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
4 ways to achieve haemostasis post XLA
la w/ vasoconstrictor pressure - damp gauze diathermy sutures surgicel
A&E if no haemostasis gained
local risk factors for delayed onset bleeding post XLA
wear off vasoconstrictor LA,
pt disturbs site with tongue/ finger,
loosening of suture
causes of acute bleeding episode in adults
congenital haemophilia
acquired haemophilia
adverse events from anticoagulant, NSAID, aspirin use
von Willebrand disease ( or acquired von willebrand syndrome)
antithrombotic therapy -warfarin/ aspirin
PLT dysfunction - e.g leukaemia
hypertension
liver disease
When to check INR pre- extraction
ideally no more than 24 hours before extraction
if pt recorded to have stable inr no more than 72 is acceptable
if inr over 4 then delay extraction until reduction
pt presents with facial swelling, what should you make note of
site size duration airway compromise fever malaise colour temperature location pus palpation (firm/mobile)
what drug preparation used for iv sedation in uk?
midazolam 5mg/5ml
3 stats need to monitor during sedation?
02 saturation
HR
BP
Sedation reversal drug?
flumazenil
3 pieces advice to give to a pt post sedation?
do not go on internet/ shopping/social media
do not drive
no signing of legal documents
do not operate machinery
What is conscious sedation?
conscious sedation
a technique in which the use of a drug/ drugs produces a state of depression in the central nervous system, enabling treatment to be carried out, but during which verbal contact is maintained throughout.
drugs and techniques used carry a margin of safety wide enough to render loss of consciousness unlikely
indications for inhalation sedation
medical conditions aggravated by stress- epilepsy, asthma, ischaemic heart disease dental anxiety anxiety gagging unpleasant/ trauma dental procedure
contraindications inhalation sedation
pt unable to nose breath- common cold, tonsilitis
1st trimester pregnancy
severe COPD
advantages of IhS over IV (6)
quicker quicker recovery recovery time independent of dose quicker onset no needles no amnesia less side effects no chaperone needed for adults
Safety features of IhS machine
quantiflex machine
oxygen flush reservoir bag scavenger system one way expiratory valve coloured cylinders (black o2, blue NO) pin index NO stops if 02 stops fail safe at 40 psi minimum o2 at 30%
Which neurotransmitter is involved in IV sedation?
What is its function?
GABA
Gamma- aminobutyric acid
inhibitory neurotransmitter in CNS
Half life midazolam?
90-150 minutes
Contraindications IV sedation?
BMI >30 or 35 depending on hospital
ASA III
Severe needle phobia
Severe behavioural problems
severe systemic disease (myasthenia gravis) severe special needs severe psychiatric problems COPD pregnancy/ lactation age - <12 y/o too young drugs - erythromycin AB
6 factors to assess pre IV sedation?
- dental - nature of anxiety, previous tx, tx plan, cooperation
- medical - systemic conditions, hx of sedation/ anaesthesia, ASA class
- drugs- medication taken
- social - availability of escort, age, dependents, occupation
- vital signs - o2, hr, rr, bp, bmi
ASA classification?
- fit and well
- mild-mod systemic
- severe systemic condition
- severe systemic condition w/ threat to life
- moribund
- brain dead
Why refer GA?
long/complex procedures requirement of complete stillness mh contraindicates sedation pt uncooperative pt anxious pt phobic benefits outweigh risks
4 stages of anaesthesia?
- induction
- excitement
- surgical anaesthesia
- overdose
What needs to be included in a referral letter for GA?
pt name, address, contact details mh history w/ drug history dental history tx plan justification GA rads
gdp name, address
A patient attends your practice complaining of pain on biting. Intra-orally you see a 9mm suppurating pocket with
vertical bony defect radiographically, associated with tooth 15
List THREE differential diagnoses (3)
SI?
tx?
symptomatic apical periodontitis - inflamm of apical periodontium - pain to bite on and TTP. (RCT required)
periodontal abscess
periapical abscess
is TTP?
Sensitivity testing- ethyl chloride thermal stimulus- reaction to thermal stimulus and how long it lingers- with tell if irreversible pulpitis
drainage of pocket
RCT, followed by permanent restoration of access cavity
XLA
sensibility testing results
ethyl chloride/ endo -ice
hypersensitivity will show pulpitis
if lingering= irreversible pulpitis
if non lingering= reversible pulpitis - in addition to no pain on biting, not TTP
if any teeth TTP or pain on biting and lingering hypersensitivity-> symptomatic apical periodontitis w/ irreversible pulpitis
no response to EPT/ ethyl = pulp necrosis, (if adjacent teeth respond)
Patient has swelling around unerupted lower 8, facial swelling + slightly unwell
6 things from history and investigation to note before looking at region in mouth (3)
pain history temperature hr rr history of size of swelling - how long been present, time span of exacerbation lymphadenopathy
types of nerve injury from la
physical, from needle, compression due to haemorrhage
chemical, from la contents or haemorrhage
the resultant nerve injury may be a combination of peri-, epi- and intra-neural trauma causing subsequent haemorrhage, inflammation and scarring resulting in demyelination (loss of nerve lining)
idb nerve damage causes
numbness lower lip + chin
parasthesia
dysaesthsia
lingual- tongue
what might a pt complain of if has sialolith?
what is it
most common place. why
investigations?
pain xerostomia thick saliva bad taste fluctuant swelling at meal times
what: calcified mass forms in salivary gland
common: submandibular duct, uphill, tortuous path
invest: palpation of gland and duct, lower occlusal radiograph, sialography
tx of sialolith?
- surgical removal-
la, secure gland and stone, incision, removal, suture, post ops - sialoendoscopic removal - basket retrieval
- shock wave lithotripsy
risk factors dry socket
smoking female mandibular tooth oral contraceptive pill posterior teeth
risks of extraction and how to manage
Pain → analgesics and warn pt. Bleeding → pressure/LA/haem agent /or/ Post-op - pt bite on damp gauze for 3x20mins then phone NHS24 or GDP. Bruising → ice pack. Swelling → limit traumatic XLA. Nerve damage → know risks before. Infection → keep clean. Limited mouth opening → monitor. Fractured tooth/restoration → advise pt risk before. Others → OAC, tuberosity fracture, mandible fracture, incorrect tooth, broken instrument, dry socket.
What is warfarin? how does it work?
anticoagulant
vitamin k agonist
inhibits clotting factors 2,7,9,10
how would you manage a warfarin extraction
Atraumatic technique, suture socket closed, can use WHVP to help clot, oral tranexamic acid, ensure haemostasis Stress post-op instructions. Review.
pt with osteoporosis. what drugs may they be on? how do these drugs work?
what other conditions are these drugs used for?
bisphosphonates
reduce bony turnover by inhibiting osteoclast recruitment, function and formation
paget’s, osteogenesis imperfecta, malignant metastasis
for a diagnosis of MRONJ what 3 criteria is needed
- pt taking bisphosphonates or similar drug - anti-angiogenics
- bone expose for >8/52
- No history of head or neck radiotherapy
how to determine high/low risk of MRONJ
low - oral bisphos <3 years
high- oral >3 years OR IV > 6/12
How to manage pt w/risk of MRONJ in practice
advise re: risks CHX before and after tx ideally pt have excellent OH drug holiday 3/12 before and after - SDCEP says no evidence Atraumatic XLA technique Haemostatis agent - surgicel Suture Post ops RV
pt attends with socket that hasnt healed 4 weeks after xla
when should a socket heal by?
what could this pt have?
mgmt?
2/3 weeks
dry socket= alveolar osteitis
Reassure patient, LA, inspect socket for sequestrate, irrigate with saline/CHX, debride gently to establish new clot, pack with alvogyl (LA and antiseptic iodoform), advise patient of post-op advice again, advise may require multiple visits to repeat treatment.
post ops advice
Start painkillers before LA wears off but expect some pain.
If bleeding, bite on damp gauze for 30mins. Still bleeding, contact GDP or NHS24.
No rinsing for 24 hours. Then gentle rinse with HSMW 3-4x daily.
Caution w/LA.
Do not disturb clot, Eat on other side of the mouth.
Do not smoke – dry socket.
No alcohol rest of day.
Relax rest of day.
Clean are gently but do not disturb clot.
If pain worse after 2-3 days, contact GDP
what tissues like to suffer from prolonged bleeding
veins
arteries
soft tissue
bone
pt presents with pain and a neck swelling, he is drooling and finding it difficult to speak.
o/e his tongue is elevated and his submandibular spaces are also raised bilaterally. What could this be?
mgmt?
Ludwig’s Angina - severe cellulitis of FoM. - skin infection occuring FoM, under tongue, usually as result of dental abscess.
untreated: airway risk, systemic infection -> septic shock, fatal
SI: sample, ct
Tx: IV antibiotics, then oral
RCT on infected tooth
Name 4 maxillary and 4 mandibular spaces
maxi: palatal, labial, buccal, infraorbital, infratemporal,
mandi: submental, buccal, sublingual, submasseteria, lateral pterygoid
70 y/o pt presents with numb area of mouth, difficulty opening his jaw and with exposed bone of the mandible, underlying his denture. what would you check in history? what could this be?
why is this more likely to be in the mandible?
tx?
how to prevent?
osteoradionecrosis
- if pt has had radiotherapy in past bone necrosis can occur delayed after this.
can be painful or there can be complete numbing in area
would need to check dose of radiation received, where and when
mandible: due to reduced blood supply in mandible than maxilla.
SI: radiographs, mri, ct,
biopsy for cancer screening
tx: surgical debridement to remove necrotic bone - seuqestrectomy. irrigation
prevention: need to be dentally fit before radiotherapy, CHX MW before and after XLA, good OH, atraumatic dental procedures
you are wanting to design a flap for removal of lower first premolar. what is it a necessity to avoid in this area? why?
mental nerve
provides sensation to lower lip, skin of chin, gingiva
perioperative risks of surgical xla
tooth,
excessive bleeding,
nerve damage,
# mandible,
damage to restorations or adjacent teeth,
soft tissue trauma
- gingival tears/loss of incisive papilla,
trismus,
difficulty of access,
abnormal resistance - ankylosis/hypercementosis,
dislocation of TMJ
aims of suturing?
- reposition gingiva
- aid haemostasis
- protect clot
- aim for healing by primary intention
- cover exposed bone
4 types of suture and e.g
monofilament resorbable - monocryl
polyfilament resorbable - vicryl
monofilament non-resorbable - prolene
polyfilament non-resorbable - mersilk
6 forceps and their uses?
upper straight
upper universal
upper molars
upper roots
3 types of elevator
warwick james
couplands
cryers
ways in which elevators can be used?
rotation, lever, wedge
function of luxator?
to break pdl, aiding in placement of forceps
what is osteomyelitis?
how does it differ to dry socket
risk factors?
mgmt?
bacterial infection of bone, inflamm and redness caused, eventually necrosis. principle factor of inflamm is infection by pyrogenic organisms.
differs to alveolar osteitis as has progression through marrow spaces
immunocompromised pts, mandible (lower blood supply) and fractured mandible
haemophilia A and B?
mgmt?
A- factor VIII
B - factor IV
refer for all procedures - not dentures
factor replacement, desmopressin for A, antifibrinolytics - tranexamic acid.
