Oral surgery Flashcards
What are the criteria for a dento-alveolar surgery flap?
must be full thickness
base must be wider than incision site
must not split interdental papilla
avoid important structures
What do you use to remove bone and why?
Must use an electric drill rather than air turbine as air turbine driven instruments can force air into the cavity and cause a surgical emphysema
the drill is cooled with sterile water to reduce heat (>55* will kill bone) and reduce infection, increase visibility
What is the difference between Asepsis, antisepsis sterilisation and disinfection?
asepsis - avoidance of pathogenic material - aseptic technique in surgery
antisepsis - application of agent which inhibits growth of microorganisms when in contact with them
sterilisation - destruction or removal of all forms of life
disinfection - inhibition or destruction of all pathogens
What types of extraction forceps are used?
upper anteriors - straight and narrow upper molars - 90* angle beak to cheek lower anteriors - 90* angle and narrow lower molars - 90* angle and two beaks cowhorns - for removal of teeth with splayed roots - penetrate bifurcation
What are elevators used for?
Elevators dilate the sockets. Always used to remove impacted teeth.
Couplands, Cryers, Warick james
What periosteal elevators are used?
These pull back the periosteum from the bone, they are blunt, curved instruments
Howarths periosteal elevator
What is the mitchells trimmer for?
this is a curette. this is used for finding a weak spot of bone overlying pathology to be removed
What are dissecting forceps for?
They hold soft tissue without damamging it, Gillies dissectors.
What order should you extract molar teeth (if all are going) and why?
Extract from the most posterior to the most anterior.
Prevents a single standing tooth left in a weakened bone - reduces chance of alveolar or tuberosity fracture
What are the techniques for removing teeth?
1/2/3 - conical roots, twist
4/5 - 2 roots - move buccal-palatally
6/7 - move buccally
What are common complications of extracting teeth?
Access - infection, small mouth, malpositioned teeth
pain - LA, infection
inability to mobilise tooth - ankylosed tooth, bulbous or diverging roots, long roots
breaking the tooth - can leave <3mm of a deeply buried apex, remove what you can
#alveolar +/- basal bone - if # restricted to alveolus, remove anything not attached and close. if other teeth are involved - splint for 4 weeks
basal bone needs ORIF
loss of tooth - STOP. try to locate, determine if pt has swallowed. if breathing changes or cannot find it - Xray
damage to other tissues - apologise to patient
dislocated jaw - relocate and provide instructions. dont continue with XLA
what different types of post-op bleeding are there?
immediate (at surgery no haemostasis achieved)
reactionary ( within 48 hours - rise in BP)
secondary (~7 days post op. infection and destruction of clot)
If a patient comes in to your surgery the day after an Xn with bleeding, how would you deal with them?
Reassure the patient that it is ok and they wont bleed to death
repeat a full Hx inc DH. Get pt to bite on gauze
suction socket, clean pt
identify source of bleeding - if coming from socket then squeeze the gingivaea of outer walls with finger and thumb. if stops, was gingival. if from bone vessels, needs packing
can use bone wax, fibrin foam, sutures, collagen sponge,
recall the next day
What suture would you use for an extraction socket?
Resorbable suture, monofilament, 18mm curved tapered needle
simple interrupted suture
knot is tied twice one way and once the other (two surgeons knot, one locking knot)
What is MRONJ and what can cause it?
medication related osteonecrosis of the jaw - non healing socket or wound >8 weeks, bone seen, halitosis
caused by monoclonal antibody medications, RANK-L inhibitors, bisphosphonates and anti-angiogenics (VEG-F inhibiotors)
What would you be looking for in someones history to see if they would be at riskof MRONJ?
A history of metastatic breast or bone cancer
osteoporosis, Pagets disease
What increases a patients risk of MRONJ?
Hx of MRONJ
If they on AR or AA drugs for management of cancer
on BPs for >5 years
on denosumab in last 9 months + systemic glucocortioid or <5years BPs + systemic glucocorticoid
How does your treatment change for a high risk patient vs a low risk patient
low risk - simple extractions, dont Px ABs
High risk - explore all other possibilities to retain teeth (RR)
for both groups, review healing
How do you raise a flap to remove: maxillary canines, palatally impacted?
Radiographs to assess position
palatal flap - incision 6-6, full thckness of mucoperiosteum and reflect back.
do not cut at 90* to mucosal crevice as can cut the palatine artery. always use envelope flap.
remove bone over bulbosity of crown
How do you raise a flap to remove: Impacted 8s
Cut down around 7 and half of 6, vertical relieving incision down into buccal mucosa
must be full thickness flap and make sure base is thicker than top.
distal reliving incision back from the 8 along the external oblique ridge
dont go lingually as risk of hitting lingual nerve
What are indications for removal of 8s?
recurrent pericoronitis unrestorable caries in 8 external or internal resorption (caused by 8 or in) cystic change periodontal disease distal of 7
When would you perform a coronectomy on an 8?
increased risk of nerve damage (proximity to nerve canal, narrowing or diversion of canal, darkening of root/interruption of tram lines, interuption of lamina dura, juxta-apical area)
What are the contraindications for a coronectomy?
predisposition to local infection (medically compromised)
mobile teeth
non-vital lower 8
horizontal or distoangular impaction where sectioning crown puts the nerve at risk
if root becomes mobile in surgery it must be removed
if there is caries in the 8
How do you perform an apicectomy?
raise a 2 or 3 sided flap reflect and retract above apex detect bony bulge over apex create bony window to visualise the apex excise apical 2mm and remove granulation tissue cut root at 90 degrees to long axis (reduces dentinal tubules exposed) seal canal with MTA close up - interrupted mattress sutures
What surgical options are there for impacted canines?
- removal
- surgical exposure and ortho alignment (attaching a bracket and gold chain to re-position)
- auto transplantation
How would you distinguish a tooth with an apical abscess?
teeth with apical abscesses are TTP, non vital, discoloured, Hx of trauma or RCT. Radiograph shows well demarcated PA radiolucency with widening of the lamina dura
how would you distinguish dry socket?
pain 2-4 days post extraction
worse than preceeding toothache
exposed bone is visible - no clot in socket
socket looks inflamed
How do you treat dry socket?
warm LA in socket so you can clean
Alvogyl in socket
CHX mw or hot salty MW, NSAIDs
What is actinomycosis and how do you treat it?
low grade infection of the bone, multiple sinuses. doesnt follow path of least resistance
6 weeks amoxicilln 500mg tds
What is ludwigs andgina?
Medical emergency
abscess and cellulitits spreading throught he submandibular space and sublingual space
patient might complain of tongue being pushed up or problems swallowing
soft tissues of FOM and neck are hard, airway is at risk
When do you do an incisional biopsy?
when the lesion is large and complete removal is not possible or advised
when the lesion is suspicious and identification of location is required
When do you do an excisional biopsy?
when the lesion is likely to be benign and you can remove the whole lesion quickly in one surgery - a second surgery would be unnecessary
what should you biopsy?
all red lesions most white lesions all white lesions in a smoker growths persistant ulcers
What is a brown tumour?
non tumour soft tissue lump
Not true tumour - giant cell lesion
associated with 2* hyperparathyroidism
What is a congenital epulis?
non tumour soft tissue lump
present at birth. pedunculated nodule.
histo path shows large granular cells. excise
what is a giant cell epulis?
non tumour soft tissue lump
(peripheral giant cell granuloma)
deep red gingival swelling, from chronic irritation.
vascular lesion, multinuclear giant cells.
excise, strip periosteum
What is a pregnancy epulis?
non tumour soft tissue lump
increased inflammatory response to plaque during pregnancy. indistinguishable from pyogenic granuloma (just on gingiva)
OHI, will reduce after birth
what is a pyogenic granuloma?
non tumour soft tissue lump
red fleshy swelling, nodular, response to recurrent trauma/non specific infectio n.
proliferation of vascular CT
What is a fibroepithelial polyp?
non tumour soft tissue lump
response to recurrent low grade trauma. sessile or pedunculated. excise with base. dense collagenous fibrous tissue lined by keratinised st sq ep
What is denture hyperplasia?
non tumour soft tissue lump
hyperplastic response to chronic trauma. rolls of tissue in the sulcus relating to denture flange. similar to FEP. complete excision, temporary removal of denture/relieve denture.
What is a mucocele?
non tumour soft tissue lump
mucous extravasation cyst - saliva leaknig from traumatised duct. compressed CT capsule
mucouse retention cyst - blockage of slaivary duct
most common in lower lip
What is a ranula?
non tumour soft tissue lump
a mucocele of the sublingual gland
if it extends down the neck, plunging ranula
What is a haemangioma?
non tumour soft tissue lump
developmental lesion of blood vessels. present at birth. blanch on pressure. Do not biopsy - most regress. can cryotherapy
what is lymphangioma?
non tumour soft tissue lump
developmental lesion, micro or macrocytic. tongue/cheek/lip or neck swellings.
What are warts/squamous papillomata?
non tumour soft tissue lump
HPV infection. multiple pappilated pink asymtomatic lumps. excise and Bx
What are Tori?
non tumour hard tissue lump
bony exostoses. both jaws. developmental abnormality, not sinister
What is a giant cell granuloma?
non tumour hard tissue lump
intrabony swelling or symptomless radiolucency. enucleate
What is Pagets disease of bone?
non tumour hard tissue lump
skull, pelvis, long bones and jaws.
max>mand
hypercementosis of roots. replacement of bone abnormality. bone pain and cranial neuropathy occuts. Cotton wool appearance of bones. Avoid GA, treat with BPs
what is fibrous dysplasia?
non tumour hard tissue lump
areaas of bone replaced by fibrous tissue
ground glass appearance of bone.
What is cherubism?
non tumour hard tissue lump
bilateral variant of fibrous dysplasia and multinucleated giant cells.
what is a radicular cyst?
cyst of the jaw
apical or lateral or residual. from reduced enamel epithelium.
marsupialise of enucleate
What is an odontogenic keratocyst?
cyst of the jaw
lined by parakeratinised epithelium, derived from remnants of dental lamina. fluid filled with low protein content. can aspirate for biochem.
outpouching walls make satellite cysts - high recurrence rate
multiloculated - look like ameloblastoma so must check
What is an aneurysmal bone cyst?
cyst of the jaw
expansile. full of vascular spongy bone. symptomless swelling.
What is a squamous cell papilloma?
benign tumour of the mouth - non odontogenic
resembles white/pink cauliflower. HPV
what is a fibroma?
benign tumour of the mouth - non odontogenic
pink and pedunculated
what is a lipoma?
benign tumour of the mouth - non odontogenic
slow growing yellowish lump from fat cells
what is an osteoma?
benign tumour of the mouth - non odontogenic
benign neoplasm of bone. smooth. unilateral, covered by mucosa - not in same place as tori
what is a neurofibroma?
benign tumour of the mouth - non odontogenic
tumour of fibroblast of peripheral nerve
what is a neurolemma?
benign tumour of the mouth - non odontogenic
tumour of schwann cells
what is an ossifying fibroma?
benign tumour of the mouth - non odontogenic
well demarcated fibro osseous lesion of jaw. painless, slow growing. buccal-lingual expansion.
radiolocent area with corticated margin.
What is an ameloblastoma?
benign tumour of the mouth - odontogenic
common tumour. 3 types - unicystic, polycystic, peripheral. uni = least aggressive - expands tissue rather than invade like the other 2
What are odontomes?
compound - denticles in a sac
complex - irregular mass of dental tissues
treat as malpositioned/impacted teeth
what is the difference betwen OAF and OAC?
OAC - oroantral communication. not lined by epithelium, can heal closed. acute
OAF - fistula, lined by epithelium. needs removal of the lining and surgically closing. chronic
what teeth are most likely to give OAC?
max 6/7/8
How do you treat OAC
inform patient
if small (<2mm) - encourage clot, suture,
if large - lift buccal advancement flap - parallel incisions - full thickness
score periosteal layer so it becomes stretchy
advance over defect and suture close
give ABs - 7 days amoxicillin 500mg TID
post op instructions: steam inhalations. no blowing nose/sneezing/playing wind instrument/using straw for 2 weeks/give decongestants
review after 6 weeks
What is osseointegration?
direct and functional structural connection between a load bearing dental implant and living bone
2 stages
1: primary osseointegration, implant anchored into bone due to frictional forces provided between osteotomy and dental implant design freatures
2: secondary osseointegration. the process of functional connection between bone and dental implant. living bone cells grow into the surface of the dental implant
What does granulation tissue mean?
Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.
what is supra-crestal soft tissue like for teeth vs implant?
more fibroblasts, less collagen, collagen fibres orientated perpendicular to root
for implant -
less fibroblasts
more collagen
collagen fibred parallel to implant crown
this will affect probing
what is sub-crestal tissue like for teeth vs implant?
tooth
anchored to bone by PDL complex, physiologic adaption, resillient
implant - anchored with direct functional contact
no physiolocical adaption
What are implant material options?
Titanium, Ti-Zr (stronger than Ti) ceramic (yittra stabilised zirconia. non-metallic coloured, high survival
What are the implant design options and what are the benefits?
bone level implants, tapered, straight, tissue level
different diameters and lengths - select due to site, indication and local anatomy
bone level for aesthetic areas
tissue level for posterior
tapered for root convergence areas
surface treatments - different roughnesses, and different treatment (sand blasting, acid etch, plasma spray) all designed for cells to stick to to aid osseointegration
what are the purpose of implants
replace missing teeth - function, aesthetics, psychologically
it is a replacement for a missing tooth, not a natural tooth
what is involved in the patient assessment?
CO, motivation, MH, DH, SH, age/skeletal maturity mouth level - EOE - aesthetic zone IOI smile line vertical maxillary excess site level
what parts of MH can affect survival or success of implant?
ASA classification, haematological probems
medications (SSRIs, PPIs, BPs, Steroids), RTxH&N, poorly controlled diabetes, CVD
What parts of SH can affect survival of implant
smoking - dose dependant <10 medium risk, >10 high risk
affects vascularity, fibroblast and osteoblast function
When is the earliest you can place an implant?
After the cessation of growth (around 20).
if not skeletally mature - get relative infra occlusion, sub optimal aesthetics
implant fenestration, occlusal disharmony
How does the width of the span affect implants?
too narrow can damage adjacent teeth or roots, risk of necrosis between teeth and implants
too wide - hard to fill, leave residual space
assess space in 3d (CBCT)
need to be aware of local anatomy
What diagnositic aids are there?
study models, Dx wax ups, surgical template, essex retainer, clinical photos, CBCT, surgical guide
how close can implants be to adjacent teeth?
minimum distance of 1.5mm
if you are placing two implants together then they need twice the biologic width
What nerves do you need to anaesthetise to extract a lower permanent molar?
inferior alveolar nerve, long buccal, lingual nerve
how to do check for IAN, long buccal and lingual nerve for anaesthesia?
check for altered sensation in the lower lip on that side, gingivae around the tooth (buccal and lingual side), altered sensation in that side of the tongue
What are different IDB techniques?
Halsteads technique
Indirect technique
Anterior ramus technique (limited mouth opening)
Gow-gates technique (long buccal at same time)
Akinosi (limited mouth opening and long buccal at the same time)
What principles of flap design should you adhere to when raising a mucoperiosteal flap?
Avoid vital structures full thickness of flap raised - not saw-toothed edges must close over bone base must be wider than the apex provide access to the surgical site be able to be closed at the end of surgery minimise trauma to papilla reflect flap clealy healing by primary intention
What guidelines can you follow for determining the removal of a wisdom tooth?
NICE (guidance on the extraction of wisdom teeth)
SIGN 43
How would you judge the relationship of a root to the IAN?
Radiographically:
- do the tramlines converge or disappear
- is there a shadow across the root
- loss of the cortical outline as it passes the root
- deflection of the roots
- bifid root apices
- diversion of the canal
- juxta apical area
What are indications for 3rd molar removal?
recurrent cases of pericoronitis caries in 8/7 periodontal disease cystic change external resorption of 8/7 mandibular fracture tumour resection autogenous transplantation to 1st molar socket pt unlikely to be able to access dental care for significant period of time orthognathic surgery GA required anyway
What are contraindications for 3rd molar removal?
likely to erupt and be functional medically contraindicated no local/systemic issues high risk of surgical fracture close association with IAN
What information is given for consent?
must be written and verbal
description of procedure in patient friendly terms
risks/warnings - pain, swelling, bruising, bleeding, infection, dry socket, jaw stiffness, damage to adjacent, potential damage to nerves (specifically - permanent risk, temporary risk, what it will feel like, distribution), jaw fracture, anesthetic
When would you consider a coronectomy?
when there is significant damage to IAN or fracture of jaw.
When you want to deliberately retain the roots
if you mobilise the roots at all, you must remove them
might need second surgery for removal
What are bisphosphonates and what are the risk categories?
anti resoptive drugs.
If patient has Hx of MRONJ, on BPs for Tx of cancer, taken them >5 years and concurrent Tx with glucocorticoid puts patient in high risk
When would you refer a patient at risk of MRONJ?
if an extraction socket has not healed within 8 weeks, or there is evidence of spontaneous MRONJ - refer to oral surgery/SCD
You have a patient who is about to start treatment with BPs, how would you manage them?
- OH is imperative - consequences of not
- examine dental tissues for evidence of active infection - Tx
- examine prosthesis for trauma potential
- teeth with poor prognoses/ poor long term retention XLa
- educate pt on signs and symptoms of MRONJ
- must be dentally fit before treatment starts
Patient on BPs at high risk needs XLA. How would you manage them?
pre-operative rinse with CHX, atruamatic surgical technique, primary closure of soft tissues without stripping periosteum
post-operative CHX until mucosa has healed. review patient until socket has healed.
do not attempt further XLA until socket has healed
How would you diagnose pt with MRONJ?
be on, or have been on, anti-resorptive medication
exposed bone or probe bone through fistula of maxfacs region >8 weeks
no obvious metastatic disease to the jaws
Why might a patient be on anti-resorptive drugs?
osteoporosis prevention of skull fractures Paget's disease of the bone, metastatic bone disease multiple myeloma renal cell carcinoma
What is used for IHS?
nitrous oxide
What are safety mechanisms on the IHS machine?
- Colour coding
- pin attachement system wont allow the wrong gas cannister
- active scavenger
- will cut out if the oxygen flow stops
- back up cylinder carried
- minimum oxygen concentration of 30%
- tubing diameter wont allow wrong cylinder connectin
- ## oxygen flush button
What is conscious sedation?
Medically induced state of relaxation where verbal communication with the patient is not lost. can be inhalational or intravenous, or oral
What are indications for conscious sedation?
anxious patients
medical conditions restricting access ot oral cavity
strong gag reflex
What is used for IV sedation and what dose?
Midazloam, 5mg in 5ml, give 1-2ml bolus, then 1ml every minute until sufficient level of sedation achieved
What is the reversal agent for midazolam and the dose?
Flumazenil is given - a short acting benzo with increased affinity for GABA receptor. 200ug in 15 seconds, 100ug per min until reversal occurs
as short acting, might need more doses
What can cause displacement of a mandibular fracture
unfavourable fracture line
excessive force
actions of muscles
What are different types of implants?
bone level, tissue level, ceramic, titanium/zirconia or titanium type 4, roxolid surface, different diameters, tapered
How are implants treated to increase bone contact?
sandblasting and acid etching the surface
What are primary and secondary stablility?
primary - osteoclasts removing surface of implant
secondary - osteoblasts building bone around
When would you use a tapered implant?
when you need increased primary stability - when you want to place a crown immediately
What would patients complain of if they have an OAF?
fluids in nose nasal tone to speech problems playing wind instruments problems smoking or using straws halitosis/bad taste/pus sinusitis
How do you tread OAF?
• Excise sinus tract/fistula • Buccal Advancement Flap • Buccal Fat Pad with Buccal Advancement Flap • Palatal Flap • Bone Graft/Collagen Membrane
What are diagnostic criteria for a fractured maxillary tuberosity?
how would you manage?
noise
movement (seen or felt)
>1 tooth moves
tear of mucosa on palate
dissect and close wound/reduce with forceps and stabilise (ortho wire + Composite, arch bar, splints)
any teeth involved need RCT
check occlusion is free
review 8 wks
What radiographic views would you take to identify a root/tooth in the antrum?
OPT
upper occlusal
periapical
how would you retrieve a root from max antrum?
• If retrievable remove at once • If not: -inform patient -take a radiograph -document in patient notes -place patient on appropriate medications -refer patient to OMFS or ENT
through socket small curettes irrigation ribbon gauze cauldwell-luc procedure endoscopic retrieval
What dental causes can sinusitis mimic?
- Periapical abscess
- Periodontal infection
- Deep caries
- Recent extraction socket
- MFPDS
- Neuralgia or atypical facial pain
What would you use to remove bone from a socket?
rongeurs (bone nibblers)
How do you keep the open exposure of a canine open?
use whiteshead varnishpack - physical barrier to healing closed
use horizontal mattress suture to hold in place
What are the different lines for reading an OM radiograph
first line is traced from one zygomaticofrontal suture to another, across the superior edge of the orbits
second line traces the zygomatic arch, crosses the zygomatic bone, and traces across the inferior orbital margins to the contralateral zygomatic arch
third line connects the condyle and coronoid process of the mandible and the maxillary antra on both sides
fourth line crosses the mandibular ramus and the occlusal plane of the teeth
The face is inspected for any asymmetry along these lines and Dolan’s lines.
What are dolans lines?
secondary lines for reading an OM view
orbital line traces the inner margins of the lateral, inferior, and medial orbital walls, and the nasal arch
zygomatic line traces the superior margin of the zygomatic arch and body, extending along the frontal process of the zygoma to the zygomaticofrontal suture
maxillary line traces the inferior margin of the zygomatic arch, body, and buttress, and the lateral wall of the maxillary sinus
Patient has diplopia and unable to look up - what is the underlying injury? how would you investigate?
orbital floor fracture
order Hess chart to asssess mobility
CT scan
list the aetiology of facial hard tissue trauma
Assault 65 % Fall 15% Sports 9% RTA 9% Industrial Iatrogenic War Associated with Social circumstances, alcohol,drugs and unemployment
What are the different imaging views you would take for a facial trauma?
Plain Radiographs: –OPG/PA Mandible –OM 15/30 Views (facial views) • CT Imaging –Midface and Orbital injuries –Axial and Coronal fine cuts required –3-dimensional CT
a symphyseal fracture is one type of fracture to the mandible, list the rest
body parasymphyseal condylar subcondylar coronoid process ramus angle
What are Hendersons 7 classifications of ZOM fractures?
- undisplaced
- zygomatic arch
- tripod # with f-z undisplaced
- tripod # with f-z displaced
- orbital blow out
- orbital rim
- communited
What is the surgical manouver to lift a fractured zygoma?
gillies lift
What is the aetiology behind panfacial and maxillary fractures?
high energy forces (RTA, falls, assault, industrial injuries, ballistics)
how would a patient present with a mid face fracture?
palatal bruising
bilateral periorbital ecchymosis
oral step deformities
what is a retrobublar haemorrhage?
medical emergency - loss of vision is possible
onset of decreasing visual acuity, pain, proptosis, opthalmoplegia, Hx of trauma
needs lateral canthotomy to decompess the orbital compartment syndrome
which nerves are at risk of damage form 8s removal?
lingual
IAN
mylohyoid
long buccal
When assessing a 3rd molar for removal, what does the depth indicate?
- Superficial – crown of 8 related to crown of 7
- Moderate – crown of 8 related to crown and root of 7
- Deep – crown of 8 related to root of 7
Signs and symptoms of peridoconitis
- Pain
- Swelling – Intra or extraoral
- Bad taste
- Pus discharge
- Occlusal trauma to operculum
- Ulceration of operculum
- Evidence of cheek biting
- Foetor oris
- Limited mouth opening
- Dysphagia
- Pyrexia
- Malaise
- Regional lymphadenopathy
Where can swelling from pericoronitis extend to?
extraoral - angle of mand, sub mand
laterally to cheek
submasseteric space
sublingual/submand
parapharyngeal space
How do you treat pericoronitis?
I+D of abscess if required LA if required irrigate with warm saline under operculum XLA upper 8s if traumatising operculum frequent HSMW analgesia only ABs if systemically unwell
What are the stages of surgery for 8s removal?
- Anaesthesia
- Access
- Bone removal as necessary
- Tooth division as necessary
- Debridement
- Suture
- Achieve haemostasis
- Post-operative instructions
- Post-operative medication
What would you use for soft tissue elevation and retraction?
Howarths periosteal elevator
wards periosteal elevator
buser periosteal elevator
bowdler-henry rake retractor
Lacks retractor
minnesota retractor
List some uses of elevators
- To provide a point of application for forceps
- To loosen teeth prior to using forceps
- To extract a tooth without the use of forceps
- Removal of multiple root stumps
- Removal of retained roots
- Removal of root apices
Where are the application points for an elevator and what actions would you use?
mesial, buccal and distal
wheel and axle, wedge, lever
What instruments could be used to debride a socket after extraction?
bone file mitchells trimmer victoria curette irrigation suction
List post-op analgesia and doses
Ibuprofen – 200 or 400mg, 6 hourly or 3 times daily.
Avoid in asthmatics, bleeding disorders/Warfarin, on other
NSAIDs – see BNF. Note some asthmatics can take it but
check, and if they’ve never had it don’t prescribe it.
• Paracetamol 500mg tablets, 2 tabs 4-6 hourly, no more
than 8 a day. Overdose serious.
• Cocodamol – contains 8mg codeine and 500mg
Paracetamol (stronger contains 30mg codeine/500mg
Paracetamol). 2 Tabs 4-6 hourly, do not exceed 8 in a day.
Whats the surgical procedure for a coronectomy?
consent LA raise flap transsect tooth 3-4mm below ADJ elevate crown (dont mobilise roots) leave pulp can reduce roots below alveolar crest if poss irrigate socket replace flap - can be physiological closure or primary closure post op advice
How do you reduce the chance of a fractured tuberosity in 8s removal?
not last standing tooth
support with finger and thumb
list some perioperative complications of surgery
# tooth/root/adjacent lingual plate/alveolus/mandible # max tuberosity # OAC/loss of tooth into sinus trauma to IAN bleeding crush/puncture/laceration injuries to soft tissue burns
list some postoperative complications of surgery
pain swelling bruising trismus para/ana/dysaesthesia altered taste infection dry socket port op bleeding haematoma osteomyelitis MRONJ/ORNJ actinomycosis
what are post operative techniques for controlling bleeding?
• Post-operative
– Pressure (finger or via swab or pack)
– LA with vasoconstrictor infiltration in
soft tissues, inject into socket, or on a
swab
– Diathermy
– Haemostatic Agents – Surgicel/Kaltostat
– Sutures
– Bone wax smeared on socket wall with
blunt instrument
– Haemostatic forceps/ artery clips
what are peri-operative techniques for controlling bleeding?
Peri-operative – Pressure – LA with vasoconstrictor – Artery forceps – Diathermy – Bone wax
what are symptoms of OAC?
hollow suction nasal sounding voice air coming through mouth bubbling of blood pt hold nose and breathe out when you look in mouth you can see air
What would you prescribe for OAC after closing?
SDCEP sinusitis meds amox 500mg TDS 7/7 ephedrine nasal drops 0.5% one in each nostril TDS menthol crystals steam inhalation CHX MW 0.2%
how can you close an OAF?
remove ep lining.
full thickness buccal advancement flap
split thickness palatal rotational flap
buccal fat pad
how can you retrieve a root in the antrum?
ribbon gauze
suction
patient can move their head to move it around
endoscope removal
What benefits does IHS have over IVS?
- non escort needed
- no needles
- rapid recover
- controls gag reflex
- little effect on CV and resp
- easier to change level of sedation and reverse
- no metabolism of drug
- fewer side effects
- mild analgesia
What are the doses of meds for IVS?
midazolam at 1mg/ml, give 1 ml bolus followed by 1ml every min until level of sedation achieved. normally 5-7mg
flumazenil at 100ug/ml - give 1ml
what drugs can affect clot formation and how?
aspirin - prevents platelet aggregation
warfarin - prevents formation of clotting factors
herparin - reduces action of platelets
NOACs - direct factor X inhibitors
