Major Topic Adrenal Cortex Anatomy

Anesahesia

Abbreviation Adren Cort Anat

Anesth

Major Topic
Fractures General Information

Abbreviation
Fractures
Gen Info

Grafts Implants
Miscellaneous

Gradfts Implants
Misc.

Biopsy Disorders/Conditions Drugs Exodontia

Biopsy Disord/Cond Drugs Exo

Temporomandibular Joint

TMJ

ORAL SURGERY & PAIN CONTROL Adren Cort

The gold standard test for primary adrenal failure is the:

. Blood glucose test

. ACTH stimulation test

. Serum creatinine level

.

BL\

iest

Cop)righr C

201 1,201 2 -

Dental Decks

The ACTH stimulation test is performed to examine the response ofthe adrenal gland to an exogenously administered dose ofACTH. Normal patients have a doubling ofthe serum cortisol level after a dose of ACTH. The serum cortisol level should rise to >20 prg dL ifthere is adequate adrenal function. Art inadequate response suggests adrenal gland hrpofirnction. Note: Cosyntropin (Cottosyz) is an ACTH analogue that stimulates the adrenal gland and its ACTH receptors.

About 20 mg of hydrocortisone is secreted by the adrenal cortex daily. During stress the cortex can increase the output to 200 rng daily.

Remmber: Patients taking steroids or people with disease ofthe adrenals will have decreased ability to produce more glucocorticoids (hydrocortisone) in times of stress fejrtractions). The reason for this is as follows:
Secretion ofglucocorticoids is stimulated by ACTH, a hormone produced in the anterior pituitary. The pituitary responds to stress by increasing ACTH output and therefore glucocorticoid production increases. A relative lack ofglucocorticoids will also increase output ofACTH. An overabundance ofcirculating systemic steroids will inhibit production ofACTH. Patients on large doses ofsteroids repress ACTH production which leads to

atroohv of adrenal cortex.

. Never regain full adrenal cortical function

. Take

as much as a year to regain

full adrenal cortical function full adrenal cortical function

Take as little as a week to regain

. Take usually a couple of days to regain full adrenal cortical function

Coplright O 201l-2012 - Denbl Decks

. Ectopic ACTH Syndrome . MENS I

. Cushing's syndrome . Addison's disease

CoplriSlr O

201 l-2012 -

Derkl

Decks

The following guidelines may help determine if a patient's adrenal function is suppressed, however, ifany doubt xists, consult the patient's physician before performing surgery.
Some 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 to regain full adrenal cortical function.

will

take as much as a year

Patients with a&enal insu{ficiency are hyperpigmented. This is most noticeable on the buccal and labial mucosa, although other areas such as the gingiva may be involved. The hyper-

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

produce pigment. Patients rvith decreased adrenal gland hormone production experience weakness, weight loss, onhostatic hypotension, nausea, and vomiting. Patients with severe adrenal insufficiency cannot increase steroid production in response to stress and in extreme situations may have cardiovascular collapse. It is important that an adrenally insufficient patient have adequate steroid replacement, since the stress oforal surgery can precipitate adrenal crisis.

ln adrenal crisis, an intravenous or intramuscular injection ofhydrccortisone must be given immediately. Supportive treatment of low blood pressure with intravenous fluids is usually
necessary. Hospitalization is required for adequate treatment and monitoring.

Cushing syndrome is a hormonal disorder caused by prolonged exposure ofthe body's tissues to high levels ofthe hormone cortisol. This results in characteristic changes in body hiatus including moon facies, truncal obesity, muscular wasting, and hirsutism. Sometimes called "hypercortisolism," it is relatively rare and most commonly affects adults aged 20 to 50. The femaleto-male incidence ratio is approximately 5:1.
Patients with Cushing's syndrome are often h)?ertensive because

offluid retention. Long-

term glucocorticoid excess can result in decreased collagen production, a tendency to bruise easily, poor wound healing, and osteoporosis. They are often at increased risk for infection.
Laboratory snrdies may reveal increased blood glucose levels because ofinterference with carbohydrate metabolism, and examination of the peripheral blood smear may demonstrate slight decrease in eosinophil and lymphocyte counts.

Important: The patient's cardiovascular status must be evaluated and treated if necessary prior to surgery.
Note: The most common cause ofCushing's syndrome is a tumor in the pituitary ofthe
hloothalamus.

. Have patient discontinue the Prednisone for two days prior to the extraction . Give steroid supplementation and remove the tooth
sedation

with local

anesthesia and

. lnstruct the palient to lake 3 grams of amoxicillin one hour prior to extraction . No special treatment is necessary prior to extraction

4
Cop)'righl O
201

l-2012 - Denral Decks

. First molar

. .

Second premolar Second molar

. Canine

CopltiShr O 20ll-2012 - Dental Decks

Important: The far here is that the patient may not have sumcient adrenal cortx secretion (adrenal insulJiciency) to withstand the stress of an xtraction without taking additional steroids. (This holds true for any palient who has been treatedfor any disease vilh steloid therapy).
Patients with adrenal insufficiency, patients on daily steroid therapy, and patients who have rccently ished a couNe of stercids should receive steroid supplement for dental procedures. The concems about adrenal insufficiency should be raised on the basis ofcases, the dentist should ask:

fin-

ofclinicrl history. In the majority

. 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 need stress-dose steroids.

will

Gneral guidelines for the management ofpatients on steroid therapy: . Steroid supplement in patients who can develop adrenal insulliciency

. Early moming appointmnts . 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

Remember: Erythema multiforme is a hypersensitivity syndrome characterized by polyrnorphous eruption ofskin and mucous membranes. Macules, papules, nodules, vesicles, or bullae and target or ("bull's-eye-shaped") lesions aie seen. A sevre form ofthis condition is known as StevensJohnson syndrome, These patients may be receiving moderate doses of systmic coficosteroids and therefore may be unable to withstand the stress ofan extraction. Consultation with theirphysician is absolutely necessary before treating these patients.

The greater palatine foramen is generally located halfway between the gingival margin and midline ofthe palate, approximately 5 mm anterior to thejunction ofthe hard and soft palate (vibrating line) distal to the apex ofthe maxillary second molar The hard palate is perfonted by the following foramina; . The incisive foramen, posterior to 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 Nerves of the palate:

. Sensory Inneryation to lhe palate: is supplied by the m^xillary (CN I/-2) nerve. The anterior part ofthe hard palate is supplied by the nasopalatine nerve which passes through the incisive foramen. The posterior part ofthe hard palate is supplied by the grater palatine nerve which passes through the greater palatine foramen. The soft palate is supplied by the lesser palatine 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 pharyngeal plexvs (motor pottion from the vagus nerve and cranial part of lhe accessory nene),
The greater palatine block or GP block is useful for dental procedures involving palatal soft tissues distal to the maxillary canine. This maxillary block anesthetizes the posterior portion of the hard palate, anteriorly as far as the maxillary first premolar and medially to the midline. Target area: the gre ater (anterior) palatirre nerve as it passes anteriorly between the sofi tissues and bone of the hard palate.

The nasopalatine nerve block anesthetizes the anterior portion ofthe hard palate (soft and hard tis.sre,r) from the mesial ofthe right first prcmolar to the mesial of the left fiIst premolar. Target area: incisive foramen, beneath the incisive papilla.

. Efferent components only

. Afferent components only . Both efferent and afferent components

Coptright

6 20ll-2012 - Denhl Decks

. Articular fossa . Anterior band of the articular disc

. Posterior band of the articular disc

. Articular eminence

. Retodiscal tissue

7
Cop'"ight
@ 201 1-201 2

, Dnial Decks

The facial nerve leaves the cranial cavity by passing through the intemal acoustic meatus, which leads to the facial canal inside the temporal bone. Finally, the nerve exits the skr.rll by way of rhe stylomasloid foramen of the temporal bone. Note: lfyou cut the facial nerve just after its exit from the sylomastoid foramen, it would cause a loss of innewation to the muscles of facial expression.
The facial nerve carries an efferent component for the muscles of facial expression and for the preganglionic parasympathetic innervation ofthe lacrimal gland (relaying in the pterygopalatine ganglion) and submandibular and sublingual glands (relar-ing in the submandibu-

lar gangliott). The afferent component serves a tiny patch of skin behind the ear, taste sensation, and the body ofthe tongue.

Clinical information:
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-

l. Bell's palsy: involves unilateral facial paralysis with

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, the patient feels excruciating short-term pain f/ic/ when facial trigger zones are touched or when speaking or masticating, setting offassociated briefmuscle spasms in the area. The right side of the tace is affected more commonly than the left. It is more common in females. Carbamazepite (Tegretol) is still the mainstay oftreatment.

The articular disc (meniscus) is composed of dense fibrous connective tissue, and it is positioned in between the condyle and the fossa, thereby dividing the joint into superior and inferiorjoint
spaces.

The articular disc (nteniscus) vaies inthickness; the thinncr ccntral intermediate zone separates the thicker portions, which are the anterior and posterior bands. The posterior band of the articular disc is the thickest of the two bands, and it is attached with posterior loose connective tissues called retrodiscal tissues (bildminar zone; postefiot attachment). The less thick anterior band of the articular disc is contiguous with the capsular ligament, the condyle, and the superior belll ofthe lateral pterygoid muscle.

\ote:

The retrodiscal tissue is highly vascularized and innervated, whereas the articular disc for the nosl part is not. Only the extreme periphery of the afiicular disc is slightly innervated.

. Frontonasal duct . Bulla ethmoidalis . Hiatus semilunaris

. Nasolacrimal duct

8
Coplright O 20ll-2012 - Dental Decks

. Submental artery . Inferior alveolar artery . Lingual artery

. Ascending pharyngeal artery

coplright A 201l-2012 - Denral Deck

Unfortunately, this opening lies high up on the medialwall ofthe sinus, so that the sinus readily accumulates fluid. Sincc the frontal and anterior ethmoidal sinuses drain into the infundibulum, which in tum drains into the hiatus semilunaris, the chance that infection may spread from these sinuses into the

maxillary sinus is great. 2 tlpes of sinusitisr acute and chronic: common clinical manifestations include sinus congestion, discharge, pressure, face pain, and headaches.

Acute Sinusitis: the most common fonn ofsinusitis, typically causcd by a cold that results in inflammation ofthe sinus membranes, normally resolves in I to 2 weeks. Sometimes a secondary bactedal infection may seftle in the passageways after a cold; bacteria normally located in thc area (Streptococcus pneutnnide dnd Hdeuophilus influenzae) may begin to increase, producing an acute bacterial sinusitis. Clinical signs ofacute sinusitis include

Severe pain, constant and localized teeth

. Tendemess to percussion ofthe maxillary posterior . A mucopurulent exudate . Any unusual motion orjarring accentuates the pain . Tendemess over the anterior sinus wall

Chronic sinusitis: an infcction ofthc sinuses that is present for longer than 1 month and requires longer duration medical therapy. Typically either chronic bacterial sinusitis or chronic noninfectious sinusitis. Chronic bacterial sinusitis is trcatcd with anttbiotics (ampicillin or auqme tin). Chronic noninfectious sinusiris often is treated with steroids (opical o/ oral) and nasal washes. Locations of sinusitis: . \Ie\illary: the most common location for sinusitis; associated with all of the common signs and s)mproms 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 spdrome, and meningitis . Frontal: usually associated with pain over the forehead and possibly fever . Ethmoid: potential complications include meningitis and orbital cellulitis. \ote: Thc maxillary sinus is innervated by the maxillary division of the trigeminal nerve (CN l/-2).
Speciiicall-v. the ASA, PSA, and MSA nerves as well as the inliaorbital nervc.

ft loops upward and then

passes deep to the posterior border

ofthe hyoglossus muscle to

enter the submandibular region. The loop ofthe artery is crossed superficially by the hypoglossal nene. The lingual artery supplies structures ofthe floor ofthe mouth and the posterior 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 sublingual gland

. Deep lingual artery: supplies the tongue

Important: The lingual artery does not accompany the conesponding nerve throughout
its course.

Remember: The inferior alveolar nerve, artery, and vein along with the lingual nerve are found in the pterygomandibular space between the medial pterygoid muscle and the ramus ofthe mandible. The inferior alveolar nerve passes lateral to the sphenomandibular ligament. The submandibular duct is crossed twice by the lingual nerve. Ifthe lingual nerve is cut after the chorda tympanijoins, there will be loss ofboth taste and tactile sensation.

Note: The lateral pterygoid muscle forms the roofofthe pterygomandibular space.

. Pterygomandibular raphe

. Mastoid

process

. Epicranial aponeurosis
. Genial tubercles on the intemal surface ofthe mandible

10 Cop)'righrO 20ll-2012 - Dntal Decks

. Facial nerve
. Trigeminal nerve . Vagus nerve . Glossopharyngeal nerve

1l
CopFight O 201l-2012 - Dnbl Decks

On each side, the pterygomandibular raphe extends from the hamulus and passes inferiorly to attach to the posterior end ofthe mandible's mylohyoid line. It is formed by the union ofthe tendinous ends ofthe superior constrictor ofthe pharynx and the buccinator muscle. Note: As the mandible moves relative to the hamulus, the length ofthe raphe is

passively increased.
The 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. l 'W 2. The deep tendon of the temporalis muscle and the superior pharyngeal constrictor muscle form a V-shaped landmark for an inferior alveolar nerve block. 3. When draining purulent exudate from an abscess of the pterygomandibular space from an intraoral approach, the buccinator muscle is most likely to
be incised.

.--..,

The nerve fibers pass to the otic ganglion via the tympanic branch ofthe glossopharyngeal nerve and the lesser petrosal nerve. Postganglionic parasympathetic fibers reach the parotid gland via the auriculotemporal nerve, which lies in contact with the deep surlace ofthe gland. Note: Postganglionic sympathetic fibers reach the gland as a plexus of nerves around the extemal carotid artery
The parotid gland is the largest ofthe major salivary glands and is entirely serous in secretion. The parotids are located below andjust anterior to the ear. The gland's capsule is from the deep cervical fascia. About 750% or more ofthe parotid gland overlies the masseter muscle. the rest is retromandibular.

The parotid gland is drained by Stenson's duct, which forms within the deep lobe and
passes from the anterior border of the gland across the masseter muscle superficially, through the buccinator muscle into the oral cavity opposite the maxillary second molar.

The external carotid artery and its terminal branches within the gland, namely, the superficial temporal and the maxillary arteries, supply the parotid gland. The lymph vessels drain 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 Notoi: 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 dos not pro-

vide any innervation to it.

ORAL SURGERY & PAIN CONTROL

A dentist 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?

Sphenomandibular ligament

. Temporomandibular ligament

. Stylomandibular ligament

12
Copyrighr C

20ll-:012

- Dental Decks

A patient comes into your dental o{fice complaining of chewing dilficulties. When you ask him to protrude his mandiblen the mandible markedly deviats to th right. Which muscle, which inserts fibers into the capsule and articular disc of the TMJ, is most likely damaged?

. Right medial pterygoid muscle

. Lefl medial pterygoid muscle . Right lateral pterygoid muscle

Cop)righl O 20ll-2012 - Dntal Decks

Thc sphenomandibular and stylomandibular ligaments are considered to be accessory ligaments. The former is attached to the lingula of the mandible and the latter at the angle of the mandible. These ligaments are responsible for limitation ofmandibular movements (thet linit excessive opening). Note: The sphenomandibular ligament is most oftcn danaged in an inferior
alveolar nerve block.
The temporomandibular ligament fabo called the lateral liganert) runs from the articular eminence to the mandibular condyle. It provides lateral reinlbrcement for the capsule. This ligament prevents posterior and inferior displacement ofthe condyle (it is the rlain srabilizing liganrent oJ the TMJ). Notei This ligament keeps the head of the condyle in the mandibular fossa if the condyle is fractured.

Collateraf figaments (medial and lateral) also referred to as "discal ligaments," are Iigaments that arise from the periphery ofthe disc, are attached to the medial and iateral poles ofthe condyle respectively, and stabilize the disc on the top ofthe condyle. These ligaments rcstrict movement of the disc away from thc condyle during function. Note: They arc composed of collagenous connective tissuc: thus they do not strelch.

Joint capsLrle Sphcnomandibular

sphcnoid bonc

Igamcnr

Styloid proccss

oftcn)poral bone Stylonandibular

llgamcnt

Anglc ofmandibular

The mandible

will also deviate toward the side of iniurv with: .,{nkylosis ofthe condyle: the most common cause ofTMJ ankylosis is trauma . A unilateral condylar fracture will deviate away from the affected side with: . Condylar hyperplasia: malocclusion is also a common occurrence with this injury

The mandible

Remember: The lateral pterygoids (right and leJi) acting together are the prime protractors of the mandible. Important: In addition to opening and protruding, the lateral pterygoids move the mandible from side to side, For right lateral excursive movements, the left lateral pterygoid muscle is the prime mover and vice versa. A patient who sustained a subcondylar fractare (unilateral condylar fracture) on lhe left side would be unable to deviate the mandible to the right (as stated qbove the mandible v,ill deviate to the side o/ injury with a unilateral condylar fracture, this patient
u'ottlrl not be able to deviate the mqndible to the right) This is normally treated by a closed

procdure involving intermaxillary fixation. This procedure immobilizes the concomitant fractures and conects the displacement ofthe jaws associated with the condylar ftacture thereby conecting the shift ofthe midline toward the side ofthe fiactured condyle
and the slight prematue posterior occlusion on that side.

. Submental lymph

nodes

Submandibular lymph nodes

. Parotid lymph nodes

14 Coplrighr O 2011,2012 - Dental Decks

Sphenopalatine artery

. Greater palatine artery

. Posterior superior alveolar artery

. Infraorbital artery

15 Coplrighr C 2011,2012 - Denral Decks

The deep cewical lymph nodes ar located along the length ofthe intemal jugular vein on each side ofthe neck, deep to the stemocleidomastoid muscle. The deep cervical nodes extend from the base ofthe skull to the root ofthe neck, adjacent to the pharynx, esophagus, and trachea. The deep cervical nodes are further classified as to their relationship to the stemocleidomastoid muscle as beins superior or inferior.

The deep cervical lymph nodes are responsible for the drainage of most of the circular chain of nodes, and receive direct efferents from the salivary and thyroid glands, the tongue, the tonsil, the nose, th pharynx, and the larynx. All these vessels join together to form the jugular lymph trunk. This vessel drains into either the thoracic duct on the left, the right lymphatic duct on the right, or independently drains into either the intemal jugular, subclavian, or brachiocephalic
velns. Some regional groups of lymph nodes: 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 fercepl the mandibular incisorsl; the aDterior two-thirds of the tong\e (except the tip); the floor ofthe mouth and vestibule; and the gingiva. The eferent lynph vessels drain into the deep cervical nodes.

. Parotid lymph

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.

The externaf carotid artery supplies most ofthe head and neck, except for the brain (the btain gets its blood supply from the internal carotid and the veltebrql arleries). The extemal carotid passes through the parotid salivary gland and terminates as the maxillary and superficial tenpo-

ral arteries. The superficial artery supplies the scalp. The maxillary artery leaves the infratemporal fossa by passing though the pterygomaxillary fissure into the pterygopalatine fossa. Here it splits up into branches that accompany the branches ofthe maxillary nerve. It supplies the muscles ofmastication, the maxillary and mandibular teeth, the palate, and almost all ofthe nasal cavity. The matrdibular teth receive blood from the inferior alveolar artery, which is a branch of the maxillary artery. The maxillary teeth also receive blood from branches ofthe maxillary artery as

follows: . Posterior teeth: from the posterior superior alveolar artery . Anterior teeth: from the anterior and middle superior alveolar artedes. Remember: The venous return ofboth dental arches is the pterygoid plexus ofveins.
Branches 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 palatine 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.

. Lingual frenum . Nasolacrimal duct . Parotid raphe

. Sublingual caruncle

16 Coplright O 20ll-2012 - Denbl Decks

. Arthrodialjoint

. Ginglymus joint . Ginglymoarthrodial joint

17 Coptright O20ll-2012 - Dental Decls

The submandibular glatds (formerly celled the submaxillary glands) arc located in the submandibular triangle ofthe neck and the floor ofthe oral cavity. The submandibular duct (Wharton's duct) is a long duct that travels along the anterior floor of the mouth. The duct opens into the oral cavity at the sublingual caruncle, a small papilla near the midline ofthe mouth floor on each side ofthe lingual fienum. Clinically, the gland is effectively palpated infe or and posterior to the body of the mandible, moving inward from the inferior border of
the mandible near its argle as the patient lowers the head. Note: The submandibular gland is a mixed gland, secreting both serous and mucous saliva, but predominantly serous secreting.

The submandibular glands are innervated by efferer,t (paras4pathetly' secretomotor fibers from the facial nerve, which run in the chorda tympani and in the lingual newe (branch of Z-3) and synapse in the submandibular ganglion. Note: This is the same as the sublingual glands. The blood supply comes from branches of the facial and lingual arte es. The veins drain into the facial and lingual veins. The lymph vessels drain into the submandibular and deep cewical lymph nodes.

Important: During its course, Wharton's duct is closely related to the large lingual nerve *.hich eventually crosses over it. This is important because if you incise the mucous membranes of the floor of the mouth, depending on where you cut, you may expose the lingual
nerve, Wharton's duct, and the sublingual gland.
needs to be cut through. 2. L).rnphadenopathy is the most common cause ofswelling ofthe tissues in the sub-

l.

To expose the duct

intraorally, only mucous membrane

,n;4 '%#

mandibular triansle.

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

Components ofthe TMJ: . Mandibular condyle (sometines called the cowlyloid process of the mandible) - the aniculating surface or functioning part of the condyle is located on the superior and anterior sudaces ofthe head of the 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 considered 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 bet\|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.
Uppe. synovial

cavity
Postglenoid
proccss

Arlicular
Joint disc

Blood vcsscls

Lower synovial
caviry Condyle Latcral ptcrygoid musclc

it is usually displaced through the periosteum and located to the lateral pterygoid plate and _ to the lateral pterygoid muscle with displacement.
. medial, inferior . medial, superior

. lateral, inferior . lateral, superior

18 Copyrigh r 20ll-2012 - Denul Decks

The carotid sheath contains all of the followlng EXCEPT one, Which one is the I9XCEP?1ON?

. Carotid artery

. Sympathetic trunk
. Jugular vein

Vagus nerve

t9
Copyrighr O 201l-2012 DentalDecks

The infratemporal fossa is an irregular space behind the maxilla. Its roof is formed by the greater wing ofthe sphenoid. The lateral pterygoid plate ofthe sphenoid is medial. La!

erally, it is limited by the coronoid process and ramus ofthe mandible. The infratemporal fossa communicates with the pterygopalatine fossa through the pterygomaxillary fissure which is a cleft between the lateral pterygoid plate and the ma,rilla. It communicates with the orbit through the inferior ort ital fissure which is between the maxilla and the greater wing ofthe sphenoid.
The pterygopalatine fossa is a small space behind and below the orbital cavity. It lies between the pterygoid plates ofthe sphenoid and palatine bone below the apex ofthe orbit.

Clinical: Ifthere is good access and adequate light, a single cautious effort to retrieve the tooth with a hemostai can be made. Ifthe effort is unsuccessful, or ifthe tooth is not visualized, the incision should be closed, the patient should be infonned, and prophylactic antibiotics should be prescribed. A secondary surgical procedure is performed 4-6 weeks later after lateral and posteroanterior radiographs are taken to locate the tooth in all three planes. After adequate anesthesia, a long needle is used to locate the tooth. Careful dissection is performed along the needle until the tooth is visualized and subsequently remoyed. Note: Ifno functional problems exist after displacement, the patient may elect not to have the tooth removed. Proper documentation of this is critical.

***The carotid sheath does not contain the sympathetic trunk, which lies posterior to the
carotid sheath and anterior to the prevertebral fascia.
The carotid sheath is located at lhe lateral boundary ofthe retropharyngeal space at the level ofthe oropharynx on each side ofthe neck deep to the stemocleidomastoid muscle. It extends from the base ofthe skull to the first rib and sternum. It contains the carotid arteries, the jugular vein, and the vagus nerve. Within the carotid sheath, the vagus nerve (CN-! lies posterior to the conrnon carotid artery and intemaljugular vein. The facial vein unites with the retromandibular vein below the border ofthe mandible and empties into the main venous structure ofthe neck, the internal jugular vein. The internal jugular vein descends through the neck within the carotid sheath and unites be-

hind the sternoclavicular joint with fte subclavian vein to form the brachiocephalic vein. The brachiocephalic veins (ngi t and lefi) unite inthe superior mediastinlun to form the superior vena cava, which retums blood to the right atrium ofthe heart.

. Posterior superior alveolar nerve

. Glossopharyngeal nerve . Facial nerve . Mylohyoid nerve

20
Coplaight O 201 l -20
1?

- Denial Deck!

r
\.

. Intemal carotid artery

. Extemal carotid artry

. Cornmon carotid artery . Aorta

Coplrighr

201l-2012 - Dental Decks

After the inferior alveolar nerve exits the mandibular canal, a small branch occurs, called the mylohyoid nerve. This newe pierces the sphenomandibular ligarnent and runs inferiorly and anteriorly in the mylohyoid groove and then onto the inferior surface ofthe mylohyoid muscle. The mylohyoid nerve serves as an effetent nerve to the mylohyoid muscle and the anterior belly ofthe digastric muscle. This nerve may in some cases also serve as an afferent nerve for the mandibular first molar.
The mylohyoid muscle is an anterior suprahyoid muscle that is deep to the digastric muscle. In addition to either elevating the hyoid bone or depressing the mandible, the muscle also forms the floor ofthe mouth and helps elevate the tongue. Note: 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. ':;t;;i 2- when the floor ofthe mouth is lowered surgically, the mylohyoid and gnioglossus 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 -paralysis ofthe 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.

The major arterial blood supply to the TMJ is derived from the superficial temporal artery and from the maxillary artery posteriorly, and from smaller masseteric, posterior deep temporal, and lateral pterygoid arteries anteriorly. The venous drainage is through a diffuse plexus around the capsule and rich venous channels that drain the retrodiscal rissue. ){ot: The two terminal branches of the extemal carotid artery are the superficial
temporal artery and the maxillary artery.

The fibrous capsule of the TMJ is innervated from a large branch of the auriculotemporalrerYe (branch ofV-3).The rnterior region ofthejoint is innervated from the masseteric nerve (also a branch of V-3) and from the posterior deep temporal nerve (a/so a bronch oJ'V-3).The sensory innervation ofthe TMJ is via the trigeminal nerve as well. The nerve fibers prirnarily follow the vascular supply and terminate as free nerve endings. Thus. the capsule, synovial tissue, and extreme periphery ofthe disc are innervated. The anicular cartilage and the central part ofthe disc contain no nervs. Both myelinated and nonmyelinated nerves are seen in the TMJ. The retrodiscal bilaminar zone has a rich neurovascular supply and is the source ofproprioception.

Remember: Most synovial joints have hyaline cartilage on their articular surface; however, a number ofjoints, such as the stemoclavicular, acromioclavicular, and TMJs, are associated with bones that develoo from intramembranous ossification. These have fi-

brocartilage articular surfaces.

Which cranial nerve provides motor innervation to the sternocleidomastoid and trapezius rnuscles?

. Glossopharyngeal (CN lX)

. Yagus (CN

))

. Accessory (CNX1) . Hypoglossal (Cir'J71)

Copright C

201

l-2012 - Dertal Decks

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

. Left on protrusion
. Right on protrusion

. Neither ofthe above, the tongue would not

be affected

23
Cop)'right O
201

l-2012 -

De

al Decks

Nerve
(cN

Site of Exit from Skull

Inlcmal acouslic mcatus

Component
Specirl snsory B.anchial molor

Function
To thc o.gan of Coni for hcaring To the semicircular canals lbrbalance Supplics de stylophaDngeus muscle

yr|,

Glossopha.J,Dgeal

cN 14

k p e c ial |irc e ra I

eJle r e n t)

(se n etu I y i s c etu I efer etlt)

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 infomation from the skin oflhc cxtemal car, intcmal surfacc ofthc tympanic membranc. uppcr pharynx. andpostcrior onc-tlird of

k%erat \)isceftt ateren,

Gnral sn$ry kenerut somtic .ffercnt)

Special $nsory ('peciat ateren,

Providcs tnstc scnsation from postcrior

one-th;d ofthc tonguc

Inncrvatcs musclcs ot thc larynx and

Bramhirl motor---{rrnill
(sp ? c ia | \' i' c e tu I etre r

n,
Inncflates thc trapezn's and stcmoclcidomasloid musclcs Inncwatcs all of the inrrins;c and mort the exlrinsic musclcs oflhc lon8uc

Brrnchial motor----{pinal
(spec i a I viscerul

etetenl

HFoglossal

Hyposlossal canal

of

IC\ XII)

ke"erut sonntk effercnt)

kenioslase$, ltlloglotsus, antl h\ oglossus

Lesions of the hypoglossal nerve:

. Hypoglossal nerve

Iesions paralyze the tongue on one side

. On protrusion, the tongue deviates to the ipsilateral fsarre/ or contralateral side, depending on the lesion site.

Lower motor 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 deviates to the right on protrusion, and the right half of the tongue will later demonstrate atrophy and fasciculations

Upper 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

Important: If the genioglossus muscle is paralyzed, the tongue has a tendency to fall back and obstruct the oropharyngeal airway with risk of suffocation.

The sublingual gland is locatsd in the oral cavity betwen the mucosa ofthe oral cavitv and the:

. Masseter muscle
. Mylohyoid muscle . Buccinator muscle . Temporalis muscle

24
Copt"ighr O
201

1,2012 - Denral Decks

. Superior to the

deep lobe

ofthe submandibular salivary gland

. Posterior surface ofthe ma-rillary tuberosity ofthe maxilla

. Anterior to the infraorbital foramen ofthe maxilla

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

25
Copyrighr O 201 1,2012 - Dnral Dcks

The sublingual glands are located in the floor ofthe mouth beneath the tongue, close to the midline. It lies between the sublingual fossa of the mandible and the genioglossus muscle ofthe tongue. The mylohyoid muscle supports the individual sublingual glands inferiorly. Unlike the submandibular gland, which drains via one large duct, the sublingual gland drains via approximately l2-20 small ducts fRivian's ducts),the majority open into the mouth on the sumrnit ofthe sublingual fold, but a few open into the submandibular
duct. The sublingual gland is ifflervated by parasympathetic secretomotor fibers from the facial nerve, which run in the chorda t)rynpani and in the lingual nerve (branch of V-3) and synapse in the submandibular ganglion. The blood supply comes from branches ofthe facial and lingual arteries. The veins drain into the facial and lingual veins. The lymph vessels drain into the submandibular and deep cervical lymph nodes.

Important: . 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
are located around the circumvallate papilla ofthe tongue. Their main function is to rinse the food away from the papilla after it has been tasted by the taste buds. They are purely serous.

\ote: Von Ebner's glands

The rrigeminal newe emerges from the anterior surface of the pons by a large sensory and a small motor roor. Ihe motor root lying medial to the sensory root. The nerve passes forward out of the postedor cranial fossa, below the superior petrosal sinus, and carries with it a pouch derived from the meningeal la)er ofdura mater. On reaching the depression on the apex ofthe petrous part ofthe temporal bone in the middle cranial fossa, the large sensory rcot expands to form the trigeminal ganglion. The motorroot of rhe rigeminal nerve is situated below the sensory ganglion and is completely separate from it. The ophthalmic, maxillary and mandibular nerves arise from the anterior border ofthe ganglion. Somatic 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 The axons of rhe neurons gnter the pons through the sensory rcot and terminate in one of the three nuclei ofthe trigeminal sensory nuclear complex:

Typ6 of Ilbere

Trigeminal Sen3ory Nucleus

spinal (dscmdind nucleus Piincipal (main) mso.y nucleus

\ote:

Proprioceptive fibers fiom muscles and the TMJ are found only in the mandibular division. The

cell bodies of proprioceptive first order neurons arc found in the mesencephalic nucleus, not the mgeminal ganglion. The TMJ, as is the case with alljoints, receives no motor innervation. The muscles rhat move the joint receive the motor innervation. Branchiomeric motor libers innervate the temporalis, masseter, medial and lateral pterygoid,
anterior belly of the digastric, mylohyoid, tensor tympani, and tensor veli pa,latjni (palati).

. Tonsillar branch ofthe facial artery

. Lingual artery
. Vertebral artery
. Ascending pharyngeal artery

Coplright O 201 l -20

12

, Dmtal

Deck

. Ophthalmic nerve

. Va,,rillary nerve
. Facial nerve . Mandibular nerve

Coplrigh! O20ll-2012 - Dental Decl!

The lingual artery arises from the anterior surface ofthe external carotid artery, opposite the tip ofthe greater comu ofthe hyoid bone. It loops upward and then passes deep to the posterior border ofthe hyoglossus muscle to enter the submandibular region. The loop ofthe artery is crossed superficially by the hypoglossal nerve. Branches include dorsal lingual artery, suprahyoid artery and sublingual artery (t'hich supplies sublingual gland).lt terrninates as the deep lingual artery, which ascends between the genioglossus and inferior longitudinal muscles. Note: The floor ofthe mouth also receives its blood supply from the lingual artery

Remember:

. Motor innervation: from the hypoglossal nerve /CNf,/,l).

. Sensory innervation: lingual (branch o-f trigeminal CN V-3) supplies the anterior twothirds. glossopharyngeal (CN1X) supplies the posterior one-third (including vallate papillae), 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; glossopharyngeal (CN L& supplies the posterior one-third.
Note: The vrtebral arteries arise from the subclavian arteries andjoin to form the basilar artery. The basilar artery is the main blood supply to the brainstem and connects to the Circle of

Willis.

Ihe ophthalmic nerve (Vl)

enters the middle cranial fossa through the superior orbital fissure and courses within the lateral wall ofthe cavemous sinus on its way to the trigeminal ganglion. The maxillart nerve enters the middle cranial fossa through foramen rotundum and may or may not pass !hroueh thc cavemous sinus en route to thc trigeminal ganglion. The mandibular nerve frc/ entets the middle cranial fossa through foramen ovale, coursing directly into the ttigcminal ganglion. The trigcminal ganglion 1n. if. a. r enilttnar ganglion ) lies in a depression known as the trigeminal cave (or Meckel's car er. Thc trigeminal nervc cxits the trigeminal ganglion and cou$cs "backward" to entcr thc mid-lat-

4r)

eral aspect ofthe pons. The mandibular division is the largcst ofthc 3 divisions ofthe trigeminal nerve. It has motor and senso+ functions. It is created by a large sensory alld a small motor root that unitsjust after passing through rhe foramen ovale to enter the iniiatemporal fossa. It immediately gives rise to a meningeal branch and Ihen di!idcs into anterior and posterior divisions.

-\nterior 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

Posterior 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 lingual 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

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

. Olfactory (CN I) . Oculomotor

(Clr'111)

. Abducens (Clr'

. Trochlear (CN IV) , Optic (CN II)

2A

Cop]rishr O 201l-2012 - Dental Decks

. All anterior teeth on the side of the injection . Canine

and first premolar on the side

ofthe injection

. All teeth in that quadrant on the side ofthe injection

. Both premolars and first molar on the side ofthe injection

Coptright

29 20ll-2012 - Dntal Decks

Site of Exit from SkuU

olfactory

(CN'
Optic

Speclrl semory
Conveys lisual infomation from lbe rerina 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 1I) (s en e N I

s o Dn

I i c elfe r e nt)

Generc t (CN

i s.en

t elle tea t)

II'

Inner!ates the superior oblique muscle

kere rul s onatic ellerest)

lnnenales rhe l.reEl rectus muscle
(se^e ru t

ICN TI'

ronatic elkrcnt)

tC}; YII)

bpeciat

,isce t etrercn,

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

of

Parasldpathetic innch..ation of the lacrinal. submandibular, and sublingual glands. as wellas mucous mcnrbrancs ofthe ke nerat viscem t elleten t) nasopharlnx and thc hard and softpalare
General sensalion from the skin ofthc concha oflhe auricle and from a small area behind the ear

ke neft I s onatic allerc nt) Provides

Special sensor.v

raste sensation from thc antcrior tworh irds oflhe longuer hard and so{i palates

Importanti Craniaf nerves

llI

(oculomolor),

Vll (facial),lX

(glossophary geal), and X {tagrsl

all har c parasympathetic activity.

need !o qive a long buccal injction in orderto extract the molars and second bicuspid. For operative proccdures, a long buccal iniection may not be needed for tbese teefi. The long buccal irjection anesthetizcs thc soft tissuc and periosteum buccal to the mrndibular molar tecth. Thc nccdle is insened in thc mucous membrane distal and buccal to the nost distal molar in lhe arch.

\bu

'fo anesthetize the lingu!l nerve: When administering an infcrio. alveolar nene block slorvly withdraw thc slringc, and whcn approximately halfits length remains within tissues, raspirate. Ifnegativc, dcposit a portion of the remaining solution /0.,1 ,r// to anesthetize the lingual nerve. Incisors may need local infiliration
for cxtractions-

Other Techniqucs of I\landibular 4nertheria: . Mental nen'e block: This nerve block is used whcn buccal sofFtissue anesthesia is ncessary 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 mandibufar opeDing (i.e., patienls r\'ilh r/lrrrrsl precludes the use ofolher mandibular lechniques. Nerves anesthetized: 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 performed blindly becausc no bony endpoints exists, the needle is advanccd 25 mm into tissue (&r dn awragesi: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. Noti 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-

. Anterior superior alveolar and middle superior alveolar nerves . Middle superior alveolar and posterior superior alveolar newes . Posterior superior alveolar and inferior alveolar nerves . Middle superior alveolar nerves and palatine nerves

30

Copright O 20l l-2012 - Dental Decks

. Increased vascular resistance

. Bradycardia . Myocardial ischemia . Mental status changes . Adrenergic response

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

. The posterior superior alveohr fP,Sl) nerve block, otherwise known as the tuberosity block or the zygomatic block, is used to achieve anesthesia for the pulps ofth maxillary third, second, and first molars (entire tooth = 7226; mesiobuccal root of the marillary first molar not anesthetized: 28%o). Target area: PSA nerve

-postedor, for superior, and medial to the posterior border of the maxilla. Note: Potential

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.

The term shock denotes a clinical slrldrome in which there is inadequate cellular perfusion and inadequate oxygen delivery for the metabolic demands ofthe tissues.

Important: Reduced cardiac output

is the main factor in all tlpes ofshock.

In 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

The stages ofshock include: -l) Compensatory (early) stage: compensatory mechanisms (fucredsed heart rdte and peripheral resistazce) maintain perfusion to vital organs, 2) Progressire stage: metabolic acidosis occurs (compensatoty mechanisms are no longer adequate), 3t lrrercrsible (refractot)) stqge). organ damage, survival is not possible.

\Iajor 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, dehydration. vomiting, diarrhea, and fluid loss fiorn bums. . Cardiogenic shock is circulatory collapse resulting from pump failure ofthe left ventricle. most often caused by massive myocardial infarction. . Septic shock is due to severe infection. Causes include the endotoxin from gram-negative bacte a. . Neurogenic shock results from severe injury or trauma to the CNS. . Anaphylactic shock occurs with severe allergic reaction.

150 L at a pressure of2000 psi at a pressure of2000 psi

. 300 L

. 600 L at a pressure of2000 psi

. 750 L

at a pressure of2000 psi

32 Coplrighr
@ 201 1,201 ?

, Denial Decks

Stage Stage Stage Stage

I II

. .
.

III
IV

Cop'"ighr O

201 I

-2012 - Dental

lkcks

Nitrous 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 Datints and denrish

The most common oatient cmDlaint is

nuse!

It is rultable for

dl.g6

and

tha"Fudc

fd may nEdiqlty
lr has

oompmmised

It is not a compleie pain rcliever, a l@alanestheiic is sdllrequired to do mosl dntal prccdues

vlrrudy !o !dEn.
oflypoxia

side efi@ts

DifiNion hypo{r nay

;n rhe abscnc

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

lmportant: Oxygen supplementation should be avoided or used with extreme caution in patients rvith severe COPD. These patients have an increased incidence ofpulmonary bullae or blebs (combined alveoft). Because ofnitrous oxide's low blood solubiliry, it can increase the r olume and pressure ofthese lung defects, which could create an increased risk ofbarotrauma and pneumothorax.

Geudel's 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 irregular. and reflexes are stillpresent.
(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 of aspiration may occur. The patient is brought to Stage III as quickly and as smoothly as
Stage

ll

possible.

(surgical anesthesia): begins with the establishment ofa regular pattern of breathing, total loss ofconsciousness and includes the period during which signs ofrespiratory or cardiovascular failure first appear. This stage has four planes.
Stage Stage

III

IV (premortem)i signals danger. This

stage is characterized by pupils that are

maximally 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.

Scopolamine

. Atropine

. Local anesthesia . Benztropine

34
Coplrighr 92011,2012 - Denlal Decks

Epinephrlne and levonordefrin ar added to local

anesthetics becruse of theiri

. Ability to increase the potency ofthe local anesthetic

. Abilify to decrease

the pain (buming) caused by the injection

ofthe local anesthetic

Vhsoconstrictive properties

. Ability to decrease the possibility ofan allergic reaction to the local anesthetic

Copyrighr O 201 1,2012 - Dntal Decks

Local anesthesia acts by reducing sensitivity which therefore reduces anxiety and stress related to treatment; salivation is also decreased.
Scopolamine, atropine and benztropine are anticholinergic drugs. Not only do they decrease the flow ofsaliva, but also decrease the secretion fiom respirctory glands during general anesthesia.

l. The duration of action of local anesthetics is directly proportional to protein lipid solubinding and lipid solubility. Increased protein binding -increased 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 very large number oflipophilic free base molecules that are able to diffuse through tbe
nerve membrane. 3. Increased blood flow duration of action. -shorter 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 topical anesthetic benzocaine also can induce methemoglobinemia, but only when administered in very large doses. 6. The administration of norepinephrine and levonordefrin should be avoidd 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.

Vasoconstrictors (i.e. , epinephrine and levonord.eJrin) are added to local anesthetics because oftheir vasoconstrictive propenics. Vasoconstriction at the site ofinjection is beneficial because it limits the uptake ofthe anesthetic by the vasculature, thereby incrersing the duration ofthe anesthetic and diminishing systemic elTects (redueing systetuic toxicity). Notet The use of a vasopressor-containing local aneslhetic also may actually be responsible for the sensation ofbuming on injection. The addition ofa vasopressor and an antioxidant (sodium bisufite) Iowers the pH ofthe solution to between 3.3 and 4, significantly more acidic than solutions not containing a vasopressor (pH about 5.5). Patients are more likely to feel the buming sensation with these solutions. Note: Malamed's book states that "local anesthetics containing the vasoconstrictor levonordefrn Qleo-Cobefrir/ have become impossible to obtain Uune 2004)". Important: To minimize the likelihood ofintravascular injection, aspiration should be performed beforc the local anesthetic solution is injected. Ifblood is aspirated, the needle must be repositioned until no retum ofblood can be elicited by aspiration. Adverse reactions following the administration ofa local anesthetic are, in general, dose-related and may rsult from high plasma levels caused by excessive dosage, rapid absorption or unintntional intravascular injection. Systemic toxicities of local .nesthetics: Initial clinical signs and symptoms of mild to moderate toxicity include: talkativeness, apprehension, excitability, sluned speech, dizziness and disorientation. The signs and symptoms ofsevere toxicity include: seizures, respiratory depression, coma, and death. Important: The excitatory manifestations may be very briefor may not occur at all, in which case the first manifestation oftoxicity may be drowsiness merging into unconsciousness and respiEtory arrest

Remember: Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest. Note: In local anesthesia, the 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 lidocalne with 1:100,000 epinephrine, the patient loses consciousness. Which of the following is the most probable cause?

. Acute toxicity . Allergic response

. Syncope
. H)?erventilation syndrome

36
Cop).righr C 201 1,2012 - Dental Decks

Which tooth has a root thrt is not consistently innervated by the PSA nerve?

. The maxillary first molar . The maxillary second molar

. The maxillary third molar

.AIl ofthe

above

Cop)righr C

201

37 l-:012 - Dental Decks

Caused by transient cerebral hypoxia Anxiety-induced events are by far the most common adverse raction associated with local anesthetics in dentistry. These may manifest in numerous ways, the most common ofwhich is syncope, In addition, they may present with a wide variety of symptoms, including hyperventilation, nausea, vomiting and altemtions in heart rate or blood pressure. Psychogenic reactions are often misdiagnosed as allergic reactions and may also mimic them, with signs such as urticaria, edema and bronchospasm.

***

Proper 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 forehad. . Follow-up treatment
- Determine lactors crusing unconsciousness.

Remember: Hyperyentilation in an anxious dental patient leads to carpopedal spasm

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

\\'hen used to achieve pulpal anesthcsia, thc PSAnerve block is eflective for thc maxillary third, second, and first molars in 77olo to 10070 ofpatients. Howevet the mesiobuccal root ofthe ma,\illary first molar is not consistenrly innervated by the PSA nrve. In approximately 28% ofpatients the middle superior ah eolar nerve provides sensory ilnervation to the mesiobuccal root ofthe maxillary first molar. There_ fore. if anesthesia ofthis tooth for either restomtive dcntistry or extraction is requircd, an infiltration injection also should be performed over the second premolar tooth. Note: Patients experience few subjective signs ofanesthesia after receiving a poste or superior alveolar nerve block, as compared to an inferior alveolar ner'-eblock (humb lip).
The risk ofa potential complication also must be considercd whencver the PSAblock is used. Insertion ofthe needle too far distally may lead to a tempo..ary (10 to 14 days) unaesthetic hematoma. As a means ofdecreasing the risk ofhematoma formation afler a PSA nerve block, the use of a "short" dcntal needle is recommended for all but the largest ofpatients. One must remember to aspirate seveial times before and during drug deposition during the PSAnerve block to avoid inadvertent intravascular injection Important: Ifa patient's face becomes distended and swollen after a posterior superior alveolar nerve

block, the 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 number, the greater the diameter ofthe lumen. A 30-gauge needle has a smaller intemal diameter 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

.
jtive aspiration.

Important: The 25-gauge needle

Largcr-gauge needles do not brcak as o{ien is the preferred needle for all injections presenting

high risk ofpos-

z\ '

. \l

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

. They prolong the duration ofaction ofthe local anesthetic . They reduce the chance ofan allergic reaction to the local anesthetic

. They

reduce the toxicity because less local anesthetic is necessary

. They reduce the rate ofvascular absorption by causing vasoconstriction .They help to make the anesthesia more profound by increasing the concentrations ofthe
local anesthetic at the nerve membrane

38
Cop)righr O
201

1,2012 - Dental Decks

'

Lrrlngospasm is an uncontrolld/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:

. Nitrous oxide . Oxygen

. Epinephrine
. Enflurane

39

Cop)rightO 20ll-2012 - Denral Decks

***

This is false.

Vasoconstrictors are invaluable to local anesthesia in dentistry. There are clear indications for their use, ofwhich improving the depth and duration ofanesthsia are the most important. Without them, local anesthetics haye a very short duration ofaction intraorally. Vasoconstriction is more important for infiltration techniques in vascular sites than it is for mandibular blocks. The presence of a vasoconstrictor may also reduce systemic toxic effects and can provide hemostasis. The most common agent for this purpose is epinephrine, which is available in fonnulations of l:50,000 (0.02 rng/ml), l:100,000 10.01 mg/ml) and l:200,000 (0.005 mg/mL). There are three main adrenergic receptor subclasss that vasoconstrictors interact with on cardiovascular tissue in the human body. These are classified as alpha receptors fbot& alpha-l and alpha-2),beta-l receptors, and beta-2 receptors. Alpha receptors are densely located on artefioles in the skin and mucous membrunes. Stimulation of these receptors leads to vasoconstriction through activation ofG proteins and subsequent opening ofcalcium channels. Beta- I receptors are located on cardiac tissue, and stimulation olthem leads to an increase in heart rate (posilive chronotropr) and aD increase in contraction force (positive i otropy), Beta-2 rcceptors, Iike alpha receptors are located primarily in vascular beds. However, these receptors are located primarily in vascular beds traversing skeletal muscle. when stimulated, beta-2 recepto$ activate adenylate cyclase, leading to vasodilation.

Epinephrine is the more potent than levonordeliin. Its affrnity for alpha versus beta receptols is roughly equivalent (50:50). Thus, although the primary event that occurs at the site ofinjection beneath the oral mucosa is vasoconstriction, the relatively low systemic levels achieved after dental local anesthetic injections can cause increases in heart rate and cardiac output, as u,ell as peripheral vasodilation in skeletal muscle beds. Note: Levonordefiin is less potent than epinephrine, its receptor affinity is 759/o alpha and2'%obeta. As noted earlier' local anesthetics containins levonordefrin have become impossible to obtain.

A patient under general anesthesia loses the laryngeal reflex. Ifblood and saliva collect near the vocal cords, this stimulates the patient to go into spasrn (aryngospasm) and the vocal cords will close. When this happens, air cannot pass through and hence the problem. The two most important steps in the initial management of a laryngospasm are appl-"-'ing oxygen under positive pressure and administering succinylcholine.

\ote: Succinylcholine

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

tracheal intubation and endoscopy procedures.

as an adverse effect of ketamine, but it is rarely obheavy, loud respirations mistaken for laryngospasm are actusened. Frequently, deep, ally due to airway positioning. Such breathing is managed simply by repositioning the patient's head. True laryngospasm during ketamine sedation is usually caused by stimulation ofthe vocal cords by instrumentation or secretions.

Laryngospasm is frequently cited

. Touch . Warm . Deep pressure . Pain

. Cold
. Motor

40 Coprigltr O'2011-?012

- Detrtal Decks

How will a larger than norm|l functional residual capacity affct nitrous oxide sedation?

. Nitrous oxide sedation will happen much quicker . Nitrous oxide sedation will take longer . Functional residual capacity does not affect nitrous oxide sedation

41

Cop"iShr O 2011,2012

- Dental Decks

Local ancsthesia causes loss of sensation by first blocking nerve conduction in thc smaller unmyelinated fibers that carry pain, and then progressing to the larger myelinated llbers for pressure and motor function. This phenomenon is called differential blockade. Differential blockade may be 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 of local anesthesia, when short sections ofnerve are blocked, the small diameter fibers are the first to fail to conduct. . 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 relati\ 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.

\otel
bodl

Nerves regain function in reverse order.

The 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 ancsrhctics work by blocking the flow ofsodium ions, thereby preventing depolarization ofthc nerve tlber and conduction or transmission ofthe imDulse.

The functional residual capacity is the amount ofair remaining in the lungs at the end of the normal expiration. Note: This air is used to provide air to the alveoli, which will aerate the blood evenly between breaths. Note: Pulmonary volumes and capacity are about 20 to 25o% less in females than in males and are greater in large and athletic persons. Nitrous oxide sedation will vary accordingly.

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

. not lipid soluble, mpid . slightly lipid soluble, delayed

. moderately lipid soluble, delayed . very lipid soluble, rapid

42 Copright O 20ll-2012 - Detrtal Decks

. Prilocaine . Bupivacaine

. Lidocaine
. Procaine

. Mepivacaine
. Articaine

43 Coptriglr
@

201|,2012 - Dnral Decks

Barbiturates exhibit a dose-dependent CNS depression with hypnosis and amnesia. They are very lipid soluble, which results in a rapid onset of action. They are used most often for induction ofanesthesia because they produce unconsciousness in less than 30 seconds.

Barbiturates: . Ultra-short acting: Methohexital (Brevital), thioper/''al (Pentothal),

and thiamylal

(Srir!

tal) . Short and intermediate acting: Amobarbrtal (Amytal), pentobarbital (Nembutql), secobarbital (Seconal), and Butabarbital fI'ioticet, Fiorinal) . Long acting: Phenobarbital (LtminaQ Most commonly used barbiturates for induction of ansthsia: . 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.

\ot.!

l. The most effctive agnt in the initial treatment of respiratory dpression due to the over dose ofbarbiturates is oxygen under positiv pressure. 2. A primary advantage of IV sedation is the ability to titrat individualized
dosage.

Procaine (Novocaine) was, at one time, the most commonly used ester local anesthetic in dentistry Il is thc protolvpe for the ester group oflocal anesthetics but is no longer available in dental cartridgc fo.m.

An easy way to identify amide local anesthetics is to rcmember that the drug name contains an i plus crine (lidocaihe, mepi|acaine, and bupivacaine). Estors such as procaine, benzocaine, and tetracaine
conlaln no
1.

Amide-t] pe local anestheticsi . Lidocairc (X),locainel: most commonly used . Pilocaine (Citanest)

. . . .

\t,rcaine (Septocaine/:

has both amide and ester linkages acatne (Carbocaine) Bnpi ac arne I I[a rc a i ne) Eridocaine /Darznestlr removed from the U.S. market in 2002

Ester-tlpe local anestheticsi . Proc i're (Novocaine) . P I opoxy caine (Raroc a i ne ) . Bcnzocaine (Monocaine)
. Tetrac ine (Pontocaine)

\Icpit

TLrpical esters are still commonly used in the practice ofdentistry Most topical local ancsthctic ointments and gels contain benzocaine (an ester e.g., Httticaine, Celacaine). Benzocaine gels typically contain I 89 6 - 20% benzocaine. Lidocaine /a n amide) ls also avallable in two foms for topical applicari(rn. EI1LA /ekrecric mixlure o.[ local anesthetic c],ea ), containsboth lidocaine and prilocaine.
a drug in this group preprovide without adverse effect local anesthetics may analgesia the ester-compound chrdes its use, one of For patients allcrgic to both esters and amides, diphenhydramine (Benadryl) is good choice

-\mides are safe, versatilc, and effective local anesthetics. Ifhypersensitivity to

Esters are potent local anesthetics slightly different in chemical structure from the amide group. Tetracaine is most commonly used. Allergic rcactions are far more common with esters'

lmportant: The local anesthetics lidocaine and prilocaine are recommended for the pregnant (Class B) patient. For the pregnant fcldsr C, patient, articaine, bupivacaine, mepivacaine, and epinephrine can bc
used.

Remember: The drug of choice in management ofan acute allcrgic reaction involving bronchospasm (an acule nat rowing oflhe rcspiralory ainray) and hypotension is epinephrine. Notei Alleryic reactions to local anesthetic are usually caused by an antigen-antibody reaction

. Slowly injecting the anesthetic solution

. Watching the patient's color change during the injection

. Using

a topical anesthetic prior to administration as

ofthe local anesthetic

. Injecting the anesthetic solution

quickly

as possible

. Using a low concentration of vasoconstrictor . Premedicating extremely anxious patients

Sympathetic, but confident handling ofthe patient

Copfighr O 201l-2012, Dntal Decks

. 0.10 mglml ofanesthetic

. I mg/ml
.
10

of anesthetic

mg/ml of anesthetic mg/ml ofanesthetic

100

45

Cop! ghtO 20ll-2012 - Dmral

Decks

The most common cause ofa transient loss ofconsciousness in the dental office is vasovagal syncope. This generally is due to a series ofcardiovascular events triggered by the emotional shess btought on by the anticipation of or delivery ofdental care. Prevention ofvasovagal syncopal reactions involves proper palent preparalon.

Remember: Any signs ofan impending syncopal episode should be quickly treated by placing the patient in a supine position with the feet elevated (Trendelenbutg posiliol,/, monitoring vital signs, loosening tight clothing and pJacing a cold compress on the forehead. Oxygen 3-4 L/minute should also be given via nasal cannula. Important: The most common early sign ofsyncope is pallor.
Vasovagal Syncope: . Most common related to injections in younger individuals . Parasympathctic response often followed by sympathetic response secondary to anxiety . Warm feeling, pale, diaphoresis, "feeling faint or sick," nausea, bradycardia, and hypotension

Most Common Medical Emergenciesi

.Hyperventilation'Acutemyocardialinfatction
. Hypoglycemia . Seizure
reactions

S).'ncope

. Asthma attack

Postural

. ,{ngina pcctons

hypotension 'Allergic

Postural Hypotension: 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 "Hl 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), endocnne
( d i a b et i c ke to ac ido s

is)

To 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 milliliters For vascoconstriction, for every I :100,000 there is 0.01 mg/ml-. Thereforc' Total milligrams = ratio x total milliters

. Neuroleptic agent + narcotic analgesic . Neuroleptic agent

nitrous oxide

. Neuroleptic agent + narcotic analgesic + nitrous oxide . Narcotic analgesic + nitrous oxide

Cop)righr

201

46 l-2012, Dental Decks

Anestl

rl

. Anaphylaxis

. Syncope . Heart attack

Seizure

17 Coplright O 201l-2012 - Dental Deck

Neurolept anesthesia is a state of neurolept analgesia and unconsciousness, produced by the combined administration ofa narcotic analgesic and a neuroleptic agent, together with the inhalation ofnitrous oxide and oxygen.
Neurolept analgesia only produces an unconscious state ifnitrous oxide is also adrninistered f.ree
below).

Neuroleptic agent + narcotic analgesic

(Droperidol) (l'entanyl)

neurolept analgesia
(conscious)

Under the influence ofthis cornbination, the patient is sedated and demonstrates psychic indifference to the environment yet remains conscious and can respond to questions and commands. Neurolcpt + nitrous oxide = neurolept anesthesia analgesia in oxygcn (wtconscious)

Induction of anesthesia is slow, but consciousness retums quickly after the inhalation ofnitrous oxide is stopped. 1. Neurolept analgesia is useful for minor surgical procedures, somc radiological pro-

Note3i. cedues, bum

,.r.._,,.i

dressing, and endoscopy. 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 depression. 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).

common adverse reaction associated with administration of local anesthesia. Remember: It often occurs when upright, though can occur when sitting. It u'ill never occur when lying. The patient may complain offeeling generalized warmth
S.u-ncope is thc most

rvith nausea and palpitations,

Thc initial event in a vasovagal syncope episode is the stress-induced release of increased amounts of catecholamines that causes the following: a decrease in peripheral
\'ascular resistance, tachycardia, and sweating. .{s blood pools in the periphcry a drop in blood prcssure appears, with a corresponding decrease in cerebral blood flow. The patient will then complain offeeling dizry or weak. Compensatory mechanisms attempt to maintain adequate blood pressure, but they soon fatigue, which lcads to vagally mediated bradycardia. Once the blood pressure drops bclou lcrels necessary to sustain consciousness. syncopc occurs.
Place the patient in a supine position with the feet elevated (Trendelenburg posilion), monitor vital signs, tight clothing should be loosencd and a cold compress placed on the forehead. Oxygen 3-4 L/minute should be given via nasal cannula.

Important: The single most important drug to use in any medical emergency, including chronic obstructive pulmonary disease, is oxygen.

Note: The primary ailway hazard for an unconscious dental patient in is tonsue obstruction. Remember: Head titt/chin lift.

a supine position

Tfeuma to muscles or blood vessels in the ls the most common etiologicNl ftctor in trismus associated with dental injections of local anesthetics,

. Pterygoid fossa . Temporal fossa

. Submandibular fossa . Infratemporal fossa

48
Copltighr O 2011,2012 - Denral Decks

. The first stalement is true, the second is false

. The first statement is false, the second statement

. Both statements are true . Both statements are false

is true

49
Cop)right O 201 I 201? - Denral Decks

Limited jaw opening, or trismus, is a relatively common complication following local anesthetic administration. In addition to tmuma to muscles or blood vessels in the infratemporal fossa, it may be caused by hematoma formation, localized muscle necrosis secondary to the anesthetic drug or vasoconstrictor, infection in the fascial space, or introduction ofa foreign body. Note; In most instances of trismus the patient rcports pain and some difficulty opening his or her mouth on the day after treatment in which a posterior superior alveolar or inferior alveolar nerve block was administered. The main symptom of trismus is the limitation of movement of thc mandible, which is often associated with pain. Symptoms will arise from one to six days following an injcction. The duration of symptoms and their severity are both variable. Note: The medial pterygoid muscle is most often af'fected.

Management of trismus: . Apply hot, moist towels to the site for approximately 20 minutcs every hour

. Warm saline rinses . Use analgesics as required

. Benzodiazepincs

. The patient should gradually open and close mouth

1e.g., Diazepam) for muscle relaxation ifdeemed necessary as a means ofphysiotherapy

Follol ing an inferior alveolar nerve block injection or a mental block injection, a prickly or tingling sensation (paresthesiq), ever' complete numbness in the lower lip, may result and persist tbr a considerable time. This is usually considered to be due to direct trauma or piercing of dre ncrve trunk by the needle. This happens more often in thc case of the mental block injection. The symptoms of paresthesia gradually diminish (uoy last from two i,eel6 to six months). a\d recov ery is usually complete.
Remember: The most common cause of paresthesia of the lower lip is thc rcmoval of mandibular third molar (especially horizo lally impqcred ones).
a

\ausea and vomiting are the most conmon adverse effects ofnitrous oxide sedation, occurring in l% to l0% of patients. Fasting is not required for patients undergoing nitrous oride sedation. The practitioner, however, may recontmend that only a light meal be consumed in the 2 hours prior to the administration of nitrous oxide. Diffusion hypoxia can occur as a result ofrapid release ofnitrous oxide from the blood stream into the alveoli, thereby diluting the concentration ofoxygen. This may lead to headache and disorientation and can be avoided by administering 1007o oxygen after nitrous oxide has been
discontinued.

Remember: The most common complication associated with nitrous oxide sedation is a behavioral problen (laughing, giddy).

Note: Some literature states that nitrous oxide is acceptable for the pregnant patient, however, from a risk management point it may be prudent not to use nitrous oxide on
any pregnant patlent.

Administration ofvolatile ansthetics (desflurane, enflurane, halothQne, isoJlurane, and sevo.flurane) is not a concern for COPD patients. All volatile anesthetics are bronchodilators and, therefore, are beneficial to patients with COPD (asthmatic bronchitis, emphysema, sand chronic bronchitis).

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

15,000 - 45,000/mml
100,000/mm3

. 75,000 -

150,000 - 450,000/mm3

. 450,000 - 600,000/mmr

Cop}right O

20ll 2012,

Denral Decks

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

. 0.018 mg

. lR mo

. 0.036 mg

51

Cop)'right C

201

l':012

- Dental Dcks

Thrombocytopenia is defined as a count of<150,000/mmr. Intraoperative bleeding can be severe with counts of 40,000-70,000/mm3, and spontaneous bleeding usually occurs at counts <20,000/mmr. The minimal 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
12yo-52ya

12'14 z/dL

Per.etiagc of RBC l!|ass in

36%48% 150,000450,00/mr

150,000-450,00/Dml RBC indices:

(]rcv)

Me

corpuscullr volume

AvmgE RBC volmes in lL

Estinales weight ofHSb in 8vera8e RBC

80 100

it

80-100

fL

28'33 pg

28-31p8
32-36 e/dL

hmoglobitr (MCH)

Estindls !Ymg. corcmealion of Hgb ir almg RBC

3l-16

r/dl

()rcHc)
Noaesl
2.

L The minimal acceptable value for the hematocrit is 30D% for elective surgery. Nomal values for coagulation: . Tcmplate bleeding time : I to 9 minutes . Prothrombin time (PT) = 1l to 16 sconds (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 K use, 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.

Important:

.I

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 local ancsthetic and vasopressor - 6 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

1.8 cc of 2%o fidocaine (which is a calpule) - 36 mg oflidocaine: 1 8 x 20 0l 018 rng of epinephrine: l 8

mg

with epinephrine 1:100,000 contains the following:

Note; Methylparabcn is no longer included
ln ,ingt.-rr. o*ot cartridges oi local anesthetic: however. it rs lbund inALL multidose

10'8 )ng of Nacl: - .90 mg ofsodium {meta) bisulfate: 1 8 x 0 - LI mg of methylparaben I .fi x I mg

18x6mg

mg

"i.i, "fIni".,.Uf.

a-*,

- sterile watcr

Percent

Solution =

Milligrams

(ng)

volume

ofcrrtridge =

Mitligrams per Crrtridg

0.5=5X1.8=9 1.0=10x1.8=18 2.0 = : 3.0 4.0=40x1.8=72

20 30

X X

1.8 18

: =

36

54

Note: Some ofthe gencric anesthtic 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 anesthetics are 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?

. Lidocaine
. Tetracaine

. Etidocaine
. Procaine . Bupivacaine

Copytighr O

201

l-2012 - Denral Decks

A significant difference between the two major groups of local anesthetics, the esters and the
amides, is the means by which the body biologically transfoms the active drug into one that is phar-

macologically inactive. Metabolism (or biotransformationl of local anesthetics is important bccause the overall toxicity of a drug depends on a balance between its rate of absorption into the bloodstrcam at the sitc ofinjection and its mte ofremoval from the blood through the processes of
tissue uptake and metabolism. The primary site of biotansformation of amide drugs is the liver. Ester local anesthetics are hydrolyzed in the pfasma to pala aminobenzoic acid (PABA) by the enzyne pseudocholinesterase. Patients with pseudocholinesterase inactivity are unable to detoxily ester tlpe agents at a normal rate. Amide type anesthetics are recommended in these patients.

Allergic reactions to amide type local anesthetics are rare but may occur as a result ofhypersensitivity to thc local ancsthetic agent itselfor due to an allergy to methylparaben or other preservatives used in many solutions. These reactions are characterized by cutancous lesions of delaycd onset or urticaria, edema, and other manifestations ofallergy. Important: For thosc patients allergic to both cstcr and amide type local anesthetics, Diphenhydramine is a safe and effective alternalive.

Estrs
Este'|s of

Quirolin
bennic acid:
Bupivacaine Dibucaine Etidocaine Lidocaine Mepivacaine Prilocaine
Ropivacaine

centbucridine

Bulacaine Cocaine Elhyl aminobenzoate (bnzocaire)

Hexylcain
Piperocaine Tetmcaine Es lers of paraminobettzoic acid :

Chloroprocaine
Procaine

Propoxycaine

Local ancsthetics readily cross the blood-brain barrier Their phannacological action on the CNS is depression, At low (therapetic, nontoxic) bloodlevels, there are no CNS eflects ofany clinical significance. At higher (toxic, overdose) levels,thc primary clinical manifestation is a generalized tonic-clonic convulsion.

With a furthcr incrcase in the blood level ofthe local anesthetic above its "therapeutic" level, adverse reactions may be observed. Because the CNS is nuch morc susceptible to the aclions oflocal anesthetics than other systems, it is not surprising that thc initial clinical signs and symptoms of overdose (toicity) are CNS in origin. Initial clinical signs and symptoms (slurred speech, tlizziness, talkctiveness, apprehension, incrcased anxiety) ofCNS toxicity are usually excitatory in nature.
Lidocaine and procaine differ somcwhat from other local anesthetics in that lhe usual progression

of signs and syn'tptoms may not be seen. Lidocaine and procaine frequently produce an initial mifd sedation or drovsi\ess (here common with lidocaine).
Sedation may develop in place of the excitatory signs. Ifeither excitation or sedation is observed in the initial 5 to l0 minutes alicr thc intraoral administration ofa local anesthetic, it should serve as a wamirg to the clinician ofa rising local anesthetic blood level and the possibility (if the blood level co ues to risel ofa more serious reaction, possibly a gcncralized conl'ulsive episode.

li

Local anesthetics havc a direct action on the myocardium and peripheral vasculature ln general, ho$ever, thc cardiovascular system appears to be nore resistant to the effects oflocal anesthetic drugs than 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 ropitacaine) produce a peripheral vasodilation, through relaxation of the smooth muscle in the walls ofblood vessels.

.9.0;3to4

.7.4;5to6
.3.6;8to9
.8.0; 2 to 3

5,{

coplrishr O 201l-2012

- Dental DecIG

. Peripheral Nervous System (PNS)

. Central Nervous System fCNt

. Autonomic Nervous System (lNS)

Cop)righr

201l-2012 - Dnral Decks

It is well known that the pH of a local anesthetic solution fdrd lre pH ofthe tissue into which it is injected) greatly influences its nerve-blocking action. Acidification oftissue decreases local anesthetic effectiveness. Inadequate anesthesia results when local anesthetics are injected into inflamed or infected
areas. Local anesthctics containing epinephrine or othcr vasopressors are acidifted by the manufacturer to inhibit the oxidation ofthe vasoprcssor. The pH ofsolutions without epinephrine is about 5.5; epinephrine-containing solutions have a pH of about 3.3. Note: Increasing pH (alkalinization) of a local anesthetic solution speeds the onset of its action, increases its clinical effectiveness, and makes its injection more comfortable. The two factors involved in the action ofa local anesthetic are diffusion ofthe drug through the nerve sheath and binding at the receptor site in the ion channel. Local anesthetics exist in ionized (cation) a d non-ionized fbare) forms, the proportions ofwhich vary with the pH ofthe environment. The non-ionized (bd.re) portion js the form that is capable ofdiffusing across nerve membranes and blocking sodium cha[nels.

base

onsetofaciion, more RN (fte molecules presnr to dilluse through nede sheath; thus onset time is de$eased

LosspK, =morc.apid
fom)

Indeased lipid solubility = Increased potncy {example procaine = lr eiidGaine = 140) Etidocaine prcduces conduction blockadear eery low concentrations, 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 liofr injection siie; lhus dereased anesthelic poidcy and

n-itrous oxide is the only inorganic gas used by the anesthesiologist. Room air contains 2l%o oxygen; you must mak sure that th patint recives at least this much oxygen. The maximun nitrous oxide limitation is 60% nitrous oxide and 40olo oxvsen.

\itrous oxide is carried in the bloodstream in physical solution. There is no metabolism or degradation ofnitrous oxide in the body. It is excreted solely via the lungs, unchanged. High blood levels olnitrous oxide can be achieved quite quickly. It is non-toxic to body tissues. Tle only toxicity with the use ofnitrous oxide is the lack ofoxygen that could result from the operator's error. The gag reflex is only slightly obtunded with nitrous oxide analgesia. lt is belie\ ed rhat nitrous oxide has its main effects on the reticular actiyating system and the limbic sl'stem.
agents. tt is the only in-

\irrous oxide is a weak anesthetic. It is used to supplement inhalation

halation anesthetic with sympathomimetic activity. It should not be used in doss higher than 60cb combined with 40% oxygen. It is known to diffuse into air containing spaces and to increase the pressure in such cavities. 100% oxygen should be administered during awakening in order to avoid diffusion hypoxia.

Remember:

. 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.

. Calcium ions

. Chloride

ions

. Potassium ions

Sodium ions

56
Coplr'ghr O 201t,2012 - Dntal Dcks

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

. Induction . Maintenance . Recovery

Coplrighr O 20ll-2012 - Denral Decks

Local anesthetics selectively inhibit the peak permeability of sodium, whose value is normally about five to six times greater than the minimum necessary for impulse conduction. The following 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 blockade The mechanism whereby sodium ions gain entry to the axoplasm ofthe nerve, thereby initiating an action potential, is altered by iocal anesthetics. The nerve membrane rcmains in a polarized state because ionic rnovemcnts rosponsible for the action potential fail to develop. Nerve block produced by local 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 anesthsia together are referred to as induction.

The depth ofgeneral anesthesia fby irhalation) vnies with the partial pressure (tension) of the anesthetic agent in the brain, and lhe rates ofinduction arrd recovery depend upon the rate ofchange oftension in this tissue (also blood supply to the lungs, pulmonary ventilation, and the concentration ofthe qnesthetic influence the rate of induction). ^Ihe signs and stages of anesthesia are most likely to be seen with anesthetic that has a slow rate of in-

duction.
a patient in surgical anestlesta. 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 resistant part ofthe CNS is the medulla oblongata (cardiac, vasomotor, and respiratory centers of the brain). 4. The most controllable route for administration of a general anesthetic is inhalation. 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 ni trous 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.

L Maintenance is the process ofkeeping

.

. Enflurane
. Halothane

. Sevoflurane . Desflurane
. Isoflurane

58

Coprighr C

201

l'2012 - Dental Dcks

. Vedian basilic vein

. \{edian cephalic vein

. Vedian antebrachial vein . .drillary vein

CopFighr O

201

59 l-2012 - DeDtal Decks

lnhalation anesthetics are substances that are brought into the body via the lungs and are distributed with the blood into the different tissues. The main target ofinhalation anesthetics (or so-cqlled yolatile anesthetics.) is the brain. Currently used inhalation anesthetics include five volatile liquids enflurane, halothane, isoflurane, sevoflurane, desflurane, and or'e gas (nitrous -fhe oxide). volattle liquids require a vaporizer for inhalational administration. The desflurane vaporizer has a heating component to allow delivery at room temperature.
Some inhalation agents have an unpleasant odor and may irritate the respiratory tract. This irritation may cause coughing and muscle spasms in the voice box, or larynx (lary-ngospasm), or in the bronchial tubes in the lungs (bronchospasm). Sevoflurane is less irritating to the air-

way than the othen and is preferred for inducing anesthesia in children.

Important: All the potent inhalation agents are capable oftriggering malignant hyperthermia LllH), a rare rnherrted disorder that is potentiallv fatal. -{dministration ofan inhalation anesthetic
is usually preceded by intravenous or intramuscular administration ofa short acting sedative hypnotic drug, often abarbiturate (Thiopental). The procedure almost always requires endotracheal intubation.

\ot

l. Administration of volatile anesthetics is not a concem for COPD patients. All volatile anesthetics are bronchodilators and therefore are beneficial to patients with
COPD.
2. Volatile anesthetics depress the cardiovascular system, and this depression results

in a reduced mean arterial pressue. 3. Desflurane, isoflulane, and sevoflurane are potent vasodilators.

This Vein lies in the lateral aspect ofthe antecubital fossa (anterior to the elbow). Avord entering the brachial artery. If the artery is entered, the following symptoms will appear: irnmediate buming at the site ofthe injection, the arm will appear blotchy, and the pulse in the arm v ill be weak compared to the other arm.

IV Sedation: . Usually done with a 21 gauge needle . Popular drug is Valium (Diazepam)
. The rate of injection of Valium is a
nrr
I

mrnure
1

cPhali' vein

of- Valium
. Injection

ml of injectable Valium contains 5 mg

is discontinued when the eyelids
Batili. vein

droop (ptosis)

Three common signs indicating when the correct level of sedation has been reached when usins Vaf ium:
1.

Blurring ofvision

cephali( vcin
Sarilic vein

2. Slurring ofspeech 3. 507o ptosis ofthe eyelids (this is called Ver-

rill's sign)
Remember: Valium is contraindicated for use in a patient with a history of narrow angle glaucoma.

Dlssociative anesthesia is a unique rnethod ofpain control that reducs anxity and produces r trancelike st|te in which the person is not asleep, bul rather feels sparated from his or her t ody. The primary medication used is:

. Demerol
. Ketamine . Pentobarbital . Promethazine hydrochloride

60

Copright O

201

l-201:

- Denlal Decks

ORAL SURGERY & PAIN CONTROL

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 of the following EXCTPT one. Which one is the EXCEPTIOI'ft

. tugidity

. Fever
. Hlpermetabolism

' Myoglobinuria
. Alkalosis

6t
Coprighl O
201

l-2012' Denhl

Decks

Dissociative anesthesia is useful in emergency situations, such as an injury. It can also be used for short procedures that are painful, such as changing bandages. This method is safe and lasts only a short time. Because a person does not usually recall the procedure, this method is useful in children. The primary medication used is called ketamine. A sedative is often given before ketamine to reduce anxiety.

Note: A person who has had dissociative anesthesia usually does not remember the procedure, especially if a sedative has been given along with the pain medication. Most people feel back to normal within a few hours. As the medication wears off, an individt;.aI (particularly adult patients) may have intense dreams and even hallucinations.
Ketamine, a phencyclidrLne (PCP) deivative, is l0 times more lipid soluble than thiopental, enabling it to cross the blood-brain barrier quickly. It produces dissociative anesthesia. which can be seen on EEG as dissociation between the thalamus and limbic system. Rapid CNS depression with hypnosis, sedation, amlesia, and intense analgesia occurs in 30-60 seconds after administration. The anesthetic induction doses are l-2 mg,&g IV, with effects lasting 5-10 minutes or 10 mg/kg intramuscular, which acts in 2-4 minutes.

Ketamine:

Increases airway secretions, creating the need for anticholinergics such as glycopyrrolare 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

MH is a hypermetabolic state involving skeletal muscle that is precipitated by certain anesthetic agents in genetically susceptible individuals. The incidence ofMH is <0.5% of all patients who are exposed to anesthetic agents. Inhalation anesthetic drugs that are krown to trigger MH include halothane, enflurane, isoflurane, desflurane, and sevoflurane. Depolarizing neurornuscular blockade agents that can trigger MH include succinylcholine, decamethonium, and suKamethonium. Classic MH most often manifests in the operating room, but it can also occur within the first few hours ofrecovery from anesthesia. When exposed to inlalational anesthetics, muscle metabolism increases, and a series ofsigns and symptoms appear, which if left untreated can lead to death. The earliest findings are an increased production olcarbon dioxide and signs of increased s),mpathetic nervous system activity.

Acute clinical manifestations of MH include tachycardia, tach)?nea, unstable blood pres-

tality ranges from

sure, cyanosis, respiratory and metabolic acidosis, fever, muscle rigidity, and death. Mor6 3%o to 73o/o.Il vsually occurs in apparently healthy children and young adults at an average age of 2l years.

When MH is diagnosed early and treated promptly, the mortality rate should be near zero. Whenever anesthesia is administered, dantrolene should be readily available as well as a protocol for managemeni of MH (100% oxygen, cooling procedures, and the correction of acidosis and hyperkalemia). Dantrolene is, at the moment, the only known drug that lreats MH. It impairs calcium-dependent muscle contraction and controls hypermetabolism 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

reaction.

. Somatogenic
. Psychogenic

. Either ofthe above

. None ofthe above

62
Coplaighr O 201 l'2012 - Dnral Decks

. Transfusion reactions
. A fat embolism

. The anesthetic or analgesics on the myocardium . Liver failure

63
Coptrighr Cl
201

I 2012,

Dental Decks

*** A psychogenic reaction

(drugs).

is caused by psychological factors rather than physical factors

Vasovagal s,'rlcope, a psychogenic raction, is the most cornmonly experienced complication associated with the use oflocal anesthetic solutions. The clinical signs closely resemble those ofshock. These psychogenic reactions readily respond to placing the patient in a supine posi-

tion.
The following drugs, when administered one hour pdor to the dental appointment, are safe and effctive ways to allay the fears ofan apprehensive adult dental patient and possibly avoid a psychogenic 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.

These drugs are not recommnded unless you have experience with them and can handle any complications that may happen from thir use.

\ote: For a dentist to use "entral sedation" (the use of a pharnracological method that produces a minimally-depressed level o.f consciousness) some states require special training
and registration with the stat.

\ote: A somatogenic reaction is the

iologic cause.

development of a reaction from an organic pathophys-

***

Leading to myocardial depression.

Common causes of postoperative hypotension: . Intravascular hypovolemia

. Rewarming vasodilation

'Hypothyroidism . Myocardial depression

***

Possible treatment options include:

. Elevation ofthe lower extremities

. Administration ofcarefully monitored fluid boluses . Administration of vasopressors (e.g., ephedrine)
The treatment is n rc n (a narcotic antagonist/ if hypotension is due to narcotics. Use aftopine (qn anticholinergic) ifbradycardia is present.

Note: Postoperative [ypgltension is most often due to post-op pain. Treat with
narcotics and sedatives. Othr common causes include:

. Hypercapnia . Anxlety . Overdistention of the bladder . HvDoxia

. Analgesia

. Excitement . Surgical
anesthesia

. Medullary paralysis

64
Copltighr O
201

l-2012 - Dental Decks

. .
.

50olo

oxygen; 50oZ nitrous oxide nitrous oxide

60%o oxy gen;40olo 40o%

oxygen; 60% nitrous oxide

70olo

. 30% oxygen;

nitrous oxide
response

. Varies according to the patient

Copyrighr O 201 1,2012 - Dental Decks

. Stage One (Anqlgesia) i The patient experiences analgesia or

a loss ofpain sensation but remains conscious and can carry on a conversation. Note: The best monitor ofthe level ofanalgesia is the

verbal response. . Stage Two (Exciteuent): The patiefimay experience delirium or become violent. Blood pressure rises and becomes iregular, and brcathing rate increases. This stage is t)?ically bypassed by
administering a barbiturate, such as Methohexital or Thiopental, before the anesthesia. . Stage Three (^laryical Anesthesio): During this stage, the skeletal muscles relax, and the patient's breathing becomes regular. Eye moyements slow, then stop, and sugery can begin. . Sttge Four (Medullary Paralysis): This stage occurs ifthe respirctory centers in the medulla oblongata ofthe brain that control breathing and other vital functions cease to function. Death can result ifthe patient cannot be rvived quickly. This stage should never be reached. Careful control 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 general 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 intubation with pharyngeal packs. 5. A patient with an acute respiratory infction is contraindicated for general anesthesia. 6. The eyes are taped shut priorto draping a patientbefqre surgery to preyent corneal

abrasion.

The dose ofthe gas combination for conscious sedation is variable and is based on the patient response. The maximum nitrous oxide limitation is 60010 nitrous oxide and 40olo oxygen. Nitrous oxide is a weak anesthetic and is used with other agents, such as thiopental, to produce surgical anesthesia. It has the fastest induction and recovery and is the safest because it does not slou breathing or blood flow to the brain. Nitrous oxide has a low blood-to-gas partition coe{Ticient (0.46) and therefore low solubility. It can leave the blood and enter air-filled cavities 34 times more quickly than nitrogen can leave the cavity to enter the blood. The use ofnitrous oxide can increase the expansion ofcompliant cavities, such as a pnumothorax, bowel gas in a bowel obstruction, and an air embolism. Importantr The oral and maxillofacial surgeon needs to be cautious when keating the recent hauma patiett (e.g., motorvehicle accident victim). An asymptomatic, undiagnosed closed pneumothorax can double in size in l0 minutes after the administration of 70%o nitrous. Nitrous oxide sedation should be postponed in patients with gashointestinal obstructions, middle ear disturbances, and, possibly, sinus infections.

Pr.ddol Coffcienb fo. hhrled Anesl]etics

ll3lothcrc
Elood: g|g
0.42 2.4

Isoflrrane

Nzo
0.46 0.68

Brrtn: blood

l.l
2.0 27

29

1.6

r.l
1.2

t.7
3.1

Mllak: blood

2.9

Frt

blood

48 90.8 1.4 47.2

t8.7

MAC Nikols oride Halo&aft

104

Agenl
Dsfluane Svofiwane
6.0
1.7 |

MAC

Ll5
0.77

. Cellulitis
. A unilateral facial paralysis

. Phlebitis

Syncope

Coplright O

20ll-201?

Denial Decks

Wtten a biopsy is being performed it ls important to:

.Incise perpendicular to the long axis ofany muscle fibers beneath the lesion
.Incise parallel to the long axis ofany muscle fibers beneath the lesion

.Incise

as deep as possible into muscle fibers beneath the lesion

.Incise at a 45 degree angle to the long axis ofany muscle fibers beneath the lesion

CoDrightO 20ll-2012 - Denral Decls

Phlebitis is irritation or inflammation ofa vein. it is sometimes seen after IV administration ofvalium. This is usually attributed to the presence ofpropylene glycol in the mixture. Phlebitis is more likely to occur if a vein in the hand or wrist is used and may be more common following repeated injections, especially in heary smokers, the elderly. and women taking oral contraccptivcs. Common signs and symptoms ofphlebitis: . Pain . Erythema

. Tendcmess . Streaking ofthe limb

Edema

Treatment: Remove the IV catheter, elevate the affected linb, apply warm, n.roist packs to thc infected site, initiate IV ant:biot:Lcs (pre./brably celazolin [Ancefl, I gm IV bolus push etety I hours),
for appropriate staphylococcus coveragc.

Thrombosis is the formation of a blood clot that may partially or completely block a blood vessel. A clot located in an inflamed, blood vessel is called thrombophlebitis. Virchow's triad is the name given to the thrce chicfcauscs ofdeep venous thrombosis fDlI): ( l) damage to the endothelial lining ofthe vessel, (2) venous stasis, and (3) a change in blood constituents attributable to postopcrativc increase in the number and adhesiveness of the patient's
platelets. The classical clinical featurcs ofDVT are: . Calfswelling . Sudden dyspnca . Feler . Tachypnea . Chcst pain A patient who has developed DVT should be staied immediately on systemic anticoagulation with

clevation of the affected Iimb.

lmportant; The most frequent respiratory complications following oral and maxillofacial surgery are: pulmonary atelectasis (mosl often in smokers), aspiration pneumonia fr?o.t, /ikely to mani.lest itlitially tu lhe patient's rigllt lwtg), and pulmonary embolus fmosl originate in lhe deep venous s,,'stems oftlrc lower extremities, especially in nonantbulatory'patients).

Whenever possible, the incisions should be oriented parallel to lines ofmuscle tension in order to minimize scarring and wound dehiscence. Note: Biopsy incisions on the face should be oriented to follow Langer's lines.

***

Four major types ofbiopsy in and around the oral cavityl

be used as an adjunct to, not a substitute for, biopsy. Indications include: 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$ hen large areas

. C)-tologyi should

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 penerrate 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 location, or whenever there is a great suspicion ofmalignancy. . Excisional biopsy: entails removal ofthe entire lesion along with at least 2 mm ofnormal marginal tissuc frorn the sides of the lesion. This technique should bc employed with smaller lesions i/1".rs tlrd, I cu in diameter) that on clinical examination appear to be benign.
can not bc ovcremphasized that all pertinent clinical information and the findings of other diagnostic modalities must b provided to the pathologist at th time ofthe initial submission

lmportant: It

ofthe specimen.

. 4 days

. 7 days

14 days

. 30 days

68

CoplriSh O

201 I -20 l2 - Denkl Decks

'

An incislonal biopsy is indicated for which ofthe followlng lesions?

. A 0.5 cm papillary fibroma ofthe gingiva . A 2.0 cm exostosis ofthe hard palate
. A 2.0 cm area ofFordyce's disease ofthe cheek

. A 3.0 cm hemangioma ofthe tongue

. A 3.0 cm area of leukoplakia ofthe soft palate

69
Coplrighr
@ 201 1,201 2

, Denial Decks

Almost all oral ulcers caused by trauma will heal within 14 days. Therefore, any ulcer that is present for 2 weeks or more should b biopsied. Biopsy is also indicated in the following instances:

. Pigmented lesions (black/bown)

. lfa

. When tissu is associated with paresthesia, this is often an ominous sign lesion suddenly enlarges, it should be biopsied

Note: Always aspirate a central bone lesion to rule out a vascular lesion. Ifa lesion seems compressible, pulsatile, blue, or a bruit is heard, beware ofa vascular lesion and biopsy only under a controlled hospital setting. *** A stethoscope is used to listen for a bruit.

,-

- . ,.

.,'Notcsl-; only

;ri*t;

the entire tumor is removed, it is called an excisional biopsy technique. lf psrtion ofthe tumor is removed, it is called an incisional biopsy technique. 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 solution (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.

l. When
a

the more common ry?es oforal ulcers, malignant lesions are usually paingrowing and do not heal spontaneously. Consequentl% biopsy ofany ulcer that is present in the mouth for more than 2 weeks is mandatorv.

Important: Unlike
1ess,

Leukoplakia is a premalignant lesion. This means that ifleft untreated, some ofthe lesions progress to carcinoma. It is because of this chance of malignant transformation that all leukoplakias should be biopsied.

Biops] Technique and Surgical Principles:

. Anesthesia: Block local anesthetic techniques are employed when possible; ifnot, infiltration may be 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 specimen 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

The 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 needlc 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.

. Pale or gray skin color . Dry mouth . Decreased skin turgor . Modified state ofconsciousness . High blood pressure

. Rapid pulse
. Reduced urine output
copyrtgtu o zor

r10or: l"nt"r oe"r,s

50 75

mg/dl, mg/dl,

125 mg/dL 150

mg/dl
mgldL

.
.

100 126

mg/dl,

175

nl

dL, 200

mg/dl

71 Cop)'right O 201l-2012 - Denbl Decks

Dehydration is the loss ofwater and important blood salts like potassium (K-) and sodium (Na"). Vital organs like the kidneys, brain, and heart can't function without a certain minimum amount of water and salt. Causes include decreased intake (ack ofwater) and. / or increased output fvomititlg, diat"rhea, Ioss ofblood, drainageJi'om burns, diabetes mellitus, diuretic use, or a lack

ofADH owing to diabetes insipidus).

Initially,

a patient suffering from dehydration the skin and mucous membranes.

will clinically demonstrate only

dryness

of

However, as dehydration progresses, the turgor for fullness) ofthe skin is lost. Ifdehydration persists, oligruria (reduced urine output) occurs as a compensation for the fluid loss. More severe degrees of fluid loss are accompanied by a shift of water from the intracellular space to the extracellular space, a process that causes severe cell dysfunction, panicularly in the brain. Systemic blood pressure falls with continuous dehydration, and declining perfusion eventually leads to death.

Fluids in several forms should be continually urged on the patient. In severely dehydrated individuals, they must get to the hospital right away. IV fluids will quickly reverse dehydration, and is often life saving in young children and infants.

Diabetes Mellitus is an absolute or relative insulin insulficiency caused either by a low output of insulin from the pancreas or by unresponsiveness of peripheral tissues to insulin. Diabetes is the leading cause of blindness, end-stagc renal disease, and non-traumatic limb amputation in the Unired States. Diabctes increases risk for cardiovascular, cerebral, and peripheral vascular disease.

\lanl patients \rith diabetes mellitus have no symptoms, and the diagnosis is made because ofabnomral blood glucose lcvels detected on a routine screening. Some patients may develop polydipsia. poll uria. polyphagia, and weight loss. In patients with severe insulin dcficiency, developmcnt ofketoacidosis may cause nausea, vomiting, lethargy, confusion, and coma. The major concem for the dentist treating a patient who has diabetes mellitus is hypoglycemia. S) mptoms of hypoglycernia: weakness, nervousness, excessive sweating, tremulousness, and palpitations. The symptoms may progress from confusion and agitation to seizures and coma without
rntervenhon.

:fu$

:Notcdl tion of

,'- - -.-,. L The treatment ofchoice for hypoglycemia in a conscious diabetic is the administraan 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% glucose solution can be given by rapid IV infusion. The glucagon injection should restore the 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 people 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 ketoncs (controlletl diabel/., usually can be treated in the nomal manner without additional 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 congstive hart failure. They note ctrdiac symptoms wlth mild activity trut are asymptomatlc at rest lYhat is the functional classilication of heart failure in your patient?

. .

Class Class

II

. Class III . Class IV

72 Cop'.riglitO20ll'2012,Denral

Decks

Match the term on the left with the correct meaning on the right.

. Apnea

Below normal CO2 in arterial blood

Increase in depth ofrespiration

. Hypercapnia . Hypocapnia
. Dyspnea . Hyperpnea . Respiratory arrest . Hyperventilation . H)?oventilation

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
73 Coprighr C
201 l-2012 -

ofdifficulty in breathing
Dolal Decls

Class I congestive heart 1'ailure is defineu as no symproms , Class II is symptoms with marked activity, Class Itl is symptoms with mild activity, and Class IV is symptoms at
rest.

Congestive heart failure (CHF) results ftom impaired pumping ability by the heart. A ventricular ejection fraction bclou, 50% is indicative ofCHF. Valvular hcart discasc, coronary artery discasc, arrhythmias, hypothyroidism, high-cardiac output syndromes, and hypertension can lcad to heart failurc. Note: Usually the left ventricle fails first, soon followed by right-sided failure. The presnting symptoms include dyspnea, orthopnea, paroxysmal noctumal dyspnea, fatigue, exercise intolerancc, and odema. Note: The most comnron sign of lefFsided heart failure is pulmonary edema, whcrcas righGsided heart failure causes pedal edma or abdominal swelling. Pharmacologic therapy: goals are to contol fluid retention, control neurohormonal activation,
and 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 systen, 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

Patient 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 epinephrine/ . Dicumarol (patients may have bleeding problem,/

Apnea Hypercapnia

Transient cessation or absence ofbreathins

Excess CO: in arterial blood

Hypocapnia
Dyspnea

Below normal CO: in arterial blood

The unpleasant sensalion ofdifficulry in brcathing Increase in depth of respiration Permanent cessation of breathing (unless corrected)

Hlperpnea
Respiratory arrest

H}?erventilation
Hy'poventilation

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-induced respiratory depression, and brain damage. 6. Stridor is a high-pitched respiratory sound, such as the inspiratory sound heard often in acute larvnseal obstruction.

. Bronchiectasis
. Atelectasis

. Pner.rmothorax . Pneumonia

74
Cop)'right () 20ll-2012 - Dnlal

Dek

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 ofthe last three years. The patient is afebrile and chest x-ray is unremsrkable. Which of the following is the most likely diagnosis?

. Viral pneumonia

. Chronic bronchitis . Emphysema

. Asthma

75 Copltight C
201

l-2012 - Dental Decks

Atelectasis occurs when mucus or a foreign object obstructs airflow in a mainstem bronchus causing collapse ofthe affected lung tissue into an airless state. It typically occurs 36 hours postoperatively and presents with mild dyspnea, low-grade fever, and hypoxia. Note: Prolonged atelectasis can lead to pneumonia'
The treatment of postoperative atelectasis is aimed at expansion of the lung, and, for most patients, incentive spirometry @ncouraging the patient to take long, slow, deep breaths) is adequate. However, in patients with severe atelectasis, endotracheal suction and
even bronchoscopy may be warranted.

Pneumothorax occurs when air leaks into the pleural space causing the lung to recoil
from the chest wall. In an awake patient, a pneumothorax typically presents with dyspnea, chest pain, absence ofbreath sounds on the affected side, and evidence ofpneumothorax on a chest x-ray. Tracheal deviation may be present.

The objective of treatment for a pneumothorax is to remove the air lrom the pleural space, allowing the lung to re-expand. In an emergency, a small needle (such as a standard intravenous needle) may be placed into the chest cavity through the ribs to relieve the excessive pressure. The definitive treatment is a chest tube, a large plastic tube that is inserted through the chest wall between the ribs to remove the air completely.
- roleg.'

la;*;Jl

of the lung) and atelectasis are two of the most patient in who has had general anesthesia. a 66mmsn causes of fever post-op complication ofoutpatient general anesthesia is 2. Th" -ost common
1. Pneumonitis (inflammation nausea.

COPD is a disease due to persistent airway obstruction. Two diseases account for the bulk of the patients with COPD: mphysema and chronic bronchitis. There is continuing debate as to \rhether this term also includes acute asthma, however as a general ru1e, it is not incft'rded as. even though it does have obstructive components to it, it is in part reversible, and is more generally considered a restrictive lung disease. ln most cases, bronchitis and emphysema occur togerher \ote: Secondary pulmonary hypertension is most often caused by COPD.

Emphysema
Description

Chronic Broncltitls "Blue bloater"

Chronic cough Late 30s and 40s Overweight Rhonchiare presmt Positive Elevated

''Pink puffei'
Dyspnea

Vajor complaint

After age 50 years

Body habitus Lune ex?Jn Peripherai edema Hemoglobin Blood gases
Chest X-ray

Thin
No advenlitious sounds

Ntgative
Normal
PO: normal or reduced Pco, normal or reduced

Po: reduced
PCO2 elevated

IJyperinflated wiih flat diaphragms Increased interstitial markings and notmal diaph.agms

Important:

l. Drugs with antiplatelet activity fasplnn) should be prescribed to COPD patients with caution. Hemoptysis has been reported after the use ofaspirin in patients with COPD.
2. COPD patients taking theophylline should not b prescribed erythromycin. Erythromycin increases the metabolism oftheophylline and may cause toxiciry.

. Respiratory acidosis
. Respiratory alkalosis . Metabolic acidosis . Metabolic alkalosis

Copltighr O

201

76 l-2012 - Denral Deckr

. Was formally known

as insulin-dependent diabetes

. Parients have little or no insulin spnrctinn nananirw

Symptoms appear abruptly and include polyuria, polydipsia, polyphagia, and weight
loss

. Accounts for

90olo

ofall

cases

ofclinical diabetes

77
Cop)right O 20ll-2012 - Denbl Decks

Acid-Base Disorders:

. Normal range: pH =

'7.35 -

7.45

Bicarbonate = 22-26 mtrol/L

Acidosis 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; if bicarbonate 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. Metabolic acidosis: Etiologies- diabetic or starvation ketoacidosis, lactic acidosis, uremia, severe dehydration. Clinical manifestations: Dyspnea on exertion and nausea and vomiting are common Metabolic alkalosis: Etiologies- vomiting, diuretic use, Cushing's syndrome, Conn sl,ndrome, and
exogenous steroids
as confusion, delirium, and coma. Cardiac arrhythmias and hypotension may be noted Respiratory acidosis: Etiologies- COPD, asthma, severe pneumonia or pulmonary edema, CNS depression fdrag.s, CNS event), acute airway obstmction, pneunothorax

Clinical manifestations: CNS symptoms such

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

Respiratory alkalosis: Etiologies- anxiety, hypoxia, CNS discase, drug use (salicylates), pregnancy, sepsis

Clinical manifestations: May

stezures. and coma

cause dizziness, perioral paresthesias, confusion, hypotcnsion,

Diabets is the most common pancreatic endocrine disorder It is a metabolic disease involving mostly carbohydrats fglucosel and lipids. It is caused by absolute deficiency of insulin (r,pe 1) or resistance of insulin's action in the peripheral tissues (Type 2). The classic triad of symptoms includes polydipsia, polyuria, and polyphagia.

be

nornal or excd nornal

Pcrcentage ofdiabclcs Reduced sensitivity of insulin's rarget clls

Dietary conhol and weigha rcductiou

. Dyspnea or tachypnea
. Wheezing

. Hlpoxemia
. Occasionally hypercapnia . Hemoptysis

78

Copright O 201l-2012 DenialDecks

.VI
. VII

\'III

.IX

79
Copyight O 20ll-2012, Dnral Decks

Asthma is a condition chamcterized by episodic reversible narrowing of the airways. The most common symptoms include episodic wheezing, cough, chest tightness, and shortness of breath. The disease can begin at any age, but about half ofpatints develop asthma before the age of 10. There are three basic pathophysiologic changes: (1) Airway inflammation (2) Airway obstruction and (3) Airway hlperresponsiveness lmportant: An acute asthmatic attack is best heated by administration ofsupplemental oxygen with an inhalaled beta2-adrenergic agonist (albuterol, terbutaline). lf the patient is resistant to beta
agonists, theophylline should be considered. In a severe asthmatic attack that is unresponsive to the above treatment, 0.3 mg of 1;1000 epinephrine should be administered subcutaneously.

Important: There are no contraindications for the use ofnitrous oxide sedation in asthmatic patients. Because anxiety is a stimulus for an asthmatic attack, nitrous oxide sedation is actually beneficial for these patients. Ifpatient is taking steroids, consult physician for the possible need for corticosteroid augmentation.
General 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 antihistamins

. 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 sensitivity. h is inportant to be sure that the patient with asthma does not have this triad when aspirin-containing preparations are prescribed.

Status asthmaticus is the most severe clinical form ofasthma, usually requiring hospitalization, that does not respond adequately to ordinary therapeutic measures. Ifnot managed properly, chronic partial airway obstruction may lead to death from respiratory acidosis (which is produced by hyp oxem i a a nd hypercapn ia).

Hemophilia A and B are inherited as a sexJitrked recessiYe trait by which males are allected and females are carriers. The majority ofpeople af{licted with hemophilia have type A and it presents under the age of 25. The signs, symptoms and clinical manifestations include excessive bleeding from minor cuts, epistaxis, hematomas, and hemarthroses. Classifi cations of Hemophilia:

. Hemophilia A:

considered the classical type, caused by a deficiency of coagulation factor (anti-hemophilic factor) . . Hemophilia B (also called Christmas disease): due to a deficiency in fzctor lX (Christmas

\ lll

(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. lmportant; A true hemophiliac is characterized by having the following:

factor) . Hemophilia C

. Prolongd partial thromboplastin time

. Normal protbrombln time (PT) . Normal platelet count

(PI!

. Normal bleeding time Note: von Willebrand's disease is inherited

as an autosomal dominant bleeding disorder, it ocDue to the absence ol von Willebrand's factot (VWF), curs with equal frequency in both seres. platelet plug. Labomtory features include a prolonged PTT primary form a in failurc to which results and prolonged bleeding time.

Thrombocytopenia: . Idiopathic thrombocytopenic pupnr^ (ITP)t autoimmune bleeding disorder in which patients 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 abnormalities. Signs and symptoms: fever, neurologic abnormalities, including headache, aphasia, or stupor.

\..

. Diabetes mellitus
. AIDS

. Vahtlar

disease

. End stage renal disease

80
Cop)'right

201

l-2012 - Dental Decks

A tall, thin patient presents to your olnce with shortness of breath. On examination you note the patint is breathing through 6pursed' lips, his expiratory phase is prolonged and lung sounds rre distant. Which of the following is the most likely diagnosis?

.Asthma

. Bronchiectasis . Cystic fibrosis

. Emphysema

81 CopyriSht O 201 I '20 12 - Dmlal Decks

Mitralvalve prolapsed
Endocarditis Papillary muscle dysfunction
Dyspna

Systolic ejection mulmu. Delaycd carotid upstr0ke

Diastolic rumble Opening snap

Important: Patients with valwlar heart

R]leumatic fever is

disease are also at risk for bacterial endocarditis.

a sequela ofa previous Group A , beta hemolytic streptococcal infection, usually ofthe upper respimtory tract. The disease involves the heart,joints, centml newous system. skin, and subcutaneous tissues. lt is characterized by an exudative and proliferative inflammatory lesion of the connective tissue, especially that ofthe heart, joints, blood vessels, and subcutaneous tissue.

Hean inflammation (carditis) drsappears gradually, usually within five months. However, it ma) permanently damage the heart valves, resulting in rheumatic heart disease. The valve benr een the left atrium and ventdcle (mitral valve) is most commonly damaged. \ote: The pulmonary valve is rarely involved. Remember: A heart murmur may have no pathological significance or may be an important clue to the presence of valvular, congenital, or other structural abnormalities ofthe heart.

The emphysema. or "pink puffer" patient is typically thin and presents with dyspnea, pu$edlip breathing and pink skin color, Arterial blood gases reveal hypoxia and hlpercapnia. Emphysema is defined as destructive changes to the alveoli walls and enlargement ofair spaces. Ir affects the lung parcnchyma distal to terminal bronchioles. Cigarette smoking is major risk faclor (increases risk by 10 to 30 times otter nonsmokers). Note: Alpha- l -antitrypsin deficiency should be suspected in patients who develop emphysema in their late 30s.

Bronchiectasis: abnormal dilatation ofthe large conducting pathways, due to congenital structural abnormalities or acquired processes. Congenital causes include cystic fibrosis and alphal-antitrypsin deficiency. Acquired processes include viral and bacterial infections, foreign bodies, and tumors. The major symptom is a cough, which is daily and productive with purulent sputum. Hemoptysis may accompany the cough. As disease progresses, exercise intolerance and dyspnea develop.

Cystic librosis: an autosomal recessive disease and most common lethal inherited disease in American whites. Most patients are diagnosed in the preteen years. It is due to a defect in cystic fibrosis transmembrane conductance regulator. S).mptoms are due to development ofthick secretions that block the airways and ductal system in other organs (usually pancreas and /1rc,.r. Common s),rnptoms include chronic cough with sputum production and dyspnea. Remember: Patients with chronic bronchitis (or any COPD) can have difficulty during oral surgery Many of these patients depend on maintaining an updght posture to breathe adequately. They frequently experience difficulty breathing ifplaced in an almost supine position or ifplaced on high-flow nasal oxygen.

Important: Patients with chronic bronchitis may be predisposed to lung cancer (bronchogenic carcinoma).

. The day before dialysis

. The day ofdialysis . The day after dialysis

. Two days before dialysis

a2
Cop)'right O 20ll-2012 - Dental Decks

. Is

natual constituent ofopium

be given only by injection

. \4ay .

Has a calming effect on gastric mucosa and more constipating

. Is stronger than morphine, more addictive,

83 Coplaight O 20ll-2012 - Dental Dech

End-stage renal disease (ESRD) rs a condition in which there is a permanent and almost complete loss of kidney function. The kidney functions at less than I 0% of its normal capacity. [n end-stage renal disease, toxins slowly build up in the body. Normal kidneys remove these toxins /i.e., urea and creatinine) from the body through urine. In chronic renal disease there is a slow, progressive decline in kidney functiot (low glomerular filtration lete ICFRI andfall in uri e output). Creatinine clearance is a measure ofGFR: . Normal range:

Male: 120 +/- 25 ml/min

***

Female:

95 +/- 20 ml/min

End-stage renal disease: GFR < l0 ml/min

Patients u,ith ESRD: . Are often on steroid therapy . Are more susceptible to post-op infections . Have an increased tendency to bleed

*** when oral surgical

tion.

procedures are undertaken on these patients, meticulous attention to good surgical technique is necessary to decrease the risks ofexcessive bleeding and infecSome important points to remember when treating patients with renal insufltciency and
rhose 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 morphine

. Perform oral surgery the day after dialysis . Consult physician for possible prophylatic antibiotics

\crr
ft'rnic

to morphinc, codcine is thc most important alkaloid of opium. Codeine has two primary therac'l1'ecIsr analgesic and antitussivc. Codcine is

relatively less polent than morphine and does not have

::e

ofmorphine. It is more likely than other opioids. othcr than morphine, to cause conii:F,r!ion and nausea- Codeine is usually combined with other drugs, for example, Empirin (Aspirin +
abuse potential

arrr.rrr./. and Tt-lenol#2,3,

with the adofconstipation, nausea, and vomiting. Opr(.id analgesics are thought to inhibit painful stimuli in the substantia gelatinosa of the spinal cord, b::i:r tem. reticular actiYating system, thalamus, and limbic systcm. Opiate receptors in each ofthcse ::eas lnreract \\'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

\ote: Jlorphine
r:rre
etTects

and 4 (Acetattinophen + Codeine). is effectivc in providing reliefofmoderate to severe pain but is associated

i' p3i: . \lu receptors: - \Iul: analgesia - Mu2: respiratory depression. bradycardia, physical dcpcndence, euphoria . Xappa receplors: analgesia, sedation, dysphoria, psychomimetic effects
. Delta rceptors: analgcsia. moduiates activity at the mu recepto.
Drug

15'60 min
10 30
I

4-5

hi
hr

Din

4i

lydcodone (Vicodin. Ltrc.r. lorrab)

l0-20

nin
3-4 h.

Oxycodon {Percodan,

Preel)
(O(r{4ntin)

l5-30 min

Oxycodode, line-rclease lomula

lhr

I2 hr

Ily&oiorphme (Dilaudid)
FenLnyl (DuEgesi.

,l-5lr
2-4

nt

haBdmal)

t2-21h1
4-7 hr

Propox}?lenc (D.aon)

+6 hr

. Midazolam . Lorazepam . Diazepam

u
CoDrisht O
201

l-2012 - Denbl Decks

. Ibuprofen
. Acetaminophen

. Naproxen

85
Copltighr O 201 I ,2012 - Dertal Dcks

Anterogmde amnesia, minimal depression of ventilation and the cardiovascular system, and sedative properties make benzodiazepines favorable preoperative medications. Clinical uses for benzodiazepines include: preoperative medication, IV sedation, induction of anesthesia, maintenance ofanesthesia and suppression of seizure activity. Benzodiazepines act by potentiating the action of GABA, an amino acid and inhibitory neurotransmitter, which results in increased neuronal inhibition and CNS depression. Benzodiazepines bind to specihc benzodiazepine receptor sites, which are found on postsynaptic nerve endings in the CNS. Benzodiazepines are the most effective oral sedative drugs used in dentistry.
The most common benzodiazepines used as amnestics in anesthesiology are: midazolam (most co 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 IV or 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, resulting in a slow onset ofaction but long duration ofaction. It requires propylene glycol to dissolYe 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 preoperative anesthesia.
1. Chloral hydrate is a sedative and hlpnotic that is widely used for pediatric sedation. 2. Emotional stress decreases the rate ofabsorption ofa drug when given orally.

Acetaminophen (Tylenol) is the only over-the-counter non-antiinflammatory analgesic commonly available in the USA. It is a weak cyclooxygenase inhibitor in peripheral tissues. thus accounting for its lack of antiinflammatory effect. It may be a more effective inhibitor ofprostaglandin synthesis in the CNS, resulting in analgesic and antipyretic action. Acetaminophen does not produce gastric ulceration like aspirin does. The combination ofacetaminophen and propoxyphene (called Darvocet-N or Wygesic) is used to treat
moderate to severe pain due to dental procedures. \ote: Propoxyphene (D&rvon) is an oral slmthetic opioid analgesic structurally similar to methadone. Darvon compound-65 is a combination of aspirin, caffeine, and propoxyphene.

, --.. l. Acetaminophen does not affect clotting time as does aspirin -it does not 1Not5l1 h6vs significant antiplatelet effects. It is effective for the same indications as in@;if
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. Aspirin is an anti-inflammatory antiplretic and analgesic that is used to relieve 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?

. Amobarbital

. Thiopental

. Phenobarbital
. Pentobarbital

86

Coprigh

O 201 l'2012 - Dental Decks

It should strour(l in rne the erqerry. elderly. lr be useo used caunously cautiously ln should De snoum _ never be given to patients on mono|mine oxidase inhibitors for psychiatric disersc and is generally contraindicated in patients receiving pbeny'toin @ilantin) for seizure disorders.

. Ibuprofen . Acetaminophen . Meperidine

. Codeine

a7
Copyrighr O 201l'2012' Dental

Dsks

Barbituates exhibit a dose-dependent central nervous system depression with hypnosis and amnesia. Barbiturates are very lipid soluble, which results in a rapid onset ofaction. They are
used most often for induction ofanesthesia because thev oroduce unconsciousness in less than 30 seconds.

Barbiturates inhibit depolarization ofneurons by binding to the GABA receptorc, which enhances the transmission ofchloride ions. Note: Barbiturates are potent cerebral vasoconstric-

tors resulting in decreases in cerebral blood flow, cerebral blood volume, and intracranial
pressure (1CPl.

Ultrashort-acting barbiturates . Methohexrtal

. Thiopental (Pentothal) . Thiamylal (Surttal)

(B rev i t a I )

Short-acting barbiturates : . P entobarbital (Nembutal) . Secobarbrtal ( S ec ona l) Intermdiate-acting barbiturales:

Amobatbital (Amytql)

. Butabarbital (Fioricet, Fiorinql) Long-acting barbiturates: . Phenobarbital (Luminal): generally not used in oral surgery

Important: Barbiturates are contraindicated in patients with respiratory disease or those

\\ ho are pregnant.

\ote: Phl"sical dependence is likely to develop with barbiturates ifabused.

be fatal.

The dependence

has a strong psychological as well as physical basis. Sudden withdrawal from high doses can

Meperidine (Demero, is a synthetic opioid analgesic with less potency than morphine. It is used for the reliefofmoderate to severe pain, for preoperative sedation, for posloperative analgesia, for obstetric anesthesia, and when given IV for supportive anesthesia. lt is probably the most widely used narcotic in Americzm hospitals. It should be used with particular caution, at a)l, in the elderly. lt is the drug ofchoice among drug abusers and must be used with extreme caution. Meperidine is the most abused drug by health professionals. The onset ofaction is

if

more rapid, but the duration ofaction is shorter, than that ofmorphine. Note: It produces slight euphoria but no miosis.

\.leperidine is often prescribed as 50 mg every 4 hours as needed for pain. It is often simultaneously presribed with the drug promethazine (Phenergan) in 25-50 mg doses every 4 hours. The promethazine is a sedative and eniances the effect ofmeperidine. Therefore, less meperi dine r-ields more analgesia when in combination with promethazine. In addition, promethazine is an anti-emetic, which helps negate some ofthe side effects ofmeperidine, namely, nausea.

Important: Concomitant administration ofmeperidine and MAO inhibitors

has resulted

in

life-threatening hyperpyrexic reactions that may culminate in seizures or coma. Monoamine

oxidase (MAO) inhibitors are a class ofdrugs used for depression and Parkinson's Disease. Examples of MAO inhibitors include isocarboxazid (brand name Marplan), phenelzine (Nardil), rranylcypromine /Parnate), ard selegiline (E ldepryl).

\lechanism of action: thought to act by increasing endogenous concentrations of norepinephrine, dopamine, and serotonin through inhibition ofthe enzyme (monoamine oxidase) re' sponsible for the breakdown of these neurolmnsmillers.
r-ote: There is a decreased effectiveness ofmeperidine in the presence of phe\ytoir (Dilan'
tin)

Rmembr: Morphine is the standard drug to which all analgesic drugs are compared. lt causes uphoria, analgesia, and drowsiness along with miosis and respiratory depression.

. Reduction of salivation
. Prevention ofcardiac slowing during general anesthesia . CNS depression

. Mydriasis
. Cycloplegia

88 Coplrighr O 201 I -20 l2 - Dental Lrects

. Respiratory depression . Minor analgesia . Decreased BMR

. All ofthe

above effects

. None ofthe above effects

89 Coplright O20ll-2012 - Dental Decks

The cholinergic blocking (anticholinergic) drtgs competitively inhibit the action of acetylcholine at parasympathetic postganglionic neuroeffector sites. The principal drugs in this category are atropine and scopolamine, which are useful in dentistry as agents to control salivary secretion and as preanesthetic medication. The desirable clinical effects ofthe anticholinergics are mydriasis, antispasmodic actions, and reduction in gastric and salivary secretions.
The pharmacologic actions ofatropine and scopolamine are similar in many respects. Atropine in the usual dose employed in dentistry does not show a CNS response. Scopolamine, however, has a depressant effect on the CNS, which accounts for its usefulness as a preanesthetic agent and perhaps its use in motion sickness in several over-the-counter preparations. Both drugs will reduce salivary flow and in large doses block the cardiacslowing effect ofthe vagus nerve.

Anticholinergic drugs should be used with considerable caution in patients with cardiovascular disease and are contraindicated in patients with glaucoma, prostate hypertrophy, and intestinal obstruction.
Side effects are common with the anticholinergic drugs and include blurred vision, tachycardia. urinary retention, constipation, decreased salivation, sweating, and dry skin. and scopolamine are also extremely useful in therapy and examination of the eye. These drugs produce dilation (nydriasis) and paralysis of accommodation for distance vision and bght (cltcloplegia). Such effects are generally long lasting and can also be manifested by larger systemic doses ofthe drugs.

\ote: Atropine

Properties of barbiturates:

. 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

\Iechanism of action of barbiturates:

. Barbiturates inhibit depolarization ofneurons by binding to the GABA recepton, which

enhances the transmission ofchloride ions.

Barbiturates: . \\'ell absorbed orally, distributed widely throughout the body . \lerabolized in the liver to inactive metabolites that are excreted in the uflne
Therapeutic uses of barbiturates: . -{nesthesia: inlluenced by duration ofaction. Thiopental is an ultra-short acting barbiturute 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, . Anxiety:

status epilepticus and eclampsia can be used as mild sedatives to relieve anxiety and insomnia de-

Drug interactions: CNS depressants, alcohol, and opioid analgesics enhance the CNS
pression of barbiturates.

Important: Barbiturates can lead to excessive sedation and cause

anesthesia, coma and even

death. Barbiturate overdoses may occur because the effective dose of the drug is not too far away ftom the lethal dose. Note: The barbiturates can produce fetal damage when administered to a pregnant woman.

. The needle should be perpendicular when it enten the tissue . Sutures should be placed at an equal distance from the
depths
rvoun d margin (2-3 mm) and at equal

. .

Sutures should be placed from mobile tissue to thick tissue Suttrres should be placed from thin tissue to thick tissue

. Suhfes should not be over-tightened

. Tissues should be closed under tension

Sutures should be 2-3 mm apart be on the side ofthe wound

90
CopyrighrO 20ll-2012 - Dntal

. The suture knot should

D{ks

. Canine

space space

. Pterygomaxillary

. Infratemporal . Pharyngeal

space

space

. Maxillary sinus

91

Cop)'|ight O 201l-2012 - Dfrlal Decks

***

This is false; sutures should not be over-tightened or closed under tension.

The interrupted suture is the most common suture method. Because each suture is independent, this procedure offers strength and flexibility in placement. Due to this advantage, if one suture is lost or becomes loose, the integrity of the remaining sutures is not compromised. The major disadvantage is the time required for placement ofthis pattem of sutures. (See./igure #1 below)
Advantages

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

Figure

#l

Figure #2

Impacted maxillary third molars are occasionally displaced into two areas: . \Iariflary sinus (antrun): from which they are removed via a Caldwell-Luc approach

.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 surgon who will use a
special technique to remove it. \ote: To minimize the chance of dislodging an impacted maxillary third molar into the infratemporal fossa during its surgical removal, develop a full-thickness mucoperiosteal nect1ap. bringing the incision anterior to the second molar (add a releasing incision place retractor distal tooth and a broad visualization ofthe impacted to improve t\d]'r'l.

to the molar while elevating it.

Remember: 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 postrior teeth because mandibular bone is too dense and does not expand in a similar fashion to that ofthe maxillary bone.

. Below the height ofthe operator's shoulder . Above the height of the operator's shoulder

. At the

same height

ofthe operator's shoulder

.It

makes no difference where the patient's upper shoulder

jaw is in relation to the operator's

92
CopFighr O 20ll-2012 - Dental Decks

. Acute pericomitis
. Acute dentoalveolar abscess

. End-stage renal

disease

. Acute infectious stomatitis

93 Copyrigll O 20ll-2012 - Dnral Decks

The chair usually has to be repositioned to be satisfactory for exodontics. For mandibular extractions, the patient should be positioned so that the occlusal plane ofthe mandibular arch is parallel to the floor when the mouth is opened. The chair should be as low as possible. For maxillary extractions, the upperjaw ofthe patient should be at the height of the operator's shoulder These positions allow the upper arm to hang loosely from the shoulder girdle and obviate the fatigue associated with holding the shoulders in an unnanrrally high position during the course ofthe day. The low positions allow lhe operator to bring the back and leg muscles into the operation to assist the arm. The chair can be tipped backward slightly for maxillary extractions. The 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 alveolar 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
Remember: recommended sequence of extraction: . Maxillary teeth before mandibular teeth

. Posterior teetlr before anterior teeth

An acute dentoalveolar abscess should not be a contmindication to extraction. It has been shosn that these infections can rcsolve very quickly when the affected tooth is removed. However. it may be

difiicult

to extract such a tooth, either because the patient is unable to open suf-

ficiently wide enough or because adequate local anesthesia cannot be obtained.

There are fe\r,tlue contraindications to the extraction ofteeth. Note: In some instances, the parients' health may be so compromised that they cannot withstand the surgical procedue. Examples 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 hyperbaric 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 of
the Jaw

Note: Causes ofexcessive bleeding after dental extractions include; injury to the inferior alveolar artery during extraction ofa mandibular tooth (usually the third mola/), a muscular arteriolar bleed from a flap procedure, or bleeding related to the patient's history [.e., patients who are on warfarix or drugs.for platelet ixhibition, pqtients vrho have hemophilia or von Wllebrand's disease, or who have chronic liver insfficiency).

. Close the wound in layers to minimize

. Apply pressure dressings

the postoperative void

. Use drains to remove any bleeding that accumulates . Allow the void to fill with blood
so that a blood clot

will form

94
Cop)righr O 20ll-2012 - Dertal Decks

. Buccal . Palatal . Mesial . Distal

95
Cop)righr O 201l'2012 - Dntal Decks

Dead space in a wound is any area that remains devoid of tissue after closure of the wound. It is created by either removing tissues in the depths of a wound or by not reapproximating tissue planes during closure. Dead space in a wound usually fills in with blood which creates a hematoma with a high potential for infection. This is more likely to happen in closed wound incisions or in an open wound that has closed over at the top too quickly, leaving "dead space" open underneath. Some of these may resolve themselves, but most need to have the fluid drained and the "dead space" needs to be closed, either by deep suturing or by re-opening the top ofthe wound and packing until it heals from the bottom up.
Ways 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

Important: Infections are uncommon in healthy patients. However, whenever a mucoperiosteal flap is elevated for a surgical extraction, there is a possibility for a subperiosteal abscess. Thus, all surgical flaps should be irrigated liberally prior to closing $ ith sutures. Note: The treatment for a subperiosteal abscess is drainage of the abscess and antibiotic treatment.

As opposed to the buccal direction in adults. This is because the deciduous molars are more palatally positioned and the palatal root is strong and less prone to fracture.

***

In general. the removal of deciduous teeth is not difficult. It is facilitated by the elasticit1. of young bone and the resorption of the root structure. Do not use the "cowhorn" forceps for extraction of lower primary molars because the sharp beaks ofthese forceps
could cause damage to the unerupted pennanent premolar teeth.

\ot

the preoperative radiograph shorvs that the permanent premolar is wedged tightly between the bell-shaped roots ofthe primary tooth, the best treatment is to section the crown of the primary molar and remove the two portions
separately. This
2.

l. If

will help in not disturbing the permanent tooth. 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 tubrosi

. Remove the tuberosity fiom the tooth and reimplant the tuberosity

Smooth the shar? edges ofthe remaining bone and suture the remaining soft tissue

. No special treatment is necessary . None ofthe above

96
Copyrighr O 201 1,2012 - Dntal Decks

. A labial frenum . A lingual frenum

. The mylohyoid ridge . The genial tubercles

. An exostosis

97
Copyrighl O 20ll-2012 - Dental Dec*s

A fracture ofthe maxillary tuberosity most commonly results from extraction ofan erupted maxillary third molar a second molar if it happens to be the last tooth in the arch.

-or

lf

the tuberosity is fractured but intact, it should be manually repositioned and stabilized

with sutues.
The complications most often seen after extraction of an freestanding, isolated maxillary

molar are: . Fractwe ofthe tuberosity . Alveolar process fiacture

Important: "Beware ofthe lone

molar'r- it is often ankylosed to the bone. Remember: The ankylosed tooth emits an atypical, sharp sound on percussion.
Key point to remember: Tuberosity ftactures may occur and should be treated at the time of she must arrange an immediate referral. at the correct vrtical dimension, the distance from l. For denture construction, pad should equal at least I cm. tuberosity to the retomolar tho crest ofthe 2. Ifthere is inadequate intermaxillary distance at the tuberosity a tuberosity reduction 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 removed flom each flap and the wound is closed. This decreases the vertical and horizontal dimensions of the tuberosity.

sugery Ifthe operator is unable to do this he /

The genial tubercles are situated on the lingual surface of the mandible at a point about mid*ay between the superior and inferior borders. There are four of them, two ofwhich are situated on each side and adjacent to the symphysis. Although usually relatively small, they may be fairly large and extend outwaxd from the surface as spinous processes. These tubercles are the area of muscle attachment for the suprahyoid muscles.

Important: 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 recommended that an envelope flap design, which has no vertical components, be
used.

Bxo

. When the root is fully formed . When the root is approximately two-thirds formed . Makes no difference how much ofthe root is formed . When the root is approximately one-third formed

Coprighr C

201

98 l-2012 - Dertal Decks

. Routinely . Never

. Ifthe patient

requests

it

. \\hen there is severe bleeding from the gingiva or ifthe gingival cuffis torn or loose

99
Copyrighl O 20ll-2012 - Dental Decks

are not formed well enough to havc developed curves and rarely fracture during extraction. When the root is fully formed, the possibility increases for abnormal root morphology and for fracturc ofthe root tips during extraction.

. Patient would be around the age of 17-21. . At this time, the bone is more flexible and the roots

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 prcautions, artibiotics. and a nasal spny to preve.l inlection and keep the osliuft
Most common complication; rmoved 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

Alveolr p1ocffs and maxillary From too much force used to rmove teelh
May occur in the area of lh .oots of lhe mandibular third molars. Lingual newe travls very close to the lingual cortex of lhe mandible in this areaCan occur in 3% ofnandibular third molar extractions. Willhal irrigalion and localtreahent forpain control

wilh

Noteq

l. 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).

\ormal post-xtraction procedure:

.
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

-{li

. The socket must be compressed by the fingers to reestablish the normal width present 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

lf bleeding persists for some time following an extraction, it may be helpful to instruct the patient to bite on a tea bag. The tannic acid in the tea bag will help promote hemostasis.

Remember: The most common cause ofpost-extraction bleeding is the failure ofthe patient to follow post-extraction instructions.

Th most commonly impacted teeth are the mandibular third molars, maxillary third molars, and the:

. Maxillary canines . Maxillary lateral incisors

. Mandibular first molars

. Mandibular premolars

100 Coplrigh! O 20l l-2012 - Dental Dcks

. Throbbing pain (often radiating) . Bilateral lymphadenopathy . Fetid odor . Bad taste . Poorly healed extraction site

101 Copl.right O

20ll-2012,

Denral Decks

Classifications of 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 of
the second molar . Class C; entire crown is embedded within the mmus

Contraindications to extraction ofimpacted teeth:

.
Roots one

. Compromised medical

status

Likely damage to

adjacent

tlid

to two thirds

fomdr

structures Extremes ofages (preteen or an asymptomatic .full bony im-

paction
of age

patient>

35 ),ea/s

* Present in young patients

* Present in young patients

The etiology ofdry socket is not absolutely clear but is thought to develop because of increased fibrinolytic activity causing accelerated lysis ofthe blood clot. It is most common lbllon ing extraction ofthe mandibular molars. Smoking, premature mouth rinsing, hot liquids. surgical trauma, and oral contraceptives all have been implicated in the development ofa dry socket. Note: Careful technique and minimal traula reduce the frequency of patients developing dry socket.

Treatment for dry socket: . Flush out debris with slightly warmed saline solution
. Place

-gently 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.
is the most common complication seen after the surgical removal 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 destroyed, and there is a risk ofcausing the localized inflammatory process to be

!!l

LDry socket
a

of

spread to the adjacent sound bone.

. An inlraoral picture should

be taken

. A mandibulax torus ifpresent, should be removed . A stent should be fabricated . A biopsy should be taken

102
Coplaight O 201 l-2012 - Dental Decls

. Venical . Horizontal
. Distoangular

. Mesioangular

103 Coplright
@ 201 1,201 2

, Dmial Decks

Maxillary tori present few problems when the maxillary dentition is present and only
occasionally interfere with speech or become ulcerated from frequent trauma to the palate.

Indications for the removal include a large, lobulated torus with a thin mucoperiosteal cover extending posteriorly to the vibrating line ofthe palate that prevents seating of a denture and also prevents a posterior seal at the fovea palatini. Other indications for the removal ofmaxillary tori are, chronic initation, interference with speech, rapid growth and
in patients that have a cancer-phobia.

Technique 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

Important: The maxillary torus should not be excised en masse to prevent entry into the nose (the palatine bone will come out with torus).

lmportant: This is the exact opposite ofimpacted maxillary third molars' where the mesioangular impactions (122o/ are the most di{ncult and the vertical f63lo) and distoangular impactions /2i / are the essiest to remove.
Surgical 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 flaps
comDletes the Drocedure.

. Rotation .

ing

. Pushing . Luxation

10,1

Coplaighr O2011,2012 - Denral Decks

. Palatal root ofthe maxillary first premolar

. Palatal root ofthe maxillary first molar

. Palatal root ofthe maxillary second molar . Palatal root of the maxillary third molar

105

coplriSh

O 201l-2012 - Dental

Deck

Luxation is the loosening ofthe tooth in the socket by progressive severing ofthe periodontal ligament fibe6. Patience and controlled force are needed, not brute strength. The force should be applied as low down the root as possible when extraciing teeth. You should support the jaw with your other hand and have a thumb and frnger on either side ofthe tooth being extracted. Note: Rotation forces can be used on single rooted teeth. Teeth are extracted by luxation forces perpendicular to the long axis ofthe tooth, not by pulling along the long axis. The fulcrum is as close to the apex ofthe tooth as possible.

Remember: The beak of the extraction forcep is designed so that most of the pressure exerted during an extraction is transmitted to the root ofthe tooth.

Important: When using dental elevators, one should always have respect for the forces genefated. Due to the large amount of leverage, dental elevators can genente tremendous forces during normal use, and have potential to cause iatrogenic damage.

\ote: A Class [I fever

Class

is used during tooth extractions (see picttu?s below) Class

l Lever

Il

Lever

Class

III

Lever

"r"l!","r

,A

f,n

.t ,A
-p*"ii'"int

."t

Important: If an entire tooth or a large fragment of one is displaced into the sinus, it should be removed. If the tooth fragment is irretrievable through the socket, it should be rerieved through a Caldwell-Luc approach ASAP. However, only perform this ifyou kno\ what you are doing. Ifnot, refer patient to an oral surgeon. \ote: If a small communication is made with the maxillary sinus during extraction of a rooth. the best treatment is leave it alone and allow the blood clot to form.
Post-operative instructions to patient: . -\'oid nose blowing for 7 days . Open mouth when sneezing . -{\.oid vigorous rinsing . Soft diet for 3 days

Ifa sinus communication should occur the following medications may

one u eek:

be prescribed

for

L Afrin: local (nasal) decorgestant Antibiotics (Amoxicillin) i. Actifed: systemic decongestant I . If the opening is of moderate size (2-6 mm),
2. .\*oie* l place over the tooth socket.

a figure-eight suture should be a

2.

Ifthe opening is large (7 mm or latger),lhe opening should be closed with

flan orocedure.

Remember: The integrity of the floor of the maxillary sinus is at greatest risk with surgery involving the removal ofa single remaining maxillary molar. The fear here is possible ankylosis.

The Caldwell-Luc procedure eliminates blind procedures and facilitates the recovery oflarge root tips or entire teeth that have been displaced .[t into the l,l.LUu rU.U

maxillary sinus. When performing this procedure an opening is msde into the faciil wall of the antrum aboye the:

. Maxillary tuberosity . Maxillary lateral incisor

. Maxillary premolar roots

. Maxillary third molar

Cop]right O

201

106 l-2012 - Dntal Deks

. 2/0

.3/0 . 4i0

.50

107
Coplaighr O 201l-2012 - Dental Decks

Ila large root fragment

or the entire tooth is displaced into the maxillary sinus (antrum),

it should be removed. The usual method is a Caldwell-Luc approach. This is a surgical procedure in which an opening is made into the maxillary sinus by way ofan incision into the canine fossa above the level ofthe premolar roots. The tooth or root is then removed. Post-operative management includes a figure-eight suture over the socket, sinus precautions, antibiotics, a nasal spray and a systemic decongestant to keep the sinus ostium open and infection free. Important: An oral surgeon to whom the patient should be referred should perform this procedure.

If

the root tip is small (2 or 3 mn), noninfected, and cannot be removed through the small opening in the socket apex, no additional surgical procedure should be performed through the socket, and the root tip should be left in the sinus. Ifthe root tip is left in the sinus, measures should be taken similar to those taken when leaving any root tip in place. The patient must be informed ofthe decision and given proper follow-up instructions.

Remember: The palatal root ofthe maxillary first molar is most often dislodged into the maxillary sinus during an extraction procedure.

\ote: If

a root tip of a mandibular third molar disappears from site while trying to retrieve it, the most likely location for it to be in is the submandibular space. Other possible locations would be the inferior alveolar canal or the cancellous bone space.

Suture size is based on strength and diameter. The gauge or thickness ofthe suture material is denoted by O gradings. As the thickness ofthe material decreases, the O grading rises. Hence 2/0 is thicker than 3/0, which is thicker than 4/0 and so on. Because suture material is foreign to the human body, the smallest-diameter suture sufficient to keep the wound closed properly should be used. Most oral and maxillofacial surgical procedure s (intraoral suturing) require the use of3/0 or 4/0 gauge material but on extraoral skin surfaces, finer gauge is preferred such as 6/0 or even finer This helps reduce scar visibility.

Note: The primary function of sutures is to help to stabilize the flap during the healing
phases without imposing needless traction on the soft tissue.

. Inflammatory phase

. Proliferative

phase

. Remodeling phase

108
Copyright O 201

2012 - Denral Decks

. l-2

days postoperatively

. 5-7 days postoperatively . 9-l I

days postoperatively

l3- l5 days postoperatively

109
Cop).righr O 201 1,2012 - Dental Decks

Wound healing 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 - Phagocytosis 2. 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
Factors that impair wound healing: diabetic patients, patients with protein deficiencics, oldcr patients. infections, foreign material, necrotic tissue, ischemia, and tension on the wound.

Remember: 370 hydrogen peroxide is the agent ofchoice for thc debridement ofintraoral wounds.

Tlre two basic categorics ofsuturcs are (l) rcsorbable and (2) nonresorbable: . Resorbable: These sufures are resorbed after a certain time, which usually coincides with healing 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) surures in approximately 30 days. These types of sutures are used for flaps with little tension, childrcn. 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 surgical 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. \ote: Resorbable sutues evoke an intense inflammatory reaction. Thjs is the main reason neither plain gut or chromic gut are used for suturing the surface ofa skin wound. When suturing an exffacdon site in the anticoagulated paticnt, a non-resorbable suture is recommended. Resorbable sutures are accompanied by an inflammatory response, increasing fibrinolytic activity, potentially resulting

in clot brcakdown.
T\\ 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 npidly rvith 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 miglarion from the wouod edges, collagen deposition in the connective tissue, contracture. and remodeling. 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.

. Mid-buccal ofthe tooth

. At the line angle ofthe tooth

. Midlingual of the tooth . Beyond the depth ofthe rnuco-buccal fold

t't0
Coplright O 201 1,2012 - Dmtal Decls

. Use a larger forcep and luxate remaining portion oftooth to the lingual
. qenqrafp rhe r^^t<

. Irrigate the area and proceed to remove the rest ofthe tooth .
Place a sedative

filling and reschedule patient

11'l
CopFighl O 20ll-2012 - Dnral Deks

Regardless of the flap design used, certain principles should be followed while incising and reflecting 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
duced by the surgery

be pro-

. 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
a

lmportant: The correct position for ending

vertical releasing incision is at

tooth line angle not

over the buccal surface of a tooth. lf it ends over a buccal surface, the edges are difficult to approximate and this may lead to pe odontal problems. Incision should never cross bony prominences as this increases the chance for wound dehiscence. Three types 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. Tle 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. Teeth with two or more roots often need to be sectioned into single entities prior to successful removal. A popular method ofsectioning is to make a bur cut between the roots, fbllowed by inserting an elcvator in the slot and tuming it 90o to causc a break. Roots can be removed by closed technique. The surgeon should begin a surgical removal if the closed technique is not immediately successful.

***

Indications for surgical extractions: . After initial attempts at forceps extraction have failed . Hypercementosis or widely divergent . Patients with dense bone . Extensive decay which has destroyed . In older patients, due to less elastic bone . Short clinical crowns with severe attrition (bruxers) most ofthe crown
Teth 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.

Remember: When luxating a tooth with forceps, the movements should be firm and delibcrate, primarily to the facial with secondary movements to the lingual. The maxillary first bicuspid is least Iikelv to be remoyed by rotation forces due to its root structure (obviously molars.tre nol removed b!* totation).
.

-.

l;otes,,

1. It is recornmended to use a bite block when removing mandibular teeth to diminish 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

. In the infratemporal fossa

. In the submandibular

space

. In the mandibular canal . In the pterygopalatine fossa

112 Cop)riglt O 201l-2012 - Dental Decks

. Replacement ofthe connective tissue by fibrillar bone . Hemorrhage and clot formation
. Replacement
srte

of granulation tissue by connective tissue and epithelialization of the

. Recontouring ofthe alveolar bone and bone maturation . Organization ofthe clot by granulation tissue

113

Coplright O 201 l-:012 - Dmral Decks

Important: 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 either be in the mandibular canal or through the lingual cortical plate. The mandibular canal is generally found buccal to the roots ofthe mandibular third molar.
tips The submandibular space is a potential space ofthe neck bounded by the oral mucosa and tongue anteriorly and medially; the superficial layer ofdep cervical fascia laterally, and the hyoid bone inferiorly. The mylohyoid muscle, stretching across the floor of the mouth, divides the submandibular space into a portion above this muscle: sublingual arrd
a portion below: submaxillary spaces.

Note: The submaxillary submental and sublingual spaces are collectively referred to as the submandibular space. This space usually drains infections from the mandibular bicuspids and molars because their apices lie below the mylohyoid muscle attachment. The submental space is the medial part of the submaxillary space. It contains the submental lymph nodes that drain the median parts ofthe lower lip, tip of the tongue' and the floor ofthe mouth. Usually drains infections from the mandibular incisors and canines because their apices lie above the mylohyoid muscle attachment.
The sublingual space is the superior part ofthe submandibular space, containing the sublingual gland and loose connective tissue surrounding the tongue.

Remember: Ludwig's angina is the most commonly encountered neck space infection
(involves the sublingual, submandibular, and submental spaces).

\ote: Glucocorticoids

have been shown to have the greatest effect on granulation tissue --

the! retard haling. 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 reduced.

. Glucocorticoids inhibit formation ofgranulation tissue by retarding capillary and fibroblast proliferation and collagen synthesis.

The same stages that occur in normal wound healing of soft tissue injuries also occur in the repair ofinjured bone. However, osteoblasts and osteoclasts are also involved to repair damaged bone tissue.

Bone 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 with

minimal callus for

. Digastric muscle

. Temporalis muscle
. Lateral pterygoid muscle

. Medial pterygoid muscle

114
Coplaight C20ll-2012 " Denta! Decks

. LeFort I . Le Fort II
. LeFort

III

. Zygomatic fractures

115
Copyright O 20ll-2012 - Dental Decks

Muscles involved in displacing mandibular fractures include the medial and lateral pterygoid, temporalis, masseter, digastric, geniohyoid, genioglossus, and mylohyoid. The lateral pterygoid displaces the condyle antriorly and medially because of its insertion on the pterygoid fovea. Muscles attached to the ramus (i.e., temporalis, n,asseter,.tnd medial pterygoid) result in superior and medial displacement ofthe proximal segment. As fractures progress anteriorly toward the canine region, the digastric, geniohyoid, genioglossus, and mylohyoid exert a posterior-inferior force on the distal segment. The lateral pterygoid muscle is the only muscle that inserts directly on the neck ofthe mandibular condyle. In subcondylar fractures, the forces of this muscle frequently result in anterior and medial displacement ol the condyle. In higher condylar fractures and in intracapsular fractures above the insertion olthe lateral pterygoid, the small fragment can occasionally be seen displaced in a pure hodzontal or vertical direction.

)tlote: Displacement of the proximal segment of the condyle usually occurs in an anteromedial direction because ofthe pull ofthe lateral pterygoid muscle. The patient will deviate to th side ofth fracture upon opening because ofthe unopposed action ofthe
contralateral lateral pterygoid muscle.

Z,vgomaticomaxillary complex (ZMC1 fractures involve four major processes: the zygomaticotiontal rcgion. inliaorbital rim, zygomatico buttress, and zygomatic arch. Zygomatic fracturcs arc commonl)' encountered in lbcial trauma because oftheir prominent position on the facial skeleton.
The rnost conlmon mechanism producing facial fractures is auto accidents. About 70 7o ofauto accidents produce somc type of lacial injury, although most are limitcd to soft tissue. The face seerns to be a favo.ite target in fights or assaults, which arc the ncxt most common mechanisrn. As with mandible fractures, midface fractures are described by the bone involved, as simple /closed),com-

pound /operr, or comminuted. Fracture type prevalence:

. Zygomaticomaxillary complex: 40 % . LeFort I: 15 70

II: l0 % III: 10 %
. Zygomatic arch: l0 o% . Alveolar process ofnaxilla: 5 %
Abnoinal mobilily ofthe boie

. Smash fractures: 5 70
. Other: 5 % maxilla and mandible are in a critical relationship to the upper airway; therefore Nofeg- 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 deformity 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.
1. The

. Hematoma . Wound dehiscence . Facial or trigeminal nerve injury

. Infection

115 Cop,.right O 20ll-2012 - Dental Decks

. Attachment of the muscle r Trrna nff.rnt""-

. Direction of muscle fibers . Line of fracture

117 Cop).righr O

20ll'2012,

Denial Decks

Of these, infection is one ofthe most problematic; it is the most frequent complication and is an
important cause of non-union.
The most common cause ofpostoperative infection is movement at the fracture site due to loose, mobile hardware, such as a loose screw in an otherwise stable plate.

Four reasons that a fracture does not heal: l. Ischemia: the navicular bone ofthe wrist. the femoml neck. and the lower third ofthe tibia are 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:
f

fat embolism is most often

a sequela

of fracfures.

nappropriate healing (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, improper 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.

The line of fracture will determine whether muscles will be able to displace the fractured segments from their original position. Favorability is determined by the forces exerted by the masticatory muscles on the lracture segments. A favorable lracture is one that is not displaced by masticatory muscle pull, and an unfavorable &acture occws when the line offracture permits the fragments to sparate.

The four muscles of mastication are the temporalis, masseter, medial pterygoid, and lateral pterygoid. After discontinuity ofthe mandible due to fracture, these muscles exert their actions on the lragments. leading to malocclusion. Signs and symptoms 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

Approximately 43% ofall patients with mandibular fractures have associated other systemic injuries. Cewical spine fractures were found in I l% ofthis group ofpatients. It is imprative to rule out cervical neck fracturs, especially in patients who are intoxicated or unconscious and in patients who are involved in vehicular accidents. Posteroantedor, lateral films, and CT ofthe neck should be reviewed with the radiologist before trcatment is initiated in these patlents.

z\
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. . )

. Simple
. Greenstick . Compound
. Comminuted

118
CopyriShr O 201 l-2012 - Dental Drcks

. Mandibular fractures

at the angle

. Fractures ofthe mandibular condyle

. Le Fort I fractures
. Zygomatic fractures . All ofthe above

1r9
Copyrighr @ 2011,2012 - Dental Decks

The ossification capability ofchildren allows faster healing and distinguishes it from the adult mandible. As a result, many mandibular fractures in children can be treated with immobilization for a shorter period or observation and soft diet only than in an adult. Note: Open reduction and intemal fixation in children is reserved for severely displaced fractures.

In an adult, the location oflacial fractures is influenced by both the resistance ofthe bone to fracture and how prominent its position on the facial skeleton is. Adult facial fractures are most commonly seen in the nasal bones followed by the zygoma, mandible, and maxilla. In children, early growth in the cranium and orbits predisposes young children to fiontal bone and orbital fractures. The following categories classil! mandibular fractures by describing the condition ofthe bone fragments at 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 segments. Infection is common. . Comminuted: are multiple fractures of a single bone. They may be simpl or comp-

ound.

the cortical portion of th bone withoutcomplete fracture ofthe bone. Greenstick fractures are closed fractures involving incomplete ftactures with flexible bone. Most often seen in children.

. Grenstick: fracture that extends only through

Remember:

(l)

The most common complication ofan open fracture is infction.

(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.

a posteroanterior oblique wate6 view or a reverse Waters view together with a posteroanterior and submgntal vertex view ofthe skull were used for evaluating zygomaticomaxillary c omplex (ZMC) fractures. However, the CT sc^n Ooth axial qnd cotonal orientations) is c\tfier'tly the diagnostic imaging ofchoice forevaluating these fractures as well as the other fraciures listed. This imaging modality shows the location of the fractures, degree of dis-

Note; For a long time in the past,

placement ofthe bones, and status ofsunounding soft tissues.

lmportant: Dysfunction ofthe infraorbital nerve is common in a patient with a ZMC fracture. An ophthalmologic examination is ofparamount importance. Also, fractures ofthe facial bones, particularly the zygomatic complex may on rare occasions be complicated by damage to the contents ofthe superior orbital fissure. Other possible complications ofthe zygomatic complex fracture include:

. Parsthesia 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
Note: The most feared, but fortunately rare, complication ofZMC fractures is blindness. Remember: By definition, the four articulating sutures (ZE ZT ZM, ard ZSJ are disrupted in this fracture. Therefore the commonly applied term "tripod fracture" is a misnomer and does not correctly describe this fracture. Most practitioners consider CT scanning to be the gold standard imaging rnodality for evaluation of mandible fractures. A CT scan allows the entire face to be evaluatcd in one study. Despite the popularity ofCT imaging, in many facilities the initial imaging studies may consist ofpanoramic radiography or a plain-view series ofthe mandible ((i.e., posteroanterioti Waters, reverse-Towne, or subtnentovertex projections) Many nrral hospitals still use a plain-vicw series ofthe mandible. Therefore familiarity with plain radiographs is important.

. Favorable, non-displaced fractures . Displaced and unstable fractures, with associated mjdface fractures, and when MMF is
contraindicated

. Either ofthe above . None ofthe above

120 CopriSht O 201l-2012

- Dental Dects

One way: by direct or primary bone healing which occurs without callus formation
a callus precursor

.One way: by indirect or secondary bone healing which occurs with

stage

. Trvo ways: by direct or primary bone healing which occurs without callus formation and indirect or secondary bone healing which occurs with a callus precursor stage

121 Coptr'ghr O
201 1,201 2

, Dntal Decks

Treatment options ofmandible fractures can be divided into rigid fixation, semirigid fixation. and non-rigid or closed reduction. Methods considered rigid fixation are the lag screw technique, compression plating, reconstruction plates, and extemal pin fixation. Miniplate fixation and wirc fixation are types of semirigid fixation. Maxillomandibular fixation ([MMFJ \\'ith i'vy loops, arch bars, or lransalveolar screw), gunning splints, and lingual splints are considered non-rigid fixation. Rigid fixation allows for primary bone healing without callous formation. Non-rigid fixation allows for secondary bone formation with inflammatory infiltration and callous lormation. Semirigid fixation allows for areas of primary and secondary bone formation. . Closed reduction is best used in the treatment of favorabl, non-displaced fractures. It is also used

in situations in which Open Reduction lntemal Fixation (OR1F) is contraindicated. Maxillonarulibrllar fixation (MMF) is obtained by applying wires or elastic bands between the upper and lower jaws, to which suitable anchoring devices can be attached, such as arch bars or skeletal screws. The standard length ofmaxillomandibular lrxatlon (MMF) is 4-6 weeks. . Open reduction involves direct exposure ofthe fracturc site and placement of intemal fixation ofthe fracture site. Open reduction is used in displaced and unstable fractures, associated midface fractures, and when MMF is contraindicated. In addition, some surgeons advocate ORIF for patient comfort and for expedited retum to activity and work. Arch bars are al$ays placed first to establish occlusion, then ORIF is performed. The plates can be placed inhaorally, extraorally via a cervical incision, or percutaneously. Dynamic compression plates (DCPJ can be used for most body, angle, symphyseal or parasymphyseal fractules.
to prcvent movement

*ith

Note: Initial management of mandibular ftactures starts after the patient has been stabilized. All fractures oftooth bcaring arcas ofthe mandible are considered open and should be treated with antibiotics that cover mouth flora, specifically gram positive and anaerobic organisms. Mouth rinses with peridex solution or half strength hydrogen peroxide in water are useful to keep the mouth clean. Timing ofrepair is controversial. Several studies have shown a decreased incidence of infection ifcompound fractures arg repaired within 48 hours. Other studies have shown no change if fractures are repaired in less than a week. Regardless ofinfection rates, patient comfort dictates that the earliest date lbr repair is the best as displaced fractures are painful.

Primary bone healing involves a direct attempt by the cortex to re-establish itselfafter interruption. Bone on one side ofthe cortex must unite with bone on the other side ofthe cortex to re-establish mechanical continuity. Under these conditions, bone-resorbing cells on one side of the f.acture sho.,\,a tunneling resorptive response, whereby they re-establish new haversian systems by proriding pathways for the penetration ofblood vessels.
Secondar! bone healing involves the classical stages offracture healing.
Stages of fracture healing:

. Stage
\\'ecks,

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
2 and 3 weeks after the

. Stage 2; Soft callus- between

-\t rhis point, the site ofthe fracture stiffens

injury the pain and swelling will decreasc. 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 bgins 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 fracIUre.
8 to I 2 weeks after the injury the fracture site remodels itself, correcting any deformities that may remain as a result of the injury. This final stage offracture hcaling can last up to several years. The rate ofhealing and the ability to remodel a fractured bone vary tremendously for each person and depend on the patient's age, health, the kind of fracture, and the bone involved. For example, children are able to heal and remodel their fractures much faster than adults.

. Stage 4: Bone remodeling- beginning about

Compartment syndrome: Severe swelling after a fracture can put so much pressure on the blood
vessels that not enough blood can get to the muscles around the fracture. The decreased blood sup-

ply can cause the muscles around the fracture to die, which can lead to long-term disability.

. Nasal bleeding . Exophthalmos

. Malocclusion
. Numbness in the infraorbital nerve distribution

122
Coplrighr O
201

1,2012 - Dntal Decks

\
.,1

. LeFort I . Le Fort II
. LeFort III

123 CopF,ghtO 201l-2012 - De alD4ks

Other signs and symptoms of a mandibular body or angle fracture include: . Lower lip numbness . Mobility, pain, or bleeding at the fracture site
The important points in treating mandibular fractures are immobilization ofthe fractures, the appropriate use ofantibiotics, and restoration of form and function. The usual treahnent for mandibular fractures that are displaced and mobile is with open reduction and intemal fixation using titanium bone plates and screws. tfthe patient has teeth, the occlusion is used as a guide for the surgeon to repair the fracture. Other methods ofrepair include splinting (/or pedistric patients) and maxillo-

nandibdar fixation

(see below)

Establishing a proper occlusal relationship by wiring the tceth together is termed maxillomandibular 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. More recentl% techniques for rigid internal fixation (NF) have ga;Lned popularity for treatment offractures. These use bone plates, bone scrcws, or both to fix the fractwe more rigidly and stabilize the bony segments during healing. Even with rigid fixation, a proper occlusal relationship must be established before reduction stabilization and fixation ofthe bony segments. Advantages ofRlF for treatment of mandibular fractures include decreased discomfort and inconvenience to the patient because [MF is eliminated or reduced, improved postoperative nutdtion, improved postoperative hygiene, and frequently better postoperative management ofpatients with multiple injuries.

Notei Mandibular angle fractures are generally more prone to the development of complications compared with the body or symphyseal areas. Multiple complications may arise but most commonly include loose hardware necessitating rcmoval, infection, malocclusion, delayed union, and fibrous union. Damage to the inferior alveolar and lingual nerve can be a complication ofthe initial injury or a consequence oftreatnent.

Types of Le Fort's fractures: . Le Fort l: the fracture line traverses the maxilla through the piriform aperture above the alveolar ridge, above the floor of the maxillary sinus, and extends poste orly to involve the pterygoid 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 fracture.
nasal bones at the frontonasal sutures. It extends 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 relatiye 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.

. Le Fort II: superiorly, this fracture traverses the

Clinical manifestations of midface fracturs: . 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

. Nasal bleeding, subconjunctival ecchymosis, maxillary hypoesthcsia, and tendemess of the bony buttresses ofthe midface are other signs and symptoms ofmidfacial and maxillary fractwes.
lmportant
The first step in the treatment ofthese is similar to the treahnent ofmandibular fractures

. Mobility of the midface

fractues which affect the occlusal relationship

to re-establish
a

proper occlusal relationship

the mandible. by placing the maxilla into proper occlusion with -

. Body . Angle

. Symphysis . Coronoid process

124 CopriShr e
201

l-2012 - Dertal Decks

Patients with hypocalcemia have an lonized calcium level blow 2.0 or serum calcium concentntion lower than 9 mg/dl. Some ofthe most common causes are:

. Hyperparathyroidism . Diabetes

and cancer

and hypothlroidism

. Renal failure and hypoalbuminemia . Grave's disease and hypopituitarism

125
Cop'right O 20ll-2012 - Dnral Decks

The location and extent of mandibular ftactures axe determined largely by the direction and intensity ofthe blow and the specific points ofweakness in the mandiblc.

The condylar neck (29.1o.4 offractures) is a safety featue which allows the blow to the jaw to be dispersed at this point rather than driving the condyle into the middle cranial fossa. Bilateral dislocated fiactures ofthe condylar necks will cause an anterior open bite and the inability to protrude the mandible. A unilateral fracture through the neck may cause forward displacement ofthe head ofthe condyle due to pull ofthe lateral pterygoid muscle. The symphysis (22'% offractures) is usually where blows are sustained. These blows often result in fractures of the subcondylar region.

Remember: The patient's mandible will deviate to the side of injury upon opening.

Note: Mandibular fiactures can almost always be identified on a panoramic radiograph. Ifa fracture is suspected, at least two different radiographs should be taken for comparison
(i.e., panoramic, posteroanterior, Waters, reverse-Tbwne, or submentovertex projections).

are regulated by parathlroid hormone and to some extent by the kidney tubules and GI mucosa. Other causes ofhypocalcemia are vitamin D deficiency, hlpoparathyroidism,

Calcium levels

pancreatitis, rhabdomyolysis, severe hypomagnesemia, multiple citrated blood transfusions, and d gs (antineoplastic agents, antimicrobials, agents used to treat hryercalcemia). Cfuonic hypocalcemia can be asymptomatic. Clinical manifestations are paresthesias of the lips and extr-emities due to increased excitability ofnervs, tetany, cramps, and abdominal pain due to spasm ofskeletal muscle, and convulsions.

\ote:

Chvostek's and Trousseau's signs are seen in hlrpocalcemia. Chvostek's is twitching

of

the facial muscles as a result of tapping over the facial nerve in the preauricular area, and Trousseau's sign is carpopedal spasm due to occlusion of the brachial artery when a blood pressure cuff is applied above systolic prcssure for 3 minutes.
an abnormally high level ofcalcium in the blood, usually more than 10.5 mg,dL. The most common causes ofhypercalcemia are hlperparathyroidism and cancer. Ilnemonic for symptoms of hypercalcemia: . Stones: renal calculi . Bons: bone destruction . Moans: confusion, lethargy, fatigue, weakness . Abdominal groans: abdominal pain, constipation, polyuria, and polydipsia

Hlpercalcemia is

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.
1.

. Duration

. Origin
. Color

Size and location to vital structures

126
Coplrighr O 20ll-2012 - Dental Decl!

. After one minute ofCPR . After two minutes of CPR . After three minutes of CPR

. Immediately when

an adult is found to be unresponsive

Coplright O

201

127 l-2012 - Dental Decks

Treatment ofchoice; should be used when it crn be safely be done without sacrilicing Creating a surgical window in the When etrucleatior would damage adjacent wall ofthe cyst, evacuating lhe sttuctules
contents

ofthe cyst; and main-

taining continuity between the cyst and the oral cavity Marsupialization is done first.

Ifcyst

Aftcr initial healing secondary

enucleation may be undertaken

is not totally obliteBted afier marsupialization heals

without injury to adjacent

strucfures

After enucleation

a curette or bur is used to rcmove I to 2 cm of bone 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

l. Marsupialization, decompiession, and the Partsch operation all refer to creating a surgiNotesl: cal window in thc wall ofthe cyst. The cyst is uncovered or "deroofed" and the cystic lining made continuous with the oral cavity or sunounding structures. The cyst sac is opened
and emptied.

2. Cysts and cysFlike lesions can be classificd as fissural or odo[togenic. Odontogenic keratocysts have a higher rate ofrecurrence than do fissural and cysts ofodontogenic inflam-

matorv onsln.

*** For an infant or child victim the EMS should

CPR

be activated after

I minute or 5 cvcles of

Cardiopulmonary Rsuscitation: -{ = 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, - their head back with . Head-tilt/chin-lift: open victim's airway by tilting

one hand while

liliing up their chin with your other hand.

B = 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, perforrn abdominal thrusls (Heimlich maneuver)
C = 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 pr 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 directly 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.

. Vascular

. Leukocytic
. Platelet

. Coagulation

129
Coplright O 20l l-2012 - Dqtal Declr

.\

When a chlld or infant has a putse but is breathtess, what is the recommended rate ofrscue breathlng?

. Once every

3 seconds

. Once every 5 seconds . Once every 8 seconds

. Once every

10 seconds

'| 30 Coplrighr O 201 I ,2012 - Dental Dcks

There 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 Important: If a patient is taking aspirin, anticoagulants, broad-spectrum antibiotics, alcohol
or anticancer medications you should be prepared to take special measures in order to control the bleeding. Note: Patients with specific systemic diseases will also have a prolonged bleeding time. These include nonalcoholic liver disease, hepatitis, cinhosis, and hypertension.

Five means ofobtaining wound hemostasis: L By assisting natural hemostatic mechanisms accomplished by placing a -usually 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 surgery 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 once every 5-6 seconds (l0-I2 breqths/minute). * A victim rvhose heart and breathing have stopped has the best chance for survival if emergency 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, whereas rhe carotid 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
r as critical with the new guidelines conceming the length of time recommended to deliver each breath to an infant or child. Now it is imoortant to deliver breaths that make

* Time is not

lctlm.

the r.ictim's chest rise.

Rescue breathin&

victim

has a

p1lse, give breath vry: In lhe cenrcrofthe

breast 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

. Class I .
Class 2

. Class 3
. Class 4

. Class 5

13.t

Cop)righr O 2011-2012 - Dental Deks

What is the most frequent cause of airw|y obstruction in an unconscious person?

. Chewing gum

. Cigarette
. Tongue

. Hard candy

132
Coplright C20ll-2012 - Dental Dcks

The ASA classification was first established in 1940 for the purpose of statistical studies and hospital records. It is useful for both outcome comparisons and as a convenient means classes. as last modified

of communicating the physical status of a patient among anesthesiologists. The five in 1961. are:
Class

Healthy patient, no medical problems

Class 2 Class 3 Class 4

Mild systemic disease

Severe systemic disease, but not incapacitating Severe systemic disease that is a constant threat to

life

Class 5

Moribund, not expected to live 24 hours regardless ofoperation

6

*** An organ donor is usually designated as a class

The first step when initiating CPR is to establish unresponsiveness (shake and shout

"Are you

OK'). Then:

CALL
catt
9l

BLOW
I
Glltt
tt utr

]lt,

G]t,

am

tlltII||l

l|t|nl

r:a

PUMP
rtl G:mt rtt !!r3r
rr

ta]I|ar

ulrl

It

;Lllr tllt lt:l rtt|llllt at Il:rftrr tal|ftt

Slt rtrrr tll llll[t ltt ta rrr'l lllll rtltllllltl

Important 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

Remember, 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

.IMR
.IGR

.ITR .INR

133
Copyright O 20ll-2012 - Denral Decks

. Applying the blood pressure cufftoo tightly . Applying the blood pressure cuff too loosely

. Overinflating the blood pressure cuff . Underinflating the blood pressure cuff . The use oftoo large or too small cuffs

t34
Cop),righr O 20ll-2012 - Dental Decks

The accuracy ofthe Prothrombin Time (PT) is known to be very system-dependent. The World Health Organization has addressed this system variability problem by (l) the establishment of primary and secondary intemational reference preparations of thromboplastin and (2) the development ofa statistical model for the calibration olthromboplastins to dedve the International Sensitivity Index (ISI) and the lNR.

INR (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

sensitivity index assigned to the test system) The recommended therapeutic ranges for standard oral anticoagulant therapy and

*** (lSI is the intemational

is calculated as (PTou1i"rr1 / PTrror-u1)rsl

high-dose therapy, respectively, are INR values of2.0-3.0 and 2.5-3.5. Other 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 candidate 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 minimal platelet count for oral surgery is 50,000

Important: Perhaps the single most important consideration in ruling out hemorrhagic disorder is historv.

Important: Use ofthe wrong cuffsize can result in enoneous readings. A normal adult blood pressure cuff placed on an obese patient's arm will produce falsely elevated readings. This same 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 dght
atrium. . 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. Blood pressure 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 diastolic 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% of patients. 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 reduced at 2 to 3 mn/second. Two readings should be performed at least one minute apart.

140-159

. Xenogenic bone
. Allogenic bone
. Autogenous bone

. Alloplastic bone

135 Cop)right
@

20ll-201?

Denral Decks

The most commonly used allogeneic bone is:

. Freeze-dried
. Demineralized freeze-dried bone . Fresh frozen

136 Coplright O2011,2012 - Denlal Decks

An autogenous bone graft is the transplantation ofbone from one site to another site within the same person. These grafts may be ofcancellous, cortical or a combination ofcortical and cancellous bone. Autogenous bone is the only gaft that possesses all ofthe lollowing properties, osteoinduction, osteoconduction, and osteogenesis. Additionally, tbere are no inmunogenic complications. The dom sides to autogmft are the finite quantity available and donor site morbidiry Types of autognous bone grafts: . Cortical grafts: advantages are due to its structural capabilities, Also has a higher concentration of BMP (bone morphogenic protein). The dtsadvantages are due to the lamellar architecture. Common donor sites: iliac crest, ribs, anterior cortex ofthe chin, lateral cortex 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 disadvantage 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 obfrom the iliac crst (anterior and posterloy'. Also used for ridge augmentained ^\ot*,
... ..-..

li

tation.

of the cytokine family of growth factors, which occurs in the organic portion of
bone called the bone malrix. 3. A costochondral rib graft may be employed with the cartilaginous portion simulating the TMJ and condyle. When used for ridge augmentation there is a great

deal ofshrinkage. 4. Bone plates, biphasic pins, titanium msh, and intraosseous wires are used in the fixation ofbone grafts. Sutues are not generally used.

Allogeneic bone is nonvital, osseous tissue harvested from one individual and transfened to another of the same species. Three forms of allogeneic bone include: fresh frozen, freezedried, and demineralized freeze-dried bone. Fresh frozen bone, howevel is rarely used due to the concem related to transmission ofdisease. . Freeze-dried bon is osteoconductive, howevel it has no osteogenic or osteoinductive capabilities. Freeze-dried allogeneic grafts are usually placed in conjunction with autogenous
grafts.

. Demineralized freeze-dried allogeneic bone lacks mechanical shength, but has osteoconductive and osteoinductive capabilities. Demineralizing the freeze-dried bone exposes the bone morphogenetic proteins which has been shown to induce bone formation.
The three processes by which bone can be repaired or regeneratd are: . Ostogenesis (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 of osteoinductive 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 osteoprogenitor 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. . Ostoinduction refers to new bone formation fiom the differentiation of osteoprogenitor cells, derived liom primitive mesench],rnal cells, into scretory osteoblasts. Such grafts help nroduce the cells that are necessary to Droduce new bone.

Which of the following refers to a horizontal osteotomy of the anterlor mandible?

. Blepharoplasty

. Genioplasty . Cervicofacial rhytidectomy

. Rhinoplasty

137 Coptrighr

201i '2012 , DentalDecks

. Autogaft . Allograft . Xenograft

Tissue removed from an animal donor and surgically transplanted 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-

. Isograft

cally non-identical individual ofthe same species

t38
Coplri8hr O 2011,2012, Dfrral Declr

Cenioplasty refers to a horizontal osteotomy of the anterior mandible. Chin implant refers to either an alloplastic implant or an autogenous implant. Alloplastic implants and sliding genioplasty represent the two currently accepted methods ofchin augmentation,

A sliding genioplasty involves removing a horseshoe shaped piece ofthe chin bone and sliding it either backwards or forwards, finally fixing it in place using titanium scrws. The most common complication after genioplasty surgery is a neurosensory disturbance, followed by
hematoma and infection.

Alloplastic augmentation can also be considered for the treatment ofa genial deficiency. The
materials most commonly used include high-density polyethylene, hard tissue replacament polymer, polyamide mesh, solid medical-grade silicone rubber, hydroxyapatite, and Gore-Tex. Problems that are frequently encountered when using alloplastic materials for the treatment ofa 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 Remember: Alloplastic grafts are inert, man-made synthetic materials. The modem artificial use metal alloplastic grafts. For bone replacement a man-made material that mimics natural bone is used. Most often this is a form of calcium ohosohate (i.e., ticalcium phosphate, calcium cqrbo qte, ot hydroxyLpatite).

joint replacement procedures

Classification ofgralts (or impla ts): . Autogenous grafts (also called autografts) are composed of tissues taken from the same individual. Most frequeltly used in oral surgery. . Allogetreic grafts fa ko called allografts) are composed oftissues taken from an individual of the 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 oral

surgery. Note: Rejection ofthe graft is most common when allografts or xenografts ofbone and cartilage
are used in oral surgery Autogenous grafts, although frequently presenting surgical and technical problems, do not as a rule involve rejection (or immunological complications).

The 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 potential occurs with an autogenous cancellous graft and hemopoietic marrow.

. Original
. Natural

. Synthetic
. Genuine

139

Coplriglu O 2011,2012

- Dental Dects

. Fibro-osseous integration . Osseointegation

. Biointegmtion

14D

CopFight O 20l l-2012 - Detrtal Dcks

The term alloplastic is synonymous with synthetic, This indicates that the material is produced from inorganic sources and contains no animal or human components. Alloplastic materials offer a prepackaged solution to common reconstructive surgical problems without the need for autogenous grafting and donor site morbidity. For bone replacement a man-made material that mimics natural bone is used. Most often hydroxyapatite (HA) is used for augmentation of the mandible. Hydroxyapatite is a dense, biocompatible material that can be produced synthetically or obtained from biologic sources such as coral. The granular or particle form is most commonly used for alveolar ridge augmentation. Note: When placed in a subperiosteal environment, HA bonds both physically and chemically to the bone. Some advantages and disadvantages of restructuring an atrophic ridge with hydroxyapatite 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

The bone-implant interfac:

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 a load-carrying implant without soft-tissue . Yields most predictable long{erm stability . Several important factors involved: materials, surface characteristics, bone, timing

of

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.

lmportant principles for success of dental implants: primary stability, amount of bone,
anatomic structures (i.e., adjqce t nqtural teeth, maxillary sinus, nasql cqvit),, inferior alveo-

lur canal).

- . , - 1. To ensure the development ofkeratinized tissue around ,,Note*'i - time to augment the soft tissue is Stage ll surgery.

a dental

implant the best

..6-:

2. Guided tissue regeneration is a surgical procedure used to eliminate a bony defect 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 rnd implant of an endosseous dental imphnt?

. Periodontal ligament . Peri-implant ligarnent . Epithelial ligament . A bone-implant interface

141

coptrighr O

201

l'2012 - Dental Decks

Which of the following faclors would have the grertest negative influence on a dental implantrs success?

. Hlpertension
. Patient over 70 years ofage

. Smoking
. Alcohol

Post by-pass surgical patient

112
Coplright O 20l l-2012 - Dental Decls

The histologic definition of osseointegration is best described by the following: The direct connection between living bone and a load-bearing endosseous implant at the light microscopic level. Only endosseous and transosseous implants are considered true osseointegrated implants. Criteria 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. .-;:;;.1,,' 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 minimum required distance lrom the apex ofa mandibular posterior implant to the superior aspct ofthe inferior alveolar canal is 2 mm. 6. Titanium and titanium alloy are the most common materials used today for twostage endosseous imPlants.

***

Because smoking affects the healing of bone and overlying tissue,

it should be con-

sidered a relative contraindication to implant placcment.

Any toothless arca can be considered for dental implants. Determining whether implarrts are an option and the type of implants to use include: the patient's rcquirements and expectations. the amount ofadditional work needed (i.e., bone groftlng), the dentist's skill level, and
the long-term prognosis.

Some 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

Important: In patients with uncontrollcd systemic

considered with extreme caution.

diseases such as diabetes, immunocompromised patients, and patients with blceding disordcrs, implant placemcnt should be

Remember: l. Thc highest failure rate is seen in the posterior maxilla where the bone is thc softest (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. 1.5 mm 4. The minimum space required for a 4.0 mm diameter implant is 7.0 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 attachment such as an "O" dng is l5 degrees.

. Blade form implants

Subperiosteal implants

. Transosseous implants . Root form implants

143
Cop).right O 201l-2012 - Dental Decks

. Cephalexin . Amoxicillin

. Clarithromycin . Erythromycin
. Azitfuomycin . Clindamycin
144 CoDright O 20l l-2012 - Denul Deck

Dental implants are divided into three categories based on their relationship to the oral tissues:

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
1. Endosseous

(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 primary indication is in the very atrophic mandible where root form implants may further compromise the strength ofthe jaw.

Remember: Osseointegrated implants are anchorcd directly to living bone. This detemlination is rnadc by radiographic and light microscopic analysis. Only endosseous and transosseous implants are considered true osseointegrated implants.

. Root form implants: cylindrical in shape, can be smooth, thrcaded, perforated, and solid or hollo$, 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 divided into three phases; surgical, healing and prosthetic. Note: These implants are the most popular, . 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 single and two stage forms. Typically made oftitanium as well.
Two basic types 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)

In adults, the new antibiotic regime recommended for the prevention of infective endocarditis is: . Amoxicillin: 2.0 grams, 30-60 minutes hour prior to the procedwe (bur 500
mg tqblets)

For those patients allergic to penicillin, . Clindamycin: 600 mg, 30-60 minutes to the procedure (bur 150 mg tablets)
The guidelines for children are: . Amoxicillin: 50 mg,&g, 30-60 minutes prior to the procedure For those patients allergic to penrcillin, . Clindamycin: 20 mglkg, 30-60 minutes prior to the procedure
These 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 erythromycin . Prophylaxis is no longer required for many dental procedures

Alternatives for patients who are allergic to penicillin and who cannot take clindamycin include cephalexin, clarithromycin, and azithromycin.

. Buccal

space

. Canine space

. Infratemporal . Submaxillary

space
space

l,ls
Coplright O 201 I -20 l2 - Dental Decks

ORALSI'RGERY&PAINCONTROL

.,

MiS

. Surgically

extract the unerupted second molar

. Uncover the crown and keep it exposed

Prescribe an anti-inflammatory medication and schedule a follow-up appointment in six months

is necessary at this time

. No treatment

1,16

Coptlighl O 201l-2012 - Dental Decks

Remember: The mylohyoid muscle, stretching across the floor ofthe mouth. divides the submandibular space into a portion above this muscle /srblingual space) and aportion below fru6lr4rillary space).

Spme

Usual Source of lnfection

Marillary Sp.ces
Canines space Buccal Spacc Canines

Maxillary molars, premolars Maxillary tbird mola$

lnfratemporal space

Maldibular

SDaces

Buccal spac
Submntal spsce Submandibular space Sublingual space

Mandibular molars, premolam Mandibular incisors Mandibular molars, premolars Mandibular molars, premolats Mandibular molars Mandibular molars, premolars Mandibular third molars
Other spaces (i fratemporal. masseteric and pterygomandibular) Other sp ces (pterygomandibular and temponl

Submaxillary space Ptqygomandibnlar space

Masseteric space

Temporal space
Masticator space

,\..oter Peniciilin V is often the preferred drug to heat odontogenic infections. It is effective against Sheptococci and oral anaerobcs. For penicillin-allergic patients, clindamycin or clarithromycin can be used

Narrow specmlm antibiotics are preferred over broad-spectrum antibiotics and bacteriocidal agnts are
preferred over bactcriostatic agents.

Dentigerous cysts are those associated with the crowns ofunerupted teeth. Some literature refers to these cysts as "follicular" or "primordial" cysts. Note: They are probably the result ofdegenerative changes in the reduced enamel epithelium. Remember: Ifcysts form when a tooth is erupting, they are called eruption cysts. These cysts interfere with normal eruption ofthe teeth. Eruption cysts are more commonly found in the child and young adult, and may be associated with any tooth. If treatment is indicated, simDle incision or "deroofing" is all that is needed.

Dentigerous cyst

Eruption cyst

. Buccal . Canine

. Submandibular
. Masticator
. Vestibular

Coplrjght C

201

117 l-2012 - Dental Decls

. Orally
. Axillary . Rectally

. Aurally

14
CopriShi O
201

1,2012 - Dental Dcls

Fascial spaces: layers offascia "create" potential fascial spaccs (they are called potential because in health there is no space/; all are filled by loose areolar connective tissue. The hyoid bone is the most important anatomic structure in the neck that limits thc spread of infection. Infections or other inflammatory conditions spread by the path ofleast resistance to rcach the fascial spaces. The most common space involved is the vestibular space. The spaces directly adjacent to the origin ofthe odontogenic infections are the primary fascial spaces. Infections spread from the origin into thcsc spaces, which are: buccal, canine, sublingual, submandibular. submental and vestibular.

Note: Canine space infections and deep temporal spacc infcctions can result in cavemous sinus thtombosis via the ophthalmic veins.

Fascial spaces that become involved following sproad of infection to the primary spaces are the secondary fascial spaces: The secondary spaces are: pterygomandibular, infratl-mporal, masseteric, lateral pharyngcal, Superflcial and deep temporal, retropharlngeal, masticator and prevertebral. Note: Lateral pharyngeal infections can traverse the rehopharyngeal and prcvertebral spaces and spread into the mediastinum. Factors that influencc the spread ofodontogenic infectioni (l) Thickncss ofbone adjacent to the offending tooth (2) Position ofmuscle attachment in relation to root tip (3) Virulcnce ofthe organism and (,1) 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 mylohyoid muscle divides this space into a portion above this muscle (suhlingual space ) and a ponron below (s u bmaxillary sp ace).

General considerations when chcking vital signs: . The patient should not have had alcohol, tobacco, caffeine, or pedormed vigorous exercise 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

Routine 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 increase in the patient's heart rate.

\ote: Abnormalities ofvital

signs are often clus to diseases, the alterations in vital signs are used to evaluate a patient's progress.

Five najor arcas to be discussed when taking a patient history: l. Chief complaint 2. History of present illness 3. Speciflrc drug allergies 4. Review of systems (heart, Iivet kidnev, brain, etc.) 5. Nature of systems.

Important: In complicated

cases, don't be hesitant to call patient's physician, previous den-

tists. or other health Drofessionals.

. Periosteum

Soft tissues

. Cortical bone . Cancellous bone

l,l9
Coplright O

20ll

2012 - DentalDecks

. Prosthetic heart valve . Complex cyanotic congenital heart disease . Prior coronary anery blpass grafi . Surgically constructed systemic pulmonary
shunts or conduits

. Mitral valve prolapse with regurgitations and./or thickened leaflets

150

CopriShr O2011,2012, Dental Decks

Osteomyelitis is a relatively rare inflammatory process within the medullary 6rareculor) porliorr of bone that involves the marow spaces. Osteomyelitis is generally classified into two major groups; suppurative and non-suppurative. Suppurative osteomyelitis is classified into acute, chronic, or infantilc osteomyelitis. Non-suppurative osteomyclitis is classified into chronic sclerosing (Jbcal and dillitse), Garre's osteomyelitis, and actinomycotic osteomyelitis.

Infection, inflammation, and ischemia are the mechanisms by which osteomyelitis spreads. The most common initiating causes are odontogenic infection and trauma. The infection usually begins in thc medullary space involving the cancellous bone. Evcntually thc cortical bone, periosteum,
and soft tissues become involved.

Note: Garrc's ostcomyelitis is characterized by localized, hard, nontender, bony swclling of the lateral and inferior aspects ofthe mandible. lt is primarily present in children and young adults and is usually associated with carious molar and low-grade infection.

Importanti Acute osteomyelitis occurs more frequently in the mandible as opposed to thc maxilla. The primary reason for this is that the blood supply to the maxilla is mucb richer and is derived from a number of different arteries, while the mandible tends to draw its primary supply from the inferior alveolar artcry Thc dcnsc ovcrlying cortical bonc ofthe mandible prevents penetration ofperiosteal blood vessels, thus the mandibular cancellous bone is more likely to become
ischemic and therelbrc infected. lmportant point: a reduced blood supply will predispose bone to osteomyelitis,
The most frequently found bacteria in patients with osteomyelitis ofthejaws include: Gram-posirire cocci /1.e., Streptococci, Staphylococcus aurers), anaerobic cocci and gram-negative rods. The treatment ofostcornyelitis ofthejaws usually includes both surgical intervention and medical managemcnt ofthe patient, as well, as sensitivity tcsting. Medical management involvcs adminisrralion ofempirical antibiotics, performing Gran stain, and the administration ofculture-guided antibiotics. Surgical treatment includes removal of loose tceth and foreign bodies; sequestrectomy:

debridement; decortication: rcsection; and reconstruction, if necessary.

Endocarditis Prophylaxis Not Recornmended

Isolated secundum atrial septal defect

Surgicall) construcled systemic pulmonary shun6 or conduits

Complex cyanotic congenital hean disease

Surgical repair ofatrial septal defect, ventricular septal defect. or Datent ductus artriosus Prior coronary artery blTass graft

Physiologic, functional, or innocent hean murmurs

\tost other coneenital caadiac malformations

Previous Kawasaki disease without valwlar dysfunction Previous rheumatic fever without vah'ular dysfunction Cardiac oacemakers and imDlanted defibrillators

Mitral valve prolapsed with regugitation andor thickened leafl ets

.i.

Why is a conventioarl handplece thrt expels forced air controindicated when performing dentoalveolar surgery?

. .

Too much bone

will

be removed

These handpieces can cause tissue emphysema or

al air embolus which

can be fatal

. These handpieces are not high-powered enough to remove bone . All ofthe above

151

Coptrighr O

201

l-2012 - Dental Decks

. E.K.G

.MRI
. Panorex
r Biopsy

't52
Coplright O 20ll-2012 - Dental Dects

Very important: Most high-speed tubine drills used in routine restorative dentistry are totally unaccptable for oral surgery. The air exhausted ftom these drills goes into the wound and may be forced deeper into tissue planes and produce tissue emphysema, a potentially
dangerous situation.

Rongeur forceps are the most commonly used instrumnts for removing bone. However, the technique that most oral surgeons use when removing bone is the bur and handpiece. lrrigation of the surgical wound during and after the cutting of bone cannot be emphasized enough. Copious amounts ofcoolant spray are crucial in minimizing osseous necrosis caused by heat generated from the bur. Irrigation serves also to cleanse the crypt and areas beneath the flap ofbony debris, tooth fragments, and blood. Distilled water is not used for irrigation because it is a hypotonic solution and will enter cells down the osmotic gradient causing cell lysis and rapid death ofbone cells. Note: An 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 alveolar process and ultimatly out through the nutrient foramina into adjacent soft tissues, resulting in formation ofa septic cellulitis and tissue emphysema. 2. Atomizing spray bottles activated by compressed air: A similar condition can be induced 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.

Routine 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
general anesthesia should have a chest x-ray and patients over 40 years old should also have an E.K.G.

*** Anyone scheduled for

Factors to be considered in the decision to hospitalize a patient for an elective procedure: . . . .

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)

. A culture for artibiotic sensitivity has been performed

. Localization ofthe infection

. A sinus tract is formed

. The patients fever

has cleared up

153

coplrighr O 20ll-2012 - Dental Decks

. Diamond excision . V-Y advarcement

. Z-plasty

t54
CoplriSht O2011,2012 - Dental Decks

Physiologically, it is at this time that nature has constructed a barrier around the abscess, walling it off from the circulation and making it possible to palpate th presence ofpurulent material within the abscess cavity (known a.t lluctuanc e ).
The important 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 breathing or swallowing, fascial space

involvement, elevated temperature

mised host defenses.

P ,/r1'O,

severe

jaw trismrrs (< I0 mm), toxic appeannce, or compro-

. Treating the infection surgically. Removal ofthe source ofinfction and drainage ofpurulence. - Methods ofdrainage ofodontogenic infcctions: endodontic ffeatment, xtraction ofthe ollending tooth or incision and drainage ofthe soft tissue. . Support the patient mdically: airway maintenanc, rehydration, analgesia, nutrition, etc. . Prescribe appropriate arltibiotics. Indications for the use ofantibiotics include: rapidly progressive swelling, difirse swclling, compromisd host defenses, involvement of fascial spaces, severe pcricoronitis and osteomyelitis. Penicillin V is often thc prefencd drug. Ifthe patient is pcnicillin-allergic, use clindamycin. Surgical 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

rNota*':

..

L For odonfogenic infections, the most common organisms are aerobic gram-positive cocci, 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.

When a frenum is positioned in such a way as to interfere with the normal alignment of teeth or results in pulling away ofthe gingiva from the tooth surface causing recession it is often removed using a surgical process known as a frenectomy.

Three surgical techniques used for . Diamond excision

a frenectomy:

Zpfasty

\ /

are effective when the mucosal and fibrous tissue band is rela-

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.
Note: Local anesthetic infilhation is usually sulficient for surgical treatment offrenal attachments. Care must be taken to avoid excssive infiltration directly in the frenum area since it may obscure the anatomy that must be visualized at the time ofexcision.

. transverse facial vein; pterygoid plexus ofveins, angular; inferior ophthalmic veins . inferior alveolar, anterior superior alveolar arteries, descending palatine; greater palatine
arteries

. supratrochlear; supraorbital veins, superficial temporal; lingual veins

. angular; inferior ophthalmic veins, transverse facial vein; pterygoid plexus ofveins

155 Coplrighr O 2011,20!2 - Dental Decks

. Closed reduction

. Operculectomy
. AlveoloplasW

. GingivoplasV

155 Cop)right O 20ll-2012 - Dnral Deks

Cavemous sinus thrombosis is an uncommon but potentially lethal extension ofodontogenic infection. Valveless veins in the head and neck allow retrogmde flow ofinfection liom the face to the sinus. The ptcrygoid plexus ofveins and angular and ophthalmic veins may contributc to retrograde flow Note: Canine space infections and deep temporal space infections can result in cavemous sinus thrcmbosis via the ophthalmic veins.

first clinical signs ofcavemous thrombosis include vascular congestion in periorbital, scleral, and retinal veins. Other clinical signs include periorbital edma, Woptosis (exophthalmos), thrombosis of the rctinal vein, ptosis, dilated pupils, absent comeal reflex, and supraorbital sensory deficits.
The

Important: The infection is life-threatening

sultation.

and requires prompt and agglessive treatment, consisting

ofeljmination ofthe source ofinfection, drainage, parenteral antibiotic therapy, and neurosurgical conRemmberi Cranial nerues
sinus.

lII,lY,Y

(ophthalnic divisio of f), and VI pass through the cavemous

-{n alveoloplasty is the surgical preparation ofthe alveolar ridges (i.e., removing undertuts d d sharp edges from areas such as the mylohyoid ridge) for the reception ofdentures or shaping and smoothing the socket margins after extractions of teeth with
subsequent suturing to insure optimal healing.

The objectives of this recontouring should be to provide the best possible tissue contour for prosthesis support, while maintaining as much bone and soft tissue as possible.

Remember: I . In some cases, the bone is well-contoured for denture or partial denture construction but the soft tissues may interfere with the fit or function of the prosthesis. These soft tissues areas include: the mandibular retromolar pad, the maxillary tuberosity, excessive alveolar ridge tissue, labial and lingual freni, or a condition called inflammatory fibrous hyperplasia. 2. A closed reduction is the closing of the space between fractured bone without cutting though the soft tissue or surrounding bone. 3. A gingivoplasty is a surgical procedure to reshape the gingivae to create a normal, functional form. 4. An operculectomy is the removal ofthe operculum, which is the flap oftissue over
an unerupted 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:

. Maxillary central incisors are involved

. Mandibular first molars

are involved

. Mandibular canines are involved . Maxillary third molars are involved

157 Coplright (1

20ll-2011

Dental Decks

ORAL SURGERY & PAIN

CONTROL

Misc.

All ofthe following are systemic contraindications to elective surgery EXCEPT one. which one is the EXCEPZOM

. Blood dyscrasias (i.e., hemophilia, Ieukemia) . Controlled diabetes mellitus

. Addison's disease or any steroid deficiency

. Fever ofunexplained origin

. Nephritis
. Any debilitating disease

. Cardiac

disease
158 Cop)righl
Ol 201

l-?012

Dental Decks

Fimt molars erupt early and are often heavily restored. AutotransplNntation in this situation involves the removal ofathird molar which may then be transfrred to the site ofan uucstorable first molar Other conditions in which tansplantation can be considered include tooth agenesis (especially ofpremolors and lateral lrcrsols), traumatic tooth loss, atopic eruption ofcanines, root rsorption, large endodontic lesions, cervical root fractures, localized juvenile periodontitis as well as other
pathologies.

Patient selction is very important for the success of autotransplantation. Candidates must be in good health, able to follow post-operative instructions, and available for follow-up visits. They
should also demonstrate an acceptable level oforal hygiene and be amenable to regular dental care. Most importantly, the patients must have a suitable recipient site and donor tooth. Note: If surgery is done on a diabetic patient antibiotic coverage should be considered particularly ifthe diabetes is not well controlled or uncontrolled. The most important criteria for success involving the recipient site is adequacy ofbone support. There must be sufficient alveolar bone support in all dimensions with adequate attached keratinized tissue to allow for stabilization ofthe transplanted tooth. The donor tooth should be positioned such that extraction will be as atraumatic as possible. Abnormal root morphology, which makes tooth rcmoval exceedingly difficult and may involve tooth sectioning, is conhaindicaled for this surgery. Teeth with either open or closed apices may be donors; ho$'ever, the most predictable results are obtained with teeth having between ore-halfto twothirds complted root development. Note: The most likely cause offailure will be a chlonic, progressive external root resorption.

Important: An allogeneic tooth tansplant rcfers to

a situation in which a tooth

from one individ-

ual is placed in another individual. The almost universal sequelae ofan allogeneic tooth hansplant is ankylosis and progressive root resorption, Remember: The change in continuity ofthe occlusal plane observed rfter allkylosis ofa tooth is caused by the continued eruption ofthe other nonankylosed teeth and glowth ofthe alveolar process.

*** Uncontrolled

diabetes mellitus is a systemic contraindication to elective surgery

can be tleated, but you need to consult with the patienfs physician before treatment. In most cases, these patients are best treated in the hospital by an oral

Important: Patients with these systemic conditions

surgeon.

Examples of contrrindications include:

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 surgery 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

. End-stage renal disease . Severe uncontrofled metabolic

\ote: Cardiac

disease, such as coronary artery disease, uncontrolled h)?rtension, and cardiac decompensation can complicate exodontia. Usually r postinfrrctioo patient is not subjected to oral surgery within six months ofhis infarction. However, emergency procedures can be performd, provided
the patient's physician has been consulted.

Important: l. Infected maxillarymolars

and mandibular molars willusually drain into the buccal space which lies between the buccinator muscle and overlying skin and superficial fascia. 2. The submandibulrr space which lies between the mylohyoid muscle and skin and superficial fascia is primarily infected by mandibular first, second and third molars.

. Buccal mucosa . Tongue and floor ofthe mouth . Palate

. Attached gingiva

159
Copyrighr O20ll-2012 - Dental Deckj

. Mydriasis

. Stidot (crowing sounds)

Sweating

. Tachycardia

160

Coptrigh

20ll-2012 - Dental Deck

The most common sites of the oral cancer are the tongue and the floor of the mouth. The other common sites are the buccal vestibule, buccal mucosa, gingiva and rarely the hard and soft palate. This cancer is extremely malignant and even ifthere is slight delay it spreads to lymph nodes of
the neck.

Squamous cell carcinoma (epidermoid carcinoma) is the most commolr form oforal cancer Oral SCC usually presents as an indunted ulcer with poorly defined borders. The lesion is characteristically painless, unless inflammation from superinfection or ch.onic mechanical irritation is present. An indolent clinical presentation in the form ofa small superficial ulceration, leukoplakia, or erythroplakia is also likely, especially in the early stages ofdevelopment.

Remember: SCC usually affects the lower lip and rarely the upper lip. This occurrence has been attributed to greater exposure ofthe lower lip to sunlight. Lip carcinoma commonly presents as an ulcer. In many cases, a keratin crust covers the ulcer. The rest ofthe lip vermilion may show actinic changes. Important: Carcinoma in situ is an epithelial dysplasia that includes all the layers ofthe epithelium but does not extend beyond the basal layer. Once the malignant cells have penetrated the basal layer into the lamina propria, early invasive squamous cell carcinoma has been established. If tumor invasiveness extends deeper into the tissues, involving fat, muscle, or other struchrres, then true invasive squamous cell carcinoma has evolved.
The degree ofhistologic dilferentiation best describes the degree ofmalignancy ofa tumor. Malignant neoplasms are histologically classified as (l) well differentiated (2) moderately differentiated. or (3) poorly differentiated (anaplostic) tumors. From a histologic point of view, poorly differentiated tumors have the highest de$ee ofmalignancy.

' . -- l. The salivary glands, blood vessels, lymphatics, muscle, bone, and other comective tisr'J\-otedt sue can also give rise to primary malignancies of the head and neck. '$6$ 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 immediate attention. It is caused by partial obstruction ofthe airway at the level ofthe larymx or trachea. Because total airway obshuction usually occurs during inspiration, there is usually adequate oxygen left in the cerebml blood to permit up to 2 minutes of consciousness. Ifthe obstruction is not recognized and managed and oxygen delivered to the victim's lungs, blood, and brain, permanent neurologic damage occurs within 3 to 5 minutes.

***stridor

Non-invasive Procedures for Obstructed Airwayr . Back blows, manual thrusts, Heimlich maneuver, chest thrust, and finger sweep lnvasive Procedures for Obstructed Airways:

*** These procedures should only be performed ifproper equipment is available.

arrways

by persons trained in these techniques and

.Tracheotomy: ls used more for long-term airway maintenance and not for emergency

. Cricothyrotomy: ls a procedure for

establishing an emergency airway where other methods are unsuitable or impossible. The access site is the cricothyroid membrane of the trachea, located on the anterior neck, between the cricoid and thyroid cartilages.

Important: A c cothyrotomy may be lifesaving in an anaphylactic raction in which a patient shows signs oflaryngeal obstruction. Ifa patient shows signs of laryngeal obstruction, that is, stridor (crowing sounds), epinephrine should be given and oxygen administered. Ifa patient loses consciousness and appears to be unable to breath, an emergency cricothyrotomy may be required to bypass the laryngeal obstruction.

. Maxillary third molar . Maxillary second molar . Mandibular third molar . Mandibular second molar

t6t
Coplrighr O 20ll-2012, Denial Decks

. Purpura, petechiae, ecchymosis . Petechiae, ecchymosis, purpura

. Ecchymosis, purpura, petechiae

. Petechiae, purpura, ecchymosis

162
Copyriglr O
201

1,2012 - Dntal Decks

The clinical picture is that ofa markedly red, swollen, suppurutive lesion. The involved tissue is very tender and often accompanied by pain radiating to the ear, throat, and floor of the mouth. Excruciating pain is produced when the opposing tooth impinges upon the inflamed tissue during mastication. There may be trismus ofthe masticator muscles on the affected side. Involvement of the cervical nodes, fever, and malaise are common. If this occurs, antibiotic theraov is indicated.

The principal etiologic factors in pericoronitis are debris and bacterial waste Droducts which have accumulated under the soft tissue flap, overlying a partially erupted tooth. This tissue is often traumatized during mastication which further exacerbates the situation. Satisfactory emergency 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.

Important: The maxillary third molar is the most frequent conbibuting factor to pericoronal infections found around mandibular third molars. Always examine the maxillary third molar, it may be supererupted or malaligned.

Postoperative ecchymosis is a result of trauma to the underlying blood vessels. Blood escapes from the vascular tree and accumulates in the tissues. It is common after extractions in elderly patients due to the fragility of the vessel walls. All patients should be $arned that it may occur following extraclions. Note: Sometimes the patient will complain ofa diffilse, non-painful, yellowish discoloration ofthe skin. Moist heat often speeds the resolution olpostoperative ecchymosis. \'{ost common adverse effcts of radiation therapy on the oral and paraoral tissues: . Rampant caries . Difficulty in swallowing . Radiation mucositis . Varying degree of trismus . Radiation dermatitis . Xerostomia

Important: Osteoradionecrosis does not develop unless the patient's oral condition is
not optimized before radiation therapy, and postirradiation dental procedures are performed without proper precautions.
l,,lote: Hlperbaric oxygen therapy must be considered an irradiated mandible.

if

surgery is to be performed on

Thrombocytopeniz (ow pbtela courr, thrt is less than _ an absolute contraindication to elective surgical procedures because of the possibility of signilicant bleeding.

. 50,000 / mm3 . 75,000 / mm3

. .

100,000 / mm3 125,000 / mm3

,63
CopI i8hr O 201l'2012
- Dental Decks

ORAL SURGERY & PAIN CONTROL

JCe

EXCEPT one.Which one

is

the EXCEPTION?

. Erlthroplasia
. Ulceration . Duration

. Slow growth . Bleeding . Induration

. Fixation
464
Copltighr e 201l-2012 '

D{tal Decl6

Patients with less than 10,000 - 20,000 platelets have been known to bleed spontaneously.

Platelet counts between 50,000 and 100,000 have not been associated with significant bleeding, provided platelet function is normal.
Possible 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 \ote3' 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 aggregation for their 7 to l0 day life span. Because approximately l0olo ofplatelets are replaced each day, it takes an average of2-3 days for bleeding time to normalize, but most experts reconmend allowing 7 days without aspirin before surgery. Other NSAIDs will alter platelet function only temporarily.

Characteristics 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
area on mucous membrane is called erythroplasia. The texture may be 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. Being neither elevated nor depressed, they present as quiet, unpretentior.N lesions. The border mal be sharp or blend imperceptibly into surrounding normal mucosa. It must constantly be

-\ red but not ulcerated

kepr in nind that early carcinoma frequently appears as an area oferythroplasia. There are certain areas ofthe oral mucosa which seem more prone to develop nalignancy. Additionally, oral cancer is more often seen in those over age 40. Because ofthis, an area ofery4hroplasia in a cancer prone area in a patient past 40 is highly suspicious for malignancy and should be biopsied on rhe day it is seen. This is especially true for those lesions whose duration exceeds 2

ueeks.

Note: Local spread of oral carcinoma is achieved by direct invasion and infiltration of adjacent structures. Perineural invasion and spread is particularly important because it can adversely influence the actual extent of the tumor Regional spread to the neck lymph nodes
occurs by the lymphatic route.

. The step osteotomy . Mandibular ramus sagittal split osteotomy

. The vertical ramus osteotomy

. The vertical body osteotomies

165 Coplaight O20ll-2012 - Dental Decks

. Postherpetic neuralgia . Buming mouth syndrome . Trigeminal neuralgia

. Temporal arteritis

r66
Coplr;ghr O
201 1-201 2

, Dental Decks

The mandibularramus sagittal split osteotomy has become one ofthe most commonly performed mandibular orthognathic procedures. The mandible is split sagittally and can either be used to advance the mandlble ftn the case of rettogn^thi^) or to set back the mandible treating progn^thi^) . lt is the standard procedure used today. Note: The position ofthe condyle is unchanged

c
{ \\,

fl,

during conection ofmandibular prognathism or retrognatnlsm.

Vertical ramus osteotomy: can be used to set

the mandible f'osteriorly. Used for the correcrion

lr(
\

ofprognathism.
Vertical body osteotomies: procedures that involve exnacting mandibular teeth bilaterally frsrd I ly bicuspidr. A picce ofbone is also rcmoved liom the mandible and you slide everything back. Used for prognathism. The step osteotomy: may be indicated in cases of
mandibular prognathism, retrognathism, asymmetry and apenognathia. By performing bilateral step-shaped cuts in rhe body ofthc mandible, the lowerjaw is divided into lhree separate. Independenrly moveable pieces.

(\_-/\

\ry

* \J? v) (v//
,,,

i\\-(

LS )
+
*

G-4

\l I

'gF? \_--jdij

l,-

)'-j

l*? ww./
)

Note: Maxillary surgeries are rcfered to as LeFort I osteotomies. The maxilla can be moved forward and down more easily than it can be moved up or back. Distraction osteogenesis fDOJ involvcs cutting an ostcotomy to separate segments ofbone and the application ofan appliance that will facilitatc thc gradual and incremental separation ofbone segments. Used for patients with cleft lip and palate as well as
other deformities

ofthe facial skeleton.

Neuropathic 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 of
treatment,

. 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 buming, 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.

. Intraorally
. Externally over the posterior surfac ofthe condyle with the mouth open . Through the external auditory meatus

. Any ofthe above

167 Coplright O 201 I,20

12 -

Dmtal Decls

. Laterally . Medially . Posteriorly

. Anteromedially

168 Coplright
@

2011"2012, Dmial Decks

The temporomatrdibular joiDt should be evaluated for tendemess and noise. When checking for joint noises (clicki g and clepitus), the joint is p lpated laterully (in front of the external auditory neatus) while the patient opens and closes the mandible.

Tenderness can be assessed by palpating the lateral aspects ofthejoints when the mouth is closed and during opening ofth mouth. The joint should also be palpated for tendemess while the patient opens maximally, and the ftngertip should be positioned slightly posterior to the condyle to apply force to detemine if therc is inflammation of the retrodiscal tissue.

Note: By placing fingertips in the patient's extemal auditory meatus, this technique can produce false

joint sounds during mandibular function because ofpressure against the thin ear canal cartilage. Remember: (l) The posterior aspect of the condyle is rounded and convex, whercas the anteroinferior aspect is concave. (2) The condyles are not symmetrical nor identical Temporomandibuhr disorders: . Myofascial pain disorder fMPD): most common

cause of masticatory pain and compromised function. The symptoms are diffuse, poorly localized in the preauricular region, often involving the muscles 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 dgenerative arthritis. . Disc displacement disorders: are seen with and without reduction (the return ofthe nonbal discto-condyle rclationship). See card 170. . Systemic rrthritic conditions: include rheumatoid axdritis, systemic lupus, and pseudogout. Patients with these conditions usually have other clinical systemic signs and s,'nptoms. . Chronic recurreot dislocation: occurs when the mandibular condyle translats anterior to the articular 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 anrylosis results in morc limitation ofmotion. Trauma is the most common cause of ankylosis. These patielts 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 the coffater{l ligaments (also called "discal ligaments") that are attached to the medial and lateral poles of rhe condyle. Attached to the anterior portion ofthe articular disc are muscle fibers from the lateral pterygoid muscle. $:llen rhe collateral ligaments become elongated or torn, they become loose which allows the lateral pterygoid muscle to pull the articulardisc out ofplace. Wlen this occurs, it is called a disc disphcement. Because

In

of rhe anteromedial direction ofthe lateral pterygoid muscle, the articular disc is usually displaced anteromedieUl. \ote: \\:hen the articulat disc is displaced anteromedially to the condyle, a click souDd is usually dmonstmred when the mouth is opened and the condyle moves past the thick posterior band ofthe afticular discThere can also be a clicking sound when the mandible moves to the opposite side as the condyle again moves pasr the thick posterior band ofthe aiticular disc. Often anothff click will be demonshated vhen the mouth is subsequently closed and the condylemoves liom the thin centalareaofthe disc and then past the thickerposrerior band as the arhcular disc once again becomes displaced. A Crepitation sound faho lnown as "Crepitus muhiple scraping or grating sounfu) is usually associated with a degenemtive process (osteoarthritis) ofthe- condyle, the dull thud is usually associated with a self-reducing subluxation ofthe condyle, and tinnitus is described as ear ringing.

\oDsurgical 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 dalt \ /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 repositioning splint protrudes the mandible into a forward position, h)?othetically recapturing the normal disc-tocondyle 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.

. Preauricular

. Submandibular
. Both are the same

169
Cop).right O 201 I -2012 - Dental Decks

. Ringing in the

ears

. Reciprocal clicking . Muscle inflammation . Headaches

170
Cop)right O
201 1'201 2

- Denial De.ks

Surgical approaches to the TMJ!

. Preauricular: the best incision to expose the TMJ. A perpendicular incision is made just ante.ior to
the 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 richly

supply 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 bst apprcach for prccedures with-in the joint space itself

Patients with pain and dysfunction whose signs and symptoms do not respond satisfactorily to nonsurgical therapy with a period of3 months may be candidates for surgery particularly ifthey are diagnosed with advance intemal derangement caused by ankylosis, rheumatoid arthritis, or severe degenerative osteoarthritis. Patients with no improvement in range and ofmotion and mouth opening despite conservative treatment arc also candidates for surgical therapy.

Surgical 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 infl amed

synovial tissues.

is used in patients with painful, persistent clickingpopping and closed lock, The disc is mobilized and a postfiior wedge may be removed, with suturing 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. Rplacement 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 arthritis, severe degenerativjoint disease, ankylosis, and neoplasia. Costochondral bone graft reconstmction is the most common autogenous material used.

. Disc repositioning swgery bpen arthroplasly):

The most common form ofpain and discomfort associated with TMJ disorders is masticatory myalgia or myofascial pain. This is a disorder characterized by pain and masticatory muscle spasm and limitedjaw opening. The condition is characterized by a unilateral dull, aching pain which increases with muscular use.

Internal derangement ofthe articular disc: . First stage: reciprocal clicking is considered pathognomonic. In the first

stage of intemal

derangement, clicking begins suddenly and spontaneously or aftet an injury. The noise is often loud and may be audible to others, but is rarely associated with severe pain. . Second stage: the second stage of disc derangement is recipmcal clicking with intermittent locking. The typical patient complains that the jaw becomes locked and there is usually, but not always, severe pain over the affected joint. . Third stage: is associated with limited opening and has been termed closed lock. a limited opening of< 27 mm and severe pain over the affected joint are characteristic findings. Not: ln contrast to the second stage, few patients are able to unlock or relocate their closed

lock and restore normal function. . Fourth stag: the final stage is characterized by an increase in opening and crepitus occurring within the joint dudng movement due to degenerative changes in the disc and articular surfaces. Note: This stage appears to be less painful than previous stages, because the neurovascular tissue is no longer impinged between the condyle and the glenoid fossa.
The occunence ofTMJ pain caused by rheumatoid arthritis depends on the severity ofthe systemic disease. Most studies show that about one third ofthe patients with rheumatoid arthritis will experience pain in the joint at some time, with nearly 60olo ofpatients suffering from bilateraljoint dysfunction. Note: Th target tissue ofrheumatoid arthritis is the synovial membrane. Progression in the TMJ follows a general scheme with exudation, cellular infiltration, and pannus formation. The articular surfaces of the temporal and condylar components are destroyed, the disc becomes grossly perforated, and the subchondral bone is resorbed.