Teeth abnormalities, TMD, cleft lip, surgery Flashcards
contraindications to orthognathic surgery
BMI >30 Bleeding problems Bisphosphinates Severe mental health issues small condyles/TMJ problems increase risk of relapse
Steps to orthognathic surgery
[4]
- Joint clinic and facial planning
- Pre-surgery ortho (2yrs)
- Surgery
- Post-surgery ortho (6months)
What is involved in pre-orthoganthic surgery orthodontics
- Extractions
- Remove dental compensation (anterior teeth) - will make class 3 and 2 patients look worse
- close gaps and align teeth
- coordinate arch widths
- level the arches
- place rigid fixation wires
What is involved in post-orthoganthic surgery orthodontics
Elastics and fixed wires used to close the gaps between the arches and secure everything in place in the new ICP.
Different orthognathic surgery techniques - list
- Bilateral sagittal split osteotomy
- Le Fort 1 osteotomy
- surgically assisted rapid maxillary expansion SARME
- Genioplasty
what is the risk of numbness to the lower lip after orthognathic surgery
30-40% permanent
How is cleft lip/palate caused
lack of mesenchyme or failure to fuse in vitro
Cleft lip and palate aetiology
Genetic + environmental
Genetic - 40% FH
Environmental - nutritional deficiency, anaemia, alcohol, smoking, obesity, anti-convulsant medication
What is a subcutaneous cleft palate/signs
translucent/blue area, bifid uvula, eating problems - where the mucosa is normal but overlying a cleft palate
Most common cleft/lip palate presentations
50% Cleft lip and palate
30% Cleft palate
20% Cleft lip
Syndromes/disorders associated with cleft lip/palate
Van der Woude
Pierre Robin
Stickler
Foetal alcohol spectrum
Pierre robin syndrome
Cleft palate, floppy tongue, mandibular retrognathia = Difficulties eating and breathing = nasopharnygeal and feeding tubes.
Can be associated with Sickler syndrome.
Stickler syndrome
Connective tissue disorder causing cardiac and retinal problems - associated with Pierre Robin sequence and cleft plate
Van der Woude syndrome
Cardiac problems, cleft palate, invaginations in lip, hypodontia
Foetal alcohol spectrum disorder
small head, low body weight, learning difficulties, coordination problems, cleft lip and palate
Neonatal cleft lip/palate management inc surgery details
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
Young cleft lip/palate children management
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
Speech therapy for cleft lip/palate patients
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
Hearing tests for cleft lip/palate patients
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.
Cleft lip/palate older children management
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.
GDP considerations when managing cleft lip/palate patients
- High caries risk
- Limited access
- Multiple appointments with other health care professions
- other syndromes and complex MH
Bone involved in the TMJ
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)
Muscles of mastication + accessory muscles
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
Normal movement of the TMJ
- Hinge movement - Rotates in mandibular/glenoid fossa
- 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.
Opening movement of the TMJ and muscles involved
35-50mm
Muscles
- Geniohyoid
- Digastric
= pull chin backwards and down = hinge movement
- Lateral pterygoid muscle pulls articular disc (and joint) = translation
Closing movement of the TMJ and muscles involved
Temporalis - pulls condyle back
Masseter
Medial pterygoid
- elevate the mandible
Protrusive movement of TMJ and muscles involved
10mm is normal
Symmetrical forward translation of condyles
- lateral pterygoids
Retrusion = temporalis
Lateral excursion movement of TMJ and and muscles involved
10mm is normal
Unilateral contraction of lateral and medial pterygoids on the ipsilateral side (lateral for opening, medial for closing)
Types of TMD
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)
Common TMD’s - different types
- 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
Myalgia and different types
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
Arthralgia
Joint pain
Disc disorders
- 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)
Disc displacement 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 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
Disc displacement with reduction and intermittent locking
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
Disc displacement without reduction (w/ limited opening)
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.
Disc displacement without reduction, without limited opening
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?)
Degenerative joint disease of TMD
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
Hypermobility and subluxation of TMD
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 .
Headache due to TMD
Due to temporalis muscle
- Palpate, movement tests
Information to get when taking a TMD history from patient
LOCK - Locking - Limited opening - Occlusal disturbances - Clicking/crepitus Pain history Recent dental work Trauma Parafunction/habits Neurological signs
Past medical considerations for TMD [5]
Joint or bone disorders e.g. arthritis, osteoporosis New medications History of cancer Trauma history Mental health Fibromyalgia or hypermobility syndromes
Extraoral exam for TMD [8]
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
Intraoral exam for TMD [3]
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
Red flags for TMD
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
Causes of TMD - predisposing, initiating, precipitating
Predisposing = Systemic condition, macrotrauma e.g. third molar removal,
Initiating = Microtrauma, strain, abnormal occlusion
Precipitating = Mental health, bruxism, para-function
Investigations for TMD (and pros/cons)
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.
Principles of management of TMD (and types of management)
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
Education for treating TMD
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
Physical therapy for treating TMD
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
Splint therapy for treating TMD - principles/requirements
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
Types of splints for treating TMD
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
Medication for treating TMD
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
Botulinum toxin for treating TMD
Botox - Botulinum toxin injected into muscles to reduce their activity e.g. for hypertrophic or parafunction.
But it is temporary
Blocks SNAP25
Arthrocentesis for treating TMD
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.
Arthroscopy for TMD
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.
Surgery for treating TMD
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
Uncommon TMJ disorders
Arthritis Neoplasms Growth disturbances Trauma - fracture w/o displacement can heal on its own - w displacement needs plating.
Persistent dislocation treatments
Due to hyper mobility e.g. Ehlers Danlos
Physio to strengthen the muscles that keep Condyle in place
Or Botox
Surgical - reposition articular eminence
Osteoarthritis of TMD
Degenerative joint disease - more symptoms if more trauma to the joint.
Symmptoms = pain, crepitus, erosions on rads, limited opening.
Needs a CT
Infective arthritis of TMD
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
Trismus diagnosis, causes and management
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
Anatomy of the TMJ
- bones
- movement
- disc
- muscles
- ligaments
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
When would you do orthognathic surgery
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
IOFTN
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
Stage 1 orthognathic surgery - facial planning
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
Orthognathic surgery - types of surgical procedures/details
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.
Post-orthognathic surgery orthodontics
3-6 months
Fixed wires and elastics are used to secure the teeth position and close any gaps between the arches
Anaplastology definition
Artificially replace a missing part of the body
e.g. using implants, obturator,
Obturators after resective/cancer surgery
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
Keloid scars
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
Extraoral implants
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
Describing/classifying cleft lip and palate
LAHSHAL
Uppercase = complete
Lowercase = incomplete
L = lip A = alveolus H = hard palate S = soft palate
Management of cleft lip and palate patients - adults
Can still get referred for treatment even if have been lost from the system
Dental abnormalities in cleft lip/palate patients and management
Hypodontia Hypoplastic enamel Ectopic/displaced teeth Microdontia Fused teeth Poor OH
Normal anatomy/histology of maxillary antrum
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)
Functions of the maxillary antrum
Mucus
Lighten the skull
Humidify and warm the air
Resonance of voice
What is an OAC
Communication between the mouth/oral cavity and maxillary sinus
OAC vs OAF
A fistula is lined with epithelium e.g. an established passage.
7+ days
Risk factors for an OAC
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
Clinical/rad signs and symptoms of an OAC (during XLA and post-op)
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
Management of OAC
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.
POIG for OAC
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
Surgical repair techniques for an OAC [5]
Buccal advancement flap \+/- Buccal fat graft Palatal rotational flap Modified palatal technique Bone grafting
Buccal advancement flap for an OAC
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
Palatal rotational flap for an OAC
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.
Buccal fat pad graft for an OAC
Buccal fat graft taken and placed over the defect, then buccal advancement flap used
For big defects or delayed closure
Management of an OAF
Remove lining and pack with surgicel, then place xenograft membrane to aid healing (GTR?)
Foreign object displacement into sinus
+ how to diagnose
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.
Management of foreign object displacement into sinus [4]
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
Fractured tuberosity - risk factors and clinical signs
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.
Management of a fractured tuberosity (if still attached to periosteum)
Stop, inform patient, consent
- Rigid splinting of the tooth to a neighbouring tooth
- Decorinate the tooth and leave the roots in the bone while it heals
- 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.
Management of a fractured tuberosity (if not attached to periosteum)
Remove segment Smooth remaining bone Manage any OAC Suture everything closed POIG and review
Creating more vertical height for implants - surgical techniques [3]
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
Acute sinusitis
2 weeks, self-limiting
Bacterial or viral
Symptoms = discharge, pressure in the face, worse when bending, tender, congestion
Manage = antibiotics if bacterial, decongestants
Chronic sinusitis
Needs antrum rinse and surgery
CBCT/OPT to rule out neoplasms or cysts
ENT referral
- Need to check antrum lining thickness and fluid levels
Unerupted teeth - causes
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)
Which teeth are most commonly unerupted
8s
Maxillary canines
5s
Maxillary incisors
Surgical transplantation of unerupted teeth
Last resort
Pre-assessment = is there enough vertical space, bone and alveolar space
Post-assessment = monitor for loss of vitality of tooth
Problems associated with 3rd molars [10]
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
Pericornitis signs/symptoms
Aching, tender, bad taste/discharge, lymphadenopathy, trismus
Red inflamed peri-coronal tissues, possibly signs of infection, debris, systemic signs e.g. lymphadenopathy, malaise
Pericoronitis management
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,
NICE guidelines for surgical removal of third molars
Only remove if signs of pathology inc recurring or severe pericoronitis.
Plaque is a risk factor, but not an indication for extraction
Prophylactic removal of third molars
Cochrane review = no evidence for benefits of prophylactic extractions vs leaving them in terms of clinical and cost.
Steps to surgical removal of third molars [6]
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)
Treatment options for impacted third molars
Monitor
Coroenectomy
Extract under GA, LA, Sedation
Coronectomy of third molars
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
Complications of third molar removal (minor)
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
Complications of third molar removal (major)
IAN/lingual nerve damage = temporary or permanent loss of or altered sensation to lip, tongue, chin on that side.
What can cause IAN/lingual nerve damage
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
IAN/lingual nerve damage impact on patient
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
Lingual nerve injuries - causes, prevention and management
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
IAN nerve injuries management
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
Management pathway for nerve damage during removal of lower third molars
- Manage lingual in the practice
- 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.
- In 1 month, if no improvement = referral
Common causes of facial trauma
Road-traffic accidents, fights, sport-related injuries
ATLS for facial trauma
Advanced trauma life support - ABCDE
ABCDE
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
Soft tissue injuries
Laceration - rupture of tissue due to trauma Abrasion Incision - sharp margins Soft tissue loss Special tissue injury e.g. eyes
Bone healing
- haemostasis and inflammation
- chondrocytes make a fibro-cartilage callus, new blood vessels and trabecular start forming
- Ob make a bony callus
- Extra blood vessels and tissue removed = remodelling into final form
Problems with bony healing
Malunion No union Hyperplastic Atrophic Necrotic Healing with a defect
Types of bone fractures
Simple - 1 break
Comminuted - broken into several fragments
Compound - communicated with outside
Displaced or non-displaced
Fractured mandible signs/symptoms
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
Principles of management of a fractured mandible
Open or Closed
Reduction +/- fixation
Types of fixation
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)
Champy’s lines
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
Le fort fractures
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.
Le fort 2 fracture - signs/symptoms
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
Zygoma fractures - signs/symptoms
Flattened face - view from above
Trismus/can’t open bc condyle can’t move
Infraorbital paraesthesia, haematoma, step
Eye signs
Nasal fractures - signs/symptoms
The eyes/socket can drift apart if the bit in the middle is completely broken = panda eyes
Nosebleeding
Can get CSF leak
Frontal sinus fractures - signs/symptoms
Flattened forehead/dent
Can communicate with brain so needs fixing asap
Glasgow Coma Scale
Rate patients depending on their motor, verbal and eye responses e.g. if they can talk, move and open their eyes like normal
Management of a compound fracture
In anterior mandible/tooth bearing areas - all fractures will be compound bc of PDL space
Give antibiotics e.g., co-amoxiclav
Why do we give IV antibiotics w facial trauma
Works quicker
Patient can’t eat or drink before surgery
Probably can’t eat or drink if fractured facial bones
Management of mandible fracture
- Admit to ward
- IV analgesia and antibiotics
- Open or closed reduction +/- fixation (or conservatively e.g. splinting/wiring)
- POIG - liquid diet for 6 weeks, gradually introduce soft foods, post-tx course of co-amoxiclav.
- Weekly reviews
Imaging to take with facial trauma (mandible fracture)
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
Tests for mandibular fracture
Imaging
Sublingual haematoma
Compression tests
Bite strength w CWR
