Oral Surgery

ORAL SURGERYIPAIN CONTROL LEGEND

Major Topic AbbreviationAdrenal cortex Adren CortAnatomy AnatAnesthesia AnesthBiopsy BiopsyDisorders/Conditions Disord/CondDrugs DrugsExodontia ExoFractures FracturesGeneral Information Gen InfoImplants/Grafts Impl/GrftsMiscellaneous Misc.TMJ TMJ

Copyright (!;)2001 - DENTAL DECKS

FracturesORAL SURGERY/PAIN CONTROLThe treatment of a mandibular fracture using only intermaxillary fixat ion (IMF) iscalled:

Open reduction Closed reduction

Copyright 2001 - DENTAL DECKS

Closed reduction

" ' It is called closed reduction because it does not Involve direct opening, exposure, and manip-ulation of the fractured area.

Forms of immobili zati on of a fracture :1. A barton bandage is the simplest form of immobilization. Primarily a f irst aid measure

until definitive therapy can be instituted.2. Intermaxi llary fixation (IMF) is establishing a proper occlusal relationship by wiring the

teeth together. This method will successfully treat most fractures of the mandible. Themain methods for such fixation are wiring, arch bars, and splints. This is the classical wayto Immobilize the fracture after closed reduction.

3. External skeletal fixation is used in most cases in which the management of a fracturedbone segment is not satisfactorily accomplished by intermaxillary fixation. It involves theplacement of screws or pins through the skin on each side of the fracture and a cold cureacrylic bar which holds the screws in proper relationship with the fracture in the reduced posi-tion. It is cumbersome and esthetically displeasing.

4. Direct intraosseous wiring combined with a period of IMF is the traditional method of bonestabilization after open reduction . This method of stabilization can be accomplished througha variety of different wiring techniques. The wire is placed through holes on either side of thefracture and immobilization is accomplished by tightening the wires.

FracturesORAL SURGERYIPAIN CONTROLZygomatic arch fractures can be nicely demonstrated by which radiographic view?

Water 's view Lateral skull view Posteroanterior skull view Submental vertex view


Subment&yerfex view

This type of fracture may not cause any problem other than perhaps a slight sinking ofthe cheekbone area. There may be some encroachment and impairment in closure ofthe jaw if it comes down and entraps the coronoid process of the mandible.

Possible complications include: Paresthesia (most common) - usually subsides The antrum (sinus) may be filled with a hematoma, which usually evacuates itself Ocular muscle balance may be impaired because of fracture of the orbital process

Important: Fractures of the facial bones, particularly the zygomatic complex mayon rare occasions be complicated by damage to the contents of the superior orbitalfissure.

Note: Fracture of the infraorbital rim presents with the following symptoms: Numbness of the following areas on the affected side: upper lip, cheek, and nose.

Remember: The Water's view is best to evaluate orbital rim areas.....

FracturesORAL SURGERYIPAIN CONTROLWhich of the following is the most common pathognomonic sign of a mandibularfracture?

Nasal bleeding Exophthalmos Malocclusion Numbness in the infraorbital nerve distribution


Malocclusion

Other signs and symptons of a mandibular body or angle fracture include: Lower lip numbness Mobility, pain, or bleed ing at the fracture site

Anatomic distribution of mandibular fractures: Angle (30%) most common site Condylar neck (25%) Symphys is area (22%) Body (17%) Ramus (2%) Coronoid process (1%) least common site

Notes:1. Indications for open reduction include continued gross displacement of the bony segments

and an unfavorable fracture that is likely to result in further displacement of the fractured seg-ments caused by muscle pull, This type of reduct ion is commonly performed for displacedangle or body fractures. Remember: Condylar neck fractures are usually treated by closedreduction .

2. In a fracture involving the angle of an edentulous mandible, the proximal segment is usu-ally displaced anteriorly and super iorly.

FracturesORAL SURGERYIPAIN CONTROLIn patients who have a LeFort II fracture, a common finding is paresthesia over thedistribution of the:

Infraorbital nerve Inferior alveolar nerve Mylohyoid nerve Hypoglossal nerve


Infraorbital nerve

Midfacial fractures include fractures affecting the maxilla, the zygoma, and the nasoorbital eth-moid complex. Midfacial fractures can be classified as: LeFort I (also called a horizontal fracture) is a horizontal segmented fracture of the alveolar

process of the maxilla, in which the teeth are usually contained in the detached portion of thebone. Result is an open bite.

LeFort II (also called a pyramidal fracture) is a unilateral or bilateral fracture of the maxilla, inwhich the body of the maxilla is separated from the facial skeleton and the separated portionis pyramidal in shape. Signs include periorbital edema, ecchymosis, subconjunctivalhemorrhage, and nose bleeding.

LeFort III (also called a transverse fracture or craniofacial dysfunction) is a fracture in whichthe entire maxilla and one or more facial bones are completely separated from the craniofa-cial skeleton. These patients will have restriction of mandibular movement.

Also zygomaticomaxillary complex fractures, zygomatic arch fractures, or nasoorbital eth-moid fractures.

Important: The first step in the treatment of these fractures which affect the occlusal relationshipis similar to the treatment of mandibular fractures - to reestablish a proper occlusal relationshipby placing the maxilla into proper occlusion with the mandible.Note: Due to the slope of the sphenoid bone comprising the floor of the cranial vault, blows tothe maxilla will cause the maxilla to be driven backwards and downwards. This may result inan open bite or Impingement of the airway.

FracturesORAL SURGERY/PAIN CONTROLAll of the following are weak points in the mandible where fractures are most com-mon except

The angle The coronoid process The condylar neck The symphysis area


The coronoid process

The location and extent of mandibular fractures are determined largely by the direc-tion and intensity of the blow and the specific points of weakness in the mandible.

The angle is the most common anatomic site of fracture of the mandible (30% of frac-tures). Frequently third molars which are impacted are located in this region and furtheradd to the weakness of the mandible in this area.

The condylar neck (25% of fractures) is a safety feature which allows a blow to thejaw to be dispersed at this point rather than driving the condyle into the middle cranialfossa. Bilateral dislocated fractures of the condylar necks will cause an anterior openbite and the inability to protrude the mandible. A unilateral fracture through the neckmay cause forward displacement of the head of the condyle due to pull of the lateralpterygoid muscle.

The symphysis area or chin (22% of fractures) is usually where blows are sustained.These blows often result in fractures of the subcondylar region. Remember: Thepatient's mandible will deviate to side of injury upon opening.

FracturesORAL SURGERYIPAIN CONTROLWhich form of reduction listed below is best used to reduce a fracture when teeth aremissing in one or more of the fractured segments?

Open reduction Closed reduction


Open reduction

Open reduction is the reduction of a fractured bone by manipulation after incisioninto skin and muscle over the site of the fracture. The most common site for openreduction is at the angle of the mandible. Once the incision is made, an intraosseouswire is placed through holes made on either side of the fracture. Reduction is accom-plished under direct vision, and immobilization is obtained by tightening the wires. Thisprocedure is usually reserved for fractures that cannot be reduced and immobilizedadequately by closed methods.

Closed reduction is the reduction of a fractured bone by manipulation without inci-sion into the skin. It is the simplest method of reduction and is used most frequentlywhen both fractured segments contain teeth. After manipulation of the bone, it is usu-ally maintained in place by intermaxillary fixation (lMF).

Remember: IMF is fixation obtained by applying wires or elastic bands between theupper and lower jaws in which suitable anchoring devices have been attached. Themost common technique for IMF is the use of prefabricated arch bars.

FracturesORAL SURGERY/PAIN CONTROLWhich of the following are likely signs and symptoms of a zygomatic fracture?

Nasal bleeding Pain over zygomatic region Numbness in the infratemporal nerve distribution Exophtalmos Diplopia All of the above


All of the above

Midfacial fractures include fractures affecting the maxilla, the zygoma, and thenasoorbital ethmoid complex. They may be classified as: LeFort I, II, or III fractures Zygomatic complex fractures (most common type of midfacial fracture) Zygomatic arch fractures Nasoorbital ethmoid fractures---The following radiographic views are often helpful to evaluate midfacial fractures:Water's view PAskull view, and submental vertex view.-Important: A zygomatic arch fracture can impinge on the coronoid process or tem-poralls muscle, causing various degrees of trismus.

Notes:1. The maxilla and mandible are in a critical relationship to the upper airway; therefore

displacement of fractures can cause obstruction of the airway resulting in respirato-ryarrest. Control of airway is vital to any treatment of a patient with facial fractures.

2. Maxillary fractures have a greater tendency towards the production of facial defor-mity than do mandibular fractures.

ORAL SURGERY/PAIN CONTROLFractures

Which muscle below is responsible for the forward displacement of the condylarhead when the neck of the condyle is fractured?

Masseter muscle Mylohyoid muscle Lateral pterygoid muscle Medial pterygoid muscle


Lateral pterygoid muscle

Three groups of muscles that are responsible for the displacement of mandibular condyles:

Group I -r Group II +- Group III 4-Masseter Digastric Lateral pterygoidMedial pterygoid MylohyoidTemporalis Geniohyoid

I alem! pterygoid

Group I: elevate mandible during mastication and will cause an upward displacement of theproximal segment.Group II: depress the mandible and will displace the distal fractured segment inferiorly andposteriorly.Group III: when the neck of the condyle is fractured, this muscle will cause forward displace-ment of the condylar head.Remember:1. The proximal segment of the fracture is that segment which lies most posteriorly yet clos-

est to the condyle.2. The distal segment of the fracture is that segment which is most distal from the condyle

(i.e. anteriorly).

ExoORAL SURGERY/PAIN CONTROLThe most severe tissue reaction is seen with which type of suture material?

Plain catgut Chromic catgut Polyglycolic acid Polyglactin 910

Copyrig ht 2001 - DENTAL DECKS

Plain catgut"""Resorbabl e sutures evoke an intense inf lammatory reacti on. Th is Is the reason neither plain nor chromic gut isused for suturing the surface of a skin wound.

PROPERTIES OF SUTURE MATERIALSResorbable sutu res Non -Resorbable sutures

TIssue Knot Tissue KnotName React iv ity secu rity Handling Name Reactiv ity Security Hand lingPlain Catgut severe poor fair Silk severe good excellentChromic Catgut moderate good good Braided Polyester moderate poor goodPolvolactin 910 minimal fair oood (if coatingPolyglycol ic acid minimal fair good sheds)

Stain less Steel Wire pract ically excellent poornone

Polypropylene minimal good fairPolyethylene minimal poor fairRes~~ from sheep intestine. susceptible to rapid digestion by proteolytic enzymes,~ns strength for 5-7 dayi> Chromic gut - "chromitized" to produce more resistance to proteolytic enzyme s. retains s rength for 9-14 daY.,. Polyglycolic ac id - does not enzymatically break down , undergoes slow hydrolysis, less sbfl than gut sutures (easier

to tie sutures), more expensive.Nonresorbable: Silk, nylon, polyester, and polypropylene. Silk is bra ided (multifitamentous) , black , and inexpensive . Itis used for Int raoral suturing. Nylon is strong, not used In the mouth , and is the suture material of choice for facial lacer-ations. Polypropylene has the least tendency to induce inflammation.

~able sutures should be removed In 5-7 days..:-,

ORAL SURGERYIPAIN CONTROLThe most frequent location for a maxillary torus is:

The right side of the hard palate The left side of the hard palate The midline of the hard palate On the soft palate


Exo

The midline of the hard palate

Here it is called the torus palatinus. They usually appear before the age of 30 andaffect females more frequently than males.Maxillary tori present few problems when the maxillary dentition is present and onlyoccasionally interfere with speech or become ulcerated from frequent trauma to thepalate.Indications for removal include a large, lobulated torus with a thin, mucoperiostealcover extending posteriorly to the vibrating line of the palate that prevents seating ofa denture and also prevents a posterior seal at the fovea palatini.Technique for removal: The maxillary torus should not be excised en masse to prevent entry into the

nose (the palatine bone will come out with torus). It should be subdivided into segments by a bur. The segments are then removed with an osteotome. Any protuberances are smoothed out with a bone file . The flap is loosely sutured. A palatal splint is placed to prevent hematoma formation and to support the flap.

ExoORAL SURGERY/PAIN CONTROLWhen removing maxillary teeth, the upper jaw of the patient should be where in rela-tion to the dentist's shoulder?

Below Above At the same height It makes no difference where the patient's upper jaw is in relation to the dentist's

shoulder


At the same height

For mandibular extractions, the patient should be positioned so that the occlusalplane of the mandibular arch is parallel to the floor when the mouth is opened. Thechair should be as low as possible.

Positioning of the surgeon: When extracting maxillary teeth, it is usually best tostand in front of and to the side of the patient for maximum visibility and leverage.When extracting mandibular teeth, it is often better to stand directly to the side orbehind the patient.

The fingers of the left hand (for a right-handed dentist) serve to: Retract the soft tissue. Provide the operator with sensory stimuli for the detection of expansion of the alve-

olar plate and root movement under the plate. Help guide the forceps into place on the tooth. Protect teeth in the opposite jaw from accidental contact with the back of the forceps. Support the mandible while performing mandibular extractions.

ExoORAL SURGERY/PAIN CONTROLWhich type of maxillary third molar impaction is most likely to be displaced into theantrum (maxillary sinus) and infratemporal space if correct extraction techniques arenot employed?

Vertical impaction Distoangular impaction Mesioangular impaction Horizontal impaction

Copyright e 2001 - DENTAL DECKS

Distoangular impaction

Impacted maxillary third molars are occasionally displaced into two areas: Maxillary sinus (antrum) - from which they are removed via a Caldwell-Luc

approach Infratemporal space - during elevation of the tooth the elevator may force the tooth

posteriorly through the periosteum into the infratemporal fossa. If access and lightare good, the tooth may be retrieved with a hemostat. If the tooth is not retrievedafter a short amount of time, the area should be closed. The patient should beinformed that the tooth has been displaced and will be removed by an oral surgeonwho will use a special technique to remove it.

ExoORAL SURGERY/PAIN CONTROLWhich of the following is the main reason to use water irrigat ion when cutting bone?

It helps to wash away debris Because heat generated by the drill affects bone vitality To decrease the smell of freshly cut bone It helps to flush out the highspeed suct ion hose


Because heat generated by the drill affects bone vitality

Irrigation of the surgical wound during and after the procedure cannot be empha-sized enough. Copious amounts of coolant spray are crucial in minimizing osseousnecrosis caused by heat generated from the bur. Irrigation serves also to cleanse thecrypt and areas beneath the flap of bony debris, tooth fragments, and blood.

ExoORAL SURGERY/PAIN CONTROLWhich sca lpe l below is universally used for oral surgical procedures?

No.2 blade No.6 blade No. 10 blade No. 15 blade

Copyright @ 2001 - DENTAL DECKS

No. 15 blade

Three types of incisions used in oral surgery :1. Linear - straight line incision used for apicoectomies2. Releasing - used when adding a vertical leg to a horizontal incision. For extrac-

tions, augmentations, etc.3. Semi-lunar - curved incision mostly used for apicoectomies

The basic principles of oral surgical flap design: Flap design should ensure adequate blood supply ; the base of the flap should be

larger than the apex. Reflection of the flap should adequately expose the operative field. Flap design should permit atraumatic closure of the wounds.

Important: The correct position for ending a vertical releasing incision is at a tooth lineangle not over the buccal surface of a tooth. If it ends over the buccal surface, theedges are difficult to approximate and this may lead to periodontal problems.

ORAL SURGERY/PAIN CONTROLExo

Which of the following are local contraindications for tooth extractions?

ANUG Irradiated jaws Malignant disease All of the above


All of the above

LOCAL ANDSYSTEMIC CONTRAINDICATIONS TO TOOTH EXTRACTIONS

Local SystemicAcute infection with uncontrolled cellulitis Uncontrolled diabetes mellitusAcute pericornitis Uncontrolled cardiac disease and dysrythmiasAcute infectious stomat itis Severe bleeding disordersMalignant disease Uncontrolled leukemias and lymphomasIrradiated jaws Debilitating diseasesANUG Patients who are taking certa in medications

(e.g., immunosuppress ives, corticostero ids,and cancer chemotherapeutic agents)

Note: An acute dentoalveolar abscess should not be a contraindication to extraction.It has been shown that these infections can resolve very quickly when the affectedtooth is removed. However, it may be difficult to extract such a tooth, either becausethe patient is unable to open sufficiently wide or because adequate local anesthesiacannot be obtained.

ORAL SURGERYIPAIN CONTROLExo

Which suture pattern (or method) listed below is most commonly used in oral surgery?

Continuous pattern Interrupted pattern


Interrupted pattern

This suture pattern or method offers strength and flexibility due to each suture beingindependent to one another. If one suture is lost or becomes loose, the integrity of theremaining sutures is not compromised. The major disadvantage is the time requiredfor placement.

Advantages of a continuous pattern or method: Ease and speed of placement Distribution of tension over the whole suture line A more watertight closure than the interrupted pattern or method

Note:1. Sutures should not be overtightened or closed under tension.2. Sutures should be 2-3 mm apart, placed from mobile tissue to fixed fiSSile and from

thin tissue to thick tissue. -

ORAL SURGERY/PAIN CONTROLExo

Which of the following is the primary direction of luxation for extracting maxillarydeciduous molars?

Buccal Palatal Mesial Distal


Palatal*** As opposed to the buccal direction in adults. This is because the deciduousmolars are more palatally positioned and the palatal root is strong and less prone tofracture.

In general, the removal of deciduous teeth is not difficult. It is facilitated by the elas-ticity of young bone and the resorption of the root structure. Do not use the "cowhorn"forceps for extraction of lower primary molars because the sharp beaks of these for-ceps could cause damage to the unerupted permanent premolar teeth.

Notes:1. If the preoperative radiograph shows that the permanent premolar is wedged

tightly between the bell-shaped roots of the primary tooth, the best treatment is tosection the crown of the primary molar and remove the two portions separately. Thiswill help in not disturbing the permanent tooth.

2. After extraction of mandibular teeth on a child in which a mandibular block wasgiven, always advise child not to bite on lip while he or she is numb. Inform parentsas well to watch child so this does not occur.

ORAL SURGERY/PAIN CONTROLDead space in a wound usually fills with:

Pus Water Blood Tissue


Exo

Blood

Dead space in a wound is any area that remains devoid of tissue after closure of thewound. It is created by either removing tissues in the depths of a wound or by not reap-proximating tissue planes during closu re. Dead space in a wound usually fills withblood which creates a hematoma with a high potent ial for infection.

Ways in which you can eliminate dead space : Close the wound in layers to minimize the postoperative void. Apply pressure dressings Use drains to remove any bleeding that accumulates. Place packing into the void until bleeding has stopped.

ORAL SURGERY/PAIN CONTROL

When would you place a suture over a single extraction socket?

Exo

Routinely Never If the patient requests it When there is severe bleeding from the gingiva or if the gingival cuff is torn or loose.


When there is severe bleeding from the gingiva or if the gingival cuff is torn orloose

Normal post-extraction procedure: All loose bone spicules and portions of the tooth, restoration, or calculus are removed from

the socket as well as from the buccal and lingual gutters and the tongue. The socket must be compressed by the fin gers to reestablish the normal width present

before the buccal plate was surgically expanded. Note : The natural recontouring of the resid-ual ridge occurs primarily by resorption of the labial-buccal cortical bone.

Sutures are usually not placed unless the papillae have been excised. The socket is covered with a gauze sponge that has been folded and moistened slightly at its

center with cold water. The patient is instructed to bite down for 5-10 minutes Remove this sponge and place another one. This should stay in place until the patient arrives

home. A printed instruction sheet is given to the patient. A prescription for pain is given if the need is anticipated.If bleeding persists for some time following an extraction, it may be helpful to instruct thepatient to bite on a tea bag. The tannic acid in the tea bag will help promote hemostasis.Remember :The most common cause of post-extraction bleeding is the failure of the patientto follow post-extraction instructions.

ORAL SURGERY/PAIN CONTROLA patient with dry socket develops a severe dull throbbing pain:

Two to three hours following a tooth extraction One day following a tooth extraction Two to four days following a tooth extraction Immediately following a tooth extraction


Exo

Two to four days following a tooth extraction

Th'e pain is often excruciating. may radiate to the ear, and is not relieved by oral analgesics.There may be an associated foul odor and taste. T!Jg.extraction site is filled with necrotic tissue.which is delaying wound healing.

Dry socket results from a pathologic process combining the loss of the healing blood clot with alocalized inflammation. It is most common following extraction of the mandibular molars.Smoking, spitting or drinking through a straw, which creates negative pressure in the oral cavity,may encourage this condition. Note: Careful technique and minimal trauma reduce the frequen-cy of patients developing dry socket.

Treatment: Flush out debris with saline solution (gent/y). Carefully dry socket. Place strip of iodoform gauze soaked in oil of cloves (eugenol). Note: The gauze provides

and attachment for the obtundent paste so it stays in the socket. Prescribe analgesic drugs if necessary.

Note: Dry socket is the most common complication seen after the surgical removal of amandibular molar. Tetracycline is sometimes given prophylactically following the removal ofimpacted mandibular third molars to prevent dry socket. Dry socket is also referred to as pos-textraction alveolitis or localized alveolar osteitis.

ORAL SURGERYIPAIN CONTROL

The ideal time to remove impacted third molars is:

When the root is fully formed When the root is approximately two-thirds formed Makes no difference how much of the root is formed When the root is approximately one-third formed


Exo

When the root is approximately two-thirds formed

- Patient would be around the age of 17-21.- At this time, the bone is more flexible and the roots are not formed well enough

to have developed curves and rarely fracture during extraction.

When the root is fully formed, the possibility increases for abnormal root morpholo-gy and for fracture of the root tips during extraction .

If the root development is insufficient (one-third or less), the tooth is more difficult toremove because it tends to roll in its crypt like a ball in a socket , which prevents easyelevation.

Notes:1. Patients who are young tolerate surgery very well. Postoperative complicat ions

are usually minimal.2. Older individuals have the most postoperative difficulties. The bone is more

dense and usually the patient responds more slowly to the entire process (anesthe-sia and surgery).


The mesioangular impaction is generally acknowledged as:

The most difficult impaction to remove The least difficult impaction to remove Neither of the above


Exo

The least difficult impaction to remove

The mesioangular impaction is also the most common and comprises about 43% of allimpacted teeth.For impacted mand ibu lar third molars the mesioangular is the least difficult to remove fol-lowed by the horizontal, vertical, and the most difficult to remove is the distoangularimpaction. Important: This is the exact opposite of impacted maxillary third molars, where themesioangular impactions are the most difficult and the vertical and distoangular impactions arethe easiest to remove.Once sufficient amounts of bone have been removed from around the impacted tooth, thetooth is usually sectioned. Sectioning allows portions of the tooth to be removed separately withelevators through the opening provided by bone removal. Note: Bone is rarely, if ever, removedon the lingual aspect of the mandible because of the likelihood of damaging the lingualnerve.

Section ing of the tooth is done for the following reasons: Allows for minimal bone removal Allows for minimal force needed to remove tooth Shortens the entire surgical procedureTooth sectioning can be performed with either a bur or chisel; however, the bur is used bymost surgeons.

Misc.ORAL SURGERY/PAIN CONTROLSquamous cell carcinoma is most easily managed when found where?

Floor of the mouth Palate Lower lip Side of the tongue


Lower lip

Squamous cell carcinoma (SCC) is the most common malignant oral tumor, repre-senting a little over 90% of all oral malignancies. It is 9 to 10 times more frequent inmales than in females and, although seen in all ages, its highest incidence is after thefourth decade. It is more common on the lips than intraorally.

95% of lip carcinomas occur on the lower lip. They are usually discovered early andonly a small percentage show lymph node metastasis. Prognosis is very good.

SCC of the tongue is the most common intraoral malignancy. The most common loca-tion is the posterior lateral border, followed by the posterior one-third or base of thetongue. It is uncommon on the dorsum or tip of the tongue. These lesions usuallymetastasize early and the prognosis is not as good as lip lesions.

The floor of the mouth is the second most common intraoral location of sec. It isseen predominantly in older men, especially those who are chronic alcoholics andsmokers. These lesions metastasize early and the prognosis is very poor.

Remember: The treatment of choice for oral cancer is surgery.

ORAL SURGERY/PAIN CONTROLMisc.

All of the following are systemic contraind ications to elective surgery except

Blood dyscras ias (i.e., hemophilia, leukemia) Controlled diabetes mellitus Addison's disease or any steroid deficiency Fever of unexpla ined origin Nephritis Any debil itating disease Cardiac disease

Copyright ~ 2001 - DENTAL DECKS

Controlled diabetes mellitus

"'Uncontrolled diabetes mellitus is a systemic contraindication to elective surgery

Important: Patients with these systemic conditions can be treated, but you need toconsult with the patient's physician before treatment. In most cases, these patients arebest treated in the hospital by an oral surgeon.

Note: Cardiac disease such as coronary artery disease, uncontrolled hypertension,and cardiac decompensat ion can complicate exodontia. Usually a postinfarctionpatient is not subjected to oral surgery within six months of his infarction.However, emergency procedures can be performed provided the patient's physicianhas been consulted.

ORAL SURGERYIPAIN CONTROLThe most common site of a pericoronal infection (pericoronitis) is:

Around the site of a recent extraction Around a newly erupted primary tooth Around periodontally involved mandibular incisors Around mandibular third molars


Misc.

Around mandibular third molars

The most typical symptoms of a pericoronal infection about the third molar are: Submandibular lymphadenopathy Trismus Pain in the region of a mandibular third molar Swollen, red tissue in the region of a mandibular third molar General condition of malaise

Treatment includes: Irrigate area If possible, establ ish drainage Place patient on antibiotics Instruct patient to rinse with warm saline mouthwashes As soon as the acute symptoms are relieved , a definitive treatment may be institut-

ed

Important: The maxillary third molar is the most frequent contributing factor to peri-coronal infections found around mandibular third molars. Always examine the maxillarythird molar, it may be supererupted or malaligned .


Which of the following can result in masticator space infections?

Misc.

Infections of the mandibular molars, especially the third molar Nonaseptic technique in local anesthesia of the inferior alveolar nerve Trauma to the mandible (either external or fracture into the socket of a diseased

third molar) All of the above


All of the above

The masseteric, pterygomandibular, and temporal spaces as a group are known asthe masticator space because they are bounded by the muscles and fascia of masti-cation. Infections of the masticator space are practically always of dental origin, partic-ularly the lower molar region. Note: Needle tract infections following an inferior alveo-lar block injection would initially involve the pterygomandibular space.

Clinically, the picture of masticator space infection is dominated by trismus, pain, andswelling occurring within a few hours following a molar extraction or trauma to themandible. These signs increase rapidly to reach a peak in 3 to 7 days. Spontaneousintraoral drainage usually takes place between the 4th and 8th day. If this does notoccur, surgical drainage is indicated.

Notes :1. The most definite clinical sign indicating extension of an odontogenic infection into

the masticator space is trismus. Trismus is difficulty in opening the mouth due to atonic spasm of the muscles of mastication.

2. Trismus may also result from passing the needle through the medial pterygoid mus-cle during an inferior alveolar nerve block.

Misc.ORAL SURGERY/PAIN CONTROLThe mandibu lar left second molar of a 14 year-old boy is unerupted. Radiographs showa small dentigerous cyst surrounding the crown. What is the treatment of choice?

Surgically extract the unerupted second molar Uncover the crown and keep it exposed Prescribe an anti-inflammatory medication and schedule a follow-up appointment in

six months No treatment is necessary at this time


Uncover the crown and keep it exposed

Dentigerous cysts are those associated with the crowns of unerupted teeth. Some lit-erature refers to these cysts as "follicular" or "primordial" cysts. Note: They areprobably the result of degenerat ive changes in the reduced enamel epithelium.

Remember: If cysts form when a tooth is erupting, they are called eruption cysts.These cysts interfere with normal eruption of the teeth. Eruption cysts are more com-monly found in the child and young adult and may be associated with any tooth. If treat-ment is indicated, simple incision or "deroofing" is all that is needed.

Misc.ORAL SURGERY/PAIN CONTROLWhich of the following statements are true concerning ecchymosis?

Ecchymosis is an area of hemorrhage into the skin and subcutaneous tissue>1 cmin diameter

An ecchymosis is often the result of injury; however, clott ing and bleeding disorderscan predispose to the formation of an ecchymosis

Grossly, an ecchymosis presents as a bluish lesion at the earliest stages of onset As the red blood cells in the lesion undergo progressive degeneration and the hemo-

globin becomes converted through bilirubin into hemosiderin , the lesion progres-sively changes color from blue through green through purple to finally a brownish dis-colorat ion

All of the above statements concerning ecchymosis are true


All of the above statements concerning ecchymosis are true

Postoperative ecchymosis is a result of trauma to the underlying blood vessels.Blood escapes from the vascular tree and accumulates in the tissues. It is commonafter extractions in elderly patients due to the fragility of the vessel walls. All patientsshould be warned that it may occur following extractions. Note: Sometimes the patientwill complain of a diffuse, non-painful, yellowish discoloration of the skin. Moist heatoften speeds the resolution of postoperative ecchymosis.

Remember : Osteoradionecrosis is the most serious potential complication afterextractions from areas previously irradiated. It is the necrosis of bone caused by expo-sure to ionizing radiation.

ORAL SURGERY/PAIN CONTROLMisc.

Incision for drainage (I & 0) in an area of acute infection should only be performedafter which of the following has occurred?

A culture for antibiotic sensitivity has been performed Localization of the infection A sinus tract is formed All of the above


Localization of the infection

Physiologically, it is at this time that nature has constructed a barrier around theabscess, walling it off from the circulation and making it possible to palpate the pres-ence of purulent material within the abscess cavity (known as fluctuance) .

Note: After you incise and drain the fluctuant mass, it may be prudent to do a culturefor antibiotic sensitivity. This should always be done if after incision and drainage theswelling does not subside despite large doses of antibiotics.

Prior to actual abscess formation, however, the infection is capable of producing acellulitis in the soft tissues of the region involved. The palpable tissues take on a con-dition known as induration (they appear hard, dense, and brawny) . Treatment duringthis period should be directed towards localizing the infection. Early employment ofantibiotics may be extremely important in a severe and life-threatening infection.Localization of the infection may be aided by using warm compresses and warm mouthrinses at frequent intervals.


Cavernous sinus thrombosis can be caused by:

An infection of the central face or paranasal sinuses Bacteremia Trauma Infections of the ear or maxillary teeth All of the above


Misc.

All of the above

Cavernous sinus thrombosis (CST) is an unusual occurrence that is rarely the resultof an infected tooth. CST is generally a fulminant process with high rates of morbidityand mortality. Fortunately, the incidence of CST has been decreased greatly with theadvent of effective antibiotics. Most cases are due to an acute infection in an otherwisehealthy individual. However, patients with chronic sinusitis or diabetes mellitus may beat a slightly higher risk. Note: The causative agent is generally Staphylococcusaureus.

Infections of the face can cause a septic thrombosis of the cavernous sinus.Furunculosis and infected hair follicles in the nose are frequent causes. Extractions ofmaxillary anterior teeth in the presence of acute infection and especially curettage ofthe socket under such circumstances can cause this condition. The infected thrombusascends in the veins against the usual venous flow. It usually occurs in the oph-thalmic vein. This is possible because of the absence of valves in the angular, facial,and ophthalmic veins.

L

Misc.ORAL SURGERY/PAIN CONTROLWhich of the following tests should be routinely performed in the preoperativeworkup for a patient that is being admitted to a hospital for surgery?

A complete blood count (CSC) A total white blood cell count An assessment of the circulating platelets A urinalysis All of the above


All of the above

Routine admission tests include:

A complete blood count that includes an evaluat ion of the hemoglobin and hema-tocrit indices

A total white blood cell count with a differential count An assessment of the circulating platelets A gross and microscopic urinalysis

Anyone scheduled for general anesthesia should have a chest x-ray and patientsover 40 years old should also have an E.K.G.

Factors to be considered in the decision to hospitalize a patient for an elective pro-cedure: Medical problems compromising treatment (diabetes, hemophilia. etc.) Difficulty and extent of surgery . Considerat ion of the individual patient (emotionally disturbed, handicapped, etc.) Cost of hospital ization (time and money)

Misc.ORAL SURGERY/PAIN CONTROLBy far and away the most commonly performed mandibular procedure for the cor-rection of mandibular retrognathia is the:

Segmental osteotomy Sagitta l split osteotomy Vertical ramus osteotomy Body osteotomy


Sagittal split osteotomy

***This is due primarily to its simplicity and versatility.The mandible is split sagittally and can either be used to advance the mandible (in thecase ofretrognathia) or set back the mandible (in treating prognathia). It is the stan-dard procedure used today. Note: The position of the condyle is unchanged duringcorrection of mandibular prognathism or retrognathism.Vertical ramus osteotomy: Is used for the correction of prognathism. The objectiveis vertical sectioning of the ramus in a line from the lower aspect of the mandibularnotch vertically downward over the mandibular foramen or just posterior to the lowerborder of the mandible at the angle.Body osteotomy: Is a procedure that involves extracting mandibular teeth bilaterally(usually bicuspids) . A piece of bone is also removed from the mandible and you slideeverything back. Used for prognathism.Segmental osteotomy: Maxillary procedure where more than one segment of bone isremoved.Note: A LeFort I osteotomy is most commonly used to correct maxillary retrog-nathia.

Misc.ORAL SURGERY/PAIN CONTROLOn physical examination, painless induration of soft tissue is suggestive of:

Normal tissue Infection Invasive malignant lesions Benign lesions


Invasive malignant lesions

Characteristics of lesions that raise the suspicion of malignancy :

Erythroplasia - lesion is totally red or speckled red and white Ulceration - lesion is ulcerated or is an ulcer Duration - more than two weeks Rapid growth Bleeding - bleeds on gentle manipulation Induration - lesion and surrounding tissue is firm to the touch Fixation - feels attached to adjacent structures

Misc.ORAL SURGERY/PAIN CONTROLMuscle fibers covered by a mucous membrane that attaches the cheek, lips, and/ortongue to associated dental mucosa is called:

Gingiva Frenum Operculum Abutment


Frenum

When a frenum is positioned in such a way as to interfere with the normal alignmentof teeth or results in pulling away of the gingiva from the tooth surface causing reces-sion it is often removed using a surgical process known as a frenectomy.

There are three surgical techniques that are used for a frenectomy: Simple excision and Z-plasty are effective when the mucosal and fibrous tissue

band is relatively narrow. These techniques relax the pull of the frenum. v-v plasty (sometimes called a localized vestibuloplasty) is often preferred when the

frenal attachment has a wide base. This technique is good for lengthening tissue andusually results in less scarring.

Note: Local anesthetic infiltration is usually sufficient for surgical treatment of frenalattachments. Care must be taken to avoid excessive infiltration directly in the frenumarea since it may obscure the anatomy that must be visualized at the time of excision.

ORAL SURGERY/PAIN CONTROLWhich of the following can be used for removing bo ne?

Rongeur forceps Chisel and mallet Bone file Bur and handpiece All of the above


Misc.

All of the above

Rongeur forceps are the most commonly used instruments for removing bone.However, the technique that most oral surgeons use when removing bone is the burand handpiece.

Very Important: Most high-speed turbine drills used for routine restorative dentistry aretotally unacceptable for removing one. The air exhausted from these drills goes into thewound and may be forced deeper into tissue planes and produce tissue emphysema,a potentially dangerous situation.

Note: Acute infected tissue emphysema is usually caused by the indiscreet use of:1. Air-pressure syringes: In drying out a root canal with a compressed air syringe,

septic material may be forced through the apical foramen into the cancellous portionof the alveolar process and ultimately out through the nutrient foramina into adjacentsoft tissues, resulting in formation of a septic cellulitis and tissue emphysema .

2. Atomizing spray bottles activated by compressed air: A similar condition can beinduced by the use of a compressed -air spray bottle for irrigation of wounds , partic-ularly in the retromolar region. It is safer to use a hand-activated syringe when irri-gating wounds or drying root canals since it is unlikely that a tissue emphysemawould be produced under these circumstances.

Misc.ORAL SURGERY/PAIN CONTROLBefore dental treatment , prophylactic antibiotic coverage is indicated for patients witheach of the following conditions except.

Previous coronary artery bypass graft surgery Rheumatic heart disease Prosthetic aortic valve Kidney damage needing hemodialysis Total joint prosthesis Mitral valve prolapse with valvular regurgitat ion


Previous coronary artery bypass graft surgery

If antibiotic prophylaxis is necessary, the following medications and dosages arerecommended by the American Heart Association :

Situation Medication DosageStandard prophylaxis Amoxicill in Adults: 2.0 g; children : 50 mg/kg orally 1 h

before procedureUnable to take Ampicill in Adults: 2.0 9 1M or IV; children 50 mg/kg 1M or

oral medication IV within 30 min before procedureAllergy to Penicillin Clindamycin Adults : 600 mg; children : 20 mg/kg orally 1 hr

or before procedureCephalex in or Adults : 2.0 g; children 50 mg/kg orally 1 hrCefadroxil before procedureAzithromycin or Adults : 500 mg; children: 15 mg/kg orally 1 hrClarithromycin before procedure

Allergic to penicill in Clindamycin or Adults: 600 mg; children: 20 mg/kg IV withinand unable to take Cefazolin 30 min before procedure Adults : 1.0 g;oral medications children: 25 mg/kg 1M or IV within 30 min

before procedure

ORAL SURGERY/PAIN CONTROLThe universal sign of laryngeal obstruction is:

Mydriasis Stridor (crowing sounds) Sweating Tachycardia


Misc.

Stridor (crowing sounds)"'Stridor is a high-pitched, noisy respiration, like the blowing of the wind. It is a sign of respira-tory obstruction, especially in the trachea or larynx.Because total airway obstruction usually occurs during inspiration, there is usually adequate oxy-gen left in the cerebral blood to permit up to 2 minutes of consciousness. If the obstruction is notrecognized and managed and oxygen delivered to the victim's lungs, blood, and brain, perma-nent neurologic damage occurs within 3 to 5 minutes.Noninasive procedures for obstructed airway: Back blows, manual thrusts, Heimlich maneuver, chest thrust, and finger sweepInvasive procedures for obstructed airways; '-' These procedures should only be performed bypersons trained in these techniques and if proper equipment is available Tracheotomy: Is used more for long-term airway maintenance and not for emergency air-

ways Cricothyrotomy: Is a procedure for establishing an emergency airway where other methods

are unsuitable or impossible. The access site is the cricothyroid membrane of the trachea,located on the anterior neck, between the cricoid and thyroid cartilages.

Important: A cricothyrotomy may be lifesaving in an anaphylactic reaction in which a patientshows signs of laryngeal obstruction. If a patient shows signs of laryngeal obstruction, thatis, stridor (crowing sounds), epinephrine should be given and oxygen administered . If a patientloses consciousness and appears to be unable to breathe, an emergency cricothyrotomy maybe required to bypass the laryngeal obstruction.

ORAL SURGERY/PAIN CONTROL Misc .

Osteomyelit is is an infection of the bone and bone marrow. It is most often causedby:

Streptococcus pyogenes Staphylococcus aureus Mycobacterium tuberculosis Neisseria meningitidis


Staphylococcus aureus

Osteomyelitis is an infection in the bones. Often, the original site of infection is else-where in the body, and spreads to the bone by the blood. This may be predisposed toinfection due to a recent minor trauma that results in a blood clot. In children, the longbones are usually affected. In adults. the vertebrae and pelvis are most commonlyaffected. Pus is produced within the bone, which may result in a bone abscess. Theabscess then deprives the bone of its blood supply. Note: Chronic osteomyelitisresults when bone tissue dies as a result of the lost blood supply.

Important: Acute osteomyelitis occurs more frequently in the mandible as opposedto the maxilla. The primary reason for this is that the blood supply to the maxilla ismuch richer and is derived from a number of different arteries, while the mandibletends to draw its primary blood supply from the inferior alveolar artery. The dense over-lying cortical bone of the mandible prevents penetration of periosteal blood vessels,thus the mandibular cancellous bone is more likely to become ischemic and thereforeinfected. Important point: Reduced blood supply will predispose bone toosteomyelitis.

Misc.ORAL SURGERY/PAIN CONTROLBody temperature can be measured in several different ways, wh ich one is the leastaccurate?

Orally Axillary Rectally Aurally


Axillary"'Rectally Is the most accu rateGeneral considerations when checking vital signs:

The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exercise within 30 minutes of theexam.Ideally the patient should be silting with feet on the floor and their back supported. The examination room should be quietand the patent comfortable.History of hypertension. slow or rapid pulse. and current medications should always be obtained.

Rout ine vital signs Include:Blood pressure (normal 120/80)Pulse rate (normal 72)Respiration rate (normal 15)Temperature can be measured in several different ways:

Oral with a glass, paper, or electronic thermometer (normal 98.6 'F/37"C)AXillary with a glass or electronic thermometer (normal 97.6'FI36.3 ' C)Rectal or 'core' with a glass or electronic thermometer (99.6FI37.7C)Aural (the ear) with an electronic thermometer (normal 99.6F/37.7'C)

Note: Abnormalities of vital signs are often clues to diseases, the aneranons in vital signs are used to evaluate a panenrsprogress.Five major areas to be discussed when taking a patient history:1. Chief complaint2. History of present Illness3. Spec ific drug allegeries4. Review of systems (heart, liver, kidney, brain, etc.)5. Nature of symptomsIn complicated cases, don't be hesitant to call patient's physician, previous dentists, or other health professionals.

Misc.ORAL SURGERY/PAIN CONTROLA surgical procedure for recontouring alveolar structures, usually in preparation fora prosthesis is called a (an):

Closed reduction Operculectomy Alveoloplasty Gingivoplasty


Alveoloplasty

An alveoloplasty is the surgical preparation of the alveolar ridges (i.e., removing under-cuts) for the reception of dentures or shaping and smoothing the socket margins afterextractions of teeth with subsequent suturing to insure optimal healing.

The objectives of this recontouring should be to provide the best possible tissuecontour for prosthesis support , while maintaining as much bone and soft tissue as pos-sible.

Remember:1. A closed reduction is the closing of the space between fractured bone without cut-

ting through the soft tissue or surrounding bond.2. A gingivoplasty is a surgical procedure to reshape the gingivae to create a nor-

mal, functional form.3. An operculectomy is the removal of the operculum. which is the flap of tissue over

an unerupted or partially erupted tooth.

Gen InfoORAL SURGERYIPAIN CONTROLWhich of the following is the most common error in recording blood pressure?

Applying the blood pressure cuff too tightly Applying the blood pressure cuff too loosely Overinflating the blood pressure cuff Underinflating the blood pressure cuff Use of the wrong size cuff


Applying the blood pressure cuff too loosely"'This will give falsely elevated readings

Use of the wrong cuff size can result in erroneous readings. A normal adult bloodpressure cuff placed on an obese patient's arm will produce falsely elevated readings.This same cuff applied to the very thin arm of a child will produce falsely low readings.The width of the compression cuff should be approximately 20% greater than the diam-eter of the extremity on which the blood pressure is being recorded.

If you need to take additional readings, a wait of at least 15 seconds is requiredbefore reinflating the blood pressure cuff.

Notes:1. Elective dental care should be postponed if the systolic blood pressure is greater

than 160 mm Hg or the diastolic pressure is greater than 100 mm Hg.2. Emergency dental care should be postponed if the systolic pressure is greater

than 180 mm Hg or the diastolic pressure is greater than 110 mm Hg.Po~'"1 .00 "\({:l\~ DQ ' " 0 0 t'~-E~EM'-'( :

\lo0 hoo \"b0ll\o


A prothrombin time (PT) of:

5-7 seconds is considered normal 6-9 seconds is considered normal 12-14 seconds is considered normal 20-25 seconds is considered normal


Gen Info

12-14 seconds is considered normal

"The PT (prothrombin time) results should be within 5-7 seconds of the control sam-ple

Other tests used to measure a patient's clotting mechanisms:

PTT (partial thromboplastin time): detects coagulation defects of the intrinsic system.Basic test for hemophilia. Normal value =25-36 seconds.

Bleeding time: (Ivy method), normal value = less than 9 minutes. Platelet counts: normal value =150,000-450,000 per 1 cu mm of blood. The mini-

mal platelet count for oral surgery is 50,000.

Important: Perhaps the single most important consideration in ruling out hemorrhag-ic disorder is history.

Note: The PT test is the bes st to erform in order to determine whether oral sur-gery can be safely performed on a patient taking coumadin (or any oral an icoequant.To be a good candidate for surgery, the PT time should be within 5-7 seconds of thecontrol sample.

ORAL SURGERY/PAIN CONTROLMajor oral surgery includes all of the following procedures except

The treatment of maxillary and mandibular fractures Exodontia Pre-prosthetic surgery Reconstructive surgery Traumatology


Gen Info

Exodontia"Including routine, multiple, and surgical extractions

Major oral surgery Includes: The treatment of fractures Pre-prosthetic surgery:

- Tuberosity reductions- Vestibuloplasty

Reconstructive surgery:- Orthognathic surgery- Facial deformities

Traumatology:- Treatment of wounds, injuries, and resulting disabilities

General concerns of surgery: Nutritional status of patient, body fluids & electrolytes, pre-op &post-op information, wound healing (i.e., primary, secondary) and most importantly infection.Note: The discipline of oral surgery is defined as "The diagnosis and surgical treatment ofinjuries, diseases, and malformation of the mouth and jaws."Remember : The difference between acceptable and an excellent surgical outcome rests on howthe surgeon handles the tissue.

Gen InfoORAL SURGERY/PAIN CONTROLAll of the following drugs can potentiate a patient's bleeding following an extractionexcept

Aspirin Anticoagulants Broad-spectrum antibiotics Antianxiety drugs Alcohol Anticancer drugs


Antianxiety drugs

If a patient is taking any one of these 5 drugs (aspirin, anticoagulants, broad-spectrumantibiotics, alcohol or anticancer) , you should be prepared to take special measuresin order to control the bleeding. Note: Patients with specific systemic diseases willalso have a prolonged bleeding time. These include nonalcoholic liver disease, hepati-tis, cirrhosis, and hypertension.Five means of obtaining wound hemostasis:1. By assisting natural hemostatic mechanisms: usually accomplished by placing a

cotton sponge with pressure on bleeding vessels or the use of a hemostat directlyon the vessel

2. By the use of heat on the cut vessels (called thermal coagulation)3. By suture ligation of the vessel4. By the placement of a pressure dressing over the wound: most bleeding from

oral surgery can be controlled this way5. By placing vasoconstrictive substances (epinephrine) on the woundRemember: Excessive bleeding causes the formation of hematomas which increasethe chance of infection.

ORAL SURGERY/PAIN CONTROLGen Info

Which of the following is the process by which the total removal of a cystic lesion isachieved?

Marsupialization Decompression Enucleation The Partsch operation


Enucleation

"" Enucleat ion is the treatment of choice whenever possible

Marsupialization, decompression, and the Partsch operation all refer to creating asurgical window in the wall of the cyst. The cyst is uncovered or "deroofed" and the cys-tic lining made continuous with the oral cavity or surrounding structures. The cyst sacis opened and emptied.Enucleation is the treatment of choice for: Congenital cysts Mucoceles Most odontogenic cystsMarsupialization is the treatment of choice for: Ranula -(Note: For a recurrent ranula treatment would also include the excision of

the sublingual gland.) When cyst is large and close to vital structuresWhether a bone cyst or other cysts are completely enucleated or treated by marsu-pialization depends on the size and location to vital structures.

ORAL SURGERY/PAIN CONTROL Gen Info

When performing CPR, if there is a pulse but the victim is not breathing, you shouldgive rescue breathing at a rate of:

2 breaths every 20 seconds 1 breath every 15 seconds 1 breath every 5 seconds 2 breaths every 30 seconds


1 breath every 5 seconds"r or 12 breaths per minute

CPRCARDIOPULMONARY RESUSCITATION

A - AirwayPlace victim flat on his/her back on a hard surface.Shake victim at the shoulders and shout ' are you okay? 'If no response, call emergency medical system - 911 then,Head-tll tlchin-Iift - open victim's airway by tilting their head back with one hand while lifting up their chin with your olherhand.

B - BreathingPosition your cheek close to victim's nose and mouth, look toward victim's chest, andLook, listen, and feel for breathing (510 seconds)If not breathing, pinch victim's nose closed and give 2 full breaths into victim's mouthIf breathswon't go in, repositionhead and try again to give breaths. If still blocked, perform abdominal thrusts (Heimlich maneu-ver)

C- CirculationCheck for carotid pulse by feeling for 510 seconds at side of victim's neck.If thera is a pulse but victim is not breathing, give rescue breathing at rate of 1 breath every 5 seconds or 12 breathsper minuteIf there Is no pu lse , begin chest compressi ons as follows:Place heel of one hand on lower part of victim's sternum. With your other hand direct ly on top of first hand, depress ster-num 1.5 to 2 inches.Perform 15 com ressions to every 2 breaths. rate: 80-100 per minute)Check for return of pu se

"'Contl nue un interrupted until advanced life support Is available

ORAL SURGERY/PAIN CONTROLWhat is the first step when init iati ng CPR?

Administer oxygen Establish unresponsiveness Administer epinephrine Place a cool towel on the person's forehead


Gen Info

Establish unresponsiveness (shake and shout, "are you OK?")Followed by ABC's: Airway (head tilt-chin lift): in most medical emergencies, this is the easiest tech-

nique for opening a victim's airway Breathing (look, listen, and feel) Circulation (check carotid pulse)

Important points to remember in CPR: If efforts are effective, the pupils will constrict If too much pressure is incorrectly applied directly over the xyphoid process, the

liver may be injured The result of interruptions in chest compressions while performing CPR is a reduc-

tion of the blood flow and fall in the blood pressure to zero

Remember, you should stop CPR only under the following conditions: If another trained person takes over CPR for you If EMS personnel arrive and take over care of the victim If you are exhausted and unable to continue If the scene becomes unsafe

Gen InfoORAL SURGERY/PAIN CONTROLSerum calcium will be increased in all of the following conditions except

Hyperparathyroidism Chronic glomeru lonephritis Diabetes mellitus Hypervitaminosis D Malignant diseases of the skeleton (i.e., multiple myeloma)


Diabetes mellitus

Calcium levels are regulated by parathyroid hormooe @creased hormone causes bone resorIGtion) which in turn increases calcium levels. Calcium is also regulated to some extent by the kid-ney tubules and GI mUcosa (iowenng pH will cause increased calcium absorption), Low serumcalcium levels will result in hyperirritabi lity of nerves and musc les,

Phosphorus concentration is also regulated by parathyroid hormone . Increased hormonecauses the kidneys to increase the rate of phosphate excretion which causes a decrease in plas-ma phosphate concentration.

Note ' ood health the ratio of calcium to phosphorus in the blood is 10: f there is a glandu-lar imbalance, especia y In regard to the parat yroi g an s, en this ratio will be maintained ata different level, causing long-term health deterioration. In part icular, a high ratio of phosphorusto calcium sensitizes the body and increases inflammatory tendencies.

BJnod glucose concentrat ion is regUlated by jnslJlin (Jowers glucose levels) !!Dd gil IcaOO-...,(increases glucose levels) . Glucose normally does not appear in the urine although it is freely fil-tered because it is reabsorbed in the proximal convoluted tubule of the kidney. Serum glucosewill be increased In diabetes mellitus, adrenal tumors, Increased growth hormone, andliver dysfunction.

ORAL SURGERYIPAIN CONTROLMinor oral surgery includes all of the following procedures except

Exodontia The treatment of maxillary and mandibular fractures The treatment of dental infections The treatment of hard tissue pathologies The treatment of soft tissue pathologies


Gen Info

The treatment of maxillary and mandibular fractures***This is considered to be major oral surgery

Minor oral surgery includes: Exodontia:

- Routine extractions, multiple extractions, and surgical extractions Treating dental infections:

- Periapical- Periodontal- Pericornitis- Facial infections (cellulitis)

Soft tissue pathology:- Biopsy- Benign lesions

Hard tissue pathology:- Alveoloplasty

ORAL SURGERY/PAIN CONTROLThe normal serum concentration of glucose is:

20-40 mg/dl 50-70 mg/dl 80-120 mg/dl 130-150 mg/dl

Copyr ight 2001 - DENTAL DECKS

Gen Info

80120 mg/dl

Normal laboratory values

Arterial blood gases:HC03 = 18 to 21 mEq/LpC0 2 =35 to 45 mmHgpH =7.38 to 7.44p02 = 80 to 100 mmHg

Calcium - 9 to 11 mg/dlCarbon dioxide - 21 to 30 mEq/LChloride = 98 to 105 mEq/LCholesterol

Total = 180 to 240 mg/dlEsters =100 to 180 mg/dl

Creatinine = 1 to 1.5 mg/dlGlucose = 80-120 mg/dl

Blood ChemistryOsmolal ity =280 to 300 mOsm/LPhosphatase

Acid =0.2 to 1.8 internat ional unitsAlkaline = 21 to 91 international units

Phosphorus = 3 to 4.5 mg/dl, 1-1.5 mEq/LPotassium =3.5 to 5.0 mEq/LProtein =5.5 to 8.0 g/dlSodium =136 to 145 mEq/LUrea nitrogen =10 to 20 mg/dl

UrinepH = 6.0 (4.7-8.0)specific gravity = 1.005 to 1.025


What is the proper rate of rescue breathing in an adult?

15 times per minute 12 times per minute 20 times per minute 25 times per minute


Gen Info

12 times per minute

CPR READY REFERENCEAdults Children Infants

Rescue breathing, victim hasa pulse, give 1 breath every 5 seconds 4 seconds 3 secondsNo pulse, locate compressionlandmark Follow ribs into notch, Same as adult One finger width

one finger on sternum below nipple lineCompressions are 2 hands stacked: Heal of one hand Two or threeperformed with heal 01 one on sternum lingers on sternum

on sternum

Rate 01 compressionper minute 80-100 80-100 At least 100Compression depth 1-1/2-2" 1-101/2" 1/2-1 "Ratio compressions to breath:1 rescuer 15:2 5:1 5:12 rescuers 5:1 5:1 5:1

Gen InfoORAL SURGERY/PAIN CONTROLThe American Society of Anesthesiologists would give what ASA classification to ahealthy young patient with an unremarkable medical history and no systemic dis-ease?

ASA-O ASA-I ASA-II ASA-V


ASA1

American Society of Anesthesiologists (ASA)Classification of Physical Status

ASA-1 A normal healthy patient

ASA-II A patient with mild systemic disease or signif icant health risk factor (such assmoking, excessive alcohol use, and obesity)

ASA-III A patient with severe disease that is not incapacitating

ASA-IV A patient with severe systemic disease that is a constant threat to life

ASA-V A moribund patient who is not expected to survive without the operation

ASA-VI A declared brain-dead patient whose organs are being removed for donor pur-poses

ORAL SURGERY/PAIN CONTROLWhich surgical approach listed below is the best to expose the TMJ?

Preauricular Submandibular Both are the same

Copy right 2001 - DENTAL DECKS

TMJ

Preauricular

Surgical approaches to the TMJ: Preauricular: The best incision to expose the TMJ. A perpendicular incision is made

just anterior to the external ear parallel to the superficial temporal artery. The inci-sion extends from one inch above the zygomatic arch to the lower extremity of theear. The condyle is approached from behind . Note: With this approach, care mustbe taken not to damage either the facial nerve or the vessels that richly supply thisarea.

Submandibular approach (Risdom approach): This is the standard surgicalapproach to the ramus of the mandible and neck of the condyle. It is not the bestapproach for procedures within the joint space itself.

Remember: The most common cause of TMJ ankylosis is trauma. However, ankylo-sis is the most common complication of rheumatoid arthritis.

ORAL SURGERY/PAIN CONTROL TMJ

What is the best way to palpate the posterior aspect of the mandibular condyle?

Intraorally Lateral to the external auditory meatus Through the external auditory meatus Any of the above


Through the external auditory meatus (canal)

The temporomandibular joint should be evaluated for tenderness and noise. Thejoint is palpated laterally (in front of the external auditory meatus) with the mandible ina closed and open position. The joint should also be palpated through the external audi-tory meatus with the mandible in a closed and open position. Note: The posterioraspect of the condyle is rounded and convex, whereas the anteroinferior aspect isconcave.

When the articular disc (or meniscus) of the joint and condyle of the mandible lackfunctional coordination, you will hear a click when a patient opens his/her mouth.Tenderness and sensitivity should be noted as well as joint noises (clicking and crepi-tus). The mandibular range of motion should also be determined. The normal range ofmovement of an adult's mandible is about 50 mm (opening) and 10 mm protrusivelyand laterally.Notes :1. NSAIDs are the first line of treatment for TMJ pain2. Benzodiazepines may be prescribed for significant muscle pain or spasms3. Moist heat to the affected area is helpful (no longer than 15 minutes per applica-

tion).4. Educate patient about bruxism and the need to avoid clenching and grinding teeth.

TMJORAL SURGERY/PAIN CONTROLWhich of the following is considered to be the most common cause of TMJ pain?

Internal derangement Degenerative joint disease (DJD) Myotascial pain dysfunct ion (MPD) syndrome None of the above


Myofascial pain dysfunction (MPD) syndrome

TMJ syndrome is divided into three categories: Myofascial pain dysfunction (MPD) syndrome: Is considered to be the most

common cause of TMJ pain. It is a disease primarily involving the muscles of mas-tication.

Internal derangement: Is defined as an abnormal relationship of the articular discto the mandibular condyle, fossa, and articular eminence (or tubercle) .

Degenerative joint disease (osteoarthritis): Is the organic degeneration of thearticular surfaces within the TMJ.

Important: The key mechanism for the cause of TMJ disorders is muscle dysfunc-tion (or muscle spasm)

MPD syndrome is believed to be a stress related disorder. This increase in stress pro-duces an increase in mandibular muscle tension and in combination with teeth clench-ing results in muscle spasm, pain, and dysfunction. Note: MPD often responds to anacrylic night guard (also called an occlusal separator or occlusal appliance) along witha soft diet, limited talking, and elimination of gum chewing. Moist heat applied to theface and nonsteroidal anti-inflammatory agents are also helpful during the acute phase.

ORAL SURGERY/PAIN CONTROLWhat is the only direction in which the TMJ can be dislocated?

Laterally Medially Anteriorly Posteriorly


TMJ

Anteriorly

Internal derangement of the TMJ is present when the posterior band of the articular discis anteriorly displaced in front of the condyle. As the articular disc translates anteriorly,the posterior band remains in front of the condyle and the bilaminar zone becomesabnormally stretched. Often the displaced posterior band will return to its normal posi-tion when the condyle reaches a certain point. This is termed anterior displaced withreduction. Note: When the articular disc reduces the patient often feels a pop orclick in the joint.In some patients the articular disc remains anteriorly displaced at full mouth opening.This is termed anterior displacement without reduction. Note: The articular disc canusually be reduced by inducing downward pressure on the posterior teeth and upwardpressure on the chin, accompanied by posterior displacement of the entire mandible.Note: The patient who has had reduction of a mandibular dislocation should beinstructed to limit opening of the mouth for two to three weeks.Remember: The most common cause of restricted mandibular movement is disc inter-ference disorders, which change the relationship of the disc and the condyle.

ORAL SURGERY/PAIN CONTROLImpl/Grfts

All of the following are contraindications to implant placement except one. Which isthe exception:

The presence of pathology within the bone The presence of limiting anatomic structures such as the inferior alveolar nerve or

maxillary sinus Unrealistic expectations of the patient Poor oral health and hygiene Patient's inability to tolerate implant procedures The patient has a pronounced gag reflex Acute illness or uncontrolled metabolic disease


The patient has a pronounced gag reflex

This may actually be an indication for the consideration of implant placement. Thisis because the patient may not be able to tolerate the placement of a removable pros-theses.

Other possible indications for implant placement include: Resorption of alveolar ridge or other anatomic considerations that do not allow for

adequate retention of conventional removable prostheses. Patient is psychologically unable to deal with removable prostheses. Medical condition for which removable prostheses may create a risk (i.e., seizure

disorder). . Loss of posterior teeth, particularly unilaterally.

Remember : Implants placed in the maxillary anterior region have the highest failure rate. Mobility of the implant is regarded as the most common sign of implant failure.

ORAL SURGERY/PAIN CONTROL Impl/Grfts

Which of the following is the most common indication for tooth transplantation?

Severe decay of a central incisor Severe decay of a first molar Severe decay of a third molar Severe decay of a canine


Severe decay of a first molar

The first molar is atraumatically removed, and the third molar is placed into thesocket. Success of the transplant is most predictable w hen the apices of the roots >of the tooth to be transplanted are ana third to one-ba lf formed with open apices andthe bordering bony plates are intact. Also, you need adequate mesiodistal width of thehost implant site, the absence of acute periapical or periodontal inflammatory states,and the general good oral health of the patient. Note: This is called an autogenoustooth transplantation, meaning a tooth from the same individual is moved toanother site. The most likely cause of failure will be a chronic, progressive externalroot resorption.

Important: The almost universal sequelae of an allogeneic tooth transplant isankylosis and progressive root resorption. An allogeneic tooth transplant meansthat a tooth from one individual is placed in another individual.

Remember: The change in continuity of the occlusal plane observed after ankylosisof a tooth is caused by the continued eruption of the other non-ankylosed teeth andgrowth of the alveolar process.


Which of the following are requirements for successful implant placement?

Mucosal seal Adequate transfer of force Biocompatibility All of the above


All of the above

Important: Mobility of the implant is regarded as the most important sign of implantfailure.

Steps in the assessment of patients prior to implant placement:

1. Dental and medical history2. Clinical examination3. Radiographic examination (panoramic and periapical)

The surgeon and restoring dentist must work together to ensure proper implantplacement and orientation. A surgical stent fabricated to the specifications of therestoring dentist can be helpful to ensure proper implant placement and orientation.Remember: Without proper planning, an implant may be successfully integratedbut impossible to restore.

ORAL SURGERYIPAIN CONTROLThe optimal bone grafting material should be of what origin?

Foreign Synthetic Autogenous Mixed


Impl/Grfts

Autogenous

Autogenous bone is bone from the same person (from one part of the body toanother). Autogenous grafts (also called an autograft) are usually employed to restorelarge areas of lost mandibular bones following oncological surgery or trauma. Of all thefacial bones resected in oncological surgery, the mandible is the most frequentlyremoved.

The bone marrow for grafting defects in the mandible and maxilla is generallyobtained from the iliac crest. Also used for ridge augmentation.

Notes:1. A costochondrial rib graft may be employed with the cartilaginous portion simu-

lating the TMJ and condyle. When used for ridge augmentation a lot of shrinkageis noted.

2. Bone plates, biphasic pins, titanium mesh, and intraosseous wires are used inthe fixation of bone grafts. Sutures are not generally used.

ORAL SURGERY/PAIN CONTROLAllaplastic grafts are:

Impl/Grfts

Those where the bone to be grafted to jaw is taken , or harvest from one's own body Taken from human donors Inert, man made synthet ic materials Harvested from animals


Inert, man made synthetic materials

For bone replacement a man made material that mimics natural bone is used . Most oftenhydroxyapatite (HA) is used for augmentation of the mandib le. Hydroxyapatite is a dense , blo-compatib le material that can be produced synthetically or obtained from biologic sources such ascoral. The granular or particle form is most commonly used for alveolar ridge augmentation.Note: When placed in a subperiosteal environment, HA bonds both physically and chemically tothe bone.Some advantages and disadvantages of restructuring an atrophic ridge with hydroxyapatitegranules: Advantages

It is a simple surgical technique suitable as an office procedure- No donor site is required to obtain autogenous bone graft material Hydroxypatite is totally biocompatibie and nonresorbable

DisadvantagesMigration of the hydroxypatite granulesPoor ridge form (inadequate heigh t)Abnormal coior under the mucosa

- Mental nerve neuropathyExcessive augmentation


Alloplastic materials used for augmentation genioplasty generally have a tendencyto do what?

Produce an immunologic response Be replaced by the host bone Migrate from the position in which they were placed at the time of surgery Be rejected


Migrate from the position in which they were placed at the time of surgery

Genioplasty is a procedure by which the position of the chin is surgically altered. Themost common techniques for genioplasty are osteotomy or augmentation with naturalor alloplastic materials.

There are two other problems that are frequently encountered when using alloplasticmaterials for genioplasty: Erosion of the chin prominence contiguous with the implant. Unpleasant sensation in the implant region when exposed to cold temperatures.

Note: The best way to enlarge the prominence of the chin for best long-term results isto reposition the lower border anteriorly by osteotomy (horizontal sliding osteotomy).

Remember: Alloplastic grafts are inert, man made synthetic materials. The modernartificial joint replacement procedures uses metal alloplastic grafts. For bone replace-ment a man made material that mimics natural bone is used. Most often this is a formof calcium phosphate (i.e.. tricalcium phosphate, calcium carbonate, or hydroxyap-atite).


The most commonly used allogeneic bone is:

Freeze-dried Artificial Neither of the above


Impl/Grfts

I

J

Freeze-dried

Allogeneic grafts (also called allografts or homografts) are composed of tissues takenfrom an individual of the same species who is not genetically related to the patient.They consist of freeze-dried bone and freeze-dried decalcified bone from anothersource (usually cadaver bone).

These grafts are treated to reduce the antigenicity. However, these treatments destroyany remaining osteogenic cells in the graft. These grafts offer a hard tissue matrix only;.!!Jis graft is eventuallv replaced by the bast bone

Important point: The host must produce all of the essential elements in the graft bedfor an allogeneic bone graft to become resorbed and replaced.

The advantages of this type of graft are that it doesn 't require another site of prepa-ration in the host and that a similar bone or a bone of similar shape to that beingreplaced can be obtained.


Implants that are surgically inserted into the jawbone are called:

Endosseous implants Subperiosteal implants Transosseus implants


Impl/Grfts

Endosseous implants---They are the most frequently used implants todayOral Implants can be categorized into three main groups:1. Endosseous Implants are implants that are surgically Inserted Into the jawbone. They are the most

frequently used Implants today. They are further subdivided into root form and blade form implants.2. SUbperiosteal Implants are frameworks specifically fabricated to l it on top of supporting areas in the

mandible or maxilla under the mucoperiosteum.3. Transosseous Implants are implants that are similar to endosseous implants in that they are surgically

inserted into the jawbone. However, these implants actually penetrate the entire jaw so that they actual-ly emerge opposite the entry site, usually at the bottom 01the chin. Note : Their primary ind ication is inthe very atrophic mandible where root form implants may lurther compromise the strength of the jaw.

Remember: Osseo lntegrated implants are anchored directly to lIying bone. This determination is..!!!.ade by radiographic and light microscopic analysis.... -Root form implants: Cylindrical in shape, can be threaded or non-threaded. 3 to 5 mm in diameter and 7 to 20 mm in length.

Typically made of titanium. Note : These implants are the most popular.Blade implants: Are wedge-shaped or rectangular in cross section. Typically made of titanium as well.Two basic types of implant placement:1. Submerged - requires a second surgical procedure (two-stage) to uncover the fixture.2. Nonsubmerged - does not require a second surgical procedure (one-stage) .


Allogeneic grafts (also called allografts) are composed of tissues taken from:

Another species An individual of the same species who is not genetically related to the recipient An individual of the same species who is genetically related to the recipient The same individual


An individual of the same species who is not genetically related to the recipientUsually cadaver boneClassification of grafts (or implants) Autogenous grafts (also called autografts) are composed of tissues taken from the same

Individual. Most frequently used in oral surgery. Allogenic grafts (also called allografts) are composed of tissues taken from an individual of

the same species who is not genetically related to the patient (usually cadaver bone). Isogeneic grans (also called isografts or syngenesioplastic grafts) are composed of tissues

taken from an individual of the same species who is genetically related to the recipient. ~enogeneic imp lants (also called xenografts or heterografts) are composed of tissues taken

from a donor of another species, for example. animal bone grafted to man (also called het-erograft). Rarely used in oral surgery.

Note: Rejection of the graft is most common when allografts or xenografts of bone and carti-lage are used in oral surgery. Autogenous grafts, although frequently presenting surgical andtechnical problems. do not as a rule involve rejection (or immunological complications).The ideal graft should: Be replaced by the host bone. Withstand mechanical forces. Produce no immunologic response (or rejection). Actively assist osteogenic (bone-form ing) processes of the host. The greatest osteogenic

potential occurs with an autogenous cancellous graft and hemopoietic marrow.

FracturesORAL SURGERY/PAIN CONTROLIf the fracture line results in a muscle pull displacing the fractured segment, it istermed a (an):

Favorable fracture Unfavorable fracture


Unfavorable fracture

The line of fracture will determine whether muscles will be able to displace the frac-tured segments from their original position: If the fracture line prevents the displacement of the fracture by muscle pull, it is

termed a favorable fracture. If the fracture line results in a muscle pull displacing the fractured segment, it is .

termed an unfavorable fracture.

The following radiographic views are often helpful to evaluate mandibular fractures: Posteroanterior view Lateral oblique view Towne view Panoramic view

Remember: The control of airway is vital to any treatment of a patient with facial frac-tures.


A patient with a paralyzed left lateral pterygoid muscle is instructed to open hismouth wide. Which direction will the mandible take upon opening?

To the right To the left Straight


To the left

-" The mandible will always deviate to the side of the injury.

A patient who sustained a subcondylar fracture on the left side would be unableto deviate the mandible to the right. This is normally treated by a closed procedureinvolving intermaxillary fixation. This procedure immobilizes the concomitant frac-tures and corrects the displacement of the jaws associated with the condylar fracturethereby correcting the shift of the midline toward the side of the fractured condyle andthe slight premature posterior occlusion on that side.


Which of the following can contribute to the non-healing (non-union) of a fracture?

Ischemia Excessive mobility Interposition of soft tissue Infection All of the above


All of the above

Four reasons that a fracture does not heal:1. Ischemia: The navicular bone of the wrist, the femoral neck, and the lower third of the tibia

are all poorly vascularized and therefore are subject to ischemic necrosis after a fracture.2. Excessive mobility: Healing is prevented and pseudoarthrosis or a pseudo-joint may

occur.3. Interposition of soft tissue: Occurs between the fractured ends.4. Infection: Compound fractures have a tendency to become Infected.

Note: A fat embolism is most often a sequela of fractures.

Inappropriate healing (three types): Delayed-union: satisfactory healing which requires greater than the normal six week period.

May be caused by infection, interposition of soft tissue or muscle between the fractured seg-ments.

Non-union: failure of the fractured segments to unite properly. May be caused by infection,improper immobilization, or interposition of soft tissue.

Mal-union: can be either delayed or complete union in an improper position. May be causedby improper immobilization or imperfect reduction.

FracturesORAL SURGERY/PAIN CONTROLA mandibular fracture that extends only through the cortical portion of the bone with-out complete fracture of the bone is called a:

Simple fracture Greenstick fracture Compound fracture Comminuted fracture


Greenstick fracture

'Greenstick fractures are closed fractures involving incomplete fractures with flexi-ble bone. Most often seen in children .

The following categories classify mandibula r fractures by describing the condition of thebone fragments at the fracture site and possible communication with the external envi-ronment: Simple - divides a single bone into two distinct parts with no external communica-

tion. These are closed fractures with no lacerations of the oral mucosa or facial tis-sues.

Compound - fracture commynicates with the outside environment (open fracture).This may occur by laceration of the oral tissues exposing the bone fragments , frac-ture of the maxilla into the sinuses, or by way of skin lacerations that would exposethe fractured segments. Infection is common.

Comminuted - multiple fractures of a single bone. They may be simple or com-pound.

Remember: The most common complication of an open fracture is infection .

FracturesORAL SURGERY/PAIN CONTROLWhich type of bone healing involves both endosteal and periosteal proliferation?

Primary (bone-fa-bone) Secondary (space fills in with cal/us)


Primary (bone-to-bone)

The healing of bone can be divided into three overlapping phases:1. Hemorrhage - occurs first and is associated with clot organization and proliferation

of blood vessels. This nonspecific phase occurs during the first 10 days.2. Callus formation - a primary callus is formed

Date post:	05-Sep-2015
Category:	Documents
Upload:	alaa
View:	67 times
Download:	5 times

Oral Surgery

Documents