Oral Surgery Flashcards
most common alloplastic bone graft?
Hydroxyappetite (Granular form or Particulate form)
- When placed subperiosteal, HA bonds mechanically and chemically
- No viable osteogenic cells, thus can’t undergo osteogenesis phase I
- completely biocompatible and nonresorbable
Autograft
- Osseous coagulum = corticol bone + blood
- Bone blend = removed bone that is titrated and mended into a plastic form
- Cancellous BM = From max. tuberosity or edentulous ridges
- Cancellous extra-oral sites = From the iliac crest
Allogenic grafts
- Fresh frozen
- Freeze-dried bone graft (FDB) = osteoconductive *most used
- Demineralized FDB (DFDB) = osteoinductive + BMP *most ideal
Xenograft = bioss
Inject LA when doing a biopsy __ cm away from site
1 cm
Put biopsy in _ % formalin
10% (4% formaldehyde)
Biopsy indications for:
- cytology
- aspiration
- incision
- excision
- mucosal change (herpes, pemphigus, PAP smear)
- lesion with fluids
- > 1 cm AND malignant
4.
Distal wedge
Must have attached keratinized ST in any edentulous space (retromolar, max. tuberosity, or M/D of any last tooth in the arch)
Conditions with multiple supernumerary teeth:
- Cleidocranial Dysplasia
- Gardner’s Syndrome
- Down Syndrome
- Sturge-Weber Syndrome
Referred Pain is due to what?
CN 7,9,10 are distributed in the sub nucleus caudal of CN V.
Max Incisors –> forehead
Max canine, 1 PM –> Nasolabial
Max 2PM –> Temporal
Max Molars –> zygomatic, temporal, occipital
Mand anteriors + PM –> mental region
Mand Molars –> posterior neck, ear, ramus
MMR
Koplick Spot = Rubeola (Measles) = v. contagious = paramyxovirus = buccal mucos
Rubella = german disease = benign virus = soft palate petechiae
Mumps = acute contagious = parositis = parotid gland
small pox
- variola
- acute viral disease
- first appears on face as macules/papules then spreads
- Oral lesions include ulcers, glossitis
childhood vs adult hypothyroidism
Child hypothyroidism = Cretinism = large tongue, class II, anterior open bite Adult hypothyroidism = myxedema (most common is Hashimotos, 2nd most common is tx for hyperthyroidism)
Pituitary tumor in adults and kids
Gigantism = Pituitary tumor in kids
Acromegaly = Pituitary tumor in adults (post epiphysis fusion)
• large tongue = Class III = longer roots
Tonic-clonic (grand mal) seizures
- Prodromal phase = usually not noticed by patient or dentist
- Aura phase = immediately precedes convulsive phase
- Convulsive = unconscious and muscle tonicity = usually 1-3 minutes. Longer than 5 mintues its called status epilepticus = medical ER (Tx: IV Diazepam)
- Post-convulsive Phase = significant CNS depression → RISK resp. depression
Most common dwarfism
Achondroplasia
- short limb dwarf (short legs, arms with normal torso)
- small maxilla
- normal size, but crowded teeth due to limited space
- class III
- most common dwarfism
- saddle-like nose appearance
Pituitary Dwarf
- underdeveloped mandible
- delayed eruption of teeth
- smaller clinical crowns
- opposite of gigantism
Hemangioma
Neuroblastoma
Lymphangioma
Neurofibroma
Hemangioma • Vascular birthmark • female • Lips, tongue, buccal mucosa (capillary type is most common) • No tx needed
Neuroblastoma = abdomen (near adrenal gland) Lymphangioma = neck, axilla Neurofibroma = schwann cells = if multiple think NF Type I or II (von Recklinghausen)
Type I DM
- children
- ketoacidosis
- polyphagia (hunger)
- polyurea (pee)
- polydypsia (thirst)
- weight loss
Lab: > 120mg/dL fasting glucose
Down Syndrome
Low risk for caries, but high risk for periodontal disease
- small, conical roots
- chronic mouth breathing
- Class III
- Hypoplastic face
Most common pathogens that cause of cellulitis
Group A Strept.
S. aureus
ANUG Bub
prevotella intermedia (spirochete)
NOTE: Localized agressive perio in children = A.a = will not have any localized factors to explain the etiology (i.e. plaque)
ESR represents what?
inflammation
- Thus, steroids will not increase ESR rates
Granulomatous inflammation
Type of chronic infection
- TB, leprosy, fungal, syphillus, cat scratch disease
Casseous = TB non-necrotizing = sarcoidosis Non-casseous = Chron's
EBV
Mono-nucleosis spot test = B cells
- Biopsy shows starry night
- X-ray shows moth eaten, poor margins
- Clinical exam shows nodular mass that are hemorrhagic
- burkitt lymphoma / Non-Hodgkin’s lymphoma. Burkitt lymphoma is the first cancer with viral etiology. African Type involves the jaws, non-african type involves the abdomen.
- nasopharyngeal carcinoma
- hairy leukoplakia (opportunistic, non-malignant white patches on tongue, AIDS)
- infectious mononucleosis
Acanthosis
Abnormal increase thickening of prickle cell layer of epithelium (due to smoking)
Define:
- Neoplasm
- Tumor
- Hyperplasia
- Anaplasia
- Hypertropy
- Carcinoma
- Sarcoma
- Hamartoma
- Choristoma
- Teratoma
- Neoplasm = uncontrolled growth of tissue
- Tumor = localized swelling (may or may not be a true neoplasm)
- Hyperplasia = proliferation in the number of cells, that is non-neoplastic
- Anaplasia = undifferentiated cells with various sizes and shapes (pleomorphism)
- Hypertrophy = size of cells
Carcinoma = Epithelium Sarcoma = Mesenchymal = CT (non-epithelium) Hamartoma = Developmental defect as an overgrowth of normal tissue in a normal location Choristoma = Normal tissue in an abnormal location Teratoma = Neoplasm of multiple tissues foreign to the organ, either benign of malignant
Cancer grade versus TNM
Neoplasm Grade = Degree of differentiation 1 Well differentiated 2 Moderately – well 3 Poor 4 Undifferentiated = Anaplasia
TNM = prognosis and degree of spread. But has no record of depth of penetration.
T size
N Regional lymph node involvement
M metastases
Enamel Hypoplasia vs Hypocalcification
Enamel Hypoplasia = normal quality (hard), but limited quantity = incomplete matrix formation = developmental = amelogenesis imperfecta
• Turner Hypoplasia = one permanent tooth affected due to damage/PA radiolucency of the primary tooth it replaced.
• Common in 1M
Enamel Hypocalcification = defective maturation of ameloblasts normal quantity (soft) = hereditary = chalky, dentin color
Quality + Quantity of enamel effected:
- Syphillus
- Sturge-Weber
- Fluorosis
- VIT A,C,D deficiency
TMJ
- Condyles are not identical
- Posterior aspect is round and convex
- Anterior-Inferior part is concave
- Disc is attached by collateral ligaments, which are medial and lateral to the condyles; dense fibrous CT
- Anterior part of the disc are held by lateral pterygoid. Disc displacement occurs when the collateral ligaments are weak/torn and the lateral pterygoids pull them anterior-medial.
- Protruded contact position is symmetrical and the underside of the TMJ meniscus moves distally relative to the superior surface of the mandibular condyle
- Ginglymoathrodial joint = glides and rotates
- Upper compartment = mandibular fossa-articular disc = sliding/translation
- Lower compartment = condyle-articular disc = rotation/hinge
- Click = disc displacement
- Crepitius = degenerative disease (arthritis)
Bone Quality
= density of corticol and trabecular bone
• Type I = mostly cortical bone (Ant. Mandible)
• Type II = thick cortical + dese cancellous
• Type III = thin cortical + dense cancellous
• Type IV = thin cortical + thin cancellous (posterior max)
• Implant failure is higher in maxilla > mand due to max posteriors having Class IV quality
Internal derangement Stages:
- Reciprocal click = rarely associated with severe pain, may occur spontaneously
- Reciprocal click with intermittent locking = locked jaw
- Closed lock
Every 1 C increase in body temp, there is a __ increase in HR
9-10 beats.minute
- Rectally is best
- Auxillary is worst
STAGE I HTN = 140-159 HR: 90-99
Normal values of:
- INR
- PT
- PTT
- Bleeding Time
- Platelet count
- PT = 11-13.5 seconds
- PTT = 25-36 seconds
- Bleeding Time =
CPR
- 4 minute golden time to begin CPR
- Pulse check: 5-10 sec
Adults:
- If no pulse: 2 breaths + 30 compressions (100/min)
- Rescue breaths: 1 breath/5 sec or 10-12 breaths/minute
- 2 inches deep
Pedo:
- Brachial a.
- Rescue breaths: 1 breath/3 sec or 20 breaths/minute
- 1/3 chest depth
Liver may be damaged if too much pressure is used
Revived person will have pupils constrict
Brain damage occurs past 3-5 minutes without O2. Body has 2 minutes of O2 before unconsciousness.
TMJ internal derangement stages
- Reciprocal click = rarely associated with severe pain, may occur spontaneously
- Reciprocal click with intermittent locking = locked jaw
- Closed lock (
Occlusal splint types
- Autoreposition (when no skeletal issues re present, just muscle or joint)
- Anterior reposition (protrudes the mandible, thus receipting the normal condyle relationship)
Which is more prone to complications post mandibular fracture?
Angle of the mandible.
Most common fracture sites of the mandible:
condyle > angle > symphysis > body > rams > coronoid process
Tx:
Wiring jaws shut = inter-maxillary fixation = maxillo-mandibular fixation
Most common facial fracture:
ZMC > nasal > LeFort I > II, III > Zygomatic arch
Stages of fracture healing
- Inflammation: lasts 2-3 weeks
- Soft callous: 2-3 weeks post fracture. New bridge forms, but not seen on x-ray
- Hard callous: 4-8 weeks post fracture. Hard bony bridge filling fracture site.
- Bone remodel: 8-12 weeks post fracture and last for several years
Wound Healing stages:
- Inflammatory = initial lag = 2-5 days
- Hemostasis (platelets, vasoconstriction, thromboplastin)
- Inflammation (vasodilation, phagoctyes) - Proliferative = fibroblast = 5 days to 3 weeks
- Granulation (fibroblasts lay collagen bed, new capillaries)
- Contraction of wound edges
- Epithelialization - Remodel = maturation = 3 weeks to 2 years
- New collagen → increased tensile strength
ZMC fracture includes what 4 anatomical sutures?
- ZF
- ZT
- ZM
- ZS
NOTE: displaced fractures largely depend on the line o fracture, not the direction of muscle fibers
Fracture Types
- Simple = divides the bone in two in a closed fracture (no communication with outside)
- Greenstick: extends only through corticol bone without a complete fracture (incomplete fractures) and are thus closed fractures = most common in kids
- Compound fractures = open fracture = infection is common)
- Multiple fractures = comminuted (may be simple or compound)
Most common in adult = nasal > zygoma > and. > maxilla
Child = frontal and orbital
What anatomical structure prevents complete removal of the maxillary 1M besides the max sinus?
root of the zygoma
- Teeth are EXT using Class II level systems
Most difficult to remove in mandible: disto-angular (opposite of maxilla)
Tx Dry Socket
localized osteitis
- Eugenol is the sedative in dressings
- no curretting!
- no Abx needed
Auto-transplant of teeth
most important success factor: adequate bone
Most common transplant: Mand 1 M
pre-general anesthesia tests
chest x-ray ECG, if over 40 y/o CBC WBC urine analysis
incision to remove:
- wide labial frenum
- mandibular tori
- Z-Y incision
- envelope flap with no vertical slits
NOTE: genial tubercules is the attachment site for the supra-hyoid. If cut, the tongue would be flaccid
EXT deciduous molars in which direction?
palatal (adult is buccal)
EXT are contraindicated in
- uncontrolled diabetics
- hematological disorders
- acute pericornitis
- end stage renal failure (No ASA, acetaminophen, NSAID, morphine, meperidine)
- acute infections (EXCEPT acute apical abscess)
IA nerve branches to what before entering the IA canal
mylohyoid nerve (thus, 1M may not have profound anesthesia in an IA block)
NOTE:
- sublingual gland is superior to the mylohyoid muscle
Major TMJ arteries and nerves
External carotid artery = superficial temporal artery + maxillary artery
Drains at retro-discal tissue
Anterior: Masseteric n. (V3) + posterior deep temporal n. (V3)
Posterior: auriculotemporal n. (V3)
Gland and duct matching
Parotid gland = Stensen duct = acinic
Submandibular gland = Wharton duct =
- submand. duct lay on the sublingual gland
Sublingual gland =Bartholin duct = mixed, but [mucous]
Ebner gland = circumvallate tongue papilla = serous (washes the food away)
LA preservative
allergy to methylparaben (PABA = para aminobenzoic acid was an allergic by product of novocaine, and also decreases effectiveness of the antibiotic sulfonamides)
LA allergies are from antibody-antigen rxn
If allergic to both amides and esters, give diphenhydramine (benadryl) .
Most common ester allergy: tetracaine (also most used)
LA cross the blood-brain barrier.
Procaine and lidocaine do not give the usual CNS excitation first….only depression.
NOTE: LA have a direct action on the myocardium (myocardial depression: lower conduction, contraction) and vasculature (peripheral vasodilation of smooth muscles), but is more resistant to response that the CNS.
Lidocaine is used via IV for V-fib correction in the E.D.
Lidocaine has FDA pregnancy category of B, and is thus safe to use. All others have C.
IA nerve block will affect what fossa for truisms?
infratemporal fossa (medial pterygoid muscle)
Tx: muscle relaxants (benzodiazepine)
paresthesia of the lower lip is most caused by?
EXT of a horizontally impacted mand. 3M
Differential blockade of LA
ORDER:
- pain (b/c normal nerves fire pain faster) = A delta, C fiber
- cold
- warm
- touch
- deep pressure
- motor (A alpha fibers)
nerves regain function in reverse order
Patient is under general anesthesia and a lcryngeospasm happens. What to do?
O2 + succinylcholine (skeletal m. relaxant)
- laryngeal reflex is lost under GA
- the spasm is usually from an adverse effect of ketamine
Shock
Tachy + heart muscle ischemia + mental status change + adrenergic response (anxiety, vomit, diarrhea) + vascular resistance (cool skin)
Stages:
- compensatory = tachy + peripheral resistance
- progressive = metabolic acidosis (compensation is not enough)
- irreversible / refractory = organ failure
max dose of epi in adult
normal adult = 0.2 mg = 200 mg of epi = 11 carpules of 1:100,000
cardiac risk: 0.04 mg = 40 mg = 2 carpules of 1:100,000
Heparin mechanism
high MW heteropolysacharide
- Neutralizes thromboplastin AND increases anti-thrombin III, thereby preventing conversion of fibrinogen to fibrin, and blocking thromboplastin generation
Warfarin stops liver from making 2,7,9,10
ASA = plavix = does no affect coagulation path, only platelets. NOTE: plavix (or Acetaminophen) does not cause stomach ulcers like ASA.
BRONJ
zometa, actonel, boniva, fosamax
- dronate
EtOH addiction is tx with?
Disulfuram / metronidazole
- Inhibits the liver enzyme aldehyde dehydrogenase, resulting in high levels of acetaldehyde when EtOH is consumed. This results in a sick feeling.
most abused drug by healthcare workers
Meperidine (Demerol)
- synthetic opioid
- not used in renal failure (along with morphine, NSAIDS, ASA, Aceto.)
- Not used with MOA inhibitors (Anti-parkinson)
- Increases concentrations of epi, NE, dopamine, serotonin leading to coma/seizures
Opportunistinc sinus infection
mucormycosis
