Oral Surgery

Question 1

Extractions

1. 4 indications for extractions
2. 4 reasons a tooth may be considered unrestorable
3. 4 pre-extraction complications

Answer 1

1. Traumatic tooth position, unrestorable tooth, symptomatic partially erupted tooth, orthodontic considerations
2. Gross caries, advanced periodontal disease, tooth/crown/root #, pulp necrosis
3. Medical history precludes extraction (uncontrolled bleeding condition, unsuitable blood results), pre-operative radiograph shows tooth is ankylosed to bone, patient refuses to consent/is unable to consent, proximity to important anatomical structures, tooth position inadequate for access/limited mouth opening

Question 2

List 4 types of peri-operative complications

Answer 2

Bleeding/haemorrhage, nerve damage, OAC, damage to adjacent tooth/restoration, lost tooth, tooth #

Question 3

List 3 causes of access/vision difficulties

Answer 3

Limited mouth opening (reduced aperture), trismus, crowded/malpositioned teeth

Question 4

List 3 causes of abnormal resistance

Answer 4

Hypercementosis, ankylosis, long/divergent/increased number of roots, thick cortical bone

Question 5

List 3 causes of tooth #

Answer 5

Caries, alignment, root, size, misdirection of force

Question 6

Jaw #

1. 3 causes
2. 3 signs/symptoms
3. Management
4. Alveolar # management

Answer 6

1. Misdirection of force, atrophic mandible, cyst in bone, impacted 8
2. Crack, step (visual/palpable), tear in gingiva at # line, abnormal disclusion
3. Immediate analgesia (LA block), radiograph (OPT/occlusal), refer, provide analgesia and antibiotics. If required, stabilise (tie free end of bone to teeth opposite # line and teeth together)
4. Suture, dissect free smooth edges

Question 7

How would you treat a TMJ dislocation

Answer 7

Relocate (condyles down and back)

Question 8

OAC

1. 3 diagnosis tools
2. Management
3. PoI

Answer 8

1. Direct vision (aspiration, good lighting - blood bubble at base of socket), nose blow test (hold nose, gently blow - bubbling at base of socket), blunt probe, radiograph
2. If small/lining intact - encourage clot, suture margins
   If large/lining torn - buccal advancement flap
3. Don’t dislodge clot, no straws, avoid wind instruments for 2 weeks, don’t rinse today, WSWM from tomorrow, avoid nose blowing, steam inhalation, closed sneezing/stifle sneezes

Question 9

Maxillary tuberosity #

1. 3 causes
2. 3 signs/symptoms
3. Management
4. How would you retrieve a root in the antrum?

Answer 9

1. Extraction in wrong order (front to back), last standing molar, unknown unerupted 8
2. Loose/mobile tuberosity/tooth, crack, tear in palate, noise
3. If small - remove and close. If large - (reduce and stabilise) replace, RCT tooth and ensure occlusion-free, then surgically remove 8wks later
4. Suction (narrow-bore), small curette, irrigation, ribbon gauze

Question 10

How do you manage a lost tooth

Answer 10

Stop and search for it. If possible inhalation, send to A&E for CXR

Question 11

Damage to adjacent tooth/restoration

1. 3 causes
2. Management

Answer 11

1. Using tooth to lean on with elevator, forceps slip and hit opposing tooth, restoration overhang in contact with tooth to be extracted
2. Temporary restoration, arrange definitive

Question 12

Broken instrument

1. 2 causes
2. Management

Answer 12

1. Instrument fatigue, incorrect use (using luxator as an elevator, etc.)
2. Retrieve, radiograph to confirm, refer if unable to retrieve

Question 13

Nerve injuries

1. 3 types
2. 5 effects of nerve damage
3. 3 types/names of nerve injuries and define

Answer 13

1. Crush injuries, cutting/shredding injuries, transection injuries
2. Anaesthesia, dysaesthesia, paraesthesia, hyperaesthesia, hypoaesthesia
3. Neurapraxia - temporary loss of function due to blockage of nerve conduction. Bruise/contusion. Epineural sheath and axons maintained
   Axonotmesis - gradual loss of function distal to injury site. More severe contusion/crush. Epineural sheath disrupted, axons maintained
   Neurotmesis - most severe type. Transection. Complete loss of nerve continuity. Epineural sheath and axons disrupted

Question 14

Bleeding/haemorrhage

1. 4 reasons
2. Soft tissue management
3. Bone management
4. 3 types of haemostatic agents

Answer 14

1. Medication side effects, undiagnosed/unmanaged clotting abnormality, liver disease/dysfunction, local factors (mucoperiosteal tear, etc.)
2. Bite on damp gauze, introduce haemostatic agents, suture, diathermy, haemostatic forceps/artery clips
3. Bite on damp gauze, introduce haemostatic agents, bone wax, pack, suture
4. Oxidised regenerated cellulose (surgicel), adrenaline-containing LA (on pledget/gauze/into socket), fibrin foam, thrombin liquid

Question 15

Surgery

1. 4 principles of surgery
2. 4 features of flap design
3. 2 methods of soft tissue retraction
4. 2 reasons for soft tissue retraction
5. 2 elevator functions (3 methods of use)
6. What handpiece and why
7. 3 methods of debridement
8. 4 aims of suturing
9. 4 types of sutures
10. 4 types of flap (draw)
11. Nerves damaged when extracting L8

Answer 15

1. Maximal access with minimal trauma, clean flap reflection down to bone, keep tissues moist, no crushing of tissues, aim for healing by primary intention to minimise scarring, re-approximate tissues,
2. Use scalpel in one, continuous motion, no sharp angles, ensure tension-free closure (relieving incisions), consider aesthetics, achieve haemostasis, aim for healing by primary intention to minimise scarring
3. Rake retractor, Howarth’s periosteal elevator
4. Improve/gain access to field, protect soft tissues
5. Loosen/remove teeth, remove retained roots
6. Electric straight handpiece with saline-called straight/fissure tungsten carbide bur. Air-driven handpieces can cause surgical emphysema
7. Handpiece, bone file, Mitchell’s trimmer, Victoria curette, irrigation, aspiration
8. Achieve haemostasis, prevent wound breakdown, re-approximate tissues, aim for healing by primary intention to minimise scarring, cover bone, ensure margins and sutures lie on sound bone
9. Envelope (with/out relieving incision), 3-sided (mesial and distal relieving incisions), semi-lunar (periradicular), triangular
10. Envelope (with/out relieving incision), 3-sided (mesial and distal relieving incisions), semi-lunar (periradicular), triangular
11. Inferior alveolar, lingual, buccal, nerve to mylohyoid

Question 16

Analgesia

1. Pain pathway
2. Aspirin analgesic, antipyretic, anti-inflammatory, metabolic features
3. 3 side effects and 4 contraindications
4. Ibuprofen - why better than aspirin, 3 side effects, 4 contraindications
5. Paracetamol - action, 2 contraindications
6. Opioids - one in dentistry, 2 contraindications, 2 problems

Answer 16

1. Trauma causes release of arachidonic acid from cell membranes, interacts with COX to activate PGG2 and PGH2 (activates PGE2), causing release of leukotrienes and influx of inflammatory products (pain, swelling, red)
2. Analgesic - COX inhibitor
   Antipyretic - reduces raised temperature in fever
   Anti-inflammatory - reduces production of PGs
   Metabolic - reduces platelet aggregation, raises BMR
3. Mucosal burns, antiplatelets/thins blood, GI upset. Not for other NSAID, antiplatelet/anticoagulant, peptic ulcer, pregnant/<16 (Reye’s)
4. Less effect on platelets and gastric mucosa (COX2 inhibitor). Dizzy/headache, tired, GI upset. Not for renal/hepatic impairment, other NSAID, LT steroids, peptic ulcer
5. Indirectly inhibits COX by reducing PGs in CNS pathway. Not for renal/hepatic impairment, alcoholics
6. Dihydrocodeine. Not for raised ICP (head injury), acute alcoholism. Tolerance, dependence

Question 17

List 4 types of post-extraction complications

Answer 17

Bruising, swelling, pain, bleeding, dry socket, OAF, trismus, infected socket, ORN, MRONJ

Question 18

List 3 causes of post-extraction pain/swelling/bruising

Answer 18

Poor technique (traumatic), rough tissue handling, tear in gingival/mucoperiosteum

Question 19

Trismus

1. Definition
2. 3 reasons that it occurs
3. Management

Answer 19

1. Limited mouth opening due to muscle spasm
2. Surgical reasons (open too long, muscle spasm), LA into muscle (masseter), haematoma in muscle
3. Soft diet, CHX MW, gentle opening techniques (wooden spatulas, trismus screw)

Question 20

OAF

1. Define
2. Treatment

Answer 20

1. Occurs secondary to OAC. Occurs if OAC heals incorrectly/doesn’t heal. Formation of epithelial-lined tract between the antrum and mouth.
2. Remove tract, suture closed

Question 21

Post-op bleed

1. 2 types (differences)
2. Management
3. PoI

Answer 21

1. Immediate - reactionary/rebound (vessels not being compressed anymore). Within 48hrs, usually ooze
   Delayed - usually 3-7days post-extraction. Often due to infection
2. Rapid history, remove clot, identify source, same as peri-operative bleed - bite on damp gauze, introduce haemostatic agents, suture, diathermy, haemostatic forceps/artery clips
3. Don’t rinse today, don’t smoke, no excess alcohol/exercise, bleeding management advice

Question 22

Dry socket

1. 2 other names
2. 4 predisposing factors
3. 4 signs/symptoms
4. Management

Answer 22

1. Localised osteitis/alveolar osteitis
2. Posterior tooth, mandibular tooth, smoking, excessive pre- and post-extraction rinsing, female, some oral contraceptive pills, previous dry socket, FH of dry socket
3. Continuous intense throbbing pain (dull throb - kept awake at night), may radiate to ear/jaw, malodour/halitosis, no signs of infection, exposed sensitive bone
4. Ensure no remaining tooth/sequestrum, analgesia (LA), irrigate to remove food trapped, debride, encourage clot formation, suture, PoI (WSMW, no excessive rinsing, don’t dislodge clot)

Question 23

Sequestrum

1. Define
2. Management

Answer 23

1. Piece of dead bone formed within diseased/injured bone

2. Remove

Question 24

Infected socket

1. Define
2. Management

Answer 24

1. Rare bacterial infection with pus discharge causing delayed healing
2. Clean socket/drain pus, irrigate, radiograph, debride, suture

Question 25

Osteomyelitis 1. Define 2. Progression 3. 3 predisposing factors 4. 3 types 5. Management 6. Radiographic appearance

Answer 25

1. Inflammation of bone marrow 2. Medullary cavity to cancellous bone to cortical bone to periosteum. Bacteria invade bone, cause local soft tissue necrosis and ischaemia 3. Odontogenic infection, # mandible, immunocompromised, comorbidities 4. Early, acute suppurative, chronic (± pus) 5. Refer, blood tests, surgery 6. Mottled bone, sequestrum, involucrum

Question 26

ORN 1. How it occurs 2. What jaw more likely to be affected and why 3. 3 prevention/treatment methods

Answer 26

1. High-dose radiation induces local enarteritis obliterates which leads to progressive fibrosis and capillary loss, leaving bone susceptible to avascular necrosis. 2. Mandible as thicker bone/poorer blood supply 3. Hyperbaric oxygen chamber, pre-operative scaling, CHX MW use, good OH, atraumatic technique, suture (primary healing), resect necrotic bone, antibiotics

Question 27

MRONJ 1. Define 2. Stages 3. High risk category

Answer 27

1. Medicated-induced osteonecrosis of the jaw. Reduced bone turnover (inhibition of osteoclastogenesis). New bone formed faster than old bone lost 2. Stage 0 - symptomatic, no necrotic/exposed bone Stage 1 - asymptomatic, necrotic bone/fistula that probes to bone Stage 2 - symptomatic, infection, necrotic bone/fistula that probes to bone Stage 3 - necrotic bone/fistula that probes to bone with one/more of: EO fistula, OAC, necrosis extends beyond alveolus, osteolysis extending to border of mandible/sinus 3. Oral/IV bisphosphonates (or RANKL inhibitors) for non-malignant bone conditions for >5yrs Oral/IV bisphosphonates (or RANKL inhibitors) for any length of time in combination with systemic glucocorticoids Anti-angiogenic/anti-resorptive drugs involved in cancer treatment/management Previous MRONJ

Question 28

Actinomycosis 1. Bacteria involved 2. What is unique 3. Management

Answer 28

1. A. israelli/viscosus 2. Erodes through tissue, doesn't follow fascial planes 3. Refer, antibiotics, LT antibiotics to prevent

Question 29

IE 1. Define 2. High risk category 3. Management

Answer 29

1. Bacterial inflammation of endocardium, particularly affecting CMP heart valves 2. Previous IE, cyanotic CHD, prosthetic valve (replacement surgery) 3. Consult with cardiologist, consider antibiotic prophylaxis