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Impacted Teeth
Fail to erupt into dental arch w/in the expected time
Mandibular third molars > maxillary third molars > maxillary canines
Primary reason is inadequate arch length
Winters Classification
For impacted third molars
Based on position of long axis of the 3rd molar in relation to the long axis of the 2nd molar
For lower molars:
o Mesioangular = easiest
o Disoangular = most difficult (D for distoangular and D for difficult)
Pell and Gregory Classification
For impacted lower third molars only
Class A: same plane as other molars
Class B: halfway down from other molars
Class C: below cervical line (CEJ) of 2nd molar (most difficult, more bone coverage & close to IAN)
Class 1: crown anterior to ramus
Class 2: half crown within ramus
Class 3: entire crown within ramus (most difficult, more bone coverage & close to IAN)
Subperiosteal Abscess
Infection/pus trapped under periosteum layer
When necrotic bone/tooth has been left behind underneath a flap following a surgical extraction
Possible whenever a mucoperiosteal flap is elevated for surgical extraction
Irrigate thoroughly to removed fractured tooth pieces or bony spicuels below the soft tissue
Tooth Displacement
Maxillary first/second molar Maxillary sinus
Maxillary third molar Infratemporal fossa**
Mandibular third molar Submandibular space
Tooth lost into oropharynx, send to ER for chest and abdominal xrays
Instrumentation
Bite block
Soft rubber block patient can bite down on
Used to keep patients mouth open which provides better visualization
Stabilizes the mandible which provides comfort for patient
Suction Tips
Yankauer suction: soft tissue (soft tip, can suck up fluid)
Frazier suction: hard and soft tissue (hole can be covered to for stronger/rapid suction)
Towel Clip
Holds drapes places around patient
Locking handle with finger and thumb rings
Careful not to pinch patient skin
Periosteal Elevator
Woodson periosteal: small and delicate
o Sharp end: lift flap
o Broad end: elevate and reflect flap
#9 Molt periosteal: larger
o Sharp end: reflect papilla, lift flap
o Broad end: elevate/separate periosteum from bone
Elevators
Parts: Blade, Shank, Handle
Grip: Palm grip, pointer finger can rest near blade for optimal control
Used to: Disrupt PDL fibers, luxate teeth, expand alveolar bone
Extraction Forceps
150: Universal uppers (A premolars, S primary)
151: Universal lowers (A premolars, S primary)
23 (Cowhorn): Lower molars, two sharp beaks to engage bifurcation
88R/L: Upper molars, two beaks for palatal root, one beak for buccal bifurcation
74 (Ash): Mandibular premolars
65: Upper root forceps
Hold blade
handle with pen
grasp for max
control
Irrigation
Use steady stream of sterile saline or water during bone removal
Prevents heat generation that can damage bone
Increases efficiency of surgical bur
Curettes
Spoon shaped end for scraping away soft tissue at base of socket
Always curette a socket once you remove the tooth to get rid of soft tissue (better clotting and healing)
Air-Driven Handpiece:
drives air into socket
air into fascial spaces
air emphysema
Hemostat
Designed for hemostasis: clamp blood vessels closed before suturing or cauterizing it
Useful for blunt dissection of soft tissue such as in I&D (insert into incision closed, open once inside)
Curved or straight beaks
Serrated end allows for grasping
Needle Holder
Short stout beaks
Face of beak is crosshatched: allows for positive grip of suture needle unlike hemostat
Suture
Needle and thread
Primary purpose is to immobilize a flap
Suture should be placed from movable tissue to non-movable tissue
Simple interrupted is the easiest and most common technique
Silk has wicking property that allows bacteria to invade
Surgical Extractions
Surgical Extraction
Surgical access via elevating mucoperiosteal flap
Surgical handpiece to remove bone or section tooth
Suture usually needed
Flap Design
Wider base to ensure adequate blood supply
Incisions over intact bone, not over bony defects or eminences
Rounded corners
Vertical releases at line angles
Avoid vital structures
Miscellaneous Flaps
Semilunar incision
o Apical to mucogingival junction
o For apicoectomy
o Apically displaced flap is impossible in maxillary palatal
Double Y incision
o Incision town the midline
o Two vertical releases at each end (double Y)
o For palatal torus removal
Surgical Handpiece Use
Remove buccal bone
o Remove bone between tooth and cortical bone to create a ditch or trough
o Create a purchase point and pathway for delivery
Remove interradicular bone
o Remove bone between tooth and cortical bone to create a ditch or trough
o Moves center of resistance apically and facilitates tooth removal
Section tooth
o Use surgical bur to split the tooth in half (mesial portion and distal portion)
o Insert an elevator to complete the break
o Extract each piece separately
CSI:
Curette
Smooth bone
Irrigate
Post-Op:
Pressure with gauze, soft diet, no negative pressure straw spit smoking
Implants
Indications
To replace a missing tooth
Three Implant Types
Subperiosteal
Transosteal
Endosteal (most common)
Implant Components
Implant body
Abutment
Abutment screw
Implant Crown
Implant Body
AKA implant or fixture
Usually axisymmetric
Sequentially enlarge the osteotomy (bone hole)
o Reduces heat generated
o Helps to maintain axis with free-hand surgery
Usually inserted into tapped holes
Anti-Rotation Component
Prevents rotation (spinning) of abutment
Provides stabilization (rocking) of abutment
Integration
Osseointegration: direct histologic contact between bone and implant surface
Fibrousintegration: presence of fibrous tissue layer between implant and bone (failure of OI)
Stability
Primary stability: when you first place implant, how well the screw pattern holds into bone
Secondary stability: osseointegration, long-term healing of the bone to the titanium alloy
Impression
Once healing is complete, final impression is made so the crown and abutment are properly oriented
Impression coping = used to transfer location and angulation of implant to a master cast
o Open tray: hole in tray (multiple units)
o Closed tray: no hole in tray (single units)
Analog = implant replica
Socket Preservation
Maintains height and width of alveolar ridge after extraction
Need to have an atraumatic extraction
Irrigate extraction site thoroughly, remove granulation tissue with curette, place graft material, cover
with resorbable collagen membrane
Primary closure is unneccessary
Biologic Width
Roughened surface for bone, smooth surface for soft tissue
Gingival fibers orient next to implant PARALLEL with cuff
Surgial Stent
Location
Agnulation
Depth
Make sure any and all implants being places are aligned properly
Implant Success
Immobile
No peri-implant radiolucency
Peri-implant bone loss <0.2 mm per year after first year
Absence of symptoms like pain
Implant Failure
Gram negative anaerobic rods and filaments
47 degrees Celsius for 1 minute or 40 degrees Celsius for 7 minutes is enough to compromise
osseointegration
Trauma & Orthognathic Surgery
Mandibular Fractures
Best evaluated with PAN
Condylar > Angle > Symphysis
o Fall on R: Angle fracture on R, Condylar fracture on L
Greenstick = not all the way through
Comminuted = crushed into multiple fragments
Simple = closed to oral cavity
Compound = open to oral cavity, bone exposed thru mucosa near teeth
Mid-face Fractures
Best evaluated with CBCT
Le Fort 1 = horizontal fracture across maxilla
2 = pyramidal fracture (orbit, nasal bone, maxilla)
Le Fort 3 = complete craniofacial disjunction
Zygomaticomaxillary complex fracture = formerly known as a tripod fracture, cased by direct blow
under the malar eminence, involves bleeding under conjunctiva
Skeletal Discrepancies
Class 2 = retrognathic mandible
Class 3 = prognathic mandible
Anterior open bite = apertognathic
Vertical maxillary excess = maxilla too long, gummy smile
Horizontal transverse discrepancy = posterior cross bite
Macrogenia = chin too big
Microgenia = chin too small
Orthognathic Surgery
To correct severe skeletal discrepancies
Lateral cephs are the main images used in treatment planning these cases
Acrylic splint used intraoperatively
Le Fort 1 osteotomy move maxilla
BSSO move mandible
Genioplast move chin
LeFort 1 Osteotomy
For retrusive maxilla or vertical maxillary excess
Distraction Osteogenesis
Bone deposition between two bone surfaces that are separated by gradual traction
For bone lengthening, but not for adding width
First phase is osteotomy phase – bone is cut
Second phase is latency period – appliance is mounted to bone on each side of cut but is not
activated for 1 week
Third phase is distraction phase – appliance is used to gradually separate the two pieces allowing new
bone to fill in the gap
Orofacial Pain
2. Neuropathic Pain
Pain independent of stimulus intensity
Damage to pain pathways: Trigeminal Neuralgia, trauma, stroke
Atypical Odontalgia
Secondary to deafferentation (removal of part of the neural pathway) as a result of endo therapy or
extraction Phantom toothache
Post-Herpetic Neuralgia
Potential Sequela of herpes zoster infection
Burning, aching, or shock-like
Tx: anti-convulsants, anti-depressants, or sympathetic blocks
Chronic Headache
Also referred to as neurovascular pain
Migraine = unilateral, pulsating, nausea and vomiting, photophobia & phonophobia
Tension type = bilateral, non-pulsating, not aggravated by routine activity
Cluster = intense pain near one eye
Tx = triptans for migraine (selective serotonin receptor agonists)
3. Psychogenic Pain
Intrapsychic disturbance – conversion reaction, psychotic delusion, malingering
4. Atypical Pain
Facial pain of unknown cause/diagnosis pending
TMD
Bony Anatomy
Condyle
Mandibular (glenoid) fossa
Articular Eminence
TMJ Muscles:
Open: lateral pterygoid
Close: masseter, temporalis, medial pterygoid
TMJ Ligaments:
Ligaments limit the movement of the mandible
Capsular ligament
Discal/collateral ligament
Posterior ligament: prevents anterior disc displacement
Lateral ligament: prevents posterior disc displacement
Opening Patterns
Deflection: deflects toward side that is stuck at max opening
Deviation: deviates toward one side then returns back to midline at maximum opening (pain,
tenderness)
Recurrent Dislocation
Mandibular condyle translates anterior to the articular eminence and requires mechanical
manipulation to achieve reduction (down and back)
Tx: Botox injection of lateral pterygoid or surgery if chronic
Ankylosis
Union b/w condyle and skull can be either bony or fibrous
Trauma is most common cause
Other causes: surgery, radio therapy, infection
Severe restricted range of motion
Bruxism
Clenching/grinding teeth
Diurnal and/or nocturnal
Usually caused or exacerbated by stress
Tx: occlusal guard to distribute occlusal forces more evenly and relax musculature
Need to puncture
capsular ligament to
access the superior
joint space
Myofascial Pain Syndrome (MPS)
Chronic muscular pain disorder
Most common cause of masticatory pain
Trigger points in muscles of mastication
Diffuse pain in preauricular region
Parafunctional habits can contribute
Tx: physical therapy, stress management, splint therapy, medications
Biopsy
2 weeks
Four categories: cytology, aspiration, incisional, excisional
Biopsy Techniques
Make Diff Dx: list of possible things, with first being most likely
Mark lesion with indelible marker
Block anesthesia is preferred because local infiltration can distort the architecture of the lesion
Direct handling will crush cells (Adson forceps, silk suture thru lesion)
Store sample in 10% formalin
Clinical examples
Large white patch on buccal mucosa that wipes off, presumed to be candidias? Cytology
Firm, rough 2X3 cm white lesion on lateral tongue that does not wipe off? Incisional
Denture wearer presents with red swelling in buccal vestibule? None, check in 2 weeks
Enucleation: surgical removal of a mass without cutting into or rupturing it (removed whole)
Marsupialization: cut a slit into an abscess or cyst, suture edges open so it can drain freely
Curettage: removal of tissue by scraping or scooping
Resection: surgical removal of cyst or tumor and normal tissue around it (wide margins)
Medical Emergencies
Syncope
Most common medical emergency
Warm then cold, BP and heart rate go down unconscious
Vasovagal syncope = most common syncope, needle anxiety
Trendelenburg position
Left lateral decubitus if pregnant to relieve inferior vena cava
Orthostatic hypotension = second most common
Dizzy spell or head rush
Blood pressure suddenly falls when standing up (esp. when dehydrated)
Epinephrine Overdose
Rapid intravascular injection of LA with epi
BP and heart rate go up, thumping heart
Angina
Chest pain (coronary arteries cannot provide enough oxygenated blood to the heart)
Stable: angina is caused by exercise, stress
Unstable: angina is less predictable, at rest
Ischemia without necrosis
ONA: oxygen, nitroglycerin, aspirin
(1) NTG (0.4 mg) – 5 min – (2) NTG – 5 min – (3) NTG, aspirin and call 911
MI
Sudden occlusion of major coronary vessel, usually LAD (left anterior descending artery)
Ischemia with necrosis
MONA: morphine, oxygen, nitroglycerin, aspirin
Hypoglycemia/Diabetes
If conscious: glucose tab or OJ
If unconscious: IV dextrose or IM glucoagon
Hypoglycemia:
Sweating
Pallor
Irritability
Hunger
Lack of coordination
Sleepiness
Hyperglycemia:
Dry mouth
Increased thirst
Weakness
Headache
Blurred vision
Frequent urination
Conscious IV Sedation for Diabetic: Have food (low calorie meal) and decrease insulin dose
Hyperventilation
Do not give oxygen
Sit upright
Brown paper bag
Asthma
Constriction and inflammation of bronchioles
Wheezing = high pitch on exhale
2 puffs from emergency inhaler (albuterol)
Avoid NSAIDS and narcotics (Aspirin CI)
Airway Obstruction
Clear the pharynx of any food, vomit, foregin objects
Check for breathing (rise and fall of chest, sound of mouth or nose)
Chin tilt upwards to extend the neck
Protrude tongue and mandible to open airway
Seizure
Protect from injury
Do not restrain
IV or IM benzo
Grand mal seizure = Dilantin/Phenytoin
Status epilepticus = Valium/Diazepam
Stroke
TIA = transient ischemic attack, mini-stroke
CVA = cerebrovascular accident, stroke
Oxygen and call 911
Caused by hyponatremia (low sodium)
Look for facial droop, arm drift, speech slur
Anaphylactic Shock
AEIOU
Albuterol
Epinephrine (0.3 mg 1:1000 = epipen)
IM antihistamine
Oxygen
YOU call 911
Anticoagulation
Check blood tests below: Aspirin = anti-platelet drug…so it
o CBC: anemia, leukopenia, thrombocytopenia will affect bleeding time… but
o Bleeding time (time to clot): platelet function NOT PT, INR, PTT (It’s not an anti-
o PT: anticoagulants, liver damage, Vit K coagulant)
o INR (extrinsic pathway): Warfarin, Coumadin, INR = 2-3,
below 3.5 for EXT
o PTT (intrinsic pathway): Heparin, renal dialysis,
hemophilia
o Herbal anticoagulants: garlic, ginger, ginkgo, ginseng
Practice Questions