INBDE Bootcamp High-Yield Oral Surgery PDF

INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Impacted teeth Congenitally missing teeth Most commonly affected: Mo...

INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Impacted teeth Congenitally missing teeth Most commonly affected: Most commonly affected: 1. Mandibular third molars 1. Maxillary and mandibular third molars 2. Maxillary third molars 2. Mandibular second premolars 3. Maxillary canines 3. Maxillary lateral incisors Extractions Indications Contraindications Severe caries Poorly controlled medical conditions Endodontic ○ Diabetes, end-stage renal disease, angina, bleeding disorder, etc. ○ Internal root resorption Immunocompromised or immunosuppressed Periodontal ○ Leukemia, lymphoma, high doses of steroids ○ Severe attachment loss History of head & neck radiation Orthodontic ○ Increased risk of osteoradionecrosis ○ Severe crowding History of bisphosphonates Cracked teeth ○ Increased risk of medication-related osteonecrosis of the jaw (MRONJ) Ankylosed teeth, complicated impactions, or supernumerary teeth ○ Not an absolute contraindication, dependent on type & duration of bisphosphonates ○ Surgical procedures should be conservative Extraction procedure Basic steps Third molars 1. Sever soft tissue attachment with periosteal elevator Extraction will eliminate periodontal problems, alleviate pain, allow cleaning of 2. Luxate tooth to expand socket second molars 3. Deliver tooth with forceps Maxillary third molars should be delivered distobuccally 4. Curette socket, smooth bone, irrigate Primary closure Forceps Physical closure of a wound at the end of surgery Seat as apically as possible, place along lingual surface, then buccal Not necessary in non-surgical extractions, as it damages mucosal tissue Deep into sulcus, along long axis of the tooth Toward the center of resistance Secondary closure Most initial movements are buccal, then lingual (due to thinner buccal plate) Wound left open at the end of surgery Rotary movement for single-rooted teeth Will heal via granulation, contraction Apical pressure to expand socket Post-op instructions Surgical extractions Gauze pressure Consider for long or divergent roots, endo-treated, crown fracture, retained roots Soft diet Often requires full-thickness flap (buccal flap to avoid lingual nerve damage) No negative pressure Removal of buccal bone to create trough No smoking Removal of interradicular or cortical bone Salt water rinse after 24 hours Sectioning of tooth © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Extractions Complications 1. Subperiosteal abscess 4. Nerve injury Infection under the periosteum due to trapped necrotic bone or tooth Common with extraction of mandibular third molars, IAN block Treatment: irrigate to remove bone or tooth Refer to OMFS if they do not have normal sensation after one month 2. Oro-antral communication (sinus exposure) 5. Tooth displacement Common with maxillary first molars Maxillary sinus: maxillary first and second molars 6 mm: flap surgery to close 6. Bleeding 3. Alveolar osteitis Risk increases for patients on blood thinners or with bleeding disorders “Dry socket”, dislodged blood clot, extremely painful Treatment: gauze pressure, sutures, hemostatic agents (gelfoam, topical thrombin) Multifactorial: associated with oral contraceptive use, smoking, and using straws Treatment: anesthetize, irrigate, dry socket paste with eugenol, pain control Flap design Flap considerations Wide base, incision over intact bone, vertical releases at line angles Avoid vital structures such as arteries, nerves, and thin tissue 0 vertical releases 1 vertical release 2 vertical releases For apicoectomy of maxillary anterior teeth Down the midline of the palate for torus removal © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Grafting Performed after some extractions to preserve ridge Performed independently to restore bony defects or gain ridge thickness Type and source Osteoconductive Osteoinductive Osteogenic Provides scaffold for new bone Presence of signals to encourage tissue growth Capable of growing tissue Autograft: same individual + + + Allograft: same species + +/- - Alloplastic: synthetic or natural materials, + - - not from living source Xenograft: other species (bovine, porcine) + - - Implants Most commonly used implant is endosteal Implant components Implant body Cover screw Healing abutment Impression coping Inserted into osteotomy Soft tissue is closed over screw Used in single stage implant placement, Inserted into implant body when taking Made of titanium, highly biocompatible Second stage surgery needed to uncover emerges from the soft tissue conventional impression Various diameters and lengths screw after healing Contours tissue for restoration Coping is different based on closed tray or open tray technique Scan body Implant analogue Abutment and screw Implant crown Used when taking digital impression for Used by lab when pouring cast to Can be custom or stock, 1 piece or 2 Cement-retained: good for esthetic zones implant crown replicate position where implant has been pieces because no screw hole placed Connects the implant body to the Screw-retained: presence of access hole, restoration easier to remove Indications and contraindications Forces exerted on implants Measurements for placement Indications 1 mm: from buccal/lingual plate, inferior Replace missing tooth border of mandible, maxillary sinus, nasal cavity Contraindications Inadequate vertical or horizontal bone 1.5 mm: from adjacent natural teeth thickness 2 mm: from IAN Uncontrolled medical conditions or immunocompromised 3 mm: from adjacent implants History of head & neck radiation or bisphosphonate use 5 mm: from mental nerve Bruxism Children and adolescents Common width of implant: 4 mm © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Implants Stability Bone quality Primary stability: biomechanical stability of the implant when it is first placed Ordered most dense to least dense: Type I: anterior mandible (best primary stability) Secondary stability: osseointegration of the implant into the bone, long-term healing Type II: posterior mandible (best osseointegration) Osseointegration describes a direct histologic connection between the bone and Type III: anterior maxilla implant Type IV: posterior maxilla (worst prognosis for implants) Trauma & surgery Traumatic injuries Orthognathic surgery Midface fractures Le Fort I - For retrusive maxilla, Le Fort I: - Horizontal across osteotomy: vertical maxillary excess maxilla - Le Fort I fracture created - Only maxillary bone to move upper jaw forward involved or upward Le Fort II: - Pyramidal across midface Bisagittal split - For retrusive or protrusive - Involves orbits and osteotomy mandible nasal bones (BSSO): - Splitting of the mandible to set it back or bring it forward Le Fort III: - Most common complication is nerve - Complete craniofacial damage (IAN) disjunction - Involves zygomatic arch Distraction - Appliance provides osteogenesis: gradual traction that allows for bone deposition Mandibular fractures - Osteotomy phase → From most common to least common: latency phase → distraction condyle > angle > symphysis phase Simple: Closed to the oral cavity Compound: Open to the oral cavity (breaks skin) Greenstick: Partial thickness fracture Comminuted: Fractured in multiple pieces © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Trauma & surgery Trauma to permanent teeth Concussion Subluxation Avulsion Extrusion Tooth has sore PDL No splinting required Tooth has increased mobility Separation of tooth from alveolus Tooth is displaced coronally Flexible splint, 2 weeks Reimplant clean tooth in socket Flexible splint, 2 weeks Storage mediums: milk > Hank’s balanced salt solution > saliva > saline Flexible splint, 2 weeks Lateral luxation Intrusion Alveolar fracture Root fracture Tooth is displaced laterally Tooth is displaced apically Alveolar bone fractured, Root fractured horizontally Flexible splint, 4 weeks Flexible splint, 4 weeks usually with lateral luxation Flexible splint for 4 weeks, Rigid splint, 4 weeks but 4 months if it is in cervical ⅓ Biopsy Cytology/brush Fine needle aspiration Incisional Excisional Scrape lesion with brush, tongue Aspirate contents with needle and Incise deep narrow wedge of lesion, Remove the entire lesion, extending to depressor syringe extending to normal tissue normal tissue For large areas with dysplastic change For radiolucent or fluid-filled lesions For lesions > 1 cm, suspected malignant For lesions < 1 cm, suspected benign © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com Wound healing Stage Time frame Physiologic process Hemostasis Immediately to two days Vasoconstriction Blood clot stabilization through clotting factor release and thrombus formation Inflammation 24 hours to two weeks Infiltration of neutrophil granulocytes, macrophages, lymphocytes Migration of keratinocytes Microbe removal and phagocytosis of debris Proliferation Three days to weeks Migration and proliferation of endothelial cells, fibroblasts, and epithelial cells Formation of granulation tissue and re-epithelization via keratinocytes Angiogenesis Wound contraction Collagen synthesis and deposition Maturation/remodeling Three weeks to years Continued deposition of collagen Secretion of growth factors, matrix metalloproteinases TMJ Disc displacement Opening patterns Other pathology With reduction: articular disc is displaced anterior to Deflection: at maximum opening, jaw moves toward Dislocation: condyle is displaced out of position in the fossa, condylar head, “click” as condyle pops over disc on the side that is stuck anterior to the articular eminence → requires manual opening/closing manipulation to move the condyle back into place Deviation: at maximum opening, jaw moves toward Without reduction: articular disc is displaced anteriorly and one side and then goes back to the midline Ankylosis: trauma, surgery, or infection causes the mandible condyle cannot reduce back into fossa, resulting in a “lock” to become fused to the fossa; can be a fibrous or bony fusion of condyle in place → ipsilateral deviation © Bootcamp.com  INBDE Bootcamp High-Yield Oral Surgery | Bootcamp.com TMJ Nonsurgical treatment Surgical treatment Counseling Arthrocentesis: flush out superior joint space Medical therapy: NSAIDs, steroids, analgesics, muscle relaxants Arthroscopy: instrument superior joint space Physical therapy Arthroplasty: disc repositioning surgery Occlusal splint Discectomy: disc repair or removal Condylotomy: vertical ramus osteotomy Total joint replacement Medical emergencies General steps = SPORT Airway obstruction Anaphylactic shock Asthma 1. Stop treatment Signs/sx: difficulty breathing, hands Severe allergic reaction Difficulty breathing due to constriction of 2. Position the patient properly around neck Signs/sx: rash, difficulty breathing, low bronchioles 3. Oxygen Tx: Clear throat of foreign objects, check BP, nausea, vomiting Signs/sx: wheezing 4. Reassure the patient for breathing, chin tilt, back blows, Tx: albuterol, epinephrine, antihistamine, Tx: albuterol inhaler 5. Take vitals Heimlich maneuver oxygen, EMS Avoid triggers of asthma attacks Prevention is key → throat pack Prevention is key → accurate health history Angina Myocardial infarction Epinephrine overdose Hyperventilation Chest pain due to ischemia of heart Ischemia of heart tissue with necrosis Due to intravascular injections of local Breathing uncontrollably, too much O2 tissue Occlusion of major coronary vessel anesthetic with epinephrine and not enough CO2 Tx: oxygen, nitroglycerin (NTG), aspirin Signs/sx: chest pain, difficulty breathing, Signs/sx: increased BP and HR Signs/sx: dizzy, weak, lightheaded ○ NTG → wait 5 min → NTG → wait nausea/vomiting, pain (jaw, neck, arm) Tx: beta blockers Tx: sit upright, decrease O2 intake by 5 min → aspirin, EMS Tx: MONA: morphine, oxygen, Prevent by calculating proper dose of breathing through one nostril or pursed ○ Position patient upright nitroglycerin, aspirin, EMS local anesthetic, aspirate during injection lips, relaxation techniques ○ Position patient upright Only condition where supplemental O2 is outright contraindicated Diabetic complications Seizure Stroke Syncope Hypoglycemic: sweating, pale, irritable, Abnormal brain electrical activity Blocked blood supply to brain or burst Fainting, most common emergency hungry, sleepy Signs/sx: uncontrollable jerking, staring, blood vessel ○ Vasovagal syncope: anxiety related ○ Conscious tx: glucose tab, juice temporary loss of consciousness or Signs/sx: facial droop, arm drift, slurring ○ Orthostatic hypotension: blood ○ Unconscious tx: IV dextrose, IM awareness speech pressure decreases upon standing glucagon, EMS Tx: remove objects from mouth, do not Tx: administer O2, EMS up Hyperglycemic: dry mouth, thirsty, restrain, benzodiazepine Signs/sx: reduced HR and BP, loss of headache, blurred vision, weak ○ Grand mal: dilantin, phenytoin consciousness ○ Tx: activate EMS ○ Status epilepticus: valium, Tx: Supine or left lateral decubitus diazepam (pregnant) position, ammonia © Bootcamp.com