Oral surgery - All Flash Cards
- What are the 4 wrong site surgery prevention protocol?
- Confirm; I see you are here for an extraction today, is that correct?
- Can you tell me which tooth it is?
- Can you point to the tooth please?
- Check accuracy with clinical records
- During an extraction, you read on the pink sticker that the tooth to be extracted is grossly carious. How can this tooth cause problems when being extracted?
A tooth that is grossly carious will make it prone to breaking when force is applied to the forceps. This may require the use of other instruments to open pockets or the need of surgical intervention.
- What must be completed before giving LA or sedation
the dental surgical safety checklist
- What four details need to be written down on the x ray boards whilst setting up for an extraction?
- Name
- CHI Number
- Tooth to be extracted
- PMH
- Why is the PMH so important before and extraction is carried out?
Patients PMH may influence treatment such as, Anticoagulants and bisphosphonates.
- What would you want to look out for when reading through the PDH before doing an extraction?
Problems with previous extractions such as, difficult extractions, bleeding, infection and dry socket.
- Describe the position of the dental chair when undergoing an upper tooth extraction?
Chair position between shoulder and elbow height, lying back 45 degrees.
- Describe your position when performing an upper tooth extraction?
Infront, to right of patient (if right-handed)
- Describe the position of the dentist when extracting a lower right tooth
Behind, right side for lower right (if right-handed)
- What is the purpose of elevators?
To expand socket and loosen tooth
- What are the ten post op instructions you would give to a patient after an extraction
- Avoid rinsing mouth for 24 hours (establish a clot, prevent dry socket)
- Avoid alcohol today – (increases bleeding)
- Avoid smoking – (prevent dry socket)
- Bite on clean cotton for 15 mins if bleeds
- How to contact you for advice if problems
- Explain use of HSMW
- Don’t bite lip
- Give analgesic advice
- Avoid strenuous exercise
- Need for review
- What are the 6 potential post op problems expected?
- Pain – to be expected
- Bleeding
- Bruising
- Swelling
- Infection
- Dry sockets (alveolar osteitis)
bone turnover is regulated by which hormones?
parathyroid hormone,
calcitriol,
calcitonin,
sex hormones,
growth hormone,
thyroid hormone,
and cortisol
bone turnover involves which two cells
Involves osteoblasts and osteoclasts
what are the 5 phases in remodelling
- Activation
- Osteoclast recruitment and resorption
- Reversal
- Osteoblast recruitment and bone formation
- Termination – quiescence (stable)
A genetic disorder causing an abnormality of the bone, in which results in a defect of collagen formation, affecting the whole skeleton is known as?
osteogenesis imperfecta
a genetic disorder causing an abnormality of the bone that results in excess osteoclastic bone resorption is known as?
osteopetrosis
which abnormality of the bone is common in women undergoing post-menopausal
osteoporosis
what can the long term high dose of steroids such as prednisolone induce
glucocorticoid-induced osteoporosis
which bone abnormality is a chronic problem in which scar-like tissue grows in place of normal bone?
fibrous dysplasia
which condition of the thyroid results in the increase turnover of bone?
hyperparathyroidism
which other group of drugs are known to cause abnormalities of the bone?
Bisphosphonates
Following extractions there is a physiological osteoclastic bone resorption. When we extract a teeth, we rely on the alveolar bone which houses the bone to mobilised and used elsewhere.
The greatest amount of bone loss is in the horizontal dimension and occurs mainly on the facial aspect of the ridge.
There is also loss of vertical ridge height, which has been described to be the most pronounced on the buccal aspect.
This resorption process results in a narrower and shorter ridge and the effect of this resorptive pattern is the relocation of the ridge to a more palatal/lingual position
What is the clinical relevance?
- The remodelling process takes 6 months
- Provision and design of bridges
- The need for immediate dentures
- The timing of dental implant placement
Drugs that affect bone remodelling
- Bisphosphonates
- Denosumab and anti-angiogenic drugs
- Steroids
- NSAID’s
- Are a non-metabolised analogues of pyrophosphate that are capable of localizing to bone and inhibiting osteoclastic function
which drug is being described
bisphosphonates
why can high concentrations of bisphosphonates be maintained within bone for long periods
bisphosphonates are not metabolised therefore these high concentrations are maintained within bone for long periods of time (approximately 10 years)
- What is the pathway of endochondral ossification?
Cartilage -> calcified cartilage -> bone
- Which of the three bone cells is derived from a haemopoietic source and is large multinucleate cell
Osteoclasts
- What is the name given to trapped osteoblasts?
Osteocytes
- Bone turnover is a continuous remodelling cycle that involves resorption and deposition, which helps keep the skeleton effectively engineered for its use and helps maintain Ca2+ levels. How long does it take bone to be completely replaced?
10 years
- How much calcium is in our body?
1kg calcium in body. 99% in bones and teeth and 1% in body fluids.
- What are the 7 roles of calcium in our body?
- Membrane permeability
- Excitation – contraction coupling
- Excitation – secretion coupling
- Hard tissue formation
- Blood clotting
- Enzyme reactions
- Secretions – e.g. milk
- Which gland is stimulated by increasing plasma calcium?
Thyroid gland
- What is the name of the hormone that is released when there is an increase in plasma calcium levels, which gland releases it and what is the function of the hormone?
Calcitonin
Thyroid gland
Kidney increased Calcium excretion and bone stimulates calcium deposition
- Which gland is stimulated by decreasing plasma calcium?
Parathyroid gland
- What is the name of the hormone that is released when there is a decrease in plasma calcium levels, which gland releases it and what is the function of the hormone?
Parathyroid hormone
Parathyroid glands
Kidney decreases Ca excretion
Bone stimulates Ca release
- which hormone is responsible for preventing HYPOCALAEMIA?
Parathyroid hormones
- parathyroid hormones act quickly to breakdown small labile pools of CA2+ in bone, which involves osteocytes, the rapid breakdown in bone is known as?
Osteocytic osteolysis.
- Which vitamin is essential for the absorption of Ca2+ in the intestine?
Vitamin D
- Where would you be standing if you were extracting a lower right 6?
Standing behind the patient
- What push must you apply before you apply any buccal and back movements to remove a tooth?
Apical push
- What is the purpose of the upper cow horn/eagle beak forceps?
Designed for badly broken tooth, better engagement with the furcation of the roots.
- Name the forcep and its function?
lower universal forcep - capable of removing all teeth from the lower quadrants.
- Name the forcep and its function?
lower molar forcep - more specialised compared to the lower universal forcep through the conformation of the beaks.
- Name the forcep and its function?
lower cow horn forcep - used to engage with roots of badly broken tooth
which tooth would you typically use the lower universal forceps on
from 3- 3
- Name the forcep and its function?
upper universal forcep - can be used to remove all upper tooth, if roots are well enegaged
- Name the forcep and its function?
upper right and left molar forcep - used in correspondance for the extraction of upper molars. upper molars have two roots bucally and 1 root palatally.
What is the term given for infections arising from tooth tissue
odontogenic infection.
Caries,
peri-apical periodontitis,
periodontitis,
pericoronitis,
osteomyelitis,
maxillary sinusitis
are examples of what type of infection:
odontogenic infection.
Osteomyelitis is more common in the mandible or the maxilla?
Mandible
What is meant by sequelae:
a condition which is the consequence of a previous disease or injury. “the long-term sequelae of infection”
What are collagenases:
collagenases are enzymes that break the peptide bonds in collagen.
What is collagenases role in infection:
collagenase will help breakdown surrounding structures, to help facilitate spread
What type of patients are more likely to get spread of infection orally:
immunocompromised and diabetic patients.
How does someone having head and neck radiotherapy affect the spread of infection:
head and neck radiotherapy affects the local vasculature, which makes blood supply to the area compromised. Nutrients and host defence is delivered via the vasculature. If your vasculature is compromised then your most likely to have more significant infections, and consequence of infections.
What is the significance of the buccal, lingual plate in relation to the apex of the tooth, and the spread of infection?
The buccal and lingual plate are relatively thin and in close proximity to the apex, making the spread of infection easier to pass.
Why would antibiotic not work effectively when the source of infection is coming from a non-vital tooth?
The antibiotic needs to be delivered to the source of infection via blood vessels. A non-vital tooth will not have a vascular supply.
How many potential routes are there for a maxillary tooths spread of infection?
5 routes
- Buccal sulcus
- Buccal space
- Antrum space, maxillary sinus
- Nasal passage
- Palatal swelling
How many potential routes are there for a mandibular tooths spread of infection?
4 routes
- Buccal sulcus
- Submandibular space
- Sublingual space
A patient presenting with a large facial swelling, with very minimal collection of pus can be diagnosed as which condition?
Cellulitis
This patient Is showing symptoms of cellulitis, the spread of infection has spread to the orbital region, why is this worrying?
Patient Is showing signs of peri-orbital oedema, this will allow if not treated, the spread of infection to reach the cavernous sinus, which can result in cavernous sinus thrombosis.
What is cavernous sinus thrombosis?.
Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart
Where would you expect to find the collection of pus, in this patient with cellulitis?
The swelling presented on the patient Is from the body’s reaction to the infection. The pus location in cellulitis patients is commonly localised to the tooth responsible for the initial infection.
What would we be worried about if the spread of infection in the mandible was close to the laryngeal inlet?
The laryngeal inlet is the opening that connects the pharynx and the larynx. If the spread of infection was in this proximity, then we would be worried about asphyxiation.
What can cause mediastinitis?
If the spread of infection caused in the mandible region progresses inferiorly towards the pharyngeal inlet, and passes through either the pretracheal, prevertebral, or the retropharyngeal space, which ultimately leads down to the chest.
What Is Ludwig’s angina?
Ludwig’s angina is a rare but serious bacterial skin infection that affects your mouth, neck, and jaw. Considered a type of cellulitis, Ludwig’s angina spreads rapidly to infect the soft tissues underneath your tongue. This serious condition is more common in adults than children.
Sepsis should be defined as life threatening organ dysfunction caused by a dysregulated host response to infection. What are the symptoms of sepsis (from the lecture)
- Slurred speech
- Extreme shivering
- Passed no urine in a day
- Severe breathlessness
- Illness so bad they feel like they’re dying
- Skin mottled/discoloured/ashen
- Rash doesn’t blanch with pressure
- Cyanosis of lip/skin/tongue
Any patient presenting with sepsis will have a temperature of what?
Temp >38 degrees or <36 degrees
Any patient presenting with sepsis will have a heart rate of what?
>90 (high risk >130/min)
Any patient presenting with sepsis will have a respiratory rate of what?
Respiratory rate >20 (high risk >25 breaths /min)
Any patient presenting with sepsis will have a WCC of what?
WCC >12 or <4
Any patient presenting with sepsis will have a BP systolic of what?
BP systolic <100 (high risk <90)
How would you manage sepsis before giving antibiotics?
Take blood cultures ideally before antibiotics to determine causative pathogen.
What is a serum lactate test?
This test measures the level of lactic acid, also known as lactate, in your blood. Lactic acid is a substance made by muscle tissue and by red blood cells
A lactate result of >2mmol/l would indicate what?
Would indicate sepsis as the normal value is 1.5 mmol/l
Principles of management of odontogenic infection: how would eliminate the cause of the infection ASAP?
Extirpate the pulp or extract the tooth.
How would you provide a path of least resistance for pus?
Incision and drainage.
How long would you weight to review your patient after local measures were practiced for an odontogenic infection?
48-72 hours.
If you have eradicated the source of odontogenic infection, would it be appropriate to prescribe antibiotics for management?
No – unless patient is immunocompromised.
If an odontogenic infection produces pus, and can track through the alveolus, it will eventually erupt through the mucosa causing a?
communication between the end of the tooth and oral cavity, allowing for pus to discharge from this tract.
This communication is currently lined with granulation tissue, which is not yet epithelialized meaning it is a sinus. When a sinus is formed what does this tell us about the stage of the infection?
Because it has not epithelialized it is been there for a long time, therefore it is a chronic infection.
Which tooth is responsible for the formation of the sinus?
The lateral incisor as the apex of the canine root is positioned much higher than the sinus.
Due to the positioning of the apex of the tooth in relation to the bone and overlying muscles allows the pus to track back extra orally through the skin, this results in the formation of a?
orocutaneous fistula.
What is a fistula?
Is an epithelial line tract connecting two body cavities.
Erosion of bone caused by a build up of pus above the attachment to buccinator, most commonly maxillary molars result in what type of infection?
Buccal space infection.
Which blade would be used for incising through mucosa and periosteum for pus drainage?
No 11 blade
What is a culture sensitivity testing?
During the incision of a swelling, puss is drained and then collected and sent away for culture, to determine the pathogen responsible, so a specific antibiotic can be given for treatment.
Most abscesses are anaerobic, which antibiotic would be recommended?
Metronidazole AB of choice.
If there is a severe infection how would you prescribe antibiotic for general measures?
Combine metronidazole and penicillin V in severe infections.
Why are we trying to move away from prescribing amoxicillin?
Because it is a broad-spectrum antibiotic. We tend to use a narrow spectrum antibiotic such as penicillin V.
Which method is used to break down the locules of puss?
Hiltons method
Elevators are known as?
Couplands
How many sizes do couplands come in?
3
1 being the narrowest and 3 being the broadest
What are couplands used for?
Used to facilitate extractions by widening the neck of the tooth, can also be used to elevate tooth as well.
What is the difference between a couplands and a luxator?
A luxator is only used to facilitate extractions by widening the socket, through an axial movement.
How many forms are there to warwick james?
Three forms, left right, straight.
When would the removal of retained roots become a surgical procedure?
Retained roots below the alveolar bone, so no point of application for elevators.
What is meant if you have an ectopic tooth?
A tooth that is in abnormal place.
What is the definition: occurs when there is prevention of complete eruption into a normal functional position due to lack of space or development in an abnormal position. This predisposes to pathological changes. this can involve only soft tissues or hard and soft tissues.
– impaction.
If a tooth is malpositioned due to congenital factors, then it is referred to as?
Ectopic
If a tooth is malpositioned due to presence of pathology, then it is referred to as?
Displaced
When a tooth is entirely covered by soft tissue and partially/totally covered in alveolar bone, it is referred as?
Completely unerupted.
When a tooth does not erupt or fully erupt because it has fused with alveolar bone, this is known as?
Ankylosed.
Arrange in order of commonest affected teeth that are impacted
- Maxillary canines
- Mandibular premolars/canines
- Maxillary third molars
- Mandibular third molars
- Maxillary incisors
- Mandibular third molars
- Maxillary canines
- Mandibular premolars/canines
- maxillary incisors
- maxillary third molars
Which guidelines is used for the removal of third molars?
National institute of clinical excellence (NICE) 2000
What is the most common indication found to remove mandibular third molars?
Pericoronitis (8-59%)
Which tooth had a higher risk of unrestorable caries which justified the removal of the mandibular third molar the 8 or 7?
Unrestorable caries 8= 7% 7= 42%
By allowing the mandibular third molar to erupt in its impacted position, can later result in what for the 7’s?
it can result in the development of unrestorable caries.
In which situation would you have the mandibular third molars prophylactic removal in medically/surgically compromised patients?
Patients undergoing head and neck radiotherapy may want the third molars removed to prevent problems arising in the future.
Why would having a transplant be an indication for the removal of third molars?
Being a transplant patient would make you immunocompromised, and having an impacted molar may result in pericoronitis, causing infection. For someone who is immunocompromised, pericoronitis needs to be prevented.
Where is the third molar commonly transplanted after extraction?
1st molar position
What is orthognathic surgery?
an operation to reposition the jaws. The operation aims to correct imbalance between the upper and lower jaws which will enable the teeth to bite together correctly; this also has the benefit of balancing and enhancing the facial appearance.
any tooth in the fracture line (fractured mandible) would be rendered as what?
Non vital
what is an operculum?
Is a flap of gum tissue over a partially erupted tooth.
Treatment of pericoronitis can involve local or general measures, if the patient is systemically well which measure would you use?
Local measures
What would be the local measure treatment for pericoronitis for mandibular third molars?
- Irrigation – warm saline water
- Oral hygiene measures
- Remove trauma if evident i.e. extract upper 8 or grind down cusps.
What would be the general measure treatments for pericoronitis for the mandibular third molar?
- Analgesics
- Antibiotics if systematically unwell/immunocompromised
- Admission in severe airway threating cases
Is pericoronitis predominately anaerobic or aerobic disease?
Anaerobic
Winters lines are used for radiographic assessment when removing impacted mandibular third molars.
What do the colors of the of the winters line represent?
White = occlusal plane.
Yellow = bone level
Red = application point for elevator
There are four possible angle of impaction of the mandibular third molars, what are they and which two are the most common?
- Vertical – 30-38%
- Mesial – 40%
- Distal – 6-15%
- Horizontal – 3-15%
radiographic signs of close relationship between the lower third molar and the IDC, can be identified name the 6 radiographic signs that determine a close relationship.
- Diversion of IDC
- Darkening of root as it is crossed by the IDC
- Loss of Lamina dura of IDC
- Narrowing of IDC
- Deflection of roots of lower third molars as they approach the IDC
- Juxta apical area
Why does the darkening of the M3M root determine a close relationship with the IDC?
If the root has crossed the IDC then it has relatively less mineralized tissue, which would show as darken roots on the radiograph.
a well-defined area of radiolucency that is apical or lateral to the roots of mandibular third molars is known as a?
juxta apical area.
Which type of X-ray would you do, to determine the close relationship between the IDC and the M3M?
CBCT
what would this image suggest in a radiographic assessment?
- The yellow lines indicate the lamina dura of the roof and floor of the IDC.
- both lines cross the roots of the 8’s
- the yellow lines are uninterrupted and haven’t changed in their appearance, when they cross the roots and no change in radiolucency in the roots.
- no narrowing or deviation of the canal.
- in third dimension this would be demonstrated at as super imposition.
what would this image suggest in a radiographic assessment?
You can see that there is a loss of lamina dura as it crosses the roots of the tooth.
A loss of the lamina dura can indicate a close relationship
Because of the close relationship, there is no/very little bone between the IDC and the M3M roots, and upon removal this can cause bruising/crushing of the canal, leading to altered sensation.
What would this image suggest in a radiographic assessment?
Loss of lamina dura as they cross the canal
Change in radiolucency in the roots, darkens where the canal crosses.
what can you make out from this radiograph?
The third molar is impacted at the level of the alveolus
The roots of the M3M are very bulbous.
Adjacent tooth has very poor prognosis, due to poorly root treated.
The relationship between the impacted M3M shows that the canal has become narrower and removing this tooth would suggest that there is a likely chance of altered sensation.
How come not all IDC appear on a radiograph?
Due to the positioning of the IDC on the mandible
- Lamina dura are visible when they sit in cortical bone and are formed through the cortex.
- If the IDC was to sit in the medullary bone, then it won’t be as mineralised (centre of the mandible).
What is the most common procedure that results in altered sensation of the lower lip and tongue?
Implant placement.
Which nerve can you not see on a radiograph, thus not assess the risk of altered sensation?
Lingual nerve.
Why do we have to give general figures for assessing risk of altered sensation for the tongue when compared to figures for altered sensation of the lip?
Because we cannot view the lingual nerve on a radiograph it is difficult to give a figure, so a general figure is given.
Post-operative alteration in sensation: what are the short term and long-term figures for both lip and tongue altered sensation?
Lower lip
Short term – 5%
Long term – 1%
Tongue
Short term – 10%
Long term – less than 1%
Taste can be affected.
Patients who under-go short term altered sensation of the lower lip are likely to return to sensation when?
A period of weeks and months
In the long term of altered sensation of the lower lip, if a patient has not recovered from altered sensation within a 12-18 months, what is the likely hood of recovery?
Very unlikely.
Which nerve branch is affected, if we lose the sensation of taste?
The chorda tympani branch on the lingual nerve.
What was the main suggested reason for short term loss of sensation of the tongue, preoperatively?
The use of instruments such as lingual retractors, are known to cause bruising of the lingual nerve.
Which alternative surgical procedure would you carry out, if there was a high risk to the IDN when extracting a M3M?
coronectomy.
What are the complications of coronectomy?
- If the roots are mobile at the time of coronectomy, they need to be removed.
- Post op infection of the roots (2.9%)
- Post operatively there is a risk of migration of the roots 14-81%.
this is a post op radiograph of a coronectomy. It shows that the mesial aspect of the enamel has been left, why would this cause a problem?
Bone cannot form on enamel, as it cannot be rendered interalveolar. So, this will mean that the bone will not heal properly causing more problems.
migration of retained roots has been reported in most coronectomy studies, and all patients should be warned of this phenomenon. The root may eventually erupt harmlessly to the mucosal surface. Current experience indicates that most roots migrate away from the IDN along the axis of the root. Neither migration nor eruptions are indications for surgical intervention unless?
The roots reach the mucosal surface and become symptomatic.
A CBCT compared to traditional DPT has a higher radiation dose and financial cost, thus a CBCT should not be used routinely in the radiographic assessment of a M3M. when can they be used?
Where conventional imaging has shown a close relationship between the M3M and the IAN canal, CBCT may be considered in carefully selected cases where the findings are expected to alter management decisions.
Verbal and written warnings should be entered into the notes before getting consent for a surgical procedure, who must witness this being done?
Nursing staff as witness
If a patient decides to decline treatment, what must they be informed of?
Likely long-term problems.
We must warn patients of post-operative complications with a greater than % incidence?
5%
When removing a tooth, the general principle/assessment is made on the radiograph, what are the 5 points planned from a radiograph?
- What would be the path of eruption (whats stopping the tooth from eruption)
- Intrinsic (tooth morphology)/extrinsic (canal, tooth) obstacles to be removed
- Required bone removal
- Point of application
- Flap design (the first thing you do)
the path of withdrawal of this M3M is indicated by the blue arrow. What is indicated by the green x’s?
the green x’s represent the extrinsic obstacles. Which happen to be the adjacent tooth and the overlying distal buccal bone.
The path of withdrawal of this M3M is indicated by the blue arrow. What is indicated by the blue dotted lines and the line?
Bone removal for the blue dotted line, this bone removal must be wide enough to remove the widest part of the tooth. The red line indicates the point of application for your elevators.
The mucoperiosteal flap, is referred to as what type of flap?
Triangular flap based on its design.
How many layers is the mucoperiosteal flap made of?
2 layers one is made of mucosa, which is very elastic vascular layer. Second is a periosteum layer which is an inelastic collagenous layer.
This image shows the markings placed to perform a triangular flap, what do each number represent for this technique.
- Distal reliving incision landmark = ascending ramus
- Peri-coronal incision cutting through the alveolar crest fibres includes the papilla between the 3m and 2m
- Mesial reliving incision down from the 2M to the depth of the sulcus
What would be the indications for creating an envelope flap?
If you have a peri coronal pathology such as a cyst or if you are unsure about how much bone you have to remove to take the tooth out.
This image shows the markings placed to perform an envelope flap, what do each number represent for this technique.
- Distal reliving incision landmark = ascending ramus
- Peri-coronal incision cutting through the alveolar crest fibres round the 3m and all around the 2m
How does peri-coronal incision differ from a triangular flap to an envelope flap?
The peri-coronal incision for the triangular flap does not extend pass the 2M compared to the envelope flap where it extends pass the 2M.
What would use so that bone does not overheat when using burs to surgically remove 3M?
saline
What are burs used for, in the removal of tooth surgically?
- To relive impaction
- Create a point of application
- Remove bone with round bur to create a narrow gutter mesiobuccally avoiding adjacent roots.
If a tooth is horizontally impacted, what must you always do what when removing the tooth?
Section the crown off.
Often, we must cut the crown off to disim-pact the tooth, what does this minimise?
Bone removal.
If you have multirooted tooth, what must you do to the furcation in order to remove the individual roots?
Divide the furcation
What is the ideal suture material to be used?
3/0 viceryl rapide
Which is the most important to suture to place after removing m3m?
the most important suture is the one placed from the buccal tissues to the lingual tissues immediately distal to the second molar tooth to encourage good periodontal health
What is the second most common impacted tooth?
Maxillary canines
What is the prevalence of impacted maxillary canines?
1.7% – 2%
80% of the impacted canines are found ectopically palatally or buccally?
Palatally
Why is it more common for the impacted maxillary canine to ectopic palatally more than buccally?
That is because of the tooth germ of the permanent canine originates on the palatal aspect of the arch.
At what age can you palpate the maxillary canines in the labial sulcus (before eruption)?
10-11 years
The aetiology of canine impaction is ultimately a result of lack of space, there are two theories that suggest this. The guidance theory described by Becker et al, in 1981 suggests which tooth and aspect is the guide for canine eruption?
Becker et al suggests that the distal aspect of the lateral incisor is the guide for canine eruption.
The aetiology of canine impaction is ultimately a result of lack of space, there are two theories that suggest this, the genetic theory described Peck et al, in 1994, considers the dental anomaly of impacted canines to be a product of what?
Polygenetic multifactorial inheritance.
Canines have the longest path of eruption, how long is the path?
22mm
Why would you use horizontal parallax?
You would use horizontal parallax to localise canines. This is done by taking periapical radiographs of the canine in question and positioning the beam in a different direction and the impacted canine would move in the same direction.
What does this sectional DPT show?
- Impacted upper right canine
- Retained deciduous canine
- The right canine seems to be overlapping to the root of the lateral incisor
- Lateral incisor is rotated
What is the follicular space?
The dental follicle is an ectomesenchymal tissue that surrounds the developing tooth germ. In a radiograph, it is seen as a normal homogeneous radiolucent space around the crown of a developing tooth and is known as the follicular space
The follicular space in this radiograph suggest that It is bigger than normal, what can be deduced from this?
The increase size in the follicular space can suggest that the impacted canine tooth is undergoing cyst formation.
What is a dilacerated tooth?
Dilaceration is an abnormal bend in the root or crown of a tooth. Although the root is affected most frequently, the bend may occur anywhere along the length of the tooth and has been noted in various teeth throughout the dentition.
What is the treatment plan for a dilacerated tooth if it is pathology free?
Left alone
Leaving the impacted canines alone is a possible treatment option, however this may cause complications later. How would leaving an impacted canine affect the roots of the lateral incisor?
Resorption of incisor roots – incidence unknown up to 12.5%
Whenever we lift a mucoperiosteal palatal flap it is always a good idea to make what for the patient?
An acrylic palatal plate used as a dressing, held by an Adams cribs.
How long is the acrylic palatal plate, used as a dressing kept in for?
1 week
This is a canine from a buccal approach, for the purpose of aesthetics, a close technique is being used. This is the same style of flap that is raised as the palatal approach, once you expose the crown of the canine, you dry it and etch the surface and bond an orthodontic bracket. These gold orthodontic brackets commonly have a gold chain attached to them, and once the flap is sutured back on, the gold chain is visible from the wound. This will allow for the orthodontic to hook it up to the fixed appliance.
What is the advantage of using this closed technique?
It makes the physiological eruption of the canine at the gingivae giving you a good contour.
What is the third most impacted tooth?
Maxillary incisors
Aetiology of delayed incisor eruption can be a result of either hereditary or environmental factors, which are the most common factors from both categories?
Hereditary = supernumeraries
Environmental = trauma (common in children)
When a patient presents with delayed incisor eruption, we would typically do a history and examination, what would be look for during the clinical examination?
- Retained deciduous teeth
- Palpable buccal/palatal mass
- Lack of space
- Erupted mesiodens/supernumeraries
What are mesiodens?
Mesiodens is a supernumerary tooth present in the midline between the two central incisors. It usually results in oral problems such as malocclusion, food impaction, poor aesthetics, and cyst formation
If you want to locate the impacted incisor in three dimensions, which radiographic technique would you use?
Parallax
What are the 5 management options for impacted teeth?
- Conservative – do nothing (not the best option when aesthetic is in question)
- Interceptive – extract
- Exposure
- Removal
- Transplantation – common for canines
Which technique is preferred when managing the canines through the exposure procedure, the open or closed technique?
Closed technique.
The open technique for incisor exposure relies on which type of flap?
Apically repositioned flap for incisor exposure
How many flaps are there in a apically repositioned flap for incisor exposure?
3
Where are the relieving incisions made for an apically repositioned flap for incisor exposure?
Mesial and distal reliving incisions are made and a peri coronal incision.
Which technique is being demonstrated?
Closed exposure technique
What are the fourth most impacted tooth?
Mandibular premolars
Why do we approach mandibular premolars from a buccal aspect rather than lingually?
We always a buccal flap to getter better access, compared to lingual flap.
what are the complications that can arise from this unerupted premolar?
- If the premolar becomes superficial is creates a communication down the gingival crevices of the adjacent premolars to the crown of the impacted premolars, leading to caries.
- Cystic transformation of the follicular tissue, causing external root resorption.
- Caries
How would you describe the follicular space of the severely ectopic mandibular premolar?
Normal
what would be the treatment plan for the ectopic mandibular premolar?
Treatment plan would be a conservative approach
- There is no pathology present
- The follicular space is of normal parameters, so has not undergone cystic development
- A bridge can be placed in the space available to create function
these maxillary premolars may need to be extracted if oral hygiene is affected. Although they have fully erupted why can you not use forceps to extract them?
Elevators would need to be used to mobilise them to get them out because, you wouldn’t be able to get the beaks of the forceps on the labial surface of the tooth.
What type of flap would be used in the mandibular premolar region, for an open/closed technique?
2 sided mucoperiosteal flap.
Why would you want to be careful when doing the mesial relieving incision in to the sulcus?
So you can avoid the branches of the mental foramen.
Supernumerary tooth come in how many forms?
3
Supplemental tooth, is a form of supernumerary tooth, where is this tooth most found?
Commonly palatal in the maxilla.
Often conical supernumeraries between central erupt, are known as?
Mesiodens
How do Tuberculate supernumerary tooth cause problems?
Tuberculate tend not to erupt, but prevent eruption of adjacent teeth, therefore removal warranted often performed with incisor exposure.
This is a supernumerary tooth erupting between the central incisors, what is the form of this supernumerary tooth?
Mesiodens
Which form of supernumerary tooth look exactly like permanent tooth?
Supplemental tooth
What are odontomes?
An odontoma, also known as an odontome, is a benign tumour linked to tooth development. Specifically, it is a dental hamartoma, meaning that it is composed of normal dental tissue that has grown in an irregular way. It includes both odontogenic hard and soft tissues.
Odontomes come in the form of compound and complex what is the physiological differences between them?
Compound form is the result of a proliferation of the dental lamina, so compound odontomes look like a bag of teeth.
Complex form tends to be a disordered aggregation of dentine, enamel, cementum and pulp, so it doesn’t look like a tooth.
John a 9 year old attends with his mum who is concerned that one of John’s front teeth has not erupted yet and he is being teased at school because of this. The baby tooth fell out 1 year ago.
- Explain your clinical examination.
- How would you investigate this tooth?
- What is a common reason for delayed eruption of incisors?
- What are the treatment options?
Clinical examination
- Crowding
- Mobility of adjacent teeth
- Trauma
- Discolouring/chipping of adjacent teeth
- Palpate lingually and labially
- Palpate cyst
Investigate tooth
- Parallax radiographs – two periapical
Common reason for delayed
- Supernumerary teeth
- Odontome
- Trauma – tooth dilacerated
Treatment options
- Not conservative – child teased and bullied
- Interceptive – no because deciduous tooth fell out year a ago
- Surgical exposure – only if tooth is in a reasonable position and not badly dilacerated
- Surgical removal if tooth badly dilacerated or patient doesn’t want orthodontic treatment
- If surgical removal is chosen then long-term replacement is required (short term cantilever bridge, denture, after 18 implant).
12 year old Amanda still has a retained tooth 53. Mum mentions that she had the same problem. You decide to investigate.
- What films will you take?
- What causes failure of canine eruption?
- What are your treatment options if Amanda does not want orthodontic appliances?
- What can happen if you decide on a conservative treatment?
- How long will the deciduous tooth last?
- What options do you have of the deciduous tooth is removed?
Films to take – parallax with two periapical views
What causes failure of canine eruption – longest eruption path, trauma to deciduous tooth, abnormality of lateral incisor.
What are the treatment options if Amanda does not want orthodontic appliance? Surgical exposure might not be favourable without orthodontic intervention
What can happen if you decide on a conservative treatment – if tooth is high then you can leave the canine, assuming no pathology with teeth.
How long will deciduous last – 2 decades lucky if in 3rd decade
What options if tooth is removed – adhesive bridge, fixed fixed bridge, implant when older.
What does MOS stand for?
Minor oral surgery
Scalpels are held in which type of grip?
Standard pen grip
Which two scalpels are generally used for creating a surgical flap?
No 15 & No 11
what type of incision is this?
Crevicular incisions
What does the green part of the blade signify?
The cutting part of the blade.
What part of the blade should you use when making a crevicular incision?
The tip outlined by red
What does the blue line represent on the model?
Blue line represents where the crevicular incisions will be
If we do nothing more and have no relieving incisions and just the crevicular incision, what type of flap would this represent?
Envelope flap
with the addition of a relieving incision represented by the number 2 and a crevicular incision represented by 1, this gives rise to what type of flap?
two-sided flap
With the addition of two relieving flaps and a crevicular incision. What type of flap is created with these incisions?
Three sided flap
What is the basic principle of relieving incisions?
To get better access
Which type of flap gives the best access?
Three sided flap.
How many units should we extend the flap from the target tooth?
Extend one unit either side, a unit being a tooth.
In reference to planning what does this green arrow represent?
Path of withdrawal
What do the different colours represent?
Green = path of withdrawal
Red = point of application
Yellow = obstacle
Tooth removal involves 7 stages what are they?
- Path of withdrawal
- Position of instruments to elevate
- Identification of obstacles
- Methods to overcome obstacles
- Bone removal
- Incision
- Flap design
What must the base of the flap be when cutting it?
Broad
What must you ensure that the flap has so it doesn’t become necrotic?
Blood supply
Do you want tension to be present on the flaps?
Without tension
What must we include in the flap design, for the aid of suturing?
Papilla
Eruption of third molars generally occurs between which age?
18-24 years
What are the 5 common indications for the removal of impacted teeth?
- Pericoronitis
- Caries
- Periodontal disease
- The presence of a cyst
- External root resorption
What are the indications to retain impacted teeth?
- The tooth will erupt and be functionally useful
- If there is a high risk to the health of the patient
- If the tooth is deeply impacted with no associated pathology
- If the risk of surgical complications is judged to be too high e.g. if there is a high risk of fracture of an atrophic mandible
- Where the surgical removal of a single third molar tooth is planned under local anaesthesia extraction of asymptomatic contralateral teeth should not normally be undertaken.
What are the management of pericoronitis?
Irrigation underneath the operculum with chlorhexidine mouthwash or warmed saline
Eliminate trauma for the opposing cusps by grinding the cusps of extracting the opposing upper third molar
Advise on the use of analgesics and to keep hydrated
If there is a fluctuant swelling then incision and drainage to release the pus is appropriate using an IDB to avoid infiltrating into an area of acute infection
If the patient has systemic signs and symptoms then referral for admission for management with IV antibiotics
Review the situation to ensure there has been resolution of the problem
Assess the third molar radiographically by DPT if not already been taken
Advise the patient on the need for surgical intervention dependent upon clinical and radiographic findings
Assessment of the mandibular third molar from the DPT
How would you classify the depth of impaction?
Superficial, moderate, and deep.
Superficial – at the level of the crown of the second molar
Moderate – at the level of the ACJ of the second molar
Deep – at the level of the roots of the second molar
What type of impaction is being refereed?
aligned correctly but there is overlying bone (hard tissue impaction) or overlying soft tissue (soft tissue impaction) occurs in 30-38% of cases
– vertical
What type of impaction is being refereed?
the crown of the third molar is orientated towards the second molar 0ccurs in approximately 40% of cases
– mesioangular
What type of impaction is being refereed?
the crown of the third molar is orientated away from the second molar occurs in 6-15% or cases
– Distoangular
What type of impaction is being refereed?
the crown of the third molar is orientated at 90 degrees to the second molar occurs in 3-15% or cases
- Horizontal
What type of impaction is being refereed?
any other orientation that does not fit with the above
- Aberrant
the flap should be broad to maximise the blood supply and the reliving incision angulated to avoid what?
Avoid cutting across parallel blood vessels.
What are the most common post-operative complications (M3M removal)
- Pain
- Swelling
- Possible bruising
- Jaw stiffness/limitation of mouth opening (trismus)
- Risk of post-operative bleeding
- Infection
- Dry socket as third molars are commonest socket affected by dry socket
Compression injuries may occur during the elevation of a third molar with roots in close proximity to the mandibular canal.
Minor compression of the nerve will give rise to a temporary conduction block known as?
neurapraxia which usually recovers spontaneously over weeks to months.
Compression injuries may occur during the elevation of a third molar with roots in close proximity to the mandibular canal.
More severe compression or crush injuries cause the axon distal to the site of the injury to degenerate (Wallerian degeneration) and recovery of sensation is dependent upon regeneration of the damaged axons. This is known as?
axonotmesis
Complete section of the nerve trunk may occur if the inferior alveolar nerve penetrates the root of a third molar and is severed during tooth removal. This is known as?
neurotmesis.
This is the definition of which type of pain?
Absence of all sensory modalities.
Anaesthesia
This is the definition of which type of pain?
Diminished sensitivity to stimulation, excluding special senses.
Hypoaesthesia
This is the definition of which type of pain?
An abnormal sensation, whether spontaneous or evoked.
Paraesthesia
This is the definition of which type of pain?
Unpleasant abnormal sensation, whether spontaneous or evoked
Dysaesthesia
This is the definition of which type of pain?
An increased response to a stimulus that is normally painful.
Hyperalgesia
This is the definition of which type of pain?
Pain due to a stimulus that does not normally provoke pain.
Allodynia
What is a Mitchell’s trimmer used for?
is an effective periosteal elevator and can also be used as a curette to clean out sockets. The sharp pointed end can be used to release bands of scar tissue from the bone.
What is the purpose of a, A lac’s retractor?
Used to retract the tongue
What would you use to stop arterial and venous by clipping the bleeding vessel and crushing it?
A Spence-wells artery forceps.
This is a Rongeures, what is the purpose of this instrument?
Rongeures are also called bone nibblers, and these are used to remove small fragment or spicules of bone.
What is the name and purpose of this instrument?
Bone file, used to smooth down bone margins.
Vicrly rapide is a sterile surgical suture composed of a copolymer made from 90% glycolide and 10% L-lactide and is used as a general-purpose suture material for intra-oral surgery as it dissolves in 7-10 days.
4/0 material refers to the thickness of the thread – the higher the number the finer the thread. Prior to this material being used, black silk sutures were used which did not dissolve, why would we use this suture over the Vicryl rapide?
These are still used in situations when you want to avoid premature wound breakdown such as managing an OAC or to ensure that your patient returns for follow up.
Failure of eruption associated with maxillary permanent incisors teeth usually presents in the mixed dentition stage and is often noticed between the ages of?
7-9
Delayed eruption of the permanent maxillary incisor teeth can be considered in the following circumstances? (three)
- Eruption of the contralateral incisor occurred more than 6 months earlier
- The maxillary incisors remain unerupted more than one year after the eruption of the mandibular incisors
- There is a significance deviation from the normal eruption sequence (for example, lateral incisors erupting prior to the central incisors)
Several local factors have been associated with delayed eruption of the maxillary incisor dentition. These include?
- Early extraction or loss of primary teeth (with or without space loss)
- Prolonged retention of primary teeth
- Crowding in the upper labial segment
- Previous trauma
- Localised pathology (supernumerary teeth, odontomes, and more rarely cystic formation)
What are the two most common causes of delayed eruption of the maxillary incisors?
- Physical obstruction due to presence of supernumerary teeth or odontomes
- Trauma to the primary tooth, which may contribute to dilaceration of the permanent successor/s
When undergoing a clinical examination for the management of unerupted maxillary incisors, what are you looking out for?
- Identify any primary teeth retained significantly beyond their normal exfoliation dates.
- Spacing
- Rotations
- Displacement of permanent teeth
- Labial or palatal swellings (may indicate the site of unerupted incisor)
The majority of canines undergoing normal eruption should be palpable in the buccal sulcus by what age?
By 10 to 11 years
The main risk from ectopic canines appears to be root resorption of which tooth?
Usually the incisors.
During history and examination practitioners should suspect that a canine is ectopic if it is not?
If it is not palpable in the buccal sulcus by the age of 10-11 years.
Why is the minor oral surgery tray set up from left to right?
The set up is designed broadly from left to right based on how we are starting to where we are finishing.
What is the name of this equipment?
Towel clips
What is the name of this equipment and what is it used for?
Mckessons mouth prop, used to prop the mouth open.
What is the name of this instrument and its function?
Molt no. 9 periosteal elevator, used to elevate the flap.
What is the name of this instrument and its function?
Mitchell’s trimmer, just like the Molt no. 9 periosteal elevator, used to elevate the flap. The triangular end is used often for the stripping of attachments from bone.
What is the name of this instrument and its function?
Howarth’s nasal rasp/periosteal elevator. Used to elevate the flap
What is the name of this instrument and its function?
Minnesota retractor, used to retract soft tissues when operating
What is the name of this instrument and its function?
Bowdler-Henry rake retractor, used for mucoperiosteal flap retractor
What is the name of this instrument and its function?
Surgical suction
What is the name of this instrument and its function? Ficklings forceps
Holding soft tissue and manipulating it.
What is the name of this instrument and its function?
Rongeurs – bone nibbler, used to remove bone
What is the name of this instrument and its function?
Bone file – files the bone
What is the name of this instrument and its function?
Irrigating syringe/needle
What is the name of this instrument and its function?
Lacks retractor – multiple uses, more commonly used to retract the tongue
What is the name of this instrument and its function?
Kilners cheek retractor – cheek retractor
What is the name of this instrument and its function?
Tooth tissue forceps
Name the two scissors
Mcindoe – top
Iris – bottom
What is the name of this equipment?
Needle holder
Applied anatomy: the middle third facial skeleton defined by which landmarks superiorly, inferiorly, and posteriorly.
Superiorly
- Frontozygomatic
- Frontonasal
- Frontomaxillary
Inferiorly
- Occlusal plane upper teeth
- Alveolar ridge (edentulous)
Posteriorly
- Pterygoid plates sphenoid
The middle third facial skeleton consists which bones/structures
- Two zygomatic bones
- Two maxillae bones
- Two zygomatic process Temporal bones
- Two palatine bones
- Two nasal bones
- Two lacrimal bones
- Vomer
- Ethmoid (and attached conchae)
- Two inferior conchae
- Pterygoid plates of sphenoid
What are the horizontal buttresses of the face?
- Superior orbital rim
- Inferior orbital rim
- Maxillary alveolus
- Palate
- Serrated edges greater wings of sphenoid
- Zygomatic arches
What are the vertical buttresses of the face?
- Nasomaxillary
- Zygomaticomaxillary
- Pterygomaxillary
What are the sagittal buttresses of the face?
- Zygomatic arches
- Palate
- Floor of orbit
what is meant by buttresses?
A structure placed against the base of another to support or stabilize it.
Which mid face structures have a low tolerance to impact?
- Nasal bones least resistant
- Zygomatic arch directly
- Maxillae – horizontal forces
Where would a Le fort 1 fracture take place?
Le fort 1 - Mobility of the maxilla; maxilla is free from the rest of the facial bones (floating palate)
Le fort 2 - Mobility of the maxilla and nose as a combined segment.
Le fort 3 - Mobilized segment to include the maxilla, nose, and zygomas.
this is a lateral aspect of which le Fort fracture line
Le Fort 1
this is a lateral aspect of which le Fort fracture line
Le Fort 2
this is a lateral aspect of which le Fort fracture line
Le Fort 3
What would be the initial management steps taken for midface trauma?
- Airway management
- Controlling any haemorrhage
- Head injury assessment
- Secondary survey – facial fracture survey (which type)
For the airway management, when assessing someone who has had a midface trauma, what will you be wanting to look out for?
- Physical anatomy changes – displacement of the maxilla and the lower face height.
- Swelling – local oedema
- Bleeding
- Foreign body
- Loss of consciousness
- Head injury and respiratory depression
Where would you expect to see the haemorrhage coming from in a midface trauma?
- Maxillary artery
- Nasal walls
- Retrobulbar haemorrhage
- Septal haemorrhage
How would a head injury be assessed when someone has had a midface trauma?
Glasgow coma scale
What are the three parameters the Glasgow coma scale uses?
- Eye opening (E)
- Verbal response (V)
- Motor response (M)
What is the Glasgow coma scale range measured from?
3-15
What would someone have to score to be brain dead/normal on the Glasgow coma scale?
3 = brain dead, 15 = normal.
These presentation and clinical findings determine which type of fracture?
- Mobility of tooth-bearing segment of the upper jaw
- Crepitus in buccal sulcus
- “Cracked-pot” percussion note from upper teeth
- Intra-oral haematoma in buccal sulcus
- Palatal haematoma?
- Fractured teeth cusps
- Bruising of upper lip and lower mid-face
- Occlusal discrepancy
- Anterior open bite tendency
- Dentures nor fitting
Le Fort 1
These presentation and clinical findings determine which type of fracture?
- Bilateral peri-orbital bruising (“panda eyes”)
- Subconjunctival haemorrhage
- Lengthening of face
- Malocclusion - AOB
- Gross oedema of face
- Nasal deformity
- CSF rhinorrhoea
- Diplopia and other visual problems
- Mobility of the upper jaw
- Palatal haematoma
Le Fort II/III
This CT scan shows which Le Fort Fracture?
Le Fort 1
This CT scan shows which Le Fort Fracture?
Le Fort 2
This CT scan shows which Le Fort Fracture?
Le Fort 3
This CT scan shows which Le Fort Fracture?
parasagittal view Le Fort 1 – anterior of maxilla, sectioning through margin of the maxillary sinus.
This CT scan shows which Le Fort Fracture?
Axial view of a Le Fort 2 – disruptions around the orbital region
This CT scan shows which Le Fort Fracture?
coronal view of a Le Fort 2 – disruption on the infraorbital region
what is the management for a patient when they have become stable after a facial trauma?
Aim is to restore normal functions such as:
- Ocular
- Nasal
- Oral
- Dental
- Aesthetics
What is panfacial bone fracture?
Panfacial bone fractures are defined as facial fractures simultaneously involving the upper, middle, and lower thirds of the face.
Fractures of the frontal bone, maxilla, zygomatic complex, nasoethmoid-orbital (NEO) region, and mandible are the most common
How would you reduce a fracture?
Disimpaction, using allot of force on impacted bone to force them back to original place.
which fracture is being fixed?
Le Fort 1
which fracture is being fixed
Le Fort 2
Which forceps would you use for disimpaction of the maxillary following facial trauma?
Rowes maxillary.
which fracture is being fixed?
Le Fort 3
What is ORIF?
Open reduction and internal fixation (ORIF) are a type of surgery used to stabilize and heal a broken bone
How does open reduction differ from closed reduction?
During an open reduction, orthopaedic surgeons reposition your bone pieces during surgery, so they are back in their proper alignment.
In a closed reduction, a healthcare provider physically moves the bones back into place without surgically exposing the bone.
What is referred to internal fixation?
Internal fixation refers to the method of physically reconnecting the bones. This might involve special screws, plates, rods, wires, or nails that the surgeon places inside the bones to fix them in the correct place. This prevents the bones from healing abnormally.
Which is the largest of the paranasal sinuses?
Maxillary sinuses
Can sinus pathology present in the mouth?
Yes
What is the most common peri-operative complications with the maxillary sins?
Development of an OAC.
What can sinusitis present itself as orally?
Tooth ache.
Why can sinusitis mimic as toothache?
The bacterial infection that has caused the sinusitis, results in the inflammation stimulating the trigeminal maxillary division nerve.
How many paranasal sinuses are there?
Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity.
The maxillary sinuses are located under the eyes;
the frontal sinuses are above the eyes;
the ethmoidal sinuses are between the eyes and the sphenoidal sinuses are behind the eyes
What are paranasal sinuses lined by? .
Ciliated epithelium
Why is the draining ostium significant in the spread of sinus infection?
The draining ostium are all in proximity of the paranasal sinuses, so if there was an infection in one sinus, it can easily spread to the other.
What is the relevant importance of the maxillary sinus in dentistry?
- Roots of the upper molars/premolars closely related to the antrum and share a common innervation
- Dental procedures complicated by problems involving the antrum such as OA communication, roots in antrum, fracture tuberosity, extruded root canal materials
Infective sinusitis is more commonly viral or bacterial?
Viral 60-70% of the time.
How would manage a patient suffering from acute sinusitis who is normally fit and healthy?
Mucolytics, inhalations for 2 weeks.
How much penicillin v would you prescribe to an immunocompromised patient suffering from acute sinusitis?
500 mg 4 x a day for 7 days
How much Doxycycline would you prescribe to an immunocompromised patient suffering from acute sinusitis?
100mg 1 x a day for 1 week, 200mg for a loading dose on the first day.
What causes mechanical obstruction of the ostium that causes sinusitis?
- Oedema of nasal mucosa
- Polyps
- Septal deviation
What is an antral lavage:
this is a procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus allowing irrigation.
What is an intranasal antrostomy?
A procedure in which the patency of the ostium is increased.
If a communication is greater than 5mm, what would happen to it in terms of closing?
Most likely it won’t close, communications less than 5mm will close.
Extraction of which tooths can result in an Oro-antral communication?
Primarily the molars, can also be the premolars too.
If an Oro-antral communication is not recognised early on, what can get develop in to?
Oro-antral fistula
When does an Oro-antral communication become an Oro-antral fistula?
This occurs when the communication becomes lined with epithelium, resulting in an epithelial tract that runs through two bodies of cavity.
How common are Oro-antral communications?
Up to 10% of upper molar extractions the 1st molar being the most common.
What happens to the sinuses at advancing age?
The sinuses get bigger (ages over 40)
What are the risk factors for the development of an Oro-antral communication?
- Large sinus
- Large and unfavourable shaped roots extending into the sinus
- Dry socket or poor healing
- Being older (over 40)
- 1st and 2nd upper molar teeth extraction
- A difficult extraction
- Infection, abscess or cysts associated with the tooth being removed
- Periodontal disease (significant bone loss)
- Hypercementosis – an excessive build up of cementum, which gives the tooth a fat appearance
If you have managed to discover that the patient has an Oro-antral communication, how would you go abouts managing the patient?
- Notify the patient of the development of this (you should have made them aware before treatment)
- Ideally close immediately – buccal advancement flap
- Place a saline soap gauze before taking alginate impression to create a plate or modified denture. (Only possible if technician is onsite)
- If in primary care and you cannot provide a buccal advancement flap or plate/modified denture, then it is important that sinusitis is prevented, patients can be prescribed antibiotics, ephedrine drops, mucolytic inhalations.
- If communication of greater than 5mm spontaneous closure unlikely.
- Review the patient at 1 week
How does ephedrine drop work?
Nasal drops, which help to shrink the mucosa, which don’t become distended, this prevents the ostium from becoming blocked.
What would blowing your nose do, if you have had surgical management to close an Oro-antral communication?
By blowing your nose you increase the pressure in the maxillary sinus, this pressure would come through orally, which can tear the sutures.
What are the two likely alternatives to an advancement flap?
- Palatal rotation flap
- Buccal fat pad
What are the negatives of the palatal rotation flap?
- Requires 2 surgical procedures
- Not well tolerated by patients
If you have a large Oro-Antral Communication, which technique would you use BEST to close the communication?
Buccal fat pad
Which technique is being used to cover the OAC?
Palatal rotation flip.
With the buccal fat pad technique, can you only use the fat pad to close the OAC?
With the Buccal fat pad technique, if possible, you can close the OAC completely with fat pad alone, however this technique still allows you place an advancement flap over the buccal fat pad.
What would be the technique used to manage this small OAF (fistula)
Managed by excising the fistula tract and a buccal advancement flap to close primarily as per OAC
The Caldwell-luc operation requires you to gain access to the maxillary sinus, this technique does not allow you to gain access through the breached OAC. How do you get access to the maxillary sinus?
The Caldwell-luc technique gives you access by drilling through the canine fossa, this procedure requires GA.
What is an antrostomy?
The surgical formation of an opening into an antrum.
What would you feel with your supporting hand if you fractured the tuberosity when extracting a last standing molar?
Sudden loosening of the tooth and bone together.
What may the patient complain of if you have fractured the tuberosity whilst extracting a molar?
Patient may complain of sharp pain at the time of fracture or may be completely asymptomatic. If sinus perforation has occurred and diagnosis is delayed, the patient may complain of reflux of fluids from mouth to nose, sinus stuffiness, or present with overt sinusitis.
What are the management plans for a fractured tuberosity?
For a small fracture without sinus perforation: dissect the segment from gingiva and periosteum and suture.
For a small fracture with sinus perforation (less than 3 to 4 mm): dissect the segment and close the socket primarily
Practice exam questions
A patient attends in pain from a carious lone standing tooth 18. Medically he has atrial fibrillation and takes rivaroxaban. He is also a heavy smoker.
What are in the implications of the medical history?
What are the implications of the smoking history?
What pre-operative warnings would you give the patient?
How would you achieve anaesthesia?
What post-operative instructions would you give him?
What forceps would you use and why?
What are in the implications of the medical history? – patient has AF and takes rivaroxaban, increased risk of bleeding. (if patient takes drugs in morning, then request not to take it in morning and 4 hours after procedure). Pack socket with haemostatic pack and suture with resorbable sutures.
What are the implications of the smoking history? Increased risk of a dry socket (not smoke for 48 hours day of and day after)
What pre-operative warnings would you give the patient? – post op pain, diet, modification of oral hygiene regime, OAC, Risk of bleeding, risk of dry socket (how is all this managed)
How would you achieve anaesthesia? – buccal and palatal infiltration lidocaine
What forceps would you use and why? – upper right molar forceps pointed beak on buccal surface which indicates two roots.
What post-operative instructions would you give him?
- No exercise
- No alcohol
- No smoking
- No eating whilst numb
- Risk of bleeding – cope with bite packs (20 mins try twice if not worked first time)
- Help if there are problems
- Simple analgesics
- Hygiene measures
One week after the extraction your patient returns complaining that they have a bad taste, pain over their right cheek and a horrible smell. When they drink fluid comes down their nose. You looked in his mouth and the socket is still open and there is no clot.
- What is your diagnosis?
- How should this be managed by you?
- What will happen if it is not managed?
- Who should you refer the patient to and what would they offer the patient?
- The patient asks could this have been avoided and do they have a claim for negligence?
- What is your diagnosis? OAC (if patient had come 2 -3 weeks later it would have developed into a fistula)
- How should this be managed by you? – explain what has happened, infection (acute maxillary sinusitis), prescribe antibiotics post covid penicillin v 500 mg 4x a day 5 days, epinephrine nasal drops to encourage drainage of the sinus and inhalations to help with drainage of the maxillary sinus by opening the ostium.
- What will happen if it is not managed? Develop to chronic maxillary sinusitis, develop to fistula
- Who should you refer the patient to and what would they offer the patient? - Dental hospital
- The patient asks could this have been avoided and do they have a claim for negligence?
No risk at OAC
Communication occurred due to secondary loss of blood clot
what is the name of the structure labelled A
A = condylar head, leading to the condylar neck
what is the name of the structure labelled B
B = coronoid process (attached to the ascending ramus)
what is the name of the structure labelled C
C = coronoid/mandibular notch (beneath this area is called the ramus of the mandible)
what is the name of the structure labelled D
D = oblique ridge
what is the name of the structure labelled E
E = angle of the mandible
what is the name of the structure labelled F
F = mental foramen (mandibular division of the trigeminal exists to innervate the lip
what is the name of the structure labelled G
G = symphysis of the mandible is at the midline, the yellow lines indicate the para symphysis, the orange lines indicate the body of the mandible.
There are 4 muscles of mastication, what are they?
- Temporalis
- Lateral pterygoid
- Medial pterygoid
- Masseter
how common are fractures of the mandible?
Second commonest after nasal fractures, 10th commonest of all bone in the body.
There are 5 types of fractures what are they?
- Simple
- Compound
- Comminuted
- Greenstick
- Pathological
Describe a simple fracture:
A simple fracture is a result of excessive force or impact on the bone, resulting in a break, but has not been displaced.
What is a compound fracture?
An open fracture, also called a compound fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. Most often, this wound is caused by a fragment of bone breaking through the skin at the moment of the injury.
What is a comminuted fracture?
Comminuted fractures are a type of broken bone. The term comminuted fracture refers to a bone that is broken in at least two places
What is a greenstick fracture?
A greenstick fracture occurs when a bone bends and cracks, instead of breaking completely into separate pieces. The fracture looks similar to what happens when you try to break a small, “green” branch on a tree.
Mandibular fracture site description, name the location of the fracture. A
A = dento-alveolar
Mandibular fracture site description, name the location of the fracture. B
B = condylar – neck and angle (point of weakness)
Mandibular fracture site description, name the location of the fracture. C
C = coronoid
Mandibular fracture site description, name the location of the fracture. D
D = ramus
Mandibular fracture site description, name the location of the fracture. E
E = angle – 3rd molar
Mandibular fracture site description, name the location of the fracture. F
F = body – canine tooth
Mandibular fracture site description, name the location of the fracture. G
G = parasymphysis
Mandibular fracture site description, name the location of the fracture. H
H = symphasis
Which sites would you expect to see fractured in a guardsmen fracture?
A guardsman fracture, also referred to as parade ground fracture, is one of the common forms of mandibular fracture which is caused by a fall on the midpoint of the chin resulting in fracture of the symphysis as well as both condyles
Name this type of fracture and why its presentation is like this?
This fracture occurs when you have bilateral parasymphysis fracture, and the muscles of the mylohyoid, genioglossus, and digastric all pulling the anterior segment down backwards, producing this what looks like a bucket handle fracture
What are the extra oral clinical features of mandibular fractures?
- Pain
- Swelling
- Bruising
- Trismus
- Concurrent soft tissue injury – cut lip, tooth fragment
- Otorrhoea external auditory meatus tear may accompany condylar fractures
- Anaesthesia/paraesthesia of lip
What are the intra oral clinical features of mandibular fractures?
- Haematoma in the floor of the mouth (Coleman’s sign) & buccal mucosa
- Malocclusion
- Tongue – stable position, swelling
- Step deformity – displacement of fracture
- Gingival laceration
- Mobility or loss of teeth – teeth inhaled, swallowed, in soft tissue
What deformity is being shown here?
Step deformity by a Para symphyseal fracture
Which would be the best Xray technique to use to screen if there is a mandibular fracture?
DPT, however there is not a DPT available then a Lateral oblique will do. It is also important to have 2 views at 90 degrees to each other.
Which technique best allows immobilisation of the bone (fracture site) to allow a period of healing. The open or closed technique?
The open technique
Which technique allows for the wiring of the jaws?
Closed technique (although the technique is becoming out of favour)
If you are reducing a fracture, what are you doing?
Aligning the bones anatomically to recreate the normal anatomy.
How long does it take for the bone to heal in an adult?
4-6 weeks
Having a cast placed on your arm, when you break your long bone is an example of closed or open technique?
Closed technique
When doing fixation with plates, would we want load bearing or load sharing and what is the difference?
We would want to prioritise load bearing, so that 100% of the functional load is supported by fixation (2 large plates), whereas load sharing is such that the load is distributed between the hardware and the bone margins.
Why are the plates placed this low?
If the plates were placed slightly higher, you would run the risk causing iatrogenic damage to the roots.
What are the indications for closed reduction?
- Non-displaced favourable factures
- Grossly comminuted fractures
- Significant loss of overlying soft tissue
- Edentulous mandibular fractures
- Fractures in children
- Coranoid process fractures
- Undisplaced or minimally condylar fractures
What are the advantages of closed reduction?
- Inexpensive
- Simple procedure
- No foreign body so reduced of infection
What are the disadvantages of closed reduction?
- Not absolutely stable
- Prolonged period of IMF up to 6 weeks
- Possible TMJ sequelae
- Decreased oral intake
- Possible pulmonary considerations
Open reduction techniques are usually done intraorally, under what circumstances would you do an extra-oral open reduction?
When you have a displaced fracture on the lower border of the mandible, that is when you would approach with a sub-mandibular approach.
What is osteosynthesis?
Surgical fixation of bone using any internal mechanical means.
what is champy’s line?
Forces of mastication produce tensional forces on the upper border and forces of compression on lower border.
Champy put forward the lines where plates and screws must be placed. Maxime Champy popularized the treatment of mandible fractures with miniplate fixation along the ideal lines of osteosynthesis.
This approach is a form of load-sharing osteosynthesis applied in simple fracture patterns with an acceptable amount of bone stock.
Does champy’s principle rely on load bearing or load sharing principle?
Load sharing
Inadequate fixation of the mandible can result to poor healing giving poor mobility and falls in to three categories, what are they?
- Non-union: non-union describes the failure of a fractured bone to heal and mend after an extended period of time
- Fibrous union - Fibrous union was defined as. any fracture site that exhibited mobility after 8 weeks. of surgical management or after 4 weeks without treatment.
- Mal-union: malunion refers to a fracture that has healed in a deformed position, or with shortening or rotation of the limb.
If a fracture involves the angle of the mandible through a third molar socket, what would be the outcome of the 3rd molar?
It would be removed upon management of the fracture.
The teeth in the fracture line are rendered what?
Non-vital. They will not be extracted unless there is a vertical fracture present.
Why is important to take radiographs of planned extractions after someone has had fixation?
Presence of plates in areas of planned extractions.
Why are condylar fractures common on facial trauma?
The condylar is part of the facial crumple zone.
A direct knock to the chin can cause trauma within the joint capsule of the condyle, where it doesn’t cause any breakage, but causes a joint perfusion, causing inflammation. What would you see radiographically and how would you manage the patient?
You would see no evidence of fracture and prescribe a two-week course of NSAID.
Which type of condylar fracture is difficult to treat, extra-capsular or intra-capsular?
Intra-capsular because you’re dealing with small fragments.
With a condylar fracture which way does the patient deviate to?
Towards the side of the fracture as the length is shortened. This will result in an open bite on the contralateral side.
If the fractured condyle is not significantly displaced then you can manage a fractured condyle conservatively, how would you manage this?
Soft diet and analgesics/anti-inflammatory
A 27 year old man attends with pain. He was tackled at rugby 2 days ago receiving blows to the jaw and since then has pain on trying to bring his teeth together and his right lower lip is numb. On examination he has a left lateral open bite.
- Give 2 reasons why he is numb.
- Give 2 reasons why he has an open bite on the left side?
- What 2 radiographic views would you request and why?
- How would you manage this?
- What is he at risk of if not managed?
- What is the ideal treatment for this injury?
- Give 2 reasons why he is numb. – 1. Direct trauma to nerve due to inflammation causing swelling. Fracture may be displaced and affecting the inferior alveolar nerve (indirect trauma to the nerve)
- Give 2 reasons why he has an open bite on the left side? Fracture of the condylar head on the right side, which has displaced and causing the shortening of the condyle. Damage to either the angle of the mandible or the parasymphysis.
- What 2 radiographic views would you request and why? – PA mandible and a DPT (or lateral oblique view) this helps get a 3rd dimension of the fractures.
- How would you manage this? – recognise fracture and respond within 48 hours (fracture is already 48 hours in, so this constitutes as an emergency, so contact nearest hospital) and prepare for surgery
- What is he at risk of if not managed? – infection, non-union/fibrous union.
- What is the ideal treatment for this injury? – ORIF of the fracture with GA within the first 48 hours.
What are the complications of endodontically treated teeth when extracting?
Endodontically treated teeth are brittle and likely to fracture easily.
What complication does the upper left 5 have?
Bulbous roots – this would require a surgical approach.
Why can you not use a high-speed handpiece to section of a tooth?
It causes surgical emphysema and introduces air into the tissues and can lead to cellulitis. There are surgical handpieces that do not introduce air into the tissues.
The zygomatic bone has 4 major parts, what are they?
- Frontal
- Medial
- Maxillary
- Temporal
how many classifications are there for fractures of the zygoma?
8
Which part of AB face structure would have to be hit to cause this depression?
depression of the malar prominence.
What is periorbital ecchymosis?
Periorbital ecchymosis (PE) is caused by blood tracking along tissue plains into periorbital tissues, causing discoloration in the upper and lower eyelids. This clinical feature is most associated with basal skull fractures
What can clinically be seen here?
Subconjunctival haemorrhage.
Epistaxis is commonly known as?
Nosebleeds
What is opthalmoplegia?
ophthalmoplegia, also called extraocular muscle palsy, paralysis of the extraocular muscles that control the movements of the eye
What is orbital dystopia?
Orbital dystopia, a common feature found in patients with facial asymmetry, refers to a degree of unevenness of the orbit that causes malposition of the orbital cavity in at least one of the three-dimensional planes
What is enophthalmos:
Enophthalmos is posterior displacement of the eye.
What is exophthalmos?
Exophthalmos, also known as proptosis, is the medical term for bulging or protruding eyeballs
A haemorrhage placed in this location is known as a what?
Retrobulbar haemorrhage is the presence of a post septal orbital haematoma and is usually due to craniofacial trauma causing an extraconal haematoma. It may cause orbital compartment syndrome which is an ophthalmologic emergency
What is diplopia?
Double vision is when you look at 1 object but can see 2 images. It may affect 1 eye or both eyes. Signs that your child may have problems with their vision include narrowing or squinting their eyes to try to see better.
Which x-ray would determine a non-displaced zygomatico-maxillary complex (ZMC)?
Confirmed by CT scan
what type of fixation method is being used?
Kirschner wire
what type of fixation method is being used
lag screw fixation
what type of fixation method is being used?
wire osteosynthesis
what is the name of the instrument that is being used for reduction of displaced zygomatic complex?
ZMC hook
explain what is happening in this reduction method?
A screw is being drilled into the displaced zygomatic complex, with the head of the head of the screw visible to manipulate with some instruments for the purpose of reduction
what is the name of the instrument that is being used for reduction of displaced zygomatic complex?
Carrol Girard T-Bar
what is the name of this white/grey discolouration of the mucosa generally asymptomatic?
Leukoedema
What is the name of this condition, where there are ectopic sebaceous glands, on the buccal mucosa?
Fordyce spots
what is the name of this ulcer?
Apthous ulcers, also known as canker sores
This ulcer is a result of mechanical trauma, the image indicates a central ulcer surrounded by keratotic margin. The keratosis is the body’s attempt to form a barrier and thicken up and this happens if the trauma is either chronic or acute?
Chronic
if you develop a white patch through frictional keratosis but no ulcer what does that suggest?
The trauma is low grade and chronic.
If you develop a white patch with an ulcer as a result of frictional keratosis, what does it suggest in reference to its development?
It would suggest an acute development
this is an example of thermal trauma causing an ulcer. If you were to eradicate the source of the trauma, how long before the symptoms resolve?
Two weeks
morsicatio buccarum is commonly known as?
Cheek biting
what is the name of this condition?
Linea alba - White tissue line at the level of the occlusal plane asymptomatic. Associated with clenching, sucking habits. Biopsy for diagnosis
this image shows remnants of amalgam in buccal tissue, giving the appearance of a tattoo. You can identify this clearly on a radiograph, why is it still important to do a biopsy on this?
There are other lesions that look the same as amalgam tattoo such mucosal melanoma
patients wearing there dentures consistently over the day without removing them, over a long period of time, tend to develop a growth of tissue surrounding the denture, causing ill fitting over time. This condition is completely asymptomatic. What is the name of this condition?
Denture induced hyperplasia and would be treated through excision.
Saliva escaping from a damaged duct and into the surrounding lip and causing it swell, forming a minor salivary gland cyst is known as a what?
Mucocoele
what is the clinical presentation of pseudomembranous candidiasis (thrush)?
White plaques that wipe free leaving a red base.
If you sent a microbiology swab of pseudomembranous candidiasis lesion and do culture and sensitivity, what would be the most likely causative agent?
Candida albicans
What is treatment option for someone suffering from pseudomembranous candidiasis (thrush)?
Systemic antifungal. If this condition is recurring then there may be an underlying condition that needs to be addressed, such as diabetes.
How does candida leucoplakia differ from pseudomembranous candidiasis (thrush)?
Does not wipe free
With candida Leucoplakia you would prescribe a two-week course of systemic antifungal, and if after two weeks the condition has not resolved, what would be the next course of action?
If the condition has not resolved in two weeks, then a biopsy would be mandatory, because there are other conditions that look like this that are potentially malignant.
what is the name of this viral lesion?
Papillomas
when a papillomas are excised, what happens to them?
They are sent for histological examination.
what is the name of this condition?
Geographic tongue, also known as benign migratory glossitis, often asymptomatic.
Lichenoid lesions form due to reaction to what?
Reaction to metal (localised contact reaction)
or medication (symmetrical pattern)
Antihypertensives -
Hypoglycaemics
NSAID’s
with lichenoid lesions, will a biopsy be necessary?
Yes to establish a definitive diagnosis and it has been stated that lichenoid lesions can go on to develop as malignant lesions
What is epulis? .
Epulis is a term given for growth on the gum
what is the name of this growth?
Fibrous epulis
what is the name of this growth?
Pyogenic granuloma. Vascularised and associated with females during pregnancy so may have hormonal association.
Someone suffering from Addison’s disease, Primary adrenal insufficiency, Deficiency of cortisol and aldosterone. In addition to pigmentation what will you see orally?
More than likely you will see oral pigmentation too.
Round or oval brown or black pigmented area on the lip or any mucosal surface (benign)
Develops in the 50+ age group
The above describes this condition, what is the name of it?
Melanotic macule
What is the name of this condition?
Lichen planus
Benign mesenchymal neoplasms are commonly known as?
Lipomas, which are made up of fat cells surrounded by a thin fibrous capsule.
