Oral Surgery Revision Notes Flashcards
Peri op complications
Wrong tooth
broken instruements
difficult access or vision
abnormal resistance
bleeding
maxiallry fracture
root in antrum
OAC
TMJ dislocation
damage to vessels
damage to nerves
Loss of tooth
How to tx bleeding
apply pressure with damp gauze
diathermy
sutures
WHVP
LA with vasoconstrictor
surgicel
Why do people bleed
due to meds - anticougulants
liver disease
bleeding disorder
alcoholism
trauamtised area with finger
blood clot dislodge
Vasoconstrictor of LA worn off
sutures became loose
Damage to nerves why
crushing on removal of tooth
cutting or shredding due to LA or flap design
Due to LA
Nerve damage during surgery
How to confirm root in antrum and tx
confirm radiographically
Raise a flap, suction, irrigation, curette, suture flap
(remove root either with cutreetes, ribbon gauze, endoscopically or Caldwell Luc approach)
Maxiallary tuberosity why they occur
lone standing molars
poor support of aveloar bone on removal of tooth
incorrect sequence of removal
concerscene
pathological gemination
tx of maxiallry tuberoisity
dissection out and closing
reducing and stabilising
tooth removed 8 weeks later
signs of maxiallry tuboosity
tear in palate
noise
vision
mobility seen
What is an OAC
a whole which is found betweeen the tooth socket and maxiallry sinus
OAF when it is left and starts to epithelialise
tx for OAc
if small then encourage clot to form and suture
larger require closure by buccal advancement flap, socket cleaned and sutures
Post op for OAC
nonoe blowing
no smoking
no drinking through straw
enourage steam inhalations
no wind insutrments
CHX rinse
nasal drops
Signs of OAC
bubbling at tooth socket
change in suction noise (echo)
blunt probe
direct vision
salty unilateral discahrge
draininage from nose
difficluty drinking trhougth straw
Why does OAc occur
previous hx of OAC
bulbous roots
closeness to maxiallry sinus
tuberoisty fracture
sturgical xla
osteoradionecroris
PA infection of molars
recurrent sinusitis
lasat standing molar
Post op complications
pain
bleeding
swelling
brusing
osteomyleitisis
osteoradionecrosis
actimycosis
permmanant/temp numbness
sequestrum
dry socket
infective endocariditis
trismus
Chronic OAF
Dry socket symptoms
pain radiating to ear
dull aching pain
hallitosis
kept awake at night with pain
snestivity of bone area
Factors for ary socket
female
mandible
molars
smoker
previous hx
truama to clot
OCP
Tx for dry socket
reassurance and anlagesics
La block
irrigate socket with saline and warm water
debridement of area
alveogyl placed
post op - warm salkty mows
review pt
Osteradionecrosis
bone death due to radiotherapy
Symptoms of osteoradioneccrosis
ulcers on gum
exposed bone
pain
swelling
trimus
numbness
Casues of osteoradionecrosis
radioathion therapy >60grays
Risks of osterioeadionecrosis
poor oh
perio
caries
xertosomia
Tx for osteoradionecrosis
hyperbaric oxygen
surgical debridgment
antibiotcis and CHX after XLA
Free flap reconstruction surgery
Actimycosis
rare bacterial infection casuing thick pus
incise and drain pus and high dose iv antibiotics
Osteomyeleitis
bone infection in mandible - streptococci or anaerobic cocci
refer for oral or iv antibiotncs and surgery
Types of biopsies
excisonal biopsy
incisional biopsy
punch biopsy
Excisonal biopsy
for mucoelses and fibrous polyps
lesion usually benign
Incisoinal biopsy
SCC, lichen planus
maglinant lesions poteintal
removes not all abnormal tissues
Punch nbiopsy
incisional biopsy - 4,6,8,mm punch
What not to biopsy
tip of tongue
things close to nerve
salivary gland duct orifice
large blood vessles
What to send in sample
10% formalin
suture to orietate
no gauze just filter paper
Asipration samples
blood sample
fine needle aspiration
aspiration from lesion
Aspiration from lesion
cysts and abscess
fine needle aspiration
from solid lesions
resorable sutures
mono - moncryl
poly - vicryl rapide
Non resorable sutures
mono - proliene
Poly - mersilk
Anaesthetsia
numbness/total loss of sensation
Paraesthesia
tingling sensation
dysathesia
unpleasant sensation
hypoaesthesia
reduced sensation
hyperaestehsia
increased sensation
Aims of suturing
achieve haemostasis
heal my primary intention
prevent wound breakdown
cover bone
repositon tissues
Handpiece for surgery
straight handpiece witha saline cooled bur
round or fissue tungsten carbide bur
Types of debridment
physical - mitchells trimmer, bone file
irrigation
suction
Causes of retained roots
Coronectomy
Trauma
caries
attemped XLA that failed
why do teeth fracture
thick dense cortical bone
caries, perio
Previous RCT
ankylosis
root shape
root number
root alignment
Radiographic report for 3rd molars
type of impaction
root morophoology and number
crown size
alveolar bone levels
perio health
surrounding anatomial structures
asscoaited path
follicular width
Depth of impactions
superficial - crown of 8 realted to crown of 7
moderate - crown of 8 related to crown/root of 7
deep - crown of 8 related to root of 7
Signs of closeness to idc
dark/bifid roots
diflection of roots
narrowing of roots
narrowing of IDC
darkening of IDC
diflection of IDC
juxta apical area
interuption of white lines
Agensis
organ failed to develop
Nerves at risk during xla of 3rd molar
lingual nerve
inferioer alveolar nerve
mylhyoid nerve
buccal nerve
Indications for xla of 3rd molar
infection
cysts
caries
medical conditions
high risk of disease
external resoprtion of 7/8
Periocrontitis
inflammation of surround soft tissue of a 3rd molar
Symptoms of periocronitis
hallitosis
pyrexia
trismus
pain
swelling
bad taste
regional lyphadenopathy
pus discharge
maliase
tissue spaces 3rd molar infection spreads to
submandibular space
sublingual space
buccal space
submassteric space
pterygomandibular space
paraphayngeal space
Submandibular draininage
extra oral - just 2cm below lower border of mandible toa void damage to the mandibular branch of the facial nerve
Sublingual draininge
intra oral draininge at FOM
Classification of fractures
site of fracture
no. og fracture lines - single, double, multi
size of fracture - uni/bi
displacement of fracture
involvment of surround tissues - simple, compound, commuication
special features to note
direction of fracture line
Factors for likelhod of displacement fractures
type of injury that occured
magnitue of forces
opposing occlusion
intact soft tissues
direction of fracture line
Tx for mandibular fractures
closed reduction
open reduction with internal fixation
Special invesitgations for mandibualr fractures
CBCT
OPT and PA
Occlsual
towns view
lateral oblique
signs and symptoms of mandibular fractures
pain, bruisng, swelling, bleeding
trismus
AOB
Mandible deviates to opposite side
mobile teeth
Asymmtery
occlsual derrangement
numbness of lower lip
step deformity
Signs and symptoms of maxiallry fracture
pain, bleeding,swelling, brusing
asymmetery
AOB
paraesthesia of infraorbital nerve
step deformity
nose bleeds
blurry vision (diplopia
flattened face
trismus
Imaging for maxiallry fractures
CBCT
opt, pa, SMV OM
Zygomatic factures radiographs
need 2 views - use occipitomental view - 2 angles 10 and 30/40 degrees
Signs and symptoms of zygomatic fracture
pain, brusing, swelling, bleeding
blurry vision
flattend face
pain on eye movement
altered sensation
paraesthedsia of inraorbital nerve
lots of tears
Causes of TMD
Bruxists
nail biting
chewing gum
Clenching/grinding teeth
ankylosis
hyperplasia
lack of posterior support
degenerative
Features of TMD
F>M
18-30 years
clicking/popping sound
headaches
trismus
crepitus
linea alba
tongue scalloping
masseteric hypertropy
NCTSL
Investigations forTMD
Ultrasound
CBCT or MRI
Arthography
Nuclear imaging
Transcrainal view
Management of TMD
reassurance
anglesics
reduce stresses
cut food into small pieces
support jaw when yawning
avoid chewing gum/nail biting
avoid wide opeing
Physical magnement of TMD
acuupuncture
TENS
Ultrasound
physio
massage/heat
relaxation
Meds for TMD
botox
anti- depressants
NSAIDS
diazepam
steriods
Blood supply to tmd
deep auricular arterty
Nerve supply to tmd
auricotemproal nerve
How the TMJ works
opens intially as a rotation movement
translates forwards and slides down the articular tubercle from the mandibular fossa
What muscle does the TMJ attach to
the lateral pterygoid muscle
Anterior displacement with reduction
there is a clicking sound
antericular disc anteriolry placed, posterior band further forwards adn streches bilaminar zone of disc
Anterior displacement without reduction
grating sound, disc infront of condyle
loss of elasticity of bilaminar zone
Functions of splints
protection of TMJ
Help with function of MOM
prevent grinding of teeth
stabilise occlusion
preven jaw head from rotating to far posterior on glenoid fossa
Clincial issues with maxillary sinus
root in antrum
OAC/OAF
sinusitits
bengin and malgninat lesions
Opening of maxillary sinus
hitaus semilunaris (below middle concha)
Causes of sinusitis
viral infection
fungal infection
XLA
forgein object
bening or malginant lesions
signs and symptoms of sinusitis
sneezing
nasal congestion and discharge
facial pain
pressure
pain in maxiallry teeth
cough
ear pain
pain onpalpation of infraorbital region
tx for sinusitits
nasal decongestions
humidiifed air
steam inhlations
bacterial - Pen V 250mg
Epitheliunm for sinuses
psedustratified ciliated columnar epithelium with gobelt cells
cilated
mobilies trapped matter and foregin material
and moves material to ostia for elimination
5 cardinal signs of inflmmation
redness
heat
swelling
loss of function
inflammation
Potential for prescribing antibiotics
immunocomporomsided
cellulitis
severe percoronitis
osteomyeletis
spread of infection past alveolar bone
lymphadenopathy
trismus
temp >30degress
SIRS
sysyemic inflammatory response system
SIRS cretieria
WBC <4x10^9 > 12 x10^9
resp >20/min
hr >90/min
temp <36/>38
Pulpal pain fibres
c fibres
perio ligamnet fibres
a delta fibres
Upper anterior spread
lip
nasiolabial region
infra orbital region
Upeer posterior spread
maxiallary antrum
palate
intra temporal region
cheek
Abscess spreading buccally above mylohoyoid vs below
above = sublingual space
below = submandibular space
What is Ludwig’s angina
i is rare type of cellulitis that occurs due to an abscess of a tooth left untreated that can spread
it is casued by a bacterial infection that spreads into the submandibular and sublingual spaces
What bacteria can causesludwigs anging
streptoccoal and staphylococcla bacteria
How does the spread of ludwigs anginga happen
epiglottis to parapharngeal spcaes to airbway obstruction
death can occur if sepsis, spread into the necka and mediasteunum
Intraoral signs of ludwigs angina
drooling
raised tongue
swelling, diffuclty breathing and swallowing
extra oral signs of ldwigs anginga
redness and swelling in the submandibular region
fever or chills
general maliase
What is cellulitis
a bcaterial infeciton that spreads into the deep layers of the skin
Paracetamol max does
4grams
500mg 1-2tabs every 4-6hrs
Carbamzepines
for trigeminal neuralgia
100/200mg tabs
contraindicaitons of carmazepine
pregnant or breast feeding
renal or hepatic impairment
cardiac impairment
skin reaction
porphyria
gluacoma
hx of bone marrow depression
Avoid parcetamol
alcohol dependenace
renal or hepatic impairment
cytotixs
lipid regualting drugs
Ibuprofen max dose
2-4g per day
avoid ibuprofen
peptic ulcerations
asthma
cardial renal or hepttic impairment
preg
elederly orther NSIADs
steriods
Ibuprofen and drug interactions
antibiotics
ACE inhibitors
beta blockers
anticogulants
antidepressants
diruetics
lithium
calcium channel blockers
Aspirin avoid
elederly
ashmatics
peptic ulceration
renal or hepatic impairment
Max does of aspirin
300mg x12 in 24hrs
Mechanism of aspirin
reduces produciton of prostaglnaidns
inhibits cox 1 and cox 2 which reduces platelet aggreation
COX 1
responsible for the reduction of prostaglandins assoicated withplatelet aggeration
COX 2
the enzyme reposnsible for most inflammatory prstaglandins
ASA classification
Amercian soceity of anaestesiilogist of medical status
ASA 1 and 2
can be trested by sedaiton dentists
ASA 3,4,5
hospital setting only sedation
ASA I
normal healthy person, non smoker and min alcholol, BMI <30
ASA II
mild systemic disease - smoker, BMI<35, controlled diabetes, mild asthma, epilpspy, preg pts, BP 140-159/90-94
ASA III
moderate systemic disease - type 1 diabetes, >3months since MI or CVA, BP 160-199/95-114, BMI<35, stable angina, COP
ASA IV
severe systemic disease - BP 200/115, unstable anginga, uncontrolled angina, <3months MI or CVA
ASA V
moribud - severe threat to life, not expected to survive
ASA VI
brain dead - organs for donation
Vital signs to monitor in sedation
BP
HR
Oxygen levels with pulse oximeter
BMI
weight/height^2
<18.5 = underweight
18.5-25 = normal
25-30 = overweight
>35= obese
Indications for sedation
phobic pts
gagging pts
parkinson’s disease - prevents resting tremor occur
cerebral palsy
learning difficulties
pt who is not coperative
Contraindications for sedation
pregnant patients
COPD
Spreading infection compromising airway
severe uncontrolled systemic disease
pyhsichatric diseases
Hypothyrodism
Hypothyroidism and sedation
contraindicated as drug metabolism slowed downa and can also lead to resp failure
Sedation and interaction with drugs
antihistamines
eryhromycin
antidepressants
alocohol
recreational drugs
antipsychiotics
opiods
Complications of drug adminstration
sexual fantasy
hyporepsonders - drug abusers, alcoholics,
hypoeresponders
oversedation
allergic reaction - given adrenaline
Contraindications of cannulation
fainting
heamatoma
venospasm - unable to locate veins
extramuscualr injection
intra-arterial injection - injection straight into an artery
Indications for inhalation sedation
needle phobia
gaggers - reduced gag reflex
anxious pts
pts medical conditions increased by stress
people with liver probs
Contraindications of inhalation sedation
common cold
severe asthma
COPD
Fear of face mask
unable to breathe through nose
1st tri of pregnancy
tonsilaaer enlargement
Advantages of inhaltion sedation
quick recovery
rapid onset
no needles
no injection
no ammnesia
few side effects
Disadvantages of inhaltion sedation
staff becomed addicted
not potent
expensive equipment
requires space for equipment
requires to breathe through nose
Colour of oxygen
black
colour of nitrous oxide
blue
Pre op instructions before inhaltion sedation
light meal before
take meds as normal
wear loose clothing
accompaoined by adult
accompained with escort for home
no alcohol
Signs of adequate sedation
feels comfortable and relaxed
reduced blink reflex
pt awake
reduced reaction to painful stimuli
reduced spontansoues movement
verbal contact mainted
Recovery from inhlation sedation
oxygen adminstered 10-20% over a period of 2mins to prevent diffuision hypoxia
Flow rate for inhaltion sedation
5-6litres
Oversedation
naseua/vomtiing
loss of consciousness
sluggish responses
inchoerent speech
mouth closes repeatedly
uncontroable laughter/tears
reduced co-operation
Equipement for inhalation sedation
Nasal hood
Gas cyclinders
Gas delivery hoses
Reservoir bag
Flow meter
Waste scavenging system
Pressure reading vavles
Post op advice following sedation
analgesics
do not sign irreversible docs for first 24hrs
do not drive or operate machinary for 24rs
rest and recovery
do not be in charge of anyone till the next day
be careful with cooking and domestic applaiances
Contraindications of IV sedation
hepatic insufficiency
porphyria
benzodazepine allergy (midazolam)
myaesthenia gravis -leads to pt being paralysed but still awake
Flumanzeil
benzodiazepine anatagonist which displaced midazolam from recptor sites blocking any action potential
Midazolam half life
90mins
Midazolam
5mg/5ml
ph3.5 allows to be soluble when ingested
medtabolised in theliver and bowel
Eve’s sign
shows motor co-ordination - t tries to touch the tip of nose with finger and theri eyes closed
Verrill’s sign
drooping of eyelids
Sites for cannulation
dorsum of hand
antecubital fossa
Why is an indwelling canula placed
to allow for emergecny drugs to be placed (teflon cannula)
Day of IV sedation
no nail varnish affect pulse oximeter
meal 1hr before procedure
wear loose clothing
no makeup so can check face colour
escort home
not to be left alone for 1st 12 hrs
not to be in charge of anyone for 1st 12 hrs
pain relief
check height, BMI, BP, MH
no alcohol
no cold (affects O2 saturation)
How does midazolam work
it binds to receptors that control sodium ion movement
receptors associated with GABA - which allows chlrodie ions from extracellular fluid to enter cells are negatively charged).
midazolam increases affinity for GABA, increasing the inbitory action of GABA
Respoonsible for anticovulsant and sedative effects
Also minimic action of inhibitory neurotransmitted gylcine - muscle relaxnt action
Potency
measure of affinity a drug has for its receptor
the strength it has on its recptor
length of time required to eliminator the drug
