5- Oral Surgery & Pain Control

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Major Topic Abbreviation Major Topic Abbreviation

Cortex Adren Cort Fractures FracturesAnat General Information Gen Info

Anesth Grafts Gradfts

Biopsy Implants Implants

Disord/Cond Miscellaneous Misc.

Drugs Temporomandibular Joint TMJ

Exo

ORAL SURGERY & PAIN CONTROL Adren Cort

The gold standard test for primary adrenal failure is the:

glucose test

stimulation test

creatinine level

iest

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ACTH stimulation test is performed to examine the response ofthe adrenal gland

an exogenously administered dose ofACTH. Normal patients have a doubling ofthe

cortisol level after a dose of ACTH. The serum cortisol level should rise to >20

dL ifthere is adequate adrenal function. Art inadequate response suggests adrenal gland

Note: Cosyntropin (Cottosyz) is an ACTH analogue that stimulates the ad-

gland and its ACTH receptors.

20 mg of hydrocortisone is secreted by the adrenal cortex daily. During stress

cortex can increase the output to 200 rng daily.

Patients taking steroids or people with disease ofthe adrenals will have de-

ability to produce more glucocorticoids (hydrocortisone) in times of stress fejr-

The reason for this is as follows:

ofglucocorticoids is stimulated by ACTH, a hormone produced in the anterior

Thepituitary responds to stress by increasing ACTH output and therefore glu-

production increases. A relative lack ofglucocorticoids will also increase out-

ofACTH. An overabundance ofcirculating systemic steroids will inhibit production

Patients on large doses ofsteroids repress ACTH production which leads to

of adrenal cortex.



regain full adrenal cortical function

as much as a year to regain full adrenal cortical function

as little as a week to regain full adrenal cortical function

usually a couple of days to regain full adrenal cortical function

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ACTH Syndrome

I

syndrome

disease

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o



following guidelines may help determine if a patient's adrenal function is suppressed,

ifany doubt €xists, consult the patient's physician before performing surgery.

Guidelines:. People on smalf doses (5 mg Prednisone/day) will have suppression when they have

been on the regimen for a month.. People taking equivalence of 100 mg cortisol/day (20-30 mg Prednisone/da1) wrll have

abnormal cortical function in a week.. Short-term therapy (1-3 days) ofeven high dose steroids will not alter adrenal cortical

function.

. A person who has been on suppressiye doses of steroids will take as much as a yearto regain full adrenal cortical function.

with a&enal insu{ficiency are hyperpigmented. This is most noticeable on the buc-

and labial mucosa, although other areas such as the gingiva may be involved. The hyper-

is a result of hypersecretion of ACTH, which can stimulate melanocytes to

pigment.

rvith decreased adrenal gland hormone production experience weakness, weight loss,

hypotension, nausea, and vomiting. Patients with severe adrenal insufficiency can-

increase steroid production in response to stress and in extreme situations may have car-

It is important that an adrenally insufficient patient have adequate

the stress oforal surgery can precipitate adrenal crisis.

an intravenous or intramuscular injection ofhydrccortisone must be given

of low blood pressure with intravenous fluids is usually

Hospitalization is required for adequate treatment and monitoring.

is a hormonal disorder caused by prolonged exposure ofthe body's tis-

to high levels ofthe hormone cortisol. This results in characteristic changes in body

including moon facies, truncal obesity, muscular wasting, and hirsutism. Some-

"hypercortisolism," it is relatively rare and most commonly affects adults

20 to 50. The femaleto-male incidence ratio is approximately 5:1.

with Cushing's syndrome are often h)?ertensive because offluid retention. Long-

glucocorticoid excess can result in decreased collagen production, a tendency to

poor wound healing, and osteoporosis. They are often at increased risk for

snrdies may reveal increased blood glucose levels because ofinterference with

metabolism, and examination of the peripheral blood smear may demon-

slight decrease in eosinophil and lymphocyte counts.

The patient's cardiovascular status must be evaluated and treated if neces-prior to surgery.

The most common cause ofCushing's syndrome is a tumor in the pituitary ofthe



discontinue the Prednisone for two days prior to the extraction

steroid supplementation and remove the tooth with local anesthesia and

the palient to lake 3 grams of amoxicillin one hour prior to extraction

special treatment is necessary prior to extraction

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molar

premolar

molar

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The f€ar here is that the patient may not have sumcient adrenal cort€x secretion (adrenal in-

to withstand the stress of an €xtraction without taking additional steroids. (This holds true

any palient who has been treatedfor any disease vilh steloid therapy).

with adrenal insufficiency, patients on daily steroid therapy, and patients who have rccently fin-a couNe of stercids should receive steroid supplement for dental procedures.

insufficiency should be raised on the basis ofclinicrl history. In the majority

the dentist should ask:

. Is it known that the patient's adrenal glands do not function adequately?

. Is the patient on chronic steroid therapy at doses ofprednisone higher than 15 mg/day?

.Has the patient been on steroid therapy at doses ofprednisone higher than l5 mg/day within the last

2 weeks?*** Ifthe answer to any ofthe above questions is yes, the dentist should assume that the patient willneed stress-dose steroids.

guidelines for the management ofpatients on steroid therapy:. Steroid supplement in patients who can develop adrenal insulliciency. Early moming appointm€nts. Shoner appointrnents. Minimize stress. Use sedation techniques when appropriate. Modiry dental treatment plan when appropriate. The major goal in these patients is to avoid precipitation ofadrenal insufnciency

Erythema multiforme is a hypersensitivity syndrome characterized by polyrnorphous

ofskin and mucous membranes. Macules, papules, nodules, vesicles, or bullae and target orlesions aie seen. A sev€re form ofthis condition is known as StevensJohnson

These patients may be receiving moderate doses of syst€mic coficosteroids and therefore

be unable to withstand the stress ofan extraction. Consultation with theirphysician is absolutely nec-

before treating these patients.

greater palatine foramen is generally located halfway between the gingival margin and mid-

ofthe palate, approximately 5 mm anterior to thejunction ofthe hard and soft palate (vibrat-

line) distal to the apex ofthe maxillary second molar

hard palate is perfonted by the following foramina;

.The incisive foramen,

posteriorto the maxillary incisors, which transmits

the nasopalatine

nerves and the terminal branches ofthe sphenopalatine artery. The greater palatine foramen, is most Iiequently located distal to the maxillary second molar,

which transmits the greater palatine vessels and nerve. The lesser palatine foramen, j ust poste.ior to the greater palatine foramen, which transmits the

lesser palatine vessels and nerve

palate:

. Sensory Inneryation to lhe palate: is supplied by the m^xillary (CN I/-2) nerve. The ante-

rior part ofthe hard palate is supplied by the nasopalatine nerve which passes through the in-

cisive foramen. The posterior part ofthe hard palate is supplied by the gr€ater palatine nerve

which passes through the greater palatine foramen. The soft palate is supplied by the lesser pala-

tine nerve which passes though the lesser palatine foramen.

. Motor Innervation: the tensor veli palatini is innervated by a muscular branch from the

mandibular division ofthe trigeminal nerve fCN Z/. All othermuscles are innervated by the pha-ryngeal plexvs (motor pottion from the vagus nerve and cranial part of lhe accessory nene),

greater palatine block or GP block is useful for dental procedures involving palatal soft tis-

distal to the maxillary canine. This maxillary block anesthetizes the posterior portion of the

palate, anteriorly as far as the maxillary first premolar and medially to the midline.

the gre ater (anterior) palatirre nerve as it passes anteriorly between the sofi tissues and

of the hard palate.

nasopalatine nerve block anesthetizes the anterior portion ofthe hard palate (soft and hard

from the mesial ofthe right first prcmolar to the mesial of the left fiIst premolar. Target

incisive foramen, beneath the incisive papilla.



components only

components only

efferent and afferent components

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fossa

band of the articular disc

band of the articular disc

eminence

tissue

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facial nerve leaves the cranial cavity by passing through the intemal acoustic meatus,

leads to the facial canal inside the temporal bone. Finally, the nerve exits the skr.rll by

of rhe stylomasloid foramen of the temporal bone.

lfyou cut the facial nerve just after its exit from the sylomastoid foramen, it would

of innewation to the muscles of facial expression.

facial nerve carries an efferent component for the muscles of facial expression and forpreganglionic parasympathetic innervation ofthe lacrimal gland (relaying in the ptery-

ganglion) and submandibular and sublingual glands (relar-ing in the submandibu-

gangliott).

afferent component serves a tiny patch of skin behind the ear, taste sensation, and the

ofthe tongue.

information:l. Bell's palsy: involves unilateral facial paralysis with no known cause, except that there

is a loss ofexcitability ofthe involved facial nerve. The onset ofthis paralysis is abrupt, and

most symptoms reach their peak in 2 days. One theory of its cause is that the facial nerve

becornes inflamed within the temporal bone, possibly with a viral etiology.

L Trigeminal neurzlgia (tic douloureLLr): also has no known cause but involves the affer-

eni nen:es of the trigeminal nerve. It usually involves the maxillary or mandibular nerve

branches but not the ophthalmic branch. One theory is that this lesion is caused by pressure

on ihe sensory root ofthe trigeminal ganglion by area blood vessels. Clinically, thepatient

feels excruciating short-term pain f/ic/ when facial trigger zones are touched or when speak-

ing or masticating, setting offassociated briefmuscle spasms in the area. The right side ofthe tace is affected more commonly than the left. It is more common in females. Carba-

mazepite (Tegretol) is still the mainstay oftreatment.

articular disc (meniscus) is composed of dense fibrous connective tissue, and it is

in between the condyle and the fossa, thereby dividing the joint into superior and

spaces.

articular disc(nteniscus)

vaies inthickness; the thinncr ccntral intermediatezone separates

thicker portions, which are the anterior and posterior bands. The posterior band of the

disc is the thickest of the two bands, and it is attached with posterior loose connective

called retrodiscal tissues (bildminar zone; postefiot attachment). The less thick anterior

of the articular disc is contiguous with the capsular ligament, the condyle, and the superior

ofthe lateral pterygoid muscle.

The retrodiscal tissue is highly vascularized and innervated, whereas the articular disc for

nosl part is not. Only the extreme periphery of the afiicular disc is slightly innervated.



duct

ethmoidalis

semilunaris

alveolar artery

artery

artery

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this opening lies high up on the medialwall ofthe sinus, so that the sinus readily accu-

fluid. Sincc the frontal and anterior ethmoidal sinuses drain into the infundibulum, which in

drains into the hiatus semilunaris, the chance that infection may spread from these sinuses into the

sinus is great.

sinusitisr acute and chronic: common clinical manifestations include sinus congestion, dis-

pressure, face pain, and headaches.

Sinusitis: the most common fonn ofsinusitis, typically causcd by a cold that results in inflam-

ofthe sinus membranes, normally resolves in I to 2 weeks. Sometimes a secondary bactedal in-

may seftle in the passageways after a cold; bacteria normally located in thc area (Streptococcus

dnd Hdeuophilus influenzae) may begin to increase, producing an acute bacterial sinusitis.

signs ofacute sinusitis include. Severe pain, constant and localized. Tendemess to percussion ofthe maxillary posterior teeth

. A mucopurulent exudate

. Any unusual motion orjarring accentuates the pain

. Tendemess over the anterior sinus wall

an infcction ofthc sinuses that is present for longer than 1 month and requires longer

medical therapy. Typically either chronic bacterial sinusitis or chronic noninfectious sinusitis.

bacterial sinusitis is trcatcd with anttbiotics (ampicillin or auqme tin). Chronic noninfectious

is treated with steroids (opical o/ oral) and nasal washes.

of sinusitis:\Ie\illary: the most common location for sinusitis; associated with all of the common signs and

but also results in tooth pain, usually in the molar region

sphenoid: rarc, but in this location can result in problems with the pituitary gland, cavemous sinus

and meningitisFrontal: usually associated with pain over the forehead and possibly fever

Ethmoid: potential complications include meningitis and orbital cellulitis.

Thc maxillary sinus is innervated by the maxillary division of the trigeminal nerve (CN l/-2).

the ASA, PSA, and MSA nerves as well as the inliaorbital nervc.

loops upward and then passes deep to the posterior border ofthe hyoglossus muscle to

the submandibular region. The loop ofthe artery is crossed superficially by the hy-

nene. The lingual artery supplies structures ofthe floor ofthe mouth and the

and inferior surface ofthe tongue. Major branches include the :

. Suprahyoid artery: supplies the suprahyoid muscles

. Doral lingual artery: supplies the tongue, tonsils, and soft palate

. Sublingual artery: supplies the floor ofthe mouth, mylohyoid muscle, and sublin-

gual gland. Deep lingual artery: supplies the tongue

The lingual artery does not accompany the conesponding nerve throughout

course.

The inferior alveolar nerve, artery, and vein along with the lingual nerve

found in the pterygomandibular space between the medial pterygoid muscle and the

ofthe mandible. The inferior alveolarnerve passes lateral to the sphenomandibu-

ligament. The submandibular duct is crossed twice by the lingual nerve. Ifthe lingual

is cut after the chorda tympanijoins, there will be loss ofboth taste and tactile sen-

The lateral pterygoid muscle forms the roofofthe pterygomandibular space.



raphe

process

aponeurosis

tubercles on the intemal surface ofthe mandible

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Facial nerve

Trigeminal nerve

Vagus nerve

Glossopharyngeal nerve

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each side, the pterygomandibular raphe extends from the hamulus and passes infe-

to attach to the posterior end ofthe mandible's mylohyoid line. It is formed by the

ofthe tendinous ends ofthe superior constrictor ofthe pharynx and the buccinator

Note: As the mandible moves relative to the hamulus, the length ofthe raphe is

increased.

pterygomandibular raphe is noted in the oral cavity as the pterygomandibular fold.

.--.., . L The buccinator muscle is pierced by the needle when performing an inferior

Notegll alveolar nerve block.2. The deep tendon of the temporalis muscle and the superior pharyngeal con-

strictor muscle form a V-shaped landmark for an inferior alveolar nerve block.

3. When draining purulent exudate from an abscess of the pterygomandibu-

lar space from an intraoral approach, the buccinator muscle is most likely to

be incised.

fibers pass to the otic ganglion via the tympanic branch ofthe glossopharyn-

nerve and the lesser petrosal nerve. Postganglionic parasympathetic fibers reach

parotid gland via the auriculotemporal nerve, which lies in contact with the deep sur-

ofthe gland. Note: Postganglionic sympathetic fibers reach the gland as a plexus of

around the extemal carotid artery

parotid gland is the largest ofthe major salivary glands and is entirely serous in se-

The parotids are located below andjust anterior to the ear. The gland's capsule is

the deep cervical fascia. About 750% or more ofthe parotid gland overlies the mas-

muscle. the rest is retromandibular.

parotid gland is drained by Stenson's duct, which forms within the deep lobe and

from the anterior border of the gland across the masseter muscle superficially,

the buccinator muscle into the oral cavity opposite the maxillary second molar.

external carotid artery and its terminal branches within the gland, namely, the su-

temporal and the maxillary arteries, supply the parotid gland. The lymph vessels

into the parotid lymph nodes and deep cervical li,mph nodes.

1. Mumps is a viral disease of the parotid gland. Parotitis is the inflammation

ofthe parotid gland.

2. Von Ebner's glands are the only other adult salivary glands which are purely

serous.

3. Although it passes through the parotid gland, the facial nerve do€s not pro-

vide any innervation to it.

Notoi:.,:



ORAL SURGERY & PAIN CONTROL

is performing a routine restoration on the left mandibular first molar,He is giving an inferior alveolar nerve block injection, where he deposits

anesthetic solution right next to the Iingula and mandibuhr foramen.Which ligament is most likely to get damaged?

ligament

ligament

ligament

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A patient comes into your dental o{fice complaining of chewing

dilficulties. When you ask him to protrude his mandiblen the

mandible markedly deviat€s to th€ right. Which muscle,

which inserts fibers into the capsule and articular disc ofthe TMJ, is most likely damaged?

medial pterygoid muscle

medial pterygoid muscle

lateral pterygoid muscle

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sphenomandibular and stylomandibular ligaments are considered to be accessory liga-The former is attached to the lingula of the mandible and the latter at the angle of the

These ligaments are responsible for limitation ofmandibular movements (thet linit ex-

opening). Note: The sphenomandibular ligament is most oftcn danaged in an inferior

nerve block.

temporomandibular ligament fabo called the lateral liganert) runs from the articular em-

the mandibular condyle. It provides lateral reinlbrcement for the capsule. This ligament

posterior and inferior displacement ofthe condyle (it is the rlain srabilizing liganrentthe TMJ). Notei This ligament keeps the head of the condyle in the mandibular fossa if the

is fractured.

figaments (medial and lateral) also referred to as "discal ligaments," are Iigaments that

from the periphery ofthe disc, are attached to the medial and iateral poles ofthe condyle re-

and stabilize the disc on the top ofthe condyle. These ligaments rcstrict movement ofdisc away from thc condyle during function. Note: They arc composed of collagenous con-

tissuc: thus they do not strelch.

Joint capsLrlesphcnoid bonc

Sphcnomandibular

Igamcnr Styloid proccss

oftcn)poral bone

Stylonandibular

llgamcnt

Anglc ofmandibular

.,{nkylosis ofthe condyle: the most common cause ofTMJ ankylosis is trauma

. A unilateral condylar fracture

mandible will deviate away from the affected side with:. Condylar hyperplasia: malocclusion is also a common occurrence with this injury

The lateral pterygoids (right and leJi) acting together are the prime pro-

of the mandible. Important: In addition to opening and protruding, the lateral

move the mandible from side to side, For right lateral excursive movements,

left lateral pterygoid muscle is the prime mover and vice versa.

patient who sustained a subcondylar fractare (unilateral condylar fracture) on lhe

side would be unable to deviate the mandible to the right (as stated qbove thev,ill deviate to the side o/ injury with a unilateral condylar fracture, this patient

be able to deviate the mqndible to the right) This is normally treated by a closed

involving intermaxillary fixation. This procedure immobilizes the con-

fractures and conects the displacement ofthe jaws associated with the condylar

conecting the shift ofthe midline toward the side ofthe fiactured condyle

the slight prematue posterior occlusion on that side.

will also deviate toward the side of iniurv with:



lymph nodes

lymph nodes

nodes

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artery

palatine artery

alveolar artery

artery

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deep cewical lymph nodes ar€ located along the length ofthe intemal jugular vein on each side

neck, deep to the stemocleidomastoid muscle. The deep cervical nodes extend from the base

skull to the root ofthe neck, adjacent to the pharynx, esophagus, and trachea. The deep cer-

nodes are further classified as to their relationship to the stemocleidomastoid muscle as beins

or inferior.

deep cervical lymph nodes are responsible for the drainage of most of the circular chain ofand receive direct efferents from the salivary and thyroid glands, the tongue, the tonsil, the

th€ pharynx, and the larynx. All these vessels join together to form the jugular lymphThis vessel drains into either the thoracic duct on the left, the right lymphatic duct on

right, or independently drains into either the intemaljugular,

subclavian, or brachiocephalic

regional groups of lymph nodes:

. Parotid lymph nodes - receive lymph from a strip of scalp above the parotid salivary gland,

from the anterior wall ofthe extemal auditory meatus, and from the lateral parts of the eyelids

and middle ear. The efferent lymph vessels drain into the deep cervical nodes.. Submandibular lymph nodes - located between the submandibular gland and the mandible;

receive lymph liom the front of the scalp, the nose, and adjacent cheek; the upper lip and lower

lip (ercept the center p.trt); tlrc paranasal sinuses; the maxillary and mandibular teeth ferceplthe mandibular incisorsl; the aDterior two-thirds of the tong\e (except the tip); the floor ofthemouth and vestibule; and the gingiva. The eferent lynph vessels drain into the deep cervical

nodes.. Submental lymph nodes - located behind the chin and on the mylohyoid muscle; receive

lymph from the tip of the tongue, the floor of the mouth beneath the tip of the tongue, the

mandibular incisor teeth and associated gingiva, the center part of the lower lip, and the

skin over the chin. The eflerent lymph vessels drain into the subrnandibular and deep

cervical nodes.

externaf carotid artery supplies most ofthe head and neck, except for the brain (the btain

its blood supply from the internal carotid and the veltebrql arleries). The extemal carotid

through the parotid salivary gland and terminates as the maxillary and superficial tenpo-

arteries. The superficial artery supplies the scalp. The maxillary artery leaves the infratempo-

fossa bypassing

thoughthe pterygomaxillary fissure into the pterygopalatine fossa. Here it

up into branches that accompany the branches ofthe maxillary nerve. It supplies the muscles

the maxillary and mandibular teeth, the palate, and almost all ofthe nasal cavity.

matrdibular t€eth receive blood from the inferior alveolar artery, which is a branch of the

artery. The maxillary teeth also receive blood from branches ofthe maxillary artery as

. Posterior teeth: from the posterior superior alveolar artery

. Anterior teeth: from the anterior and middle superior alveolar artedes.

The venous return ofboth dental arches is the pterygoid plexus ofveins.

ofthe maxillary artery that accompany the branches ofthe maxillary nerve;

l. The posterior superior alveolar artery descends on the posterior surface ofthe maxilla and

supplies the maxillary sinus and the maxillary molar and premolar teeth.

2. The infraorbital artery ente$ the orbital cavity thrcugh the inferior orbital fissure. lt ends

by emerging on the face with the infraorbital nerve.

3. The greater palatine artery descends through the grcater palatine canal with the greater pala-

tine nerve. tt is distributed to the mucous membrane covering the oral surface ofthe hard palate.

4. Tbe pharyngeal branch passes backward to supply the mucous membrane ofthe roofofthe

nasopharynx.

5. The sphenopalatin€ artery passes thrcugh the sphenopalatine foramen into the nasal cavity.

It supplies the mucous membrane ofthe nasal cavity.



frenum

duct

caruncle

joint

joint

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submandibular glatds (formerly celled the submaxillary glands) arc located in the

triangle ofthe neck and the floor ofthe oral cavity. The submandibular duct

duct) is a long duct that travels along the anterior floor of the mouth. The duct

into the oral cavity at the sublingual caruncle, a small papilla near the midline oftheon each side ofthe lingual fienum. Clinically, the gland is effectively palpated in-

or and posterior to the body of the mandible, moving inward from the inferior border ofits argle as the patient lowers the head. Note: The submandibular gland is

ixed gland, secreting both serous and mucous saliva, but predominantly serous secreting.

glands are innervated by efferer,t (paras4pathetly' secretomotor fibers

the facial nerve, which run in the chorda tympani and in the lingual newe (branch ofsynapse in the submandibular ganglion. Note: This is the same as the sublingual

The blood supply comes from branches of the facial and lingual arte es. The veins

into the facial and lingual veins. The lymph vessels drain into the submandibular and

cewical lymph nodes.

During its course, Wharton's duct is closely related to the large lingual nerve

eventually crosses over it. This is important because if you incise the mucous mem-

of the floor of the mouth, depending on where you cut, you may expose the lingual

and the sublingual gland.

l. To expose the duct intraorally, only mucous membrane needs to be cut through.

2. L).rnphadenopathy is the most common cause ofswelling ofthe tissues in the sub-mandibular triansle.

TMJ has characteristics ofboth a hinge joint and a gliding joint, it is classified as a gingly-joint. A unique feature ofthe TMJ is that it is rigidly connected to both the dentition and

contralateral TMJ.ofthe TMJ:

. Mandibular condyle (sometines called the cowlyloid process of the mandible) - the aniculating sur-

face or functioning part of the condyle is located on the superior and anterior sudaces ofthe head ofthe condyle. This surface is covered with a dense layer oflibrous connective tissue.. Articular fossa - this fossa is the anterior three-fourths ofthe laryer mandibular fossa. It is consid-

ered to be a notr-functioning portion ofthejoint. Remember: The mandibular fossa (g/enoidfossa)

is rhe remporal component ofthe TMJ; it is bounded in front by the articular eminence, and behind,

b-v the tympanic part of the temporal bone, which separates it from the extemal auditory meatus.

. Articular eminence (also called the articular tubercle) - is aidge that extends mediolaterallyjust

in fiont ofthe mandibular fossa. It is considered to be the functional portion ofthejoint. It is lined

$ ith a thick dense layer of librous connective tissue.. -A.rticular disc /a/,ro called the meniscus) - is a biconcave librocartilaginous disc interposed be-

t\|een the condyle ofthe mandible and the mandibtiar (glenoid) fossa ofthe temporal bone which pro-

!ides the gliding surface for the mandibular condyle, resulting in smoothjoint movement. The cenhal

part is avascular and devoid ofnerv€ tissue, only the extreme periphery is slightly innervated.

Postglenoid

proccss

Blood vcsscls

Condyle

Uppe. synovialcavity

Arlicular

Joint disc

Lower synovial

caviry

Latcral ptcrygoid musclc



it is usually displaced through the periosteum and locatedto the lateral pterygoid plate and _ to the lateral pterygoid

muscle with displacement.

inferior

superior

inferior

superior

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The carotid sheath contains all of the followlng EXCEPT one,

Which one is the I9XCEP?1ON?

artery

trunk

vein

nerve

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infratemporal fossa is an irregular space behind the maxilla. Its roof is formed by

greater wing ofthe sphenoid. The lateral pterygoid plate ofthe sphenoid is medial. La!it is limited by the coronoid process and ramus ofthe mandible. The infratempo-

fossa communicates with the pterygopalatine fossa through the pterygomaxillary

is a cleft between the lateral pterygoid plate and the ma,rilla. It communi-

with the orbit through the inferior ort ital fissure which is between the maxilla and

greater wing ofthe sphenoid.

pterygopalatine fossa is a small space behind and below the orbital cavity. It lies be-

the pterygoid plates ofthe sphenoid and palatine bone below the apex ofthe orbit.

Ifthere is good access and adequate light, a single cautious effort to retrieve the

with a hemostai can be made. Ifthe effort is unsuccessful, or ifthe tooth is not vi-

incision should be closed, the patient should be infonned, and prophylactic

should be prescribed. A secondary surgical procedure is performed 4-6 weeks

and posteroanterior radiographs are taken to locate the tooth in all three

After adequate anesthesia, a long needle is used to locate the tooth. Careful dis-

is performed along the needle until the tooth is visualized and subsequently re-

Note: Ifno functional problems exist after displacement, the patient may elect not

the tooth removed. Proper documentation of this is critical.

carotid sheath does not contain the sympathetic trunk, which lies posterior to the

sheath and anterior to the prevertebral fascia.

carotid sheath is located at lhe lateral boundary ofthe retropharyngeal space at the

ofthe oropharynx on each side ofthe neck deep to the stemocleidomastoid muscle.extends from the base ofthe skull to the first rib and sternum. It contains the carotid ar-

the jugular vein, and the vagus nerve. Within the carotid sheath, the vagus nerve

lies posterior to the conrnon carotid artery and intemaljugular vein.

facial vein unites with the retromandibular vein below the border ofthe mandible and

into the main venous structure ofthe neck, the internal jugular vein. The in-jugular vein descends through the neck within the carotid sheath and unites be-

the sternoclavicular joint with fte subclavian vein to form the brachiocephalic

The brachiocephalic veins (ngi t and lefi) unite inthe superior mediastinlun to form

superior vena cava, which retums blood to the right atrium ofthe heart.



superior alveolar nerve

nerve

20

Coplaight O 201 l -20 1? - Denial Deck!

carotid artery

carotid art€ry

carotid artery

Coplrighr @ 201l-2012 - Dental Decks



the inferior alveolar nerve exits the mandibular canal, a small branch occurs, called

mylohyoid nerve. This newe pierces the sphenomandibular ligarnent and runs inferi-

and anteriorly in the mylohyoid groove and then onto the inferior surface ofthe my-

muscle. The mylohyoid nerve serves as an effetent nerve to the mylohyoid muscle

the anterior belly ofthe digastric muscle. This nerve may in some cases also serve as

afferent nerve for the mandibular first molar.

mylohyoid muscle is an anterior suprahyoid muscle that is deep to the digastric mus-

In addition to either elevating the hyoid bone or depressing the mandible, the muscle

floor ofthe mouth and helps elevate the tongue.

The sublingual gland is located superior to the mylohyoid muscle.

. . l. When placing the film for a periapical view of the mandibular molars, it is

Note{r the mylohyoid muscle that gets in the way if it is not relaxed.

2- when the floor ofthe mouth is lowered surgically, the mylohyoid and g€-

nioglossus muscles are detached.

3. An injection into the parotid gland (capsule) uthen atlempting to administer

an inferior nerve block may cause a Bell's palsy facial expression-paralysisofthe forehead muscles, the eyelid and ofthe upper and lower lips on the same

side ofthe face that the injection was given. Important: Ifthe parotid capsule

injection happens, care must be taken to protect the eye from injury and drying

using lubrication and an eye patch.

4. Remember: The bone of the maxilla is more porous than that of the

mandible, therefore, it can be infiltrated anywhere.

arterial blood supply to the TMJ is derived from the superficial temporal

and from the maxillary artery posteriorly, and from smaller masseteric, posterior

temporal, and lateral pterygoid arteries anteriorly. The venous drainage is through

diffuse plexus around the capsule and rich venous channels that drain the retrodiscal

){ot€: The two terminal branches of the extemal carotid artery are the superficialand the maxillary artery.

fibrous capsule of the TMJ is innervated from a large branch of the auriculotem-(branch ofV-3).The rnterior region ofthejoint is innervated from the mas-

(also a branch of V-3) and from the posterior deep temporal nerve (a/so

ronch oJ'V-3).The sensory innervation ofthe TMJ is via the trigeminal nerve as well.

nerve fibers prirnarily follow the vascular supply and terminate as free nerve endings.

the capsule, synovial tissue, and extreme periphery ofthe disc are innervated. The

cartilage and the central part ofthe disc contain no nerv€s. Both myelinated and

nerves are seen in the TMJ. The retrodiscal bilaminar zone has a rich neu-

supply and is the source ofproprioception.

Most synovial joints have hyaline cartilage on their articular surface; how-

a number ofjoints, such as the stemoclavicular, acromioclavicular, and TMJs, are

with bones that develoo from intramembranous ossification. These have fi-articular surfaces.



Which cranial nerve provides motor innervation to thesternocleidomastoid and trapezius rnuscles?

(CN lX)

(CN ))

(CNX1)

(Cir'J71)

Copright C 201 l-2012 - Dertal Decks

After a stroke on the right side ofthe brain that affects the rightupper motor neurons, the tongue deviates to the:

on protrusion

on protrusion

ofthe above, the tongue would not be affected

23

Cop)'right O 201 l-2012 - De al Decks



Nerve Site of Exit from Skull Component Function

yr|,Inlcmal acouslic mcatus Specirl s€nsory To thc o.gan of Coni for hcaring

To the semicircular canals lbrbalance

14B.anchial molorkp e c ial |irc e ra I eJle r e n t)

(se n etu yis c e u efer etlt)

k%erat \)isceftt ateren,

G€n€ral s€n$ry

kenerut somtic .ffercnt)

Special $nsory('peciat ateren,

Supplics de stylophaDngeus muscle

Paraslmprlhctic inncrvation of thc smoolh

musclc rnd gllnds oflhe pharynx. larlnx,and visccra ofthc lhomx and abdomcn

Cadics visccral scnsory inlbrmation from

thc carotid sinus and body

Providcs gcncol scnsalion infomationfrom the skin oflhc cxtemal car, intcmal

surfacc ofthc tympanic membranc.

uppcr pharynx. andpostcrior onc-tlird of

Providcs tnstc scnsation from postcrior

one-th;d ofthc tonguc

Bramhirl motor---{rrnill

(sp ? c ia | \'i' c etu etre r n,

Brrnchial motor----{pinal

(spec i aI viscerul etetenl

Inncrvatcs musclcs ot thc larynx and

Inncflates thc trapezn's and

stcmoclcidomasloid musclcs

Hyposlossal canal

ke"erut sonntk effercnt)Inncwatcs all of the inrrins;c and mort ofthe exlrinsic musclcs oflhc lon8uc

kenioslase$, ltlloglotsus, antl h\ oglossus

nerve:. Hypoglossal nerve Iesions paralyze the tongue on one side. On protrusion, the tongue deviates to the ipsilateral fsarre/ or contralateral side, de-

pending on the lesion site.

neuron lesion:

Lesions to the hypoglossal nerve causes paralysis on the ipsilateral fsame) side:

. Tongue deviates to the paralyzed side on protrusion (the paralwed muscles v,ill

lag. cartsing th? tip to dcviote).. Musculature atrophies on the paralyzed side. Tongue fasciculations occur on the paralyzed side

Example: With a neck wound that cuts the right hypoglossal nerve, the tongue de-

viates to the right on protrusion, and the right half of the tongue will later demon-

strate atrophy and fasciculations

motor neuron lesion:

Causes paralysis on the contralateral side:. Tongue deviates to the side opposite the lesion. Musculature atrophies on side opposite the lesion

Example: After a stroke on the right side of the brain that affects the right upper

motor neurons, the tongue deviates to the left on protrusion, and the left half of the

tongue will atrophy

If the genioglossus muscle is paralyzed, the tongue has a tendency to fall

the oropharyngeal airway with risk of suffocation.



The sublingual gland is locatsd in the oral cavitybetwe€n the mucosa ofthe oral cavitv and the:

muscle

muscle

muscle

muscle

24

Copt"ighr O 201 1,2012 - Denral Decks

the deep lobe ofthe submandibular salivary gland

surface ofthe ma-rillary tuberosity ofthe maxilla

to the infraorbital foramen ofthe maxilla

apex of the petrous part of the temporal bone in the middle cranial fossa

25

Copyrighr O 201 1,2012 - D€nral D€cks



glands are located in the floor ofthe mouth beneath the tongue, close to

midline. It lies between the sublingual fossa of the mandible and the genioglossus

ofthe tongue. The mylohyoid muscle supports the individual sublingual glands in-

Unlike the submandibular gland, which drains via one large duct, the sublingual

drains via approximately l2-20 small ducts fRivian's ducts),the majority open into

mouth on the sumrnit ofthe sublingual fold, but a few open into the submandibular

sublingual gland is ifflervated by parasympathetic secretomotor fibers from the fa-

nerve, which run in the chorda t)rynpani and in the lingual nerve (branch of V-3) andin the submandibular ganglion. The blood supply comes from branches ofthe

and lingual arteries. The veins drain into the facial and lingual veins. The lymph ves-

drain into the submandibular and deep cervical lymph nodes.

. The lymph vessels ffom both the sublingual and submandibular glands drain into the

submandibular and the deep cervical lymph nodes. Bartolin's duct, a common duct that drains the anterior part ofthe sublingual gland

in the region ofthe sublingual papilla, may be present. The submandibular duct lies on the sublingual gland. The sublingual gland is a mixed salivary gland, secreting both mucous and serous

saliva, but predominantly mucous-secreting

Von Ebner's glands are located around the circumvallate papilla ofthe tongue.

main function is to rinse the food away from the papilla after it has been tasted by

taste buds. They are purely serous.

rrigeminal newe emerges from the anterior surface of the pons by a large sensory and a small motormotor root lying medial to the sensory root. The nerve passes forward out of the postedor

fossa, below the superior petrosal sinus, and carries with it a pouch derived from the meningealmater. On reaching the depression on the apex ofthe petrous part ofthe temporal bone in

middle cranial fossa, the large sensory rcot expands to form the trigeminal ganglion. The motorrootrhe rigeminal nerve is situated below the sensory ganglion and is completely separate from it. The

maxillary and mandibular nerves arise from the anterior border ofthe ganglion.

sensory cell bodies ofthe ganglion,s sensory libers enter the:. Ophthalmic division 1f-1) to supply general sensation to the orbit and skin of face above eyes. \Iaxillary division (Y-2) to supply general sensation to rhe nasal cavity, maxillary teeth, palate,and skin over maxilla. \landibular division fZ-3) to supply general sensation to the mandible, TMJ, mandibular teeth,floor ofmouth, tongue and skin ofmandible

of rhe neurons gnter the pons through the sensory rcot and terminate in one of the threeofthe trigeminal sensory nuclear complex:

Typ6 of Ilbere Trigeminal Sen3ory Nucleus

spinal (d€scmdind nucleus

Piincipal (main) mso.y nucleus

Proprioceptive fibers fiom muscles and the TMJ are found only in the mandibular division. Thebodies of proprioceptive first order neurons arc found in the mesencephalic nucleus, not the

The TMJ, as is the case with alljoints, receives no motor innervation. The musclesmove the joint receive the motor innervation.

motor libers innervate the temporalis, masseter, medial and lateral pterygoid,belly of the digastric, mylohyoid, tensor tympani, and tensor veli pa,latjni (palati).



branch ofthe facial artery

artery

artery

pharyngeal artery

Coplright O 201 l -20 12 , Dmtal Deck

nerve

nerve

nerve

nerve

Coplrigh! O20ll-2012 - Dental Decl!



lingual artery arises from the anterior surface ofthe external carotid artery, opposite the

ofthe greater comu ofthe hyoid bone. It loops upward and then passes deep to the poste-

border ofthe hyoglossus muscle to enter the submandibular region. The loop ofthe artery

crossed superficially by the hypoglossal nerve. Branches include dorsal lingual artery,

artery and sublingual artery (t'hich supplies sublingual gland).lt terrninates as the

lingual artery, which ascends between the genioglossus and inferior longitudinal mus-

Note: The floor ofthe mouth also receives its blood supply from the lingual artery

.Motor innervation:

from the hypoglossal nerve/CNf,/,l).

. Sensory innervation: lingual (branch o-f trigeminal CN V-3) supplies the anterior two-

thirds. glossopharyngeal (CN1X) supplies the posterior one-third (including vallate papil-

lae), vagus /CN X) through the internal laryngeal nerve supplies the area near the

epiglottis.

r-ote: Besides the posterior l/3 of the tongue the glossopharyngeal nerve also supplies

sensory innervation to the tonsil, nasopharynx and pharynx areas.

. Taste: facial (CN VII) via chorda tympani supplies the antedor two-thirds; glossopha-

ryngeal (CN L& supplies the posterior one-third.

The v€rtebral arteries arise from the subclavian arteries andjoin to form the basilar ar-

The basilar artery is the main blood supply to the brainstem and connects to the Circle of

ophthalmic nerve (Vl) enters the middle cranial fossa through the superior orbital fissure and

within the lateral wall ofthe cavemous sinus on its way to the trigeminal ganglion. The maxil-

nerve 4r) enters the middle cranial fossa through foramen rotundum and may or may not pass

thc cavemous sinus en route to thc trigeminal ganglion. The mandibular nerve frc/ entets the

cranial fossa through foramen ovale, coursing directly into the ttigcminal ganglion. The trigcm-

ganglion 1n. if. a. r enilttnar ganglion ) lies in a depression known as the trigeminal cave (or Meckel'ser. Thc trigeminal nervc cxits the trigeminal ganglion and cou$cs "backward" to entcr thc mid-lat-

aspect ofthe pons.

mandibular division is the largcst ofthc 3 divisions ofthe trigeminal nerve. It has motor and sen-

functions. It is created by a large sensory alld a small motor root that unitsjust after passing through

foramen ovale to enter the iniiatemporal fossa. It immediately gives rise to a meningeal branch and

di!idcs into anterior and posterior divisions.

Division: Smaller, mainly motor, with I sensory branch (huccal):

. \lasseteric: innenates thc masseter muscle and provides a small branch to the TMJ

. Anterior and posterior deep temporal: innervates the temporalis muscle

. )Iedial pter!goid: innervates the medialpterygoid muscle

. Lateral pterygoid: innervatcs the lateral pterygoid muscle

. Buccal: supplies the skin ovcr the buccinator muscle before passing through it to supply the mucous

membrane lining its inner surface and the gingiva along the mandibrlar molars

Division: Larger, mainly sensory with I motor branch frene to m!-lohroid)l

. Auriculotemporali supplies the TMJ, auricle, and extemal auditory meatus

. Lingual: supplies the mucous membrane ofthc anterior 2/3 ofthe tongue and gingiva on the lin-

gual side ofthe mandibular teeth. lnferior alveolar: largest branch ofthc mandibular division; innervates all mandibular teeth and the

gingiva from the premolars anteriorly to the midline via the mental branch. Mylohyoid: supplics thc mylohyoid and the anterior belly ofthe digastric muscle

The trigeminal ncrve contains no parasympathetic component at its o.igin.



(CN I)

(Clr'111)

(Clr' @

(CN IV)

(CN II)

2A

Cop]rishr O 201l-2012 - Dental Decks

anterior teeth on the side of the injection

and first premolar on the side ofthe injection

teeth in that quadrant on the side ofthe injection

premolars and first molar on the side ofthe injection

29

Coptright @ 20ll-2012 - D€ntal Decks



Site of Exitfrom SkuU

olfactory(CN'

Speclrl semory

Optic(CN 1I)

Conveys lisual infomation from lbe rerina

(s en e N I s o Dn I c elfe rent)

Generc t i s.en t elle tea t)

Supplics fourofthe six extlaocular muscles ofrhe eye and

ihe levaror palpebrae superioris muscle of lhe upper eyelid

Parasympathetic innen ation of rhe constrictor pupillae and

(CN II' kere rul s onatic ellerest)Inner!ates the superior oblique muscle

ICN TI' (se^e ru ronatic elkrcnt)lnnenales rhe l.reEl rectus muscle

tC}; YII) bpeciat ,isce t etrercn,

ke nerat viscem t elleten t)

ke neft s onatic allerc nt)

Special sensor.v

Supplies lhe muscles of facial expression: posleriorbelly ofdigastric nusclei stylohyoid. and sraped'us muscles

Parasldpathetic innch..ation of the lacrinal. submandibular,

and sublingual glands. as wellas mucous mcnrbrancs ofthenasopharlnx and thc hard and softpalare

General sensalion from the skin ofthc concha oflhe auricle

and from a small area behind the ear

Provides raste sensation from thc antcrior tworh irds oflhelonguer hard and so{i palates

Craniaf nerves llI (oculomolor), Vll (facial),lX (glossophary geal), and X {tagrslhar c parasympathetic activity.

need !o qive a long buccal inj€ction in orderto extract the molars and second bicuspid. For operative pro-

a long buccal iniection may not be needed for tbese teefi. The long buccal irjection anesthetizcs thc

and periosteum buccal to the mrndibular molar tecth. Thc nccdle is insened in thc mucous mem-

distal and buccal to the nost distal molar in lhe arch.

anesthetize the lingu!l nerve: When administering an infcrio. alveolar nene block slorvly withdraw thc

and whcn approximately halfits length remains within tissues, r€aspirate. Ifnegativc, dcposit a por-the remaining solution /0.,1 ,r// to anesthetize the lingual nerve. Incisors may need local infiliration

Techniqucs of I\landibular 4nertheria:

. Mental nen'e block: This nerve block is used whcn buccal sofFtissue anesthesia is n€cessary anterior to

the mcntal tbramen (around the second premolar) ro the midline and skin of the lower lip and chin. The

needle is insened in mucobuccal fold tt orjust antcrior lo thc mental foramen. Ttrget area: mental ncne

as it exits thc mcntal foftfien (usuall! located berween the apices (t the-lirst and second prcnblars).. Vazirani-Alkinosi closed-mouth mandibular block: although this tcchnique can be used *'henever

mandibular anesthesia is desired, its primary indication remains those situations in which limited mandibu-

far opeDing (i.e., patienls r\'ilh r/lrrrrsl precludes the use ofolher mandibular lechniques. Nerves anes-

thetized: inferior alveoiat incisive, mcntal. lingual, mylohyoid nen'es. Are! of needle insertion: soft tissue

overlying the medial /1lrgl/d/) border ofthe mandibular ramus dirccily adjacent to the maxillary tuberosity

at the height ofthe mucogingival junction ad.lacent to the maxillary third molar. Not€: The injeclion is per-

formed blindly becausc no bony endpoints exists, the needle is advanccd 25 mm into tissue (&r dn awrage-si:ed adult).'fhe distance is measured from the maxillary tuberosiry.. The Cow-Cates technique; this technique is a true mandibulirr nene block because it provides sensory

anesthcsia to virtually the entire distribution ofV3 ftnferior alrcolar, lingual, n\,lob'oid. nenlal, itcis[w,

auriculotenporal, ancl buccal ner|es). hs primary use is when a conlentional inferior alveolar nervc block

is unsuccessful. Not€i Patient must cxtcnd his or hcr neck and open *ide for the duration ofihe technique

lthe nnaie hen assunes a more.frontal position and is closer to the andibular nerw trunv. Extraoral

landmarksi comcr ofmouth, tragus ofear, and intcrtragic notch Area of needle insertion: lhe needle is

positioncd so that it is insened just distal 1o thc moxillary sccond molar at the height of its mesiolingual

cusp. The needle is slowly advance until bone lneck ofthe concl.rle) is conlacted. The avelagc deplh ofsofF

tissue penetration to bone is 25 mm. The needle tip is withdrawr I mm, aspirate, and slowly deposit solu-



superior alveolar and middle superior alveolar nerves

superior alveolar and posterior superior alveolar newes

superior alveolar and inferior alveolar nerves

superior alveolar nerves and palatine nerves

30

Copright O 20l l-2012 - Dental Decks

ischemia

status changes

response

31

Cop).righr O 201 I -2012 - Dental Decks



. The posterior superior alveohr fP,Sl) nerve block, otherwise known as the tuberos-

ity block or the zygomatic block, is used to achieve anesthesia for the pulps ofth€ max-

illary third, second, and first molars (entire tooth = 7226; mesiobuccal root of the

marillary first molar not anesthetized: 28%o). Target area: PSA nerve-postedor,superior, and medial to the posterior border of the maxilla. Note: Potential for

hematoma formation.. The middfe superior veolar (MSA) nerve block is useful for procedures where the

maxillary premolar teeth or the mesiobuccal root ofthe first molar require anesthesia.

Target area: maxillary bone above the apex ofthe maxillary second premolar.

Note: The MSA nerve is present in only about 28% ofthe population.. The anterior superior alveolar (ASA) nerve block or infraorbital nerve block provides

profound pulpal and buccal soft-tissue anesthesia from the maxillary central incisor

through the premolars in about 72 o/o of patients. Target area: infraorbital foramen

(belov' the infraorbital notch).

Remember: In order to extract the maxillary first molar, you must numb both the PSA

and MSA nerves as well as the greater (anterior) palatine newe for palatal anesthesia

lsolt tissuel.

term shock denotes a clinical slrldrome in which there is inadequate cellular perfusion and

oxygen delivery for the metabolic demands ofthe tissues.

Reduced cardiac output is the main factor in all tlpes ofshock.

eeneral. shock is characterized bv:."lncreased vascular resistance: co61 mottled skin, oliguria. Tachycardia. Adrenergic response: diaphoresis, anxiety, vomiting, diarrhea

. \l]'ocardial ischemia

. \lental status changes

stages ofshock include: -l) Compensatory (early) stage: compensatory mechanisms (fu-

heart rdte and peripheral resistazce) maintain perfusion to vital organs, 2) Progres-

stage: metabolic acidosis occurs (compensatoty mechanisms are no longer adequate),

lrrercrsible (refractot)) stqge). organ damage, survival is not possible.

Categories of Shock:. Hlpovolemic shock is produced by a reduction in blood volume. Cardiac output will be

lou,due to inadequate left ventricular filling. Causes include severe hemonhage, dehydra-

tion. vomiting, diarrhea, and fluid loss fiorn bums.. Cardiogenic shock is circulatory collapse resulting from pump failure ofthe left ventri-

cle. most often caused by massive myocardial infarction.. Septic shock is due to severe infection. Causes include the endotoxin from gram-nega-

tive bacte a.

. Neurogenic shock results from severe injury or trauma to the CNS.

. Anaphylactic shock occurs with severe allergic reaction.



L at a pressure of2000 psi




I

II

III

IV

32

Coplrighr @ 201 1,201 ? , Denial Decks

Cop'"ighr O 201 I -2012 - Dental lkcks



oxide:. ls a colorless, nonirritating gas with a pleasant, mild odor and taste. Has a blood,/gas partition coe{Iicient of 0.47 and is thus poorly soluble in blood. ls excreted unchanged by the lungs. ls the oldest gaseous anesthetic in use today. ls the only inorganic substance used as an anesthetic. As a general anesthetic, the only disadvantage is its lack ofpotency

l. Nitrous oxide should be stored under pressure in steel cylinders painted blue.

2. Oxygen is stored in green tanks.

3. A full E cylinder ofoxygen contains approximately 600 L at a prcssure of2000 psi.

4. At 2 L/min, a full E cylinder will deliver oxygen for approximately 300 min, or 5 hrs.

Advintigei tnd Dhrdvrnarge ofNit o|'s Oridc Anrlgelia

There isa"nisus€" etential witb both Dati€nts and denrish

The most common oatient cmDlaint is nuse!

It is rultable for dl.g6 and tha"Fudcfd may nEdiqlty oompmmised

It is not a compleie pain rcliever, a l@alanestheiic is sdllrequired to

do mosl d€ntal prcc€dues

lr has vlrrudy !o !dEn. side efi@ts

;n rhe abscnc€ oflypoxiaDifiNion hypo{r nay occur; ms}e sure you give I 00% oxygen at

ihe md ofdmlal prccedurc to prevent it.

lmport nt: Tle inhalatim of 1 00% oxygen is contraiDdicared for a

It is ritat ble dd prodlrlr €uphoria

Oxygen supplementation should be avoided or used with extreme caution in pa-

rvith severe COPD. These patients have an increased incidence ofpulmonary bullae or(combined alveoft). Because ofnitrous oxide's low blood solubiliry, it can increase the

and pressure ofthese lung defects, which could create an increased risk ofbarotrauma

pneumothorax.

Stages of Anesthesia:

St|ge | (amnesia and analgesia)': begins with the administration of anesthesia and

continues to the loss of consciousness. Respiration is quiet, though sometimes irregu-

lar. and reflexes are stillpresent.

Stage ll (delirium and excitement):begins with the loss ofconsciousness and includes

the onset oftotal anesthesia. During this stage the patient may move his limbs, chatter

incoherently, hold his breath, or become violent. Vomiting with the attendart danger ofaspiration may occur. The patient is brought to Stage III as quickly and as smoothly as

possible.

Stage III (surgical anesthesia): begins with the establishment ofa regular pattern ofbreathing, total loss ofconsciousness and includes the period during which signs ofres-

piratory or cardiovascular failure first appear. This stage has four planes.

Stage IV (premortem)i signals danger. This stage is characterized by pupils that aremaximally dilated and skin that is cold and ashen. Blood pressure is extremely low,

often unmeasurable. Cardiac arrest is imminent. Rememtrer: The eyes appear geatly

enlarged in size and nonreactive to bright light when functional circulation to the brain

has stopped.



anesthesia

34

Coplrighr 92011,2012 - Denlal Decks

Epinephrlne and levonordefrin ar€ added to local

anesthetics becruse of theiri

to increase the potency ofthe local anesthetic

to decrease the pain (buming) caused by the injection ofthe local anesthetic

properties

to decrease the possibility ofan allergic reaction to the local anesthetic

Copyrighr O 201 1,2012 - D€ntal Decks



anesthesia acts by reducing sensitivity which therefore reduces anxiety and stress re-

salivation is also decreased.

atropine and benztropine are anticholinergic drugs. Not only do they decrease

flow ofsaliva, but also decrease the secretion fiom respirctory glands during general anes-

l. The duration of action of local anesthetics is directly proportional to protein

binding and lipid solubility. Increased protein binding-increased

lipid solu-

biliry - increased duration ofaclion.

2. The lower the pKa (dissociation constant) of the local anesthetic, the faster

the onset ofaction. Important point: a local anesthetic with a low pKa has a verylarge number oflipophilic free base molecules that are able to diffuse through tbe

nerve membrane.

3. Increased blood flow-shorter

duration of action.

4. Metabisulfite is an antioxidant that protects the vasoconstrictor from oxidation.

It has a low incidence of allergenicity.

5. The local aresthetic prilocaine can produce methemoglobinemia in patients

with subclinical methemoglobinemia when administered in large doses. The top-

ical anesthetic benzocaine also can induce methemoglobinemia, but only when

administered in very large doses.

6. The administration of norepinephrine and levonordefrin should be avoid€d in

patients receiving tricyclic antidepressants. There is an increased sensitivity to

vasoconstrictors.

***Epinephdne should be used cautiously.

7. The administration ofvsoconstrictors in patients being ffeated with nonselective

beta-blockers (i.e., Propranolol) increases the likelihood ofa serious elevation

ofthe blood pressure accompanied by a reflex bradycardia. Use vasoconstricton

cautiously.

(i.e. , epinephrine and levonord.eJrin) are added to local anesthetics because oftheirpropenics. Vasoconstriction at the site ofinjection is beneficial because it limits the up-

ofthe anesthetic by the vasculature, thereby incrersing the duration ofthe anesthetic and dimin-

systemic elTects (redueing systetuic toxicity). Notet The use of a vasopressor-containing local

may actually be responsible for the sensation ofbuming on injection. The addition ofa

and an antioxidant (sodium bisufite) Iowers the pH ofthe solution to between 3.3 and 4, sig-more acidic than solutions not containing a vasopressor (pH about 5.5). Patients are more

to feel the buming sensation with these solutions. Note: Malamed's book states that "local anes-

containing the vasoconstrictor levonordefrn Qleo-Cobefrir/ have become impossible to obtain

2004)".

To minimize the likelihood ofintravascular injection, aspiration should be performed be-

the local anesthetic solution is injected. Ifblood is aspirated, the needle must be repositioned until

ofblood can be elicited by aspiration.

reactions following the administration ofa local anesthetic are, in general, dose-related and may

from high plasma levels caused by excessive dosage, rapid absorption or unint€ntional in-

injection.

toxicities of local .nesthetics: Initial clinical signs and symptoms of mild to moderate tox-

include: talkativeness, apprehension, excitability, sluned speech, dizziness and disorientation. The

symptoms ofsevere toxicity include: seizures, respiratory depression, coma, and death.The excitatory manifestations may be very briefor may not occur at all, in which case the

manifestation oftoxicity may be drowsiness merging into unconsciousness and respiEtory arrest

manifestations are usually depressant and are characterized by brady-

hypotension, and cardiovascular collapse, which may lead to cardiac arrest. Note: In local anes-

depression ofrespiration is a manifestation ofth€ toxic effects ofthe solution.

L For a normrl heafthy (AM I) p^tient the maximum dose of epinephrine is 0-2 mg or 200

pg, this equates to roughly 11 cartridges of I :100,000 epinephrine.

2. In a cardiac risk patient the maximum dose ofepinephrine is 0.04 mg or 40 pg, this equates

roughly to two cartridges of l:000,000 epinephrine.



After receiving rn injection of a local rnesthetic containing 29lo lidocalnewith 1:100,000 epinephrine, the patient loses consciousness.

Which of the following is the most probable cause?

toxicity

response

syndrome

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Cop).righr C 201 1,2012 - Dental Decks

Which tooth has a root thrt is not consistently

innervated by the PSA nerve?

maxillary first molar

maxillary second molar

maxillary third molar

ofthe above

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Cop)righr C 201 l-:012 - Dental Decks



Caused by transient cerebral hypoxia

events are by far the most common adverse r€action associated with local

in dentistry. These may manifest in numerous ways, the most common ofwhichIn addition, they may present with a wide variety of symptoms, including hyper-

nausea, vomiting and altemtions in heart rate or blood pressure. Psychogenic re-

are often misdiagnosed as allergic reactions and may also mimic them, with signs such

urticaria, edema and bronchospasm.

management of syncope:

. Place patient in supine position with feet slightly elevated @endelenburg position)

. Establish airway (head tilt/chin lift)- Administer 1007o oxygen via face mask. 02 is indicated fbr the treahnent ofall

types ofsyncope except for hlTrerventilation syndrome.. Monitor vital signs and support patient

- Pupils may dilate from brain not getting oxygen.. Maintain your composure. Apply cool, wet towel to patient's foreh€ad.. Follow-up treatment

- Determine lactors crusing unconsciousness.

Hyperyentilation in an anxious dental patient leads to carpopedal spasm

spasm ofthe hand, thumbs, foot, or toes).

used to achieve pulpal anesthcsia, thc PSAnerve block is eflective for thc maxillary third, second,

first molars in 77olo to 10070 ofpatients. Howevet the mesiobuccal root ofthe ma,\illary first molar

not consistenrly innervated by the PSA n€rve. In approximately 28% ofpatients the middle superior

provides sensory ilnervation to the mesiobuccal root ofthe maxillary first molar. There_

if anesthesia ofthis tooth for either restomtive dcntistry or extraction is requircd, an infiltration in-

also should be performed over the second premolar tooth. Note: Patients experience fewsigns ofanesthesia after receiving a poste or superior alveolar nerve block, as compared to

inferior alveolar ner'-eblock (humb lip).

risk ofa potential complication also must be considercd whencver the PSAblock is used. Insertion

needle too far distally may lead to a tempo..ary (10 to 14 days) unaesthetic hematoma. As a means

the risk ofhematoma formation afler a PSA nerve block, the use of a "short" dcntal nee-

is recommended for all but the largest ofpatients. One must remember to aspirate seveial times be-

and during drug deposition during the PSAnerve block to avoid inadvertent intravascular injection

Ifa patient's face becomes distended and swollen after a posterior superior alveolar nerve

following treatment is recommended:

. Place cold packs and pressure on the affected side

. Explain to the patient that he/she may become black and blue on that sids

L Gauge ofa needle refers to the diameter ofthe lumen ofthe needle: the smaller the num-

ber, the greater the diameter ofthe lumen. A 30-gauge needle has a smaller intemal diame-ter than a 25-gauge needle. In the United States, ncedles are color-codedby gauge: 25-gauge,

red; 27-gauge, yellow; and 3O-gauge, blue.

2. Positive aspiration is directly correlated to needlc gauge.

3. Larger-gauge needles (i.e., 25-gauge) have distinct advantages over smaller ones:

. Less deflection as the needle passes through the tissues

. This leads to greater accuracy in needle insertion and, hopefully, to incrcascd success

lales. Largcr-gauge needles do not brcak as o{ien

The 25-gauge needle is the preferred needle for all injections presenting a high risk ofpos-

aspiration.



All ofthe following are rersons that vasoconstrictors are included in localanesth etics EXCEPT one. Which one is th e EXCEPTIOM

prolong the duration ofaction ofthe local anesthetic

chance ofan allergic reaction to the local anesthetic

reduce the toxicity because less local anesthetic is necessary

reduce the rate ofvascular absorption by causing vasoconstriction

help to make the anesthesia more profound by increasing the concentrations oftheanesthetic at the nerve membrane

38

Cop)righr O 201 1,2012 - Dental Decks

Lrrlngospasm is an uncontroll€d/involuntary muscular contraction (spasm)

ofthe laryngeal cords. It is a well known, infrequent but serious post-surglcal

complication. In the operating room it is treated by ldministering:

39

Cop)rightO 20ll-2012 - Denral Decks



This is false.

are invaluable to local anesthesia in dentistry. There are clear indications foruse, ofwhich improving the depth and duration ofanesth€sia are the most important.

them, local anesthetics haye a very short duration ofaction intraorally. Vasoconstric-

is more important for infiltration techniques in vascular sites than it is for mandibular

The presence of a vasoconstrictor may also reduce systemic toxic effects and can

hemostasis. The most common agent for this purpose is epinephrine, which is avail-

in fonnulations of l:50,000 (0.02 rng/ml), l:100,000 10.01 mg/ml) and l:200,000 (0.005

are three main adrenergic receptor subclass€s that vasoconstrictors interact with on car-tissue in the human body. These are classified as alpha receptors fbot& alpha-l and

receptors, and beta-2 receptors. Alpha receptors are densely located on arte-

the skin and mucous membrunes. Stimulation of these receptors leads to vasocon-

through activation ofG proteins and subsequent opening ofcalcium channels. Beta- I

are located on cardiac tissue, and stimulation olthem leads to an increase in heart

(posilive chronotropr) and aD increase in contraction force (positive i otropy), Beta-2 rc-

Iike alpha receptors are located primarily in vascular beds. However, these receptors

located primarily in vascular beds traversing skeletal muscle. when stimulated, beta-2 re-

activate adenylate cyclase, leading to vasodilation.

is the more potent than levonordeliin. Its affrnity for alpha versus beta receptols

roughly equivalent (50:50). Thus, although the primary event that occurs at the site ofin-

beneath the oral mucosa is vasoconstriction, the relatively low systemic levels achieveddental local anesthetic injections can cause increases in heart rate and cardiac output, as

as peripheral vasodilation in skeletal muscle beds. Note: Levonordefiin is less potent

epinephrine, its receptor affinity is 759/o alpha and2'%obeta. As noted earlier' local anes-

containins levonordefrin have become impossible to obtain.

patient under general anesthesia loses the laryngeal reflex. Ifblood and saliva collect

the vocal cords, this stimulates the patient to go into spasrn (aryngospasm) and the

cords will close. When this happens, air cannot pass through and hence the prob-

The two most important steps in the initial management of a laryngospasm are ap-

oxygen under positive pressure and administering succinylcholine.

Succinylcholine is a skeletal muscle relaxant that is used when performing endo-

intubation and endoscopy procedures.

is frequently cited as an adverse effect of ketamine, but it is rarely ob-

deep, heavy, loud respirations mistaken for laryngospasm are actu-

due to airway positioning. Such breathing is managed simply by repositioning the

head. True laryngospasm during ketamine sedation is usually caused by stimu-

ofthe vocal cords by instrumentation or secretions.



pressure

40

Coprigltr O'2011-?012 - Detrtal Decks

How will a larger than norm|l functional residual

capacity aff€ct nitrous oxide sedation?

sedation will happen much quicker

oxide sedation will take longer

residual capacity does not affect nitrous oxide sedation

41

Cop"iShr O 2011,2012 - Dental Decks



ancsthesia causes loss of sensation by first blocking nerve conduction in thc smaller un-

that carry pain, and then progressing to the larger myelinated llbers for pressure

motor function. This phenomenon is called differential blockade. Differential blockade may

due to the size ofthe nerve, the p.esence or absence ofmyelin, and firing frequency.

. Size of nerve: local anesthetics prefcrentially block small fibers bccausc the distancc ovcr

which such fibers can passively propagate an electrical impulse is shorter During the onset oflocal anesthesia, when short sections ofnerve are blocked, the small diameter fibers are the firstto

fail toconduct.

. Preserce or absence of myelin: For myelinated nerves, three successive nodes of Ranvier

must by blocked to halt impulse propagation. The thicker the nerve fiber, the farther apart the

nodes tend to be, which explains, in part, the greate. resistance to block of lary€ fibers (e.g.,

nlotorfbers to skeletol muscle). Myelinated fibers tend to become blocked before unmyelinated

fibers of the same diameter n-ote: Sodium channels are very dense at the nodes of Ranvier in

nvelinated fibers which contributes to thern being blocked before unmyelinated libers of the

same drameter.. Firing frequency; sensory fibers, especially pain fibers, have a high firing rate and a rela-

ti\ cly long action potential duration frp to 5 msec). Motor fibcrs fire at a slower rate and have

shoner action potential duration (< 0.5 msec).AdeltaandC fibers are small diameter fibers that

participate in high-frequency pain tnnsmission. Therefore, they are blocked sooner with lower

concentmtions of local anesthetics than are A alpba (motot) frbers to skeletal muscle.

Nerves regain function in reverse order.e\tent ofanesthesia depends on a variety offactors, including the amount ofmedication used,

temperature, pH, the arnount of protein binding, and dilution by tissue fluids. Local ancs-

work by blocking the flow ofsodium ions, thereby preventing depolarization ofthc nerve

and conduction or transmission ofthe imDulse.

functional residual capacity is the amount ofair remaining in the lungs at the end

the normal expiration. Note: This air is used to provide air to the alveoli, which willthe blood evenly between breaths.

Pulmonary volumes and capacity are about 20 to 25o% less in females than in males

are greater in large and athletic persons. Nitrous oxide sedation will vary accord-

air volumes during rest and exercise are of physical and clinical interest

they can be measured using a spirometer. The main volumes ofinterest are:

. Tidal Volume (TV): amount of air breathed in and out during quiet breathing

. Expiratory Reserve Volume (ERV): amount ofair forced out ofthe lungs in a max-

imal expiration, over and above that expired in normal breathing. Inspiratory Reserve Volume (IRV): amount ofair inlaled in a maximal inspiration,

over and above that inhaled in normal breathing

. \'ital Capacity (VC): TV + ERV + IRV. Residual Volume (RV): volume of air that remains in the lungs at all times (can't be

neosured by spir)metry). Total Lung Capacity (TLC): VC + RV



lipid soluble, mpid

lipid soluble, delayed

lipid soluble, delayed

lipid soluble, rapid

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43

Coptriglr @ 201|,2012 - D€nral Decks



a dose-dependent CNS depression with hypnosis and amnesia. They are

lipid soluble, which results in a rapid onset of action. They are used most often for in-

because they produce unconsciousness in less than 30 seconds.

. Ultra-short acting: Methohexital (Brevital), thioper/''al (Pentothal), and thiamylal (Srir!

tal). Short and intermediate acting: Amobarbrtal (Amytal), pentobarbital (Nembutql), seco-

barbital (Seconal), and Butabarbital fI'ioticet, Fiorinal). Long acting: Phenobarbital (LtminaQ

commonly used barbiturates for induction of an€sth€sia:

. Thiopental (Pentothal): Usually prepared as a 2.5To solution. An induction dose of 3-5

mg&g produces a loss ofconsciousness within 30 seconds and recovery in 5-10 minutes.

Because the elimination half-life is 6-12 hor.rrs, patients may experience a slow recovery.

When injected intravenously, it can be initating. Usually prepared as 2.5olo solution. pH is

1 0.5.. llethohexital /Brcvitdr: is somewhat less lipid soluble and less ionized at physiologic pH

than thiopental. An induction dose of l-2 mg,&g produces loss ofconsciousness in less than

20 seconds and recovery in 4-5 minutes. The elimination half-life ofmethohexital is 3 hours,

rrhich ailows a clearance rate that is 3 to 4 times faster than that ofthiopental. pH is 10.5.

The side effect most often seen is hiccoughs. This is believed to be caused by rapid injec-

tion of the Brevital.

. l. The most eff€ctive ag€nt in the initial treatment of respiratory d€pression due

\ot.! to the over dose ofbarbiturates is oxygen under positiv€ pressure.

2. A primary advantage of IV sedation is the ability to titrat€ individualized

dosage.

(Novocaine) was, at one time, the most commonly used ester local anesthetic in dentistry Il is

protolvpe for the ester group oflocal anesthetics but is no longer available in dental cartridgc fo.m.

easy way to identify amide local anesthetics is to rcmember that the drug name contains an i plus -(lidocaihe, mepi|acaine, and bupivacaine). Estors such as procaine, benzocaine, and tetracaine

no1.

pe local anestheticsi

Lidocairc (X),locainel: most commonly used

Pilocaine (Citanest)

\t,rcaine (Septocaine/: has both amide and ester linkages

\Icpit acatne (Carbocaine)

Bnpi ac arne I I[a rc a ine)

Eridocaine /Darznestlr removed from the U.S. market in 2002

Ester-tlpe local anestheticsi

. Proc i're (Novocaine)

. P I opoxy caine (Raroc a ine )

. Bcnzocaine (Monocaine)

. Tetrac ine (Pontocaine)

still commonly used in the practice ofdentistry Most topical local ancsthctic oint-

and gels contain benzocaine (an ester e.g., Httticaine, Celacaine). Benzocaine gels typically

I 89 6 - 20% benzocaine. Lidocaine /a n amide) ls also avallable in two foms for topical applica-

EI1LA /ekrecric mixlure o.[ local anesthetic c],ea ), containsboth lidocaine and prilocaine.

are safe, versatilc, and effective local anesthetics. Ifhypersensitivity to a drug in this group pre-

its use, one of the ester-compound local anesthetics may provide analgesia without adverse effectpatients allcrgic to both esters and amides, diphenhydramine (Benadryl) is

^good choice

are potent local anesthetics slightly different in chemical structure from the amide group. Tetra-

is most commonly used. Allergic rcactions are far more common with esters'

The local anesthetics lidocaine and prilocaine are recommended for the pregnant (Class B)

pregnant fcldsr C, patient, articaine, bupivacaine, mepivacaine, and epinephrine can bc

The drug of choice in management ofan acute allcrgic reaction involving bronchospasm

acule nat rowing oflhe rcspiralory ainray) and hypotension is epinephrine.

Alleryic reactions to local anesthetic are usually caused by an antigen-antibody reaction



injecting the anesthetic solution

color change during the injection

a topical anesthetic prior to administration ofthe local anesthetic

the anesthetic solution as quickly as possible

a low concentration of vasoconstrictor

extremely anxious patients

confident handling ofthe patient

Copfighr O 201l-2012, D€ntal Decks

mglml ofanesthetic

mg/ml of anesthetic

mg/ml of anesthetic

mg/ml ofanesthetic

45

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common cause ofa transient loss ofconsciousness in the dental office is vasovagal syncope.

generally is due to a series ofcardiovascular events triggered by the emotional shess btought on by

anticipation of or delivery ofdental care. Prevention ofvasovagal syncopal reactions involves proper

preparalon.

signs ofan impending syncopal episode should be quickly treated by placing the pa-

in a supine position with the feet elevated (Trendelenbutg posiliol,/, monitoring vital signs, loos-

tight clothing and pJacing a cold compress on the forehead. Oxygen 3-4 L/minute should also be

via nasal cannula. Important: The most common early sign ofsyncope is pallor.

Most common related to injections in younger individuals

Parasympathctic response often followed by sympathetic response secondary to anxietyWarm feeling, pale, diaphoresis, "feeling faint or sick," nausea, bradycardia, and hypotension

Common Medical Emergenciesi

S).'ncope . Asthma attack

Hypoglycemia . Seizure

Postural hypotension 'Allergic reactions

,{ngina pcctons

Management

Slo\\'to change position from laying to sifting to standing

\eed for change in medication'l (depends on severity)

Rcccnt change in medication

Rule out precipitating causes

pervenlilation syndrome"- most commonly seen in dental office

Related to anxiety/ panic

Associated with lightheadedness. dizziness, chest pain, dysphagia, nausea

Rule out morc se ous potential conditions including pulmonary (aslhtna, PE), cardia. (CHF), en-

docnne ( d a b et i c ke to ac ido s is)

calculate the amount, in milligrams, ofany anesthetic and vasoconstrictor in a given solution:

For local anesthetics, for every 1o% solution there is l0 mg/ml. Therefore:

Total milligrams = 7o ofthe solution x l0 x total millilitersFor vascoconstriction, for every I :100,000 there is 0.01 mg/ml-. Thereforc'

Total milligrams = ratio x total milliters



agent + narcotic analgesic

agent - nitrous oxide

agent + narcotic analgesic + nitrous oxide

analgesic + nitrous oxide

46

Cop)righr e 201 l-2012, Dental Decks

Anestlrl

attack

17

Coplright O 201l-2012 - Dental Deck



anesthesia is a state of neurolept analgesia and unconsciousness, produced by the

ofa narcotic analgesic and a neuroleptic agent, together with the inhala-

ofnitrous oxide and oxygen.

analgesia only produces an unconscious state ifnitrous oxide is also adrninistered f.ree

Neuroleptic agent + narcotic analgesic = neurolept analgesia

(Droperidol) (l'entanyl) (conscious)

the influence ofthis cornbination, the patient is sedated and demonstrates psychic indiffer-

to the environment yet remains conscious and can respond to questions and commands.

Neurolcpt+

nitrous oxide = neurolept anesthesiaanalgesia in oxygcn (wtconscious)

of anesthesia is slow, but consciousness retums quickly after the inhalation ofnitrous

is stopped.

1. Neurolept analgesia is useful for minor surgical procedures, somc radiological pro-

Note3i. cedues, bum dressing, and endoscopy.

,.r.._,,.i 2. Neuroleptic agents such as droperidol (laapsine) causc areduction in all-{iety and

a state of indift'erence.

3. Droperidol is an antiemetic and has adrenergic blocking (a/p ha block) activity.

4. Neurolept analgesia,/anesthesia may be especially useful in the elderly, debilitated

or seriously ill patient.

5. The combination ofdroperidol and fentanyl (Sublimaze),is lnnovar.

6. Innovar produces slight circulatory effects, but can cause siSnificant respirutory de-pression.

7. The low incidence of extmpyramidal side effects associated with droperidol use

may bc cffectively treated with the anti-cholinergic (anti-muscairlc, dmg, benztropine

(Coge tin).

is thc most common adverse reaction associated with administration of local

Remember: It often occurs when upright, though can occur when sitting.

u'ill never occur when lying. The patient may complain offeeling generalized warmth

nausea and palpitations,

initial event in a vasovagal syncope episode is the stress-induced release of in-

of catecholamines that causes the following: a decrease in peripheral

resistance, tachycardia, and sweating.

pools in the periphcry a drop in blood prcssure appears, with a corresponding

in cerebral blood flow. The patient will then complain offeeling dizry or weak.

mechanisms attempt to maintain adequate blood pressure, but they soon

lcads to vagally mediated bradycardia. Once the blood pressure drops

lcrels necessary to sustain consciousness. syncopc occurs.

the patient in a supine position with the feet elevated (Trendelenburg posilion),vital signs, tight clothing should be loosencd and a cold compress placed on

forehead. Oxygen 3-4 L/minute should be given via nasal cannula.

The single most important drug to use in any medical emergency, includ-

pulmonary disease, is oxygen.

The primary ailway hazard for an unconscious dental patient in a supine position

tonsue obstruction. Remember: Head titt/chin lift.



Tfeuma to muscles or blood vessels in the ls

the most common etiologicNl ftctor in trismus associated withdental injections of local anesthetics,

fossa

fossa

fossa

48

Copltighr O 2011,2012 - Denral Decks

first stalement is true, the second is false

first statement is false, the second statement is true

statements are true

statements are false

49

Cop)right O 201 I 201? - Denral Decks



jaw opening, or trismus, is a relatively common complication following local anesthetic

addition to tmuma to muscles or blood vessels in the infratemporal fossa, itbe caused by hematoma formation, localized muscle necrosis secondary to the anesthetic

vasoconstrictor, infection in the fascial space, or introduction ofa foreign body.

In most instances of trismus the patient rcports pain and some difficulty opening his or

on the day after treatment in which a posterior superior alveolar or inferior alveolar

block was administered.

symptom of trismus is the limitation of movement of thc mandible, which is often

with pain. Symptoms will arise from one to six days following an injcction. The du-

symptoms and their severity are both variable. Note: The medial pterygoid muscle isoften af'fected.

trismus:. Apply hot, moist towels to the site for approximately 20 minutcs every hour. Warm saline rinses. Use analgesics as required. Benzodiazepincs 1e.g., Diazepam) for muscle relaxation ifdeemed necessary. The patient should gradually open and close mouth as a means ofphysiotherapy

ing an inferior alveolar nerve block injection or a mental block injection, a prickly or

sensation (paresthesiq), ever' complete numbness in the lower lip, may result and per-

tbr a considerable time. This is usually considered to be due to direct trauma or piercing

dre ncrve trunk by the needle. This happens more often in thc case of the mental block in-

The symptoms of paresthesia gradually diminish (uoy last from two i,eel6 to sixa\d recov ery is usually complete.

The most common cause of paresthesia of the lower lip is thc rcmoval of a

third molar (especially horizo lally impqcred ones).

and vomiting are the most conmon adverse effects ofnitrous oxide sedation, oc-

in l% to l0% of patients. Fasting is not required for patients undergoing nitrous

sedation. The practitioner, however, may recontmend that only a light meal be con-

in the 2 hours prior to the administration of nitrous oxide. Diffusion hypoxia can

as a result ofrapid release ofnitrous oxide from the blood stream into the alveoli,diluting the concentration ofoxygen. This may lead to headache and disorienta-

and can be avoided by administering 1007o oxygen after nitrous oxide has been

The most common complication associated with nitrous oxide sedation is

problen (laughing, giddy).

Some literature states that nitrous oxide is acceptable for the pregnant patient,

from a risk management point it may be prudent not to use nitrous oxide on

pregnant patlent.

ofvolatile an€sthetics (desflurane, enflurane, halothQne, isoJlurane, and

is not a concern for COPD patients. All volatile anesthetics are bron-

and, therefore, are beneficial to patients with COPD (asthmatic bronchitis,

sand chronic bronchitis).

Sedation with nitrous oxide should be aYoided in patients with COPD.



5,000 - 45,000/mml

- 100,000/mm3

- 450,000/mm3

600,000/mmr

Cop}right O 20ll 2012, Denral Decks

How many milligrams ofepin€phrine are in cach certridge(1.8 cc) of 2oh lidocrine with 1:100,000 epinephrine?

mg

51

Cop)'right C 201 l':012 - Dental D€cks



is defined as a count of<150,000/mmr. Intraoperative bleeding can be severe with

of 40,000-70,000/mm3, and spontaneous bleeding usually occurs at counts <20,000/mmr. The

recommended platelet count beforc surgery is 75,000/mmr.

Dctinttiod

While blood .ell coutrt 5,000 10,000/mmr 5.000-10,000/ndl

l4- l6 e/dl 12'14 z/dL

Per.etiagc of RBC l!|ass in 12yo-52ya 36%48%

150,000-450,00/Dml 150,000450,00/mrRBC indices:

Me corpuscullr volume(]rcv)

AvmgE RBC volmes in lL 80 100 it 80-100 fL

h€moglobitr (MCH)Estinales weight ofHSb in

8vera8e RBC

28'33 pg 28-31p8

Estindls !Ymg. corcmea-lion of Hgb ir almg€ RBC

3l-16 r/dl 32-36 e/dL

()rcHc)

L The minimal acceptable value for the hematocrit is 30D% for elective surgery.

2. Nomal values for coagulation:. Tcmplate bleeding time : I to 9 minutes. Prothrombin time (PT) = 1l to 16 s€conds (comparcd to nonnal control). Partial thromboplastin time (PTT) = activated, 32-46 seconds fcoupared to norual

lmportant: PT rvill be increased by warfarin, vitamin K deficiency, fat malabsorption,

livcr disease, DIC, and, artificially, increase toumiquet time. Warfarin blocks vitamin Kuse, whereas broad-spectrum antjbiotics elevate PT by killing normal bowel flora, which

decreases vitamin K absorption. Heparin in high doses also will increase PT by altering

factor X. FFP (fresh frozen plasma) 'rtill reverse warfa.in effects immediately.

cc oI2o/o lidocaine with epinephrine 1:100,000 contains the following:

l0 mg of lidocaine: Blockade ofnerve conduction

0.01 mg ofcpineph ne: lncrease depth and duration ofanesthesia; decrease absorption of

local ancsthetic and vasopressor6 mg ofNaCL: Isotonicity ofthe solution

0.5 mg of sodium (meta) bisulfatc: Antioxidant

I mg of methylparaben: Bacteriostatic agent

Stenle Naler: A diluent to provide the volume ofsolution in a cartridge

of 2%o fidocaine (which is a calpule) with epinephrine 1:100,000 contains the following:

36 mg oflidocaine: 1 8 x 20 mgNote; Methylparabcn is no longer included

018 rng of epinephrine: l 8 x 0l mgln ,ingt.-rr. o*ot cartridges oi local anes-

10'8 )ng of Nacl: 18x6mgthetic: however. it rs lbund inALL multidose

.90 mg ofsodium {meta) bisulfate: 1 8 x 0 5"i.i, "fIni".,.Uf.

a-*,LI mg of methylparaben I .fi x I mg

sterile watcr

Noaesl

Percent Solution = Milligrams (ng) x volume ofcrrtridge = Mitligrams per Crrtridg€

0.5=5X1.8=91.0=10x1.8=182.0 = 20 X 1.8 : 36

3.0 : 30 X 18 = 54

4.0=40x1.8=72

Some ofthe gencric anesth€tic cartridges are now containing 1.7 cc ofanesthelic'



Plasma

Kidney

Liver

52

Coplrigh @ 20ll-2012, Denral Decks

The initial cllnical signs and symptoms of CNS toxicity for local anestheticsare usually excitrtory in nature. However, it is also possible that the €xcitatory

phase of the reaction may be extremely briefor may not occur at all.This is true especially with which two Iocal aneshetics?

Copytighr O 201 l-2012 - Denral Decks



significant difference between the two major groups of local anesthetics, the esters and the

is the means by which the body biologically transfoms the active drug into one that is phar-

inactive. Metabolism (or biotransformationl of local anesthetics is important bc-

the overall toxicity of a drug depends on a balance between its rate of absorption into the

at the sitc ofinjection and its mte ofremoval from the blood through the processes ofuptake and metabolism.

primary site of biotansformation of amide drugs is the liver. Ester local anesthetics are hy-

in the pfasma to pala aminobenzoic acid (PABA) by the enzyne pseudocholinesterase. Pa-

with pseudocholinesterase inactivity are unable to detoxily ester tlpe agents at a normal rate.

type anesthetics are recommended in these patients.

reactions to amide type local anesthetics are rare but may occur as a result ofhypersensi-

to thc local ancsthetic agent itselfor due to an allergy to methylparaben or other preserva-

used in many solutions. These reactions are characterized by cutancous lesions of delaycd

urticaria, edema, and other manifestations ofallergy. Important: For thosc patients aller-

to both cstcr and amide type local anesthetics, Diphenhydramine is a safe and effective alter-

Est€rsEste'|s of bennic acid:

Bulacaine

Cocaine

Elhyl aminobenzoate (b€nzocaire)

Hexylcain€

PiperocaineTetmcaine

Es lers ofparaminobettzoic acid :ChloroprocaineProcaine

Propoxycaine

Bupivacaine

Dibucaine

EtidocaineLidocaine

MepivacainePrilocaine

Ropivacaine

Quirolin€centbucridine

ancsthetics readily cross the blood-brain barrier Their phannacological action on the CNS

At low (therapetic, nontoxic) bloodlevels, there are no CNS eflects ofany clini-

significance. At higher (toxic, overdose) levels,thc primary clinical manifestation is a general-

tonic-clonic convulsion.

a furthcr incrcase in the blood level ofthe local anesthetic above its "therapeutic" level, ad-

be observed. Because the CNS is nuch morc susceptible to the aclions oflocal

other systems, it is not surprising that thc initial clinical signs and symptoms of(toicity) are CNS in origin. Initial clinical signs and symptoms (slurred speech, tlizziness,

apprehension, incrcased anxiety) ofCNS toxicity are usually excitatory in nature.

and procaine differ somcwhat from other local anesthetics in that lhe usual progression

signs and syn'tptoms may not be seen. Lidocaine and procaine frequently produce an initial

sedation or drovsi\ess (here common with lidocaine).

in place of the excitatory signs. Ifeither excitation or sedation is observed

the initial 5 to l0 minutes alicr thc intraoral administration ofa local anesthetic, it should serve

a wamirg to the clinician ofa rising local anesthetic blood level and the possibility (if the blood

co li ues to risel ofa more serious reaction, possibly a gcncralized conl'ulsive episode.anesthetics havc a direct action on the myocardium and peripheral vasculature ln general,

thc cardiovascular system appears to be nore resistant to the effects oflocal anesthetic

the CNS.

. Direct action on the myocardium: Local anesthetics produce a myocardial dcpression that is

related to the local anesthetic blood level. Local anesthctics decrease electrical excitability ofthe

myocardium, decrease the conduction rate, and decrease the lbrce ofcontraction. Direct action on the peripheral vasculature: All local aneslhetlcs (except cocaine and ropi-

tacaine) produce a peripheral vasodilation, through relaxation of the smooth muscle in the

walls ofblood vessels.



2 to 3

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Nervous System (PNS)

Nervous System fCNt

System (lNS)

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is well known that the pH of a local anesthetic solution fdrd lre pH ofthe tissue into which it is in-

greatly influences its nerve-blocking action. Acidification oftissue decreases local anesthetic ef-

Inadequate anesthesia results when local anesthetics are injected into inflamed or infected

anesthctics containing epinephrine or othcr vasopressors are acidifted by the manufacturer

inhibit the oxidation ofthe vasoprcssor. The pH ofsolutions without epinephrine is about 5.5; epi-

have a pH of about 3.3. Note: Increasing pH (alkalinization) of a local

solution speeds the onset of its action, increases its clinical effectiveness, and makes its in-

more comfortable.

two factors involved in the action ofa local anesthetic are diffusion ofthe drug through the nerve

and binding at the receptor site in the ion channel. Local anesthetics exist in ionized (cation) a d

fbare) forms, the proportions ofwhich vary with the pH ofthe environment. The non-ion-

(bd.re) portion js the form that is capable ofdiffusing across nerve membranes and blocking sodium

oxide is the only inorganic gas used by the anesthesiologist. Room air contains 2l%o

you must mak€ sure that th€ pati€nt rec€ives at least this much oxygen. The max-

nitrous oxide limitation is 60% nitrous oxide and 40olo oxvsen.

oxide is carried in the bloodstream in physical solution. There is no metabolism orofnitrous oxide in the body. It is excreted solely via the lungs, unchanged. High

levels olnitrous oxide can be achieved quite quickly. It is non-toxic to body tissues.

only toxicity with the use ofnitrous oxide is the lack ofoxygen that could result from the

The gag reflex is only slightly obtunded with nitrous oxide analgesia. lt is be-

ed rhat nitrous oxide has its main effects on the reticular actiyating system and the lim-sl'stem.

oxide is a weak anesthetic. It is used to supplement inhalation agents. tt is the only in-

anesthetic with sympathomimetic activity. It should not be used in dos€s higher than

combined with 40% oxygen. It is known to diffuse into air containing spaces and to in-

the pressure in such cavities. 100% oxygen should be administered during awakening

order to avoid diffusion hypoxia.

. The first symptom ofnitrous oxide analgesia is tingling of the hands.

. Nausea is the most common side effect ofnitrous oxide analgesia.

.The correct total liter flow ofnitrous oxide/oxygen is determined by the amount necessary

to keep the reservoir bag 1/3 to 2/3 full.. MAC (minimal alveolar concentrqtioz) ofnitrous oxide is 104. MAC is the concentration

of an inhaled anesthetic at I atm that prevents skeletal muscle movement's response to a

painful stimulus (e.g., suryical skin incision) in 50%o of patients.

LosspK, =morc.apid onsetofaciion, more RN (ftebase fom) molecules pres€nr to dilluse through nedesheath; thus onset time is de$eased

Indeased lipid solubility = Increased pot€ncy

{example procaine = lr eiidGaine = 140)

Etidocaine prcduces conduction blockadear eery lowconcentrations, wherea prccaine poorly sqpresses

neNc conductiol. even at higher concenhations

lnreased protein bindiDg aUows anesrhetic cations

(RNrD io be more nmly arrached to proteins locat.da(sil6: lhus duration ofaciion is increased

lncreased diftusbrlrry = De(eased rime ofonset

Greater vasodilaror dciivity = lnreasedblood flow to

region = Rapid renoval ofanesrhetic moleculd liofrinjection siie; lhus dereased anesthelic poidcy and



ions

ions

ions

56

Coplr'ghr O 201t,2012 - D€ntal D€cks

Coplrighr O 20ll-2012 - Denral Decks

Which of the follo\Ding is that phrse of rnesthesia that begins withthe adminlstration of anesthetic and continuing until the desired level



anesthetics selectively inhibit the peak permeability of sodium, whose value is normallyfive to six times greater than the minimum necessary for impulse conduction. The

sequence is a proposed mechanism of action of local anesthetics:

l. Displacement ofcalcium ions from the sodium channel receptor site, which permits...

2. Binding oflocal anesthetic molecule to this receptor site, which thus produces...

3. Blockade ofthe sodium charmel, and a...

4. Decrease in sodium conductance, which leads to...

5. Depression oflhe rate ofelectrical depolarization, and a...

6. Failure to achieve the threshold potential level, along with a...

7. Lack ofdevelopment ofpropagated action potentials, which is called...

8. Conduction blockademechanism whereby sodium ions gain entry to the axoplasm ofthe nerve, thereby initiating an

potential, is altered by iocal anesthetics. The nerve membrane rcmains in a polarized state

ionic rnovemcnts rosponsible for the action potential fail to develop. Nerve block produced

anesthetics is called a nondepolarizing nerve block.

l. Local anesthetics reversibly block nerve impulse conduction and produce

reyersible loss of sensation at their administration site. The side of action of local

anesthetics is at the lipoprotein sheath ofthe nerves.

2. Local anestbetics are clinically effective on both axons and free nerve endings.

3. Important; Small, myeliDated nerv€ libers which conduct pain and tempenture

sensations, are affected first, followed by touch, proprioception, and skeletal

muscle tone.

4. Emergenc€ from a local anesthetie nerve block follows the same diffusion

pattems as induction does; however, it does so in reverse order.5. Recovery is usually a slower process than induction beaause the anesthetic is

bound to the drug receptor site in tbe sodium channel and therefore is released more

slowly than it is absorbed.

6. Potassium, calcium, and chloride conductance's remain unchangcd.

Stage I and Stage II of general anesth€sia together are referred to as induction.

depth ofgeneral anesthesia fby irhalation) vnies with the partial pressure (tension) ofagent in the brain, and lhe rates ofinduction arrd recovery depend upon the

ofchange oftension in this tissue (also blood supply to the lungs, pulmonary ventila-the concentration ofthe qnesthetic influence the rate of induction). ^Ihe signs and

of anesthesia are most likely to be seen with anesthetic that has a slow rate of in-

L Maintenance is the process ofkeeping a patient in surgical anestlesta.

2 . Recovery is the phase of anesthesia commencing when surgery is complete and

the delivery of the anesthetic is terminated and ending when the alesthetic has

been eliminated from the body.

3. The behavior of patients under general anesthesia suggests that the most re-

sistant part ofthe CNS is the medulla oblongata (cardiac, vasomotor, and res-

piratory centers of the brain).

4. The most controllable route for administration of a general anesthetic is in-

halation.5. Minimum alveolar concentration {MAC): alveolar concentration ofanesthetic

at which 50% ofthe palients are unresponsive to a standard surgical stimulus.

6. Meyer-Overton theory: anesthesia commences when a chemical substance

reaches a certain molar concentmtion in the hydrophobic phase.

7. Second gas effect: this occurs when one gas speeds the rate ofincrease ofthe

alveolarpartial pressure ofa second gas. Potent agents are administered with nitrous oxide so that the potent agent will be delivered in increased amounts to the

alveoli as gas rushes to replace the nitrous oxide absorbed by pulmonary blood.



58

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basilic vein

cephalic vein

antebrachial vein

vein

59

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anesthetics are substances that are brought into the body via the lungs and are dis-the blood into the different tissues. The main target ofinhalation anesthetics (or

yolatile anesthetics.) is the brain. Currently used inhalation anesthetics include fiveliquids enflurane, halothane, isoflurane, sevoflurane, desflurane, and or'e gas (nitrous

-fhevolattle liquids require a vaporizer for inhalational administration. The desflurane

has a heating component to allow delivery at room temperature.

inhalation agents have an unpleasant odor and may irritate the respiratory tract. This ir-may cause coughing and muscle spasms in the voice box, or larynx (lary-ngospasm),

bronchial tubes in the lungs (bronchospasm). Sevoflurane is less irritating to the air-than the othen and is preferred for inducing anesthesia in children.

All the potent inhalation agents are capable oftriggering malignant hyperthermia

a rare rnherrted disorder that is potentiallv fatal.

ofan inhalation anesthetic is usually preceded by intravenous or intramus-

administration ofa short acting sedative hypnotic drug, often abarbiturate (Thiopental).

procedure almost always requires endotracheal intubation.

l. Administration of volatile anesthetics is not a concem for COPD patients. All

\ot€ volatile anesthetics are bronchodilators and therefore are beneficial to patients with

COPD.

2. Volatile anesthetics depress the cardiovascular system, and this depression resultsin a reduced mean arterial pressue.

3. Desflurane, isoflulane, and sevoflurane are potent vasodilators.

Vein lies in the lateral aspect ofthe antecubital fossa (anterior to the elbow). Avord

the brachial artery. If the artery is entered, the following symptoms will ap-

irnmediate buming at the site ofthe injection, the arm will appear blotchy, and the

in the arm v ill be weak compared to the other arm.

Sedation:. Usually done with a 21 gauge needle

. Popular drug is Valium (Diazepam)

. The rate of injection of Valium is a I

nrr mrnure c€Phali' vein

-1 ml of injectable Valium contains 5 mg

of Valium. Injection is discontinued when the eyelids

droop (ptosis)Batili. vein

indicating when the correct

of sedation has been reached when usins Vaf

1. Blurring ofvision2. Slurring ofspeech

3. 507o ptosis ofthe eyelids (this is called Ver-

rill's sign)

Valium is contraindicated for use in

with a history of narrow angle glaucoma.

cephali( vcin

Sarilic vein



Dlssociative anesthesia is a unique rnethod ofpain control that reduc€s anxi€ty

and produces r trancelike st|te in which the person is not asleep, bul ratherfeels s€parated from his or her t ody. The primary medication used is:

hydrochloride

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Malignant hyperthermi^ (MH) is a pharmacogenetic disorder in which a

genetic variant in the individual alters that person's response to certain

drugs. The major clinical characteristics of MII include all ofthe following EXCTPT one. Which one is the EXCEPTIOI'ft

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ORAL SURGERY & PAIN CONTROL



anesthesia is useful in emergency situations, such as an injury. It can also be

for short procedures that are painful, such as changing bandages. This method is safe

lasts only a short time. Because a person does not usually recall the procedure, this

is useful in children. The primary medication used is called ketamine. A sedative

often given before ketamine to reduce anxiety.

A person who has had dissociative anesthesia usually does not remember the

especially if a sedative has been given along with the pain medication. Most

feel back to normal within a few hours. As the medication wears off, an individ-

(particularly adult patients) may have intense dreams and even hallucinations.

a phencyclidrLne (PCP) deivative, is l0 times more lipid soluble than thiopen-

enabling it to cross the blood-brain barrier quickly. It produces dissociative anesthe-

which can be seen on EEG as dissociation between the thalamus and limbic system.

with hypnosis, sedation, amlesia, and intense analgesia occurs in

seconds after administration. The anesthetic induction doses are l-2 mg,&g IV, withlasting 5-10 minutes or 10 mg/kg intramuscular, which acts in 2-4 minutes.

Increases airway secretions, creating the need for anticholinergics such as glycopyrr-

olare in the preoperative period

lncreases BB heart rate, and cardiac output , but not respirations

Produces bronchial smooth muscle relaxation because of sympathetic stimulation

[s a potent cerebral vasodilator

Side effects include: hypertension, increased pulse and delirium

is a hypermetabolic state involving skeletal muscle that is precipitated by certain

agents in genetically susceptible individuals. The incidence ofMH is <0.5% ofpatients who are exposed to anesthetic agents. Inhalation anesthetic drugs that are

to trigger MH include halothane, enflurane, isoflurane, desflurane, and sevoflurane.

neurornuscular blockade agents that can trigger MH include succinylcholine,

and suKamethonium. Classic MH most often manifests in the operating

it can also occur within the first few hours ofrecovery from anesthesia. When

to inlalational anesthetics, muscle metabolism increases, and a series ofsigns and

appear, which if left untreated can lead to death. The earliest findings are an

production olcarbon dioxide and signs of increased s),mpathetic nervous sys-

activity.

manifestations of MH include tachycardia, tach)?nea, unstable blood pres-

cyanosis, respiratory and metabolic acidosis, fever, muscle rigidity, and death. Mor-

ranges from 6 3%o to 73o/o.Il vsually occurs in apparently healthy children and young

at an average age of2l

years.

MH is diagnosed early and treated promptly, the mortality rate should be near zero.

anesthesia is administered, dantrolene should be readily available as well as a

for managemeni of MH (100% oxygen, cooling procedures, and the correction

and hyperkalemia). Dantrolene is, at the moment, the only known drug that

MH. It impairs calcium-dependent muscle contraction and controls hypermetabo-

manifestations.



ST]RGERY& PAft CO:{TROL Anesth

The following signs: nausea, pallor, cold perspiration, widely

dilated pupils, eyes rolled up, and brief convulsions are

indicative of a patient having a _ reaction.

ofthe above

ofthe above

62

Coplaighr O 201 l'2012 - D€nral Decks

fat embolism

anesthetic or analgesics on the myocardium

failure

63

Coptrighr Cl 201 I 2012, Dental Decks



A psychogenic reaction is caused by psychological factors rather than physical factors

s,'rlcope, a psychogenic r€action, is the most cornmonly experienced complication

with the use oflocal anesthetic solutions. The clinical signs closely resemble those

These psychogenic reactions readily respond to placing the patient in a supine posi-

following drugs, when administered one hour pdor to the dental appointment, are safe and

ways to allay the fears ofan apprehensive adult dental patient and possibly avoid a

reaction in the dental chair:. Diazepan\ (Vqlium): 5- l0 mg orally 1PO). Pentobarbital (Nembutal):50- 100 mg orally /POl. Secobarbital f^9econal): 50-100 mg orally (PO). Promethazine (P,lr energan): 25 mg orally (PO)

Note dosages and route of administration.

drugs are not recomm€nded unless you have experience with them and can handle

complications that may happen from th€ir use.

For a dentist to use "ent€ral sedation" (the use of a pharnracological method that

a minimally-depressed level o.f consciousness) some states require special training

registration with the stat€.

A somatogenic reaction is the development of a reaction from an organic pathophys-

cause.

Leading to myocardial depression.

causes of postoperative hypotension:

Intravascular hypovolemia

Rewarming vasodilation

Myocardial depression

Possible treatment options include:. Elevation ofthe lower extremities. Administration ofcarefully monitored fluid boluses. Administration of vasopressors (e.g., ephedrine)

treatment is n rc n (a narcotic antagonist/ if hypotension is due to narcotics. Use

(qn anticholinergic) ifbradycardia is present.

Postoperative [ypgltension is most often due to post-op pain. Treat withand sedatives. Oth€r common causes include:

. Hypercapnia

. Anxlety

. Overdistention of the bladder

. HvDoxia



anesthesia

paralysis

50olo oxygen; 50oZ nitrous oxide

0%o oxy gen;40olo nitrous oxide

oxygen; 60% nitrous oxide

oxygen; 70olo nitrous oxide

according to the patient response

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Copyrighr O 201 1,2012 - Dental Decks



tage One (Anqlgesia) i The patient experiences analgesia or a loss ofpain sensation but remains

and can carry on a conversation. Note: The best monitor ofthe level ofanalgesia is the

response.

tage Two (Exciteuent): The patiefimay experience delirium or become violent. Blood pres-

rises and becomes iregular, and brcathing rate increases. This stage is t)?ically bypassed bya barbiturate, such as Methohexital or Thiopental, before the anesthesia.

Stage Three (^laryical Anesthesio): During this stage, the skeletal muscles relax, and the pa-

breathing becomes regular. Eye moyements slow, then stop, and sugery can begin.

ttge Four (Medullary Paralysis): This stage occurs ifthe respirctory centers in the medulla

ofthe brain that control breathing and other vital functions cease to function. Death canifthe patient cannot be r€vived quickly. This stage should never be reached. Careful con-

ofthe amounts ofanesthetics administered Drevent this occurrence.

l. The medulla is the last area ofthe brain to be depressed during general anesthesia.

This area is the most vital part of the brain and contains lhe cardiac, the vasomotor,

and respiratory centers ofthe bmin.

2. The most reliable sign of "oxygen want" while monitoring a patient dudng gen-

eral anesthesia is an increased pulse rate, Cyanosis may also be present.

3.The emeryency most frequently experienced during outpatient general anesthesia is

respiratory obstruction.4. The best anesthetic techlique used in oral suryery to avoid aspiration of blood or

other debris when a patient is under general anesthesia is endotracheal intubationwith pharyngeal packs.

5. A patient with an acute respiratory inf€ction is contraindicated for general anes-

thesia.

6. The eyes are taped shut priorto draping a patientbefqre surgery to preyent corneal

abrasion.

dose ofthe gas combination for conscious sedation is variable and is based on the patient re-

The maximum nitrous oxide limitation is 60010 nitrous oxide and 40olo oxygen.

oxide is a weak anesthetic and is used with other agents, such as thiopental, to produce

anesthesia. It has the fastest induction and recovery and is the safest because it does not

breathing or blood flow to the brain.

oxide has a low blood-to-gas partition coe{Ticient (0.46) and therefore low solubility. It can

the blood and enter air-filled cavities 34 times more quickly than nitrogen can leave the cav-

to enter the blood. The use ofnitrous oxide can increase the expansion ofcompliant cavities,

as a pn€umothorax, bowel gas in a bowel obstruction, and an air embolism.

The oral and maxillofacial surgeon needs to be cautious when keating the recent hauma

(e.g., motorvehicle accident victim). An asymptomatic, undiagnosed closed pneumothorax

double in size in l0 minutes after the administration of 70%o nitrous. Nitrous oxide sedation

postponed in patients with gashointestinal obstructions, middle ear disturbances, and,

sinus infections.

Pr.ddol Co€ffcienb fo. hhrled Anesl]etics

ll3lothcrc Isoflrrane Nzo

Elood: g|g 0.42 2.4 0.46 0.68

Brrtn: blood l.l 29 1.6 r.l t.7

Mllak: blood 2.0 2.9 1.2 3.1

Frt blood 27 48

t8.7 90.8 1.4 47.2

MAC Agenl MAC

Nikols oride 104 D€sfluane 6.0

Ll5 S€vofiwane 1.7 |

Halo&aft 0.77



unilateral facial paralysis

Coplright O 20ll-201? Denial Decks

Wtten a biopsy is being performed it ls important to:

perpendicular to the long axis ofany muscle fibers beneath the lesion

parallel to the long axis ofany muscle fibers beneath the lesion

as deep as possible into muscle fibers beneath the lesion

at a 45 degree angle to the long axis ofany muscle fibers beneath the lesion

CoDrightO 20ll-2012 - Denral Decls



is irritation or inflammation ofa vein. it is sometimes seen after IV administration ofval-is usually attributed to the presence ofpropylene glycol in the mixture.

is more likely to occur if a vein in the hand or wrist is used and may be more common

repeated injections, especially in heary smokers, the elderly. and women taking oral

signs and symptoms ofphlebitis:. Pain . Erythema. Tendcmess . Streaking ofthe limb. Edema

Remove the IV catheter, elevate the affected linb, apply warm, n.roist packs to thc in-

initiate IV ant:biot:Lcs (pre./brably celazolin [Ancefl, I gm IV bolus push etety I hours),appropriate staphylococcus coveragc.

is the formation of a blood clot that may partially or completely block a blood ves-

A clot located in an inflamed, blood vessel is called thrombophlebitis.

triad is the name given to the thrce chicfcauscs ofdeep venous thrombosis fDlI):damage to the endothelial lining ofthe vessel, (2) venous stasis, and (3) a change in blood con-

to postopcrativc increase in the number and adhesiveness of the patient's

clinical featurcs ofDVT are:

Calfswelling . Sudden dyspnca

Feler . Tachypnea

Chcst pain

patient who has developed DVT should be staied immediately on systemic anticoagulation with

of the affected Iimb.The most frequent respiratory complications following oral and maxillofacial surgery

pulmonary atelectasis (mosl often in smokers), aspiration pneumonia fr?o.t, /ikely to mani-

itlitially tu lhe patient's rigllt lwtg), and pulmonary embolus fmosl originate in lhe deep ve-

s,,'stems oftlrc lower extremities, especially in nonantbulatory'patients).

Whenever possible, the incisions should be oriented parallel to lines ofmuscle tension in order

minimize scarring and wound dehiscence. Note: Biopsy incisions on the face should be oriented

follow Langer's lines.

ofbiopsy in and around the oral cavityl

. C)-tologyi should be used as an adjunct to, not a substitute for, biopsy. Indications include:

$ hen large areas ofmucosal change must be monitored for dysplastic change, such as herpes or

pemphigus. Technique: the lesion is scraped repeatedly and firmly with a moistened tongue de-

pressor or cement spatula. The cclls obtained are smeared evenly on a glass slide, and the slide

rs inrnediately immersed in a fixing solution and cxamincd under lhe microscope.

..\spiration biopsy or fine needle aspiration /FN,4): is the use ofa needle and syringe to pen-

errate a lesion lbr aspimtion ofits contents. Indications include: it should be carried out on all

lcsions thought to contain fluid (rith the possible exception ofa mucocele) or any intraosseous

lc,rion belbre surgical exploration. Technique: an l8-gauge needle is connected to a 5 or l0 ml

s1 ringe. The area is anesthetized and the I 8-gauge needle is inserted into the depth of the mass

during aspiration.. Incisional biopsy: rcmovcs only a representative portion or portions of a lesion along with

a representation ofadjacent normal tissue. Indications: ifthe arca under investigation appears

diflicult to excise because ofits extensive size (larger than I cm itl diameter) or hazardous lo-

cation, or whenever there is a great suspicion ofmalignancy.. Excisional biopsy: entails removal ofthe entire lesion along with at least 2 mm ofnormal mar-

ginal tissuc frorn the sides of the lesion. This technique should bc employed with smaller le-

sions i/1".rs tlrd, I cu in diameter) that on clinical examination appear to be benign.

It can not bc ovcremphasized that all pertinent clinical information and the findings ofdiagnostic modalities must b€ provided to the pathologist at th€ time ofthe initial submission

specimen.



days

days

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An incislonal biopsy is indicated for which ofthe followlng lesions?

0.5 cm papillary fibroma ofthe gingiva

2.0 cm exostosis ofthe hard palate

2.0 cm area ofFordyce's disease ofthe cheek

3.0 cm hemangioma ofthe tongue

3.0 cm area of leukoplakia ofthe soft palate

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Coplrighr @ 201 1,201 2 , Denial Decks



all oral ulcers caused by trauma will heal within 14 days. Therefore, any ulcer that

present for 2 weeks or more should b€ biopsied.

is also indicated in the following instances:

. Pigmented lesions (black/bown)

. When tissu€ is associated with paresthesia, this is often an ominous sign

. lfa lesion suddenly enlarges, it should be biopsied

Always aspirate a central bone lesion to rule out a vascular lesion. Ifa lesion seems

pulsatile, blue, or a bruit is heard, beware ofa vascular lesion and biopsy only

a controlled hospital setting. *** A stethoscope is used to listen for a bruit.

,- - . ,. l. When the entire tumor is removed, it is called an excisional biopsy technique. lfonly a psrtion ofthe tumor is removed, it is called an incisional biopsy technique.

;ri*t; 2. Brush biopsies are not recommended due to the number of false positives.

3. After removal, the tissr.re should be immediately placed in l07o formalin solu-

tion (4okformaldehyde)that is at least 20 times the volume ofthe surgical specimen.

The tissue must be totally immersed in the solution, and care should be taken to be

sure that the tissue has not become lodged on the wall of the container above the

level of formalin.

4. A negative incisional biopsy report ofa highly suspicious oral lesion suggests

that another biopsy specimen is necessary in view ofthe clinical impressions. The

key is a highly suspicious oral lesion. Tissue samplings should be obtained from

multiple sites ofthe lesion.

Unlike the more common ry?es oforal ulcers, malignant lesions are usually pain-

growing and do not heal spontaneously. Consequentl% biopsy ofany ulcer that is pres-

in the mouth for more than 2 weeks is mandatorv.

is a premalignant lesion. This means that ifleft untreated, some ofthe lesions progress to

It is because of this chance of malignant transformation that all leukoplakias should be

Technique and Surgical Principles:

. Anesthesia: Block local anesthetic techniques are employed when possible; ifnot, infiltration maybe used but the solution should bc injcctcd at lcast I cm away from the lesion. Tissue stabilization: Use fingers or clamps. Hemostasis: Cauze compresses (dvol righ speed suction) or gatze-wrappcd suction tip on a low-

volume suction device. Idcision: Sharp scalpel. Extent oftissue: Obtain some normal tissue adjacent to lesion ifpossible. Handling of tissue: Use a traction suture through the specimen, not tissue forceps to avoid speci-

men trauma. Traction sutures can also mark a point on the specimen so that the lesion can be oriented

should thcrc bc a positive margin.. Specimen care: Alter removal, the tissue should be immediately placed in l07o formalin solution

that is at least 20 timcs thc volume ofthe surgical specimen. Note: No othcr solution is acceptable.

. wound management: Requires either a pimary closve (prefe,"d6l-r, or placement ofperiodontal

drcssings in cascs ofgingival or palatal biopsies where secondary hcaling will be necessary

. Recordsi A Biopsy Data Sheet should be accurately filled out

Method ofTissue Removal Varies Among the Type of Biopsies:

l.ln a needle (percutareo&t biopsy, the tissuc samplc is simply obtained by use ofa s)nnge. A nee-

dlc is passed into the tissue to be biopsied, and cells arc removcd through the needle.

2. In an open biopsy, an incision is made in the skin. the organ is exposed, and a tissue samplc is

taken.

3. A closed biopsy involves a much smaller incision than open biopsy. The small incision is made to

allow insertion ofa visualization device, which can guide the physician to the appropdate area to take

the sample.



or gray skin color

mouth

skin turgor

state ofconsciousness

blood pressure

output

copyrtgtu o zor r10or: l"nt"r oe"r,s

mg/dl, 125 mg/dL

mg/dl, 150 mg/dl

mg/dl, 175 mgldL

nl dL, 200 mg/dl

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is the loss ofwater and important blood salts like potassium (K-) and sodium

Vital organs like the kidneys, brain, and heart can't function without a certain min-

amount of water and salt. Causes include decreased intake (ack ofwater) and. / oroutput fvomititlg, diat"rhea, Ioss ofblood, drainageJi'om burns, diabetes melli-

diuretic use, or a lack ofADH owing to diabetes insipidus).

a patient suffering from dehydration will clinically demonstrate only dryness ofskin and mucous membranes.

as dehydration progresses, the turgor for fullness) ofthe skin is lost. Ifdehy-persists, oligruria (reduced urine output) occurs as a compensation for the fluid

More severe degrees of fluid loss are accompanied by a shift of water from the in-

space to the extracellular space, a process that causes severe cell dysfunction,

in the brain. Systemic blood pressure falls with continuous dehydration, and

perfusion eventually leads to death.

in several forms should be continually urged on the patient. In severely dehy-

they must get to the hospital right away. IV fluids will quickly reverse

is often life saving in young children and infants.

Mellitus is an absolute or relative insulin insulficiency caused either by a low output ofthe pancreas or by unresponsiveness of peripheral tissues to insulin. Diabetes is the

cause of blindness, end-stagc renal disease, and non-traumatic limb amputation in the

States. Diabctes increases risk for cardiovascular, cerebral, and peripheral vascular disease.

patients \rith diabetes mellitus have no symptoms, and the diagnosis is made because ofab-glucose lcvels detected on a routine screening. Some patients may develop polydip-

poll uria. polyphagia, and weight loss. In patients with severe insulin dcficiency, developmcnt

may cause nausea, vomiting, lethargy, confusion, and coma.

for the dentist treating a patient who has diabetes mellitus is hypoglycemia.

mptoms of hypoglycernia: weakness, nervousness, excessive sweating, tremulousness, and pal-

The symptoms may progress from confusion and agitation to seizures and coma without

,'- - -.-,. L The treatment ofchoice for hypoglycemia in a conscious diabetic is the administra-

tion of an oral carbohydrate (packets of table sugdr, orunge iuice, cola beverages,

candy bars, etc.)

2. The treatment ofchoice for hypoglycernia in an unconscious diabctic patient: EMS

should bc contacted. Then I mg ofglucagon can be injected lM, or 50 ml of 50% glu-

cose solution can be given by rapid IV infusion. The glucagon injection should restorethe patient to a conscious state within 15 minutes; then some form oforal sugar can be

glvcn.

3. People with well-controlled diabetes are no more susceptible to infections than peo-

ple without diabetes, but they have more di{Iiculty containing infections (this is caused

hy dltercd leukocyte function).4. Patients who take insulin daily and check their urine regularly for the sugar and ke-

toncs (controlletl diabel/., usually can be treated in the nomal manner without addi-

tional drugs or diet alterations. lmportant: Ifany doubt exists as to the patient's medical

status, consultation with the patient's physician is indicated. Do not assume anything!



Your 60-year-old patient presents with cong€stive h€art failure. Theynote ctrdiac symptoms wlth mild activity trut are asymptomatlc at rest

lYhat is the functional classilication of heart failure in your patient?

I

II

III

IV

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Match the term on the left with the correct meaning on the right.

arrest

Below normal CO2 in arterial blood

Increase in depth ofrespiration

An increase in both rate and depth ofrespiration

Permanent cessation of breathing (arless corrected)

Transient cessation or absence of brealhino

Excess CO2 in arterial blood

A reduced rate and depth ofrespiration

The unpleasant sensation ofdifficulty in breathing

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I congestive heart 1'ailure is defineu as no symproms , Class II is symp-

with marked activity, Class Itl is symptoms with mild activity, and Class IV is symptoms at

heart failure (CHF) results ftom impaired pumping ability by the heart. A ventricular

50% is indicative ofCHF. Valvular hcart discasc, coronary artery discasc,

oidism, high-cardiac output syndromes, and hypertension can lcad to heart

Usually the left ventricle fails first, soon followed by right-sided failure. The pre-

dyspnea, orthopnea, paroxysmal noctumal dyspnea, fatigue, exercise

odema. Note: The most comnron sign of lefFsided heart failure is pulmonary

failure causes pedal ed€ma or abdominal swelling.

therapy:goals are

to contol fluid retention, control neurohormonal activation,control sYmDtoms.. Diuretic; fe.g., Lasix, Aldactone, Zaroxolyn), are uscd to control fluid retention. ACE inhibitors fe.g., Captopril, Lisinopril), which interfere with the renin-angiotensin sys-

ten, are required ofall paticnts with cardiac failure unlcss contraindicated. Vasodilators, including hydralazine and nitrates, are used when the use ofACE inhibitors is

not oossible. Beta blockers feg. , Car-vedilol, Bisoprolol, Metopt'olol, lten o/of, should be used in patients

with left ventricular dysfunction, unless contmindicated. Digitalis can improve symptoms and exercise tolerance by increasing cardiac contractility. Other medications include oxygen and morphine. Aspirin, NSAIDs, and calcium channel blockers should be avoided

treatment and dental managemcnt considerations:. Prolonged rest, administration ofoxygen. Digitalis (patients are prone to nousea and vomiting). Diuretics/vasodilators (patients are prone to orlhostqtic hlpotension: a\oid excessive epi-

nephrine/. Dicumarol (patients may have bleeding problem,/

Transient cessation or absence ofbreathins

Excess CO: in arterial blood

Below normal CO: in arterial blood

The unpleasant sensalion ofdifficulry in brcathing

Increase in depth of respiration

Permanent cessation of breathing (unless corrected)

An increase in both rate and depth ofrespiration

A reduced rate and deDth ofresDiration

1. Hyperventilation results in the loss of carbon dloxrde (CO) from the blood

:aotes 0+pocqpnia), thereby causing a decrease in blood pressure and sometimes fainting.

2. Hypoventitation results in an increased level of carbon dioxide lCO/ in the

blood (hypercopnia).

J. The respiratory rate is l0-20 breaths/min in normal adults and 44 breaths/min in

infants. A respiratory rate of >20lmin is considered tachypnea, and a respiratory

rate < lO/min is bradypnea.,1. Kussmaul breathing is an increase in both rate and depth of respiration and is

synonymous with hyperventilation.

5. Cheyne-Stokes breathing is altemating hyperpnea, shallow respiration, and

apnea. Children and the elderly normally show this pattern in sleep. In normal

adults, causes of this pattem of breathing include heart failure, uremia, drug-in-

duced respiratory depression, and brain damage.

6. Stridor is a high-pitched respiratory sound, such as the inspiratory sound heard

often in acute larvnseal obstruction.



pneumonia

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A Ss-year-old male presents to your ollice with a long history of a productlve

cough. The patient states the cough has been present for 6 months each ofthelast three years. The patient is afebrile and chest x-ray is unremsrkable.

Which of the following is the most likely diagnosis?



occurs when mucus or a foreign object obstructs airflow in a mainstem

ofthe affected lung tissue into an airless state. It typically oc-

postoperatively and presents with mild dyspnea, low-grade fever, and hy-

Note: Prolonged atelectasis can lead to pneumonia'

treatment of postoperative atelectasis is aimed at expansion of the lung, and, for

patients, incentive spirometry @ncouraging the patient to take long, slow, deep

adequate. However, in patients with severe atelectasis, endotracheal suction and

bronchoscopy may be warranted.

occurs when air leaks into the pleural space causing the lung to recoil

the chest wall. In an awake patient, a pneumothorax typically presents with dyspnea,

pain, absence ofbreath sounds on the affected side, and evidence ofpneumothorax

a chest x-ray. Tracheal deviation may be present.

of treatment for a pneumothorax is to remove the air lrom the pleural

allowing the lung to re-expand. In an emergency, a small needle (such as a stan-

needle) may be placed into the chest cavity through the ribs to relieve

excessive pressure. The definitive treatment is a chest tube, a large plastic tube that is

through the chest wall between the ribs to remove the air completely.

. 1. Pneumonitis (inflammation of the lung) and atelectasis are two of the mostroleg.' 66mmsn causes of fever in a patient who has had general anesthesia.

2. Th" -ost common post-op complication ofoutpatient general anesthesia is

nausea.

is a disease due to persistent airway obstruction. Two diseases account for the bulk ofpatients with COPD: €mphysema and chronic bronchitis. There is continuing debate as

\rhether this term also includes acute asthma, however as a general ru1e, it is not incft'rded

even though it does have obstructive components to it, it is in part reversible, and is more

considered a restrictive lung disease. ln most cases, bronchitis and emphysema occur\ote: Secondary pulmonary hypertension is most often caused by COPD.

Emphysema Chronic Broncltitls

''Pink puffei' "Blue bloater"

complaint Dyspnea Chronic cough

After age 50 years Late 30s and 40s

Thin Overweight

ex?Jn No advenlitious sounds Rhonchiare presmt

edema Ntgative Positive

Normal Elevated

gases PO: normal or reduced

Pco, normal or reduced

Po: reduced

PCO2 elevated

X-ray IJyperinflated wiih flat diaphragms Increased interstitial markings and notmal diaph.agms

Drugs with antiplatelet activity fasplnn) should be prescribed to COPD patients with cau-

Hemoptysis has been reported after the use ofaspirin in patients with COPD.

COPD patients taking theophylline should not b€ prescribed erythromycin. Erythromycin

the metabolism oftheophylline and may cause toxiciry.



acidosis

alkalosis

acidosis

alkalosis

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formally known as insulin-dependent diabetes

little or no insulin spnrctinn nananirw

appear abruptly and include polyuria, polydipsia, polyphagia, and weight

loss

for 90olo ofall cases ofclinical diabetes

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Normal range: pH = '7.35 - 7.45 Bicarbonate = 22-26 mtrol/LAcidosis vs Alkalosis. IfpH is less than 7.35, the patient is acidemic. lfpH is greater than 7.45, the patient is alkalemic

Determine primary process

. After evaluating pH, look at PCO2 and bicarbonate

- IfpH is acidemic and PCO2 is greater than 45 mmHg, the primary procoss is respiratory; ifbicarbonate is less than 22, the primary process is metabolic

- IfpH is alkalemic and the PCO2 is less than 35 mmHg, the primary process is respiratory;

ifbicarbonate is greater than 26, the primary process is metabolic.acidosis: Etiologies- diabetic or starvation ketoacidosis, lactic acidosis, uremia, severe

Clinical manifestations: Dyspnea on exertion and nausea and vomiting are common

alkalosis: Etiologies- vomiting, diuretic use, Cushing's syndrome, Conn sl,ndrome, and

Clinical manifestations: CNS symptoms such as confusion, delirium, and coma. Cardiac ar-

rhythmias and hypotension may be noted

Etiologies- COPD, asthma, severe pneumonia or pulmonary edema, CNS

fdrag.s, CNS event), acute airway obstmction, pneunothorax

Clinical manifestations: Related to degree and duration ofacidosis and presence ofhypoxia.

In acute disease, CNS symptoms such as confusion, anxicty, psychosis, and seizures may be

noted: In chronic disease, there is lethargy, fatigue, and confusion

alkalosis: Etiologies- anxiety, hypoxia, CNS discase, drug use (salicylates), preg-

sepsis

Clinical manifestations: May cause dizziness, perioral paresthesias, confusion, hypotcnsion,

stezures. and coma

the most common pancreatic endocrine disorder It is a metabolic disease

mostly carbohydrat€s fglucosel and lipids. It is caused by absolute deficiency

insulin (r,pe 1) or resistance of insulin's action in the peripheral tissues (Type 2). The

triad of symptoms includes polydipsia, polyuria, and polyphagia.

be nornal or exc€€d nornal

ofdiabclcs

Reduced sensitivity of insulin's rarget c€lls

Dietary conhol and weigha rcductiou



or tachypnea

hypercapnia

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is a condition chamcterized by episodic reversible narrowing of the airways. The most

include episodic wheezing, cough, chest tightness, and shortness of breath.

disease can begin at any age, but about half ofpati€nts develop asthma before the age of 10.

are three basic pathophysiologic changes: (1) Airway inflammation (2) Airway obstruction

(3) Airway hlperresponsiveness

An acute asthmatic attack is best heated by administration ofsupplemental oxygen

an inhalaled beta2-adrenergic agonist (albuterol, terbutaline). lf the patient is resistant to beta

theophylline should be considered. In a severe asthmatic attack that is unresponsive to the

mg of 1;1000 epinephrine should be administered subcutaneously.

There are no contraindications for the use ofnitrous oxide sedation in asthmatic pa-

Because anxiety is a stimulus for an asthmatic attack, nitrous oxide sedation is actually ben-

for these patients. Ifpatient is taking steroids, consult physician for the possible need for

augmentation.

guidelines for the management ofpatients with asthma:. Minimize stress: short appointments, use sedation techniques (nib'ous, diozepam or olher oral

a n t ianie t,v med icq t iotls).. Avoid antihistamin€s. Minimize epinephrine \se (local anesthesid trp to 2 carpules of 226 lidocaine with 1:100,000

epinephrihe may be used). Avoid erythromycins and clarithromycin in patients on theophylline. Be arvare ofaspirin sensitivity; there is a clinical triad ofasthma, nasal polyps, and aspirin sen-

sitivity. h is inportant to be sure that the patient with asthma does not have this triad when as-

pirin-containing preparations are prescribed.

is the most severe clinical form ofasthma, usually requiring hospitalization,

does not respond adequately to ordinary therapeutic measures. Ifnot managed properly, chronic

airway obstruction may lead to death from respiratory acidosis (which is produced by hy-

ia a nd hypercapn ia).

and B are inherited as a sexJitrked recessiYe trait by which males are allected and

are carriers. The majority ofpeople af{licted with hemophilia have type A and it presents

the age of 25. The signs, symptoms and clinical manifestations include excessive bleeding

cuts, epistaxis, hematomas, and hemarthroses.

of Hemophilia:. Hemophilia A: considered the classical type, caused by a deficiency of coagulation factor

\ lll (anti-hemophilic factor) .

. Hemophilia B (also called Christmas disease): due to a deficiency in fzctor lX (Christmas

factor). Hemophilia C (a/s o called Rosenthal's syndrome)', not sex-linked, less severe bleeding. Due

to a deficiency qf factor XL Rare disorder but more common in Ashkenazi Jews.

A true hemophiliac is characterized by having the following:. Prolong€d partial thromboplastin time (PI!. Normal protbrombln time (PT). Normal platelet count. Normal bleeding time

von Willebrand's disease is inherited as an autosomal dominant bleeding disorder, it oc-

with equal frequency in both seres. Due to the absence ol von Willebrand's factot (VWF),results in failurc to form a primary platelet plug. Labomtory features include a prolonged PTT

prolonged bleeding time.

. Idiopathic thrombocytopenic pupnr^ (ITP)t autoimmune bleeding disorder in which pa-

tients develop antibodies against their own platelets. Signs and symptoms: no splenomegaly, su-

perficial bleeding ofthe skin, mucous membranes, and genitourinary tract.. Thrombotic thrombocytopenic purpura (TTP)| chaftcterized by severe thrornbocytopenia,

micrcangiopathic hemolytic anemia (ftave presence of schislocytes), andneu,rologic abnormal-

ities. Signs and symptoms: fever, neurologic abnormalities, including headache, aphasia, or stu-

por.



mellitus

disease

stage renal disease

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A tall, thin patient presents to your olnce with shortness of breath.

On examination you note the pati€nt is breathing through 6pursed' lips,

his expiratory phase is prolonged and lung sounds rre distant.

Which of the following is the most likely diagnosis?

fibrosis

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Mitralvalve prolapsed

Endocarditis

Papillary muscle dysfunction

Dyspn€a

Systolic ejection mulmu.Delaycd carotid upstr0ke

Diastolic rumble

Opening snap

Patients with valwlar heart disease are also at risk for bacterial endocarditis.

fever is a sequela ofa previous Group A , beta hemolytic streptococcal infection,

ofthe upper respimtory tract. The disease involves the heart,joints, centml newous sys-

and subcutaneous tissues. lt is characterized by an exudative and proliferative in-

the connective tissue, especially that ofthe heart, joints, blood vessels,

inflammation (carditis) drsappears gradually, usually within five months. However, itpermanently damage the heart valves, resulting in rheumatic heart disease. The valve

een the left atrium and ventdcle (mitral valve) is most commonly damaged.

The pulmonary valve is rarely involved.

heart murmur may have no pathological significance or may be an important

to the presence of valvular, congenital, or other structural abnormalities ofthe heart.

"pink puffer" patient is typically thin and presents with dyspnea, pu$ed-

breathing and pink skin color, Arterial blood gases reveal hypoxia and hlpercapnia. Em-

is defined as destructive changes to the alveoli walls and enlargement ofair spaces.

affects the lung parcnchyma distal to terminal bronchioles. Cigarette smoking is major risk

(increases risk by 10 to 30 times otter nonsmokers). Note: Alpha- l -antitrypsin defi-should be suspected in patients who develop emphysema in their late 30s.

abnormal dilatation ofthe large conducting pathways, due to congenital struc-

abnormalities or acquired processes. Congenital causes include cystic fibrosis and alpha-

deficiency. Acquired processes include viral and bacterial infections, foreign

and tumors. The major symptom is a cough, which is daily and productive with puru-

sputum. Hemoptysis may accompany the cough. As disease progresses, exercise intoler-

and dyspnea develop.

librosis: an autosomal recessive disease and most common lethal inherited disease inpatients are diagnosed in the preteen years. It is due to a defect in cys-

fibrosis transmembrane conductance regulator. S).mptoms are due to development ofthick

that block the airways and ductal system in other organs (usually pancreas andCommon s),rnptoms include chronic cough with sputum production and dyspnea.

Patients with chronic bronchitis (or any COPD) can have difficulty during oral

Many of these patients depend on maintaining an updght posture to breathe ade-

They frequently experience difficulty breathing ifplaced in an almost supine position

ifplaced on high-flow nasal oxygen.

Patients with chronic bronchitis may be predisposed to lung cancer (bron-

carcinoma).



dialysis

day ofdialysis

dialysis

days before dialysis

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s a natual constituent ofopium

4ay be given only by injection

as a calming effect on gastric mucosa

s stronger than morphine, more addictive, and more constipating

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renal disease (ESRD) rs a condition in which there is a permanent and almost

of kidney function. The kidney functions at less than I 0% of its normal

[n end-stage renal disease, toxins slowly build up in the body. Normal kidneys re-

these toxins /i.e., urea and creatinine) from the body through urine. In chronic renal

there is a slow, progressive decline in kidney functiot (low glomerular filtration lete

andfall in uri e output).

clearance is a measure ofGFR:. Normal range:

Male: 120 +/- 25 ml/minFemale: 95 +/- 20 ml/min

*** End-stage renal disease: GFR < l0 ml/min

u,ith ESRD:. Are often on steroid therapy. Are more susceptible to post-op infections. Have an increased tendency to bleed

when oral surgical procedures are undertaken on these patients, meticulous attentiongood surgical technique is necessary to decrease the risks ofexcessive bleeding and infec-

important points to remember when treating patients with renal insufltciency and

on hemodialysis:. \er er measure the patient's blood pressure on the ann where the dialysis shunt has been

created

. Avoid the use ofdmgs that are metabolized or excreted by the kidney

. Ar oid the lollowing analgesics: aspirin, acetaminophen, NSAlDs, meperidine, and mor-

phine. Perform oral surgery the day after dialysis. Consult physician for possible prophylatic antibiotics

to morphinc, codcine is thc most important alkaloid of opium. Codeine has two primary thera-

c'l1'ecIsr analgesic and antitussivc. Codcine is relatively less polent than morphine and does not have

abuse potential ofmorphine. It is more likely than other opioids. othcr than morphine, to cause con-

and nausea- Codeine is usually combined with other drugs, for example, Empirin (Aspirin +

and Tt-lenol#2,3, and 4 (Acetattinophen + Codeine).

Jlorphine is effectivc in providing reliefofmoderate to severe pain but is associated with the ad-etTects ofconstipation, nausea, and vomiting.

analgesics are thought to inhibit painful stimuli in the substantia gelatinosa of the spinal cord,

tem. reticular actiYating system, thalamus, and limbic systcm. Opiate receptors in each ofthcselnreract \\'ith neuroffansmitters ofthe autonomic nervous system, producing alterations in reaction

p.rrnlul stimuli. Actions ofopioid analgesics can be defined by their activity al three specific recepior

. \lu receptors:

- \Iul: analgesia - Mu2: respiratory depression. bradycardia, physical dcpcndence, euphoria. Xappa receplors: analgesia, sedation, dysphoria, psychomimetic effects. Delta r€ceptors: analgcsia. moduiates activity at the mu recepto.

Drug

15'60 min 4-5 hi

10 30 Din 4i hr

I lydcodone (Vicodin. Ltrc.r. lorrab) l0-20 nin

Oxycodon€ {Percodan, Preel) l5-30 min 3-4 h.

Oxycodode, line-rclease lomula (O(r{4ntin) lhr I2 hr

Ily&oiorphme (Dilaudid) ,l-5lr

2-4 nt

FenLnyl (DuEgesi. haBdmal) t2-21h1

4-7 hr

Propox}?lenc (D.aon) +6 hr



uCoDrisht O 201 l-2012 - Denbl Decks

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amnesia, minimal depression of ventilation and the cardiovascular system, and

make benzodiazepines favorable preoperative medications. Clinical uses

benzodiazepines include: preoperative medication, IV sedation, induction of anesthesia,

ofanesthesia and suppression of seizure activity. Benzodiazepines act by poten-

the action of GABA, an amino acid and inhibitory neurotransmitter, which results inneuronal inhibition and CNS depression. Benzodiazepines bind to specihc benzo-

which are found on postsynaptic nerve endings in the CNS. Benzo-

are the most effective oral sedative drugs used in dentistry.

used as amnestics in anesthesiology are: midazolam (most

m

mon). lorazepam. and diazepam.. iN{.id^zolam (Uersedl: is the most lipid soluble ofthe three and, as a result, has a rapid onset

and a relatively short dumtion ol action. Is prepared as a water-soluble compound that is

transformed into a lipid-soluble compound by exposure to the pH ofblood upon injection.

This unique property ofmidazolam improves patient comfort when administered by the IVor lM route. This prevents the need for an organic solvent such as propylene glycol, which

is required for diazepam and lorazepam.. Diazeparn (Velium): is water-insoluble and requires the organic solvent propylene glycol

to dissolved it. The onset time is slightly slower than that of midazolam.. Lorazepam (Ativan)r ls the least lipid soluble ofthe three main benzodiazepines, result-

ing in a slow onset ofaction but long duration ofaction. It requires propylene glycol to dis-

solYe it. which increases its venoirritation. Lorazepam is a more powerful amnestic agent

than midazolam, but its slow onset and long duration ofaction limit its usefulness for pre-

operative anesthesia.

1. Chloral hydrate is a sedative and hlpnotic that is widely used for pediatric se-

dation.

2. Emotional stress decreases the rate ofabsorption ofa drug when given orally.

(Tylenol) is the only over-the-counter non-antiinflammatory analgesic

available in the USA. It is a weak cyclooxygenase inhibitor in peripheral tis-

thus accounting for its lack of antiinflammatory effect. It may be a more effective

ofprostaglandin synthesis in the CNS, resulting in analgesic and antipyretic ac-

does not produce gastric ulceration like aspirin does. The combina-ofacetaminophen and propoxyphene (called Darvocet-N or Wygesic) is used to treat

to severe pain due to dental procedures.

Propoxyphene (D&rvon) is an oral slmthetic opioid analgesic structurally similar

methadone. Darvon compound-65 is a combination of aspirin, caffeine, and

, --.. l. Acetaminophen does not affect clotting time as does aspirin-it

does not

h6vs significant antiplatelet effects. It is effective for the same indications as in-

termediate-dose aspirin. It is therefore useful as an aspirin substitute, especially

in children with viral infections (who are at a riskfor Reye s syndrome iJ they

take aspirin).

2.

Aspirinis an anti-inflammatory antiplretic and analgesic that is used to re-

lieve headaches,toothaches, minor aches and pains, and to reduce fever The GI

tract rapidly absorbs it.

3.Talwin compound combines the strong analgesic properties ofpentazocine

and the analgesic, anti-inflammatory and fever-reducing properties ofaspirin.

It is used for the relief of moderate pain. It does not produce euphoria.

4. The most appropriate time to administer the initial dose of an analgesic to

control postoperative pain is before the effect ofthe local anesthetic wears off.

5. Remember: the following analgesics should be avoided in patients with

renal disease: aspirin, acetaminophen, NSAIDs, meperidine and morphine.



Which oftbese barbiturates can be classilied as

,n ultrr-short-acting compound?

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-

should be used cautiously in the elderly. It should

\

_ snoum De useo caunously ln rne erqerry. lr strour(l

never be given to patients on mono|mine oxidase inhibitors forpsychiatric disersc and is generally contraindicated in patients

receiving pbeny'toin @ilantin) for seizure disorders.

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exhibit a dose-dependent central nervous system depression with hypnosis and

Barbiturates are very lipid soluble, which results in a rapid onset ofaction. They are

most often for induction ofanesthesia because thev oroduce unconsciousness in less than

seconds.

inhibit depolarization ofneurons by binding to the GABA receptorc, which en-

transmission ofchloride ions. Note: Barbiturates are potent cerebral vasoconstric-

resulting in decreases in cerebral blood flow, cerebral blood volume, and intracranial

barbiturates :

. Thiopental (Pentothal)

. Thiamylal (Surttal)

. Methohexrtal (B rev i t a I )

:

. P entobarbital (Nembutal)

. Secobarbrtal (S ec ona l)

barbiturales:. Amobatbital (Amytql). Butabarbital (Fioricet, Fiorinql)

barbiturates:. Phenobarbital (Luminal): generally not used in oral surgery

Barbiturates are contraindicated in patients with respiratory disease or those

ho are pregnant.

Phl"sical dependence is likely to develop with barbiturates ifabused. The dependence

a strong psychological as well as physical basis. Sudden withdrawal from high doses can

fatal.

(Demero, is a synthetic opioid analgesic with less potency than morphine. It is

for the reliefofmoderate to severe pain, for preoperative sedation, for posloperative anal-

for obstetric anesthesia, and when given IV for supportive anesthesia. lt is probably the

widely used narcotic in Americzm hospitals. It should be used with particular caution, if

in the elderly. lt is the drug ofchoice among drug abusers and must be used with extremeMeperidine is the most abused drug by health professionals. The onset ofaction is

the duration ofaction is shorter, than that ofmorphine. Note: It produces slight

but no miosis.

is often prescribed as 50 mg every 4 hours as needed for pain. It is often simulta-

presribed with the drug promethazine (Phenergan) in 25-50 mg doses every 4 hours.

promethazine is a sedative and eniances the effect ofmeperidine. Therefore, less meperi

r-ields more analgesia when in combination with promethazine. In addition, promethazine

an anti-emetic, which helps negate some ofthe side effects ofmeperidine, namely, nausea.

Concomitant administration ofmeperidine and MAO inhibitors has resulted in

reactions that may culminate in seizures or coma. Monoamine

(MAO) inhibitors are a class ofdrugs used for depression and Parkinson's Disease. Ex-

of MAO inhibitors include isocarboxazid (brand name Marplan), phenelzine (Nardil),/Parnate), ard selegiline (E ldepryl).

thought to act by increasing endogenous concentrations of norepi-

and serotonin through inhibition ofthe enzyme (monoamine oxidase) re'

for the breakdown of these neurolmnsmillers.

There is a decreased effectiveness ofmeperidine in the presence of phe\ytoir (Dilan'

Morphine is the standard drug to which all analgesic drugs are compared. lt€uphoria, analgesia, and drowsiness along with miosis and respiratory depression.



of salivation

ofcardiac slowing during general anesthesia

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depression

analgesia

BMR

ofthe above effects

ofthe above effects

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cholinergic blocking (anticholinergic) drtgs competitively inhibit the action ofat parasympathetic postganglionic neuroeffector sites. The principal drugs

category are atropine and scopolamine, which are useful in dentistry as agents to

secretion and as preanesthetic medication. The desirable clinical effects

anticholinergics are mydriasis, antispasmodic actions, and reduction in gastric and

secretions.

pharmacologic actions ofatropine and scopolamine are similar in many respects. At-in the usual dose employed in dentistry does not show a CNS response. Scopo-

however, has a depressant effect on the CNS, which accounts for its usefulness

a preanesthetic agent and perhaps its use in motion sickness in several over-the-counter

Both drugs will reduce salivary flow and in large doses block the cardiac-

ofthe vagus nerve.

drugs should be used with considerable caution in patients with cardio-

disease and are contraindicated in patients with glaucoma, prostate hypertrophy,

intestinal obstruction.

effects are common with the anticholinergic drugs and include blurred vision, tachy-

urinary retention, constipation, decreased salivation, sweating, and dry skin.

Atropine and scopolamine are also extremely useful in therapy and examination ofeye. These drugs produce dilation (nydriasis) and paralysis of accommodation for

vision and bght (cltcloplegia). Such effects are generally long lasting and can

be manifested by larger systemic doses ofthe drugs.

. CNS depressants: CNS depression with barbiturates is additive with alcohol and opioids

. Have no significant analgesic effect even at doses that produce general anesthesia

. Ha\e anticonvulsant effects

of action of barbiturates:. Barbiturates inhibit depolarization ofneurons by binding to the GABA recepton, which

enhances the transmission ofchloride ions.

. \\'ell absorbed orally, distributed widely throughout the body

. \lerabolized in the liver to inactive metabolites that are excreted in the uflne

uses of barbiturates:. -{nesthesia: inlluenced by duration ofaction. Thiopental is an ultra-short acting barbitu-

rute used IV to induce surgical anesthesia. Note: After IV administration, the last tissue to

become saturated as a result of redistribution is fat (as conrpared to liver, brain, and mus-

. ,{nticonvulsant phenobarbital used in long-term management of tonic-clonic seizures,

status epilepticus and eclampsia. Anxiety: can be used as mild sedatives to relieve anxiety and insomnia

CNS depressants, alcohol, and opioid analgesics enhance the CNS de-

of barbiturates.

Barbiturates can lead to excessive sedation and cause anesthesia, coma and even

Barbiturate overdoses may occur because the effective dose of the drug is not too far

ftom the lethal dose.

The barbiturates can produce fetal damage when administered to a pregnant woman.



needle should be perpendicular when it enten the tissue

should be placed at an equal distance from the rvoun d margin (2-3 mm) and at equal

should be placed from mobile tissue to thick tissue

should be placed from thin tissue to thick tissue

should not be over-tightened

should be closed under tension

should be 2-3 mm apart

suture knot should be on the side ofthe wound

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space

space

space

space

sinus

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This is false; sutures should not be over-tightened or closed under tension.

interrupted suture is the most common suture method. Because each suture is in-

this procedure offers strength and flexibility in placement. Due to this advan-

if one suture is lost or becomes loose, the integrity of the remaining sutures is not

The major disadvantage is the time required for placement ofthis pattem

sutures. (See./igure #1 below)

ofa continuous pattern or method /See/igri re #2 below)

. Ease and speed ofplacement

. Distribution oftension over the whole suture line

. A more watertight closure than the interrupted pattem or method

maxillary third molars are occasionally displaced into two areas:. \Iariflary sinus (antrun): from which they are removed via a Caldwell-Luc ap-

proach.Infratemporal space: during elevation ofthe tooth the elevator may force the tooth

posteriorly through the periosteur into the infratemporal fossa. If access and light

are good, the tooth may be retrieved with a hemostat. lfthe tooth is not retrieved after

a shon amount of time, the area should be closed. The patient should be infomed that

the tooth has been displaced and will be removed by an oral surg€on who will use a

special technique to remove it.

To minimize the chance of dislodging an impacted maxillary third molar into the

fossa during its surgical removal, develop a full-thickness mucoperiosteal

bringing the incision anterior to the second molar (add a releasing incision f nec-

to improve visualization ofthe impacted tooth and place a broad retractor distal

the molar while elevating it.

L When performing a surgical removal ofa mandibular molar, do not section through

the entire tooth. The lingual plate is often thin, and complete sectioning may perforate

the plate and injure the lingual nerve.

2. The inferior alveolar nerve most often lies truccal and slightly apical to the roots

ofa mandibular third molar.

3. Buccal to lingual movement is not elficient when removing mandibular post€rior

teeth because mandibular bone is too dense and does not expand in a similar fashion

to that ofthe maxillary bone.

Figure #l Figure #2



the height ofthe operator's shoulder

the height of the operator's shoulder

the same height ofthe operator's shoulder

makes no difference where the patient's upper jaw is in relation to the operator's

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pericomitis

dentoalveolar abscess

disease

infectious stomatitis

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chair usually has to be repositioned to be satisfactory for exodontics. For mandibu-

extractions, the patient should be positioned so that the occlusal plane ofthe mandibu-

arch is parallel to the floor when the mouth is opened. The chair should be as low as

maxillary extractions, the upperjaw ofthe patient should be at the height ofThese positions allow the upper arm to hang loosely from the

girdle and obviate the fatigue associated with holding the shoulders in an un-

high position during the course ofthe day. The low positions allow lhe operator

bring the back and leg muscles into the operation to assist the arm. The chair can be

backward slightly for maxillary extractions.

fingers ofthe left hand (for a right-handed dentist) serye lo:. Retract the soft tissue. Provide the operator with sensory stimuli for the detection ofexpansion ofthe alveo-

lar plate and root movement under the plate

. Help guide the forceps into place on the tooth

. Protect teeth in the oppositejaw from accidental contact with the back ofthe forceps

. Support the mandible while performing mandibular extractions

recommended sequence of extraction:

. Maxillary teeth before mandibular teeth

. Posterior teetlr before anterior teeth

acute dentoalveolar abscess should not be a contmindication to extraction. It has been

that these infections can rcsolve very quickly when the affected tooth is removed. How-

it may be difiicult to extract such a tooth, either because the patient is unable to open suf-

wide enough or because adequate local anesthesia cannot be obtained.

are fe\r,tlue contraindications to the extraction ofteeth. Note: In some instances, the pa-health may be so compromised that they cannot withstand the surgical procedue.

of contraindications include:

. End-stage renal disease

. Ser ere uncontrolled metabolic diseases (i.e., uncontolletl diabetes mellitus)

. -A.d\ anced cardiac conditions (unstable angina)

. Patients \\'ith leukemia and lymphoma should be treated before extraction ofteeth

. Parients \r'ith hemophilia or platelet disorders should be treated before extruction ofteeth

. Parients with a history ofhead and neck cancer need to be treated with care because even

minor surgery can lead to osteoradionecrosis, Not€: These patients are often treated with hy-

perbaric oxygen therapy pdor to dental sugery.. Pericomitis: infection ofthe soft tissues around a partially erupted mandibular third molar

\ote: This infection should be treated p or to removal of the maxillary third molar. Acute infectious stomatitis and malignant disease are relative contraindications. Patients being treated with tV bisphosphonates increases the risk ofosteoradionecrosis ofthe Jaw

Causes ofexcessive bleeding after dental extractions include; injury to the inferior alve-

artery during extraction ofa mandibular tooth (usually the third mola/), a muscular arte-

bleed from a flap procedure, or bleeding related to the patient's history [.e., patients who

on warfarix or drugs.for platelet ixhibition, pqtients vrho have hemophilia or von Wlle-

disease, or who have chronic liver insfficiency).



wound in layers to minimize the postoperative void

pressure dressings

any bleeding that accumulates

the void to fill with blood so that a blood clot will form

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space in a wound is any area that remains devoid of tissue after closure of the

It is created by either removing tissues in the depths of a wound or by not

tissue planes during closure. Dead space in a wound usually fills in with

creates a hematoma with a high potential for infection. This is more likelyin closed wound incisions or in an open wound that has closed over at the top

quickly, leaving "dead space" open underneath. Some of these may resolve them-

need to have the fluid drained and the "dead space" needs to be closed,

by deep suturing or by re-opening the top ofthe wound and packing until it heals

the bottom up.

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

Infections are uncommon in healthy patients. However, whenever a mu-

flap is elevated for a surgical extraction, there is a possibility for a subpe-

abscess. Thus, all surgical flaps should be irrigated liberally prior to closing

th sutures. Note: The treatment for a subperiosteal abscess is drainage of the abscess

antibiotic treatment.

As opposed to the buccal direction in adults. This is because the deciduous molars

more palatally positioned and the palatal root is strong and less prone to fracture.

general. the removal of deciduous teeth is not difficult. It is facilitated by the elastic-

of young bone and the resorption of the root structure. Do not use the "cowhorn"for extraction of lower primary molars because the sharp beaks ofthese forceps

cause damage to the unerupted pennanent premolar teeth.

l. If the preoperative radiograph shorvs that the permanent premolar is

\ot€ wedged tightly between the bell-shaped roots ofthe primary tooth, the best treat-

ment is to section the crown of the primary molar and remove the two portions

separately. This will help in not disturbing the permanent tooth.

2. After extraction ofmandibular teeth on a child in which mandibular block

was given, always advise child not to bite on his/her lip while he or she is numb.

lnform Darents as well to watch the child so this does not occur.



During extrrction ofa madllary third molar, you realize the tub€rosi

tuberosity fiom the tooth and reimplant the tuberosity

shar? edges ofthe remaining bone and suture the remaining soft tissue

special treatment is necessary

ofthe above

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frenum

mylohyoid ridge

tubercles

exostosis

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fracture ofthe maxillary tuberosity most commonly results from extraction ofan erupted

third molar-or

a second molar if it happens to be the last tooth in the arch.

the tuberosity is fractured but intact, it should be manually repositioned and stabilized

sutues.

seen after extraction of an freestanding, isolated maxillary

are:. Fractwe ofthe tuberosity. Alveolar process fiacture

"Beware ofthe lone molar'r- it is often ankylosed to the bone.

The ankylosed tooth emits an atypical, sharp sound on percussion.

point to remember: Tuberosity ftactures may occur and should be treated at the time ofIfthe operator is unable to do this he / she must arrange an immediate referral.

l. For denture construction, at the correct v€rtical dimension, the distance from

tho crest ofthe tuberosity to the retomolar pad should equal at least I cm.

2. Ifthere is inadequate intermaxillary distance at the tuberosity a tuberosity re-

duction can be performed to remove excess tuberosity. An elliptic incision is made

over the tuberosity and carried down to bone. This wedge is resected, The buccal

and palatal tissues axe undermined subperiosteally. Submucous wedges are re-

moved flom each flap and the wound is closed. This decreases the vertical and hor-

izontal dimensions of the tuberosity.

genial tubercles are situated on the lingual surface of the mandible at a point about

between the superior and inferior borders. There are four of them, two ofwhich

and adjacent to the symphysis. Although usually relatively small,

be fairly large and extend outwaxd from the surface as spinous processes. These

are the area of muscle attachment for the suprahyoid muscles.

Ifthe genial tubercles were removed, the tongue would be flaccid.

l. When removing the mylohyoid ridge, be careful to protect the lingual

nerve.

2. When removing a mandibular exostosis (mandibular torus) it is recom-

mended that an envelope flap design, which has no vertical components, be

used.



Bxo

the root is fully formed

the root is approximately two-thirds formed

no difference how much ofthe root is formed

the root is approximately one-third formed

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patient requests it

there is severe bleeding from the gingiva or ifthe gingival cuffis torn or loose

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. 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 havc de-

veloped curves and rarely fracture during extraction.

root is fully formed, the possibility increases for abnormal root morphology and for

ofthe root tips during extraction.

Noteql. Patients who arc young tolerate surgery very well. Postoperative complications are

usually ninimal.2. Older individuals have the most postoperative difficulties, The bone is more

dense and usually the patient responds more slowly to the entirc process (anesthesia

and surgery).

post-€xtraction procedure:. -{li loose bone spicules and portions ofthe 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 fingers to reestablish the normal width pres-

ent before the buccal plate was surgically expanded. Note: The natural recontouring

of the residual ridge occurs primarily by resorption ofthe 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 insfucted to bite down on the pressure dressing for 30-60 minutes

. -{ printed instruction sheet is given to the patient

. .A. prescription for pain is given ifthe need is anticipated

bleeding persists for some time following an extraction, it may be helpful to instruct

patient to bite on a tea bag. The tannic acid in the tea bag will help promote hemo-

The most common cause ofpost-extraction bleeding is the failure ofthe pa-

to follow post-extraction instructions.

Can be avoided by innially creating an adequately sized incisiot

caused by too much forc€; treated witlr pressure to stop bleeding and left

Manqed wilh a figure-eighl sulure over the socket, sinus pr€cautions,

artibiotics. and a nasal spny to preve.l inlection and keep the osliuft

Most common complication; r€moved with elevators /i.e., srfaiarr,cryer, sro!, and rool tip picks.

Fracture of teelh or reslorations

For exampl€, maxillary molar rool into the maxillary sinus

From too much force used to r€move teelhlveolr p1ocffs and maxillary

newe trav€ls very close to the lingual cortex of lhe mandible in this area-

May occur in the area of lh€ .oots of lhe mandibular third molars. Lingual

Can occur in 3% ofnandibular third molar extractions. Willh€al wilhirrigalion and localtreahent forpain control



Th€ most commonly impacted teeth are the mandibularthird molars, maxillary third molars, and the:

canines

lateral incisors

molars

premolars

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(often radiating)

lymphadenopathy

odor

taste

healed extraction site

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impacted teeth

Angulation: Mesioangular lecsl diJlicult to rcmove for mandibular impaclionsl, distoangular

(most dillicult to remove fol mandibulu impactions),v ertical and horizontal

Pell and Gregory Classification: rclationship to anterior border ofthe ramus

. Class 1: normal position anterior to the ramus

. Class 2: one-halfofthe crown is within th€ ramus

. Class 3: entire crown is embedded within the ramus

Relationship to occlusal plane:

. Class A: tooth at the same plane as othgr molant

.Class B: occlusal pane ofthird nolar is between the occlusal plane and the cervical line ofthe second molar

. Class C; entire crown is embedded within the mmus

Contraindications to extraction

ofimpacted teeth:

. Compromised medical status

. Likely damage to adjacent

structures. Extremes ofages (preteen or

an asymptomatic .full bony im-

paction i a patient> 35 ),ea/s

of age

etiology ofdry socket is not absolutely clear but is thought to develop because of in-

fibrinolytic activity causing accelerated lysis ofthe blood clot. It is most common

ing extraction ofthe mandibular molars. Smoking, premature mouth rinsing, hot

surgical trauma, and oral contraceptives all have been implicated in the develop-

ofa dry socket. Note: Careful technique and minimal traula reduce the frequency

patients developing dry socket.

for dry socket:. Flush out debris with slightly warmed saline solution

-gently!!l

. Place a sedative dressing in socket (eugenol). The dressing should be removed within

48 hours and replaced until the patient becomes as)lnptomatic. Note: (l) The gauze

provides an aftachment for the obtundent paste so it stays in the socket (2) Eugenol is

the active component in most sedative dressings.. Nonsteroidal anti-inflammatory analgesics should be prescribed ifnecessary.*** Antibiotics are senerallv not indicated.

LDry socket is the most common complication seen after the surgical removal

of a mandibular molar.

2. Curetting a dry socket can cause the condition to worsen because healing

will be further delayed, any natural healing already taking place will be de-

stroyed, and there is a risk ofcausing the localized inflammatory process to be

spread to the adjacent sound bone.

* Present in young patients

tlid to two thirds fom€dr

Present in young patients



inlraoral picture should be taken

mandibulax torus ifpresent, should be removed

stent should be fabricated

should be taken

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tori present few problems when the maxillary dentition is present and only

with speech or become ulcerated from frequent trauma to the palate.

for the removal include a large, lobulated torus with a thin mucoperiosteal

extending posteriorly to the vibrating line ofthe palate that prevents seating of a

and also prevents a posterior seal at the fovea palatini. Other indications for the

ofmaxillary tori are, chronic initation, interference with speech, rapid growth and

patients that have a cancer-phobia.

for removal:. A stent should be fabricated prior to removal of a palatal torus. This is done on a

study model that has had the exostosis removed.. A double-Y incision should be made over the midline ofthe torus. After careful elevation ofthe flaps, the torus should be scored multiple times in the

anterior, posterior, and transverse dimensions. An osteotome can be used to remove each ofthese small portions. A large bur or bone file is used to smooth the area. After thorough irrigation, the wound is closed loosely with horizontal mattress su-

tlrles. The stent is placed to prevent hematoma formation and to support the flap

The maxillary torus should not be excised en masse to prevent entry into the(the palatine bone will come out with torus).

This is the exact opposite ofimpacted maxillary third molars' where the mesioan-

impactions (122o/ are the most di{ncult and the vertical f63lo) and distoangular impactions

/ are the essiest to remove.

principles for removing impacted teeth:

L Adequat€ exposure (adequate-sized-flap): an envelope flap is most often used, but releasing

incisions are common. Note; The base portion ofthe flap should always be wider thar the apex

portion ofthe llap to maintain adequate blood supply to the released soft tissues.

2. Bone removal: a trough ofbone on the buccal aspect of the tooth down to the cervical line

should be removed initially, more bone removal may be required depending on the particular

tooth. Important; Bone is rarely, ifever, removed on the lingual aspect ofthe mandiblc because

ofthe likelihood ofdamaging the lingual nerve.

3. Tooth sectioning: sectioning ofthe tooth may also be needed. This is most often perfomred

with a straight bur, such as a No. 8 round bur, or with a fissure bur, such as a No. 557 or 703.

4. Copious irrigation of the wound is very important and replacement ofthe soft tissue flapscomDletes the Drocedure.



ing

10,1

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root ofthe maxillary first premolar

root ofthe maxillary first molar

root ofthe maxillary second molar

root of the maxillary third molar

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coplriSh O 201l-2012 - Dental Deck



is the loosening ofthe tooth in the socket by progressive severing ofthe periodon-

ligament fibe6. Patience and controlled force are needed, not brute strength. The force

be applied as low down the root as possible when extraciing teeth. You should support

jaw with your other hand and have a thumb and frnger on either side ofthe tooth being ex-

Note: Rotation forces can be used on single rooted teeth. Teeth are extracted by lux-forces perpendicular to the long axis ofthe tooth, not by pulling along the long axis. The

is as close to the apex ofthe tooth as possible.

The beak of the extraction forcep is designed so that most of the pressure ex-

during an extraction is transmitted to the root ofthe tooth.

When using dental elevators, one should always have respect for the forces gen-

to the large amount of leverage, dental elevators can genente tremendous forces

use, and have potential to cause iatrogenic damage.

A Class [I fever is used during tooth extractions (see picttu?s below)

Class l Lever Class Il Lever Class III Lever

f,n,A .t ,A ."t

"r"l!","r- - p*"ii'"int

If an entire tooth or a large fragment of one is displaced into the sinus, itbe removed. If the tooth fragment is irretrievable through the socket, it should be

through a Caldwell-Luc approach ASAP. However, only perform this ifyouwhat you are doing. Ifnot, refer patient to an oral surgeon.

If a small communication is made with the maxillary sinus during extraction of a

best treatment is leave it alone and allow the blood clot to form.

to patient:

. -\'oid nose blowing for 7 days

. Open mouth when sneezing

. -{\.oid vigorous rinsing

. Soft diet for 3 days

sinus communication should occur the following medications may be prescribed for

u eek:

L Afrin: local (nasal) decorgestant

2. Antibiotics (Amoxicillin)

i. Actifed: systemic decongestantI . If the opening is of moderate size (2-6 mm), a figure-eight suture should be

place over the tooth socket.

2. Ifthe opening is large (7 mm or latger),lhe opening should be closed with a

flan orocedure.

The integrity of the floor of the maxillary sinus is at greatest risk with sur-

involving the removal ofa single remaining maxillary molar. The fear here is pos-

ankylosis.

\*oie* l



The Caldwell-Luc procedure eliminates blind procedures and facilitates therecovery oflarge root tips or entire teeth that have been displaced into the,l.LUu rU.U .[t

maxillary sinus. When performing this procedure an openingis msde into the faciil wall of the antrum aboye the:

tuberosity

lateral incisor

premolar roots

molar

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large root fragment or the entire tooth is displaced into the maxillary sinus (antrum),

should be removed. The usual method is a Caldwell-Luc approach. This is a surgical

in which an opening is made into the maxillary sinus by way ofan incision

the canine fossa above the level ofthe premolar roots. The tooth or root is then re-

Post-operative management includes a figure-eight suture over the socket, sinus

antibiotics, a nasal spray and a systemic decongestant to keep the sinus os-

open and infection free. Important: An oral surgeon to whom the patient should

referred should perform this procedure.

the root tip is small (2 or 3 mn), noninfected, and cannot be removed through the

opening in the socket apex, no additional surgical procedure should be performed

the socket, and the root tip should be left in the sinus. Ifthe root tip is left in the

measures should be taken similar to those taken when leaving any root tip in place.

patient must be informed ofthe decision and given proper follow-up instructions.

The palatal root ofthe maxillary first molar is most often dislodged into

maxillary sinus during an extraction procedure.

If a root tip of a mandibular third molar disappears from site while trying to re-

it, the most likely location for it to be in is the submandibular space. Other pos-

locations would be the inferior alveolar canal or the cancellous bone space.

size is based on strength and diameter. The gauge or thickness ofthe suture ma-

is denoted by O gradings. As the thickness ofthe material decreases, the O grading

is thicker than 3/0, which is thicker than 4/0 and so on.

suture material is foreign to the human body, the smallest-diameter suture

to keep the wound closed properly should be used. Most oral and maxillofacial

procedure s (intraoral suturing) require the use of3/0 or 4/0 gauge material but

extraoral skin surfaces, finer gauge is preferred such as 6/0 or even finer This helps

scar visibility.

The primary function of sutures is to help to stabilize the flap during the healing

without imposing needless traction on the soft tissue.



phase

phase

phase

108

Copyright O 201 I 2012 - Denral Decks

-2 days postoperatively

days postoperatively

I days postoperatively

l5 days postoperatively

109

Cop).righr O 201 1,2012 - Dental Decks



is a process that can be divided into three phases:

1. Inflammatory Phase (initial lag phase)

. Immediate to 2-5 days

. Hemostasis

- Vasoconstnction

- Platelet aggregation

- Thromboplastin makes clot. Inflammation

- Vasodilation

- Phagocytosis2. Proliferative phase (fibroblastic phase)

. 2 days to 3 weeks

. Granulation

- Fibroblasts lay bed ofcollagen

- Fills defect and produces new capillaries. Contraction

- Wound edges pull together to reduce defect

. Epithelialization

3. Remodeling Phase (maturation phase)

. 3 weeks to 2 years

. Nerv collagen fonns which increases tensile shength to wounds

. Scar tissue is only 80 percent as strong as original tissue

that impair wound healing: diabetic patients, patients with protein deficiencics, oldcr pa-

infections, foreign material, necrotic tissue, ischemia, and tension on the wound.

370 hydrogen peroxide is the agent ofchoice for thc debridement ofintraoral wounds.

two basic categorics ofsuturcs are (l) rcsorbable and (2) nonresorbable:. Resorbable: These sufures are resorbed after a certain time, which usually coincides with heal-

ing of the *'ound. These sutures are made of gut or vital tissue (catgut, collagen, lascia, etc.) and.

are plain or chromic, or ofsynthetic material, e.g., polyglycolic acid (Dexon). Plain catgut sutures

are resorbed postsurgically over 8 days, chromic sutures in 12- 15 days, and q.nthetic (Dercn) su-

rures in approximately 30 days. These types of sutures are used for flaps with little tension, chil-

drcn. mentally handicapped patients, and gcnerally for patients who cannot retum to the oIfice to

ha\-e the sufues removed.

. \onresorbable: These suturcs rcmain in the tissues and are not resorbed. but have to be cut and

removed about 5-7 days aftcr thcir placement. They are fabricated ofvarious materials, mainly sur-

gical silk (nonoflamenlous or mukiflame tous), in many diameters ancl lengths) ar'd srrrgical

conon surure. Silk sutures are the easiest to use and the most economical, and have a satisfactory

abili\" to hold a knot.

Resorbable sutues evoke an intense inflammatory reaction. Thjs is the main reason neither

gut or chromic gut are used for suturing the surface ofa skin wound. When suturing an exffac-

site in the anticoagulated paticnt, a non-resorbable suture is recommended. Resorbable sutures

accompanied by an inflammatory response, increasing fibrinolytic activity, potentially resulting

brcakdown.

o basic methods ofwound healing fsof tissrel:

l. Primar) intention (also called primary c/osrre); involves minimal re-epithelialization and col-

lagen formation, allowing the wound to be "sealed" within 24 hrs. Healing occurs more npidlyrvith a lower risk ofinfection, with less scar formation and less tissue loss than wounds allowed

to heal by sccondary intention. Examples include: well repaired and well-reduccd bone fractures.

2. Secondary intention (also called secondary closure). involves re-epithelialization via migla-

rion from the wouod edges, collagen deposition in the connective tissue, contracture. and remod-

eling. The site fills in with granulation tissue. Healing is slower and results in scarring and wound

depression. Examples include: extraction sockets, poorly reduced iiactures, and large ulcers.



ofthe tooth

the line angle ofthe tooth

of the tooth

the depth ofthe rnuco-buccal fold

t't0

Coplright O 201 1,2012 - Dmtal Decls

a larger forcep and luxate remaining portion oftooth to the lingual

rhe r^^t<

the area and proceed to remove the rest ofthe tooth

sedative filling and reschedule patient

11'l

CopFighl O 20ll-2012 - D€nral Deks



of the flap design used, certain principles should be followed while incising and

the gingiva. These include:

. Incision should be made with a firm. continuous stroke

. lncision should not cross underlying bony defect that existed prior to surgery, or would be pro-

duced by the surgery. Vertical incisions are madc in the concavities between bony eminences. Terminatiqn ofvertical incision at the gingival crest must be at the line angle ofthe tooth. Vertical incision should not extend beyond the depth ofthe muco-buccal fold. Base ofthe flap must be as wide as the width ofthe free edge (supraperiosteal vessels running

verticalU shoxld not be transected)

. Periosteum must be reflected as an integral part ofthe flap

The correct position for ending a vertical releasing incision is at a tooth line angle notthe buccal surface of a tooth. lf it ends over a buccal surface, the edges are difficult to ap-

and this may lead to pe odontal problems. Incision should never cross bony promi-

as this increases the chance for wound dehiscence.

ofincisions used in oral surgery:

1 LiI|ear: straight line incision used for apicoectomies.

2. Releasing: used when adding a vertical leg lo a horizontal creation incision. For extractions,

augmentations, etc.

3. Semi-lunar: curved incision mostly used for apicoectomies.

basic principles oforal surgical flap design:

. Flap design should ensure adequate blood supply; the base ofthe flap should be largcr than

the apex. Reflection ofthe flap should adequately expose the operative field. Flap design should permit atraumatic closure ofthe wounds. Flap should be closed over bone ifpossible

This can be done with a chisel, elevator, or most easily with a bur.

with two or more roots often need to be sectioned into single entities prior to successful re-

popular method ofsectioning is to make a bur cut between the roots, fbllowed by insert-

an elcvator in the slot and tuming it 90o to causc a break.

can be removed by closed technique. The surgeon should begin a surgical removal if thetechnique is not immediately successful.

for surgical extractions:. After initial attempts at forceps extraction have failed . Hypercementosis or widely divergent. Patients with dense bone. In older patients, due to less elastic bone . Extensive decay which has destroyed

. Short clinical crowns with severe attrition (bruxers) most ofthe crown

are resistant to crush but are not resistant to shear Therefore:. Place the beaks ofthe forceps opposite to each other at the same level on the tooth.

. The beaks should be applied in a line parallel with the long axis ofthe tooth.

When luxating a tooth with forceps, the movements should be firm and delibcrate, pri-

to the facial with secondary movements to the lingual. The maxillary first bicuspid is least

be remoyed by rotation forces due to its root structure (obviously molars.tre nol re-

b!* totation).

. -. 1. It is recornmended to use a bite block when removing mandibular teeth to diminish

l;otes,, pressure on the contralateral TMJ.

2. Distilled water is not used for irrigation because it is a hypotonic solution and will

cnter cells down the osmotic gndient, causing cell lysis and rapid death ofbone cclls.

3. Buccal to lingual movement is not efficient when rcmoving mandibular posterior

teeth because mandibular bone is too dense and does not expand in a fashion similar

to that ofmaxillary bonc.

4. The root ofth€ zygoma can interfere with efficicnt removal ofa ma,rillary first molar



the infratemporal fossa

the submandibular space

the mandibular canal

the pterygopalatine fossa

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ofthe connective tissue by fibrillar bone

and clot formation

of granulation tissue by connective tissue and epithelialization of the

ofthe alveolar bone and bone maturation

ofthe clot by granulation tissue

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To prevent this, avoid all apical pressures when removing the roots or root

ofall mandibular molars. Ifa mandibular molar root tip is displaced inferiorly, it may

be in the mandibular canal or through the lingual cortical plate. The mandibular

generally found buccal to the roots ofthe mandibular third molar.

submandibular space is a potential space ofthe neck bounded by the oral mucosa

tongue anteriorly and medially; the superficial layer ofd€ep cervical fascia laterally,

the hyoid bone inferiorly. The mylohyoid muscle, stretching across the floor of the

the submandibular space into a portion above this muscle: sublingual arrd

below: submaxillary spaces.

The submaxillary submental and sublingual spaces are collectively referred to as

submandibular space. This space usually drains infections from the mandibular

and molars because their apices lie below the mylohyoid muscle attachment.

space is the medial part of the submaxillary space. It contains the

lymph nodes that drain the median parts ofthe lower lip, tip of the tongue'

the floor ofthe mouth. Usually drains infections from the mandibular incisors and

because their apices lie above the mylohyoid muscle attachment.

sublingual space is the superior part ofthe submandibular space, containing the sub-

gland and loose connective tissue surrounding the tongue.

Ludwig's angina is the most commonly encountered neck space infection

the sublingual, submandibular, and submental spaces).

Glucocorticoids have been shown to have the greatest effect on granulation tissue --

retard h€aling. This is believed to be due to the fact that:

. Glucocorticoids interfere with the migration ofneutrophils and mononuclear phagocytes

into a site of inflammation; the phagoq'tic and digestive ability ofmacrophages is also re-

duced.. Glucocorticoids inhibit formation ofgranulation tissue by retarding capillary and fibrob-

last proliferation and collagen synthesis.

same stages that occur in normal wound healing of soft tissue injuries also occur in the

ofinjured bone. However, osteoblasts and osteoclasts are also involved to repair dam-

bone tissue.

heals by primary and secondary intention as does soft tissue.

. Primary intention bone repair involves both endosteal and periosteal proliferation. This

type of bone repair occurs when either the bone is incompletely fractured or a surgeon

closely reapproximates the fractued ends ofa bone. Littl€ librous tissue is produced withminimal callus for



muscle

muscle

pterygoid muscle

muscle

I

Fort II

III

fractures

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involved in displacing mandibular fractures include the medial and lateral ptery-

temporalis, masseter, digastric, geniohyoid, genioglossus, and mylohyoid. The lat-pterygoid displaces the condyle ant€riorly and medially because of its insertion on

pterygoid fovea. Muscles attached to the ramus (i.e., temporalis, n,asseter,.tnd me-

pterygoid) result in superior and medial displacement ofthe proximal segment. As

progress anteriorly toward the canine region, the digastric, geniohyoid, ge-

mylohyoid exert a posterior-inferior force on the distal segment.

lateral pterygoid muscle is the only muscle that inserts directly on the neck oftheIn subcondylar fractures, the forces of this muscle frequently re-

in anterior and medial displacement ol the condyle. In higher condylar fractures

in intracapsular fractures above the insertion olthe lateral pterygoid, the small frag-

can occasionally be seen displaced in a pure hodzontal or vertical direction.

Displacement of the proximal segment of the condyle usually occurs in an an-

direction because ofthe pull ofthe lateral pterygoid muscle. The patient willto th€ side ofth€ fracture upon opening because ofthe unopposed action ofthe

lateral pterygoid muscle.

(ZMC1 fractures involve four major processes: the zygomati-

inliaorbital rim, zygomatico buttress, and zygomatic arch. Zygomatic fracturcs arc

encountered in lbcial trauma because oftheir prominent position on the facial skeleton.

rnost conlmon mechanism producing facial fractures is auto accidents. About 70 7o ofauto ac-

produce somc type of lacial injury, although most are limitcd to soft tissue. The face seernsa favo.ite target in fights or assaults, which arc the ncxt most common mechanisrn. As with

fractures, midface fractures are described by the bone involved, as simple /closed),com-

/operr, or comminuted.

type prevalence:

. Zygomaticomaxillary complex: 40 %

. LeFort I: 15 70

II: l0 %

III: 10 %. Zygomatic arch: l0 o%

. Alveolar process ofnaxilla: 5 %

. Smash fractures: 5 70

. Other: 5 %

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

displacemcnt of ftactures can cause obstruction ofthe airway resulting in respiratory

arrest. Control ofthc airway is vital to any trcatment ofa patient with facial ftactures.

2. Maxillary fractures have a greater tendency towafds the production of facial defor-

mity than do mandibular fractures.

3- Maxillary Lefort fractures, orbital fractures and zygomatic fractures usually require

intemal rigid fixation.

3. Thc highest incidence of fmctures occLlrs in young males between the ages of l5 and

24. These fractures are usually the result oftrauma.

Nofeg-

Abnoinal mobilily ofthe boie



dehiscence

or trigeminal nerve injury

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of the muscle

nff.rnt""-

of muscle fibers

of fracture

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these, infection is one ofthe most problematic; it is the most frequent complication and is an

cause of non-union.common cause ofpostoperative infection is movement at the fracture site due to loose,

hardware, such as a loose screw in an otherwise stable plate.

reasons that a fracture does not heal:

l. Ischemia: the navicular bone ofthe wrist. the femoml neck. and the lower third ofthe tibiaare 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 occuls between the fractured ends.

4. Infection: compound fractures have a tendency to become infected.

Important: a fat embolism is most often a sequela of fracfures.

(three rypes) :

l. Delayed-union: satisfactory healing which requires greater than the normal six week period.

May be caused by infection, interposition ofsoft tissue or muscle between the fracture segments.2. Non-union: failure ofthe ftactwe segnents to unite properly. May be caused by infection, im-proper immobilization, or interposition ofsoft tissue.

3. Mal-unionr can be either delayed or complete union in an improper position. May be caused

by improper immobilization or imperfect reduction.

line of fracture will determine whether muscles will be able to displace the fractured

from their original position. Favorability is determined by the forces exerted by the

muscles on the lracture segments. A favorable lracture is one that is not dis-

by masticatory muscle pull, and an unfavorable &acture occws when the line offrac-permits

the fragments to s€parate.four muscles of mastication are the temporalis, masseter, medial pterygoid, and lateral

After discontinuity ofthe mandible due to fracture, these muscles exert their actions

the lragments. leading to malocclusion.

that may be associated with mandibular fractwes:. Pain and tendemess at tbe fracture site. Changes in occlusion. Ecchymosis ofthe floor ofthe mouth or skin. Crepitation on manual palpation. Changes in mandibular range of motion. Soft tissue bleeding. Sensory disnrrbances (numbness ofthe lower lip). Der iarion ofthe mandible on opening

. Soft tissue swelling

. Trismus

. Step-in occlusion

. Palpable fracture line intraorally or at the inl'erior border ofthe mandible

ofall patients with mandibular fractures have associated other systemic

spine fractures were found in I l% ofthis group ofpatients. It is imp€rative

rule out cervical neck fractur€s, especially in patients who are intoxicated or unconscious

in patients who are involved in vehicular accidents. Posteroantedor, lateral films, and CT

neck should be reviewed with the radiologist before trcatment is initiated in these pa-



fn general, mandibular fractures are less common in children than in adults.When mandibular fractures occur in children. fractures ofthe

r . . matrdible, particularly in the condylar region]lii&iitely common. )

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CopyriShr O 201 l-2012 - Dental Drcks

fractures at the angle

ofthe mandibular condyle

I fractures

fractures

ofthe above

1r9

Copyrighr @ 2011,2012 - Dental Decks



ossification capability ofchildren allows faster healing and distinguishes it from the adult

a result, many mandibular fractures in children can be treated with immobiliza-

a shorter period or observation and soft diet only than in an adult. Note: Open reduc-

and intemal fixation in children is reserved for severely displaced fractures.

an adult, the location oflacial fractures is influenced by both the resistance ofthe bone to

and how prominent its position on the facial skeleton is. Adult facial fractures are

commonly seen in the nasal bones followed by the zygoma, mandible, and maxilla. In

early growth in the cranium and orbits predisposes young children to fiontal bone

orbital fractures.

following categories classil! mandibular fractures by describing the condition ofthe boneat the fiacture site and possible communication with the extemal environment:

. Simple: divides a single bone into two distinct parts with no extemal communication.

These are closed fractures with no lacerations ofthe oral mucosa or facial tissues.

. Compound: fracture communicates with the outside environment (open fracture). This

may occlu by laceration of the oral tissues exposing the bone fragments, fracture of the

maxilla into the sinuses, or by way ofskin lacerations that would expose the fracture seg-

ments. Infection is common.. Comminuted: are multiple fractures of a single bone. They may be simpl€ or comp-

ound.. Gre€nstick: fracture that extends only through the cortical portion of th€ bone without-

complete fracture ofthe bone. Greenstick fractures are closed fractures involving incom-

plete ftactures with flexible bone. Most often seen in children.(l) The most common complication ofan open fracture is inf€ction.

(2) Any jaw fracture extending through tooth beaxing bone is considered an open

fracture due to potential tears in the PDL and exposure ofthe fiacture to the oral

flora.

For a long time in the past, a posteroanterior oblique wate6 view or a reverse Waters view

with a posteroanterior and submgntal vertex view ofthe skull were used for evaluating zy-

c omplex (ZMC) fractures. However, the CT sc^n Ooth axial qnd cotonal ori-

is c\tfier'tly the diagnostic imaging ofchoice forevaluating these fractures as well as the

fraciures listed. This imaging modality shows the location of the fractures, degree of dis-ofthe bones, and status ofsunounding soft tissues.

Dysfunction ofthe infraorbital nerve is common in a patient with a ZMC fracture. An

is ofparamount importance. Also, fractures ofthe facial bones, par-

the zygomatic complex may on rare occasions be complicated by damage to the contents

orbital fissure.

possible complications ofthe zygomatic complex fracture include:

. Par€sthesia fmoJl con,aon): usually subsides

. The antrum /s,rrs) may be filled with a hematoma, which usually evacuates itself

. Ocular muscle balance rnay be impaired because offracture ofthe orbital process

Note: Fracture ofthe infraorbital rim presents with the following symptoms:

. Numbness ofthe followi.g areas on the affected side; upper lip, cheek, and nose

The most feared, but fortunately rare, complication ofZMC fractures is blindness.

By definition, the four articulating sutures (ZE ZT ZM, ard ZSJ are disrupted in this

the commonly applied term "tripod fracture" is a misnomer and does not cor-

describe this fracture.

practitioners consider CT scanning to be the gold standard imaging rnodality for evaluation

mandible fractures. A CT scan allows the entire face to be evaluatcd in one study. Despite the

ofCT imaging, in many facilities the initial imaging studies may consist ofpanoramic

a plain-view series ofthe mandible ((i.e., posteroanterioti Waters, reverse-Towne,

subtnentovertex projections) Many nrral hospitals still use a plain-vicw series ofthe mandible.

familiarity with plain radiographs is important.



non-displaced fractures

and unstable fractures, with associated mjdface fractures, and when MMF is

ofthe above

ofthe above

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CopriSht O 201l-2012 - Dental Dects

way: by direct or primary bone healing which occurs without callus formation

way: by indirect or secondary bone healing which occurs with a callus precursor

by direct or primary bone healing which occurs without callus formation

indirect or secondary bone healing which occurs with a callus precursor stage

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Coptr'ghr O 201 1,201 2 , D€ntal Decks



options ofmandible fractures can be divided into rigid fixation, semirigid fixation. and

or closed reduction. Methods considered rigid fixation are the lag screw technique,

plating, reconstruction plates, and extemal pin fixation. Miniplate fixation and wircare types of semirigid fixation. Maxillomandibular fixation ([MMFJ \\'ith i'vy loops, arch

or lransalveolar screw), gunning splints, and lingual splints are considered non-rigid fixation.

fixation allows for primary bone healing without callous formation. Non-rigid fixation al-

secondary bone formation with inflammatory infiltration and callous lormation. Semi-

allows for areas of primary and secondary bone formation.

reduction is best used in the treatment of favorabl€, non-displaced fractures. It is also used

situations in which Open Reduction lntemal Fixation (OR1F) is contraindicated. Maxillo-

(MMF) is obtained by applying wires or elastic bands between the upper andjaws, to which suitable anchoring devices can be attached, such as arch bars or skeletal

length ofmaxillomandibular lrxatlon (MMF) is 4-6 weeks.

involves direct exposure ofthe fracturc site and placement of intemal fixation

prcvent movement ofthe fracture site. Open reduction is used in displaced and unstable fractures,

associated midface fractures, and when MMF is contraindicated. In addition, some surgeons

ORIF for patient comfort and for expedited retum to activity and work. Arch bars are al-

placed first to establish occlusion, then ORIF is performed. The plates can be placed inhao-

extraorally via a cervical incision, or percutaneously. Dynamic compression plates (DCPJ

be used for most body, angle, symphyseal or parasymphyseal fractules.

Initial management of mandibular ftactures starts after the patient has been stabilized. Alloftooth bcaring arcas ofthe mandible are considered open and should be treated with an-

that cover mouth flora, specifically gram positive and anaerobic organisms. Mouth rinses

peridex solution or half strength hydrogen peroxide in water are useful to keep the mouth

Timing ofrepair is controversial. Several studies have shown a decreased incidence of in-

ifcompound fractures arg repaired within 48 hours. Other studies have shown no change ifare repaired in less than a week. Regardless ofinfection rates, patient comfort dictates that

lbr repair is the best as displaced fractures are painful.

bone healing involves a direct attempt by the cortex to re-establish itselfafter interrup-

Bone on one side ofthe cortex must unite with bone on the other side ofthe cortex to re-es-

continuity. Under these conditions, bone-resorbing cells on one side of the

sho.,\,a tunneling resorptive response, whereby they re-establish new haversian systems by

pathways for the penetration ofblood vessels.

bone healing involves the classical stages offracture healing.

of fracture healing:. Stage l: lnflammation - bleeding from the fractured bone and sunounding tissue causes the

liactured area to swell. This stage begins the day you fracture the bone and lasts about 2 to 3

\\'ecks,. Stage 2; Soft callus- between 2 and 3 weeks after the injury the pain and swelling will decreasc.

-\t rhis point, the site ofthe fracture stiffens and new bone begins to form. The new bone cannot

be seen on x-rays. This stage usually lasts until 4 to 8 weeks after the injury.. Stage 3: Hard callus- between 4 and 8 weeks, the new bonc b€gins to bridge the fracture. This

bony bridge can be scen on x-rays. By 8 to l2 weeks afterthe injury new bone has filled the frac-

IUre.. Stage 4: Bone remodeling- beginning about 8 to I 2 weeks after the injury the fracture site re-

models itself, correcting any deformities that may remain as a result of the injury. This final

stage offracture hcaling can last up to several years.

ofhealing and the ability to remodel a fractured bone vary tremendously for each person

the patient's age, health, the kind of fracture, and the bone involved. For example,

are able to heal and remodel their fractures much faster than adults.

syndrome: Severe swelling after a fracture can put so much pressure on the blood

that not enough blood can get to the muscles around the fracture. The decreased blood sup-

can cause the muscles around the fracture to die, which can lead to long-term disability.



bleeding

in the infraorbital nerve distribution

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\

.,1

I

II

III

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signs and symptoms of a mandibular body or angle fracture include:. Lower lip numbness. Mobility, pain, or bleeding at the fracture site

important points in treating mandibular fractures are immobilization ofthe fractures, the ap-

use ofantibiotics, and restoration of form and function. The usual treahnent for mandibu-

fractures that are displaced and mobile is with open reduction and intemal fixation using titanium

plates and screws. tfthe patient has teeth, the occlusion is used as a guide for the surgeon to

the fracture. Other methods ofrepair include splinting (/or pedistric patients) and maxillo-

fixation (see below) .

. Establishing a proper occlusal relationship by wiring the tceth together is termed maxillo-

mandibular lixation (MMF) or intermaxillary fixation (IMF). The nost common technique

includes the use ofa prefabricated arch bar that is adapted and wired to teeth in each arch; the

maxillary arch bar is wired to the mandibular arch bar, thereby placing the teeth in their proper

relationship. Other wiring techniques such as Ivy loop or continuous loop wiring have also been

used for the same purpose.

recentl% techniques for rigid internal fixation (NF) have ga;Lned popularity for treatment

These use bone plates, bone scrcws, or both to fix the fractwe more rigidly and stabi-

the bony segments during healing. Even with rigid fixation, a proper occlusal relationship must

established before reduction stabilization and fixation ofthe bony segments. Advantages ofRlF

treatment of mandibular fractures include decreased discomfort and inconvenience to the pa-

because [MF is eliminated or reduced, improved postoperative nutdtion, improved postoper-

and frequently better postoperative management ofpatients with multiple injuries.

Mandibular angle fractures are generally more prone to the development of complicationswith the body or symphyseal areas. Multiple complications may arise but most com-

include loose hardware necessitating rcmoval, infection, malocclusion, delayed union, and

Damage to the inferior alveolar and lingual nerve can be a complication ofthe ini-

injury or a consequence oftreatnent.

of Le Fort's fractures:. Le Fort l: the fracture line traverses the maxilla through the piriform aperture above the alve-

olar ridge, above the floor of the maxillary sinus, and extends poste orly to involve the ptery-

goid plates. This fracture allows the maxillae and hard palate to move separately fiom the upper

face as a single detached block. Le Fort I fracture is often referred to as a transmaxillary frac-

ture.. Le Fort II: superiorly, this fracture traverses the nasal bones at the frontonasal sutures. It ex-

tends laterally through the lacrimal bones, crossing the floor ofthe orbit, fracturing the medial

and inferior orbital rirns, and fracturing the pterygoid plates posteriorly. ln this fracture, the aF

tachment of the zygomatic bones to the skull at the lateral orbital rims and at the zygomatic

arches is preserved. As a result ofthis fracture, the maxillary and nasal regions are movable rel-

atiye to the rest ofthe midface and skull. Because ofits triangular pattem, this fracture is oftcn

refened to as a pyramidal fracture.. Le Fort tll: this fracture line involves fracture ofall the buttress bones linking the maxilla to

the skull. This fracture allows the entire upper face (nasal, maxillary and zygomatic regions) to

move relative to the skull. [n this fracture, there is a craniofacial disjunction with a separation at

the liontozygomatic suture, nasofrontal junction, orbital floot and zygomatic arch latcrally.

manifestations of midface fractur€s:. Clinical diagnosis ofmidface fractures is reasonably easy to make when therc is a displacement

ofthe fracture, which is often manifested by the presence ofmalocclusion, mainly antedor open

bite. Pain and swelling are the other signs ofmidface fractures

. Mobility of the midface

. Nasal bleeding, subconjunctival ecchymosis, maxillary hypoesthcsia, and tendemess of the

bony buttresses ofthe midface are other signs and symptoms ofmidfacial and maxillary fractwes.

The first step in the treatment ofthese fractues which affect the occlusal relationship

similar to the treahnent ofmandibular fractures

-to re-establish a proper occlusal relationship

placing the maxilla into proper occlusion with the mandible.



process

and cancer

and hypothlroidism

failure and hypoalbuminemia

disease and hypopituitarism

124

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Patients with hypocalcemia have an lonized calcium level

b€low 2.0 or serum calcium concentntion lower than 9 mg/dl.Some ofthe most common causes are:



location and extent of mandibular ftactures axe determined largely by the direction and

ofthe blow and the specific points ofweakness in the mandiblc.

condylar neck (29.1o.4 offractures) is a safety featue which allows the blow to the jawbe dispersed at this point rather than driving the condyle into the middle cranial fossa. Bi-

dislocated fiactures ofthe condylar necks will cause an anterior open bite and the in-to protrude the mandible. A unilateral fracture through the neck may cause forward

ofthe head ofthe condyle due to pull ofthe lateral pterygoid muscle.

symphysis (22'% offractures) is usually where blows are sustained. These blows often

in fractures of the subcondylar region.

The patient's mandible will deviate to the side of injury upon opening.

Mandibular fiactures can almost always be identified on a panoramic radiograph. Ifais suspected, at least two different radiographs should be taken for comparison

panoramic, posteroanterior, Waters, reverse-Tbwne, or submentovertex projections).

levels are regulated by parathlroid hormone and to some extent by the kidney tubules

GI mucosa. Other causes ofhypocalcemia are vitamin D deficiency, hlpoparathyroidism,

severe hypomagnesemia, multiple citrated blood transfusions,

d gs (antineoplastic agents, antimicrobials, agents used to treat hryercalcemia). Cfuonic

can be asymptomatic. Clinical manifestations are paresthesias of the lips anddue to increased excitability ofnerv€s, tetany, cramps, and abdominal pain due to

ofskeletal muscle, and convulsions.

Chvostek's and Trousseau's signs are seen in hlrpocalcemia. Chvostek's is twitching offacial muscles as a result of tapping over the facial nerve in the preauricular area, and

sign is carpopedal spasm due to occlusion of the brachial artery when a blood

cuff is applied above systolic prcssure for 3 minutes.

is an abnormally high level ofcalcium in the blood, usually more than 10.5

The most common causes ofhypercalcemia are hlperparathyroidism and cancer.

Ilnemonic for symptoms of hypercalcemia:. Stones: renal calculi. Bon€s: bone destruction

. Moans: confusion, lethargy, fatigue, weakness

. Abdominal groans: abdominal pain, constipation, polyuria, and polydipsia

1. Renal failure with oliguria is the most common cause oftrue hyperkalemia (roo

much potassium in the blood). Sorne signs and symptoms include nausea, vomiting,

diarrhea, and ventricular fibrillation leading to cardiac arrest.

2. Usually the fi$t sign ofhypokalemia is skeletal muscle weakness or cramping.

3. The major extracellular cation is sodium.

4. The major intracellular cation is potassium.



\

and location to vital structures

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one minute ofCPR

two minutes of CPR

three minutes of CPR

when an adult is found to be unresponsive

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Treatment ofchoice; should be used when

it crn be safely be done without sacrilicing

Creating a surgical window in the

wall ofthe cyst, evacuating lhe

contents ofthe cyst; and main-

taining continuity between thecyst and the oral cavity

When etrucleatior would damage adjacent

sttuctules

Ifcyst is not totally obliteBted afier

marsupialization heals

Marsupialization is done first.Aftcr initial healing secondary

enucleation may be undertaken

without injury to adjacent

strucfures

After enucleation a curette or bur

is used to rcmove I to 2 cm ofbone around the entire periphery

of the cystic cavity

. When remo\ring an odontogenic

keratoc'st. Any cyst that recws after what was

deemed thorough Emoval

Notesl:

l. Marsupialization, decompiession, and the Partsch operation all refer to creating a surgi-

cal window in thc wall ofthe cyst. The cyst is uncovered or "deroofed" and the cystic lin-

ing made continuous with the oral cavity or sunounding structures. The cyst sac is openedand emptied.

2. Cysts and cysFlike lesions can be classificd as fissural or odo[togenic. Odontogenic ker-

atocysts have a higher rate ofrecurrence than do fissural and cysts ofodontogenic inflam-

matorv onsln.

For an infant or child victim the EMS should be activated after I minute or 5 cvcles of

R€suscitation:

{ = Airway

. Place victim flat on his/her back on a hard surface.

. Shake victim at the shoulde$ and shout "are you okay?"

. If no respons€, call emergency medical system-

911 then,

. Head-tilt/chin-lift: open victim's airway by tilting their head back with one hand while

liliing up their chin with your other hand.

= Breathing. Position your cheek close to victim's nose and mouth, look toward victim's chest, and. Look, listen, and feel for breathing (5-10 seconds). Ifnot breathing, pinch victim's nose closed and give 2 full breaths into victim's mouth. Ifbreaths won't go in, reposition head and try again to give breaths. Ifstill blocked, per-

forrn abdominal thrusls (Heimlich maneuver)

= Circulation

. Check for carotid pulse by feeling for 5- 10 seconds at side of victim's neck.

. lfthere is a pulse but victim is not breathing, give rescu€ breathing at rate ofl breath

every 5-6 seconds or l0-12 breaths p€r minute.If there is no pulse, begin chest compressions as follows:

- Place heel ofone hand on mid-position of victim's stemum. With your other hand di-

rectly on top offirst hand, depress stemum L5 to 2 inches.

- Perform 30 compressions to every 2 bre ths (rute ofcompressions: 100/min).

- Check lor a pulse after the fiISt minute and every few minutes thereafter.

Continue uninterrupted until advanced life support is available.



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Coplright O 20l l-2012 - Dqtal Declr

3 seconds

every 5 seconds

seconds

every 10 seconds

'| 30

Coplrighr O 201 I ,2012 - Dental D€cks

When a chlld or infant has a putse but is breathtess,

what is the recommended rate ofr€scue breathlng?

.\



are three phases ofhemostasis:

l Vascular phase

. Vasoconstriction

. Begins immediately after injury

2. Platelet phase. Platelets and vessel walls become sticky. Mechanical plug ofplatelets seals offopenings ofcut vessels

. Begins seconds after injury

3. Coagulation phas€

. Blood lost into surrounding area coagulates through extrinsic and common pathways. Blood in vessels in area ofinjury coagulates through intrinsic and common pathways

. Slower than other phases

If a patient is taking aspirin, anticoagulants, broad-spectrum antibiotics, alcohol

you should be prepared to take special measures in order to con-

the bleeding. Note: Patients with specific systemic diseases will also have a prolonged

These include nonalcoholic liver disease, hepatitis, cinhosis, and hypertension.

means ofobtaining wound hemostasis:

L By assisting natural hemostatic mechanisms-usually

accomplished by placing a

cotton sponge with pressure on bleeding vessels or the use ofa hemostat directly on the

lessel.

2. By the use of heat on the cut vessels (called thermal coagulation)

.i. By suture ligation ofthe vessel

.1. By the placement ofa pressure dressing over the wound most bleeding fiom oral sur-

gery can be controlled this way.

5. By using vasoconstrictive substances (epinephrine) in local anesthetics

When an adult has a pulse but is breathless, the recommended rate ol rescue breathing is

every 5-6 seconds (l0-I2 breqths/minute).

A victim rvhose heart and breathing have stopped has the best chance for survival if emer-

medical services are activated and CPR is begun within four minutes.

5-10 seconds is used to assess the pulse. The brachial pulse is assessed in infants, whereascarotid pulse should be assessed in children and adults.

The best indicator ofeffective ventilation is seeing the chest rise when delivering breaths.

lfchest compressions are interrupted, the blood flow and blood pressure will drop to zero.

-{r least I sec,breath is the length of time recommended to deliver each breath to an adult

Time is not as critical with the new guidelines conceming the length of time recommended

each breath to an infant or child. Now it is imoortant to deliver breaths that make

r.ictim's chest rise.

Rescue breathin& victim has ap1lse, give breath €v€ry:

In lhe cenrcrofthebreast bone, between

the nipples

In the cantcr of the

b.east bone, hetween

the nipples

One finger width below

the nipple line

Compressions arc preformed

wi&:Heal of I hand, second

hand on top

About l/3 to l/2 the d@th ofthe chest



I

2

3

4

5

13.t

Cop)righr O 2011-2012 - Dental Deks

gum

candy

132

Coplright C20ll-2012 - Dental D€cks

What is the most frequent cause of airw|yobstruction in an unconscious person?



ASA classification was first established in 1940 for the purpose of statistical studies

hospital records. It is useful for both outcome comparisons and as a convenient means

communicating the physical status of a patient among anesthesiologists. The fiveas last modified in 1961. are:

Class I-

Healthy patient, no medical problems

Class 2-

Mild systemic disease

Class 3

-Severe systemic disease, but not incapacitating

Class 4-

Severe systemic disease that is a constant threat to life

Class 5-

Moribund, not expected to live 24 hours regardless ofoperation

*** An organ donor is usually designated as a class 6

first step when initiating CPR is to establish unresponsiveness (shake and shout - "Are you

Then:

BLOW

catt 9l I

tt ]lt,utr G]t,GlltttlltII||l

am r:al|t|nl

ta]I|ar ulrlrr rtl G:mt Itrtt !!r3r

;Lllrtllt lt:lrtt|lllltat Il:rftrrtal|ftt

Slt rtrrr tll llll[tltt ta rrr'l lllll rtltllllltl

points to remember in CPR:. The first maneuver the rescuer should use to open the airway in an otherwise uninjured patient

is the head tilt with chin lift

. If eforts are effective, the pupils will constrict. Iftoo much pressurc is incorrectly applied directly over the xyphoid process, the liver may

be injured

you should stop CPR only under the following conditions:

.lfanother trained person takes over CPR lbr you

. lf EMS personnel arrive and take over care of the victim

. lfyou are exhausted and unable to continue

. [f the scene becomes unsafe

PUMP



133

Copyright O 20ll-2012 - Denral Decks

the blood pressure cufftoo tightly

the blood pressure cuff too loosely

the blood pressure cuff

the blood pressure cuff

use oftoo large or too small cuffs

t34

Cop),righr O 20ll-2012 - Dental Decks



accuracy ofthe Prothrombin Time (PT) is known to be very system-dependent. The

has addressed this system variability problem by (l) the es-

of primary and secondary intemational reference preparations of thrombo-

and (2) the development ofa statistical model for the calibration olthromboplastins

the International Sensitivity Index (ISI) and the lNR.

(International normalized ratio):. Developed to improve consistency oforal anticoagulant therapy. Converts the PT ratio to a value that would have been obtained usins a standard PT

method. INR is calculated as (PTou1i"rr1 / PTrror-u1)rsl*** (lSI is the intemational sensitivity index assigned to the test system)

. The recommended therapeutic ranges for standard oral anticoagulant therapy and

high-dose therapy, respectively, are INR values of2.0-3.0 and 2.5-3.5.

tests used to measure a patient's clotting mechanisms:. Prothrombin time (PT): the nonnal range is I I to 13.5 seconds. To be a good can-

didate for surgery the PT time should be within 5-7 seconds ofthe control sample. Partiaf Thromboplastin Time (PTT)t detects coagulation defects of the intrinsic

system. Basic test for hemophilia. Normal value is 25-36 seconds.. Bf eeding time (Iry method): nomal value is less than 9 minutes. Platelet counts: normal value is 150,000 - 450,000 per I cu mm ofblood. The min-

imal platelet count for oral surgery is 50,000

Perhaps the single most important consideration in ruling out hemorrhagic

is historv.

Use ofthe wrong cuffsize can result in enoneous readings. A normal adult blood

cuff placed on an obese patient's arm will produce falsely elevated readings. This

cuffapplied to the very thin arm ofa child will produce falsely low readings.

. Before performing a blood pressure reading, the patient should be comfortably seated with

the back and arm supported, the legs uncrossed, and the upper arm at the level ofthe dghtatrium.. Proper cuff size selection is critical to accurate measurement. The bladder length and

width of the cuff should be 80% and 40%, respectively, of the arm circumf'erence. Bloodpressure measurement erors are generally worse in cuffs that are too small vs those that

are too big.. Blood pressure measurement in sitting and recumbent positions is acceptable. The dias-

tolic blood pressure can be expected to be about 5 mm Hg higher in the sitting position.. A difference in blood pressure between the two arms can be expected in about 20% ofpatients. The higher value should be the one used in treatment decisions.. When measuring blood pressure, the cuffshould be inflated to 30 mm Hg above the point

at which the radial pulse disappears. The sphygmomanometer pressure should then be re-

duced at 2 to 3 mn/second. Two readings should be performed at least one minute apart.

140-159



bone

bone

bone

bone

135

Cop)right @ 20ll-201? Denral Decks

The most commonly used allogeneic bone is:

freeze-dried bone

136

Coplright O2011,2012 - Denlal Decks



autogenous bone graft is the transplantation ofbone from one site to another site within

same person. These grafts may be ofcancellous, cortical or a combination ofcortical and

Autogenous bone is the only gaft that possesses all ofthe lollowing prop-

osteoinduction, osteoconduction, and osteogenesis. Additionally, tbere are no in-complications. The dom sides to autogmft are the finite quantity available and

site morbidiryof autog€nous bone grafts:

. Cortical grafts: advantages are due to its structural capabilities, Also has a higher con-

centration of BMP (bone morphogenic protein). The dtsadvantages are due to the lamellar

architecture. Common donor sites: iliac crest, ribs, anterior cortex ofthe chin, lateral cor-

tex ofthe rumus/extemal oblique ridge.. Cancellous grafts: advantages are mostly based on its rich cellular capability. The most

abundant supply can be harvested from the anterior or posterior iliac crest. The only disad-

vantage arises from th€ fact that they do not possess any macroscopic structuml integrity.

Thus the graft cannot be rigidly fixed and will deform, migrate, or resorb ilplaced under

tension or compressive functional forces.

1. The bone manow for grafting defects in the mandible and ma"rilla is generally ob-

\ot€*, tained from the iliac cr€st (anterior and posterloy'. Also used for ridge augmen-

..-.. li tation.

of the cytokine family of growth factors, which occurs in the organic portion ofbone called the bone malrix.

3. A costochondral rib graft may be employed with the cartilaginous portion sim-ulating the TMJ and condyle. When used for ridge augmentation there is a great

deal ofshrinkage.4. Bone plates, biphasic pins, titanium m€sh, and intraosseous wires are used in

the fixation ofbone grafts. Sutues are not generally used.

bone is nonvital, osseous tissue harvested from one individual and transfened to

of the same species. Three forms of allogeneic bone include: fresh frozen, freeze-

and demineralized freeze-dried bone. Fresh frozen bone, howevel is rarely used due

to transmission ofdisease.

. Freeze-dried bon€ is osteoconductive, howevel it has no osteogenic or osteoinductive ca-pabilities. Freeze-dried allogeneic grafts are usually placed in conjunction with autogenous

grafts.

. Demineralized freeze-dried allogeneic bone lacks mechanical shength, but has osteo-

conductive and osteoinductive capabilities. Demineralizing the freeze-dried bone exposes

the bone morphogenetic proteins which has been shown to induce bone formation.

processes by which bone can be repaired or regenerat€d are:

. Ost€ogenesis (osteogenic potentia, is the formation of new bone from osteoprogenitor

cells. Spontaneous osteogenesis is the formation ofnew bone from osteoprogenitor cells

in a wound. Transplanted osteogenesis is formation of new bone from osteoprogenitor

cells placed into the wound from a distant site. Osteogenic grafts include the advantages ofosteoinductive and osteoconductive grafts, in addition to the advantages of transplanting

fully differentiated osteocompetent cells that will immediately produce new bone.. Osteoconduction is the formation ofnew bone from host-derived or fansplanted osteo-

progenitor cells along a biologic or alloplastic framework, such as along the fibrin clot in

tooth extraction or along a hydroxyapatite block. Osteoconductive grafts provide only a

passive framework or scaffolding. The grafted material therefore does not have the ability

to actually produce bone. This type of graft simply conducts bone-forming cells from the

host bed into and around the scaffolding.. Ost€oinduction refers to new bone formation fiom the differentiation of osteoprogenitor

cells, derived liom primitive mesench],rnal cells, into s€cretory osteoblasts. Such grafts help

nroduce the cells that are necessary to Droduce new bone.



Which of the following refers to a horizontalosteotomy of the anterlor mandible?

137

Coptrighr e 201i '2012 , DentalDecks

Tissue removed from an animal donor and surgically trans-

planted to a human

Tissue surgically removed fiom one area of a person's body,

such as the iliac crest, and transplanted in another site on the

same person

Tissue surgically transplanted from an individual of the same

species who is genetically related to the recipient

Tissue surgically transplanted from one individual to a geneti-

cally non-identical individual ofthe same species

t38

Coplri8hr O 2011,2012, Dfrral Declr



refers to a horizontal osteotomy of the anterior mandible. Chin implant refers to

an alloplastic implant or an autogenous implant. Alloplastic implants and sliding ge-

represent the two currently accepted methods ofchin augmentation,

genioplasty involves removing a horseshoe shaped piece ofthe chin bone and slid-

it either backwards or forwards, finally fixing it in place using titanium scr€ws. The most

genioplasty surgery is a neurosensory disturbance, followed by

infection.

augmentation can also be considered for the treatment ofa genial deficiency. The

used include high-density polyethylene, hard tissue replacament

mesh, solid medical-grade silicone rubber, hydroxyapatite, and Gore-Tex.

that are frequently encountered when using alloplastic materials for the treatment

genial deficiency:

l. Migration from the position in which they were placed at the time of sugery

2. Erosion ofthe chin prominence contiguous with the implant

3. Unpleasant sensation in the implant region when exposed to cold temperatwes

Alloplastic grafts are inert, man-made synthetic materials. The modem artificial

replacement procedures use metal alloplastic grafts. For bone replacement a man-made

mimics natural bone is used. Most often this is a form of calcium ohosohate

ticalcium phosphate, calcium cqrbo qte, ot hydroxyLpatite).

ofgralts (or impla ts):. Autogenous grafts (also called autografts) are composed of tissues taken from the same in-dividual. Most frequeltly used in oral surgery.. Allogetreic grafts fa ko called allografts) are composed oftissues taken from an individual ofthe same species who is not genetically related to thc patient fi/ sually cadaver bone).

. lsogeneic grafts (also called isografts) are composed oftissues taken from an individual ofthe

same species who is getretically related to the recipient.. xenogeneic implants (also called xenografls or heterografls) are composed oftissues taken

from a donor ofanother species, for example, animal bone grafted to man. Rarely used in oralsurgery.

Rejection ofthe graft is most common when allografts or xenografts ofbone and cartilage

in oral surgery Autogenous grafts, although frequently presenting surgical and technical

do not as a rule involve rejection (or immunological complications).

ideal graft should:. Be replaced by the host bone. Withstand mechanical forces. Produce no immunologlc rcsponse (or lejection). Actively assist osteogenic (bone-forming) processes of the host. The greatest osteogenic po-

tential occurs with an autogenous cancellous graft and hemopoietic marrow.



integration

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Coplriglu O 2011,2012 - Dental Dects

14D

CopFight O 20l l-2012 - Detrtal D€cks



alloplastic is synonymous with synthetic, This indicates that the material is pro-

from inorganic sources and contains no animal or human components. Alloplastic

offer a prepackaged solution to common reconstructive surgical problems with-

need for autogenous grafting and donor site morbidity.

bone replacement a man-made material that mimics natural bone is used. Most often(HA) is used for augmentation of the mandible. Hydroxyapatite is a

biocompatible material that can be produced synthetically or obtained from biologic

as coral. The granular or particle form is most commonly used for alveo-

ridge augmentation. Note: When placed in a subperiosteal environment, HA bonds

physically and chemically to the bone.

advantages and disadvantages of restructuring an atrophic ridge with hydroxya-

granules:

. Advantages:

- It is a simple surgical technique suitable as an office procedure

- No donor site is required to obtain autogenous bone graft material

- Hydroxyapatite is totally biocompatible and nonresorbable. Disadvantages:

- Migration ofthe hydroxyapatite granules

- Poor ridge form /inadequate height)- Abnormal color under the mucosa

- Mental nerve neuropathy - usually occurs from excessive augmentation

- Cannot participate in phase I osteogenesis since no viable osteogenic cells are

Dresent

Fibro-osseous integration. Connective tissue-encapsulated implant within bone. \ot seen often with newer materials

Osseointegration. .A direct structural and functional connection between living bone and the surfaces of

a load-carrying implant without soft-tissue. Yields most predictable long{erm stability. Several important factors involved: materials, surface characteristics, bone, timing

Biointegration. lmplant interface that is achieved with bioactive materials such as hydroxyapatite (I1,4)

or bioglass that bond directly to bone.

. HA coated implants appear to develop bone faster than do non-coated implants but, after

a yeal there is little difference between coated and non-coated.

principles for success of dental implants: primary stability, amount of bone,(i.e., adjqce t nqtural teeth, maxillary sinus, nasql cqvit),, inferior alveo-

canal).

- . , - 1. To ensure the development ofkeratinized tissue around a dental implant the best

time to augment the soft tissue is Stage ll surgery.-2. Guided tissue regeneration is a surgical procedure used to eliminate a bony de-

fect around a dental implant. This process decreases the connective tissue growth

while increasing the groMh of bone in the defect.

3. A gentle surgical technique requires that you do not heat bon€ above 47oC.

Above this temperature, bone tissue damage occws,



Which of the following is found between th€ bone rndimplant of an endosseous dental imphnt?

ligament

interface

141

coptrighr O 201 l'2012 - Dental Decks

over 70 years ofage

by-pass surgical patient

112

Coplright O 20l l-2012 - Dental Decls

Which of the following faclors would have the grertestnegative influence on a dental implantrs success?



definition of osseointegration is best described by the following: The direct

living bone and a load-bearing endosseous implant at the light micro-

level. Only endosseous and transosseous implants are considered true osseointegrated

for success ofa dental implant:. Clinical immobility under load-bearing conditions. Symptom free. Minimal loss of crestal bone

. No peri-implant radiolucency

. Success rate of 857o after 5 years and 80o/o after l0 years

... - 1.In order for an implant to be successful you need adequate transfer offorce and

Noteal biocompatibility.2.Handpieces for preparation of dental implant receptor sites are lowspeed/high

torque.

3. In the event an endosseous dental implant is mobile, the proper procedure is to

remove the failed implant, debride the socket, and consider placing a bone graft

with a resorbable membrane.

4. You need a minimum of10 mm ofbone height to place an endosseous (rootJbrm)

dental implant.

5. The minimumrequired distance

lromthe apex

ofamandibular posterior implant

to the superior asp€ct ofthe inferior alveolar canal is 2 mm.

6. Titanium and titanium alloy are the most common materials used today for two-

stage endosseous imPlants.

Because smoking affects the healing of bone and overlying tissue, it should be con-

a relative contraindication to implant placcment.

toothless arca can be considered for dental implants. Determining whether implarrts are

option and the type of implants to use include: the patient's rcquirements and expecta-

the amount ofadditional work needed (i.e., bone groftlng), the dentist's skill level, and

long-term prognosis.

indications for implant placement:

. Fixed restoration of single or multiple teeth in a partially edentulous jaw

. Retention of a removable prosthesis in a partially edentulous jaw

. Retention of a prosthesis in a completely edentulous jaw

. Rctcntion ofa fixed prosthesis in a completely edentulous maxilla or mandible

In patients with uncontrollcd systemic diseases such as diabetes, immuno-

patients, and patients with blceding disordcrs, implant placemcnt should be

with extreme caution.

l. Thc highest failure rate is seen in the posterior maxilla where the bone is thc soft-

est (D4) quality.

2. Mobility of the implant is regarded as the most common sign of implant failure.

3. A dental implant supported prosthesis should fit passively on thc dental implant.

4. The minimum space required for a 4.0 mm diameter implant is 7.0 mm-

1.5 mm

on each side ofthe implant plus the diameter olthe implant

5. The maximum amount of taper to allow for proper draw on an overdenture attach-

ment such as an "O" dng is l5 degrees.



form implants

implants

implants

143

Cop).right O 201l-2012 - Dental Decks

144

CoDright O 20l l-2012 - Denul Deck



are divided into three categories based on their relationship to the oral tis-

1. Endosseous implants are implants that are surgically inserted into the jawbone. Thcy arc

thc most frequently used implants today. They are further subdivided into root form and blade

(plate) form.2. Subperiosteal implants are framcworks specifically fabricated to fit on top of supporting

areas in the mandible or maxilla under the mucoperiosteum. This type of implant "rides on"

bone.

3.Transosseous implants are implants that are similar to endosseous implants in that they are

inserted into thejawbone. However, these implants actually penetrate the entirejaw so that they

actually emerge opposite the cntry site, usually at the bottom ofthe chin. Note: Their primaryindication is in the very atrophic mandible where root form implants may further compromise

the strength ofthe jaw.

Osseointegrated implants are anchorcd directly to living bone. This detemlination

by radiographic and light microscopic analysis. Only endosseous and transosseous im-

are considered true osseointegrated implants.

. Root form implants: cylindrical in shape, can be smooth, thrcaded, perforated, and solid or hol-

lo$, vented, coated, or tcxtured. They are available in various widths (3.2 mm to 7 nm) and

lenglhs (8 mm to 18rufi/. Typically made of titanium. Treatment with root form implants is di-

vided into three phases; surgical, healing and prosthetic. Note: These implants are the most pop-

ular,. Blade implants folso known as plate form implants): arc fTatter in appearance and are utilized

rvhen there is insufficient width ofbone but adequate depth is present. They are available in sin-

gle and two stage forms. Typically made oftitanium as well.

ofimplant placement:

l. Submerged: requires a second surgical prccedlre (two'stage) to uncover the fixturc

2. Nonsubmerged: does not require a sccond surgical proccdurc (one-slage)

adults, the new antibiotic regime recommended for the prevention of infective endo-

is:

. Amoxicillin: 2.0 grams, 30-60 minutes hour prior to the procedwe (bur 500

mg tqblets)

those patients allergic to penicillin,. Clindamycin: 600 mg, 30-60 minutes to the procedure (bur 150 mg tablets)

guidelines for children are:. Amoxicillin: 50 mg,&g, 30-60 minutes prior to the procedure

those patients allergic to penrcillin,. Clindamycin: 20 mglkg, 30-60 minutes prior to the procedure

new guidelines involve a number of changes from the previous set ofguidelines:

. Only one antibiotic dosage is required

. The recommended antibiotic for penicillin-allergic patients is clindamycin not eryth-

romycin. Prophylaxis is no longer required for many dental procedures

patients who are allergic to penicillin and who cannot take clin-

include cephalexin, clarithromycin, and azithromycin.



space

space

space

space

l,lsCoplright O 201 I -20 l2 - Dental Decks

ORALSI'RGERY&PAINCONTROL .,MiS

extract the unerupted second molar

the crown and keep it exposed

an anti-inflammatory medication and schedule a follow-up appointment in

treatment is necessary at this time

1,16

Coptlighl O 201l-2012 - Dental Decks



The mylohyoid muscle, stretching across the floor ofthe mouth. divides the submandibular

into a portion above this muscle /srblingual space) and aportion below fru6lr4rillary space).

Spme Usual Source of lnfection

Marillary Sp.ces

Canines space Canines

Buccal Spacc Maxillary molars, premolars

lnfratemporal space Maxillary tbird mola$

Maldibular SDaces

Buccal spac€ Mandibular molars, premolam

Subm€ntal spsce Mandibular incisors

Submandibular space Mandibular molars, premolars

Sublingual space Mandibular molars, premolats

Submaxillary space Mandibular molars

Ptqygomandibnlar space Mandibular molars, premolars

Masseteric space Mandibular third molars

Temporal space Other spaces (i fratemporal. masseteric and

pterygomandibular)

Masticator space Other sp ces (pterygomandibular and temponl

Peniciilin V is often the preferred drug to heat odontogenic infections. It is effective against Shep-

and oral anaerobcs. For penicillin-allergic patients, clindamycin or clarithromycin can be used

specmlm antibiotics are preferred over broad-spectrum antibiotics and bacteriocidal ag€nts are

over bactcriostatic agents.

cysts are those associated with the crowns ofunerupted teeth. Some litera-

refers to these cysts as "follicular" or "primordial" cysts. Note: They are proba-

the result ofdegenerative changes in the reduced enamel epithelium.

Ifcysts form when a tooth is erupting, they are called eruption cysts. These

interfere with normal eruption ofthe teeth. Eruption cysts are more commonly found

the child and young adult, and may be associated with any tooth. If treatment is indi-

incision or "deroofing" is all that is needed.

Dentigerous cyst

Eruption cyst



117

Coplrjght C 201 l-2012 - Dental Decls

14CopriShi O 201 1,2012 - Dental D€cls



spaces: layers offascia "create" potential fascial spaccs (they are called potential because in

there is no space/; all are filled by loose areolar connective tissue. The hyoid bone is the most

in the neck that limits thc spread of infection. Infections or other inflam-

conditions spread by the path ofleast resistance to rcach the fascial spaces. The most common

involved is the vestibular space.

spaces directly adjacent to the origin ofthe odontogenic infections are the primary fascial spaces.

spread from the origin into thcsc spaces, which are: buccal, canine, sublingual, submandibu-

vestibular.

Canine space infections and deep temporal spacc infcctions can result in cavemous sinus thtom-

via the ophthalmic veins.

spaces that become involved following sproad of infection to the primary spaces are the sec-fascial spaces: The secondary spaces are: pterygomandibular, infratl-mporal, masseteric, lateral

Superflcial and deep temporal, retropharlngeal, masticator and prevertebral.

Lateral pharyngeal infections can traverse the rehopharyngeal and prcvertebral spaces and spread

the mediastinum.

the spread ofodontogenic infectioni (l) Thickncss ofbone adjacent to the of-

(2) Position ofmuscle attachment in relation to root tip (3) Virulcnce ofthe organism and

Status ofpatient's immune system

. l. The masticator space contains the contents ofthe pterygomandibular space and is con-

\otes, tinuous with the lempoml space-

: 2.Thc most delinite clinical sign indicating extension ofan odontogenic infection into the

'' -'r'- masticator space is trismus. Trismus is difficulty in opening the mouth due to a tonic spasm

of thc muscles ofmastication.

3. Trismus may also result from passing the needlc through the medial pterygoid muscle

during an inferior alveolar nerve block.

4. other s),rnptoms offascial space infection include pain, dysphagia, and dysphonia.

5. The submandibular space is continuous with the latcral pharyngeal space. The mylohy-

oid muscle divides this space into a portion above this muscle (suhlingual space ) and a

ponron below (s u bmaxillary sp ace).

considerations when ch€cking vital signs:. The patient should not have had alcohol, tobacco, caffeine, or pedormed vigorous exer-

cise u ithin 30 minutes of the exam. tdeally the patient should be sitting with feet on the floor and their back supported The

eramination room should be quiet and the patient comfortable. History of hypertension, slow or rapid pulse, and current medications should always be

obrained

Vital Signs:. Blood pressure: normal 120/80. Pulse rate: normal 72

. Respiralion mte: normal 15

. Temperature can be measured in several different ways:

- Oral with a glass, paper, or electronic thermometer ft?ozral 98.C F / 3TC)

- Arilfary with a glass or elechonic thermometer (normal 97.f F / 36.3'C)

- Rectaf or "core" with a glass or electronic thermometer (rornal 99.6"F / j7.7"C)

- Aurzl (the eqr) Nith an electronic thermometer (normal99.6"F / 37.7C)

*** For every l"C rise in body temperature, there is a corresponding 9-10 beats/min in-crease in the patient's heart rate.

Abnormalities ofvital signs are often clu€s to diseases, the alterations in vital signs are

to evaluate a patient's progress.

najor arcas to be discussed when taking a patient history: l. Chief complaint 2. His-

of present illness 3. Speciflrc drug allergies 4. Review of systems (heart, Iivet kidnev,

etc.) 5. Nature of systems.

In complicated cases, don't be hesitant to call patient's physician, previous den-

health Drofessionals.



tissues

bone

l,l9Coplright O 20ll 2012 - DentalDecks

valve

congenital heart disease

coronary anery blpass grafi

constructed systemic pulmonary shunts or conduits

valve prolapse with regurgitations and./or thickened leaflets

150

CopriShr O2011,2012, Dental Decks



is a relatively rare inflammatory process within the medullary 6rareculor) porliorr

bone that involves the marow spaces. Osteomyelitis is generally classified into two major

suppurative and non-suppurative. Suppurative osteomyelitis is classified into acute,

infantilc osteomyelitis. Non-suppurative osteomyclitis is classified into chronic scle-

(Jbcal and dillitse), Garre's osteomyelitis, and actinomycotic osteomyelitis.

and ischemia are the mechanisms by which osteomyelitis spreads. The

initiating causes are odontogenic infection and trauma. The infection usually begins

thc medullary space involving the cancellous bone. Evcntually thc cortical bone, periosteum,

soft tissues become involved.

Garrc's ostcomyelitis is characterized by localized, hard, nontender, bony swclling of theand inferior aspects ofthe mandible. lt is primarily present in children and young adults and

associated with carious molar and low-grade infection.

Acute osteomyelitis occurs more frequently in the mandible as opposed to thc max-

The primary reason for this is that the blood supply to the maxilla is mucb richer and is de-

a number of different arteries, while the mandible tends to draw its primary supply

the inferior alveolar artcry Thc dcnsc ovcrlying cortical bonc ofthe mandible prevents pen-

blood vessels, thus the mandibular cancellous bone is more likely to become

and therelbrc infected. lmportant point: a reduced blood supply will predispose bone

most frequently found bacteria in patients with osteomyelitis ofthejaws include: Gram-posi-

cocci /1.e., Streptococci, Staphylococcus aurers), anaerobic cocci and gram-negative rods.

ofostcornyelitis ofthejaws usually includes both surgical intervention and medicalofthe patient, as well, as sensitivity tcsting. Medical management involvcs adminis-

ofempirical antibiotics, performing Gran stain, and the administration ofculture-guided an-

Surgical treatment includes removal of loose tceth and foreign bodies; sequestrectomy:

decortication: rcsection; and reconstruction, if necessary.

Endocarditis Prophylaxis Not Recornmended

Isolated secundum atrial septal defect

Surgical repair ofatrial septal defect, ventricular septal

defect. or Datent ductus art€riosus

construcled systemic pulmonary

Prior coronary artery blTass graftomplex cyanotic congenital hean disease

Physiologic, functional, or innocent hean murmurs

other coneenital caadiac malformations Previous Kawasaki disease without valwlar dysfunction

Previous rheumatic fever without vah'ular dysfunction

Cardiac oacemakers and imDlanted defibrillators

valve prolapsed with regugitationthickened leafl ets



Why is a conventioarl handplece thrt expels forced air

.i. . . controindicated when performing dentoalveolar surgery?

much bone will be removed

handpieces can cause tissue emphysema or al air embolus which can be fatal

handpieces are not high-powered enough to remove bone

ofthe above

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important: Most high-speed tubine drills used in routine restorative dentistry are to-

unacc€ptable for oral surgery. The air exhausted ftom these drills goes into the wound

may be forced deeper into tissue planes and produce tissue emphysema, a potentially

situation.

are the most commonly used instrum€nts for removing bone. However,

oral surgeons use when removing bone is the bur and handpiece.

of the surgical wound during and after the cutting of bone cannot be emphasized

Copious amounts ofcoolant spray are crucial in minimizing osseous necrosis caused

heat generated from the bur. Irrigation serves also to cleanse the crypt and areas beneath

flap ofbony debris, tooth fragments, and blood. Distilled water is not used for irrigationit is a hypotonic solution and will enter cells down the osmotic gradient causing cell

and rapid death ofbone cells.

acute infected tissue emphysema is usually caused by the indiscreet use of:

I . 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 portion ofthe alve-

olar process and ultimat€ly out through the nutrient foramina into adjacent soft tissues, re-

sulting in formation ofa septic cellulitis and tissue emphysema.

2. Atomizing spray bottles activated by compressed air: A similar condition can be in-duced by the use ofa compressed-air spray bottle for irrigation ofwounds, particularly in

the retromolar region. It is safer to use a hand-activated sytinge when irrigating wounds or

drying root canals since it is unlikely that a tissue emphysema would be produced under

these circumstances.

Admission Tests

. A complete blood count that includes an evaluation ofthe hemoglobin and hemat-

ocrit indices. A total white blood cell count with a differential count

. A gross and microscopic urinalysis

Anyone scheduled for general anesthesia should have a chest x-ray and patients over

years old should also have an E.K.G.

be considered in the decision to hospitalize a patient for an elective proce-

. Medical problems compromising treatment (diabetes, hemophilia, etc.)

. Difficulty and extent of surgery

. Consideration ofthe individual patient (emotionally disturbed, handicopped, etc.)

. Cost of hospitalization (time and money)



culture for artibiotic sensitivity has been performed

ofthe infection

sinus tract is formed

fever has cleared up

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advarcement

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it is at this time that nature has constructed a barrier around the abscess, walling it off from

circulation and making it possible to palpate th€ presence ofpurulent material within the abscess cavity

a.t lluctuanc e ).

components in treatment ofodontogenic infection are:

. Determirling rhe severity ofinfection

. Dctermining whether the infection is at the cellulitis or abscess stage

. Evaluating the state ofthe patient's host defense mechanisms. Compromised host defenses include: severe

diabetes, alcoholism, malnutrition, uremia, leukemia, malignant tumors, lymphoma, o. someone on cancer

chemotheftpeutic or immunosuppressive agents.. Determine whether paticnt should bc treated by a general dentist or an oral surgcon. Criteria for referral

to an oral surgeon include: rapidly progressive infection, difficulty i breathing or swallowing, fascial space

involvement, elevated temperature P ,/r1'O, severe jaw trismrrs (< I0 mm), toxic appeannce, or compro-

mised host defenses.. Treating the infection surgically. Removal ofthe source ofinf€ction and drainage ofpurulence.

- Methods ofdrainage ofodontogenic infcctions: endodontic ffeatment, €xtraction ofthe ollending

tooth or incision and drainage ofthe soft tissue.

. Support the patient m€dically: airway maintenanc€, rehydration, analgesia, nutrition, etc.

. Prescribe appropriate arltibiotics. Indications for the use ofantibiotics include: rapidly progressive swelling,

difirse swclling, compromis€d host defenses, involvement of fascial spaces, severe pcricoronitis and os-

teomyelitis. Penicillin V is often thc prefencd drug. Ifthe patient is pcnicillin-allergic, use clindamycin.

principles ofincision and drainage:

. Before incision. obtain fluid for culture

. Incise the abscess in healthy skin or mucosa and in a cosmetically or functionally acceptable place, using

blunr disscction and thorough exploration ofthe involved space

. Use one-way drains in intraoral abscesses; use through-and-through dminage in extraoral cases

. Remove the dmin gradually from deep sites

.. L For odonfogenic infections, the most common organisms are aerobic gram-positive cocci,rNota*': anaerobic gram-positive cocci, and anaerobic gmm-negative rods.

2. Streptococcus species lwhich arc highly virulent a d aerobic) initiate lhe infectious proccss,

a cellullhs then occurs, followed by proliferation ofanacrobic organisms.

a frenum is positioned in such a way as to interfere with the normal alignment ofor results in pulling away ofthe gingiva from the tooth surface causing recession it

often removed using a surgical process known as a frenectomy.

techniques used for a frenectomy:

. Diamond excision \ are effective when the mucosal and fibrous tissue band is rela-

. Zpfasty / tively narrow. These techniques relax the pull of the frenum.

. V-Y advancement is often preferred when the frenal attachment has a wide base.

This technique is good for Iengthening tissue and usually results in less scarring.

anesthetic infilhation is usually sulficient for surgical treatment offrenal at-

Care must be taken to avoid exc€ssive infiltration directly in the frenum area

it may obscure the anatomy that must be visualized at the time ofexcision.



facial vein; pterygoid plexus ofveins, angular; inferior ophthalmic veins

alveolar, anterior superior alveolar arteries, descending palatine; greater palatine

supraorbital veins, superficial temporal; lingual veins

inferior ophthalmic veins, transverse facial vein; pterygoid plexus ofveins

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reduction

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sinus thrombosis is an uncommon but potentially lethal extension ofodontogenic infection.

veins in the head and neck allow retrogmde flow ofinfection liom the face to the sinus. The

ofveins and angular and ophthalmic veins may contributc to retrograde flowCanine space infections and deep temporal space infections can result in cavemous sinus thrcm-

via the ophthalmic veins.

first clinical signs ofcavemous thrombosis include vascular congestion in periorbital, scleral, and

veins. Other clinical signs include periorbital ed€ma, Woptosis (exophthalmos), thrombosis ofrctinal vein, ptosis, dilated pupils, absent comeal reflex, and supraorbital sensory deficits.

The infection is life-threatening and requires prompt and agglessive treatment, consisting

source ofinfection, drainage, parenteral antibiotic therapy, and neurosurgical con-

Cranial nerues lII,lY,Y (ophthalnic divisio of f), and VI pass through the cavemous

alveoloplasty is the surgical preparation ofthe alveolar ridges (i.e., removing under-d d sharp edges from areas such as the mylohyoid ridge) for the reception ofden-or shaping and smoothing the socket margins after extractions of teeth with

suturing to insure optimal healing.

of this recontouring should be to provide the best possible tissue

prosthesis support, while maintaining as much bone and soft tissue as possi-

I . In some cases, the bone is well-contoured for denture or partial denture construction

soft tissues may interfere with the fit or function of the prosthesis. These soft

areas include: the mandibular retromolar pad, the maxillary tuberosity, exces-

alveolar ridge tissue, labial and lingual freni, or a condition called inflammatory

hyperplasia.

A closed reduction is the closing of the space between fractured bone withoutthough the soft tissue or surrounding bone.

A gingivoplasty is a surgical procedure to reshape the gingivae to create a normal,

An operculectomy is the removal ofthe operculum, which is the flap oftissue overunerupted or partially erupted tooth.



ORAL SURGERY & PAIN CONTROL Misc.

While there are many reasons for autotransplanting teeth, tooth loss as a

res[lt ofdental caries is the most comrnon indication, especially when:

central incisors are involved

first molars are involved

canines are involved

third molars are involved

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ORAL SURGERY & PAIN CONTROL Misc.

All ofthe following are systemic contraindications to elective surgeryEXCEPT one. which one is the EXCEPZOM

dyscrasias (i.e., hemophilia, Ieukemia)

diabetes mellitus

disease or any steroid deficiency

ofunexplained origin

debilitating disease

disease

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Cop)righl Ol 201 l-?012 Dental Decks



molars erupt early and are often heavily restored. AutotransplNntation in this situation in-

the removal ofathird molar which may then be transf€rred to the site ofan uucstorable first

Other conditions in which tansplantation can be considered include tooth agenesis (especially

and lateral lrcrsols), traumatic tooth loss, atopic eruption ofcanines, root r€sorption,

endodontic lesions, cervical root fractures, localized juvenile periodontitis as well as other

very important for the success of autotransplantation. Candidates must be in

health, able to follow post-operative instructions, and available for follow-up visits. They

also demonstrate an acceptable level oforal hygiene and be amenable to regular dental care.

importantly, thepatients

musthave a

suitable recipientsite and donor tooth. Note:

Ifsurgery

done on a diabetic patient antibiotic coverage should be considered particularly ifthe diabetes is

well controlled or uncontrolled.

most important criteria for success involving the recipient site is adequacy ofbone support.

be sufficient alveolar bone support in all dimensions with adequate attached keratinized

allow for stabilization ofthe transplanted tooth.

donor tooth should be positioned such that extraction will be as atraumatic as possible. Ab-

which makes tooth rcmoval exceedingly difficult and may involve tooth

is conhaindicaled for this surgery. Teeth with either open or closed apices may be donors;

predictable results are obtained with teeth having between ore-halfto two-

compl€ted root development. Note: The most likely cause offailure will be a chlonic, pro-

external root resorption.

An allogeneic tooth tansplant rcfers to a situation in which a tooth from one individ-

is placed in another individual. The almost universal sequelae ofan allogeneic tooth hansplant

ankylosis and progressive root resorption, Remember: The change in continuity ofthe oc-

plane observed rfter allkylosis ofa tooth is caused by the continued eruption ofthe other non-

and glowth ofthe alveolar process.

Uncontrolled diabetes mellitus is a systemic contraindication to elective surgery

Patients with these systemic conditions can be tleated, but you need to consult with the pa-

physician before treatment. In most cases, these patients are best treated in the hospital by an oral

contrrindications include:

. End-stage renal disease

. Severe uncontrofled metabolic diseases /1. e., uncontrolled diabetes mellitus)

. Advanced cardiac conditions (uhstable a gina)

. Patients with leukemia and lymphoma should be treated before extraction ofteeth

. Patients with hemophilia or platelet disorders should be tleated before extraction ofteeth

. Patients with a history ofhead and neck cancer need to be treated with care because even minor sur-

gery can lead to osteoradionecrosis. Notei These patients are often treated with hyperbaric oxygen

therapy prior to dental surgery. Pericomitis: infection ofthe soft tissues around a partially erupted mandibular third molar

Note: This infection should be treated pdor to rcmoval of the maxillary third molar.. Acute infectious stomatitis and malignant disease are relative contraindications

. Patients being treated with IV bisphosphonates increases the risk ofosteoradionecrcsis ofthe jaw

Cardiac disease, such as coronary artery disease, uncontrolled h)?€rtension, and cardiac de-

can complicate exodontia. Usually r postinfrrctioo patient is not subjected to oral sur-

within six months ofhis infarction. However, emergency procedures can be perform€d, provided

patient's physician has been consulted.

l. Infected maxillarymolars and mandibular molars willusually drain into the buccal space which lies

etween the buccinator muscle and overlying skin and superficial fascia.

. The submandibulrr space which lies between the mylohyoid muscle and skin and superficial fas-

ia is primarily infected by mandibular first, second and third molars.



mucosa

and floor ofthe mouth

gingiva

(crowing sounds)

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sites of the oral cancer are the tongue and the floor of the mouth. The other

sites are the buccal vestibule, buccal mucosa, gingiva and rarely the hard and soft palate.

cancer is extremely malignant and even ifthere is slight delay it spreads to lymph nodes ofneck.

carcinoma (epidermoid carcinoma) is the most commolr form oforal cancer Oral

usually presents as an indunted ulcer with poorly defined borders. The lesion is characteris-

painless, unless inflammation from superinfection or ch.onic mechanical irritation is pres-

An indolent clinical presentation in the form ofa small superficial ulceration, leukoplakia, or

is also likely, especially in the early stages ofdevelopment.

SCC usually affects the lower lip and rarely the upper lip. This occurrence has beento greater exposure ofthe lower lip to sunlight. Lip carcinoma commonly presents as an

In many cases, a keratin crust covers the ulcer. The rest ofthe lip vermilion may show ac-

changes.

Carcinoma in situ is an epithelial dysplasia that includes all the layers ofthe epithe-

but does not extend beyond the basal layer. Once the malignant cells have penetrated the basal

into the lamina propria, early invasive squamous cell carcinoma has been established. If tumor

deeper into the tissues, involving fat, muscle, or other struchrres, then true in-

squamous cell carcinoma has evolved.

ofhistologic dilferentiation best describes the degree ofmalignancy ofa tumor. Ma-

neoplasms are histologically classified as (l) well differentiated (2) moderately differenti-

or (3) poorly differentiated (anaplostic) tumors. From a histologic point of view, poorly

have the highest de$ee ofmalignancy.

' . -- l. The salivary glands, blood vessels, lymphatics, muscle, bone, and other comective tis-

sue can also give rise to primary malignancies of the head and neck.

2. Cancer ofthe breast, prostate, lung, kidney, thyroid, hematopoietic system, and colon

can metastasize to the head and neck region.

is a high-pitched, noisy respiration, like the blowing ofthe wind. It demands im-

It is caused by partial obstruction ofthe airway at the level ofthe larymx or

total airway obshuction usually occurs during inspiration, there is usually adequate

left in the cerebml blood to permit up to 2 minutes of consciousness. Ifthe obstruc-

is not recognized and managed and oxygen delivered to the victim's lungs, blood, and

permanent neurologic damage occurs within 3 to 5 minutes.

Procedures for Obstructed Airwayr. Back blows, manual thrusts, Heimlich maneuver, chest thrust, and finger sweep

Procedures for Obstructed Airways:*** These procedures should only be performed by persons trained in these techniques and

ifproper equipment is available.

.Tracheotomy: ls used more for long-term airway maintenance and not for emergency

arrways. Cricothyrotomy: ls a procedure for establishing an emergency airway where other

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

A c cothyrotomy may be lifesaving in an anaphylactic r€action in which a pa-

shows signs oflaryngeal obstruction. Ifa patient shows signs of laryngeal obstruction,

is, stridor (crowing sounds), epinephrine should be given and oxygen administered. Ifaloses consciousness and appears to be unable to breath€, an emergency cricothyro-

may be required to bypass the laryngeal obstruction.



third molar

second molar

third molar

second molar

t6tCoplrighr O 20ll-2012, Denial Decks

ecchymosis, purpura

petechiae

purpura, ecchymosis

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clinical picture is that ofa markedly red, swollen, suppurutive lesion. The involved tissue

very tender and often accompanied by pain radiating to the ear, throat, and floor of the

Excruciating pain is produced when the opposing tooth impinges upon the inflamed

during mastication. There may be trismus ofthe masticator muscles on the affected side.

of the cervical nodes, fever, and malaise are common. If this occurs, antibiotic

indicated.

principal etiologic factors in pericoronitis are debris and bacterial waste Droducts

have accumulated under the soft tissue flap, overlying a partially erupted tooth. This tis-

is often traumatized during mastication which further exacerbates the situation.

treatment is as follows:L Carefully cleanse beneath the tissue flap using a dental scaler if available. Then flush

thoroughly with an irrigating syringe, warm saline and/or Chlorhexidine Gluconate.

2. Instruct the patient to dnse with warm saline hourly.

3. Prescribe a soft diet and instruct tbe patient to refiain fiom chewing on the affected side

ofthe mouth.4. Repeat treatment daily until the inflammatory reaction subsides.

The maxillary third molar is the most frequent conbibuting factor to pericoro-

found around mandibular third molars. Always examine the maxillary third

it may be supererupted or malaligned.

ecchymosis is a result of trauma to the underlying blood vessels. Blood es-

from the vascular tree and accumulates in the tissues. It is common after extrac-

in elderly patients due to the fragility of the vessel walls. All patients should be

that it may occur following extraclions. Note: Sometimes the patient will com-ofa diffilse, non-painful, yellowish discoloration ofthe skin. Moist heat often speeds

resolution olpostoperative ecchymosis.

common adverse eff€cts of radiation therapy on the oral and paraoral tissues:

. Rampant caries . Difficulty in swallowing

. Radiation mucositis . Varying degree of trismus

. Xerostomia . Radiation dermatitis

Osteoradionecrosis does not develop unless the patient's oral condition is

before radiation therapy, and postirradiation dental procedures are per-

without proper precautions.

Hlperbaric oxygen therapy must be considered if surgery is to be performed onirradiated mandible.



Thrombocytopeniz (ow pbtela courr, thrt is less than _an absolute contraindication to elective surgical procedures

because of the possibility of signilicant bleeding.

/ mm3

/ mm3

/ mm3

/ mm3

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ORAL SURGERY & PAIN CONTROL JCe

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Copltighr e 201l-2012 ' D{tal Decl6

EXCEPT one.Which one is the EXCEPTION?



\ote3'

with less than 10,000 - 20,000 platelets have been known to bleed spontaneously.

counts between 50,000 and 100,000 have not been associated with significant

is normal.

etiologies for low platelet counts are:

. Idiopathic thrombocytopenic purpura (1ZP)

. Disseminated intravascular coaeulation (DIC )

. Marrow invasion or aplasia

. Hypersplenism. Drugs

. Cirrhosis

. Transfusions

. Viral infections (infectious mononuc leosis)

l. Normal platelet count is 150,000 - 450,000

2. Emergency procedures may be done with a few as 30,000 platelets if the

dentist is working closely with the patient's hematologist and uses excellent

techniques of tissue management

3.Bleeding time is a screening test that assesses platelet number and function.

4. Aspirin irreversibly blocks cyclooxygenase function, inlibiting platelet ag-

gregation for their 7 to l0 day life span. Because approximately l0olo ofplateletsare replaced each day, it takes an average of2-3 days for bleeding time to nor-

malize, but most experts reconmend allowing 7 days without aspirin before sur-

gery. Other NSAIDs will alter platelet function only temporarily.

of lesions that raise the suspicion of malignancy:. Er!'throplasi& lesion is totally red or speckled red and white. L'lceration: lesion is ulcerated or is an ulcer.

Duration: more than two weeks. Rapid grolvth. Bleeding: Bleeds on gentle manipulation. Induration; lesion and sunounding tissue is firm to the touch. Firation: feels attached to adjacent structures

red but not ulcerated area on mucous membrane is called erythroplasia. The texture may

normai or roughened. Size is variable, some being so small as to vinually escape detection

hereas large areas are conspicuous to casual inspection. There are usually no symptoms.

neither elevated nor depressed, they present as quiet, unpretentior.N lesions. The border

be sharp or blend imperceptibly into surrounding normal mucosa. It must constantly be

nind that early carcinoma frequently appears as an area oferythroplasia. There are cer-

areas ofthe oral mucosa which seem more prone to develop nalignancy. Additionally, oral

more often seen in those over age 40. Because ofthis, an area ofery4hroplasia in a

prone area in a patient past 40 is highly suspicious for malignancy and should be biop-

on rhe day it is seen. This is especially true for those lesions whose duration exceeds 2

Local spread of oral carcinoma is achieved by direct invasion and infiltration of adja-

invasion and spread is particularly important because it can ad-

influence the actual extent of the tumor Regional spread to the neck lymph nodes

by the lymphatic route.



step osteotomy

ramus sagittal split osteotomy

vertical ramus osteotomy

vertical body osteotomies

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neuralgia

mouth syndrome

neuralgia

arteritis

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mandibularramus sagittal split osteotomy has be-

ofthe most commonly performed mandibular

procedures. The mandible is split sagittally

either be used to advance the mandlble ftn the

of rettogn^thi^) or to set back the mandible fl,progn^thi^) . lt is the standard procedure used

Note: The position ofthe condyle is unchanged

conection ofmandibular prognathism or retrog-

ramus osteotomy:can be used to set

mandible f'osteriorly. Used for the correcrion

body osteotomies: procedures that involve

mandibular teeth bilaterally frsrd I ly bicuspidr.

picce ofbone is also rcmoved liom the mandible and you

back. Used for prognathism.

step osteotomy: may be indicated in cases ofprognathism, retrognathism, asymmetry and

By performing bilateral step-shaped cuts

rhe body ofthc mandible, the lowerjaw is divided into

separate. Independenrly moveable pieces.

surgeries are rcfered to as LeFort I osteotomies. The maxilla can be moved forward

down more easily than it can be moved up or back. Distraction osteogenesis fDOJ involvcs cutting

ostcotomy to separate segments ofbone and the application ofan appliance that will facilitatc thc grad-

and incremental separation ofbone segments. Used for patients with cleft lip and palate as well as

deformities ofthe facial skeleton.

painr. Trigeminal neuralgia: prototypic neuropathic fascial pain; Typically there is a triggcr point and

the pain presents as electrical, sharp, shooting, and episodic (seconds to minutes in dwation). Most

commonly seen in patients over 50 years of age. Carbamazepine (Tegretol) is still the mainstay oftreatment,. Odontalgia secondary to deafferent^tion (atypical odontalgia): occ.urs as a result of trauma or

!$gery hoot canal or eil/4cliox). Results from damage to the afferent pain transmission system.

. Postherpetic neuralgia: is a potential sequela ofa herpes zoster infection. Pain is described as bum-

ing, aching, or electric shock-like. Treated with antidepressants, anticonwlsants, or sympathetic

blocks. Ramsey Hunt syndrome is a herpes zoster infection of the sensory and motor branches ofCN

VII and CN VIll.. \euromas: may occur after nerve injury This atea (neuroma) can become very sensitive to stimuli

and cause chronic neuropathic pain.

. Burning mouth syndrome: is most commonly seen in postmenopausal females. Chiefcomplaints

are pain, dryness, and buming ofthe mouth and tongue. Some complain ofaltered taste sensation. Half

ofpatients get befter without treatment over a 2 year pcriod.. Chronic headache: categorized as being either migraine, tension type, or cluster. Temporal arteritis fgra nt cell at'teritis): is the most common folm ofvasculitis that occurs in adults.

Almost all patients are over the age of50. Commonly causes headaches,joint pain, facialpain, fever,

and difficulties with vision, and sometimcs permanent visual loss in one or both eyos. Often difficult

to diagnose.

c{

i lr(

\\, \

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LS

-(i\\

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+ I 'gF?\_--jdij

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l,-



over the posterior surfac€ ofthe condyle with the mouth open

the external auditory meatus

ofthe above

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temporomatrdibular joiDt should be evaluated for tendemess and noise. When checking for joint

(clicki g and clepitus), the joint is p lpated laterully (in front of the external auditory neatus)

the patient opens and closes the mandible.

can be assessed by palpating the lateral aspects ofthejoints when the mouth is closed and

ofth€ mouth. The joint should also be palpated for tendemess while the patient opens

and the ftngertip should be positioned slightly posterior to the condyle to apply force to

if therc is inflammation of the retrodiscal tissue.

By placing fingertips in the patient's extemal auditory meatus, this technique can produce false

sounds during mandibular function because ofpressure against the thin ear canal cartilage.

(l) The posterior aspect of the condyle is rounded and convex, whercas the

aspect is concave. (2) The condyles are not symmetrical nor identical

disorders:

. Myofascial pain disorder fMPD): most common cause of masticatory pain and compromised func-

tion. The symptoms are diffuse, poorly localized in the preauricular region, often involving the mus-

cles of mastication. The pain and tendemess develop as a result of abnormal muscle function and

h'?eractivity. It can be the rcsult ofdisc displacement disorders or d€generative arthritis.. Disc displacement disorders: are seen with and without reduction (the return ofthe nonbal disc-

to-condyle rclationship). See card 170.. Systemic rrthritic conditions: include rheumatoid axdritis, systemic lupus, and pseudogout. Pa-

tients with these conditions usually have other clinical systemic signs and s,'nptoms.. Chronic recurreot dislocation: occurs when the mandibular condyle translat€s anterior to the ar-

ticular eminence and requires mechanical manipulation to achieve reduction. It is associated with

pain and muscle spasm.

. Ankylosis: can occur intracapsularly or extracapsularly, and can b€ fihous or bony. Bony anrylo-

sis results in morc limitation ofmotion. Trauma is the most common cause of ankylosis. These pa-

tielts have a severely restricted mnge ofmotion that may be accompanied by pain.

a healthy temporcmandibularjoint ffM"/), the articulardisc is seated on th€ condyle and is held in place by

coffater{l ligaments (also called "discal ligaments") that are attached to the medial and lateral poles ofcondyle. Attached to the anterior portion ofthe articular disc are muscle fibers from the lateral pterygoid

rhe collateral ligaments become elongated or torn, they become loose which allows the lateral ptery-

muscle to pull the articulardisc out ofplace. Wlen this occurs, it is called a disc disphcement. Becauserhe anteromedial direction ofthe lateral pterygoid muscle, the articular disc is usually displaced antero-

\\:hen the articulat disc is displaced anteromedially to the condyle, a click souDd is usually d€mon-

when the mouth is opened and the condyle moves past the thick posterior band ofthe afticular disc-

be a clicking sound when the mandible moves to the opposite side as the condyle again moves

the thick posterior band ofthe aiticular disc. Often anothff click will be demonshated vhen the mouth is

the condylemoves liom the thin centalareaofthe disc and then past the thickerpos-

band as the arhcular disc once again becomes displaced. A Crepitation sound faho lnown as "Crepi-

-muhiple scraping or grating sounfu) is usually associated with a degenemtive process (osteoarthritis)

condyle, the dull thud is usually associated with a self-reducing subluxation ofthe condyle, and tinni-

is described as ear ringing.

therapy for TMJ dysfunction

. Prtient education: parafunctional habi6 fe.g., nail and pencil bitittg) and stress can be associated with

myofascial pain disordet (MPD). These habits or sttess should be d€alt \ /ith by a trained professional..lvledic.tions: for TMJ disorden include NSAIDs, steroids, narcotic and non-narcotic analgesics, antide_

oressants. and muscle relaxants.. Physical therrpy: treannent may include biofeedback, ultrasoun4 transcutaneous electrical stimulation

/IENS.,/, massage, thermo-ffeatment, €xercise, and iontophoresis.. Occfusaf splints: can be classified as either iutorepositioning a/or m*tcle or joint pain when no speciJic

anatomically based pathologic entity can be identifed) ot ,ftefior repositioning. The anterior reposition-

ing splint protrudes the mandible into a forward position, h)?othetically recapturing the normal disc-to-

condyle relationship. occlusal modification may be accomplished via equilibration, full mouth

reconstruction, orthodontics and orthognathic sugery. Arthrocentesis: for patients with intemal dera[gement. A few milliliters ofsalin€ or lactated ringers are

injected into the superior j oint space.



are the same

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the ears

clicking

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approaches to the TMJ!. Preauricular: the best incision to expose the TMJ. A perpendicular incision is made just ante.ior tothe extemal ear parallel to the superficial tempoml afiery. The incision extends from one inch above

the zygomatic arch to the lower extremity ofthe ear The condyle is approached ftom behind. Note:

With this approach, care must be taken not to damag€ either the facial nerve or the vessels that richlysupply this area.

. Subma[dibular approach (Risdon approacr): this is one standard surgical approach to the ramus

ofthe mandible rnd neck ofthe condyle. [t is not th€ b€st apprcach for prccedures with-in the joint

space itself

with pain and dysfunction whose signs and symptoms do not respond satisfactorily to nonsur-

therapy with a period of3 months may be candidates for surgery particularly ifthey are diagnosedadvance intemal derangement caused by ankylosis, rheumatoid arthritis, or severe degenerative os-

Patients with no improvement in range and ofmotion and mouth opening despite conserva-

treatment arc also candidates for surgical therapy.

trertments:.Arthroscopy allows direct visualization ofthe anatomic structure ofthe TMJ, biopsy ofpathologic

tissue, and .emoval of osteoarthritic fibrillation tissue, as well as direct injection of steroid into in-

fl amed synovial tissues.. Disc repositioning swgery bpen arthroplasly): is used in patients with painful, persistent clicking-popping and closed lock, The disc is mobilized and a postfiior wedge may be removed, with sutur-

ing used to reposition the disc in a better anatomic position.. Dfuc repair or remov^l (discectomy): is irldicated when the disc is severely damaged. Results vary

widely as to whether it is a viable option for patients. R€placement materials have been prcblematic,

so there is a tendency to favor autogenous mateials(i.e.,

temporalis muscle andfascia).. Condylotomy:is accomplished by performing an inhaoral vertical mmus osteotomy. Has been used

for the treatment of intemal demngement with and without reduction and chronic dislocation.. Total joint replacement: is indicated in the severely pathologic joint, as seen in rheumatoid arthri-

tis, severe degenerativ€joint disease, ankylosis, and neoplasia. Costochondral bone graft reconstmc-

tion is the most common autogenous material used.

is masticatory

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5- Oral Surgery & Pain Control