Oral Surgery Flashcards
Mandibular Fractures from least common to most
Coronoid process 1% Ramus 2% Alveolar Process 3% Body 16% Symphysis 22% Angle 24% Condyle 29%
Impacted tooth
one that fails to erupt in the expected window of time
unerupted tooth
impacted teeth, and those in the process of erupting
Impacted third molar difficulty based on angulation impaction from easiest to most difficult
Mesioangular (easiest)
Horizontal
Vertical
Distoangular (hardest)
3rd molar impaction classifications
1, 2, 3, A, B, C
1 = completely outside of the ramus 2 = less than 1/2 in the ramus 3 = more than 1/2 in ramus A = at occlusal plane B = above CEJ, below occlusal plane C = below CEJ
Treatment for torn flap
repair the tear
treatment for puncture wound
leave the puncture open
ORIF
open reduction internal fixation
lay a flap, position fracture, and screw into place
used for fractures that are mobile and teeth are repositioned
CR-MMF
closed reduction maxillo-mandibular fixation
Le fort 1 fracture
horizontal fracture of the maxilla at the level of nasal fossa
le fort 2 fracture
pyramidal fracture of the maxilla, including nasal bones and the medial orbit
le fort 3 fracture
fracture through the maxilla, zygoma, nasal bones, orbit, ethmoid, base of skull
what is apertognathia
anterior open bite
macrogenia
large chin
how is trigeminal neuralgia treated
anticonvulsant drugs and microvascular decompression
how is odontalgia treated
endo or EXT
how is post herpetic neuralgia treated
anticonvulsants and antidepressants
features of tension headaches
squeezing
non-throbbing
mild-moderate severity
features of cluster headaches
associated with agitation
episodic, localized, retro-orbital pain, ipsilateral lacrimation and ptosis
features of temporal arteritis
squeezing refractory pain, jaw caludication, visual disturbance
C-reactive proteins
high ESR (erythrocyte sedimentation rate)
Arterial Dissection features
neck pain +- cerebral ischemia
encephalitis/meningitis features
diffused generalized headache
confusion
fever
nuchal rigidity (can flex neck)
Cerebral hemorrhages features
abrubt severe headache
focal persistant neurological deficit
+- nausea and vomiting
Subarachnoid hemorraghes features
sudden explosive headache
nuchal rigidity
+- focal neurological deficit
+- nausea and vomiting
post herpetic neuralgia features
severe localized burning pain that conforms to dermatomal pattern
rash or skin discoloration
reversible cerebral vasoconstriction features
mostly in females
history of migranes, pregnancy, or vasoactive drugs
sudden onset, severe and recurrent headaches
nausea, vomiting, photophobia, confusion, visual blurring
exacerbated by valsalva
Inoculation phase of odontogenic infection
first 3 days of symptoms
soft, mildly tender, doughy swelling
Cellulitis phase of odontogenic infectino
after 3-5 days
swelling becomes hard, red, indurated, and acutely tender
Abscess stage of odontogenic infection
after 5-7 days
anaerobes dominante
liquefied abscess in the center of the swollen area
Resolution stage of odontogenic infection
abscess drains spontaneously or surgically drained though the skin or mucosa
immune system takes over, healing begins
Treatment principles for odontogenic infection
- determine severity of infection
- Evaluate the patients defense mechanism
- Should I refer?
- Surgical Treatment (drain and remove cause)
- support the patient medically
- Choose appropriate antibiotic
- Post operative evaluation and assessment
drain in the inoculation stage? cellulitis stage? abscess stage?
inoculation typically not
can’t usually in cellulitis stage
always in abscess stage
Which portion of the TMJ tissues are most highly vascularized and innervated
retrodiscal tissues
What types of bacteria are commonly involved in odontogenic infectinos
aerobic gram positive cocci
anaerobic gram positive cocci
anaerobic gram negative rods
What is the predominant group of aerobic bacteria involved in odontogenic infections
Strep Viridans
S. anginosus
S. Intermedius
S. constellatus
What is the predominant group of anaerobic gram positive cocci found in odontogenic infections (65%)
Streptococcus and Peptostreptococcus
What is the predominant group of anaerobic gram negative rods found in odontogenic infections (75%)
Prevotella
Porphyromonas
Fusobacterium
What is the first thing you do before you treat any infection
collect a sample of the specimen by inserting a large needle (18 gauge) into the infection.
(if it’s full of blood don’t continue)
place sample on aerobic and anaerobic culturettes and request a gram stain, aerobic and anaerobic cultures, and antibiotic sensitivity testing
What are the indications for antibiotic use when treating infectinos
- swelling beyond the alveolar process and deep into fascial spaces
- cellulitis
- trismus
- lymphadenopathy
- Temperature >101
- Severe pericornitis
- Osteomyelitis
What antibiotics are useful for odontogenic infectinos
penicillin amoxicillin clindamycin azithromycin metronidazole
what is different about metronidazole than the other antibiotics typically used in treating odontogenic infections
metronidazole is only for abligate anaerobes
what is the typical amount of time between treatment of an odontogenic infection and follow up appointments
2-3 days
Define the sublingual space vs. submandibular space
sublingual space is superior to the mylohyoid muscle and inferior to the epithelium of the floor of the mouth
submandibular space is inferior to the mylohyoid muscle and superior to the platysma
What is osteomyelitis
inflammation of the medullary part of the bone
is osteomyelitis more common in the mandible than the maxilla
yes, due to relative differences in blood supply
how is osteomyelitis treated
antibiotics or surgery (debridement or resection)
What are bisphosphonates used to treat
IV: multiple myeloma pagets disease and metastatic diseases Oral: used to treat osteoporosis
how do bisphosphonates work
they inhibit osteoclastic activity = decreased bone resorption
how is MRONJ diagnosed
non-healing bony exposure in jaws for at least 8 weeks with current or former bisphosphonate use
without history of radiation to the jaw
before beginning bisphosphonate use, what should a dentist tdo for their patients
plan any procedures involving bone prior to them beginning therapy
EXT, tori removal, alveoplasty
What is stage 1 MRONJ and how is it treated
exposed and necrotic bone or fistula that probes to bone. no evidence of infection
antibacterial mouth rinse, 3 month follow up, pt education
what is stage 2 MRONJ and how is it treated
exposed and necrotic bone or fistula that probes to bone. with signs of infection (pain, redness, pus)
Systemic treatment with oral antibiotics, antibacterial mouth rinse, pain control, debridement
What is stage 3 MRONJ and how is it treated
exposed and necrotic bone or fistula that probes to bone. with signs of infection (pain, redness, pus) with one of the following: exposed bone beyond alveolus, pathologic fracture, extra-oral fistula, oral/antral/nasal communication
antibiotic therapy, pain control, antibiotic mouth rinse, surgical debridement/ressection
What is a cytology biospy and how is it done
a cytology brush is rotated on the lesion 5-10 times to obtain cells from all 3 epithelial layers. the cells are transferred to a slide and fixed.
results are negative/positive/atypical
more biopsy for positive/atypical
When are incisional biospies performed
lesions: > than 1 cm polymorphic suspicous for malignancy anatomical area with high morbitiy
when are excisional biopsies performed
lesions: < 1 cm vascular lesions pigmented lesions remove lesions and uninvolved tissues
hard tissue biopsy steps
- aspirate (vascular consider arteriogram)
- FTMPF over sound bone
- avoid neurovascular structures
- 1mm of osseous tissue around lesion curetted
fissural cyst vs. odontogenic cyst
fissural - derived from epithelial remnants trapped along fusion lines
odontogenic cysts - form from tooth development tissues
Cyst treatment options
enucleation - removal of the mass, or structure
marsupialization - opening the cyst and suturing it open
Enucleation and currettage - enucleate and curette the wall of the cavity
What are the most common malignancies in the mouth
epidermoid carcinomas (squamous cell)
What is critical length in local anesthesia
three nodes of ranvier need to be blocked to achieve complete anesthesia
What is the order in which sensations dissapear and reappear with local anesthesia
pain
temperature
touch
pressure
what does increased blood supply to an area do to local anesthetic
decreases the duration of action
why does marcaine (bupivicaine) have a long duration of action
it has high protein binding characteristics
what affects an anesthetics duration of action
lipid solubility, protein binding
what is the effect of pKa on local anesthetics
lower pKa (closes to physiologic ph 7.4) means faster onset
what are the signs of mild to moderate toxicity to LA
talkative
apprehension
excitability
slurred speech
dizziness
disorientation
what are the signs of severe LA toxicity
seizures
coma
respiratory depression
death
before 1985 what were most allergies to LA from
methylparaben (preservative)
what is the metabisulfite in LA for
antioxidant present with vasoconstrictors
what anesthetic is likely to cause methemoglobemia
prilocaine >600 mg for 70 kg adult
second is septocaine
what is the most potent local anesthetic
bupivicaine (marcaine)
what are the least potent local anesthetics
Prilocaine and Septocaine
Septocaine 4% (articaine)
ester and amide combo
Metabolized in blood and liver
pKa = 7.7
MRD = 7 mg/kg
Bupivicaine .5% marcaine
amide
metabolized in the liver
pka = 8.1
MRD = 90 total
Lidocaine 2% (Xylocaine)
amide
metabolized by liver
pka = 7.7
MRD = 7mg/kg and 500 total
Mepivicaine 3% carbocaine
amide
metabolized by liver
pka = 7.6
MRD = 6.6 mg/kg and 400 total
Prilocaine 4%
amide
metabolized by the liver
pka = 7.8
MRD = 8mg/kg and 600 total
what percentage of broken needles are 30 guage
97%
