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104 Cards in this Set
- Front
- Back
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preprosthetic surgery
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the surgical improvement of the denture bearing area and surrounding tissues (hard and soft) to support the best possible prosthetic replacement
a fxnal biologic platform for supportive or retentive mechanisms that will maintain or support prosthetic rehabiliation w/out contributing to further bone or tissue loss |
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the ideal alveolar ridge
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-proper jaw relationship
-proper configuration of alveolar process (broad U-shaped ridge w/ vertical components as parallel as possible) -no bony or soft tissue protuberances or undercuts -adequate attached keratinized mucosa in the primary denture bearing area -adequate vestibular depth; adequate bone heigth and width -"fixed tissue" under dentures -absence of redundant tissue -no obstructing fena or scar bands; no displacing muscle attachments |
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factors that impact fit of prosthesis (ex. denture or RPD)
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-bone quantity
-bone contour -muscle attachments -gingiva vs. mucosa |
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considerations for minor preprosthetic surgery
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-most can be done w/ LA
-advanced forms of pain control/sedation are helpful -pts are often old, infirm, and require workup and monitoring -restorative phase in 4-8 weeks postop |
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name some minor preprosthetic osseous surgical procedures
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bony recontouring of alveolar ridges:
simple alveoloplasty II II w/ buccal or labial cortical reduction intraseptal alveolectomy and cortical plate in-fracture (alveolar height preserved, width is lost; pinch the socket together) max tuberosity reduction tori removal: max and mand |
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alveoloplasty disadvantages
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accelerates bone loss
increased post-op pain potential complications - oral-antral communication in maxilla |
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name some minor preprosthetic soft tissue surgical procedures
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-labial frenectomy
-lingual frenectomy -maxillary tuberosity reduction -mandibular retromolar pad reduction -unsupported hypermobile tissue -inflammatory fibrous hyperplasia (caused by dentures) -inflammatory papillary hyperplasia of the palate |
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indications for frenectomy
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ankyloglossia - tongue tied (lingual frenum), when this impairs speech
to improve denture seating and stability |
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name some major preprosthetic surgical procedures
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relative ridge augmentation - moderate resorption; involves sulcus lenghthening (vestibuloplasty)
absolute ridge augmentation - extreme resorption of body of mandible (<2cm at mid-body); osteotomy and bone grafting indicated |
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limitations of bone grafting w/out use of dental implants
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ALL of newly grafted bone is gone w/in 5 years unless supported by dental implants (typically)
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name some major preprosthetic soft tissue surgical procedures
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vestibuloplasty - restore alveolar ridge height by lowering the muscles (mand)
3 types: mucosal advancement; secondary epithelization (Kazanjian's and/or Obwegeser's technique); and grafting (mucosal and skin graft done to prevent granulation and relapse of the area) |
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when are zygomatic implants used
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when there is severe bone loss in maxilla
these are pretty freaky lookin' on x-ray |
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what is distraction osteogenesis
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gradual bone lengthening - a process in which a bone is grown towards a distractor (look at the pictures in the slides)
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unerupted tooth vs. impacted tooth
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unerupted - failed to erupt into oral cavity at normal time and age
impacted - tooth that is completely or partially buried in soft tissue or bone |
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commonly unerupted and impacted teeth (in order of commonality??)
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mandibular 3rd molars
max K9s mand 2nd premolars max 2nd premolars mand K9s |
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failure to eruption etiology
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-injury to tooth germ
-crowding or disproportionate tooth and jaw size -premature loss of decidous predecessor and gingival fibromatosis -supernumerary teeth -tumors or cysts -cleft palate and alveolus |
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indications for removal of impacted teeth
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-pain or foci of infection (pericoronitis)
-damage to adjacent teeth -involvement in pathology (cysts/tumors) -orthodontic or prophylactic -interference in line of osteotomies and fractures |
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pericoronitis
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infection involving soft tissue surrounding crown of partially erupted tooth
-usually caused by streptococci and anaerobic bacteria -it may present as acute or chronic infection -acute infection develops over hours and days and associated possibly w/ systemic manifestation |
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impacted teeth - treatment options
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-no treatment (asymptomatic; vital structures are at risk in course of operation; acute pericoronitis - heal infection first)
-conservative management (bring to into occlusion by ortho; if tooth mesial to it has poor prognosis, mesial drifting might allow this tooth to replace it) -surgical repositioning and transplantation -exposure of teeth w/ or w/out orthodontic applicatoin -surgical removal |
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best timing for removal of impacted/unerupted teeth
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-before sclerosis of bone
-earlier to follicle atrophy -when it is infection-free -before complete development of roots -when 2/3 of root is formed |
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when does postoperative pt management begin
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PREOPERATIVELY
prepare pts in advance so they know what to expect after surgery (informed consent) after procedure provide detailed instructions; include what pt is likely to experience and WHY |
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post-op hemostasis instructions
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Pressure (damp guaze over socket for 30 min)
Bite, Don't Chew |
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is post-op oozing normal
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yes, up to 24 hours - mostly saliva mixed w/ blood
do not spit it out, swallow, avoid negative pressure in mouth (to not dislodge blood clot) |
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if heavy recurrent bleeding post-op
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reapply damp guaze for 30 min (or a moistened tea bag)
elevate head ice |
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when should pt take 1st dose of pain medication post-op
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before LA wears off
pain more effectively controlled in earlier stage than at peak |
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diabetic pt considerations post-op
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maintain ideal glucose levels
consider more liberal use of antibiotics |
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edema post-op
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may increase for 24-72 hours
ice application for first 24 hours and elevate head |
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heat application post-op
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only after edema has reached its peak
heat increases fluid mobility and will remove excess fluid (after peak) |
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swelling that increases after 3rd postoperative day --=>
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may indicate infection
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ecchymosis post-op
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older pts due to decreased tissue tone
lasts 2-4 days post-op resolves in 7-10 days |
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oral infections are mostly poly-microbial, however, which type of microbe predominates
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anaerobes (75%)
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acute infection microbe types vs. chronic infection microbe types
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acute = mostly gram + aerobes
chronic = mostly anaerobes |
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cellulitis vs abscess
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cellulitis - aerobic, diffuse borders, no pus, more serious, acute
abscess - anaerobic, circumscribed, pus, less serious, chronic |
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indications for antibiotics
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- severity of infection (acute onset)
- adequacy of removing source of infection - state of pt's host defense |
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penicillin
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-beta lactam
-MOST COMMONLY USED IN ORAL SURGERY -1st choice for odontogenic infection -bactericidal -G(+) cocci and rod, spirochetes, anaerobes groups: natural (narrow spectrum), extended spectrum - include G(-), combine beta-lactamase inhibitor (fights bacteria often resistant to penicillin), penicillinase-resistant (salivary gland infections) -may lead to GI upset and diarrhea; some people are allergic |
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clindamycin
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-most G(+) and anaerobic organisms and Staph
-good bone penetration -useful in severe odontogenic infection ---> C. difficile; expensive |
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metronidazole
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-G(-) anaerobic
-well absorbed into abscesses -bactericidal -avoid in liver failure and pregnant women -disulfiram action w/ alcohol, warfarin |
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cephalosporin
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-G(+) cocci, and many G(-) rods
-2nd choice |
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antibiotics points to remember
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-use the right drug
-use the right dose -use correct dosing schedule -avoid combination of bacteriostatic and bacteriocidal drugs -consider if infection is present >3 days or if no improvement |
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top 4 most common reasons for antibiotic failure
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1- failure to surgically eradicate source of infection
2- too low blood antibiotic concentration 3- inability of antibiotic to penetrate site of infection 4- impaired/inadequate host defenses |
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3 characteristics of pain that occur after extraction
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1- pain is not severe and can be managed in most pts w/ mild analgesics
2- peak pain experience occurs 12 hrs after extraction and diminishes rapidly after that 3- significant pain from extraction rarely persists longer than 2 days post-surgery |
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analgesic
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drug or preparation that will reduce or eliminate pain
use the least amt of mildest drug likely to be effective |
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mild pain drugs
moderate pain drugs severe pain drugs |
mild (non-narcotics - ibuprofen (peak blood level at 1-2 hours) or acetaminophen (peak blood level at 30 minutes) -- can combine NSAID and Acetaminophen
moderate (narcotics - addictino potential) - codeine (high dose can lead to respiratory depression) or hydrocodone severe - oxycodone (lethal effect w/ alcohol) |
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opioid antagonists
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compete w/ opioids for receptor sites
naloxone - oldest nalmefene - newer, longer duration naltrexone - used in maintenance of opiate free states in opiate addicts |
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mode of action of corticosteroids post-surgery
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supression of each stage of inflammtory response
inhibit production of vasoactive substances such as prostaglandins and leukotrienes as well as decreasing number of chemical attractants like cytokines recommended to give dose of steroids = to 300 mg of cortisol during complex oral surgical procedures |
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commonly used steroids in oral surgery
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dexamethasone
methylprednisolone betamethasone |
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airway problems postoperative (hospitalized pt)
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after extubation - narrowing or obstruction of airway can occur; often due to trauma to mucosal lining during intubation that leads to edema
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name some common postoperative concerns (hospitalized pt)
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postoperative airway problem
nausea and vomitting fever fluid and electrolytes - make sure pt is getting needed liquids and Na+, K+, and Cl- to avoid hypovoemia (shock??); often this is done through IV during surgery (Ringer's solution) blood transfusion - rarely required |
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how to prevent complications
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-preoperative assessment (pt hx's)
-know your limitations -adequate treatment plan -follow surgical principles |
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how to avoid soft tissue injuries
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-make flaps of adequate size
-retractors should contact bone -reposition and secure flaps properly -preserve viable tissue |
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if during extraction, root/tooth goes into infratemporal fossa
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if initial attempt to retrieve fails, refer to OMS for delayed removal
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immunity against intraoral infection is dependent on...
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-humoral immune response
-cell mediated immune response -local factors in immune response problems w/ any of above increase potential for infection |
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etiology of odontogenic infections (5 areas from where infections can begin)
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1- pulpal infections
2- periapical abscess 3- periodontal abscess 4- pericoronal abscess 5- infections from root stumps |
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predominant type of organism in oral infections
acute vs. chronic |
aneaerobes - 75% in most
acute - gram+ aerobes chronic - anaerobes predominate |
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cellulitis
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-diffuse, reddened, brawny, swelling tender on palpation
-inflammatory process not yet forming a true abscess -micro-organisms have just begun to overcome host defenses and spread |
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abscess formation
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-inflammatory response matures and abscess develops
-localized collection of pus |
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when palpating area of swelling, what are you looking for...
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-induration - no bounce back
-fluctuant - fluid like movement w/in tissues -doughy |
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definitive treatment of oral and para-oral infections
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-remove cause
-drain -prescribe appropriate antibiotic -supportive care (rest, nutrition) -re-eval |
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indications for to perform culture on infection
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-rapidly spreading
-post-op infection -non-responsive infection -recurrent infection -compromised host defenses |
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principles of antibiotic selection
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-narrow spectrum
-based on ident. of causative organism and sensitivity -compatible w/ pts drug hx -empiric therapy -narrowest spectrum w/ lowest toxicity -bactericidal -be aware of cost to pt |
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most common antibiotics in oral infections
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penicillin, clindamycin, metronidazole
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space infections that can arise from a maxillary odontogenic infection
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buccal space
canine space infraorbital space infratemporal space temporal space |
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common mandibular space infections (all end in space, not typed however)
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sublingual
submental submandibular buccal masticator (submasseteric) |
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name some serious (life-threatening) space infections
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ludwig's angina
cavernous sinus thrombosis lateral pharyngeal space infection retropharyngeal space infection |
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ludwig's angina
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bilateral sublingual, submandibular, submental, and cervical infection or CELLULITIS displacing tongue w/ potential AIRWAY OBSTRUCTION
cause - periapical abscess related to lower molar teeth treatment - hospitalize immediately; culture anaerobes; IV-antibiotics; drain; monitor airway |
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cavernous sinus thrombosis
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marked edema and congestion of eyelids and conjunctiva as result of impaired venous drainage; initally unilateral and rapidly --> bilateral
treatment - hospitalization; neurosurgical consult; intensive antibiotic therapy; heparin to prevent extension of thrombosis |
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isolated dento-alveolar fractures are more commonly seen among...
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children and adolescents
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different classifications of dento-alveolar injuries
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-dental hard tissue injury (tooth fracture)
-periodontal injury (concussion; subluxation; extrusive/intrusive luxation; lateral luxation; avulsion) -alveolar bone injury -gingival injury -any combination of above |
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key items to assess when examining pt w/ dentoalveolar fracture
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-consciousness of pt
-time of injury -med hx -clean the area -clinincal and x-ray exam (displacement, mobility, periradicualt damage, pulpal damage) |
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before treating dento-alveolar fracture, what 2 things should you consider
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-tetanus booster
-antibiotic therapy |
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prognosis of dentoalveolar fracture influenced by...
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-open root apices (younger pts)
-intact gingival tissue -abscence of root fracture -periodontal bone support |
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facts about injuries to primary dentition
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-70% involove max CI
-intrusion, lateral luxation and avulsion are most common -intruded teeth are likely to normally erupt spontaneously -damage to developing permanent teeth by displaced tooth is a recognizable problem treatment - if displacement is minimal w/ no occlusal interference, monitor w/out treatment; anything major - extract |
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avulsion
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-complete displacement of tooth our of socket
-time out of mouth is critical (if PDL dries for >2 hrs, all cells are dead) -place tooth in milk, saliva, water, or HBSS -immediate replantation and semi-rigid splinting for 1-2 weeks is best -RCT w/in 2 weeks (remove pulp first, obturate only after no signs of resorption) -recall and re-eval |
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management of loosened, luxated and extruded teeth
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reposition and splint for 1-3 weeks w/ semi-rigid splint: acid etch composite, arch bar, ortho wire, stainless-steel wire-loop, vacuum formed splint
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alveolar injury facts
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-in mand = assoc. w/ complete fracture of load bearing area; in max = often isolated
-teeth might not be damaged but deviilization should be expected -often two distinct fragment containing teeth -treatment - reposition and splint for 3-4 weekds; monitor pulp vitality; root apices in line of fracture or pulpal healing are jeopardized |
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the phases of normal hemostasis
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1- vascular phase - blood vessel is damaged, vasoconstriction results
2- platelet phase - platelets adhere to the damaged surface and form temporary plug 3- coagulation phase - through intrinsic/extrinsic pathways, the conversion of fibrinogen to fibrin is completed; fibrin bind tightly binds the platelets to form a clot |
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normal hemostasis is dependent upon
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vessel wall integrity
adequate numbers of platelets properly functioning platelets adequate levels of clotting factors proper function of fibrinolytic pathway |
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in healthy pts, postoperative bleeding is mainly due to....
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-local causes (vs. systemic causes in less than healthy pts)
- these originate either in soft tissue or bone |
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soft tissue bleeding - local causes of hemorrhage
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-arterial - bright red and spurting (greater palatine artery in post of hard palate, buccal artery lateral to retromolar pad)
-venous - dark red and flows steadily and heavily -capillary - bright red in color and is more of a minimal ooze |
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osseous (bony) bleeding - local causes of hemorrhage
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-originates either from nutrient canals in alveolar region, central vessesl (inferior alveolar artery), or from central vascular lesions (hemangioma or vascular malformation)
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name some systemic causes of hemmorhage in oral surgery
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hemophilia, Von Willebrand's disease; thrombocytopenia (decreased platelet count), leukemia; pts w/ uncontrolled hypertension; H/O prosthetic heart valve replacement; stroke victims (on blood thinners)
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types of hemorrhage
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-primary - during surgery, as result of injury (laceration) of artery; also occurs post-op in infected area w/ lots of granulation tissue; this bleeding is normal and easily controlled
-intermediate/reactionary - occurs w/in few hours post-op; result of failure of coagulation to occur; also in pts who unknowingly disturb/dislodge the clot -secondary - 7-10 days post-op, due to partial division of blood vessel in combination w/ infection; not frequently encountered after oral surgery procedures |
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management of primary hemorrhage
to manage intermediate and secondary, identify cause and treat in similar manner as primary |
-pressure
-electrocautery to control soft tissue bleeding -secure/ligate blood vessels w/ silk sutures -hemostatic agents like bone wax, surgicel (osseous bleeding) |
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local measures or synthetic materials used to aid in hemostasis
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-surgicel - oxidised regenerated cellulose
-gelfoam w/ activated thrombin -avitene (microfibrillar collagen) -collagen plug -tranexamic acid 5% (in syringe) |
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laboratory measures for managing pts w/ normal bleeding
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-platelet count - normal is 100-450K; any <100,000 = thrombocytopenia
-bleeding time - normal is 2-8 minutes -prothrombin time - effective ness of extrinsic pathway; 10-15 secs -partial thromboplastin time - measure effectiveness of intrinsic path; 25-40 secs |
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weakest spots on the mandible
distribution of fractures in most likely areas |
angle of mandible or 3rd molar area - 24.5%
socket of K9 or symphysis area - 22% condyle - 29.1% - the most common mandibular fracture, can --> retroauricular ecchymosis (hearing problems), staph infections, meningitis, and other joint problems |
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blood supply of the mandible - important to note for mandibular fractures
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-internal max artery from external carotid
-endosteal supply via ID artery and vein through mandibular foramen -periosteal supply, important in elderly pts as aging diminishes inferior alveolar artery |
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nerve injuries associated w/ mandibular fractures
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-inferior alveolar nerve through mandibular foramen and mental nerve through mental foramen
-inferior dental nerve -facial nerve palsy by direct trauma to ramus |
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greenstick fracture
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incomplete fracture, periosteum intact (typical in children
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simple fracture
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does not violate mucosa or skin
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open fracture
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associated w/ bone exposures through tissue avulsions
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comminuted fracture
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involving multiple fragments of bone which are independently dislocated
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fracture of ramus: type 1 and 2
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type 1 - single fracture - mimics low condylar fracture that runs below sigmoid notch
type 2 - comminuted fracture - common w/ missile injuries; little displacement due to effects of muscles |
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midline fracture of mandible
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-most common missed fracture (always a fine crack)
-often assoc w/ condylar fracture -long K9 tooth represents weak area and contributes to this fracture |
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treatment options for pts w/ mandibular fracture
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-no treatment - soft diet
-maxillomandibular fixation -open reduction - rigid/non-rigid fixation -external pin fixation -lag screw, DCP |
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principles of treating mandibular fracture
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-reduce fragments in good position
-immobilization until bony union appears -soft tissue repair -restore fxnal alignment of teeth |
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goals of rigid fixation in mandibular fractures
advantages of rigid fixation |
-rapid union of bone segments
-complete restoration of original or designed bone form -early active mobilization advantages - direct bone healing; early (immediate) post-op fxn; improved pt comfort; and other common sense advantages |
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open reduction and internal fixation (O.R.I.F) mini plating technique for fixation of mandibular fractures
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-always fixed monocortically
-2 screws on each side of fracture line |
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commonly used rigid fixation techniques
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non-compression small plates
compression plates miniplates lag screws resorbable plates and screws |
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buttresses of the midfacial skeleton
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-midface is made up of thin bones encased and supported by buttresses
-this absorbs and transmits forces applied to facial skeleton -they are weak in the sutures, lining tissues, and air-fill cavities - CRUMPLE ZONE |
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vertical buttresses of midface
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-nasomaxillary
-zygomaticomaxillary -pterygomaxillary |
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horizontal buttresses of midface
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-frontal bar
-zygomatic process of temporal bone -maxillary alveolus and palate -greater wing of sphenoid bone |
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zygomatic fractures
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-most commonly cause cheek deformities
-can be connected w/ fractures of orbital floor (eye damage) |
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Le Fort fracture patterns
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-Le Fort I - maxilla to base of nose; floating maxilla or Guerin fracture
-Le Fort II - base of nose to superior orbital area; mobility of maxillary and nasal complex; Fish Face deformity; injury to infra-orbital nerve -Le Fort III - superior orbital area to ears; disconnection of face from cranium (craniofacial dysjunction) |
