Oral Surgery Flashcards
patient attends emergency clinic with pain associated with partially erupted LR8. on examination you notice a pericoronal abscess and operculum is inflamed. how would you manage this?
LA
incise localised pericoronal abscess
irrigate with warm saline or chlorehexidine mouthwash under the operculum with a blunt needle
radiographic signs linked to a significantly increased risk of nerve injury 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
At what age do third molars usually erupt?
between 18 and 24
What are mandibular third molars usually impacted against?
adjacent tooth
alveolar bone
surrounding mucosal soft tissues
a combination of these factors
consequences of impacted third molars
caries
pericoronitis
cyst formation
what nerves are at risk during mandibular third molar surgery?
inferior alveolar
lingual
nerve to mylohyoid
long buccal
indications for extracting third molars
infection
- caries
- pericoronitis
- periodontal disease
- local bone infection
cysts
tumour
external resorption of 7 or 8
high risk of disease
medical indications e.g.g immunosuppressed
accessibility
autotransplantation
what is pericoronitis?
inflammation around the crown of a partially erupted tooth
how does pericoronitis occur?
food and debris gets trapped in the operculum resulting in inflammation and infection
what type of microorganisms are responsible for periocoronitis?
anaerobic microbes
e.g. streptococci, actinomyces, fusobacterium
pericoronitis signs and symptoms
pain
swelling
bad taste
pus discharge
ulceration of operculum
evidence of cheek biting
limited mouth opening
dysphagia
malaise
regional lymphadenopathy
pericoronitis treatment
incision of localised pericoronal abscess if present
- LA IDB - depends on pain/patient
irrigation with warm saline or chlorhexidine mouthwash (10-20ml syringe with blunt needle under the operculum)
XLA of upper third molar if traumatising the operculum
patient instructions on frequent warm saline or chlorhexidiene mouthwashes
pericoronitis - instructions to give patient
analgesia
instruct patient to keep fluid levels up and keep eating
- soft diet if necessary
generally do not prescribe antibiotics unless more severe case, systemically unwell, e/o swelling or immunocompromised e.g. diabetes
if large e/o swelling, systemically unwell, trsimus or dysphagia - refer to max fax or A&E
pericoronitis predisposing factors
partial eruption and vertical or distoangular impaction
opposing maxillary 2nd or 3rd molar causing mechanical trauma contributing to recurrent infection
poor oH
insufficient space between ascending ramus of lower jaw and distal aspect of mandibular 2nd molar
white race
full dentition
XLA 3rd molars - things to assess in radiographic examination:
only if surgical intervention is being considered
OPT to determine
- presence or absence of disease
- depth and orientation of impaction
working distance
periodontal status
any associated pathology
relationship of upper third molars to maxillary sinus or lower third molars to inferior dental canal
radiographic signs associated with a significant increased risk of nerve injury 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 other imaging is possible if conventional imaging has shown a close relationship between the third molar and the inferior dental canal?
cone beam CT
post operative complications of third molar surgery
pain
swelling
bruising
jaw stiffness/limited mouth opening
bleeding
infection
dry socket
what percentage of patients may experience temporary numbness or parasthesia to the lower lip/chin following lower third molars extraction?
10-20%
may take weeks or months to improve
< 1% permanent
surgical extraction - steps
anaesthesia
access
bone removal as necessary
tooth division
debridement
suture
achieve haemostasis
post op instructions
surgical removal - anaesthesia options
LA
IV sedation and LA
general anaesthetic
how is access gained during a surgical extraction
mucoperioesteal flap is raised
- lingual flap may also be raised
use scalpel in one firm continuous stroke
aims of suturing
reposition tissues
cover bone
prevent wound breakdown
achieve haemostasis
what is a coronectomy?
removal of the crown of the tooth with deliberate retention of root adjacent to the inferior alveolar nerve
alternative to surgical removal of entire tooth where there appears to be an increased risk of IAN damage with surgical removala
coronectomy steps
flap design as necessary to gain access
transection of tooth 3-4mmm below crown
elevation of crown without mobilising roots
socket irrigated
flap replaced
coronectomy follow up
review in 1-2 weeks
further 3-6 monthly review then 1 year
radiographic review - 6 months or 1 year or both
- some take immediate or 1 week post op radiograph
coronectomy - warnings to patient
if root is mobilised during crown removal the entire tooth must be removed
leaving roots behind can result in infection (rare)
can get a slow healing/painful ‘socket’
roots may migrate later and begin to erupt through mucosa
- may require extraction
Facial fractures - how would you carry out an e/o exam?
palpate bony margins of facial skeleton
examine eyes
- double vision
- restriction of movement
- subconjunctival haemorrhage
palpate condyles and check movements
- note any swelling, bruising, lacerations and altered sensation
- damage to trigeminal
evidence of cerebrospinal fluid leaking from nose or ears?
I/O exam - facial fracture
assess for alterations or step in occlusion
fractured or displaced teeth
lacerations and bruises
check stability of maxilla
- bimanual palpation
- one hand attempting to mobilise from intra oral approach
- other hand noticing any movement from extra oral sites
mandible fracture clinical signs
pain and swelling
deranged occlusion
paraesthesia in distribution of IAN
floor of mouth haematoma
zygoma fracture clinical signs
clinical flattening of cheekbone prominence
parasethesia in distribution of infraorbital nerve
diplopia (double vision), restricted eye movements, sub-conjunctival haemorrhage
limited lateral excursions of mandible movements
palpable step in infraorbital bony margin
orbit fracture clinical signs
diplopia
restricted eye movements
subconunjunctival haemorrhage
maxilla fracture clinical signs
maxilla is mobile
deranged occlusion
gross swelling if high level fracture
bilateral circumorbital bruising
subcojunctival haemorrhage
CSF leaking from nose or ear
nasal fracture clinical signs
swelling
bilateral circumorbital bruising
clinical deviation of nasal bridge
nose bleed
mandible fracture radiographic views
OPT
PA mandible
- posteroanterior
zygoma fracture radiographic views
Occipotomental (OM)
Maxillary fracture radiographic views
OM
CT for complicated fractures
nasal fracture radiographic views
occlusal
facial fracture management
close approximation of fragments
immobilisation for around 6 weeks
How does trauma and infection lead to pain?
- trauma and infection lead to the breakdown of membrane phospholipids
- this produces arachidonic acid
- Arachidonic acid can be broken down to form prostaglandins
- prostaglandins sensitise tissues to other inflammatory products resulting in pain
Arachidonic acid produces Leukotrienes when broken down, what does this result in?
- bronchoconstriction
- smooth muscle contraction
Outline the mechanism of action for aspirin
- inhibits cycle-oxygenases COX 1 and COX 2
- thus reduces production of prostaglandins
outline the antipyretic properties of aspirin
- prevents temperature raising effects of interleukin-1
- thus reduces elevated temperature in fever
- does not reduce normal temperature
Outline the anti-inflammatory properties of aspirin
- prostaglandins are vasodilators
- therefore affect capillary permeability
- aspirin reduces redness, swelling and pain at injury site
What are the possible adverse effects of aspirin?
- mucosal aspirin burns
- GIT problems
- hypersensitivity
- overdose
Why can aspirin lead to GIT problems?
prostaglandins PGE and PGI2:
- inhibit gastric acid secretion
- increase blood flow through gastric mucosa
- help production of mucin by cells in stomach lining
- can lead to ulcers and gastro-oesophageal reflux
When is aspirin completely contraindicated?
- under 16s
- patients with previous or active peptic ulceration
- patients with haemophilia
- patients with hypersensitivity to aspirin or other NSAIDs
Give 2 ways in which ibuprofen differs in effect from aspirin
- less effects on platelets
- irritant to gastric mucosa lesser than with aspirin
What is the maximum adult dose for ibuprofen?
2.4g
What is the treatment for ibruprofen overdose?
activated charcoal
Outline the mode of action for paracetamol
- hydroperoxides are generated from metabolism of arachidonic acid by COX, which then exerts a passive feedback stimulating COX activity
- feedback blocked by paracetamol, indirectly inhibiting COX
Where is the main site of action of paracetamol?
the thalamus of the brain
When would you take caution for prescribing paracetamol?
patients with:
- hepatic impairment
- renal impairment
- alcohol dependence
What are the potential side effects of paracetamol?
- rashes
- blood disorders
- liver damage
What are the potential drug interactions of paracetamol?
- anti-coagulants (prolonged used may enhance anticoagulant effects of the coumarins)
- cytotocics
- lipid-regulating drugs
- domperidone
- metoclopramide
What is the maximum daily adult dose for paracetamol?
4g
Outline possible downsides of opiods
- dependence
- tolerance
- constipation
- urinary and bile retention
What are the side effects of opioids?
- nausea
- vomiting
- drowsiness
- respiratory depression and hypotension in larger doses
- dry mouth
- sweating
- bradycardia
- rashes
- palpitations
- hallucinations
- mood changes
- tachycardia
- mood changes
When are opioids completely contraindicated?
- acute respiratory depression
- acute alcoholism
- raised inter cranial pressure/head injury
Which patients should be prescribed opioids with extra caution?
- hypotention
- asthma
- pregnant/breast feeding
- hypothyroidism
Give examples of possible peri-operative extraction complications
- difficult access
- abnormal resistance
- fracture of tooth or root
- fracture of alveolar bone
- jaw fracture
- loss of tooth
- soft tissue damage
- damage to nerves or vessels
- damage to adjacent teeth
- dislocation of TMJ
- wrong tooth
- broken instruments
- haemorrhage
What factors may lead to difficult access?
- trismus
- reduced opening of mouth
- crowded teeth
What factors may lead to abnormal resistance?
- thick cortical bone
- shape of roots e.g. hooked roots
- number of roots e.g. 3 rooted molars
- ankylosis
What factors make a tooth more vulnerable to fracture during extraction?
- caries
- alignment
- size
- root morphology e.g. ankylosis
What are the risk factors for OAC following extraction?
- upper molars or premolars extracted
- close relation to sinus on radiograph
- large, bulbous roots
- previous OAC
- recurrent sinusitis
define paraesthesia
a tingling sensation
define dysaesthesia
an unpleasant sensation/pain
define hypoaesthesia
reduced sensation
define hyperaestheisa
increases or heightened sensation
Give reasons why excessive bleeding can occur during an extraction
- local factors e.g. mucoperiosteal tears
- undiagnosed clotting abnormalities
- liver disease
- medication e.g. warfarin
management of maxillary sinus involvement
inform patient
if small or sinus intact
- encourage clot
- suture margins
- antibiotic
- post op instructions
if large or lining torn
- close with buccal advancement flap
- antibiotic and nose blowing instructions
neuropraxia definition
- contusion of nerves
- continuity of epieneural sheath and axons maintained
axonotmesis definition
- continuity of axons disrupted
- epieneural sheath maintained
neurotmesis definition
- complete loss of nerve continuity
OAC acute management
inform patient
if small or sinus lining intact
- encourage clot
- suture margins
- antibiotic
- post op instructions
if large or lining torn
- close with buccal advancement flap
OAC - post op instructions
avoid blowing nose or sneezing with pinched nostrils as both actions can increase sinus pressure and cause wound breakdown
also avoid
- smoking
- sucking through straws
- blowing up balloons or air mattresses
- playing a wind or brass musical instrument
- snorkeling or scuba diving
also advisable to keep a soft diet and avoid any sharp/hard foods that may interfere with healing wound
chronic OAF - common patient complaints
problems with fluid consumption
- fluids going into nose
problems with speech or singing
- nasally quality
problems playing brass/wind instruments
problems smoking
problems using a straw
bad taste/pus discharge
- post-nasal drip
pain/sinusitis type symptoms
root or tooth in maxillary sinus - management
confirm radiographically
- OPT
- occlusal
- or periapical
- or CBCT
decision on retrieval
- if in doubt or retrieval difficult - refer
root or tooth in maxillary sinus - ways to retrieve
through extraction socket
- open fenestration with care
- suction
- small curettes
- irrigation or ribbon gauze
- close as for OAC
Calwell-Luc approach
- buccal/labial sulcus
- buccal window cut in bone
ENT
- endoscopic retrieval
Sinusitis signs and symptoms
facial pain
pressure
congestion
nasal obstruction
paransal drianage
hyposomia
- reduced ability to smell or detect odors
fever
headache
dental pain
halitosis
fatigue
cough
ear pain
anaesthesia/parasthesia over cheek
Causes of TMD
myofascial pain
- problems with the muscles
disc displacement
- anterior with reduction
- anterior without reduction
degenerative disease
- localised = osteoarthrtis
- generalised = rheumatoid arthrtis
chronic recurrent dislocation
ankylosis
hyperplasia
neoplasia
infection
TMJ myofascial pain aetiology
inflammation of muscles of mastication or TMJ itself
- usually secondary to parafunctional habits
may be a history of trauma, either directly to joint or indirectly e.g. sustained mouth opening during dental treatment
stress
- muscles tense up
TMD special investigations
not usually required
radiographic evaluation if pathology suspected:
- OPT
- CT/CBCT
- MRI
- Ultrasound
- Arthtography
- Transcranial view
- Nuclear imaging
TMD common clinical features
females > males
most common between 18-30
intermittent pain of several months or years
muscle/joint/ear pain, particularly on wakening
trismus/locking
cicking/poppung joint noises
headaches
crepitus indicates less degenerative changes
TMD - differential diagnosis
dental pain
sinusitis
headache
ear pathology
atypical face pain
trigemina neuralgia
salivary gland pathology
referred neck pain
condylar fracture
temporal arteritis
TMD treatment options
patient education
counselling
physical therapy
medications
splints
occlusal adjustment
TMJ surgery
TMD physical therapy options
Physiotherapy
massage/heat
relaxation
acupuncture
TENS (transcutaneous electronic nerve stimulation)
hypnotherapy
advice to give patients with TMD
soft diet
masticate bilaterally
no wide opening
no chewing gum
cut foods into small prices
stop parafunctional habits e.g. nail biting, grinding
support mouth on opening e.g. yawning
What is anterior disc displacement with reduction?
most common cause of TMJ clicking
disc is initially displaced anteriorly during opening until disc reduction occurs
signs/symptoms of anterior disc displacement with reduction
jaw tightness/locking
- jaw movement is impaired for a short period of time until disc reduces
mandible may initially deviate to affected side before returning to midline
may eventually progress to osteoarthritis if left untreated
Disc displacement with reduction - treatment
counselling
limited mouth opening
bite raising appliance
surgery occasionally may be required
no treatment required if painless
- reassurance
trismus from trauma - features
can occur after minor ‘traumatic events’
- IDB
- prolonged dental treatment
- infection
will usually resolve spontaneously
trismus management options - if no resolution after acute phase
physiotherapy
Therabite
jaw screw
What is disc displacement without reduction?
displaced disc remains in a displaced position regardless of the age of opening
disc displacement without reduction - clinical features
reduced mouth opening
no click
pain may be present in front of the ear
TMJ surgery intra and post operative complications
broken instruments
middle ear perforation
glenoid fossa perforation
haemorrhage
haemarhrosis
dysocclusion
perforation of tympanic membrane
malar fracture clinical signs
periorbital bruising and swelling
subconjunctival bruising
sensory deficit in distribution of infraorbital nerve
diplopia
epistaxis
step deformity
facial flatness - flattening of cheekbone prominence
limited mouth opening
Suspected malar/zygoma fracture - how to assess
palpate for irregularities of supraorbital ridge
palpate for irregularities of infraorbital ridge and zygoma
palpate for depression of zygomatic arch
manouvre to ascertain motion in maxilla
zygoma fracture initial care
exclude ocular injury
prophylactic antibiotics
avoid blowing nose
zygoma fracture definitive managemnet
review when swelling subsided
further radiographs +/- CT scans
informed consent
closed reduction +/- fixation
open reduction +internal fixation
describe Le Fort I fracture and common signs
horizontal fracture of the anterior maxilla
can be unilateral or bilateral
signs
- mobility of maxilla
- deranged occlusion
- ecchymosis of maxillary buccal sulcus and palate
- “cracked pot” percussion of teeth
describe Le Fort II fracture and common signs
pyramidal fracture involving nasal bridge, maxilla, lacrimal bones, orbital floor and inferior orbital rim
signs
- mobility of mid face
- gross facial swelling
- racoon eyes
- epistaxis
- deranged occlusion
- subconjunctival haemorrhage
- ecchymosis of maxillary buccal sulcus and palate
- numbness/paraesthesia in V2 region
describe Le fort III fracture and clinical signs
complete separation of mid face from cranium
fracture involves nasal bones, medial, inferior and lateral orbital walls, pterygoid processes and zygomatic arches
common signs
- racoon eyes
- increased facial height
- flattening of facial profile
- mobility of maxilla, nose and zygoma
- anterior open bite
- ecchymosis over mastoid region
Classifications of mandibular fracture
greenstick
- incomplete fracture, frequently seen in children
simple
- separation of bone with no/minimal fragmentation
comminuted
- bone has been fragmented usually in line with high velocity impacts
open
- fracture communicates with the outside environment e.g. mouth
mandible fracture - surgical options
closed reduction
- uses inter-maxillary fixation to immobilise fractured segments to allow for bony healing
open reduction and internal fixation
mandibular fracture - post op
post op imaging
- OPT + PA mandible
soft diet 4-6 weeks
antibiotics
analgesia
CHX mouthwash
education for those in IMF
follow-up in clinic
advice to give patient who has suffered orbit fracture
avoid blowing nose
sleep wit head of bed elevated
cold compress to reduce peri orbital oedema
Chronic OAF - patient complaints
problems with fluid consumption
- fluids from nose
problems with speech or singing
- nasal quality
problems playing brass/wind instruments
problems smoking
problems using straw
halitosis, pus discharge, bad taste
pain/sinusitis type symptoms
Oro-antral fistula - management
excise sinus tract
raise flap
antral washout
suture
Maxillary tuberosity fracture aetiology
single standing molar
extracting in wrong order
inadequate alveolar support
fractured tuberosity diagnosis
noise
movement noted both visually or with supporting fingers
more than one tooth movement
tear in soft tissue of palate
tuberosity fracture mansgemt
reduce and stabilise
- orthodontic buccal arch wire with composite
- arch bar
- lab made splint
dissect out and close wound primarily
Root in antrum - how to retrieve
through extraction socket
- open fenestration with care
- suction
- small curettes
- irrigation
- close as for OAC
OR
Caldwell-Luc approach
- buccal labial sulcus
- buccal window cut in bone
OR
ENT referral
- endoscopic retrieval
sinusitis signs and symptoms
facial pain
pressure
congestion
nasal obstruction
paransal drainage
hyposomia
fever
headache
dental pain
fatigue
cough
ear pain
altered sensation over cheek
sinusitis - common issues to rule out
periapical abscess
periodontal infection
deep caries
recent extraction socket
TMD
neuralgia or atypical facial pain
sinusitis indicators
discomfort on palpation of infraorbital region
a diffuse pain in maxillary teeth
equal sensitivity from percussion of multiple teeth in same region
pain that worsens with head or facial movements
sinusitis treatment options
decongestants to reduce mucosal oedema
humidified air
antibiotics (if symptoms haven’t improved and bacterial sinusitis suspected)
Pen V 2x250mg 4 times a day for 5 days
Doxycycline 2x100mg first day then 100mg for 4 days
where can infection of the upper central incisors teeth spread to?
lip
nasolabial region
lower eyelid
where can upper lateral infection spread to?
palate
- less common
where can infection of the upper premolars and molars spread to?
cheek
infra temporal region
maxillary antrum
- very rare
palate
- less common
infection of the lower anterior teeth can spread to…
the mental and submental space
infection of the lower premolars and molars can spread to…
buccal space
submasseteric space
sublingual space
submandibular space
lateral pharyngeal space
surgical management of infection spread
establish drainage
- extra oral
- intra oral
remove source of infection
antibiotic therapy
bilateral cellulitis of the sublingual and submandibular spaces (Ludwig’s angina) - I/O features
raised tongue
difficulty breathing
difficulty swallowing
drooling
bilateral cellulitis of the sublingual and submandibular spaces (ludwig’s angina) - E/O features
redness and bilateral swelling in submandibular region
Ludwigs angina - systemic features
increased
- heart rate
- respiratory rate
- temperature
- white cell count
normal respiratory rate ranges between
12-20
normal oxygen saturation
> or = 96%
normal body temp
36.1-38
high systolic blood pressure
> 220
normal heart rate
50-90bpm
national early warning score (AVPU)
alert
responds to verbal commands
responds to pain
completely unresponsive
What is Ludwig’s angina
bilateral infection of submandibular space
Ludwig’s angina management in GDP
diagnosis
seek advice
Ludwig’s angina and soi - secondary care management
diagnosis
sepsis 6
National early warning score
What is the sepsis 6?
give high flow oxygen
take blood cultures
give IV antibiotics
give a fluid challenge
measure lactate
measure urine output
should be done in the first hour
Ludwig’s angina - most common bacteria strains responsible
anaerobic gram negative bacilli
- streptococcus angionous
- anaerobic streptococci
What is SIRS ? give the 4 features
Severe inflammatory response syndrome
- temp <36 or 38C
- pulse >90/min
- respiratory rate >20/min
- white cell count <4000/mm3 or >12000/mm3
2 criteria required for SIRS diagnosis
Sepsis is characterised by
SIRS + suspected or confirmed infection
Sepsis - define
life threatening organ dysfunction caused by dysregulated host response to infection
What is a biopsy?
a sample of tissue taken for histopathological analysis
Biopsy - advantages
can confirm or establish a diagnosis
determine prognsoiss
Features of an excisional biopsy
all clinically abnormal tissue removed
usually fairly confident of provisional diagnosis
usually benign lesions
incisional biopsy features
representative tissue sample
larger lesions
uncertain diagnosis
What is a punch biopsy?
type of incisional biopsy
removes core of tissue
minimal damage
may not require suture
How to choose an area for biopsy
choose representative sample
not necessary to include normal tissue margin
try to avoid important structures
Functions of the paranasal sinuses
resonance to the voice
reserve chambers for warming inspired air
reduce weight of the skull
The maxillary sinus opens at…
the semilunar hiatus
flap design options for closing an OAC
buccal advancement flap
buccal fat pad with buccal advancement flap
palatal rotational flap
bone graft/collagen membrane
fractured tuberosity - diagnosis (signs)
noise
movement noted both visually or with supported fingers
more than one tooth movement
tear in tissue of palate
tuberosity fracture management
reduce and stabilise
- orthodontic buccal arch wire with composite
- arch bar
- or lab made splint
or dissect out and close wound primarily
if you splint a tooth following a tuberosity fracture, what must you also do?
remove or treat pulp
ensure tooth is out of occlusion
consider antibiotics
give post op instructions
surgically remove the tooth 4-8 weeks later
What surgical procedure is done to correct maxillary skeletal discrepancies?
Le Fort 1 osteotomy
What surgical procedure is used to correct mandibular skeletal discrepancies?
sagittal split mandibular osteotomy
when it comes to bone grafts their are 4 options - name them
autografts
- graft taken from patient themselves
- e.g. rib
allografts
- bone from other human
xenografts
- from animals
- e.g. Bio-Oss
synthetic
- e.g. tricalcium phosphate
Pre prosthetic surgery soft tissue procedures - give examples
excisional
- frenectomy
- pappilary hyperplasia
- maxillary tuberosity reduction
ridge extension procedures
- vestibuloplasty
outline different TMJ diseases
TMJ dysfunction
jaw dislocation
osteoarthritis
rheumatoid arthritis
chondromatosis
foreign body granuloma
tumour
ankylosis
traumatic damage
radiation damage
infection
TMJ - 2 types of trauma
macrotrauma
- singular large trauma e.g. fracture
microtrauma
- caused by overloading joint over ra prolonged period of time
TMJ surgery post op management
pain management
joint rest
- soft diet
- avoid wide opening
physical therapy
restoration of occlusal stability
TMJ surgical procedures
disc placation
eminectomy
meniscectomy
high condylar shave
condylectomy
reconstructive procedures
indications for TMJ reconstruction
joint destruction
- trauma
- infection
- previous surgery
- radiation
anklysosis
tumours
- giant cell lesions
- firbo-osseous lesions
- myxomas
give at least 6 signs and symptoms of TMD
clicking
popping
crepitus
earache
trismus
headache
tender muscles of mastication
tongue scalloping
attrition
linea alba
which 2 muscles would you palpate in a patient with suspected TMD?
masseter
temporalis
patient attends with facial swelling - give at least 4 features you would need to note concerning swelling
size
colour
site
heat
texture
induration
pus
palpation
duration
airway compromisation
