Unit 310 Flashcards
Examples of major oral surgery?
treatment and reconstructive surgery for oral cancer
orthognathic surgery to correct skeletal problems
head and neck trauma surgery
During MOS treatments what is the dental nurses main role?
reassurance and monitoring of the patient
Replacements after extractions:
bridge, denture, implant
Why may an extraction be necessary?
tooth is causing infection and pain due to gross caries, periodontal disease or trauma
Why may a tooth need to be removed for orthodontic reasons?
poorly positioned to be aligned with ortho treatment, provide space in the dental arch for movement
What does bacteraemia mean?
infection has spread into the blood stream - patient generally unwell
raise of concern with elderly and medically compromised patients
How does a dentist decide on the complexity of an extraction procedure?
what tooth is involved
how many roots
roots curved
position in the jaw bone - near any sinuses?
What does root resorption mean?
the progressive loss of part or parts of the tooth due to odontoclasts.
What are odontoclasts?
a cell, that is responsible for breaking down the roots of deciduous teeth so they will eventually fall out.
What is considered with deciduous tooth extractions:
has root resorption occurred, is the underlying permanent tooth present could it be damaged during xla?, infection present?, age and co-operation may they need to be referred?.
What is considered with permanent tooth extractions:
infection present?, medications, co-operation adult patients with special needs may need sedation, age older patients have more friable soft tissues, grossly carious tooth is likely to need surgical.
What are simple extractions?
the tooth or root is removed whole from the dental arch without any surgical procedures.
How is a tooth actually extracted during simple extractions?
it is pushed out of the socket by the root.
What are forceps used to do?
Grip a tooth or root at its neck before applying appropriate wrist actions to loosen the tooth/root in its socket.
What are luxators used to do?
widen the socket and sever the periodontal ligament attachment.
What are elevators used to do?
prise the tooth/root out of the socket
e.g. cryers, warwick james, winters
What are fine bore aspirators?
disposable narrow suction tips used to suck away all the blood + tooth debris and maintain good moisture control
What are haemostats?
Gelatine sponges or oxidised cellulose packs that are inserted into the socket after extraction to aid blood clotting and achieve haemostasis.
How to tell if a forcep is upper?
Handles and blades roughly in line with each other
How to tell if a forcep is lower?
right angles to each other for easier access to the lower arch
How to tell if a forcep is for multirooted molar teeth?
blades that are shaped like beaks so they can grip the FURCATION area between the roots
How to tell if a forcep is for single rooted tooth?
Smooth blades
Upper incisor and canine forceps look like:
straight with single rounded blades and have both wide and narrow patterns
Upper root forceps look like:
similar to upper incisor and canines but have narrow straight blades
Upper pre-molar forceps look like:
slightly curved handles and single rounded blades
Upper left molar forceps:
curved handles and a beaked blade to the right of the instrument and a rounded blade to the left to grip the buccal/palatal roots “beak to cheek”
Upper right molar forceps:
curved handles and the beaked blade is to the left of the instrument
Upper bayonet forceps:
third molars
extended handles and angled blades or have angled pointed blades to gain access to fractured roots.
Lower anterior forceps:
single rounded blades at right angles to the handle that are particularly useful for extracting lower premolars.
Lower root forceps:
similar to anterior with narrow and straight blades that are also useful for extracting small/crowded incisors
Lower molar forceps:
beaked blades at right angles to the handles to grip the furcation of two roots
Lower cowhorn forceps:
curved and pointed blades at right angles to the handles
MOLAR teeth
What does furcation mean?
the area where the roots divide and branch into multiple teeth at a time
What are elevators specifically used to elevate?
retained roots and impacted teeth where access to the root or tooth is not possible with forceps
Cryers elevators:
left and right patterns
can be used on either side depending whether they are engaged mesially and distally.
tips are triangular and pointed
Winters elevators:
Similar bladed design as cryers but have a cork scew styled handle to give more leverage
Warwick james elevators:
Left, right and straight patterns
tips are similar to the round blade of forceps
Couplands chisel:
single bladed chisel, available for splitting multirooted teeth.
A bite pack is placed over the socket and the patient is asked to bite on this for how long?
30 minutes
What does haemostasis mean?
stop the bleeding
Within a bite pack there is a gauze covering what is the reason for this?
to prevent wool fibres becoming stuck in the blood clot as it forms.
What does the “no touch” technique of dental instruments help maintain?
infection control
Throughout an extraction procedure what will the dental nurse check for?
any signs of distress to notify the dentist
When extraction instruments are being used the nurse may be required to stabilise the patients head or mandible.
Whichever technique is used to extract a tooth or root is considered a surgical one. So if the working area is not treated as a sterile field what could happen?
risk of cross infection
What precautions are taken by the dental team to prevent cross infection during an extraction?
Sterile bagged instruments, PPE, disposable items, sterile field
suction equipment - should be ran through immediately after procedure with required disinfectant solution to remove all traces of blood from its inner workings
During an extraction the chair should be covered with a single use impervious membrane (e.g chair sleeve) why?
to prevent blood contamination
In regards to decontamination after extraction with instruments before placing them in the autoclave to sterilise what should they go in first?
washer disinfector unit or an ultrasonic bath
Preoperative instructions:
LA, aspirin is not advised to be taken prior extraction due to the prevention of blood clotting, light snack prior, if the patient is nervous they should bring a friend or family member to put them at ease.
How should postoperative instructions be given?
verbally and written
Postoperative complications tend to occur because of what?
disturbance to the blood clot that forms in the area
Postoperative instructions:
pain swelling bruising, analgesics may be taken as normal other than ASPIRIN, alcohol exercise and hot drinks should be avoided for 24 hours, hot salt mouth rinses should be carried out the next day for up to 1 week, bite packs provided with instructions, emergency phone number incase complications occur (attend A&E, 999)
What procedures are referred to as surgical?
removal of soft tissue alone or soft tissue and alveolar bone to gain access to tooth/root.
Multi-rooted tooth may need to be dissected into sections with a single root attached then extracted separately.
Why may surgical extractions be necessary?
retained root left in the alveolar bone, grossly carious, roots are curved, tooth is partially erupted and impacted, tooth is unerupted but has associated pathology e.g. cyst.
What does ankylosed mean?
deciduous tooth has failed to exfoliate because the root has become cemented to the alveolar bone and natural exfoliation cannot occur.
Surgical extractions fall into what categories?
-soft tissue exposure
-tooth sectioning
- raising of a mucoperiosteal flap
What differs surgical extractions to simple?
the list of instruments
Extractions involving soft tissue exposure- retained roots?
when a section of root remains after a previous extraction, the surrounding gingivae will grow over the stump. Bone will NOT regrow over the stump. So when a denture is placed it may be tender during chewing for the patient.
Implants - when a radiograph is taken an implantologist will decide on surgical removal
Following a soft tissue exposure extraction a radiograph is taken to see what?
the position of the retained root.
For edentulous patients a location device should be used- lead foil from an x-ray packet molded around an available tooth to locate
Soft tissue exposure procedure:
2 sided incision on top of the retained root, luxator is used, forceps are NOT used, incision is then closed after removal using sutures.
Extractions involving tooth sectioning - multi-rooted teeth?
Unfavourable root curvature or gross root caries that prevents simple forceps removal of roots.
Sometimes it may be necessary to remove some of the septal bone that lies between the roots and forms the individual socket walls.
Extractions involving tooth sectioning procedure:
use of high speed turbine and diamond bur (usually crown prep)
couplands chisel to achieve final separation of roots
surgical handpiece and bone burs to remove any septal bone
Extractions involving mucoperiosteal flaps
unerupted or impacted tooth
buried retained root
root curvature requires extensive bone removal
gross root caries
What is the mucoperiosteal flap?
teeth lie in sockets of alveolar bone with a covering of mucoperiosteum over the bone that runs into the gingivae around each tooth.
The mucoperiosteal flap has to be sutured back into place how long can it take for the reattachment to occur?
7 days
Patients with a compromised medical history may require the surgical procedure to be carried out in a hospital or dental clinic environment.
What does an osteotrimmer do?
raises the corners of the mucoperiosteal flap off the underlying alveolar bone.
During surgical procedures what type of irrigation is used?
saline
What are austin and kilner retractors used to do?
protect and retract the cheeks, lips and tongue from the surgical field - provides clear access for the dentist.
What does a rake retractor do?
retracts the mucoperiosteal itself.
What is a bone rongeurs used to do?
nibble away bony spicules and produce a smooth bone surface for healing
What are disecting forceps used to do?
to hold the loose flap edges taut during suturing
What is a periosteal elevator?
complete the elevation of the flap off the bone
What is tooth impaction?
unerupted tooth is prevented from fully erupting by having its path blocked by either bone or another tissue
The most common teeth that become impacted are:
third molars - wisdom teeth
Vertical impaction
the tooth is upright but impacted into the ramus of the mandible
Horizontal impaction
the tooth is lying on its side facing forwards backwards or across the dental ridge.
Mesio-angular impaction
the tooth is tilted forwards into the second molar tooth
Disto-angular impaction
the tooth is titled backwards into the ramus of the mandible
Wisdom teeth that are difficult and causing infection/food trapping tend to be referred to a specialist oral surgeon for extraction, what about impacted wisdom teeth that are asymptomatic?
Usually left in situ as there are risks involved in having the tooth surgically removed.
What does asymptomatic mean?
causing no problems
What are the risks involved with having teeth extracted surgically?
extensive bone removal can weaken the mandible, postop pain and swelling, inferior dental nerve and lingual nerve can be temporarily or permanently damaged, trismus.
What does trismus mean?
limited mouth opening
Complications that occur during extraction:
damage to adjacent nerves, fracture of the tooth, perforation of the maxillary sinus and loss of a tooth.
Complications that may occur after an extraction:
bleeding and infection of the bony socket.
What is the most common risk of extraction?
possibility of damage to one of the trigeminal nerve branches - can be decided due to radiograph, pt should be referred to specialist.
Patients who are medically compromised and are taking haemophiliacs or anticoagulants should be referred to a specialist.
Complication of extraction: tooth fracture
Grossly carious or heavily filled tooth is likely to fracture
If tooth fracture extends subgingivally may be difficult without bone removal
root fracture when the roots are fine or curved, surgical procedure may be necessary to remove.
If small apical pieces of root fracture during extraction they can be left in situ to rise themselves to the alveolar ridge surface
Complication of extraction: bone fracture
The twisting and rotary movements required can cause thin pieces of the alveolar bone from around the socket wall to fracture or from the bony septum.
Any fractures of bone need to be checked found and removed as this will prevent the healing process - localised infection of the socket
Complication of extraction: Oroantral fistula
extraction of the upper premolar and molar teeth ONLY
maxillary sinus lies over and between the roots, sometimes the root can be pushed into the sinus and it will act as a foreign body and cause infection - they should be referred after this
What is an oroantral fitsula?
long rooted upper premolar or molar teeth sometimes go into the sinus naturally and when they are extracted an opening will be created between the antrum and the oral cavity.
Oroantral fitsula, if the opening is small what will happen?
close naturally within a week, patient is instructed not to blow their nose during this healing period.
What can the presence of a fitsula look like?
appearance of air bubbles in the socket
Oroantral fitsula, if the opening is large what will happen?
surgical repair either by direct suturing or raising the gingival flap off the palate and swinging it across to seal the fistula.
Complication of extraction: loss of tooth
The tooth can be dropped during removal, if the tooth is swallowed it can be allowed to pass naturally, if the tooth has been inhaled (coughing fit) the patient should be sent to hospital for x-rays to locate the tooth as it can cause serious respiratory infection.
Lodged in the main bronchi - removed by bronchoscope
Further into the respiratory tract - thoracic surgery
Complication of extraction: Bleeding
Primary haemorrhage
bleeding stops within 5 minutes of completion of the extraction with the use of a bite pack.
Elderly patients and those with hypertension may routinely have a haemostatic sponge/sutures placed
How does the socket form a blood clot?
torn blood vessels constrict the slow blood flow
platelets circulating in the blood are exposed to air n wound site which causes them to become sticky and clump together.
Clotting mechanisms - protein fibrinogen = fibrin
fibrin chemically seals the cut vessels so haemorrhage ends.
What does fibrin do?
chemically seals the cut vessels
Complication of extraction: Bleeding
Reactionary Haemorrhage
bleeding that occurs several hours after extraction - tends to be caused by the patient not following postop instructions and disturbing the clot - bite pack reapplied
What is an additional cause of primary haemorrhage?
failure of blood clotting process so that uncontrolled bleeding occurs.
Uncommon but serious
Tend to occur in patients taking anticoagulant drugs, those with liver disease and some rare blood diseases e.g haemophilia
Patients who take the anticoagulant - warfarin, need to have what checked before a dentist decides on in practice XLA or referral to a hospital?
INR score of more than 4 needs to be treated in hospital
A patient who takes warfarin had an xla within practice today as INR score was within the normal range, however excessive bleeding has occurred, what can the dentist give the patient to reverse the effects of the warfarin?
Vitamin K
What precautions should be took for patients taking aspirin?
use of a haemostatic sponge and suture
Patients taking modern anticoagulent`s such as clopidogrel should be treated with extreme caution as unlike warfarin there is no drug to reverse this.
Complication of extraction: Bleeding
Secondary Haemorrhage
The blood clot is lost early and the socket becomes infected with a breakdown of the healing mechanism.
Occurs after 24 hours from the extraction being carried out
cleaning the socket, pressure and haemostatic sponge will solve the problem.
Complication of extraction: Infection
What is an infection of the extraction socket called?
localised osteitis = dry socket
Painful condition that occurs 2-3 days after XLA
acute inflammation of the bone osteitis lining the socket and is caused by microbial invasion.
What is the cause of localised osteitis?
microbial invasion
Other than periodontal infection and smoking what can cause a dry socket (localised osteitis)?
Infection of the blood clot
failure of formation of a blood clot
disturbance of the blood clot
What can be done to prevent infection of the socket after XLA?
pre-extraction scaling of the teeth reduces gingival infection
Application of chlorhexidine to the gingival crevice before extraction helps to reduce the risk
Disturbance of a blood clot is more common in the MANDIBLE due to the thicker layer of compact bone
How to treat dry socket (localised osteitis)?
Any food debris or necrotic clot tissue is removed with irrigation and the use of tweezer and then a sedative dressing such as alvogyl is carefully placed in the socket.
Irrigants that can be used during dry socket treatment:
sterile saline solution, local anaesthetic solution, purified water
The use of chlorhexidine should NOT be used during dry socket treatment as it can cause an allergic reaction to the bony socket.
If a patient rings and the dental nurse is around regarding post extraction, the dental nurse must contact the dentist for instructions.
Recommend provision of a mouthwash to be carefully and gently rinsed around the mouth to remove the unpleasant taste and clean the area.
What is an accidental extraction?
An unplanned situation where a tooth is lost from its socket unexpectedly and can occur for several reasons.
For example when extracting a deciduous molar roots the premolar crown can be dislodged and extracted by accident too, however the premolar can immediately be replanted in its socket.
same for trauma to the incisor as a child
During an accidental extraction how could a tooth be replanted?
The periodontal membrane and pulp should retain their vitality and the tooth subsequently erupts as normal - must be IMMEDIATELY replanted.
If a tooth has been replanted what is the correct name for the tooth?
avulsed
After care of a replanted tooth:
x-ray is taken no further treatment
Splint can sometimes be recommended to immobilise it for a week as well as a root fill if the tooth becomes non-vital
When should antibiotics be given after extraction?
Back up treatment, evidence of localised infection, evidence of systemic involvement e.g. high temperature.
Reasons the use of antibiotics is contradicted?
Source of infection is better removed from extraction or lancing the infection
resistant strains of bacteria are likely to develop if antibiotics are overprescribed
long term consequences for the normal bacteria flora
increase blood thinning
antibiotics that are usually recommended:
- amoxicillin 500mg
-metronidazole 200-400mg
-erythromycin 250mg
What is an operculectomy procedure?
surgical removal of the gingival flap (operculum) overlying a partially erupted tooth - Lower third molar
The area may be constantly bitten and traumatised by the upper teeth - causing pain and inflammation
becomes more painful patients will reduce their oral hygiene efforts - plaque and debris build up causing an infection = pericoronitis
in severe cases - trismus will develop
What is periocronitis?
build up of plaque and food debris under the gum tissue around the wisdom teeth = infection
Treatment for pericronitis?
Irrigation of the underside of the flap to remove debris using chlorhexidine or oxygen releasing solution (peroxyl mouthwash)
Anti-inflammatory analgesics = ibruprofen
operculectomy procedure
How is the operculum removed during operculectomy?
Surgical removal of the operculum using electrosurgical cautery unit
cuts the tissue as well as cauterising it
3 day course of metronidazole
What is an alveolectomy and alveoplasty procedure?
Remove pieces of the alveolar ridge or smooth and alter its shape.
If the bone is left sticking out it can make dentures seat incorrectly
or to help placement of implants
How is the alveolectomy and alveoplasty procedure done?
mucoperiosteal flap must be raised to gain access to the ridge and then bone rongeurs or surgical burs to remove all bony projections.
What is an gingivectomy and gingivoplasty procedure?
Periodontal surgery techniques, adjust the shape of the gingivae and aid oral hygiene measures so that more effective plaque removal is possible or to lengthen the crowns of the teeth before restoration.
Can false pockets be surgically removed by a gingivectomy and how is this done?
YES
removal of a strip of gingival margin level with the point of the epithelial attachment.
confined to cases with excessive gum overgrowth (gingival hyperplasia), caused by certain drugs used for medical conditions e.g. phenytoin for epilepsy, hypertension and following organ transplants.
What instruments are used during a gingivectomy and how are they used?
Gingivectomy knife - excess gum removed “Blakes gingivectomy knife”
The strip of gum is removed with tweezers
the raw gum is covered with zinc oxide/eugonel periodontal pack such as coe-pak to protect the gum and promote healing
Pack is removed a week later and scaling is done.
What is crown lengthening?
It is a procedure similar to gingivectomy/gingivoplasty where the exposure of more root surface prior to crown prep is necessary - due to insufficient retention for a crown.
What is a gingivoplasty?
surgical recontouring of the gingivae once periodontal health has been established.
How is a gingivoplasty carried out?
electrosurgical cautery unit which cuts and coagulates bleeding tissues at the same time.
Postoperative instructions that are given to patients prior a gingival surgery?
perscribed analgesic drugs to relieve after pain
given an appointment a week later to remove sutures or pack
avoid smoking
soft diet, chlorhexidine mouthwashes are advised.
What is periodontal flap surgery?
For patients who do not respond to plaque control procedures.
Uses similar techniques and instruments as a surgical extraction of unerupted teeth but do not fully raise the mucoperiosteal flap.
What kind of teeth conditions are likely to need periodontal flap surgery?
irregular gingival pocketing, complex/uneven pattern of bone loss, involvement of furcation.
Periodontal flap surgery procedure:
incision made through the gingival papilla of the tooth, down to the tooth surface, the remaining gingival flap is then exposed to all the hidden subgingival calculus.
subgingival calc is removed using curettes or an ultrasonic scaler
What antibiotic/medicament systems are placed in the accessible areas during a periodontal flap surgery to help with healing?
gengigel, dentomycin, periochip
What procedure gives a “long in the tooth” appearance?
periodontal flap surgery
Why are oral biopsies done?
for pathological examination and diagnosis
What are incisional biopsies?
Large lesions may have just a section of tissue removed
What are excisional biopsies?
smaller lesions, the whole of the tissue is removed
What is a cyst?
fluid filled sac confined with a soft tissue lining
Where are dental/apical cyst found?
abnormal cavity in the bone, at the apex of a dead tooth.
What do dentigerous or follicular cysts prevent?
surrounding and preventing eruption of an unerupted tooth
If a cyst is left untreated what can happen?
enlarges causing swelling of the jaw and displacement of other teeth
What is a frenectomy?
removal of a frenum (band of fibrous tissue), attaches the tongue and lips to the underlying bone.
lingual frenectomy affects what?
speech
lingual frenectomy is performed
Labial frenectomy can cause what?
median diastema - upper labial frenum is to large it may allow a wide gap to persist between the upper central incisors
the fit of upper dentures
What factors will be considered when a patient is deciding on if implants are suitable for them?
Their level of oral and general health and their standard of oral hygiene are sufficient to make implant treatment successful in the long term.
What will the implantologist assess when seeing if a patient is suitable for implants?
- qaulity of bone - more compact bone the better
- sufficient depth of bone to place length of implant - longer the better
-sufficient thickness of bone, 1mm rim buccolingually/palataly, 1.5mm rim from each adjacent tooth - the implant is the same diameter as the root of the tooth it is to place.
If a patient is attending for implant treatment and a radiograph shows the maxillary antrum (sinus) is to close to the alveolar ridge what procedure may be recommended prior?
sinus lift
A patient who is edentulous has a OPG took which shows the bone throughout the mandibular ridge has resorbed what may this patient require prior to implants?
Bone regeneration - artificial bone
Bone grafts
One-stage technique implants:
implant is placed into the bone with its top end protruding through the sutured soft tissue, so that the restoration can be attached immediately
Two-stage technique implants: first stage..
implant is placed into the bone with its top end beneath the sutured soft tissues and protected from overlying tissue growth by a cover scew for several months.
Two stage technique implants: second stage…
the implant site is reopened, the cover screw removed and replaced with a healing abutment which projects into the oral cavity for weeks and then is eventually replaced with final restoration.
Majority of implants in the UK are classed as
solid
Why is a guide hole made in the bone during implants?
Pilot drill
purchase point is made for the twist drills to locate, otherwise the drills would slip across the surface of the bone.
During implants what are the twist drills used to do?
create the required length of hole in the bone
During implants what are diameter drills used to do?
widen the hole made for the implant placement in a procedure called osteotomy
What is the osteotomy procedure?
hollow implant is to be inserted, a trephine mill is used to cut out a ring of bone only
How can the implantologist tell the angulation and the depth the drilling should be?
three dimensional scan and radiographs
What instruments remove the scew tap in implants?
screw tool
torque ratchet
What is peri-implantitis?
same as periodontal disease but for implants
Smokers have a higher implant failure rate
Why are periodic radiographs took after implants?
to check the bone levels around the implant
Looseness of the implant can require urgent attention why?
indicates either a fracture of the implant or loss of the osseointegration between the bone and the implant
How can a dental nurse tell if a patient is in pain?
patients grimacing, wincing, crying
How can a dental nurse tell if a patient may be feeling unwell?
patient may feel faint and become pale/clammy
How can a dental nurse tell if a patient may be choking?
debris or a tooth may be lost to the back of the mouth
Anxiety can cause what medical emergency?
angina or cardiac arrest
It is important to maintain a —- —— if an unexpected complication occurs
calm manner
