ORAL SURGERY 2 MIDTERM REVIEWER COMPLICATIONS: 1.

DRY SOCKET

this cavity usually contains liquid, air (gas) , cheesy like substance

2.

3.

Aka LOCALIZED OSTEITIS or LOCALIZED ALVEOLITIS Due to too much gargling Due to dislodgement of the clot Causes severe pain and foul odor Devoid of clot, there is bone with exposed nerve endings More common in lower jaw Never curette a dry socket to induce bleeding o There may be infection due to microorganisms being pushed into the cancellous bone Place a dressing with an antibiotic agent (either ZOE slow set or readily available medication) EMPHYSEMA May be due to bubbles that are trapped inside the closed flap Bubbles come from compressed air from rotary handpieces CREPITUS Found in i. Acute infective emphysema ii. Fractured jaw

Run fingers upward (mandible) or downward (maxilla)/ milking on the flap to remove the debris and bubbles before you suture

SUTURING Start suturing at a known point o To prevent pocket formation To prevent hypersensitivity of the adjacent tooth Sutures must be properly spaced Sutures are usually loose after a few days because the swollen gingiva at the time of suturing has already subsided MANAGEMENT OF ORAL CYSTS CYST Is different from a tumor It is a pathologic cavity Usually found in bone, soft tissue or both Usually has an epithelial lining that demarcates it from the normal structures

FORMATION OF CYST: 1. ODONTOGENIC or FOLLICULAR CYST PRIMORDIAL CYST Instead of a tooth forming, a cyst formed Anodontia, Oligodontia are the most common sign & symptom DENTIGEROUS CYST Crown of the tooth forms but root did not form, instead, became a cyst either on the crown (central) or lateral to the crown (lateral) RADICULAR CYST Attached to the root of a completely formed tooth From a pus formation that became a cyst RESIDUAL CYST When an extracted site was not curetted and formed a residual cyst 2. FISSURAL CYST When epithelium is trapped in between the forming parts, a cyst is formed 3. MUCOUS-RETENTION CYST Concerned with the salivary glands a. MUCOCOELE Duct is torn and secretions get trapped underneath the mucosa b. DERMOID CYST Products of the dermis found inside of the cyst At the midline of the floor of the mouth c. RANULA Found at the floor of the mouth Clinically resembles the belly of the frog Secretion inside is mucoid and it stretches (gel-like consistency) 4. PSEUDO-CYST or FALSE CYST Do not possess a lining of epithelium *At the onset, cysts are asymptomatic

*if the cyst is ODONTOGENIC, the tooth near it is NON-VITAL *if the cyst is NON-ODONTOGENIC, the tooth near it is VITAL CORTICAL EXPANSION When the cyst becomes larger, it expands the bone, until it cracks and there is crepitus felt. Then, after a while, it becomes doughy or ping-pong ball hard *there is no typical clinical appearance of a cyst. It will depend on the time of the discovery of the cyst *cysts are clinically STERILE. There are no microorganisms involved, therefore, antibiotics are unnecessary *the cyst usually is round because there is pressure all around it. External pressure is lesser than internal pressure. *if it is a soft tissue, it will dampen or impinge the surrounding structures *if it is on bone, it will erode the surrounding bone *best treatment for cystic lesions: REMOVE EVERYTHING! ENUCLEATION Process of taking the cyst out completely *recurrence of cystic lesions is very high *intracystic pressure is greater than extracystic pressure. *convex part of the curette must come in contact with the cystic sac (separate it from the bone first) *there will be deposition and bone replacement after enucleation *for soft tissue: aspirate the content first before removing the sac, the sac will detach itself from the surrounding (remove the barrel of the syringe and replace a new one if the barrel is full but never remove and replace the syringe) *for Upper, NEVER split nor section (do not make the tooth smaller than it already is) LIPIODOL A fatty substance that is radiopaque

Cystic lesions are usually associated with epithelium (Stratified Squamous Epithelium)

Used to see the size of a cystic lesion in radiographs Used to fill the cystic cavity

Dilatation of a vessel Spaces on the bone (skull) that makes the head lighter

4.

to help in protecting the respiratory tract from

Cyst in the oral cavity is sterile Not usually caused by bacteria Wont respond to antibiotics SCLEROTIC BONE Thickened bone Area of bone deposition Dentigerous cysts are usually associated with impacted teeth MUCOCOELE Usually formed due to habits Associated with salivary glands INCISIVE CANAL CYST Heart shaped cyst TRAUMATIC BONE CYST Type of pseudocyst 4 SURGICAL TREATMENT MODALITIES 1. ENUCLEATION Complete removal Contraindication: when cyst is very large 2. MARSUPIALIZATION Aka Partsch, decompression or deroofing 3. INITIAL MARSUPIALIZATION FOLLOWED BY COMPLETE ENUCLEATION When sufficient bone has formed 4. ENUCLEATION FOLLOWED BY CURETTAGE Where bone is removed by a bur POSTAGE-STAMP METHOD Method of creating a window by making holes SEQUESTRUM Necrotic bone BOVINE BONE Bone from cattle MAXILLARY SINUS DISORDERS OF DENTAL ORIGIN AND THEIR MANAGEMENT SINUS A communication between one body cavity with another body cavity Pus drains from one cavity to another

PNEUMATIC BONE Good example: SKULL Space in bone filled with air PARANASAL SINUSES 4 paired cavities around the nasal cavities o Maxillary o Frontal o Ethmoid o Sphenoid SINUSITIS The lining of the sinus is inflamed HYPOPHYSEAL FOSSA Aka SELLA TURCICA There should be no communication between maxillary sinus and oral cavity MAXILLARY SINUS Aka ANTRUM OF HIGHMORE Starts as an embryonic sac (Tubular Sac), air enters and it creates a space that is pyramidal in shape Process of pneumatization o Must stop as it reaches the limit of size o 15-20mL of air is normal Designed only to contain air and may also contain mucous INNERVATION OF MAXILLARY SINUS Pain of maxillary sinusitis mimics the pin of toothache due to the same innervations

NASAL CONCHAE shell-like presence of bone meatus that separates the nasal cavity into 3 parts o each has its own specific epithelial lining o INFERIOR MEATUS Stratified squamous nonkeratinized epithelium o SUPERIOR MEATUS Neuro-epithelium (contains terminal ends of nerves) Stimulus must be volatile If it is injured, there is very little recovery of terminal nerve endings o MIDDLE MEATUS Pseudo-stratified squamous columnar ciliated Has communication between MAXILLARY SINUS and MAXILLARY OSTIUM NASOLACRIMAL DUCT

Has communication with maxillary ostium and middle meatus Has lysozymes that is why there is salty taste o For protection

EUSTACHIAN TUBE Connection of ears to the maxillary ostium Ear, nose and throat are all connected by MIDDLE MEATUS CONTINUOUS PNEUMATIZATION Occupies the space where bone is gone SINUS LIFT Inject bone graft material so that there is enough bone for the implant to be attached to and the graft pushes the pneumatized maxillary sinus HISTOLOGY OF THE MAXILLARY SINUS MEMBRANE Pseudostratified columnar ciliated epithelium with goblet cells GOBLET CELLS

The inner loop of innervation: ASAN, Nasopalatine, MSAN May cause phantom pain Angina Pectoris may present as pain on the lower jaw may never radiate on the lower jaw

FUNCTIONS OF THE MAXILLARY SINUS 1. to give resonance to voice 2. to help warm and moisten the air before it enters the rest of the respiratory tract a. if the air is dry and cold, it may cut through the respiratory tract, especially the alveoli b. very vascular (blood is warm) 3. to reduce the weight of the skull

o Secretes mucous o Glands o Found in between the epithelium SCHNEIDERIAN MEMBRANE o Membrane found inside the sinus o The mucous functions like a flypaper Very sticky Protect VIBRISAE o first filter of the nose

inflammation of the schneiderian membrane not the cavity or space

ORO-ANTRAL PERFORATIONS SIGNS OF OROANTRAL PERFORATIONS unilateral epistaxis increased bleeding air passing freely through oral cavity and nasal cavity fluid passing freely nasal twang radiograph WHAT YOU SHOULDNT DO! Do not curette Do not probe Do not ask the patient to pinch the nose and blow there will be tearing of the schneiderian membrane (iatrogenic perforation) Do not irrigate Do not pack with gauze or gelfoam Do not blow air INSTRUCT THE PATIENT Do not smoke Do not use straw Do not rinse vigorously Do not suck Do not play with the wound using tongue Do not strain (lifting heavy objects) No strenuous activities MANAGEMENT: PRIMARY CLOSURE

POST NASAL DRIP mucous drips posteriorly to the throat SCHNEIDERIAN MEMBRANE mucous must be adequate lining is thin sinusitis may be due to an infection of dental origin SMOKED SCHNEIDERIAN MEMBRANE sinus membrane thickens and hardens hyperplasia of the epithelium o there may also be dysplasia that would lead to cancer of sinus HEALTH OF MAXILLARY SINUS IS MAINTAINED BY: patency of the maxillary ostium good function of the cilia o smoking paralyzes the cilia modulate secretion of mucous by goblet cells effective control of mucous flow of mucous through ostium into the nasal vestibule no allergy no inflammatory diseases of the sinus no hyperplasia, no hypertrophy of the schneiderian membrane TRANSILLUMINATION one of the diagnostic test used to check for the condition of the maxillary sinus placed infraorbitally in the dark room light that pass through should be clear NON ODONTOGENIC INFECTIONS OF THE MAXILLARY SINUS the maxillary sinus was previously considered sterile recent studies have should that maxillary sinus MAXILLARY SINUSITIS

not creep to the raw bone (space) and meet the epithelium of the oral cavity o clot will not be established if this occurs, the communication will remain open and will now become an OROANTRAL FISTULA schneiderian membrane will become infected due to food impaction and may cause excess mucous production and will result to suppuration due to inflammation pus may leak to the fistula and drip to the tongue of the patient Primary Closure of the Oroantral Fistula is done after cleaning and removing the epithelium (schneiderian membrane) CLEANING IN 2 WAYS: 1. CALDWEL LUC 2. ANTRAL LAVAGE *do culture sensitivity test to check if it is ok to close the oroantral fistula WHY A FISTULA HAPPENS: non-recognition or non-closure of oroantral perforation breakdown of clot in socket epithelization of oroantral perforation from gingiva *remove the epithelium before you close the oroantral fistula emptying the necrotic contents maintaining patency of maxillary ostium BERGERS TECHNIQUE

Cut the bone with a rongeur so that there is easier coaptation of the flaps There should be a water-tight seal when you suture SUTURING WITH EVERSION o Leave extra flap when you suture so that when there is pulling during healing, there is still enough tissue left PALATAL SPLINT o Made up of self-curing clear resin used to support the flap Sagging of the flap can casue an infected hematoma Palatal root of 1st Molar & 3rd molar may cause sinus perforations give decongestants to shrink the schneiderian membrane if the communication is not closed, the schneiderian membrane (epithelium) will

approximate the palatal and buccal flaps

PALATAL PEDICLE FLAP the palatal flap must carry the artery for blood supply swing it to the side then approximate never make perpendicular incisions on the palate! *there will be reepithelialization for the bare area CONTACT INHIBITION when the two sides of epithelium reach each other, they stop

to close, you can use a gauze, palatal splint

MEMBRANE-ASSISTED CLOSURE membrane is something that prevents the connection of the bone and tissue GTR guided tissue regeneration Membrane is like a shield GORTEX brand of GTR wherein water cannot pass through CALDWEL LUC TECHNIQUE Create a long wide U incision Create a postage-stamp Engage the middle with a bur but dont go through and through When the bur is locked in the middle, pull it out Curette the area TROCAR Instrument that has a hook that can penetrate bone Breaks the inferior meatal wall It is like creating a new ostium (intranasal osteotomy) Depends on the patency of the Maxillary Ostium

Weakness due to undermining of the bone by pathologic lesions (cysts, tumors) Bone in children has more organic components (water) Bone in older people have more inorganic components (less water) Infection spreads more rapidly in children than in older people due to the inorganic components

i.

Due to the organic component of the bone and the wide marrow spaces that would dissipate the force

PATHOLOGIC FRACTURES Metabolic fracture No trauma, no weight bearing but there is fracture SPONTANEOUS FRACTURE Fractures without any trauma May be due to metabolic fracture TYPES OF FRACTURES 1. SIMPLE FRACTURE Break in the bone but there is no break in the continuity of the covering 2. COMPOUND FRACTURE There is the break in the skin and periosteum Communication between bone and external environment May cause infection 3. COMMINUTED FRACTURE There is fragmentation of the bone Crushing of bone into several pieces 4. COMPLEX FRACTURE Different fracture sites in one bone 5. SIMPLE COMMINUTED FRACTURE There is crushing of bone but covering is still intact 6. COMPOUND COMMINUTED FRACTURE Bone is crushed but there is tearing of covering All fractures caused by gunshot wounds (always) i. Gunshot woulds always have a point of entry and a point of exit ii. Point of entry is small but point of exit is large iii. There is avulsion 7. GREENSTICK FRACTURE Commonly found in children One side is fractured; the other side is bent

CALDWEL LUC open with flap LUC perforation with trocar May do either or both

MANAGEMENT OF JAW FRACTURES teeth are not located directly at the jaws teeth are located at the alveolar bone FRACTURE pathologic discontinuity of the bone most of the time, the cause is trauma TRAUMATIC FRACTURES caused by an external force fracture travels along the grain GRAIN

MAXILLARY FRACTURES (LE FORT) 1. LE FORT 1 Fracture lines travel above the maxillary apices and not at the level of the roots because it is only alveolar fracture It will be detached from the maxilla It doesnt drop easily because it is held together by muscles and soft tissue Line of exhymmosis on the sutures Pathognomonic sign: FLOATING JAW Fracture line separates the inferior portion from the maxilla Fracture goes through the lower 3rd of the septum and involves the maxillary sinus GUERINS FRACTURE i. On the nasal floor 2. LE FORT 3 Fracture line runs approximately along the area where the cranial and facial part of the skull is connected i. Line from glabella to prosthion to external occipital protuberance Series of convexities and concavities disappear The person looks like a dish or a bowl Pathognomonic sign: DISH FACE

Aka TRANSVERSE FRACTURE

MANDIBLE vertically MAXILLA horizontally

NON-TRAUMATIC FRACTURES Caused by metabolic imbalance (osteoporosis)

ANTERIOR CRANIAL FOSSA has a communication with the nose through the cribriform plate of ethmoid bone May lead to Le Fort 2 or 3 CSF might come out and leak due to the tear of the dura mater o Clinical condition is known as CEREBROSPINAL RHINORRHEA o Clinical significance is there is infection through the communication creating brain abscess o If it dries with starching, it is mucous but if it doesnt, it is CSF

-Rosette Go 020911