Oral Surgery Flashcards
what teeth are the straight upper anterior forceps used for
canine to canine
what teeth are the upper universal forceps used for
5-5
what teeth are cowhorns used for
lower 6s
what to tell patients about pain after an extraction
expect it to be sore when LA wears off
will settle over the next few days
normal pain killers should work (paracetamol and ibuprofen)
start painkillers before anaesthetic wears off
keep on top of pain before it starts
regular analgesia for 1-3 days then as required
max dose of ibuprofen
2.4g
max dose of paracetamol
4g
what post op advice do we give to patients to prevent post op bleeding
do not explore socket
do not exercise that day
avoid hot and hard foods
eat on other side of mouth
avoid alcohol that day
what is post op advice about rinsing
do not rinse out for several hours/next day
HSMW 4x/day after eating
rinse gently and do not spit forcefully
what is post op advice about bleeding
damp gauze and bite on for 20-30 mins
contact practice during day or NHS24 during out of hours
what is post op advice about sutures
leave them alone and do not pull at them
they should dissolve themselves
if they come out and the area is not bleeding or painful then leave it alone
what retracts a flap
howarths periosteal elevator or rake retractor
what is used to remove bone
electrical straight handpiece with saline cooled bur
uses of elevators
provide a point of application for forceps
loosen teeth prior to using forceps
extract a tooth without the use of forceps
removal or multiple root stumps
removal of retained roots
removal of apices
what instruments debride sockets
bone file/handpiece
mitchells trimmer or victoria curette
what are the aims of suturing
reposition tissues
cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention
how to achieve haemostasis peri-operatively
LA with vasoconstrictor
artery forceps
diathermy
bone wax
how to achieve haemostasis post-operatively
pressure
LA infiltration
diathermy
WHVP
surgicel
sutures
what are the nerves that can be damaged with removal of third molars
lingual
inferior alveolar
mylohyoid
buccal
what is the process of peri-radicular surgery
anaesthesia
flap design
bone removal
remove apex
clean with ultrasonic
seal with MTA
suture
why would peri-radicular surgery fail
extra root or bifid root
too little apex removed
seal of incorrect shape
lateral perforation problem
displacement of seal
lateral canals
inadequate periodontal support
what do you do if jaw fracture occurs during an extraction
inform patient
take OPT
refer urgently
ensure analgesia
stabilise
if delay then prescribe ABX and splint teeth either side of fracture to prevent movement
how do you diagnose an OAC
bone at trifurcation of roots
radiographic position
bubbling of blood
nose holding test and blow (be careful)
direct vision
good light and suction
blunt probe
risk factors for an OAC
XLA molars and premolars
close relationship of roots to sinus
last standing molars
large, bulbous roots
older patient
previous OAC
recurrent sinusitis
management of an OAC
inform patient
encourage clot and suture
or buccal advancement flap
what is the aetiology of a tuberosity fracture
single standing molar
unerupted wisdom tooth
gemination
extracting in wrong order
inadequate alveolar support
how do you diagnose a tuberosity fracture
noise
movement noted
more than one tooth movement
tear on palate
management of tuberosity fracture
dissect out and close wound or reduce and stabilise
reduction and fixation
remove or treat pulp
ensure occlusion free
antibiotics
post op instructions
remove tooth 8 weeks later (probably surgically)
list the post operative complications that we warn patients of before extractions
pain
bleeding
swelling
bruising
jaw stiffness
dry socket
infection
nerve damage risk
what percentage of extractions and what percentage of lower 8 extractions does a dry socket occur
2-3% all extractions
20-35% of lower 8s
when does a dry socket occur and how long does it take to resolve
3-4 days after XLA
takes 7-14 days to resolve
symptoms of a dry socket
dull aching pain
throbs/radiates to ear
exposed bone is sensitive and source of pain
smell and bad taste
predisposing factors for dry socket
molars
mandible
smokers
female
OCP
vasoconstrictor in LA
infection from tooth
excessive trauma during XLA
excessive mouth rinsing post extraction
family history/previous dry socket
what is the management of dry socket
reassurance
LA
irrigate with warm saline
curettage/debridement
alvogyl
analgesia and HSMW advice
review patient/change packs
do not prescribe ABX
prevention of ORN
scaling/CHX
careful extraction
antibiotics
hyperbaric oxygen
treatment of ORN
irrigation
remove loose sequestra
resection of bone
soft tissue closure
hyperbaric oxygen
what are the risk factors when considering risk category of MRONJ patients
dental treatment
duration of bisphosphonate drug therapy
dental implants
other concurrent medication
previous drug history
drug holidays
what is the prophylaxis given for IE
amoxicillin 3g one hour before procedure
how to diagnose acute apical periodontitis
TTP
non-vital tooth
increased mobility
loss of lamina dura
radiolucency at apex
widening of PDL
cause of traumatic periodontitis
parafunction
treatment of an acute apical abscess
soft tissue incision and drainage
XLA/extirpate
what local factors do you look at when considering the need for ABX
toxicity
airway compromised
dysphagia
trismus
lymphadenitis
location
5 cardinal signs of inflammation
heat
redness
swelling
pain
loss of function
what are the SIRS signs
raised temperature
raised HR
raised respiratory rate
raised white cell count
features of ludwigs angina
raised tongue
difficulty breathing and swallowing
drooling
diffuse redness and swelling bilaterally
increased HR, rep, temp, white cells
therapeutic indications for XLA of 8
infection (caries, pericoronitis, perio, bone infection)
cysts
tumours
external resorption of 7 or 8
what to tell a patient about pericoronitis
the gum around your wisdom tooth is inflamed
this is due to food trapping and inflammation/infection
this is usually self-limiting and we can clean underneath it to help it
signs and symptoms of pericoronitis
pain
swelling
bad taste
pus discharge
occlusal trauma to operculum
ulceration of operculum
evidence of cheek biting
foetor oris
limited mouth opening
dysphagia
pyrexia
malaise
lymphadenopathy
treatment of pericoronitis
incision if required
IDB ?
irrigate with saline/CHX
scale under operculum
extract upper 8
analgesia advice
keep fluid levels up
ABX if systemically unwell
predisposing factors to pericoronitis
partial eruption and vertical/distoangular impaction
opposing 8 causing trauma
upper respiratory tract infections
poor OH
insufficient space between ascending ramus and distal aspect of M2M
white race
full dentition
what questions are important to ask the patient if they present with pericoronitis
how long
how many episodes
how often
severity
requirement for ABX
what is important to look at intra-orally in patients with pericoronitis
state of dentition
M2M
eruption status of M3M
occlusion
OH
caries
perio
what do you look at radiographically with M3Ms
disease presence
anatomy of tooth
depth of impaction
orientation of impaction
working distance
follicular width
perio status
IAN canal
what are the 3 signs which have been associated with significantly increased risk of nerve injury during third molar surgery
diversion of inferior dental canal
darkening of the root where crossed by canal
interruption of white lines of canal
radiographic signs of close proximity of third molar to IAN canal
interruption of white lines
darkening of root where crossed by canal
diversion/deflection of IAN canal
deflection of root
narrowing of IAN canal
narrowing of root
dark and bifid root
juxta apical area
how do you tell the angulation of a wisdom tooth on a radiograph
follow the curve of spee and draw an imaginary line through long axis of molar
how would you explain the procedure of wisdom tooth removal to a patient
we will numb you with an injection
may involve raising a flap of gum and a bit of drilling to remove some bone so we can get better access to the tooth
the tooth might come out in more than 1 part
we may have to place some stitches at the end but these will dissolve
what risk is specific to lower 8 surgery
numbness or tingling of lower lip, chin, tongue and altered taste which can be permanent or temporary
instruments used to reflect a flap
mitchells trimmer
howarths periosteal elevator
ash periosteal elevator
curved warwick james elevator
what do you use to retract a flap
howarths periosteal elevator
rake retractor
minnesota retractor
aim of a coronectomy
reduce risk of IAN damage
where do you cut the crown for a coronectomy
3-4mm below enamel of crown into dentine
what do you warn the patient of before a coronectomy
if root is mobilised during crown removal the entire tooth must be removed
leaving roots behind could result in infection
can get a slow healing/painful socket
roots may migrate later and begin to erupt through mucosa and require extraction
how would you explain the structure of the TMJ to a patient in relation to a clicking jaw and pain
the head of your jaw bone sits inside a cavity in your skull (show with hands)
between these 2 bones lies a disc
clicking in your jaw is a result of the disc not moving in time with the bone sliding forwards and backwards when opening and closing
the disc does not have a nerve supply so you cannot feel pain on this part but the area behind this is supplied with a nerve and can get crushed between the two bones which causes the pain
what are the causes of TMD on an anatomical level
myofascial pain
disc displacement (with/without reduction)
degenerative disease
chronic recurrent dislocation
ankylosis
hyperplasia
neoplasia
infection
what is the pathogenesis of TMD
inflammation of muscles of mastication or TMJ secondary to parafunctional habits
trauma
stress
psychogenic
occlusal abnormalities
what do you look for extraorally with TMD
MoM
TMJ clicks and crepitus
jaw movements
facial asymmetry
what do you look for intraorally with TMD
interincisal mouth opening
signs of parafunction (cheek biting/linea alba/tongue scalloping/NCTSL)
what is included in the differential diagnosis of 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 treatment options for TMD
patient education (counselling, avoid chewy foods, jaw exercises)
medication - NSAIDs, muscle relaxants, tricyclic antidepressants, botox, steroids
physical therapy (physio, massage, TENS)
splints
what counselling advice do you give patients with TMD
reassure them
soft diet
masticate bilaterally
no wide opening
no chewing gum
dont incise food
cut food into small pieces
stop parafunctional habits
support mouth on opening
what splints can be used for TMD
bite raising appliances
anterior repositioning splint
what is the irreversible treatment option for people with TMD
TMJ surgeries (arthroscopy, disc-repositioning surgery, disc repair/removal)
treatment for anterior disc displacement with reduction
counselling
limit mouth opening
bite raising appliance
occasionally surgery
what do patients complain of with a chronic OAC
problems with fluid consumption
problems with speech or singing
problems playing wind/brass instruments
problems smoking/using straw
bad taste/odour/halitosis
pain/sinusitis symptoms
signs and symptoms of sinusitis
facial pain
pressure
congestion
nasal obstruction
paranasal drainage
hyposmia
fever
headache
dental pain
halitosis
fatigue
cough
ear pain
what would indicate sinusitis over a dental cause when examining a patient
discomfort on palpation of infraorbital region
diffuse pain in maxillary teeth
equal sensitivity from percussion of multiple teeth in same region
pain that worsens with head or facial movements
first line treatment of sinusitis
steam inhalation
first line antibiotic for bacterial sinusitis
phenoxymethylpenicillin 250mg
2 tablets four times a day for 5 days
what are the various tissue sampling techniques
aspiration
fine needle aspiration biopsy
excisional biopsy
incisional biopsy
punch biopsy
when would you use an aspiration technique to obtain a sample and what are the advantages of this
to get a blood sample from an abscess or to get cells from solid lesions (cysts)
it avoids contamination by oral commensals and protects anaerobic species
gives you an idea of what type of cyst is present and whether a lesion is solid or fluid filled
when are excisional biopsies undertaken
for benign lesions only (polyps/hyperplasia)
when are incisional biopsies undertaken
larger lesions of uncertain diagnosis
so the surgeon can go in later and know where to remove more from
how do you send a biopsy sample to pathology
place in 10% formalin in pathology pot
suture to orientate sample can be helpful
complete pathology form and do diagram
then sent by courier to QEUH
what type of paper can be used to put a sample on before going into the pathology pot and what can you absolutely not put it on
can put on filter paper
do not put on gauze as this distorts the sample
what is included on the pathology form
patient details
contact number
tick histopathology/cytology
date and time of collection of sample
provisional diagnosis/clinical details
nature of specimen
what is a fibrous epulis and what does it look like
swelling arising from gingivae
hyperplastic response to irritation
smooth surface, rounded swelling
pink and pedunculated
treatment for fibrous epulis
excisional biopsy and dressing
remove source of irritation
what is a fibrous overgrowth and what does it look like
fibroepithelial polyp
frictional irritation or trauma caused it
semi-pedunculated or sessile
pink and smooth surface
treatment for fibrous overgrowth
excisional biopsy
what is the difference between a fibrous epulis and a fibroepithelial polyp
an epulis is attached to the gingiva
a polyp is attached to the mucosa
what is a giant cell epulis and what does it look like
peripheral giant cell granuloma
multi-nucleated giant cells in a vascular stroma
deep rep/purple/broad base
treatment of a giant cell epulis
surgical excision with curettage
dressing
what is a haemangioma and what does it look like
haematoma
developmental overgrowth
exophytic
blue in colour
pressure will cause loss of colour
treatment of haemangioma
surgical removal or more commonly cryotherapy
what is a lipoma and what does it look like
benign neoplasm of fat
soft swelling
pale yellow
sessile
what is a pyogenic granuloma
failure of normal healing
overgrowth of granulation tissue
red in colour
treatment of pyogenic granuloma
surgical excision and curettage of base
what is the difference between a pyogenic granuloma and a pregnancy epulis
same thing histologically
pregnancy epulis arises during pregnancy due to hormonal changes affecting responses to irritation, these can regress after birth of baby
pyogenic granuloma is unrelated to pregnancy
what is a squamous cell papilloma and what does it look like
benign neoplasm
pedunculated
white surface
cauliflower appearance
what is a mucocele
mucous extravasation cyst
damage to minor salivary gland causing saliva to leak into the submucosal layer and forming a soft bluish swelling which is fluid filled
treatment of a mucocele
surgical excision (moon shaped and vertical)
warn about recurrence
what can a squamous cell carcinoma look like
lump
red or white patch
non-healing ulcer
ulcer with rolled margins and induration
what is the criteria for urgently referring for cancer
- persistent unexplained head and neck lumps for >3 weeks
- unexplained ulceration/swelling/induration of oral mucosa > 3 weeks
- unexplained red or mixed red and what patches > 3 weeks
- persistent hoarseness > 3 weeks
- persistent pain in throat or pain on swallowing > 3 weeks
presenting signs and symptoms of oral cancer
pain on eating
difficulty swallowing
unilateral earache
trismus
dysarthria
sensory loss
unexplained loosening of teeth
submucosal mass lesion
verrucous lesions
hemi-tongue atrophy
fracture of mandible
nasal obstruction/blood stained
coughing blood
unexplained weight loss
clinical signs and symptoms of a mandible fracture
pain, swelling, limitation of function
occlusal derangement
numbness of lower lip
loose or mobile teeth
bleeding
AOB
facial asymmetry
deviation of mandible to opposite side
sublingual haematoma
2 point vertical mobility
abnormal sensation contralateral to side of injury
pain contralateral to side of injury
if a patient comes to you with a mandible fracture what do you do
fast
analgesia advice
antibiotics for open fractures
liquid diet
immediate discussion with OMFS team
what is a simple mandible fracture
bone only involved
what is a compound mandible fracture
bone and skin involved
what is a comminuted mandible fracture
bone and skin involved but very messily
what factors influence whether a mandible fracture would be displaced
direction of fracture line
opposing occlusion
magnitude of force
mechanism of injury
intact soft tissue
other associated fractures
what radiographs do you need for a mandible fracture
OPT and PA mandible or CBCT
what is the treatment of mandible fractures once the patient is in hospital
control of pain and infection
reduction and fixation
if undisplaced then no treatment
if displaced then ORIF or closed reduction and fixation
what are the signs of a midface fracture
epistaxis without blow to nose
V2 numbness without blow to nose
subconjunctival bleed
midface mobility
malocclusion
surgical emphysema around eye
swelling after nose blowing
diplopia
change of appearance
CSF coming from nose
signs of cranio-orbital trauma
dents
numbness of scalp
diplopia
scars/wounds overlying
NOE fractures
CSF leak
what to do if a patient comes in with zygoma fracture
call OMFS
no nose blowing for 6 weeks
soft diet
give warning about retrobulbar bleed
clinical signs of a zygoma fracture
periorbital bruising and swelling
subconjunctival ecchymoses
sensory deficit
diplopia/visual impairment
subcutaneous emphysema
epistaxis
step deformity
definitive management of a zygoma fracture
closed reduction and fixation
or ORIF
characteristic signs of cysts
tooth mobility
numbness
increasing in size
discolouration
cause loss of vitality of teeth
swelling
absence of tooth
egg shell crackling sound when pressing on area
what type of cyst is a radicular cyst
inflammatory odontogenic
presentation of radicular cyst
asymptomatic but may become infected
well-defined round radiolucency with corticated margins continuous with lamina dura of non-vital tooth
histology of a radicular cyst
epithelial lining
connective tissue capsule
inflammation in capsule
mucous metaplasia, cholesterole clefts, rushton bodies
what type of cyst is a dentigerous cyst
developmental odontogenic cyst
presentation of a dentigerous cyst
unerupted teeth
corticated margins attached to ACJ of tooth
may displace tooth involved
variable displacement of cortical bone
histology of dentigerous cyst
thin non-keratinised stratified squamous epithelium
what type of cyst is an OKC
developmental odontogenic cyst
features of an OKC
scalloped margins
can be multi or unilocular
cause displacement of adjacent teeth
grows along the bone
mandible more often
histology of an OKC
epithelial lining with parakaeratosis
palisading cells (solider like)
daughter cysts
no rete pegs so it is friable
what syndrome can be associated with multiple OKCs
basal cell naevus syndrome
what type of cyst is a nasopalatine duct cyst
developmental non-odontogenic cyst
presentation of a nasopalatine duct cyst
asymptomatic
anterior maxilla
salty discharge sometimes
displace teeth or cause palatal swelling
involves midline
corticated radiolucency over roots of central incisors, often unilocular
histology of nasopalatine duct cyst
variable epithelial lining
non-keratinised stratified squamous and modified respiratory epithelium
what type of cyst is a solitary bone cyst
non-odontogenic cyst without epithelial lining
presentation of a solitary bone cyst
asymptomatic
resolves on its own
premolar/molar mandible
may be scalloped and may project between roots of adjacent teeth
where does a stafne cavity occur
mandible lingual area in angle or posterior body
what kind of fluid aspirate would come from inflammatory or developmental cysts
clear straw coloured
what kind of fluid aspirate would come from an OKC
cream semi-solid
surgical options for treatment of cysts
enucleation
marsupialisation
how to explain enucleation to a patient and what the advantages and disadvantages of it are
remove the whole cystic lesion
means that we can examine the whole thing
not much aftercare needed and it is closed with stitches
risk of a jaw bone fracture if the cyst is very large and if the whole cyst is not removed it can lead to recurrence
can be damaging to adjacent teeth, nerves and bone structures
how to explain marsupialisation to a patient and what the advantages and disadvantages of it are
make a small window into the wall of the cyst and remove the contents of the cyst
we then stitch the wall of the cyst to the surrounding healthy tissue but keep the window open in the hopes that this encourages the cyst to decrease in size. This may be followed up by complete removal at a later date
can help spare teeth, bones and nerves
means that the whole lining is not available to examine and that the opening that we made might close and the cyst can reform
it is hard to clean and needs lots of aftercare
what type of tumour is an ameloblastoma
benign epithelial tumour
presentation of an ameloblastoma
usually mandible
multicystic or unicystic
well-defined corticated and scalloped margins
can have soap bubble appearance
displaces adjacent structures, thins bony cortices and causes knife edge external root resorption
histology of ameloblastoma
islands present within fibrous tissue backgrounds
islands are bordered by cells resembling ameloblasts
tissue in middle of follicles in loose tissue
cystic change within follicles
why is there a high recurrence rate of ameloblastomas
there is no connective tissue capsule meaning that cells can grow and infiltrate into the jaw
how do you manage an ameloblastoma
surgically resection it with a margin
what type of tumour is an adenomatoid odontogenic tumour
benign epithelial
presentation of adenomatoid odontogenic tumours
unilocular radiolucency with internal calcifications around crown of unerupted maxillary canine
internal calcifications/radiopacities
presentation of a calcifying epithelial odontogenic tumour
posterior mandible
slow growing
internal radiopacities
internal septa
unilocular/multilocular
presentation of odontogenic myxoma
mandible
well defined radiolucency with thin corticated margin
soap bubble appearance/tennis racket pattern
slow growth along bone before bucco-lingual expansion
scallops between teeth
why would teeth fracture during an extraction
thick cortical bone
root shape
root number
ankylosis
caries
previous RCT
alignment
when do you not remove a retained root
preserve bone height
near vital anatomical structures
present for number of years with absence of PA pathology
give patient the option
can be left alone and monitored to ensure caries free/no PA
what are the landmarks for an IDB
coronoid notch of mandibular ramus
posterior border of mandible
pterygomandibular raphe
lower premolar teeth of opposite side
what are the common LA solutions
2% lidocaine 1:80,000 adrenaline
2% lidocaine plain
3% prilocaine with felypressin
4% articaine 1:100,000 adrenaline
3% mepivicaine plain
features of lidocaine
rapid onset
half life of 1.5-2 hrs
effects of adrenaline in anaesthetic
vasoconstricts arteries
reduces bleeding
delays resorption of lidocaine
doubles duration of anaesthesia
contraindications to lidocaine
heart block and no pace maker
allergy to LA
hypotension
impaired liver function
features of articaine
half life of 20 mins
contraindications of articaine
sickle cell patients
other haemoglobinopathies
max safe dose of lidocaine
4.4mg/kg
max safe dose of prilocaine
6mg/kg
max safe dose of articaine
7mg/kg
max safe dose of mepivicaine
4.4mg/kg
how many mg of lidocaine in a 2.2ml solution
44
how many mg of prilocaine in a 2.2ml solution
66
how many mg of articaine in a 2.2ml solution
88
what are the systemic complications of LA
psychogenic stress
interaction with other drugs
cross infection
allergy
collapse
toxicity
how do you manage psychogenic stress after LA
lay flat and raise legs
loosen neck clothing
ventilate room
glucose in sweet drink
what are the local complications of LA
failure to achieve anaesthesia
prolonged anaesthesia
pain
trismus
haematoma
intra-vascular injection
blanching
facial paresis
broken needle
infection
soft tissue damage
contamination
what causes trismus after giving LA
damage to medial pterygoid
injection too low/forceful/rapid
how to manage trismus after LA
reassurance
muscle relaxant
anti-inflammatory
presentation of facial palsy after LA
cannot use any muscles on that side of the face at all
complete unilateral motor nerve paralysis within minutes of inferior dental blocks
cause of facial palsy after LA
local injected into parotid gland too far posteriorly
