Oral surgery Flashcards
what guidelines are adhered to concerning 3rd molar removal?
SIGN
in what circumstances is 3rd molar removal not advised?
- 8s erupted healthily
- MH contraindicates XLA
- high risk of surgical complication
- high risk of mandibular fracture
in what circumstances is 3rd molar removal advised?
IMOGaT
I infection
M MH indicated e.g radiotx
O occupation/lifestyle limits access to care
Ga under Ga and risk outweighs risk of another Ga
T tooth transplantation (autogenous)
in what circumstances is 3rd molar removal strongly advised?
ICPCR I infection is recurrent- pericoronitis C caries present in 8 or adjacent 7 assoc/w/8 P periodontal disease in 7 assoc/w/8 C cyst/ other pathology R resorption of 8 or 7 assoc/w/8
in what circumstances is 3rd molar removal considered?
mandibular fracture near site of 8
autogenous transplantation
unerupted 8 in atrophic mandible
opp 8 causing symptoms
what do you assess on radiograph before removing 8s
PPLARRB proximity to id canal pathologies level of impaction angle of impaction root number root form bone loss
briefly describe surgical removal of 8s
informed consent
la - idb and long buccal +/- intraligamentary or sedation + la
access w/flap, bone removal or tooth resection
what structures are at risk when removing bone during xla mand 8s
lingual nerve,
7s
types of nerve damage
neurotaxia
axonotmesis
neurotmesis
uses of iodine containing products
alvogyl - contains iodoform (iodine containing antimicrobial), used for tx of osteitis
BIPP - contains iodoform, used in impregnated ribbon gauze as packing for secondary healing
percentage risk of temp and permanent nerve damage after xla 8s?
temporary- 10-20%
permanent - 1%
5 post op complications from 3rd molar removals
post op pain, bleeding, bruising, swelling infection, nerve damage, damage to adjacent structures jaw stiffness/ limited opening further surgery
What are the 5 radiographic signs of proximity of tooth to ID canal
SI to check proximity?
DDDTN
diversion id canal deflection of roots darkening of roots tramlines interrupted narrowing of canal
CBCT
what is the juxta-apical area
non- pathological radiolucency relating to roots of lower molars.
likely to be continuity of IAN lamella w/ the periodontal lamina dura of the associated tooth
What might a patient expect with temp nerve damage? (4)
tingling, pain, loss or heightened sensation
in area of lip cheek chin tongue
lasting up to 1 year
what are the principles of flap design?
wide base w/ own blood supply large enough for appropriate access avoid crushing tissues avoid sharp angles avoid interdental papilla aim for healing by primary intention margins over sound bone avid
what does the lingual nerve supply?
what nerve is it branched from?
sensory to anterior 2/3s tongue
branched from mandibular branch of trigeminal nerve (V3)
what nerve is responsible for taste in the tongue? what is this branched from?
name another significant role for this nerve
chorda tympani
from facial nerve (CNVII)
secretomotory function for sublingual and submandibular salivary glands
describe the process of debridement
PIS
Physical - removal of sequestrae and edges
Irrigation - w/ sterile saline
Suction - under flap and in socket - to remove debris
what is pericoronitis?
signs and symptoms?
inflammation of the operculum
most common in mandibular 3rd molars
tooth partially or fully erupted
pain, swelling, bad taste, halitosis, malaise, pyrexia, discharge, limited mouth opening
how to manage pericoronitis
a) acute episode
b) long term management
a) la for pain incise and drain abscess I&&&D irrigate with chx/saline ohi analgesia
b) xla opposing 8 if traumatising- only after cessation of acute symptoms
Risk factors for an OAC
extraction of maxillary 1st and 2nd molars large antrum roots in antrum divergent roots hypercementosis ankylosis
clinical signs and symptoms of OAC
air rushing blood bubbling in socket visual inspection fluid "going in to nose" when drinking loss of socket blood clot in days following XLA bone in bifurcation of roots
How do you manage an OAC
inform pt
if small -> leave, prescribe AB
if large -> buccal advancement flap w/sutures, prescribe AB
advise pt on smoking, nose blowing, straw use, wind instruments, sneezing
book review appt.
XLA lone upstanding molar give 3 complications,
clinical diag and management of 2
OAC, fractured tuberosity, root/tooth lost in antrum
oac- blood bubbling, visual inspection, air rushing, bone in bifurcation of roots
fractured tuberosity - sound of fracture, tear in soft tissue of palate, movement of >1 tooth
oac- inform pt, if small leave prescribe ab, if large buccal advancement flap with sutures, prescribe ab, give advice on: smoking, straw, nose blowing, wind instruments. book in for review appt.
tuberosity - referral to OMFS
if small w/o sinus perf - dissect segment, suture
if small w/ sinus perforation- dissect fragment, closure of socket and gelfoam to obturate opening,
if large, consider disecting tooth from segment, then suture for stability, wire stabilisation may be needed if involving multiple teeth. local/autogenous flaps used
advice: sinusitis, communications, poor fit prosthesis
what flap do you use to close oac?
describe shape
2 alternative flap designs?
buccal advancement flap
3 sided
including papillae on either side
just encroaching on to reflective mucosa
alternatives:
palatal rotational flap
or buccal fat pad (with overlying buccal mucosa)
a patient returns to your surgery 10 days after XLA UL6. she complains of her nose “dribbling” when she drinks and feeling very “bunged up”.
how do you investigate?
outline your management?
OAF- fistula takes on average 7-8 days to form!!
investigation: history, clinical exam, radiographs
mgmt: la remove fistula inspect socket remove debris, sequelae cut buccal advancement flap reflect flap and cover socket suture w/non resorbable sutures (mersilk) ensure haemostasis post op instructions
non resorbable = more stable, flap will have more retention
score flap for more movement
pt with mandibular fracture. other than pain bruising swelling list signs and symptoms (6)
step deformity limitation in function tooth mobility facial assymetry lower lip numbness displacement of teeth bleeding
how would you assess a mandibular fracture
radiograph
opt and pa mandible
What 4 factors could cause a fracture to be displaced?
tx
pull of attached muscle
magnitude of force
opposing occlusion
angulation of fracture line
tx: do nothing, ORIF, IMF
open reduction, internal fixation
intermaxillary screw fixation
6 signs and symptoms of TMJ
pain on opening/closing clicking of TMJ crepitus of TMJ linear alba tongue scalloping facial assymetry
two muscles to palpate for TMJD
masseter
temporalis
conservative advice of TMJ management (8)
avoid wide mouth opening relaxation therapy mastication on both sides acupuncture no chewing gum counselling reassurance avoiding hard/sticky foods hot compresses supported yawning splints- hard/soft analgesia muscle relaxants
how does a splint aid in TMJ tx?
acts as habit breaker of parafunctional habit
reduces load on TMJ
decreases abnormal activity
stabilises occlusion
What is arthrocentesis?
MoA?
aspiration of joint cavity following injection of a sterile saline into superior joint space of the TMJ.
aids in release of the disc .:. increase in mouth opening, increase in lateral movements and decrease in pain
MoA- injected saline breaks down fibrous adhesion and washes away inflammatory exudate
