OSB1- MOS Flashcards
Explain process of removing a tooth in MOS and the instruments used
-12 Blade to incise around gingival margin and medial relieving incision, full thickness to bone. Include interdental papilla so easier to suture
-Rase flap with Ash number 9 molt periosteal elevator
-Rake retractor to retract
-Remove bone with surgical handpiece and Rosehead bur
-Section the roots with fissure bur in upward direction
-Couplands in furcation to ensure each roots can move individually and to elevate root
-Forceps to remove roots
-Debride socket using Mitchel’s trimmer, curettage and suction and saline. Remove sharp bone
-suture
Why bone is removed
-to reveal the tooth
-removes support for tooth
- creates application point for the elevator
- to access furcation in order to section the roots
Explain the suture process and instruments used
-30 vicryl resorbable (takes 2 weeks to resorb)
-Pass needle at 90 degrees angle at least 3mm from wound edge
-Pull through until little tail left on one side
-Surgeons knot to secure- 2 throws clockwise around needle holders, then 2 throws anti-clockwise, 1 throw clockwise.
-Too much tension causes necrosis, too loose prevents wound healing
- Relieving incision may also need closing but not always.
What is Mitchell’s trimmer used for. What is most Ash periosteal elevator used for. And the Howarths periosteal elevator
- deriding socket after extraction
- raising full thickness mucoperiosteal flap
- initial raising of the flap
How to scrub up
-Open kit
-Put on mask
-Wash hands – using hibiscrub. Takes 2 minutes. Rinse with water with the water dripping from fingers to elbows. Hold hands above elbows. Dry with sterile towel from fingers to wrists, 1 for each hand
-Pick up corner of gown, place arms through sleeves, don’t push beyond cuffs. Colleague will fasten the back
-With hands still in cuff, pick up glove of opposing hand and put it on, over cuff of gown. Then put on other glove
The soft tissue layers you need to cut through
muscosa (epithelium + lamina propria), submucosa, periosteum
How long does vicryl suture take to resorb
4-6 weeks (realistically 1-4 weeks)
Reasons for using elevators
-to provide an application point for forceps
-to loosen teeth prior to using forceps
-to dislodge a whole tooth from its socket
-to extract tooth roots
-dilate socket
Examples of when elevators should not be used
-When you cannot see root
-When a root fragment is close to antrum (incorrect force may result in displacing root into antrum)
- When a root fragment is in close proximity to a vital structure e.g the ID canal
List surgical principles (9)
-Pain free surgery (LA, behavioural management)
-Aspetic technique (sterile)
-Adequate access (flap)
-Minimal damage (to nerves, vessels, teeth, bone)
-Arrest of haemorrhage
-Debridement (removing necrotic, infected or foreign tissue. Saline irrigation)
-Wound closure (sutures)
-Drainage
-Prevention of infection (good technique, sterile, minimal damage, debride POI)
Peri and post operative ways of managing bleeding
1)Peri-operatively
*LA with vasoconstrictor
*resorbable suture
*Electrocautery e.g. bipolar/ chemical cautery e.g. silver nitrate sticks
*Haemostatic pack (SURGICEL/ GELITACEL)
Bone wax – useful for bony bleeds, but delays healing so only used if other measures fail
2)Post-operatively
* Pressure
*Tranexamic acid
*Replace blood loss
*Further investigation of cause
*Other specialities
Principles of flap design
- Maximise access to surgical site
- Designed to aid healing (ensure adequate blood supply – broad base)
- Considers vital structures (mental and lingual nerves, greater palatine artery, nasopalatine nerves and arteries)
Advantage of a one sided and three sided flap. 1,2 or 3 most common
1= better blood supply
2=most common
3= better access
Aftercare instructions for normal XLA
-don’t rinse today but tomorrow for 3 days rinse with warm salt water after every meal
-no hot liquids or alcohol today
-no eating for 3 hours, soft diet for rest of day
-no smoking for 24 hours day
-no physical activity today
-brush as usual, be gentle in area
-if bleeds bite on gauze
-take usual pain meds
-get in contact if infection, excess pain, bleeding swelling, tenderness, fever, unpleasant smell
-wear denture as normal
What should be explained to patient before getting consent for MOS. Risks to let them know about
-Treatment: extraction of tooth under LA with or without cutting gum, bone removal, sutures
-Risks: pain, swelling, bleeding, bruising, dry socket, jaw stiffness, infection, OAC, root fracture, maxillary tuberosity fracture, temporary/ altered sensation to lip, side of tongue, cheek, chin. Damage to adjacent teeth
-lower 8 - IAN, lingual, trismus
-Benefits: prevent infection. removes pain
-Alternative treatment: leave, root canal
Allowance of paracetamol and ibuprofen
-Paracetamol= 4g max in 24 hours. 2x500mg tabs every 4 hrs. 25g is fatal. 10-15g causes acute liver damage
-Ibuprofen= 1 or 2 x 200mg tabs, 3 x daily. Max 3200 mg per day
Risks of MOS
-damaged adjacent teeth
-retained root
-root displacement into nerve, antrum
-OAC
-fractured mandible, tubersoty
-sequestrum / necrotic bone leading to infection
-soft tissue burn
-crushing of flap during raising or retraction
-poor healing due to poor flap design
-neurovascular damage
-dry socket (day 3 pain)
What is the healing timeline after XLA, from haemostasis to bone formation
-Vasoconstriction, platelet plug within 5-10 mins, mature clot with fibrin in 24 hours
-Clot replaced by granulation tissue in 5-10 days
-Epithelialisation takes 2-3 weeks
-Keritinisation of epithelium 6 weeks
-Early osteoid after 3 weeks
-Mature bone- 3-6 months
-Cortical bone not until a few years
Considerations for High BP and XLA (risks and recommendations)
-Risk= bleeding, MI
-Check if well controlled, recent BP measurements
-Conisder postponing if >160/100mmHg
-Adrenaline contraindicated
Considerations for 1) angina and 2) recent MI for XLA: risks
1) Risk of angina attack or MI. Ensure GTN is readily available. Enquire frequency of attacks
2) Risk of MI. No extractions within 3 months of last MI attack. No GA within 6 months of attack
Considerations for XLA if previous endocarditis or prothetic heart valve.
-Increased risk of infective endocarditis
-Ensure patient aware of increased risk
-Explain the symptoms so knows what to look out for if does occur - achy, SOB, chest pain on breathing, flu-like,
-Record discussion
-Not routinely done prophylaxis. Only prophylaxis considered if high risk -liase with cardiologist
-Reinforce good OH
Considerations for XLA with liver disease: risks and recommendations
-Increased bleeding due to reduced coagulation factors
-Reduced healing
-Reduced drug metabolism
-Increased infection risk if have Hepatitis
-Liase with patient’s physician. Consider a coagulation screen and full blood count.
-Check BNF for prescribing (metabolism different)
-avoid sedation- may lead to coma
-Avoid lidocaine and other amides as metabolised in liver. But if ester allergy then:
-Articaine = better option, as metabolised in plasma. 2 cartridges max
-Prilocaine better option as metabolised in lungs and kidneys. Max 2 cartridges
Considerations for XLA if kidney disease: risks and recommendations
-Increased bleeding due to platelet dysfunction
-May be immunocompromised so increased infection risk
-Liase
-Dialysis patients best treated after dialysis as optimal renal function. And so heparin is out of their system
-no prophylaxis
-Don’t advise NSAIDs
Considerations for diabetes XLA patient: risks and recommendations
-Risk of hypoglycaemic emergency - ask if have not eaten and taken insulin
-Have impaired wound healing so increased risk of infection: ensure local measures
-Increased dry socket risk
-Morning appointments better as glucose level more stable
-Ask about most recent blood glucose reading. Safe to treat if 5-15 mol/l [Hypoglycamia= <4]
Consideration for epileptic patient for XLA
-Risk of seizure if triggered by stress, bright lights
-Enquire about frequency of seizures and triggers
-ensure they have eaten before
-IV sedation may be better for its anticonvulsant effects
Considerations for XLA if haemophilia A and B or von Willebrand
-Increased bleeding due to deficiency of VII and IX and von willebran’s factor
-Don’t start any tx before consulting doctor
-Consider referral to hospital
-pre: given factor concentrates (8/9) then measure plasma levels
-peri: avoid IDB due to deep tissue injury. PDL or intraosseous better. Articaine better for mandibular infiltrations. Surgicel and sutures
-post: tranexamic acid mouth rinse, gauze, post-op instructions. Keep patient for 30 mins before discharging
-mild A: given DDAVP 30-60 mins before which raises factor 8 and wWF
Considerations for XLA if patient on anticoagulants (warfarin, apixaban, dabigatran, rivaroxaban)
-Increased bleeding risk
-Check BNF for interactions
-Take haemostatic measures
-Warfarin: check INR<4 taken 24 hours before
For high risk procedures (3+ XLA or surgical)-
-Apixaban and dabigatran: miss morning dose then take evening dose >4 hours after
-Rivaroxaban: delay daily dose till >4 hours after
But never interrupt it if DVT or PE in last 3 months, or on med for cardioversion, stent, prosthetic heart valve
Considerations for XLA if patient taking aspirin or clopidogrel
-increased risk of bleeding
-liase, heamostatic measures, check BNF
-Do not stop single or dual antiplatelet therapy (as takes 7-10 days for effects to stop anyway)
Considerations for XLA if patient on chemotherapy and radiotherapy
Chemo can cause Thrombocytopoenia, Neutropenia, increased infection, reduced healing
- so avoid if possible
-Check platelets >100 or >50 at the lowest.
-Radiotherapy causes risk of osteoradionecrosis so avoid if possible. Ensure dentally fit prior to starting. Refer these patients to OS
Considerations for XLA if patient on bisphosphonates
-MRONJ risk
-High risk of taking for >5 years, concurrent systemic glucocorticoids, being treated for cancer, previously diagnosed with MRONJ
-Liase
-Avoid extraction if possible. If not then make as atraumatic as possible
-Don’t stop meds as will have no effect (stay in system for up to 10 years)
- 8 week review after
Name1) resorptive and 2) non-resorptive dressings after XLA to manage bleeding
- Oxidised cellulose (surgicel) - synthetic so can be used by everyone, creates a matrix for platelets to bind to
-Gelatin (for non-vegetarians)
-Haemostatic collagen - Bone wax - good if bleeding from bone. Press down with damp gauze. useful for bony bleeds, but delays healing so only used if other measures fail
they are haemostatic agents
Management of small OAC, large OAC and OAF
-Small= don’t blow nose for 2 weeks, sneeze with mouth open, ephedrine nasal spray
-Large= splint for 2 weeks, suture, antibiotics
-OAF= epithelializes creating a permanent tract that cannot heal = bad. Refer to MaxFacs for Surgical closure- 1st line is buccal advancement flap
-Antibiotics if infected or to prevent sinusiits- phenoxymethylpenicillin
If aware of OAC then prescribe antibiotics
Considerations for XLA with Paget’s
Disorganised bone remodelling
Hypercementosis
Maxilla more commonly affected
Prescribe antibiotics after routine extractions
LA consideration during 3rd trimester of pregnancy
Avoid felypressin (induced labour, but need high amounts so should not cause an issue)
RAD features that increase risk IAN damage
-tramline narrowing, disappearing, deviation
-radiolucent banding across the root
-darkening root apices
Explain gow-gates and akinosi technique. What nerves are anaesthetised
-Mandibular nerve blocks: Blocks long buccal, IAN, accessory, auriulotemporal and mylohyoid nerves
-Gow-gates= just distal to the maxillary 2nd molar and at the height of the ML cusp. Barrel angled with premolars
-Akinosi= good if limited mouth opening. mucobuccal fold near the maxillary second molar.
Management of sequestration during extraction
-piece of dead detached bone. Will resorb naturally
-if confident in diagnosis then can remove in practice
