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Complex Adult Dentistry > Oral Surgery > Flashcards

Oral Surgery Flashcards

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1
Q

What is exodontia?

A

Tooth extraction

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2
Q

What are the principles of exodontia?

A

Expansion of bony socket
Separation of attachment of PDL
Separation of gingival soft tissues

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3
Q

What are the average bone losses in the first 1-6 months post exodontia in mm?

A

Horizontal loss 3.8mm

Vertical height reduction 1.24mm

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4
Q

Which plate (buccal/lingual) exhibits the most resorption post exodontia?

A

Buccal plate

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5
Q

What is the healing cascade post exodontia?

A

Clot formation fibrin mesh work. 24-48h
Epithelial migration over socket & clot becomes granular. 7 Days
granulation tissue become collagen &early bone. 20 Days
Bone marrow occupies socket replacing woven bone. 8 weeks

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6
Q

How is the clot formed post exodontia?

A

Haemorrhage
Bleeding
Platelet aggregation
Clot formation (platelets and leukocytes in fibrin gel).
2-3 days inflammatory cell clean site prior to new tissue formation.

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7
Q

What is a periotome?

A

Like a sharp flat plastic used to sever PDL

Not used in LDI (expensive)

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8
Q

How is a periotome used?

A

Long axis of blade Inserted into socket along medial and distal sides

Not used in facial plate because it’s thin and easily damaged

Wait 10-20 seconds with instrument in situ

Then used as a lever

Slow pressure otherwise tip will break

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9
Q

What are luxators?

A

Thin and sharp sever PDL
Effective
Bone preserving
Separate tooth and bone before extraction

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10
Q

How is a luxator used?

A

Chops a size matching root diameter
Apply apical pressure
Gently rock to sever PDL
Vacuum broken remove tooth with forceps

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11
Q

What is an elevator?

A

Rotate around a fulcrum to lever tooth out of socket

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12
Q

What are the three ways to use an elevator?

A

Lever
Wedge - similar to a luxator
Wheels and axel - between teeth and rotated

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13
Q

What are the three types of elevator?

A

Couplands straight ones
Warwick James straight and left and right hockey stick

Cryers left and right and mega sharp

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14
Q

What are the 5 pairs of sinuses in the maxilla?

A 
Frontal sinus 
Ethmoid sinus 
Sphenoid sinus 
Nasal cavity 
Maxillary sinus
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15
Q

What is the average volume of the maxillary sinus?

A

10.5-18 cm3

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16
Q

What is the ostium?

A

This is where the maxillary sinus drains into middle meatus of the nasal cavity

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17
Q

What are vascular canals in the sinus?

A

This are tuberositys wishing the bone lining the sinus where vessels run

Important when carrying out sinus surgery.

(Infra Osseous artery’s)

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18
Q

What are the four functions of the maxillary sinus?

A

Vocal resonance
Olfactory function (smell)
Warming & humidifying air
Decreasing the weight if the scull

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19
Q

What is pneumatisation?

A

This is where the sinus drops down between roots.

This is poorly understood

This increases with age and tooth loss.

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20
Q

What is the schneiderian membrane?

A

This is the membrane that lines the maxillary sinus.

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21
Q

What is the thickness of the schneiderian membrane and how does the alter with gender?

A

0.34-3.11mm

Males usually thicker

Related to biotype

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22
Q

What is a septa?

A

These are thin bony projections between walls of the sinuses.

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23
Q

What is the relevance of the maxillary sinus?

A

Exodontia
Endodontics
Implants

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24
Q

What are complications involving the maxilla related to exodontia?

A

Oro-antral communication (OAC)
Oro-antral Fistula (OAF)
Displacement if teeth/roots
Maxillary tuberosity fracture

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25
What is an Oro-antral communication (OAC) ?
This is a non epithelialised passage between the oral cavity and the maxillary antrum which can be as a result of exodontia
26
What is an oro-antral fistula (OAF)?
A pathological epithelial lined passage between the oral cavity and maxillary antrum
27
How is an OAF formed?
From an OAF that’s untreated, it’s a chronic version.
28
What cause an Oro-antral communication?
``` Roots close to the sinus Thin alveolar bone Peri apical pathology Root morphology Lone standing molars Traumatic extractions ```
29
What are the signs and symptoms of an OAC?
Signs - visible -resonant ``` Symptoms- Bubbling into nose/mouth Discharge Congestion and pain Sinus symptoms Air escaping into mouth ```
30
What must you not do if a patient may have a suspected OAC?
Don’t get them to blow nose because if OAC isn’t present it may cause one
31
What are signs and symptoms of a fistula?
Signs - soft tissue perforations Prolapse of sinus lining Discharge Symptoms- Bubbling Air escaping
32
What are the options for an OAC (5options)?
If tiny, spontaneous healing may occur Buccal advancement flap Palatial advancement flap Buccal fat pad Playlet rich fibrin (PRF) membrane closure
33
What is a buccal advancement flap?
This is where the buccal tissue is pulled over to close. Works best in first attempt Reduces sulcus depth (denture counter indication) Tissue is thin so can perforate Sharp bone must be removed first Not good for large OAC
34
What is a palatial advancement flap?
This is where skin from the palate is rotated around to cover OAC This has a good blood supply More tissue with less tension Thi her tissue and preserves sulcus depth Granulating palate bone (sore) will regrow tissue to Ensure that it is cut long enough so it will rotate and cover OAC otherwise it’s useless
35
What is a buccal fat pad?
This is taking tissue from the buccal fat pad to fill OAC It’s used in conjunction with buccal advancement flap or palatial advancement flap It’s for larger OAC’s
36
What’s is playlet rich fibrin?
Patients blood is taken and centrifuged Playlet rich fibrin with healing cells gel is removed and sutured in place (Favoured option) Not available on NHS
37
What is important about suturing over an OAC?
Has to be watertight otherwise it will break down
38
What are treatment options for a displaced root?
Gentle suction Leave Refer for lateral window removal
39
What are the 6 places a fractured tooth root be?
``` Socket Mucoperiosteum Antrum Swallowed Inhaled Suctioned ```
40
What is antral regime?
This is what’s used to care for an OAC after it’s been managed conservatively
41
What are the 6 components of an antral regime?
``` Analgesia No nose blowing Sneeze like a horse (let it out) No straws Decongestants Consider broad spectrum antibiotics ```
42
What are tuberosity fractures?
Fracture of bone.
43
How do you manage a tuberosity fracture?
If it’s attached and small leave it Splint if moving Refer If significant bleeding out the bone back in get them to bite on gauze and emergency referral
44
How do you know if it’s a dental sinus infection?
It’s almost always unilateral
45
What are the dental causes of acutely odontogenic maxillary sinusitis?
Periapical infection Periodontitis Peri-implantitis Post extraction infection Trauma Odontogenic cyst Osteomyelitis Displacement into sinus
46
What Bacteria cause non odontogenic acute sinusitis?
Predominantly aerobic bacteria Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhails Staphylococcus aureus
47
What bacteria cause odontogenic acute sinusitis?
Commonly anaerobes ``` Viridans streptococci Fusobacterium Prevotealla Peptostreptoccus Porphyromonas ```
48
What bacteria cause odontogenic chronic sinusitis?
Polymocrobrial, viridans streptococci and anaerobes Similar to acute but reduced number of bacteria
49
What are signs and symptoms of sinusitis?
Pain and feeling unwell Throbbing pain worse when leaning forward Congestion
50
What happens if sinusitis spreads?
Orbital cellulitis Cavernous sinus thrombosis Meningitis Inter-cranial abscess
51
What is the STOP Mnemonic?
Site (tissue present)? Translucency/opaque? Outline (margins)? Previous imaging?
52
What are some big red flags?
Loss of symmetry and tissue masses Distorted anatomy and displaced teeth Bone erosions Teeth floating
53
What to do if odontogenic cause is excluded?
GP/ENT referral
54
What to do if odontogenic cause is confirmed (acute &chronic)?
Acute Antimocrobrial therapy Early and aggressive Analgesia Decongestants - ephedrine nasal drops Chronic Eliminate source of infection Antimicrobrials
55
What do I need to know about a sinus cyst?
Radio graphic changes (1/3 have mucosal thickening) Radiological analysis If in doubt CBCT If it’s well circumscribed and asymptomatic it’s not likely to be sinister Remember red flags
56
If you suspect cancer what are some things you should ask?
Are you experiencing any unexplained weight loss And vision disturbance Any tiredness
57
What are symptoms of neoplasia in a sinus?
``` Neoplasia erode tissue and bone They may cause bleeding or nasal discharge Have radiological features Cause mobile teeth Ocular symptoms and neorogical signs ```
58
What is impaction?
Obstruction in the eruption pathway of
59
What is the average eruption completion of the third molar?
Early 20s
60
What are the three types of impaction of a third molar?
Partially covered by soft tissue Completely covered by soft tissues Completely covered by bone
61
What are the four classifications if impaction?
Mesioangular - tilts mesialy Horizontal - lies horizontally Vertical - good path but won’t erupt Distoangular - most difficult to treat
62
What impaction classification is most common?
Vertical Mesioangular Horizontal Distoangular
63
What are the statistics about third molars?
Quarter of population have impacted ones Higher in females One of most common procedures on NHS Most common OMFS procedure
64
What are the most common issues with mesioangular impaction?
Pericoronitis Caries Perio Distal caries in second molar
65
What is a simptom and a sign?
Symptom - something patient notices Pain swelling Sign - observed by professional Palpitation lumps BOP
66
What is pericoronitis
Partially erupted teeth with operculum covering it causes food packing and infection
67
What is an operculum?
Flap of gingival tissue overlying 8s
68
What are symptoms of pericoronitis ?
``` Pain Halitosis Swelling Erythema Bad taste ```
69
What happens when pericoronitis progresses?
``` Tiramus Purexia Lymphadenopathy Malaise Dysphagia ```
70
What is trismus?
Limited mouth opening
71
What is pyrexia?
Fever
72
What is lymphadenopathy?
Swelling of lymph nodes and glands
73
What is malaise?
General unwellness
74
What is Dysphagia?
Difficulty swallowing
75
Where can swellings appear?
Submandibular Sublingual Buccal space
76
What are issues with submandibular and sublingual swellings?
If they are bilateral then this can obstruct the airway
77
What symptoms can mimic pericoronitis?
Quinsy Peritonsilar abscess Tonsillitis (Non are our issue)
78
How do we treat pericoronitis?
If no systemic involvement Irrigate with warm saline give pt syringe to take home Take paracetamol ibuprofen etc Don’t use chlorohexadone given anaphylaxis systemically found from treating dry sockets.
79
What are the treatment options for pericoronitis with systemic involvement?
Metronidazole 400mg 3 times a day three days (anaerobic) Amoxicillin 500mg 3 times a day for 3 days
80
What happens if pericoronitis does not improve with antibiotics?
Removal of molar tooth May have wrong antibiotic May have non compliant patient
81
What are the indications for third molar removal?
Any good reason | Including caries in the 7
82
Is there any evidence with third molars and crowding?
These don’t cause crowding
83
What impact successful surgery?
Social and medical history
84
What impact does high bMI have on third molar surgery?
Worse healing Short necks Small mouths
85
What is different for ginger people?
Bleed more | Require more analgesia because of lower pain tolerance
86
What radiographs are indicated for third molars?
Periapicals and OPTs CBCT
87
What is the CBCT indication?
OPT doesn’t give enough info | Might change treatment plan
88
What nerves can be affected when thinking about third molars?
Lingual nerve Mylohyoid nerve Inferior alveolar nerve Long buccal nerve
89
What are the indications that suggest a risky third molar surgery?
``` Superimposed IAN Diversion of INA at apex Darkening of root where INA crosses it Interruption of white lines of canal Darkening of roots associated with widening canal Juxta apical area ```
90
What are the indications for tooth roots & how does this make the extraction?
``` Underdeveloped roots Conical roots - favourable Roots with widened PDL - favourable Splayed roots - challenging might leave roots in. Relationship to second molar ```
91
What are the indications around bone and age in third molar surgery?
18 and younger bone very soft less needs to be removed, less dens so will cut and expand better. Better healing. 35 and over much more dense not as flexible more bone removal required worse healing
92
What are the predictors of difficulty for third molar removal?
Alveolar bone level Tooth position Application depth Doing of elevation
93
Are there any neurological issues with treating maxillary third molars?
No
94
What sedation options are there for third molar removal?
LA LA&IV/Inhilation sedation LA&GA
95
What are the warnings to all patients undergoing any kind of oral surgery?
``` Pain Swelling Bleeding Bruising Infection Dry socket Difficulty opening Damage to adjacent teeth ```
96
What do you need to warn patients about with third molar surgery?
Damage to chorda timpani supplying slight taste IA Nerve lingual nerve So lower lip, skin of the chin, side of the tongue, gingivae of lower teeth, lower teeth and taste This can be pins and needles, pain or complete loss of sensation temporarily or permanently Will be bruised, time off work and swelling rarely leading to hospitalisation
97
When is the lingual nerve at risk
Anything too lingual when carrying out a procedure Or kebabing when suturing
98
What happens to the long buccal nerve in third molar surgery?
Gets sacrificed only supplies small amount of buccal tissue
99
What is risk of maxillary third molar surgery?
Fractured tuberosity OAC Damage to adjacent teeth
100
What is critical for third molar exodontia?
Good anaesthesia
101
What anaesthetics and nerves would you numb before molar extraction?
Lower - lidocaine IA block Articaine long buccal nerve Upper - Articaine buccal and palatial
102
What is an operculectomy?
Removes soft tissue flap over third molar
103
What is the periosteum?
Part of bone containing cells for remodelling
104
What pre-op meds could be given to a straight forward third molar case?
Ibuprofen
105
What is given post op after third molar removal?
Ibuprofen and paracetamol
106
What can be given in addition for complex third molar surgeries?
Steroids dexamethasone
107
What are the indications for air generating turbines in surgery?
No air at all can cause surgical emphysema which is medical negligence Non air generating rotors
108
What is a coronectomy?
Removing just the crown of the tooth when the molars are high risk
109
What happens if roots move in coronectomy?
Roots have to be removed as well.
110
What is an apicectomy/root end surgery
Removing the apex of a tooth
111
What is a hemisection
This is premolarisation of a tooth- cutting it in half
112
What is decompression
When there is a large anterior lesion and a surgical drain is put in to encourage healing before apicectomy
113
What is special about MTA
Osteoinductive and very biocompatible
114
What are the indexation for endodontic surgery
To eliminate/reduce infection when’re this isn’t possible non surgically
115
How is endodontic surgery carried out?
``` Raise a flap Remove bone to reach apex Clear granulation tissue Remove apical 3mm roots at 90 degree angle Remove 3mm GP and fill with MTA Done ```
116
What are counter indications that need to be considered in endo surgery
``` Tooth Supporting bone Flap design Crowns Veneers Issues of recession Depth of sulcus Size and site of lesion ```
117
3 types of flap design
Standard rectangular- includes papilla Sub marginal - 3mm from gingival margin saves papilla and negates recession Papilla base - leaves papilla but it to the gingival margin let’s you see more but negates recession abit more.
118
What factors affect endodontic surgery outcome
``` Age Sex Health Tooth location Clinical signs and symptoms Lesion size Bone loss Coronal restoration Resurgerey Level of resection Root filling material Haemostatic agent Bone grafting ```
119
Why do root canals fail
Presence of bacteria in the root canal. Or biofilm outside if the canal.
120
How do you do an endodontic retreat don’t restorability assessment
Make sure no cracks Good amount of dentine This will only be found out when restoration removed so make pt aware
121
What could be suggested by a halo or J shaped bone los pattern surrounding a whole root on a radiograph.
Root fracture
122
What can surgical endo be carried out?
After endo non surgical retreat meant and failure because this improves endo surgery outcome
123
How is GP removed
Hand files one large mass Use of rotary instruments Braiding technique-push 2-3 files down around GP and twist to pull out like a claw Solvent as last resort
124
What files are used to remove GP
Headstrom files engage and help pull it out
125
What are solvents used to remove root filling.
Endosolv - will dissolve rubber dam, one drip needed
126
What mechanised rotary instruments are available for specific retreatment of a root canal
Pro taper D1-3 Very stiff and can easily extrude a canal Reciprocating files : Wave one gold - middle and apical third removal Reciproc file good for whole removal
127
What are the two types of healing
Primary - like a cut where there is no tissue loss etc | Secondary - tissue lost distance between margins heal is with a scar
128
What are the four stages of healing
Haemostasis Inflammatory phase Proliferation phase Remodelling phase
129
What happens in the inflammatory phase of healing
Cellularisation Vascularisation Vasodilation (Redness heat swelling)
130
What happens in proliferation phase
Fibrin strands form structure Fibroblasts lay ground substance and tropocollagen Capillary formation and collagen formation
131
What happens in the Re-modelling phase
Collagen fibres destroyed and replaced with better orientated collagen fibres Wound strength increases Vascularity and erythema decreases Wound contracts
132
What are considerations that need to be made relating to factors that influence healing
Foreign material Necrotic tissue Ischaemia Wound tension
133
Which does necrotic tissue impact healing
Acts as a barrier to ingrowth of reparative cells and can feed the bacteria
134
How does ischaemia impact healing
``` Reduction in blood supply Tissue necrosis Reduction in delivery of antibiotics Antibodies Nutrients ```
135
Patient factors that influence healing
``` Age Heart disease Diabetics Anticoagulants Steroids Bisphosphonates Immunosuppressants BMI (airway, access, medical) ```
136
What are the key surgical primciples
Adequate access Adequate light Surgical field free of excess blood / saliva
137
What are key principles of preservative surgery
``` Sufficient access Preserve vital structures Protect soft tissue Preserve blood supply Closure on sound bone ```

Complex Adult Dentistry (5 decks)

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