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Oral surgery tutorials Flashcards

1
Q

What Anaesthetic is not recommended for pregnant women? and what ingredient causes the issue?

A
  • Citanest ; contains fellypressin which can induce labour
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2
Q

Standing positions of right handed operator?

A
  • Infront at 7 O’clock
    Upper anteriors
  • Infront
    Upper molars
    Upper premolars
    Left lower molars
  • Behind right shouder - 11O’clock
    Right lower molars
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3
Q

What is the patient position for extractions in upper dentition?

A
  • Patient head just below their shoulder height
  • Semi-supine
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4
Q

What is the best patient position for extractions in the lower dentition?

A
  • Patient head just below dentist elbow height
  • Upright
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5
Q

Describe the technique for using forceps to extract a multi-rooted tooth (3)

A
  • Apical pressure
  • Figure of 8 movements
  • Buccal expansion
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6
Q

Describe the technique for using forceps to extract a single rooted tooth? (2)

A
  • Apical pressure
  • Rotational movement
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7
Q

Give 3 principles in positioning extraction instruments?

A
  • Pressure applied away from soft tissues
  • Do not lean against teeth
  • Forceps engage the roots
  • Use under direct vision
  • Support instrument with other hand
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8
Q

What are the 3 actions in which you can use elevators?

A
  • Wedge
  • Lever
  • Wheel and axle
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9
Q

Give 5 post-op haemostasis methods?

A
  • Apply pressure
  • LA with vasoconstrictor
  • Suturing
  • Sugicel packing
  • Bone wax
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10
Q

What 3 things may be important in terms of scheduling an appointment for a patient on an anticoagulant?

A
  • Treat early in the day
  • Treat early in the week
  • Timing with anticoagulant intake
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11
Q

Give 4 systemic haemostatic agents?

A
  • Tranexamic acid
  • DDAVP (desmopressin)
  • Vitamin K
  • Replace missing clotting factors
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12
Q

What type of drug is Warfarin?

A

Vitamin K antagonist

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13
Q

What does INR stand for?

A

International normalised ratio

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14
Q

Give the normal INR for a non-warafrin patient?

A

1

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15
Q

Give the normal INR for a patient who is stably coagulated by warafrin

A

2-3

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16
Q

What should you do if a patient is taking warfarin and their INR is above 4 ?
They are getting an extraction

A
  • Delay treatment
  • Investigate and refer to patient haematologist
  • If an emergency patient refer to second care
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17
Q

If there is evidence of a patient being stably coagulated, what is the maximum time an INR can be taken before an extraction can go ahead?

A

72 hours

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18
Q

A patient requiring an extraction is on apixaban. What pre-op instructions will you give to the patient regarding his medication? (2)

A
  • Skip morning dose
  • Take it in the usual time in the evening
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19
Q

A patient requiring extractions is on rivaroxaban. What pre-op instructions will you give the patient regarding his medication?

A
  • Delay morning dose to 4 hours after haemostasis achieved
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20
Q

What information you would want to know about the patient who is on anti-coagulants or anti-platelets regarding their medical history

A
  • If they are taking any NSAIDs such as ibuprofen and diclofenac - as may increase bleeding risk
  • Their INR record if they are taking warfarin
  • Kidney, liver and blood conditions
  • Any herbal or complementary medicines
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21
Q

Name DOAC that are taken twice a day?

A
  • Apixaban
  • Dabigatran
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22
Q

Name DOAC that are taken once a day in the morning?

A
  • Edoxaban
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23
Q

Give examples of injectable anticoagulants

A
  • Dalteparin
  • Enoxaparin
  • Tinzaparin
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24
Q

What post op instructions would you give specifically for a patient who had an extraction?

A
  • Rest while the local anaesthetic wears off and the clott fully forms (2-3 hours)
  • Avoid rinsing your mouth until the next day
  • Avoid sucking hard or disturbing the clot
  • Avoid hot liquid and hard foods
  • The day after treatment gently rinse with warm salty water 3-4 times a day for 5 days ( ts in glass of water)
  • Avoid using NSAIDs for pain and use paracetamol instead
  • Contact details for any questions or emergency
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25
Give 2 types of antiplatelets?
* Aspirin * Clopidogrel
26
A patient requiring extraction is on an anti-platelet what should you do? (3)
* Do the treatment * limit initial treatment area * consider staging treatment plan * Use atraumatic technique * Apply local haemostatic measures * Expect prolonged bleeding and warn patient about risk of prolonged swelling and bruising
27
Give 4 principles of suturing?
* Laid on sound bone * Achieve haemostasis * Reposition tissues * Do not close wound under tension
28
When to use a monofilament suture?
* Mucogingival surgery
29
When to use a non resorbable suture?
OAF
30
When you can use a resorbable suture?
* Post XLA haemostasis
31
How would you manage a patient for an extraction if they are on injectable anticoagulants? (low dose)
* Treat without interrupting medication
32
How would you manage a patient for an extraction if they are on injectable anticoagulants on high or uncertain of the dose?
* Consult prescribing clinician
33
What should you assess when treating a patient with anticoagulants or antiplatelet drugs?
* Bleeding risk of dental treatment * Duration of treatment with drug * Any other relevant medical complications * Type of drug the patient is taking
34
In what groups of patient is it advised to not interrupt anticoagulant/antiplatelet medication?
* Pts with metal prosthetic heart valves or coronary stents * Pts who had a pulmonary embolism or deep vein thrombosis in the last 3 months * Pts on anticoagulant therapy for cardioversion
35
What are the 4 categories of pain-related TMDs?
* Myofacial pain * Arthralgia - pain in joint * Displacement of joint with or without reduction * Headaches
36
Give 4 causes of TMD?
* Stress * Trauma * Mandibular displacement * Medical history - fibromyalgia * Anatomy of joint
37
What are 4 signs of TMD?
* Hypertrophy of MoM * Crepitus * Deviation on opening * Pain on palpating TMJ
38
What symptoms may a TMD patient complain of? (6)
* Pain in the morning * Intermittent pain * Headache * Clicking sounds * Limited mouth opening * TMJ pain
39
When should a TMJ patient be referred to oral medicine or maxfax for specialist investigations? (4)
* Crepitus * Severe trismus * Failure of primary treatment * To carry out further investigations
40
Give 3 specialist investigations used to diagnose TMD?
* Arthroscopy * CT scan of joint * MRI Scan
41
Give 3 management options for TMD in primary care?
* Counseling * Bite splint * Physiotherapy
42
What counselling advice can you give a patient with TMD? (8)
* Stop parafunctional habits * Manage stress * Avoid chewing gum * Soft food diet * Cut food into smaller pieces * Avoid chewy food * Avoid incising food * Support mouth when yawning
43
Give 3 management options for TMD in secondary care?
* Botox * Tricyclic antidepressants * Joint replacement
44
What drugs can be used to manage TMD?
* NSAID's * Diazepam * Amitriptyline * Gabapentin
45
Give 2 sources of information which you can recommend for patient to read about TMD?
* NHS Information * British association of oral surgeons
46
What type of joint is the TMJ?
Modified hinge (atypical) synovial joint
47
What artery supplies the TMJ?
Deep auricular
48
What nerve supplies the TMJ?
* Auriculotemporal nerve * Masseteric nerve * Posterior deep temporal ** all branches of V3 **
49
What muscles are involved in elevation?
* Temporalis * Masseter * Medial pterygoid
50
What muscles are involved in protrusion?
* Medial pterygoid * Lateral pterygoid * Masseter
51
What muscles are involved in retraction
* Deep part of masseter * Posterior fibres of temporalis
52
What muscles are involved in lateral deviation?
* Ipsilateral masseter * Contralateral lateral pterygoid * both work with temporalis
53
What muscles are involved in depression? (3)
* Mylohyoid * Geniohyoid * Digastric works with gravity
54
In terms of dis and condylar movement, describe how disc displacement with reduction occurs?
* Articular disc displaced anteriorly to the condyle during opening * Leading to difficulty in opening the mouth wide until disc reduction occurs * This results in lockjaw then the joint clicks
55
What are the main symptoms of disc displacement with reduction? (4)
* Clicking * Dislocation of joint * Pain * Deviation on opening
56
What is the risk of not treating symptomatic disc displacement with reduction?
Progress to osteoarthritis
57
How can you manage disc displacement with reduction?
* Counselling * Limit mouth opening * Bite raising appliance * Surgery
58
Give 5 signs of a mandibular fracture?
* Numbness of lower lip * Mandibular deviation * Occlusal derangement * Pain * Mobile teeth
59
What are the ways for classifying mandibular fractures? (6)
* involvement of surrounding tissues * number of fractures * Side of fracture * Site of fracture * Direction of fracture * Specific fractures * Displacement of fracture
60
What radiographs can be used to assess mandibular fractures?
* Towne's view * PA mandible * OPT * Occlusal oblique
61
What is the treatment for undisplaced mandibular fracture?
* Accept and monitor
62
What is the treatment of a displaced mandibular fracture?
* Closed reduction with internal fixation * Open reduction with internal fixation
63
Give the bones that are involved in the three types of Le Fort fractures ?
1 - maxilla 2- maxilla and nasoethmoidal 3- maxilla , nasoethmoidal and zygomato-orbital
64
Give 5 signs of a zygomatico-orbital fracture?
* Epistaxis * Diplopia * Bony step deformity * Peri-orbital bruising * Swelling * Subconjunctival haemorrhage
65
How would you clinically assess for a zygomatico-orbital fracture?
* Palpate for depression of Supraorbital region infraorbital ridge zygomatic arch * Observe the movement of maxilla
66
What radiograph can be used for a zygomatico-orbital fracture?
* Occiptomental ( parallax 0-30 degrees )
67
What initial management should you carry out for a zygomatico-orbital fracture? (4)
* Rule out damage to orbital nerve - color vision test , visual acuity test * Prophylactic ABs * Avoid nose blowing * Refer to maxillofacial department
68
What are the 4 types of skull radiographs in maxillofacial trauma?
* Occipitomental * PA mandible * Reverse Towne * CBCT
69
What is the occipitomental view primarily used for?
Maxillary middle third fractures
70
What PA mandible used for? (3)
* Ramus fractures * Lower condylar fracture * Angle of the mandible fracture
71
What is Reverse Towne view used for ?
* TMJ investigations * Coronoid notch * Condylar fracture
72
What is CBCT primarily used for in fractures?
Spatial assessment of fractures in three planes - coronal - axial - saggital
73
What are 5 radiographic signs of fractures?
* Sharply defined radiolucent line * Radiopaque line * Change in normal outline or shape of bone * Opacification - new bone formation * Surgical emphysema (air)
74
What are 5 common fracture patterns that can be seen radiographically?
* Mandibular displacement * Zygomatic arch fracture * Tripod fracture * Orbital blowout * Nasoethmoidal complex
75
Identify fracture?
* Fracture of right condylar neck of mandible (subcondylar fracture)
76
Identify fracture?
* Fracture of right body of mandible * Fracture of left angle of mandible
77
What type of radiograph is this?
PA mandible
78
What is this? and what type of image?
* Left inferior orbital blowout fracture * CBCT
79
What is this radiographic view?
* Occipitomental
80
* 25 year old patient complaining of toothache * I/O - localised swelling in lower left quadrant What is your provisional diagnosis?
* Acute periapical abscess ( lower left region)
81
* 25 year old patient complaining of toothache * I/O - localised swelling in lower left quadrant What 4 further investigations will you carry out?
* Percussion * Sensibility testing * Peri-apical of the lower left molar * Mobility testing of 46,45,43
82
* 25 year old patient complaining of toothache * I/O - localised swelling in lower left quadrant How will you manage this case? (5)
* Assess cause of abscess using special investigations * Inform patient of treatment options for his case * Carry out emergency treatment for the patient * Provide analgesia advice + CHX 0.2% twice daily for 7D * Give instructions on what to do if infection returns
83
* 25 year old patient complaining of toothache * I/O - localised swelling in lower left quadrant when would you review after carrying out emergency treatment?
48-72 hours
84
Give 3 methods for abscess drainage post-incision?
* Hilton technique - for areas of major nerves trunks * Pressure + gauze * Extra-oral drain
85
What common bacteria is found in dentoalveolar abscesses?
* Anearobic - P.intermedia * Strepcocci - S.angiosus
86
What antibiotics are effective against P.intermedia?
* Penicillin * Metronidazole
87
What Antibiotics are effective against S.angiosus?
* Penicillin * Erythromycin * Clindamycin
88
What part of microorganism do penicillin act against?
Cell wall
89
What part of microorganism do erthromycin and clindamycin act against?
Protein synthesis
90
What part of microorganism do metronidazole act against?
DNA synthesis
91
*Patient comes one week after draining an abscess with resolved dental pain *C/O increased neck swelling and difficulty swallowing * voice is hoarse and appears to be drooling * E/O - right sided red and warm facial swelling * I/O - reduced mouth opening, elevated and tender right FoM Name 4 spaces in the head and neck which might be involved in the current spread of infection?
* Buccal space * Submasseteric space * Submandibular space * Sublingual space
92
*Patient comes one week after draining an abscess with resolved dental pain *C/O increased neck swelling and difficulty swallowing * voice is hoarse and appears to be drooling * E/O - right sided red and warm facial swelling * I/O - reduced mouth opening, elevated and tender right FoM What are 5 questions that you should ask this patient?
* When did the dental pain stop? * When did the swelling begin? * When did the dysphagia begin? * Is the swelling increasing or decreasing in size? * Do you have a fever?
93
*Patient comes one week after draining an abscess *C/O increased neck swelling and difficulty swallowing * voice is hoarse and appears to be drooling * E/O - right sided red and warm facial swelling * I/O - reduced mouth opening, elevated and tender right FoM What immediate investigation might be appropriate?
* SIRS investigation ( Systemic Inflammatory response syndrome)
94
What is SIRS?
Severe immune response to infection which presents with a significant risk of sepsis
95
What is the Diagnosing criteria for sepsis?
* Temperature less than 36 or more than 38 * Pulse rate more than 90 beats per min * Respiratory rate more than 20 breaths per minute * White cell count less than 4 or more than 12 g/l
96
What diagnosis is made when the SIRS criteria are met?
* 2 or more critria met = SEPSIS * Look for one sign of SEPSIS red flags
97
What treatment pathway when SEPSIS is diagnosed?
* Sepsis emergency pathway * Need to seek advice from consultant
98
How would you describe the key features to a consultant when suspecting sepsis?
* Situation = pt name ,age, diagnosis (severe spreading submandibular odontogenic tumour/ ludwig's angina) * Background = history, signs and symptoms * Assessment = I/O and E/O findings in details * Recommendation = what you think should be done and why? | SBAR
99
*Patient comes one week after draining an abscess *C/O increased neck swelling and difficulty swallowing * voice is hoarse and appears to be drooling * E/O - right sided red and warm facial swelling * I/O - reduced mouth opening, elevated and tender right FoM If the patient was to be admitted to a hospital how would they be managed? (6)
* ABCDE * Sepsis 6 + resuscitation * IV antibiotics * Incision and drainage under GA * XLA of infected teeth * Pus aspirate sent to lab with susceptibility testing
100
What 1st line antibiotics is used for dento-alveolar infections?
Pen V 250mg oral Send = 40 tablets Label = 2 tablets x4 daily
101
What choice of ABs is used for dentoalveolar infections in patients who are allergic to penicillin?
Metronidazole 400mg Send = 15 tablets Label = 1 tablet x3 daily
102
Despite effective antimicrobial activity against oral anaerobes, clindamycin is not routinely used instead of metronidazole - why?
Because it is linked to increased risk of C.Difficile infection
103
Co-amoxiclav can be used as a second line antibiotic, What 2 drugs are found in co-amoxiclav?
Amoxicillin and Clavulanic acid ( stops bacterial breakdown of amoxicillin)
104
When should you prescribe co-amoxiclav? for a dental infection?
* If they are likely to be managed in secondary or emergency care * Seek advice first
105
What is SEPSIS?
A dysregulated host response causing life-threatening organ dysfunction
106
Give 3 red flags of sepsis?
* New deterioration in GCS (glasgow coma scale) / AVPU * Heart rate more than 130/min * Respiratory rate more than 25/min * Rash * Recent chemotherapy
107
What is glasgow coma scale?
A clinical scale to measure level of consciousness after a brain injury
108
You assess a patient and they have one sepsis red flag present. What must be done next?
* Dial 999 *State red flag Sepsis * SBAR * Arrange bluelight transfer * Administer PO2 > 94% in COPD patients between 88-92%
109
What information to include on prescriptions? (7)
* Patient information * Medication name * Number of days of treatment * Instructions on when to take the medication and how * Drug formulation + dose + quantity * minimum dose interval to take drug * Signature and prescriber information
110
Give 8 general indications of XLA of Impacted M3M?
* therapeutic indications * Surgical indications * Medical indications * Accessibility - limited access * Patient age - complications increase with age * Autotransplantation * General anaesthetic
111
Give 3 surgical indications for removal of impacted M3M?
* Fractured mandible * in resection of diseased tissue * orthognathic
112
Give 4 therapeutic indications for removal of third molars?
* Recurrent pericornitis * Impacted third molars * Cysts * Tumours * External root resorption of 7 or 8
113
Give 4 medical factors for considering prophylactic removal of 3rd molars?
* Planned bisphosphonate treatment * Pre-chemo or radiotherapy * Awaiting cardiac surgery * immunosuppressed
114
What is pericoronitis?
Inflammation of operculum surrounding partially erupted 8 from food trap and poor clearance causing infection
115
What are the signs and symptoms of pericoronitis? (5)
* Pain * Difficulty eating * Foul taste in mouth * bad smell * Sinus (extra or intra-oral)
116
What are 5 predisposing factors for pericoronitis? (5)
* Partially erupted tooth * mechanical trauma from opposing 7 or 8 * white race * full dentition * poor OH
117
What are all the management options for for acute and recurrent pericoronitis? (7)
* Incision and drainage of abscess * Irrigation - warm saline ± CHX mouthwash or gel * LA w/PMPR under operculum * Advise on analgesia - NSAIDs, frequent warm saline / CHX mouthwash or gel * XLA upper 8 (if traumatising operculum) * XLA lower 8 - routine, surgical corenectomy
118
What 5 extra-oral checks should you carry out for lower third molars XLA ?
* TMD assessment * limitation of opening * lymphadenopathy * Asymmetry * Trigeminal neuralgia exclusion
119
What 5 intra-oral checks should you carry out for lower 3rd molars extraction?
* Soft tissues * hard tissues * Mandibular second molar * Eruption status of M3M * Occlusion * Caries status * Periodontal status * OH
120
Give 5 important pre-op factors to assess before going ahead with mandibular third molars extraction?
* Angulation of impaction * Depth of impaction * Proximity to nearby anatomy * Condition of 7 * Access to area * working distance (distal of lower 7 to ramus of mandible)
121
What 3 radiographic signs show an intimate relationship between the third molar and the IAN canal, which significantly increases risk of post-op nerve injury?
* Darkening of the roots where crossed by the canal * Deflection of the canal * interruption of the white lines of the canal * Juxta apical area * deflection of the root * Dark and bifid root
122
If close proximity of the lower third molar is suspected, what other investigations should you carry out?
CBCT
123
What is the most common third molar impaction angulation?
Mesio-angular impaction
124
List all the treatment options for an impacted third molar?
* Monitor * Corenectomy * Routine XLA * Surgical XLA
125
Other than pain, bleeding , bruising and swelling give 6 risk factors that you would discuss with the patient
* Altered taste * Jaw stiffness * Temporary/permanent loss of sensation in tongue, lip and chin * Infection * Dry socket * Damage to adjacent teeth and restorations * Further surgical procedures
126
After what time its less likely for a nerve to recover ?
18-24 months
127
What percentage of patients may experience temporary numbness?
10-20%
128
What percentage of patients may experience permanent numbness?
* less than 1%
129
What are 3 principles of surgical access?
* maximal access with minimal trauma * Scalpel used in single stroke * minimal trauma to papillae
130
What are 3 principles of reflection?
* Begin reflection from relieving incision * Free anterior papillae before proceeding distally * Reflect flap down to bone cleanly
131
What are 3 principles of bone removal?
* Electric saline-cooled straight handpiece with tungsten carbide bur (fissure or round) * Create a narrow deep buccal gutter * Remove bone distal to mesial
132
What are 3 principles of debridement?
* Physical - remove sharp edges * Irrigation - saline under flap * Suction - aspirate to remove debris
133
Three principles of suturing?
* Reposition tissues * Sutures should be laid on sound bone * Wounds not closed under tension
134
3 instruments used in reflecting a flap?
* Warwick James elevators * Howarth's elevator * Mitchell's trimmer
135
3 instruments used in tissue retraction?
* Minnesota retractor * Rake retractor * Howarths's elevator
136
At what point on the tooth should you section horizontally for corenectomy?
3-4mm below enamel cementum junction
137
Where would you section the tooth if you are planning to remove the whole tooth?
Above ECJ
138
What are the two types of sectioning during a mandibular third molar extraction?
* Horizontal * Vertical
139
When would vertical sectioning be indicated?
When the roots are are separate
140
What is the goal of vertically sectioning a tooth?
* Dividing the tooth into smaller sections for easier extraction
141
What is the indication for a coronectomy?
* When there is a high risk of of permanent damage to IAN if surgical extraction would be carried out * Coronectomy reduces the risk of damage to the IAN
142
What is a contraindication for a coronectomy?
Pulp of tooth is affected by caries or infection
143
4 things to warn a patient about when consenting for a coronectomy?
* If root mobilised during treatment the whole tooth should come out - likely with conically fused roots * Roots may have to be removed in the future * You might get a slow healing or painful socket * leaving the root behind may cause infection - rarely
144
Outline the procedure for a coronectomy? (7)
* Pre-op CBCT and assessment then LA * cut two of three sided flap to expose 3rd molar * Create buccal gutter using straight hand piece * Horizontally section the crown 3-4mm below ECJ * Remove coronal portion * Debride bone and remove sharp edges * Irrigate underflap and suture
145
When would you review a patient after a Coronectomy?
* 1-2 weeks * then 3-6 months * then 1 year
146
What is the main risk associated with a XLA of upper 3rd molars?
Maxillary tuberosity fracture
147
What is a cyst?
A pathological cavity that can be filled with fluid , semi-fluid or gas that is not caused by puss accumulation
148
What are the 2 main categories of cysts?
Odontogenic and non-odontogenic
149
What 3 epithelial remnants are linked to the development of odontogenic cysts? and from where do they originate?
* Rests Malassez - hertwig's epithelial root sheath * Rests of serres - dental lamina * Reduced enamel epithelium - enamel organ
150
What teeth are radicular cysts mostly associated with?
non-vital
151
What are the radiographic signs of a radicular cyst? (4)
* Round well-defined radiolucency * Unilocular * Corticated margins * Continuous with lamina dura of non-vital tooth
152
How do you differentiate between a radicular cyst and a periapical granuloma radiographically ?
* Radicular cysts are larger , usually more than 15mm * Radicular cysts contain epithelial lining and inflammatory cells whereas periapical granuloma contains granulation tissue
153
Give 3 histological signs of a radicular cyst?
* Epithelial lining * Connective tissue capsule * Inflammation
154
What would expect an syringe aspirate of a radicular cyst to be ?
* Clear straw fluid
155
What are the 2 types of inflammatory collateral cysts ?
* Paradental cyst * Buccal bifurcation cyst
156
What is the most common location of a paradental cyst ?
* Distal aspect of partially erupted lower 3 molars
157
What is the most common location of a buccal bifurcation cyst?
Buccal aspect of lower first molar
158
Describe how dentigerous cysts arise?
* Cystic change in dental follicle where reduced enamel epithelium is not fully resorbed * Fluid accumulation leading to the cyst formation
159
What is the most common tooth associated with a dentigerous cyst?
* Lower third molar * Upper canine
160
What are the radiographic signs of a dentigerous cyst? (5)
* Well defined radiolucency * Unilocular * Corticated margins associated with CEJ of unerupted crown * Displacement of tooth involved * May lead to bony expansion
161
What are some histopathological signs of dentigerous cysts?
* thin non keratinised stratified squamous epithelium
162
What may be the cyst contents of a dentigerous cyst?
* Cholesterol crystals * Proteinaceous , yellowish fluid
163
What is the normal size of a follicular space ?
2-3mm
164
What 2 radiographic signs would you look for to consider a cyst to be dentigerous rather than an enlarged follicle?
* Aymmetrical radiolucency * More than 10mm in size
165
What is an eruption cyst?
A dentigerous cyst associated with an erupting tooth
166
What 2 teeth are eruption cysts associated with?
* deciduous incisors * First permanent molars
167
What cells are linked to the formation of OKC's ?
* Rests of Serres from the remnants of dental lamina
168
Give the radiographic signs of an odontogenic keratocyst ?
* Well defined radiolucency * Multilocular * Scalloped margins
169
What are the risks associated with OKC?
* may displace teeth * May grow disto-mesially * High rate of recurrence
170
What is found in the contents of an OKC when aspirating it ?
* White creamy thick aspirate * Low protein content (through protein test)
171
What are some histological signs of an OKC?
* thin folded parakeratinised squamous epithelium * Daughter cysts * thin connective tissue wall * No inflammation
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What is the reason for the high recurrance rates of OKC's? (3)
* it is an infiltrative growth which means enucleation may leave some of the cells leading to recurrence * daughter cells * Thin friable lining
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What syndrome is associated with multiple OKCs?
* Basal cell naevus syndrome ( Gorlin-Goltz)
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What are the signs of gorlin goltz syndrome other than multiple OKCs ?
* Multiple basal cell carcinomas on skin * Calcification of falx cerebri ( calcified dura matter in skull) * Mandibular prognathism
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Examples of non odontogenic epithelial cysts?
* Nasapalatine duct cyst
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What cells are linked to the formation of nasopalatine duct cysts?
Nasopalatine duct epithelial remnants
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What are the radiographic signs of nasopalatine duct cyst ?
* well defined round, ovoid or heart shaped radiolucency * Sclerotic margin * Unilocular * Over roots of maxillary incisors in anterior maxilla
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What is the normal size of the incisive fossa? and when should you assume the radiographic presentation is a nasopalatine duct cyst?
Normal size of incisive fossa is less than 6mm , assume NDC if radiolucency is greater than 10mm
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What are some examples of non-odontogenic non-epithelial cysts ?
* Solitary bone cyst * Aneurysmal bone cyst * Stafne cavity - not really a cyst
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What are the radiographic signs of solitary bone cyst?
* Well defined radiolucency with an irregular corticated margin * Scalloped * Spreads between roots and furcations of adjacent teeth
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What are the radiographic signs of stafne cavity?
* Round or oval well demarcated radiolucency * Between premolar region and angle of the jaw * Located below inferior dental canal
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What may stafne cavity contain?
* Ectopic salivary tissue in continuity with SMG
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What 3 radiographs that can be taken for cyst management?
* OPT * CBCT * MRI
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Give 3 biopsy methods for cyst management?
* Aspiration from cyst * Incisional biopsy * Enucleation
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What is the aim of enucleation?
* Remove the whole cyst in a single appointment
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What are 3 advantages of enucleation?
* Whole lining can be examined pathologically * Little aftercare required * Heals by primary closure
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What are 3 disadvantages of enucleation?
* Risk of damage to nearby structures ( adj teeth or IAN) * Mandible fracture * Recurrence
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What is the goal of marsupialisation? (2)
* Create a surgical window to and suturing the cyst walls to the surrounding epithelium * This reduce the size of the cyst before enucleation
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Which cysts are more likely to be marsupialised?
* OKC * Large dentigerous cysts
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What are 3 disadvantages of marsupialisation?
* Needs further surgery to remove cyst * Long treatment time * Chance of re-infection and might be uncomfortable
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What is segmental resection?
Removal of cysts with the margin of normal bone
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When is segmental resection used ? 2
* Ameloblastoma * Sarcoma * Odontogenic myxoma * Commonly used in odontogenic tumours
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What are 5 ways in which endodontic treatment might fail? with one example of each
* Obstruction to instrumentation - clacification * Root filling errors - underfilled or overfilled * Secondary pathology - apical cyst * poor host tissue response * Post placement * Lateral perforation
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What are 2 aims of periradicular surgery?
* Remove existing infection * Achieve apical seal
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What 3 flap designs are used in peri-radicular surgery?
* Semilunar flap * Triangular flap * Rectangular flap
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Give 2 instruments used in root end preparation?
* Rotary bur * Ultrasonic
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Give 3 retrograde root filling materials?
* Amalgam * ZOE * MTA
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Give 5 reasons for failure of peri-radicualr surgery?
* Inadequate seal * Inadequate support - too much apex removed , poor perio status , apical third fracture * Poor healing response * Exposure of root apex
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What is periradicular surgery?
Surgical intervention at the apical region of the root to eliminate persistent or complex endodontic infections
200
Give 3 reasons why a root may fracture during an extraction?
* Gross caries * Tooth heavily restored * Root dilacerated
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Give 3 indications for leaving a root in situ? (3)
* Proximity to IAN * Overdentures * Preserve ridge for future implant placement
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What is an OAC?
Pathological communication between oral cavity and the maxillary sinus
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What is the difference between OAC and OAF?
OAF is chronic communication between the oral cavity and the maxillary sinus involving the formation of epithelial lining
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What are 5 risk factors of an OAC?
* Previous OAC * Older patient * Extraction of maxillary molars and premolars * Root proximity to sinus * Large bulbous roots * Last standing molars * Recurrent sinusitis
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What are 3 peri-op signs of OAC?
* Direct vision (dark hole) * Bubbling at socket * Change in suction sound * Bone removed at trifurcation
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What are 4 post op signs of OAC?
* Fluid from nose when drinking * Difficulty smoking or playing sound instruments * Non healing socket * Unilateral discharge
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5 ways in which an OAC might happen other than extractions?
* Cysts and tumours * Osteonecrosis * Impants * Trauma * Tuberosity fracture
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What are 3 types of OAF closure methods?
* Buccal advancement flap * Palatal rotation flap * Bone graft
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* Extraction of UL7 appt * History of pain from ULQ * O/E - only retained roots of 7 * Radiographically - close proximity of roots to maxillary sinus * Post extraction you suspect OAC What should you do first?
* Inform the patient about the incident and this risk was accounted for * Assure the patient that this can be managed * Close using buccal advancement flap or refer
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Does the size of an OAC affect its management?
Yes
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How would you manage an OAC that is less than 2mm?
* Debride socket and encourage clot formation * Suture * Give post op advice * Review in one week | May heal spontaneously
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How would you manage an OAC that is more than 2mm?
* Debride socket to encourage clot formation * Suture with buccal advancement flap over OAC *Consider ABS * Post op advice * review in one week
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What instructions would you give a patient after OAC treatment? (5)
* Avoid touching socket to not disrupt healing * Sneeze with mouth open * No nose blowing * Avoid smoking * Avoid drinking through a straw * You may benefit from inhalation of menthol crystals steam * Use decongestants * CHX MW
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What 2 prescriptions would you consider post OAC treatment ?
* Ephedrine 0.5% nasal drops - 2 drops 4xd as required , usr for maximum 7 days * Pen V 250mg oral = 2 tablets 4xd for 5 days
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What are the risks associated with not closing the OAC? (4)
* Recurrent sinusitis * Food trapping * Infection * Impaired healing
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What % of patients get sinusitis if OAC not closed?
* 50% within 2 days * 90% within 2 weeks
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* Pt had UR6 XLA **6 weeks** ago * Past week had a horrible taste in mouth * Feels blocked nose and feeling unwell * Pain in upper Jaw O/E - pus discharge from UR6 What is your diagnosis?
OAF
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* Pt had UR6 XLA **6 weeks** ago * Past week had a horrible taste in mouth * Feels blocked nose and feeling unwell * Pain in upper Jaw O/E - pus discharge from UR6 How will you manage this patient?
* Inform patient about findings and gain consent * Immediate management or referral * Immediate management = Excise sinus tract Drain sinus Debride socket Suture with BAF Abs Post op instructions Review in one week
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* XLA of carious 26 * During XLA crown had decoronated and 2 roots were romoved * One root is missing PA taken for assessment Where is third root located?
Displaced through alveolar bone into right maxillary sinus
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* XLA of carious 26 * During XLA crown had decoronated and 2 roots were romoved * One root is missing PA taken for assessment Describe how you can manage this patient?
* Inform pt about findings * Gain consent for monitoring if small ( risk of sinusitis and infection) * Do immediate management or refer
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* XLA of carious 26 * During XLA crown had decoronated and 2 roots were romoved * One root is missing PA taken for assessment You decide to proceed with immediate management , describe what you will do?
* Raise BAF * Use copious amounts of saline and suction to see if you can retrieve the root * Widen the socket using water cooled bur to increase chance of retrieval * Use ribbon gauze to retrieve
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What 2 management options could you consider when treating a patient with lost root in sinus other than retrieval through socket?
* Endoscopic approach * Caldwell luc procedure
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BDS4 Exam Prep (72 decks)

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