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Oral medicine > Teeth abnormalities, TMD, cleft lip, surgery > Flashcards

Teeth abnormalities, TMD, cleft lip, surgery Flashcards

1
Q

contraindications to orthognathic surgery

A 
BMI >30
Bleeding problems
Bisphosphinates
Severe mental health issues
small condyles/TMJ problems increase risk of relapse
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2
Q

Steps to orthognathic surgery

[4]

A
  1. Joint clinic and facial planning
  2. Pre-surgery ortho (2yrs)
  3. Surgery
  4. Post-surgery ortho (6months)
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3
Q

What is involved in pre-orthoganthic surgery orthodontics

A
  1. Extractions
  2. Remove dental compensation (anterior teeth) - will make class 3 and 2 patients look worse
  3. close gaps and align teeth
  4. coordinate arch widths
  5. level the arches
  6. place rigid fixation wires
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4
Q

What is involved in post-orthoganthic surgery orthodontics

A

Elastics and fixed wires used to close the gaps between the arches and secure everything in place in the new ICP.

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5
Q

Different orthognathic surgery techniques - list

A
  • Bilateral sagittal split osteotomy
  • Le Fort 1 osteotomy
  • surgically assisted rapid maxillary expansion SARME
  • Genioplasty
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6
Q

what is the risk of numbness to the lower lip after orthognathic surgery

A

30-40% permanent

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7
Q

How is cleft lip/palate caused

A

lack of mesenchyme or failure to fuse in vitro

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8
Q

Cleft lip and palate aetiology

A

Genetic + environmental
Genetic - 40% FH
Environmental - nutritional deficiency, anaemia, alcohol, smoking, obesity, anti-convulsant medication

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9
Q

What is a subcutaneous cleft palate/signs

A

translucent/blue area, bifid uvula, eating problems - where the mucosa is normal but overlying a cleft palate

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10
Q

Most common cleft/lip palate presentations

A

50% Cleft lip and palate
30% Cleft palate
20% Cleft lip

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11
Q

Syndromes/disorders associated with cleft lip/palate

A

Van der Woude
Pierre Robin
Stickler
Foetal alcohol spectrum

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12
Q

Pierre robin syndrome

A

Cleft palate, floppy tongue, mandibular retrognathia = Difficulties eating and breathing = nasopharnygeal and feeding tubes.

Can be associated with Sickler syndrome.

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13
Q

Stickler syndrome

A

Connective tissue disorder causing cardiac and retinal problems - associated with Pierre Robin sequence and cleft plate

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14
Q

Van der Woude syndrome

A

Cardiac problems, cleft palate, invaginations in lip, hypodontia

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15
Q

Foetal alcohol spectrum disorder

A

small head, low body weight, learning difficulties, coordination problems, cleft lip and palate

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16
Q

Neonatal cleft lip/palate management inc surgery details

A

Special bottle for feeding that doesn’t rely on suckling

Wait until babies are thriving and then surgery for cleft lip (3 months) and cleft palate (6 months).

Cleft lip - make muscles lie horizontally like lip

Cleft palate - nasal epithelium, muscles and oral epithelium closure (3 layers)

Alveolar defect not fixed
Remove any neonatal teeth

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17
Q

Young cleft lip/palate children management

A

Class 3 incisors due to previous surgery

Dental anomalies - missing teeth, displaced/ectopic teeth, microform teeth, fused teeth, hypoplastic enamel

Poor OH - painful surgery sites, fistulas so poor diet, altered saliva, tongue movement, hard to clean displaced teeth, hospital burnout

Speech therapy and hearing therapy

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18
Q

Speech therapy for cleft lip/palate patients

A

Nasal speech because of fistulas

Can’t pronounce T sounds etc bc tongue avoids the roof of the palate where surgery was

For all patients

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19
Q

Hearing tests for cleft lip/palate patients

A

Can get glue ear if the defect affects the middle ear draining through the Eustachian tube. May need to place a tube to drain ear (Grommets), or hearing aid or child can grow out of it w age.

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20
Q

Cleft lip/palate older children management

A 
9-11 years old
Fix alveolar defects with grafts to close fistulas, align maxilla so teeth can erupt normally.
Unfavorable skeletal growth e.g. class 3 can affect options- may need orthognathic surgery but need to consider previous surgeries, scars and effects on speech.

Any gaps that can’t be fixed with bone grafts may need to be accepted or use restorative dentistry to improve aesthetics.

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21
Q

GDP considerations when managing cleft lip/palate patients

A
  • High caries risk
  • Limited access
  • Multiple appointments with other health care professions
  • other syndromes and complex MH
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22
Q

Bone involved in the TMJ

A

Bones involved

  • Temporal bone (mastoid process, styloid process, external auditory meatus, mandibular/glenoid fossa, articular eminence of zygomatic arch)
  • Zygomatic bone
  • Maxilla
  • Mandible (condyle, mandibular notch, coronoid process, neck, ramus, angle, body)
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23
Q

Muscles of mastication + accessory muscles

A

MoM

  • temporalis (temporal fossa and coronoid process)
  • masseter (attaches to zygomatic arch and angle of the jaw)
  • Lateral pterygoid (lateral pterygoid plate and inner border of the angle of mandible and articular disc, 2x heads and fuses at the mandible)
  • Medial pterygoid (medial pterygoid plate and inner border of the angle of mandible, 2x heads and fuses at the mandible)

Accessory

  • geniohyoid (attaches to the chin and hyoid bone)
  • digastric (chin, hyoid and mastoid)
  • buccinator
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24
Q

Normal movement of the TMJ

A
  1. Hinge movement - Rotates in mandibular/glenoid fossa
  2. Forward and downwards translation

Articular disc inbetween the condyle and glenoid fossa - concave and divides joint into upper and lower.

  • Upper = translation movements
  • Lower = hinge/rotation

The normal opening is 35-50mm

Reinforced with fibrous articular capsule and ligaments e.g. TMJ ligament which limits posterior and lateral movements of TMJ.

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25
Q

Opening movement of the TMJ and muscles involved

A

35-50mm

Muscles
- Geniohyoid
- Digastric
= pull chin backwards and down = hinge movement

  • Lateral pterygoid muscle pulls articular disc (and joint) = translation
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26
Q

Closing movement of the TMJ and muscles involved

A

Temporalis - pulls condyle back

Masseter
Medial pterygoid
- elevate the mandible

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27
Q

Protrusive movement of TMJ and muscles involved

A

10mm is normal

Symmetrical forward translation of condyles
- lateral pterygoids

Retrusion = temporalis

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28
Q

Lateral excursion movement of TMJ and and muscles involved

A

10mm is normal
Unilateral contraction of lateral and medial pterygoids on the ipsilateral side (lateral for opening, medial for closing)

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29
Q

Types of TMD

A

Non-TMD

  • dental
  • salivary glands
  • pharynx, ear, etc.

Uncommon TMD

  • neoplasms
  • inflammatory arthritis (RA, SLE, ankylosing spondylitis)
  • Growth disturbances

Common TMD
- Muscle
- Disc displacement with reduction
- Disc displacement with reduction and intermittent locking
- Disc displacement without reduction and reduced opening
- Disc displacement without reduction, without reduced opening
- Degenerative joint disease
- Subluxation
(acute or chronic >3months)

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30
Q

Common TMD’s - different types

A
  • Muscle/myalgia
  • Arthralgia
  • Disc displacement with reduction
  • Disc displacement with reduction and intermittent locking
  • Disc displacement without reduction and reduced opening
  • Disc displacement without reduction, without reduced opening
  • Degenerative joint disease
  • Subluxation
    (acute or chronic >3months)
  • Headache due to TMD
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31
Q

Myalgia and different types

A

Muscle pain from MoM e.g. masseter and temporalis

  • Local myalgia is a specific point
  • Myofascial is anywhere within the muscle boundaries
  • Myofascial with referral is outside the muscle boundaries e.g. headaches
  • Fibromyalgia
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32
Q

Arthralgia

A

Joint pain

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33
Q

Disc disorders

A
  • Disc displacement with reduction
  • Disc displacement with reduction and intermittent locking
  • Disc displacement without reduction and reduced opening
  • Disc displacement without reduction, without reduced opening
    (acute or chronic >3months)
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34
Q

Disc displacement with reduction

A

Disc displaced anteriorly at rest, so retro-discal tissue fills the joint space instead (Innervated so the patient may get pain if condyle is pushing on this)

During opening/translation movement, the articular disc clicks back into place (= pop/clock noise) and the rest of the translation movement is normal

During closing, the articular disc gets displaced forwards again and makes another click/pop noise

No limited movement or locking
The jaw will deviate to the affected side but correct itself

Symptoms = pain, clicking, deviating jaw which corrects, arthralgia

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35
Q

Disc displacement with reduction and intermittent locking

A

Disc displaced anteriorly at rest, so retro-discal tissue fills the joint space instead (Innervated so the patient may get pain if condyle is pushing on this)

During opening/translation movement, the articular disc folds over or needs some massaging (so it is locked) before it clicks back into place (= pop/clock noise) and the rest of the translation movement is normal

During closing, the articular disc gets displaced forwards again and makes another click/pop noise

No permanent locking or limited movement
Jaw will deviate to the affected side but correct itself

Symptoms = pain, click, deviating jaw, intermittent locking

More likely when patient has kept mouth open for long time/excessive opening

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36
Q

Disc displacement without reduction (w/ limited opening)

A

Progression of the disc disorders with reduction

Disc displaced anteriorly at rest, so retro-discal tissue fills the joint space instead (Innervated so the patient may get pain if condyle is pushing on this)

During opening/translation movement, the articular disc folds over and doesn’t click into place. This limits/blocks the translation movement of the condyle so it is locked and can only open so far.

No clicking
Pain because all the movement is on the innervated retro-discal tissue

Symptoms = pain, locking so trouble eating, talking, drinking, etc., deviation to ipsilateral side without correcting, limited excursive movements.

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37
Q

Disc displacement without reduction, without limited opening

A

Chronic >3 months
Progression of DD w/o reduction + limited opening

The retro-discal tissue adapts and stretches to the continued trauma by scarring, losing innervation and becomes a pseudo-articular disc and then the patient can open and close again almost like normal.

Takes a long time for this to happen (a year?)

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38
Q

Degenerative joint disease of TMD

A

Crackling/crepitus heard/felt in the joint
Bone destruction

On OPT - get joint space narrowing, sclerosis of joint, erosion of condyle. CT is better.

Symptoms = pain, limited range of movement, joint noises, arthralgia

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39
Q

Hypermobility and subluxation of TMD

A

Condyle displaces beyond the articular eminence
Can be due to a hypermobility syndrome e.g. Ehlers Danlos

Subluxation is partial dislocation, when the patient can reduce it themselves
Luxation is complete dislocation and needs surgical/medical intervention

Signs/symptoms = opening beyond 50mm, TMJ clicking and locking in a wide-open position .

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40
Q

Headache due to TMD

A

Due to temporalis muscle

- Palpate, movement tests

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41
Q

Information to get when taking a TMD history from patient

A 
LOCK
- Locking
- Limited opening
- Occlusal disturbances
- Clicking/crepitus
Pain history
Recent dental work
Trauma
Parafunction/habits
Neurological signs
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42
Q

Past medical considerations for TMD [5]

A 
Joint or bone disorders e.g. arthritis, osteoporosis
New medications
History of cancer
Trauma history
Mental health
Fibromyalgia or hypermobility syndromes
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43
Q

Extraoral exam for TMD [8]

A

Visual exam - any swellings, asymmetry, muscle hypertrophy, clenching
Palpation of muscles and TMJ - feel for clicking
Movements
- Excursive, opening and measuring the distance
- Opening against pressure
- Look for deviations or locking on opening
Lymph/neck exam
Neurological exam - light/sharp touch test
Palpate the temporal artery (arteritis)
Skeletal classification - class 2 posturing

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44
Q

Intraoral exam for TMD [3]

A

Palpate TMJ and muscles
Teeth signs = broken restorations or fractured teeth, TSL, signs of clenching e.g. frictional keratosis
Occlusion - skeletal class, incisal relationship, ICP, RCP, interfering contacts

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45
Q

Red flags for TMD

A 
Swellings
Usual cancer symptoms
Fever/signs of infection
Getting worse with treatment
Neurological signs - hearing, vision, smell, etc.
Changes to the occlusion
Acute severe signs
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46
Q

Causes of TMD - predisposing, initiating, precipitating

A

Predisposing = Systemic condition, macrotrauma e.g. third molar removal,

Initiating = Microtrauma, strain, abnormal occlusion

Precipitating = Mental health, bruxism, para-function

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47
Q

Investigations for TMD (and pros/cons)

A

OPT - excludes non-TMD issues, can be done in primary care
CT - shows and assesses degenerative disease and condyle damage (type 1-4). But needs a referral, ionising radiation. Can do a functional CT
MRI - non-ionising. It shows soft tissues and synovial fluid.
USS - non-ionising, shows the soft tissues and disc. Can show the function of the TMJ.

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48
Q

Principles of management of TMD (and types of management)

A

Least invasive/preventive treatment tried first.
Aim to restore function, remove pain and resolve patient’s concerns.

Education
Physical therapy
Splints
Medication
Surgery
Others
- psychological therapy
- acupuncture
- botox
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49
Q

Education for treating TMD

A

Informing patients of the diagnosis, and explaining what’s happening and why they are getting the symptoms can empower the patient and be enough to help with the pain.

Educating them on prevention so they can take control of the disease and its management

  • Yawning advice
  • Sleep advice - not on the front
  • Diet advice e.g. small chunks, soft food, no excessive chewing
  • Reducing parafunction and bad habits
  • Reduce stress
  • Leaflets
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50
Q

Physical therapy for treating TMD

A

Exercises to open up the jaw (for limited movement)
Exercises to strengthen the muscles or relieve pain
In clinical, the scissor technique to open the jaw
Acupuncture
Jaw massages

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51
Q

Splint therapy for treating TMD - principles/requirements

A 
Non-invasive and can be done in primary care
CRRROP
- Cognitive awareness
- Realignment of jaws into a better position
- Restore vertical dimension
- Repositioning TMJ 
- Occlusal disengagement
- Placebo effect
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52
Q

Types of splints for treating TMD

A

Directive splints
- Anterior repositioning splint protrudes the jaw forward into an optimal position for anterior disc displacement to heal and improve

Permissive splints
Soft splints (not strong evidence, can make things worse, hard to adjust but cheap and easy to make)
Hard splints e.g Tanner, Michigan - need to be full coverage, can make them so they create an ideal occlusion
Lucia Jig - disengages posterior teeth to help find CR, reprogrammed muscles, instant relief, diagnose TMD
Bilaminate =  2 layered hard and soft splint
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53
Q

Medication for treating TMD

A

Muscle relaxants e.g. amitriptyline
Antidepressants/anxiolytics
Analgesia/NSAIDs
Steroids can reduce inflammation
Botox - Botulinum toxin injected into muscles to reduce their activity e.g. for hypertrophic or parafunction
Benzodiazepines for muscle relax but can cause addiction

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54
Q

Botulinum toxin for treating TMD

A

Botox - Botulinum toxin injected into muscles to reduce their activity e.g. for hypertrophic or parafunction.
But it is temporary
Blocks SNAP25

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55
Q

Arthrocentesis for treating TMD

A

For acute closed/locked joint

Large bone needle injected into TMJ capsule and joint washed with a steroid to reduce inflammation and pain.

Needs to be done under GA but surgery isn’t that invasive.
Can only be done twice bc can damage condyles.

56
Q

Arthroscopy for TMD

A

Endoscope fed into TMJ space to wash it out w steroid to reduce inflammation (arthrocentesis), remove any adhesions, diagnose further problems, etc.
Needs to be done under GA and is more invasive than arthrocentesis alone.

57
Q

Surgery for treating TMD

A

Rare bc risk of damage to facial nerve and auriculotemporal nerve.

Discectomy - remove the disc and replace it with another one e.g. temporalis muscle flap
Discoplasty - surgically repositioning the disc

58
Q

Uncommon TMJ disorders

A 
Arthritis
Neoplasms
Growth disturbances
Trauma
- fracture w/o displacement can heal on its own
- w displacement needs plating.
59
Q

Persistent dislocation treatments

A

Due to hyper mobility e.g. Ehlers Danlos
Physio to strengthen the muscles that keep Condyle in place
Or Botox
Surgical - reposition articular eminence

60
Q

Osteoarthritis of TMD

A

Degenerative joint disease - more symptoms if more trauma to the joint.

Symmptoms = pain, crepitus, erosions on rads, limited opening.

Needs a CT

61
Q

Infective arthritis of TMD

A

Bacteria in synovium which is bad bc close to skull base and cranial fossa.

Symptoms = pyrexia, swelling, limited opening and can lead to ankylosis and fusion of the joint bc of the inflammation

62
Q

Trismus diagnosis, causes and management

A

The normal opening is 35-50mm

Extracapsular causes - fibrosis of ligaments, muscles, radiotherapy

  • Trauma
  • Infections

Intracapsular causes

  • Trauma
  • Infection
  • Neoplasm
  • arthritis
  • something blocking the movement,
  • DD w/o reduction

Referral if:

  • Opening <1.5mm
  • Getting worse/progressive
  • Acute signs of infection e.g. lymph
  • No clicking history
  • Neuralgia not due to myofascial
63
Q

Anatomy of the TMJ

  • bones
  • movement
  • disc
  • muscles
  • ligaments
A

The TMJ is a synovial joint

Condyle fits into the mandibular fossa, and rotates/translated forwards and down along the articular eminence

The articular disc splits the TMJ into the upper and lower compartment. Lower does the hinge/rotation movements, upper does the translation.

The articular disc isn’t innervated so no pain, but behind it is the retro-discal tissue which is innervated.

Lateral pterygoid muscle inserts into the articular disc (and lateral pterygoid plate)

The capsule around the joint and 3x ligaments support the joint and limit distal/lateral movements of the joint e.g. TMJ ligament

64
Q

When would you do orthognathic surgery

A

IOTN 4/5 with excellent OH
Patients getting occlusal disturbances or functional difficulties
Severe malocclusion (class 2 or 3)
Abnormalities e.g. anterior open bite, severe overjet (reverse or excessive normal), traumatic overbite, scissor bite, severe asymmetries, craniofacial abnormalities e.g. cleft palate
When functional appliances or camouflaging/dental compensation won’t work
Patient needs to be fully grown

65
Q

IOFTN

A

Index of Orthognathic Functional Treatment Need

No need
Mild need
Moderate need
- Look at overjet or reverse overjet
- Asymmetry
- Overbite 
- Exposed labial gingiva of uppers (<3mm)
- open bite
Great need
Very great need
- Soft tissue trauma w overbite
- severe overjet
- Cleft lip/palate
- Upper labial gingiva exposed (>3mm)
- Scissor bite
- Sleep apnoea
- Trauma or pathology
- All with occlusal disturbances or functional dificulties
66
Q

Stage 1 orthognathic surgery - facial planning

A 
Take all the soft tissue and hard tissue measurements and see how much they deviate from normal
Patient's ICE
Ceph, OPT, 3D planning with CT, 
Study models and photos
A dental and periodontal exam
67
Q

Orthognathic surgery - types of surgical procedures/details

A

Use wafer guides in surgery (prepared beforehand using models) to guide where the new jaw positions will be.

Bilateral sagittal split osteotomy

  • split the angle/body of the mandible through it’s thickness and slide the 2 pieces apart to move the mandible forwards
  • Secure with titanium plates

Le Fort 1 osteotomy

  • Separate the maxilla from the base of the skull
  • Move up, forwards, down, etc
  • Place titanium plates

Genioplasty

  • Done from inside the mouth
  • Risk of damage to the lingual nerve

SARME

  • surgically assisted rotational maxillary expansion
  • Device is placed into the palate and the patient turns it over a long period of time and it slowly widens the maxilla.
68
Q

Post-orthognathic surgery orthodontics

A

3-6 months

Fixed wires and elastics are used to secure the teeth position and close any gaps between the arches

69
Q

Anaplastology definition

A

Artificially replace a missing part of the body

e.g. using implants, obturator,

70
Q

Obturators after resective/cancer surgery

A

Need to wait until all the healing and treatment are completed before planning final implants
Obturators can be an intermediate to close any intra-oral gaps or communications
It will need to be replaced as the lesion heals and changes shape

71
Q

Keloid scars

A

Hyperplastic scar tissue - excessive healing
Excise excessive scar tissue and use steroid injections or pressure dressing (reduces blood supply) to reduce the risk of reoccurrence

72
Q

Extraoral implants

A

Higher risk of infections
Need the implants to be secured by cortical bone (to stop rotation) and cancellous bone. Both provide support and blood supply.
Cover with a skin graft - need a good seal

73
Q

Describing/classifying cleft lip and palate

A

LAHSHAL
Uppercase = complete
Lowercase = incomplete

L = lip
A = alveolus
H = hard palate
S = soft palate
74
Q

Management of cleft lip and palate patients - adults

A

Can still get referred for treatment even if have been lost from the system

75
Q

Dental abnormalities in cleft lip/palate patients and management

A 
Hypodontia
Hypoplastic enamel
Ectopic/displaced teeth
Microdontia
Fused teeth
Poor OH
76
Q

Normal anatomy/histology of maxillary antrum

A

Ciliated pseudostratified columnar epithelium (respiratory)

Medial wall = lateral nasal wall w the ostium where the sinus drains (against gravity bc of the ciliated epithelium)
Floor = alveolar bone of maxilla and hard palate
Roof = orbital floor (+infraorbital foramen)
Lateral/anterior wall is the maxilla (cheek area, has the canine fossa which is the thinnest part and good for access)

77
Q

Functions of the maxillary antrum

A

Mucus
Lighten the skull
Humidify and warm the air
Resonance of voice

78
Q

What is an OAC

A

Communication between the mouth/oral cavity and maxillary sinus

79
Q

OAC vs OAF

A

A fistula is lined with epithelium e.g. an established passage.
7+ days

80
Q

Risk factors for an OAC

A 
Pneumatised sinus (expanded)
Lone standing molar
Age
Long roots
Ankylosed roots
Divergent roots
Bulbous roots
Operator technique, excessive apical force
Patient not following POI
Apical bone resportion after pathology e.g. Cyst, PAP, granuloma
81
Q

Clinical/rad signs and symptoms of an OAC (during XLA and post-op)

A

During

  • fogging mirror
  • lining/epithelium moving
  • Hallow sound when aspirating
  • bubbles when breathing
  • Lining or concave piece of bone on the root
  • can see the hole

Post-op

  • sinusitis symptoms
  • liquid regurgitation in the nose
  • Discharge
  • air escaping in both directions (Valsalvin test)
  • Pain

Rad will show a physical defect in the floor of the sinus

82
Q

Management of OAC

A

If <2mm = remove sharp/loose bone fragments, pack w surgicel, suture closed, POIG and review - to encourage spontaneous healing

2-4mm = same or surgically depending on the patient RF, MH, hygiene

4+mm or fistula (>7days) = surgical closure. Needs a CBCT.

83
Q

POIG for OAC

A

Don’t hold in sneezes
Don’t use straws/sucking
Don’t blow your nose
Don’t travel/do anything that will change air pressure

Anticongestants
Antibiotics
Good OH
Steam inhalations

84
Q

Surgical repair techniques for an OAC [5]

A 
Buccal advancement flap
\+/- Buccal fat graft
Palatal rotational flap
Modified palatal technique
Bone grafting
85
Q

Buccal advancement flap for an OAC

A

Buccal flap raised - full-thickness, flared margins, periosteal relief
Advanced over the defect and sutured onto healthy bone so may need to remove some palatal mucosa
Watertight suturing
- Good outcomes, minimal complications
- Good blood supply for healing
- Easy
- But can cause a reduction in vestibular depth so bad for dentures

86
Q

Palatal rotational flap for an OAC

A

A palatal flap rotated to cover the defect, the blood supply from the greater palatine artery
For very big defects that aren’t responding to other methods
Painful healing, affects the blood supply to the area and can cause necrosis.

87
Q

Buccal fat pad graft for an OAC

A

Buccal fat graft taken and placed over the defect, then buccal advancement flap used
For big defects or delayed closure

88
Q

Management of an OAF

A

Remove lining and pack with surgicel, then place xenograft membrane to aid healing (GTR?)

89
Q

Foreign object displacement into sinus

+ how to diagnose

A

Can be during XLA, implants
Can be due to poor technique from the operator, excessive force, etc.
Diagnose initially using OPT/PA but then need a CBCT to see exactly where it is and plan the surgery.

90
Q

Management of foreign object displacement into sinus [4]

A

Remove it, delay removal or referral.

Alveolar approach

  • If object is between the intact sinus lining and the mucosa/bone
  • Aspiration and good lighting
  • Suture and close defect

Trans-alveolar approach

  • If the object is just into the sinus
  • Can try flushing the sinus with saline and aspirating/using tweezers
  • Or buccal flap raised and OAC visualised/widened/explored and object removed that way. But will need to close and repair the surgical site.

Caldwell Luc

  • Buccal flap above premolars raised
  • Window into the sinus (anterior approach/like from the cheek)
  • Irrigate and debride sinus and remove the object
  • Close with a membrane and seal everything
  • Need GA and surgeon, can cause loss of vitality to teeth and complications e.g. nose bleed, fistula,
  • But get direct visualisation and preserves alveolar bone

Functional endoscopic sinus surgery FESS (ENT)

  • Nasal approach, minimally invasive
  • Can’t be used if the object is too far posteriorly or too large, time consuming and difficult
  • Complications = CSF leak, infection, bleeding
91
Q

Fractured tuberosity - risk factors and clinical signs

A

RF = long roots, divergent roots, bulbous roots, ankylosed roots. Pneumatised sinus, lone-standing tooth, age, operator excessive force and poor technique e.g. not supporting alveolar ridge, too much elevation.

Signs = blanching of palatal mucosa, movement of the alveolar ridge, tearing of mucosa, bleeding (greater palatine artery - need to be careful!). Might get an OAC.

92
Q

Management of a fractured tuberosity (if still attached to periosteum)

A

Stop, inform patient, consent

  1. Rigid splinting of the tooth to a neighbouring tooth
  2. Decorinate the tooth and leave the roots in the bone while it heals
  3. If small piece of tuberosity, can dissect it off the periosteum and then smooth and suture everything

POIG and rebook in 2 months to surgically extract the tooth.

93
Q

Management of a fractured tuberosity (if not attached to periosteum)

A 
Remove segment
Smooth remaining bone
Manage any OAC
Suture everything closed
POIG and review
94
Q

Creating more vertical height for implants - surgical techniques [3]

A

Direct sinus lift

  • Implant placed and pushes sinus lining up a bit but doesn’t pierce it
  • Bone graft is placed around the implant to create new bone

Lateral sinus window
- Lateral window into the sinus, then lift lining and place bone chips + GTR to create new bone.

Trapdoor technique
- Bone section moved up (+ sinus membrane) and bone graft material is placed under it + GTR

95
Q

Acute sinusitis

A

2 weeks, self-limiting
Bacterial or viral
Symptoms = discharge, pressure in the face, worse when bending, tender, congestion
Manage = antibiotics if bacterial, decongestants

96
Q

Chronic sinusitis

A

Needs antrum rinse and surgery
CBCT/OPT to rule out neoplasms or cysts
ENT referral
- Need to check antrum lining thickness and fluid levels

97
Q

Unerupted teeth - causes

A

Physical obstruction e.g. cyst, supernumerary, neoplasm
Lack of space - crowding, ectopic/impacted, micrognathia, premature loss of primary

Syndromes = Gardener’s, cleidocranial dysplasia (supernumerary, hypoplastic maxilla, Pierre Robin (retrognathia, floppy tongue, crowding)

98
Q

Which teeth are most commonly unerupted

A

8s
Maxillary canines
5s
Maxillary incisors

99
Q

Surgical transplantation of unerupted teeth

A

Last resort
Pre-assessment = is there enough vertical space, bone and alveolar space
Post-assessment = monitor for loss of vitality of tooth

100
Q

Problems associated with 3rd molars [10]

A 
Cheek/tongue biting
Caries and PAP or in the 7s
Periodontal disease
Pericoronitis
Altered occlusion
Crowding 
Cysts
Get in the way of orthognathic surgery
Make OH harder
Root resorption
101
Q

Pericornitis signs/symptoms

A

Aching, tender, bad taste/discharge, lymphadenopathy, trismus

Red inflamed peri-coronal tissues, possibly signs of infection, debris, systemic signs e.g. lymphadenopathy, malaise

102
Q

Pericoronitis management

A

Clean pockets w saline or chlorhexidine
Give OHE
Antibiotics if systemic signs - metronidazole
Can remove peri-coronal tissues, XLA, reduce the opposing tooth, extract the opposing tooth,

103
Q

NICE guidelines for surgical removal of third molars

A

Only remove if signs of pathology inc recurring or severe pericoronitis.
Plaque is a risk factor, but not an indication for extraction

104
Q

Prophylactic removal of third molars

A

Cochrane review = no evidence for benefits of prophylactic extractions vs leaving them in terms of clinical and cost.

105
Q

Steps to surgical removal of third molars [6]

A

Pre-assessment radiograph - 1/4 OPT or PA

  • to locate the tooth and determine angulation
  • mesial or horizontal impaction is easiest to resolve
  • distal impaction causes pericoronitis and extraction is more difficult
  • Buccal/lingual angulations are the most difficult
  • to see proximity to IAN - CBCT
  • anticipate any problems e.g. OAC
  • surrounding bone, crown, root anatomy (fused, curved, divergent) and any pathology (cysts, infection, external resorption)
106
Q

Treatment options for impacted third molars

A

Monitor
Coroenectomy
Extract under GA, LA, Sedation

107
Q

Coronectomy of third molars

A

For when you can’t remove the root due to proximity to IAN, MRONJ/ORN risk, medically compromised

Leave apical 3mm of root
Buccal flap (to avoid lingual nerve)
Incision of the tooth at 45 degrees (to avoid lingual nerve and reduce mobility)
Cover root and suture
POIG
108
Q

Complications of third molar removal (minor)

A 
Pain, bleeding, bruising, infection, dry socket, swelling
Damage to adjacent teeth
Mandibular fracture (if large radiolucency/pathology/thin bone/bone pathology)
OAC
Tuberosity fracture
Fractured tooth
Subsequent surgery
Trismus
TMD
109
Q

Complications of third molar removal (major)

A

IAN/lingual nerve damage = temporary or permanent loss of or altered sensation to lip, tongue, chin on that side.

110
Q

What can cause IAN/lingual nerve damage

A

Lingual flaps
Instrumentation in the wrong place, excessive force, slipped
Not anticipating where the nerve will be

Trauma
Needlestick or injecting directly into nerve
Articaine as IDB
Implants
Soft tissue injury
Surgery
111
Q

IAN/lingual nerve damage impact on patient

A

Dysthesia, paraesthesia
Tingling, burning, pain or numbness
To lower lip, chin, tongue, floor of mouth
Can’t eat, speak properly, dribbling, keep biting lip/tongue

112
Q

Lingual nerve injuries - causes, prevention and management

A

Lingual flaps, retraction - avoid
Cut out the damaged section and direct repair of the nerve by suturing the other 2 ends together (repositioning).
Dexamethasone and antibiotics
Measure outcome with soft, pin prick nerve tests
Usually get some sensation back

113
Q

IAN nerve injuries management

A

Control bleeding by temporary gauze packing and avoid surgicel
Surgical if no improvement or pain
- Decompress nerve e.g. remove any bony or soft tissue attachments to free the nerve more

114
Q

Management pathway for nerve damage during removal of lower third molars

A
  1. Manage lingual in the practice
  2. Review appointment - if complete numbness, refer to a specialist. If not, wait some 1 month but inform the patient of what’s happened and do nerve test to monitor.
  3. In 1 month, if no improvement = referral
115
Q

Common causes of facial trauma

A

Road-traffic accidents, fights, sport-related injuries

116
Q

ATLS for facial trauma

A

Advanced trauma life support - ABCDE

117
Q

ABCDE

A

Airway - and C spine - jaw thrust if worried about the neck. Maintain airway and spine.
Breathing - give 02, but type 2 failure is when they’re holding onto their CO2 which oxygen won’t fix.
Circulation - high pulse and low breathing rate means they’re bleeding
Disability e.g. Glasgow coma scale, neurological damage
Exposure/everything else

118
Q

Soft tissue injuries

A 
Laceration - rupture of tissue due to trauma
Abrasion
Incision - sharp margins
Soft tissue loss
Special tissue injury e.g. eyes
119
Q

Bone healing

A
  1. haemostasis and inflammation
  2. chondrocytes make a fibro-cartilage callus, new blood vessels and trabecular start forming
  3. Ob make a bony callus
  4. Extra blood vessels and tissue removed = remodelling into final form
120
Q

Problems with bony healing

A 
Malunion
No union
Hyperplastic
Atrophic
Necrotic
Healing with a defect
121
Q

Types of bone fractures

A

Simple - 1 break
Comminuted - broken into several fragments
Compound - communicated with outside
Displaced or non-displaced

122
Q

Fractured mandible signs/symptoms

A 
Gormless look
Mouth open/anterior open bite - locked
Step defect where the fracture is 
Altered occlusion
Lacerated soft tissues
Dysthesia 
Gaps between teeth
Swelling, pain, bruising, bleeding
SUBLINGUAL HAEMATOMA = diagnostic
123
Q

Principles of management of a fractured mandible

A

Open or Closed

Reduction +/- fixation

124
Q

Types of fixation

A

Closed

  • screws into jaw = scarring looks bad, infection
  • Intermaxillary fixation (but can’t clean teeth = perio/caries and very uncomfortable)

Open = surgical

  • Load-bearing (takes all the weight off bones)
  • Load sharing (shares weight with the bones)
  • Flexible or rigid (flexible puts more weight on the bones and lets them move a bit like normal)
125
Q

Champy’s lines

A

Lines of tension in jaw - place plates here to support it

Butterfly fracture of the jaw is one that follows all of Champy’s lines

126
Q

Le fort fractures

A

1 - maxilla separated from the base of the skull
2 - orbital floor and nose involved
3 - the top third of the face e.g. top of the nose and lateral orbital walls.

127
Q

Le fort 2 fracture - signs/symptoms

A 
Gormless
Anterior open bite/locked
Trismus
Step deformity/deranged occlusion
Paraesthesia
Palate/soft palate step, laceration
Odd percussion of upper teeth
Gaps
Soft tissue lacerations
Lengthened face
128
Q

Zygoma fractures - signs/symptoms

A

Flattened face - view from above
Trismus/can’t open bc condyle can’t move
Infraorbital paraesthesia, haematoma, step
Eye signs

129
Q

Nasal fractures - signs/symptoms

A

The eyes/socket can drift apart if the bit in the middle is completely broken = panda eyes
Nosebleeding
Can get CSF leak

130
Q

Frontal sinus fractures - signs/symptoms

A

Flattened forehead/dent

Can communicate with brain so needs fixing asap

131
Q

Glasgow Coma Scale

A

Rate patients depending on their motor, verbal and eye responses e.g. if they can talk, move and open their eyes like normal

132
Q

Management of a compound fracture

A

In anterior mandible/tooth bearing areas - all fractures will be compound bc of PDL space
Give antibiotics e.g., co-amoxiclav

133
Q

Why do we give IV antibiotics w facial trauma

A

Works quicker
Patient can’t eat or drink before surgery
Probably can’t eat or drink if fractured facial bones

134
Q

Management of mandible fracture

A
  1. Admit to ward
  2. IV analgesia and antibiotics
  3. Open or closed reduction +/- fixation (or conservatively e.g. splinting/wiring)
  4. POIG - liquid diet for 6 weeks, gradually introduce soft foods, post-tx course of co-amoxiclav.
  5. Weekly reviews
135
Q

Imaging to take with facial trauma (mandible fracture)

A

Plain film images e.g. antero-posterior plane PA mandible or OPT (for the condyles).
Need at least 2 planes to confirm and check for other fractures and for parallax.
Others = CT, MRI
CT for condylar fracture

136
Q

Tests for mandibular fracture

A

Imaging
Sublingual haematoma
Compression tests
Bite strength w CWR

Oral medicine (4 decks)

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