PPQ's Flashcards
1
Q
- Trigeminal nerve
- Label the maxillary and mandibular branches of trigeminal nerve
A
Picture diagram.
2
Q
- What foramen does the ophthalmic branch pass through?
A
Superior orbital fissure.
3
Q
- What foramen does the maxillary branch pass through?
A
- Foramen rotundum
4
Q
- What foramen does the mandibular branch pass through?
A
Foramen ovale.
5
Q
- What is the origin, insertion, innervation and function of the muscles of mastication: -
A
Masseter:
- Origin – zygomatic arch
- Insertion – lateral surface and angle of mandible
- Action – elevates and deep fibres retrude mandible
- Testing – clench teeth together
- Innervation – masseteric branch of mandibular division of trigeminal nerve
Temporalis:
- Origin – floor of temporal fossa
- Insertion – coronoid process and anterior border of Ramus
- Action – elevates and retracts mandible
- Testing – clench teeth and palpate all fibres (anterior, middle and posterior)
- Innervation – anterior division of deep temporal nerve branches of mandibular division of trigeminal nerve –
Medial pterygoid:
- Origin – deep head medial surface of lateral outer hood plate and superficial head to tuberosity of maxilla
- Insertion – medial surface of angle of mandible
- Action – elevates and assists in protrusion of mandible
- Testing – intra oral can be painful
- Innervation – nerve to medial pterygoid of the mandibular division of trigeminal nerve
Lateral pterygoid:
- Origin – lateral surface of lateral pterygoid plate
- Insertion – anterior border of Congolese and intra articulator disc via 2 independent heads – inferior to head of consult; superior to intra articulate disc
- Testing – response to resisted movement by putting finger far back of maxilla and move jaw side to side
- Innervation – anterior division nerve to lateral pterygoid branch of mandibular division of trigeminal nerve
6
Q
Patient comes in with a right body mandibular fracture
- Other than pain, bruising and swelling. List 6 other signs and symptoms associated with mandibular fractures
A
- Pain, swelling, limitation of function
- Occlusal derangement
- Numbness of lower lip
- Loose or mobile teeth
- Bleeding both internally and externally out of the ear
- Anterior open bite
- Facial asymmetry
- Deviation of the mandible to the opposite side
7
Q
- Two radiographic views required for mandibular fractures
A
- Direction of the fracture line
- Opposing occlusion
- Magnitude of force
- Mechanism of injury
- Intact soft tissue
- Other associated fractures
8
Q
- What does displacement of fragments depend on?
A
- Pull of the attached muscles
- Angulation and direction of fracture line
- Integrity of the periosteum
- Extent of communication
- Displacement of blow
9
Q
- List 3 management options for mandibular fractures?
A
- Undisplaced fracture – no treatment (monitor)
- Displaced or mobile fracture – closed reduction and fixation (IMF) or open reduction internal fixation (ORIF)
10
Q
You have extracted tooth 26 but the bleeding won’t stop.
- List how you would manage the situation and gain haemostasis (4 ways)?
A
- Ensure you have an accurate medical and drug history and identify where bleeding is coming from
- Apply firm Pressure by biting on damp packs of gauze or finger pressure
- Haemostasis agents – LA with vasoconstrictor
- Haemostasis aids – WHVP, bone wax, fibrin foam
- Suture the socket
- Ligation of vessels with Diathermy
- Surgical haemostasis
11
Q
- What is a local risk factor for delayed onset of bleeding?
A
- Local anaesthetic with vasoconstrictor wears off
- Loosening of the sutures
- Patient causes trauma to the socket with tongue, finger, food etc,
12
Q
- List 2 conditions for each of the following – congenital and acquired bleeding disorders
A
- Congenital = haemophilia A and B, Von willebrands’ disease
- Acquired = warfarin, anti-platelet drugs – clopidogrel
13
Q
- What should an INR be for a patient on warfarin for oral surgery to be carried out?
A
- <4 treat without interrupting their anticoagulant medication
14
Q
Patient attends with suspected dry socket
- What is the scientific term for a dry socket?
A
- Alveolar/localised osteitis
- It occurs when the blood clot at the site of the extraction fails to develop, dislodges or dissolves before the would have fully healed
15
Q
- What are the predisposing risk factors for dry socket?
A
- Molars more common – increased risk anterior to posterior
- Mandible more common than maxilla
- Smoking increases risk due to reduced blood supply
- More common in females than males
- Oral contraceptive pill can increase risk
- Excessive trauma during extraction procedure
- Excessive mouth rinsing post extraction
- Family history or previous dry sockets
16
Q
- What are the treatment options? for dry socket
A
- Supportive: Reassurance and use systemic pre-emptive analgesics, Give patients information on dry sockets
- Management:
- Give LA to relieve pain,
- Irrigate socket with warm saline to wash out food and debris,
- Curettage/debridement - encourage bleeding and new clot formation
- Use WHVP or Alvogyl to encourage clot formation
- Advise patient on analgesia and hot salty mouthwash/CHX use
17
Q
Patient attends with pericoronitis of the lower 8
- What is pericoronitis?
A
- It is inflammation in the soft tissues around the crown of the tooth which only occurs when there is communication between the tooth and the oral cavity
- The tooth is normally partially erupted and visible but occasionally there may be very little evidence of communication and careful probing distal to the 2nd molar is required to show the small communication
- Food and debris gets trapped under the operculum resulting in inflammation or infection occurring
18
Q
- What are the signs and symptoms of pericoronitis?
A
- Pain, swelling, ulceration of operculum
- Halitosis, bad taste in the mouth
- Plus discharge
- Occlusal trauma to the operculum
- Dysphagia, trismus, pyrexia, malaise, regional lymphadenopathy
19
Q
- How is periodontitis treated?
A
- Incision Nd drainage of liaised pericoronal abscess washing underneath operculum with CHX or antiseptic Talbot’s iodine
- Extraction of 3rd molar
- Analgesia use and CHX mouthwash
- Only prescribe antibiotics if severe or if patient is systemically unwell or immunocompromised
- If patient has large extra oral swelling, systemically unwell, trismus, dysphagia, they should be referred to maxfacs or A&E
20
Q
- What 6 radiographic signs show a close relationship of lower 8 with IAN?
A
- Diversion/deflection of the inferior dental canal
- Darkening of the root where crossed by the canal
- Interruption of the white lines/lamina dura of the canal
- Deflection of the root
- Narrowing of the inferior dental canal
- Juxta apical area – well circumscribed Radiolucent area lateral to the root rather than at the apex
21
Q
- What imaging is requested when an 8 is close to IAN?
A
- Cone beam CT scanning to assess 3D position of the root to IAN
- OPT ca also he requested
22
Q
- What risks should be explained to the patient with regards to damage to IAN of extracting the tooth?
A
- Dysaesthesia – painful, uncomfortable sensation of lower lip, chin and tongue
- Altered taste
- Numbness (anaesthesia) or tingling (paraesthesia) of the lower lip, chin and side of tongue
- Temporary IDN anaesthesia: May take weeks/months to improve , 10-30% depending of difficulty of XLA and proximity to IDN
- Permanent IDN anaesthesia: Less than 1% of cases – rare
- Lingual nerve anaesthesia: Temporary = 0.25-23% risk, Permanent = 0.14-2% risk
23
Q
Treatment option for patient who needs 8 XLA but 8 is close to IAN?
A
Coronectomy.
24
Q
- Name 2 scenarios where there would be an increased risk of bleeding for a patient and 2 post operative methods of achieving haemostasis
A
Patient with a congenital bleeding disorder – Haemophilia A
- Atraumatic technique
- Suture the socket closed and use haemostatic aids if required such as WHVP
- May require factor replacement therapy or oral tranexamic acid
- Ensure bleeding stops before they leave surgery
- Stress the importance of the post-op instructions
- Review
Patient on warfarin – need to ensure INR <4
- Atraumatic technique
- Ensure INR <4 24 hours prior to appointment
- Use haemostatic agents; suturing; oral tranexamic acid if required
- Ensure bleeding stops before they lesbian surgery
- Stress the importance of the post op instructions
- Review
25
Q
- Patient attends with suspected OAF - How would you diagnose a OAF?
A
- Nose holding test – nose pinched between thumb and index finger and air will rush out of the socket
- Direct visual assessment if you can visualise a communication
- Bubbling of flood from extraction site
- Searching for an echo with good light and suction
- Using a blunt probe
26
Q
- What symptoms would a patient be complaining of with OAF?
A
- Problems with fluid consumption (fluid coming from the nose)
- Problems with speech or singing (nasal sounding)
- Problems placing wind instruments
- Problems smoking or using a straw
- Bad taste/odour/halitosis/pus discharge
- Pain and sinusitis type symptoms
27
Q
- What treatment is used for OAF?
A
- Excise the sinus tract/fistula
- Perform a buccal advancement flap +/- buccal fat pad or palatal flap
- May require bone graft or collagen membrane
- Antral washout
28
Q
- What is the difference between an OAF and OAC
A
- An OAF is a chronic epithelial lined tract between the maxillary sinus and oral cavity whereas an OAC is an acute communication which is nit epithelial lined.
29
Q
- What are 6 signs and symptoms of TMD?
A
- Intermittent pain of several months or years in duration
- Pain on opening
- Limited mouth opening
- Muscle/joint/ear pain particularly on wakening
- Trismus and locking commonly associated
- Clicking and popping joint noises
- Associated headaches
- Crepitus (late degenerative changes)
- Signs of wear – Linea Alba, wear facets, tongue scalloping
- Facial asymmetry
30
Q
- What 2 muscles should be palpated when querying TMD?
A
Masseter, tmeporalis.
31
Q
- What are the common causes of TMD?
A
- Inflammation of the muscles of mastication or TMJ secondary to parafunctional habits
- Trauma either directly or indirectly to the joint
- Stress
- Psychogenic
- Occlusal abnormalities
- Degenerative disease – localised (osteoarthritis); systemic (RA)
- Disc displacement – anterior +/- reduction
- Neoplasia
- Infections
32
Q
- What nerve supplies the TMJ?
A
- Auriculotemporal and masseteric branches of mandibular branch of trigeminal nerve
33
Q
- What conservative advice is given to manage this patient?
A
- Reassurance about the condition
- Soft diet with food cut into small pieces
- Masticate bilaterally without wide openings
- Stopping parafunctional habits – grinding, bruxism, nail biting, chewing gum
- Supporting mouth opening on yawning
- Jaw exercises – massages, relaxation techniques
- Splints – bite raising appliance (Michigan) and Ned splints
- Medication – NSAIDs, muscle relaxants, tricyclic antidepressants, Botox, steroids
34
Q
What are the mechanisms of a bite splint?
A
- Exact function is unknown but it is thought that they stabilise the occlusion and improve the function of the masticatory muscles, thereby decreasing abnormal activity.
- They also protect the teeth in cases of tooth grinding and clenching acing as a habit breaker
35
Q
- What is arthrocentesis?
A
- Procedure during which the jaw joint is washed out with sterile saline and anti- inflammatory steroids.
- This breaks fibrous adhesion and flushes away inflammatory exudate.
36
Q
- Give 2 possible surgical options? TMD
A
- Arthroscopy
- Disc repositioning/repair + removal always surgery
37
Q
- What are 6 signs and symptoms of ZOC fractures involving orbit floor?
A
- Asymmetry – swelling followed by flattening
- Alteration in sensation (infraorbital nerve damage)
- Lacerations of excoriations
- Peri-orbital ecchimosis
- Sub-conjunctival haemorrhage – biggest indicator of fracture
- Numb cheek
- Visual disturbances – decreased acuity
- Diplopia – swelling, motility and positional issues
- Pain on eye movement
- Epiphora – excessive watering of the eye
38
Q
- What imaging would you take to confirm ZOC fracture diagnosis?
A
- Occipitomental (OM) views 15/30o (facial views)
- CT scan for complex fractures or blow outs
- Use Campbell’s lines to interpret facial injuries on radiographs
39
Q
- What are the management options for ZOC fractures?
A
- None:leave and monitor
- Exposure and repair of fracture: Or ORIF (open, reduction and internal fixation)
- Closed reduction: Gillies loft – arch lifted out for realignment; Malar hook or buttress plate for F-Z displacement
- Post-op Instructions:
- Avoid nose blowing, Post op steroids – dexamethasone 4-8mg, Eye observation overnight – retrobulbar haemorrhage, Pain management
40
Q
- What are 2 local and 2 general factors for implant placement
A
- Local – alveolar bone levels; suitable space to place Implant 7mm
- General – smoking status; bisphosphonate use
41
Q
What factors does an implantologist consider before placing an implant
A
- Smoking status
- Medical and drug history
- Alveolar bone quality and quantity
- Oral hygiene and periodontal status
- Patient motivation and compliance
- Overall occlusion
- Patient aesthetic
42
Q
- What bone dimensions are required and how are they best measured?
A
- 1.5mm horizontal bone round implant
- 3mm between implants
- > 5mm space for the papilla between bone crest and contact points
- 7mm spacing between crowns
- 2mm from adjacent structures (maxillary sinus; IAN)
- Assessed with CBCT
43
Q
- Give 3 alternative treatment options instead of an implant?
A
- Accept space
- Removable partial denture
- Bridge
44
Q
A patient attends your surgery for provision of a complete upper with extraction of 17 required
- Name 3 possible complications associated with extraction of lone standing upper molars
A
- Oro-antral communication
- Fractured maxillary tuberosity
- Loss of tooth or Root in the antrum/pterygoid space
45
Q
- Of the 3, describe how you would diagnose the above?
- OAC:
A
- Bubbling of blood from extraction site
- Nose holding test – nose pinched and air will rush out of socket
- Direct visual assessment
- Searching for echo with good light and suction
- Using blunt probe gently
- Bone in trifurcation
- Pre and post op radiographs
46
Q
Diagnose fractured maxillary tuberosity
A
- Noise of the fracture
- Movement noted both visually or with supporting fingers
- More than 1 tooth moves
- Visual tear on the palate
47
Q
Loss of tooth or root in antrum diagnosis
A
- Post op radiographs
- Visual assessment
48
Q
- What flap design is used for OAC?
A
- Large OAC or if the lining is for will be closed with a Buccal advancement flap
49
Q
- Outline your management of the possible complications listed above
OAC:
A
- Inform the patient, reassurance and explain what OAC is
- If it is small or sinus lining intact:
- Encourage clot formation and suture margins
- Use of prophylactic antibiotics
- Small <2mm usually heal with normal clot and routine mucosa healing
- If it is large or lining is torn:
- Close with buccal advancement flap
- Antibiotics 7days and nose blowing instructions
- Conservative advice:
- No forcefully blowing of nose or stifling sneeze
- Steam and menthol inhalation is advantageous
- Avoid use of straw and refrain from smoking and drinking alcohol
50
Q
Fractured tuberosity management
A
- Dissect out and close the wound; reduce and stabilise with fingers or forceps
- Fixation:
- Orthodontic buccal arch wire spot; arch bar or splints
- Always check:
- Occlusion, antibiotic and antiseptic use, remove and treat involved pulp, post op instructions
- Remove the tooth 8 weeks later
51
Q
Root in antrum management
A
- Surgical:
- Caldwell-luc approach – buccal sulcus/window cut in the bone
- Open fenestration with care
- Efficient suction and narrow bore
- Use small curettes and irrigate or use ribbon gauze to remove all fragments
- Close with buccal advancement flap
- ENT involvement – endoscopic retrieval
