11. Oral Surgery

Question 1

Extractions

1. 3 types of instruments
2. Function of elevators and 3 techniques
3. Function of luxators
4. 4 indications for extractions

Answer 1

1. Forceps, elevators, luxators
2. Dilate sockets to facilitate extractions, establish effective and logical point of application, remove teeth, remove retained roots. Wheel and axle, wedge, lever
3. Break PDL, increasing access and mobility
4. Unrestorable teeth, symptomatic PE teeth, traumatic position, ortho indications, interference with denture construction

Question 2

Peri-operative complications 1

1. 3 causes of access/vision difficulties and 2 Mx options
2. 4 causes of abnormal resistance
3. 3 causes of crown fracture
4. 3 causes of root fracture
5. 3 causes of dento-alveolar fractures
6. Management of dento-alveolar fracture
7. 3 causes of jaw fracture
8. Jaw fracture management
9. 3 causes of maxillary tuberosity #
10. 3 features of Dx
11. Mx

Answer 2

1. Trismus, produced aperture, crowded/malpositioned teeth, small mouth. Mouth props, other opening devices, XGA
2. Inadequate initial pressure, thick cortical bone, divergent roots, number of roots, hypercementosis, ankylosis, sclerotic bone
3. Caries, alignment, size, thick cortical bone
4. Fused, convergent, divergent, extra roots, abnormal morphology, hypercementosis, ankylosis
5. Thin bone, inappropriate direction of force, excessive force, inappropriate instrument use
6. Dissect fractured bone free, suture, stabilise teeth, free mucoperiosteum, smooth edges
7. Impacted 8s, large cyst, atrophic mandible, application of force in the wrong direction
8. X-ray (OPT/PA mandible), ensure analgesia, refer to OMFS. If delayed referral - stabilise fracture (tie free ends of bone to to on opposite side of fracture and tie teeth on opposite sides of fracture site together), antibiotics if compound
9. Extraction of single standing molars, extraction in wrong order, unknown unerupted 8, pathological gemination, inadequate alveolar support
10. Crack, mucosal tear, mobility, mobile teeth
11. If small - dissect out bone and close
    If large - reduce and stabilise, ensure tooth attached to tuberosity is occlusion-free, XLA 8wks later
    Antibiotics if compound

Question 3

Peri-operative complications 2

1. How to manage tooth loss
2. 3 causes of damage to adjacent teeth/restorations
3. Management
4. How to manage wrong tooth extractions
5. 2 causes of broken instruments
6. Management
7. 2 causes of jaw dislocation
8. Management
9. 5 types of nerve damage
10. Define neurapraxia
11. Define axonotmesis
12. Define neurotmesis

Answer 3

1. Stop and search. If risk of inhalation/ingestion of cannot be accounted for -> CXR in A&E
2. Inappropriate application point of elevators, large overhang contacting tooth to be extracted, hit opposing teeth with forceps
3. Pre-XLA warning, temp dressing, arrange definitive
4. Attempt to replant immediately, splint, tell patient. Never event
5. Incorrect use, instrument fatigue
6. Attempt to retrieve or refer
7. Inadequate jaw support, inappropriate application point, excessive force, open too long
8. IDB, relocation, post-op advice (soft diet, supported yawning)
9. Anaesthesia, paraesthesia, dysaesthesia, hyperaesthesia, hypoaesthesia
10. Mild contusion. Continuity of epineural sheath and axons are maintained. Temp (6-8wks) loss of function due to blockage of nerve conduction. Sunderland grade I
11. Crush/more severe contusion (moderate). Continuity of axons maintained, continuity of epineural sheath is disrupted. Sunderland grade II-IV. Motor and sensory function distal to point of injury are completely lost over time, leading to Wallerian degeneration due to ischaemia
12. Transection. Severe. Continuity of epineural sheath and axons disrupted. Complete loss of nerve continuity (complete section of nerve). Sunderland grade V

Question 4

Post-operative complications 1

1. 3 causes of post-op pain
2. 2 causes of post-op oedema
3. 2 causes of post-op ecchymosis
4. 3. causes of post-op trismus
5. Mx
6. 3 local reasons for bleeding
7. 3 systemic reasons for bleeding
8. Define 3 types of bleeding
9. Describe Mx for peri- or post-op bleeding

Answer 4

1. Rough tissue handling, laceration/soft tissue tears, exposed bone, incomplete extraction
2. Rough tissue handling, pull/tear flaps, crushing tissue with forceps
3. Poor surgical technique, rough tissue handling
4. Oedema, muscle spasm, mouth open for too long, haematoma into muscle, IDB into MP, damage to TMJ
5. Soft diet, gentle opening, monitor. May require opening exercises
6. Mucoperiosteal tears, alveolar bone #, cutting vessels
7. Clotting abnormalities, liver disease, medications
8. Immediate/primary - where true haemostasis has not been achieved
   Reactionary/rebound - <48hrs. Due to rise in BP opening up small divided vessels (hot drinks, exertion, alcohol)
   Secondary - >48hrs. Usually due to infection destroying clot or ulcerating local vessels
9. Reassurance, medical history
   Bite on damp gauze, suction to identify source
   LA with vasoconstrictor (inject/on pledget), haemostatic agents - packing (oxidised regenerated cellulose, fibrin foam, thrombin liquid and powder, gelatine sponge), suturing
   Diathermy, ligatures, bone wax
   Systemic - tranexamic acid

Question 5

Post-operative complications 2

1. Define bony sequestrum
2. Mx
3. 2 other names for dry socket
4. 4 predisposing factors
5. 4 symptoms
6. Mx
7. Infected socket Mx
8. Pathophysiology of ORN
9. How to prevent
10. How to Mx
11. Definition of osteomyelitis
12. Pathogenesis
13. 2 predisposing factors
14. 3 types
15. Radiographic appearance
16. Mx

Answer 5

1. Piece of dead bone tissue formed within diseased/injured bone
2. Remove
3. Alveolar/localised osteitis
4. Posterior tooth, mandible, smoking, female, OCP, excessive post-XLA rinsing, LA vasoconstrictor, traumatic XLA
5. Moderate/severe dull aching throb, radiates around ear/jaw, continuous, sleep disturbance, exposed bone, bad taste/malodour
6. LA, ensure no tooth fragments/sequestrum, irrigate and debride, place WHVP, PoI (no smoking, no rinsing today, WSWM tomorrow), review
7. LA, ensure no tooth fragments/sequestrum, irrigate and debride, ABX if systemically unwell
8. Radiation therapy induces endarteritis obliterans which leads to progressive fibrosis and capillary loss, leaving bone susceptible to avascular necrosis. Slowed bone turnover, ineffective self-repair. Gradually worsens
9. Atraumatic technique, primary closure, CHX MW, pre-XLA hyperbaric O2
10. Irrigate and debride necrotic debris, remove sequestra, resect exposed bone with margin, primary closure, hyperbaric O2
11. Bone marrow inflammation
12. Begins in medullary cavity, spreads to cortical bone, then to periosteum. Bacteria invade cancellous bone, leading to soft tissue inflammation and oedema in closed bone marrow spaces. Increase in tissue hydrostatic pressure and compromised blood supply causing tissue ischaemia and necrosis
13. Immunocompromised, odontogenic infection, mandibular tooth
14. Early, acute suppurative, chronic ± pus
15. Moth-eaten/mottled. If long-standing, involucrum (radiopacity surrounding radiolucency)
16. LT antibiotics ± surgery

Question 6

Post-operative complications 3

1. 3 medications that cause MRONJ
2. 3 indications for bisphosphonates
3. 3 MRONJ risk factors
4. Describe 4 stages of MRONJ
5. Define low risk MRONJ categories
6. Define high risk MRONJ categories
7. MRONJ prevention
8. MRONJ treatment
9. 2 bacteria that cause actinomycosis
10. What is unusual about the spread of infection
11. How to treat/manage
12. Define IE
13. Name 3 groups of patients at high-risk of IE
14. How to manage high-risk patients

Answer 6

1. Bisphosphonates, antiresorptives, biologics, antiangiogenics, RANK-L inhibitors
2. Multiple myeloma, osteoporosis, Paget’s (LT steroids)
3. Extremes of age, bisphosphonates ± steroids, systemic conditions affecting bone turnover, malignancy and invasive dental procedures
4. Stage 0 - no necrotic bone clinically. Symptomatic, radiographic changes, non-specific clinical findings
   Stage 1 - exposed and necrotic bone/fistula that probes to bone
   Asymptomatic, no clinical infection
   Stage 2 - exposed and necrotic bone/fistula that probes to bone
   Infection ± pus drainage (pain, local erythema)
   Stage 3 - exposed and necrotic bone/fistula that probes to bone
   One or more of exposed/necrotic bone extending beyond alveolus, EO fistula, OAC, osteolysis extending to sinus floor or inferior border of mandible
5. Oral/IV bisphosphonates for <5yrs without systemic steroids or denosumab without systemic steroids
6. Oral/IV bisphosphonates for >5yr, oral/IV bisphosphonates or denosumab with systemic steroids, anti-resprotive or anti-angiogenic for cancer, previous MRONJ
7. Avoid surgery where possible. Atraumatic, primary closure
8. Limited sequestrectomy and coverage of exposed bone
9. A. israelli, A, naselundii, A. viscosus
10. Erodes through tissues rather than following fascial planes and spaces
11. High-dose ABX and surgery
12. Inflammation of endocardium, particularly heart valves of CMP caused by bacteria
13. Prosthetic valve, prev IE, cyanotic CHD
14. Consider prophylactic ABX - consult with GP/cardiologist

Question 7

Post-operative instructions

1. Name and describe 9 key post-op instructions that should be given

Answer 7

1. Pain - normal, will settle over 1wk. Normal painkillers before anaesthetic wears off (can alternate NSAIDs/paracetamol)
   Bleeding - unlikely, don’t explore socket, rest for today. Bleeding advice (bite on damp gauze, repeat, contact)
   Smoking - avoid
   Infection - rinse from tomorrow with WSMW
   Sensitivity to adjacent teeth
   Jaw stiffness - normal for few days, should settle
   Swelling - variable, max extent 2 days post-Rx. Alternate hot/cold compress
   Bruising - variable, max extent 2-3 days post-Rx. Cold compress
   Sutures - if present, leave and resorb
   Contact details if unusual/pain, etc. (OOH too)

Question 8

LA

1. What are 2 functions of LA
2. How does LA work
3. 2 types of LA esters
4. 4 types of LA amides
5. Purpose of vasoconstrictor
6. 2 types
7. 2 types of topical anaesthetic and function
8. Describe 2 types of LA injections
9. How to confirm anaesthesia
10. 6 complications of LA
11. Describe 4 advanced LA techniques
12. Max doses of lidocaine, articaine and prilocaine
13. Contraindication for felypressin/octapressin
14. 4 key anatomical landmarks for IDB

Answer 8

1. Prevent pain, reduce bleeding
2. Blocks voltage-gated Na channels. LA binds to a site in Na channel and blocks it, preventing Na influx. This blocks AP generation and propagation. Block persists so long as sufficient number of channels are blocked. Smaller diameter axons have fewer Na channels and are more susceptible to LA block. Na channels are concentrated at nodes of Ranvier in myelinated axons. To block AP, LA needs to act on several along the axon
3. Benzocaine, procaine, cocaine
4. Lignocaine, artisane, prilocaine, bupivicaine, mepivicaine
5. Act locally to constrict BVs, reduce bleeding and blood flow and help to increase duration of LA and keep/hold LA in tissues (prevents wash out of LA)
6. Adrenaline, felypressin
7. 2% lidocaine gel, 20% benzocaine. Superficial soft tissue manipulation and surface anaesthesia
8. Infiltration - LA deposited around terminal nerve branches (inject distal to apex of tooth into mucogingival fold)
   Nerve block - LA deposited beside nerve trunk, abolishing sensation distal to site. Line up correctly, advance to bony contact, withdraw slightly, aspirate, inject slowly (30s). Final quarter administered during slow withdrawal to anaesthetise lingual nerve. If bony contact too soon, reposition mesially
9. Ask patient - rubbery, tingly, numb, swollen/fat (IDB - lower lip and chin to midline, BM, gingiva anterior to mental foramen and lingual gingivae)
10. Failure, prolonged (temporary/permanent), pain during/after, trismus, heamatoma, intra-vascular, blanching, facial palsy (into parotid - CNVII. Reassure patient, ensure not stroke - raise arms, close eyes, cover eye with patch until blink reflex returns), allergy (usually to preservatives), broken needle, interaction with other drugs, toxicity, infection, soft tissue damage
11. Palatal anaesthesia - chasing anaesthesia (follow blanching), intraligamentary (quicker diffusion), intraosseous (into bone), intrapulpal, Now Gates (open mouth aim for neck of condyle), Varizani-Akinosi (closed mouth; trismus; insert needle buccal to teeth on same site as injection site)
12. 4.4mg/kg lido, 7mg/kg art, 8mg/kg pril
13. Pregnancy

14. Coronoid notch
Junction of buccal fat pad/pterygomandibular raphe
Contralateral 4-6s
5-10mm above lower occlusal plane
Bone contact 25-30mm in

Question 9

Analgesia

1. 2 functions of paracetamol
2. Max dose
3. 2 cautions
4. How does aspirin work
5. 2 functions
6. 4 contraindications
7. 2 functions of ibuprofen
8. Max dose
9. 2 contraindications
10. What is diclofenac
11. Max dose
12. What is co-codamol
13. Midazolam dose for anxiety

Answer 9

1. Analgesic, antipyretic
2. 4g/day
3. Hepatic/renal impairment, alcohol-dependent
4. Non-selective COX inhibitor that reduces production of PGs by inhibiting COX-1 and COX-2
5. Antiplatelet, anti-inflammatory
6. PUD, <16yrs old (Reye’s), asthmatics, other NSAIDs, bleeding problems, pregnant, steroids
7. Analgesic, anti-pyretic
8. 2.4g/day
9. Peptic ulcers, pregnant, other NSAIDs, LT steroids, renal/cardiac/hepatic impairment
10. PoM NSAID, more potent
11. 150mg/day
12. Codeine and paracetamol
13. 2mg tablets up to 15mg

Question 10

Surgery 1

1. 8 key stages
2. 4 methods of preventing site contamination
3. 4 key aims of surgery
4. 5 principles of access
5. What is the ideal type of flap
6. 2 purposes of soft tissue retraction
7. 3 instruments used
8. What instrument used for bone removal and tooth division and why
9. How is bone removed
10. Function of irrigation
11. Definition of debridement
12. 3 types
13. 3 instruments used
14. 4 aims of suturing
15. 2 principles of suture technique
16. Function and 2 types of biopsies
17. 2 indications for cryosurgery

Answer 10

1. Anaesthesia, access, bone removal, tooth division, debridement, suturing, haemostasis, POI and post-op meds
2. HH/scrubbing, PPE (sterile gloves, gowns, mask), no touch technique, op site prep
3. Max access with minimal trauma, preserve and protect soft tissues, healing by primary intention (minimise scarring), tension–free wound closure, flap margins and sutures on sound bone
4. Wide-based crevicular incision using scalpel in one firm continuous motion, full thickness incision to bone (through mucoperiosteum), no sharp angles, adequate size, flap reflection cleanly down to bone, minimise trauma to papillae, no crushing of soft tissues, keep tissues moist
5. 2-sided (good access, good reflection, better aesthetics)
6. Improved access to field, protect soft tissues
7. Howarth’s, Wards, Lack’s, Minnesota, rake retractor
8. Electric straight handpick with a saline-cooled tungsten carbide bur (usually round or fissure). Air-driven can cause surgical emphysema
9. Deep narrow buccal gutter (with mesial/distal extension). Allows for correct application of elevators
10. Prevents heat necrosis of bone, damage to soft tissue, clogging of bur, allows field to be kept clean of debris
11. Removal of dead, damaged or infected tissue to improve healing potential of remaining healthy tissue
12. Surgical, mechanical, chemical
13. Bone file, handpick, Mitchell’s trimmer, Victoria curette, irrigation, suction
14. Approximate/reposition tissues, compress BVs, achieve haemostasis, cover bone, prevent wound breakdown, encourage healing by primary intention
15. Tension-free wound closure, evert wound edges in apposition, do not overtighten
16. Surgical diagnostic method
    Incisional - FNA, punch, true cut
    Excision - for small/obviously benign lesions
17. Vascular malformations, mucoceles, atypical facial pain, viral warts, superficial BCC, post-enucleation of OKC

Question 11

Third Molars 1

1. How often are they absent
2. 4 nerves at risk of damage during SR of L8
3. Define unerupted tooth
4. Define partially erupted tooth
5. Define impacted tooth
6. 2 reasons for impaction
7. 4 strong indications for L8 removal
8. 3 relative indications
9. 4 contraindications
10. 4 indications for prophylactic extraction
11. How is angulation of impaction measured and name 5 types
12. Describe depth of impaction categories

Answer 11

1. Up to 25%
2. IAN, lingual, nerve to mylohyoid, (long) buccal
3. Tooth lying within jaws, entirely covered by soft tissue, partially/completely covered by bone
4. Tooth that has failed to erupt fully into normal position. May/not be seen, but in communication with oral cavity
5. Tooth prevented from completely erupting into normal functional position
6. Lack of space, obstruction (other tooth), abnormal eruption path
7. Recurrent pericoronitis, abscesses, PA pathology, unrestorable, caries in 7 which cannot be adequately treated, cyst/pathology formation, 8 causing resorption of 7
8. Active/previous significant infection, MH (removal > retention), limited access to dental care (astronaut, etc.)
9. MH precludes extraction, risk of surgical complications too high, where successful eruption likely and tooth will be functional, deeply impacted asymptomatic tooth
10. Continual food trapping, stagnation area, risk of future GAs if GA required, MH, denture construction/implants, pre-RTx, cardiac surgery, bisphosphonates
11. Measured against occlusal curve of Spee
    Vertical, mesial, distal, horizontal, transverse/aberrant
12. Measured from alveolar crest to max depth of crown
    Superficial - 8 crown related to 7 crown
    Moderate - 8 crown related to 7 crown and root
    Deep - 8 crown related to 7 root

Question 12

Third Molars 2

1. Define pericoronitis
2. Define operculum
3. 4 clinical features
4. 3 Rx options
5. 4 tissue spaces infection can spread
6. 8 post-op complications of SR of L8
7. % risks of temporary and permanent paraesthesia
8. Define coronectomy
9. Key indication (and investigation required)
10. 3 risks
11. 3 contraindications
12. 6 signs of close root relationship with IDC

Answer 12

1. Inflammation of soft tissues around crown of tooth. Requires communication between tooth and mouth. Food trapped under operculum
2. Flap of gingivae overlying tooth
3. Pain (throbbing), swelling (red, tender operculum), pus, bad taste, ulceration, bad smell, trismus, dysphagia, lymphadenopathy, pyrexia, malaise, fever
4. Abscess I+D; XLA U8 if traumatising operculum; XLA L8 after acute episode resolution, ABX
5. Buccal, submasseteric, sublingual, submandibular, parapharyngeal
6. Pain, swelling, bruising, bleeding, infection, dry socket, altered taste, temporary altered sensation, permanent altered sensation
7. Temp - 20% (10-20%)
   Perm - 1% (<1%)
8. Removal of crown of tooth with deliberate retention of roots
9. L8 roots appear closely involved/related (radiographically) to IDC
10. Infection, slow healing, pain, roots may migrate and erupt, removal of entire tooth if root mobilised
11. Mobile tooth/root, non-vital tooth, where sectioning puts nerve at risk (horizontal/disto-angular impaction), predisposition to local infection/immune comp
12. Diversion/deflection of IDC (white lines not parallel), darkening of root where crossed by canal, interruption of white lines/canal lamina dura (loss of continuity), root deflection, canal narrowing, root narrowing, dark and bifid root, junta-apical area

Question 13

Maxillary Sinus 1

1. Type of epithelium
2. 2 functions
3. What is found in posterior wall
4. Function of cilia
5. How is an OAC formed
6. 2 Dx methods
7. Mx
8. 4 POI
9. Define OAF
10. 3 clinical features
11. 2 Dx methods
12. Mx
13. Root in sinus Dx
14. 3 Mx options (including approach)

Answer 13

1. Pseudostratified columnar
2. Voice resonance, reserve chamber for warming air, reduce weight of skull
3. PSA nerves and vessels
4. Mobilise trapped particulate matter and foreign material within the sinus and move this towards the ostia for the elimination into the nasal cavity
5. When a tooth with roots projecting into the sinus is extracted, leaving an opening between the sinus and oral cavity
6. Direct vision (good suction and lighting), probe (gentle), nose holding/blow test, bubbling of blood at base of socket
7. Small - encourage clot and suture margins
   Large - close with BAF
8. Don’t dislodge clot, avoid using straws, playing wind instruments and nose blowing, WSMW from tomorrow, decongestants/steam inhalation, closed sneezing
9. Formation/creation of a pathological epithelial-lined tract between mouth and maxillary sinus. Chronic and occurs secondary to OAC
10. Liquid reflux into nose, minor nose bleeds, nasal speech/singing, problems playing brass/wind instruments, bad taste, sinusitis-type symptoms
11. Direct vision, nose holding/blow test
12. Remove sinus tract (excision), primary closure/BAF
13. Radiograph (OPT/occlusal)
14. Through socket (small curette, narrow-bore suction), OAF-type approach (flap), Caldwell-Luc approach, FESS (endoscopic retrieval)

Question 14

Maxillary Sinus 2

1. Define sinusitis
2. 4 clinical features
3. Cause of acute sinusitis
4. Cause of chronic sinusitis
5. 4 dental pathologies that mimic sinusitis
6. 3 indictors of sinusitis
7. Mx options
8. 4 traumatic/iatrogenic causes of sinusitis

Answer 14

1. Paranasal inflammation and infection
2. Pain/pressure or altered sensation over cheeks (infraorbital region), nasal dischage/congestion, nasal obstruction, hyposmia, headache, fever, dental pain, fatigue, cough, earache, halitosis
3. Following URTI bacterial superinfection of cilia, foreign bodies
4. Foreign bodies, poor drainage
5. TMD, deep caries, PA abscess, perio infection, atypical facial pain, recent extraction sockets
6. Tenderness over cheeks, diffuse maxillary tooth pain, pain that worsens with head movements
7. Decongestants (steam/menthol inhalation, pseudoephedrine), ABX, removal of foreign bodies
8. Orbital wall #, RCT apical perforation, extraction, sinus lifts/implant placement, deep perio Rx, nasal packing, NG tube, mechanical ventilation, foreign objects in sinus

Question 15

TMD 1

1. Define TMD and give 3 other names
2. 4 causes of TMD
3. 6 clinical features of TMD
4. 6 differential Dx of TMD
5. Describe 6 types of conservative advice
6. Describe 3 other types of reversible Rx
7. What are 3 types of TMJ surgery that could be used

Answer 15

1. Pain associated with area of face involving MoM and TMJ. Myofascial pain dysfunction, pain dysfunction syndrome, TMJ, TMD, facial arthromyalgia
2. Myofascial pain, anterior disc displacement ± reduction, degenerative disease (OA, RA), chronic recurrent dislocation, ankylosis, hyperplasia, neoplasia, infection, stress, psychogenic, direct/indirect trauma, parafunctional habits
3. Intermittent pain, muscle/joint/ear pain particularly on waking, trismus/jaw locking, clicking and popping noises, headaches, crepitus
4. TMD, dental pain, sinusitis, ear pathology, SG pathology, referred pain (neck), headache, atypical facial pain, TN, angina, condylar fracture, temporal arteritis
5. No chewing gum, replace missing posterior teeth, supported yawning, soft diet, hot compress, massage, stress Mx (relaxation), reduce opening distance
6. Physiotherapy, hypnotherapy, jaw exercises (screw, spatula, therabite), meds (NSAIDs, muscle relaxants, TCAs, botox, steroids), splints
7. Arthrocentesis, arthroscopy, arthrotomy, condylotomy (high condylar shave) TJR

Question 16

Muscles of Mastication

Give the origin, insertion and function for the following muscles:

1. Temporalis
2. Masseter
3. Medial pterygoid
4. Lateral pterygoid
5. What 2 muscles can be easily palpated

Answer 16

1. Origin - temporal fossa and deep temporal fascia
   Insertion - Coronoid process and anterior border of ramus
   Function - elevation and retrusion
2. Origin - temporal process of zygomatic bone and zygomatic arch
   Insertion - angle and ramus
   Function - elevation and protrusion
3. Origin - maxillary tuberosity and medial surface of lateral pterygoid plate
   Insertion - medial surface of ramus and angle
   Function - elevation and protrusion
4. Origin - infra temporal surface of greater wing of sphenoid and lateral surface of lateral pterygoid plate
   Insertion - neck of mandible (fovea) and capsule/intracapsular disc
   Function - depression and protrusion
5. Temporalis, masseter

Question 17

Sedation 1

1. Define conscious sedation
2. 3 methods/techniques of conscious sedation
3. 5 indications
4. 5 contraindications
5. Describe ASA classification

Answer 17

1. Technique in which the use of a drug or drugs produces a state of depression of the CNS enabling Rx to be carried out, but during which verbal contact with the patient is maintained through the period of sedation.
   The drugs and techniques used to provide conscious sedation for dental Rx should carry a margin of safety wide enough to render unintended LoC unlikely. The level of sedation must be such that the patient remains conscious, retains protective reflexes and is able to understand and respond to verbal commands
2. IV, IS, oral, trans mucosal
3. ASA I or II, mild/moderate learning difficulties, moderate/severe anxiety, medical conditions aggravated by stress (epilepsy, HTN, asthma), medical conditions that inhibit excellent cooperation (Parkinson’s, CP), traumatic/difficult/unpleasant procedures (SR L8), excessive gag reflex
4. Severe/uncontrolled systemic disease, severe mental disability, severe psychogenic problems, unaccompanied, unwilling/uncooperative, narcolepsy, hypothyroidism
5. I - normally healthy
   II - mild systemic disease
   III - moderate systemic disease (limits activity but not incapacitating)
   IV - severe systemic disease that is a constant threat to life
   V - moribund patient who is not expected to survive >24hrs
   VI - Declared brain-dead patient whose organs are being removed for donor purposes

Question 18

Sedation 2 - Inhalation Sedation

1. 5 advantages
2. 5 disadvantages
3. 5 indications
4. 5 contraindications
5. Give 5 key pieces of equipment
6. Describe technique
7. 2 complications
8. 4 signs of adequate sedation
9. 5 key safety features

Answer 18

1. Flexible duration, rapid onset, rapid recovery, no injection required, few side effects, can be used in kids
2. Problems with nasal hood staying in place, coordination of nasal breathing with open mouth, not very potent, expensive, difficulty determining actual dose
3. Mild/moderate anxiety, ASA I or II, enhanced gag reflex, traumatic procedure, medical conditions aggravated by stress, unaccompanied adult requiring sedation
4. Blocked nose, tonsillitis, severe COPD (ASA III or more), neuromuscular disease (MS), pregnancy (first trimester), adequately trained staff not available
5. Gas cylinders, pressure reducing valve, flow control metres, reservoir bag, gas delivery hoses, nasal hood, waste has scavenging system
6. Machine on, mix to 100% O2, flow 5-6l/min. Nasal hood on, patient breathe through nose, check reservoir bag movements, O2 reduced by 10% first min and 5% every other min until patient feels different. Rx finished then O2 increased by 10-20% every min. 2-3mins of 100% O2 to prevent diffusion hypoxia, nasal hood removed, machine off
7. Over-sedation - nausea, headache, vomiting, unresponsive
   Panic - reduce sedation, reassure patient
8. Relaxation, warmth, giddiness, paraesthesia, lethargy, lessened pain awareness, slowed response to commands (but still responsive)
9. Air entrapment valve, oxygen flush button, oxygen monitor, colour coding, reservoir bag, scavenging system, pressure dials, pressure reducing valve

Question 19

Sedation 3 - IV Sedation

1. 5 advantages
2. 5 disadvantages
3. 5 indications
4. 5 contraindications
5. What drug is used in what concentration and describe increments used
6. What is GABA
7. How is GABA affected by sedation
8. 3 side effects of sedation
9. Name reversal agent and concentration and how to use
10. Risk of flumazenil
11. 3 vital signs to monitor
12. 5 complications of IV sedation
13. 3 signs of adequate sedation
14. 2 common cannulation sites

Answer 19

1. Good sedation and muscle relaxation, lessened pain awareness, forget after Rx, easy to control/titrate, few side effects if done properly
2. IV cannula, difficulty assessing sedation level, behaviour during recovery, swallowing efficacy, escort for 24hrs, doesn’t address anxiety
3. ASA I or II, >12yrs old, mild/moderate anxiety, traumatic procedure, medical conditions aggravated by stress, cerebral palsy, Parkinson’s
4. ASA III or IV, COPD, <12yrs old, pregnancy, NM diseases (myasthenia gravis), hepatic insufficiency, intracranial pathology
5. Midazolam. 1mg/ml. 1-2ml bolus then 0.5-1ml increments every 2 mins
6. Inhibitory neurotransmitter
7. BNZ act on CNS receptors to enhance the effect of GABA, reducing neuronal excitability and prolonging time for receptor repolarisation
8. Resp depression, hypotension, tachycardia
9. Flumazenil. 100mcg/ml. Injected in the same volume as midazolam, but can be given in larger boluses if ME
10. Shorter half life than midazolam so may wear off and re-sedate patient
11. Oxygen sats, BP, HR
12. Venospasm, intra-arterial infection, extravascular injection, haematoma, fainting, hyper-response, hypo-response, paradoxical reaction, allergic reaction, over-sedation, sexual fantasy
13. Slurring/slowing of speech, delayed response to commands, relaxed, Verrill’s sign (halfway eyelid ptosis), Eve’s sign (can’t touch nose)
14. Dorsum of hand, antecubital fossa

Question 20

TMJ Surgery 1

1. 5 indications
2. Define internal derangement
3. Describe difference between anterior disc displacement with and without reduction
4. Name and briefly describe 5 types of TMJ surgery

Answer 20

1. Neoplasia/other pathology, ankylosis, recurrent chronic dislocation, developmental disorders, OA, trauma, TMD, internal derangement, chronic severe limited mouth opening
2. Painful clicking. Lack of coordinated movement between condyle and articular disc. Condyle has to overcome mechanical obstruction before full point movement can be achieved
3. With reduction - disc displaced anteriorly during opening until disc reduction occurs. Disc returns to normal on closing. After closing, process repeats. Short-lasting tightness
   Without reduction - condyle cannot translocate as normal. Permanent tightness/locking. Requires disc relocation
4. Arthrocentesis - lavage of upper joint space (endoscopic) using Hartman’s/hyaluronic acid to break down adhesions and remove inflammatory exudate, allowing disc to reposition
   Arthroscopy - endoscopic lavage of joint space, adhesion removal, removal of damaged tissue, plication to reposition disc
   Arthrotomy - open joint surgery, lavage of space and removal of disc (discectomy)
   Condylotomy - high condylar shave. Condyle repositioned anteriorly and inferiorly beneath disc, improving function
   TJR - where gross destruction of joint architecture and marked reduced function. Condylar head and glenoid fossa replaced

Question 21

Orthognathic Surgery

1. Purpose
2. 3 indications
3. Name and briefly describe 4 common surgical procedures

Answer 21

1. Correct conditions of jaw and face caused by underlying skeletal disharmonies
2. Gross jaw deficiencies, airway defects, TMJ pathology, acromegaly, trauma, soft tissue discrepancies
3. LFI - disarticulate maxilla from BoS and reposition
   LFII - midface advancement
   LFIII - move entire mid face and zygoma complex
   SSO - separation of ramus from body (BSSO)
   Vertical subsigmoid osteotomy - mandible posterior movement
   Bimax - LFI and SSO

Question 22

Bone Grafts and Implants

1. 3 indications
2. 5 contraindications
3. Describe osseointegration
4. Describe 4 types of bone graft

Answer 22

1. Bone preservation and prevention of resorption, restore aesthetics and function, denture retention
2. RTx to jaw, LT bisphosphonates, poor OH, perio disease, pathology, uncontrolled diabetes, poor bone quality or quantity
3. Direct abutment of bone to implant surface such that osteoblasts can be seen on electron micrographs to be growing on the implant surface
4. Autograft - own tissue (chin, ramus, iliac crest, rib)
   Allograft - other (donor) human
   Xenograft - anomal
   Alloplast - synthetic bone substitute

Question 23

Fractures 1

1. 6 clinical features of mandible #
2. 2 Ix requested
3. 3 Mx options
4. 7 classification methods
5. 4 factors contributing to displacement
6. 6 clinical features of maxillary #
7. 2 Ix requested
8. 3 Mx options
9. Describe 3 classification systems
10. 6 clinical features of ZOC #
11. 2 Ix requested
12. 3 Mx options
13. Describe Henderson’s classification
14. 3 aetiological reasons for OMF trauma

Answer 23

1. Pain, swelling, bruising
   Limitation of function (trismus), occlusal derangement (disclusion), lower lip/chin numbness, loose/mobile teeth, bleeding, AOB, asymmetry, deviation to opposite side, step deformity, gap between teeth, SL haematoma, battle signs
2. OPT, PA mandible, CBCT
3. Control pain and infection; If undisplaced, KUO; closed reduction (IMF); ORIF. POI - soft/liquid diet for 6wks, rest, analgesia
4. Side, number, site, type (involvement of surrounding tissues), displacement, direct of # line, specific types
5. Direction of #line, opposing occlusion, magnitude of force, mechanism of injury, intact soft tissues, other associated fractures
6. Pain, swelling, bruising, mobile teeth, tooth loss, disclusion, trismus, otorrhoea, rhinorrhoea, cracked cup sound, bleeding, infraorbital numbness, mid face mobility, retruded mid face, orbital rim step deformity
7. CBCT, OPT
8. If undisplaced, KUO; closed reduction (IMF), ORIF
9. LFI - horizontal. Detachment of tooth-bearing portion of maxilla via line from anterior margin of ant nasal aperture running laterally and back to lower third of pterygoid plate
   LFII - pyramidal. Detachment of true mid face, involvement of inferior orbital rim
   LFIII - transverse. Detachment of entire facial skeleton from cranial base. Involves z arch and FZ suture
10. Pain, swelling, bruising (bilateral ecchymosis), subconjunctival haemorrhage, infraorbital numbness, trismus, lacerations or excoriations, facial flattening, orbital rim step deformity, proptosis, diplopia, tethering, enophthalmos, reduced visual acuity
11. OM 15d and 30d views, CBCT
12. If undisplaced, KUO; closed reduction (IMF), ORIF (Gillies lift)

13.I – undisplaced
II – zygomatic arch
III – tripod # with F-Z undisplaced
IV – tripod # with F-Z displaced
V – orbital blowout 
VI – orbital rim #
VII – comminuted #

14. Assaults, RTA, industrial, iatrogenic, falls, war

Question 24

Dentofacial Infections

1. 2 key microbes
2. 5 cardinal signs of inflammation/infection
3. Standard Rx of dentofacial infection
4. 3 emergency signs for OMFS referral

Describe which fascial space/plane that untreated infections of the following teeth can invade into:

5. Lower anteriors (2 and why)
6. Lower posteriors (7 and why)
7. Upper anteriors (2)
8. Upper posteriors (5)
9. 5 indications for ABX with dento-facial infections
10. 3 signs of Ludwig’s angina

Answer 24

1. S. anginosus, P. intermedia
2. Heat, redness, swelling, pain, loss of function
3. I+D, remove source (often XLA), PO analgesia/ABX
4. Airway compromise, swallowing difficulties, rapid spreading facial infection (over midline), sepsis risk
5. Submental, sublingual (roots above mylohyoid attachment/line)
6. Sublingual (roots above mylohyoid attachment) or submandibular (roots below mylohyoid attachment), buccal (roots below buccinator attachment), submasseteric, parapharygneal, retropharyngeal, pterygomandibular
7. Infraorbital, palate
8. Buccal (roots above buccinator attachment), superficial temporal, deep temporal, infratemporal, palate
9. Immunocompromised, extremes of age, FoM, associated systemic symptoms (fever, malaise), lymphadenopathy, dysphagia, airway compromise
10. Bilateral abscess and cellulitis of SM and SL spaces
    Raised FoM, board-hard neck, FoM and tongue, systemic symptoms, skin hot to touch

Question 25

Cysts 1

1. Definition
2. How do they arise
3. 6 clinically features
4. 2 key Ix
5. Describe 2 Rx options
6. Name 3 odontogenic
7. Name 3 non-odontogenic
8. How common is radicular
9. How does radicular arise
10. Mx
11. 2 histological features
12. 2 other types of radicular cyst
13. How does an inflammatory paradental cyst present
14. Define dentigerous
15. How common
16. How does it appear
17. 2 histological features
18. Name variant associated with anterior teeth and (young) kids
19. Difference between enlarged follicle and dentigerous cyst

Answer 25

1. Pathological cavities with fluid, semi-fluid or gaseous content, not create by pus accumulation
2. Odontogenic epithelium (cell rests of Malaise or glands or Serres)
3. Asymptomatic, pressure build-up, tooth mobility, tooth displacement, tooth discolouration, delayed eruption, ectopic eruption, swelling, discomfort, altered sensation, bone perforation, bad taste, sinus tract
4. Radiographs (usually unilocular, well corticated, unicentric expansion), aspiration Bx
5. Enucleation - removal of entire cystic lesion including lining and fibrous CT wall. Single visit, good for path and primary closure. Gold standard unless v large or high risk of recurrence
   Marsupialisation - de-roof and gradual deflation. Surgical window in cyst wall, removal of intracystic contents and suturing cyst wall open. Encourages cyst to decrease in size and usually followed by enucleation. For when enucleation contraindicated (risk of damage to important structure, difficult access, risk of jaw #)
6. Radicular, residual, dentigerous, OKC
7. Nasopalatine, simple bone, aneurysmal, Stafne cavity
8. 60-70%
9. Tooth pulpitis (caries/trauma) leading to necrosis, PA granuloma (apical bone inflammation), stimulation of rests of Malaise, epithelial proliferation and radicular cyst formation and growth
10. RCT of tooth
11. Thin (often incomplete) epithelial lining, fibrous CT wall/capsule with inflammation present. Epithelial hyperplasia/ulceration if infection present
12. Residual (cyst left after extraction), inflammatory lateral perio
13. Usually adjacent to crown but doesn’t surround it, related to erupted/PE tooth. Pouch lined by non-keratinised epithelium. Usually 8s, associated with recurrent pericoronitis
14. Developmental cyst that forms around crown of unerupted tooth
15. 10-15%
16. Wall attached to ACJ and entire crown sits in cystic cavity
17. Thin non-keratinised mucosa, layer of fibrous CT sandwiched between reduced enamel epithelium and oral mucosal epithelium
18. Eruption cyst
19. <2.5mm diameter - follucle
    >4.2mm diameter - probable cyst
    >10mm diameter - cyst

Question 26

Cysts 2

1. Prev name for OKC
2. 2 unique features
3. 3 features that increase risk of recurrence
4. How common
5. Key radiographic appearance (and 3 other differentials)
6. 3 histological features
7. Key FNA feature vs normal cysts
8. Syndrome associated with multiple OKCs and superficial BCCs
9. Key difference between radicular and nasopalatine
10. What is unique about simple bone cysts and how are they managed

Answer 26

1. KCOT
2. Aggressive growth (bone infiltration), high rate of recurrence
3. Site, size, residual cells (daughter cells in CT wall)
4. 5-10%
5. Multilocular, scalloped, drowns in AP direction usually in mandible ramus/angle
   Ameloblastoma, giant cell lesion, odontogenic myxoma, cherubsim, aneurysmal bone cyst
6. Thin epithelium, parakeratosis, pallasading basal
   layer, thin capsule, daughter cysts/satellite cysts, low soluble protein content (<4g/dl)
7. Keratin/cheese-like semi-solid fluid. Normal is clear fluid
8. Gorlin-Goltz syndrome
9. NP - associated with vital teeth so PDL space present
10. Often empty cavities devoid of lining. Resolve spontaneously or after trauma (debridement, exploration)

Question 27

Odontogenic Tumours 1

1. 4 types of non-odontogenic tumours
2. 4 types of odontogenic tumours
3. 2 clinical features of papillomas
4. 2 clinical features of osteomas and syndrome associated with multiple
5. 2 clinical features of ossifying fibromas
6. 2 radiographic features
7. 2 histological features
8. 3 types of ameloblastoma
9. 3 clinical features
10. 2 Ix
11. How to reduce recurrence
12. 3 histological features

Answer 27

1. SC papilloma, fibroma, lipoma, osteoma, osteoblasto, ossifying fibroma
2. Ameloblastoma, adenomatoid odontogenic tumour, calcifying epithelial odontogenic tumour, myxoma, ameloblastic fibroma, odontome
3. White/pink, cauliflower appearance
4. Smooth, hard benign neoplasms of bone. Unilateral, covered by normal mucosa. Gardner syndrome
5. Slow growing, well demarcated, painless, expansive growth
6. Well-defined radiolucency, well-corticated
7. Cellular fibrous tissue, immature bone, acellular calcifications
8. Unicystic, polycystic, peripheral
9. Slow growing, expansive growth, locally destructive, rarely metastasise
10. CBCT, Bx
11. Clear surgical margins
12. Islands of follicles, peripheral cells resemble ameloblasts, centre resembles stellate reticulum which may show changes

Question 28

Odontogenic Tumours 2

1. Radiographic appearance of adenomatoid odontogenic tumours
2. Why low recurrence rate
3. Radiographic appearance of calcifying epithelial odontogenic tumours
4. Radiographic appearance of odontogenic myxomas
5. 2 histological features
6. Why high recurrence rate
7. Describe difference between 2 types of odontomes

Answer 28

1. Patchy calcification
2. Capsule
3. Radiolucency with scattered radiopacities
4. Multilocular ‘soap bubble’ appearance
5. Very loose CT, sparse cells, high quantity of glycans
6. Soft/gelatinous tissue which can tear easily
7. Compound - multiple small teeth (denticles) in fibrous sac. Tissue formed in correct order
   Complex - irregular mixture of dental hard tissues formed/mixed in a random order