oral surgery need to know Flashcards
what are the uses of elevators?
- to provide a point of application for forceps
- to loosen teeth prior to using forceps
- to extract a tooth without the use of forceps
- removal of multiple root stumps
- removal of retained roots
- removal of root apices
what are the main aims of suturing?
- reposition tissues
- cover bone
- prevent wound breakdown
- achieve haemostasis
- encourage healing by primary intention
what are the different types of sutures?
- non-absorbable
- absorbable
- poly-filament
- monofilament
what nerves are at risk of damge during extraction of a lower third molar?
- inferior alveolar nerve
- lingual nerve
- mylohoid nerve
- buccal nerve
name two different flap designs
- envelope
- 3-sided
how would you manage an OAF?
if communication is small/maxillary sinus is intact;
* encourage clot
* suture margins of communication
* prescribe antibiotics
* give post-op instructions
if communication is large/lining of communication is torn then;
* close hole with buccal advancement flap
* give antibiotics and nose blowing instructions
what are the different types of nerve damage?
- anasthesia- numbness
- parathesia- tingling
- dysaesthesia- pain, unpleasant feeling
- hypoaesthesia- reduced sensation
- hyperaesthesia- heightened sensation
how do you manage a dry socket?
- support and reassure the patient
- LA block
- irrigate with warm saline solution
- remove the previous blood clot to encourange new clotting
- advise pt on analgesia and hot salty mouthwashes- should not be swished around
what is a sequestrum?
a piece of dead bone that has become separated during the process of necrosis from normal/sound bone
what is osteomyelitis?
inflammation of bone marrow
why is the mandible particularly affected by osteomyelitis?
primary blood supply is inferior alveolar artery and dense overlying cortical bone limitis penetration of periosteal blood vessels
has a poor blood supply and more likely to become ischaemic and infected
what two types of bleeding can occur post extraction?
primary bleeding
* occurs within 48 hours of extraction
* caused by vessels opening up as the vasoconstriction effects of LA wear off /toothbrush/tongue/sutures becoming loose
secondary bleeding
* often due to infections occurring 3-7 days after the extraction
* usually mild but can occasionally cause a major bleed
give methods for achieving haemostasis after extraction
- apply firm pressure with damp gauze
- surgical oxidised cellulose- surgicel
- suture the socket
- bone wax can be placed in the socket
what nerves are infected by an IDB?
- inferior alveolar nerve
- lingual nerve
- some fibres of incisive and mental branches may also be anaesthetised
what are the 2 types of resorbable suture?
- monofilament- monocryl
- polyfilament- vicryl rapide
what are the two types of non-resorbable sutures?
- monofilament- prolene
- multifilament-black silk
name 5 general oral surgery principles that should be adhered to when carrying out flap surgery
- create maximal access with minimal trauma- bigger flaps heal just as quickly as small ones
- use the scalpel in one firm continuous stroke
- minimise trauma to dental papilla
- keep the tissues mosie
- aim for healing by primary intention to minimise scarring
what handpiece and bur are used to cut bone?
- straight electrical hand piece with saline cooled bur
- round of fissure tungsten carbide burs
- air drive handpieces may lead to surgical emphysema and embolisms to form
describe factors which influence flap design
- the type of surgery being carried out
- proximity of important structures such as nerves and muscles e.g. lingual nerve can be damaged during surgical removal of lower 3rd molars
- depending on the area of the mouth e.g. to improve aesthetics
- ability to access/visualise and ability to suture it back
give methods of debridement prior to suturing
mechanical
* bone file/ handpiece to remove any sharp bony edges
* mitchell’s trimmer/victoria currette for soft tissue debris
irrigation
* sterile saline/water put into socket under flap to wash out debris
suction
* aspirate under flap to remove debris
list peri operative complications of extractions
- abnormal resistance e.g. thick cortical bone
- fracture of tooth or alveolar bone
- involvement of the maxillary antrum
- soft tissue damage
- damge to nerves
- dislocation of TMJ
- damage to adjacent teeth and restorations
- wrong tooth extracted
where is the mental foramen located?
- anterior surface of the mandible
- transmits the terminal branches of the inferior alveolar nerve and mental artery
- located roughly between apices of premolars on the mandible
what does the mental nerve give sensation to?
- buccal soft tissue anterior to the mental foramen
- lip and chin
- anterior teeth on that side if the arch
describe the use of triangular flaps for extraction
- 3 sided flap
- used for retained single roots
describe the use of envelope flaps for extraction
- 2 sided flap
- used for retained two rooted teeth
describe the use of semilunar flaps for extraction
- 1 sided flap
- used for periapical involvement
name 4 indications to extract a tooth
- symptomatic partially erupted teeth
- traumatic position
- orthodontic indications
- interference with construction of dentures
name 2 drugs in which care must be taken when carrying out an extraction
- warfarin
- clopidogrel
why must you take care during extraction on a patient who takes warfarin?
- increased risk of bleeding- anticoagulants prevent clots from forming and growing
- insufficient activation of vitamin K affects clotting factors II, VII, IX, X
- anti clotting protein C and S are inhibited
why must you take care during extraction on a patient who takes clopidogrel?
- anti-platelet drug
- platelet inhibition occurs and fibrin clot production is reduced
- this reduced a clot being produced at the site of extraction
- there is less chance of a spontaneous bleed on patients on this drug alone compared to patients with dual therapy or warfarin
what drug counteracts benzodiazepine sedation?
fumazenil
what are the 2 types of sedation?
inhalation (nitrous oxide)
intravenous (midazolam)
give contraindications for inhalation sedation
- pts undergoing bleomycin therapy (high O2)
- nasal blockages
- pts with musculoskeletal and neuromuscular diseases/problems
what is the clinical name for dry socket?
localised alveolar osteitis
what is dry socket?
occurs when the blood clot at the site of the tooth extraction fails to develop or dislodges/dissolves before the wound has fully healed
what are the predisposing factors of dry socket?
- lower molarts
- smoking
- more common in females
- oral contraceptive pill
- excessive trauma during extraction
- excessive mouth rinse which washes clot away
- patients who have had dry socket before
what are the symptoms of dry socket?
- moderate to severe dull aching pain
- pain that keeps pt awake at night
- paint hat throbs and radiates to the ear
- exposed bone is sensitive
- halitosis and bad taste in the mouth
how long does dry socket take to resolve?
7-14 days
what nerves must be anaesthetised to remove tooth 48 safely
- inferior alveolar nerve
- lingual nerve
- long buccal nerve
what are two different ways to assess anaesthesia has been achieved?
- probe around tooth and ask patient if they feel anything sharp
- ask if the patients lips and tongue feel numb
what are 3 clinical reasons that could account for neurological-sensory deficits?
- crushing injury
- cutting/shredding injury
- transection of the nerve
- damage due to LA
what are the aims of raising a flap?
- allows better access to the tooth if finding any difficulty to extract e.g. abnormal resistance, ankylosis etc.
- helps with closure of an OAF
state the aims of retracting a flap
- protection of the soft tissue
- better access and vision
during an extraction, the patient’s root fractures. what radiograph should you take?
periapical
what analgesix is most appropriate post extraction for a patient who takes warfarin?
paracetemol
how us facial palsy caused during an IDB?
if the clinician doesn’t hit bone and inserts too far back, LA is depositied in the parotid gland
the facial nerve runs through parotid gland and due to dense fascia around the gland, the LA will remain for a long time and cause paralysis of the facial muscles that the nerve innervates
Q
how would you initially manage. apatient with facial palsy?
reassure- tell patient sensation will return after a few hours
keep eye patch over eye to prevent drying out as pt cannot blink
what guidance document would you refer to for advice on dealing with patients on warfarin?
SDCEP anticoagulants and antiplatelets document
when should INR be tested before an extraction?
no longer than 24 hours before the procedure
below which INR level would it be safe to carry out an extraction?
4
if all of your attempts to achieve haemostasis are unsuccessful, what should you do?
refer the patient to A&E immediately
a patient with an otherwise healthy dentition needs tooth 34 extracted. what are common peri-operative complications that can occure?
- damage to adjacent teeth i.e. 33 or 35
- crown or root fracture of tooth 34
- fracture of the mandible
- abnormal resistance- thick cortical bone or divergent roots
when does fracture of alveolar bone usually occur during extraction?
in the buccal plate
to canines or molars
what do you do if a jaw facture occurs during extraction?
inform the patient
post-op radiograph
refer (phone call)
ensure analgesia
stablise
if delay - prescribe antibiotic
define neurapraxia
contusion of nerve/ continuity of epineural sheath and axons maintained
define axonotmesis
continuity of axons
epineural sheath disrupted
define neurotmesis
complete loss of nerve continuity/nerve transected
what are the aetiological factors of a tuberosity fracture during extraction?
single standing molar
inadequate alveolar support
unknown unerupted wisdom tooth
name the main causes of haemorrhage during extraction
local factors- mucoperiosteal tear or fracture of alveolar plate/socket wall
very few due to undiagnosed clotting abnormality
liver disease (clotting factors made in the liver)
medication e.g. warfarin
how do you control a soft tissue haemorrage during extraction?
pressure
suture
LA with adrenaline (vasconstrictor)
diathermy
how do you control a haemorrhage from bone during extraction?
pressure with swab
LA injected into socket
blunt instrument
bone wax
pack
how would you manage a TMJ dislocation during extraction?
relocate immediately
give analgesia and advise on supported yawning
if relocation not possible;
1. LA into masseter intra-orally
2. immediate referral
what is an alveolar nerve block (IDB) used for?
pulp of lower molars and second premolars
what is a mental (incisive) nerve block used for?
dental pulp of lower premolars and canine
buccal gingivae of lower first premolar and canine
what is a long buccal infiltration used for?
buccal gingivae of lower molars and second premolar
how do you test that anaesthesia has been achieved?
ask the patient if they feel numb/tingling
probe around site and check if pain felt
give possible causes of neuro-sensory deficits
crushing injury
cutting/shredding injury
transection of the nerve
damage due to LA
draw flap of retained root of lower premolar
What is the dental terminology for pins and needle feeling or partial loss of sensation ?
Parasthesia
What is the dental terminology for painful, unpleasant sensation lasting for a fraction of a second ?
dysesthesia
What is the dental terminology for total loss of sensation?
Anaesthesia
What are 3 clinical reasons that could account for neurological-sensory deficits?
crushing injury
cutting/shredding injury
transection of the nerve
damage due to LA
What type of surgical flap should be used to remove retained roots of tooth 44 ?
2 sided flap
