OSCE DOC - Oral surgery Flashcards
Facial Trauma- right orbitozygomatic fracture
State the fracture type most likely from the photo available and clinical history.
Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture.
What are obvious signs and symptoms for this OZ fracture?
Signs and symptoms of zygoma fracture:
Peri-orbital ecchymosis
Swelling then flattening
Lacerations or excoriations
Sub-conjunctival haemorrhage
Numb cheek- usually infraorbital nerve
Visual disturbance- decreased acuity, diplopia, pain on eye movement
Step deformity
Trismus
I/O features:
Tenderness of the zygomatic buttress
Bruising / swelling / haematoma
Occlusal derangement and step deformities
Lacerations (especially gingivae)
Loose or broken teeth
Anaesthesia / paraesthesia of teeth in the upper right quadrant and gingivae above incisor / canine
Facial Trauma- right orbitozygomatic fracture
State the fracture type most likely from the photo available and clinical history.
Suggest further investigations for this fracture type, what you can see on the investigation,
Radiograph - OM 15/30 (Occiptal mental)
CBCT
- On the radiograph always compare with the opposite side. Should see a fracture and radio-opacity in the sinus.
Facial Trauma- right orbitozygomatic fracture
State the fracture type most likely from the photo available and clinical history.
What is the further management if you had this patient present to you in a standard dental surgery.
- Refer by phone for urgent referral to maxfax
- If the fracture is symptomatic then ORIF will be carried out and patient will then be kept in for eye observation, steroids for swelling (declamethasone 4mg-8mg) and told to avoid nose blowing.
- For asymptomatic cases can conservatively manage.
State the fracture type most likely from the photo available and clinical history.
Brusing and lower lip numbness.
Mandibular fracture
Facial Trauma- Mandibular Trauma (6 mins)
State the fracture type most likely from the photo available and clinical history.
Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture.
What are the E/O signs and symptoms?
- Pain
- Lacerations
- Bleeding
- Swelling
Facial asymmetry - Palpation of mandible bilaterally (condyle, ramus, body, symphysis)
- Limitation of mandibular movement? (reduced interincisal opening)
- Mandibular deviation on opening and lateral movement?
- Tenderness of TMJ?
- Examination of sensation of lower lip / chin region- areas supplied by mental nerve
(mandibular division of trigeminal nerve)
Facial Trauma- Mandibular Trauma (6 mins)
State the fracture type most likely from the photo available and clinical history.
Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture.
What are the I/O signs and symptoms?
- Lacerations (especially gingivae)
- Bruising / swelling / haematoma
- Occlusal derangement and step deformities
- Loose or broken or mobile teeth
- Anaesthesia / paraesthesia of teeth in lower jaw / lip on side of fracture
- AOB due to bilateral ramus / sub-condylar fracture
What are some pathological causes of mandibular fractures?
Pathological Causes of mandibular fracture
* Osteoporosis
* Osteomyelitis
* Paget’s disease
* Expanding cystic lesion
* Osteogenesis imperfecta
* Hyperparathyroidism
* ORN
* Primary and secondary tumours
Ameloblastomas
Facial Trauma- Mandibular Trauma (6 mins)
State the fracture type most likely from the photo available and clinical history.
Suggest further investigation for this fracture type, what you can see on the investigation.
Two radiographs- OPT and PA mandible
* CT more commonly used now
Identification of relevant radiographic findings:
* Fractures- most possible more than one
* Previously parasymphyseal fracture and bilateral condylar fractures
* Always compare right side from left
Facial Trauma- Mandibular Trauma (6 mins)
State the fracture type most likely from the photo available and clinical history.
What would be the further management if you had this patient present to you in a standard dental surgery.
Stages of management:
1. Clinical examination
1. Radiographic assessment for fractures – more than one compare right side with left
1. Treatment
1. Management:
1. Urgent phone to an OMFS unit or A&E department for advice and urgent referral
Tx Mandible fracture
* Reassure
* Explain that numbness relaed to damage to ID nerve
* PA mandible and OPT OR CBCT
* NSAIDS and AB
* LA
* Refer to OMFS
* ORIF and Closed reduction with IMF
Pus Aspirate and Completion of Pathology Form (6 mins)
26 dentoalveolar abscess
Please completely fill out form and send sample off to the lab. Talking through everything that you will need on the form and how the sample is sent to the lab.
- Patient details correctly entered onto form
* Sticker (CHI number, hospital number, name, sex, address, DOB)
* Hospital department, date, time, consultant, requested by, phone no. - Clinical details entered onto form
* Pain, swelling, etc. (C/O, HPC)
* Other relevant information- e.g., MH
* Provisional diagnosis- e.g., dentoalveolar abscess - Specimen details including site
* Type of sample- pus aspirate
* Details of site- e.g. buccal mucosa of 26 - Investigation
* Culture and sensitivity testing- bacterial / fungal
* PCR and viral load- virus
* Histopathology- tissue biopsies
* Wearing appropriate PPE when handling specimen - Examination gloves worn when handling specimen
* Removal of needle
* Needle safely removed- needle removed from syringe with sheath intact
* Disposal of needle in yellow sharps bin
* Sealing syringe for transport
* Red cap placed onto syringe hub
* Label syringe with patient details and placed in plastic bag attached to request form
* Fully labelled syringe in sealed bag with red hub cap in place and needle removed
* Specimen should be sent to- The Pathology Dept, Queen Elizabeth University Hospital
Explain to this patient what an OAC and OAF are.
- ‘An OAC is an acute communication of maxillary air sinus with the oral cavity’
- This sometimes happens when an upper molar, wisdom or premolar tooth is extracted. It can also occur when trying to retrieve a fragment of tooth root that may have broken off during an extraction.
- ‘In your case the communication hasn’t closed over and instead has healed by epithelialising forming a fistula and a permanent communication of the air sinus and the mouth’ (like getting ears pierced)
- ‘This is something we want to manage as it makes you more prone to developing sinus infections’
Management of OAF
- Acute small
- Acute large
- Chronic
OAF management:
Inform patient and gain consent to monitor, close or refer
* Acute- if small (<2mm) or sinus lining intact- may heal spontaneously (encourage clot, suture margins)
* Acute- if large or lining torn- close (or refer for closure) with buccal advancement flap (2 cuts into gum, and stretch tissue over the communication) – non resorbable sutures
* Chronic- excise sinus tract / fistula- removing epithelium+ buccal advancement flap (or buccal fat pad, palatal flap, bone graft)
Antibiotics:
* Prophylactic antibiotics- as perforation into sinus will introduce oral bacteria
* Phenoxymethylpenicillin, 250mg, 5 days, send- 40 tablets, take 2 tablets 4 times daily
* Amoxicillin, 500mg, 7 days, send- 21 capsules, take 1 capsule 3 times daily
* Doxycycline, 100mg, 7 days, send- 8 capsules, take 1 capsule daily (take 2 on day 1)
What are some risk factors for an OAC?
Risk Factors OAC
* Extraction of upper molars and premolars
* Close relationship of roots to sinus on radiograph
* Last standing molars
* Large, bulbous roots
* Older patient
* Previous OAC
* Recurrent sinusitis
What are some perioperative signs of an OAC?
- Bone at trifurcation of roots comes away (sinus floor segment)
- Bubbling at socket
- Valsalva test- nose blowing, raises pressure in sinus (can create OAC)
- Change in suction sound (echo/resonance)
- Direct vision
What are some post operative signs of an OAC?
- Unilateral discharge (clear/pus)
- Fluid from nose when drinking
- Salty discharge
- Difficulty smoking/drinking through straw
- Non-healing socket
- Nasal sounding voice
What is the management of an OAC <2mm.
Give your initial management and then how you would manage if patient had sinisitis and the OAC wasnt healing after a week.
- Pack and monitor, review in week, no nose blowing, no sneeze stifling, CHX, avoid straws, smoking cessation, steam/methol inhalation
- If not healing- Close with BAF (may refer)
- Ephedrine nasal drops 0.5% 1-2 drops 4 times per day for 7 days (keeps sinuses patent)
- Otrivine drops can be used
- AB as for sinusitis- Pen V- 500mg QDS 5 days (only if acute spreading infection- preventive?)
- ALT: Doxycycline, 100mg, 7 days, send- 8 capsules, take 1 capsule daily (take 2 on day 1)
TMD (6 mins)
A 27-year-old teacher Mrs Smith presents with a bunch of E/O and I/O signs of TMD.
Click on both sides, sore muscles, sore in the morning, tongue scalloping and cheek biting (linea alba).
Please discuss the diagnosis with the patient, and conservative management for this condition. You do not need to obtain further information from the patient.
Diagnosis:
‘Mrs Smith, you have a very common condition, in fact around 75% of the population get it at one point in their life… it is called temporomandibular disorder, or TMD…’
Explanation:
‘The jaw joint sits in the base of the skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired, e.g., if you climb a mountain your legs are sore for the next few days’
‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. The muscles get inflamed and sore’
‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’
‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’
Could draw a diagram to show the disc and explain that when muscles are not in harmony, the disc is pulled at the wrong time, to create clicking noise or disc trapped in front of jaw bones crushing the tissue that can cause pain’
Treatment
1. Explain that the treatment will take many forms and will take a while to work
2. The important point is to rest the jaw as much as possible
3. Soft food diet. examples mashed potatoes and scambled egg.
4. Limit mouth opening, supported yawning
5. Limit parafuctional habits, biting nails, pens, clenching and grinding. No chewing gum
6. She should apply heat to muscles and NSAIDs
7. Arrange follow up to check her progress and if conservative approach isnt working can make patient a soft bite raising appliance.
Answer any questions
Pericoronitis- Prescription (6 mins)
Patient has severe pericoronitis, is feeling unwell and has pus suppurating from the site.
You have irrigated but feel antibiotics are required to treat the patient.
Note the patient is an alcoholic.
You are provided with all the details and a prescription pad to write a prescription.
For pericoronitis
* Metronidazole or amoxicillin
Amoxicillin prescription:
* Metronidazole is the first choice antibiotic, but it’s contraindicated due to an alcohol problem
* Still get a mark for prescribing metronidazole but have to mention alcoholism on prescription for pharmacist
Prescription:
* Amoxicillin capsules, 500mg
* Send- 9 capsules
* Label- 1 capsule 3 times daily for 3 days
* Patient’s name- correct place (2 marks)
* Patient’s address, postcode- in full (2 marks)
* Patient’s CHI- correct area (2 marks)
* Number of days treatment- correct number of days- 3 (2 marks)
* Acceptable drug and formulation- amoxicillin, 500mg capsules (1 mark)
* Correct drug dose- 500mg (2 marks)
* Correct frequency- 3x a day (2 marks)
* Correct duration of treatment- three days (2 marks)
* Total number of capsules- 9 (2 marks)
* Prescription signed and dated- correct area (2 marks)
* Written in indelible ink- pen used (2 marks)
* Scribble out remainder of the pad.
* Write any instructions if needed (i.e avoid alcohol or UV etc)
What are some key signs on an OPT that there may be a high risk of IAN damage if you extract the lower 8’s.
- Interruption of tramlines by tooth- can be upper border only or both
- Diversion/deflection- pathway changes (bends to take shape of apices- follows
outline) - Deflection of root- appears that is curved away from canal (to avoid it)
- Darkening of root where canal crosses- appears as dark banding
- Narrowing of canal- goes back to full width after it passes apices
- Narrowing of root as it crosses canal
- Dark bifid root- appears to split or divide of the canal
- Juxta apical area(lateral as opposed to tip)- radiolucency around the root (well
defined/corticated)- lamina dura is intact and appearance is not pathological
Practical
Suturing- Horizontal Mattress Suture (6 mins)
- Correct choice of instruments- Kilner Needle Holders and Gillies Toothed Tissue Forceps
2 marks - Mount the needle 1/3 from end
2 marks - Correct grasp of needle holder
- Hold the needle holders in your dominant hand by placing the thumb and ring finger into the rings and the index finger on the hinge of the blade
2 marks - Correct hold for tissue forceps
- Hold in pen grip
1 mark - Atraumatic handling of flap of tissue with tissue forceps
2 marks - Insert the needle at right angles to the wound edge and perpendicular to the surface
2 marks - Insert the needle at appropriate distance from the wound edge
~2-5mm
2 marks - Pass the needle through flap and retrieve it with an instrument
**not fingers
2 marks - Demonstrate adequate pronation and supination of hand
2 marks - Remount needle correctly as above without use of fingers
- Remount 1/3 length from thread end
2 marks - Take a full bit on second side and retrieve it with an instrument (not fingers)
- Attempt to reinsert at the same depth in the opposite side of the wound and emerge out of the tissue at the same distance from the wound edge as the insertion
- Suture exits wound similar distance from wound edge as insertion point
2 marks - Needle secure during tying of knot
- Accept any combination of:
- double throw then single throw +/- third throw
- 3 single throws
- Must demonstrate flat knot after initial throw and throws in opposing directions to ensure a secure knot
- Needle placed to side and not flying around and / or thread gathered and needle held secured / or needle clipped
4 marks - 1st throw- two turns, grasp suture at free end, approximate edges
2 marks - 2nd throw- one turn in opposite direction, grasp suture at free end and tighten
2 marks - 3rd throw- in opposite direction again
No extra marks - Cut suture to length suitable for wound site and material used
2 marks - Knot to side of the wound
2 marks - Final apposition of wound
- Ensure wound ends close together but no tension on wound and secure knot
2 marks - Needle disposed of safely when finished- if not, clip it
2 marks
Notes:
Pick up the needle holder, not the curved clip
Pick the toothed tweezers
Don’t give up- if you don’t complete the suture, still dispose of the needle
Put the needle in the sharps
Practice- kits in outreach, videos online
Suturing and Pathology Form (12 mins)
Please suture (simple interrupted) a cut on (mannequin head foam pad) left dorsum of tongue.
Following this, please complete the histopathological form provided FULLY using the patient data provided, the clinical data and photo (of fibroepithelial polyp).
1.Patient details correctly entered onto form
Sticker (CHI number, hospital number, name, sex, address, DOB)
- Hospital department, date, time, consultant, requested by, phone no.
- Clinical details entered onto form
Pain, etc.
CO, HPC, MH, DH, SH, provisional diagnosis
Other relevant information- e.g., present for 6 months with gradual increase in size, MH nil of note
Provisional diagnosis- e.g., fibroepithelial polyp - Specimen details including site
Type of sample- excisional biopsy
Details of site- excised lump from left dorsum of tongue - Investigation
Culture and sensitivity testing- bacterial / fungal
PCR and viral load- virus
Histopathology- tissue biopsies - Wearing appropriate PPE when handling specimen
Examination gloves worn when handling specimen - Place sample in path pot without touching formalin
- Sealing syringe for transport
- Cap tightened
- Label syringe with patient details and placed in plastic bag attached to request form
- Fully labelled
