Nashville Topic Review Flashcards
(313 cards)
1
Q
Whats is your physical exam for an infection patient?
A
Vital signs
Palpate Extraoral, lymphadenopathy
Intraoral Look for decayed teeth, drainable abscess, FOM swelling, Uvula Deviation
1
Q
What questions should you ask about your infection patient?
A
History, Onset, Duration, Rate of Progression, Previous Treatment, Any Medical Conditions, PSH, ALL
Signs of airway impingement (secretions/tracheal deviation)
2
Q
What initial imaging for an infection patient?
A
Screening Pano and CT with Contrast (don’t forget to check renal function)
3
Q
What creatinine level before proceeding with a CT with contrast?
A
Less than 1.5 mg/dl
Creatinine is a muscle water products, the levels indicate kidney filtration
4
Q
If creatinine is high what other imaging can you order?
A
MRI or Ultrasound
5
Q
What type of imaging should you order if you suspect osteomyelitis?
A
T2 MRI (can also order this for cavernous sinus thrombosis)
6
Q
Describe the pathogenesis of an infection:
A
Respiratory aerobic bacteria deplete O2, creates O2 poor environment, anaerobes take over and secrete toxins, an abscess results
7
Q
Describe the buccal space:
A
The buccal space is superficial to the buccinator muscle and deep to the platysma muscle and the skin. The buccal space is part of the subcutaneous space, which is continuous from head to toe.
8
Q
Describe the submandibular space:
A
located on the superficial surface of the mylohyoid muscle between the anterior and posterior bellies of the digastric muscle.[
9
Q
Describe the canine space:
A
Overlying the maxilla near the canine tooth root and covered by the levator labii superioris muscle.
10
Q
Describe the sublingual space:
A
Below the tongue, above the mylohyoid muscle
11
Q
Describe the infratemporal space space:
A
lateral aspect of the skull, situated inferior to the temporal fossa and deep to the ramus of the mandible.
12
Q
Describe the lateral pharyngeal space space:
A
lateral to the pharynx from the base of skull to hyoid
13
Q
Describe the retropharyngeal space
A
Posterior to the pharynx and esophagus, and extends from the base of the skull to the thoracocervical junction as the alar fascia attaches to the buccopharyngeal fascia (at a variable level between the C6 and T6 vertebral bodies)
14
Q
What separates the lateral pharyngeal space from the retropharyngeal space?
A
The carotid sheath
15
Q
What are reasons to treat patients in the hospital?
A
Temp over 101
Dehydration
Threat to airway
Need for general
Inpatient control of systemic Disease
16
Q
Why is glycemic control important for infection patients?
A
Glucose >200 will cause neutrophil dysfunction and problems, cause endothelial transport problems
17
Q
What nursing orders should you order for infection patients?
A
Head of bed elevated
O2
Suction
IV access
Emergency Airway Kit
Abx
Blood Cultures
+/- steroids and pain meds
18
Q
What are the most common bacteria that cause intraoral abscesses?
A
Anaerobes = 75% gram + cocci (strep, peptostrep)
gram - rods: prevotella, fuso
Aerobes = 25% strep viridians, eikenella, stap
19
Q
What is the SIRS and what is Septic Shock?
A
Systemic Inflammatory Response Syndrome (SIRS)
Septic Shock: sepsis with drops in BP and organ failure such as vasodilation, renal failure, ARDS, DIC; pt has release of mediators such as tumor necrosis factor
20
Q
Describe the mallampati classifications:
A
I – visualization of the soft palate, fauces, uvula, anterior and posterior pillars
II – visualization of soft palate, fauces and uvula
III – visualization of soft palate and base of uvula
IV – soft palate is not visible at all
21
Q
Describe Steps to a Tracheostomy
A
Position neck fully extended with a shoulder roll
Mark landmarks - sternal notch, cricoid and thyroid cartilages, and incision site (1/2 between cricoid and sternal notch)
Infiltrate local anesthetic
3cm transverse incision through skin with blunt dissection in the midline through subcutaneous fat to superficial layer of deep cervical fascia
Strap muscles retracted laterally and thyroid isthmus is visualized - depending on position, it is either retracted superiorly or, more commonly, clamped and divided to allow access to trachea
Identify cricoid cartilage and tracheostomy is made between 3rd and 4th rings - window cut
Blunt tracheal hook inserted and retracted superiorly (tell anesthetist to partially withdraw the tube until tip is visible superiorly in window)
Tracheostomy tube is inserted and gently rotated into place
22
Q
Whats the treatment of Actinomyces?
A
Long term PCN and removal of any sinus tracts
23
Q
Describe Surgical Treatment of Infection
A
Remove the tooth or offending agent
If extra-oral, incise in healthy tissue when possible
Adequate drainage – must get subperiosteal Exploration of all involved spaces - blunt dissection
Copious irrigation
Establish dependent drainage
Drain placement: more serious infections consider continuous irrigation drains for 3 days
24
What do you order after surgery for an infection patient?
IVF hydration
Nutrition with Glycemic control
IV antibiotics
DVT prophylaxis
25
What is the dosage of PCN and what is its action?
500 mg qid, children 25-50 mg/kg/day
Bactericidal – interferes with cell wall synthesis of bacteria during growth phase
Oral strep, anaerobes, actinomycosis, eikenella
26
What is the dosage of Augmetin and what is its action?
Amoxicillin / Clavulanic acid, 500 – 875 mg bid
Beta – lactamase inhibitor – bactericidal
27
What is the clindamycin dosage and what is its action?
50-600 mg qid, children 15-30 mg/kg/day
Bactericidal (high dose) or bacteriostatic (low dose) – interferes with protein synthesis, metabolized in liver, excreted in urine, excellent abscess penetration
Does not cross blood brain barrier
Covers: Oral strep, staph, anaerobes
28
What does clindamycin not cover?
Does not kill Eikenella
And Does not cross BBB
29
What causes PSEUDOMEMBRANOUS COLITIS?
C. difficile produces toxins A and B -> destroy enterocyte cytoskeleton
Results in leaks between enterocytes
30
How do you treat pseudomembraneous colitis?
Discontinue current abx use
Antibiotic treatment 10-14 days
Oral vancomycin - bacteriostatic
Metronidazole (500mg tid)
31
Why use steroids in an infection?
Decreases airway swelling
Reduced pain
Decreased trismus Normalization of Body temp Decreased Hospital stay
Concerns of worsened outcomes secondary to the immunosuppressive nature of corticosteroids are NOT supported in the literature
32
Any regression in patient after infection what should you do?
Any regression obtain new contrasted CT to evaluate for missed or new fluid collections that require drainage
33
What is the purpose of leaving a drain?
Facilitate gravity dependent drainage Allow for irrigation
Prevent closure of tissue margins
34
When do you remove a drain?
Remove when drainage appears complete with mainly serosanguineous drainage
Typically between 3-5 days
May also withdraw gradually in very deep or through-and-through drains
Leaving too long may result in secondary infections
35
List the criteria for extubation:
Stable Vitals
Postive Air leak test
Acceptable vent readings
Vital capacity >15 mm/kg
Minute Ventilation of 6-10L/min
Inspiratory pressures of >25 cm H2O
Normal ABG
36
What is CERVICOFACIAL NECROTIZING FASCIITIS?
Fast infection that progresses and spreads in the subcutaneous tissues
Caused by Group A beta hemolytic Strep as well as e. coli, clostridium and pseudomonas
Mortality (25-75%) caused by toxin induced circulatory collapse; can occur in as little as 48 hours
37
CERVICOFACIAL NECROTIZING FASCIITIS may have Soft tissue crepitation from gas forming bacteria - Type 2 only - which bacteria cause this?
Strep. Pyogenes and Staph Aureus
38
Explain how you treat CERVICOFACIAL NECROTIZING FASCIITIS:
Early diagnosis - Most accurate step in diagnosis is a fresh frozen section biopsy
Immediate surgical debridement with removal of all non-viable tissue including fascia
IV antibiotics to cover GPC, facultative anaerobes, gram negative rods and aerobes (cefotaxime, gentamicin, and flagyl)
Wounds should be left open and packed with anti-microbial soaked gauze
Follow-up with culture directed antibiotics
Role of HBO therapy is controversial
39
Describe DESCENDING NECROTIZING MEDIASTINITIS:
pharyngeal, or cervical infection spreading into the mediastinum
40
What planes does mediastinitis spread along?
Lateral pharyngeal space to Retropharyngeal to Pretracheal and Paraesophageal planes
41
How do you treat DESCENDING NECROTIZING MEDIASTINITIS?
Broad Spectrum antibiotic coverage to prevent further spread
Transcervical incision with extension to the bilateral sternocleidomastoid muscles
Thoracotomy - for more advanced cases
Drainage of pericardial effusion through subxiphoid incision
42
In an orbital infection what does afferent reflex defect tell you?
indicates optic nerve involvement
43
What is a classification for orbital infections?
CHANDLER CLASSIFICATION SYSTEM
Group 1: inflammatory edema (preseptal cellulitis)
Group 2: orbital cellulitis Group 3: subperiosteal abscess
Group 4: orbital abscess
Group 5: cavernous sinus thrombosis
44
Whats the treatment for preseptal orbital cellultiis?
Antibiotic to cover community- acquired MRSA (Clinda or TMP/SMX)
If needed Transcutaneous drainage Transconjunctival drainage, Transnasal endoscopic Drainage through ethmoid sinus
45
What is POSTSEPTAL ORBITAL CELLULITIS?
Demonstrates true infection of orbital contents with fat and ocular muscle involvement
Ophthalmoplegia
Decreased visual acuity
Proptosis
46
Where is the most common place for a post septal orbital abscess?
Common abscess location is medial or superomedially
47
What is the treatment for POSTSEPTAL ORBITAL CELLULITIS/ABSCESS?
Vancomycin, Augmentin, metronidazole, ceftriaxone, Piperacillin-tazobactam, or levofloxacin
Orbital abscess requires immediate surgical drainage
Transconjunctival with or without transcaruncular or lateral canthotomy extensions
Endoscopic sinus surgery is indicated in patients with severe destructive rhinosinusitis
48
What are EMISSARY VEINS?
Areas of skull where infection spreads from superficial vein to intracranial vein
Example: Deep facial vein thru pterygoid plexus via vesalius vein to cavernous sinus
49
What is CAVERNOUS SINUS THROMBOSIS?
Vascular thrombosis secondary to retrograde spread of orofacial infections
Severe headache, fever, malaise occur first
49
What is the pathway of infection to the cavernous sinus?
Facial veins -> Angular Vein -> Ophthalmic Veins -> Cavernous Sinus
Emissary to Pterygoid plexus (slower spread)
49
What are the signs of cavernous sinus thrombosis?
First sign of thrombosis is generally CN6 palsy - lateral gaze palsy
Drooping of the eyelid (ptosis), dilation of the pupil (mydriasis), and eye muscle weakness result from cranial nerve III dysfunction. Total palsy of the nerve leads to an eye that is facing down and lateral “down and out”
50
What is the treatment of cavernous sinus thrombosis?
Antibiotics long term (6 weeks) Vancomycin + Ceftriaxone, Zosyn, or Unasyn. Switch to oral once drainage and good response, anti-coagulation, steroids
Surgery is directed both at the primary source of infection and obtaining a culture
51
What imaging should you order if you are concerned about cavernous sinus thrombosis?
Contrast-enhanced magnetic resonance imaging (MRI) and magnetic resonance venography
CT if this is not available
52
For cavernous sinus thrombosis when do you stop anticoagulation?
Duration - until symptoms have regressed
53
What are the Surgical Drainage options for cavernous sinus thrombosis?
Endoscopic transnasal Transcaruncular
Caldwell Luc
54
What are some signs that the orbital cellulitis has progressed to cavernous sinus thrombosis?
Dilated pupil or pupils
Visual loss
Papilledema
Fifth cranial nerve dysfunction Bilateral eye involvement Inflammatory cells in the CSF
55
In an initial orthognthatic eval what are your first questions?
What is the patient’s chief complaint—why did she go to the orthodontist in the first place?
How long has this been a problem/concern?
PMH/Meds/Allergies/Soc Hx/Surg Hx
Age? Recent growth?
56
Describe what the facial thirds are?
Upper third – hairline to glabella
Middle third – glabella to subnasale
Lower third – subnasale to menton
subdivided into 1/3 maxillary and 2/3 mandibular
57
Describe your extraoral physical exam for an orthognathic patient:
MIDLINES (maxillary, mandibular and chin)
Upper lip length
Tooth to lip at rest and high smile
Interpupillary distance
Malar projection, paranasal support
Alar base width
58
How much gingival show is allowed in planning?
Amount of maxillary incisor exposed during full smile varies, but want no more than 2 mm gingival exposure at full smile
Treat to incisor exposure at rest, not at full smile, to avoid over treating the vertical maxillary position
59
Frontonasal angle
125-135 degrees
60
Nasolabial angle
85-105 degrees
61
Lip-Chin-Throat angle
110+5 degrees
62
Labiomental angle
120+10 degrees
63
What is Bolton's analysis:
used to determine if tooth size discrepancies exist between the arches
64
What is a Relative vs absolute transverse discrepancy
The transverse discrepancies may be relative (i.e., the original position of the jaws and dentition in malocclusion may appear to be abnormal in the original malocclusion and normal once the jaws are positioned in a Class I relationship) or the transverse discrepancy may be absolute (when the jaws are positioned in a Class I relationship, the maxillary width is deficient for the mandibular dentition).
65
What are the orthodontic goals prior to orthognathic surgery?
Level, align and coordinate the arches
Decompensate teeth - paying particular attention to the AP and vertical position of the incisors
Address any tooth size discrepancies—interdental stripping, maintaining appropriate space for peg-shaped laterals
Position teeth over basal bone
Diverge roots of teeth adjacent to planned interdental osteotomies
Avoid orthodontic attempts to close open bites
66
What cases do you not want to level the occlusal plane?
Class II deep bite malocclusion with excessive curve of Spee - advance the mandible along the incisor-molar plane to increase facial height, tripod the occlusion, then use vertical elastics to extrude premolars and close lateral open bite post-surgically
Patients with large vertical steps in the occlusal plane - maintain steps via segmental archwires to level in segments, correct with segmental surgery
67
What are your options to increase arch space?
Expand the arch orthodontically
Procline incisors
Interproximal reduction
Extractions
68
What teeth would you extract for a class 2 div 1 patient?
Upper second premolar: decreases maxillary crowding, and allows for greater advancement
Lower 1st premolar: decreases anterior crowding
69
What teeth would you extract for a class 3 patient prior to orthognathic surgery?
upper 1st premolars - allows for retraction of flared maxillary incisors
Lower 2nd premolars if mandibular crowding exists and want to avoid proclination of lower anterior teeth
70
When do you need to extract third molars prior orthognathic surgery?
If treatment plan includes BSSO, consider removal of third molars at least 6-9 months prior to BSSO to decrease risk of an unfavorable split
Also allows an opportunity to see how the patient responds to the “adversity” of a surgical procedure prior to orthognathic surgery
71
At what age should orthognathic surgery be performed?
At or near completion of growth (F~16, M~18)
72
How do you assess that a patient’s growth is complete?
Serial cephalometric film superimpositions at 6 month intervals
Serial hand-wrist films to evaluate the epiphysis-diaphysis relationship (Fishman method)
73
What are the advantages of plates during BSSO surgery?
Less nerve compression
Less condylar torque
Adaptable for asymmetry cases
Can use plate to help position proximal segment
74
What are the advantages of screws during BSSO surgery?
Less hardware
Positional screws over lag technique
“L” configuration more stable than straight line
75
What are the most common places for bad splits?
Buccal plate fracture of proximal segment
Lingual plate fracture of distal segment
Subcondylar osteotomy
Split extends up into/through condylar head
76
Release patient from MMF and there is an open bite or gross malocclusion what happened?
INCOMPLETE SEATING OF CONDYLE IN FOSSA
Avoid by applying “seating” pressure along ascending ramus and inferior border before placing bone plates/screws
Treat by removing plates/screws, placing patient back into MMF, seat condyle/ proximal segment and replace plates/screws, then release MMF and reevaluate
77
Hows does IAN injury occur during orthognathic surgery?
Can occur medially secondary to retraction with Seldin retractor during the medial horizontal osteotomy
Transection within the osteotomy due to saw/bur/osteotome (frequency of 2-3.5%)
Direct injury during placement of hardware
78
If you visualize IAN injury what can you do?
Primary repair 8-0 or 9-0 prolene if transection witnessed
79
What are the advantages of IVRO?
Faster procedure
Little or no hardware reduced costs Decreased risk to IAN
Good for rotational asymmetries
Less relapse associated with setbacks
80
What are the disadvantages of IVRO surgery?
MMF required if no fixation used
Condylar sag
More difficult to apply rigid fixation when needed
Decreased area of overlapping bony contact
81
Bleeding after IVRO is caused by what artery?
Sigmoid notch - masseteric artery
Medial ramus – inferior alveolar artery – osteotomy too anterior (IAN disturbance)
82
Describe LF1 Osteotomy steps:
Measure and record vertical position of maxillary incisors (K-wire at nasofrontal junction vs measuring from medial canthus)
Circumvestibular incision ~7mm above mucogingival junction from 1st molar to 1st molar
Expose anterior maxilla vertically to infraorbital nerves, posterior maxilla to pterygomaxillary junction
Dissect intranasally along lateral nasal wall, nasal floor to protect nasal mucosa
Internal vertical reference points 10mm apart in pyriform and buttress areas
Horizontal osteotomy with reciprocating saw from buttress to pyriform
Lateral nasal wall osteotomies with guarded osteotome to depth of 20-30mm
Nasal-septal osteotomy
Pterygoid plate osteotomies – aim chisel inferiorly
Downfracture and mobilize the maxilla
83
What is the common place for bleeding during a Le Fort 1 osteotomy?
Injury to pterygoid musculature with pterygomaxillary osteotome
Venous – pterygoid venous plexus
Arterial – Descending palatine artery, posterior superior alveolar artery, or sphenopalatine artery, internal maxillary artery
84
Patient has bradycardia/asystole during down fracture - what happened?
Trigeminal cardiac reflex: stop manipulating the maxilla, atropine, ACLS if necessary
85
What factors increase the risk of avascular maxillary necrosis?
Increased risk with larger advancement (>10mm); segmental maxillary surgery; pressure from palatal coverage splint
86
Anterior open bite following stabilization of the maxilla what happened?
Likely secondary to inadequate bone reduction of posterior maxilla causing distraction of condyle during plating
87
Deviated nasal septum after le fort surgery - what caused this?
failure to trim septal cartilage for impaction
88
Chronic sinusitis after Le Fort surgery - what caused this?
Possible blockage of osteum during impaction
89
What are the indications for a SURGICAL ASSISTED RAPID PALATAL EXPANSION (SARPE)?
Transverse discrepancy >7mm; or
Isolated transverse discrepancy without need for vertical or sagittal correction
Patients who have previously failed orthodontic expansion
90
What are the contraindications for a SARPE?
Transverse discrepancy <7mm in combination with other vertical and/or sagittal discrepancies requiring maxillary repositioning
Apertognathia with excessive curve of Spee where arch form will be leveled with segmental surgery
91
When do you activate a SARPE distractor?
5-day latency period following initial operation, then expansion appliance activated one quarter turn (0.25mm) twice daily
92
How long do you distract a SARPE patient for?
Complete expansion within first four weeks post-op then “lock” appliance with acrylic or wire for 6 months to allow for consolidation
93
Describe the 4 phases of cleft orthognathic surgery?
Phase I orthodontics during mixed dentition to expand the maxilla to minimize transverse discrepancy for future treatment
Phase II orthodontics = pre-surgical orthodontics as with non-cleft orthognathic surgery; try to avoid mandibular extractions
Phase III is orthognathic surgery
Phase IV is post-surgical orthodontic treatment
94
What makes cleft orthgonathic surgery so hard?
Palatal scarring and tissue non-compliance may prevent positioning of maxilla into preplanned position
Place as close to planned position as possible, then finish the correction in the mandible
Orthodontic appliances may need to be more “robust” due to increased difficulty with mobilizing the maxilla
Higher risk of post-surgical relapse requires overcorrection during treatment planning
95
How do you treat relapse in a cleft orthognathic patient?
Treat relapse with reverse-pull headgear and class III elastics to counteract relapse
96
How do you modify your surgery for cleft orthognathics?
Surgical approach to the maxilla only differs from traditional orthognathic approach in bilateral cleft cases and those with severe palatal scarring
modify vestibular incision to leave a midline band of mucosa along facial aspect; use a small vertical incision to permit placement of the nasal-septal osteotome
Bring 2nd splint in case cannot get it advanced.
96
What are the TMJ diagnostic questions?
How long have you been in pain?
Has there been any changes in the pain?
Is there anything that increases or decreases the pain?
Can you show me exactly where it hurts?
What type of diet do you eat?
What previous treatments have you tried?
Have any of the previous treatments provide relief?
97
Describe the PATHOGENESIS FOR DEGENERATIVE CHANGES OF AURICULAR CARTILAGE
Stress from bruxism
Chronic microtrauma
Compression and shearing
Chondrocyte damage – Collaganases Proteogylcan chain splitting and water loss Loss of cartilage resilience
98
What imaging do you order initially for a TMJ patient
Panorex – initial screening
99
Describe what a T1 image looks like:
Bright Fat, and bone marrow, dark water and disc, better for anatomy
100
Describe what a T2 image looks like:
Bright brain, and fluid (BRIGHT FLUIDS effusions)
Dark fat; better for pathology with edema and effusions
101
Describe non-invasive treatment of TMJ:
Jaw rest/Soft diet
Stretch/PT
Ice/Moist Heat
Orthotic splint
Elavil 10-30mg at bedtime
NSAIDs – Mobic 7.5mg per day
Goal is improve function and decrease pain
102
What are the indications for TMJ surgery?
Significant pain and/or dysfunction when non-surgical therapy has failed
Evidence of disease on imaging
More localized the pain and/or dysfunction to the joint the better the prognosis
More diffuse the pain and/or dysfunction the worse the prognosis
Failure to manage associated myofascial pain and dysfunction will worsen the surgical success rate
103
What is the treatment algorithm for painful clicking?
Non surgical, Arthrocentesis, Disc Reposition
104
What is the treatment algorithm for painful locking?
Step 1: Arthrocentesis (establish movement)
Step : Arthroscopy
Step: Arthroplasty with preservation, or Discetomy
105
What are the indications for arthrocentesis?
TMJ Arthralgia
Anterior displaced disc with reduction/pain
Anterior displaced disc without reduction chronic or acute Previously operated joints without pain relief
106
What are the contraindications for arthrocentesis?
Severe limited opening - Bony or Fibrous ankylosis
107
Describe an arthrocentesis procedure?
Single or double lavage port
10-2 point, 10mm and 2mm inferior to canthal-tragal line/Second port is 10mm anterior
Lavage joint, break adhesions with hydraulic pressure, 100ml LR, manipulate jaw/joint
Steroid (Kenalog) in joint
Advantages – minimally invasive, office procedure under IV sedation, easy technique, 70-95% success rate (similar to arthroscopy)
108
What size port do you use for an arthroscopy?
Diagnostic – can be done in clinic under IV sedation with .7mm scope
109
Describe the grade of synovitis:
Type 1: vasodilation
Type 2: Hyperemia, vasodilation
Type 3: hyperemia, severe vasodilation
Type 4: Obilterate vascular patterns
110
What are the indications for condylotomy?
Wilkes Stage II or early Stage III
Painful popping / clicking
111
Describe a preauricular incision
3-4 cm incision in preauricular skin crease, may have slight superior 1-2 cm curve, inferior aspect does not go below lobule of ear
Dissect through skin and subcutaneous tissue to depth of temporalis fascia (glistening white)
Oblique incision parallel to the frontal branch of facial nerve through the superficial layer of the temporalis fascia above Zygomatic arch
Dissection with periosteal elevator beneath the superficial layer of the temporalis fascia to strip the periosteum off the lateral Zygomatic arch
Horizontal incision just below the lateral rim of the glenoid fossa will expose superior joint space, dissection is then continued inferiorly removing the attachment of the capsule to the disc which will expose the inferior joint space
112
What are some indications for an alloplastic joint?
Indications
Failed previous surgeries
Degenerative arthritis OA/RA
Loss of vertical mandibular height and occlusal relationship secondary to condylar resorption, trauma, pathology or developmental deformity
Ankylosis Fibrous and/or Bony Not for Chronic Pain only
113
What is the name of the TMJ classification ankylosis system?
Sawhney (1986)
Type1 - Flattened condylar head close to joint
space
Type 2 - Flattened condyle close to glenoid fossa, bony fusion outer articular surface
Type 3 - Bony block bridging ramus and arch
Type 4 - Wide bony block bridging ramus and arch, replaces architecture of joint
114
How is radiation ordered for ankylosis?
Consider low dose radiation – day 4, 20Gy in 10 fractions
115
What rib do you harvest for a costochondral graft?
Harvest contralateral 5-7th rib
May consider right 6th to eliminate cardiogenic pain confusion
116
Describe harvesting a rib?
Harvest contralateral 5-7th rib
Harvest 7-10cm with 1 cm cartilage
Contour cartilage to < 5mm leaving costochondral junction
Curve rib to contour ramus, fixate with screws or wires
MMF 2-4 weeks
Soft diet 6 months, Gentle range of motion exercises, Control loading of joint
117
Whats a common complication with a rib graft?
Pneumothorax – treat locally with red rubber catheter
Resorption of Rib
Ankylosis – may need possible radiation treatment, adults have increased risk of re- ankylosis
Limited function with no translation, limited excursive
Variable growth, usually undergrowth, but may overgrow, in general growth is not symmetrical with unaffected side
118
What the most common tumor of the axial skeleton?
Osteochondroma
119
What are the things to consider with reconstruction?
Most important thing is to determine the quality of the soft tissue
Most important thing is to determine the quality of the soft tissue
Most important thing is to determine the quality of the soft tissue
120
What is the largest defect you can use for an iliac crest?
10cm (beyond this you need a vascularized graft)
121
If you have poor soft tissue what are your options for reconstruction?
1st stage ex-fix soft tissue graft or pectoralis, 2nd stage iliac crest
122
Where is the Anterior Iliac Crest?
Anterior Iliac Crest is between the AIS and tubercle of ilium
The inguinal ligament, satorius muscle attached
123
How much cancellous bone does the anterior iliac crest have?
50 cc
124
What is the most commonly injured nerve while performing an anterior iliac crest graft?
Lateral cutaneous branch of the ilohypogastric nerve
Others include: Lateral femoral cutaneous nerve runs with AIS, usually damaged during retraction
125
What are the muscles you retract during an anterior iliac crest graft approach?
External Oblique, Transverse abdominal, Iliacus, Tensor fascia Lata, Gluteus
126
Describe the anterior iliac crest harvest:
Place a hip roll
Mark out the AIS and Crest
Incision is made 3 cm lateral and 1 cm posterior to the AIS (5cm in length)
Skin, subq, down to fascia and make incision on the bone between muscles
Dissect the iliacus medially to expose the crest, osteotomy to obtain a block
Harvest 50 cc of bown, Do not undermine the AIS due to fracture risk
127
How much bone does a posterior Iliac crest graft provide?
100 cc
128
Describe the posterior iliac crest harvest technique:
Position in the jacknife position with a hip roll
8 cm curvilinear incision 3 cm from midline with superior extension
Skin, subq, periosteum
Reflect the gluteus maximus and medius
Harvest 100 cc of bone
129
What are the most common complications from iliac crest grafts?
Gait problems, Retroperitoneal Hemorrhage, Hematoma, Ileus,Fracture, Sensory issues
130
What causes Gait Disturbance after an iliac crest graft?
Stripping from the fascia lata muscle laterally
131
What causes retroperitoneal hemorrhage after an iliac crest graft?
Poor hemostasis, and damage to the Deep Circumflex Iliac Artery
132
Whats a common reason for fracture after an iliac crest graft?
Undermining AIS, results in satorius muscle pull
133
What causes pain and burning along lateral thigh after iliac crest graft?
Damage to lateral femoral cutaneous nerve (meralgia paresthetica) especically when the nerve does not run deep to the inguinal ligament
134
For a Fibula how much bone proximal and distal should you leave?
8cm for ankle and knee stability
135
Whats the diameter needed in a fibula for implants?
15mm is good for implants
136
Where does the peroneal artery arise from for a fibula graft?
Posterior tibial artery 90 percent of the time
137
In a 3 vessel run off what shows a contraindication for a fibula free flap?
Peronea Magna (8 percent of the time), both anterior and posterior tibial arterial are hypoplastic there is a large dominant peroneal artery that supplies the whole leg (CONTRAINDICATION)
138
What provides venous outflow in fibula free flap?
Venae comitantes (2 veines that run parallel to an artery) run parallel to peroneal artery
139
What is required for vessel evaluation prior to a fibula free flap?
MRA is required to check for 3 vessel run off and is preferred now over doppler or angiography
140
What muscle can you include with fibula paddle?
You can include the soleus or flexus hallicus longus to increase skin survival due to more muscle perforators
141
What nerve can you include with a fibula free flap?
Can incorporate the lateral cutaneous or sural nerve for grafting
142
What are common complications with fibula free flaps?
Flap loss, skin paddle loss, compartment syndrome, ischemia
143
What causes weakness in dorsiflexion in the foot after a fibula free flap?
Scarring of the flexor hallucis longus or injury to the peroneal nerve
Equinovarius deformity, injury to commom peroneal nerve
144
How do you classify maxillary defects?
Brown classification
Class 1 → maxillectomy with no oralantral fistula hard palate, no alveolus
Class 2 → low maxillectomy
Class 3 → high maxillectomy
Class 4 → radical Maxillectomy
A = unilateral, B = Bilateral crosses midline, C = entire alveolus and hard palate
145
What are some indications for 3rd molar removal?
Pericoronitis
Prevention of dental disease (periodontal and caries)
Orthodontics
Prevention or Treatment of cysts/tumors
Angle fractures are 2.8 times greater with impacted 3rd molar present
146
What are some contraindications for third molar removal?
Advanced Age
IAN proximity
Sinus Proximity
Risk of Mandibular Fracture during removal
Previous History of H and N radiations
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Where is the lingual nerve during thirds removal?
Mean is 2.5mm inferior from the crest and 2.5mm medial
10-15 percent after superior to the crest
25 percent are in direct contact with lingual cortex
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Should you use antibiotics for third molars?
Poor evidence to support use of routine prophylactic antibiotics
Single dose abx may be beneficial in reducing alveolar osteitis
Peridex may be beneficial as well
149
How do NSAIDs help after 3rd molar removal?
Reduce pain and swelling by reducing postop prostaglandins which peak 4-5 hrs following trauma
150
What is alveolar osteitis?
Occurs 3-5 days after extraction, 1-25% of cases
Secondary breakdown and loss of normal clot
Fibrinolytic agents might be from tissue, saliva or bacteria
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What are the risk factors for alveolar osteitis?
Smoking, Female, Oral contraceptives
Poor hygeine, preoperative periocoronitis,
Type of impaction, length of procedure, experience of surgeon
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Whats the treatment for alveolar osteitis?
Gentle irrigation and food debris removal
Placement of eugenol (not much but can be neurotoxic)
153
What are some causes of bleeding after 3rd molar removal?
Soft tissue or vessel injury
Undiagnosed AVM
Known coagulopathy = Hemophilia A, B, VonWillebrand Disease
Anticoagulants = warfarin, DOAC, or anti platelets
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How do you manage bleeding from 3rd molar injury?
Hold firm pressure with gauze for 3 minutes
Debride and inspect the area
Adminster more local with vasoconstrictor
Intralveolar hemostatic agents = gelform, surgicel, avtine, thrombin, bone wax
TXA
155
How does TXA work?
Inhbitis the plasminogen to plasmin (clot breakdown), 10x more potent than amicar
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If all else fails and bleeding continues in office after thirds what do you need to consider?
Angiography and embolization
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How do you manage a tooth being displaced into the infratemporal fossa?
Stop obtain film and local it, try to recover it through the socket
Place patient on antibiotics, is asymptomatic can consider leaving it in place and monitoring the patient
If symptomatic WAIT 4-6 weeks for fibrosis, and consider CT scan with needle guided fluoroscopy for removal
158
How do you manage a tooth displaced into the sinus?
Removed usually to prevent infection
Attempt to retrieve through the O-A communication suction through socket
If unsuccessful Caldwell-Luc with subeqent closure of OA
159
How do you manage a tooth displaced into the sublingual/submandibular space?
Films needed to local (CT)
Use digital pressure along lingual aspect or at inferior border
If unsuccessful may need extraoral approach 4-6 weeks later after fibrosis
160
What is the management for a displaced tooth?
Best treatment is prevention (pharyngeal screen)
If aspiration occurs
Asymptomatic → abominal and chest x-ray to local and may need bronchoscopy to retrieve
Symptomatic → consider intubatio or cricothyrotomy based on obstruction level
161
How common are nerve injuries after third molar surgery?
IAN = 0-1 percent permanent, 1.5% temp
Lingual = 0-.5 percent permanent, 0.4-1.5% temp
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What are the risk factors for nerve injury during thirds removal?
ROOD criteria for IAN = Root Darkening, Deflection, White line interruption, narrowing of canal, diversion of canal, bifid root apex
Age greater than 25, Female > Male
Depth of impaction
Position; Horizontal = IAN, Distal = Lingual
Lingual orientiation = Lingual nerve
Duration of surgery
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Explain the classification of nerve injuries:
Sunderland 1 = axons intact termporary loss; full recovery
Sunderland 2 = mild crush or taction injury; 2-4 month recovery
Sunderland 3 = moderate to severe crush or traction; microsurgery if no recovery at 3 months
Sunderland 4 = endoneurial injury leads to neuromal; microsurgery indicated at 3 months
Sunderland 5 = complete transection, poor prognosis, microsurgery is indicated
164
What is the first test you perform for neurosensory testing - for an injured IAN?
Level A test = Brush Stroke directional with light von frey filaments, 2 point discrimination with Boley gauge
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What does level A testing test for neurosensory testing?
Evaluates A-Beta Fibers are large myelinated fibers that are most susceptible to injury
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What is level B testing?
Contact detection with von Frey monofilament, blunt wood stick
Tests smaller A-beta and myelinated A-delta fibers
Normal B consistent with a functional nerve recovery
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What is level C testing?
Introduces noxious stimuli, such as deep pin prick or themal stimulus
If patient responds to level C, they may have adequate level of protection from self trauma
No response → surgical repair at 3 months
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What are indications for nerve exploration?
Observed transection of nerve
Observed injury with immediate post traumatic symptoms
Presence of foreign body
Unchanging anesthesia hypoesthesia for 3 months
Intractable neuropathic pain
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What are contraindications for trigeminal nerve exploration?
Objective signs of imrpovement
Deafferentation pain not relieved by a nerve block
Signs of central sensitization, regional spreading
Excessive time, unrealistic expectations
170
What is the timing for nerve exploration?
If you witness the injury, do it at the time of transection
Unwitnessed, controversial but go to surgery at 3 months if no recovery
171
How do you treat a neuroma?
Excision, if decompression/examination, these lesions are excised 2-3 mm proximal and distal, evaluate for herniation and axoplasm, trim nerve stumps for repair
172
How is a neurorrhaphy performed?
Direct neurorrhaphy completed when it is possible to reapproximate the cut ends of the nerve in a tension-free (<25g) manner. Place sutures (7-0, 8-0, or 9-0 Prolene) in three to five circumferential locations. Area of repair is then protected with an alloplastic nerve wrap (NeuraGen sleeve or AxoGuard)
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What do you perform when there is tension at the nerve and it cannot be re-approximated?
Indirect neurorraphy. Graft may be an autograft (sural nerve, auriculotemporal nerve), or a processed cadaveric allograft (Avance). Area of repair is then protected with an alloplastic nerve wrap (NeuraGen sleeve or AxoGuard).
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What is nerve entubulation?
Use of an autogenous or alloplastic conduit to span the continuity defect of the nerve to support regeneration without the use of an interpositional graft.
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Why would you perform a nerve redirection?
Unrepairable nerve stump is sutured directly into adjacent skeletal muscle. May decrease the risk of neuroma formation
176
Why would you perform a coronectomy?
Roots of lower tooth are closely associated with IAN where removal of the tooth puts nerve at significant risk of injury
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What are the contraindications to a coronectomy?
Acute infection around the tooth or infection of the tooth itself
Exudate associated with chronic infection
Mobile tooth/roots
Situations where coronectomy puts neurovascular structures at risk of injury (horizontal impaction with tooth in direct contact with the NVB)
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How is a coronectomy performed?
Goal is to remove all coronal structure without damaging adjacent structures or mobilizing tooth roots
Reduce remaining tooth structure so that roots are at least 3mm below the crest of the lingual and buccal plates to allow bone healing
Primary closure of soft tissue
Post Operative radiograph
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On physical exam for impacted canines what are you looking for?
▸ Count the teeth – determine what you have and what you don’t
▸ Permanent/Primary
▸ Condition of the soft tissue
▸ Presence of palatal or labial bulge to correlate clinical and radiographic exam
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Mom asks you why the canines did not come in...what do you tell her?
▸ Genetic Theory suggests that impactions are primarily caused by gene mediation
▸ Guidance Theory proposes an environmental factor, specifically the lack of normal contact between the lateral incisor root and the erupting canine
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What is the normal dosage for CBCT?
80 uSv
182
How do you treat EXISTING ROOT RESORPTION?
▸ Evaluate mobility of existing dentition
▸ Adequate imaging to determine degree of resorption
▸ Degree of resorption determines prognosis
▸ Consider extraction and orthodontic/implant substitution of hopeless teeth
▸ If keeping resorbed teeth, adequate expectations need to be established with patient/
parent
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What are your management options for impacted canines?
▸ Surgical exposure and bracketing
▸ Extraction and premolar substitution
▸ Extraction and implant placement
▸ Autotransplantation
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What are the advantages for close flap forced eruption?
The impacted tooth can be aligned while it is erupted
There are no packings or open wounds
Labial attached gingiva is maintained
Less scarring and periodontal concerns
For palatal impactions, less postoperative pain
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What are the disadvantages of closed flap forced eruption?
Cannot see erupting tooth without a radiograph
If bracket de-bonds it requires another surgery to re-bracket
May take longer to erupt canine compared with open forced eruption
Orthodontists prefer to see tooth during forced-eruption process to help align
Excessive orthodontic force can impede eruption or cause root resorption
186
What bone disease increases the risk of implant failure?
Osteoporosis increased chance of failure in patients with thin cortical bone vs. thick cortical bone
187
What should do with implants patients on zometa or aredia?
Avoid dental implants in Zometa/Aredia pts; no data on risks for patients on antiangiogenic meds
188
What you do with a patient on an oral bisphosphonate prior to implant treatment?
PO – >4years, consider 2 month pre-op drug holiday and 3-4 month post-op drug holiday; very low risk of BRONJ
189
Loss of all facial bone to the apex of socket what should you tell the patient about same day implant or Loss of 3-6mm of facial bone: graft site and delay implant placement?
We will graft site and delay implant placement
190
If you lose how much facial bone can you still place an immediate implant?
Loss of less than 3mm facial bone: may be able to place implant immediately if depth of placement doesn’t compromise hygiene for eventual restoration
191
If you place bovine bone in the sinus graft how long should you wait to place an implant?
may require 6-9 months for consolidation before implant placement
192
If you place mineralized allograft bone in the sinus graft how long should you wait to place an implant?
4 months for implant stability, it has osteoconductive properties
193
What is the difference between demineralized bone graft and mineralized?
Demineralized is thought to have osteoinductive and osteoconductive properties
194
What is BMP combined with?
rhBMP-2 combined with type 1 bovine collagen sponge carrier
rhBMP-2 as a lyophilized powder in vials; reconstituted with sterile water; results in concentration of 1.5 mg/mL
Solution applied to an absorbable collagen sponge (ACS) and allowed to sit for a minimum of 15 minutes before use
195
What is BMP FDA approved for?
FDA approved for use in sinus lift bone grafts and for alveolar socket defects
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What is BMP contraindicated in?
pregnancy or planned pregnancy within 12 months of use, allergy to components, active infection at site, presence of or in patients actively under treatment for malignancy, skeletal immaturity (<18yo)
197
What do you perform a direct sinus lift?
If native bone height is 4mm or less = direct (open) approach
197
What is the goal of a sinus?
Goal of sinus lift grafting is to provide adequate bone height for placement of at least a 10mm length implant
198
How much bone do you need for an indirect lift?
If native bone height is 5mm or more = indirect (osteotome) approach
199
How much bone graft do you put into a sinus?
Volume of graft material ~ 2-5cc
200
How do you manage a sinus membrane perforation?
elevate membrane around the area of perforation, if possible, to allow for placement of a resorbable membrane which extends 3-5mm beyond the margin of the perforation
201
Patient has vertigo after indirect sinus lift how do you treat it?
Treated with Epley repositioning maneuver (Detachment of otoliths from the utricular macula Treated with Epley repositioning maneuver)
202
What are the 3 types of gingival biotypes?
Thick scalloped
Thick flat
Thin scalloped
203
How deep do you place an implant?
Should be 3mm apical to free gingival margin of intended final restoration
This allows for prosthetic abutment placement and formation of biologic
width
204
Where should you place an implant in the facial-lingual position?
Should be 1-2mm palatal from the anticipated facial margin of the restoration
205
How close can an implant be to a tooth?
Implant to tooth distance -- 1.5 mm
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How close can an implant be to another implant?
Inter-implant distance – 3.0 mm
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Minimum space requirement to fit 3.0mm implant is?
6mm
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How do you evaluate a patient is old enough for implants?
Evaluate with serial Cephs every 6 months to demonstrate 1 year of no growth
209
What happens if you place an implant in a growing patient?
Premature placement results in implant in infra-occlusion
210
What is the minimum vertical clearance for a screw retained implant?
Minimum of 4 mm is required for most implant systems for screw retained crown
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What is the minimum vertical clearance for a cement retained implant?
Cement retained crown requires 7 mm intraocclusal height
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What are the advantages of screw retained implants?
Amenable to decreased inter-arch situations
Retrievable - can be removed for cleaning, repair, or surgical intervention
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What are the disadvantages of screw retained implants?
Require precise, prosthetically driven placement
Manufacturing process more technique sensitive and demanding
214
CEMENT RETAINED ADVANTAGES are:
Able to correct for angulation errors of compromised placement
Less demanding fabrication
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What are the disadvantages of cement retained implants?
Issues with removal of excess cement which can lead to peri-implantitis, bone loss, and implant failure
Not easily retrieved for repairs
216
Interdental papilla distance from crestal bone needs how much for a papilla?
<5mm is ideal (100 percent of the time)
217
What are the options for reduced buccal lingual bone width prior to implant?
Block graft
Particulate graft
Particulate + membrane coverage
218
What is osteogenesis? What grafts have this?
Occurs when surviving osteoprogenitor cells within a grafted material differentiate into osteoblasts and form new bone within the recipient site.
Autogenous grafts represent the only available graft with osteogenic capability.
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What is osteoconduction? What grafts have this?
Occurs when grafted material functions as a scaffold for the ingrowth of vascular tissue and mesenchymal cells from the recipient site. Bone apposition occurs within the graft site, and the grafted material is eventually resorbed and replaced with viable bone.
Examples: allografts, xenografts, and synthetic grafts.
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What is osteoinduction? What grafts have this?
Involves new bone formation through the recruitment and stimulation of recipient site osteoprogenitor cells using bone growth factors transplanted within the grafted material.
Examples: rhBMP-2 Infuse (Medtronic, Memphis, TN, USA) and BMP potentially released during the demineralization process of banked bone.
221
What do you do if your ramus buccal onlay graft fractures off during implant placement and what could you do to prevent it?
Abort procedure, graft area and place implant secondarily
Place implant if stable, and graft along buccal aspect, place membrane
Consider ridge split procedure
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ONLAY GRAFT EXPOSURE; Graft becomes exposed 2 weeks following placement what do you do?
Consider reduction of exposed bone with rotary instrument
Saline rinses
223
Ho wo do your prevent lack of papilla from implant placement?
Make sure you have planned for adequate horizontal positioning (1.5mm between implant and tooth or 3mm between implants)
Height of contact point on provisional (Should be <5mm from crest of ridge)
224
What are the options for full arch restorations?
Implant retained over denture (Locator/Bar)
Implant retained fixed detachable appliance (Hybrid)
Full arch implants with crown/bridge
225
What is an implant retained overdenture made of?
Acrylic denture base and acrylic denture teeth
226
How much space is required for an implant retained overdenture?
Require ~3mm vertical space
Can correct up to 40 degrees implant angulation
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How much space is required for a hybrid?
Requires 12-15mm of vertical space from implant platform to incised edge
228
How is A-P spread determined?
A-P spread determined by distance from center of anterior implant to distal aspect of most distal implant
229
Whare the Pathogens of peri-implantitis:
Porphyromonas gingivitis
Prevotella intermedia
Actinobacillis actinomycetemcomitans Peptostreptococcus micros Fusobacterium necleatum
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PERI-IMPLANTITIS treatment options:
Non-surgical debridement
Antibiotic therapy: Systemic vs. topical/local
Minocycline
Slow-release doxycycline
Surgical debridement
Guided Tissue Regeneration procedures
231
What is are first questions you need to ask for a trauma case?
Has all ACLS protocol been completed?
What was the mechanism of injury?
Was the accident witnessed or unwitnessed?
Was there loss of consciousness?
They most likely will state that all ACLS has been completed If that is the case move on
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What are the zones of the neck
I – Clavicle to Cricoid
II – Cricoid to Angle of mandible
III – Angle of mandible to base of skull
233
What must the wound penetrate for neck exploration?
Wound must penetrate platysma for exploration
234
Simple favorable fractures may be treated with what?
closed reduction
235
What are the absolute indications for open treatment of a condyle fracture?
Inability to achieve closed reduction
Fractures in the middle cranial fossa
Lateral extra capsular
dislocation of the condylar head
Foreign body within the joint capsule
236
What are the approaches used for a condyle fracture open repair?
Retromandibular approach Transoral
Submandibular
Preauricular – high fractures only Endoscopic
237
Describe LeFort 1-3 fractures:
Lefort I – horizontal fracture
Lefort II – pyramidal fracture
Lefort III – complete craniofacial dysjunction
238
What are the approaches for a zygoma fracture?
Gilles – temporal for arch
Keen – buccal sulcus for arch
Dingman – eye brow
239
How do you manage a lid laceration?
Always primarily
1/3 lid loss – close with direct advancement
1⁄2 lid loss – lateral canthotomy and advancement
> 1⁄2 lid loss – require local flap
240
What is the treatment for hyphema?
Bed rest, atropine, consider Amicar 50mg/kg q 4h x 5 days
241
How do alpha2-adrenergic agonists (alphagan) decrease IOP?
decrease aqeous humor production and increases uveoscleral outflow
242
How do beta-adrenergic receptor antagonisists (timolol) decrease IOP?
decreases aqueous humor productionby the ciliary body
243
Displaced posterior table fractures – greater than one cortex are treated with?
cranialization with pericranial flap
244
What syndromes are associated with cleft lift?
Van der Woude
Only orofacial anomalies, Cleft Lip with or without Palate
Lip pits, autosomal dominant 90% penetrance but variably expressed
Treacher Collins
Down’s syndrome
Fetal Alcohol Syndrome
Oro-Facial Digital Syndrome
245
What is Pierre Robin Sequence?
Micrognathia, Glossoptosis, Airway Obstruction
246
How do you manage Pierre Robin Sequence?
May require airway management, consider Mandibular DO
247
What is Stickler’s Syndrome?
Cleft Palate
Eye – retinal detachment, myopia, cataract
Skeletal – Micrognathia, midface Hypoplasia, Spondyloepiphyseal Dysplasia
Ear – Neurosensory hearing loss
248
What can cause cleft lips?
Folic acid deficiency in periconception period
Exposure to alcohol, retinoids, anticonvulsants (phenytoin, Valproic acid), corticosteroids
249
Once have child with cleft, the risk of second child is ?
2-5%
After two affected children, the risk increases to 9 – 12 %
250
When are dentofacial orthopedics performed
first few weeks of life if needed, taping or splint
251
What is the rule of 10s?
10 grams of hemoglobin, 10 weeks, and 10 lbs
many centers delaying repair until after 12 weeks due to better esthetic results
252
When is Cleft Palate Repaired?
time before the progression of natural speech
253
What is VPI repaired?
2.5-5 years with pharyngeal flap
254
When is a nasolabial revision performed?
3-5 years once nasal growth is completed if needed
255
Whats included in phase 1 cleft orthodontics?
before alveolar grafting, minimal maxillary expansion, do not move
teeth into cleft site
256
When is alveolar maxillary grafting performed in a child with a cleft?
8-12 years, when canine root is 1/2 to 2/3 formed and has not erupted into cleft site
257
Describe a millard rotation advancement:
Goal is to create a continuous sphincter of orbicularis oris
Creation of a 3-layered closure (skin, orbicularis muscle, and mucosa)
Excision of hypoplastic tissue from the cleft margins
Approximation of anatomic land- marks
258
What is the goal of closing the cleft palate?
Goal is to provide separation of the oral and nasal cavities
Creation of a functional velopharyngeal mechanism
The levator veli palatini, palatoglossus, and palatopharyngeus aberrantly attach to the posterior hard palate
259
Describe how a maxillary cleft occurs:
Occurs due to failure of fusion of maxillary processes, median nasal process, and palatal shelves during the first trimester
260
Describe how a repair of maxillary cleft occurs:
Sulcular incision made on the buccal side of the cleft with horizontal extension superior to the mucogingival-junction and carried posteriorly to tuberosity
Incision on the palatal side of the cleft with sharp dissection used to separate palatal mucosa from the nasal mucosa
Nasal mucosa is reflected from the bony walls of the cleft
Nasal mucosa is closed in water tight manner
Palatal mucosa closed
261
If area does not close in tension free manner for a cleft grafting procedure what do you do?
Reevaluate length of incisions
Scoring of periosteum to allow advancement
If still not adequate – consider removing bulkiness of graft to allow for closure
262
Describe velopharyngeal insufficiency:
The 3 muscles of the palate (levator veli palatini, tensor veli palatini, and uvularis) work in concert with the palatopharyngeus, the palatoglossus, and the pharyngeal constrictor muscles to produce VP closure
Failure to function causes air escape with “plosives” and hyper nasal speech
263
What is the scale to evaluate sleep apnea?
Epworth sleepiness scale
5 or more obstructive events per hour of sleep and presence of symptoms
15 or more obstructive events per hour of sleep, irregardless of symptoms
264
What are the types of sleep apnea disorders?
Central - Lack of airflow from absence of respiratory effort (CNS disorders – brainstem neoplasm’s, infraction)
Obstructive - Lack of airflow with continued respiratory effort
Mixed – combination of above
265
Describe how the epworth sleepiness scale works:
How likely are you to dose off or fall asleep in these situations?
0 never, 1 slight, 2 moderate, 3 high chance
sitting, watching tv, public place, passenger in car
Grater than 10 you are sleepy and need an eval
266
Describe the exam for sleep apnea:
Oral cavity eval, micrognathia, macroglossia, tonsillar hypertrophy
Flexible endoscope nasopharyngeal exam
Mueller’s maneuver
Consider Sleep Endoscopy - done under general anesthesia
267
What is the initial imaging for sleep apnea?
Cephalometry
Soft palate length - posterior nasal spine to uvula tip, mean 35 mm
Posterior airway space - smallest AP distance base of tongue to posterior pharyngeal wall, mean 11 mm
Hyoid to mandibular plane distance - from anterior-superior limit of hyoid to mandibular plane, ideal < 15 mm
268
What is a classification system for anatomical sites of obstruction in the upper airway?
Type I – narrow oropharynx/retropalatal - large tonsils, uvula, pillar webbing
Type II – oral and hypopharyngeal obstruction retropalatal/retrolingual low arched palate and large tongue
Type III – hypopharyngeal obstruction retrolingual only floppy epiglottis, enlarged lingual tonsils
Most OSA patients have combined problems
269
What is a test you can order for a patient to test for sleep apnea?
Polysomnography
270
What is apnea?
breathing interruption > 10 seconds
271
What is hypopnea?
more than 50% decrease in nasal airflow or more than 2/3 decrease in tidal volume with 3% decrease in oxygen saturation
272
What are Respiratory effort-related arousals (RERAs)?
More than 50% decrease in nasal pressure and increased work of breathing associated with arousal
273
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What is the Apnea hypopnea index (AHI):
Apneas and Hypopneas per hour
5-15 is mild
15-30 moderate
30 is severe
275
What is Respiratory disturbance index (RDI):
Apneas, Hypopneas, and RERAs per hour
10-30 is mild
30-50 moderate
50 is severe
276
What happens when SaO2 drops below 75 for patients while asleep?
Multiple PVCs, AV blocks, Asystole
277
Whats the difference between CPAP or BIPAP?
BiPAP machines produces two levels of pressure – inhale pressure and exhale pressure – while CPAP only delivers a single pressure. This ultimately allows patients to get more air in and out of their lungs, and most machines have a breath timing feature that allows the pressure to be customized to achieve a desired breath rate throughout the night.
278
Describe the Stanford Protocol for treating sleep Apnea:
Phase 1: Nasal surgery, UPP, Tonsillectomy, Hyoid Suspension, Genioglossus advancement
Phase 2: MMA
279
Describe the components of a hypoglossal nerve stimulator:
Breathing monitor: placed next to the rib
Pulse Generator: 1.5 cuff that gets signal placed below the chest and collarbone and connects to the electode
Cuff Electrode: fits around the CN 12 under the tongue and makes the tongue stick out
280
Who is the inspire indicated for?
Inspire is indicated for use to treat a subset of patients with moderate to severe obstructive sleep apnea who have failed CPAP
Patients also need to be BMI lower than 32
281
What are contraindications for inspire?
Pregnancy: Inspire sleep apnea treatment is contraindicated for patients who are or who plan to become pregnant as the safety of the therapy during pregnancy has not been established.
Implanted devices: Patients with certain implanted devices, such as pacemakers or defibrillators, may not be eligible for Inspire sleep apnea therapy due to potential interactions with the device.
MRI: Patients who require an MRI other than what is described in the Inspire labeling.
Anatomic issues: Any anatomical finding that would compromise the performance of upper airway stimulation.
282
What surgery has the highest success rate for OSA?
MMA
Newer OMS research has shown that MMA should be done first and use UPPP done secondarily if MMA fails
283
What is a classification system for facial wrinkling of the skin?
Glogau scale
Mild 28-35
Moderate 35-50
Advanced 50-65
Severe 60-75
284
Whats the difference between superficial wrinkles and mimetic wrinkles?
Superficial: Photoaging and texture changes (lack of colalgen)
Mimetic: Deep dermal creases and perpendicular to muscles
285
What is Dermatochalasis?
excess skin of upper/lower eyelids
286
What is blepharochalasis?
relaxation of orbital skin with herniation of upper lid orbital fat (less common than dermatochalasis)
287
What is the internal nasal valve?
Internal Nasal Valve: Angle formed between caudal edge of upper lateral cartilages and septum, 10 - 15 degrees
288
What is the external nasal valve?
Connects the upper lateral cartilage and lateral crura of the lower lateral cartilage to the piriform aperture
289
What is a normal nasolabial angle?
100 - 110 degrees
289
Where do you need to keep botox?
Is a polypeptide with HEAT LABILE bonds (must keep cold!)
Dilute with preservative free normal saline
290
What a normal dose of botox?
Normal dose per patient per visit is 25 - 50 units
291
What's the MOA of Botox?
Binds to cholinergic motor endplate permanently blocking release of ACH for presynaptic vesicles
292
How long does botox last?
Paralytic effects last 3-4 months, return is due to collateral sprouting of new axons
293
What are some examples of fillers?
Short acting: Juvederm
Long acting: Radiesse
Permanent: Artefill (Bovine Collagen)
294
How do you treat overfill of fillers?
Treat overfill with hyaluronidase
295
Whats an example of a partial superficial chemical peal?
Retinoic acid, salicylic acid, 5-20% TCA, Jesner’s solution, 20-30% TCA
296
Whats an example of a very deep reticular dermis peel?
Compound phenols, Baker’s solution
297
What are the examples of lasers?
Erdium YAG - Superficial to medium
CO2 - Superficial to deep
(1st pass pink, 2nd grey, 3rd dermis (yellow))
298
What is microdermabrasian?
very superficial exfoliation or epidermis via silica
299
What is dermabrasian?
rotary with diamond grit or sand paper, can be very deep
300
What are the contraindications to skin resurfacing?
Immunosuppression
History of hypertrophic scarring / keloid Isotretinoin within 1 yr
Collagen vascular disease
301
What is the skin resurfacing pre-treatment protocol?
Topical retinol - 0.05% retinoin
Hydroquinone - hyperpigmentation prophylaxis
Valtrex 1 day prior then 7-14 days post-op
No Accutane (isoretinoin) for 1 yr prior (delayed reepithelialzation)
302
How do you treat prigmentary changes after resurfacing?
Pigmentary changes —> Treat with topical hydroquinone 4% BID
303
Describe the upper blepharoplasty procedure:
Mark patient while upright
Incision —> upper eyelid crease
Women 8.5 - 10mm above superior lid margin
Men 7-8mm above superior lid margin
Superior incision should leave 18-21mm of upper eyelid skin
Pinch test for lag opthalmos
Excision of skin-muscle flap
Fat de-bulking after opening orbital septum
Check hemostasis
Close
304
Medial fat pad more pale in color than brighter yellow central fat pad
305
What do you need to remember to release when doing an endoscopic brow lift?
Always release corrugator insertions
306
Whats the difference between imbrication and plication?
Imbrication —> cutting or excising of SMAS with reapproximation
Plication —> Folding of SMAS upon itself
