OMFS 2 Sweep 1 Flashcards
(135 cards)
1
Q
A —– is imperative prior to definitive treatment
A
histological diagnosis
2
Q
A true cyst contains an
A
epithelial lining
3
Q
Inflammatory
A
Periapical Cyst
Residual Cysts
4
Q
Developmental
A
Dentigerous Cyst Odontogenic Keratocyst Lateral Periodontal Cyst Glandular Odontogenic Cyst Calcifying Odontogenic Cysts (Gorlin’s Cyst
5
Q
MANAGEMENT OF CYSTS
A
Enucleation
Enucleation & curettage (E&C)
Marsupialization
Staged marsupialization & enucleation (decompression technique)
6
Q
Enucleation
Treatment of choice for —–
Removal of the entire cystic lesion without —–
——– allows a cleavage plane between lesion and bony cavity
A
cystic lesions
rupture
Fibrous connective tissue (CT) wall
7
Q
Enucleation Indications ------ Common examples ------
A
Any cyst that can be removed in entirety & safely without harming adjacent structures
Dentigerous cyst
Periapical cyst
8
Q
Enucleation
Advantages
—– examination of the entire cystic wall
——- is curative in certain situations
A
Histopathologic
Initial biopsy/treatment
9
Q
Enucleation
Disadvantages
A
Possible pathological fracture
Devitalization of teeth
Injury to nerve
10
Q
Enucleation
Technique
A
Gain access to cyst
Aspirate
Use largest curette that defect will allow: Cleavage plane
Concave surface toward bone
Visualize bony cavity for soft tissue remnants
Smooth bony margins and obtain water tight primary closure
11
Q
Enucleation Post-operative course Diet/activity modification Meticulous oral hygiene May require close follow-up with periodic panoramic radiograph (every ------) -----months for bony fill Expanded bone will recontour over time
A
6 months
6-12
12
Q
Enucleation & Curettage (E&C)
——- first
Mechanical (burs) curettage is performed to remove —— of bone at the entire periphery of the bony cavity
Can use the curette aggressively to accomplish, but outcome is better with mechanical
A
Cyst is enucleated
1-2mm
13
Q
Enucleation & curettage
Indications
When removing a known ——-
Second surgery after ——
A
aggressive cyst such as an OKC (high recurrence)
recurrence when 1st surgery (enucleation) was deemed curative
14
Q
Enucleation & curettage
Advantage
——-
A
Destroys any suspected epithelial remnants, decreasing chance of recurrence
Damage to neurovascular bundle
Dental pulps stripped
15
Q
Marsupialization
Open a cystic lesion and maintain —– to an adjacent cavity
(Oral cavity, maxillary sinus, or nasal cavity)
Decreases —– pressure
Cyst shrinkage
Bony fill
Sole treatment (rarely) or as a preliminary step before ——–
A
patency
intracystic
definitive enucleation of the smaller cyst
16
Q
Marsupialization Indications ---- at risk with enucleation Difficult ----- to all portions of cyst Increases ---- rate Medical compromise
A
Adjacent vital structures
surgical access
recurrence
17
Q
Marsupialization Advantages --- to perform Can spare ----- Either ------ or makes it -----
A
Simple
vital structures
completely resolves lesion
much smaller and easier to treat and reconstruct
18
Q
Marsupialization Disadvantages Cannot ----- Areas left behind may be ----- Patient inconvenience with ------ Occasional secondary infections
A
histologically examine the entire cystic wall
more aggressive than piece removed
home care
19
Q
Marsupialization
Technique
A
Aspirate
Create 1cm or large elliptical incision in soft tissue
Create bony window
Piece of cystic lining removed and submitted for
20
Q
Marsupialization; histopatholgic exam ----- evacuated Keep ------ patent Thick cystic lining: suture to ---- Thin/friable cystic lining: ------
A
Cystic contents
window into cyst
oral mucosa
pack cavity for 10-14 days to prevent oral mucosa from healing over window
21
Q
Marsupialization
Post-operative course
—- is responsible for irrigating the cystic cavity
Cavity may become secondarily infected
Routine follow-up with —– to assess progress
**How long do you leave the cavity open?
Until —— have been met
A
Patientradiographic evaluation
goals for choosing marsupialization
22
Q
Staged marsupialization & enucleation
Known as “——” technique
A
decompression
Opening cyst to oral cavity (marsupialization) and surgical plan is to make the cyst smaller (decompression) for final E&C at a later date
This is more commonly performed vs. marsupialization alone
23
Q
Staged marsupialization & enucleation
Lesion marsupialized and allowed time for:
——
Routine follow-up with radiographic assessment until bone fill stalls and/or goals met
Enucleate remaining cyst
—– around opening of cyst
Remove all —–
A
Bone cover of vital structures
Increased strengthening of jaw
Elliptical incision
cystic lining
24
Q
Staged marsupialization & enucleation
Indications
Concern for ——-
Size of lesion
Marsupialization alone does not resolve lesion
Need to examine entire lesion histopathologically
A
injury to adjacent anatomical structures
25
```
Staged marsupialization & enucleation
Advantages
Develops a ---- cystic lining
Reduces ------ complete healing
Same as for marsupialization
Simple to perform
Can save vital structures
Completely resolves lesion or makes it smaller and easier to treat and reconstruct
```
thickened
morbidity and accelerates
26
Staged marsupialization & enucleation
Disadvantages
----- marsupialization
Patient inconvenience
Occasional secondary infection
Cannot histologically examine the entire cystic wall
However, ------ can remedy this concern
Same as for
secondary enucleation
27
Periapical
Remove ------
---- +/- curettage
------ if necessary
underlying process – RCT or extraction
Enucleate
Antibiotics
28
Residual
E&C
29
Dentigerous cyst
------
If larger – consider --------
Extraction of affected tooth + E&C
staged marsupialization and E&C
30
Odontogenic Keratocyst (OKC)
---- with potential -----
If larger – consider -----
E&C
extraction
staged marsupialization and E&C
31
Lateral periodontal cyst
| ---- with preservation of ----
Enucleation
tooth
32
Glandular odontogenic cyst
----- and -----
Some advocate -----
Enucleation
curettage
more aggressive treatment (resection
33
Calcifying odontogenic cyst (Gorlin’s)
| ----- and ------
Enucleation
curettage
34
Epithelial tumors
Ameloblastoma
Adenomatoid odontogenic tumor
Calcifying epithelial odontogenic tumor (Pindborg)
Squamous odontogenic tumor
35
Mixed epithelial & ectomesenchymal tumors
Ameloblastic fibroma
Ameloblastic fibro-odontoma
Odontoma
36
Ectomesenchymal tumors
Odontogenic fibroma
Odontogenic myxoma
Cementoblastoma
37
Tumors: Poorer prognosis in ----- due to undetected growth
maxilla
38
```
Enucleation & Curettage of Jaw Tumors
Indications
------ tumors
Most ------ tumors
Medically compromised
```
Slow-growing, non-aggressive
odontogenic
39
Enucleation & Curettage of Jaw Tumors
| Tumor Types
```
Odontoma
Ameloblastic fibroma/fibro-odontoma
AOT
Cementoblastoma
Odontogenic fibroma
```
40
Enucleation & Curettage Tumor Surgical Technique
Local removal of the tumor by instrumentation or direct contact with the lesion
Technique same as for cysts
May have to section lesional tissue
41
Resection of Jaw Tumors
Indications
----- lesions either by histopath or clinical behavior
Tumors need a margin of ----- to decrease chance of recurrence
Tumors that would be difficult to remove in entirety by -----
Aggressive
uninvolved tissue (hard or soft)
enucleation/curettage alone
42
Resection of jaw: tumor types
```
Tumor Types
Ameloblastoma
Myxoma
CEOT
Squamous odontogenic tumor
```
43
```
Resection Technique - tumors:
Lesion is removed with a ---- margin of uninvolved tissue
Marginal – maintains continuity at -----
Segmental – ------- portion removed
Total – remove -----
```
1cm
inferior border
full-thickness
entire jaw
44
Osteoinduction
| New bone formation from differentiation of ---- cells, derived from ------- cells, into ------.
osteoprogenitor
mesenchymal
osteoblasts
45
Osteoinduction
| Differentiation is influenced by ------ from the bone -----.
bone inductive proteins
matrix
46
Osteoinduction
Host cells must be stimulated to differentiate into the osteoblasts by ------.
transplanted growth factors and cytokines
47
BMP (Bone Morphogenic Protein)
Initiates -------.
Member of the ----- family of growth factors
osteoinduction
cytokine
48
BMP (Bone Morphogenic Protein)
Acts on ---- cells to induce differentiation into
------.
progenitor
osteoblasts
49
BMP (Bone Morphogenic Protein)
Higher in --- bone vs. -----.
cortical
cancellous
50
Osteoconduction
| Formation of new bone from either ------ along a biologic framework.
host-derived or transplanted osteoprogenitor cells
51
Osteoconduction
| Provide only ------
passive framework or “scaffolding.”
52
Osteoconduction
| Does not ------- – conducts ------- from host into/around the scaffolding.
actually produce bone
bone forming cells
53
Osteogenesis
Formation of new bone from ----- cells.
Have ------- and ------ properties.
Only ------- grafts possess all these criteria.
osteoprogenitor
osteoinductive, conductive
autogenic
54
Two-Phase Theory of Osteogenesis PHASE I
Transplanted cellular bone produces new -----. The amount of bone regeneration depends of the amount of ------------.
Considerable amount of cell death occurs during grafting procedures, and this phase may not lead to an impressive amount of regeneration.
Determines ------ of bone that the graft will form.
Most active within------ weeks.
osteoid
transplanted bone cells that survive
quantity
4
55
Two-Phase Theory of Osteogenesis PHASE II
------- from the graft bed begin after grafting, and ------ from host connective tissue soon begins.
Initial ------- is resorbed and replaced by ------ bone. As the initial graft is resorbed, ------ proteins are released from the matrix.
Determines ------.
Begins at ------ and peaks around -------.
Remodeling process continues indefinitely.
Angiogenesis and fibroblastic proliferation
osteogenesis
woven bone, lamellar, bone morphogenic
quality
2 weeks, 6 weeks
56
Autografts: possible ----- properties
osteogenic
57
```
Allografts/Homografts
------
Cadaver bone
Carries ------ in some cases
Replaced by patient’s own bone
No donor site morbidity
Readily available
Disadvantages include no ------ for phase I osteogenesis, longer ------ period, encapsulation, disease transmission, graft/host reaction and patient acceptance.
```
Osteoconductive
inductive proteins
viable cells, consolidation
58
```
Xenograft
Grafts transplanted between individuals of different
species (i.e. bovine bone/Bio-Oss)
No donor site morbidity
-------
Carrier for ------ proteins (possible)
Limitless quantity
Disadvantages include expense and longer ----- period, disease transmission and patient acceptance
```
Osteoconductive
inductive
consolidation
59
BMP-2=Infuse® has been approved for ----- and grafting of ----- defects
sinus floor augmentation
mandibular
60
Recombinate grafts not approved for
Not approved in children/skeletally immature patients
61
Diseases associated with bone healing problems
Drug (Medication) Related Osteonecrosis (MRONJ) of the Jaws
Osteo-Radio-Necrosis (ORN)
Osteomyelitis
62
Drugs associated with MRONJ
- Bisphosphonates
2- Anti-Resorptive agents (e.g: Denosumab )
3- Anti-Angiogenic medications (e.g: Tyrosine kinase inhibitors and monoclonal antibodies targeting VEGF)
63
What are Bisphosphonates (BP)?
Synthetic analogs of inorganic pyrophosphate
64
How do Bisphosphonates work?
How do they work?
High affinity for Ca2+
Inhibition of osteoclasts
May inhibit capillary neo-angiogenesis
65
BP indications:
| Oral
Osteoporosis and Osteopenia
Paget’s disease
Osteogenesis- Imperfecta
66
IV
Bone metastases associated with solid tumors
Hypercalcemia of malignancy
Multiple myeloma
67
Diagnosis of MRONJ
Current or previous treatment with a ----
Exposed bone in the ------ that has persisted for more than ---- weeks
No history of ----- to the jaws
bisphosphonate
maxillofacial region
Eight
radiation therapy
68
Fosamax (alendronate)
| Actonel (risedronate)
Oral BP
69
Aredia (pamidronate)
Zometa (zolendronate)
Reclast (zolendronate)
IV BP
70
Boniva (inandronate)
IV and Oral BP
71
Anti-angiogenic agents: e.g:
Sunitinib
72
Why in the jaws ? MRONJ
Increased bone turnover in the jaws (Remodeling rate is 10 times more than long bones )
Thin overlying oral mucosa due to jaw anatomy.
73
```
Asymptomatic patient taking oral BP
Sound recommendations are still lacking
<4 years : -----
<4 years +risk factor (Steroid/anti-Angiogenic meds.) :-------
>4 years: --------
```
proceed with planned treatment
Stop BP therapy 2 months prior to treatment
Drug holiday for 2 months
74
Clinical Stage 1 MRONJ
Exposed/necrotic bone
Asymptomatic
No infection
Treatment
Oral antimicrobial rinses (e.g. Peridex)
75
Clinical Stage 2 MRONJ
Exposed/necrotic bone
Pain
Infection
Treatment
Oral antimicrobial rinses
Antibiotic therapy
76
Clinical Stage 3 MRONJ
```
Findings
Exposed/necrotic bone
Pain
Infection
One or more of the following:
Fracture, extra-oral fistula, oro-nasal communication. osteolysis
```
Treatment
Surgical debridement or resection
Antibiotic therapy
77
Osteo-Radio-Necrosis (ORN)
A condition in which Irradiated bone becomes exposed through a wound in the overlying skin and/or mucosa and persist without healing for 3 to 6 months
78
ORN Three Hs theory
Hypoxia
Hypovascularity
Hypocellularity
79
ORN Stage 1
Superficial involvement, only Cortical bone exposed
Treated with Conservative : Chlorhexidine MW
80
ORN Stage 2
Localized involvement with involvement of cortical and medullary bone
Treatment:
Conservative : Local debridement w,w/o HBO
Chlorhexidine MW
81
ORN Stage 3
Diffuse involvement including inferior border. Usually associated with pathologic fracture and possible osteo-cutaneous fistula
Treatment:
Surgical resection and reconstruction
82
Hyperbaric Oxygen Treatment may
Stimulates:
collagen synthesis
Angiogenesis
Epithelialization
83
Osteomyelitis
An inflammatory process of the bone marrow that involves cancellous and cortical bone with a tendency of progression.
84
Osteomyelitis occurs more in
mandible than maxilla
85
Osteomyelitis Predisposing factors
Immune-compromised patients:
DM
Alcoholism (malnutrition)
Myeloproliferative disease : leukemia, sickle cell
Chemotherapy
Fractures and Odontogenic infections in immune-compromised patients
Osteopetrosis (AlbersSchonberg disease
86
Radiogrpahic“Moth-eaten” appearance
| Radio-opacities Sequestra (islands of necrotic non-resorbed bone)
Osteomyelitis
87
Clindamycin is the Antibiotic of choice for
osteomyelitis
88
Osteomyelitis:
Hospitalization may be required for ----
Mild cases : -----
Severe cases : up to -----
IV Abx
4 weeks
6 months
89
Osteomyelitis: Surgical:
Debridement/Marginal resection/Segmental re section (depend on involvement to remove dead bone
90
Buccal plate
1mm
91
Lingual plate
1mm
92
Sinus
1mm
93
IAN
2mm superior
94
Mental foramen
5mm from anteiror/bony foramen
95
Inferior border
1mm
96
Adjacent tooth
2mm
97
Implant to implant distance
3mm
98
Block graft
Augment horizontal dimension of alveolus
Harvested graft traditionally shaped like a block
----- bone
Block maintains space under soft tissue while remodeling
Site ready for implant placement --- months
Cortical +/- cancellous
4-6
99
Intraoral Donor Sites
| chin & Ramus
Limited quantity
Isolated defects of 1-2cm in size
No cancellous needed
Small but real risk of paresthesia
100
Extraoral Donor Site
| Iliac crest
Large quantity of bone
Two surgeon “team” allows for harvest and site preparation simultaneously
Requires sterile field and anesthetic/surgical support that may limit venue and increase cost
Extraoral scar and site distant from oral cavity may not be well accepted by the patient
101
For bone grafting w/prosthetic:
Temporary prosthesis
Non-load bearing
Limit wear
102
Difficult to obtain vertical augmentation due to ----
pressure from Soft tissue envelope or a prosthesis
103
Vertical graft concerns:
Increased risk of ------
Inadequate ------- to recipient bed
------ rates greater than with horizontal augmentation
graft/membrane exposure
adaptation and/or fixation of the bone graft
Resorption
104
Latency phase of distraction O
Revascularization
Osteoprogenitor cells accumulate
4-7 days
105
Distraction phase of distraction O
1mm per day
osteoblast induction
Woven bone formation
106
Consolidation phase of distraction O
2-3 months
active distraction complete
Bony regenerate remodels into mature bone
107
Autograft ready in ---- vs. allograft (-------)
| BMP quick but cost prohibitive
4 months, 6-8 months
108
Indirect sinus lift Augmentation yield ~
4mm of bone
109
– Closed lock:
like a catch, but stays that way for minutes, hours, days, etc.
110
– Catching:
opens easily part way but gets caught at 1-2 finger-widths of opening, then opens the rest of the way
111
Stiffness:
can stretch more (with pain) vs. moves ok then hits a brick wall
112
Palpate posterior maxillary vestibule
• Lateral/posterior – ------
• Posterior on ascending ramus – --------
masseter origin
temporalis insertion
113
– “----” MR units are not suitable for TMJ imaging
Open
114
– ----maximizes contrast, resolution
T1
115
– ---- demonstrates fluid, higher S/N ratio
T2
116
Rotational movement: --- mm
• Translational movement: ----- mm
• Lateral excursions move contralateral joint------
20
40-50
: 7-10 mm
117
• Why might one skip arthrocentesis?
* Long duration of symptoms
* History of failed steroid injection/arthrocentesis
* Long history of late, hard, painful pop
* Unable to obtain MRI
* Certain implants, severe claustrophobia, morbid obesity
* Anticipated difficulty with arthrocentesis • Obesity; anxious but has anesthetic risks
118
Arthrocentesis
| • Indications
* Acute closed lock
* Acute trauma (hemarthrosis)
* Capsulitis/synovitis
119
Arthrocentesis
| Advantages
* Minimally invasive
* Fast, simple procedure – usually done in office
* Does not require general anesthetic
* Highly effective at increasing joint mobility, reducing pain
120
Arthrocentesis
| • Disadvantages
• Indications not well established except for acute closed
lock
• May not adequately release adhesions, etc.
• Limited success for chronic or more severe conditions
121
Indications for Arthroscopy
* Pain and dysfunction with the following conditions: • Decreased condylar translation due to disk hypomobility
* Anteriorly displaced disk with or without reduction • Closed lock
* Traumatic injury
122
Advantages of Arthroscopy
* Minimally invasive
* Outpatient procedure
* Rapid recovery
* Excellent success (80-95%)
* Low morbidity
* Allows examination under anesthesia
123
Disadvantages of Arthroscopy
* Advanced disease may not improve
* Disk unlikely to reposition
* Failure usually requires open surgery
* Requires aggressive postoperative physical therapy and patient compliance
* Morbidity includes nerve or middle ear injury (both extremely rare)
124
Adhesion types •
Light, filmy
| • Fibrous bands • Pseudowall
125
Disk pathology
* Neovascularization • Fibrillation
| * Perforation
126
Adhesion lysis
* Light adhesions – in course of inspection
* Heavier bands, walls –
* Use blunt trocar
* Sweeping motion lateral-medial
* Light contact with articular surface
* Reassess with arthroscope
127
Lavage
| • Quantity rarely a concern, typically ----- or more • Lactated Ringer’s vs. Normal Saline?
2-300ml
128
• Arthrotomy:
Incision into the joint
129
• Arthroplasty:
Repair, revision, and/or
| reconstruction of joint tissues (hard and soft)
130
• Meniscectomy=
Discectomy: Removal of the disk
131
Disk Repair/Repositioning Procedures
| • Indications
* Minimal disk displacement
| * Otherwise generally healthy joint tissues • Near-normal disk morphology
132
Disk Repair/Repositioning Procedures
| Disadvantages:
• Often do not change disk position • Pop or click may recur
133
Meniscectomy (Discectomy) with/without Interpositional Graft
| • Graft Materials (if used):
* Dermis
* Temporal fascia
* Auricular cartilage
134
Meniscectomy (Discectomy) with/without Interpositional Graft
| Indications
* Severe degenerative changes in disk
* Disk beyond repair
* Severe interference with normal function (for example, patient with late, hard, painful pop on mouth opening due to disk reduction)
135
Meniscectomy (Discectomy)
| Disadvantages
Disadvantages
• Malocclusion or failure uncommon but possible
• Replacement requires graft harvest
• Replacement may offer little benefit over meniscectomy without graft
• Alloplastic materials (artificial disks) not available
