1-Oral surg

Question 1

Surgical plan (10 steps)

Answer 1

1. draw image
2. mhx
3. flap type + content
4. Flap elev + instru (molt #9 periosteal elevator)
5. bone removal + bur [(tungsten carbide) round]
6. sectioning of tooth + bur (fissure bur)
7. delivery path + instru (luxator + elevator)
8. would closure + suture type (abs/non-abs & mono/braided)
9. Medications to prescribe + reasons (NSAIDs + paracetamol + oxy)
10. post-op followup

Question 2

Flap design (4 things) WAAM

Answer 2

1. wider base
2. access
3. avoid (vital struct)
4. Margins over sound

Question 3

flap margins to avoid

Answer 3

1. over bony
2. over non-sound bone
3. over papilla
4. mid-buccal of crown
5. releasing incisions on 1)lingual 2)palatal 3)at mental foramen (i.e. 2nd premol)

Question 4

1. Flap types

Answer 4

1. Envelope (least access)
2. 3-corner (most common)
3. 4 corner (most access + apical access)
4. semilunar (apicectomy)
5. pedicle (OAC)
6. y-incision (palatal torus)

Question 5

Bone guttering + bur? 2 advantages?

Answer 5

1. gutter along buccal in M-D (Round or Fissure bur)

2. Adv = 1)aplication point/easier to disp 2)improved visi for sectioning

Question 6

2 indications for tooth sectioning + bur? 2 adv?

Answer 6

1. i) resists elevation even after bone removal ii)divergents roots - i.e. no common path of removal
2. i)less force & dec risk for damage ii)less bone needs to be removed - less damage/increased

Question 7

Purpose of suturing

Answer 7

1. Reducing chance of infection
2. Assists haemostasis and healing
3. healing by primary intention so reduces scarring

Question 8

Disadv of Abs/Non-abs & Braided/mono-fil (adv are pretty much the inverse of their counterpart)

Answer 8

Abs - can dissolve early
non-abs - need removal
Braided - can tear tissue/bacteria adhere
monofilament - weak

Question 9

5 mandatory steps before exodontia can be done

Answer 9

1. clinical exam
2. med hx
3. radiograph
4. dx
5. consent

Question 10

3 types of bleeding and causes

Answer 10

**ITS NOT PRIM, SEC, TERT. REACTIONARY IS THE SECOND ONE!!!
primary = immediately after trauma, before clot forms
reactionary = 8-12 hours after surgery when vasoconstrictive effects of LA wear off
secondary = 7-10days due to infection produced enzymes dissolving clot

Question 11

Incisional biopsy

Answer 11

1) uncertain dx OR malignancy OR >1cm
2) Narrow/deep WEDGE >4mm/>6mm + NORMAL TISSUE
3) non-representative - multiple sites required to FULLY MAP LESION

Question 12

Excisional biopsy

Answer 12

1) dx certain + <1cm

2) Ellipsoid Length 2x width, 2-3mm margin of normal tissue

Question 13

Other 5 types of biopsies

Answer 13

Note: Excision, incision, punch, exfoliative - superficial lesions ——-fine needle cytology, fine needle core biopsy, trephine for deep

1) Punch biopsy - not used in mouth, rot can distort
2) exfoliative cytology - least representative/invasive
3) fine needle asp/non-asp cytology - no architecture
4) fine needle core biopsy - some architecture
5) trephines - architecture, but high risk bleed/damage

Question 14

Biopsy Transport

Answer 14

1. 10% formalin (i.e. 4% formaldehyde)
2. michel’s solution
3. saline

Question 15

8 Intra-op complications of extraction

Answer 15

1. iatrogenic lacerations
2. fracture of maxillary tuberosity
3. fracture of mandible
4. excessive primary bleeding
5. root tip fracture
6. dislodgement of tooth/bone fracture into tissue space
7. Max sinus involvement
8. IAN involvement

Question 16

solution to iatrogenic laceration (intra-op comp1/8)

Answer 16

1. achieve hemostasis 2. suture 3. inform patient of incident

Question 17

Solution to fracture of maxillary tuberosity (intra-op comp 2/8)

Answer 17

1) stop immediately 2) take opg 3) refer to oral surgeon

Question 18

Solution to fracture of mandible (intra-op comp 3/8)

Answer 18

1) stop immediately 2) take opg 3) refer to oral surgeon

Question 19

7 Solution to excessive primary bleeding (intra-op comp 4/8)

Answer 19

1. pressure
2. clot stabilizing agent (surgicel/gelfoam)
3. tranexamic acid
4. sutures
5. adrenaline
6. bone wax
7. electro-cautery

Question 20

2 possible solutions to root tip fracture (intra-op comp 5/8)

Answer 20

2 possibilities

1) <4mm, no infection/apical radiolucency, below lvl of bone–> Tx = leave
2) otherwise: Tx1 = nonsurg- rootpick Tx2 = surgical - conventional technique or Open window technique

Question 21

4 possibilities when it comes to tooth/bone fracture dislodged into soft tissue space (intra-op comp 6/8)

(max sinus value of root is <3mm, don’t confuse with root tip fracture which is <4mm)

Answer 21

POSSIBILITY 1 = CAN’T FIND AFTER SEARCHING
1) take chest x-ray to rule out aspiration

POSSIBILITY 2: under mucosa/into infratemporal/into submandibular:
1) massage back into socket 2) if unsuccessful –>refer to Oral surgeon

POSSIBILITY 3: INTO MAX SINUS (<3mm & not infected/apical patho)

1) attempt to retrieve
2) if unsuccessful –> leave and treat as OAC

POSSIBILITY 4: INTO MAX SINUS (>3mm or infected)
1) must retrieve –> enlarge socket

Question 22

Maxillary sinus involvement (intra-op comp 7/8).

i don’t know what an OAF is. I know OAC, but OAF is apparently when OAC becomes epithelially lined if not closed…. and its importance is that the epithelium has to be removed if flap surgery being done, so as to close over sound bone, not tissue at margins.

Answer 22

3 scenarios possible:

1) <2mm wide –> tx = sinus precautions
2) 2-6mm –> tx = 1)sinus precautions 2)surgicel/gel foam+suture 3)AB - augmentin or doxycycline
3) >6mm –> tx= 1)sinus prec 2)buccal flap adv (1st choice) OR pedicle flap 3)AB - augmentin or doxycycline

Question 23

IAN involvement (intra-op comp 8/8).

don’t know a tx, just refer to OS. It should have never happened in the first place.

Answer 23

7 signs of of IAN involvement
A) 4 root sign: darkening (key sign), deflection, narrowing, bifid
B) 3 canal signs: displacement (key sign), interruption, narrowing

Question 24

8 post-op complications of extractions

Answer 24

1. Reactionary bleeding
2. swelling (e.g. trismus)
3. bruising
4. infection/secondary bleeding
5. alveolar osteitis
6. MRONJ
7. Osteoradionecrosis
8. nerve damage

Question 25

Reactionary bleeding (post-op comp 1/8)

Answer 25

``` Cause = vasocontrictor of LA wearing off Tx = will self-resolve ```

Question 26

Swelling (trismus) - more common in surgical exos (post-op comp 2/8)

Answer 26

``` Cause = 1)hematoma 2) muscle damage 3)too much LA injected into closed space Tx = cold compress and monitor, self-resolves ```

Question 27

Bruising - common (post-op comp 3/8)

Answer 27

``` Cause = extravasated RBCs, common in elderly and patients on anticoags b/c they have trouble clotting. Tx = will self resolve ```

Question 28

Secondary bleeding (post-op comp 4/8)

Answer 28

``` Cause = secondary infection Tx = AB (Amoxicillin and metronidazole?) ```

Question 29

Alveolar osteitis (post-op comp 5/8)

Answer 29

``` Cause = clot dislodged, unknown etiology Tx = 1)Alvogel optional (most common cause of foreign body rxn in dent) 2) analgesics ``` Typically resolves in a week (can take up to 2)

Question 30

MRONJ (medication related osteonecrosis of the jaw) (post-op comp 6/8) CAUSE IF ANTIRESROPTIVE DRUG = REMODELLING CAUSE IF ANTIANGIOGENIC DRUG = ISCHEMIA Pre-op risk assess Post-op Diagnosis Tx if Dx Antiresorptive drugs = bisphos (alendronate, risedronate) + Rank-L inhib (denosumab aka prolia) Antiangiogenic drug (zoledronic acid)

Answer 30

A) Pre-op risk assessment for referral- high risk if any of the following: 1)prev hx 2)>4y on Rank-L(e.g. denosamab)/bisp 3)currently on Rank-L(e.g. denosamab)/bisphos + extra risk fact B) Post-op dx - 4criteria: 1) Current/prev tx w/ ANTIRESORPTIVES/ANTIANGIOGNEIC 2) exposed bone/bone probed through fistula 3) has persisted for >8w 4) no hx of radiotherapy or cancer (b/c its 100% more likely to be osteoradionecrosis or cancer causing resorb instead of meds) ``` Tx stage 0 (dx, but no necro) -->nothing stage 1 (necro bone) -->CHX Stage 2 (necro bone + inf) --> CHX + AB + debride Stage 3 (necro bone + maj inf) --> CHX + AB + resection ```

Question 31

Osteoradionecrosis (post-op comp 7/8)

Answer 31

Cause = radiation induced proliferation of endocytes narrowing BV-->ishemia -->necrosis. DOESN'T ALWAYS OCCUR, and if it occurs it could self-resolve in <3m. Prevent by: don't do surgery in radio field in the 2 weeks leading upto or 3 months after the radiotherapy Dx criteria: 1)radiotherapy + no current cancer 2)persisting >3m Tx: 1) debride bone back to bleeding margins 2)drugs to dilate BV

Question 32

Nerve damage (post-op comp 8/8)

Answer 32

Cause commonly IAN involvement or releasing cut of flap damaging lingual. If temporary or injection related then monitor and should return back to normal If severed or involvement-->refer to OS immediate to rejoin if possible.