Oral surgery questions Flashcards
1
Q
What foramen does the ophthalmic branch of the trigeminal nerve pass through?
A
Superior orbital fissure
2
Q
What foramen does the maxillary branch of Trigeminal nerve pass through?
A
Foramen rotundum
3
Q
What foramen does the mandibular division of the trigeminal nerve pass through?
A
Foramen ovale
4
Q
What is the origin, insertion, innervation and function of the masseter ?
A
- Origin - zygomatic arch
- Insertion - lateral surface and angle of mandible
- innervation - masseteric branch of V3
- Function - elevates and retrude mandible
5
Q
What is the function of the medial pterygoid muscle?
A
- Elevation
- Protrusion
- Lateral movements
6
Q
How to test the masseter?
A
Clench teeth together and palpate area
7
Q
What is the origin, insertion, innervation and function of the Temporalis ?
A
- Origin - floor of temporal fossa
- Insertion - coronoid process and anterior border of ramus
- Innervation - deep temporal nerve (anterior part) of V3
- Function - elevates and retracts mandible
8
Q
How to test the temporalis?
A
Clench teeth together and palpate all fibres ( middle, posterior and anterior)
9
Q
What is the origin , insertion , innervation of the medial pterygoid?
A
Origin -
** deep head** : palatine bone
** Superficial head** : Maxillary tuberosity
Insertion -
* Medial surface of the ramus and angle of the mandible
Innervation
Medial prterygoid nerve of V3
10
Q
How to test medial pterygoid muscle?
A
Intra-orally and can be painful
11
Q
What is the origin, insertion, innervation and the lateral pterygoid ?
A
- Origin -
infratemporal crest of greater wing of sphenoid bone (superior)
lateral surface of lateral pterygoid plate (inferior) - Insertion - anterior border of the condyle (superior) and pterygoid fovae (inferior)
- Innervation - anterior division to lateral pterygoid branch of V3
12
Q
How to test lateral pterygoid?
A
Move jaw side to side ( put finger on tragus of ear)
13
Q
What is the function of the lateral pterygoid?
A
- positions disk in closing (superior)
- protrudes and depresses mandible and causes lateral movements (inferior)
14
Q
What is the function of the supra-hyoid muscles?
A
elevate hyoid bone and depress mandible
15
Q
Describe histopathology of SCC
A
- increased mitotic activity
- abnormal keratinisations (keratin pearls)
- Hyper- chromatic nuclei
- cellular pleomorphism
- basal cell hyperplasia
- irregular epithelial stratification
- disturbed polarity of basal cells
- drop shaped rete pegs
- connective tissue stroma with inflammation (lymphocytes and histocytes)
16
Q
What are 80% of SCC?
A
well differentiated or moderately differentiated
17
Q
Other than pain, swelling and bruising what 6 other signs are associated with a mandibular fracture?
A
- occlusal derangement
- numbness of lower lip
- loose or mobile teeth
- bleeding in the ear
- facial asymmetry
- anterior open bite
- deviation of the mandible to one side
18
Q
What radiographic views are required for a mandibular fracture?
A
- OPT and PA mandible
- Town’s view
- CT Scan - axial, sagittal, coronal
- Occlusal
- Lateral Oblique
19
Q
What factors are considered for a mandibular fracture tx?
A
- direction of fracture line
- opposing occlusion
- magnitude of force
- mechanism of injury
- Intact soft tissue
20
Q
What does displacement of fragments depend on in a mandibular fracture?
A
- Angulation and direction of fracture line
- Location of fracture
- Pull of the attached muscles
- Integrity of the periosteum
- Extent of communication (soft tissue injuries)
- Displacement of blow
21
Q
List 3 management options for mandibular fractures?
A
- Undisplaced fracture - monitor
- Displaced or mobile fracture - closed reduction and fixation + open reduction and internal fixation
22
Q
Bleeding after extraction of 26 that won’t stop
how would you manage?
A
- Ensure you have an accurate medical and drug history and identify where bleeding is coming from
- Apply pressure with damp gauze and ask patient to bite on it
- Use LA with vasoconstrictor
- Bone wax or fibrin foam
- Suture the socket
- Diathermy to close blood vessels
- Haemocollagen sponge
- Floseal
23
Q
What is a local risk factor for delayed onset of bleeding?
A
- LA with vasoconstrictor wears off
- Loosening of the sutures
- Patient causes trauma to the socket with tongue, finger or food etc..
24
Q
Examples of acquired bleeding disorder?
A
- Warfarin
- Anti-platelet drugs such as clopidogrel
25
Examples of congenital bleeding disorders?
* Haemophilia A and B
* Von Willebrand's disease
26
When should you check the INR if the patient is on a new anticoagulant other than warfarin?
* INR does not need to be checked
* Instead assess bleeding risk of procedure
* If high :
Miss Apixaban and Dabigatran morning dose
Delay Rivaroxaban and edoxaban morning dose
27
What should an INR for a patient on warfarin for procedure to be carried out?
* Below 4 without interrupting anticoagulant
28
What is the scientific name for a dry socket?
* Alveolar osteitis
29
How does a dry socket occur?
When the blood clot at the site of the extraction fails to develop, dislodges or dissolves before the wound have fully healed
30
Predisposing risk factors for a dry socket? (9)
* more common in molars - increased risk anterior to posterior
* more common in mandible
* more common in females
* Smoking increases risk due to reduced blood supply
* Oral contraceptive pills increase risk
* Traumatic extraction
* Excessive mouth rinsing post extraction
* Family history
* Previous dry socket
31
What are the treatment options for dry socket?
* Reassurance and educate about dry socket
* Use analgesics
* Give LA to relieve pain
* Irrigate socket with warm saline
* Curettage/debridement - encourage bleeding
* Use alvogyl to encourage clot formation
* Advice on hot salty mouthwash use + CHX
* Review
32
What to tell patient if asked about the risk of numbness after extraction?
* You might experience temporary numbness or permanent numbness this depends on the proximity of the nerve and the difficulty of extraction
* Usually there is 10-30% risk of temporary numbness and less than 1% permanent numbness
33
What is the risk of anaesthesia of the lingual nerve ?
* Temporary - 0.25 - 23%
* Permanent - 0.14 - 2%
34
How would you diagnose an OAF? (8)
* Nose holding test - pinch nose and air will flow out of socket
* Visually
* Using a blunt probe to check for communication
* Using light and suction (suction sound will have an echo in case of communication)
* Bubbling at the extraction site
* Ask patient for symptoms
* Radiographs , pre op and post op
* Bone in trifurcation of tooth after extraction
35
What symptoms would a patient with OAF be complaining of ? (9)
* Problems with fluid intake (come out of nose)
* Problems with playing wind instruments
* Problems with speech and singing (nasal sounding)
* Pain
* Sinusitis symptoms
* Problems with smoking and using a straw
* Bad taste
* Halitosis
* Pus discharge
36
What treatment is used for OAF? (4)
* Excise fistula/sinus tract
* Perform a buccal advancement flap
* May require bone graft or collagen membrane
* Antral washout ( irrigate)
37
What is the difference between OAF and OAC?
* OAF - chronic epithelial lined tract between the maxillary sinus and the oral cavity
* OAC - acute communication between the maxillary sinus and the oral cavity which is not epithelial lined
38
Signs and symptoms of TMD? (10)
* Intermittent pain of several months or years in duration
* pain on opening
* limited mouth opening
* muscle/joint/ear pain particularly on waking up
* Trismus and locking of jaw
* headaches
* clicking and popping joint noises
* Crepitus due to late degenerative changes
* Signs of wear in the mouth such as tongue scalloping , wear facets and linea alba
* Facial asymmetry
39
What two muscles should you palpate when examining for TMD?
* Masseter
* Temporlis
40
What are the causes of TMD? (8)
* Parafunctional habits leading to inflammation of muscles of mastication
* Trauma to joint
* Stress - psychogenic
* Occlusal abonrmalities (malocclusion)
* Degenerative disease ; RA , localised osteoarthritis
* Anterior disc displacement ± reduction
* Neoplasm
* Infection
41
What nerve supplies the TMJ?
* Auriculotemporal and Masseteric branches of V3
42
What conservative treatment options for TMD? (11)
* Reassurance and education about the condition
* Soft diet with food cut into small pieces
* Masticate bilaterally
* Do not open mouth wide
* Stop parafunctional habits such bruxism, grinding, nail biting , chewing gum , clenching
* Support jaw when yawning
* Splints
* Medications
* Acupuncture
* CBT
* Jaw exercises - relaxation technique and massage
43
What medications are used in the management of TMD?
* Tricyclic antidepressants
* NSAIDS
* Botox
* Steroid
44
What types of splints are used in TMD?
* Bite raising - michigan splint
* Hard splint
* Soft splint
45
What is the mechanisms of a bite splint? (4)
* Stabilise occlusion
* Improve function of the masticatory muscles
* thereby act as a habit breaker to reduce parafunctional habits
* They also protect the teeth from parafunctional habits
46
What to exclude when diagnosing TMD?
* Closed lock
* Dislocation
47
What is arthrocentesis ?
* Procedure during which the jaw joint is washed out with sterile saline and anti-inflammatory steroids using a fine needle
* This breaks fibrous adhesion and flushes away inflammatory exudate
* Relief symptoms temporarily
48
What is the only way to see the synovial membrane in TMD?
* Arthroscopy
* It allow you to see abnormal structures within the joint
* allows you to check for any inflammation
49
Give examples of TMD surgeries
- Disc plication
- Meniscectomy
- Condylectomy
- High condylar shave
- Eminectomy
50
What are the signs and symptoms of zygomatic orbital fractures involving the orbit floor? (9)
* Asymmetry - swelling followed by flattening
* Alteration in sensation (infra orbital nerve damage)
* Peri-orbital ecchymosis
* Numb cheek
* Sub-conjuctival haemorrhage
* Blurry vision
* Diplopia
* Pain on eye movement
* Epiphora - excessive watering of the eye
* Step deformity ( if zygoma is fractured and displaced)
51
What sign is considered the biggest indicator of a zygomatic orbital fracture?
Subconguctival haemorrhage
52
What imaging would you take to confirm ZOC fractures?
* Occipitomental views 15/30 (facial views)
* CT scan - for more complex fractures
* Use campbell's lines to interpret facial injuries on radiographs
53
What to test if suspected zygomatic fracture?
Make patient move eyes in all directions by following the movement of your fingers to make sure that the eye muscles are not affected
54
What are the initial care of zygomatic orbital fractures?
* Check airway first!
* exclude occlular injuries
* prophylactic antibiotics
* avoid blowing nose
55
What are the management options for zygomatic orbital fractures?
* Nothing - leave and review when swelling subside
* Further radiographs/ CT
* Closed reduction ± F
* Open reduction with internal fixation ( intraoral incisions , coronal flap procedure , facial incisions)
56
Give an approach for closed reduction ?
* Gillies approach - incision in temporal area and apply an instrument to lift a displaced cheek bone
* Malar hook or buttress plate for F-Z displacement
57
What post-op instructions would you give to a patient with a zygomatic orbital fracture?
* Avoid nose blowing
* Use post op steroids - dexamethasone
* Observe eye overnight for a retrobulbar bleeding
* Use of analgesics
58
Name possible common complications for extracting a standing alone maxillary molar?
* OAC
* root or tooth lost in maxillary sinus
* Maxillary tuberosity fracture
59
How would you diagnose a fractured maxillary tuberosity? (5)
* Noise of the fracture
* Movement noted when extracting the tooth ( visually or with supporting fingers)
* More than one tooth moves
* Visual tear in the palate
* Tuberosity attached to extracted tooth
60
How to diagnose a tooth that is lost in the antrum?
* Post op radiograph
* Visual assessment by exploring socket
* Extracted tooth have missing parts
61
How to manage a very small or an intact sinus lining OAC?
* encourage clot formation and suture margins
* use prophylactic ABS
* Small <2mm usually heal with normal clot and routine mucosa healing
62
For how many days do you give ABS after managing a large OAC with a buccal advancement flap?
7 days + give nose blowing instructions
63
What conservative advice would you give a pt about OAC?
* No nose blowing
* Sneeze with mouth open
* Steam and menthol inhalation
* Avoid using a straw
* Avoid smoking or drinking alcohol
* Avoid flying and doing strenous activity
64
How to manage a fractured tuberosity?
* Dissect out and close the wound
* Stabilised with fingers and forceps and apply fixation if tooth still intact
* Fixation can be through :
Orthodontic buccal arch wire spot
Arch bar
Splint
* Then check occlusion
* prescribe ABS
* Treat pulp
* give post op instructions
Then remove the tooth after 8 weeks when bone heals
65
How to retrieve a root/fragments lost in antrum?
* Caldwell-luc approach through buccal sulcus window
* Same as OAF retrieve through socket ( open fenestration with care , use small curettes and irrigate , use ribbon gauze to remove all fragments)
then close with buccal advancement flap
* Endoscopic retrieval - ENT involved
66
Impacted 8
What are SIGN guidelines for not advising removal of wisdom teeth? (4)
* In patients whose 3rd molars would be judged to **erupt successfully and have functional role** in the dentition
* If **contraindicated with medical history** as the risks are more than the benefits
* **Deeply impacted** with **no** signs or history of local or systemic **pathology**
* when it is the **second surgical extraction** in the same visit **under LA**
67
What are the SIGN guidelines for advising removal of wisdom teeth? (5)
* Causes significant infection
* Patients with predisposing factors with poor access to healthcare
* Prior to cancer treatment where risks outweigh benefits
* Patients who agreed to tooth implant procedure or orthognathic surgery
* When GA for removing a 3rd molar - remove the rest
68
What are the strong indications for removal of wisdom teeth?
* Associated with pericoronitis , PA pathology or cellulitis
* Dentigerous cyst
* When it is partially erupted or unerupted in close proximity to an area prior to implant placement or denture construction
* Obstructing treatment of the 7 ( restorative or periodontal)
* ERR of 8 or 7 associated with 8
* When it is in an atrophic mandible
* Fractured mandible cases where 3 is involved
* autogeneous transplantation
69
What is assessed radiographically before the removal of 3rd molars? (9)
* Angulation of impaction
* Root size, shape, length , morphology and presence of apical hooks
* Follicular width (2.5 normal)
* Crown size and condition - shape, size , caries presence
* Alveolar bone level - point of elevation and density
* Periodontal status
* Proximity to antrum and IAN
* Associated pathologies
* Risk of nerve damage
70
What associated pathologies are assessed radiographically before XLA of wisdom tooth? (2)
* Dentigerous cyst
* Tumours
* Caries - pericoronal infections
71
How to confirm and assess if a third molar is close to the IAN? (3)
* darkening of root where crossed by the canal
* Diversion of the IAN
* interruption of white lines of the canal
72
Incidence of temporary vs permanent loss of sensation when extracting 3rd molar?
T - 10-30%
P - less than 1%
73
What type of flap is used for the removal of an impacted lower 3rd molar?
3 sided flap
74
Post op complications after XLA of 3rd molard? (9)
* Swelling
* bruising
* bleeding
* pain
* Dysaesthesia (painful)
* Altered taste
* Numbness (anaesthesia)
* Tingling (paraesthesia)
* Jaw stiffness
75
Ways to achieve haemostasis after an extraction?
* pressure using damp guaze through biting or fingers
* LA with adrenaline
* Diathermy
* Whitehead's varnish pack (WHVP)
* sutures
76
What term is used for post op bleeding that occurs within 48 hours of XLA?
* reactionary
* LA wears off
* sutures loose or lost
* patient traumatise area with tongue, finger or food
77
What term is used for post op bleeding that occurs within 3-7 days after XLA?
* Secondary
* often due to infection
* can be medication related
* usually mild ooze but can be major
78
How to manage achieve haemostasis in bone bleeding?
* pressure via swab
* LA on swab
* blunt instruments
* bone wax
* Pack
* haemostatic agents
79
What tissues could be responsible for the prolonged bleeding after XLA and give example to manage each
* Soft tissues - suture or LA
* Bone - WHVP or bone wax
* Vessels (veins and arteries, arterioles ) - diathermy
80
Give 4 risk factors of bleeding problems post XLA?
* medical conditions - Haemophilia A/B , VWD , liver disease/cirrhosis
* Medications - warfarin, anticoagulants
* Lifestyle - alcoholic
* Poor compliance to post op instructions
81
What information would you give a patient that will get open curretage for deep pockets to gain consent?
* Explain the procedure - open the gums and physical removal of calculus and sharp edges - irrigation suction and suturing - this will be under LA
* Risks - gingival recession, infection , bleeding , bruising , non healing and pain
* Benefits - effectively remove deposits which lead to gaining the attachment of the gums , have better outcomes than repeating non surgical options
* Outcomes - it results in clinical improvement and reduce pocket depth
* Other options - non surgical options , regenerative surgery, GTR and GBR , furcation resective treatment, mucogingival surgery
* Risks of not having the treatment - risk of tooth loss , increase in mobility, increase in pocket depth, possible pathologies
82
If a patient complains of central crushing pain across chest and down of left arms (pt have a history of IHD) , what is the likely diagnosis ?
* Myocardial infraction - end point of ischaaemia that result in death of heart tissue due to absence of blood supply
83
What is your immediate management if you diagnose a patient with myocardial infraction in he is still conscious?
* Assess the patient ABCDE
* Give oxygen 100% for 15l/min
* Give GTN spray 2 puffs sublingually , repeat in 3 minutes if pain remains
* If still does not get better or no response call 999 and administer aspirin 300mg ( state to hospital)
* If patient is unresponsive start BLS
84
In what forms can you deliver post op instructions? (3)
* Verbal - emphasis of important aspects
* Written sheet with written aftercare
* Give contact details in case they have any questions of a complication occurs
* Ensure patient know who to contact in emergency and that they understand clearly the post operative advice
85
What do you want the patient to know to minimise any post operative advice?
* standard post surgical advice :
Pain is common can use analgesics prior to LA wearing off and then for every 4-6 hours ( Should settle over a week)
Bleeding , can be stopped by applying damp gauze and biting for 30 minutes , ensure to not explore the area
or traumatize with brush or tongue
Do not rinse for 24 hours and then do it gently
Do not do strenous activity
Avoid hard, sticky, hot food and drinks
Avoid alcohol and smoking as may delay healing
Bruising is normal and can occur , reduce with warm and cold packs
Pain a stiffness of TMJ will settle over 1-2 weeks
Seek advice if any adverse complications
* Sutures advice
* Antiseptic mouthwash advice
* Bruising and swelling advice
86
What post op advice would you give regards suturing? (4)
* leave sutures alone and do not pull them out
* if they get loose but no bleeding , do not touch and leave alone
* Ensure the patient know if they have resorbable or non resorbable sutures to know if they should come back for removal
* If sutured become uncomfortable as the area heals they can come back to get them removed early
87
What post op advice would you give patient regarding antiseptics?
Use CHX 2x3 per day an hour before and after eating
88
What post op advice would you give patient regarding bruising and swelling?
* Use ice/cold packs can reduce area by placing on for 5 minutes on and off for an hour and repeat
* Do not use hot packs as they will result in further swelling
89
When should the next review be after placing sutures?
After one week
90
When should the next review be after removing sutures and why? ( for periodontal pocket surgery after surgical instrumentation)
After 2 months as it allows healing to occur
* organisation's of blood clots and replacement by collagenous connective tissue
* Attachment of long junctional epithelium (2-4 weeks)
* Reduction in probing depths as a result of gingival recession and gain of clinical attachment
91
What clinical findings would determine success of periodontal treatment?
* Probing depth < 4mm
* Bop < 10%
* Plaque levels < 15%
* If significant reduction of bleeding on probing , plaque levels and pocket depth compared to baseline records
92
What are the landmarks of an inferior alveolar nerve block?
* between the coronoid notch and the pterygoid mandibular raphe in the pterygomandibular space
* 1 cm above occlusal plane
93
Give examples of IAN block technique's ?
* Gow-gates - all mandibular division of the trigeminal nerve
* Akinosi block - when the mouth is closed
* Halstead technique - normal technique
94
How to manage a patient if you accidentally injected in the parotid gland when giving an IDN block?
* Explain what has happened and why it happened
* Ensure the patient that this is reversible
* Give them eye-patch until eye reflex comes back to normal
* Advise that length of paralysis varies but mostly will resolve within few weeks
* Note the incident in notes and submit a DATIX
* Review the patient ( ideally 24-48 hours after)
95
What does dentally fit means before treatment of cancer?
* free from any active dental disease prior the start of cancer treatment
96
What is a multi-diciplinary team ?
It is a team of individuals from different specialities who decide on the best holistic treatment plan and treatment options for a cancer patient
97
List members of MDT for oral cancer treatment? (6)
* Radiologist
* Maxillofacial surgeon
* Restorative dentist
* Radiotherapist ( radiation oncologist)
* Chemotherapist ( medical oncologist)
* Palliative care consultant
98
What risks is an oral cancer patient at risk of other than mucositis after radiotherapy? (6)
* Xerostomia
* Increased risk of poor wound healing
* Increased risk of infection
* Oral ulceration
* Caries
* Osteoradionecrosis
99
What are the oral side effects of chemotherapy? (8)
* High risk of infection
* Bleeding and bruising
* Xerostomia
* Mouth ulceration
* Halitosis
* Reduced sense of taste
* Mucositis
* MRONJ
100
What are the grades of mucositis?
0 (none) - nothing to note
1 (mild) - oral soreness, erythema
2 (moderate) - oral soreness , erythema, ulcers and solid diet tolerated
3 (severe) - oral ulcers and liquid diet only
4 (life-threatening) - oral alimentation impossible
101
How is mucositis managed ? (8)
* Sook on ice cubes for cooling effect
* Use gelclair, caphasol, ot sodium bicarbonate mouthwash
* Avoid using steroids as may risk candidiasis
* Use calcium and phosphate mouthwash to create lining
* Use morphine lollipops for pain relief
* Avoid smoking, alcohol and spicy/hot foods and drinks
* Smooth teeth and dentures to prevent further ulcers
* low level laser light therapy - UBV light
102
How can mandibular fractures be classified?
A. involvement of surrounding soft tissue
Simple
Compound (bone exposed)
Comminuted (bone broken in at least 2 points)
B. Number of fractures
Single
double
multiple
C. Side of fracture
Unilateral
Bilateral
D. Site of fracture
E. Direction of fracture line
Favourable
Unfavourable
F. Specific fractures
Green stick fractures
pathological fractures
G. Displacement of fracture
Displaced
non displaced
103
What are the sites that can be affected in a mandibular fracture? (8)
* Angle
* sub-condylar
* Para-symphyseal
* Body
* Ramus
* Coronoid
* Condylar fracture
* Alveolar process
104
What would you place in dentate patient following a mandibular fracture to stabilise the teeth? (2)
* metal arch bars
* interdental eyelet wiring
105
What modification would you to edentulous patients following a mandibular fracture? (2)
* modified dentures
* gunning's splint
106
What are the signs and symptoms of maxillary fractures? (8)
* Swelling
* bruising
* nose bleeds
* altered sensation
* restricted eye movement
* malocclusion
* tooth mobility
* palatal split
* Diplopia
* facial asymmetry
107
What is the Le fort classification for maxillary fractures?
Type 1 - floating palate - horizontal maxillary fracture spreading teeth from upper face
Type 2 - floating maxilla - pyramidal fracture involving nasofrontal suture
Type 3 - floating face - transverse craniofacial disjunction where maxilla is detached from base of skull
108
What can be the types of central middle third face fractures?
* nasal bone
* unilateral maxillary fracture
* le fort I (part nasal)
* le fort II ( nasal + zygoma)
* le fort III ( whole middle face)
* various combinations
109
What special radiographs would you use for maxillary fractures?
* Occiptomental 15/30
* CT scan - coronal view
110
How is maxillary fractured managed?
* monitor and pain relief
* open reduction internal fixation (ORIF)
* Closed reduction and fixation
111
What is a cyst?
* A pathological cavity with fluid, semi-fluid or gaseous content that is not created by pus accumulation
112
Epithelial inflammatory odontogenic cysts
* Radicular cysts - can be residual (left after extraction)
* Inflammatory colateral cysts ( paradental and mandibular buccal bifurcation)
113
Developmental epithelial Odontogenic cysts
* Dentigerous cyst (&eruption cyst)
* Odontogenic keratocyst
* Lateral periodontal cyst (bortyoid odontogenic)
* gingival cysts
* glandular odontogenic
* calcifying odontogenic
* orthokeratinised odontognic
114
developmental non odontogenic cysts
nasopalatine duct cyst
115
non odontogenic cysts (epithelial)
nasolabial
nasopalatine
globulomacillary
median
116
Give 2 treatment options of cysts?
* marsupialisation
* enucleation
117
What is segmental resection? and when is it used?
removal of the tumour with margins of normal bone
mainly used for:
ameloblastoma and sacroma
118
non odontogenic cysts (non epithelial)
* Solitary bone cyst
* aneurysmal cyst
* stafne idiopathic bone cavity ( not really a cyst)
119
What is enucleation?
Removal of all cystic content
120
Advantages and disadvantages of enucleation?
**Advantages**
* whole lining can be examined
* little aftercare
* allows primary closure
**Disadvantages**
* Risk of mandibular fracture
* incomplete removal can lead to recurrence
* risk of damage to adjacent structures
* clot filled cavity may become infected
* tooth loss can occur
121
What is marsupialisation?
* Creation of a surgical window in the wall of the cyst removing the contents and suturing the cyst wall to the surrounding epithelium
* encourages the cyst to decrease in size and then followed by enucleation at a later date
122
What is the advantages and disadvantages of marsupialisation?
** Advantages**
* simple to perform
* may spare vital structures
** Disadvantages**
* cyst may reform
* complete lining not available for histological examination
* difficult to keep clean and lots of aftercare is needed
123
What are the indications of marsupialisation?
* If enucleation would damage surrounding structures (ID nerve)
* Difficult access to area
* To allow eruption of a teeth affected by a dentigerous cyst
* Elderly or medically compromised patient who is unable to withstand extensive surgery
* very large cysts which would risk jaw fracture
124
How does a radicular cyst develop?
* These are dental or periapical cysts that are associated with non-vital teeth
* inflammation due to apical periodontitis following necrosis of pulp (pulpitis)
* this leads to proliferation of rests of malassez from hertwig's root sheath
125
Where does Dentigerous cyst originate from?
* Reduced enamel epithelium from enamel organ
126
What are dentigerous cysts mostly associated with?
impacted mandibular third molars
127
What is eruption cysts mostly associated with?
* impacted primary incisors or first permanent molars
128
How does a radicular cyst appear radiographically? (3)
* well defined radiolucency around the apex of a non vital tooth
* unilocular
* corticated margins of the lesion continuous with lamina dura on either side of the root
129
How does a radicular cyst appear histologically? (7)
* connective tissue capsule
* incomplete epithelial lining
* rests of malassez present
* cholesterol clefts
* hyaline / rushton bodies present
* variable inflammation
* mucous metaplasia
130
What are the indications of orthognathic surgery? (3)
* when growth is complete
* severe class II or III ( severe AP/vertical discrepancy )
* cleft lip and palate patients at age 18-20
* when there is appearance, functional concerns associated with a severe skeletal discrepancy
131
What are the risks of Orthognathic surgery? (6)
* Relapse
* Nerve damage
* Bleeding
* TMJD
* Unobtainable results for patients with high expectations
* Infection
132
What investigations are carried out before orthognathic surgery?
* Radiographs - CBCT , lateral ceph, OPT
* Clinical photographs (2d,3d)
* Study models
133
Give two types of mandibular surgery
Sagittal split osteotomy - advancement and setback
inverted L ramus osteotomy - advancement
Vertical Subsigmoid osteotomy - set back
134
Types of maxillary surgery
Le fort 1 osteotomy (superior, inferior, forward)
Anterior maxillary osteotomy (posterior)
135
Types of chin surgery
genioplasty
* this can be augmentation, set-back , rotation , reduction advancement
136
What are the principals of flap design? (11)
* maximal access with minimal trauma as big flaps heal as quick as small flaps
* wide base incision - ensure good circulation
* use the scalpel in one firm continuous stroke
* No sharp angles
* minimise trauma to dental papilla
* Flap reflection should be down to bone
* no crushing of the tissue
* keep the tissue moist
* make sure wounds are not closed during tension
* ensure flap margin and sutures lie on sound bone
* aim for healing by primary intension
137
Briefly describe the surgical removal of an impacted lower 8 (9)
* Anaesthesia achieved
* Access area by raising a buccal mucoperiosteal flap ± lingual flap
* Remove bone as necessary with electrical straight hand-piece on buccal aspect of the tooth onto the distal aspect of the impaction ( deep narrow getter around crown)
* Tooth division ( horizontal section where crown sectioned from roots)
* Retrieval with forceps or elevator
* Debridement of the area through physical removal of debris, irrigation with saline and suction under flap)
* Suture and ecnourage healing by primary intention
* achieve haemostasis
* Post op instruction and analgesics
138
What is the use of iodine during extraction of lower 8?
* Used to achieve haemostasis
* It is present in whitehead varnish pack and in alvogyl
139
What are the peri-operative complications of removing a lower impacted 8? (4)
* Risk of restoration fracture
* Risk of jaw fracture in patients with
atrophic mandible (low height <2cm)
or if 8 is close to border of mandible,
or a large cyst is associated with the 8
* Risk of damage to adjacent structures
* Risk of nerve damage
140
List post op complication of XLA of an impacted 8 ? (12)
* Pain
* swelling
* bruising
* bleeding
* jaw stiffness
* Dry socket
* Infection
* Dysaesthesia (painful)
* Anaesthesia , paraesthesia (tingling)
* Temporary or permanent anaesthesia of IDN nerve
* Temporary or permanent anaesthesia of lingual nerve
* Altered taste
141
Name three types of nerve damage?
Neuropraxia - blockage of nerve conduction due to contusion
Axonotmesis -myelin sheath damaged
Neurotmesis - nerve is transected
142
List the radiographic signs showing a close relationship of 3s to IAN?
* Diversion or deflection of the nerve canal
* Darkening of the root where crossed by the canal
* interruption of the white lines of the canal
* deflection of the root
* narrowing of the canal
* juxta apical area ( radiolucenncy around root instead of apex)
143
Juxta apical area
a well circumscribed radiolucent area lateral to the root rather than at the apex
144
What are the aims of suturing ? (6)
* approximate and reposition tissues
* compress blood vessels
* cover the bone
* prevent wound breakdown
* Achieve haemostasis
* Encourage healing by primary intention
145
Name 4 types of sutures and give examples
* resorbable
monofilament - monocryl
multifilament - vicryl rapide
* non-resorbable
monofilament - prolene
multifilament - mersilk (used in OAF and exposure of canines)
146
What are the 3 surgical principles for extraction after radiotherapy?
* atraumatic procedure
* aim to achieve primary closure
* review in 2 months
147
What might a patient complain of if they have a sialolith? (6)
* meal times symptoms
* slowly progressive swelling over a period of weeks until it becomes fixed in size
* pain
* xerostomia or thick saliva
* bad taste
* rush of saliva in mouth when swelling resolves
148
What gland is mostly affected by sialoliths and why?
Submandibular gland mostly affected due to position of gland and the uphill path of saliva secretion
149
What investigations can be done to a sialolith? (4)
* low dose plain radiographs - lower true occlusal
* palpation of gland both intra or extra orally
* Sialography - when infection free
* isotope scan if gland function is uncertain
150
How can you manage a sialolith?
* surgical removal of sialolith if practical
* Sialography sialoendoscopic removal by basket retrieval
* Shock wave lithotripsy
* consider gland removal if fixed swelling
151
What are the selection criteria for sialolith removal?
* stone must be mobile
* duct should be patent and wide
* parotid gland stone should be at anterior border of the gland
* submandibular gland stone should be at the main duct lumen distal to posterior border of the mylohyoid
152
Describe the procedure of surgically removing a sialolith?
* Preoperative preparation, including patient assessment and anesthesia.
* Incision and exposure of the duct.
* Careful stone removal.
* Duct and wound management to ensure patency and cleanliness.
* Postoperative care, including antibiotics and pain management.
* Follow-up to monitor healing and address any complications.
153
What is used to reflect a flap ?
- mitchell's trimmer
- howarth's periosteal elevator
- Ash periosteal elevator
- curved warwich james elevator
154
How to prevent nerve damage caused by extraction?
* careful radiographical assessment prior to extraction
* precise technique
155
How to prevent limited mouth opening post extraction?
use atraumatic technique
156
How prevent broken instrument during extraction?
Avoid applying too much pressure when using instrument
157
How to manage an extraction differently for a patient who is on warfarin?
* Check INR is below 4
* Atraumatic technique
* limit initial treatment area
* Stage complex procedures
* Use additional haemostatic aids : suturing , WHVP , Oral transexamic acid
* Ensure haemostasis achieved before patient leaves
* Stress the importance of post op instructions
* Book review appointment and give contact details
158
When should warfarin be checked prior to extraction?
ideally no more than 24 hours prior XLA ( 72 hours if pt is stably anti-coagulated)
159
What are bisphosphonates ?
They are a class of drugs used to help prevent or treat bone loss by inhibiting osteoclast recruitment, function and formation
Thus reduce bone turnover
160
What are conditions that bisphosphonates are used for ? (5)
* Osteoporosis
* Paget's disease
* Osteogenesis imperfecta
* Malignant metastasis
* Multiple myeloma
161
How is MRONJ diagnosed?
* no history of head and neck surgery
* exposed bone and lack of extraction site healing at week 8 of review
* Must be on bisphosphonates , anti-angiogenic drugs or RANKL inhibitors
162
Who is at low risk of developing MRONJ?
* Patients with osteoporosis only with no other co-morbidities who take oral bisphosphonates for less than 5 years
163
Who is at high risk of developing MRONJ? (7)
* Cancer patients
* previous MRONJ patients
* who have a cumulative drug dose of bisphosphonates
* treatment with a bisphosphonate and anti-angiogenic together
* Taking IV medication (bisphosphonate or antiangiogenic)
* Systemic glucocorticoids ( meds end with -one)
* following an invasive dental procedure and mucosal trauma
164
How to manage a patient at risk of mronj receiving an extraction?
* Tell pt about the risk of MRONJ due to medication
* Advice on excellent OH
* CHX use prior and after XLA
* Drugs may be stopped prior to XLA but need to consult prescribing clinician
* Atraumatic XLA technique
* Limit initial treatment site and stage complex treatment
* Use of haemostatic agents
* post op instructions
* Review patient
165
What is pericoronitis?
* inflammation of the soft tissues around the crown of a tooth , mostly a 3rd molar which only occurs when there is a communication between the tooth and the oral cavity
* the tooth is normally partially erupted and visible but occasionally there may be very little evidence and distal probing on the 2nd molar to show the communication
* Food and debris gets trapped under the operculum resulting in inflammation or infection
166
What are the signs and symptoms of pericoronitis? (10)
* Pain , swelling and ulceration of the operculum
* Halitosis
* Bad taste
* Pus discharge
* Trauma to operculum by opposing arch
* Dysphagia
* Trismus
* Pyrexia
* malaise
* lymphadenopathy
167
How is pericoronitis managed?
* incise and drain pericoronal abscess
* irrigate under operculum using CHX or Talbot's iodine
* XLA 3rd molar
* Analgesia and CHX mouthwash
* ABS only if severe, systemically unwell or immunocompromised
* Refer to maxfax or A&E
168
When should you refer pericoronitis patient to maxfax/ A&E
* Large extra oral swelling
* Systemically unwell
* trismus
* dysphagia
169
What might be a treatment option for pericoronitis if you cannot extract the 3rd molar due to close proximity to IAN?
Corenectomy
170
What teeth are mostly affected by pericoronitis?
3rd molars
171
Give long term peri-coronitis treatment options?
* XLA or surgical removal of tooth causing symptoms
* XLA of tooth opposing operculum if it is causing the trauma
* Corenectomy if tooth roots have close relation to IAN
172
What is osteoradionecrosis?
* It is a condition of non-vital bone or necrotic bone as a result of radiotherapy
* Any bone turnover at the site affected is very slow and self repair is ineffective
* This can progress and get worse overtime
173
What are the risk factors of osteoradionecrosis? (5)
* Radiation of the head and neck especially more than 60 grays
* mandible is affected more than maxilla
* when necessary dental procedures have not been carried out prior to extraction therapy
* Poor oral hygiene
* Post radiotherapy damage through trauma, biopsy , irritation to the area within 1 year
174
Why does osteocardionecrosis affects the mandible more than the maxilla?
Due to poor blood supply as the blood supply to the maxilla is greater than the mandible
175
If pt required extraction prior to radiotherapy when should you extract ?
2 weeks prior to radiotherapy
176
How can osteoradionecrosis be prevented? (6)
* XLA of teeth of poor prognosis at least 2 weeks prior to radiotherapy
* ensuring patient is dentally fit prior to radiotherapy
* OHI - keeping good OH throughout
* use of CHX before and after XLA
* ABS post operation
* Using atraumatic extraction technique
177
How is osteoradionecrosis managed ? (4)
* Surgical debridement
irrigation of necrotic debris
removing necrotic and infected tissues
removing loose necrotic bone
* Surgical microvascular reconstructive surgery - restore blood flow to area
* Grafts - bone and soft tissue
* Hyperbaric oxygen therapy - increase local tissue oxygenation and vascular ingrowth to hypoxic areas
178
What is sequestrectomy ?
Removal of loose necrotic bone
* can be used to manage ORN
179
Give 6 different forceps used for extraction and their uses ?
* straight upper anterior - upper 3-3
* upper universal - upper anterior and premolars (roots)
* upper molars left and right - upper molars (beak to cheek)
* lower universal - lower anteriors
* lower molar - lower molars
* cowhorn's forceps - mandibular 6s
180
Name 3 types of elevators?
* Warwick james
* Cryer's
* Couplands
181
What movements are used for elevators?
* Wheel and axle (rotation)
* Lever
* Wedge
182
What are the uses of elevators? (6)
* provide point of application for forceps
* loosen teeth prior to extraction
* extract the tooth without the use of forceps
* removal of multiple root stumps
* removal of retained roots
* removal of root apices
183
What is the function of a luxator ?
Break the PDL to aid forceps use
184
What is osteomyelitis ?
It is a bacterial infection of bone resulting in inflammation of the bone marrow which in turn can cause tissue necrosis due to an increase in tissue pressure (lower blood supply)
185
What are the risk factors of osteomyelitis? (6)
* Odontogenic infections
* Pts with myeloproliferative disease - leukaemia
* chemotherapy patients
* fractures of the mandible
* immunocompromised patients
* malnourished patients
186
How is osteomyelitis managed ?
* refer to specialist
* medical treatment
* surgical treatment
187
What is the medical treatment of osteomyelitis? (3)
* Antibiotics for up to 6 weeks or 6 months for chronic cases
* May require IV antibiotics in acute cases
* Blood tests and glucose levels should be checked
188
What is the surgical treatment for osteomyelitis?
* Debridement - remove any loose necrotic bone
* remove of any non vital tooth in area
* Drain pus
* corticotomy - removal of bony cortex or perforation of bony cortex
* fractured mandible - remove any screws and plates in the area
* excision of necrotic bone
189
What is the nerve supply for the submandibular gland?
Chorda tympani which is a branch of the facial nerve via the submandibular ganglion
* parasympathetic
190
What is the innervation of the parotid gland?
Sensory - auriculotemporal nerve and greater auricular nerve
Parasympathetic - auriculotemporal and glossopharyngeal
191
What is the secretion of the submandibular gland
mixed
* serous and mucous secretions
192
What is the secretion of the parotid gland?
Serous
193
What is the nerve supply of the sublingual gland?
Chorda tympani from the facial nerve via the submandibular gangliontic
* Parasympathetic
194
What is the secretions of the sublingual gland?
mixed but predominantly mucous
195
What information is required when taking a history and investigating a patient with a swelling before looking the mouth? (8)
* Pain history and thorough medical history
* temperature
* breathing rate
* if airway is compromised
* heart rate
* lymphadenopathy
* did the swelling increase in size?
* how long swelling has been present
196
What things would you note about a facial swelling? (9)
* Site
* Size
* color
* heat from area
* texture - firm or mobile or fluctuant
* pus discharge
* involvement of any other structures (eyes?)
* duration of swelling
* clear or diffuse borders
197
What are the Criteria perimeters for SIRS?
2 or more positive SIRS factors ± suspected or conrfirmed infection
* Temp below 36 or above 38
* Respiratory rate more than 20 breaths / min
* Pulse more than 90 beats/min
* white cell count less than 4 or more than 12
198
What do you do when you suspect sepsis ?
* Urgent referral to MAXFAX or A&E
199
What is Ludwig's angina?
* A bilateral cellulitis infection of the sublingual and submandibular spaces which can compromise the airway
200
What are the features/signs of Ludwig's angina? (6)
* Raised tongue
* Difficulty breathing
* Difficulty swallowing
* Drooling
* Diffuse eryhtema of the submandibular region EO
* Swelling of the submandibular region
201
Name 4 maxillary spaces? (4)
* infraorbital space
* infra-temporal space
* Palatal
* Buccal
202
Name 5 mandibular spaces
* Buccal space
* Submandibular
* Sublingual
* Lateral pharyngeal
* Sub-masseteric
203
What the routes of spread of odontogenic infections?
* Maxillary abscess
* Mandibular abscess
204
Where does the infection spread from the lower anteriors? (2)
Mental and submental space
205
Where does the infection spread from the lower premolars and molars? (5)
* Buccal space
* Sub-massetetic space
* Sublingual space
* Sub-mandibular space
* Lateral-pharyngeal space
206
Where does the infection spread from the upper anteriors? (4)
* Lip
* Nasolabial region
* Lower eyelid (infraorbital)
* Palate
207
Where does the infection spread from the upper lateral incisors? (1)
Palate (less common)
208
Where does the infection spread from the upper molars and premolars?
* Cheeck (buccal)
* infra-temporal
* Maxillary antrum - very rare
* Palate - less common
209
List the cranial nerves (12)
* Olfactory - smell
* Optic - vision
* Occulomotor - eye movement and pupil constriction
* Trochlear - eye movement
* Trigeminal - touch and pain from face and head and mastication
* Abducens - eye movement
* Facial - muscles of facial expression and taste (ant2/3 of tongue)
* Vestibulocochlear - hearing and balance
* Glossopharyngeal - taste (post 1/3 of tongue) , sensory from tongue pharynx and tonsils
* Vagus - sensory, motor and autonomic function of glands, digestion and cardiac system
* Spinal accessory - muscles used in head movement
* Hypoglossal - controls muscles of the tongue
| OOOTTAF VGV SH
210
How to test the olfactory nerve?
* examine each nostril with smelling objects such as peppermint
* notice change in smell
211
How to test the optic nerve?
* Visual acuity test from 6m away chart
* covering each eye at a time
212
How to test oculumotor nerve?
Shine torch into eye and check response
213
How to test trochlear nerve ?
* follow eyes with object movement
214
How to test trigeminal nerve?
* light touch and pin prick assessment
* muscles of mastication motor function (clench)
215
How to test abducens ?
Make H movement with finger and get eye to follow this
216
How to test facial nerve?
* Facial asymmetry
* eye brow movements
* close eye
* smile
* blow out cheeks
217
How to test vestibulocochlear nerve?
* Rinne's test into each ear separately
218
How to test glossopharyngeal nerve
Coughing reflex
219
How to test vagus nerve?
* let patient say ah and check palate movement
* test gag reflex
220
How to test accessory nerve?
* turn head from side to side against resistance
* shrug shoulders against resistance
221
How to test hypoglossal nerve?
* Open mouth and inspect tongue
* protrude tongue and move from side to side
222
Maximum doses of lidocaine 2% + 1:8000 adrenaline
4.4 mg/kg
500 Microg of adrenaline
223
Max dose of prolicaine 4% ?
6mg/kg
224
Max dose of Mepivicaine 3%?
4.4mg/kg
225
Max dose of articaine 4%
7mg/kg
226
What are the signs of referral for suspicion of cancer?
* Persistent or unexplained head and neck lumps > 3 weeks
* Persistent or unexplained ulceration > 3 weeks
* Hoarseness > 3weeks
* Pain in throat or swelling > 3 weeks
* Unexplained difficulty of tasting/chewing/speaking
227
