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oral surgery 4th year > third molars summary > Flashcards

third molars summary Flashcards

1
Q

eruption

A
  • approx 18-24yrs, varies
  • may still be present and begin to erupt in elderly/edentulous pt
    CO denture rocking/no longer fits
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2
Q

crown and root calcification

A
  • crown: begins 7-10yo, completed by 18yo
  • root: completed btw 18-25yo
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3
Q

stats of missing

A
  • at least 1 missing in 25% adults
  • maxilla
  • female
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4
Q

guidance and their summary

A

SIGN 43 2000 - must justify the need of surgical removal
NICE 2000 - discourage removal unless pathology assoc.

most up to date (currently in use):
FDS RCS 2020 (Faculty of dental surgery, royal college of surgeons) - change from soley therapeutic approach to mixed intervention

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5
Q

nerves at risk during SR L8s

A

lingual
IAN
mylohyoid and long buccal - less common and effects less obvious

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6
Q

location of lingual n

A

varies

  • lies on superior attachment of mylohyoid muscle
  • at level of lingual plate in 15-18%
  • 0-3.5mm medial to mandible
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7
Q

impacted meaning

A

tooth eruption is blocked
- full/ partial functional position

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8
Q

incidence of impacted lower third molar

A

around 50%

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9
Q

consequence of impaction

A
  • caries
  • periconronitis
  • cyst formaiton
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10
Q

U removal indications

A 
cheek biting/buccally erupted
overeruption
traumatising L operculum
PE and impacted
non-fct
pt undergoing GA
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11
Q

therapeutic indication of wisdom extraction

A
  • caries (8/7)
  • pericoronitis
  • periodontal disease (7d)
  • local bone infection
  • Dentigerous cyst
  • tumours
  • external root resorption of 7/8
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12
Q

SIGN vs NICE

A

SIGN - ≥1 episode of infection

NICE >1

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13
Q

imaging

A

OPT
(+/- PA)
+/- CBCT (3D relationship to nerve)

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14
Q

clinical assessment of M3M

A

eruption status - how many cusps seen
PD status - pockets distal to 7?
TMJ - rule out TMJ, similar pain to pericoronitis
exclude other causes
local infection
caries/resorption
occlusal relationship
regional LNs
any associated pathology
degree of surgical access
working space
STs

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15
Q

Types of imapction

A

- plus transverse (buccal / lingual)
- aberrant ( in odd place)

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16
Q

working space

A

distance between L7 and ascending ramus

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17
Q

radiological assessment

A
  • orientation and position (impaction)
  • impaction depth
  • relationship to IDC/MS

follicular width
working distance
crown - size, shape, caries
roots - number, morphology, apical hooks
bone levels
adjacent tooth
any surrounding pathology
- dentigerous cyst
- loss of bone distal to crown

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18
Q

when to consider when follicle turning to dentigerous cyst?

A

if follicle > 3mm (5mm)size
if >10mm can assume is cyst

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19
Q

3 key radiographic signs of M3M - possible increased risk to IAN

A

diversion/deflection of canal
darkening of root where crossed by canal
interruption of tram line / lamina dura of canal

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20
Q

8 radiographic signs of possible increased risk to IAN - M3M removal

A

diversion/deflection of canal
darkening of root
interruption of white lines/LD of canal
deflection of root
narrowing of IDC
narrowing of root
dark and bifid root
juxta apical area?

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21
Q

juxta apical area

A

well-defined radiolucent area adjacent that isn’t related to PA pathology
can appear corticated
lamina dura round tooth intact
lateral to root rather than apex

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22
Q

what is the most common orientation of impaction? M3M

A

mesial 40%

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23
Q

what is orientation of impaction measured against?

A

the curve of spee

  • curve of occlusal plane
  • draw lines through long axis of 7 and 8 and compare
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24
Q

what are the types of depth of impaction and what does it indicate?

A
  1. superficial - 8 crown relate to 7crown
  2. moderate - 8 crown to 7 crown+root
  3. deep - 8 crown to 7 root
  • amount of bone removal required
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25
Q

why is L. disto-angular 8s difficult to extract?

A
  • bone removal required (ascending ramus dense bone)
  • vector of movement during elevation is distal so tooth has nowhere to go
  • roots of 8 often v close to roots of 7 - can make it difficult to get an application point to elevate (also care not to damage 7 roots during mesial bone removal)
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26
Q

pericoronitis definition

A
  • Inflammation around the crown of a PE tooth
  • need communication with oral cavity
    if not visible careful probing 7d for comunication
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27
Q

pericoronitis aetiology

A
  • food and debris get trapped under operculum - inflammation/infection
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28
Q

S+S of pericoronitis

A 
pain
swelling (IO or EO)
bad taste
pus discharge
occlusal trauma to operculum
ulceration of operculum
evidence of cheek biting
foetor oris
limited mouth opening
dysphagia
pyrexia
malaise
regional lymphadenopathy
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29
Q

which LNs are often raised and palpable in pericoronitis?

A

SM or upper cervical chain

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30
Q

pericoronitis EO swelling

A

severe cases

often at angle of mandible and may extend into SM region

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31
Q

spread of infection of pericoronitis

A

laterally into cheek
distobuccally under masseter (submasseteric abscess and profound trismus)
sublingual
SM
area around tonsils and paraphyaryngeal space (dysphagia)
less commonly - through anterior pillar of fauces area into SP (dysphagia)

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32
Q

tx of pericoronitis

A
  • I+D of pericoronal abscess if required +/- IDB
  • irrigation
  • warm saline in 10-20ml syringe w blunt needle
    under operculum
  • ext U8 if traumatising operculum
  • usually no ABs unless severe
    systemically unwell
    EO swelling
    immunocompromised e.g. diabetic
  • if large EO swelling, systemically unwell, trismus, dysphagia - refer to MF/A+E - phone first for advice
  • pt instructions
-  no removal of 8 until pericoronitis resolved
-  removal of periculum not recommended - will just grow back
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33
Q

pericoronitis pt instructions

A

freq warm saline or MW
- teaspoon salt warm water
analgesia
keep fluid levels up and keep eating (soft diet)

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34
Q

pericoronitis astringent/antiseptic

A

e.g. talbots iodine - applied with college tweezers - one drop beneath operculum
not if have incised a localised pus collection
not on fresh/open wounds

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35
Q

ext of L8 pericoronitis

A

generally don’t ext affected 8 until acute episode has resolved
- unless in hospital with GA for I+D - ext tooth then

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36
Q

operculectomy

A

prev

no longer carried out - often grows back

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37
Q

predisposing factors for pericoronitis

A
  • PE (usually 20-25yrs) and vertical or distoangular impaction
  • opposing maxillary 8 causing mechanical trauma contributing to recurrent infection
  • upper resp tract infections, stress and fatigue PC
  • poor OH
  • Previous episodes of pericoronitis
  • insufficient space between ascending ramus of L jaw and distal aspect of 7
  • white race
  • a full dentition
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38
Q

SDCEP pericoronitis when to send pt to hospital (emergency )

A
  • FOM swelling
  • Difficulty breathing
  • Trismus
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39
Q

SDCEP pericoronitis when to prescribe ABx

A
  • spread of infection (cellulitis / swelling)
  • systemic involvement (fever, malaise)
  • not resolved by local measures
  • symptoms or pus >7 days
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40
Q

local measures for pericoronitis

A

irrigation and debridement (US)

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41
Q

1st line ABs for pericoronitis

A

metronidazole 400mg, 3 days , x3 daily

avoid alcohol, not if on warfarin

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42
Q

2nd line Abs for pericoronitis

A

amoxicillin 500mg, 3 days, 9 capsules x3 daily

- hypersensitivity reactions

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43
Q

RCS FDS guidelines - factors regarding M3M status

A

pt age and medical status (complications and recovery)
risk of complications (IAN/leaving M3M in situ)
pt access e.g. military
opposing contralateral 8 if having GA

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44
Q

RCS FDS guidelines - diseased/high risk of disease development and asymptomatic

A

assess likelihood of disease development - high/low risk
high risk - consider surgical
if any doubt and tooth has higher risk of surgical complications - active surveillance until symptoms develop/early disease progression has been proven

quiescent pathology may inc undiagnosed 7/8:

  • caries
  • PDD
  • resorption (internal or external)
  • cysts or tumours
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45
Q

RCS FDS guidelines - diseased/high risk of disease development and symptomatic

A

consideration for therapeutic exts is indicated for:
single severe acute or recurrent subacute pericoronitis
unrestorable caries of M3M or to assist Rx of adjacent tooth
PDD compromising M3M and/or adjacent tooth
resorption of M3M and/or adjacent tooth
fractured M3M
M3M periapical abscess, irreversible pulpitis or acute spreading infection
surrounding pathology (cysts/tumours) associated w M3M

tx to be considered:

  • therapeutic removal of M3M (or coronectomy)
  • removal of U3M
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46
Q

RCS FDS guidelines - non-diseased/low risk of development and asymptomatic

A

clinical review and radiographs if indicated. Make assessment of risk of disease and review interval

factors for consideration for prophylactic removal

  • medical: planned medical tx/therapy that may complicate the likely surgery of M3Ms inc: pharmaceutical therapy (bisphosphonates, antiangiogenics, chemo), radio of HandN, immunosuppressant therapy
  • surgical: M3M lies within perimeter of a surgical field: mandibular fractures, orthognathic surgery, resection of disease (benign and malignant lesions)
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47
Q

RCS FDS guidelines - non-diseased/low risk of development and symptomatic

A

leave deeply impacted M3Ms with no associated disease
manage other diagnoses causing pain in the region
- TMD
- parotid disease
- skin lesions
- migraines or other primary headaches
- referred pain from angina, cervical spine
- oropharyngeal oncology

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48
Q

RCS FDS guidelines - main reason for removal

A

infection

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49
Q

RCS FDS guidelines - significant radiological signs of risk to IAN

A

diversion of IAN canal
darkening of root
interruption of cortical white line

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50
Q

RCS FDS guidelines - CBCT

A

not routinely
evidence it doesn’t offer benefit in reducing incidence of IAN neurosensory disturbance
- if findings expected to alter tx decision
- see if direct contact or bony wall between

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51
Q

RCS FDS guidelines - common tx

A 
referral
clinical review
removal of M3M
ext of U8
coronectomy
52
Q

RCS FDS guidelines - less common tx

A

operculectomy
surgical exposure
presurgical ortho
surgical reimplantation/autotransplantation

53
Q

RCS FDS guidelines - comment on NICE 2000

A

discouraged prophylactic removal

- but evidence this isn’t always best - delays surgery and damage to 7

54
Q

RCS FDS guidelines - why do coronectomy?

A

if close to IAN, reduce risk of injury

55
Q

RCS FDS guidelines - coronectomy risks

A

pain and infection

potential future need for removal of the roots

56
Q

RCS FDS guidelines - coronectomy contraindications

A 
non-vital
caries with risk of pulpal involvement
tooth mobility
apical disease
association with cystic tissue that is unlikely to resolve if root left in situ
tumours
IC
prev radio to H+N/tx before radio
NM disorders
diabetes
unable to return for tx easily should complications occur
57
Q

RCS FDS guidelines - CHX benefits

A

effective (gel more) - prevents alveolar osteitis

58
Q

RCS FDS guidelines - adverse events of CHX

A 
staining
altered taste
burning sensation
hypersensitivity
mucosal lesions
59
Q

RCS FDS guidelines - routine radiographic screening of UE8s with no disease or symptoms

A

not recommended

60
Q

RCS FDS guidelines - clinical review

A

just reviewing S+S
only xray if clinical S/S of disease
- routine BWs should inc distal of 7

61
Q

RCS FDS guidelines - active surveillance

A

non-op management strategy for retained M3Ms - prescribed, regularly scheduled set of follow up visits that inc both clinical and radiographic examinations

62
Q

explaining procedure to pt

A

flap - small cut in gum to get access
sectioning - cut tooth into smaller pieces to remove it
possible drilling
sutures (stitches) - whether dissolvable

63
Q

intra-op complications

A
  • fracture of tooth, root, alveolar plate, tuberosity
  • TMJ dislocation
  • haemorrhage
  • ST damage
  • OAC
  • loss of tooth/root
  • broken instruments
  • damage to Rx in 7
  • if edentulous/atrophic mandible, aberrant 8 close to lower border, large cystic lesion associated w 8 - explain risk of jaw fracture
    • because your L jaw is thin - it is rare but could break, we would arrange for it to be sorted
    • break can sometimes happen post-op
  • direct trauma to IA NV bundle
64
Q

loss of tooth/root into:

A

lingual space
MS
pterygoid space

65
Q

ST damage

A

puncture/laceration with instruments - gingivae/FOM/palate
burns - from handpiece resting on L lip
crush - papillae/lip
tears - gingivae/palate

66
Q

damage to Rx in 7

A

if this happens temp Rx placed at time then back for permanent Rx

67
Q

post-op complications of M3M extraction

A

pain
swelling
bruising
bleeding
infection with pus
jaw stiffness/limited mouth opening
dry socket (localised osteitis)
Nerve damage :

  • numbness (anaesthesia) or
  • tingling (paresthesia) of L lip, chin, side of tongue
    usually temporary - recovery up to 18-24m
  • dysaesthesia (rare)
  • reduced sensation - hypoaesthesia
  • heightened sensation - hyperaesthesia

altered taste (rare)

68
Q

rare post-op complications

A

Osteomyelitis
Osteoradionecrosis
MRONJ
actinomycosis

69
Q

how to explain dry socket to a pt

A

a slower healing painful socket
1-2wks to settle
come and see us

70
Q

why can altered taste result?

A

chorda tympani arises from facial nerve CNVII , taste buds from ant 2/3 tongue, carries fibres via lingual nerve - CNV3

71
Q

how to explain dysaesthesia to a pt

A

painful, uncomfortable, unpleasant sensation of L lip, chin, tongue, sometimes neuralgic type pain

72
Q

should you do CBCT?

A

if concerns of close proximity from radiograph - offer CBCT

- but would scan change tx?

73
Q

damage to IDN stats

A 
 temporary (weeks/months)
 - average 10-20%

permanent
 - average 1% and under
 - higher 5% and above if IDC and roots close proximity
74
Q

discussing risks to nerves

A
  • can recover up to 18-24m but after this time not much hope for any further recovery
  • if close proximity suggested by xray/confirmed by CBCT - explain in relation to the nerve that supplies lip/chin/teeth/gums on that side
  • explain risks to side of tongue remain average because nerve runs in STs and can’t be seen on xrays
  • talk about IDC to pt (canal nerve runs in) - can only see bony canal
75
Q

tx options

A
  • do nothing - monitor
    • may need local measures - irrigate, review, pt advice,
      risk of recurrence, food trap
  • (surgical) extraction
  • CBCT
  • coronectomy
76
Q

surgical access - flap design principle

A
  • max access with min trauma
  • larger flaps heal just as quickly as smaller ones
  • wide-based incision - circulation
  • use scalpel in one firm continuous stroke
  • no sharp angles
  • adequate sized flap
  • flap reflection should be down to bone and done cleanly
  • minimise trauma to papillae
  • no crushing
  • keep tissue moist
  • ensure flap margins and sutures will lie on sound bone
  • ensure wounds aren’t closed under tension
  • aim for healing by primary intention - minimise scarring
77
Q

stages of surgery of M3M ext

A
  • anaesthesia
  • access
  • bone removal and tooth division as necessary
  • debridement
  • suture
  • haemostasis
  • POIs
  • post-op medication
78
Q

access

A

buccal mucoperiosteal flap

+/- lingual flap (debate)

79
Q

ST retraction/reflection

A

access

protect STs

80
Q

retraction

A
  • should be on bone at all times not on STs - needs to go under periosteum
  • avoid dissection occurring superficial to periosteum
    • reduce ST bruising/trauma
  • may get post-surgery tingling due to pressure on nerve (temp)
81
Q

what facilitates retraction?

A

flap design

82
Q

where should you commence flap-raising?

A

commence flap raising at base of relieving incision (already gaping/bone visible)

83
Q

instruments for ST retraction

A

minnesota retractor
rake retractor
howarth’s periosteal elevator

84
Q

instruments for ST reflection

A

Ash periosteal elevator

Howarth’s periosteal elevator

Curved Warwick james elevator
Mitchell trimmer

85
Q

most difficult reflection - reflect with min trauma

A
  • papilla - tend to be well-tethered - try to release it before proceeding with reflection distally (avoid tears)
  • mucogingival jct
86
Q

why raise flap?

A

access to surgical site
improve visibility, visualise application point
facilitate bone removal

87
Q

flap considerations

A

important structures (esp for relieving incision) e.g. nerves
blood supply and healing
aesthetics
ease of suturing post-op

88
Q

flaps and papillae

A

need to either include or exclude papillae

89
Q

atraumatic/passive retraction

A

rest firmly on bone

aware of adjacent structures e.g. mental n

90
Q

3-sided flap

A
  • Distal relieving incision - runs out buccally to avoid RM pad as sometimes lingual nerve runs there
  • intracrevicular incision
  • mesial relieving incision
    • better to include papilla as easier to suture back up
91
Q

lingual flap and risk

A

variable use
depends on procedure, visibility, access, amount and area of bone removal and surgeon
can lead to stretching of lingual n which runs close to lingual aspect of L8s
more morbidity with less experienced operators

92
Q

envelope flap

1-sided flap

A

Pros:

  • easier to suture back
  • lower risk of damage to vital structures
  • Reduced scarring
  • wider base assures vascularity

Cons:

  • reduced access, challenging to reflect
  • tearing
  • periodontal damage and recession due to sulcular incision
93
Q

what blade to cut a flap?

94
Q

how to cut a flap?

A
  • incise with firm continuous stroke
  • feel area with finger first
  • pen grip
  • finger rest on sound support
  • use non-dominant index finger to apply tension to mucosa
  • full thickness through mucosa and periosteum to bone
95
Q

crevicular incision

A

hold scalpel in LA of tooth

blade kept immediately against tooth surface

96
Q

relieving incision

A
  • typically anterior to papilla
  • draw blade downward/forwards across mucogingival jct
  • draw blade** forward more horizontally** having crossed MGJ (to level of apices of teeth)
    • to make wider base so better blood supply
97
Q

drilling

A
  • electrical straight handpiece with saline cooled bur
    • avoid surgical emphysema (air driven/ turbine) - can get infected
  • round or fissure SS (often bone) and tungsten carbide (often teeth) burs
  • plenty irrigation (avoid bony necrosis + visibility)
  • protect STs
98
Q

buccal gutter

A
  • start distal (just in front of lingual plate) and bring bur buccally and mesially for safety of lingual n (prevent drill slipping into lingual space)
  • on buccal aspect of tooth and onto distal aspect of impaction
  • aim - deep narrow gutter (at least as deep as bur head)
    • need to get to bleeding cancellous bone
  • irrigate - visibility/avoid bony necrosis
  • away from important structures where possible
  • usually create gutter extending MD with position of application point dependant on root morphology/access
99
Q

aim of bone removal

A

allow correct application of elevators on M and B of tooth, better visual access

100
Q

when would you section a tooth?

A

if tooth removal still not possible with elevators +/- forceps and adequate bone removal

101
Q

horizontal tooth sectioning

A
  • make cut higher than for a coronectomy so easier to get roots
  • above CEJ
  • only drill approx 5/6 through - leave E to protect adjacent structures then twist elevator to snap and Lever off
102
Q

vertical tooth sectioning

A

works best on 2 rooted teeth
elevate M+D aspects separately
be v careful of roots of 7
occ need to section each root

103
Q

lingual split technique

A
  • old technique
  • prev used under GA, often in younger pts
  • requires lingual flap
  • lingual wall of 8 socket removed using a mallet and chisel
  • can remove tooth in one piece by rotating it lingually
  • takes away some bone behind tooth
    • good for distally impacted teeth
104
Q

forceps commonly used for L

A

molars, cowhorns, universal, roots

105
Q

forceps commonly used for U

A

8s, molars, universal, roots, Bayonet

106
Q

types of debridement

A

physical
irrigation
suction

107
Q

physical debridement

A
  • bone file/handpiece to remove sharp bony edges
  • Mitchell’s trimmer/Victoria Curette to remove ST debris
  • don’t scrape right at bottom of socket - risk IDN
  • debris and any follicular or granulation tissue from chronic infection should be curetted
    • esp if hidden behind 7
108
Q

irrigation debridement

A

sterile saline into socket and under flap

must irrigate below flap before you reposition it

109
Q

suction debridement

A

aspirate under flap to remove debris

check socket for retained apices etc

110
Q

2 methods of suturing

A

flap closure
anatomical repositioning

111
Q

When do you do flap closure

A

some suture flap across socket to lingual side, effectively closing the wound completely
- do if on bisphosphonates/MRONJ risk

112
Q

anatomical repositioning

A

most prefer to return flap to its original position, leaving a socket

113
Q

aims of suturing

A

reposition tissues
cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention

114
Q

how to suture flap

A
  • usually use mesial suture first as your positioning suture
    • can redo it more securely at end
  • need suture in each papilla
  • put a suture in the vertical relieving incision if risk of bleeding
  • normally use resorbable
115
Q

post-op advice

A
  • pain
  • expect it - take analgesia before LA wears off
    aid healing
  • don’t rinse for several hrs, then hot salty MW
  • softer/cooler foods for rest of day, softer foods for next
    week, eat on other side
  • don’t explore socket with fingers/tongue
  • be careful not to bite/burn L lip whilst numb
  • brush rest of teeth as normal
  • no smoking/avoid as long as can - increased risk of dry
    socket regardless
  • CHX MW x2 daily - not straight after brushing/around
    eating
  • avoid alcohol and exercise that day (increase bp - bleed)
  • deal w bleeding
    • damp gauze/tissue and bite for 20-30mins
    • contact details - you/A+E
  • other symptoms to expect
    • swelling - peak 48hrs, resolves 7-10days, if develops after 2-3 days likely infection, ice packs 5mins on off for
      1hr that day
    • bruising - settles 1-2wks
    • jaw stiffness/limited opening, usually settles 1-2wks
  • sutures
    • usually resorbable - may take a few days up to 2 wks to
      resorb
    • if non-resorbable (prolene) - warn pt they need removed
  • contact details
116
Q

indications for coronectomy

A

high risk of IAN injury
vital M3M
healthy non-IC pt
access to care for (and understanding of) related coronectomy risks

117
Q

Tara Renton paper 2005

A

Randomised controlled trials
shows much lower risk to IAN with coronectomy compared to SR

118
Q

principles of coronectomy

A
  • remove all enamel
  • tooth roots must not be mobile after decoronation
  • smooth finish to decoronated tooth and surrounding bone
119
Q

what is coronectomy?

A

alternative to SR of entire tooth when there appears to be an increased risk of IAN damage with SR
crown removed with deliberate retention of root adjacent to IAN

120
Q

aim of coronectomy

A

reduce risk of IAN damage

121
Q

risks of coronectomy

A
  • if root is mobilised during crown removal the entire tooth must be removed (more likely with conical fused roots)
  • leaving roots could result in infection (rare)
  • can get a slow healing/painful “socket”
  • roots may migrate later and begin to erupt through the mucosa, may require ext
122
Q

coronectomy procedure

A
  • LA
  • raise flap - generally standard 8 designs
  • (bone removal)
  • transection of tooth 3-4mm below the E of the crown into D
  • elevate/lever crown off without mobilising the roots
    • only go 2/3-3/4 through with drill as if cut all way through risk to lingual nerve and artery
  • pulp left in place untxed
  • if necessary - further reduction of roots with a rosehead bur to 3-4mm below alveolar crest - not always possible
  • irrigate socket
  • flap replaced - some reposition flap leaving socket open, some close flap completely (primary closure with periosteal release if necessary)
  • HAPOI
123
Q

follow up of coronectomy

A

variable
review 1-2wks, 3-6m, 1yr
some review at 2yrs but most discharge back to GDP after 6m/1yr

radiographic review

  • 6m or 1yr or both
  • after that if symptomatic
  • some take an immediate or 1wk post-op radiograph
124
Q

U8s ext

A
  • generally easier to remove can do in practice
  • but occ v difficult
  • remove by elevation (Wj, Couplands) +/- forceps (U8s)
  • support tuberosity w finger and thumb
  • if undue resistance to elevation/ext then excessive force can fracture the tuberosity
  • use forceps and support to reduce risk
  • if not possible to get access to a PE U8 - can raise buccal flap +/- bone removal
125
Q

peri-op control of bleeding

A

pressure
LA w vasoconstrictor
artery forceps
diathermy
bone wax

126
Q

post-op control of bleeding

A

pressure (finger/swab)
LA w vasoconstrictor infiltration in STs, inject into socket or on a swab
diathermy
haemostatic agents - surgicel/kaltostat
sutures
bone wax smeared on socket wall with a blunt instrument
haemostatic forceps/artery clips

127
Q

Contraindication of coronectomy

A

◦ Immunosuppressive
◦ Carious tooth
◦ Periodontal involved (mobile)
◦ Career wouldn’t allow regular checkup ( military )

oral surgery 4th year (10 decks)

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