrocytes
Collagen fibres in proteoglycan matrix
What is the effect of inflammatory disease on proteoglycans?
Inflammatory diseases produce proteases which degrade proteoglycans
What are the innervated components of the TMJ?
Capsule
Synovial tissue
Subchondral bone
What is the effect of compressive forces on collagen?
Compression may damage proteoglycans which protect collagen
What does TMJ inflammation lead to the production of?
Proteases
Hyaluronidase
What does synovitis lead to?
Chronic adhesive capsulitis and disc displacement
What is the effect of shearing forces in the TMJ?
May cause the break up of collagen fibrils
What are the effects of degenerative changes on the TMJ?
Cartilage degeneration: chondromalacia/collagen/fibrillation/subchondral bone exposure
Disc perforation
Multiple adhesions and adhesive capsulitis
Osteophytes
Flattening of condyle and eminence
Subchondral cysts
What is included in the conservative management of TMJ dysfunction?
Counselling
Pain management
Joint rest
Physical therapy
Restoration of occlusal stability
What are the functions of a bite appliance?
Eliminates occlusal interferences
Prevents the joint head from rotating so far posteriorly in the glenoid fossa
Reduces loading on the TMJ
What are the investigations for TMJ dysfunction?
Radiographic
Arthrogram
MRI scan
Arthroscopy
What are examples of arthroscopic procedures?
Diagnosis
Biopsy
Lysis and lavage
Disc reduction- release, cautery, suturing
Removal of loose bodies
Eminectomy
What are examples of intra and post operative complications of arthroscopic procedures?
Iatrogenic scuffing
Broken instruments
Middle ear perforation
Glenoid fossa perforation
Extravasation
Haemorrhage
Haemarthrosis
Damage to Vn and VIIn
Infection
Dysocclusion
Laceration of EAM
Perforation of tympanic membrane
What is the post operative management when dealing with TMJ dysfunction?
Joint rest- soft diet, avoid wide opening
Pain management
Physical therapy
Restoration of occlusal stability
What are examples of surgical procedures to manage TMJ dysfunction?
Disc plication
Eminectomy
High condylar shave
Condylotomy
Meniscectomy
Condylectomy
Reconstructive procedures
What are the indications for TMJ reconstruction?
Joint destruction
Ankylosis
Developmental deformity
Tumours
What are examples of joint destruction causes that indicate for TMJ reconstruction?
Trauma
Infection
Tumours
Previous surgery
Radiation
What are examples of slow growing tumours associated with indication for TMJ reconstruction?
Giant cell lesions
Fibro-osseous lesions
Myxomas
What is type I ankylosis of the TMJ?
Flattening deformity of condyle, little joint space and extensive fibrous adhesions
What is type II ankylosis of the TMJ?
Bony fusion at outer edge of articular surface
What is type III ankylosis of the TMJ?
Marked fusion bone between upper part of ramus of mandible and zygomatic arch
What is type IV ankylosis of the TMJ?
Entire joint replaced by mass of bone
At what age does sinus formation occur?
Between 3rd and 4th foetal months with evaginations of the mucosa of the nasal cavity
Discuss the sizes of the sinuses at birth;
Maxillary and ethmoid are relatively large at birth
Sphenoid and frontal undergo expansion within the first few years of life
What are the functions of the paranasal sinuses?
Adds resonance to the voice
Reserve chambers for warming inspired air
Reduces the weight of the skull
What is the avg volumetric space of the maxillary sinus?
15ml
What are the dimensions of the maxillary sinus?
37mm high
27mm wide
35mm antero-posteriorly
What is the opening of the maxillary sinus called?
Optimum
Where is the ostium?
Middle meats (semi-lunar hiatus)
What is the approximate diameter of the ostium of the maxillary sinus?
4mm
Where are the alveolar canals to the maxillary teeth in relation to the sinus
Found on the posterior wall of the sinus cavity
What type of epithelium of the sinuses?
Pseudo-stratified ciliates columnar epithelium
What is the function of the cilia in the sinuses?
Mobilise trapped particulate matter and foreign material within the sinus
Moves this material toward the ostia for elimination into the nasal cavity
What is the clinical significance of the maxillary sinus?
Oro-antral communication
Oro-antral fistula
Root in the antrum
Sinusitis
Benign lesions
Malignant lesions
What are the factors associated with the diagnosis of an oro-antral communication/fistula?
Size of tooth
Radiographic position of roots in relation to the antrum
Bone at trifurcation of the roots
Bubbling of blood
Nose holding test (risk of creating OAC)
Direct vision
Good light and suction (echo)
Blunt probe (take care- risk of creating OAC)
What is the management of an oro-antral communication if small or sinus lining is intact?
Inform patient
Encourage clot
Suture margins
Antibiotic (debatable)
Post op instructions (minimising pressure formation within sinus and mouth)
What is the prognosis for small OAC’s?
<2mm usually heal with normal blood clot formation and routine mucosal healing
What is the management of oro-antral communication if large or sinus lining is torn?
Inform patient
Close with buccal advancement flap
What are the steps of raising a buccal advancement flap?
Flap designed
Flap raised
Trimming of the buccal bone (occasionally)
Incise the periosteum
Check flap can be brought across defect tension free
Suturing
What complaints are associated with a chronic OAF?
Problems with fluid consumption (fluids from nose)
Problems with speech or singing (nasal quality)
Problems playing brass/wind instrument
Problems smoking cigarette or using a straw
Bad taste/odour/halitosis/pus discharge (post-nasal drip)
Pain/sinusitis type symptoms
What must be done in a OAF case prior to buccal advancement flap?
Excision of sinus tract
Antral wash out (occasionally)
What are the flap design options in OAF?
Buccal advancement flap
Buccal fat pad with buccal advancement flap
Palatal flap
Bone graft/collagen membrane
Rotated tongue flap (historic)
What is the aetiology of maxillary tuberosity fracture?
Single standing molar
Unknown un erupted molar or wisdom tooth
Pathological germination/concresence
Extracting in the wrong order
Inadequate alveolar support
How is a fractured maxillary tuberosity diagnosed?
Noise
Movement noted both visually or with supporting fingers
More than one tooth movement
Tear in soft tissue of palate
What is the management of a fractured maxillary tuberosity?
Reduce and stabilise; orthodontic buccal arch wire with composite, arch bar, lab-made splints
Dissect out and close wound primarily
What should be done when splinting a tooth following a maxillary tuberosity fracture?
Remove or treat pulp
Ensure it is out of occlusion
Consider antibiotics and antiseptics
Post op instructions
Remove tooth surgically 4-8 weeks later
What should be done if there it root/tooth in the maxillary sinus?
Confirm radiographically by OPT, occlusal or periapical (+/- CBCT)
Decision on retrieval
If in doubt or retrieve difficult— refer
How is a root in the antrum/sinus retrieved?
OAF approach (through extraction socket)
Caldwell-Luc approach
ENT
Discuss retrieval of roots in the antrum/sinus taking an OAF type approach:
Open fenestration with care
Suction- efficient and narrow bore
Small curettes
Irrigation or ribbon gauze
Close as for oro-antral communication
Discuss retrieval of roots in the antrum/sinus taking an Caldwell-Luc approach:
Buccal/labial sulcus
Buccal window cut in bone
What should be remembered when examining patients with maxillary discomfort?
Close relationship of the sinuses and the posterior maxillary teeth
The aetiology of paranasal sinus inflammation and infection
Patients with sinusitis usually present to the dentist first
What is the aetiology of sinusitis precipitated by?
Viral infection: inflammation and oedema, obstruction of ostia, trapping of debris within the sinus cavity
What may alter mucociliary clearance patterns?
Allergens
Inflammation
Anatomical abnormalities
What happens when the sinus can no longer evacuate its contents efficiently?
Build up of pressure
Opportune situation for bacterial overgrowth of normal flora
What are the signs and symptoms of sinusitis?
Facial pain
Pressure
Congestion (fullness)
Nasal obstruction
Paranasal drainage
Hyposmia
Fever
Headache
Dental pain
Halitosis
Fatigue
Cough
Ear pain
Anaesthesia/paraesthesia over the cheek
What may sinusitis present similarly to?
Periapical abscess
Periodontal infection
Deep caries
Recent extraction socket
TMD
Neuralgia or atypical facial pain/chronic midfacial pain
What are the indicators of sinusitis?
Discomfort on palpation of infraorbital region
A diffuse pain in the maxillary teeth
Equal sensitivity from percussion of multiple teeth in the same region
Pain that worsens with head or facial movements
What are the aims of sinusitis treatment?
Treat presenting symptoms
Reduce tissue oedema
Reverse obstruction of the ostia
What are the treatment options for sinusitis?
Decongestants to reduce mucosal oedema (ephedrine nasal drops 0.5% one drop each nostril up to 3x daily, max 7 days)
Humidified air
When should antibiotics be used for sinusitis?
Is symptomatic treatment is not effective/symptoms worsen
Signs and symptoms point to a bacterial sinusitis
What is the antibiotic regime for sinusitis?
Amoxicillin 500mg, 3x daily 7 days
Doxycycline 100mg, 1x daily 7 days (200mg loading dose)
What are the causes of sinusitis?
Fungal
Trauma
Benign sinus lesions
Malignant lesions
What trauma can cause sinusitis?
Sinus wall fractures
Orbital floor fractures
Root canal therapy
Tooth extractions
Dental implants/ sinus lifts
Deep periodontal treatment t
Nasal packing
Nasogastric tubes
Mechanical (nasal) intubation
What are examples of benign sinus lesions associated with sinusitis?
Polyps
Papillomas
Antral psuedocysts
Mucoceles and mucous retention cysts
Odontogenic cysts/tumours expanding into the maxillary sinus
What are the stages of blood clot formation?
Vasoconstriction
Platelet plug
Fibrosis of platelet plug
What is a biopsy?
Sample of tissue for histopathological analysis
Allows confirmation or establishment of a diagnosis and can aid with determining prognosis
What are examples of tissue sampling techniques?
Aspiration
Aspiration from lesion
Fine needle aspiration biopsy
What are examples of aspiration tissue sampling techniques?
Blood sample
What are the benefits/downsides of aspiration from lesion?
Avoids contamination by oral commensals
Protects anaerobic species
May also aspirate cystic lesions
Aspiration will determine whether a lesion is solid or fluid filled
May occasionally yield blood
What is fine needle aspiration biopsy?
Aspiration of cells from solid lesions
Neck swellings, salivary gland lesions, cytology
What are the features of an excisional biopsy?
Removal of all clinically abnormal tissue
Confidence in provisional diagnosis
When should an excisional biopsy be done?
Benign lesions (fibrous overgrowths, denture hyperplasia, mucocoeles)
Discrete lesions
What are the features of an incisional biopsy?
Representative tissue sample
Larger lesions
More uncertain in provisional diagnosis
What conditions is a incisional biopsy useful in?
Leukoplakia
Lichen planus
Squamous cell carcinoma
What is a punch biopsy?
Incisional biopsy
Hollow trephine 4, 6, or 8mm in diameter
Removes core of tissue
Minimal damage
May not require suture/ only minimal suturing
What factors are associated with selecting the biopsy site?
Must be large enough
Must be representative
Maybe more than one biopsy
Include perilesional tissue
How should samples be sent to the pathology lab?
Placed immediately into 10% formalin (dont place on gauze swap)
Suture may help the pathologist orientate the sample
Include relevant clinical information on the pathology form to aid diagnosis
What is the effect of sutures in regard to a specimen?
Can be useful for orientation
What is the effect of gauze in regard to a specimen?
Distorts the sample so dont use
What is the effect of filter paper in regard to a specimen?
Reduces sample distortuib
What should be done to the pot containing the sample?
Label as fully as possible
Correct usage should ensure no leaks
Do not confuse with the tooth collection pots
Where should specimens be sent to?
The Pathology Dept
Queen Elizabeth University Hospital
How are specimens sent?
By courier, under very strict instructions
What factors are associated with choosing biopsy area?
Chose a representative sample
Not necessary to include ‘normal tissue’ margin
Try to avoid salivary gland duct orifices, tip of tongue, areas close to nerves and larger blood vessels
What are examples of soft tissue lesions?
Carcinoma
Denture hyperplasia
Fibrous epulis
Fibrous overgrowth
Giant cell epulis
Pregnancy epulis
Haemangioma/lymphangioma
Lipoma
Pyogenic granuloma
Squamous cell papilloma
Salivary gland lesions
Lichen planus
Lichenoid reactions
Pemphigus
Pemphigoid
Behcet’s
Leukoplakia
Erythroplakia
What is a fibrous epulis?
Swelling arises from the gingivae
Hyperplastic response to irritiation
What are examples of irritations that can cause fibrous epulis’
Overhanging restoration
Subgingival calculus
How to fibrous epulis’ appear?
Smooth surface, rounded swelling
Pink and pedunculated
How are fibrous epulis’ sampled and treated?
Excisional biopsy
Coe pack dressing
Remove source of irriation
What is a fibrous overgrowth?
Fibroepithelial polyp
What can cause a fibrous overgrowth?
Frictional irritation or trauma
How do fibrous overgrowths appear?
Semi-pedunculated or sessile
Pink
Smooth surface
Where do fibrous overgrowths usually present?
Buccal mucosa and inner surface of lip
How are fibrous overgrowths sampled?
Surgical excision
No need for deep excision or normal margin
What is giant cell epulis?
Peripheral giant cell granuloma
Multi-nucleated giant cells in vascular stroma
When and where does giant cell epulis commonly present?
Teenagers
Anterior regions of mouth
How does giant cell epulis present?
Deep red or purple
Broad base
Why should a giant cell epulis be radiographed?
To ensure it is not centrally originating (would appear as a radiolucency)
How is a giant cell epulis sampled?
Surgical excision with curettage of base
Coe pack dressing
What are the features of a haemangioma?
Exophytic
Blue in colour
Pressure will cause loss of colour
How are haemangiomas sampled/removed?
Surgical removal or cryotherapy
What is a down side of cryotherapy?
No histological diagnosis
What is a lipoma?
Benign neoplasm of fat
How does lipoma present?
Soft swelling
Pale yellow
Sessile
How is lipoma sampled?
Excision
How is a pregnancy epulis managed?
Small lesions may not require excision and may regress after birth
Larger lesions should be excised
What is the cause of a pyogenic granuloma?
Failure of normal healing
What is a pyogenic granuloma?
Overgrowth of granulation tissue
What are example causes of pyogenic granuloma?
May be related to extraction sockets or traumatic soft tissue injuries
How are pyogenic granulomas managed?
Surgical excision
Curettage of base
Where do squamous cell papilloma present commonly?
Palate
Buccal mucosa or lips
What is a squamous cell papilloma?
Benign neoplasm
How do squamous cell papilloma present?
Usually pedunculate
White surface
Cauliflower appearance
How is squamous cell papilloma managed?
Excision at base
What is squamous cell papilloma similar to?
Viral warts
What is denture hyperplasia?
Roll of excess tissue on outer aspect of denture flange and alveolar ridge caused by a poorly fitting denture
How is denture hyperplasia managed?
Trim denture flange
Remove excess tissue
If large area use Coe pack dressing to ensure sulcus depth is maintained
Where is commonly affected by denture hyperplasia?
Lower labial sulcus
What is the cause of a leaf fibroma?
Chronic irritation form denture
Why is a leaf fibroma flattened not rounded?
Due to the denture covering it
How does a leaf fibroma present?
Pedunculated
How is a leaf fibroma managed?
Excision
What is a mucocoele?
Mucous extravasation cyst
Where are mucocoeles commonly?
Minor salivary glands
How are mucocoeles formed?
Damage to minor salivary gland
Saliva leaks into submucosal layer
Soft bluish swelling- fluid filled
What is a ranula?
Mucocoele on the floor of mouth
What is the management of a mucocoele?
Surgical excision
Blunt dissection
What risk is associated with swellings in upper lips?
More commonly neoplastic than simple mucocoeles
How may squamous cell carcinoma present?
A lump, red or white patch, non-healing ulcer
Commonly appears as an ulcer with a rolled margin and induration
How is suspected squamous cell carcinoma sampled?
Incisional biopsy
What are the four causes of bone loss?
Congenital
Pathology
Natural
Trauma
What are the methods of ridge augmentation?
Bone grafts
Inferior dental nerve retraction
Distraction osteogenesis
Zygomatic implants
Growth factors; bone morphogenic protein (BMP)
What are examples of local bone grafts?
Chin
Ramus
Tuberosity
Coronoid process
What are examples of distant bone grafts?
Iliac crest
Calverium
What is an allograph?
Graft from same species
What is an autograft?
Graft from the patients own body
What is a Zenograft?
Graft from an animal
What is an onlay graft?
Graft is placed over site
What is an interpositional graft?
Graft placed in between two structures
What are examples of congenital bone loss?
Hypodontia
Cleft
What are the basic principles of distraction osteogenesis?
Osteotomy (location and direction)
Latency
Distraction (vector, rate and rhythm)
Consolidation
Remodelling
What is osteotomy?
Cutting of the bone
What is latency? (distraction osteogenesis)
Period of time (around 10 days) following osteotomy
What is the rate of distraction?
1mm per day (half in morning, half in afternoon- rhythm)
What does vector mean in regard to distraction?
Direction of the movement
What is consolidation?
After space is made, device is left in situ for 2-3 months to allow bone remodelling
What is the length of a zygomatic implant?
45-55mm
What are the indications for a zygomatic implant?
Severe maxillary atrophy
Sinus pneumotisation
To avoid harvesting of bone graft
Hemimaxillectomy
What are BMPS?
Active osteoinductive factors
Extracellular proteins stored in bone matrix
Convert UMCs into osteoblasts and stimulate angiogenesis
Which BMPs induce bone formation?
15 BMPs
BMP2
BMP4
BMP7
What does BMP stand for?
Bone morphogenetic proteins
What are the basic principles of surgical removal?
Risk assessment: good planning, medical history
Aespetic technique
Minimal trauma to hard and soft tissues
What are the stages of surgical removal?
Anaesthesia
Access
Bone removal as necessary
Tooth division as necessary
Debridement
Suture
Achieve haemostasis
Post operative instructions
How is access gained for a third molar removal?
Raising a buccal mucoperiosteal flap (with/without raising a lingual flap)
What are the principles to follow when raising a flap?
Maximum access with minimal trauma
Large flaps heal as quickly as smaller ones
Use the scalpel in one firm continuous stroke
Minimise trauma to dental papilla
What instruments are used for reflection?
Mitchell’s trimmer
Howarth’s periosteal elevator
Ash periosteal elevator
Curved Warwick James elevator
What are the stages of reflection?
Commence raising flap at base of relieving incision
Undermine/free anterior papilla before proceeding with reflection distally (avoid tears)
Reflect with periosteal elevator firmly on bone
What factors should be considered when reflecting with a periosteal elevator?
Avoid dissection occurring superficial to periosteum
Reduce soft tissue bruising/trauma
What areas are the most difficult to reflect with minimal trauma?
Papilla
Mucogingival junction
What factors are important in regard to retraction?
Access to field
Protection of soft tissues
Flap design facilitates retraction
Atraumatic/passive retraction
What instruments can be used for retraction?
Howarth’s periosteal elevator
Rake retractor
Minnesota retractor
How is atraumatic/passive retraction achieved?
Rest firmly on the bone
Have an awareness of adjacent structures
What handpiece is used for bone removal and why?
Electrical straight handpiece with saline cooled bur
Air driven handpicks may lead to surgical emphysema
What burs are used for bone removal?
Round or fissure stainless steel and tungsten carbide burs
Where is the drill placed in regard to bone removal?
Buccal aspect of the tooth and to the distal aspect of the impaction
What is the aim when drilling for bone removal?
Create a deep, narrow gutter around the crown of the wisdom tooth
Should allow correct application of elevators in the mesial and buccal aspects of the tooth
What are the factors to consider when looking at a good quality drill unit/bur?
Free-standing drill unit/ straight handpiece
Tungsten carbide burs
Plenty of irrigation
What is the most common type of tooth separation?
Crown sectioned from the roots
How is a horizontal crown section carried out?
Tooth is sectioned just above the enamel-cementum junction
Where is the tooth sectioned for a coronectomy?
Tooth is sectioned below the enamel cementum junction
Why is a tooth sectioned above the ACJ for horizontal sectioning?
Leaves some crown behind and allows orientation and elevation
When is vertical crown section carried out?
Where the roots are separate
What does vertical crown sectioning allow?
Removal of the distal portion of the crown and distal root followed by elevation of the mesial portion of the crown and mesial root
What are the types of debridement?
Physical
Irrigation
Suction
How is physical debridement carried out?
Bone files or handpiece to remove sharp bony edges
Mitchell’s trimmer or Victoria curette to remove soft tissue debris
How is irrigation debridement carried out?
Sterile saline into socket and under flap
How is suction irrigation carried out?
Aspirate under the flap to remove debris
Check socket for retained apices
What are the aims of suturing?
Reposition tissues
Cover bone
Prevent wound breakdown
Achieve haemostasis
When is a coronectomy carried out?
Alternative to surgical removal of entire tooth when there is increased risk of IAN damage with surgical removal
What are the stages of a coronectomy?
Flap design to gain access to tooth
Transection of tooth 3-4mm below the enamel of the crown into dentine
Elevate/lever crown off without mobilising the roots
Pulp left in place- untreated
(If necessary further reduction of the roots with a rose head bur to 3-4mm below alveolar crest)
Socket irrigated
Flap replaced
When should a coronecromy be followed up?
Review 1-2 weeks
Further review 3-6 months then 1 year
Can be reviewed at 2 years
Radiographic review- 6 months, 1 year or both (if symptomatic 1 week post op)
When is a coronectomy patient discharged back to their GDP?
After 6 months/1 year review
What warnings should be given to a patient in regard to their coronectomy?
If the root is mobilised during crown removal the entire tooth must be removed (more likely with conical fused roots)
Leaving roots behind could result in infection
Can get a slow healing/painful ‘socket’
The roots may migrate later and begin to erupt through the mucosa and may require extraction
Discuss extraction in regard to upper third molars:
Generally easier than lower
Removed by elevation only or elevation and forceps extraction (straight or curved Warwick James or couplings)
Bayonet forceps may be used
