CDS Oral Surgery

Question 1

Process of acute apical abscess formation

Answer 1

Irreversible pulpitis - loss of tooth vitality - apical periodontitis - acute apical abscess

Question 2

Infection from maxillary molar spreads buccally above the insertion of the buccinator

Answer 2

Spreads into buccal space causing buccal swelling

Question 3

Maxillary molar infection breaks through buccally below the insertion of the buccinator

Answer 3

Drains into the mouth creating a draining sinus on the attached mucosa
Quite painless usually but a bad taste and possibly a bubble present

Question 4

Why is infection from a maxillary molar more likely to spread buccally than palatally?

Answer 4

Infection follows the path of least resistance, bone is less dense buccaly

Question 5

Which tooth in the upper arch is most likely to have infection spread palatally?

Answer 5

Lateral incisor - root is quite palatally placed

Question 6

What happens if infection from maxillary tooth spreads upwards?

Answer 6

Into maxillary sinus - can cause sinusitis, rare

Question 7

Infection from lower tooth spreads lingually and perforates the bone above the insertion of mylohyoid

Answer 7

Spreads into the sublingual space, creating a sublingual abscess

Question 8

Infection from lower tooth spreads lingually and perforates the bone below the insertion of mylohyoid

Answer 8

Spreads into the submandibular space

Question 9

Does sublingual or submandibular infection cause more problems?

Answer 9

Submandibular

Question 10

Infection from lower tooth spreads buccally and perforates the bone above the insertion of buccinator

Answer 10

Draining sinus into the mouth

Question 11

Infection from lower tooth spreads buccally and perforates the bone below the insertion of buccinator

Answer 11

Buccal space infection and swelling

Question 12

Which direction is infection in the posterior lower teeth likely to spread?

Answer 12

Lingually - bone is thinner than buccally

Question 13

Which direction is infection in the lower anterior teeth likely to spread?

Answer 13

Labially

Question 14

What determines whether infection spreads into sublingual or submandibular space from the lower teeth?

Answer 14

Which tooth is affected in relation to the mylohyoid line
Premolars more likely to end up in the sublingual space
7 or 8 infections most likely into the submandibular space

Question 15

Masticatory spaces

Answer 15

Pterygomandibular space
Infratemporal space
Deep temporal space
Superficial temporal space
Masseteric space
Infection can easily spread between lots of these spaces as all of them communicate with each other

Question 16

Result of infection spreading to masticatory spaces on the muscles

Answer 16

Severe trismus - the muscles go into spasm

Question 17

Pterygomandibular space

Answer 17

Bound by the mandible, medial and lateral pterygoid muscles

Question 18

Infratemporal space

Answer 18

Infratemporal fossa region

Question 19

Deep temporal space

Answer 19

Deep to temporalis

Question 20

Superficial temporal space

Answer 20

Superficial to temporalis

Question 21

Masseteric space

Answer 21

Between the masseter and the ramus of the mandible

Question 22

Path of infection spreading to masticatory spaces

Answer 22

Sublingual/submandibular spreads backwards into the jaw

Question 23

Where can infection spread to from masticatory spaces?

Answer 23

Lateral pharyngeal space
then
Retropharyngeal space
then
Prevertebral space

Question 24

Clinical appearance of infection in the lateral pharyngeal space

Answer 24

Oral cavity has an area being pushed in around the lateral pharyngeal space, a bulge in the pharynx

Question 25

Where can infection in the retropharyngeal space spread to?

Answer 25

Upwards - base of the skull Downwards - superior mediastinum

Question 26

Where can infection in the prevertebral space spread to?

Answer 26

Upwards - base of the skull Downwards - inferior mediastinum

Question 27

What can infection spread to the mediastinum cause?

Answer 27

Cardiac tamponade

Question 28

What can infection spreading to the base of the skull lead to?

Answer 28

Abscess on the brain

Question 29

Infection in the cavernous sinus

Answer 29

Infection can spread into the cavernous sinus, resulting in a cavernous sinus thrombosis - rare

Question 30

Path of upper vs lower tooth infection to cavernous sinus

Answer 30

Upper - infraorbital space - valveless veins in this region - cavernous sinus Lower - Lateral pharyngeal space - infratemporal space - pterygoid plexus which communicates with the brain - valveless veins - cavernous sinus

Question 31

Infection from upperr anterior spread

Answer 31

Lip Nasiolabial Lower eyelid

Question 32

Infection from upper lateral incisor spread

Answer 32

Palate Face

Question 33

Upper premolars and molars infection spread

Answer 33

Cheek Infra-temporal region Maxillary antrum (v rare) Palate

Question 34

Chronic draining abscess

Answer 34

Infection drains into mout Blister forms, bursts, bad taste, disappears then comes back

Question 35

Clinical sign of infraorbital infection

Answer 35

Loss of nasiolabial fold

Question 36

Lower anterior teeth infection spread

Answer 36

Mental and submental space Tend to stick there but could spread into the sublingual or submandibular space

Question 37

Lower premolars and molars infection spread

Answer 37

Buccal space Submasseteric space Sublingual space Submandibular space Lateral pharyngeal space

Question 38

Clinical sign of submandibular space infection

Answer 38

Can't feel the border of the mandible

Question 39

Surgical management of large abscesses

Answer 39

Sometimes under local, otherwise it requires hospital admission and GA Establishment of drainage - get rid of pus Incise the skin if necessary - if possible do this intra-orally, may need to be extra-orally Remove source of infection - extirpate pulp or extract - ideally immediately but v difficult to anaesthetise pt when they have severe infection

Question 40

Antibiotic therapy for large abscesses

Answer 40

Depends on lots of factors Not offered if you can remove the cause and obtain proper drainage and no need in pts that are not systemically unwell Consider Toxicity Desirability Medical history

Question 41

SIRS

Answer 41

Systemic inflammatory response syndrome Raised temp Raised HR Raised resp rate Raised white cell count

Question 42

What does SIRS indicate?

Answer 42

Antibiotic therapy and urgent hospital referral

Question 43

Anatomical consideration when incising submandibular abscess

Answer 43

Consider the marginal mandibular branch of the facial nerve, which runs down the border of the mandible and ends at the corner of the mouth. Always go at least 2 fingers with below the inferior border of the mandible. If the branch is damaged it can stop patients smiling on that side of the face.

Question 44

How to drain abscess once incised

Answer 44

Finger into the hole or Hilton technique

Question 45

Hilton technique

Answer 45

To drain an abscess - use scissors or instrument with two ends, insert instrument in closed position and open in the incision, stretching the tissues.

Question 46

Once you have surgically drained an abscess how is it managed?

Answer 46

Drain is sutured in for a few days and covered with a dressing Dressing is repeatedly replaced until it is clean

Question 47

Ludwig's angina

Answer 47

Bilateral cellulitis of the sublingual and submandibular spaces

Question 48

Ludwig's angina features

Answer 48

Raised tongue Difficulty breathing Difficulty swallowing Drooling Diffuse redness and swelling bilaterally in submandibular region SIRS

Question 49

Why does Ludwig's angina require urgent treatment?

Answer 49

Can compromise the airway

Question 50

Is gram positive or gram negative purple?

Answer 50

Gram positive

Question 51

Cocci vs bacili

Answer 51

Cocci - round Bacili - rod shape

Question 52

Streptococcus structure

Answer 52

chains

Question 53

Capnophilic bacteria meaning

Answer 53

Need carbon dioxide to survive and grow

Question 54

What type of microorganism does metronidazole work on?

Answer 54

Only strict anaerobes

Question 55

Types of acquired resistance

Answer 55

Mutation Acquisition of new DNA - transformation, transduction or conjugation

Question 56

DNA transformation

Answer 56

Uptake of short fragments of naked DNA by naturally transformable bacteria

Question 57

DNA transduction

Answer 57

Transfer of DNA from one bacterium into another via bacteriophages

Question 58

DNA conjugation

Answer 58

Transfer of DNA material via sexual pilus, required cell to cell contact

Question 59

Altered target site antibiotic resistance

Answer 59

The path of entry for the antibiotic into the bacteria cell has changed shape and the antibiotic can no longer get in the attack the inside of the bacteria

Question 60

Pulp hyperaemia

Answer 60

Increased blood supply to the pulp Pulp can recover from minor trauma at this stage, going back to normal or an acute pulpitis could develop Sharp pain lasting for seconds when stimulated, resolving after stimulus Caries approaching pulp but tooth can still be restored without treating pulp Reversible pulpitis

Question 61

Acute pulpitis

Answer 61

Sudden onset inflammation of the pulp Constant severe pain Reacts to thermal stimuli Referral of pain/ poorly localised pain Little response to analgesics Becoming irreversible This can become a chronic pulpitis which will flare up every now and then (goes between acute and chronic)

Question 62

Chronic pulpitis spread out of the pulp chamber becomes

Answer 62

Acute apical periodontitis

Question 63

Acute apical periodontitis can develop into ___ when actual infection is present (not just inflammation)

Answer 63

Acute apical abscess

Question 64

Abscess

Answer 64

A collection of dead neutrophils and other cells

Question 65

Chronic apical infection

Answer 65

Can go back and forth with acute apical abscess, when the abscess subsides but there is ongoing low grade infection around the apex

Question 66

Apical cyst

Answer 66

Can form from long term chronic apical infection Painless but can increase in size over time or become infected - painful

Question 67

Open pulpitis symptoms

Answer 67

Can be less severe as the exposed pulp releases pressure

Question 68

Acute pulpitis diagnosis

Answer 68

History Visual exam Negative TTP usually as PDL is not yet inflamed Pulp testing is ambiguous Radiographs won't show much except from a big cavity Diagnostic LA - numb the pt next to suspected tooth and see if the pain goes away Removal of restorations if necessary

Question 69

What can happen once there is an acute pulpitis?

Answer 69

It can to and fro with chronic pulpitis or develop into an acute apical periodontitis

Question 70

Acute apical periodontitis diagnosis

Answer 70

Easy diagnosis TTP Tooth is non vital (unless traumatic) Radiographs - loss of lamina dura, radiolucent shadow (may indicate an old lesion eg. flare up of apical granuloma), delay in changes of apex of tooth, widening of apical periodontal space and possible resorption of the root

Question 71

Cause of traumatic periodontitis

Answer 71

Parafunction - clenching or grinding

Question 72

Diagnosis of traumatic periodontitis

Answer 72

Clinical exam of the occlusion - functional positioning, posturing TTP Normal vitality Radiographs - may show generalised widening or periodontal space

Question 73

Treatment for traumatic periodontitis

Answer 73

Occlusal adjustment Therapy for parafunction

Question 74

Causes of acute apical abscess

Answer 74

Acute apical periodontitis can develop into this Pericoronitis - inflammation around a crown, usually PE Periodontal abscess - pulp is fine, abscess develops directly in the periodontium Sialadenitits - infection of the glands, usually one of the major salivary glands, resulting in swelling and redness, dryness and pus

Question 75

Acute apical abscess organisms

Answer 75

Polymicrobial Anaerobes play an important part Strep anginosus, prevotella intermedia both common

Question 76

Antibiotics effective against strep anginosus examples

Answer 76

Penicillin Erythromycin

Question 77

When does antimicrobial resistance occur?

Answer 77

When microorganisms such as bacteria viruses fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective

Question 78

How do antibiotics fight infection?

Answer 78

Inhibit bacterial cell wall synthesis, damage cell membranes, disrupt bacterial metabolism and restrict the ability to multiply

Question 79

Broad spectrum antibiotics

Answer 79

Target several classes including good bacteria, making them unsuitable for self limiting conditions

Question 80

Where can antibiotic resistant bacteria occur?

Answer 80

In anyone who uses antibiotics, and can live in that person for up to a year

Question 81

Altered target site

Answer 81

Mechanism of antibiotic resistance The way that the antibiotic gets into the bacteria cell has changed shape and the antibiotic can no longer get in to attack the inside of the bacteria

Question 82

Enzymatic inactivation

Answer 82

Mechanism of antibiotic resistance Bacteria produces enzymes which destroy antibiotics or prevent binding to target sites and having effect on the bacteria

Question 83

What is the usual antibiotic resistance mechanism of prevotella and fusobacterium?

Answer 83

Beta-lactamase enzymes

Question 84

Carbapenems

Answer 84

New class of beta lactam antiobiotics developed to counteract ESBLs Almost generate a forcefield around the beta lactam molecule (BUT bacteria have developed a carbapenemase enzyme)

Question 85

ESBLs

Answer 85

Extended spectrum beta lactamases Enzyme produced by bacteria which reduce the choice of antibiotics that can work

Question 86

CPE

Answer 86

Carbapenemase producing eneterobacterales - almost untreatable

Question 87

Enterobacterales

Answer 87

Group of gram negative bacili found in common infections such as E.coli

Question 88

Last therapeutic option to treat complex infections caused by multi drug resistant bacteria

Answer 88

Carbapenems

Question 89

Decreased uptake mechanism

Answer 89

Mechanism of antibiotic resistance Thick gelatinous capsule around bacterial cell wall - very difficult to get antibiotics to penetrate the mucopolysaccharide

Question 90

What is the key to treating any dental infection?

Answer 90

Remove the source - extraction or extirpation of the pulp

Question 91

Methods of resistance

Answer 91

Mutation Inactivation Efflux - antimicrobials pumped out of cell

Question 92

Two routes of infection from oral cavity to periapical region

Answer 92

Through crown - carious cavity or trauma -> pulp -> apical foramen Via periodontal ligament

Question 93

Endogenous infection

Answer 93

Infectious agent is derived from our own flora

Question 94

Examples of microbial agents involved in acute dental infection

Answer 94

Strep anginosus (gram +ve cocci) Prevotella intermedia (gram -ve bacili)

Question 95

What clinical specimen is best for investigation of microbials in acute periapical infection?

Answer 95

Aspirated pus (has not been contaminated with saliva flora)

Question 96

Examples of microbial agents involved often in periodontal abscess

Answer 96

Anaerobic streptococci Prevotella intermedia

Question 97

Treatment for localised infection

Answer 97

Establish and document a diagnosis Remove the source of infection

Question 98

Examples of microbial agents involved in pericoronitis

Answer 98

Predominantly mixed oral anaerobes - e.g. P intermedia, S.anginosis

Question 99

Treatment for pericoronitis

Answer 99

Local measures such as operculectomy, systemic tx only if systemic symptoms, metronidazole if appropriate

Question 100

Microbial cause of dry socket and tx

Answer 100

Localised alveolar osteitis Mixed oral flora Does NOT require antibiotics, local tx such as curettage of socket, rinse, alvogyl

Question 101

Predisposing factors for osteomyelitis of the jaws

Answer 101

Bisphosphonate therapy Impaired vascularity of bone (radiotherapy, Pagets disease) Foreign bodies (implants) Compound fractures Impaired host defences (diabetes)

Question 102

Treatment of osteomyelitis of the mandible

Answer 102

LA, curettage, IV antibiotics

Question 103

Microbiology involved in osteomyelitis of the mandible

Answer 103

Anaerobic gram -ve bacilli Anaerobic streptococci S anginosus, S aureus

Question 104

Management of salivary gland infection

Answer 104

Drain the pus Flucloxacillin and metronidazole

Question 105

Microbiology of salivary gland infection

Answer 105

S aureus and mixed anaerobes

Question 106

What needs documented when treating an infection?

Answer 106

Diagnosis Antibiotic choice, dose, route and duration Review date Document deviation from guidance

Question 107

Ludwig's angina

Answer 107

Bilateral infection of the submandibular space Most commonly caused by anaerobic gram negative bacilli Strep anginosus and anaerobic streptococci, could be staph aureus

Question 108

Most common microbial associated with hospitalisation from dental infection

Answer 108

S milerii and mixed anaerobes

Question 109

Sepsis

Answer 109

Life threatening organ dysfunction caused by disregulated host response to infection SIRS + suspected/confirmed infection

Question 110

SIRS

Answer 110

Systemic inflammatory response syndrome Temp <36 or 38+ Heart rate >90/min Resp rate >20/min WCC <4000/μL or >12000/μL

Question 111

Sepsis six

Answer 111

Give high flow oxygen Take blood cultures Give IV antibiotics Give a fluid challenge Measure lactate Measure urine output

Question 112

S I R for choice of antibiotics

Answer 112

Susceptible at standard dose Susceptible at increased dose Resistant even with increased dose

Question 113

What is a breakpoint of an antibiotic?

Answer 113

A chosen concentration (mg/L) of an antibiotic which defines whether a species of bacteria is susceptible or resistant to the antibiotic

Question 114

Resistance

Answer 114

A high likelihood of therapeutic failure even when there is increased exposure

Question 115

Stewardship

Answer 115

An organisational or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness A coherent set of actions which promote using antimicrobials responsibly

Question 116

2 key ways of tackling AMR

Answer 116

Reducing the need for and unintentional exposure to antimicrobials Optimising the use of antimicrobials

Question 117

Responsibilities of stewardship

Answer 117

Vaccination Infection prevention and control Public health interventions - e.g sanitation, oral health Antimicrobial prescribers

Question 118

WHO global action plan on antimicrobial resistance 5 strategic objectives

Answer 118

Improve awareness and understanding Strengthen the knowledge through surveillance and research Reduce the incidence of infection Optimise the use of antimicrobial medicines Ensure sustainable investment

Question 119

Recommended first line when antibiotics required for acute dento-alveolar infection

Answer 119

Phenoxymethylpenicillin

Question 120

What is penicillin V most effective against?

Answer 120

Oral streptococci Anaerobes Selected gram negative cocci

Question 121

Amoxicillin compared to Pen V

Answer 121

Possesses the same spectrum plus more active against gram negative cocci and members of the family enterobacteriaceae

Question 122

Strep anginosus is invariably sensitive to _____

Answer 122

Amoxicillin and Pen V

Question 123

what is the problem with using amoxicillin over Pen V?

Answer 123

Broader spectrum of activity so it has a greater impact on selection of resistance in the host micro flora

Question 124

Recommended dose of first line antibiotics for acute dentoalveolar infection

Answer 124

Phenyoxymethylpenicillin 500mg 6 hourly 5 days Important to review after 24-48 hours

Question 125

Examples of unacceptable reasons for dental antibiotic prescribing

Answer 125

Workload pressures Unsure of diagnosis Treatment had to be delayed

Question 126

Three examples of oral health conditions that antibiotics DO NOT WORK FOR

Answer 126

Acute pulpitis Gingivitis Sinusitis

Question 127

Alternative causes of acute apical abscess (not usual route of acute pulpitis to apical periodontitis)

Answer 127

Periodontal abscess - pulp is fine, abscess develops directly in the periodontium Pericoronitis - inflammation around a crown, usually partially erupted Sialadenitis - infection of the glands, usually one of the major salivary glands, resulting in swelling and redness, dryness and pus

Question 128

Cervico-facial actinomycosis

Answer 128

Very chronic pus producing infection which can develop after an extraction

Question 129

5 cardinal signs of inflammation

Answer 129

Heat Swelling Pain Redness Loss of function

Question 130

Symptoms of early stage abscess before the infection has broken through bone and into soft tissues

Answer 130

Almost identical to acute apical periodontitis Severe unremitting pain Acute tenderness in function Acute tenderness to percussion No swelling, redness or heat until the abscess spreads out from within the jaw bone

Question 131

Symptoms of acute apical abscess that has perforate through bone

Answer 131

Pain often remits initially due to release in pressure (unless in the palate) Swelling, redness and heat (in soft tissues) become increasingly apparent As swelling increases pain returns There is initial reduction in tenderness to percussion of the tooth as pus escapes into the soft tissues

Question 132

Factors determining the site of spread of dental infection

Answer 132

Position of the tooth in the arch Root length Muscle attachments

Question 133

Potential spaces in proximity to lesion that dental infection could spread into

Answer 133

Submental space Sublingual space Submandibular space Buccal space Infraorbital space Lateral pharyngeal space Palate

Question 134

Need for antibiotics in case of dental infection is determined by

Answer 134

Severity Absence of adequate drainage Patients medical condition Local factors

Question 135

Local factors denoting need for antibiotics

Answer 135

Toxicity (if pt is systemically unwell) Airway compromisation Dysphagia Trismus Lymphadenitis Location - floor of mouth

Question 136

Systemic factors denoting need for antibiotics in case of dental infection

Answer 136

Immunocompromised pt - acquired causes (HIV), drug induces (steroids/cytostatics), blood disorders (leukaemias), poorly controlled diabetes, extremes of age

Question 137

Reversible pulpitis

Answer 137

A level of inflammation in which returning to a normal state is possible if noxious stimuli removed The pulp is inflamed due to caries or a restoration etc, if the cause is removed, the pulp will recover to normal health Usually mild to moderate tooth pain, no pain without stimulus, subsides in <5secs, no mobility, no pain on percussion

Question 138

Irreversible pulpitis

Answer 138

Higher level of inflammation where the dental pulp has been damaged beyond the point of recovery Sharp throbbing sever pain upon stimulation and pain may be spontaneous or occur without stimulation, pain persists after stimulus is removed, >5secs TX - RCT or extraction

Question 139

Periapical granuloma

Answer 139

Chronic apical periodontitis Mass of chronically inflamed granulation tissue at apex of tooth (plasma cells, lymphocytes and few histocytes with fibroblasts and capillaries) NOT a true granuloma because not granulomatous inflammation (it has epithelioid histiocytes mixed with lymphocytes and giant cells)

Question 140

Etiology of an apical radicular cyst

Answer 140

Caries/trauma/periodontal disease Death of dental pulp Apical bone inflammation Dental granuloma Stimulation of epithelial rests of Malassez (remnants of embryological origin) Epithelial proliferation Periapical cyst formation

Question 141

% of minor salivary gland tumours that are malignant

Answer 141

40-50%

Question 142

Coughing blood suggests

Answer 142

Lung cancer Could be pharynx or larynx

Question 143

When to make an urgent referral for suspected oral cancer?

Answer 143

Persistent unexplained head and neck lumps >3 weeks Unexplained ulceration or swelling/induration of the oral mucosa persisting >3 weeks All unexplained red or mixed red and white patches of the oral mucosa persisting for > 3weeks Persistent (not intermittent) hoarseness lasting for >3 weeks Persistent pain in the throat or pain on swallowing lasting for >3weeks

Question 144

Ludwig's angina

Answer 144

Pus either side of the mylohyoid line

Question 145

Mylohyoid line

Answer 145

Bony ridge on the internal surface of the mandible, running posteriosuperiorly. The site of origin for the mylohyoid muscle

Question 146

Most important issue associated with Ludwig's angina

Answer 146

Airway problems due to the swelling causing the tongue to rise up

Question 147

Upper central infection tends to cause swelling where?

Answer 147

Lip

Question 148

Upper laterals, canines and first premolar infections are likely to cause swelling where?

Answer 148

Eye

Question 149

Upper 2nd premolar and molar infections are likely to spread and swell where?

Answer 149

Sinus, cheek, temple

Question 152

Where is a lower incisor infection likely to cause infection?

Answer 152

Mental/submental

Question 153

Where are infections of lower canines and premolars likely to cause swelling?

Answer 153

Submandibular

Question 154

Where are lower molar infections likely to cause swelling?

Answer 154

Pharynx/cheek

Question 155

What determines the spread of infection of a dental infection?

Answer 155

The root length of the tooth and its position in the arch in relation to the mylohyoid line

Question 156

Triangle of danger

Answer 156

Named so because of the connection from the facial veins into the cavernous sinus Infection which enters the veins in this area can cause cerebral abscess

Question 157

Cavernous sinus

Answer 157

A vascular space under the pituitary gland, with nerves and blood vessels running through it

Question 158

Types of elevators

Answer 158

Warwick James - right left and straight Cryer's - right and left Coupland's - size 1, 2, 3

Question 159

Name and what they are used for

Answer 159

Left to right Upper root forceps - retained roots Upper straight forceps - upper anteriors Upper universals - canines and premolars Upper molar forceps (left and right) Upper third molar bayonet forceps

Question 160

Describe upper molar forceps and why are they shaped this way?

Answer 160

One rounded and one pointed beak The pointed beak is designed to engage the furcation on the buccal side

Question 161

Name and what they are used for

Answer 161

Left to right Lower root forceps - retained roots Lower universal forceps - lower incisors, canines and premolars Lower molar forceps Cowhorn forceps - lower molars, often broken down ones that are not easily gripped

Question 162

Patient positioning for extractions

Answer 162

Upper tooth - supine 45-90 degrees Lower tooth - more upright 0-45 degrees At a comfortable height for the operator

Question 163

Where should the operator be positioned for an extraction of a lower right tooth?

Answer 163

Behind the right shoulder

Question 164

Where should the operator be positioned for extraction of an upper right tooth?

Answer 164

To the front of the patient on their RHS

Question 165

Where should the operator be positioned for extraction of an upper left tooth?

Answer 165

To the front of the patient on their RHS

Question 166

Where should the operator be positioned for extraction of an lower left tooth?

Answer 166

To the front of the patient on their RHS

Question 167

Describe extraction technique with forceps

Answer 167

Make sure soft tissues are clear of the forceps Position forceps as far down the tooth as possible without traumatising the gingivae Place the thumb and forefinger of the non dominant hand on the alveolar bone to support it Apply apical pressure and carry out extraction movements - on multi rooted teeth such as molars this is buccal expansion and figure of 8, on single rooted teeth (and sometimes premolars) use rotation

Question 168

Procedure following extraction

Answer 168

Check apices are intact Check socket is clear If RR or bony sequestrum that is easily removed, remove it Place dampened gauze and get patient to bite, applying pressure Check for haemostasis after 5-10 minutes Give post-op instructions

Question 169

What are luxators and elevators for?

Answer 169

Used to aid extraction of retained roots and teeth Used to aid mobility before using forceps

Question 170

Luxator

Answer 170

Used to tear and sever the periodontal ligament, creating mobility

Question 171

How do elevators work?

Answer 171

By creating space by using - Wedge - Lever or - wheel and axle motions

Question 172

How to tell the difference between a luxator and a coupland's elevator?

Answer 172

Luxators have a rounded edge

Question 173

Name and what are they used for

Answer 173

Warwick James (left, straight, right) Used as elevators to create space Particularly handy when extracting third molars

Question 174

Answer 174

Left and right Used as elevators to create space Particularly useful when used in the furcation area of a molar tooth

Question 175

How to hold elevators?

Answer 175

Bottom of the handle in the palm Curve middle, ring and pinkie fingers around the handle Put index finger on the shank for support and control

Question 176

How to use a luxator?

Answer 176

Position the same as when using forceps - Support alveolar bone with non dominant hand - Luxate in the buccal sulcus from mesial to distal Lack of stability can cause soft tissue trauma

Question 177

How to use a Coupland's?

Answer 177

Lever or wedge motion

Question 178

Correct positioning when extracting a tooth allows you to..

Answer 178

Keep your arms close to your body Provides stability and support Allows you to keep your wrists straight enough to deliver adequate force with your arm and shoulder, and not with your fingers/hand, the force can thus be controlled in the face of sudden loss of resistance from a root or fracture of the bone

Question 179

Types of suture technique

Answer 179

Simple interrupted Horizontal mattress Vertical mattress Figure of 8 Continuous

Question 180

What type of suture is this?

Answer 180

Vertical mattress

Question 181

What type of suture is this?

Answer 181

Vertical mattress

Question 182

What type of suture is this?

Answer 182

Horizontal mattress

Question 183

Approximately how far from the wound edge should sutures be placed?

Answer 183

2-5mm

Question 184

Describe a vertical mattress suture

Answer 184

A shallower, more superficial suture closer to the wound edge, within a deeper, further from the wound edge suture

Question 185

Why use resorbable sutures?

Answer 185

In areas where the suture requires to be buried, or is difficult to remove Used for most intra-oral wounds

Question 186

Why use non resorbable sutures?

Answer 186

Sutures retain tensile strength and remain in the tissue until removed Often used in areas where high tensile strength is required for a longer period of time Such as OAC, skin closure, or to hold dressings when exposing canines

Question 187

Example of resorbable mono filament suture

Answer 187

Monocryl

Question 188

Example of resorbable polyfilament suture

Answer 188

Vicryl, Velosorb, Polysorb

Question 189

Example of non resorbable monofilament suture

Answer 189

Nylon Prolene

Question 190

Example of non resorbable poly filament suture

Answer 190

Silk

Question 191

What is the difference between monofilament and polyfilament?

Answer 191

Monofilament - sutures are made from a single strand. These are less likely to facilitate an infection because it is more difficult for bacteria to colonise on a single strand Polyfilament - Sutures are made from several smaller strands twisted together and can be easier to handle. They are often contraindicated in contaminated wounds due to wicking

Question 192

What is wicking/the wick effect?

Answer 192

Studies have shown multifilament sutures can absorb fluids and bacteria thus enabling infection to penetrate the body along the suture tract

Question 193

Advantage of polyfilament sutures

Answer 193

Can be easier to handle

Question 194

Disadvantage of polyfilament sutures

Answer 194

Wicking/ the wick effect

Question 195

Advantage of monofilament sutures

Answer 195

Less likely to facilitate an infection because it is more difficult for bacteria to colonise a single strand

Question 196

Consideration of LA in pregnant women

Answer 196

Citanest contains felypressin which may induce labour

Question 197

Which type of elevator's are you more likely to use wheel and axle motion with?

Answer 197

Cryer's

Question 198

Required INR for warfarin patients for extraction and which guidelines?

Answer 198

SDCEP 1-4

Question 199

How do new oral anti-coagulants work?

Answer 199

by inhibiting the action of factor 10a on the coagulation cascade

Question 200

Bones associated with the TMJ

Answer 200

Temporal Sphenoid Zygomatic Maxilla Mandible

Question 201

Describe the structure of the mandible

Answer 201

2 superior processes - condyloid and coronoid The mandibular notch is between the two Inferior to this is the neck, the ramus and then the angle Moving anteriorly there is the body of the mandible, beginning just lateral to the mental foramina, where the mental nerve exits to provide sensory innervation to the chin and some of the mandibular teeth. In the midline of the body is the mandibular symphysis.

Question 202

Describe the internal aspect of the mandible

Answer 202

The mandibular foramen, where the inferior alveolar nerve enters into the mandibular canal and the submandibular fossa, which the submandibular gland is pressed against are on the internal aspect

Question 203

Answer 203

A - Coronoid process B - Angle C - Ramus D - Neck E - Condyloid process F - Mandibular notch

Question 204

Answer 204

Body of the mandible (left) Mental foramen

Question 205

Where is the mental nerve derived from?

Answer 205

It is a branch of the inferior alveolar nerve which is a branch of the mandibular nerve which is the third division of the trigeminal nerve

Question 206

What does the mental nerve innervate?

Answer 206

It provides sensory innervation to the chin and lip, anterior buccal mucosa and some mandibular teeth

Question 207

Where does the mental nerve exit the skull through?

Answer 207

Mental foramen

Question 208

Through what does the inferior alveolar nerve enter the mandibular canal?

Answer 208

Through the mandibular foramen

Question 209

Where does the condyloid process articulate with to give the TMJ?

Answer 209

Mandibular fossa of the temporal bone

Question 210

What is anterior movement of the TMJ limited by?

Answer 210

Articular eminence

Question 211

Where is the articular eminence located?

Answer 211

On the zygomatic arch, just anterior to TMJ

Question 212

Answer 212

A - zygomatic arch B - articular tubercle/eminence C - mandibular fossa D - Styloid process E - Mastoid process F - External auditory meatus

Question 213

What type of joint is the TMJ?

Answer 213

Synovial

Question 214

What is the TMJ?

Answer 214

A synovial joint at the articulation between the condyloid process of the mandible and the mandibular fossa of the temporal bone, found in the a region known as infratemporal fossa

Question 215

What is the region of the skull that TMJ is found in?

Answer 215

Infratemporal fossa

Question 216

What splits the TMJ into an upper and a lower compartment?

Answer 216

Articular disc

Question 217

Answer 217

A - articular disc B - articular tubercle/eminence C - Articular capsule D - Ramus of mandible E - Mandibular condyle F - Inferior joint cavity G - Superior joint cavity H - Mandibular fossa

Question 218

what is the difference between the upper and lower compartments of the TMJ?

Answer 218

Gliding movements such as protrusion and retraction or side to side are permitted in the upper Rotational movements such as elevation and depression are permitted in the lower

Question 219

What must happen before depression of the mandible will be allowed?

Answer 219

The condylar process must move anteriorly within the upper compartment of the TMJ

Question 220

What will happen if the condylar process moves anteriorly beyond the articular eminence and how is this fixed?

Answer 220

MoM will spasm and TMJ will become dislocated Put downward pressure on the lower molars and guide the head of the mandible back into the mandibular fossa

Question 221

What is the lateral temporomandibular ligament and its role?

Answer 221

Attaches to zygomatic arch and posterior portion of the neck of the mandible Limits posterior movement of the mandible

Question 222

What limits posterior movement of the mandible?

Answer 222

Lateral temporomandibular ligament

Question 223

Answer 223

1 - joint capsul 2 - lateral temporomandibular ligement 3 - sphenomandibular ligament 4 - styloid process 5 - stylomandibular ligament

Question 224

What are the medial ligaments to the TMJ?

Answer 224

Sphenomandibular ligament Stylomanidbular ligament

Question 225

What is the function of the sphenomandibular and stylomandibular ligaments?

Answer 225

Limiting lateral movement of the TMJ

Question 226

Where does the sphenomandibular ligament run from/to?

Answer 226

From the ramus to the sphenoid bone

Question 227

Where does the stylomandibular ligament run from/to?

Answer 227

From the ramus to the styloid process

Question 228

Muscles of mastication

Answer 228

Temporalis Masseter Lateral pterygoid Medial pterygoid

Question 229

Which bone are the pterygoid plates part of?

Answer 229

Sphenoid

Question 230

Where are the pterygoid muscles located in relation to the mandible?

Answer 230

The pterygoid muscles are located medial to the mandible

Question 231

Describe medial pterygoid structure

Answer 231

Has two heads Deep head - attached to medial aspect of the lateral pterygoid plate Superficial - attached to the maxilla and the palatine bones Both heads run posterior inferiorly to reach a point at which they fuse and will then insert onto the ramus of the mandible

Question 232

Answer 232

1 Lateral pterygoid 2 Medial pterygoid

Question 233

Describe lateral pterygoid structure

Answer 233

Superior head attaches to the roof of the infratemporal fossa and the lateral portion of the lateral pterygoid plate Inferior head attaches to lateral portion of lateral pterygoid plate Moving posteriorly both heads will fuse and attach to the condylar process of the mandible

Question 234

What happens when lateral pterygoid muscles act bilaterally?

Answer 234

They protrude the jaw

Question 235

Which action of the lateral pterygoids is paramount to the opening of the mouth?

Answer 235

Acting bilaterally to protrude the jaw

Question 236

What does unilateral contraction of the lateral pterygoids do?

Answer 236

Swings the jaw to the contralateral side

Question 237

What does bilateral action of the medial pterygoid muscles do?

Answer 237

Closes the jaw and assists in protrusion

Question 238

What does unilateral contraction of medial pterygoid muscles do?

Answer 238

Swings the jaw to the contralateral side

Question 239

Where does temporalis arise from and attach to?

Answer 239

From the temporal fossa, attaching to the coronoid process of the mandible

Question 240

Describe the difference between the anterior and posterior fibres of temporalis

Answer 240

The anterior fibres run vertically and will assist in closing the jaw The posterior fibres run horizontally and will retract the mandible

Question 241

Where is masseter located?

Answer 241

On the lateral side of the mandible

Question 242

Structure of masseter

Answer 242

Superficial head - attached to zygomatic bone Deep head - attached to zygomatic arch Inferiorly both heads attach to the ramus and angle of the mandible

Question 243

Action of masseter

Answer 243

Elevates the mandible to close the mouth

Question 244

Innervation of muscles of mastication

Answer 244

All innervated by the mandibular division of the trigeminal nerve

Question 245

When is the TMJ most stable?

Answer 245

When the jaw is closed with teeth in occlusion

Question 246

What is the most common kind of TMJ displacement?

Answer 246

Anterior dislocation - the condyloid process moves anterior to the articular eminence and the MoM spasm, preventing retraction of the mandible

Question 247

What opposes anterior dislocation of the TMJ?

Answer 247

Articular eminence, lateral temporomandibular ligament, and the contraction of medial pterygoid, masseter and temporalis

Question 248

Origin of the masseter

Answer 248

2 origins Zygomatic buttress of the zygomatic bone and medial aspect of zygomatic process of the temporal bone

Question 249

Insertion of the masseter

Answer 249

Lateral surface of the angle of the mandible

Question 250

Origin of temporalis

Answer 250

Temporal fossa

Question 251

Insertion of temporalis

Answer 251

Coronoid process

Question 252

Origin of medial pterygoid

Answer 252

Medial surface of the lateral pterygoid plate

Question 253

Insertion of the medial pterygoid

Answer 253

Medial side of the angle of the mandible

Question 254

Lateral pterygoid origin

Answer 254

2 origins Lateral surface of lateral pterygoid plate and the base of skull/top of infratemporal fossa

Question 255

Insertion of the lateral pterygoid

Answer 255

Pterygoid fovea at the condyle

Question 256

Blood supply to the TMJ

Answer 256

Deep auricular artery (branch of the 1st part of the maxillary artery)

Question 257

Nerve supply to the TMJ and why is this relevant to symptoms?

Answer 257

Auriculotemporal, masseteric, posterior deep temporal nerve Auriculotemporal nerve also supplies parts of EAM and some with TMD get pain in the ear

Question 258

Suprahyoid muscles

Answer 258

Digastric Mylohyoid Geniohyoid Stylohyoid

Question 259

Infrahyoid muscles

Answer 259

Thyrohyoid Sternohyoid Sternothyroid Omohyoid

Question 260

Answer 260

A Digastric (anterior belly) B Geniohyoid C Mylohyoid D Stylohyoid E Digastric (posterior belly)

Question 261

Answer 261

A Thyrohyoid B Sternothyroid C Omohyoid (superior belly) D Sternohyoid E Omohyoid (inferior belly)

Question 262

Which part of the articular disc can not feel pain and why?

Answer 262

The anterior band of the articular disc Does not have sensory innervation

Question 263

What does the articular disc do during jaw movements?

Answer 263

Slides back and forth with the condyle

Question 264

Causes of TMD

Answer 264

Myofascial pain (muscles) Disc displacement (anterior with or without reduction) Degenerative such as osteoarthritis or rheumatoid arthritis Chronic recurrent dislocation Ankylosis (very rare) Hyperplasia (one condyle grows more) Neoplasia (tumours) Infection (incredibly rare)

Question 265

What could be a localised degenerative cause of TMD?

Answer 265

Osteoarthritis

Question 266

What could be a systemic degenerative cause of TMD?

Answer 266

Rheumatoid arthritis

Question 267

What does it mean if anterior disc displacement is 'with reduction'?

Answer 267

With reduction - disc eventually slips back into place Without reduction - stuck in front of the condyle permanently

Question 268

Appearance of condylar hyperplasia

Answer 268

Facial asymmetry Chin points away from the side of the condyle that is growing more

Question 269

Possible neoplastic causes of TMJ (rare)

Answer 269

Osteochondroma - overgrowth of bone and cartilage Osteoma - benign bony tumour Osteosarcoma - malignant bone tumour

Question 270

How to relocate a dislocated TMJ?

Answer 270

Hold jaw with thumbs inside the mouth on the buccal surfaces of lower molars and push down and backwards slowly Sometimes muscle relaxants such as benzodiazepines are necessary

Question 271

Possible pathogenesis to myofascial pain TMJ

Answer 271

Inflammation in the MoM or TMJ secondary to parafunctional habits Trauma - either directly to the joint or indirectly such as sustained opening Stress Psychogenic Occlusal abnormalities (no evidence)

Question 272

Social history considerations for a TMD patient

Answer 272

Occupation, stress, home life, sleeping pattern, recent bereavement, relationships, habits, hobbies

Question 273

E/O exam of TMD patient

Answer 273

MoM Joint - clicks/ crepitus Jaw movements Facial asymmetry

Question 274

Intra-oral exam for TMD patient

Answer 274

Interincisal mouth opening - could use Willis bite gauge Signs of parafunction - tongue scalloping, biting cheeks, linea alba, occlusal NCTSL

Question 275

When are you more likely to do special investigations for TMD?

Answer 275

Suspicion of pathology

Question 276

Common clinical features of TMD

Answer 276

Females > males Age 18-30 Intermittent pain of several months or years Muscle/joint/ear pain, particularly on waking Trismus/locking Clicking/popping Headaches

Question 277

Potential differential diagnoses for TMD

Answer 277

Dental pain Sinusitis Ear pathology Salivary gland pathology Referred neck pain Headache Atypical facial pain Trigeminal neuralgia Angina Condylar fracture Temporal arteritis

Question 278

What is temporal arteritis?

Answer 278

Inflammation of the temporal artery which can result in blindness Presents as very severe pain in the temporal region

Question 279

Treatment for TMJ dysfunction

Answer 279

Patient education Counselling Jaw exercises Medication (Electromyographic recording)

Question 280

What medication can be used to treat TMD?

Answer 280

NSAIDs Muscle relaxants Tricyclic antidepressants Botox Steroids

Question 281

What does TMD counselling include?

Answer 281

Soft diet Masticate bilaterally No wide opening No chewing gum Don't incise food Cut food into small pieces Stop parafunctional habits Support mouth on opening such as yawning

Question 282

Physical therapy for TMD

Answer 282

Physiotherapy Massage/heat Acupuncture Relaxation Ultrasound therapy TENS Hypnotherapy

Question 283

Examples of irreversible treatment for TMD

Answer 283

Occlusal adjustment TMJ surgery

Question 284

How might patients with TMJ disc displacement present?

Answer 284

Painful clicking TMJ The click is due to a lack of coordinated movement between the condyle and the articular disc Jaw tightness/locking The mandible may deviate initially to the affect side

Question 285

What can happen if TMJ disc displacement is left untreated?

Answer 285

Osteoarthritis

Question 286

Treatment for TMJ disc displacement

Answer 286

Counselling, limited mouth opening, bite raising appliance (occasionally surgery)

Question 287

What is this?

Answer 287

Jaw screw For trismus Placed between incisors then on twisting, opens the mouth

Question 288

Treatment for trismus

Answer 288

Physio therapy Therabite jaw rehabilitation system Jaw screw

Question 289

Guidelines for TMJ dysfunction

Answer 289

NICE

Question 290

When would you refer a TMD patient to oral med or OMFS?

Answer 290

History of trauma or fracture to TMJ complex Markedly limited mouth opening suggesting disc displacement without reduction Pain or reduced function in people with rheumatic joint disease Worsening symptoms lasting >3 months despite primary care tx Other chronic pain comorbidities Recurrent dislocation Severe pain and dysfunction not responding to conservative management

Question 291

What should you consider before assessing a trauma case?

Answer 291

ATLS - Advanced Trauma Life Support, treat the greatest threat to life first ABCD - Airway, breathing, circulation, disability

Question 292

What is the Glasgow Coma Scale?

Answer 292

Used to assess head injuries Eye opening, verbal response and motor response are all considered and given points in order to give a GCS score

Question 293

Glasgow Coma Scale scores

Answer 293

Mild 13-15 Moderate 9-12 Severe 3-8

Question 294

Glasgow Coma Scale Eye opening scores

Answer 294

Spontaneous - 4 To sounds - 3 To pressure - 2 None - 1

Question 295

Glasgow Coma Scale verbal response scores

Answer 295

Orientated - 5 Confused - 4 Words - 3 Sounds - 2 None - 1

Question 296

Glasgow Coma Scale motor response scores

Answer 296

Obey commands - 5 Localising - 5 Normal flexion - 4 Abnormal flexion - 3 Extension - 2 None - 1

Question 297

Indicators of mandible fracture

Answer 297

Sublingual haematoma 2 point mobility vertically Abnormal sensation contralateral to the side of injury Pain contralateral to the side of injury Numbness that can't be explained by direct injury to the nerve

Question 298

What is needed to diagnose a mandible fracture?

Answer 298

2 regular Xrays or a CT scan (there is no role for half OPGs)

Question 299

How to manage a mandible fracture

Answer 299

Fast the patient Analgesia - can swallow tablets with small amount of water Antibiotics for open fractures - amoxicillin and metronidazole or equivalent Liquid diet Immediate discussion with OMFS team

Question 300

What region would be considered a midface fracture?

Answer 300

Eyebrows to maxillary teeth, including zygoma

Question 301

Important signs of broken bone in the midface

Answer 301

Epistaxis (nose bleed) without a blow to the nose V2 numbness without a direct blow to the nerve Subconjunctival bleed Midface mobility Malocclusion Surgical emphysema around eye Swelling after nose blowing Diplopia Change of appearance Clear liquid CSF running out of nose

Question 302

Diplopia

Answer 302

Double vision

Question 303

What causes a subconjunctival bleed?

Answer 303

Seen in some midface fractures Conjunctiva has been torn by the fracture, and blood turns the white of the eye deep red (not the whole eye)

Question 304

Epistaxis

Answer 304

Nose bleed

Question 305

How to check for midface mobility?

Answer 305

Hold forehead still and pull palate backwards and forwards

Question 306

What is meant by surgical emphysema?

Answer 306

Air in the soft tissues Seen around the eye in some midface fractures

Question 307

What is required to assess a midface fracture?

Answer 307

2 Xrays

Question 308

Le fort fractures

Answer 308

The face breaks in three particular patterns in the midface All fractures extend into the pterygoid columns, if the pterygoids aren't broken then you don't have a Le Fort fracture

Question 309

How to tell which type of Le Fort fracture?

Answer 309

Hold head and pull on teeth If teeth move - Le Fort I If nose moves - Le Fort II If eyes move - Le Fort III

Question 310

Management of zygoma fracture

Answer 310

No indication for routine antibiotics Call OMFS - vast majority will be followed up in 7-10 days No nose blowing Soft diet for their comfort Give warning re retrobulbar bleed, as this can lead to blindness (rare)

Question 311

Retrobulbar bleed

Answer 311

Rare, sight-threatening emergency, that results in accumulation of blood in the retrobulbar space

Question 312

Orbit fracture

Answer 312

Breaking of just the eye socket, deep segments rather than the rim - would be zygoma fracture

Question 313

Management of orbit fracture

Answer 313

Ensure visual acuity and diplopia documented Discuss with OMFS Don't bother CTing No need for routine antibiotics No nose blowing Give warning re retrobulbar bleed

Question 314

Indicators of an orbit fracture

Answer 314

Eyebrow sign - gas leaks and rises to just below eyebrow Eye may be sunken or dropped down

Question 315

When would you give warning about retrobulbar bleed?

Answer 315

Zygoma fracture Orbit fracture

Question 316

Management of maxilla fracture (le fort type)

Answer 316

Fast the patient Antibiotics Discussion with OMFS Liquid diet No nose blowing Most will need assessed on the day

Question 317

Pathognomic features of zygoma fracture

Answer 317

Unilateral epistaxis when the noe has not been injured Eyebrow sign Paraesthesia when trauma was distant to extraosseous infraorbital nerve Buttress tenderness

Question 318

Nasal Orbital Ethmoidal fracture pathognomic features

Answer 318

Retropositioned nose Buttress not tender Epistaxis Often numb Steps at IOR, pyriform, glabella Hyperteloric (eyes drift apart)

Question 319

Naso-maxillary fracture pathognomic features

Answer 319

Tender IOR/pyriform Buttress intact Often numb Unilateral epistaxis without blow to the nose Same as zygoma EXCEPT buttress

Question 320

Where is the parasymphasis of the mandible?

Answer 320

Anterior to mental foramen

Question 321

Most common imaging for midface fractures?

Answer 321

OPG and PA mandible (two angulations of PA mandible for zygoma or orbit)

Question 322

What does SIRS stand for?

Answer 322

Systemic inflammatory response syndrome

Question 323

SIRS Systemic Inflammatory Response Syndrome criteria

Answer 323

Fever 38C + Hypothermia <36C Tachycardia - high pulse >90bpm Tachypnoea - high breathing rate >20 breaths/min Change in blood count (WBC count >1200) Partial pressure CO2 <32mmHg

Question 324

Hot potato syndrome

Answer 324

Infection causes raised floor of mouth, patient talks like they have hot potato in their mouth

Question 325

Where must you never incise an intraoral abscess in GDP?

Answer 325

Floor of mouth

Question 326

Should you suture the wound from draining an abscess?

Answer 326

No - allows more drainage

Question 327

What are rongeurs?

Answer 327

Bone nibblers Used to remove small fragments of bone

Question 328

What excisional soft tissue surgery might be used for before provision of dentures?

Answer 328

Frenoplasty Papillary hyperplasia Flabby ridges Denture induced hyperplasia Maxillary tuberosity reduction Retromolar pad reduction

Question 329

Why might a labial frenoplasty be required?

Answer 329

Oral hygiene issues

Question 330

What risk must be considered during a buccal frenoplasty?

Answer 330

Risk of damaging the mental nerve

Question 331

When might a lingual frenoplasty be necessary?

Answer 331

Tongue tie

Question 332

When might a buccal frenoplasty be necessary?

Answer 332

High buccal frenum in a denture patient This would break the seal and displace the lower denture every time the patient moves

Question 333

What should be done if denture associated papillary hyperplasia does not resolve with removal of the denture?

Answer 333

Excisional surgery

Question 334

Vestibuloplasty

Answer 334

Surgery to deepen the sulcus in order to achieve better denture retention by having more space for extending the flange

Question 335

When might hard tissue excisional surgery be considered before provision of dentures?

Answer 335

Removal of retained teeth/roots/pathology Ridge defect correction (alveoplasty) Mandibular tori Maxillary tori Maxillary tuberosity Exostoses Undercuts Genial tubercle reduction Mylohyoid ridge reduction

Question 336

Why might retained roots or "buried" teeth become a problem in denture provision?

Answer 336

If the ridge resorbs these may end up palpable or visible and interfere with the fitting surface

Question 337

What can be seen here and what is the most likely cause?

Answer 337

Well defined, unilocular, corticated radiolucency Residual cyst - apical radicular cyst in relation to one of the teeth in the region, tooth has been removed but the cyst has remained

Question 338

How would you manage this?

Answer 338

Biopsy to determine what it is CBCT to see relation to the IAN Then decide on final tx plan

Question 339

What surgical technique would be used for this and why?

Answer 339

Alveoplasty to prevent interference with denture retention

Question 340

What is the likely cause of this?

Answer 340

Retained lower anteriors for much longer than the posteriors

Question 341

What is this and how would you manage it/why?

Answer 341

Knife edge ridge This is sharp and can be uncomfortable when wearing a denture or traumatic to soft tissues Smooth this ridge to make it more comfortable but do not take too much away as this could negatively affect denture retention

Question 342

Management of a maxillary torus in denture patients

Answer 342

Surgically remove the bony projection OR design denture around it e.g. horseshoe shape

Question 343

Why might a large maxillary tuberosity occur?

Answer 343

Large bony tuberosity OR lots of excess fibrous tissue surrounding normal bone

Question 344

Which two structures on the mandible can become prominent and might require removal/reduction with very sever bone resorption?

Answer 344

Genial tubercle Mylohyoid ridge

Question 345

Examples of hard tissue augmentation procedures that might be done for denture patients

Answer 345

Autografts Allografts Xenografts Synthetic grafts

Question 346

Autografts

Answer 346

Bone taken from elsewhere in the body for a graft eg hip bone being used to augment the maxillary ridge

Question 347

Allografts

Answer 347

Bone taken from human cadavers for bone grafts Commonly used for alveolar bone for implants

Question 348

Xenografts

Answer 348

Bone from animals, usually cows, can be horses Used to provide framework for bone regeneration

Question 349

Pros/cons of synthetic bone grafts

Answer 349

No risk of disease transmission No cultural/religious/ethical issues Can be very effective but some can have a lower rate of being accepted by the body Customisable to be exact shape/size/porosity that you want

Question 350

When would inferior alveolar nerve relocation be done? And describe the procedure

Answer 350

In severe cases of bone resorption the mental foramen can end up at the surface In some cases the entire IAN can be just covered by soft tissue rather than by bone Denture fitted to these tissues will press on the nerve causing numbness and pain To reposition you would open up to expose the nerve, drill a channel deeper down in the body of the mandible and reposition the nerve further down

Question 351

Why might implants be provided for complete denture patients?

Answer 351

For implant retained overdentures

Question 352

23 year old pt attends reporting pain from LL for 18 months, pt says pain is from wisdom tooth and asks for it to be removed. What do you want to know?

Answer 352

SOCRATES HPC - past episodes of pericoronitis/antibiotics/swelling history Systemic MH, meds, allergies PDH, anxiety, previous extractions, any problems SH - smoking, drinking, occupation, caring responsibilities

Question 353

How will you carry out a comprehensive assessment of someone reporting signs of pericoronitis?

Answer 353

Extra oral TMJs Lymphnodes Asymmetry MoM Mouth opening Intra oral Soft tissues Dentition Caries Perio OH Working distance L8 erupted? Condition of adjacent 7 Presence of other 8s

Question 354

Assessment findings

Answer 354

LL8 partially erupted- approx 1/2 occlusal surface is visible LL8 appears vertically impacted on clinical examination Operculum appears infllamed

Question 355

Patient reports recurrent episodes of pain from LL quadrant and on examination you find this. What is your next step?

Answer 355

OPT

Question 356

Report

Answer 356

OPT diagnostically acceptable Vertical/slighty distoangular LL8 superficial impaction LL8 crown healthy - no signs of caries LL8 crown wider than roots LL8 has at least 2 roots LL8 apices appear close to ID canal but no signs of intimate relationship LL7 appears sound Adequate bone levels

Question 357

Pericoronitis recurring LL8 What are the treatment options

Answer 357

Clinical review - monitor at regular examination, only require radiographs if change in signs or symptoms Surgical removal of LL8 (No indication for further imaging or coronectomy in this case as no intimate relationship with ID canal, no indication for XLA UL8 as doesn't look to be occluding against operculum)

Question 358

What information do you need to give to ensure pt is making informed decision about surgical removal of LL8?

Answer 358

Discuss option of LA/Conscious sedation/GA (and referral if required) Regarding procedure: Pain, Swelling, Bleeding, Infection, Jaw stiffness, Dry socket Temporary (2-20%) or Permanent (<1%) damage to nerve, possibility of numbness, tingling or painful sensation Areas affected could include side of chin, lip, tongue, gums or cheek Small risk of loss of taste Surgical approach: cut in gum, bone removal which will feel like vibration/water, pressure, stitches (dissolving)

Question 359

Usual age of eruption for third molars

Answer 359

18-24 years

Question 360

When can crown calcification of 8s start to be seen radiographically?

Answer 360

7-9 for uppers 8-10 for lowers (completed by about 18)

Question 361

What age is root calcification of 8s complete?

Answer 361

18-25

Question 362

How common is it that and adult has 1 or more third molars present?

Answer 362

1 in 4

Question 363

Agenesis

Answer 363

Failure of an organ to develop

Question 364

Is third molar agenesis more common in mandible or maxilla?

Answer 364

Maxilla

Question 365

Is third molar agenesis more common in men or women?

Answer 365

Women

Question 366

What age would you expect to see third molars radiographically, after which they almost never develop?

Answer 366

14

Question 367

What is a common reason for older patients to have issues with third molars?

Answer 367

Third molars causing problems with dentures

Question 368

Impacted

Answer 368

Tooth eruption is blocked Failure to erupt into either a full or partial functional position, or at all

Question 369

What is the most common reason for third molars failing to erupt?

Answer 369

Impaction

Question 370

What are M3Ms usually impacted against?

Answer 370

Adjacent tooth, alveolar bone, surrounding mucosal soft tissue or a combination of these factors

Question 371

Eruption of impacted third molars

Answer 371

Impacted third molars can be unerupted, partially erupted or fully erupted

Question 372

Fully erupted

Answer 372

Whole occlusal surface through the mucosa and exposed to the oral cavity

Question 373

Incidence of impacted lower 3rd molars

Answer 373

36-59%

Question 374

Consequences of third molar impaction

Answer 374

Caries (in 8 or 7) Pericoronitis Cyst formation (often results from the failure of the follicle to separate)

Question 375

What does it mean if a tooth appears unerupted clinically, but radiographically there is caries?

Answer 375

This suggests that there is a communication between this tooth and the oral cavity, since the bacteria is able to reach it and cause caries Probe carefully distal to 7 to try to find this communication

Question 376

4 nerves at risk during 3rd molar surgery

Answer 376

Inferior alveolar nerve Lingual nerve Nerve to mylohyoid Long buccal nerve

Question 377

Which two nerves are most likely to be damaged during third molar surgery?

Answer 377

Inferior alveolar nerve Lingual nerve

Question 378

Inferior alveolar nerve

Answer 378

Peripheral sensory nerve formed from the mandibular division of the trigeminal nerve. Supplies all the mandibular teeth (on its side) and mucosa and skin of the lower lip and chin on that side

Question 379

Inferior alveolar nerve and third molar relationship

Answer 379

Position in relation to the mandibular third molar varies greatly Usually need radiograph before third molar surgery to see this Risk to the nerve should be considered

Question 380

Lingual nerve

Answer 380

Branch of the mandibular division of the trigeminal nerve supplying anterior two thirds of the dorsal and ventral mucosa of the tongue Also gives off a branch which supplies lingual gingivae and FoM

Question 381

Lingual nerve position

Answer 381

Lingual nerve varies in position Close relationship to the lingual plate in the mandibular and retromolar area At or above level of the lingual plate in 15-18% Between 0.3-5mm medial to mandible Must be very careful to avoid during third molar surgery

Question 382

Guidelines for 3rd molar surgery

Answer 382

NICE and SIGN basically dictate that because of the related risks, you must be able to justify third molar surgery with pathology - caries, significant infection, perio, cyst RCS FDS - more recent acknowledges that you might be delaying inevitable surgery which could make it more difficult in future, and recommended changing from a solely therapeutic approach to a mixed range of interventions

Question 383

Therapeutic indications for third molar surgery

Answer 383

Infection - caries, pericoronitis, perio, local bone infection, most common Cysts Tumours External resorption of 7 or 8

Question 384

If there is any history of pericoronitis..

Answer 384

Removal of any symptomatic third molar should always be considered

Question 385

1st and 2nd most common reasons for removal of third molars

Answer 385

1st caries 2nd pericoronitis

Question 386

Why is restoring a caries lower 8 usually not done?

Answer 386

Access and moisture control make it very difficult 8s are not really necessary

Question 387

What type of third molar impaction is more prone to causing bone loss distal to the lower 7

Answer 387

Horizontal and mesio angular impaction

Question 388

What is the best way to reduce bone loss distal to a 7, if there is a horizontally or mesio angular impacted 8?

Answer 388

Early extraction of the third molar Late removal, especially after age 30 has not been shown to improve periodontal status of the adjacent 7

Question 389

Most common age range for cyst formation

Answer 389

20s-50s

Question 390

When do cysts normally first become symptomatic?

Answer 390

When they become very large and/or infected

Question 391

Most common type of cyst to be found associated with third molars

Answer 391

Indigenous cyst

Question 392

Indigenous cyst

Answer 392

Arises from the reduced enamel epithelium separation from the crown

Question 393

Are cysts associated with third molars more common in mandible or maxilla?

Answer 393

Mandible

Question 394

Why is prophylactic removal or coronectomy of a disease free lower 8 to prevent cyst formation not routine?

Answer 394

This would prevent development of a cyst but the number of cysts that you're going to prevent by doing this would be fairly small so it is not usually an indication

Question 395

Tumours as indication to removal third molars

Answer 395

If the tumour is close to the lower 8 it might be extracted as part of a cancer, in part of the dissection as may other teeth If the pt has tumour anywhere in the body and will be having radiotherapy, it might be indication to remove lower 8 because of the future ORN risk

Question 396

Why might resorption be indication for third molar removal?

Answer 396

External resorption is the destruction of tissue, the cause of inflammation is often unclear but left untreated it is usually progressive External resorption of the third molar or of the second molar caused by the third molar should always make us consider third molar removal

Question 397

Most common age for external resorption of lower 7 by lower 8

Answer 397

21-30 (relatively rare)

Question 398

Non therapeutic indications for extractions of third molars

Answer 398

Surgical indications High risk of disease Medical indications Accessibility Patient age Auto transplantation General anaesthetic

Question 399

Examples of possible surgical indications for third molar removal

Answer 399

Tooth is within surgical field - orthognathic, fractured mandible, in resection of diseased tissue

Question 400

What are high risk of disease indications for third molar removal?

Answer 400

Mesio angular or horizontally impacted lower 8 High risk of caries for 8 or 7 and of periodontal bone loss

Question 401

Medical indications for removal of third molars

Answer 401

needing signed off dentally fit e.g. Awaiting cardiac surgery Immunosuppressed (or about to become) Before going on bisphosphonates Before starting radiotherapy or chemotherapy

Question 402

When might you be more likely to consider removal of 8s in a perfectly healthy patient?

Answer 402

If they have limited access to the dentist e.g. submariners

Question 403

Why is patient age an indicator in 3rd molar removal?

Answer 403

Complications and recovery time increase with age, so it might make sense to taje the tooth out while the patient is young

Question 404

Where would an 8 usually be moved to in autotransplantation?

Answer 404

Lower 6 position

Question 405

Why might you be more inclined to take out a third molar in someone alongside other dental treatment?

Answer 405

If they were going for GA

Question 406

Pericoronitis

Answer 406

Inflammation around the crown of a partially erupted tooth Tooth is normally partially erupted

Question 407

What causes pericoronitis?

Answer 407

Food and debris gets trapped under the operculum of a partially erupted tooth, resulting in inflammation or infection

Question 408

Describe pericoronitis infection

Answer 408

Usually transient and self-limiting

Question 409

Most common age for pericoronitis

Answer 409

20-40

Question 410

General health factor in pericoronitis

Answer 410

Upper respiratory tract infection can become pericoronitis

Question 411

What type of microbes are likely to be involved in pericoronitis?

Answer 411

Anaerobes

Question 412

Examples of bacteria found in pericoronitis infections

Answer 412

Streptococci Actinomyces Prioponibacterium Beta-lactamase producing prevotella Bacteroides Fusobacterium Staphylococci

Question 413

Pericoronitis signs and symptoms

Answer 413

Pain Swelling Bad taste/halitosis Pus Occlusal trauma to operculum Ulceration of operculum Evidence of cheek biting Limited mouth opening Dysphagia Pyrexia Malaise Regional lymphadenopathy

Question 414

What might be seen in severe pericoronitis?

Answer 414

Extra oral swelling Most commonly starting at the angle of the mandible Can spread anywhere, commonly submandibular areas

Question 415

If pericoronitis infection spreads distobuccally under the masseter, what is this called? and give a characteristic sign

Answer 415

Submasseteric abscess Pt can not open mouth

Question 416

What symptom might arise from spread of pericoronitis infection into the parapharyngeal space?

Answer 416

Dysphagia This might present with drooling

Question 417

Pericoronitis treatment

Answer 417

IF pt is acutely symptomatic you might - Incise pericoronal abscess - Irrigate under operculum with chlorhexidine or saline using blunt syringe (10-20ml) - Extract upper third molar if traumatising operculum - Instruct pt on warm salt water or chlorhexidine MW - Antibiotics if systemically unwell, extra-oral swelling, immunocompromised - If large extra oral swelling, significantly unwell, trismus, dysphagia - refer to OMFS or A&E (generally do not remove the third molar during an acute episode of pericoronitis)

Question 418

Why is operculectomy now not done very often?

Answer 418

Within weeks or months the operculum grows back to where it was so not much is gained

Question 419

Method of pericoronitis management that is no longer in favour

Answer 419

Operculectomy

Question 420

Predisposing factors for pericoronitis

Answer 420

Partial eruption and vertical or distoangular impaction Opposing maxillary 2nd or 3rd molar causing mechanical trauma URTI Stress/fatigue Poor OH Insufficient space between ascending ramus and distal aspect of M2M White race Full dentition

Question 421

Most current guidelines on third molar management

Answer 421

RCS FDS

Question 422

When is it appropriate to take out a third molar with no associated pathology?

Answer 422

If the risk and likelihood of it causing problems at some point in the future is too high

Question 423

History during assessment of patient presenting with third molar

Answer 423

General appearance - asymmetry, difficulty speaking, look unwell C/O and HPC Medical history Dental history Social history

Question 424

3 components of assessment of pt presenting with third molar

Answer 424

History Clinical examination Radiographic assessment (if indicated)

Question 425

HPC for pericoronitis

Answer 425

How long, how many episodes, how often, severity, requirement for antibiotics SOCRATES

Question 426

Underlying systemic diseases that might interfere with normal healing

Answer 426

Diabetes Chronic renal disease Liver disease Bleeding disorder Immunosuppressed Radio or chemotherapy

Question 427

Medications relevant during third molar treatment planning

Answer 427

Contraceptive - increased risk of dry socket Steroid therapy - increased risk of wound infection and delayed healing Bisphosphonates - MRONJ Anticoagulants and antiplatelets

Question 428

What would you ask if a patient has previous extractions, and you are planning third molar management?

Answer 428

How did they find it? Any sedation/GA Surgical Any delay in healing Any issues post op

Question 429

Extra-oral exam of patient presenting with third molars

Answer 429

TMJ Mouth opening Lymphadenopathy Facial asymmetry MoM

Question 430

Why is it important to examine TMJ when a patient presents with third molars?

Answer 430

TMD can give pre-auricular pain very similar to pericoronitis Good to know if there's a click before surgery so that pt does not think surgery caused this

Question 431

Intra-oral examination of patient presenting with third molar

Answer 431

Soft tissues Dentition M2M Working space Eruption status of M3Ms Condition of dentition Occlusion Oral hygiene Caries Perio

Question 432

When would you do radiographic assessment of a patient presenting with third molars?

Answer 432

Only if surgical intervention is being considered

Question 433

What radiograph(s) would you take to assess third molars?

Answer 433

OPT

Question 434

What can be determined from an OPT to assess third molars?

Answer 434

Presence or absence of disease Anatomy of 3M (crown size, shape, condition, root formation, crown:root) Depth of impaction Orientation of impaction Working distance Follicular width Periodontal status Relationship or proximity of U8s to maxillary sinus, and L8s to IAN canal Any other associated pathology

Question 435

Superficial impaction

Answer 435

When the crown of the 8 is sitting at the same height as the crown of the adjacent seven

Question 436

Deep impaction

Answer 436

When the crown of the 8 is at the same level as the roots of the adjacent 7

Question 437

Moderate impaction

Answer 437

When the crown of the 8 is level with crown and root of the adjacent 7

Question 438

Dental follicle

Answer 438

Tissue that surrounds the crown of a developing tooth As the tooth pushes into oral cavity you normally lose this but if a tooth is unerupted this would appear as radiolucency

Question 439

What does dental follicle becoming bigger than expected indicate?

Answer 439

Suggests pathology such as a cyst Concern at anything over 2.5-3mm

Question 440

Why is it important to discuss the relationship of the M3M with the inferior dental CANAL (not the nerve) when discussing radiographs?

Answer 440

Nerves can not be seen radiographically, you are looking at the canal

Question 441

Signs of close proximity of M3Ms to the inferior dental canal

Answer 441

Interruption of the white lines/lamina dura of the canal Darkening of the root where crossed by the canal Diversion/deflection of the inferior dental canal Deflection of root Narrowing of canal Narrowing of root Dark and bifid root apex Juxta apical area

Question 442

Three radiographic signs associated with significantly increased risk of nerve injury during third molar surgery

Answer 442

Interruption of the white lines of the canal Diversion of the canal Darkening of the root where crossed by the canal

Question 443

Juxta apical area

Answer 443

A well circumscribed radiolucent region lateral to the root of the third molar, usually not right at the apex Usually well defined, can appear corticated Lamina dura of the root still intact and appearance not pathological

Question 444

What do guidelines suggest about further imaging after OPT for third molars

Answer 444

Where conventional imaging has shown a close relationship between the third molar and the inferior dental canal, CBCT may be of benefit

Question 445

What information can CBCT give you on the relationship between M3M and inferior alveolar nerve canal?

Answer 445

Is there bone between the ID canal and apices of the tooth Is the tooth actually compressing the canal

Question 446

Why is CBCT better than CT for third molar assessment?

Answer 446

Limited FoV of CBCT is advantageous in terms of image reconstruction and the radiation dose to the patient

Question 447

% of different angulations of third molars

Answer 447

Vertical 30-38% Mesial around 40% Distal around 6-15% Horizontal 3-15% Transverse or aberrant less common

Question 448

Most difficult third molar angulation to remove

Answer 448

Distal

Question 449

Most common third molar angulation

Answer 449

Mesial

Question 450

What is angulation of third molars measured against?

Answer 450

Curve of Spee

Question 451

Curve of Spee

Answer 451

Curve as you follow the natural cusps of the dentition

Question 452

Angulation of M3Ms

Answer 452

LR8 is mesially impacted LL8 is horizontally impacted

Question 453

Why is it important to measure angulation of lower third molar impactions against the curve of spee?

Answer 453

It is easy to confuse a distal angulation with a vertical angulation Distal is much more difficult to extract

Question 454

Why are distally impacted M3Ms so difficult to extract

Answer 454

it is very unlikely you will get it out intact without distal bone removal, and the roots of distally impacted 8s are often very close to roots of the 7 so it can be difficult to get and application point and you need to be very careful not to damage the 7

Question 455

Angulation of L8s

Answer 455

LR8 is horizontally impacted LL8 is distally impacted

Question 456

Angulation of L8s

Answer 456

LR8 is vertically impacted LL8 is distally impacted

Question 457

Angulation of LR8

Answer 457

LR8 is transversely impacted

Question 458

Position of LL8

Answer 458

Aberrant position

Question 459

Why is it good to assess depth of impaction radiographically?

Answer 459

Gives an indication of the amount of bone removal required

Question 460

Depth of impactions of L8s

Answer 460

LR8 is moderate LL8 is superficial

Question 461

Depth of impaction

Answer 461

Superficial

Question 462

Depth of impaction

Answer 462

Moderate impaction

Question 463

What must be considered if 7 next to an impacted 8 has a large or overhanging restoration?

Answer 463

Risk of restoration fracture during extraction of the 8 - pt must be warned of this if they have - Large restoration - Crown - Overhangs If this happens the tooth would need to be temporised and dealt with later

Question 464

Common treatment options for impacted M3Ms

Answer 464

Referral Clinical review Removal Extraction of the maxillary 3rd molar Coronectomy

Question 465

Clinical review of M3M

Answer 465

Review signs and symptoms associated, can be done at regular review No indication for radiographic assessment unless clinically there are signs/symptoms

Question 466

Coronectomy of M3M

Answer 466

Removing the crown and leaving the roots in situ Only usually considered if close relationship between M3M and IAN canal

Question 467

Less common treatment options for M3Ms

Answer 467

Operculectomy Surgical exposure Pre-surgical orthodontics Autotransplantation

Question 468

Important aspects of decision making in M3M treatment planning

Answer 468

Decision should be made jointly between patient and clinician Patient involvement - communicate findings, risk status, tx options including risks and benefits Good notekeeping Current status of patient and M3M Risk of complication Patient access to treatment

Question 469

How to manage asymptomatic 3rd molars with disease present or high risk of disease development

Answer 469

Clinician should use their expertise to assess the risk eg of caries, perio, etc then consider surgical intervention This might be affected by risk of complications eg proximity to IAN canal in which case the decision might be active surveillance

Question 470

Active surveillance of M3M

Answer 470

Monitoring the tooth with radiographs at regular intervals Sometimes done for asymptomatic M3Ms either with disease present or high risk of disease developing

Question 471

What can you consult for M3M treatment planning?

Answer 471

Summary of the management of patients with Mandibular Third Molars from the RCS FDS guidelines

Question 472

Management of asymptomatic M3M with no disease present/low risk of disease

Answer 472

Clinical review is likely to be the most appropriate management Pt medical history may change this e.g. if tooth is in surgical field

Question 473

Management of symptomatic M3M with high risk of or disease present

Answer 473

Consider cause of the symptoms - caries, perio etc Then consider tx options

Question 474

Management of symptomatic M3Ms with no disease present and low risk of disease

Answer 474

Consider other causes of symptoms - consider TMJ, salivary gland disease It would not be indicated to remove a deeply impacted M3M if it is disease free

Question 475

Which patients may only be able to tolerate 3rd molar removal under GA?

Answer 475

Extremely anxious Contraindications to sedation Other factors complicating the surgery e.g. extensive resection being done at the same time

Question 476

When would you explain risk of jaw fracture to a patient having extraction of M3M?

Answer 476

Edentulous/atrophic mandible Aberrant lower 8 close to lower border Large cystic lesion associated with the tooth

Question 477

How would you explain the procedure of M3M surgical extraction to a patient?

Answer 477

Minor surgical procedure Cut flap Possible drilling Stitches - 2-3 weeks to dissolve If tooth is likely to need sectioned explain this

Question 478

Risks to explain to pt having M3M removal

Answer 478

If 2nd molars have large restorations explain risk of restoration fracture Pain Swelling Bruising Jaw stiffness/limited mouth opening Bleeding Infection Dry socket Numbness or tingling

Question 479

Why is the jaw sometimes stiff with limited opening after M3M extraction?

Answer 479

Mouth has been open for a long time with pressure on the lower jaw

Question 480

Factors making dry socket more common

Answer 480

Extraction of 8s Females Mandible Smokers If pt has had dry socket before Contraceptive pill

Question 481

Nerve anaesthesia feeling

Answer 481

Numbness

Question 482

Nerve paraesthesia feeling

Answer 482

Tingling

Question 483

% of patients who experience temporary IAN damage after M3M extraction

Answer 483

10-20%

Question 484

% of patients who experience permanent IAN damage after M3M extraction

Answer 484

<1%

Question 485

% of patients who experience temporary lingual nerve damage after M3M extraction

Answer 485

0/25-23%

Question 486

% of patients who experience permanent lingual nerve damage after M3M extraction

Answer 486

0.14-2%

Question 487

What is the time frame for nerve recovery?

Answer 487

Most will happen within 9 months but nerves have been shown to have recovery up to 18-24months after surgery After this any recovery very unlikely

Question 488

Chorda tympani

Answer 488

Carries taste sensation from anterior two third of the tongue Carries fibres via lingual nerve Arises from facial nerve

Question 489

Most common sensation from nerve damage during M3M surgery

Answer 489

Numbness - anaesthesia Tingling - paraesthesia

Question 490

Rarer sensations from nerve damage during M3M surgery

Answer 490

Painful uncomfortable sensation - dysaesthesia Reduced sensation - hypoaesthesia Increased sensation - hyperaesthesia

Question 491

When would you not opt for CBCT having seen close relationship of M3M and IAN canal on OPT?

Answer 491

IF the results will not change the txp - Patient wants full surgical removal regardless of the risk - Grossly carious lower 8 not suitable for coronectomy

Question 492

What must be included in a M3M referral letter

Answer 492

SBAR Situation Background (HPC) Assessment Recommendation

Question 493

When is a surgical removal required?

Answer 493

When tooth cannot be removed with forceps alone

Question 494

Basic principles of surgical extraction

Answer 494

Risk assessment Aseptic technique Minimal trauma to hard and soft tissues

Question 495

Surgical removal process

Answer 495

Anaesthesia Access Bone removal as necessary Tooth division as necessary Debridement - ensure all apices are accounted for Suture Achieve haemostasis Post op instructions

Question 496

Access for surgical removal

Answer 496

Access to the tooth is gained by raising a buccal mucoperiosteal flap (+/- raising a lingual flap) Maximum access with minimal trauma Larger flaps heal just as quickly as smaller Use scalpel in one continuous stroke Minimise trauma to papillae

Question 497

Reflection of soft tissues for surgical extraction

Answer 497

Commence reflection at base of relieving incision Undermine/free the papillae before proceeding with reflection distally to avoid tears (Warwick James) Reflect with periosteal elevator firmly on bone in order to avoid dissection occurring superior to periosteum and reduce soft tissue bruising/trauma

Question 498

Instruments used to reflect surgical flap

Answer 498

Mitchel's trimmer Howarth's periosteal elevator Ash periosteal elevator

Question 499

Instruments used to retract surgical flap

Answer 499

Howarth's periosteal elevator Rake retractor Minnesota retractor

Question 500

Why is it important to retract the flap during surgical extractions

Answer 500

Access to the operative field Protect the soft tissues

Question 501

Name left to right

Answer 501

Howarth's periosteal elevator Rake retractor Minnesota retractor

Question 502

What is important for atraumatic retraction of soft tissues during surgical extractions?

Answer 502

Rest firmly on bone Awareness of adjacent structures e.g. mental nerve

Question 503

Why are air driven handpieces not used during surgical extractions?

Answer 503

May cause surgical emphysema

Question 504

Bone removal process for surgical extraction

Answer 504

Electrical straight handpiece with SS or Tungsten carbide saline cooled bur (to avoid bone necrosis) Round bur used to cut buccal gutter and on to distal aspect of impaction, starting distally and coming mesial (reduces risk to lingual nerve and other soft tissues behind M3M) Buccal gutter as narrow and deep as poss Bone removed to allow application of elevators

Question 505

What is done after bone removal during surgical extraction?

Answer 505

Operator must assess the possibility of removing the tooth in one piece with elevators and forceps If this is not possible and adequate bone has been removed the tooth should then be sectioned with drillOPerator Most commonly sections between crown and roots, then sometimes further separation of the roots from each other Operator may prefer to section vertically

Question 506

A 68 year old female with history of a fractured neck of femur has been given 2 drugs to prevent her getting another fracture. Give two drug types and examples that this could be

Answer 506

Anti-resorptives - bisphosphonates - zoledronic acid Vitamin supplements - Vit D

Question 507

What significant oral condition may arise from taking some anti-resorptive drugs?

Answer 507

Medication related osteo necrosis of the jaw

Question 508

Four ways in which MRONJ can be prevented

Answer 508

Patient education OHI Consider high fluoride toothpaste Make pt dentally fit before starting antiresorptives Remove risk factors where poss eg sharp denture flange Smoking cessation advice Non-invasive alternative treatment such as RCT

Question 509

Management options for MRONJ

Answer 509

Monitoring Specific OHI for exposed bone Antiseptic MW Occasionally antibiotics Minimal surgical debridement in select cases Primary closure where possible Remove traumatic causes Consult GMP to check if drug modification or replacement is appropriate Symptomatic relief Topical analgesics Radiographs to establish differential diagnosis Referral to secondary care

Question 510

Top to bottom

Answer 510

Frontal sinus Sphenoid sinus Ethmoidal air cells Maxillary sinus

Question 511

Which of the sinuses are most well formed at birth?

Answer 511

Maxillary and ethmoid Formation occurs withing 3-4th foetal month

Question 512

Functions of paranasal sinuses

Answer 512

Resonance to the voice Reserve chambers for warming inspired air Reduce the weight of the skull

Question 513

Which of the sinuses is usually the largest?

Answer 513

Maxillary

Question 514

Maxillary sinus description

Answer 514

Pyramid shaped cavity within the body of each maxilla Volume approx 15ml in average adult 37mmH 27mmW 35mmAP on average

Question 515

Ostium of the maxillary sinus

Answer 515

Located medially near the roof of the maxillary sinus Drains into middle meatus Approx 4mm diameter Lined with mucosa Can become narrowed or blocked during episodes of inflammation or disease

Question 516

What is generally found on the posterior wall of the maxillary sinus cavity?

Answer 516

The alveolar canals that transport the posterior superior alveolar vessels and nerves to the maxillary posterior teeth

Question 517

Roots of maxillary molars and sometimes premolars may project into ____

Answer 517

The floor of the maxillary sinus The roots may perforate the bone so that only the mucosal lining of the sinus covers them

Question 518

Epithelium of the sinuses

Answer 518

Pseudostratified ciliated columnar epithelium

Question 519

What is the role of the cilia in the maxillary sinus

Answer 519

1. Mobilised trapped particulate matter and foreign material within the sinus 2. Move this material towards the ostia for elimination into the nasal cavity

Question 520

Possible issues with maxillary sinus

Answer 520

OAC - acute OAF - chronic Root (or entire tooth) pushed into the sinus Sinusitis Benign lesion Malignant lesions

Question 521

How is an OAC usually created?

Answer 521

On extraction of upper molar with roots projecting onto the floor of the maxillary sinus, a communication between the sinus and the mouth is created by either breaking the bone, or tearing the lining of the sinus

Question 522

Why is an OAC a problem?

Answer 522

Bacteria from the mouth can now enter into the sinus, which can result in sinusitis and make other functions problematic

Question 523

How do you diagnose an OAC?

Answer 523

Size of tooth Radiographic position of roots in relation to sinus Bone at trifurcation of roots Bubbling of blood Nose holding test Direct vission Good light and suction - echo Blunt probe

Question 524

Which two ways that you would investigate whether an OAC has been created could potentially create an OAC if not careful?

Answer 524

Nose holding test Probing

Question 525

OAF

Answer 525

Oro-antral communication that persists as an opening, and a sinus tract forms and become epithelialized Oro antral fistula

Question 526

When might a pre-op assessment suggest likelihood of and OAC?

Answer 526

Roots of the tooth for XLA appear to by within the sinus or projecting onto lining of the sinus Very thin bone in the area

Question 527

What is this?

Answer 527

OAC

Question 528

What is this?

Answer 528

OAF

Question 529

What is shown here?

Answer 529

OAF radiographic appearance

Question 530

Management of OAC

Answer 530

Tell the patient If small or sinus lining intact - encourage clot, suture margins, possible antibiotic, post op instructions minimising pressure formation within sinuses and the mouth - avoid straws, balloons, singing, smoking, blowing nose If large or lining torn - close with buccal advancement flap, can refer urgently to OS for this

Question 531

OACs <2mm prognosis

Answer 531

Usually heal with normal blood clot formation and routine mucosal healing

Question 532

What type of flap is usually used to close an OAC?

Answer 532

Buccal advancement flap

Question 533

Buccal advancement flap

Answer 533

Three sided flap with a crestal incision and two relieving incisions Flare base to ensure that there is bloody supply to all of the flap

Question 534

Procedure of closing OAC with buccal advancement flap

Answer 534

Lift the flap of mucosa, sometimes need to chip away some buccal bone. This flap will not stretch easily across so you need to incise the periosteum of the flap (fresh blade) on the underside. This will make the flap loose enough to stretch it over the OAC. Be very careful when incising the periosteum not to cut the flap off. One initial suture. Usually resorbable sutures, but sometimes these dissolve too quickly. Then follow with more sutures for complete primary closure.

Question 535

Patients with an OAF may complain of

Answer 535

* Problems with fluid consumption, fluids from nose * Nasal quality to speech and singing * Problems playing brass/wind instruments * Problems smoking or using a straw * Bad taste/odour/halitosis/pus discharge * Pain/sinusitis type symptoms

Question 536

OAF management

Answer 536

The same as the OAC closure except first you must excise the epithelialized sinus tract, then perform buccal advancement flap. Sometimes an antral washout is also required - if chronic sinusitis and sinus is full of infection, this is flushed out and aspirated. This can cause reduction in sulcus depth.

Question 537

Potential flap designs for OAC/ OAF closure

Answer 537

* Buccal advancement flap * Buccal fat pad with buccal advancement flap - if bigger OAF or OAC, two layer closure, very effective * Palatal flap - incredibly painful, leaves exposed bone on the palate * Bone graft/collagen membrane * Rotated tongue flap (historical)

Question 538

Aetiology of fractured maxillary tuberosity

Answer 538

* Single standing molar * Unknown unerupted molar or wisdom tooth * Pathological gemination/concrescence * Extracting in wrong order (you should start posterior and move forward) * Inadequate alveolar support

Question 539

Diagnosis of fractured maxillary tuberosity

Answer 539

* Noise * Movement noted both visually or with supporting fingers * More than one tooth movement * Tear in soft tissue of palate

Question 540

Management of maxillary tuberosity fracture

Answer 540

if noticed early enough Reduce and stabilise * Orthodontic buccal arch wire with composite * Arch bar * Splints (lab made) If bone removed - dissect out and primary closure of wound

Question 541

If maxillary tuberosity fracture is treated by splinting tooth must remember:

Answer 541

* Remove or treat pulp * Ensure it is out of occlusion * Consider antibiotics and antiseptics * Post-op instructions * Remove the tooth surgically 4-8 weeks later

Question 542

Management of a root or tooth in the maxillary sinus

Answer 542

Confirm radiographically by OPT, occlusal or periapical (+/-CBCT) CBCT should be done on the day of retrieval as it can move around Decision on retrieval If in doubt or retrieval difficult - refer

Question 543

How to manage?

Answer 543

You can leave this piece of root because if it has not torn the lining, it will not cause sinusitis or other problems and it will not move from there

Question 544

Removal of root in the maxillary sinus process

Answer 544

Open fenestration with care Suction - efficient and narrow bore Small curettes Irrigation or ribbon gauze Close as for OAC Careful not to tear lining If this doesn't work - Caldwell-Luc approach (buccal window cut in bone) If unretrievable - refer to ENT for endoscopic retrieval

Question 545

What must you remember when examining patients with maxillary discomfort?

Answer 545

- Close relationship of the sinuses and the posterior maxillary teeth - The aetiology of paranasal sinus inflammation and infection - Patients with sinusitis often present to the dentist first

Question 546

Aetiology of Sinusitis

Answer 546

Mostly precipitated by the effects of a viral infection (debate over antibiotics) Inflammation and oedema Obstruction of ostia Trapping of debris within sinus cavity Mucociliary clearance patterns may be altered by allergens, inflammation, anatomic abnormalities Normal function further disrupted by cellular damage to mucosal lining, affecting ciliary function Build up in sinus and bacterial overgrowth

Question 547

2 effects of sinus not being able to evacuate its contents efficiently

Answer 547

Build up of pressure Stagnation in sinuses - opportune situation for bacterial overgrowth of normal flora

Question 548

Signs and symptoms of sinusitis

Answer 548

* Facial pain * Pressure * Congestion * Nasal obstruction * Paranasal drainage * Hyposmia * Fever * Headache * (dental pain) * Halitosis * Fatigue * Cough * Ear pain * Anaesthesia/paraesthesia over cheek

Question 549

Dental causes that must be ruled out with similar symptoms to sinusitis

Answer 549

- PA abscess - Periodontal infection - Deep caries - Recent extraction socket - TMD - Neuralgia or atypical facial pain/chronic midfacial pain

Question 550

Specific indicators of sinusitis, that indicate the symptoms do not have a dental cause

Answer 550

Discomfort on palpation infraorbitally A diffuse pain the maxillary teeth Equal sensitivity from percussion of multiple teeth in the same region Pain that worsens with head or facial movement (jump up and down, bend and stand up)

Question 551

Treatment aims for patients with sinusitis

Answer 551

Treat presenting symptoms Reduce tissue oedema Reverse obstruction of the ostia

Question 552

Sinusitis treatments

Answer 552

Decongestants to reduce mucosal oedema - ephedrine nasal drops 0.5% one drop up each nostril up to three times daily when required (max 7 days as will cause atrophy of sinus and nose lining) Humidified air also helpful (steam/menthol inhalations)

Question 553

Why can't you use decongestants long term?

Answer 553

Will cause atrophy of the lining of the sinus and the nose

Question 554

Antibiotics for sinusitis

Answer 554

Only to be used if symptomatic treatment not effective/symptoms worse AND Signs and symptoms point to bacterial sinusitis Amoxicillin 500mg 3x daily 7 days Doxycycline 100mg 1x daily 7 days (200mg loading dose) SDCEP guidance

Question 555

Fungal infections of sinuses

Answer 555

Very rarely non-resolving sinusitis may be due to a fungal infection This can cause expansion of the bony walls by increased mucous secretion and fungal growth (this can happen with other types of infection too)

Question 556

What types of trauma can cause sinusitis by violating the integrity of the bony cavity and sinus membrane?

Answer 556

Sinus wall fractures Orbital floor fractures RCT Extractions Implants/sinus lifts Deep perio treatment Nasal packing Nasogastric tubes Mechanical (nasal) intubation

Question 557

What is a sinus lift?

Answer 557

Procedure used to reduce volume of the sinus to increase amount of bone available usually for implants

Question 558

Benign sinus lesions

Answer 558

Polyps, papillomas, antral pseudocysts, mucoceles, mucous retention cysts, odontogenic cysts/tumours expanding into the sinus

Question 559

Malignant lesions of the maxillary sinus

Answer 559

Primary tumours Local spread from adjacent sites

Question 569

How much alveolar bone support should you have for a post?

Answer 569

At least half of post length into the root in bone