Oral surgery Flashcards
(118 cards)
1
Q
When do third molars erupt and why do they sometimes fail to?
A
They are the last teeth to erupt at 18-23 years. They are often absent or fail to erupt into normal occlusion. An impacted tooth is one which is prevented from reaching normal position by the presence of another structure. This is usually an adjacent tooth but may include the ascending ramus or overlying soft tissues. Removal of the third molars is one of the commonest surgical procedures carried out in the NHS.
2
Q
What problems are associated with 3rd molars?
A
- Abnormal position which can lead to cheek biting (upper 8s)
- Caries, pulp and periapical pathology in 2nd and 3rd molars
- Periodontal problems
- pericoronitis
Resorption (internal and external for 7s) - Cyst formation
- Difficulty with OHI and food packing
- Crowding of lower incisors
- Often involved in line of mandibular fractures
- In the way of orthognathic surgery
- Potential risk in the future for vulnerable and medically compromised patients
3
Q
What is pericoronitis?
A
It is inflammation in the soft tissues around the crown of a partially erupted tooth. It is caused by bacterial infection and/or trauma. It is the most commonly sited reason for the extraction of 8’s.
4
Q
What are the symptoms of pericoronitis?
A
- Pain or discomfort
- Soft tissue swelling in the region of the partially erupted tooth
- Difficulty eating, swallowing or opening the mouth
- Tenderness on closing if opposing tooth is in contact with inflamed soft tissues
- Unpleasant taste or smell
- May feel unwell with pyrexia
- May be a recurring problem
5
Q
What are the signs of pericoronitis?
A
- Inflammation in the soft tissues around the crown or the partially erupted tooth
- Localised intraoral swelling
- Evidence of trauma from opposing tooth?
- +/- pus
- +/- local lymphadenopathy
- +/- facial swelling
6
Q
What is the management of teeth with pericoronitis?
A
First manage with local measures:
- Irrigation beneath gum flap with saline/chlorhexidine mouthwash
- Remove upper 8 if traumatic occlusion
- Advise HSMW/chlorhexidine and analgesics
- Antibiotics if spreading infection or if medical problems, immuncompromised etc. Give metronidazole 200mg tds (anaerobic)
- Drain pus if present
- Formal review
7
Q
What should be done at review?
A
- Assess the outcome of the treatment and manage appropriately
- Assess 3rd molars
- Likely to erupt and be functional - monitor
- Unlikely to erupt - if problematic consider removal if not then leave and monitor
- Persistent, recurrent or severe problems - consider removal
8
Q
What clinical guidelines are available for the removal of third molars?
A
- Royal college of surgeons of England 1997
- NICE 2000/3
- American association of oral and maxillofacial surgery 2007 - recommend removal of third molars at young age
9
Q
What do the NICE guidelines say about removal of third molars?
A
- Routine practice of prophylactic removal of pathology free impacted third molars should be discontinued on the NHS
- Removal should be limited to patients with evidence of pathology
- Surgical removal of impacted third molars should be limited to patients with evidence of pathology
- Plaque formation is a risk factor but is not in itself an indication for surgery
- Adherence to guidelines should be audited and history and justification should be documented
- This will save money if prophylactic removal of third molars is discontinued
- Numbers of patients on the waiting list might reduce if these criteria are applied
- Not ethical to expose patients to unnecessary procedures
10
Q
What are the NICE guidelines on pericoronitis?
A
The degree to which the severity of the recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. A first episode unless severe should not be an indication for surgery. Second or subsequent episodes should be considered appropriate indication for surgery.
11
Q
What justification is there for prophylactic removal?
A
- To prevent crowding
- Reduce complications in older individuals
- Better able to cope when young
- If GA then do all at once
12
Q
What does a cochrane review advise with regards to removal of third molars?
A
It is from 2002 but was edited in 2008. It is independent of NICE. It states that there is no difference in clinical effectiveness between removal and retention. There is no difference in cost effectiveness between removal and retention. The conclusion is that there is no clear evidence to support or refute the benefits of prophylactic third molar removal other than prevention of late lower incisor crowding.
It appears to be more cost effective to leave in situ, prophylactic removal with subsequent nerve damage would be negligent.
13
Q
What should be assessed in a radiograph of a third molar?
A
- Diagnosis
- Type of impaction
- Depth of tooth within bone
- Crown form
- Root form and number
- Coronal or root pathology
- Other pathology (cyst, caries in 2nd molar)
- Relationship with mandibular canal (IAN)
Assess the entire tooth, adjacent molar, surrounding bone, ID canal and lower border.
14
Q
What are the types of impaction?
A
- Vertical - the easiest to extract, risk of pericoronitis
- Mesio-angular - more difficult, risk of food packing and caries in 2nd molar
- Horizontal - even more difficult, risk of food packing and caries in 2nd molar
- Disto-angular - very difficult, risk of pericoronitis
- Transverse - tricky
Buccal or lingual version adds additional complexity.
15
Q
What is the most appropriate radiograph for third molars?
A
Sectional panoramic films are most appropriate for the assessment of third molars because it is often difficult to get all of the tooth and the mandibular canal on a periapical film. The object here is to assess the degree of surgical difficulty. A CT scan may be taken to determine the location of the ID nerve.
16
Q
What should you note about the roots in the radiograph?
A
- Fused or conical
- Straight and separate
- Pincer shaped - needs division
- Complex
17
Q
What pathology would you look at in a radiograph of a third molar?
A
- Caries and periapical disease
- Dentigerous cyst - risk of fracture
- External resorption with secondary osteomyelitis
18
Q
How would you manage different proximities to the ID canal?
A
- Ideal - roots clear of the canal
- No increased risk - canal cortication visible
- Canal narrowed - roots have an intimate relationship with nerve
- Canals deviated - same as above
- Superior cortical boundary not visible - if you can’t see the two white lines then the nerve is right next to the root
- Dark band across the root - high risk
19
Q
How do you decide the treatment for a third molar?
A
Ask yourself is the third molar the cause of the patients problem? Does the patient need immediate care? for example a dressing to treat acute pulpitis. What are the risks and benefits of the various treatment options and get informed consent.
20
Q
What are the treatment options for a third molar?
A
- Removal
- Observation
- Operculectomy (remove flap of gum overlying tooth
- Coronectomy (removing crown)
Can be done with LA, LA and sedation, GA (day case) or GA (in patient).
21
Q
What is coronectomy and how is it done?
A
It is the removal of the crown of a tooth and leaving the roots in place.
- Raise buccal flap
- Cut at 45 degrees to crown, passing completely through (minimises risk of mobilising roots)
- Use fissure bur to reduce root to 3mm below alveolar crest
- Periosteal release and primary closure
22
Q
When is coronectomy used and the risks and contraindications?
A
The evidence for it is unclear but it is increasingly utilised with high risk cases. It appears to be a valid technique for reducing the risk of IAN damage.
It can be used when the tooth is in close proximity to IDN, no evidence of active infection or tooth mobility and avoid horizontal/mesio-angular teeth.
The patient must be warned of the potential for a second procedure to remove roots if they erupt or become infected (root removal in 2-6% of cases). Mobility of roots appears to be predominant factor for success. It is not indicated for co-morbidity patients e.g. chemotherapy, diabetes, immunosuppressed, bisphosphonates.
23
Q
What minor complications can occur with third molar extraction?
A
- Pain, swelling, trismus
- Infection
- Fracture including tuberosity
- Bleeding and bruising
- TMJ problems
- Temporary nerve damage
- Periodontal problems
- Damage to other teeth
- Oral-antral communication
Displacement of upper 8’s into pterygomandibular fissure (have retractor round the back of 8’s to prevent this)
24
Q
When does pain, swelling and trismus occur after extraction?
A
Pain is guaranteed after surgical removal of lower 3rd molars and can be severe. Pre-operatively warn the patient and advise on analgesics. Swelling and trismus is also guaranteed after surgical removal. It is variable but can be marked. Pre-operately warn the patient and provide advice on how to minimise (NSAIDs).
25
Are infections likely and should antibiotics be used?
There is a higher rate of incidence of post-operative infection in lower third molar sockets. There needs to be good oral hygiene post operatively. There is no good evidence for routine use of antibiotics. Consider all the variables as antibiotics do have a role for example in co-morbidity, local and systemic.
26
What does damage to adjacent teeth include and how do you manage this risk?
It includes mobilisation of second molars, damage to restorations and fracture of adjacent teeth. Pre-operatively assess the adjacent teeth clinically and radiographically, warn the patient and have a plan in place to minimise the risk and deal with the complication.
27
Why may the mandible fracture?
- Elderly, edentulous patients with atrophic mandible
- Pre-existing bone pathology
- Large bone defects
- Excessive use of force - cryers, large elevators
28
What can cause trigeminal nerve damage and what is the incidence?
```
Removal of wisdom teeth is the most common cause, also implantology, other surgery such as orthognathic, trauma, soft tissue surgery, needle stick (neuropraxia) and endodontics. The incidence is:
IAN:
- Temporary 5-7%
- Permanent 0.5-1%
Lingual:
- Temporary 3-7%
- Permanent 0.3-0.5%
Know these figures.
There are a minimum of 300 (pss 600) lingual nerve injuries a year and a higher rate of IAN injuries.
```
29
What nerves are around lower wisdom teeth?
On the lingual side there is the lingual nerve and below this the mylohyoid nerve. On the buccal side there is the long buccal nerve and below this the inferior alveolar nerve.
30
What causes lingual nerve injuries?
They are mainly drill injuries, lingual flaps still being raised and coronectomy. A lingual flap is made in some cases and a retractor placed down to protect the lingual nerve. This can lead to crushing of the nerve so is not done.
31
What are the effects of trigeminal nerve injury?
- Complete loss of sensation to half the anterior tongue and/or chin/lip
- Paraesthesia - reduced sensation
- Dysaesthesia - pain, tingling, burning
- Allodynia (painful response to non-painful stimuli)
- Loss of taste
32
What do patients with nerve injuries complain of?
- Pain, unpleasant burning and tingling
- Feel like they're dribbling
- Bite their lip
- Avoid eating in public
- Don't enjoy kissing
- Bite their tongue
- Tongue feels like a large lump of jelly
- Lose food under their tongue
- Don't enjoy food
33
What is the current management of lingual nerve injury?
It is managed with a surgical technique where a lingual flap is raised and the lingual periosteum is divided. The central and distal nerve stumps are identified and mobilised. The damaged segment of the nerve (4-14mm mean 9.5mm) is excised and there is direct reapposition with 5-10 (mean 7) 8/0 ethilon epineural sutures. All patients are given dexamethasone and antibiotics. It is effective and the majority of patients regain some sensation and fewer patients tend to bite their tongue.
34
How can the outcomes of lingual nerve repair be measured and which ones show significant improvement?
- Light touch
- Pin prick
- Two-point discrimination
- Gustatory response
- Altered sensation - dysaesthesia
- Subjective assessment
Significant improvement shown with light touch stimuli, pin prick stimuli, gustatory stimuli and two point discrimination. Will never return to normal.
35
What is the step by step management of lingual nerve repair?
If the division of the lingual nerve is noted during the operation there should be immediate microsurgical repair or urgent referral. When reviewing the patient if there is a problem, the patient should be informed and monitor the recovery by doing light touch, pink prick or 2 point discrimination. Review 3 months after injury and if there is some recovery continue to monitor but if there is no evidence of recovery consider referral to a specialist centre for exploration/repair.
36
Should you repair the IAN immediately at the time of third molar removal?
The nerve is usually well supported within the mandibular canal. Even after transection the ends do not usually retract so primary repair is not normally required. Control bleeding with temporary packing with gauze.
37
What should you avoid following injury to IAN?
Diathermy, whitehead's varnish and other medicaments, surgicel (neurotoxic) and bone wax.
38
How do injuries to the IAN occur in implantology?
It can be from the drill or implant. Many drills are longer than the implant length (Y dimension can be 1.5mm). It can occur due to overdrilling e.g. in low resistance bone and slippage of drill or pressing at roof of canal. It can occur due to miscalculation of the position of the IAN. Immediate placement (primary stability) is more likely to cause IAN. The safety zone is 2-4mm.
39
How can the mental foramen be avoided with implants?
4mm anterior to ensure avoidance of anterior loop. Consider surgical exposure.
40
What factors may indicate damage to the nerve?
- Sudden give
- Electric shock
- Arterial bleed (large percentage of injuries are secondary to haematoma)
- May be sensible to wait 2 days and then place implant to prevent compression ischaemia
- No evidence though
41
What is the management post nerve injury due to implants?
There is good evidence that neural recovery with implant related injuries is inversely proportional to time. Ideally you should remove the implant within 24-36 hours. There should be a post-operative call the same day or the following day. Short term you should remove the implant. The patient should be informed. Take a radiograph for localisation of the lesion. Evaluate the time that has elapsed, the proximity of the implant etc. Neurosensory evaluation.
42
What are the indications for surgical intervention after nerve damage?
- Persistent anaesthesia
| - Dysaesthesia/pain
43
What does IAN decompression/neurolysis involve?
- Cannot excise complete segment
- Can remove bony obstruction
- Can remove bony compression
- Can remove soft tissue tethering/tension
Can remove neuroma - dysaesthesia
44
What is the result of IAN decompression?
It reduces the number of patients with dysaesthesia, significantly improves the level of sensation, the level of improvement is modest. It gives no improvement in some patients, never results in complete recovery and we cannot predict who will benefit. It should be offered to patients with severe symptoms.
45
How do needle stick injuries cause injury to nerves?
The incidence of permanent nerve injury following nerve block is very low. Incidence has been reported to be between 1 in 20000 and 1 in 850000. Most nerve injuries are caused by multiple injections and there can be direct injection of the agent intraneurally also. There is a disproportionate increase with articaine.
46
How does articaine cause more nerve damage?
It makes up 25% of sales compared to 54% with lidocaine and makes up 30% of cases compared with 35% with lidocaine. It is high risk for permanent dysaesthesia with IAN blocks. It is good for infiltrations but avoid mental area and IANs. Most lidocaine injuries recover.
47
How do endodontic filling materials cause damage?
Most are endotoxic so contact surgeon immediately.
48
What phases is eruption of permanent teeth divided into?
- Pre-eruptive movement (follicle)
- Intra-osseous movement (follicle)
- Mucosal penetration
- Pre-occlusal movement
- Occlusal function
49
What systemic factors affect eruption?
Delayed eruption due to eruption obstacles
- Gingival fibromatosis
- Cherubism
- Gorlin Goltz syndrome
- Cleidocranial dysplasia
- Pierre-Robin
Delayed eruption due to genetic factors:
- Down syndrome (irregular eruption sequence)
- Amelogenesis imperfecta (disturbed enamel formation and eruption)
- Mucopolysaccharidoses
Endocrine diseases :(delayed eruption, small teeth, abnormal teeth):
- Hypopituitarism
- Hypothyroidism (cretinism)
- Hypoparathyroidism
- Pseudohypoparathyroidism
50
What local factors can prevent eruption?
Local obstruction due to:
- Retention of deciduous predecessor
- Loss of space
- Crowing
- Supernumerary or supplemental teeth
- Scar tissue
- Compact bone
- Eruption cyst
- Dentigerous cyst
- Odontoma
- Odontogenic tumours
- Fibromatosis
- Ankylosis
51
What are the symptoms of failure to erupt?
- Failure to erupt as expected
- Over long retention of deciduous predecessor
- Proclination of adjacent teeth
- Loosening of teeth
- Pain
- Swelling
52
What can cause failure of eruption?
Mechanical obstruction by a supernumerary tooth, cyst or odontogenic tumour.
Insufficient space due to micrognathia (small jaw) and premature loss of deciduous teeth. It can also be due to head and neck syndromes e.g. cleidocranial dysostosis, Pierre Robin sequence. It can be caused by genetic and endocrine abnormalities e.g. hypothyroidism and hypopituitarism.
53
What dental effects does cleidocranial dysplasia cause?
- Hypoplastic maxilla and zygomas
- Hypoplastic or absent clavicles
- Multiple supernumerary teeth
- Abnormal tooth morphology
- Normal eruption of primary teeth
- Severe eruption problems with permanent teeth
54
What dental effects does Pierre-Robin sequence cause?
- Retrognathic mandible
- Crowding/uneruption dentition, problem due to small pushed back jaw
- Airway issues
- Early modern treatment (distraction osteogenesis) reduces impact, screws placed in jaw to increase dimension of body of mandible
55
What is the incidence of midline supernumerary teeth and the most common sites of supernumerary teeth?
Supernumerary teeth occur in 15% of patients with clefts. The incidence of midline supernumerary teeth is 1-3%. The most common site is the maxillary midline, then 9s and then supernumerary mandibular premolars. They may prevent eruption of permanent dentition or orthodontics.
56
Why can wisdom teeth erupt under dentures?
This is due to resorption of the mandible so the tooth becomes visible it is not erupting.
There can be internal resorption of unerupted teeth.
57
What is the incidence of unerupted/ectopic canine and where is it using located?
The prevalence of no-eruption and ectopic eruption of maxillary canines is about 1.7%. The canine is second only to the lower third molar in its frequency of impaction. In 85% of cases the canine is found palatal to the lateral incisor.
58
How are ectopic canines localised using radiography?
Radiological localisation of unerupted canines:
- Periapical - standard and parallax (vertical and horizontal) use of SLOB rule
- Anterior occlusal
- OPT
- CBCT
59
What are the complications of unerupted teeth?
- Often no clinical effects
- Cyst formation
- Pericoronitis
- Resorption of adjacent teeth
- Eruption later under bridge or denture
- Hypercementosis
- Internal resorption
60
What is the treatment of unerupted maxillary canines?
- No treatment
- Extraction of the deciduous canine
- Surgical removal
- Surgical exposure
- Surgical transplantation
61
What are the requirements for exposure and the types?
The patient must be willing to wear a fixed orthodontic appliance so well motivated. The patient must be considered to be unsuitable for interceptive extraction of the deciduous canine. The degree of malposition of the ectopic canine should not be too great to preclude orthodontic alignment.
The exposure can be palatal:
- Open
- Closed (bracket and gold chain)
Or buccal:
- Apically repositioned flap
- Closed exposure (bracket and gold chain)
62
What are the indications and requirements for surgical transplantation?
Indications:
- Last resort option
- When it is not possible to expose and orthodontically align canine
- Patient does not want prolonged orthodontics
- Failed alignment after surgical exposure
Pre-operative assessment:
- There must be sufficient room in arch
- Must be sufficient room vertically
- Sufficient alveolar bone available
63
What are the maxillary sinuses and their function?
They are the largest paranasal sinus. It is a pyramidal shaped air cavity with the apex facing laterally and is bilateral. It is lined by respiratory epithelium (ciliated pseudostratified columnar epithelium). They reduce the weight of the skull, has a role in voice resonance and humidification of air. It is involved in mucous production and efficient cilia beat and push the mucous towards the ostea where drainage takes place. The maxillary sinus drains into the nose via the ostium (middle). The osteum is halfway up the medial wall. It is not dependent on gravity which is why they can become congested.
64
What are the anatomical borders of the maxillary sinus?
- Infraorbital surface of maxilla (S)
- Alveolar process (I)
- Lateral wall of nose (M)
- Zygoma (L)
- Maxilla (A/M/L)
The superior aspect (roof) is formed of the orbital floor (brittle and thin) and the infraorbital bundle traverses.
65
What does the medial wall of the maxillary sinus consist of?
It consists of the lateral border of the nose and contains the ostium and is cartilagenous in places.
66
What does the floor of the maxillary sinus consist of?
It is the alveolar process of the maxilla and hard palate. It is thinnest near the tooth bearing alveolus. In children it is adjacent to the nasal floor and in adults it is 5-10mm lower. It is close to the apices of teeth.
67
What does the lateral wall consist of?
Anteriorly there is a cheek area which also forms the lateral wall and lateral maxilla. Called antero-lateral wall. It contains the canine fossa which is the thinnest part and is less than 2mm and it is good for surgical access.
68
What is the most common place for oro-antral communication?
The floor of the maxillary sinus can extend from the canine to the molar region. The root apices are closely associated with the floor. The most common area for communication is the palatal root of the first molar.
69
What are the OAC risk factors?
- Long/divergent/dilacerated/ankylosed roots
- Lone standing molar
- Hypercementosis, tooth shape: bulbous roots or bony sclerosis
- Loss of apical periapical bone (periodontal disease, cysts, granuloma)
- Pneumatisation of sinus
- Impacted upper molar - increased surgical difficulty
- Poor technique - excessive force, incorrect use of instruments
- Cleft lip and palate
- Displacement of foreign object into sinus
- Tuberosity fracture
- Failure to follow antral regime
- Build up of pressure in cavity - nose blowing, sneezing, blowing balloons, altitude
70
What is an OAC?
An open communication between the oral cavity and the maxillary sinus.
71
What teeth are most at risk?
There is conflicting evidence but research suggests:
- Upper 2nd molars
- Upper 1st molars
- Upper 3rd molars
- Upper 2nd premolar
- Upper 1st premolar
Important factors affect it such as thinner antral floor (1-7mm) and bone resorption related to chronic apical periodontitis.
72
What are the clinical/radiographic signs of an OAC?
- Movement of antral lining during respiration
- Emanating bubbles from socket during respiration
- Hollow sound when aspirating socket
- Fogging of mirror
- Extracted tooth attached to concave bone or fractured tuberosity
- Post-operative radiograph - defect sinus floor
73
What are the signs and symptoms of an OAC?
- Purulent discharge
- Bad taste
- Liquid regurgitation through nose
- Air escape (both directions) - Valsalvin test - can have false negative due to infection/debris
74
What is the management of an OAC? (depending on size)
<2mm
- Promote spontaneous healing
- Gentle irrigation of socket and debridement of sharp bone
- Resorbable haemostatic agent (surgicel)
- Suturing loose edges
- Antral regime and review (not blowing nose, stop sneezing etc)
- Vacuum splint
2-4mm:
- Conservative vs surgical repair - assess risk factors
>4mm or OAF:
- Surgical repair
75
What is the conservative management of OACs?
Many OACs are undetected and heal spontaneously. Give instructions to the patient of no nose blowing and give OHI. You may prescribe broad spectrum antibiotics such as penicillin if there are risk factors. Also can give vacuum splint and nasal decongestants.
76
What active treatment can be done for OACs?
- Suturing (resorbable/non-resorbable)
- Packing - resorbable (oxidised cellulose) or non-resorbable (BIPP (bismuth iodoform paraffin paste) or ribbon gauze)
- Splints
- Conservative regimen - antibiotics, decongestants etc
77
What is an OAF?
It is when the communication of the oral cavity and maxillary sinus is lined by epithelium (more than 7 days after surgery). It won't heal unless you surgically repair it.
78
What are the signs and symptoms of an OAF?
- Purulent discharge
- Bad taste
- Liquid regurgitation through nose
- Air escape - both directions (Valsalvin test)
- Episodic sinusitis
- Nasal voice
- Epistaxis
- Prolapse of antral mucosa into mouth
- Whistling sound
- Radiographic evidence - CBCT/occipitomental
Radiography will show this
79
What are the different types of surgical repair for OAF?
- Buccal advancement flap (Rehrmann 1936)
- Buccal fat pad graft (Egyedi 1977) if above hasn't worked
- Palatal rotation/palatal finger flap (Ashley, 1939)
- Trapezoid flap
- Modified palatal flap/pedicle connective tissue flap (Ito and Hara 1988)
- Autogenous bone grafting
- Only top three are used really in order of preference
80
What is a buccal advancement flap?
It is when you raise a full thickness mucoperiosteal flap with slightly tapered edges which you bring over the socket. Membranes e.g. bioguide are sometimes used to help healing. If there was a fistula you would need to do fistula removal using an excision line along with the flap. The epithelial lining needs to be removed.
81
What are the benefits and negatives of a buccal advancement flap?
Surgical closure with buccally advanced flap has a good success rate, low morbidity and good blood supply. However it can cause a decrease in vestibular sulcus depth which has implications for prosthodontics.
82
How is a palatal rotation flap done and when is it sometimes used?
It relies on the greater palatine artery. You identify where this is and then cute about 2cm around it and bring the tissue over the close the socket. It is very painful for the patient and potentially compromises blood supply to the palate. The length/width ratio is important >2.5mm flap necrosis. It is a painful donor site and is seldom used except for larger OAFs. The area is left to heal by secondary intention.
83
What is a buccal fat pad graft?
It is the same as a buccal advancement flap but you use a lobule of buccal fat tissue and place it into the socket. This also has relatively good outcomes.
84
What teeth are usually involved with the displacement of a foreign object into the sinus and how can it be avoided?
Upper third molars make up 0.6-3.8% of iatrogenic cases of foreign body entrapment in the antrum. The most common teeth in order is upper 6 palatal root, 3rd molar (whole tooth) and 2nd molar root. To avoid have awareness of the risk such as age, RCT, ankylosis, proximity and take a radiograph. Avoid apical pressure and use controlled force and a safe technique.
85
What is the management of displacement of a foreign object into the sinus?
- Alveolar approach
- Caldwell Luc approach
- Functional endoscopic sinus surgery FESS
To retrieve a foreign object use light and you need good suction. Determine the location: between mucosa and alveolar bone or between intact sinus lining and floor of sinus.
86
What is the (trans)alveolar approach?
- Fill sinus with saline and use suction to retrieve the root or
- 2 or 3 sided buccal flap and flap design should permit closure with advancement
- Flap elevated subperiosteally
- Bone removal to enable visualisation and removal interdental septae
- Retrieve root with tweezers
- Closure of buccal advancement with/without fat pad or collagen membranes
87
What is the Caldwell-Luc procedure?
It is done under LA. An incision is created in the lateral aspect of the premolar region. An ultrasonic is used to create a buccal window into the sinus.
88
What are the advantages and disadvantages of the Caldwell-Luc procedure?
Advantages:
- Trapdoor approach
- Good access
- Preserves alveolar bone
- Method of choice for delayed procedures
Disadvantages:
- Trauma, loss of vitality to adjacent teeth
- Fistula formation
- Epistaxis
- Infraorbital nerve damage - paraesthesia, neuralgia
89
What is FESS?
It is a conservative approach. The maxillary sinus is accessed via an enlarged middle meatus antrosotomy. This minimises complications associated with other surgical options. It is expensive, time consuming and requires skill. The risks are infection, epistaxis, CSF leak, difficulty retrieving posterior/inferior or large foreign bodies.
The decision needs to be made whether to retrieve, delay or refer. Delay if patient is too tired to have it same day.
90
If you are delaying treatment what should you do?
Document info (size, position etc), take a radiograph (PA, OPT, OM, CT), suture the socket, refer antibiotics, refer, inform patient.
91
What are the post-operative instructions for a foreign body in the antrum?
This is similar to the conservative regimen:
- Decongestants
- Antibiotics
- Avoid nose blowing
- OHI
92
What is a fractured tuberosity and why is it a concern?
It occurs at the most distal aspect of the maxilla. It contains the socket of the third molar. The fracture is a cause for concern as there will be a large OAC and it will be a stability issue later for prosthodontics. It is associated with upper molar extractions usually 7 or 8.
93
What are the risk factors for a fractured tuberosity?
- Divergent/dilacerated/ankylosed roots
- Removal of impacted upper molar
- Lone standing upper molar
- Pneumatised maxillary sinus
- Increased age
- Poor technique - uncontrolled force, inadequate maxillary alveolus support, excessive elevation
94
What are the clinical signs of a fractured tuberosity?
- Tooth and tuberosity are felt to move together with extraction movement
- Fracture noise
- Palatal tear
- Bleeding
- Assess, continue vs abandon extraction? Immediate vs delayed repair?
95
What is the management of a fractured tuberosity if it is still attached to the periosteum?
- Rigid splinting to adjacent teeth with composite and ortho wire/suck down splint, soft diet, antibiotics, rebook for surgical extraction in 6-8 weeks to allow healing
- Or section crown to enable roots and tuberosity to heal and suture, soft diet, antibiotics, rebook for surgical extraction in 6-8 weeks
- Or remove fractured tuberosity if small, subperiosteal dissection of mucoperiosteum off the fragment (if no OAD this is an option)
96
What is the management of a fractured tuberosity if it is completely separate from soft tissues (+/- OAC)?
- Smooth sharp edges of residual bone
- If no OAC suture and antral regime and review
- If OAC treat according to defect size and antral regime and review
97
How can the sinus be used if there is inadequate height for implants?
You may access the sinus if there isn't enough vertical bone height. You access in the same way as the Caldwell-Luc procedure. You could use the summers technique where a flap isn't raised. The implant is placed and it very gently goes into the sinus by a few mm. The aim is to maintain integrity of the sinus lining and limit graft to restoring alveolar bone and avoid impairing sinus drainage.
The lateral window approach can be done using a Piezosurgery kit. We access the sinus through a buccal flap and use the kit to create a lateral window. You push the sinus lining up so you have lots of space and then pack it with particulate/artificial bone substitute so the implant is still sat in bone (graft). You leave it for 6-9 months to allow healing and then the implant can be placed with the increased vertical height.
98
What is chronic sinusitis and the treatment?
Inflammation of the sinus which can be bacterial or viral. It mimics toothache. There can be nasal discharge, pressure, pain when bending over/lying down. The treatment is broad spectrum antibiotics and decongestants for a bacterial cause. If chronic - antral wash out and nasal surgery. Request radiograph (CT of sinuses) and the sinus will appear opacified. Amoxicillin or if not working co-amoxiclav.
99
What are the types of respiratory failure?
Read notes before this - facial trauma. Respiratory failure can be type I or type II. Type I respiratory failure is failure to get oxygen in and type II is failure to get carbon dioxide out. Patients with emphysema tend to have type II respiratory failure. If CO2 increases so does the ph (acidic gas) and this leads to depression of respiratory drive so there is CO2 narcosis – you forget to breathe.
100
What happens if you lose a lot of blood?
There will be haemorrhagic/hypervolaemic shock. There are different levels of shock depending on how much blood is lost. The classes of haemorrhagic shock are I-IV (look at table). If stroke volume goes down, the heart rate will increase to keep cardiac output up so there is tachycardia. Probably no blood pressure changes for type I. Respiratory rate tends to increase. Urine output will stay above 30mls an hour at haemorrhagic shock I. In type II the pulse rate increases but the blood pressure is still normal. Type III the blood pressure will be decreased. The urine output starts to decrease as the body wants to keep fluid. Type IV there will be no urine, increased pulse rate, decreased blood pressure, confusion and lethargy.
101
What is the Glasgow coma scale?
You work out the number of points score by looking at best motor response, best verbal response and eye opening. The score is from 3-15. 3-8 is considered a coma. Look at scores in notes.
102
What are the soft tissue injuries?
- Abrasion
- laceration/incision - laceration is blunt force trauma and skin has burst, incision has been made with a sharp edge
- Tissue loss
- Think about special structures such as eyes, eyelids, lips, nerves, arteries
103
How does bone heal?
- Haematoma
- Fibrocartilage callus formation
- Bony callus formation (consolidation)
- Remodelling
Blood clot forms and is invaded by new blood vessels. Phagocytes clean fracture and any germs present. Chondroblasts cells produce collagen and a soft callus forms (fibrocartilaginous) This turns into bone and remodels. Osteoclasts and osteoblasts work on bone. Within 28 days there is hard callus formation. Then remodelling as callus is wider than bone.
104
What are the problems if healing doesn't go to plan?
- Malunion - heals in wrong place
- Non-union (doesn't heal)
- Hypertrophic
- Oligotrophic
- Atrophic
- Necrotic
- Defect
105
What are the fracture patterns?
- Mandible
- Midface
- Zygoma
- Nasoethmoidal
- Frontal
106
What are the features of a fractured mandible?
- Look gormless
- Swelling
- Bruising
- Anterior open bite
- Step deformity – mandible
- Paraesthesia
- Pain
- You may see deranged occlusion, step deformity, mucosal tears/bruising, lost/displaced or fractured teeth
107
What are the parts of the mandible?
There is the symphysis and parasymphysis, anterior body, mid body and posterior body and angle and ramus and condyle and coronoid process.
108
What is a butterfly fragment?
It is a fracture coming off another fracture.
109
What are the types of fracture?
Categorise fracture as simple (broken in 2), comminuted (several bits) or compound (open to air, bone end is sticking out, higher risk of infection). Mandible fracture is often compound but rarely gets infected as blood supply is so good. Fracture can be displaced or non-displaced (is there a gap between the pieces of bone).
110
How are fractures managed?
- Reduction
- Fixation
- Intermaxillary fixation IMF
Champy described use of miniplates in mandibles. He talked about the lines of tension in the mandible.
There are external fixators which are load bearing and pin into the bone. Not pleasant.
111
What is reduction?
It is physical movement of bits of bone back to each other and putting things back where they came from. It can be closed (not making a cut) or open.
112
What is fixation?
There is load sharing vs load bearing. Load bearing fixation is attaching metal which takes force from one end, bypasses fracture and puts load at other end. A load sharing fixation roughly splints the bone in the right place but the bulk of the force still goes through the bone. It can be rigid vs flexible. Rigid fixation uses metal which transmits force, flexible allows bone to take some of the weight). There are miniplates (small and used in jaw).
113
What is intermaxillary fixation?
Physically wire the jaws together. Archbars are used to wire to the teeth and this is tightened and attached to another archbar. This is intermaxillary fixation. Load bearing will use a bigger plate.
114
What is the categorisation of midface fractures?
The three patterns are Le fort I, II and III. I is maxilla, II involves the nasal bones aswell. Type III involves the zygomatic arch.
115
What are the features of a midface fracture?
It requires blunt force usually in excess of a punch. It has a classical facial appearance. The person looks gormless, may have palpable step deformity, infraorbital nerve paraesthesia in le fort II. You may see anterior open bite, deranged occlusion, sulcus haematoma, odd percussion note (crapped cup), gross bruising of the palate, midline palatal split.
116
What are the features of a zygoma fracture?
- Periorbital haematoma
- Facial flattening
- Palpable infra-orbital/fronto-zygomatic step
- Infraorbital paraesthesia
- Trismus
May see:
- Subconjunctival haemorrhage
- Pupillary level
- Enophthalmos
- Diplopia
117
What are the features of a nasoethmoidal fracture?
- Nasal deformity
- Traumatic telecanthus
- Disrupted medial canthus
- Bilateral ‘panda’ eyes
- Epistaxis - nosebleed
- Epiphora – running eyes
- CSF leak
118
What are the features of a frontal fracture?
- Bruising
- Swelling
- Indent in head
