Flashcards in Oral Surgery Deck (312):
Trigeminal nerve (CN V)
largest CN, the principal general sensory nerve to the head and face, sensory and motor
motor root exits foramen ovale
does CN V have parasympathetics at its origin?
mandibular division of CN V innervates how many muscles?
CN V somatic SENSORY bodies of the ganglion's sensory fibers enter the 3 divisions:
V1 Ophthlamic - ORBIT and SKIN above eyes
V2 Maxillary - nasal cavity, max teeth, palate, skin over maxilla
V3 Mandibular - mandible, TMJ, mand teeth, FOM, tongue, skin of mandible
CN V, axons of neurons enter the __ through the sensory root and terminate in 1 of 3 nuclei of the trigem sensory nuclear complex (3)
1. mesencephalic - proprioception ex. muscle spindle
2. main sensory - general sensation ex. touch
3. spinal nucleus - pain and temp
proprioceptive fibers from muscles and TMJ found in which CN V division?
cell bodies of proprioceptive 1st order neurons are found in the __ nucleus
mesencephalic NOT the trigem ganglion
branchiomeric motor fibers innervate which muscles?
Medial and Lateral Pterygoids
Anterior belly of the Digastric
Tensor veli palatini
Mandibular Div (V3) of the trigem passes through __ and supplies sensory/motor? innervation to these muscles
to tensor veli palatini, tensor tympani, muscles of mastication (temporalis, masster, lateral and medial pterygoids), anterior belly of digastric, mylohyoid muscles
CN V3 sensory innervation (4 nerves)
1. long buccal (sensory only) -> cheek, md buccal gingiva
2. auriculotemporal (sensory only) -> TMJ, auricle, external auditory meatus
3. lingual (sensory only) -> FOM, mand lingual gingiva, anterior 2/3 tongue
4. inferior alveolar nerve (sensory & motor!) -> mand teeth, chin skin, lower lip
massteric nerve is a branch of CN V3 that carries sensory/motor? fibers to the TMJ's anterior portion
auriculotemporal nerve is a branch of VN V3 that provides major sensory/motor? innervation to the TMJ's posterior portion
also transmits pain in the TMJ __ and __
pain in TMJ capsule and disc periphery
nerve to mylohyoid muscle is a branch of the mandibular nerve (V3), functions to?
elevate hyoid bone, base of tongue, FOM
-sublingual gland is superior to mylohyoid muscle
when the floor of the mouth is lowered surgically, the __ and __ muscles are detached
mylohyoid & genioglossus
suprahyoid muscles (4) and their innervations
1. Digastrics (ant and post) - CN V3 (ant), CN VII (post)
2. Mylohyoid - CN V3
3. Geniohyoid - C1 via hypoglossal CN XII
4. Stylohyoid - CN VII
infrahyoid muscles (4) and their innervations
all innervated by Ansa Cervicalis (loop formed by branches of cervical plexus C1, C2, C3)
hypoglossal nerve is a motor nerve supplying what muscles?
all intrinsic and extrinsic tongue muscles EXCEPT palatoglossus (vagus nerve)
unilateral lesions of the hypoglossal nerve cause deviation of the protruded tongue to the affected or opposite side?
affected side, cause of lack of fxn of genioglossus on diseased side
if the __ muscle is paralyzed, the tongue can fall back and obstruct the oropharyngeal airway
carotid sheath location? what does it contain?
lateral boundary of retropharyngeal space at level of oropharynx, deep to SCM muscle
contains carotid arteries, internal jugular vein, vagus nerve, deep cervical lymph nodes
when you retract the carotid sheath, the __ __ __ stays because it is not within the sheath
cervical sympathetic trunk
facial vein unites with the __ vein below the border of the mandible and empties into the internal jugular vein
internal jugular vein descends through neck inside carotid sheath, eventually to forms the
superior vena cava -> right atrium
max 1st molar innervated by what nerves
middle superior and posteiror superior alveolar
what injection must you give to ext all molars and 2nd PM?
greater (anterior) palatine nerve is a branch of the maxillary (CN V2) that innervates?
GP foramen is where?
soft tissue to posterior 2/3 of hard palate -> canine (overlaps with nasopalatine)
btw 2nd and 3rd max molar, ~1 cm from palatal gingival marign toward midline
which cranial nerves have parasympathetic activity?
Cranial nerves (12)
I - olfactory - smell
II - optic - sight
III - oculomotor - eyeball movement, pupils, vision
IV - trochlear - eyeball movement
V - trigem - sensation to face, scalp, teeth, muscles of mastication, mandible movement
VI - abducens - eyeball movement
VII - facial - taste, face muscles, saliva secretion
VIII - vestibulocochlear - hearing, equilibrium
IX - glossopharyngeal - taste, sensory for cardiac, respiratory, bp reflexes, pharynx contraction, saliva
X - vagus - sensory in cardiac, respiratory, bp reflex, larynx, decr HR, peristalsis, incr. digestive secretions
XI - accessory - contract neck and shoulder
XII - hypoglossal - motor to tongue except palatoglossus
external carotid artery supplies?
passes through the __ gland
most of head and neck cept brain
through parotid salivary gland
terminates as max and superficial temporal arteries
maxillary artery supplies what?
max and mand teeth, muscles of mastication, palate, nasal cavity
IA artery -> mand teeth
PSA artery -> post max teeth
ASA & MSA -> ant max teeth
venous return of both dental arches is?
pterygoid plexus of veins
greater (descending) palatine artery supplies?
hard palate, gingiva of max teeth and lateral nasal wall
lesser palatine also does tonsils
lingual artery supplies?
arises from? terminates as?
blood to tongue (also gets blood from tonsillar branch of facial artery and ascending pharyngeal artery)
also supplies FOM
arises from external carotid artery, terminates as deep lingual artery
does NOT accompany its nerve throughout its course
lingual artery branches (4)
deep lingual - anterior 2/3 tongue
inferior alveolar nerve and artery, and lingual nerve are found in the __ space?
PTERYGOMANDIBULAR SPACE btw medial pterygoid and ramus of mandible
IA nerve passes lateral to sphenomandibular ligament
tongue sensory innervation
lingual nerve (branch of V3) - ant 2/3 tongue
glossopharyngeal (CN IX) - post 1/3, vallate papillae, tonsil, nasopharynx, pharynx
vagus (CN X) via internal laryngeal nerve - near epiglottis
facial nerve (CN VII) via chorda tympani - taste to ant 2/3
facial nerve CN VII exits cranium through __ and extends laterally around mandible thorugh the __ gland
fxns of facial nerve
1. motor - muscles of expression, post belly digastric, stylohyoid, stapedius
2. sensory (proprioception) - muscles of facial expression
3. motor (parasympathetic) - tear secretion from lacrimal gland, salivary from sublingual and submand glands
4. sensory (taste and sweet) - taste buds ant 2/3 tongue, FOM, palate
Parotid gland is a pure __ gland supplied by general visceral efferent (motor) nerve fibers of the __ nerve.
supplied by what artery?
SEROUS, glossopharyngeal nerve
Stenson's duct - pierces buccinator, crosses masster where it opens opposite max 2nd molar
external carotid artery
lymph -> parotid nodes to deep cervical lymph nodes
the only other adult salivary glands purely serous
-around circumvallate papilla of tongue
-fxn to rinse food away from papilla
__ is a viral disease of the parotid gland
Wharton's duct (submandibular) is closely related to what nerve?
blood supply from?
parasympathetic secretomotor fibers from FACIAL NERVE
sublingual gland is the smallest salivary gland that contains mostly ___ acini
-in FOM below tongue, close to midline
-has many small RIVIAN ducts
-secretory units are mucous secreting with serous demilumes
lymphatic drainage from the sublingual and submandibular glands goes to what lymph nodes
submandibular, deep cervical
sometimes the numerous sublingual ducts join to make a main excretory duct called __ that empties into the __ duct
Bartholin's Duct -> submandibular
in the H&N, all lymph ultimately rains into the __ lymph nodes
-form a chain along course of the internal jugular vein
-efferent lymph vessels join to form jugular lymph trunk, drains into thoracic duct or right lymphatic duct
regional lymph nodes (3)
2. submandibular - max and mand teeth, ant 2/3 tongue, paranasal sinuses
3. submental - mand incisors and gingiva, tip tongue, FOM, center lip
maxillary sinuses open into
max division of trigem nerve (CN V2 - incl ASA, PSA, MSA, infraorbital)
antibiotics to treat sinus infxns
ampicillin - sinusitis from upper respiratory infxns
penicillin and amoxicillin - sinusitis caused by odontogenic foci
max sinus communication
if tooth or large fragment displaced, what do you do?
if small then just allow blood clot
if fragment then remove it, if you can't get it thru socket then use Caldwell-Luc approach
integrity of max sinus floor is at greater risk with surgery removing a single remaining max molar cause of
pterygopalatine fossa is a small space where?
what nerve and artery passes through?
behind and below orbital cavity
max nerve (V2) and artery
buccinator originates from 3 areas:
what arteries supply it?
pterygomandibular raphe (btw buccinator and superior constrictor), maxillary and mandibular alveolar processes
facial and maxillary arteries
action - compress cheeks against molars for sucking and blowing
these muscles are the primary protractors of the mandible
-open and protrude, mandible side to side
ex. right lateral movement, the LEFT is the mover
mandible deviates toward/away site of injury in condylar ankylosis, unilateral condylar fracture, latearl pterygoid injury
mandible deviates toward/away site of injury in cases of condylar hyperplasia
what muscle forms the roof of the pterygomandibular space?
masticator space is composed of what 3 spaces?
infxns are almost always of dental origin from what region?
masseteric, pterygomandibular, temporal
mandibular molar region
TRISMUS, pain, swelling
needle tract infxn after IA block initially involve what space?
most definite clinical sign indicating extension of odontogenic infxn into masticator space
-can also be caused by passing needle through medial pterygoid muscle during IA block
temperomandibular joint is the articulation btw mandibular condyle and squamous portion of what bone?
TMJ components (4)
1. mandibular condyle (condyloid process)
2. articular fossa (mandibular or glenoid)
3. articular eminence (articular tubercule)
4. articular disc (meniscus)
condyle surface is covered with
vascular layer of fibrous CT
articular fossa (mandib or glenoid)
concave fossa, anterior 3/4 of larger mandib fossa
articular eminence (articular tubercule) is a
CONVEX ridge lined with fibrous CT (fibrocartilage)
FUNCTIONAL and articular portion of the TMJ
articular disc is
bioconcave, saddle shaped, made of fibrous CT
-central intermediate zone separates anterior and posterior bands
-posterior band has RETRODISCAL tissue/bilaminar zone which is VASCULAR and INNERVATED
-anterior band is thinner, contiguous with capsular, condyle, superior belly of lateral pterygoid
muscles acting on TMJ
masseter, temporalis, pterygoids, digastric
3 TMJ ligaments are
1. Temperomandibular (lateral)
major one from articular eminence to condyle, the ONLY one that directl ysupports TMJ capsule
-prevents posterior and inferior displacement of condyle
accessory ligament, separates infratemporal from parotid region, located on POSTERIOR border of mandible
accessory ligament, located on MEDIAL surface of mandible
4 arteries that vascularize TMJ
1. Middle meningeal (branch of maxillary, terminal branch of external carotid)
2. Ascending pharyngeal
3. Deep auricular
4. Superficial temporal (terminal branch of external carotid)
TMJ syndrome divided in 3 categories
1. Myofascial pain
2. Internal derangement (disc displacement)
3. Degenerative join disease (osteoarthritis)
what's the syndrome that's the most common cause of TMJ pain?
myofascial pain dysfunction (MPD)
-involves muscles of mastication
-responds to night guard
internal derangement (disc displacement) is
most common direction for disc to be displaced?
abnormal relationship of articular disc to condyle, fossa and articular eminence
anteriorly - retrodiscal tissue (bilaminar zone) becomes abnormally stretched
if posterior band returns to normal position then this condition is called
anterior displacement with reduction
"pop" or "click"
subluxation (dislocation or open lock) is when
pt can't close mouth
disc displacement WITH redxn is when
disc is out of place, hear a "click", painless
patient has normal opening or "S" shaped, TMJ is only ROTATING (not translating), reciprocal clicking on opening and closing
-on closing, the disc is forward to condyle
disc displacement WITHOUT reduction (closed lock) is when
jaw deviates toward/opposite affected side?
what direction are disc displacements?
clicking and opping is gone with limited opening and pain, a HARD-END feel
deviates TO affected side
NO reciprocal click
most displacements -> ANTERIOR and MEDIAL
most common cause of restricted mandibular movement is
disc interference disorders
best way to palpate posterior aspect of the condyle is?
EXTERNALLY over posterior surface of condyle with mouth open
-palpate laterally in front of external auditory meatus while pt opens and closes
what is the best incision to expose the TMJ?
anterior to external ear, parallel to superficial temporal artery, be careful of facial nerve
__ approach is the standard to approach the mandibular ramus and neck of the condyle
the most common cause of TMJ ankylosis
most common complication of rheumatoid arthritis
control of __ is vital to tx any pt with a facial fracture
highest incidence of fractures occurs in what population
young males 15-24, trauma
3 muscle groups displace the condyles
1. masseter, medial pterygoid, temporalis
-ELEVATE mandible during mastication, causes UPward displacement of proximal segment
2. digastric, mylohyoid, geniohyoid, lateral pterygoid
-DEPRESS mandible and displaces DISTAL segment inferiorly and posteriorly
3. lateral pterygoid
-FORWARD displacement of condylar head when the condylar neck is fractured
30% of fractures in the mandible happen in the
25% in the
22% in the
17% in the
1. ANGLE - proximal segment usually displaced anteriorly and superiorly
2. condylar neck
3. symphysis (chin)
4. body of mandible
5. ramus (2%)
6. coronoid process (1%)
on opening, pt's mandible deviates toward/opposite injury?
most common pathognomonic sign of mandibular fracture is
open reduction is?
most common site is?
the reduction of a fractured bone by manipulation after incision into skin and muscle over fracture site
mostly at ANGLE of mandible
best when teeth are missing in one or more of the fractured segments, when there's continued gross displacement of the segments
condylar neck fractures best treated by what method?
closed reduction is?
intermaxillary fixation is?
rdxn of fractured bone by manipulation without incision into skin
applying wires or elastics btw jaws, most common is PRE-FAB arch bars
bilateral sagittal split osteotomy most common to correct?
mandibular retrognathia (Class II malocclusion)
split mandible can be advanced or set back
*position of condyle is UNCHANGED
vertical ramus osteotomy is used to correct
body osteotomy is used to correct
mandibular PROgnathism (Class III malocclusion)
-ext mand teeth bilaterally (usually PMs)
ways to immobilize a fracture (4)
1. Barton bandage
2. Intermaxillary fixation (IMF)
3. external skeletal fixation
4. Direct intraosseous wiring + IMF, traditional method after OPEN RDXN
mand fracture that extends only thru cortical portion of bone without complete fracture; most common in KIDS
classifications of mandibular fractures (3)
1. simple - 2 parts with no external communication (closed)
2. compound - communicates with outside (open), most common complication is INFECTION
3. comminuted - multiple fractures of a single bone that can be either single or compound
unfavorable fracture occurs if fracture line results in ___
favorable fracture occurs if fracture line __
muscle pull displacing the fracture segment
prevents displacement of fracture by muscle pull
midfacial fractures affect these 3 structures
nasoorbital ethmoid complex
6 types of midfacial fractures
1. LeFort I
2. LeFort II
3. LeFort III
4. Zygomatic complex
5. Zygomatic arch
6. Nasoorbital Ethmoid
1. LeFort I - HORIZONTAL, causes OPEN BITE, used to correct Mx RETROgnathia
2. LeFort II - PYRAMIDAL, PARESTHESIA common over infraorbital nerve
3. LeFort III - TRANSVERSE or CRANIOFACIAL dysfunction, restricted mandibular movement
4. Zyogmatic complex - most common, can have paresthesia, hematoma in sinus, impaired ocular muscle
5. Zygomatic arch - no probs
6. Nasoorbital Ethmoid
what are the 1st and 2nd most common fractures of facial bones?
2. zygomatic bone
signs and symptoms of zygomatic fracture
binocular diplopia, trismus, ipsilateral epistaxis
what view is best to evaluate orbital rim areas?
symptoms of fracture of infraorbital rim?
numb upper lip, cheek, nose on affected side
3 radiographic views for midfacial fractures
2. PA skull
3. submental vertex
blows to the maxilla drive the maxilla in what direction? results in what kind of bite?
back and down -> open bite or impinged airway
segmental osteotomy is?
maxilla sectioned into 2+ pieces
fracture healing (4)
1. Endosteal proliferaiton - in bone
2. Periosteal proliferation - in CT
3. Primary (bone to bone) healing - endosteal and periosteal proliferation
4. Secondary bone healing - mostly endosteal proliferation
3 phases for healing bone
1. hemorrhage - first 10 days
2. callus formation - in 10-20 days, then a secondary callus
3. functional reconstruction - line up Haversion systems, bold will be molded, takes 2-3 years
4 reasons fractures don't heal
2. excess mobility
3. interposition of soft tissue
___ is the most of often sequela of fractures
3 types of inappropriate healing
1. delayed-union: satisfactory healing
2. non-union: failure of segments to unite properly
3. mal-union: can be delayed or complete union in an improper position
Geudel's stages of general anesthesia (4)
1- Amnesia & Analgesia - best monitor is VERBAL
2- Delirium/Disinhibition & Excitement - loss of consciousness, onset of total anesthesia
3- Surgical Anesthesia - regular pattern of breathing, total loss of consciousness, 4 planes, spinal reflexes depressed, no pain reflexes
4- Premortem or Medullary Depression - signals danger, dilated pupils, cold skin, low bp, cardiac arrest imminent, severe respiratory and cardiovascular depression
3 agents for surgical anesthesia
cyclopropane - good muscle relaxant
halothane - not good muscle relaxant, not good analgesic, halogenated hydrocarbons are assoc. with liver damage if toxic doses are used
methoxyflurane - good muscle relaxant, respiratory depressant, good analgesic
ASA classes (6)
I - healthy
II - mild systemic disease
III - severe disease not incapacitating
IV - severe systemic disease, threat to life
V - moribound pt not expected to survive without operation
VI - brain dead
elements of general anesthesia include (4)
__ is the last area of the brain depressed during general anesthesia
-contains cardiac, vasomotor, respiratory centers of the brain
most reliable sign of "oxygen want" is
increased pulse rate
cyanosis may also be present
most common emergency during outpatient general anesthesia is
best anesthetic technique used in OS to avoid aspiration of blood or other debris when a pt is under general is
endotracheal intubation with pharyngeal packs
pt with __ infxn is contraindicated in general anesthesai
starts with admin of anesthetic and continues until desired level of pt unresponsiveness is reached
rate and recovery depends on rate of change of tension in tissue, blood supply to lungs, pulmonary ventilation, concentration of anesthetic influence
when surgery is complete and delivery of anesthetic is terminated; ends when anesthetic is eliminated in the body
reduces anxiety and produces a trance-like state where the person is not asleep but feels separated from their body, good for KIDS, they usually don't remember, can have intense dreams or hallucinations
__ is the primary med used in dissociative anesthesia
KETAMINE, but usually give them a sedative first to reduce anxiety
local anesthetics are most effective in tissue about pH __ cause __
locals are alkaloid bases combined with acids to make water-soluble salts
local anesthetics affect the nerve membrane by INCR/DECR? membrane's permeability to Na+ and INCR/DECR membrane's excitability
DECR membrane permeability
DECR membrane's excitability
bind to inactivation gates of fast voltage gated Na channels
K, Ca, Cl conductances are unchanged
reversibly block nerve impulse conduction and produce reversible loss of sensation
which nerve fibers are affected first by local? and last?
small NONmyelinated nerve fibers (pain, temp) > touch > proprioception > skeletal muscle tone
max. allowable dose of 2% lido with 1:100000 epi?
carbo with no epi?
max dose of epi for cardiac-risk pt?
3.2 mg/lb or 7 mg/kg
0.04 mg (if 1:50000 then 1 carp, if 1:100000 then 2 carps, if 1:200000 then 4 carps)
there is 0.018 mg epi in each carp of 2% lido with 1:100000 epi
1 cc 2% lido with 1:100000 epi has how much
20 mg lido
0.01 mg epi
6 mg NaCl
0.5 mg sodium-metabisulfate (preservative to stabilize epi)
1 mg methylparaben
allergic rxns are more common in esters or amides?
usually caused by an antigen-antibody rxn
PABA esters include
procaine (novocain)* was the prototype
tetracaine/pontocaine (most common)
ester local anesthetics undergo rapid biotransformation in __
amides undergo biotransformation where?
hydrolysis to PABA by the enzyme pseudocholinesterase (can't detox ester agents at a normal rate so use amides instead)
amides in LIVER by microsomal enzymes
amide local anesthetics include
LIDOCAINE/XYLOCAINE (most common)
what do you use for pts allergic to esters and amides?
local anesthesia works by?
reducing anxiety and sensitivity during the procedure
__ is the local anesthetic that may manifest toxicity clinically by initial depression and drowsiness
-usually it's stimulation first
what 2 anesthetics can show cross-allergenicity?
lido and mepivacaine
first clinical sign of mild lidocaine toxicity is?
related to CNS excitation
how do you tx sustained convulsive rxns to locals?
side effects of lido systemic absorption
4 reasons why vasoconstrictors (ex. epi) are placed in locals
1. prolong duration of action*
2. reduce toxicity
3. reduce rate of vascular absorption by causing vasoconstriction
4. more profound anesthesia by incr. concentrations at nerve membrane
do vasoconstrictors reduce the change of developing an allergic rxn?
3 anesthetics that contain epi
what anesthetic contains levonordefrin (neo-cobefrin)?
which one has norepi?
vasoconstrictors act at what receptors to constrict arterioles?
cocaine is an instrinsic vasoconstrictor that does what?
increases PRESSOR activity of both epi & NE
local anesthetics depress small/big? myelinated or non? nerve fibers FIRST and what last?
small non-melinated first
then large, myelinated fibers last
variations depend on nerve diameter and distance btw nodes of Ranvier
clinically, order of loss of nerve fxn from a local anesthetic is (5)
pain - temperature - touch and pressure - proprioception - skeletal muscle tone
what is the drug of choice for managing an acute allergic rxn involving bronchospasm and hypotension?
inhalation anesthetic with fastest onset
it inhibits what enzyme that is required for vit B12 production?
-poorly soluble in blood
-in surgery provides light anesthesia
inhibits methionine synthetase
cons of N2O
inhalation of 100% oxygen is contraindicated in a pt with what condition?
nausea, diffusion hypoxia
hypoxemia, respiratory disease, emotional instability, contagious diseases
OK for pregnant pt
N20 works where? organic or inorganic?
main effect on what systems?
first symptom is?
CNS, INORGANIC, excreted by lungs (unchanged)
reticular activating and limbic systems
tingling of hands
neurolept analgesia only produces an unconscious state if __ is also administered
neuroleptic (droperidol) + narcotic analgesic (fentanyl) is
neurolept ANALGESIA (conscious)
neuroleptic + narcotic analgesic + N2O is
nitrous oxide and ethylene are useful only for __ and __
sedation and analgesia
N2O: ventricular fibrillation is LEAST LIKELY to occur with nitrous
ethylene: rapid induction and recovery, but explosive and stinks
primary danger with using N2O > 80% conc. is
inhalation anesthetic, but irritates airway
SPEED of inhalation induction of anesthetics depend on 5 things
1. gas solubility* (more soluble, slower rate of induction)
2. inspired gas partial pressure
3. ventilation rate
4. pulmonary blood flow
5. arteriovenous conc. gradient
admin of inhalation anesthetic is usually preceded by administration of what drug
IV or intramuscular admin of a short-acting sedative hypnotic (often a BARBITURATE)
barbiturates do what to the CNS?
2 major effects?
drugs to avoid in pts taking barbiturates?
last tissue to become saturated?
DEPRESS the CNS
effects - sedative, hypnotic
avoid - phenothiazines, alcohol, antihistamines, antihypertensives
FAT is the last to be saturated cause it's not as vascular
properties - respiratory depression, induction of liver microsomal enzymes, tolerance development, suppression of REM sleep, hyperanalgesia (incr sensitivity to pain)
most effective agent in initial tx of respiratory depression from overdose of barbiturates is
oxygen under positive pressure
most resistant part of CNS under general anesthesia is the
most controllable route of admin of general anesthetic is
most common drug used to attain general anesthesia is
most common side effect?
-an IV barbiturate, induce anesthesia in short surgery as supplement to other aneshetics
side effect - hiccoughs
malignant hyperthermia is what kind of condition?
autosomal dominant inherited condition, life threatening, acute pharmacogenetic disorder in pts undergoing general anesthesia
sudden rapid rise in body temp, incr. muscle metabolism (tachycardia, tachypnea, sweating, cyanosis, incr CO2 production, muscle rigidity)
the only drug that treats malignant hyperthermia
optimum site for IV sedation is what vein?
avoid entering what artery?
median cephalic vein
avoid brachial artery
IV sedation usually with what drug?
3 common signs that indicate correct level of sedation has been reached?
signs - blurred vision, slurring of speech, 50% ptosis of eyelids (Verrill's sign)
phlebitis (thrombophlebitis) of a vein after admin of IV valium is usually due to __ in the mixture
clinical observations of phlebitis? (4)
obs - vessels are hard, sensitive to pressure, area is erythematous and warm, limb is pale/cold/swollen
scopolamine is a drug structurally similar to
good for preventing __
good for motion sickness
-depresses CNS, a sedative and anti-spasmodic
-rdxn of secretions by competitive block of ach and other cholinergic stimuli
anticholinergic drugs work by:
interfering with binding of Ach at its receptor
-categorized by ionization state of nitrogen (affects ability to penetrate CNS)
-it's an anti-sialogue (decreases saliva!)
tertiary anticholinergic compounds include?
atropine, benztropine, scopolamine
-atropine is contraindicated for nursing mothers and pts with glaucoma (atropine causes MYDRIASIS, dilated pupils)
-these decr saliva flow and secretion from respiratory glands
quaternary anticholinergic compounds include?
glycopyrrolate, ipratropium, probanthine - can't penetrate CNS
1. tidal - air inhaled
2. residual - what doesn't participate in ventilation
3. expiratory reserve - what can be exhaled in addition to TV
4. inspiratory reserve - what can be inhaled in addition
5. vital capacity - total lung capacity
6. functional reserve capacity - air left in lungs at end of expiration
pulmonary volumes and capacity or __ % less in females than males
laryngospasm is a
how do you manage?
acute spasm of vocal cords and epiglottis
manage by applying oxygen under positive pressure and aministering succinylcholine
universal sign of laryngeal obstruction is?
what do you administer?
STRIDOR (crowing sounds)
give epi and oxygen
if oxgen doesn't get to lungs, blood, brain, permanent neurologic damage occurs in how many minutes?
tracheotomy is for
long-term airway maintenance
EMERGENCY airway, ex. anaphylactic rxn
in an IA block, needle passes through mucous membrane and what muscle? and lies lateral to what muscle?
passes through BUCCINATOR and is lateral to the MEDIAL PTERYGOID
-if it goes posterior at level of mandibular foramen, it penetrates the PAROTID GLAND
most common cause of post-op hypotension?
how do you treat it?
anesthesia/analgesics on the myocardium
if it was from narcotics -> Narcan
if there is bradycardia -> atropine (anti-cholinergic)
vasovagal syncope is
how do you manage?
a psychogenic rxn (caused by psychological factors), most common complication assoc. with local anesthetics
-initial event is stress induced release of incr. catecholamines
-signs resemble shock, early sign is PALLOR (pale)
-put pt in supine position, legs elevated above heart (trendelenburg position), cool towel
most common cause of transient loss of consciousness in a dental office is
3 drugs when given 1 hr before appt are safe to fearful patients
1. diazepam (valium)
2. promethazine (phergan)
3. pentobarbital (nembutal) or secobarbital (seconal)
hyperventilation in an anxious pt can lead to a __ spasm
carpodedal spasm (hand, thumbs, foot, toes)
a somatogenic reaction is
development of a rxn from an organic pathophysiologic cause
Shock symptoms include:
the main factor in all types of shock is __
the 3 stages of shock are:
symp - tired, sleepy, confused, cold sweaty skin, BP drops
main factor is reduced cardiac output!
1. compensatory stage - incr HR and peripheral resistance
2. progressive stage - metabolic acidosis
3. irreversible/refractory - organ damage
cardiogenic shock is most commonly caused by
-collapse from pump failure of the LEFT VENTRICLE
5 major types of shock
septic - from endotoxin from gram (-) bacteria
the most abused drugs by dental professionals is
-narcotic analgesic to releive pain, cough suppressant
-compares with MORPHINE
admin of meperidine and __ can cause life threatening hyperpyrexic rxns that can lead to seizures and coma
euphoria, analgesia, drwosiness, miosis, respiratory depression
2 tests that should be done before using a general anesthetic are
urinalysis (urine pH should be 6)
CBC includes 4 things
1. hematocrit - min is 30% for elective surgery
3. total leukocytes (WBC)
4. total erythrocytes (RBC)
normal values for coagulation
template bleeding time = __ min
prothrombin time = __ sec
partial thromboplastin time = __ sec
platelets = __K/ml
local contraindications to tooth extractions include
acute infection with uncontrolled cellulitis
acute infectious stomatitis
systemic contraindications to tooth ext
-uncontrolled: diabetes mellitus, cardiac disease, dysrythmias, leukemias and lymphomas
-severe bleeding disorders
-pts on immunosuppressives, corticosteroids, cancer chemotherapeutic agents
conditions that require abx prophylaxis prior to OS
1. prosthetic heart valve
2. rheumatic valve disease
3. most congenital heart malformations
NOT pacemakers cause endocardium isn't involved
standard prophylaxis for
amox - 2 g
clinda - 600 mg
ideal time to remove impacted 3rd molars is when root is approx. how much formed?
complication most seen after ext of isolated max molare are
fracture of tuberosity or sinus floor
cavernous sinus thrombosis (CST) is usually caused by?
usually occurs in what vein?
late complication of an infection (staph aureus) of the central face or paranasal sinuses
OPHTHALMIC VEIN cause of absence of valves in angular, facial, ophthalmic veins
the most common neck space infection that involves the sublingual, submandibular, and submental spaces
submandibular space drains infxns from what teeth? where in relation to mylohyoid?
mand premolars and molars -> apices lie BELOW mylohyoid
sublingual space contains what gland
submental space drains infections from what teeth? where in relation to mylohyoid?
medial part of submaxillary space
-drains from mand incisors and canines -> their apices lie ABOVE mylohyoid
most common site for supernumerary tooth is
maxillary incisor area, called a "mesiodens"
what Class lever is used for ext?
-teeth are ext by LUXATION perpendicular to long axis
loosening of tooth by progressive severing of PDL fibers
what scalpel is used universally for all OS
3 incisions used in OS
1. linear - for apicoectomies
2. releasing - do it at the LINE ANGLE
3. semi-lunar - for apicoetomies
suture sizing is based on 2 things
strength and diameter
smallest diameter should be used
ex. 9-0 has least strength and smallest diameter
3-0 and 4-0 are most common
most severe tissue rxn occurs with what kind of suture material?
plain catgut (resorbable - cause inflammatory rxn)
3 types of Resorbable sutures
1. plain gut - from sheep intestin, susceptible to rapid digestion
2. chromic gut - more resistant
3. polyglycolic acid - doesn't break down, more $
3 types of Non-Resorbable sutures
1. silk - multifilamentous, for INTRAORAL suturing
2. nylon - for FACIAL LACERATIONS
3. polypropylene - least likely to inflame
should remove in 5-7 days
what is the Caldwell-Luc approach
opening made into max sinus via incision into canine fossa above level of premolar roots
teeth are resistant to crush but are not resistant to __
-> place forcep beaks parallel to long axis
what is the primary direction for extracting:
max primary/deciduous molars? adult max molars?
max primary/decid -> PALATAL
adult -> BUCCAL
genial tubercules are the attachment for what muscle?
-on lingual surface of mandible
-NEVER excise cause if you did the tongue would be flaccid
dry socket is most common after ext what teeth
-usually 2-4 days after tooth ext
-tx by flushing, place EUGENOL sedative dressing
pericoronitis assoc. with
crown of partially erupted tooth, most common with mand 3rd molar
5 phases of healing an extraction site
1. hemorrhage and blood clot
2. granulation tissue *GLUCOCORTICOIDS retard healing!
3. replacement of GT by CT and epithelialization
4. replacement of CT by fibrillar bone
5. recontour alveolar bone and bone maturation
3 stages of wound healing
1. inflammatory - vascular and cellular, neutrophils and lymphocytes predominate, macrophage is most important cell in healing!
2. proliferative (firbroblastic) - new collagen and blood vessels
3. maturation (remodeling)
what is the agent of choice to debride intraoral wounds?
primary intention involves
both endosteal and periosteal proliferation
-little fibrous tissue is produced, with minor callus formation
secondary intention involves
mostly ENDOsteal proliferation
-lots fibrous tissue formed and callus is formed
greatest osteogenic potential occurs with what kind of graft?
autogenous cancellous graft and hemopoietic marrow
allogenic grafts (allografts or homografts)
most common is FREEZE-DRIED bone, or freeze-dried decalcified bone
autogenous grafts (autografts)
-most often used in OS
-to restore large areas of lost mandibular bones after surgery or trauma
bone marrow for grafting is usually taken from
the ILIAC CREST (also used for ridge augmentation)
isogenic grafts (isografts or syngenesioplastic grafts)
SAME SPECIES, but GENETICALLY RELATED
xenogenic implants (xenografts or heterografts)
not used in surgery
rejection of grafts is most common with these 2 types
ALLOgraft and XENOgraft
SYNTHETIC, tends to migrate from position where it was placed
hydroxyapatite is most commonly used for what procedure?
-when placed in a subperiosteal environment, it bonds physically and chemically to bone
-cons: migration, poor ridge form, abnormal color, mental nerve neuropathy
high speed turbine drills are ok/not ok?
2 techniques for frenectomy
1. simple excision and Z-plasty - when it's narrow
2. V-Y plasty (localized vestibuloplasty) - good for lengthening, less scars
best way to enlarge prominence of chin is by
osteotomy - horizontal sliding
closed reduction is
closing the space btw a fractured bone without cutting through soft tissue or surrounding bone
systemic contraindications to elective surgery include
-blood dysplasias (hemophilia, leukemia)
-uncontrolled diabetes mellitus
-Addison's disease or any steroid deficiency
-cardiac disease (usually not within 6 months of infarction)
most common indication for tooth transplantation is severe decay of what tooth?
success is most predictable when roots are how much formed?
most likely cause of failure is what?
1st molar (3rd molar placed)
roots 1/3-1/2 formed with open apices
failure with chronic, progressive EXTERNAL root resorption
sequelae -> ankylosis and root resorption
contraindications to implant placement include
-pituitary and adrenal insufficiency
-hx of uncontrolled bleeding
implants placed where have the highest failure rate?
3 types of bone-implant interface (integrations)
1. fibro-osseous integration - CT encapsulated implant within bone
2. osseointegration - most predictable long term stability, anchored into living bone
3. biointegration - hydroxyapatite or bioglass that bonds to bone
3 main groups of implants
1. endosseous - most common (80%), comes in 2 types
-root-form: cylindrical, most common
-blade-form (plate-form): when not enough bone
2. subperiosteal - below periosteum but above bone
3. transosseous - in atrophic mandible where root form could compromise strength of jaw
implant success requires
adequate transfer of force and biocompatibility
histo - 35-90% bone contact, CT adhesion above bone
clinically - no significant bone loss, no infxn, no mobility
4 types of biopsies
1. incisional - only part of lesion, a highly suspicious lesion
2. excisional - most often for oral lesions
3. needle - aspiration
4. exfoliative cytology - pap smear
what is the fixative used for routine biopsy?
persists over 2 weeks, persistent hyperkeratotic changes, malignant characteristics, inflammatory lesion that doesn't respond to local tx in 2 weeks, persistent swelling
dentigerous cysts (primordial/follicular)
assoc. with crowns of unerupted tooth, result of degenerative changes in reduced enamel epithelium
can incise or "deroof"
total removal of cystic lesion, used for congenital cysts, mucoceles, odontogenic cysts
marsupialization, decompression, partsch operation all create a __ in the wall of a cyst
surgical window, sac is opened and emptied
__ is the tx for ranulas, or a cyst large and close to vital structures
symptoms of dehydration
secondary pulmonary hypertension is most often caused by what condition
COPD disorders (4)
1. bronchial asthma - dyspnea and wheezing
2. emphsema - often with chronic bronchitis
3. bronchiectasis - purulent sputum, hemoptysis
4. chronic bronchitis - excess mucus, productive cough, assoc. with smoking
common results of chronic bronchitis
cor pulmonale - enlarged heart right ventricle, airway narrowing, squamous metaplasia
collapse of part or all of a lung
-most common anesthetic complication within first 24 hrs after general anesthesia
-prolonged can lead to PNEUMONIA
presence of air in pleural cavity
__ and __ are the 2 most common causes of fever in a pt who had general anesthesia
pneumonitis (lung inflamed)
asthma is a syndrome with these 3 symptoms
what drugs to avoid?
how do you treat acute asthma attack?
dyspnea, cough, wheezing
avoid: aspirin, NSAIDs, barbiturates, narcotics, erythromycin
tx -> inhale selective beta 2 agonist (terbutaline, albuterol) -> if doesn't work then EPI
most severe clinical form of asthma is
-airway obstruction can lead to respiratory acidosis -> death
bleeding time is
hereditary bleeding disorder, mostly males
PTT is PROLONGED
normal PT, BT
hemophelia __ and __ are sex linked recessive
A - factor VIII deficiency
B (christmas disease) - factor IX (plasma thromboplastin component) deficiency
hemophelia C (Rosenthal's syndrome) has a deficiency in
factor XI (plasma thromboplastin antecedent)
Von Willebrand's disease is inherited how?
-deficient in VWF (binding site for factor VIII, facilitates platelet adhesion to collagen for platelet plug)
most common cause of hemorrhagic disorders
3 ways this happens
thrombocytopenia, low platelets < 150K
1. decr. platelet production by bone marrow
2. incr. trapping of platelets by spleen
3. faster destruction of platelets
thrombocytopenia clinical features
purpuric lesions, nosebleeds, GI bleeding, urinary tract bleeding, severe hemorrhage
2 concerns when doing surgery on thrombocytopenia pts
post-op bleeding and
drugs that can potentiate bleeding after ext include
best test to determine if OS can be safe on a pt taking coumadin
normal prothrombin time
this test detects coagulation defects of the intrinsic system, basic test for hemophilia
partial thromboplastin time (PTT)
normal is 25-36 sec
anti-coagulants include these drugs
pts will most likely have prolonged __ and __ times
dicumarol, heparin, antithrombin III, enoxaparin, warfarin
long PT and BT
__ and __ drugs inhibit platelet aggregation
hemorrhage into skin and subcutaneous tissue
-RBCs degrade, hemoglobin converted through bilirubin hemosiderin
most serious potential complication after ext on pt previously irradiated
-condition of non-vital bone
osteomyelitis is most often caused by what organism
in kids what bones, in adults?
-reduced blood supply predisposes bone to osteomyelitis
kids -> long bones
adults -> vertebrae, pelvis
acute osteomyelitis more common in mandibule because blood supply better in max.
ABC of CPR
breathing - 12 breaths/min
circulation - 15 compressions every 2 breaths
if CPR is effective, the pupils will __
if you did too much pressure then what organ may be injured?
interrupting compressions can result in?
can damage LIVER
less blood flow and BP drop to 0!
if normal BP cuff on obese pt, then reading will be low/high?
in congestive heart failure, what part of the heart fails first?
common CHF signs
signs - exertional dyspnea, paroxysmal nocturnal dyspnea (earliest and most common sign!), peripheral edema, cyanosis
what is given to manage pts with chest discomfort or possible MI?
nitroglycerin given sublingually
calcium levels are regulated by what hormone
-if more PTH then bone resorption to increase calcium levels
low serum calcium will cause __ of nerves and muscles
serum calcium is increased in these 4 conditions
2. chronic glomerulonephritis
3. hypervitaminosis D
4. multiple myeloma
DEcreased in diabetes mellitus
phosphorus conc. is regulated by what hormone?
-increase in hormone cause increase in phosphate excretion -> decrease in plasma phosphorus conc.
in health, ratio of calcium:phosphorus in blood is
blood glucose conc. is regulated by __ and __
insulin and glucagon
serum glucose is increased in these conditions:
normal serum conc. of glucose is __ mg/dl
incr. growth hormone
glucocorticoid secretion is stimulated by __ which is produced in the __
by ACTH, produced in the anterior pituitary
__ secretes 20 mg of hydrocortisone daily
pts on lots of steroids repress production of __
it takes how long to regain full adrenal cortical fxn?
ACTH -> atrophy of adrenal cortex
erythema multiforme is a hypersensitivity syndrome charactereized by:
a severe form is called the __ syndrome
polymorphouse eruption, bullae and target "bulls eye shaped" lesions
severe form -> Stevens-Johnson Syndrome
Cushin's syndrome is caused by?
most common cause?
prolonged exposure of body's tissues to high levels of CORTISOL hormone
most common cause is pituitary adenomas
metabolic alkalosis major effect on body is
over-excitable nervous system, can cause tetany (tonic spasm)
causes - diuretics, vomiting gastric acid, overactive adrenal gland (cushing's syndrome)
tx -> ammonium chloride
respiratory alkalosis major cause?
hyperventilation, liver cirrhosis, low oxygen in blood (high altitude), apirin overdose
LESS COMMON than respiratory acidosis
tx -> ammonium chloride
metabolic acidosis causes?
CNS depressed, disorientation, comatosed
-always during CPR
major causes - chronic renal failure, diabetic ketoacidosis, lactic acidosis, poisons, diarrhea
tx -> sodium bicarb
respiratory acidosis causes?
buildup of CO2 in blood
causes - hypoventilation, emphysesma, chronic bronchitis, severe pneumonia, pulmonary edema, astha
tx -> sodium bicarb
most common pancreatic endocrine disorder and metabolic disease invooving glucose and lipids
classic triad of diabetes is
how to tx hypoglycemia in UNCONSCIOUS diabetic?
unconscious -> IV injection of 50% dextrose in water
conscious -> admin of oral carb (eat)
#1 cause of kidney disease, 40% of kidney failures is
(high BP is 2nd cause)
end stage renal disease (SRD) is when there is?
pts often taking what drugs?
permanent and almost complete loss of kidney function
-pts often on steroid therapy, more tendency for infxn and bleeding
whn tx pts with renal insufficiency and pts on hemodialysis you should
avoid drugs metabolized or excreted by kidneys
avoid NSAIDs (nephrotoxic)
do OS day after dialysis
rheumatic fever is an acute inflammatory disease with systemic manifestations and involved with heart valves, which foollows what infection?
how to tx?
group A beta-hemolytic streptococcus
NOT an infection, this is an inflammatory RXN to an infection
tx with penicillin
clinical dx of rheumatic fever when 2 criteria met.
what are the major jones criteria?
major jones - carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules
minor - fever, arthralgia, hx of rheumatic fever, EKG changes, lab tests