Theme 3 - Principles of Oral Surgery Flashcards
What are the surgical principles?
- Pain free surgery
- Aseptic technique
- Prevention of infection
- Wound closure
- Drainage
- Arrest of haemorrhage
- Debridement
- Adequate access
- Minimal damage
How can you control bleeding peri-operatively?
- LA with vasoconstrictor
- Bone wax
- Electrocautery e.g. bipolar or chemical cautery e.g. silver nitrate
- Haemostatic pack e.g. gelita-cel/surgicell
- Tie vessel/suture
How can you control bleeding post-operatively?
- Pressure
- Transexamic acid
- Replace blood loss
What may be removed during debridement of a wound?
Necrotic, infected or foreign material e.g. loose bone, ST pathology/granuloma
What can you close a wound with?
What is the criteria for wound closure?
Suture, Staples, Glue
- Close in layers if deep
- Ensure support
- Close approximation of wound edges
- Tension free
What are the stages of infection?
1) Inoculation and acute inflammation 0-3days = soft swelling, pus from apex of tooth through cancellous bone and cortical plate
2) Cellulitis 3-7 days = hard erythematous swelling, painful and warm to touch
3) Abscess >5days = undermines skin or mucosa making it compressible and shiny
If tissue fluid from cellulitis was drained what would it look like?
Serosanguineous fluid with flecks of pus
What is sepsis and what is released?
A life-threatening organ dysfunction caused by a dysregulated host response to infection.
Release of mediators: NO, Bradykinin, Histamine, Prostagladins, endotoxins
What is septic shock?
Profound circulatory, cellular and metabolic abnormalities with a greater mortality than sepsis alone. No hypovolaemia (circulatory vol okay).
What is the quick Sepsis Related Organ Failure Assessment (qSOFA)?
GCS < 15 (dropped by more than 1)
RR >/= 22
Systolic BP </= 100
If more than 2 of these that are not pre-existing it is a positive screen
What are the 7 red flags of sepsis?
Respiratory rate >25
Serum lactate >2
Heart rate >150
V or less on AVPU
Systolic BP <90
Purpuric rash
O2 require to keep SaO2 >90%
What is the treatment of sepsis (Sepsis 6)?
Give:
- Fluids (maintain circulatory volume to maintain BP)
- Oxygen (Target sats 94-99%)
- Antibiotics
Take:
- Cultures
- Lactate (predicts mortality)
- Fluid balance
Localise and manage source of infection
What are the worrying features affecting the airway from an odontogenic infection?
- Voice (hot potato voice as oedema around glottis or back of oral cavity)
- Swallowing or drooling (narrowed oropharynx = descending oedema / infection)
- Tongue position (up and forwards)
- FOM palpation (hard or raised)
What are the worrying features affecting the eyes from an odontogenic infection?
If spreading towards mesial canthis - angular veins of the globe link directly to cavernous sinus and have no valves so bacteria spreads easily
How can you check a patients systemic wellbeing from an odontogenic infection?
Temp, pulse and RR
What is Ludwigs Angina?
Bilateral submandibular and sublingual cellulitis. Tongue lifts, oedema of glottis as it spreads through lateral pharyngeal space to larynx
What is the treatment of Ludwigs Angina?
Bilateral through and through drains
How can an infection spread intracranially?
1) Sinuses (nasal)
2) Angular veins of medial canthus
3) Pterygoid plexus
4) Direct via fascial planes or base of skull
What are the worrying signs and symptoms of intracranial spread of an infection/ cavernous sinus thrombosis?
- Altered conscious level (GCS)
- Spread towards eye causing proptosis (bulging), opthalmoplegia (unable to close eye), or ptosis (drooped eyelid)
How can infection spread into the cavernous sinus?
What structures does it contain?
Via angular veins as no valves
CN III, IV, V1, V2, V ganglion, VI, internal carotid artery
What are the signs and symptoms of a mediastinal infection?
- Pleuritic retrosternal chest pain radiating to neck or between shoulder blades
- Spreading erythema down sternal notch
- Crepitus: chest or neck
- Hammar sign (crunching sound on auscultation of heart)
- Radiographs (CT)
How can odontogenic infection spread to a mediastinal infection?
Rare. Pretracheal fascia, deep cervical fascia or lateral pharyngeal spaces
How can an odontogenic infection spread by lymphatics?
First into superficial LNs:
- Submental = from FoM, tip of tongue, lower lip and chin
- Submandibular = from face, cheeks, upper lips and ant. 2/3 tongue
These drain into deep cervical LN along internal jugular vein
What are the main functions of fascia?
- Support of structures
- Pathways for neurovascular structures
- Facilitate movement - rigid structure for sliding
- Mechanical protection of structures
- Circulatory function - promote venous drainage through maintaining shape of structures
What is tissue space?
Areas defined by fascial layers. Normally occupied by loose connective tissue which can be destroyed by bleeding, tumours, hyaluronase, collagenase and the ‘space’ is revealed
Why would you get a palatal abscess from an upper lateral incisor?
Apex of this tooth most palatal than any other (except palatal root of 6)
How can you predict if an abscess will present intra or extra orally?
Governed on buccal side by buccinator:
- Below = extra
- Above = intra
Governed on lingual side by mylohyoid:
- Below = extra
- Above = intra
If there is poor host resistance where can an infected wisdom tooth spread?
Tracks up coronoid process
In what tissue space would there be profound trismus?
Submasseteric space
When draining an abscess by an incision through the skin, how would you make the cut and why?
2cm below inferior border of mandible. Ensures you are away from mandibular branch of facial nerve (1981 rule ie 19% run below, 81% on border).
Then put finger in wound, break lobuse of pus and corregated drain sewn in.
The maxillary sinus:
a) What is it lined with?
b) What happen with age?
c) What are its functions?
a) Respiratory epithelium - cilia for drainage against gravity
b) Pneumatises (increases in size)
c) Respiration - humidifies air before it reaches the lungs, lightening of skull, speech- resonance
What is a communication?
What is a fistula?
Communication = hole between oral cavity and sinus
Fistula = communication unreated, tract epithelialises over 7-10days
How do you diagnose an OAC?
- Immediately after extraction or when elevating a root and it disappears
- Observation of bubbling of saliva and no bone in socket
- Radiograph
- Do not force nasal expiration (mucosal lining may prolapse into mouth) and do not probe
How do you conservatively manage an OAC?
- Inform pt
- No nose blowing for 2 weeks and sneeze with mouth open
- OHI to avoid infection, salt water rinse and soft toothbrush
- Nasal decongestants to reduce sinusitis (ephedrine 0.5%)
- Steam inhalations
- Broad spectrum antibiotics e.g. amoxicillin
- Review healing
How is an OAC managed with a splint?
2 weeks without removal to prevent fluid and food passage between mouth and sinus (infection risk) and to prevent a fistula forming.
Don’t get alginate stuck in sinus - place small piece damp gauze over socket
How is an OAC managed with a buccal advancement flap surgery?
3 sided buccal mucoperiosteal flap raised, underlying periosteum released with scalpel, flap place across socket onto bone without tension and sutured. For better closure: 2 layer closure with buccal fat pad
If a fistula has formed and is being surgically managed, what must be done first?
Must be excised by running scalpel blade around and debriding it from socket. Otherwise fistula reforms.
How is an OAC managed with a palatal advancement flap surgery?
Keratinsed mucosa raised incorperating vessels, and rotated and sutured. Leaves areas of palate without mucosa which heals by secondary intention, aided with a coverplate and co-pack.
What pathologies can affect the maxillary sinus?
- Infection from sinus or abscess
- Radicular cysts or keratocysts can raise and displace lining of sinus
- Tumour (SCC erodes walls of sinus)
- Fibrous dysplasia - abnormal bone growth and replaced with fibrous tissue, ground glass radiograph
- Pagets - multisystem, chaotic remodelling of bone leading to swelling, cotton wool radiograph
How is an extreme OAC or cleft palate repaired with a tongue flap?
Done on a pedicule to maintain blood supply while mucosa revascularizes. Flap sutured to palate and left attached for 4 weeks before release
What types of fractures can affect the maxillary sinus?
- Sinus wall fracture (no intervention if butresses intact)
- Zygoma fractures
- Orbital floor fracture (Orbital contents displaced into roof of sinus - enophthalmos, restriction of eye movement and double vision)
- LeFort fractures
What are the 2 approaches for surgically removing a root that has displaced into the maxillary sinus?
1) Through the socket - raise a buccal flap, remove bone from base of socket to widen hole, artery clip or flush with saline
2) Caldwell-luc - enter sinus higher up bucally behind canine eminence, window of bone cutout of sinus wall. Better access less likely to cause fistula as margins of defect away from flap. Under GA and second line.
What is the procedure of a maxillary sinus lift?
Buccal window into bone, sinus lining elevated creating mucoperiosteal pocket. Bio-oss packed. Bio-guide placed to prevent ST infiltration when healing. For implant placement if floor of sinus low.
What would a pt be C/O if they present with sinusitis?
Pain on bending forwards and generalised toothache posteriorly. Discharge/bad taste. Nasal blockage or congestion. Reduced sense of smell
What are the causes of sinusitis?
If dental extraction can remove. Foreign body. Reduced drainage
What is the treatment of sinusitis (NICE) if lasted more than 10 days?
Consider high dose nasal corticosteroid for 14 days.
Antibiotics:
1st = phenoxymethylpenicillin 500mg 4x day for 5 days
1st if systemically very unwell = co-amoxiclav
If allergy to penicillin = Doxycline or clarithromycin
If pregnant and penicillin allergy = erythromycin
What is the treatment of sinusitis (NICE) if lasted 10 days or less?
No antibiotic
Give advice on self care - ibuprophren, nasal decongestants, steam, warm facepack
Seek help if become systemically unwell or no improvement after 3 weeks
Why might LA fail?
- Poor operator technique
- Pharmaceutical reasons e.g. expiry date, improper storage
- Treatment reasons e.g. cons vs endo
- Anatomical reasons
- Pathological reasons
- Psychological reasons
What is the effect of depositing LA quickly?
LA diffuses over larger area so lower concentration
What is the difference between articaine and lidocaine?
Articaine better at diffusing though bone - chemical structure and higher concentration (3.81x more effective)
But no difference in effectiveness with IANB and increased risk of nerve damage with articaine so always use lidocaine for blocks
What anatomical structures may be a barrier to LA diffusion?
1) Dense cortical bone e.g. mandible
2) Zygomatic buttress around upper 6s - inject mesial/distal to buttress or articaine to overcome
3) PDL - difference in number of perforations in socket walls, fewer in lower incisor region
If you think the position of the foramina is why the LA has failed, where are the
a) Mandibular foramen
b) Mental foramen
most likely to be?
a) Higher
b) should be below second premolar but can be forward or back. Palpate with finger but don’t inject
Why do IANB have higher success rate with posterior teeth?
Coring - has to diffuse futher for anterior and more accessory nerves anterior
What are the cross over innervations of the
a) Maxilla
b) Mandible
a) greater palatine nerve and nasopalatine nevre
b) Auriculo temporal, long buccal, nerve to mylohyoid, lingual, cervical
Why is an inflamed pulp 8x more likely to fail with LA?
Alteration of tissue pH
Increased vascularity so loss of LA
Loss of LA via draining sinus
Hyperalgesia
What supplementary technique can be used when LA fails?
Intraligamentary, intrapapillary, intraosseous
What is the last LA technique you should try if all else fails in a) Maxilla b) Mandible?
a) Superior alveolar nerve block
b) Akinosi/gow gates
What is the technique for a Gow’s Gates?
Get pt to open mouth wide, line up angle of mouth to intra-tragal notch. Insert below palatal cusps of upper 7
What is the technique for an Akinosi-Vazirani?
