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oral surgery 4th year > third molars summary > Flashcards

third molars summary Flashcards

1
Q

eruption

A

approx 18-24yrs, varies
≥1 missing in 25% adults
may still be present and begin to erupt in elderly/edentulous pt
- CO denture rocking/no longer fits

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2
Q

guidance

A

SIGN43 1999/2000
NICE 2000
FDS 2020

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3
Q

nerves at risk during SR L8s

A

lingual
IAN
mylohyoid and long buccal - less common and effects less obvious

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4
Q

UE

A

tooth lying within jaws, completely covered by ST and partially/ completely covered by bone

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5
Q

location of lingual n

A

varies
lies on superior attachment of mylohyoid muscle
at/above level of lingual plate in 15-18%
0-3.5mm medial to mandible

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6
Q

PE

A

failed to erupt fully into a normal position
partially visible/in communication with oral cavity
- probe gently distal to 7

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7
Q

impacted

A 
prevented from completely erupting into normal fct position
 - lack of space
 - abnormal eruption path
 - obstruction
PE/UE
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8
Q

U removal indications

A 
cheek biting/buccally erupted
overeruption
traumatising L operculum
PE and impacted
non-fct
pt undergoing GA
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9
Q

SIGN vs NICE

A

SIGN - ≥1 episode of infection

NICE >1

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10
Q

pericoronitis diagnosing

A

generalised soreness
exacerbated by eating and traumatising operculum
+ response to vitality testing

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11
Q

imaging

A

OPT
(+/- PA)
+/- CBCT

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12
Q

clinical assessment

A 
eruption status
exclude other causes
local infection
caries/resorption
PD status
occlusal relationship
TMJ
regional LNs
any associated pathology
degree of surgical access
working space
STs
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13
Q

working space

A

distance between L7 and ascending ramus

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14
Q

radiological assessment

A 
orientation and position (impaction)
working distance
crown - size, shape, caries
roots - number, morphology, apical hooks
bone levels
follicular width
relationship to IDC/MS
adjacent tooth
any surrounding pathology
 - dentigerous cyst
 - loss of bone distal to crown
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15
Q

3 key radiographic signs of possible increased risk to IAN

A

diversion/deflection of canal
darkening of root
interruption of white lines/LD of canal

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16
Q

radiographic signs of possible increased risk to IAN

A 
diversion/deflection of canal
darkening of root
interruption of white lines/LD of canal
deflection of root
narrowing of IDC
narrowing of root
dark and bifid root
juxta apical area?
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17
Q

juxta apical area

A

well-defined PA area adjacent that isn’t related to pathology
can appear corticated
LD round tooth intact
around apex/slightly lateral

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18
Q

orientation/angulation of impacted 8s

A 
vertical
mesial
distal
horizontal
transverse
aberrant
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19
Q

what is the most common orientation of impaction?

A

mesial

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20
Q

what is orientation of impaction measured against?

A

the curve of spee

  • curve of occlusal plane
  • draw lines through LA of 7 and 8 and compare
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21
Q

what does the depth of impaction indicate?

A

amount of bone removal required

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22
Q

superficial depth of impaction

A

crown of 8 related to crown of 7

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23
Q

mod depth of impaction

A

crown of 8 related to crown and root of 7

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24
Q

deep depth of impaction

A

crown of 8 related to root of 7

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25
Q

disto-angular 8s

A

often L ones most difficult to remove
vector of movement during elevation is distal so tooth has nowhere to go
roots of 8 often v close to roots of 7 - can make it difficult to get an application point to elevate (also care not to damage 7 roots during mesial bone removal)

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26
Q

pericoronitis definition

A

inflammation in STs around crown of a tooth
need communication with oral cavity
- normally PE and visible but may need to probe
food and debris get trapped under operculum - inflammation/infection

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27
Q

S+S of pericoronitis

A 
pain
swelling (IO or EO)
bad taste
pus discharge
occlusal trauma to operculum
ulceration of operculum
evidence of cheek biting
foetor oris
limited mouth opening
dysphagia
pyrexia
malaise
regional lymphadenopathy
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28
Q

which LNs are often raised and palpable in pericoronitis?

A

SM or upper cervical chain

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29
Q

pericoronitis pain

A

variable
increases in intensity as condition develops
often described as throbbing

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30
Q

pericoronitis IO swelling

A

over affected site
causes further discomfort on occlusion and as it progresses pt is hesitant to bring teeth into occlusion
operculum swollen, red and tender, +/- pus/bad taste, trauma, ulceration

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31
Q

pericoronitis EO swelling

A

severe cases

often at angle of mandible and may extend into SM region

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32
Q

spread of infection of pericoronitis

A

laterally into cheek
distobuccally under masseter (submasseteric abscess and profound trismus)
sublingual
SM
area around tonsils and paraphyaryngeal space (dysphagia)
less commonly - through anterior pillar of fauces area into SP (dysphagia)

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33
Q

tx of pericoronitis

A 
I+D of pericoronal abscess if required +/- IDB
irrigation
 - warm saline/CHX in 10-20ml syringe w blunt needle 
   under operculum
ext U8 if traumatising operculum
some use astringent/antiseptic
usually no ABs unless severe
 - systemically unwell
 - EO swelling
 - IC e.g. diabetic
if large EO swelling, systemically unwell, trismus, dysphagia - refer to MF/A+E - phone first for advice
pt instructions
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34
Q

pericoronitis pt instructions

A

freq warm saline or CHX MW
- teaspoon salt warm water
analgesia
keep fluid levels up and keep eating

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35
Q

pericoronitis astringent/antiseptic

A

e.g. talbots iodine - applied with college tweezers - one drop beneath operculum
not if have incised a localised pus collection
not on fresh/open wounds

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36
Q

ext of L8 pericoronitis

A

generally don’t ext affected 8 until acute episode has resolved
- unless in hospital with GA for I+D - ext tooth then

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37
Q

operculectomy

A

prev

no longer carried out - often grows back

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38
Q

predisposing factors for pericoronitis

A

PE (usually 20-25yrs) and vertical or distoangular impaction
opposing maxillary 8 causing mechanical trauma contributing to recurrent infection
upper resp tract infections, stress and fatigue PC
poor OH
insufficient space between ascending ramus of L jaw and distal aspect of 7
white race
a full dentition

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39
Q

SDCEP pericoronitis initial management

A

determine if airway compromised - pt unable to swallow own saliva/push tongue forwards out of their mouth
- yes: emergency care/999

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40
Q

SDCEP pericoronitis adults

A

recommend analgesia
no ABs unless signs of spreading infection (e.g. limited mouth opening, facial swelling), systemic infection, IC pt, persistent swelling
rinse 0.2% CHX MW
seek urgent dental care

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41
Q

SDCEP pericoronitis children

A

optimal analgesia
soft toothbrushing around area
rinsing mouth after food

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42
Q

pericoronitis SDCEP subsequent care for adults

A

US scaling/debridement to remove any foreign body, under LA
irrigate 0.2% CHX MW
ext if repeated episodes
ext/adjust an opposing tooth where there is trauma to the inflamed operculum if the position of the tooth suggests it is unlikely to achieve fct in future

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43
Q

local measures for pericoronitis

A

irrigation and debridement

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44
Q

1st line ABs for pericoronitis

A

metronidazole 400mg, 9 tablets, x3 daily

avoid alcohol, not if on warfarin

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45
Q

2nd line Abs for pericoronitis

A

amoxicillin 500mg, 9 capsules x3 daily

- hypersensitivity reactions

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46
Q

RCS FDS guidelines - current status of pt and M3M

A

history
exam
radiographs? - pan if surgery

warn pt current symptom and disease status may change over time therefore tx options and risks
- aware of risks and benefits of each option

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47
Q

RCS FDS guidelines - factors regarding M3M status

A

pt age and medical status (complications and recovery)
risk of complications (IAN/leaving M3M in situ)
pt access e.g. military
opposing contralateral 8 if having GA

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48
Q

RCS FDS guidelines - diseased/high risk of disease development and asymptomatic

A

assess likelihood of disease development - high/low risk
high risk - consider surgical
if any doubt and tooth has higher risk of surgical complications - active surveillance until symptoms develop/early disease progression has been proven

quiescent pathology may inc undiagnosed 7/8:

  • caries
  • PDD
  • resorption (internal or external)
  • cysts or tumours
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49
Q

RCS FDS guidelines - diseased/high risk of disease development and symptomatic

A

consideration for therapeutic exts is indicated for:
single severe acute or recurrent subacute pericoronitis
unrestorable caries of M3M or to assist Rx of adjacent tooth
PDD compromising M3M and/or adjacent tooth
resorption of M3M and/or adjacent tooth
fractured M3M
M3M periapical abscess, irreversible pulpitis or acute spreading infection
surrounding pathology (cysts/tumours) associated w M3M

tx to be considered:

  • therapeutic removal of M3M (or coronectomy)
  • removal of U3M
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50
Q

RCS FDS guidelines - non-diseased/low risk of development and asymptomatic

A

clinical review and radiographs if indicated. Make assessment of risk of disease and review interval

factors for consideration for prophylactic removal

  • medical: planned medical tx/therapy that may complicate the likely surgery of M3Ms inc: pharmaceutical therapy (bisphosphonates, antiangiogenics, chemo), radio of HandN, immunosuppressant therapy
  • surgical: M3M lies within perimeter of a surgical field: mandibular fractures, orthognathic surgery, resection of disease (benign and malignant lesions)
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51
Q

RCS FDS guidelines - non-diseased/low risk of development and symptomatic

A

leave deeply impacted M3Ms with no associated disease
manage other diagnoses causing pain in the region
- TMD
- parotid disease
- skin lesions
- migraines or other primary headaches
- referred pain from angina, cervical spine
- oropharyngeal oncology

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52
Q

RCS FDS guidelines - main reason for removal

A

infection

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53
Q

RCS FDS guidelines - significant radiological signs of risk to IAN

A

diversion of IAN canal
darkening of root
interruption of cortical white line

54
Q

RCS FDS guidelines - CBCT

A

not routinely
evidence it doesn’t offer benefit in reducing incidence of IAN neurosensory disturbance
- if findings expected to alter tx decision
- see if direct contact or bony wall between

55
Q

RCS FDS guidelines - common tx

A 
referral
clinical review
removal of M3M
ext of U8
coronectomy
56
Q

RCS FDS guidelines - less common tx

A

operculectomy
surgical exposure
presurgical ortho
surgical reimplantation/autotransplantation

57
Q

RCS FDS guidelines - comment on NICE 2000

A

discouraged prophylactic removal

- but evidence this isn’t always best - delays surgery and damage to 7

58
Q

RCS FDS guidelines - why do coronectomy?

A

if close to IAN, reduce risk of injury

59
Q

RCS FDS guidelines - coronectomy risks

A

pain and infection

potential future need for removal of the roots

60
Q

RCS FDS guidelines - coronectomy contraindications

A 
non-vital
caries with risk of pulpal involvement
tooth mobility
apical disease
association with cystic tissue that is unlikely to resolve if root left in situ
tumours
IC
prev radio to H+N/tx before radio
NM disorders
diabetes
unable to return for tx easily should complications occur
61
Q

RCS FDS guidelines - CHX

A

effective (gel more) - prevents alveolar osteitis

62
Q

RCS FDS guidelines - adverse events of CHX

A 
staining
altered taste
burning sensation
hypersensitivity
mucosal lesions
63
Q

RCS FDS guidelines - routine radiographic screening of UE8s with no disease or symptoms

A

not recommended

64
Q

RCS FDS guidelines - clinical review

A

just reviewing S+S
only xray if clinical S/S of disease
- routine BWs should inc distal of 7

65
Q

RCS FDS guidelines - active surveillance

A

non-op management strategy for retained M3Ms - prescribed, regularly scheduled set of follow up visits that inc both clinical and radiographic examinations

66
Q

explaining procedure to pt

A

flap - small cut in gum to get access
sectioning - cut tooth into smaller pieces to remove it
possible drilling
sutures (stitches) - whether dissolvable

67
Q

intra-op complications

A 
fracture of tooth, root, alveolar plate, tuberosity
TMJ dislocation
haemorrhage
ST damage 
OAC
loss of tooth/root
broken instruments
damage to Rx in 7
if edentulous/atrophic mandible, aberrant 8 close to lower border, large cystic lesion associated w 8 - explain risk of jaw fracture
 - because your L jaw is thin - it is rare but could break, we would arrange for it to be sorted
 - break can sometimes happen post-op
direct trauma to IA NV bundle
68
Q

loss of tooth/root into:

A

lingual space
MS
pterygoid space

69
Q

ST damage

A

puncture/laceration with instruments - gingivae/FOM/palate
burns - from handpiece resting on L lip
crush - papillae/lip
tears - gingivae/palate

70
Q

damage to Rx in 7

A

if this happens temp Rx placed at time then back for permanent Rx

71
Q

post-op complications

A 
pain
swelling
bruising
jaw stiffness/limited mouth opening
bleeding
infection with pus
 - usually localised, rarely can be larger with abscess and 
   EO swelling that may require hospital and drainage - v 
   rare
dry socket (localised osteitis)
numbness (anaesthesia) or tingling (paresthesia) of L lip, chin, side of tongue
 - usually temporary - recovery up to 18-24m
altered taste (rare)
dysaesthesia (rare)
reduced sensation - hypoaesthesia
heightened sensation - hyperaesthesia
72
Q

rare post-op complications

A

OM
ORN
MRONJ
actinomycosis

73
Q

how to explain dry socket to a pt

A

a slower healing painful socket
1-2wks to settle
come and see us

74
Q

why can altered taste result?

A

chorda tympani arises from facial nerve, taste buds from ant 2/3 tongue, carries fibres via lingual nerve

75
Q

how to explain dysaesthesia to a pt

A

painful, uncomfortable, unpleasant sensation of L lip, chin, tongue, sometimes neuralgic type pain

76
Q

should you do CBCT?

A

if concerns of close proximity from radiograph - offer CBCT

- but would scan change tx?

77
Q

damage to IDN stats

A 
L lip/chin to that side
 temporary (weeks/months)
 - average 10-20%
 - higher than average 30%+
permanent
 - average 1% and under
 - higher 5% and above if IDC and roots close proximity
78
Q

discussing risks to nerves

A

can recover up to 18-24m but after this time not much hope for any further recovery
often discuss warnings as one e.g. lip/chin and side of tongue - %s similar
if close proximity suggested by xray/confirmed by CBCT - explain in relation to the nerve that supplies lip/chin/teeth/gums on that side
explain risks to side of tongue remain average because nerve runs in STs and can’t be seen on xrays
talk about IDC to pt (canal nerve runs in) - can only see bony canal
can’t give exact figure of increased risk to IDC - don’t have 100 pts in your surgery with nerve in exact same place as them

79
Q

tx options

A 
do nothing - monitor
 - may need local measures - irrigate, review, pt advice, 
   risk of recurrence, food trap
(surgical) extraction
CBCT
coronectomy
80
Q

surgical access

A

max access with min trauma
larger flaps heal just as quickly as smaller ones
wide-based incision - circulation
use scalpel in one firm continuous stroke
no sharp angles
adequate sized flap
flap reflection should be down to bone and done cleanly
minimise trauma to papillae
no crushing
keep tissue moist
ensure flap margins and sutures will lie on sound bone
ensure wounds aren’t closed under tension
aim for healing by primary intention - minimise scarring

81
Q

basic principles of surgery

A

risk assessment
- good planning, MH
aseptic technique
minimise trauma to hard and soft tissues

82
Q

stages of surgery

A 
anaesthesia
access
bone removal and tooth division as necessary
debridement
suture
haemostasis
POIs
post-op medication
83
Q

access

A

buccal mucoperiosteal flap

+/- lingual flap (debate)

84
Q

ST retraction/reflection

A

access

protect STs

85
Q

retraction

A

should be on bone at all times not on STs - needs to go under periosteum
avoid dissection occurring superficial to periosteum
- reduce ST bruising/trauma
may get post-surgery tingling due to pressure on nerve (temp)

86
Q

what facilitates retraction?

A

flap design

87
Q

where should you commence flap-raising?

A

commence flap raising at base of relieving incision (already gaping/bone visible)

88
Q

instruments for ST retraction

A

minnesota
bowdler-henry rake retractor
howarth’s periosteal elevator

89
Q

instruments for ST reflection

A

Ash periosteal elevator

Howarth’s periosteal elevator

90
Q

most difficult reflection - reflect with min trauma

A

papilla - tend to be well-tethered - try to release it before proceeding with reflection distally (avoid tears)
mucogingival jct

91
Q

why raise flap?

A

access to surgical site
improve visibility, visualise application point
facilitate bone removal

92
Q

flap considerations

A

important structures (esp for relieving incision) e.g. nerves
blood supply and healing
aesthetics
ease of suturing post-op

93
Q

flaps and papillae

A

need to either include or exclude papillae

94
Q

atraumatic/passive retraction

A

rest firmly on bone

aware of adjacent structures e.g. mental n

95
Q

3-sided flap

A

DRI - runs out buccally to avoid RM pad as sometimes lingual nerve runs there
intracrevicular incision
mesial relieving incision
- better to include papilla as easier to suture back up

96
Q

lingual flap

A

variable use
depends on procedure, visibility, access, amount and area of bone removal and surgeon
can lead to stretching of lingual n which runs close to lingual aspect of L8s
more morbidity with less experienced operators

97
Q

envelope flap

A

doesn’t have relieving incisions - just around neck of tooth
but often incs DRI because won’t get enough expansion otherwise
- tissues may tear in uncontrolled manner
easier to suture back but doesn’t give as good visual access

98
Q

what blade to cut a flap?

A

number 15

99
Q

how to cut a flap?

A

incise with firm continuous stroke
- feel area with finger first
- pen grip
- finger rest on sound support
- use non-dominant index finger to apply tension to mucosa
full thickness through mucosa and periosteum to bone

100
Q

crevicular incision

A

hold scalpel in LA of tooth

blade kept immediately against tooth surface

101
Q

relieving incision

A

typically anterior to papilla
draw blade downward/forwards across mucogingival jct
draw blade forward more horizontally having crossed MGJ (to level of apices of teeth)
- to make wider base so better blood supply

102
Q

drilling

A

electrical straight handpiece with saline cooled bur
- avoid surgical emphysema (air driven) - can get infected

round or fissure SS (often bone) and tungsten carbide (often teeth) burs
protect STs

103
Q

buccal gutter

A

start distal (just in front of lingual plate) and bring bur buccally and mesially for safety of lingual n (prevent drill slipping into lingual space)
on buccal aspect of tooth and onto distal aspect of impaction
aim - deep narrow gutter (at least as deep as bur head)
- need to get to bleeding cancellous bone
irrigate - visibility/avoid bony necrosis
away from important structures where possible
usually create gutter extending MD with position of application point dependant on root morphology/access

104
Q

aim of bone removal

A

allow correct application of elevators on M and B of tooth, better visual access

105
Q

when would you section a tooth?

A

if tooth removal still not possible with elevators +/- forceps and adequate bone removal

106
Q

horizontal tooth sectioning

A

make cut higher than for a coronectomy so easier to get roots
above CEJ
only drill approx 5/6 through - leave E to protect adjacent structures then use and twist elevator to snap. Lever off

107
Q

vertical tooth sectioning

A

works best on 2 rooted teeth
elevate M+D aspects separately
be v careful of roots of 7
occ need to section each root

108
Q

lingual split technique

A

old technique
prev used under GA, often in younger pts
requires lingual flap
lingual wall of 8 socket removed using a mallet and chisel
can remove tooth in one piece by rotating it lingually
takes away some bone behind tooth
- good for distally impacted teeth

109
Q

forceps commonly used for L

A

molars, cowhorns, universal, roots

110
Q

forceps commonly used for U

A

8s, molars, universal, roots, Bayonet

111
Q

types of debridement

A

physical
irrigation
suction

112
Q

physical debridement

A

bone file/handpiece to remove sharp bony edges
Mitchell’s trimmer/Victoria Curette to remove ST debris
don’t scrape right at bottom of socket - risk IDN
debris and any follicular or granulation tissue from chronic infection should be curetted
- esp if hidden behind 7

113
Q

irrigation debridement

A

sterile saline into socket and under flap

must irrigate below flap before you reposition it

114
Q

suction debridement

A

aspirate under flap to remove debris

check socket for retained apices etc

115
Q

2 methods of suturing

A

flap closure

anatomical repositioning

116
Q

flap closure

A

some suture flap across socket to lingual side, effectively closing the wound completely
- do if on bisphosphonates/MRONJ risk

117
Q

anatomical repositioning

A

most prefer to return flap to its original position, leaving a socket

118
Q

aims of suturing

A 
reposition tissues
cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention
119
Q

how to suture flap

A

usually use mesial suture first as your positioning suture
- can redo it more securely at end
need suture in each papilla
put a suture in the vertical relieving incision if risk of bleeding
normally use resorbable

120
Q

post-op advice

A

pain
- expect it - take analgesia before LA wears off
aid healing
- don’t rinse for several hrs, then hot salty MW
- softer/cooler foods for rest of day, softer foods for next
week, eat on other side
- don’t explore socket with fingers/tongue
- be careful not to bite/burn L lip whilst numb
- brush rest of teeth as normal
- no smoking/avoid as long as can - increased risk of dry
socket regardless
- CHX MW x2 daily - not straight after brushing/around
eating
- avoid alcohol and exercise that day (increase bp - bleed)
deal w bleeding
- damp gauze/tissue and bite for 20-30mins
- contact details - you/A+E
other symptoms to expect
- swelling - peak 48hrs, resolves 7-10days, if develops
after 2-3 days likely infection, ice packs 5mins on off for
1hr that day
- bruising - settles 1-2wks
- jaw stiffness/limited opening, usually settles 1-2wks,
keep eating and drinking
sutures
- usually resorbable - may take a few days up to 2 wks to
resorb
- if non-resorbable (prolene) - warn pt they need removed
*contact details

121
Q

indications for coronectomy

A

high risk of IAN injury
vital M3M
healthy non-IC pt
access to care for (and understanding of) related coronectomy risks

122
Q

Tara Renton paper 2004

A

shows much lower risk to IAN with coronectomy compared to SR

123
Q

principles of coronectomy

A

remove all enamel
tooth roots must not be mobile after decoronation
smooth finish to decoronated tooth and surrounding bone

124
Q

what is coronectomy?

A

alternative to SR of entire tooth when there appears to be an increased risk of IAN damage with SR
crown removed with deliberate retention of root adjacent to IAN

125
Q

aim of coronectomy

A

reduce risk of IAN damage

126
Q

risks of coronectomy

A

if root is mobilised during crown removal the entire tooth must be removed (more likely with conical fused roots)
leaving roots could result in infection (rare)
can get a slow healing/painful “socket”
roots may migrate later and begin to erupt through the mucosa, may require ext
may not work/risk needing 2nd procedure

127
Q

Abs

A

not used routinely
- consider for prolonged, difficult procedures or in IC pts e.g. diabetic
can administer pre, peri or post op
under GA sometimes one IV dose given peri-op
amoxicillin/metronidazole - 3/5/7 days

128
Q

coronectomy procedure

A

LA
raise flap - generally standard 8 designs
(bone removal)
transection of tooth 3-4mm below the E of the crown into D
elevate/lever crown off without mobilising the roots
- only go 2/3-3/4 through with drill as if cut all way through risk to lingual nerve and artery
pulp left in place untxed
if necessary - further reduction of roots with a rosehead bur to 3-4mm below alveolar crest - not always possible
irrigate socket
flap replaced - some reposition flap leaving socket open, some close flap completely (primary closure with periosteal release if necessary)
HAPOI

129
Q

follow up of coronectomy

A

variable
review 1-2wks, 3-6m, 1yr
some review at 2yrs but most discharge back to GDP after 6m/1yr
radiographic review
- 6m or 1yr or both
- after that if symptomatic
- some take an immediate or 1wk post-op radiograph

130
Q

U8s ext

A

generally easier to remove
but occ v difficult
remove by elevation (Wj, Couplands) +/- forceps (U8s)
support tuberosity w finger and thumb
- if undue resistance to elevation/ext then excessive force can fracture the tuberosity
- use forceps and support to reduce risk
if not possible to get access to a PE U8 - can raise a buccal flap +/- bone removal

131
Q

peri-op control of bleeding

A 
pressure
LA w vasoconstrictor
artery forceps
diathermy
bone wax
132
Q

post-op control of bleeding

A

pressure (finger/swab)
LA w vasoconstrictor infiltration in STs, inject into socket or on a swab
diathermy
haemostatic agents - surgicel/kaltostat
sutures
bone wax smeared on socket wall with a blunt instrument
haemostatic forceps/artery clips

oral surgery 4th year (9 decks)

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