Oral Surgery YR4 Flashcards
Why would be decide to raise a mucosal flap?
Gain ACCESS to an object/structure e.g. aretained root / apex (but could also be forintrabony pathology or ORIF of a fracture)Flaps permit targetted bone removalMucosal flaps can also be useful to cover upexposed structures such as OAC closure orexposed dentine
Describe a One sided envelope BMPF?
crevicular incision only - at gingival marginextend atleast one tooth each side of the toothin question but furtherextension improves accessTypically requires 2 sutures to close (one in each papillae mesial and distal to the extracted tooth)
What is BMPF?
Buccal MucoPeriosteal Flaps
Describe a Two sided design BMPF?
Two sided design BMPF - crevicular and one relievingincision, usually mesial for best accessMost common flap designTypically requires 3 sutures to close (mesial + distal papillae around extracted tooth and across the relieving incision)
Describe a Three sided BMPF?
Three sided BMPF - crevicular and two relievingincisions mesial and distalTypically requires 4 sutures to close – mesial + distalpapillae of the extracted socket and one in each relieving incision – but distal relieving incisions can bedifficult to suture due to limited access posteriorly
Why should you include the interdental papillae in the BMPF?
to aid closure – easier to suture the thick gingival papillae than thinner (mid)-buccal gingival mucosa
Name the 3 principles of BMPF design?
- Access- for an application point- to section the tooth e.g. furcation2. Adjacent Structures- nerves e.g. mental- adjacent crown margins to avoid recession- canine prominence3. Healing- replace the flap on bone for stability- maintain blood supply with a wide base
What is the definition of adequate access?
Start with an envelope andadd relieving incisions asneeded.Generally 3 sided BMPFs givethe best access to the buccalbone adjacent to the root
What to think about when planning access for flap design?
Access to the point of application forelevatorsChanging the path of removal by sectioningfrom the furcationAvoid vital structures
What to think about when designing a flap for the lower premolars?
Place the mesial relieving incision anterior to the first premolar to avoid the mental nerve but avoid crevicularincisions over the canine prominence to minimise recession.
How to promote healing for flap design?
by preserving blood supply – wide base
When suturing over the bone, what must you do?
Place the mesial relieving incisionaway from the area of bone removal/lossto provide support for the incision margin when closed
Describe the process to remove a mesio-angulary impacted partially eruped LL8?
- Mucoperiosteal flap marginsincised – 3 sided BMPF2. Flap retracted from buccal side3. Collar of bone guttered frombuccal side of LL84. Sectioning of toothThe groove has been drilled only half way through thetooth bucco-lingually to protect the lingual nerve5. Elevator used to separate the 2 roots6. Distal root delivered with forceps7. Mesial root elevated into the space created by removal of the distal root – disimpacted – thendelivered8. Socket debrided and washed withcopious sterile saline9. Wound closure with sutures
Describe the palatal flap for buried canines?
- Sacrifice the incisive bundle – no clinicalsignificance to the resulting area of anaesthesia2. Extensive crevicular incision extending from UR6 to UL4 on the palatal aspect as no relieving incisions possible3. Buried canine located and exposedby drilling overlying bone
Name 2 types of flap design is for oro-antral communiction?
Buccal Advancement Flap:- based on a 3 sided BMPF with the periosteal layerscored to permit extension of the flap to the palatal side- pull flap across defect and suturePalatal Rotational Flap:- based arounnd the greater palantine vascular bundle
What is the main side effect of a buccal advancement flap?
Results in loss of buccal sulcus depth makingsubsequent denture fit difficult without further sulcus deepening surgery.
What is the definition of a palatal rotational flap?
Technically difficult so usually done under GAwhen buccal advancement closure fails.Either full thickness allowing the donor site togranulate over OR partial thickness pedicle leaving periosteum covering the donor site on the palate
Name 2 types of peri-raduclar surgery?
Root end resection (apicectomy)Retrograde root filling (RRF)
What is the flap design for peri-radicular surgery?
3 sided full thickness BMPF- Risk of gingival recession in thevisible anterior region especiallynoticeable with crowned teeth
What flap design can be used for peri-raducular surgery to minimise the risk of gingival recession?
Luebke –Oschenbein sub-marginal flap:- Minimises risk of gingival recession- Difficult to suture as the horizontal incision is inattached gingivae- Requires at least 4mm of attached gingivaeSemi-lunar flap:- poor healing (flap margin not on solid bone)- minimised gingival recession
What are the 2 main aims of suturing after MOS?
Maintain haemostasis (stabilise blood clots orhaemostatic intrasocket agents)Provide adequate tension for wound closureand promote healing by supporting tissuemargins until sufficiently healed to supportthemselves
What other advantages are there to suture after MOS?
- Reduce post-operative pain• Reduce recession around adjacent tooth margins• Promote healing by primary intention• Prevent bone exposure – reduce infection/osteomyelitis risk• Hold grafts/membranes in position to enable function
Name the 9 ideal suture thread properties for MOS?
- Adequate and uniform tensile strength– Predicatble resorbtion to avoid patient’s returning forsuture removal– Appropriate tensile strength retention in vivo, holding the wound securely throughout the critical healing period, followed by rapid absorption.– Sterile– Biologically inert– Prevents bacterial proliferation and ‘seeding’ of wounds – suture abscess– High knot security– Easy handling – low memory, bright colour (which doesn’tleach)– Cost effective
Name the 7 ideal suture needle proeprties for MOS?
- Maintains sharpness to repeatedly incise mucosawithout tearing– Malleable to form appropriate shapes/curves forintraoral use– Strength to maintain structural integrity– Sterile– Biologically inert– Cost effective
Name the 3 types of suture materials for MOS?
ResorbableNon-resorbable
Give 2 examples of resorbable sutures?
- Vicryl - polyglactin (coated or the more rapidlyresorbing ‘Rapide’)– Others e.g. polydiaxanone (PDS II), catgut
Give 3 examples of non-resorbable sutures?
black silk (BSS) / ethilon / prolene
When are non-resorbable preffered over resorbable sutures?
For specific tasks where maintaining tensile strength isimportant (e.g. OAC closure) or resorption products arepossibly undesirable for healing with minimal scarringe.g. aesthetic zone implants.
What is the defintion of a monofilament suture?
is made of a single strand
What is the defintion of a braided suture?
have multiple monofilaments wound around each other
What are the advantages of monofilament sutures?
cause less tissue drag and are less likely to track and harbour bacteria at the surgical sites
What are the disadvantages of monofilament sutures?
Monofilament suture materials are generally harder to handle than multifilament (braided) sutures because of their memory.
Name 3 examples of monobraided sutures?
PDS IIethilonprolene
Name 2 examples of braided sutures?
VicrylBSS
Explain how rosorbable sutures work? And which is better and why?
Hydrolysis (e.g. vicryl) is more predictable than enzymatic proteolysis and phagocytosis (e.g. catgut) with less tissue inflammatory reaction and scarring
What affects resorbability
Thicker gauges of suture material will take longer to resorband sutures in more vascular areas will resorb quicker.
Describe the changes in tensile strength of vicryl and coated vicryl?
Vicryl-Rapide loses 50% of its tensile strength at 5 days and100% in 10 days (sutures usually fall out and are swallowed/spat out rather than completely resorbed (which takes 50days).• Coated Vicryl loses 50% of its tensile strength at 3 weeks andis completely resorbed in 70 days.
What is the rule of thumb for suture gauges?
Use of the smallest suture that approximates the tissue’sown tensile strength is ideal to adequately close wounds
What suture material is best for oral mucosa?
3/0 Vicryl-Rapide or 4/0 coated Vicryl
Name the 6 types of sture needles?
Curved needles (1/4, 3/8 or 1/2 circle) and 19-22mm indiameter are typically used intraorally due to limited access.Straight and 1/2 curve
How to hold the suture needle using a needle holder?
Reverse cutting triangular body needles are used to minimise ‘cutting through’ at mucosal tissue margins• Needles are held in needle holders at the (solid metal) body adjacent to the swage area to prevent fracture at the junction where the suture material joins the needle and still allow rotation of the needle body in tissue
When is 4/0 Coated vicryl used?
delicate or maceratedmucosa. Easy to pull toohard and break the suturewhen suturing.
When is 3/0 vicryl rapide used?
across sockets andapplying pressure to achievehaemostasis
What are blunt ended scissors used for?
cuttingsutures without accidentlydamaging adjacent softtissues such as the tongue orlips.
What are toothed tissue forceps used for?
manipulating oralmucosa without crushingtissue and causing woundmargin necrosis
What are locking needle holders used for?
to securely hold the sutureneedle and a smoothjoint to allow suture toslide over when tying asurgical knot
Main suture technique?
simple interrupted
Describe a horizontal mattress suture?
for closingOACs to evert tissue margins andobtain an air tight seal. Can also belooped around a tooth to cuff thetissue tightly to the toothpotentially minimising post-healingrecession.
Deswcribe a continious suture?
quicker for largewounds than multiple interruptedsutures but if any part comesundone the whole wound dehisces.
Surgical Sieve? Acromym VITAMIN CDEF
V - vascularI - infection/inflammationT - TraumaA - autoimmuneM - metabolicI - iatrogenic N - neoplasticC - congenital D - degenerativeE - endocrine/environmental F - functional
Name all types of cancer?
CarcinomaSarcomaChondromaMyomaAdenomaOsteoma
Kaposi’s sarcoma? Where? Why? Type?
PalateAIDSVascular tumour BVs
Haematoma?
Blood in adea
Ludwig’s angina?
Infection sub-neck
Ibuprofen max dose?
2.4g 200mg tablet12 tablets
Max dose for Paracetamol?
4g500mg per tablet8 tablets
What are Winter’s classification of impacted wisdom teeth?
VerticalMesioangularHorizontalDistoangular
Name 6 local reasons for the failure of eruption of 8s?
Displaced follicle (ectopic position)CrowdingSupernumerary/supplemental teethImpacted into adjacent toothPathology - cyst, tumour or fibrous dysplasiaMissing tooth
Name 3 general factors that cause failure if eruption of 8s?
Pathology:- developmental conditions- Down’s syndrome- skeletal disorders
