Oral Maxillofacial Surgery

adren cort
The gold standard test for primary adrenal failure is the:

blood glucose test
ACTH stimulation test
serum creatinine level
BUN test
i
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ORAL SURGERY & PAIN CONTROL
adren cort
A person who has been on suppressive doses of steroids will?
Select all that apply.
take as long as a year to regain full adrenal cortical function
take as long as a month to regain full adrenal cortical function
may show signs of hyperpigmentation
- does not require consultation with a physician prior to surgery
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ACTH stimulation test
The ACTH stimulation test is performed to examine the response of the adrenal gland
to an exogenously administered dose of ACTH. Normal patients have a doubling of the
serum Cortisol level after a dose of ACTH. The serum Cortisol level should rise to >20
mg/dL if there is adequate adrenal function. An inadequate response suggests adrenal
gland hypofunction. Note: Cosyntropin (Cortrosyn) 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 mg daily.
Remember: Patients taking steroids or people with disease of the adrenals will have de-
creased ability to produce more glucocorticoids (hydrocortisone) in times of stress (ex-
tractions). The reason for this is as follows:
Secretion of glucocorticoids is stimulated by ACTH, a hormone produced in the anterior
pituitary. The pituitary responds to stress by increasing ACTH output and, therefore, glu-
cocorticoid production increases. Arelative lack of glucocorticoids will also increase out-
put of ACTH. An overabundance of circulating systemic steroids will inhibit production
of ACTH. Large doses of steroids repress ACTH production, which leads to atrophy of
adrenal cortex.
take as long as a year to regain full adrenal cortical function
may show signs of hyperpigmentation
The following guidelines may help determine if a patient's adrenal function is suppressed, however,
if any doubt exists, consult the patient's physician before performing surgery.
Some Guidelines:
People on small doses (5 mg prednisone/day) will have suppression when they have
been on the regimen for a month.
People taking the equivalence of 100 mg cortisol/day (20-30 mg prednisone/day) will have ab-
normal cortical function in a week.
Short-term therapy (1-3 days) of even high-dose steroids will not alter adrenal cortical func-
tion.
A person who has been on suppressive doses of steroids will take as long as a year
to regain full adrenal cortical function.
Patients with adrenal insufficiency are hyperpigmented. This is most noticeable on the buccal and
labial mucosa, although other areas such as the gingiva may be involved. The hyperpigmentation
is a result of hypersecretion of ACTH, which can stimulate melanocytes to produce pigment.
Patients with decreased adrenal gland hormone production experience weakness, weight loss, or-
thostatic hypotension, nausea, and vomiting. Patients with severe adrenal insufficiency cannot in-
crease 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 of oral surgery can precipitate adrenal crisis.
In adrenal crisis, an intravenous or intramuscular injection of hydrocortisone must be given im-
mediately. Supportive treatment of low blood pressure with intravenous fluids is usually neces-
sary. Hospitalization is required for adequate treatment and monitoring.
adren cort
Patients with glucocorticoid hypersecretion have:
ectopic ACTH Syndrome
MEN I
cushing syndrome
addison disease
3
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adren cort
A 52-year-old woman requests removal of a painful mandibular second molar.
She tells you that she has not rested for 2 days and nights because of the pain.
Her medical history is unremarkable, except that she takes 20 mg of pred-
nisone daily for erythema multiforme. How do you treat this patient?
have patient discontinue the prednisone for 2 days prior to the extraction
give steroid supplementation and remove the tooth with local anesthesia and
sedation
instruct the patient to take 3 grams of amoxicillin 1 hour prior to extraction
no special treatment is necessary prior to extraction
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cushing syndrome
Cushing syndrome is a hormonal disorder caused by prolonged exposure of the body's tis-
sues to high levels of the hormone Cortisol. This results in characteristic changes in body
hiatus, including moon facies, truncal obesity, muscular wasting, and hirsutism. Some-
times called "hypercortisolism," it is relatively rare and most commonly affects adults
aged 20 to 50. The female-to-male incidence ratio is approximately 5:1.
Patients with Cushing syndrome are often hypertensive because of fluid 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 studies may reveal increased blood glucose levels because of interference with
carbohydrate metabolism, and examination of the peripheral blood smear may demon-
strate slight decrease in eosinophil and lymphocyte counts.
Important: The patient's cardiovascular status must be evaluated and treated if neces-
sary prior to surgery.
Note: The most common cause of Cushing syndrome is a tumor in the pituitary gland.
give steroid supplementation and remove the tooth with local anesthesia and sedation
Important: The fear here is that the patient may not have sufficient adrenal cortex secretion (adrenal in-
sufficiency) to withstand the stress of an extraction without taking additional steroids. (This holds true
for any patient who has been treated with steroid therapy).
Patients with adrenal insufficiency, patients on daily steroid therapy, and patients who have recently fin-
ished a course of steroids should receive steroid supplementation for dental procedures.
The concerns about adrenal insufficiency should be raised on the basis of clinical history. In the majority
of cases, the dentist should ask:
Is it known that the patient's adrenal glands do not function adequately?
Is the patient on chronic steroid therapy at doses of prednisone higher than 15 mg/day?
Has the patient been on steroid therapy at doses of prednisone higher than 15 mg/day within the last
2 weeks?
*** If the answer to any of the above questions is yes, the dentist should assume that the patient will
need stress-dose steroids.
General guidelines for the management of patients on steroid therapy:
Steroid supplementation in patients who can develop adrenal insufficiency
Early morning appointments
Shorter appointments
Minimize stress
Use sedation techniques when appropriate
Modify dental treatment plan when appropriate
The major goal in these patients is to avoid precipitating of adrenal insufficiency
Remember: Erythema multiforme is a hypersensitivity syndrome characterized by polymorphous
eruption of skin and mucous membranes. Macules, papules, nodules, vesicles, or bullae and target or
("bull's-eye-shaped") lesions are seen. A severe form of this condition is known as Stevens-Johnson
syndrome. These patients may be receiving moderate doses of systemic corticosteroids and therefore
may be unable to withstand the stress of an extraction. Consultation with their physician is absolutely nec-
essary before treating these patients.
anat
Which of the following foramen/location pairings are correct?
greater palatine foramen/distal to the apex of maxillary 1 st molar
incisive foramen/posterior to the interproximal space of the central incisors
lesser palatine foramen/lateral to the greater palatine foramen
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anat
The facial nerve carries which of the following?
efferent components
afferent components
sympathetic components
parasympathetic components
incisive foramen/posterior to the interproximal space of the central incisors
The greater palatine foramen is generally located halfway between the gingival margin and mid-
line of the palate, approximately 5 mm anterior to the junction of the hard and soft palate (vibrat-
ing line) distal to the apex of the maxillary second molar.
The hard palate is perforated by the following foramina:
The incisive foramen, posterior to the maxillary incisors, transmits the nasopalatine nerves
and the terminal branches of the sphenopalatine artery
The greater palatine foramen, is most frequently located distal to the maxillary second molar,
transmits the greater palatine vessels and nerve
The lesser palatine foramen, just posterior to the greater palatine foramen, transmits the lesser
palatine vessels and nerve
Nerves of the palate:
Sensory Innervation to the palate: is supplied by the maxillary (CN V-2) nerve. The ante-
rior part of the hard palate is supplied by the nasopalatine nerve, which passes through the in-
cisive foramen. The posterior part of the hard palate is supplied by the greater palatine nerve
which passes through the greater palatine foramen. The soft palate is supplied by the lesser pala-
tine nerve which passes through the lesser palatine foramen.
Motor Innervation: the tensor veli palatini is innervated by a muscular branch from the
mandibular division of the trigeminal nerve (CN V). All other muscles are innervated by the pha-
ryngeal plexus (motor portion from the vagus nerve and cranial part of the accessory nerve),
The greater palatine block or GP block is useful for dental procedures involving palatal soft tis-
sues 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 greater (anterior) palatine nerve as it passes anteriorly between the soft tissues and
bone of the hard palate.
The nasopalatine nerve block anesthetizes the anterior portion of the hard palate (soft and hard
tissues) from the mesial aspect of the right first premolar to the mesial aspect of the left first pre-
molar. Target area: incisive foramen, beneath the incisive papilla.
efferent components
afferent components
parasympathetic components
The facial nerve leaves the cranial cavity by passing through the internal acoustic meatus,
which leads to the facial canal inside the temporal bone. Finally, the nerve exits the skull by
way of the stylomastoid foramen of the temporal bone.
Note: If you cut the facial nerve just after its exit from the stylomastoid foramen, it would
cause a loss of innervation 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 of the lacrimal gland (relaying in the ptery-
gopalatine ganglion) and submandibular and sublingual glands (relaying in the submandibu-
lar ganglion).
The afferent component serves a tiny patch of skin behind the ear, taste sensation, and the
body of the tongue.
Clinical information:
1. Bell palsy: involves unilateral facial paralysis with no known cause, except that there is
a loss of excitability of the involved facial nerve. The onset of this paralysis is abrupt, and
most symptoms reach their peak in 2 days. One theory of its cause is that the facial nerve
becomes inflamed within the temporal bone, possibly with a viral etiology.
2. Trigeminal neuralgia (tic douloureux): also has no known cause but involves the affer-
ent nerves 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 the sensory root of the trigeminal ganglion by area blood vessels. Clinically, the patient
feels excruciating short-term pain (tic) when facial trigger zones are touched or when speak-
ing or masticating, setting off associated brief muscle spasms in the area. The right side of
the face is affected more commonly than the left. It is more common in females. Carba-
mazepine (Tegretol) is still the mainstay of treatment.
anat
Which component of the TMJ has the most vasculature and innervation?
articular fossa
anterior band of the articular disc
posterior band of the articular disc
articular eminence
retrodiscal tissue
7
anat
The maxillary sinus opens into the middle meatus of the nose through the:
frontonasal duct
bulla ethmoidalis
> hiatus semilunaris
nasolacrimal duct
retrodiscal tissue
The articular disc (meniscus) is composed of dense fibrous connective tissue, and it is
p o ^ d m between the condyle and the fossa, thereby dividing the joint into superior and
inferior joint spaces.
band o f , h e J Z d i - is contjuou, with ,he capsular ligament, me condyle, and the supenor
belly of the lateral pterygoid muscle.
Note- The retrodiscal tissue is highly vascularized and innervated, whereas the articular disc for
the most part is not. Only the extreme periphery of the articular disc is slightly innervated.
hiatus semilunaris
Unfortunately, this opening lies high up on the medial wall of the sinus, so that the sinus readily accu-
mulates fluid. Since the frontal and anterior ethmoidal sinuses drain into the infundibulum, which in
turn drains into the hiatus semilunaris, the chance that infection may spread from these sinuses into the
maxillary sinus is great.
2 types of sinusitis: acute and chronic: common clinical manifestations include sinus congestion, dis-
charge, pressure, face pain, and headaches.
Acute Sinusitis: the most common form of sinusitis, typically caused by a cold that results in inflam-
mation of the sinus membranes, normally resolves in 1 to 2 weeks. Sometimes a secondary bacterial in-
fection may settle in the passageways after a cold; bacterial populations normally located in the area
(Streptococcus pneumoniae and Haemophilus influenzae) may begin to increase, producing an acute
bacterial sinusitis.
Clinical signs of acute sinusitis include:
Severe pain, constant and localized
Tenderness to percussion of the maxillary posterior teeth
A mucopurulent exudate
Any unusual motion or jarring accentuates the pain
Tenderness over the anterior sinus wall
Chronic sinusitis: an infection of the 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 treated with antibiotics (ampicillin or augmentin). Chronic noninfectious
sinusitis often is treated with steroids (topical or oral) and nasal washes.
Locations of sinusitis:
Maxillary: the most common location for sinusitis; associated with all of the common signs and
symptoms but also results in tooth pain, usually in the molar region
Sphenoid: rare, but in this location can result in problems with the pituitary gland, cavernous sinus
syndrome, and meningitis
Frontal: usually associated with pain over the forehead and possibly fever
Ethmoid: potential complications include meningitis and orbital cellulitis.
Note: The maxillary sinus is innervated by the maxillary division of the trigeminal nerve (CN V-2).
Specifically, the ASA, PSA, and MSA nerves as well as the infraorbital nerve.
anat
The arises from the anterior surface of the external carotid artery
and then passes near the greater cornu of the hyoid bone.
submental artery
inferior alveolar artery
lingual artery
ascending pharyngeal artery
g
anat
The buccinator and superior pharyngeal constrictor muscles of the pharynx are
attached to each other at the:
pterygomandibular raphe
mastoid process
epicranial aponeurosis
genial tubercles on the internal surface of the mandible
10
anat
Which of the following are involved in the path for parasympathetic innervation
of the parotid gland?
trigeminal nerve
glossopharyneal nerve
vagus nerve
otic ganglion
pterygopalatine ganglion
11
anat
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 lingula and mandibular foramen.
Which ligament is most likely to get damaged?
sphenomandibular ligament
temporomandibular ligament
stylomandibular ligament
12
glossopharynealnerve
otic ganglion
The pterygopalatine ganglion is responsible for innervation of the lacrimal gland and other
glands of the nasal cavity. The other parasympathetic ganglia include the ciliary, sub-
mandibular, and otic.
The nerve fibers pass to the otic ganglion via the tympanic branch of the glossopharyn-
geal nerve and the lesser petrosal nerve. Postganglionic parasympathetic fibers reach
the parotid gland via the auriculotemporal nerve, which lies in contact with the deep sur-
face of the gland. Note: Postganglionic sympathetic fibers reach the gland as a plexus of
nerves around the external carotid artery.
The parotid gland is the largest of the major salivary glands and is entirely serous in se-
cretion. The parotids are located below and just anterior to the ear. The gland's capsule is
from the deep cervical fascia. About 75% or more of the parotid gland overlies the mas-
seter muscle, the rest is retromandibular.
The parotid gland is drained by Stenson 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 su-
perficial temporal and the maxillary arteries, supply the parotid gland. The lymph vessels
drain into the parotid lymph nodes and deep cervical lymph nodes.
1. Mumps is a viral disease of the parotid gland. Parotitis is the inflammation
Notes of the parotid gland.
2. Ebner glands are the only other adult salivary glands that are purely serous.
3. Although it passes through the parotid gland, the facial nerve does not pro-
vide any innervation to it.
sphenomandibular ligament
The sphenomandibular and stylomandibular ligaments are considered to be accessory liga-
Len s Therrmer is attached to the lingula of the mandible and the latter at the angle of the
mand bl These ligaments are responsible for limitation of mandibular movements (they lunrt ex-
cessive opentng). Note: The sphenomandibular ligament is most often damaged m an inferior
alveolar nerve block.
Th
P
tPmnnromandibular ligament (also called the lateral ligament) runs from the articular em-
men S S S S S condyle. It rovides lateral reinforcement for the capsul. This ligament
e ve nt s posterior and inferior displacement of the condyle (it is the mam stabihzmg ligament
^ S Nate: This ligament keeps the head of the condyle i n the mandibular fossa if the
condyle is fractured.
Collateral ligaments (medial and lateral) also referred to as "discal ligaments," are ligaments that
arise from the periphery of the disc, are attached to the medial and lateral poles of the condyle re-
ecttve y Z E l S the disc on the top of the condyle. These ligaments restrict movement f
the d7sc away from the condyle during function. Note: They are composed of collagenous con-
nective tissue; thus they do not stretch. ^
Joint capsule
Sphenomandibular
ligament
Spine of
sphenoid bone
/ N v Styloid process
of temporal bone
Stylomandibular
ligament
Angle of mandibular
anat
Which of the following injuries would cause a patient to deviate toward the
side of injury when protruding?
damage to the lateral pterygoid muscle
ankylosis of the condyle
condylar hyperplasia
unilateral condylar fracture
13
anat
Which lymph nodes directly receive lymph from the anterior two-thirds of the
tongue (except the tip)?
submental lymph nodes
submandibular lymph nodes
parotid lymph nodes
14
damage to the lateral pterygoid muscle
ankylosis of the condyle
unilateral condylar fracture
The mandible will also deviate toward the side of injury with:
Ankylosis of the condyle: the most common cause of TMJ ankylosis is trauma
A unilateral condylar fracture
The mandible will deviate away from the affected side with:
Condylar hyperplasia: malocclusion is also a common occurrence with this injury
Remember: The lateral pterygoids (right and left) acting together are the prime pro-
tractors 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 fracture (unilateral condylar fracture) on the
left side would be unable to deviate the mandible to the right (as stated above, the
mandible will deviate toward the side of injury with a unilateral condylar fracture, this pa-
tient would not be able to deviate the mandible to the right). This is normally treated by
a closed procedure involving intermaxillary fixation. This procedure immobilizes the
concomitant fractures and corrects the displacement of the jaws associated with the condy-
lar fracture, thereby correcting the shift of the midline toward the side of the fractured
condyle and the slight premature posterior occlusion on that side.
submandibular lymph nodes
The deep cervical lymph nodes are located along the length of the internal jugular vein on each side
of the neck, deep to the sternocleidomastoid muscle. The deep cervical nodes extend from the base
of the skull to the root of the neck, adjacent to the pharynx, esophagus, and trachea. The deep cer-
vical nodes are further classified as to their relationship to the sternocleidomastoid muscle as being
superior or inferior.
The deep cervical lymph nodes are responsible for the drainage of most of the circular chain of
nodes, and they receive direct efferents from the salivary and thyroid glands, the tongue, the
tonsil, the nose, the 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 it independently drains into either the internal jugular, subclavian, or
brachiocephalic veins.
Some regional groups of lymph nodes:
Parotid lymph nodes - receive lymph from a strip of scalp above the parotid salivary gland,
from the anterior wall of the external 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 from the front of the scalp, the nose, and adjacent cheek; the upper lip and lower
lip (except the center part); the paranasal sinuses; the maxillary and mandibular teeth (except
the mandibular incisors); the anterior two-thirds of the tongue (except the tip); the floor of the
mouth and vestibule; and the gingiva. The efferent lymph vessels drain into the deep cervical
nodes.
Submental lymph nodes - located behind the chin and on the mylohyoid muscle; receive
lymph from the tip of the tongue, the floor of the mouth beneath the tip of the tongue, the
mandibular incisor teeth and associated gingiva, the center part of the lower lip, and the
skin over the chin. The efferent lymph vessels drain into the submandibular and deep
cervical nodes.
anat
Which artery descends on the posterior surface of the maxilla and supplies
the maxillary sinus and the maxillary molar and premolar teeth?
sphenopalatine artery
greater palatine artery
posterior superior alveolar artery
infraorbital artery
15
anat
Which oral landmark marks the opening of the submandibular duct?
lingual frenum
nasolacrimal duct
parotid raphe
sublingual caruncle
16
posterior superior alveolar artery
The external carotid artery supplies most of the head and neck, except for the brain (the brain
gets its blood supply from the internal carotid and the vertebral arteries). The external carotid
passes through the parotid salivary gland and terminates as the maxillary and superficial tempo-
ral arteries. The superficial temporal artery supplies the scalp. The maxillary artery leaves the in-
fratemporal fossa by passing through the pterygomaxillary fissure into the pterygopalatine fossa.
Here it splits up into branches that accompany the branches of the maxillary nerve. It supplies the
muscles of mastication, the maxillary and mandibular teeth, the palate, and almost all of the nasal
cavity.
The mandibular teeth receive blood from the inferior alveolar artery, which is a branch of the
maxillary artery. The maxillary teeth also receive blood from branches of the maxillary artery as
follows:
Posterior teeth: from the posterior superior alveolar artery.
Anterior teeth: from the anterior and middle superior alveolar arteries.
Remember: The venous return of both dental arches is the pterygoid plexus of veins.
Branches of the maxillary artery that accompany the branches of the maxillary nerve:
1. The posterior superior alveolar artery descends on the posterior surface of the maxilla and
supplies the maxillary sinus and the maxillary molar and premolar teeth.
2. The infraorbital artery enters the orbital cavity through the inferior orbital fissure. It ends
by emerging on the face with the infraorbital nerve.
3. The greater palatine artery descends through the greater palatine canal with the greater pala-
tine nerve. It is distributed to the mucous membrane covering the oral surface of the hard palate.
4. The pharyngeal branch passes backward to supply the mucous membrane of the roof of the
nasopharynx.
5. The sphenopalatine artery passes through the sphenopalatine foramen into the nasal cavity.
It supplies the mucous membrane of the nasal cavity.
sublingual caruncle
The submandibular glands (formerly called the submaxillary glands) are located in the
submandibular triangle of the neck and the floor of the oral cavity. The submandibular
duct (Wharton 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 mid-
line of the mouth floor on each side of the lingual frenum. Clinically, the gland is effec-
tively palpated inferior and posterior to the body of the mandible, moving inward from
the inferior border of the mandible near its angle as the patient lowers the head. Note: The
submandibular gland is a mixed gland, secreting both serous and mucous saliva, but pre-
dominantly secreting serous mucous.
The submandibular glands are innervated by efferent (parasympathetic) secretomotor
fibers from the facial nerve, which run in the chorda tympani and in the lingual nerve
(branch ofCN V3) 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
arteries. The veins drain into the facial and lingual veins. The lymph vessels drain into the
submandibular and deep cervical lymph nodes.
Important: During its course, Wharton's duct is closely related to the large lingual nerve
that eventually crosses over it. This is important because, if you incise the mucous mem-
branes of the floor of the mouth, depending on where you cut, you may expose the lin-
gual nerve, Wharton duct, and the sublingual gland.
1. To expose the duct intraorally, only mucous membrane needs to be cut
Notes through.
2. Lymphadenopathy is the most common cause of swelling of the tissues in the
submandibular triangle.
anat
TheTMJ is a/an:
arthrodial joint
ginglymus joint
ginglymoarthrodial joint
17
anat
When a maxillary third molar is displaced into the infratemporal fossa, 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
ginglymoarthrodial joint
Because the TMJhas characteristics of both a hinge joint and a gliding joint, it is classified as a gingly-
moarthrodial joint. A unique feature of the TMJ is that it is rigidly connected to both the dentition and
the contralateral TMJ.
Components of the TMJ:
Mandibular condyle (sometimes called the condyloid process of the mandible) - the articulating sur-
face or functioning part of the condyle is located on the superior and anterior surfaces of the head of
the condyle. This surface is covered with a dense layer of fibrous connective tissue.
Articular fossa - this fossa is the anterior three-fourths of the larger mandibular fossa. It is consid-
ered to be a nonfunctioning portion of the joint. Remember: The mandibular fossa (glenoid fossa)
is the temporal component of the TMJ; it is bounded in front by the articular eminence, and behind,
by the tympanic part of the temporal bone, which separates it from the external auditory meatus.
Articular eminence (also called the articular tubercle) - is a ridge that extends mediolaterally just
in front of the mandibular fossa. It is considered to be the functional portion of the joint. It is lined
with a thick dense layer of fibrous connective tissue.
Articular disc (also called the meniscus) - is a biconcave fibrocartilaginous disc interposed be-
tween the condyle of the mandible and the mandibular (glenoid) fossa of the temporal bone which pro-
vides the gliding surface for the mandibular condyle, resulting in smooth joint movement. The central
part is avascular and devoid of nerve tissue. Only the extreme periphery is slightly innervated.
Postglcnoid
process
Blood vessels
Condyle
v
Lateral pterygoid muscle
Upper synovial
cavity
Articular
eminence
Joint disc
Lower synovial
cavity
lateral, inferior
The infratemporal fossa is an irregular space behind the maxilla. Its roof is formed by
the greater wing of the sphenoid. The lateral pterygoid plate of the sphenoid is medial. Lat-
erally, it is limited by the coronoid process and ramus of the mandible. The infratempo-
ral fossa communicates with the pterygopalatine fossa through the pterygomaxillary
fissure, which is a cleft between the lateral pterygoid plate and the maxilla. It communi-
cates with the orbit through the inferior orbital fissure, which is found between the max-
illa and the greater wing of the sphenoid.
The pterygopalatine fossa is a small space behind and below the orbital cavity. It lies be-
tween the pterygoid plates of the sphenoid and palatine bone below the apex of the orbit.
Clinical: If there is good access and adequate light, a single cautious effort to retrieve the
tooth with a hemostat can be made. If the effort is unsuccessful, or if the tooth is not vi-
sualized, the incision should be closed, the patient should be informed, 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 dis-
section is performed along the needle until the tooth is visualized and subsequently re-
moved. Note: If no functional problems exist after displacement, the patient may elect not
to have the tooth removed. Proper documentation of this is critical.
anat
The carotid sheath contains which of the following?
carotid artery
sympathetic trunk
jugular vein
vagus nerve
19
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anat
Which nerve may, in some cases, also serve as an afferent nerve for the
mandibular first molar, which needs to be considered when there is failure of
the inferior alveolar local anesthetic block?
posterior superior alveolar nerve
glossopharyngeal nerve
facial nerve
> mylohyoid nerve
20
carotid artery
jugular vein
vagus nerve
*** 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 the lateral boundary of the retropharyngeal space at the
level of the oropharynx on each side of the neck deep to the sternocleidomastoid muscle.
It extends from the base of the skull to the first rib and sternum. It contains the carotid ar-
teries, the jugular vein, and the vagus nerve. Within the carotid sheath, the vagus nerve
(CNX) lies posterior to the common carotid artery and internal jugular vein.
The facial vein unites with the retromandibular vein below the border of the mandible and
empties into the main venous structure of the neck - the internal jugular vein. The in-
ternal jugular vein descends through the neck within the carotid sheath and unites be-
hind the sternoclavicular joint with the subclavian vein to form the brachiocephalic
vein. The brachiocephalic veins (right and left) unite in the superior mediastinum to form
the superior vena cava, which returns blood to the right atrium of the heart.
mylohyoid nerve
Just before entering the mandibular canal, the inferior alveolar nerve gives off a motor
branch known as the mylohyoid nerve. The inferior alveolar nerve travels along with the
inferior alveolar artery and vein within the mandibular canal and divides into the mental
and incisive nerve branches at the mental foramen. The inferior alveolar nerve provides
sensation to the mandibular posterior teeth. The mylohyoid nerve pierces the spheno-
mandibular ligament and runs inferiorly and anteriorly in the mylohyoid groove and then
onto the inferior surface of the mylohyoid muscle. The mylohyoid nerve serves as an ef-
ferent nerve to the mylohyoid muscle and the anterior belly of the 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 mus-
cle. In addition to either elevating the hyoid bone or depressing the mandible, the muscle
also forms the floor of the mouth and helps elevate the tongue.
Note: The sublingual gland is located superior to the mylohyoid muscle.
1. When placing the film for a periapical view of the mandibular molars, it is
Notes the mylohyoid muscle that gets in the way if it is not relaxed.
2. When the floor of the mouth is lowered surgically, the mylohyoid and ge-
nioglossus muscles are detached.
3. An injection into the parotid gland (capsule) when attempting to administer
an inferior nerve block may cause a facial expression paralysis of the fore-
head muscles, the eyelid, and the upper and lower lips on the same side of the
face that the injection was given. Important: If the parotid capsule injection
happens, care must be taken to protect the eye from injury and drying using lu-
brication 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.
anat
Which of the following provides branches for the most direct blood supply to
the temporomandibular joint?
internal carotid artery
external carotid artery
common carotid artery
aorta
21
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anat
Which of the following muscle nerve combinations are correct?
trapezius m. / accessory n.
stylopharyngeus m. / glossopharyngeal n.
sternocleidomastoid m. / accessory n.
cricothyroid m. / superior laryngeal n.
22
external carotid artery
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
tissue. Note: The two terminal branches of the external 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 auriculotem-
poral nerve (branch ofCN V3). The anterior region of the joint is innervated from the
masseteric nerve (also a branch ofCN V3) and from the posterior deep temporal nerve
(also a branch ofCN V3). The sensory innervation of the TMJ is via the trigeminal nerve
as well. The nerve fibers primarily follow the vascular supply and terminate as free nerve
endings. Thus, the capsule, synovial tissue, and extreme periphery of the disc are inner-
vated. The articular cartilage and the central part of the disc contain no nerves. Both
myelinated and
nonmyelinated nerves are seen in the TMJ. The retrodiscal bilaminar zone has a rich neu-
rovascular supply and is the source of proprioception.
Remember: Most synovial joints have hyaline cartilage on their articular surface; how-
ever, several joints, such as the sternoclavicular, acromioclavicular, and TMJs, are asso-
ciated with bones that develop from intramembranous ossification. These have
fibrocartilage articular surfaces.
trapezius m. / accessory n.
stylopharyngeus m. / glossopharyngeal n.
sternocleidomastoid m. / accessory n.
cricothyroid m. / superior laryngeal n.
Nerve
Vestibulocochlear
(CN VIII)
Glossopharyngeal
(CN IX)
Accessory
(CNXI)
Hypoglossal
(CNXJI)
Site of Exit from Skull
Internal acoustic meatus
Jugular foramen
Jugular foramen
Hypoglossal canal
Component
Special sensory
(special afferent)
Branchial motor
{special visceral efferent)
Visceral motor
(general visceral efferent)
Visceral sensory
(general visceral afferent)
General sensory
(general somatic afferent)
Special sensory
(special afferent)
Branchial motorspinal
root
(special visceral efferent
Somatic motor
(general somatic efferent)
Function
To the organ of Corti for hearing
To the semicircular canals for balance
Supplies the stylopharyngeus muscle
Parasympathetic innervation of the smooth
muscle and glands of the pharynx, larynx,
and viscera of the thorax and abdomen
Carries visceral sensory information from
the carotid sinus and body
Provides general sensation information
from the skin of the external ear, internal
surface of the tympanic membrane,
upper pharynx, and posterior one-third of
the tongue
Provides taste sensation from posterior
one-third of the tongue
Innervates the trapezius and
sternocleidomastoid muscles
Innervates all of the intrinsic and most of
the extrinsic muscles of the tongue
(genioglossus, styloglossus, and hyoglossus
muscles)
anat
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
right on protrusion
neither of the above, the tongue would not be affected
23
anat
The sublingual gland is located in the oral cavity between the mucosa of the
oral cavity and the:
1
masseter muscle
mylohyoid muscle
> buccinator muscle
temporalis muscle
24
left on protrusion and the left half of the tongue will atrophy
Lesions of the hypoglossal nerve:
Hypoglossal nerve lesions paralyze the tongue on one side
On protrusion, the tongue deviates to the ipsilateral (same) or contralateral side, de-
pending on the lesion site.
Lower motor neuron lesion:
Lesions to the hypoglossal nerve causes paralysis on the ipsilateral (same) side:
Tongue deviates to the paralyzed side on protrusion (the paralyzed muscles will
lag, causing the tip to deviate).
Musculature atrophies on the paralyzed side
Tongue fasciculations occur on the paralyzed side
Example: With a neck wound that cuts the right hypoglossal nerve, the tongue de-
viates to the right on protrusion, and the right half of the tongue will later demon-
strate atrophy and fasciculations
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.
mylohyoid muscle
The sublingual glands are located in the floor of the mouth beneath the tongue, close to
the midline. It lies between the sublingual fossa of the mandible and the genioglossus
muscle of the tongue. The mylohyoid muscle supports the individual sublingual glands in-
feriorly. Unlike the submandibular gland, which drains via one large duct, the sublingual
gland drains via approximately 12-20 small secretory ducts (ducts ofRivinus ducts), the
majority open into the mouth on the summit of the sublingual fold, but a few open into
the submandibular duct.
The sublingual gland is innervated by parasympathetic secretomotor fibers from the fa-
cial nerve, which run in the chorda tympani and in the lingual nerve (branch ofCN V3)
and synapse in the submandibular ganglion. The blood supply comes from branches of
the 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 from both the sublingual and submandibular glands drain into the
submandibular and the deep cervical lymph nodes
Bartholin duct, a common duct that drains the anterior part of the sublingual gland
in the region of the 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 it predominantly secretes mucous
Note: Ebner glands are located around the circumvallate papilla of the 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.
anat
The trigeminal ganglion located is located:
superior to the deep lobe of the submandibular salivary gland
posterior surface of the maxillary tuberosity of the maxilla
anterior to the infraorbital foramen of the maxilla
the apex of the petrous part of the temporal bone in the middle cranial fossa
25
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anat
The tongue receives its blood supply from which of the following?
tonsillar branch of the facial artery
lingual artery
vertebral artery
26
the apex of the petrous part of the temporal bone in the middle cranial fossa
The trigeminal nerve emerges from the anterior surface of the pons by a large sensory and a small motor
root, the motor root lying medial to the sensory root. The nerve passes forward out of the posterior
cranial fossa, below the superior petrosal sinus, and carries with it a pouch derived from the meningeal
layer of dura mater. On reaching the depression on the apex of the petrous part of the temporal bone in
the middle cranial fossa, the large sensory root expands to form the trigeminal ganglion. The motor root
of the trigeminal nerve is situated below the sensory ganglion and is completely separate from it. The
ophthalmic, maxillary, and mandibular nerves arise from the anterior border of the ganglion.
Somatic sensory cell bodies of the ganglion's sensory fibers enter the:
Ophthalmic division (CN VI) to supply general sensation to the orbit and skin of face above eyes
Maxillary division (CN V2) to supply general sensation to the nasal cavity, maxillary teeth, palate,
and skin over maxilla
Mandibular division (CN V3) to supply general sensation to the mandible, TMJ, mandibular teeth,
floor of mouth, tongue, and skin of mandible
The axons of the neurons enter the pons through the sensory root and terminate in one of the three
nuclei of the trigeminal sensory nuclear complex:
Types of Fibers
Pain and temperature
Light touch
Discriminative touch
Pressure
Proprioception
Trigeminal Sensory Nucleus
Spinal (descending) nucleus
Principal (main) sensory nucleus
Mesencephalic nucleus
Ascending Pathway
Ventral trigeminothalamic tract
Ventral trigeminothalamic tract
(Dorsal trigeminothalamic tract subserves discriminative
touch and pressure)
Projects to motor nucleus of V to control the jaw jerk
reflex and force of bite
Note: Proprioceptive fibers from muscles and the TMJ are found only in the mandibular division. The
cell bodies of proprioceptive first order neurons are found in the mesencephalic nucleus, not the
trigeminal ganglion. The TMJ, as is the case with all joints, receives no motor innervation. The muscles
that move the joint receive the motor innervation.
Branchiomeric motor fibers innervate the temporalis, masseter, medial and lateral pterygoid,
anterior belly of the digastric, mylohyoid, tensor tympani, and tensor veli palatini (palati).
tonsillar branch of the facial artery
lingual artery
The lingual artery arises from the anterior surface of the external carotid artery, and travels
obliquely toward the greater cornu of the hyoid bone. It loops upward and then passes deep to
the posterior border of the hyoglossus muscle to enter the submandibular region. The loop of
the artery is crossed superficially by the hypoglossal nerve. Branches include dorsal lingual
artery, suprahyoid artery, and sublingual artery (which supplies sublingual gland). It termi-
nates as the deep lingual artery, which ascends between the genioglossus and inferior longi-
tudinal muscles. Note: The floor of the mouth also receives its blood supply from the lingual
artery.
Things to remember about the tongue:
Motor innervation: from the hypoglossal nerve (CNXII).
Sensory innervation: lingual (branch of trigeminal CN V3) supplies the anterior two-
thirds, glossopharyngeal (CNIX) supplies the posterior one-third (including vallate papil-
lae), vagus (CN X) through the internal laryngeal nerve supplies the area near the
epiglottis.
Note: Besides the posterior third of the tongue, the glossopharyngeal nerve also supplies
sensory innervation to the tonsil, nasopharynx and pharyngeal areas.
Taste: facial (CN VII) via chorda tympani supplies the anterior two-thirds; glossopha-
ryngeal (CNIX) supplies the posterior one-third.
Note: The vertebral arteries arise from the subclavian arteries and join to form the basilar ar-
tery. The basilar artery is the main blood supply to the brain stem and connects to the circle of
Willis.
anat
Which of the following nerves exits the skull through the foramen ovale?
ophthalmic nerve
maxillary nerve
facial nerve
mandibular nerve
27
anat
Which of the following muscle/nerve pairings are correct?
lateral rectus m. / abducens n.
superior oblique m. / trochlear n.
medial rectus m. / abducens n.
inferior rectus m. / occulomotor n.
28
mandibular nerve
The ophthalmic nerve (CN VI) enters the middle cranial fossa through the superior orbital fissure and
courses within the lateral wall of the cavernous sinus on its way to the trigeminal ganglion. The maxil-
lary nerve (CN V2) enters the middle cranial fossa through foramen rotundum and may or may not pass
through the cavernous sinus en route to the trigeminal ganglion. The mandibular nerve (CN V3) enters
the middle cranial fossa through foramen ovale, coursing directly into the trigeminal ganglion. The
trigeminal ganglion (a.k.a. semilunar ganglion ) lies in a depression known as the trigeminal cave (or
Meckel cave). The trigeminal nerve exits the trigeminal ganglion and courses "backward" to enter the
mid-lateral aspect of the pons.
The mandibular division is the largest of the 3 divisions of the trigeminal nerve. It has motor and sen-
sory functions. It is created by a large sensory and a small motor root that unites just after passing through
the foramen ovale to enter the infratemporal fossa. It immediately gives rise to a meningeal branch and
then divides into anterior and posterior divisions.
Anterior Division: Smaller, mainly motor, with 1 sensory branch (buccal):
Masseteric: innervates the masseter muscle and provides a small branch to the TMJ
Anterior and posterior deep temporal: innervates the temporalis muscle
Medial pterygoid: innervates the medial pterygoid muscle
Lateral pterygoid: innervates the lateral pterygoid muscle
Buccal: supplies the skin over the buccinator muscle before passing through it to supply the mucous
membrane lining its inner surface and the gingiva along the mandibular molars
Posterior Division: Larger, mainly sensory, with 1 motor branch (nerve to mylohyoid):
Auriculotemporal: supplies the TMJ, auricle, and external auditory meatus
Lingual: supplies the mucous membrane of the anterior 2/3 of the tongue and gingiva on the lin-
gual side of the mandibular teeth
Inferior alveolar: largest branch of the mandibular division; innervates all mandibular teeth and the
gingiva from the premolars anteriorly to the midline via the mental branch
Mylohyoid: supplies the mylohyoid and the anterior belly of the digastric muscle
Remember: The trigeminal nerve contains no parasympathetic component at its origin.
lateral rectus m. / abducens n.
superior oblique m. / trochlear n.
inferior rectus m. / oculomotor n.
Nerve
Olfactory
(CNI)
Optic
(CNII)
Oculomotor
(CNIII)
Trochlear
(CNIV)
Abducens
(CN VI)
Facial
(CN VII)
Site of Exit
from Skull
Cribriform plate
of ethmoid bone
Optic foramen
Superior orbital
fissure
Superior orbital
fissure
Superior orbital
fissure
Stylomastoid
foramen
Component
Special sensory
(special afferent)
Special sensory
(special afferent)
Somatic motor
Visceral motor
Somatic motor
Somatic motor
Branchial motor
(special visceral efferent)
Visceral motor
General sensory
(general somatic afferent)
Special sensory
(special afferent)
Function
Sense of smell
Conveys visual information from the retina
Supplies four of the six extraocular muscles of the eye and
the levator palpebrae superioris muscle of the upper eyelid
Parasympathetic innervation of the constrictor pupillae and
ciliary muscles
Innervates the superior oblique muscle
Innervates the lateral rectus muscle
Supplies the muscles of facial expression; posterior belly of
digastric muscle; stylohyoid, and stapedius muscles
Parasympathetic innervation of the lacrimal, submandibular,
and sublingual glands, as well as mucous membranes of the
nasopharynx and the hard and soft palate
General sensation from the skin of the concha of the auricle
and from a small area behind the ear
Provides taste sensation from the anterior two-thirds of the
tongue; hard and soft palates
Important: Cranial nerves HI (oculomotor),
(vagus) all have parasympathetic activity.
VII (facial), IX (glossopharyngeal), and X
anesth
Which of the following teeth could be removed without pain after
administration of an inferior alveolar and lingual nerve block?
all anterior teeth on the side of the injection
canine and first premolar on the side of the injection
all teeth in that quadrant on the side of the injection
both premolars and first molar on the side of the injection
29
anesth
The maxillary first molar is innervated by which of the following nerves?
anterior superior alveolar
middle superior alveolar
posterior superior alveolar
greater palatine
ascending pharyngeal
30
canine and first premolar on the side of the injection
You need to give a long buccal injection to extract the molars and second bicuspid. For operative procedures,
a long buccal injection may not be needed for these teeth. The long buccal injection anesthetizes the soft tis-
sue and periosteum buccal to the mandibular molar teeth. The needle is inserted in the mucous membrane dis-
tal and buccal to the most distal molar in the arch.
To anesthetize the lingual nerve: When administering an inferior alveolar nerve block, slowly withdraw the
syringe, and when approximately half its length remains within tissues, reaspirate. If negative, deposit a por-
tion of the remaining solution (0.1 mL) to anesthetize the lingual nerve. Incisors may need local infiltration
for extractions.
Other Techniques of Mandibular Anesthesia:
Mental nerve block: This nerve block is used when buccal soft tissue anesthesia is necessary anterior to
the mental foramen (around the second premolar) to the midline and skin of the lower lip and chin. The
needle is inserted in mucobuccal fold at or just anterior to the mental foramen. Target area: mental nerve
as it exits the mental foramen (usually located between the apices of the first and second premolars).
Vazirani-Akinosi closed-mouth mandibular block: Although this technique can be used whenever
mandibular anesthesia is desired, its primary indication remains those situations in which limited mandibu-
lar opening (i.e., patients with trismus) precludes the use of other mandibular techniques. Nerves anes-
thetized: inferior alveolar, incisive, mental, lingual, mylohyoid nerves. Area of needle insertion: soft tissue
overlying the medial (lingual) border of the mandibular ramus directly adjacent to the maxillary tuberosity
at the height of the mucogingival junction adjacent to the maxillary third molar. Note: The injection is per-
formed blindly because no bony end points exist, the needle is advanced 25 mm into tissue for an average-
sized adult). The distance is measured from the maxillary tuberosity.
The Gow-Gates technique: this technique is a true mandibular nerve block because it provides sensory
anesthesia to virtually the entire distribution of CN V3 (inferior alveolar, lingual, mylohyoid, mental, inci-
sive, auriculotemporal, and buccal nerves). Its primary use is when a conventional inferior alveolar nerve
block is unsuccessful. Note: Patient must extend his or her neck and open wide for the duration of the tech-
nique (the condyle then assumes a more frontal position and is closer to the mandibular nerve trunk). Ex-
traoral landmarks: corner of mouth, tragus of ear, and intertragic notch. Area of needle insertion: the
needle is positioned so that it is inserted just distal to the maxillary second molar at the height of its mesi-
olingual cusp. The needle is then slowly advanced until bone (neck of the condyle) is contacted. The aver-
age depth of soft tissue penetration to bone is 25 mm. The needle tip is withdrawn 1 mm, aspirate, and slowly
deposit solution.
middle superior alveolar
posterior superior alveolar
The posterior superior alveolar (PSA) nerve block, otherwise known as the tuberos-
ity block or the zygomatic block, is used to achieve anesthesia for the pulps of the max-
illary third, second, and first molars (entire tooth = 72%; mesiobuccal root of the
maxillary first molar not anesthetized = 28%). Target area: PSA nerve posterior,
superior, and medial to the posterior border of the maxilla. Note: Potential for
hematoma formation.
The middle superior alveolar (MSA) nerve block is useful for procedures where the
maxillary premolar teeth or the mesiobuccal root of the first molar require anesthesia.
Target area: maxillary bone above the apex of the maxillary second premolar.
Note: The MSA nerve is present in only about 28% of the 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 % of patients. Target area: infraorbital foramen
(below 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 nerve for palatal anesthesia
(soft tissue).
anesth
Which of the following characterize shock?
decreased vascular resistance
bradycardia
myocardial ischemia
mental status changes
adrenergic response
31
anesth
A full E cylinder of oxygen contains approximately:
150 L at a pressure of 2000 psi
32
myocardial ischemia
mental status changes
adrenergic response
The term "shock" denotes a clinical syndrome in which there is inadequate cellular perfusion
and inadequate oxygen delivery for the metabolic demands of the tissues.
Important: Reduced cardiac output is the main factor in all types of shock.
In general, shock is characterized by:
Increased vascular resistance: cool mottled skin, oliguria
Tachycardia
Adrenergic response: diaphoresis, anxiety, vomiting, diarrhea
Myocardial ischemia
Mental status changes
The stages of shock include: 1) Compensatory (early) stage: compensatory mechanisms (in-
creased heart rate and peripheral resistance) maintain perfusion to vital organs, 2) Progres-
sive stage: metabolic acidosis occurs (compensatory mechanisms are no longer adequate),
3) Irreversible (refractory stage): organ damage, survival is not possible.
Major categories of shock:
Hypovolemic shock is produced by a reduction in blood volume. Cardiac output will be
low due to inadequate left ventricular filling. Causes include severe hemorrhage, dehydra-
tion, vomiting, diarrhea, and fluid loss from bums.
Cardiogenic shock is circulatory collapse resulting from pump failure of the left ventri-
cle, most often caused by massive myocardial infarction.
Septic shock is due to severe infection. Causes include the endotoxin from gram-nega-
tive bacteria.
Neurogenic shock results from severe injury or trauma to the CNS.
Anaphylactic shock occurs with severe allergic reaction.
Nitrous oxide:
Is a colorless, nonirritating gas with a pleasant, mild odor and taste
Has a blood/gas partition coefficient of 0.47 and is thus poorly soluble in blood
Is excreted unchanged by the lungs
Is the oldest gaseous anesthetic in use today
Is the only inorganic substance used as an anesthetic
As a general anesthetic, the only disadvantage is its lack of potency
1. Nitrous oxide should be stored under pressure in steel cylinders painted blue.
Notes 2. Oxygen is stored in green tanks.
3. A full E cylinder of oxygen contains approximately 600 L at a pressure of 2000 psi.
4. At 2 L/min, a full E cylinder will deliver oxygen for approximately 300 min, or 5 hrs.
Advantages and Disadvantages of Nitrous Oxide Analgesia
Advantages
Good analgesia
It is nonflammable
It is suitable for all ages and therapeutic
for many medically compromised
patients
It has virtually no adverse side effects
in the absence of hypoxia
It is titratable and produces euphoria
Disadvantages
There is a "misuse" potential with both patients and dentists
The most common patient complaint is nausea
It is not a complete pain reliever, a local anesthetic is still required to
do most dental procedures
Diffusion hypoxia may occur; make sure you give 100% oxygen at
the end of dental procedure to prevent it.
Important: The inhalation of 100% oxygen is contraindicated for a
person who has COPD
Important: Oxygen supplementation should be avoided or used with extreme caution in pa-
tients with severe COPD. These patients have an increased incidence of pulmonary bullae or
blebs (combined alveoli). Because of nitrous oxide's low blood solubility, it can increase the
volume and pressure of these lung defects, which could create an increased risk of barotrauma
and pneumothorax.
anesth
According to Guedel's stages of anesthesia, the proper use of nitrous oxide
achieves which level of anesthesia?
stage I
stage II
stage III
. stage IV
33
copyright S> 2013-2014 - Dental Decks
anesth
Which of the following are drugs that help to reduce salivary flow during
treatment?
scopolamine
atropine
local anesthesia
benztropine
34
copyri ght 2013-2014 - Dental Decks
stage I
Guedel's Stages of Anesthesia:
Stage I (amnesia and analgesia): begins with the administration of anesthesia and
continues to the loss of consciousness. Respiration is quiet, though sometimes irregu-
lar, and reflexes are still present.
Stage II (delirium and excitement): begins with the loss of consciousness and includes
the onset of total anesthesia. During this stage, the patient may move his limbs, chatter
incoherently, hold his breath, or become violent. Vomiting with the attendant danger of
aspiration may occur. The patient is brought to Stage III as quickly and as smoothly as
possible.
Stage III (surgical anesthesia): begins with the establishment of a regular pattern of
breathing, total loss of consciousness, and includes the period during which signs of
respiratory or cardiovascular failure first appear. This stage has four planes.
Stage IV (premortem): 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. Remember: The eyes appear greatly
enlarged in size and nonreactive to bright light when functional circulation to the brain
has stopped.
all answers are correct
Local anesthesia acts by reducing sensitivity which reduces anxiety and stress related to treat-
ment; salivation is also decreased.
Scopolamine, atropine, and benztropine are anticholinergic drugs. Not only do they decrease
the flow of saliva, but they also decrease the secretion from respiratory glands during general
anesthesia.
1. The duration of action of local anesthetics is directly proportional to protein
Notes binding and lipid solubility. Increased protein binding increased lipid solu-
bility = increased duration of action.
2. The lower the pKa (dissociation constant) of the local anesthetic, the faster
the onset of action. Important point: a local anesthetic with a low pKa has a very
large number of lipophilic free base molecules that are able to diffuse through the
nerve membrane.
3. Increased blood flow shorter duration of action.
4. Metabisulfite is an antioxidant that protects the vasoconstrictor from oxidation.
It has a low incidence of allergenicity.
5. The local anesthetic prilocaine can produce methemoglobinemia when ad-
ministered in larger doses in patients with subclinical methemoglobinemia. The
topical anesthetic benzocaine also can induce methemoglobinemia, but only
when administered in very large doses.
6. The administration of levonordefrin should be avoided in patients receiving tri-
cyclic antidepressants. There is an increased sensitivity to vasoconstrictors.
*** Epinephrine should be used cautiously.
7. The administration of vasoconstrictors in patients being treated with nonselec-
tive beta-blockers (i.e., propranolol) increases the likelihood of a serious eleva-
tion of the blood pressure accompanied by a reflex bradycardia. Use
vasoconstrictors cautiously.
anesth
Epinephrine and levonordefrin are added to local anesthetics because of their:
ability to increase the potency of the local anesthetic
ability to decrease the pain (burning) caused by the injection of the local anesthetic
vasoconstrictive properties
ability to decrease the possibility of an allergic reaction to the local anesthetic
35
anesth
After receiving an injection of a local anesthetic containing 2% lidocaine with
1:100,000 epinephrine, the patient loses consciousness. Which of the following
is the most probable cause?
acute toxicity
allergic response
syncope
hyperventilation syndrome
36
vasoconstrictive properties
Vasoconstrictors (i.e., epinephrine and levonordefrin) are added to local anesthetics because of their
vasoconstrictive properties. Vasoconstriction at the site of injection is beneficial because it limits the up-
take of the anesthetic by the vasculature, thereby increasing the duration of the anesthetic and dimin-
ishing systemic effects (reducing systemic toxicity). Note: The use of a vasopressor-containing local
anesthetic also may actually be responsible for the sensation of burning on injection. The addition of a
vasopressor and an antioxidant (sodium bisulfite) lowers the pH of the solution to between 3.3 and 4, sig-
nificantly more acidic than solutions not containing a vasopressor (pH about 5.5). Patients are more
likely to feel the burning sensation with these solutions. Note: Malamed's book states that "local anes-
thetics containing the vasoconstrictor levonordefrin (Neo-Cobefrin) have become impossible to obtain
(June 2004)."
Important: To minimize the likelihood of intravascular injection, aspiration should be performed be-
fore the local anesthetic solution is injected. If blood is aspirated, the needle must be repositioned until
no return of blood can be elicited by aspiration.
Adverse reactions following the administration of a local anesthetic are, in general, dose-related and may
result from high plasma levels caused by excessive dosage, rapid absorption, or unintentional in-
travascular injection.
Systemic toxicities of local anesthetics: Initial clinical signs and symptoms of mild to moderate tox-
icity include: talkativeness, apprehension, excitability, slurred speech, dizziness, and disorientation. The
signs and symptoms of severe toxicity include: seizures, respiratory depression, coma, and death.
Important: The excitatory manifestations may be very brief or may not occur at all, in which case the
first manifestation of toxicity may be drowsiness merging into unconsciousness and respiratory arrest.
Remember: Cardiovascular manifestations are usually depressant and are characterized by brady-
cardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest. Note: In local anes-
thesia, the depression of respiration is a manifestation of the toxic effects of the solution.
1. For a normal healthy (ASA I) patient, the maximum dose of epinephrine is 0.2 mg or 200
Notes
m
g
; m
j
s
equates to roughly 11 cartridges of 1:100,000 epinephrine. (The maximum dose of
lidocaine is 7mg/kg of body weight. Thus, for healthy adult patients, epinephrine is usually the
limiting factor.)
2. In a cardiac risk patient, the maximum dose of epinephrine is 0.04 mg or 40 mg, which
equates roughly to two cartridges of 1:100,000 epinephrine.
syncope
*** Caused by transient cerebral hypoxia
Anxiety-induced events are by far the most common adverse reaction associated with local
anesthetics in dentistry. These may manifest in numerous ways, the most common of which
is syncope. In addition, they may present with a wide variety of symptoms, including hyper-
ventilation, nausea, vomiting, and alterations in heart rate or blood pressure. Psychogenic re-
actions 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 (Trendelenburg position)
Establish airway (head tilt/chin lift)
- Administer 100% oxygen via face mask. 0
2
is indicated for the treatment of all
types of syncope except for hyperventilation 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 forehead.
Follow-up treatment
- Determine factors causing unconsciousness.
Remember: Hyperventilation in an anxious dental patient leads to carpopedal spasm
(a spasm of the hand, thumbs, foot, or toes).
Which tooth has a root that
the maxillary first molar
the maxillary second molar
the maxillary third molar
all of the above
is NOT consistently innervated by the
anesth
PSA nerve?
37
copyrighte>20!3-2014-Dental Decks
anesth
Which of the following are reasons that vasoconstrictors are included in local
anesthetics?
they prolong the duration of action of the local anesthetic
they reduce the chance of an allergic reaction to the local anesthetic
they reduce the toxicity because less local anesthetic is necessary
they reduce the rate of vascular absorption by causing vasoconstriction
they help to make the anesthesia more profound by increasing the concentrations of
the local anesthetic at the nerve membrane
38
copyright a 2013-2014 - Dental Decks
the maxillary first molar
When used to achieve pulpal anesthesia, the PSA nerve block is effective for the maxillary third, second,
and first molars in 77% to 100% of patients. However, the mesiobuccal root of the maxillary first molar
is not consistently innervated by the PSA nerve. In approximately 28% of patients, the middle superior
alveolar nerve provides sensoiy innervation to the mesiobuccal root of the maxillary first molar. There-
fore, if anesthesia of this tooth for either restorative dentistry or extraction is required, an infiltration in-
jection also should be performed over the second premolar tooth. Note: Patients experience few
subjective signs of anesthesia after receiving a posterior superior alveolar nerve block, as compared to
an inferior alveolar nerve block (numb lip).
The risk of a potential complication also must be considered whenever the PSA block is used. Insertion
of the needle too far distally may lead to a temporary (10 to 14 days) unaesthetic hematoma. As a means
of decreasing the risk of hematoma formation after a PSA nerve block, the use of a "short" dental nee-
dle is recommended for all but the largest of patients. One must remember to aspirate several times be-
fore and during drug deposition during the PSA nerve block to avoid inadvertent intravascular injection.
Important: If a 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 side
1. Gauge of a needle refers to the diameter of the lumen of the needle: the smaller the num-
Notes ber, the greater the diameter of the lumen. A 30-gauge needle has a smaller internal diame-
ter than a 25-gauge needle. In the United States, needles are color-coded by gauge: 25-gauge,
red; 27-gauge, yellow; and 30-gauge, blue.
2. Positive aspiration is directly correlated to needle 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 increased success
rates
Larger-gauge needles do not break as often
Important: The 25-gauge needle is the preferred needle for all injections presenting a high risk of pos-
itive aspiration.
they prolong the duration of action of the local anesthetic
they reduce the toxicity because less local anesthetic is necessary
they reduce the rate of vascular absorption by causing vasoconstriction
they help to make the anesthesia more profound by increasing the concentrations of
the local anesthetic at the nerve membrane
Vasoconstrictors are invaluable to local anesthesia in dentistry. There are clear indications for their
use, of which improving the depth and duration of anesthesia are the most important. Without
them, local anesthetics have a very short duration of action intraorally. Vasoconstriction is more im-
portant 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 formulations of 1:50,000
(0.02 mg/mL), 1:100,000 (0.01 mg/mL) and 1:200,000 (0.005 mg/mh).
There are three main adrenergic receptor subclasses that vasoconstrictors interact with on cardio-
vascular tissue in the human body. These are classified as alpha receptors (both alpha-1 and alpha-
2), beta-1 receptors, and beta-2 receptors. Alpha receptors are densely located on arterioles in the
skin and mucous membranes. Stimulation of these receptors leads to vasoconstriction through ac-
tivation of G proteins and subsequent opening of calcium channels. Beta-1 receptors are located on
cardiac tissue, and stimulation of them leads to an increase in heart rate (positive chronotropy) and
an increase in contraction force (positive inotropy). Beta-2 receptors, like alpha receptors, are lo-
cated primarily in vascular beds. However, these receptors are located primarily in vascular beds
traversing skeletal muscle. When stimulated, beta-2 receptors activate adenylate cyclase, leading
to vasodilation.
Epinephrine is the more potent than levonordefrin. Its affinity for alpha versus beta receptors is
roughly equivalent (50:50). Thus, although the primary event that occurs at the site of injection be-
neath 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 well as periph-
eral vasodilation in skeletal muscle beds. Note: Levonordefrin is less potent than epinephrine, its
receptor affinity is 75% alpha and 25%> beta. As noted earlier, local anesthetics containing lev-
onordefrin have become impossible to obtain.
anesth
Laryngospasm is an uncontrol l ed/i nvol untary muscular contraction (spasm)
of the laryngeal cords. It is a well known, infrequent but serious postsurgical
compl i cati on. In the operati ng room, it is treated by admi ni steri ng:
nitrous oxide
oxygen
epinephrine
enflurane
39
anesth
Following a local anesthetic i nj ecti on, anesthetic effects wi l l disappear and
reappear in a defi ni te order. Arrange the fol l owi ng sensations in increasing
order of resistance to conducti on.
touch
warm
deep pressure
pain
cold
motor
40
oxygen
A patient under general anesthesia loses the laryngeal reflex. If blood and saliva collect
near the vocal cords, this stimulates the patient to go into spasm (laryngospasm), and the
vocal cords will close. When this happens, air cannot pass and, hence the problem. The
two most important steps in the initial management of a laryngospasm are applying oxy-
gen under positive pressure and administering succinylcholine.
Note: Succinylcholine is a skeletal muscle relaxant that is used when performing endo-
tracheal intubation and endoscopy procedures.
Laryngospasm is frequently cited as an adverse effect of ketamine, but it is rarely ob-
served. Frequently, deep, heavy, loud respirations mistaken for laryngospasm are actu-
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 stimu-
lation of the vocal cords by instrumentation or secretions.
I.pain 4. touch
2. cold 5. deep pressure
3. warm 6. motor
Local anesthesia causes loss of sensation by first blocking nerve conduction in the smaller un-
myelinated fibers that carry pain, and then progressing to the larger myelinated fibers for pressure
and motor function. This phenomenon is called differential blockade. Differential blockade may
be due to the size of the nerve, the presence or absence of myelin, and firing frequency.
Size of nerve: local anesthetics preferentially block small fibers because the distance over
which such fibers can passively propagate an electrical impulse is shorter. During the onset of
local anesthesia, when short sections of nerve are blocked, the small diameter fibers are the first
to fail to conduct.
Presence 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 greater resistance to block of large fibers (e.g.,
motor fibers to skeletal muscle). Myelinated fibers tend to become blocked before unmyelinated
fibers of the same diameter. Note: Sodium channels are very dense at the nodes of Ranvier in
myelinated fibers, which contributes to them being blocked before unmyelinated fibers of the
same diameter.
Firing frequency: sensory fibers, especially pain fibers, have a high firing rate and a rela-
tively long action potential duration (up to 5 msec). Motor fibers fire at a slower rate and have
shorter action potential duration (< 0.5 msec). Both A delta and C fibers are small diameter fibers
that participate in high-frequency pain transmission. Therefore, they are blocked sooner with
lower concentrations of local anesthetics than are A alpha (motor) fibers to skeletal muscle.
Note: Nerves regain function in reverse order.
The extent of anesthesia depends on a variety of factors, including the amount of medication used,
body temperature, pH, the amount of protein binding, and dilution by tissue fluids. Local anes-
thetics work by blocking voltage gated sodium channels, thereby preventing depolarization of the
nerve fiber and conduction or transmission of the impulse.
anesth
How will a larger than normal functional residual capacity affect 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
anesth
Which of the following correctly describe barbiturates?
not lipid soluble
moderately lipid soluble
very lipid soluble
delayed onset of action
rapid onset of action
42
nitrous oxide sedation will take longer
The functional residual capacity is the amount of air remaining in the lungs at the end
of the normal expiration. (It is the sum of Expiratory Reserve Volume (ERV) and Resid-
ual Volume (RV)). 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 25% less in females than in males
and are greater in large and athletic individuals. Nitrous oxide sedation will vary ac-
cordingly.
Respiratory air volumes during rest and exercise are of physical and clinical interest, and
they can be measured using a spirometer. The main volumes of interest are:
Tidal Volume (TV): amount of air breathed in and out during quiet breathing
Expiratory Reserve Volume (ERV): amount of air forced out of the lungs in a max-
imal expiration, over and above that expired in normal breathing
Inspiratory Reserve Volume (IRV): amount of air inhaled in a maximal inspiration,
over and above that inhaled in normal breathing
Vital Capacity (VC): TV + ERV + IRV
Residual Volume (RV): volume of air that remains in the lungs at all times (can't be
measured by spirometry)
Total Lung Capacity (TLC): VC + RV
very lipid soluble
rapid onset of action
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 in-
duction of anesthesia because they produce unconsciousness in less than 30 seconds.
Barbiturates:
Ultra-short acting: Methohexital (Brevital), thiopental (Pentothal), and thiamylal (Suri-
tal)
Short and intermediate acting: Amobarbital (Amytal), pentobarbital (Nembutal), seco-
barbital (Seconal), and butabarbital (Fioricet, Fiorinal)
Long acting: Phenobarbital (Luminal)
Most commonly used barbiturates for induction of anesthesia:
Thiopental (Pentothal): Usually prepared as a 2.5% solution. An induction dose of 3-5
mg/kg produces a loss of consciousness within 30 seconds and recovery in 5-10 minutes.
Because the elimination half-life is 6-12 hours, patients may experience a slow recovery.
When injected intravenously, it can be irritating. Usually prepared as 2.5% solution. pH is
10.5.
Methohexital (Brevital): is somewhat less lipid soluble and less ionized at physiologic pH
than thiopental. An induction dose of 1-2 mg/kg produces loss of consciousness in less than
20 seconds and recovery in 4-5 minutes. The elimination half-life of methohexital is 3 hours,
which allows a clearance rate that is 3 to 4 times faster than that of thiopental. pH is 10.5.
The side effect most often seen is hiccups. This is believed to be caused by rapid injection
of the Brevital.
1. The most effective agent in the initial treatment of respiratory depression due
Notes to the overdose of barbiturates is oxygen under positive pressure.
2. A primary advantage of IV sedation is the ability to titrate individualized
dosage.
anesth
Which of the following local anesthetics are available in North America?
prilocaine
bupivacaine
procaine
lidocaine
tetracaine
articaine
43
anesth
Which of the following are appropriate treatments for an impending vasovagal
syncopal episode?
sit patient in upright position
place patient in supine position
monitor vitals
oxygen administration
loosen tight clothing
> place a cold compress on patients forehead
44
prilocaine lidocaine
bupivacaine articaine
Procaine (Novocaine) was, at one time, the most commonly used ester local anesthetic in dentistry. It is
the prototype for the ester group of local anesthetics but is no longer available in dental cartridge form.
An easy way to identify amide local anesthetics is to remember that the drug name contains an i plus -
caine (lidocaine, mepivacaine, and bupivacaine). Esters such as procaine, benzocaine, and tetracaine
contain no i.
Amide-type local anesthetics: Ester-type local anesthetics:
Lidocaine (Xylocaine): most commonly used Procaine (Novocaine)
Prilocaine (Citanest) . Propoxycaine (Ravocaine)
Articaine (Septocaine): has both amide and ester linkages Benzocaine (Monocaine)
Mepivacaine (Carbocaine) . Tetracaine (Pontocaine)
Bupivacaine (Marcaine)
Etidocaine (Duranest): removed from the U.S. market in 2002
Topical esters are still commonly used in the practice of dentistry. Most topical local anesthetic oint-
ments and gels contain benzocaine (an ester, e.g., Hurricaine, Cetacaine). Benzocaine gels typically
contain 18% - 20% benzocaine. Lidocaine (an amide) is also available in two forms for topical applica-
tion. EMLA (eutectic mixture of local anesthetic cream), contains both lidocaine and prilocaine.
Amides are safe, versatile, and effective local anesthetics. If hypersensitivity to a drug in this group pre-
cludes its use, one of the ester-compound local anesthetics may provide analgesia without adverse effect.
For patients allergic to both esters and amides, diphenhydramine (Benadryl) is a good choice.
Esters are potent local anesthetics slightly different in chemical structure from the amide group. Tetra-
caine is most commonly used. Allergic reactions are far more common with esters.
Important: Lidocaine has an FDA Pregnancy Category rating of B. Lidocaine 2% with epinephrine
1:100,000 is the drug of choice in the treatment of pregnant women. Articaine, bupivacaine, and mep-
ivacaine have an FDA Pregnancy Category rating of C.
Remember: The drug of choice in management of an acute allergic reaction involving bronchospasm
(an acute narrowing of the respiratory airway) and hypotension is epinephrine.
Note: Allergic reactions to local anesthetic are usually caused by an antigen-antibody reaction.
place patient in supine position oxygen administration place a cold compress on patients
monitor vitals .loosen tight clothing forehead
The most common cause of a transient loss of consciousness in the dental office is vasovagal syncope. This
generally is due to a series of cardiovascular events triggered by the emotional stress brought on by the antic-
ipation of or delivery of dental care. Prevention of vasovagal syncopal reactions involves proper patient prepa-
ration.
Remember: Any signs of an impending syncopal episode should be quickly treated by placing the patient in
a supine position with the feet elevated (Trendelenburgposition), monitoring vital signs, loosening tight cloth-
ing and placing a cold compress on the forehead. Oxygen 3-4 L/minute should also be given via nasal cannula.
Important: The most common early sign of syncope is pallor.
Vasovagal Syncope:
Most commonly related to injections in younger individuals
Parasympathetic response often followed by sympathetic response secondary to anxiety
Warm feeling, pale, diaphoresis, "feeling faint or sick," nausea, bradycardia, and hypotension
Most Common Medical Emergencies:
Syncope Asthma attack
Hyperventilation Acute myocardial infarction
Hypoglycemia Seizure
Postural hypotension . Allergic reactions
Angina pectoris
Postural Hypotension: Management
Slow to change position from laying to sitting to standing
Need for change in medication? (depends on severity)
Recent change in medication
Rule out precipitating causes
"Hyperventilation syndrome"- most commonly seen in dental office
Related to anxiety/ panic
Associated with lightheadedness, dizziness, chest pain, dysphagia, nausea
Rule out more serious potential conditions including pulmonary (asthma, PE), cardiac (CHF), en-
docrine (diabetic ketoacidosis)
anesth
For local anesthetics, for every 1 % solution there is:
0.10 mg/mL of anesthetic
'1 mg/mL of anesthetic
10 mg/mL of anesthetic
45
anesth
Which of the following are needed in combination to produce neurolept-
anesthesia?
narcotic analgesic
neuroleptic agent
nitrous oxide
46
r
Use the following to calculate the amount, in milligrams, of anesthetic or vasoconstrictor in a given solution:
a. For local anesthetic, a 1% solution has 10 mg/mL
100% solution would be 1000 mg/mL
** Total milligrams = (% of the solution) x (lOmg/mL) x (mL of solution)
34 mg = (2) x (10) x (1.7) for a standard 2% lidocaine solution
b. For vasoconstrictor, 1; 100,000 means 1 gram per 100,000 mL. This equates to 0.01 mg/mL.
Total milligrams = (ratio in mg/mL) x (mL of solution)
.017 mg epi = (.01 mg/mL) x (1.7 mL)
Calculation of Milligrams of Local Anesthetic
Per Dental Cartridge (1.7 ml Cartridge)
Local Anesthetic
Articaine
Bupivacaine
Lidocaine
Mepivacaine
Mepivacaine
Prilocaine
Percent concentration
4
0.5
2
2
3
4
mg/ml
40
5
20
20
30
40
x 1.7 ml = mg/Cartridge
68
8.5
34
34
51
68
Maximum Recommended Dosages (MRDs) of Local Anesthetics Available in North America
Local Anesthetic
Articaine
With vasoconstrictor
Bupivacaine
Lidocaine
No vasoconstrictor
Mepivacaine
No vasoconstrictor
Prilocaine
No vasoconstrictor
Maximum Recommended Dosage
mg/kg
7
1.3
4.4
4.4
4.4
4.4
6.0
6.0
mg/lb
3.2
0.6
2.0
2.0
2.0
2.0
2.7
2.7
MRD(mg)
500
90
300
300
300
300
400
400
narcotic analgesic
neuroleptic agent
nitrous oxide
Neuroleptanesthesia is a state of neuroleptanalgesia and unconsciousness, produced by the combined
administration of a narcotic analgesic and a neuroleptic agent, together with the inhalation of nitrous
oxide and oxygen.
Neuroleptanalgesia only produces an unconscious state if nitrous oxide is also administered (see below).
Neuroleptic agent + narcotic analgesic = neuroleptanalgesia
(droperidol) ff'entanyl) (conscious)
Under the influence of this combination, the patient is sedated and demonstrates psychic indifference to
the environment yet remains conscious and can respond to questions and commands.
Neuroleptanalgesia + nitrous oxide = neuroleptanesthesia
in oxygen (unconscious)
Induction of anesthesia is slow, but consciousness returns quickly after the inhalation of nitrous oxide
is stopped.
1. Neurolept analgesia is useful for minor surgical procedures, some radiological procedures,
Notes burn dressing, and endoscopy.
2. Neuroleptic agents such as droperidol (Inapsine) cause a reduction in anxiety and a
state of indifference.
3. Droperidol is an antiemetic and has adrenergic blocking (alpha blocking) activity.
4. Neurolept analgesia/anesthesia may be especially useful in the elderly, debilitated, or se-
riously ill patient.
5. The combination of droperidol and fentanyl (Sublimaze), is Innovar.
6. Innovar produces slight circulatory effects, but can cause significant respiratory de-
pression.
7. The low incidence of extrapyramidal side effects associated with droperidol use may be
effectively treated with the anticholinergic (antimuscarinic) drug, benztropine (Cogentin).
anesth
The most common cause of loss of consciousness in the dental office is:
anaphylaxis
syncope
heart attack
seizure
47
anesth
Trauma to muscles or blood vessels in the is the most
common etiological factor in trismus associated with dental injections of
local anesthetics.
pterygoid fossa
temporal fossa
submandibular fossa
infratemporal fossa
48
copyright C 2013-2014- Dental Decks
syncope fainting
Syncope is the most common adverse reaction associated with administration of local
anesthesia. Remember: It often occurs when upright, although it can occur when sit-
ting. It will never occur when lying. The patient may complain of feeling generalized
warmth with nausea and palpitations.
The initial event in a vasovagal syncope episode is the stress-induced release of in-
creased amounts of catecholamines that cause the following: a decrease in peripheral
vascular resistance, tachycardia, and sweating.
As blood pools in the periphery, a drop in blood pressure appears, with a corresponding
decrease in cerebral blood flow. The patient will then complain of feeling dizzy or weak.
Compensatory mechanisms attempt to maintain adequate blood pressure, but they soon
fatigue, which leads to vagally mediated bradycardia. Once the blood pressure drops
below levels necessary to sustain consciousness, syncope occurs.
Place the patient in a supine position with the feet elevated (Trendelenburgposition),
monitor vital signs, tight clothing should be loosened 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, includ-
ing chronic obstructive pulmonary disease, is oxygen.
Note: The primary airway hazard for an unconscious dental patient in a supine position
is tongue obstruction. Remember: Head tilt/chin lift.
infratemporal fossa
Limited jaw opening, or trismus, is a relatively common complication following local anesthetic
administration. In addition to trauma 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 of a foreign body.
Note: In most instances of trismus the patient reports 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 the mandible, which is often
associated with pain. Symptoms will arise from 1 to 6 days following an injection. The duration
of symptoms and their severity are both variable. Note: The medial pterygoid muscle is most
often affected.
Management of trismus:
Apply hot, moist towels to the site for approximately 20 minutes every hour
Warm saline rinses
Use analgesics as required
Benzodiazepine (e.g., diazepam) for muscle relaxation if deemed necessary
The patient should gradually open and close mouth as a means of physiotherapy
Following an inferior alveolar nerve block injection or a mental block injection, a prickly or
tingling sensation (paresthesia), even complete numbness in the lower lip, may result and per-
sist for a considerable time. This is usually considered to be due to direct trauma or piercing
of the nerve trunk by the needle. This happens more often in the case of the mental block in-
jection. The symptoms of paresthesia gradually diminish (may last from 2 weeks to 6 months),
and recovery is usually complete.
Remember: The most common cause of paresthesia of the lower lip is the removal of a
mandibular third molar (especially horizontally impacted ones).
anesth
There are no contraindications for the use of nitrous oxide sedation in
asthmatic patients.
Because anxiety is a stimulus for an asthmatic attack, nitrous oxide sedation
is actually beneficial for these patients.
both statements are true
both statements are false
the first statement is true, the second is false
the first statement is false, the second is true
49
anesth
A normal platelet count is:
15,000 -45,000/mm
3
75,000 -100,000/mm
3
150,000 -450,000/mm
3
450,000 - 600,000/mm
3
50
both statements are true
Nausea and vomiting are the most common adverse effects of nitrous oxide sedation, oc-
curring in 1% to 10% of patients. Fasting is not required for patients undergoing nitrous
oxide sedation. The practitioner, however, may recommend that only a light meal be con-
sumed in the 2 hours prior to the administration of nitrous oxide. Diffusion hypoxia can
occur as a result of rapid release of nitrous oxide from the blood stream into the alveoli,
thereby diluting the concentration of oxygen. This may lead to headache and disorienta-
tion and can be avoided by administering 100% oxygen after nitrous oxide has been
discontinued.
Remember: The most common complication associated with nitrous oxide sedation is
a behavioral problem (laughing, giddy).
Note: Some literature states that nitrous oxide is acceptable for the pregnant patient,
however, from a risk management perspective, point it may be prudent not to use nitrous
oxide on any pregnant patient. Greater concern lies with office workers, such as dental as-
sistants who might be continually exposed to nitrous oxide. Pregnant assistants should
not work in or near rooms where nitrous oxide is being administered.
Administration of volatile anesthetics (desflurane, enflurane, halothane, isoflurane, and
sevoflurane) is not a concern for COPD patients. All volatile anesthetics are bron-
chodilators and, therefore, are beneficial to patients with COPD (asthmatic bronchitis,
emphysema, and chronic bronchitis).
Important: Sedation with nitrous oxide should be avoided in patients with COPD.
150,000 - 450,000/mm
3
Thrombocytopenia is defined as a count of <150,0007mrrf. Intraoperative bleeding can be severe with counts
of 40 000-70 000/mm\ and spontaneous bleeding usually occurs at counts <2 0 , 0 0 0 W. The rmntmal rec-
ommended platelet count before surgery is 75,000/mm
3
.
White blood cell count
Red blood cell count
Hemoglobin
Hematocrit
Platelet count
Definition
Percentage of RBC mass in
blood volume
Male
5,000-10,000/mm
3
4.5-5.9 x 10
6
/mm
3
4.5-5.9 x lO'/mm
3
14-16 g/dL
42%-52%
150,000-450,000/mm
3
Female
5,000-10,000/mm
3
12-14 g/dL
36%-48%
150,000-450,000/mm
RBC indices:
Mean corpuscular volume
(MCV)
Mean corpuscular
hemoglobin (MCH)
Mean corpuscular
hemoglobin concentration
(MCHC)
Average RBC volumes in fL
Estimates weight of Hgb in
average RBC
Estimates average concentra-
tion of Hgb in average RBC
80-100 fL
28-33 pg
32-36 g/dL
80-100 fL
28-33 pg
32-36 g/dL
Notes
1. The minimal acceptable value for the hematocrit is 30% for elective surgery.
2. Normal values for coagulation:
Template bleeding time = 1 to 9 minutes
Prothrombin time (PT) = 11 to 16 seconds (compared to normal control)
Partial thromboplastin time (PTT) = activated, 32-46 seconds (compared to normal con-
Important- PT will be increased by warfarin, vitamin K deficiency, fat malabsorption, liver dis-
ease DIC and artificially increased tourniquet time. Warfarin works by blocking vitamm K
dependent clotting facors, whereas broad-spectrum antibiotics elevate PT by killing normal
bowel flora which decreases vitamin K absorption. Heparin in high doses also will increase PT
by altering factor X. Note: FFP (fresh frozen plasma) will reverse warfarin effects immediately.
anesth
Which of the following pairings are correct regarding the amount of
epinephrine in 1.7cc of solution?
2% lidocaine 1:200,000 / .0085 mg epinephrine
51
anesth
The primary site of biotransformation of amide drugs is the:
plasma
lung
* kidney
liver
52
See card #45 for more detailed explanation of calculations
1 mL of 2% lidocaine with epinephrine 1:100,000 contains the following:
- 20 mg of lidocaine: Blockade of nerve conduction
- 0.01 mg of epinephrine: Increase depth and duration of anesthesia; decrease absorption of
local anesthetic and vasopressor
- 6 mg of NaCL: Isotonicity of the solution
- 0.5 mg of sodium (meta) bisulfate: Antioxidant
- 1 mg of methylparaben: Bacteriostatic agent
- Sterile water: A diluent to provide the volume of solution in a cartridge
1.7 mL of 2% lidocaine (which is a carpule) with epinephrine 1:100,000 contains the follow-
m
^' Note: Methylparaben is no longer
- 34 mg of lidocaine: (1.7 mL x 20 mg/mL)
m d u d e d m s i n g l e
.
u s e d e n t a l c a r
.
- .017 mg of epinephrine: (1.7 mL x .01 mg/mL)
t r i d g e s o f
,
o c a l a n e s t h e t i c ; h o w
.
- 10.2 mg of NaCl: (1.7 mL x 6 mg/mL) ^
[t {& found m A L L m u l t i d o s e
- 0.85 mg of sodium (meta) bisulfate: (1.7 mL x 0.5 mg/ mL)
v i a l s o f i n j e c t a b l e d
Calculations of Milligrams per Cartridge
Percent Solution
0.5
1.0
2.0
3.0
4.0
Milligrams (mg) X Volume of Cartridge
per Milliliter (mL)
5 X 1.7
10 X 1.7
20 X 1.7
30 X 1.7
40 X 1.7
= Milligrams per Cartridge
8.5
17
34
51
68
liver
A significant difference between the two major groups of local anesthetics, the esters and the
amides, is the means by which the body biologically transforms the active drug into one that is phar-
macologically inactive. Metabolism (or biotransformation) of local anesthetics is important be-
cause the overall toxicity of a drug depends on a balance between its rate of absorption into the
bloodstream at the site of injection and its rate of removal from the blood through the processes of
tissue uptake and metabolism.
The primary site of biotransformation of amide drugs is the liver. Ester local anesthetics are hy-
drolyzed in the plasma to para-aminobenzoic acid (PABA) by the enzyme pseudocholinesterase. Pa-
tients with pseudocholinesterase inactivity are unable to detoxify ester type 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 of hypersensi-
tivity to the local anesthetic agent itself or due to an allergy to methylparaben or other preserva-
tives used in many solutions. These reactions are characterized by cutaneous lesions of delayed
onset or urticaria, edema, and other manifestations of allergy. Important: For those patients aller-
gic to both ester and amide-type local anesthetics, diphenhydramine is a safe and effective alter-
native.
Classification of Local Anesthetics
Esters
Esters of benzoic acid:
Butacaine
Cocaine
Ethyl aminobenzoate (benzocaine)
Hexylcaine
Piperocaine
Tetracaine
Esters of paraminobenzoic acid:
Chloroprocaine
Procaine
Propoxycaine
Amides
Articaine
Bupivacaine
Dibucaine
Etidocaine
Lidocaine
Mepivacaine
Prilocaine
Ropivacaine
Quinoline
Centbucridine
anesth
The initial clinical signs and symptoms of CNS toxicity for local anesthetics are
usually excitatory in nature. However, it is also possible that the excitatory
phase of the reaction may be extremely brief or may not occur at all. This is true
especially with which local aneshetics?
lidocaine
tetracaine
etidocaine
procaine
bupivacaine
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anesth
The pH of normal tissue is ; the pH of an inflamed area is .
9.0; 3 to 4
7.4; 5 to 6
3.6; 8 to 9
8.0; 2 to 3
54
lidocaine
procaine
Local anesthetics readily cross the blood-brain barrier. Their pharmacological action on the CNS
is depression. At low (therapeutic, nontoxic) blood levels, there are no CNS effects of any clini-
cal significance. At higher (toxic, overdose) levels, the primary clinical manifestation is a general-
ized tonic-clonic convulsion.
With a further increase in the blood level of the local anesthetic above its "therapeutic" level, ad-
verse reactions may be observed. Because the CNS is much more susceptible to the actions of local
anesthetics than other systems, it is not surprising that the initial clinical signs and symptoms of
overdose (toxicity) are CNS in origin. Initial clinical signs and symptoms (slurred speech, dizziness,
talkativeness, apprehension, increased anxiety) of CNS toxicity are usually excitatory in nature.
Lidocaine and procaine differ somewhat from other local anesthetics in that the usual progression
of signs and symptoms may not be seen. Lidocaine and procaine frequently produce an initial
mild sedation or drowsiness (more common with lidocaine).
Sedation may develop in place of the excitatory signs. If either excitation or sedation is observed
in the initial 5 to 10 minutes after the intraoral administration of a local anesthetic, it should serve
as a warning to the clinician of a rising local anesthetic blood level and the possibility (if the blood
level continues to rise) of a more serious reaction, possibly a generalized convulsive episode.
Local anesthetics have a direct action on the myocardium and peripheral vasculature. In general,
however, the cardiovascular system appears to be more resistant to the effects of local anesthetic
drugs than the CNS.
Direct action on the myocardium: Local anesthetics produce a myocardial depression that is
related to the local anesthetic blood level. Local anesthetics decrease electrical excitability of the
myocardium, decrease the conduction rate, and decrease the force of contraction.
Direct action on the peripheral vasculature: All local anesthetics (except cocaine andropi-
vacaine) produce a peripheral vasodilation through relaxation of the smooth muscle in the
walls of blood vessels.
7.4; 5 to 6
It is well known that the pH of a local anesthetic solution (and the pH of the tissue into which it is in-
jected) greatly influences its nerve-blocking action. Acidification of tissue decreases local anesthetic ef-
fectiveness. Inadequate anesthesia results when local anesthetics are injected into inflamed or infected
areas. Local anesthetics containing epinephrine or other vasopressors are acidified by the manufacturer
to inhibit the oxidation of the vasopressor. The pH of solutions without epinephrine is about 5.5; epi-
nephrine-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 in-
jection more comfortable.
The two factors involved in the action of a local anesthetic are diffusion of the drug through the nerve
sheath and binding at the receptor site in the ion channel. Local anesthetics exist in ionized (cation) and
non-ionized (base) forms, the proportions of which vary with the pH of the environment. The non-ion-
ized (base) portion is the form that is capable of diffusing across nerve membranes and blocking sodium
channels.
Factors Affecting Local Anesthetic Action
Factor
pK.
Lipid solubility
Protein binding
Nonnervous tissue
diffusibility
Vasodilator activity
Action Affected
Onset
Anesthetic potency
Duration
Onset
Anesthetic potency
and duration
Description
Lower pK
a
= more rapid onset of action, more RN (free
base form) molecules present to diffuse through nerve
sheath; thus onset time is decreased
Increased lipid solubility = Increased potency
(example: procaine = 1; etidocaine = 140)
Etidocaine produces conduction blockade at very low
concentrations, whereas procaine poorly suppresses
nerve conduction, even at higher concentrations
Increased protein binding allows anesthetic cations
(RNH~) to be more Firmly attached to proteins located at
receptor sites; thus duration of action is increased
Increased diffusibility * Decreased time of onset
Greater vasodilator activity * Increased blood flow to
region = Rapid removal of anesthetic molecules from
injection site; thus decreased anesthetic potency and
decreased duration
anesth
Nitrous oxide works on the:
peripheral nervous system (PNS)
central nervous system (CNS)
autonomic nervous system (ANS)
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anesth
The primary action of local anesthetics in producing a conduction block is to
decrease the permeability of the ion channels to:
calcium ions
chloride ions
potassium ions
sodium ions
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central nervous system (CNS)
Nitrous oxide is the only inorganic gas used by the anesthesiologist. Room air contains 21%
oxygen; you must make sure that the patient receives at least this much oxygen. The max-
imum limitation is 60% nitrous oxide and 40% oxygen.
Nitrous oxide is carried in the bloodstream in physical solution. There is no metabolism or
degradation of nitrous oxide in the body. It is excreted solely via the lungs, unchanged. High
blood levels of nitrous oxide can be achieved quite quickly. It is nontoxic to body tissues. The
only toxicity associated with the use of nitrous oxide is the lack of oxygen that could result
from the operator's error. The gag reflex is only slightly obtunded with nitrous oxide analge-
sia. It is believed that nitrous oxide has its main effects on the reticular activating system and
the limbic system.
Nitrous oxide is a weak anesthetic. It is used to supplement inhalation agents. It is the only in-
halation anesthetic with sympathomimetic activity. It should not be used in doses higher than
60% combined with 40% oxygen. It is known to diffuse into air-containing spaces and to in-
crease the pressure in such cavities. 100% oxygen should be administered during awakening
in order to avoid diffusion hypoxia.
Remember:
The first symptom of nitrous oxide analgesia is tingling of the hands.
Nausea is the most common side effect of nitrous oxide analgesia.
The correct total liter flow of nitrous oxide/oxygen is determined by the amount necessary
to keep the reservoir bag 1/3 to 2/3 full.
MAC (minimal alveolar concentration) of nitrous oxide is 104. MAC is the concentration
of an inhaled anesthetic at 1 atm that prevents skeletal muscle movement in response to a
painful stimulus (e.g., surgical skin incision) in 50% of patients.
sodium ions
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:
1. Displacement of sodium ions from the sodium channel receptor site, which permits...
2. Binding of local anesthetic molecule to this receptor site, which thus produces...
3. Blockade of the sodium channel, and a...
4. Decrease in sodium conductance, which leads to...
5. Depression of the rate of electrical depolarization, and a...
6. Failure to achieve the threshold potential level, along with a...
7. Lack of development of propagated action potentials, which is called...
8. Conduction blockade
The mechanism whereby sodium ions gain entry to the axoplasm of the nerve, thereby initiating an
action potential, is altered by local anesthetics. The nerve membrane remains in a polarized state
because ionic movements responsible for the action potential fail to develop. Nerve block produced
by local anesthetics is called a nondepolarizing nerve block.
1. Local anesthetics reversibly block nerve impulse conduction and produce
Notes reversible loss of sensation at their administration site. The site of action of local
anesthetics is at the lipoprotein sheath of the nerves.
2. Local anesthetics are clinically effective on both axons and free nerve endings.
3. Important: Smallest, unmyelinated nerve fibers that conduct pain and
temperature sensations are affected first, followed by touch, proprioception, and
skeletal muscle tone.
4. Emergence from a local anesthetic nerve block follows the same diffusion patterns
as induction; however, it does so in reverse order.
5. Recovery is usually a slower process than induction because the anesthetic is bound
to the drug receptor site in the sodium channel and, therefore, is released more slowly
than it is absorbed.
6. Conductance of potassium, calcium, and chloride remains unchanged.
anesth
Which of the following is the phase of anesthesia that begins with the
administration of anesthetic and continues until the desired level of
patient unresponsiveness is reached?
induction
maintenance
recovery
57
anesth
Volatile liquids require a vaporizer for inhalational administration.
Which one additionally requires a heating component to allow delivery at
room temperature?
enflurane
halothane
sevoflurane
desflurane
isoflurane
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induction
*** Stage I and Stage II of general anesthesia together are referred to as induction.
The depth of general anesthesia (by inhalation) varies with the partial pressure (tension) of
the anesthetic agent in the brain, and the rates of induction and recovery depend on the rate
of change of tension in this tissue (also blood supply to the lungs, pulmonary ventilation,
and the concentration of the anesthetic influence the rate of induction). The signs and stages
of anesthesia are most likely to be seen with anesthetic that has a slow rate of induction.
1. Maintenance is the process of keeping a patient in surgical anesthesia.
Notes 2. Recovery is the phase of anesthesia commencing when surgery is complete and
the delivery of the anesthetic is terminated and ending when the anesthetic has
been eliminated from the body.
3. The behavior of patients under general anesthesia suggests that the most re-
sistant part of the CNS is the medulla oblongata (cardiac, vasomotor, and res-
piratory centers of the brain).
4. The most controllable route for administration of a general anesthetic is in-
halation.
5. Minimum alveolar concentration (MAC): alveolar concentration of anesthetic
at which 50% of the patients are unresponsive to a standard surgical stimulus.
6. Meyer-Overton theory: anesthesia commences when a chemical substance
reaches a certain molar concentration in the hydrophobic phase.
7. Second gas effect: this occurs when one gas speeds the rate of increase of the
alveolar partial pressure of a 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.
desflurane
Inhalation anesthetics are substances that are brought into the body via the lungs and are dis-
tributed with the blood into the different tissues. The main target of inhalation anesthetics
(or so-called volatile anesthetics) is the brain. Currently used inhalation anesthetics include
five volatile liquids (enflurane, halothane, isoflurane, sevoflurane, desflurane) and one gas
(nitrous oxide). The volatile liquids require a vaporizer for inhalational administration. The des-
flurane 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 ir-
ritation may cause coughing and muscle spasms in the voice box, or larynx (laryngospasm),
or in the bronchial tubes in the lungs (bronchospasm). Sevoflurane is less irritating to the air-
way than the others and is preferred for inducing anesthesia in children.
Important: All the potent inhalation agents are capable of triggering malignant hyperthermia
(MH), a rare inherited disorder that is potentially fatal.
Administration of an inhalation anesthetic is usually preceded by intravenous or intramus-
cular administration of a short-acting sedative hypnotic drug, often a barbiturate (thiopental).
The procedure almost always requires endotracheal intubation.
1. Administration of volatile anesthetics is not a concern for COPD patients. All
Notes 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 pressure.
3. Desflurane, isoflurane, and sevoflurane are potent vasodilators.
anesth
The optimum site for IV sedation for an outpatient is the:
> median basilic vein
median cephalic vein
median antebrachial vein
1
axillary vein
59
anesth
Dissociative anesthesia is a unique method of pain control that reduces
anxiety and produces a trancelike state in which the person is not asleep, but
rather feels separated from his or her body. The primary medication used is:
< demerol
ketamine
pentobarbital
promethazine hydrochloride
60
median cephalic vein
This vein lies in the lateral aspect of the antecubital fossa (anterior to the elbow). Avoid
entering the brachial artery. If the artery is entered, the following symptoms will ap-
pear: immediate burning at the site of the injection, the arm will appear blotchy, and the
pulse in the arm will 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 1
ml/minute
1 mL of injectable Valium contains 5 mg
of Valium
Injection is discontinued when the eyelids
droop (ptosis)
Cephalic vein
Three common signs indicating when the correct
level of sedation has been reached when using Val-
ium:
1. Blurring of vision
2. Slurring of speech
3. 50% ptosis of the eyelids (this is called Ver-
rill's sign)
Remember: Valium is contraindicated for use in
a patient with a history of narrow-angle glaucoma.
Median
cephalic vein
Cephalic vein
Basilic vein
Median
cubital vein
Basilic vein
ketamine
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 individ-
ual (particularly adult patients) may have intense dreams and even hallucinations.
Ketamine, a phencyclidine (PCP) derivative, is 10 times more lipid soluble than thiopen-
tal, enabling it to cross the blood-brain barrier quickly. It produces dissociative anesthe-
sia, which can be seen on EEG as dissociation between the thalamus and limbic system.
Rapid CNS depression with hypnosis, sedation, amnesia, and intense analgesia occurs in
30-60 seconds after administration. The anesthetic induction doses are 1-2 mg/kg 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 glycopyrr-
olate in the preoperative period
Increases BP, heart rate, and cardiac output, but not respirations
Produces bronchial smooth muscle relaxation because of sympathetic stimulation
Is a potent cerebral vasodilator
Side effects include hypertension, increased pulse, and delirium
anesth
Malignant hyperthermia (MH) is a pharmacogenetic disorder in which a
genetic variant in the individual alters that person's response to certain drugs.
Which of the following describe the major clinical characteristics of MH?
> rigidity
fever
hypermetabolism
myoglobinuria
alkalosis
61
anesth
The following signs: nausea, pallor, cold perspiration, widely dilated pupils,
eyes rolled up, and brief convulsions are indicative of a patient having a
reaction.
somatogenic
psychogenic
either of the above
none of the above
62
rigidity
fever
hypermetabolism
myoglobinuria
MH is a hypermetabolic state involving skeletal muscle that is precipitated by certain anes-
thetic agents in genetically susceptible individuals. The incidence of MH is <0.5% of all pa-
tients who are exposed to anesthetic agents. Inhalation anesthetic drugs that are known to
trigger MH include halothane, enflurane, isoflurane, desflurane, and sevoflurane. Depolar-
izing neuromuscular blockade agents that can trigger MH include succinylcholine, de-
camethonium, and suxamethonium. Classic MH most often manifests in the operating room,
but it can also occur within the first few hours of recovery from anesthesia. When exposed
to inhalational anesthetics, muscle metabolism increases, and a series of signs and symp-
toms appear, which, if left untreated, can lead to death. The earliest findings are an in-
creased production of carbon dioxide and signs of increased sympathetic nervous system
activity.
Acute clinical manifestations of MH include tachycardia, tachypnea, unstable blood pres-
sure, cyanosis, respiratory and metabolic acidosis, fever, muscle rigidity, and death. Mor-
tality ranges from 63% to 73%. It usually occurs in apparently healthy children and young
adults at an average age of 21 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 management of MH (100% oxygen, cooling procedures, and the correction of
acidosis and hyperkalemia). Dantrolene is, at the moment, the only known drug that treats
MH. It impairs calcium-dependent muscle contraction and controls hypermetabolic mani-
festations.
psychogenic
*** A psychogenic reaction is caused by psychological factors rather than physical factors.
Vasovagal syncope, a psychogenic reaction, is the most commonly experienced complication
associated with the use of local anesthetic solutions. The clinical signs closely resemble those
of shock. These psychogenic reactions readily respond to placing the patient in a supine posi-
tion.
The following drugs, when administered 1 hour prior to the dental appointment, are safe and
effective ways to allay the fears of an apprehensive adult dental patient and possibly avoid a
psychogenic reaction in the dental chair:
diazepam (Valium): 5-10 mg orally (PO)
pentobarbital (Nembutal): 50-100 mg orally (PO)
secobarbital (Seconal): 50-100 mg orally (PO)
promethazine (Phenergan): 25 mg orally (PO)
*** Note dosages and route of administration.
These drags are not recommended unless you have experience with them and can handle
any complications that may happen from their use.
Note: For a dentist to use "enteral sedation" (the use of a pharmacological method that
produces a minimally depressed level of consciousness) some states require special training
and registration with the state.
Note: A somatogenic reaction is the development of a reaction from an organic pathophys-
iologic cause.
anesth
Postoperative hypotension is usually due to the effect of:
transfusion reactions
a fat embolism
the anesthetic or analgesics on the myocardium
liver failure
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anesth
Anesthesia performed with general anesthetics occurs in four stages which
may or may not be observable because they can occur very rapidly.
Which stage is the one in which skeletal muscles relax and the patient's
breathing becomes regular?
analgesia
excitement
surgical anesthesia
medullary paralysis
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the anesthetic or analgesics on the myocardium
*** Leading to myocardial depression.
Common causes of postoperative hypotension:
Intravascular hypovolemia
Rewarming vasodilation
Hypothyroidism
Myocardial depression
*** Possible treatment options include:
Elevation of the lower extremities
Administration of carefully monitored fluid boluses
Administration of vasopressors (e.g., ephedrine)
The treatment is Narcan (a narcotic antagonist) if hypotension is due to narcotics. Use
atropine (an anticholinergic) if bradycardia is present.
Note: Postoperative hypertension is most often due to post-op pain. Treat with
narcotics and sedatives. Other common causes include:
Hypercapnia
Anxiety
Overdistension of the bladder
Hypoxia
surgical anesthesia
Stage One (Analgesia): The patient experiences analgesia or a loss of pain sensation but remains
conscious and can carry on a conversation. Note: The best monitor of the level of analgesia is the
verbal response.
Stage Two (Excitement): The patient may experience delirium or become violent. Blood pres-
sure rises and becomes irregular, and breathing rate increases. This stage is typically bypassed by
administering a barbiturate, such as methohexital or thiopental, before the anesthesia.
Stage Three (Surgical Anesthesia): During this stage, the skeletal muscles relax, and the pa-
tient's breathing becomes regular. Eye movements slow, then stop, and surgery can begin.
Stage Four (Medullary Paralysis): This stage occurs if the respiratory centers in the medulla
oblongata of the brain that control breathing and other vital functions cease to function. Death can
result if the patient cannot be revived quickly. This stage should never be reached. Careful con-
trol of the amounts of anesthetics administered prevent this occurrence.
1. The medulla is the last area of the brain to be depressed during general anesthesia.
Notes This area is the most vital part of the brain and contains the cardiac, the vasomotor,
and respiratory centers of the brain.
2. The most reliable sign of "oxygen want" while monitoring a patient during gen-
eral anesthesia is an increased pulse rate. Cyanosis may also be present.
3.The emergency most frequently experienced during outpatient general anesthesia is
respiratory obstruction.
4. The best anesthetic technique used in oral surgery 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 infection is contraindicated for general anes-
thesia.
6. The eyes are taped shut prior to draping a patient before surgery to prevent corneal
abrasion.
anesth
The recommended gas combination dose for conscious sedation is:
50% oxygen; 50% nitrous oxide
varies according to the patient response
65
anesth
The propylene glycol in IV valium can cause:
cellulitis
> a unilateral facial paralysis
phlebitis
syncope
66
varies according to the patient response
The dose of the gas combination for conscious sedation is variable and is based on patient response.
The maximum nitrous oxide limitation is 60% nitrous oxide and 40% 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
slow breathing or blood flow to the brain.
Nitrous oxide has a low blood-to-gas partition coefficient (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 of nitrous oxide can increase the expansion of compliant cavi-
ties, such as a pneumothorax, bowel gas in a bowel obstruction, and an air embolism.
Important: The oral and maxillofacial surgeon needs to be cautious when treating the recent trauma
patient (e.g., motor vehicle accident victim). An asymptomatic, undiagnosed closed pneumothorax
can double in size in 10 minutes after the administration of 70% nitrous. Nitrous oxide sedation
should be postponed in patients with gastrointestinal obstructions, middle ear disturbances, and,
possibly, sinus infections.
Partition Coefficients for Inhaled Anesthetics
Blood: gas
Brain: blood
Muscle: blood
Fat: blood
Oil: blood
Desflurane
0.42
1.3
2.0
27
18.7
Halothane
2.4
2.9
3.4
51
224
Isoflurane
1.4
1.6
2.9
45
90.8
N
2
0
0.46
1.1
1.2
2.3
1.4
Sevoflurane
0.68
1.7
3.1
48
47.2
Minimal Alveolar Concentration (MAC) of Commonly Used Agents
Agent
Nitrous oxide
Isoflurane
Halothane
MAC
104
1.15
0.77
Agent
Desflurane
Sevoflurane
MAC
6.0
1.71
phlebitis
Phlebitis is irritation or inflammation of a vein that is sometimes seen after IV administration of
valium. This is usually attributed to the presence of propylene 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 heavy smokers, the elderly, and women taking oral
contraceptives.
Common signs and symptoms of phlebitis:
Pain Erythema
Tenderness Streaking of the limb
Edema
Treatment: Remove the IV catheter, elevate the affected limb, apply warm, moist packs to the in-
fected site, initiate IV antibiotics (preferably cefazolin [Ancef], 1 gm IVbolus push every 8 hours),
for appropriate staphylococcus coverage.
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 triad is the name given to the three chief causes of deep venous thrombosis (DVT): (I)
damage to the endothelial lining of the vessel, (2) venous stasis, and (3) a change in blood con-
stituents attributable to postoperative increase in the number and adhesiveness of the patient's
platelets.
The classical clinical features of DVT are:
Calf swelling Sudden dyspnea
Fever Tachypnea
Chest pain
A patient who has developed DVT should be started immediately on systemic anticoagulation with
elevation of the affected limb.
Important: The most frequent respiratory complications following oral and maxillofacial surgery
are: pulmonary atelectasis (most often in smokers), aspiration pneumonia (most likely to mani-
fest initially in the patient's right lung), and pulmonary embolus (most originate in the deep ve-
nous systems of the lower extremities, especially in nonambulatory patients).
biopsy
When a biopsy is being performed, it is important to:
incise perpendicular to the long axis of any muscle fibers beneath the lesion
1
incise parallel to the long axis of any 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 of any muscle fibers beneath the lesion
67
biopsy
How long should one wait before obtaining a biopsy of an oral ulcer?
4 days
7 days
> 14 days
> 30 days
68
incise perpendicular to the long axis of any muscle fibers beneath the lesion
*** Whenever possible, the incisions should be oriented parallel to the lines of minimal tension in
order to minimize scarring and wound dehiscence. Note: Biopsy incisions on the face should be ori-
ented to follow Langer's lines.
Four major types of biopsy in and around the oral cavity:
Cytology: should be used as an adjunct to, not a substitute for, biopsy.
Indications include: when large areas of mucosal change must be monitored for dysplastic
change, such as herpes or pemphigus. Technique: the lesion is scraped repeatedly and firmly
with a moistened tongue depressor or cement spatula. The cells obtained are smeared evenly on
a glass slide, and the slide is immediately immersed in a fixing solution and examined under the
microscope.
Aspiration biopsy or fine-needle aspiration (FNA): is the use of a needle and syringe to pen-
etrate a lesion for aspiration of its contents. Indications include: it should be carried out on all
lesions thought to contain fluid (with the possible exception of a mucocele) or any intraosseous
lesion before surgical exploration. Technique: an 18-gauge needle is connected to a 5- or 10-
mL syringe. The area is anesthetized and the 18-gauge needle is inserted into the depth of the
mass during aspiration.
Incisional biopsy: removes only a representative portion or portions of a lesion along with
a representation of adjacent normal tissue. Indications: if the area under investigation appears
difficult to excise because of its extensive size (larger than 1 cm in diameter) or hazardous lo-
cation, or whenever there is a great suspicion of malignancy.
Excisional biopsy: entails removal of the entire lesion along with at least 2 mm of normal mar-
ginal tissue from the sides of the lesion. This technique should be used with smaller lesions (less
than 1 cm in diameter) that, on clinical examination, appear to be benign.
Important: It can not be overemphasized that all pertinent clinical information and the findings of
other diagnostic modalities must be provided to the pathologist at the time of the initial submission
of the specimen.
14 days 2 weeks
Almost all oral ulcers caused by trauma will heal within 14 days. Therefore, any ulcer that
is present for 2 weeks or more should be biopsied.
Biopsy is also indicated in the following instances:
Pigmented lesions (black/brown)
When tissue is associated with paresthesia, this is often an ominous sign
If a lesion suddenly enlarges, it should be biopsied
Note: Always aspirate a central bone lesion to rule out a vascular lesion. If a lesion seems
compressible, pulsatile, or blue, or if a bruit is heard, beware of a vascular lesion and biopsy
only under a controlled hospital setting. *** A stethoscope is used to listen for a bruit.
1. When the entire tumor is removed, it is called an excisional biopsy technique. If
Notes
o n
i y
a
portion of the 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 tissue should be immediately placed in 10% formalin solu-
tion (4% formaldehyde) that is at least 20 times the volume of the surgical specimen.
The tissue must be totally immersed in the solution, and care should be taken to en-
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 of a highly suspicious oral lesion suggests
that another biopsy specimen is necessary in view of the clinical impressions. The
key is a highly suspicious oral lesion. Tissue samplings should be obtained from
multiple sites of the lesion.
Important: Unlike the more common types of oral ulcers, malignant lesions are usually pain-
less, exhibit growth, and do not heal spontaneously. Consequently, biopsy of any ulcer that is
present in the mouth for more than 2 weeks is mandatory.
biopsy
An incisional biopsy is indicated for which of the following lesions?
a 0.5-cm papillary fibroma of the gingiva
a 2.0-cm exostosis of the hard palate
a 2.0-cm area of Fordyce disease of the cheek
a3.0-cm hemangioma of the tongue
a 3.0-cm area of leukoplakia of the soft palate
69
copyright S 2013-2014 - Dental Decks
disord/cond
Which of the following symptoms that suggest that your patient is dehy-
drated?
pale or gray skin color
dry mouth
decreased skin turgor
modified state of consciousness
high blood pressure
rapid pulse
reduced urine output
70
a 3.0-cm area of leukoplakia of the soft palate
Leukoplakia is a premalignant lesion. This means that if left untreated, some of the lesions progress to
carcinoma. It is because of this chance of malignant transformation that all leukoplakic lesions should
be biopsied.
Biopsy Technique and Surgical Principles:
Anesthesia: Block local anesthetic techniques are employed when possible; if not, infiltration may
be used but the solution should be injected at least 1 cm away from the lesion
Tissue stabilization: Use fingers or clamps
Hemostasis: Gauze compresses (avoid high speed suction) or gauze-wrapped suction tip on a low-
volume suction device
Incision: Sharp scalpel
Extent of tissue: Obtain some normal tissue adjacent to lesion if possible
Handling of tissue: Use a traction suture through the specimen, not tissue forceps, to avoid spec-
imen trauma. Traction sutures can also mark a point on the specimen so that the lesion can be oriented
should there be a positive margin.
Specimen care: After removal, the tissue should be immediately placed in 10% formalin solution
that is at least 20 times the volume of the surgical specimen. Note: No other solution is acceptable.
Wound management: Requires either a primary closure (preferably) or placement of periodontal
dressings in cases of gingival or palatal biopsies where secondary healing will be necessary
Records: A Biopsy Data Sheet should be accurately filled out
The Method of Tissue Removal Varies Among the Type of Biopsies:
1. In a needle (percutaneous) biopsy, the tissue sample is simply obtained by use of a syringe. A nee-
dle is passed into the tissue to be biopsied, and cells are removed through the needle.
2. In an open biopsy, an incision is made in the skin, the organ is exposed, and a tissue sample is
taken.
3. A closed biopsy involves a much smaller incision than open biopsy. The small incision is made to
allow insertion of a visualization device, which can guide the physician to the appropriate area to take
the sample.
pale or gray skin color
dry mouth
decreased skin turgor
modified state of consciousness
rapid pulse
reduced urine output
Dehydration is the loss of water and important blood salts like potassium (K
+
) and sodium
(Na
+
). Vital organs, such as the kidneys, brain, and heart, can't function without a certain
minimum amount of water and salt. Causes include decreased intake (lack of water) and/or
increased output (vomiting, diarrhea, loss of blood, drainage from burns, diabetes melli-
tus, diuretic use, or a lack of ADH owing to diabetes insipidus).
Initially, a patient suffering from dehydration will clinically demonstrate only dryness of
the skin and mucous membranes.
However, as dehydration progresses, the turgor (or fullness) of the skin is lost. If dehy-
dration persists, oliguria (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 in-
tracellular space to the extracellular space, a process that causes severe cell dysfunction,
particularly 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 dehy-
drated individuals, they must get to the hospital right away. IV fluids will quickly reverse
dehydration and are often life saving in young children and infants.
disord/cond
Patients with a fasting plasma glucose level higher than or a random
plasma glucose of greater than have diabetes mellitus.
50mg/dL, 125mg/dL
75mg/dL, 150mg/dL
lOOmg/dL, 175mg/dL
126mg/dL,200mg/dL
71
disord/cond
Your 60-year-old patient presents with congestive heart failure. They note
cardiac symptoms with mild activity but are asymptomatic at rest. What is the
functional classification of heart failure in your patient?
class I
class II
class III
class IV
72
126mg/dL,200mg/dL
Diabetes mellitus is an absolute or relative insulin insufficiency 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-stage renal disease, and nontraumatic limb amputation in the United States. Diabetes
increases risk for cardiovascular, cerebral, and peripheral vascular disease.
Many patients with diabetes mellitus have no symptoms, and the diagnosis is made because of abnor-
mal blood glucose levels detected on a routine screening. Some patients may develop polydipsia,
polyuria, polyphagia, and weight loss. In patients with severe insulin deficiency, development of ke-
toacidosis may cause nausea, vomiting, lethargy, confusion, and coma.
The major concern for the dentist treating a patient who has diabetes mellitus is hypoglycemia. This most
often occurs when the medications used to reduce high blood glucose cause levels to drop beyond what
is physiologically needed for the body to function. Symptoms of hypoglycemia: weakness, nervousness,
excessive sweating, tremulousness, and palpitations. The symptoms may progress from confusion and
agitation to seizures and coma without intervention.
1. The treatment of choice for hypoglycemia in a conscious diabetic is the administration of
Notes an oral carbohydrate (packets of table sugar, orange juice, cola beverages, candy bars, etc.)
2. The treatment of choice for hypoglycemia in an unconscious diabetic patient: EMS should
be contacted. Then 1 mg of glucagon can be injected IM, or 50 ml of 50% glucose solution
can be given by rapid IV infusion. The glucagon injection should restore the patient to a con-
scious state within 15 minutes; then some form of oral sugar can be given.
3. People with well-controlled diabetes are no more susceptible to infections than people
without diabetes, but they have more difficulty containing infections (this is caused by altered
leukocyte function).
4. Patients who take insulin daily and check their urine regularly for sugar and ketones (con-
trolled diabetics) usually can be treated in the normal manner without additional drugs or
diet alterations. Important: If any doubt exists as to the patient's medical status, consulta-
tion with the patient's physician is indicated. Do not assume anything!
class III
Class I congestive heart failure is defined as no cardiac symptoms with activity, Class II is symp-
toms with marked activity, Class III is symptoms with mild activity, and Class IV is symptoms at
rest
Congestive heart failure (CHF) results from impaired pumping ability by the heart. A ventricular
ejection fraction below 50% is indicative of CHF. Valvular heart disease, coronary artery disease,
arrhythmias, hypothyroidism, high cardiac output syndromes, and hypertension can lead to heart
failure. Note: Usually the left ventricle fails first, soon followed by right-sided failure. The pre-
senting symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, exercise
intolerance, and edema. Note: The most common sign of left-sided heart failure is pulmonary
edema, whereas right-sided heart failure causes pedal (peripheral) edema or abdominal swelling.
Pharmacologic therapy: goals are to control fluid retention, control neurohormonal activation,
and control symptoms.
Diuretics (e.g., Lasix, Aldactone, Zaroxolyn), are used to control fluid retention
ACE inhibitors (e.g., captopril, lisinopril), which interfere with the renin-angiotensin sys-
tem, are required of all patients with cardiac failure unless contraindicated
Vasodilators, including hydralazine and nitrates, are used when the use of ACE inhibitors is
not possible
Beta blockers (e.g., carvedilol, bisoprolol, metoprolol, atenolol), should be used in patients
with left ventricular dysfunction, unless contraindicated
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 management considerations:
Prolonged rest, administration of oxygen
Digitalis (patients are prone to nausea and vomiting)
Diuretics/vasodilators (patients are prone to orthostatic hypotension; avoid excessive epi-
nephrine)
Dicumarol (patients may have bleeding problem,)
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Apnea
Hypercapnia
Hypocapnia
Dyspnea
Hyperpnea
Respiratory arrest
Hyperventilation
Hypoventilation
Transient cessation or absence of breathing
Excess C0
2
in arterial blood
Below normal C0
2
in arterial blood
The unpleasant sensation of difficulty in breathing
Increase in depth of respiration
Permanent cessation of breathing (unless corrected)
An increase in both rate and depth of respiration
A reduced rate and depth of respiration
1. Hyperventilation results in the loss of carbon dioxide (COf) from the blood
Notes (hypocapnia), thereby causing a decrease in blood pressure and sometimes fainting.
2. Hypoventilation results in an increased level of carbon dioxide (CO2) in the
blood (hypercapnia).
3. The respiratory rate is 10-20 breaths/min in normal adults and 44 breaths/min in
infants. A respiratory rate of >20/min is considered tachypnea, and a respiratory
rate <10/min is bradypnea.
4. Kussmaul respiration is an increase in both rate and depth of respiration and is
synonymous with hyperventilation.
5. Cheyne-Stokes breathing is alternating hyperpnea, shallow respiration, and
apnea. Children and the elderly normally show this pattern in sleep. In normal
adults, causes of this pattern of breathing include heart failure, uremia, drug-in-
duced respiratory depression, and brain damage.
6. Stridor is a high-pitched respiratory sound, such as the inspiratory sound heard
often in acute laryngeal obstruction.
atelectasis
Atelectasis occurs when mucus or a foreign object obstructs airflow in a main stem
bronchus causing collapse of the affected lung tissue into an airless state. It typically oc-
curs 36 hours postoperatively and presents with mild dyspnea, low-grade fever, and hy-
poxia. 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 (encouraging 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 of breath sounds on the affected side, and evidence of pneumothorax
on a chest x-ray. Tracheal deviation may be present.
The objective of treatment for a pneumothorax is to remove the air from the pleural
space, allowing the lung to re-expand. In an emergency, a small needle (such as a stan-
dard 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.
1. Pneumonitis (inflammation of the lung) and atelectasis are two of the most
Notes common causes of fever in a patient who has had general anesthesia.
2. The most common post-op complication of outpatient general anesthesia is
nausea.
disord/cond
A 55-year-old male presents to your office with a long history of a productive
cough. The patient states that the cough has been present for 6 months dur-
ing each of the last 3 years. The patient is afebrile and chest x-ray is unre-
markable.
viral pneumonia
chronic bronchitis
emphysema
asthma
75
disord/cond
Which of the following acid-base abnormalities will develop in a patient with
recurrent vomiting of gastric contents?
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
76
copyrights 2013-2014- Dental Decks
chronic bronchitis
COPD is a disease due to persistent airway obstruction. Two diseases account for the bulk of
the patients with COPD: emphysema and chronic bronchitis. There is continuing debate as
to whether this term also includes acute asthma. As a general rule, it is not included because
it is partly reversible and is more generally considered a restrictive lung disease. In most cases,
bronchitis and emphysema occur together. Note: Secondary pulmonary hypertension is most
often caused by COPD.
Comparison of Emphysema and Chronic Bronchitis
Description
Major complaint
Age of onset
Body habitus
Lung exam
Peripheral edema
Hemoglobin
Blood gases
Chest X-ray
Emphysema
"Pink puffer"
Dyspnea
After age 50 years
Thin
No adventitious sounds
Negative
Normal
PO, normal or reduced
PCO, normal or elevated
Hyperinflated with flat diaphragms
Chronic Bronchitis
"Blue bloater"
Chronic cough
Late 30s and 40s
Overweight
Rhonchi arc present
Positive
Elevated
P0
2
reduced
PC0
2
elevated
increased interstitial markings and normal diaphragms
I mpor t ant :
1. Drugs with antiplatelet activity (aspirin) should be prescribed to COPD patients with cau-
tion. Hemoptysis has been reported after the use of aspirin in patients with COPD.
2. COPD patients taking theophylline should not be prescribed erythromycin. Erythromycin
increases the metabolism of theophylline and may cause toxicity.
metabolic alkalosis
Acid-Base Disorders:
Normal range: pH = 7.35 - 7.45 Bicarbonate = 22-26 mmol/L
Acidosis vs Alkalosis
If pH is less than 7.35, the patient is acidemic
If pH is greater than 7.45, the patient is alkalemic
Determine primary process
After evaluating pH, look at PC0
2
and bicarbonate
- If pH is acidemic and PC0
2
is greater than 45 mmHg, the primary process is respiratory; if
bicarbonate is less than 22, the primary process is metabolic
- If pH is alkalemic and the PC0
2
is less than 35 mmHg, the primary process is respiratory;
if bicarbonate 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 syndrome, Conn syndrome, and
exogenous steroids
Clinical manifestations: CNS symptoms such as confusion, delirium, and coma. Cardiac ar-
rhythmias and hypotension may be noted
Respiratory acidosis: Etiologies- COPD, asthma, severe pneumonia or pulmonary edema, CNS
depression (drugs, CNS event), acute airway obstruction, pneumothorax
Clinical manifestations: Related to degree and duration of acidosis and presence of hypoxia.
In acute disease, CNS symptoms such as confusion, anxiety, psychosis, and seizures may be
noted; In chronic disease, there is lethargy, fatigue, and confusion
Respiratory alkalosis: Etiologies- anxiety, hypoxia, CNS disease, drug use (salicylates), preg-
nancy, sepsis
Clinical manifestations: May cause dizziness, perioral paresthesias, confusion, hypotension,
siezures, and coma
disord/cond
Which statement below is true regarding type 2 diabetes?
was formally known as insulin-dependent diabetes
patients have little or no insulin secretion capacity
symptoms appear abruptly and include polyuria, polydipsia, polyphagia, and weight
loss
accounts for 90% of all cases of clinical diabetes
77
disord/cond
The clinical presentation of acute asthma includes which of the following?
dyspnea or tachypnea
wheezing
hypoxemia
occasionally hypercapnia
hemoptysis
78
accounts for 90% of all cases of clinical diabetes
Diabetes is the most common pancreatic endocrine disorder. It is a metabolic disease
involving mostly carbohydrates (glucose) and lipids. It is caused by absolute deficiency
of insulin (type 1) or resistance of insulin's action in the peripheral tissues (type 2). The
classic triad of symptoms includes polydipsia, polyuria, and polyphagia.
= . _ - , , .
*~uiujiausuu oi ype i ana l ype L uiaueies ivieuitus
Characteristic
Level of insulin
Typical age of onset
Percentage of diabetes
Basic defect
Associated with obesity
Speed of development of symptoms
Development of ketosis
Treatment
Type 1 Diabetes
None
Childhood
10-20%
Destruction of beta cells
No
Rapid
Common if untreated
Insulin injections, dietary management
Type 2 Diabetes
May be normal or exceed normal
Adulthood
80-90%
Reduced sensitivity of insulin's target cells
Usually
Slow
Rare
Dietary control and weight reduction;
occasionally oral hypoglycemic drugs
dyspnea or tachypnea
wheezing
hypoxemia
occasionally hypercapnia
Asthma is a condition characterized by episodic reversible narrowing of the airways. The most common symp-
toms include episodic wheezing, cough, chest tightness, and shortness of breath. The disease can begin at any
age, but about half of patients develop asthma before the age of 10. There are three basic pathophysiologic
changes: (1) airway inflammation (2) airway obstruction and (3) airway hyperresponsiveness
Important: An acute asthmatic attack is best treated by administration of supplemental oxygen with an in-
halaled betan-adrenergic agonist (albuterol, terbutaline). If 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 of nitrous oxide sedation in asthmatic patients. Because
anxiety is a stimulus for an asthmatic attack, nitrous oxide sedation is actually beneficial for these patients. If
patient is taking steroids, consult physician for the possible need for corticosteroid augmentation.
General guidelines for the management of patients with asthma:
Minimize stress: short appointments, use sedation techniques (nitrous, diazepam or other oral antianxi-
ety medications).
Avoid antihistamines
Minimize epinephrine use (local anesthesia up to 2 carpules of 2% lidocaine with 1:100,000 epinephrine
may be used)
Avoid erythromycins and clarithromycin in patients on theophylline
Be aware of aspirin sensitivity: there is a clinical triad of asthma, nasal polyps, and aspirin sensitivity. It
is important to be sure that the patient with asthma does not have this triad when aspirin-containing prepa-
rations are prescribed.
Status asthmaticus is the most severe clinical form of asthma, usually requiring hospitalization, that does not
respond adequately to ordinary therapeutic measures. If not managed properly, chronic partial airway ob-
struction may lead to death from respiratory acidosis (which is produced by hypoxemia and hypercapnia).
disord/cond
Which of the following coagulation factors is deficient in hemophilia B?
-VI
VII
VIII
IX
79
disord/cond
A history of rheumatic fever, IV drug abuse, or heart murmur should alert the
dentist to the possibility of:
diabetes mellitus
AIDS
valvular disease
end-stage renal disease
80
copyright O 2013-2014- Dental Decks
IX
Hemophilia A and B are inherited as a sex-linked recessive trait by which males are affected and
females are carriers. The majority of people afflicted 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.
Classifications of Hemophilia:
Hemophilia A: considered the classical type, caused by a deficiency of coagulation factor
VIII (antihemophilic factor).
Hemophilia B (also called Christmas disease): due to a deficiency in factor IX (Christmas
factor)
Hemophilia C (also called Rosenthal syndrome): not sex-linked, less severe bleeding. Due
to a deficiency of factor XI. Rare disorder but more common in Ashkenazi Jews.
Important: A true hemophiliac is characterized by having the following:
Prolonged partial thromboplastin time (PTT)
Normal prothrombin time (PT)
Normal platelet count
Normal bleeding time
Note: von Willebrand disease is inherited as an autosomal dominant bleeding disorder, it occurs
with equal frequency in both sexes. Due to the absence of von Willebrand factor (VWF), which re-
sults in failure to form a primary platelet plug. Laboratory, features include a prolonged PTT and
prolonged bleeding time.
Thrombocytopenia:
Idiopathic thrombocytopenic pupura (ITP): autoimmune bleeding disorder in which pa-
tients develop antibodies against their own platelets. Signs and symptoms: no splenomegaly, su-
perficial bleeding of the skin, mucous membranes, and genitourinary tract.
Thrombotic thrombocytopenic purpura (TTP): characterized by severe thrombocytopenia,
microangiopathic hemolytic anemia (have presence of schistocytes), and neurologic abnormal-
ities. Signs and symptoms: fever, neurologic abnormalities, including headache, aphasia, or stu-
por.
> valvular disease
Summary of Major Valvular Disease
Etiology
Symptoms
Cardiac signs
Aortic Stenosis
Rheumatic fever
Angina
Syncope
Systolic ejection murmur
Delayed carotid upstroke
Mitral Stenosis
Rheumatic fever
Dyspnea
Orthopnea
Paroxysmal noc-
turnal dyspnea
Diastolic rumble
Opening snap
Aortic Regurgitation
Endocarditis
Marfan syndrome
Dyspnea
Orthopnea
Angina
Diastolic blowing murmur
Mitral Regurgitation
Mitral valve prolapsed
Endocarditis
Papillary muscle dysfunction
Dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Holosystolic apical murmur
Important: Patients with valvular heart disease are also at risk for bacterial endocarditis.
Rheumatic fever is a sequela of a previous Group A, beta-hemolytic streptococcal infection,
usually of the upper respiratory tract. The disease involves the heart, joints, central nervous sys-
tem skin and subcutaneous tissues. It is characterized by an exudative and proliferative in-
flammatory lesion of the connective tissue, especially that of the heart, joints, blood vessels,
and subcutaneous tissue.
Heart inflammation (carditis) disappears gradually, usually within 5 months. However, it may
permanently damage the heart valves, resulting in rheumatic heart disease. The valve be-
tween the left atrium and ventricle (mitral valve) is most commonly damaged.
Note: 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 of the heart.
disord/cond
A tall, thin patient presents to your office with shortness of breath.
On examination, you note the patient is breathing through "pursed" lips,
his expiratory phase is prolonged, and lung sounds are distant.
Which of the following is the most likely diagnosis?
asthma
bronchiectasis
cystic fibrosis
emphysema
81
copyright > 2013-2014 - Dental Decks
disord/cord
Special considerations must be taken when treating a patient on renal dialy-
sis. Which of the following should be considered?
treat the day before dialysis
treat the day after dialysis
NSAIDs are the best analgesic to use
morphine is acceptable for use as an analgesic
be aware of shunts when taking the patients blood pressure
consider that the patient may be on steroid therapy
82
emphysema
The emphysema or "pink puffer" patient is typically thin and presents with dyspnea, pursed-
lip breathing and pink skin color. Arterial blood gases reveal hypoxia and hypercapnia. Em-
physema is defined as destructive changes to the alveoli walls and enlargement of air spaces.
It affects the lung parenchyma distal to terminal bronchioles. Cigarette smoking is major risk
factor (increases risk by 10 to 30 times compared to nonsmokers). Note: Alpha-1-antitrypsin
deficiency should be suspected in patients who develop emphysema in their late 30s.
Bronchiectasis: abnormal dilatation of the large conducting pathways, due to congenital struc-
tural 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 spu-
tum. Hemoptysis may accompany the cough. As disease progresses, exercise intolerance and
dyspnea develop.
Cystic fibrosis: an autosomal recessive disease that is the most common lethal inherited dis-
ease in American whites. Most patients are diagnosed in the preteen years. It is due to a de-
fect in cystic fibrosis transmembrane conductance regulator. Symptoms are due to development
of thick secretions that block the airways and ductal system in other organs (usually pancreas
and liver). Common symptoms 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 upright posture to breathe ade-
quately. They frequently experience difficulty breathing if placed in an almost supine position
or if placed on high-flow nasal oxygen.
Important: Patients with chronic bronchitis may be predisposed to lung cancer (bron-
chogenic carcinoma).
treat the day after dialysis
be aware of shunts when taking the patients blood pressure
consider that the patient may be on steroid therapy
Fr,d staae renal disease (ESRD) is a condition in which there is a permanent and almost
L l l e t e los" of kdney function. The kidney functions at less than 10% of its normal
c a a c S In end-stage renal disease, toxins slowly build up in the body. Normal kidneys remove these
S , urea and creatinine) from the body through urine. In chronic renal disease, there is a slow,
progressive decline in kidney function (low glomerular filtration rate [GFR] and fall in urine output).
Creatinine clearance is a measure of GFR:
Normal range:
Male: 120 +/- 25 mL/min
Female: 95 +/- 20 mL/min
*** End-stage renal disease: GFR < 10 mL/min
Patients with ESRD:
Are often on steroid therapy
Are more susceptible to post-op infections
Have an increased tendency to bleed
*** When oral surgical procedures are undertaken on these patients, meticulous attention to good
surgical technique is necessary to decrease the risks of excessive bleeding and infection.
Some important points to remember when treating patients with renal insufficiency and those on he-
^ Ne l e ' r measure the patient's blood pressure on the arm where the dialysis shunt has been created
Avoid the use of drugs that are metabolized or excreted by the kidney
. Avoid the following analgesics: aspirin, acetaminophen, NSAIDs, meperidine, and morphine
Perform oral surgery the day after dialysis
Consult physician for possible prophylatic antibiotics
drugs
Codeine, a widely used analgesic in dentistry:
is a natural constituent of opium
may be given only by injection
has a calming effect on gastric mucosa
is stronger than morphine, more addictive, and more constipating
83
drugs
is the least lipid soluble of the three main benzodiazepines,
resulting in a slow onset of action but a long duration of action.
midazolam
lorazepam
diazepam
84
is a natural constituent of opium
Next to morphine, codeine is the most important alkaloid of opium. Codeine has two primary thera-
peutic effects: analgesic and antitussive. Codeine is relatively less potent than morphine and does not have
the abuse potential of morphine. It is more likely than other opioids, other than morphine, to cause con-
stipation and nausea. Codeine is usually combined with other drugs, for example, Empirin (aspirin +
codeine), and Tylenol #2, 3, and 4 (acetaminophen + codeine).
Note: Morphine is effective in providing relief of moderate to severe pain but is associated with the ad-
verse effects of constipation, nausea, and vomiting.
Opioid analgesics are thought to inhibit painful stimuli in the substantia gelatinosa of the spinal cord,
brain stem, reticular activating system, thalamus, and limbic system. Opiate receptors in each of these
areas interact with neurotransmitters of the autonomic nervous system, producing alterations in reaction
to painful stimuli. Actions of opioid analgesics can be defined by their activity at three specific receptor
types:
Mu receptors:
- Mul : analgesia - Mu2: respiratory depression, bradycardia, physical dependence, euphoria
Kappa receptors: analgesia, sedation, dysphoria, psychomimetic effects
Delta receptors: analgesia, modulates activity at the mu receptor
Pharmacokinetics of Selected Oral Opioid Analgesics
Drug
Opioid Agonists
Morphine
Codeine
Hydrocodone (Vicodin, Lorcet, Lortab)
Oxycodone (Percodan, Percocet)
Oxycodone, time-release formula (OxyContin)
Hydromorphone (Dilaudid)
Meperidine (Demerol)
Fentanyl (Duragesic transdermal)
Methadone
Propoxyphene (Darvon)
Onset of Action
15-60 min
10-30 min
10-20 min
15-30 min
1 hr
15-30 min
10-15 min
12-24 hr
30-60 min
15-60 min
Duration of Action
4-5 hr
4-6 hr
4-8 hr
3-4 hr
12 hr
4-5 hr
2-4 hr
3 days
4-7 hr
4-6 hr
lorazepam
Anterograde 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 of anesthesia, and suppression of seizure activity. Benzodiazepines act by po-
tentiating the action of GABA, an amino acid and inhibitory neurotransmitter, which results
in increased neuronal inhibition and CNS depression. Benzodiazepines bind to specific ben-
zodiazepine receptor sites, which are found on postsynaptic nerve endings in the CNS. Ben-
zodiazepines are the most effective oral sedative drugs used in dentistry.
The most common benzodiazepines used as amnesties in anesthesiology are midazolam (most
common), lorazepam, and diazepam.
Midazolam (Versed): is the most lipid soluble of the three and, as a result, has a rapid onset
and a relatively short duration of action. Is prepared as a water-soluble compound that is
transformed into a lipid-soluble compound by exposure to the pH of blood upon injection.
This unique property of midazolam improves patient comfort when administered by the IV
or IM route. This prevents the need for an organic solvent such as propylene glycol, which
is required for diazepam and lorazepam.
Diazepam (Valium): is water-insoluble and requires the organic solvent propylene glycol
to dissolve it. The onset time is slightly slower than that of midazolam.
Lorazepam (Ativan): is the least lipid soluble of the three main benzodiazepines, result-
ing in a slow onset of action but long duration of action. It requires propylene glycol to dis-
solve it, which increases its venoirritation. Lorazepam is a more powerful amnestic agent
than midazolam, but its slow onset and long duration of action limit its usefulness for pre-
operative anesthesia.
1. Chloral hydrate is a sedative and hypnotic that is widely used for pediatric se-
Notes dation.
2. Emotional stress decreases the rate of absorption of a drug when given orally.
drugs
Which of the following drugs would be BEST given to a patient with a history
of gastric ulcers?
aspirin
ibuprofen
acetaminophen
naproxen
85
drugs
Which of these barbiturates can be classified as an ultra-short-acting compound?
amobarbital
thiopental
phenobarbital
> pentobarbital
86
acetaminophen
Acetaminophen (Tylenol) is the only over-the-counter non-antiinflammatory analgesic
commonly available in the USA. It is a weak cyclooxygenase inhibitor in peripheral tis-
sues, thus accounting for its lack of antiinflammatory effect. It may be a more effective
inhibitor of prostaglandin synthesis in the CNS, resulting in analgesic and antipyretic ac-
tion. Acetaminophen does not produce gastric ulceration like aspirin does. The combina-
tion of acetaminophen and propoxyphene (called Darvocet-N or Wygesic) is used to treat
moderate to severe pain due to dental procedures.
Note: Propoxyphene (Darvon) is an oral synthetic opioid analgesic structurally similar
to methadone. Darvon compound-65 is a combination of aspirin, caffeine, and
propoxyphene.
1. Acetaminophen does not affect clotting time as does aspirin it does not
Notes have significant antiplatelet effects. It is effective for the same indications as in-
termediate-dose aspirin. It is, therefore, useful as an aspirin substitute, espe-
cially in children with viral infections (who are at a risk for Reye syndrome if
they take aspirin).
2. Aspirin is an antiinflammatory, antipyretic, and analgesic agent 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 of pentazocine
and the analgesic, antiinflammatory, and fever-reducing properties of aspirin. 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 of the local anesthetic wears off.
5. Remember: the following analgesics should be avoided in patients with
renal disease: aspirin, acetaminophen, NSAIDs, meperidine and morphine.
thiopental
Barbiturates exhibit a dose-dependent central nervous system depression with hypnosis and
amnesia. Barbiturates are very lipid soluble, which results in a rapid onset of action. They are
used most often for induction of anesthesia because they produce unconsciousness in less than
30 seconds.
Barbiturates inhibit depolarization of neurons by binding to the GAB A receptors, which en-
hances the transmission of chloride ions. Note: Barbiturates are potent cerebral vasoconstric-
tors resulting in decreases in cerebral blood flow, cerebral blood volume, and intracranial
pressure (ICP).
Ultra-short-acting barbiturates:
Thiamylal (Surital)
Methohexital (Brevital)
Thiopental (Pentothal) -no longer available in the United States
Short-acting barbiturates:
Pentobarbital (Nembutal)
Secobarbital (Seconal)
Intermediate-acting barbiturates:
Amobarbital (Amytal)
Butabarbital (Fioricet, Fiorinal)
Long-acting barbiturates:
Phenobarbital (Luminal): generally not used in oral surgery
Important: Barbiturates are contraindicated in patients with respiratory disease or those
who are pregnant.
Note: Physical dependence is likely to develop with barbiturates if abused. The dependence
has a strong psychological as well as physical basis. Sudden withdrawal from high doses can
be fatal.
drugs
should be used cautiously in the elderly. It should never be given to
patients on monoamine oxidase inhibitors for psychiatric disease and is
generally contraindicated in patients receiving phenytoin (Dilantin) for
seizure disorders.
ibuprofen
acetaminophen
meperidine
codeine
87
drugs
Atropine and scopolamine have similar pharmacologic effects.
Which of the following actions do they share?
Select all that apply:
reduction of salivation
prevention of cardiac slowing during general anesthesia
ens depression
mydriasis
cycloplegia
88
meperidine
Meperidine (Demerol) is a synthetic opioid analgesic with less potency than morphine. It is
used for the relief of moderate to severe pain, for preoperative sedation, for postoperative anal-
gesia, for obstetric anesthesia, and, when given IV, for supportive anesthesia. It is probably the
most widely used narcotic in American hospitals. It should be used with particular caution, if
at all, in the elderly. It is the drug of choice among drug abusers and must be used with extreme
caution. Meperidine is the most abused drug by health professionals. The onset of action is
more rapid, but the duration of action is shorter, than that of morphine. Note: It produces slight
euphoria but no miosis.
Meperidine is often prescribed as 50 mg every 4 hours as needed for pain. It is often simulta-
neously prescribed with the drug promethazine (Phenergan) in 25-50 mg doses every 4 hours.
The promethazine is a sedative and enhances the effect of meperidine. Therefore, less meperi-
dine yields more analgesia when in combination with promethazine. In addition, promethazine
is an antiemetic, which helps negate some of the side effects of meperidine, namely, nausea.
Important: Concomitant administration of meperidine and MAO inhibitors has resulted in
life-threatening hyperpyrexic reactions that may culminate in seizures or coma. Monoamine
oxidase (MAO) inhibitors are a class of drugs used for depression and Parkinson disease. Ex-
amples of MAO inhibitors include isocarboxazid (Marplan), phenelzine (Nardil), tranyl-
cypromine (Parnate), and selegiline (Eldepryl).
Mechanism of action: thought to act by increasing endogenous concentrations of norepi-
nephrine, dopamine, and serotonin through inhibition of the enzyme monoamine oxidase, re-
sponsible for the breakdown of these neurotransmitters.
Note: There is a decreased effectiveness of meperidine in the presence of phenytoin (Dilan-
tin)
Remember: Morphine is the standard drug to which all analgesic drugs are compared. It
causes euphoria, analgesia, and drowsiness along with miosis and respiratory depression.
mydriasis
cycloplegia
reduction of salivation
prevention of cardiac slowing during general anesthesia
The cholinergic blocking (anticholinergic) drugs competitively inhibit the action of
acetylcholine at parasympathetic postganglionic neuroeffector sites. The principal drags
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
of the anticholinergics are mydriasis, antispasmodic actions, and reduction in gastric and
salivary secretions.
The pharmacologic actions of atropine and scopolamine are similar in many respects. At-
ropine, in the usual dose used in dentistry, does not show a CNS response. Scopolamine,
however, has a depressant effect on the CNS, which accounts for its usefulness as a pre-
anesthetic agent and perhaps its use in motion sickness in several over-the-counter prepa-
rations. Both drags will reduce salivary flow and in large doses, block the cardiac-slowing
effect of the vagus nerve.
Anticholinergic drags should be used with considerable caution in patients with cardio-
vascular disease and are contraindicated in patients with glaucoma, prostate hypertrophy,
and intestinal obstruction.
Side effects are common with the anticholinergic drags and include blurred vision, tachy-
cardia, urinary retention, constipation, decreased salivation, sweating, and dry skin.
Note: Atropine and scopolamine are also extremely useful in therapy and examination of
the eye. These drugs produce dilation (mydriasis) and paralysis of accommodation for
distance vision and light (cycloplegia). Such effects are generally long-lasting and can
also be manifested by larger systemic doses of the drags.
drugs
A sedative dose of a barbiturate should be expected to produce:
respiratory depression
minor analgesia
decreased BMR
all of the above effects
none of the above effects
ORAL SURGERY&^f^CONTROL
89
exo
All of the following are true statements concerning the principles of suturing
technique EXCEPT one. Which one is the EXCEPTION!
the needle should be perpendicular when it enters the tissue
sutures should be placed at an equal distance from the wound margin (2-3 mm) and at
equal depths
sutures should be placed from mobile tissue to thick tissue
sutures should be placed from thin tissue to thick tissue
sutures should not be overtightened
tissues should be closed under tension
sutures should be 2-3 mm apart
90
exo
What areas are impacted maxillary third molars occasionally displaced into?
Select all that apply?
canine space
pterygomaxillary space
infratemporal space
pharyngeal space
1
maxillary sinus
91
exo
For maxillary extractions, the upper jaw of the patient should be:
> below the height of the operator's shoulder
above the height of the operator's shoulder
- at the same height of the operator's shoulder
it makes no difference where the patient's upper jaw is in relation to the operator's
shoulder
92
infratemporal space
maxillary sinus
Impacted maxillary third molars are occasionally displaced into two areas:
Maxillary sinus (antrum): from which they are removed via a Caldwell-Luc ap-
proach
Infratemporal space: during elevation of the tooth the elevator may force the tooth
posteriorly through the periosteum into the infratemporal fossa. If access and light
are good, the tooth may be retrieved with a hemostat. If the tooth is not retrieved after
a short amount of time, the area should be closed. The patient should be informed that
the tooth has been displaced and will be removed by an oral surgeon who will use a
special technique to remove it.
Note: To minimize the chance of dislodging an impacted maxillary third molar into the
infratemporal fossa during its surgical removal, (1) develop a full-thickness mucope-
riosteal flap, bringing the incision anterior to the second molar (add a releasing incision
if necessary), to improve visualization of the impacted tooth, and (2) place a broad re-
tractor distal to the molar while elevating it.
Remember:
1. When performing a surgical removal of a 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 buccal and slightly apical to the roots
of a mandibular third molar.
3. Buccal-to-lingual movement is not efficient when removing mandibular posterior
teeth because mandibular bone is too dense and does not expand in a similar fashion
to that of the maxillary bone.
at the same height of the operator's shoulder
The chair usually has to be repositioned to be satisfactory for exodontics. For mandibu-
lar extractions, the patient should be positioned so that the occlusal plane of the mandibu-
lar arch is parallel to the floor when the mouth is opened. The chair should be as low as
possible. For maxillary extractions, the upper jaw of the 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 un-
naturally high position during the course of the day. The low positions allow the 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 of the left hand (for a right-handed dentist) serve to:
Retract the soft tissue
Provide the operator with sensory stimuli for the detection of expansion of the alveo-
lar plate and root movement under the plate
Help guide the forceps into place on the tooth
Protect teeth in the opposite jaw from accidental contact with the back of the forceps
Support the mandible while performing mandibular extractions
Remember: recommended sequence of extraction:
Maxillary teeth before mandibular teeth
Posterior teeth before anterior teeth
exo
Which of the following are contraindications to tooth extraction.
acute pericoronitis
acute apical abscess
acute infectious stomatitis
93
Which of the following are ways of eliminating dead space?
close the wound in layers to minimize the postoperative void
apply pressure dressings
use drains to remove any bleeding that accumulates
allow the void to fill with blood so that a blood clot will form
exo
94
acute pericoronitis
acute infectious stomatitis
An acute apical abscess should not be a contraindication to extraction. It has been shown that these
infections can resolve very quickly when the affected tooth is removed. However, it may be diffi-
cult to extract such a tooth, either because the patient is unable to open sufficiently wide enough
or because adequate local anesthesia cannot be obtained.
There are few true contraindications to the extraction of teeth. Note: In some instances, the pa-
tients' health may be so compromised that they cannot withstand the surgical procedure.
Examples of contraindications include:
End-stage renal disease
Severe uncontrolled metabolic diseases (i.e., uncontrolled diabetes mellitus)
Advanced cardiac conditions (unstable angina)
Patients with leukemia and lymphoma should be treated before extraction of teeth
Patients with hemophilia or platelet disorders should be treated before extraction of teeth
Patients with a history of head and neck cancer need to be treated with care because even minor
surgery can lead to osteoradionecrosis. Note: These patients are often treated with hyperbaric
oxygen therapy prior to dental surgery.
Pericoronitis: infection of the soft tissues around a partially erupted mandibular third molar
Note: This infection should be treated prior to removal of the maxillary third molar.
Acute infectious stomatitis and malignant disease are relative contraindications
Treatment with IV bisphosphonates increases the risk of osteonecrosis of the jaw
Note: Causes of excessive bleeding after dental extractions include: injury to the inferior alveolar
artery during extraction of a mandibular tooth (usually the third molar), a muscular arteriolar bleed
from a flap procedure, or bleeding related to the patient's history (i.e., patients who are on warfarin
or drugs for platelet inhibition, patients who have hemophilia or von Willebrand disease, or who
have chronic liver insufficiency).
close the wound in layers to minimize the postoperative void
apply pressure dressings
use drains to remove any bleeding that accumulates
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 them-
selves, but most need to have the fluid drained, and the "dead space" needs to be closed,
either by deep suturing or by reopening the top of the 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 mu-
coperiosteal flap is elevated for a surgical extraction, there is a possibility for a subpe-
riosteal abscess. Thus, all surgical flaps should be irrigated liberally prior to closing
with sutures. Note: The treatment for a subperiosteal abscess is drainage of the abscess
and antibiotic treatment.
exo
Which of the following is the primary direction of luxation for extracting
maxillary deciduous molars?
buccal
palatal
mesial
distal
95
exo
During extraction of a maxillary third molar, you realize the tuberosity has
also been extracted. What is the proper treatment in this case?
remove the tuberosity from the tooth and reimplant the tuberosity
smooth the sharp edges of the remaining bone and suture the remaining soft tissue
no special treatment is necessary
none of the above
96
palatal
*** 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 elastic-
ity 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 of these forceps
could cause damage to the unerapted permanent premolar teeth.
1. If the preoperative radiograph shows that the permanent premolar is
Notes wedged tightly between the bell-shaped roots of the primary tooth, the best treat-
ment is to section the crown of the primary molar and remove the two portions
separately. This will help in not disturbing the permanent tooth.
2. After extraction of mandibular 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.
Inform parents to watch the child so this does not occur.
smooth the sharp edges of the remaining bone
and suture the remaining soft tissue
A fracture of the maxillary tuberosity most commonly results from extraction of an erupted
maxillary third molar or a second molar if it happens to be the last tooth in the arch.
If the tuberosity is fractured but intact, it should be manually repositioned and stabilized
with sutures.
The complications most often seen after extraction of an freestanding, isolated maxillary
molar are:
Fracture of the tuberosity
Alveolar process fracture
Important: "Beware of the lone molar" it is often ankylosed to the bone.
Remember: The ankylosed tooth emits an atypical, sharp sound on percussion.
Key point to remember: Tuberosity fractures may occur and should be treated at the time of
surgery. If the operator is unable to do this, he/she must arrange an immediate referral.
1. For denture construction, at the correct vertical dimension, the distance from
Notes the crest of the tuberosity to the retromolar pad should equal at least 1 cm.
2. If there 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 are undermined subperiosteally. Submucous wedges are
removed from each flap, and the wound is closed. This decreases the vertical and
horizontal dimensions of the tuberosity.
exo
Which of the following can be safely excised in preparing the edentulous
mandible for dentures?
labial frenum
lingual frenum
mylohyoid ridge
genial tubercles
exostosis
97
exo
The ideal time to remove impacted third molars is:
when the root is fully formed
when the root is approximately two-thirds formed
makes no difference how much of the root is formed
when the root is approximately one-third formed
98
labial frenum
lingual frenum
mylohyoid ridge
exostosis
The genial tubercles are situated on the lingual surface of the mandible at a point about
midway between the superior and inferior borders. There are four of them, two of which
are situated on each side and adjacent to the symphysis. Although usually relatively small,
they may be fairly large and extend outward from the surface as spinous processes. These
tubercles are the area of muscle attachment for the suprahyoid muscles.
Important: If the genial tubercles were removed, the tongue would be flaccid.
1. When removing the mylohyoid ridge, be careful to protect the lingual
Notes nerve.
2. When removing a mandibular exostosis (mandibular torus), it is recom-
mended that an envelope flap design, which has no vertical components, be
used.
when the root is approximately two-thirds formed
Patient would be around the age of 17-21.
At this time, the bone is more flexible and the roots are not formed well enough to have de-
veloped curves and rarely fracture during extraction.
When the root is fully formed, the possibility increases for abnormal root morphology and for
fracture of the root tips during extraction.
Complications of Surgery
Complication
Tearing of the flap
Puncture wounds
Orai-antral communications
Root fracture
Injury to adjacent teeth
Tooth displacement
Alveolar process and
maxillary tuberosity fractures
Trauma to inferior alveolar
nerve
Dry socket
Comment
Can be avoided by initially creating an adequately sized incision
Caused by too much force; treated with pressure to stop bleeding and left
open to heal by secondary intent.
Managed with a figure-eight suture over the socket, sinus precautions,
antibiotics, and a nasal spray to prevent infection and keep the ostium
open
Most common complication; removed with elevators (i.e., straight,
Cryer, Stout) and root tip picks.
Fracture of teeth or restorations
For example, maxillary molar root into the maxillary sinus
From too much force used to remove teeth
May occur in the area of the roots of the mandibular third molars. Lingual
nerve travels very close to the lingual cortex of the mandible in this area.
Can occur in 3% of mandibular third molar extractions. Will heal with
irrigation and local treatment for pain control
1. Patients who are young tolerate surgery very well. Postoperative complications are
Notes usually minimal.
2. Older individuals have the most postoperative difficulties. The bone is more
dense and usually the patient responds more slowly to the entire process (anesthesia
and surgery).
exo
When would you place a suture over a single extraction socket?
routinely
never
if the patient requests it
when there is severe bleeding from the gingiva or if the gingival cuff is torn or loose
99
exo
The 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
when there is severe bleeding from the gingiva or if the
gingival cuff is torn or loose
Normal postextraction procedure:
All loose bone spicules and portions of the tooth, restoration, or calculus are removed
from the socket as well as from the buccal and lingual vestibules and the tongue
The socket must be compressed by the fingers to reestablish the normal width pres-
ent before the buccal plate was surgically expanded. Note: The natural recontouring
of the residual ridge occurs primarily by resorption of the 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 instructed to bite down on the pressure dressing for 30-60 minutes
A printed instruction sheet is given to the patient
A prescription for pain is given if the need is anticipated
If 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 hemo-
stasis.
Remember: The most common cause of postextraction bleeding is the failure of the
patient to follow postextraction instructions.
maxillary canines
Classifications of impacted teeth
Angulation: Mesioangular (least difficult to remove for mandibular impactions), distoangular
(most difficult to remove for mandibular impactions), vertical and horizontal
Pell - Gregory Classification: relationship to anterior border of the ramus
Class 1: normal position anterior to the ramus
Class 2: one-half of the crown is within the ramus
Class 3: entire crown is embedded within the ramus
Relationship to occlusal plane:
Class A: tooth at the same plane as other molars
Class B: occlusal plane of third molar is between the occlusal plane and the cervical line of
the second molar
Class C: third molar is below the cervical line of the second molar
Factors That Make Impaction
Surgery Less Difficult
Mesioangular position
Class 1 ramus
Class A depth
Roots one third to two thirds formed*
Fused conic roots
Wide periodontal ligament*
Large follicle*
Elastic bone*
Separated from second molar
Separated from alveolar nerve*
Soft tissue impaction
* Present in young patients
Factors That Make Impaction
Surgery More Difficult
Distoangular position
Class 3 ramus
Class C depth
Long, thin roots*
Divergent curved roots
Narrow periodontal ligament*
Thin follicle*
Dense, inelastic bone*
Contact with second molar
Close to inferior alveolar canal
Complete bony impaction
* Present in older patients
of impacted teeth:
Compromised medical status
Likely damage to adjacent
structures
Extremes of ages (preteen or
an asymptomatic full bony im-
paction in a patient > 35 years
of age
All of the following are cardinal signs of a
EXCEPT one. Which one is the EXCEPTION?
throbbing pain (often radiating)
bilateral lymphadenopathy
fetid odor
bad taste
poorly healed extraction site
localized osteitis
exo
(dry socket)
101
exo
Before removing a palatal torus:
an intraoral picture should be taken
a mandibular torus, if present, should be removed
a stent should be fabricated
a biopsy should be taken
102
bilateral lymphadenopathy
The etiology of dry socket is not absolutely clear, but is thought to develop because of in-
creased fibrinolytic activity causing accelerated lysis of the blood clot. It is most common
following extraction of the mandibular molars. Smoking, premature mouth rinsing, hot
liquids, surgical trauma, and oral contraceptives all have been implicated in the develop-
ment of a dry socket. Note: Careful technique and minimal trauma reduce the frequency
of patients developing dry socket.
Treatment for dry socket:
Flush out debris with slightly warmed saline solution gently!!!
Place a sedative dressing in socket (eugenol). The dressing should be removed within
48 hours and replaced until the patient becomes asymptomatic. Note: (1) The gauze
provides an attachment for the obtundent paste so it stays in the socket (2) Eugenol is
the active component in most sedative dressings (3) If gel foam or another resorbable
material is used then, the dressing does not need to be removed (4) The medical term
for dry socket is alveolar osteitis
Nonsteroidal antiinflammatory analgesics should be prescribed if necessary.
*** Antibiotics are generally not indicated.
1. Dry socket is the most common complication seen after the surgical removal
Notes of a mandibular molar.
2. Curetting a dry socket can cause the condition to worsen because healing
will be further delayed, any natural healing already taking place will be de-
stroyed, and there is a risk of causing the localized inflammatory process to be
spread to the adjacent sound bone.
a stent should be fabricated
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 of the palate that prevents seating of a
denture and also prevents a posterior seal at the fovea palatini. Other indications for the
removal of maxillary tori are chronic irritation, 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 of the torus
After careful elevation of the flaps, the torus should be scored multiple times in the
anterior, posterior, and transverse dimensions
An osteotome can be used to remove each of these 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-
tures
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).
exo
For impacted mandibular third molars, place the following in their correct
order from the least difficult to most difficult to remove.
vertical
1
horizontal
distoangular
mesioangular
103
exo
Which two major forces are used for routine tooth extractions?
rotation
pulling
pushing
luxation
104
exo
The root of which tooth is most often dislodged into the maxillary sinus during
an extraction procedure?
palatal root of the maxillary first premolar
palatal root of the maxillary first molar
palatal root of the maxillary second molar
palatal root of the maxillary third molar
105
exo
The Caldwell-Luc procedure eliminates blind procedures and facilitates the
recovery of large root tips or entire teeth that have been displaced into the
maxillary sinus. When performing this procedure, an opening is made into
the facial wall of the antrum above the:
maxillary tuberosity
maxillary lateral incisor
maxillary premolar roots
maxillary third molar
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palatal root of the maxillary first molar
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
retrieved through a Caldwell-Luc approach ASAP. However, only perform this if you
know what you are doing. If not, refer patient to an oral surgeon.
Note: If a small communication is made with the maxillary sinus during extraction of a
tooth, the best treatment is leave it alone and allow the blood clot to form.
Postoperative instructions to patient:
Avoid nose blowing for 7 days
Open mouth when sneezing
Avoid vigorous rinsing
Soft diet for 3 days
If a sinus communication should occur, the following medications may be prescribed for
1 week:
1. Afrin: local (nasal) decongestant
2. Antibiotics (amoxicillin)
3. Actifed: systemic decongestant
1. If the opening is of moderate size (2-6 mm), a figure-eight suture should be
Notes placed over the tooth socket.
2. If the opening is large (7 mm or larger), the opening should be closed with a
flap procedure.
Remember: The integrity of the floor of the maxillary sinus is at greatest risk with sur-
gery involving the removal of a single remaining maxillary molar. The fear here is pos-
sible ankylosis.
maxillary premolar roots
If a 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 of an incision
into the canine fossa above the level of the premolar roots. The tooth or root is then re-
moved. Postoperative management includes a figure-eight suture over the socket, sinus
precautions, antibiotics, a nasal spray, and a systemic decongestant to keep the sinus os-
tium 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 mm), 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. If the 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 of the decision and given proper follow-up instructions.
Remember: The palatal root of the maxillary first molar is most often dislodged into
the maxillary sinus during an extraction procedure.
Note: If a root tip of a mandibular third molar disappears from site while trying to re-
trieve it, its most likely location is the submandibular space. Other possible locations
would be the inferior alveolar canal or the cancellous bone space.
exo
Which suture grading below is the thickest?
2/0
3/0
4/0
5/0
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exo
Which of the following events are correctly paired with the stages of wound
healing?
fibroblasts lay a bed of collagen / proliferative phase
platelet aggregation / inflammatory phase
> contraction of the wound / remodeling phase
> thromboplastin makes a clot / inflammatory phase
108
2/0
Suture size is based on strength and diameter. The gauge or thickness of the suture ma-
terial is denoted by O gradings. As the thickness of the 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 procedures (intraoral suturing) require the use of 3/0- 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.
fibroblasts lay a bed of collagen / proliferative phase
platelet aggregation / inflammatory phase
thromboplastin makes a clot / inflammatory phase
Contraction of the wound occurs during the proliferative phase of wound healing, which is one of three
phases:
1. Inflammatory Phase (initial lag phase)
Immediate to 2-5 days
Hemostasis
- Vasoconstriction
- Platelet aggregation
- Thromboplastin makes clot
Inflammation
- Vasodilation
- Phagocytosis
2. Proliferative phase (fibroblastic phase)
2 days to 3 weeks
Granulation
- Fibroblasts lay bed of collagen
- 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
New collagen forms, which increases tensile strength to wounds
Scar tissue is only 80% as strong as original tissue
Factors that impair wound healing: diabetes, protein deficiencies, older age, infections, foreign mate-
rial, necrotic tissue, ischemia, and tension on the wound.
Remember: 3% hydrogen peroxide is the agent of choice for the debridement of intraoral wounds.
exo
Sutures placed intraorally are normally removed:
1-2 days postoperatively
109
exo
Regardless of the flap design used, certain principles should be followed
while incising and reflecting the gingiva. With this in mind, the termination
of a vertical incision at the gingival crest must be:
midbuccal of the tooth
at the line angle of the tooth
midlingual of the tooth
beyond the depth of the mucobuccal fold
110
The two basic categories of sutures are (1) resorbable and (2) nonresorbable:
Resorbable: These sutures are resorbed after a certain time, which usually coincides with healing
of the wound. These sutures are made of gut or vital tissue (catgut, collagen, fascia, etc.) and are plain
or chromic, or of synthetic material, e.g., polyglycolic acid (Dexon). Plain catgut sutures are resorbed
postsurgically over 8 days, chromic sutures in 12-15 days, and synthetic (Dexon) sutures in approxi-
mately 30 days. These types of sutures are used for flaps with little tension, in children and mentally
handicapped patients, and generally for patients who cannot return to the office to have the sutures re-
moved.
Nonresorbable: These sutures remain in the tissues and are not resorbed, but have to be cut and re-
moved about 5-7 days after their placement. They are fabricated of various materials, mainly surgi-
cal silk (monofilamentous or multifilamentous) in many diameters and lengths) and surgical cotton
suture. Silk sutures are the easiest to use, are the most economical, and have a satisfactory ability to
hold a knot. One of the disadvantages of silk sutures is that they wick bacteria due to their braided na-
ture. Although much more expensive, many surgeons prefer the use of Vicryl sutures.
Note: Resorbable sutures evoke an intense inflammatory reaction. This is the main reason neither plain
gut nor chromic gut are used for suturing the surface of a skin wound. When suturing an extraction site
in the anticoagulated patient, a nonresorbable suture is recommended. Resorbable sutures are accompa-
nied by an inflammatory response and increasing fibrinolytic activity,which may potentially result in
clot breakdown.
Two basic methods of wound healing (soft tissue):
1. Primary intention (also called primary closure): involves minimal re-epithelialization and colla-
gen formation, allowing the wound to be "sealed" within 24 hrs. Healing occurs more rapidly with a
lower risk of infection and with less scar formation and less tissue loss than wounds allowed to heal
by secondary intention. Examples include: well-repaired and well-reduced bone fractures.
2. Secondary intention (also called secondary closure): involves re-epithelialization via migration
from the wound 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 fractures, and large ulcers.
at the line angle of the tooth
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
Incision should not cross underlying bony defect that existed prior to surgery or were produced
by the surgery
Vertical incisions are made in the concavities between bony eminences
Termination of vertical incision at the gingival crest must be at the line angle of the tooth
Vertical incision should not extend beyond the depth of the mucobuccal fold
Base of the flap must be as wide as the width of the free edge (supraperiosteal vessels running
vertically should not be transected)
Periosteum must be reflected as an integral part of the flap
Important: The correct position for ending a vertical releasing incision is at a tooth line angle not
over the buccal surface of a tooth. If it ends over a buccal surface, the edges are difficult to ap-
proximate and this may lead to periodontal problems. Incision should never cross bony promi-
nences as this increases the chance for wound dehiscence.
Three types of incisions used in oral surgery:
1 Linear: straight line incision used for apicoectomies.
2. Releasing: used when adding a vertical leg to a horizontal creation incision. For extractions,
augmentations, etc.
3. Semilunar: curved incision mostly used for apicoectomies.
The basic principles of oral surgical flap design:
Flap design should ensure adequate blood supply; the base of the flap should be larger than
the apex
Reflection of the flap should adequately expose the operative field
Flap design should permit atraumatic closure of the wounds
Flap should be closed over bone if possible
exo
While attempting to remove a grossly decayed mandibular molar, the crown
fractures. What is the recommended next step to facilitate the removal of this
tooth?
use a larger forcep and luxate remaining portion of tooth to the lingual
separate the roots
irrigate the area and proceed to remove the rest of the tooth
place a sedative filling and reschedule patient
111
exo
While extracting a mandibular third molar, you notice that the distal root tip
is missing. Where is it most likely to be found?
in the infratemporal fossa
in the submandibular space
in the mandibular canal
in the pterygopalatine fossa
112
separate the roots
*** 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 re-
moval. A popular method of sectioning is to make a bur cut between the roots, followed by insert-
ing an elevator in the slot and turning it 90 to cause 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 roots
In older patients, due to less elastic bone Extensive decay which has destroyed
Short clinical crowns with severe attrition (bruxers) most of the crown
Teeth are resistant to crush but are not resistant to shear. Therefore:
Place the beaks of the 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 of the tooth.
Remember: When luxating a tooth with forceps, the movements should be firm and deliberate, pri-
marily to the facial with secondary movements to the lingual. The maxillary first bicuspid is least
likely to be removed by rotation forces due to its root structure (obviously molars are not re-
moved by rotation).
1. It is recommended to use a bite block when removing mandibular teeth to diminish
Notes pressure on the contralateral TMJ.
2. 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 of bone cells.
3. Buccal to lingual movement is not efficient when removing mandibular posterior
teeth because mandibular bone is too dense and does not expand in a fashion similar
to that of maxillary bone.
4. The root of the zygoma can interfere with efficient removal of a maxillary first molar.
in the submandibular space
Important: To prevent this, avoid all apical pressures when removing the roots or root tips
of all mandibular molars. If a 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 gen-
erally found buccal to the roots of the mandibular third molar.
The submandibular space is a potential space of the neck bounded by the oral mucosa and
tongue anteriorly and medially; the superficial layer of deep cervical fascia laterally; and the
hyoid bone inferiorly. The mylohyoid muscle, stretching across the floor of the mouth, serves
as the inferior boundary of the sublingual space and the superior boundary of the submaxil-
lary spaces.
Note: The submaxillary, submental and sublingual spaces are collectively referred to as the
submandibular space. The submaxillary space usually drains infections from the mandibu-
lar bicuspids and molars because their apices lie below the mylohyoid muscle attachment.
The submental space is the medial part of the submaxillary space. It is however, important
to note that it lies above the mylohyoid unlike the submaxillary space. It contains the
submental lymph nodes that drain the median parts of the lower lip, tip of the tongue, and
the floor of the mouth. It 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 of the submandibular space, containing the sublin-
gual gland and loose connective tissue surrounding the tongue.
Remember: Ludwig angina is the most commonly encountered neck space infection (in-
volves the sublingual, submandibular, and submental spaces).
exo
Arrange the following five phases of healing of an extraction site in their
correct order.
replacement of the connective tissue by fibrillar bone
hemorrhage and clot formation
replacement of granulation tissue by connective tissue and epithelialization of the
site
recontouring of the alveolar bone and bone maturation
organization of the clot by granulation tissue
113
fractures
,f a subcondylar fracture occurs, which of the following muscles will displace
the condyle both anteriorly and medially?
digastric muscle
temporalis muscle
lateral pterygoid muscle
medial pterygoid muscle
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Five phases of healing of an extraction site:
1. hemorrhage and clot formation
2. organization of the clot by granulation tissue
3. replacement of granulation tissue by connective tissue and
epithelialization of the site
4. replacement of the connective tissue by fibrillar bone
5. recontouring of the alveolar bone and bone maturation
Note: Glucocorticoids have been shown to have the greatest effect on granulation tissue
they retard healing. This is believed to be due to the fact that:
Glucocorticoids interfere with the migration of neutrophils and mononuclear phagocytes
into a site of inflammation; the phagocytic and digestive ability of macrophages is also re-
duced.
Glucocorticoids inhibit formation of granulation tissue by retarding capillary and fibrob-
last proliferation and collagen synthesis.
The same stages that occur in normal wound healing of soft tissue injuries also occur in the
repair of injured bone. However, osteoblasts and osteoclasts are also involved in repairing
damaged bone tissue.
Bone healing occurs by 2 ways:
Healing by first intention (Primary union)
Healing by second intention (Secondary union)
In case of healing by primary intention, there is not much loss of cells and tissues. The ends
of the flap will approximate in some time and the tooth extraction recovery will occur in some
time whereas in case of healing by secondary intention, there is extensive loss of cells and tis-
sues. The ends of the flap don't approximate and the healing occurs from bottom to the top and
from margins inwards. Healing by secondary intention is slow as compared to faster healing
by primary intention.
lateral pterygoid muscle
Muscles involved in displacing mandibular fractures include the medial and lateral ptery-
goid, temporalis, masseter, digastric, geniohyoid, genioglossus, and mylohyoid. The lat-
eral pterygoid displaces the condyle anteriorly and medially because of its insertion on
the pterygoid fovea. Muscles attached to the ramus (i.e., temporalis, masseter, and me-
dial pterygoid) result in superior and medial displacement of the proximal segment. As
fractures progress anteriorly toward the canine region, the digastric, geniohyoid, ge-
nioglossus, 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 of the
mandibular condyle. In subcondylar fractures, the forces of this muscle frequently re-
sult in anterior and medial displacement of the condyle. In higher condylar fractures
and in intracapsular fractures above the insertion of the lateral pterygoid, the small frag-
ment can occasionally be seen displaced in a pure horizontal or vertical direction.
Note: Displacement of the proximal segment of the condyle usually occurs in an an-
teromedial direction because of the pull of the lateral pterygoid muscle. The patient will
deviate to the side of the fracture on opening because of the unopposed action of the
contralateral lateral pterygoid muscle.
fractures
are second only to nasal fractures in frequency of involvement.
le fort I
le fort II
le fort III
1
zygomatic fractures
115
fractures
The most frequent complication associated with mandibular fracture
management is:
hematoma
wound dehiscence
facial or trigeminal nerve injury
infection
116
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zygomatic fractures
Zygomaticomaxillary complex (ZMC) fractures involve four major processes: the zygomaticofrontal re-
gion, infraorbital rim, zygomatic buttress, and zygomatic arch. Zygomatic fractures are commonly en-
countered in facial trauma because of their prominent position on the facial skeleton.
The most common mechanism producing facial fractures is auto accidents. About 70% of auto accidents
produce some type of facial injury, although most are limited to soft tissue. The face seems to be a fa-
vorite target in fights or assaults, which are the next most common mechanism. Specific terminology is
used to describe the different types of fractures that occur. Simple fractures are closed, while compound
fractures are open and exposed through a wound. A comminuted fracture occurs when the bone has
broken into multiple pieces.
Fracture type prevalence:
Zygomaticomaxillary complex: 40 %
LeFortI: 15%
II: 10%
III: 10%
Zygomatic arch: 10%
Alveolar process of maxilla: 5%
Smash fractures: 5%
Other: 5%
Signs of a Bone Fracture
Notes
Pain
Contour deformity
Ecchymosis
Abnormal mobility of the bone
Numbness
Hematoma
Crepitation
1. The maxilla and mandible are in a critical relationship to the upper airway; therefore dis-
placement of fractures can cause obstruction of the airway resulting in respiratory arrest.
Control of the airway is vital to any treatment of a patient with facial fractures.
2.Maxillary fractures have a greater tendency toward the production of facial deformity than
do mandibular fractures.
3. Maxillary Le fort fractures, orbital fractures, and zygomatic fractures usually require in-
ternal rigid fixation.
4. The highest incidence of fractures occurs in young males between the ages of 15 and 24.
These fractures are usually the result of trauma.
infection
Common Complications Associated with
Mandibular Fracture Management
Infection
Malocclusion
Damage to tooth roots
Wound dehiscence
Osteomyelitis
Delayed union or nonunion
Facial or trigeminal nerve injury
Hematoma
Tooth injury
Of these, infection is one of the most problematic; it is the most frequent complication and is an
important cause of nonunion.
The most common cause of postoperative infection is movement at the fracture site due to mo-
bile hardware, such as a loose screw in an otherwise stable plate.
Four reasons that a fracture does not heal:
1. Ischemia: the navicular bone of the wrist, the femoral neck, and the lower third of the 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: occurs between the fractured ends.
4. Infection: compound fractures have a tendency to become infected.
*** Important: a fat embolism is most often a sequela of fractures.
Inappropriate healing (three types):
1. Delayed union: satisfactory healing which requires greater than the normal 6-week period.
May be caused by infection, interposition of soft tissue or muscle between the fracture segments.
2. Non union: failure of the fracture segments to unite properly. May be caused by infection, im-
proper immobilization, or interposition of soft tissue.
3. Mai union: can be either delayed or complete union in an improper position. May be caused
by improper immobilization or imperfect reduction.
fractures
What determines whether muscles will displace fractured segments from their
original position?
attachment of the muscle
type of fracture
direction of muscle fibers
line of fracture
117
fractures
In general, mandibular fractures are less common in children than in adults.
When mandibular fractures occur in children, fractures of the
mandible, particularly in the condylar region, are relatively common.
simple
greenstick
compound
comminuted
118
line of fracture
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 fracture segments. A favorable fracture is one that is not dis-
placed by masticatory muscle pull, and an unfavorable fracture occurs when the line of frac-
ture permits the fragments to separate.
The four muscles of mastication are the temporalis, masseter, medial pterygoid, and lateral
pterygoid. After discontinuity of the mandible due to fracture, these muscles exert their actions
on the fragments, leading to malocclusion.
Signs and symptoms that may be associated with mandibular fractures:
Pain and tenderness at the fracture site
Changes in occlusion
Ecchymosis of the floor of the mouth or skin
Crepitation on manual palpation
Changes in mandibular range of motion
Soft tissue bleeding
Sensory disturbances (numbness of the lower lip)
Deviation of the mandible on opening
Soft tissue swelling
Trismus
Palpable fracture line intraorally or at the inferior border of the mandible
Approximately 43% of all patients with mandibular fractures have associated systemic in-
juries. Cervical spine fractures were found in 11% of this group of patients. It is imperative
to rule out cervical neck fractures, especially in patients who are intoxicated or unconscious
and in patients who are involved in vehicular accidents. Posteroanterior and lateral films and
CT of the neck should be reviewed with the radiologist before treatment is initiated in these
patients.
greenstick
The ossification capability of children allows faster healing and distinguishes it from the adult
mandible. As a result, many mandibular fractures in children can be treated with immobiliza-
tion for a shorter time or may simply require observation and a soft diet. Note: Open reduc-
tion and internal fixation in children are reserved for severely displaced fractures.
In an adult, the location of facial fractures is influenced by both the resistance of the bone to
fracture and the prominence of its position on the facial skeleton. Adult facial fractures are most
commonly seen in the nasal bones followed by the zygoma, mandible, and maxilla. In chil-
dren, early growth in the cranium and orbits predisposes young children to frontal bone and
orbital fractures.
The following categories classify mandibular fractures by describing the condition of the bone
fragments at the fracture site and possible communication with the external environment:
Simple: divides a single bone into two distinct parts with no external communication.
These are closed fractures with no lacerations of the oral mucosa or facial tissues.
Compound: fracture communicates with the outside environment (open fracture). This
may occur by laceration of the oral tissues exposing the bone fragments, fracture of the
maxilla into the sinuses, or by way of skin lacerations that would expose the fracture seg-
ments. Infection is common.
Comminuted: are multiple fractures of a single bone. They may be simple or comp-
ound.
Greenstick: fracture that extends only through the cortical portion of the bone without-
complete fracture of the bone. Greenstick fractures are closed fractures involving incom-
plete fractures with flexible bone. Most often seen in children.
Remember: (1) The most common complication of an open fracture is infection.
(2) Any jaw fracture extending through tooth-bearing bone is considered an open
fracture due to potential tears in the PDL and exposure of the fracture to the oral
flora.
fractures
Computed tomography (CT) scan is the gold standard for evaluation of which
of the following?
mandibular fractures at the angle
fractures of the mandibular condyle
le fort I fractures
zygomatic fractures
119
fractures
Closed reduction is best used in the treatment of:
favorable, nondisplaced fractures
displaced and unstable fractures, with associated midface fractures, and when MMF is
contraindicated
either of the above
none of the above
120
mandibular fractures at the angle
fractures of the mandibular condyle
le fort I fractures
zygomatic fractures
Note: For a long time in the past, a posteroanterior oblique Waters view or a reverse Waters view together
with a posteroanterior and submental vertex view of the skull were used for evaluating zygomatico-
maxillary complex (ZMC) fractures. However, the CT scan (both axial and coronal orientations) is
currently the diagnostic tmaging modality of choice for evaluating these fractures as well as the other
fractures listed. This imaging modality shows the location of the fractures, degree of displacement of the
bones, and status of surrounding soft tissues.
Important: Dysfunction of the infraorbital nerve is common in a patient with a ZMC fracture An oph-
thalmologic examination is of paramount importance. Also, fractures of the facial bones, particularly
the zygomatic complex, may, on rare occasions, be complicated by damage to the contents of the su-
perior orbital fissure.
Other possible complications of the zygomatic complex (ZMC) fracture include:
Paresthesia (most common): usually subsides
The antrum (sinus) may be filled with a hematoma, which usually evacuates itself
Ocular muscle balance may be impaired because of fracture of the orbital process
Note: Fracture of the infraorbital rim presents with the following symptoms:
Numbness of the following areas on the affected side: upper lip, cheek, and nose
Note: The most feared, but fortunately rare, complication of ZMC fractures is blindness.
Remember: By definition, the four articulating sutures (ZF, ZT, ZM, and ZS) are disrupted in this frac-
ture. Therefore, the commonly applied term "tripod fracture" is a misnomer and does not correctly de-
scribe this fracture.
Most practitioners consider CT scanning to be the gold standard imaging modality for evaluation of
mandibular fractures. A CT scan allows the entire face to be evaluated in one study. Despite the popu-
larity of CT imaging, in many facilities the initial imaging studies may consist of panoramic radiogra-
phy or a plain view series of the mandible i.e., posteroanterior, Waters, reverse Towne, or submentovertex
projections. Many rural hospitals still use a plain view series of the mandible. Therefore familiarity with
plain radiographs is important.
favorable, nondisplaced fractures
Treatment options of mandibular fractures can be divided into rigid fixation, semirigid fixation,
and nonrigid or closed reduction. Methods considered rigid fixation are the lag screw technique,
compression plating, reconstruction plates, and external pin fixation. Miniplate fixation and wire
fixation are types of semirigid fixation. Maxillomandibular fixation ([MMF] with ivy loops, arch
bars, or transalveolar screw), gunning splints, and lingual splints are considered nonrigid fixation.
Rigid fixation allows for primary bone healing without callous formation. Nonrigid fixation al-
lows for secondary bone formation with inflammatory infiltration and callous formation. Semi-
rigid fixation allows for areas of primary and secondary bone formation.
Closed reduction is best used in the treatment of favorable, nondisplaced fractures. It is also used
in situations in which Open Reduction Internal Fixation (ORIF) is contraindicated. Maxillo-
mandibular 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 of (MMF) is 4-6 weeks.
Open reduction involves direct exposure of the fracture site and placement of internal fixation
to prevent movement of the fracture site. Open reduction is used in displaced and unstable fractures,
with associated midface fractures, and when MMF is contraindicated. In addition, some surgeons
advocate ORIF for patient comfort and for expedited return to activity and work. Arch bars are al-
ways placed first to establish occlusion, then ORIF is performed. The plates can be placed intrao-
rally, extraorally via a cervical incision, or percutaneously. Dynamic compression plates (DCP)
can be used for most body, angle, symphyseal, or parasymphyseal fractures.
Note: Initial management of mandibular fractures starts after the patient has been stabilized. All
fractures of tooth-bearing areas of the mandible are considered open and should be treated with an-
tibiotics 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 of repair is controversial. Several studies have shown a decreased incidence of in-
fection if compound fractures are repaired within 48 hours. Other studies have shown no change if
fractures are repaired in less than a week. Regardless of infection rates, patient comfort dictates that
the earliest date for repair is the best as displaced fractures are painful.
fractures
The process of fracture healing can occur in:
one way: by direct or primary bone healing which occurs without callus formation
one way: by indirect or secondary bone healing which occurs with a callus precursor
stage
two 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
fractures
The most common pathognomonic sign of a mandibular fracture is:
nasal bleeding
exophthalmos
malocclusion
numbness in the infraorbital nerve distribution
122
two 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
Primary bone healing involves a direct attempt by the cortex to reestablish itself after interrup-
tion. Bone on one side of the cortex must unite with bone on the other side of the cortex to reestab-
lish mechanical continuity. Under these conditions, bone-resorbing cells on one side of the fracture
show a tunneling resorptive response, whereby they reestablish new haversian systems by provid-
ing pathways for the penetration of blood vessels.
Secondary bone healing involves the classical stages of fracture healing.
Stages of fracture healing:
Stage 1: Inflammation (Immediately following fracture) - bleeding from the fractured bone
and surrounding tissue causes the fractured area to swell. This stage begins the day you fracture
the bone and lasts about 2 to 3 weeks.
Stage 2: Soft callus (2 to 3 weeks after fracture) - the pain and swelling will decrease. At this
point, the site of the fracture stiffens and new bone begins to form. The new bone cannot be seen
on radiographs. This stage usually lasts until 4 to 8 weeks after the injury.
Stage 3: Hard callus (4 to 8 weeks after fracture) - the new bone begins to bridge the fracture.
This bony bridge can be seen on radiographs. By 8 to 12 weeks after the injury, new bone has
filled the fracture.
Stage 4: Bone remodeling (8 to 12 weeks after fracture) - the fracture site remodels itself, cor-
recting any deformities that may remain as a result of the injury. This final stage of healing can
last for several years.
The rate of healing and the ability to remodel a fractured bone vary tremendously for each person
and depend on the patient's age, health, type of fracture, and the bone involved. For example, chil-
dren are able to heal and remodel their fractures much faster than adults.
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.
malocclusion
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 of the fractures, the ap-
propriate use of antibiotics, and restoration of form and function. The usual treatment for mandibu-
lar fractures that are displaced and mobile is with open reduction and internal fixation using titanium
bone plates and screws. If the patient has teeth, the occlusion is used as a guide for the surgeon to
repair the fracture. Other methods of repair include splinting (for pediatric patients) and maxillo-
mandibular fixation (see below).
Establishing a proper occlusal relationship by wiring the teeth together is termed maxillo-
mandibular fixation (MMF) or intermaxillary fixation (IMF). The most common technique
includes the use of a 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 recently, techniques for rigid internal fixation (RTF) have gained popularity for treatment
of fractures. These use bone plates, bone screws, or both to fix the fracture more rigidly and stabi-
lize the bony segments during healing. Even with rigid fixation, a proper occlusal relationship must
be established before reduction stabilization and fixation of the bony segments. Advantages of RIF
for treatment of mandibular fractures include decreased discomfort and inconvenience to the pa-
tient because IMF is eliminated or reduced, improved postoperative nutrition, improved postoper-
ative hygiene, and frequently better postoperative management of patients with multiple injuries.
Note: 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 com-
monly include loose hardware necessitating removal, infection, malocclusion, delayed union, and
fibrous union. Damage to the inferior alveolar nerve (or lingual nerves) can be a complication of
the initial injury or a consequence of treatment.
fractures
Which type of Le Fort fracture is often referred to as a pyramidal fracture?
le fort I
le fort I
le fort I
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fractures
The least common site for a mandibular fracture to occur is the:
body
angle
symphysis
coronoid process
124
le fort II
Types of Le Fort' s fractures:
Le Fort I: the fracture line traverses the maxilla through the piriform aperture above the alve-
olar ridge, above the floor of the maxillary sinus, and extends posteriorly to involve the ptery-
goid plates. This fracture allows the maxillae and hard palate to move separately from the upper
face as a single detached block. Le Fort I fracture is often referred to as a transmaxillary frac-
ture.
Le Fort II: superiorly, this fracture traverses the nasal bones at the frontonasal sutures. It ex-
tends laterally through the lacrimal bones, crossing the floor of the orbit, fracturing the medial
and inferior orbital rims, and fracturing the pterygoid plates posteriorly. In this fracture, the at-
tachment of the zygomatic bones to the skull at the lateral orbital rims and at the zygomatic
arches is preserved. As a result of this fracture, the maxillary and nasal regions are movable rel-
ative to the rest of the midface and skull. Because of its triangular pattern, this fracture is often
referred to as a pyramidal fracture.
Le Fort III: this fracture line involves fracture of all 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. In this fracture, there is a craniofacial disjunction with a separation at
the frontozygomatic suture, nasofrontal junction, orbital floor, and zygomatic arch laterally.
Clinical manifestations of midface fractures:
Clinical diagnosis of midface fractures is relatively easy to make when there is a displacement
of the fracture, which is often manifested by the presence of malocclusion (most often present-
ing as anterior open bite).
Mobility of the midface
Nasal bleeding, subconjunctival ecchymosis, maxillary hypoesthesia, and tenderness of the
bony buttresses.
Important: The first step in the treatment of these fractures is to reestablish the correct occlusal
relationship between then maxilla and mandible.
coronoid process -1.3% of mandibular fractures
The location and extent of mandibular fractures are determined largely by the direction and
intensity of the blow and the specific points of weakness in the mandible.
Anatomic Distribution of Mandibular Fractures
Area of Mandible
Condyle
Angle
Symphysis
Body
Alveolar process
Ramus
Coronoid Process
% of Fractures
29.1
24.5
22
16
3.1
1.7
1.3
The condylar neck (29.1% of fractures') is a safety feature that allows the blow to the jaw to
be dispersed at this point rather than driving the condyle into the middle cranial fossa. Bilat-
eral dislocated fractures of the condylar necks will cause an anterior open bite and the in-
ability to protrude the mandible. A unilateral fracture through the neck may cause forward
displacement of the head of the condyle due to pull of the lateral pterygoid muscle.
The symphysis (22% of fractures) 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 on opening.
Note: Mandibular fractures can almost always be identified on a panoramic radiograph. If a
fracture is suspected, at least two different radiographs should be taken for comparison
(i.e., panoramic, posteroanterior, Waters, reverse Towne, or submentovertexprojections).
gen info
Patients with hypocalcemia have an ionized calcium level below 2.0 or serum
calcium concentration lower than 9 mg/dL.
Some of the most common causes are:
hyperparathyroidism and cancer
diabetes and hypothyroidism
renal failure and hypoalbuminemia
graves disease and hypopituitarism
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gen info
Whether a bone cyst or other cysts are completely enucleated or treated by
marsupialization depends on the:
duration
origin
color
size and location to vital structures
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ORALSURGERY & PAIN CONTROL
renal failure and hypoalbuminemia
Calcium levels are regulated by parathyroid hormone and, to some extent, by the kidney
tubules and GI mucosa. Other causes of hypocalcemia are vitamin D deficiency, hy-
poparathyroidism, pancreatitis, rhabdomyolysis, severe hypomagnesemia, multiple citrated
blood transfusions, and drugs (antineoplastic agents, antimicrobials, agents used to treat hy-
percalcemia). Chronic hypocalcemia can be asymptomatic. Clinical manifestations are pares-
thesias of the lips and extremities due to increased excitability of nerves, tetany, cramps, and
abdominal pain due to spasm of skeletal muscle, and convulsions.
Note: Chvostek and Trousseau signs are seen in hypocalcemia. Chvostek is twitching of the
facial muscles as a result of tapping over the facial nerve in the preauricular area, and
Trousseau sign is carpopedal spasm due to occlusion of the brachial artery when a blood pres-
sure cuff is applied above systolic pressure for 3 minutes.
Hypercalcemia is an abnormally high level of calcium in the blood, usually more than 10.5
mg/dL. The most common causes of hypercalcemia are hyperparathyroidism and cancer.
Mnemonic for symptoms of hypercalcemia:
Stones: renal calculi
Bones: bone destruction
Moans: confusion, lethargy, fatigue, weakness
Abdomi nal groans: abdominal pain, constipation, polyuria, and polydipsia
1. Renal failure with oliguria is the most common cause of true hyperkalemia (too
Notes much potassium in the blood). Some signs and symptoms include nausea, vomiting,
diarrhea, and ventricular fibrillation leading to cardiac arrest.
2. Usually the first sign of hypokalemia is skeletal muscle weakness or cramping.
3. The major extracellular cation is sodium.
4. The major intracellular cation is potassium.
size and location to vital structures
Treatment of Cysts of the Jaws
Technique
Enucleation
Marsupialization,
decompression, and
the Partsch operation
Marsupialization
followed by
enucleation
Description
Shelling out without rupture
Creating a surgical window in the
wall of the cyst, evacuating the
contents of the cyst; and main-
taining continuity between the
cyst and the oral cavity
Indications
Treatment of choice; should be used when
it can be safely be done without sacrificing
adjacent structures
When enucleation would damage adjacent
structures
Enucleation with
curettage
Marsupialization is done first.
After initial healing secondary
enucleation may be undertaken
without injury to adjacent
structures
After enucleation a curette or bur
is used to remove 1 to 2 cm of
bone around the entire periphery
of the cystic cavity
If cyst is not totally obliterated after
marsupialization heals
When removing a keratocystic
odontogenic tumor (KOT)
Any cyst that recurs after what was
deemed thorough removal
1. Marsupialization, decompression, and the Partsch operation all refer to creating a sur-
Nor.es gical window in the wall of the cyst. The cyst is uncovered or "deroofed" and the cys-
tic lining made continuous with the oral cavity or surrounding structures. The cyst sac
is opened and emptied.
2. Cysts and cyst-like lesions can be classified as fissural or odontogenic. Keratocystic
odontogenic tumors (KOT) have a higher rate of recurrence than do fissural and cysts
of odontogenic inflammatory origin.
gen info
At what point should the EMS be activated with adult victims?
after 1 minute of CPR
after 2 minutes of CPR
after 3 minutes of CPR
immediately when an adult is found to be unresponsive
127
The normal value for blood urea nitrogen (BUN) is:
2-5 mg/dL
7-18mg/dL
23-30 mg/dL
33-50 mg/dL
gen info
128
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immediately when an adult is found to be unresponsive
*** For a victim less than 8 years of age, the EMS should be activated after 1 minute or 5
cycles of CPR. This is because, in younger patients, the most likely cause of arrest is respi-
ratory.
Cardiopulmonary Resuscitation:
A= Airway
Place victim flat on his/her back on a hard surface.
Shake victim at the shoulders and shout "are you okay?"
If no response, call emergency medical system 911 then,
Head-tilt/chin-lift: open victim's airway by tilting their head back with one hand while
lifting 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)
If not breathing, pinch victim's nose closed and give 2 full breaths into victim's mouth
If breaths won't go in, reposition head and try again to give breaths. If still blocked, per-
form abdominal thrusts (Heimlich maneuver)
C = Circulation
Check for carotid pulse by feeling for 5-10 seconds at side of victim's neck.
If there is a pulse but victim is not breathing, give rescue breathing at rate of 1 breath
every 5-6 seconds or 10-12 breaths per minute
If there is no pulse, begin chest compressions as follows:
- Place heel of one hand on midposition of victim's sternum. With your other hand di-
rectly on top of first hand, depress sternum 1.5 to 2 inches.
- Perform 30 compressions to every 2 breaths (rate of compressions: 100/min).
- Check for a pulse after the first minute and every few minutes thereafter.
*** Continue uninterrupted until advanced life support is available.
7-18 mg/dL
Blood Chemistry Tests and Hematology Reference Values
Test
Blood urea nitrogen
(BUN)
Carbon dioxide
(includes bicarbonate)
Chloride
Creatinine
Glucose
Potassium
Sodium
Calcium
Phosphorus
Protein
Alkaline phosphatase
Normal Value
7-18 mg/dL
23-30 mmol/L
98-106 mEq/L
0.6-1.2 mg/dL
Fasting: 70-110 mg/dL
Random: 85-125 mg/
dL
3.5-5 mEq/L
101-111 mEq/L or 135-
148 mEq/L (depending
on test)
8.8-10.0 mg/dL
2.7-4.5 mg/dL
6-8 g/dL
20-70 U/L
Clinical Significance
Increased in renal disease and dehydration; decreased
in liver damage and malnutrition
Elevated in vomiting and pulmonary disease;
decreased in diabetic acidosis, acute renal failure and
hyperventilation
Increased in dehydration, hyperventilation, and CHF;
decreased in vomiting, diarrhea, and fever
Increased in kidney disease
Increased in diabetes and severe illness;
decreased in insulin overdose or
hypoglycemia
Increased in renal failure and acidosis;
decreased in vomiting and diarrhea
Increased in dehydration and diabetes insipidus;
decreased in burns, diarrhea, or vomiting
Increased in excess PTH production and in cancer;
decreased in alkalosis
Elevated in kidney disease; decreased in excess PTH
Increased in dehydration, multiple myeloma;
decreased in kidney disease, liver disease, poor
nutrition and severe burns
Increased in liver disease and metastatic bone disease
gen info
Which of the following are stages of hemostasis?
Select all that apply:
vascular
leukocytic
platelet
coagulation
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gen info
When a child less than 8 years of age has a pulse but is breathless, what is the
recommended rate of rescue breathing?
once every 3 seconds
130
vascular
platelet
coagulation
There are three phases of hemostasis:
1. Vascular phase
Vasoconstriction
Begins immediately after injury
2. Platelet phase
Platelets and vessel walls become sticky
Mechanical plug of platelets seals off openings of cut vessels
Begins seconds after injury
3. Coagulation phase
Blood lost into surrounding area coagulates through extrinsic and common pathways
Blood in vessels in area of injury 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 con-
trol the bleeding. Note: Patients with specific systemic diseases will also have a prolonged
bleeding time. These include nonalcoholic liver disease, hepatitis, cirrhosis, and hypertension.
Five means of obtaining wound hemostasis:
1. By assisting natural hemostatic mechanisms usually accomplished by placing a
cotton sponge with pressure on bleeding vessels or the use of a hemostat directly on the
vessel.
2. By the use of heat on the cut vessels (called thermal coagulation)
3. By suture ligation of the vessel
4. By the placement of a pressure dressing over the woundmost bleeding from oral sur-
gery can be controlled this way.
5. By using vasoconstrictive substances (epinephrine) in local anesthetics
once every 3 seconds - (20 breaths/min)
* When an adult has a pulse but is breathless, the recommended rate of rescue breathing is
once every 5-6 seconds (10-12 breaths/minute).
* A victim whose heart and breathing have stopped has the best chance for survival if emer-
gency 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
the carotid pulse should be assessed in children and adults.
* The best indicator of effective ventilation is seeing the chest rise when delivering breaths.
* If chest compressions are interrupted, the blood flow and blood pressure will drop to zero.
* At least 1 sec/breath is the length of time recommended to deliver each breath to an adult
victim.
* Time is not as critical with the new guidelines concerning the length of time recommended
to deliver each breath to an infant or child. Now it is important to deliver breaths that make
the victim's chest rise.
CPR Ready Reference
Rescue breathing, victim has a
pulse, give breath every:
No pulse, locate compression
landmark
Compressions are preformed
with:
Compression rate
Compression depth
Compression Ventilation ratio
Adults
8 years and up
5-6 seconds
In the center of the
breast bone, between
the nipples
Heal of 1 hand, second
hand on top
Child
1 to 8 years
3 seconds
In the center of the
breast bone, between
the nipples
Heel of one hand
Infants
Under 1 year
3 seconds
One finger width below
the nipple line
Two fingers
About 100/min
1.52 inches About 1/3 to 1/2 t le depth of the chest
30:2
gen info
The American Society of Anesthesiologists would give what classification to
a patient with a severe systemic disease that is a constant threat to life?
class 1
class 2
class 3
class 4
class 5
131
gen info
What is the most frequent cause of airway obstruction in an unconscious
person?
chewing gum
cigarette
tongue
hard candy
132
class 4
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
of communicating the physical status of a patient among anesthesiologists. The five
classes, as last modified in 1961, are:
Class 1 Healthy patient, no medical problems
Class 2 Mild systemic disease
Class 3 Severe systemic disease, but not incapacitating
Class 4 Severe systemic disease that is a constant threat to life
Class 5 Moribund, not expected to live 24 hours regardless of operation
*** An organ donor is usually designated as a class 6
tongue
The first step when initiating CPR is to establish unresponsiveness (shake and shout - "Are
OK"). Then:
CAL L
you
CALL 911
PUMP
1 , r
BLOW
POSITION HANDS
IN THE CENTER OF
THE CHEST
CONTINUE WITH TWO BREATHS
AND 30 PUMPS UNTIL HELP ARRIVES
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 efforts are effective, the pupils will constrict
If too much pressure is incorrectly applied directly over the xyphoid process, the liver may be
injured
Remember, you should stop CPR only under the following conditions:
If another trained person takes over CPR for you
If EMS personnel arrive and take over care of the victim
If you are exhausted and unable to continue
If the scene becomes unsafe
gen info
Which of the following is a calculated value developed to normalize the
reporting of prothrombin time (PT)?
IMR
IGR
ITR
INR
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gen info
Which of the following is the most common error in blood pressure
measurement?
applying the blood pressure cuff too tightly
applying the blood pressure cuff too loosely
overinflating the blood pressure cuff
underinflating the blood pressure cuff
the use of too large or too small cuffs
134
INR
The accuracy of the prothrombin time (PT) is known to be very system-dependent. The
World Health Organization has addressed this system variability problem by (1) the es-
tablishment of primary and secondary international reference preparations of thrombo-
plastin and (2) the development of a statistical model for the calibration of thromboplastins
to derive the International Sensitivity Index (ISI) and the INR.
INR (international normalized ratio):
Developed to improve consistency of oral anticoagulant therapy
Converts the PT ratio to a value that would have been obtained using a standard PT
method
INR is calculated as ( PT
p a t i e n t
/ PT
n o r ma l
) .
x
** (ISI is the international sensitivity index assigned to the test system)
The recommended therapeutic ranges for standard oral anticoagulant therapy and
high-dose therapy, respectively, are INR values of 2.0-3.0 and 2.5-3.5.
Other tests used to measure a patient's clotting mechanisms:
Prothrombin Time (PT): the normal range is 11 to 13.5 seconds. To be a good can-
didate for surgery, the PT time should be within 5-7 seconds of the control sample
Partial Thromboplastin Time (PTT): detects coagulation defects of the intrinsic
system. Basic test for hemophilia. Normal value is 25-36 seconds.
Bleeding Time (Ivy method): normal value is less than 9 minutes
Platelet Counts: normal value is 150,000 - 450,000 per 1 cu mm of blood. The min-
imal platelet count for oral surgery is 50,000
Important: Perhaps the single most important consideration in ruling out hemorrhagic
disorder is history.
the use of too large or too small cuffs
Important: Use of the wrong cuff size can result in erroneous readings. A normal adult blood
pressure cuff placed on an obese patient's arm will produce falsely elevated readings. This
same cuff applied to the very thin arm of a 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 of the right
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 circumference. Blood
pressure measurement errors are generally worse in cuffs that are too small vs those that
are too big.
Blood pressure measurement in sitting and recumbent positions is acceptable. The dias-
tolic blood pressure can be expected to be about 5 mm Hg higher in the sitting position.
A difference in blood pressure between the two arms can be expected in about 20% of
patients. The higher value should be the one used in treatment decisions.
When measuring blood pressure, the cuff should be inflated to 30 mm Hg above the point
at which the radial pulse disappears. The sphygmomanometer pressure should then be re-
duced at 2 to 3 mm/second. Two readings should be performed at least 1 minute apart.
Category
Normal
Prchypertension
High blood pressure
Stage 1
Stage 2
Systolic
Less than 120
120-139
And
Or
Diastolic
Less than 80
80-89
140-159
160 or higher
Or
Or
90-99
100 or higher
grafts
Which of the following is the gold standard for bone regenerative grafting
materials for several reasons, including the capability to support osteogenesis
and having osteoinductive and osteoconductive properties?
xenogenic bone
allogeneic bone
autogenous bone
alloplastic bone
135
grafts
The most commonly used allogeneic bone is:
freeze-dried
demineralized freeze-dried bone
> fresh frozen
136
autogenous bone
An autogenous bone graft is the transplantation of bone from one site to another site within
the same person. These grafts may be of cancellous, cortical, or a combination of cortical and
cancellous bone. Autogenous bone is the only graft that possesses all of the following prop-
erties: osteoinduction, osteoconduction, and osteogenesis. Additionally, there are no im-
munogenic complications. The downsides to autograft are the finite quantity available and
donor site morbidity.
Types of autogenous bone grafts:
Cortical grafts: advantages are due to its structural capabilities. Also has a higher con-
centration of BMP (bone morphogenetic protein). The disadvantages are due to the lamel-
lar architecture. Common donor sites: iliac crest, ribs, anterior cortex of the chin, lateral
cortex of the ramus/external oblique ridge.
Cancellous grafts: advantages are mostly based on its rich cellular capability. The most
abundant supply can be harvested from the anterior or posterior iliac crest. The only disad-
vantage arises from the fact that they do not possess any macroscopic structural integrity.
Thus, the graft cannot be rigidly fixed and will deform, migrate, or resorb if placed under
tension or compressive functional forces.
1. The bone marrow for grafting defects in the mandible and maxilla is generally ob-
Notes tained from the iliac crest (anterior and posterior). Also used for ridge augmen-
tation.
2. BMP is a protein complex responsible for initiating osteoinduction. BMP is part
of the cytokine family of growth factors, which occurs in the organic portion of
bone called the bone matrix.
3. A costochondral rib graft may be employed with the cartilaginous portion sim-
ulating the TMJ and condyle. When used for ridge augmentation, there is a great deal
of shrinkage.
4. Bone plates, biphasic pins, titanium mesh, and intraosseous wires are used in
the fixation of bone grafts. Sutures are not generally used.
freeze-dried
Allogeneic bone is nonvital, osseous tissue harvested from one individual and transferred to
another of the same species. Three forms of allogeneic bone include: fresh frozen, freeze-
dried, and demineralized freeze-dried bone. Fresh frozen bone, however, is rarely used due
to the concern related to transmission of disease.
Freeze-dried bone is osteoconductive, however, it has no osteogenic or osteoinductive ca-
pabilities. Freeze-dried allogeneic grafts are usually placed in conjunction with autogenous
grafts.
Demineralized freeze-dried allogeneic bone lacks mechanical strength, but has osteo-
conductive and osteoinductive capabilities. Demineralizing the freeze-dried bone exposes
the bone morphogenetic proteins, which has been shown to induce bone formation.
The three processes by which bone can be repaired or regenerated are:
Osteogenesis (osteogenic potential) is the formation of new bone from osteoprogenitor
cells. Spontaneous osteogenesis is the formation of new 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 of new bone from host-derived or transplanted osteo-
progenitor cells along a biologic or alloplastic framework, such as along the fibrin clot in
tooth extraction or along a hydroxyapatite block. Osteoconductive grafts provide only a
passive framework or scaffolding. The grafted material, therefore, does not have the abil-
ity to actually produce bone. This type of graft simply conducts bone-forming cells from the
host bed into and around the scaffolding.
Osteoinduction refers to new bone formation from the differentiation of osteoprogenitor
cells, derived from primitive mesenchymal cells, into secretory osteoblasts. Such grafts help
produce the cells that are necessary to produce new bone.
grafts
Which of the following refers to a horizontal osteotomy of the anterior
mandible?
> blepharoplasty
genioplasty
cervicofacial rhytidectomy
rhinoplasty
137
copyright > 2013-2014 - Dental Decks
grafts
Match the term on the left with the correct description on the right.
autograft tissue removed from an animal donor and surgically transplanted to
a human
allograft tissue surgically removed from one area of a person's body, such as
the iliac crest, and transplanted in another site on the same person
xenograft tissue surgically transplanted from an individual of the same species
who is genetically related to the recipient
isograft tissue surgically transplanted from one individual to a genetically
nonidentical individual of the same species
138
genioplasty
Genioplasty 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 ge-
nioplasty represent the two currently accepted methods of chin augmentation.
A sliding genioplasty involves removing a horseshoe-shaped piece of the chin bone and slid-
ing it either backward or forward, finally fixing it in place using titanium screws. 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 of a genial deficiency. The
materials most commonly used include high-density polyethylene, hard tissue replacement
polymer, polyamide mesh, solid medical grade silicone rubber, hydroxyapatite, and Gore-Tex.
Problems that are frequently encountered when using alloplastic materials for the treatment
of a genial deficiency:
1. Migration from the position in which they were placed at the time of surgery
2. Erosion of the chin prominence contiguous with the implant
3. Unpleasant sensation in the implant region when exposed to cold temperatures
Remember: Alloplastic grafts are inert, man-made synthetic materials. The modern artificial
joint replacement procedures 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 phosphate
(i.e., tricalciumphosphate, calcium carbonate, or hydroxyapatite).
autograft: tissue surgically removed from one area of a person's body, such as
the iliac crest, and transplanted in another site on the same person
allograft: tissue surgically transplanted from one individual to a genetically
non-identical individual of the same species
xenograft: tissue removed from an animal donor and surgically transplanted
to a human
isograft: tissue surgically transplanted from an individual of the same species
who is genetically related to the recipient
Classification of grafts (or implants):
Autogenous grafts (also called autografts) are composed of tissues taken from the same in-
dividual. Most frequently used in oral surgery.
Allogeneic grafts (also called allografts) are composed of tissues taken from an individual of
the same species who is not genetically related to the patient (usually cadaver bone).
Isogeneic grafts (also called isografts) are composed of tissues taken from an individual of the
same species who is genetically related to the recipient.
Xenogeneic implants (also called xenografts or heterografts) are composed of tissues taken
from a donor of another species, for example, animal bone grafted to man. Rarely used in oral
surgery.
Note: Rejection of the graft is most common when allografts or xenografts of bone 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 immunologic response (or rejection)
Actively assist osteogenic (bone-forming) processes of the host. The greatest osteogenic po-
tential occurs with an autogenous cancellous graft and hemopoietic marrow.
grafts
The term alloplastic is synonymous with:
original
natural
synthetic
genuine
139
implants
In reference to the bone-implant interface, which of the following yields the
most predictable long-term stability?
fibro-osseous integration
osseointegration
biointegration
140
synthetic
The term alloplastic is synonymous with synthetic. This indicates that the material is pro-
duced from inorganic sources and contains no animal or human components. Alloplastic
materials offer a prepackaged solution to common reconstructive surgical problems with-
out 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 alveo-
lar 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 hydroxya-
patite 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 of the hydroxyapatite granules
- Poor ridge form (inadequate height)
- Abnormal color under the mucosa
- Mental nerve neuropathy - usually occurs from excessive augmentation
- Cannot participate in phase 1 osteogenesis since no viable osteogenic cells are
present
osseointegration
The bone-implant interface:
Fibro-osseous integration
Connective tissue-encapsulated implant within bone
Not seen often with newer materials
Osseointegration
A direct structural and functional connection between living bone and the surfaces of
a load-carrying implant without soft-tissue
Yields most predictable long-term stability
Several important factors involved: materials, surface characteristics, bone, timing
Biointegration
Implant interface that is achieved with bioactive materials, such as hydroxyapatite
(HA) or bioglass, that bond directly to bone.
HA-coated implants appear to develop bone faster than do non-coated implants but,
after a year, there is little difference between coated and non-coated implant.
Important principles for success of dental implants: primary stability, amount of bone,
anatomic structures (i.e., adjacent natural teeth, maxillary sinus, nasal cavity, inferior alveo-
lar canal).
1. To ensure the development of keratinized tissue around a dental implant, the best
Notes time to augment the soft tissue is Stage II surgery.
2. Guided tissue regeneration is a surgical procedure used to eliminate a bony de-
fect around a dental implant. This process decreases the connective tissue growth
while increasing the growth of bone in the defect.
3. A gentle surgical technique requires that you do not heat bone above 47C.
Above this temperature, bone tissue damage occurs.
implants
Which of the following is found between the bone and implant of an
endosseous dental implant?
periodontal ligament
peri-implant ligament
epithelial ligament
a bone-implant interface
141
implants
Which of the following factors would have the greatest negative influence on
a dental implant's success?
hypertension
patient over 70 years of age
smoking
alcohol
post-by pass surgical patient
142
a bone-implant interface
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 micro-
scopic level. Only endosseous and transosseous implants are considered true osseointegrated
implants.
Criteria for success of a dental implant:
Clinical immobility under load-bearing conditions
Symptom free
Minimal loss of crestal bone
No peri-implant radiolucency
1. For an implant to be successful, you need adequate transfer of force and bio-
Notes compatibility.
2. Handpieces for preparation of dental implant receptor sites are low speed/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 of 10 mm of bone height to place an endosseous (rootform)
dental implant.
5. The minimum required distance from the apex of a mandibular posterior implant
to the superior aspect of the inferior alveolar canal is 2 mm.
6. Titanium and titanium alloy are the most common materials used today for two-
stage endosseous implants.
smoking
*** Because smoking affects the healing of bone and overlying tissue, it should be con-
sidered a relative contraindication to implant placement.
Any toothless area can be considered for dental implants. Determining whether implants are
an option and the type of implants to use include: the patient's requirements and expecta-
tions, the amount of additional work needed (i.e., bone grafting), 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
Retention of a fixed prosthesis in a completely edentulous maxilla or mandible
Important: In patients with uncontrolled systemic diseases such as diabetes, immuno-
compromised patients, and patients with bleeding disorders, implant placement should be
considered with extreme caution.
Remember:
1. The highest failure rate is seen in the posterior maxilla where the bone is the soft-
est (D4) quality.
2. Mobility of the implant is regarded as the most common sign of implant failure.
3. A dental implant supported prosthesis should fit passively on the dental implant.
4. The minimum space required for a 4.0-mm diameter implant is 7.0 mm 1.5 mm
on each side of the implant plus the diameter of the implant
5. The maximum amount of taper to allow for proper draw on an overdenture attach-
ment, such as an "O" ring, is 15 degrees.
implants
Currently, the most popular used implants are:
blade form implants
subperiosteal implants
transosseous implants
1
root form implants
143
misc.
To prevent infective endocarditis in patients at risk for such infections,
the American Heart Association (AHA) frequently issues guidelines for
prophylactic antibiotic coverage during dental procedures. In accordance
with the most recently revised AHA guidelines, which of the following are
acceptable antibiotic options for the prevention of infective endocarditis?
cephalexin
amoxicillin
> clarithromycin
erythromycin
azithromycin
clindamycin
144
misc.
The roots of the third, second, and first molars are all below the level of the
mylohyoid. Infection of these teeth pass through the root, directly into the
and then to the lateral pharyngeal space.
buccal space
canine space
> infratemporal space
submaxillary space
145
misc.
The mandibular left second molar of a 14-year-old boy is unerupted.
Radiographs show a small dentigerous cyst surrounding the crown.
What is the treatment of choice?
surgically extract the unerupted second molar
uncover the crown and keep it exposed
prescribe an antiinflammatory medication and schedule a follow-up appointment in
6 months
> no treatment is necessary at this time
146
submaxillary space
Remember: The mylohyoid muscle, stretching across the floor of the mouth, serves as the inferior bor-
der of the sublingual space and the superior border of the submaxillary space.
Fascial Spaces and Infection
Space
Maxillary Spaces
Canines space
Buccal Space
Infratemporal space
Mandi bul ar Spaces
Buccal space
Submental space
Sublingual space
Submaxillary space
Pterygomandibular space
Masseteric space
Temporal space
Masticator space
Usual Source of Infection
Canines
Maxillary molars, premolars
Maxillary third molars
Mandibular molars, premolars
Mandibular incisors
Mandibular molars
Mandibular third molars
Other spaces (infratemporal, masseteric, and
pterygomandibular)
Other spaces (pterygomandibular and temporal
spaces)
Important: Anatomic variability exists and the descriptions given above represent the space in which
an infection from a tooth is most likely to drain.
Note: Penicillin V is often the preferred drug to treat odontogenic infections. It is effective against strep-
tococci and oral anaerobes. For penicillin-allergic patients, clindamycin or clarithromycin can be used.
Narrow-spectrum antibiotics are preferred over broad-spectrum antibiotics, and bacteriocidal agents are
preferred over bacteriostatic agents.
uncover the crown and keep it exposed
Dentigerous cysts are those associated with the crowns of unerupted teeth. Some litera-
ture refers to these cysts as "follicular" or "primordial" cysts. Note: They are proba-
bly the result of degenerative changes in the reduced enamel epithelium.
Remember: If cysts form when a tooth is erupting, they are called eruption cysts. These
cysts interfere with normal eruption of the teeth. Eruption cysts are more commonly found
in the child and young adult and may be associated with any tooth. If treatment is indi-
cated, simple incision or "deroofing" is all that is needed.
Dentigerous cyst
Eruption cyst
misc.
Which of the following are considered primary fascial spaces?
buccal
canine
submaxillary
masticator
vestibular
147
misc.
Body temperature can be measured in several different ways, which one is the
most accurate?
orally
axillary
rectally
aurally
148
buccal
canine
submaxillary
vestibular
Fascial spaces: layers of fascia "create" potential fascial spaces (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 the spread of infection. Infections or other inflammatory conditions
spread by the path of least resistance to reach the fascial spaces. The most common space involved is the
vestibular space.
The spaces directly adjacent to the origin of the odontogenic infections are the primary fascial spaces. Infec-
tions spread from the origin into these spaces, which are buccal, canine, sublingual, submaxillary, submental,
and vestibular. Note: Canine space infections and deep temporal space infections can result in cavernous sinus
thrombosis via the ophthalmic veins.
Fascial spaces that become involved following spread of infection to the primary spaces are the secondary fas-
cial spaces.The secondary spaces are pterygomandibular, infratemporal, masseteric, lateral pharyngeal, su-
perficial and deep temporal, retropharyngeal, masticator, and prevertebral. Note: Lateral pharyngeal infections
can traverse the retropharyngeal and prevertebral spaces and spread into the mediastinum.
Factors that influence the spread of odontogenic infection: (1) Thickness of bone adjacent to the offending
tooth (2) Position of muscle attachment in relation to root tip (3) Virulence of the organism and (4) Status of
patient's immune system.
1. The masticator space contains the contents of the pterygomandibular space and is continuous
Notes with the temporal space.
2. The most definite clinical sign indicating extension of an odontogenic infection into the masti-
cator space is trismus. Trismus is difficulty in opening the mouth due to a tonic spasm of the mus-
cles of mastication.
3. Trismus may also result from passing the needle through the medial pterygoid muscle during
an inferior alveolar nerve block.
4. Other symptoms of fascial space infection include pain, dysphagia, and dysphonia.
5. The submandibular space is continuous with the lateral pharyngeal space. The mylohyoid mus-
cle divides this space and serves as the inferior border of the sublingual space and the superior bor-
der of the submaxillary space.
rectally
***Axillary is the least accurate
General considerations when checking vital signs:
The patient should not have had alcohol, tobacco, caffeine, or performed vigorous exer-
cise within 30 minutes of the exam
Ideally, the patient should be sitting with feet on the floor and their back supported. The
examination room should be quiet and the patient comfortable
History of hypertension, slow or rapid pulse, and current medications should always be
obtained
Routine Vital Signs:
Blood pressure: normal 120/80
Pulse rate: normal 72
Respiration rate.- normal 15
Temperature can be measured in several different ways:
- Oral with a glass, paper, or electronic thermometer (normal 98.6F/37C)
- Axillary with a glass or electronic thermometer (normal 97.6F/ 36.3C)
- Rectal or "core" with a glass or electronic thermometer (normal 99.6F/37.7C)
- Aural (the ear) with an electronic thermometer (normal 99.6F/37.7C)
*** For every 1C rise in body temperature, there is a corresponding 9-10 beats/min in-
crease in the patient's heart rate.
Note: Abnormalities of vital signs are often clues to diseases, the alterations in vital signs are
used to evaluate a patient's progress.
Five major areas to be discussed when taking a patient history: 1. Chief complaint 2. His-
tory of present illness 3. Specific drug allergies 4. Review of systems (heart, liver, kidney,
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 professionals.
misc.
Osteomyelitis usually begins in the medullary space involving the
periosteum
soft tissues
cortical bone
cancellous bone
ORAL SURGERY & PAINCONTROL
149
misc.
Which conditions would require preoperative antibiotic prophylaxis for the
prevention of bacterial endocarditis?
prosthetic heart valve
complex cyanotic congenital heart disease
prior coronary artery bypass graft
surgically constructed systemic pulmonary shunts or conduits
mitral valve prolapse with regurgitation and/or thickened leaflets
150
prosthetic heart valve
complex cyanotic congenital heart disease
surgically constructed systemic pulmonary shunts or conduits
mitral valve prolapse with regurgitation and/or thickened leaflets
,
Cardiac Conditions Stratification for Risk of Endocarditis
Endocarditis Prophylaxis Recommended
High Risk
Prosthetic heart valves
Surgically constructed systemic pulmonary
shunts or conduits
Complex cyanotic congenital heart disease
Prior bacterial endocarditis
Moderate Risk
Most other congenital cardiac malformations
Acquired valvular dysfunction
Hypertrophic cardiomyopathy
Mitral valve prolapse with regurgitation and/
or thickened leaflets
Endocarditis Prophylaxis Not Recommended
Negligible Risk
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal
defect, or patent ductus arteriosus
Prior coronary artery bypass graft
Mitral valve prolapse
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvular dysfunction
Previous rheumatic fever without valvular dysfunction
Cardiac pacemakers and implanted defibrillators
cancellous bone
Osteomyelitis is a relatively rare inflammatory process within the medullary (trabecular) portion
of bone that involves the marrow spaces. Osteomyelitis is generally classified into two major
groups: suppurative and nonsuppurative. Suppurative osteomyelitis is classified into acute,
chronic, or infantile osteomyelitis. Nonsuppurative osteomyelitis is classified into chronic scle-
rosing (focal and diffuse), Garre 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 the medullary space involving the cancellous bone. Eventually the cortical bone, periosteum,
and soft tissues become involved.
Note: Garre osteomyelitis is characterized by localized, hard, nontender, bony swelling of the lat-
eral and inferior aspects of the mandible. It is primarily present in children and young adults and
is usually associated with a carious molar and low-grade infection.
Important: Acute osteomyelitis occurs more frequently in the mandible as opposed to the max-
illa. The primary reason for this is that the blood supply to the maxilla is much richer and is de-
rived from a number of different arteries, while the mandible tends to draw its primary supply
from the inferior alveolar artery. The dense overlying cortical bone of the mandible prevents pen-
etration of periosteal blood vessels, thus the mandibular cancellous bone is more likely to become
ischemic and, therefore, infected. Important point: a reduced blood supply will predispose bone
to osteomyelitis.
The most frequently found bacteria in patients with osteomyelitis of the jaws include Gram-posi-
tive cocci (i.e., streptococci, Staphylococcus aureus), anaerobic cocci, and gram-negative rods.
The treatment of osteomyelitis of the jaws usually includes both surgical intervention and medical
management of the patient, as well, as sensitivity testing. Medical management involves adminis-
tration of empirical antibiotics, performing a Gram stain, and the administration of culture-guided
antibiotics. Surgical treatment includes removal of loose teeth and foreign bodies; sequestrectomy;
debridement; decortication; resection; and reconstruction, if necessary.
misc.
Why is a conventional handpiece that expels forced air contraindicated when
performing dentoalveolar surgery?
too much bone will be removed
these handpieces can cause tissue emphysema or an air embolus, which can be fatal
these handpieces are not high-powered enough to remove bone
all of the above
151
misc.
Anyone scheduled for general anesthesia should have a chest x-ray and patients
over 40 years old should also have a/an:
ECG
MRI
panorex
biopsy
152
these handpieces can cause tissue emphysema or an air embolus,
which can be fatal
Very important: Most high-speed turbine drills used in routine restorative dentistry are to-
tally unacceptable for oral surgery. The air exhausted from 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 instruments for removing bone. However,
the technique that most oral surgeons use when removing bone is the bur and handpiece.
Irrigation of the surgical wound during and after the cutting of bone cannot be emphasized
enough. Copious amounts of coolant 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 of bony 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 of bone cells.
Note: An acute infected tissue emphysema is usually caused by the indiscreet use of:
1. 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 of the alve-
olar process and ultimately out through the nutrient foramina into adjacent soft tissues, re-
sulting in formation of a septic cellulitis and tissue emphysema.
2. Atomizing spray bottles activated by compressed air: A similar condition can be in-
duced by the use of a compressed-air spray bottle for irrigation of wounds, particularly in
the retromolar region. It is safer to use a hand-activated syringe when irrigating wounds or
drying root canals since it is unlikely that a tissue emphysema would be produced under
these circumstances.
ECG
Routine Admission Tests
A complete blood count that includes an evaluation of the hemoglobin and hemat-
ocrit indices
A total white blood cell count with a differential count
A gross and microscopic urinalysis
*** Anyone scheduled for general anesthesia should have a chest x-ray, and patients over
40 years old should also have an ECG.
Factors to be considered in the decision to hospitalize a patient for an elective proce-
dure:
Medical problems compromising treatment (diabetes, hemophilia, etc.)
Difficulty and extent of surgery
Consideration of the individual patient (emotionally disturbed, handicapped, etc.)
Cost of hospitalization (time and money)
misc.
Incision for drainage (l&D) in an area of acute infection should only be
performed after:
a culture for antibiotic sensitivity has been performed
localization of the infection
a sinus tract is formed
the patients fever has cleared up
153
misc.
Which of the following techniques is best for a wide-based frenectomy?
diamond excision
v-y advancement
z-plasty
154
localization of the infection
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 the presence of purulent material within the abscess cavity
(known as fluctuance).
The important components in treatment of odontogenic infection are:
Determining the severity of infection
Determining whether the infection is at the cellulitis or abscess stage
Evaluating the state of the patient's host defense mechanisms. Compromised host defenses include severe
diabetes, alcoholism, malnutrition, uremia, leukemia, malignant tumors, lymphoma, or someone on cancer
chemotherapeutic or immunosuppressive agents.
Determine whether patient should be treated by a general dentist or an oral surgeon. Criteria for referral
to an oral surgeon include rapidly progressive infection, difficulty in breathing or swallowing, fascial space
involvement, elevated temperature (>101F), severe jaw trismus (<10 mm), toxic appearance, or compro-
mised host defenses.
Treating the infection surgically. Removal of the source of infection and drainage of purulence.
- Methods of drainage of odontogenic infections: endodontic treatment, extraction of the offending tooth,
or incision and drainage of the soft tissue.
Support the patient medically: airway maintenance, rehydration, analgesia, nutrition, etc.
Prescribe appropriate antibiotics. Indications for the use of antibiotics include rapidly progressive swelling,
diffuse swelling, compromised host defenses, involvement of fascial spaces, severe pericoronitis, and os-
teomyelitis. Penicillin VK. is often the preferred drug. If the patient is penicillin-allergic, use clindamycin.
Surgical principles of incision 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
blunt dissection and thorough exploration of the involved space
Use one-way drains in intraoral abscesses; use through-and-through drainage in extraoral cases
Remove the drain gradually from deep sites
1. For odontogenic infections, the most common organisms are aerobic gram-positive cocci,
Notes anaerobic gram-positive cocci, and anaerobic gram-negative rods.
2. Streptococcus species (which are highly virulent and aerobic) initiate the infectious process,
a cellulitis then occurs, followed by proliferation of anaerobic organisms.
v-y advancement
When a frenum is positioned in such a way as to interfere with the normal alignment of
teeth or results in pulling away of the gingiva from the tooth surface causing recession, it
is often removed using a surgical process known as a frenectomy.
Three surgical techniques used for a frenectomy:
Diamond excision \ are effective when the mucosal and fibrous tissue band is rela-
Z-plasty / 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 lengthening tissue and usually results in less scarring.
Note: Local anesthetic infiltration is usually sufficient for surgical treatment of frenal at-
tachments. Care must be taken to avoid excessive infiltration directly in the frenum area
since it may obscure the anatomy that must be visualized at the time of excision.
misc.
An orofacial infection can reach the cavernous sinus through two routes:
an anterior route via the and , and a posterior route via the
and the .
transverse facial vein; pterygoid plexus of veins, 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 of veins
155
misc.
A surgical procedure used to recontour the supporting bone structures in
preparation of a complete or partial denture is called a/an:
closed reduction
operculectomy
alveoloplasty
gingivoplasty
156
copyrightS2013-2014-Dental Decks
OR
A
T_STJRGERY^&PATN CONTROL
angular; inferior ophthalmic veins, transverse facial vein; pterygoid plexus of veins
Cavernous sinus thrombosis is an uncommon but potentially lethal extension of odontogenic infection.
Valveless veins in the head and neck allow retrograde flow of infection from the face to the sinus. The
pterygoid plexus of veins and angular and ophthalmic veins may contribute to retrograde flow.
Note: Canine space infections and deep temporal space infections can result in cavernous sinus throm-
bosis via the ophthalmic veins.
The first clinical signs of cavernous thrombosis include vascular congestion in periorbital, scleral, and
retinal veins. Other clinical signs include periorbital edema, proptosis (exophthalmos), thrombosis of
the retinal vein, ptosis, dilated pupils, absent corneal reflex, and supraorbital sensory deficits.
Important: The infection is life-threatening and requires prompt and aggressive treatment, consisting
of elimination of the source of infection, drainage, parenteral antibiotic therapy, and neurosurgical con-
sultation.
Remember: Cranial nerves III, IV, V (ophthalmic division ofV), and VI pass through the cavernous
sinus.
Differences Between Cellulitis and Abscess
Characteristic
Duration
Pain
Size
Localization
Palpation
Presence of pus
Degree of seriousness
Bacteria
Cellulitis
Acute
Severe/generalized
Large
Diffuse borders
Doughy to indurated
No
Greater
Aerobic
Abscess
Chronic
Localized
Small
Well circumscribed
Fluctuant
Yes
Less
Anaerobic
alveoloplasty
An alveoloplasty is the surgical preparation of the alveolar ridges (i.e., removing under-
cuts and sharp edges from areas such as the mylohyoid ridge) for the reception of den-
tures 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 possi-
ble.
Remember:
1. In some cases, the bone is well-contoured for denture or partial denture construc-
tion, 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, ex-
cessive alveolar ridge tissue, labial and lingual freni, or a condition called inflamma-
tory fibrous hyperplasia.
2. A closed reduction is the closing of the space between fractured bone without
cutting through 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 of the operculum, which is the flap of tissue over
an unerupted or partially erupted tooth.
misc.
While there are many reasons for autotransplanting teeth, tooth loss as a result
of dental caries is the most common indication, especially when:
maxillary central incisors are involved
mandibular first molars are involved
mandibular canines are involved
maxillary third molars are involved
157
misc.
Which of the following are systemic contraindications to elective surgery?
blood dyscrasias (i.e., hemophilia, leukemia)
controlled diabetes mellitus
addison disease or any steroid deficiency
fever of unexplained origin
nephritis
any debilitating disease
cardiac disease
158
mandibular first molars are involved
First molars erupt early and are often heavily restored. Autotransplantation in this situation in-
volves the removal of a third molar which may then be transferred to the site of an unrestorable first
molar. Other conditions in which transplantation can be considered include tooth agenesis (especially
of premolars and lateral incisors), traumatic tooth loss, atopic eruption of canines, root resorption,
large endodontic lesions, cervical root fractures, localized juvenile periodontitis, as well as other
pathologies.
Patient selection is very important for the success of autotransplantation. Candidates must be in
good health, able to follow postoperative instructions, and available for follow-up visits. They should
also demonstrate an acceptable level of oral 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 if the diabetes is not
well controlled or uncontrolled.
The most important criteria for success involving the recipient site is adequacy of bone support.
There must be sufficient alveolar bone support in all dimensions with adequate attached keratinized
tissue to allow for stabilization of the transplanted tooth.
The donor tooth should be positioned such that extraction will be as atraumatic as possible. Ab-
normal root morphology, which makes tooth removal exceedingly difficult and may involve tooth
sectioning, is contraindicated for this surgery. Teeth with either open or closed apices may be donors;
however, the most predictable results are obtained with teeth having between one-half to two-
thirds completed root development. Note: The most likely cause of failure will be a chronic, pro-
gressive external root resorption.
Important: An allogeneic tooth transplant refers to a situation in which a tooth from one individ-
ual is placed in another individual. The almost universal sequelae of an allogeneic tooth transplant
is ankylosis and progressive root resorption. Remember: The change in continuity of the oc-
clusal plane observed after ankylosis of a tooth is caused by the continued eruption of the other non-
ankylosed teeth and growth of the alveolar process.
blood dyscrasias (i.e., hemophilia, leukemia)
addison disease or any steroid deficiency
fever of unexplained origin
nephritis
any debilitating disease
cardiac disease
*** Uncontrolled diabetes mellitus is a systemic contraindication to elective surgery.
Important: Patients with these systemic conditions can be treated, but you need to consult with the patient's
physician before treatment. In most cases, these patients are best treated in the hospital by an oral surgeon.
Examples of contraindications include:
End-stage renal disease
Severe uncontrolled metabolic diseases (i.e., uncontrolled diabetes mellitus)
Advanced cardiac conditions (unstable angina)
Patients with leukemia and lymphoma should be treated before extraction of teeth
Patients with hemophilia or platelet disorders should be treated before extraction of teeth
Patients with a history of head and neck cancer need to be treated with care because even minor surgery
can lead to osteoradionecrosis. Note: These patients are often treated with hyperbaric oxygen therapy prior
to dental surgery.
Pericoronitis: infection of the soft tissues around a partially erupted mandibular third molar.
Note: This infection should be treated prior to removal of the maxillary third molar.
Acute infectious stomatitis and malignant disease are relative contraindications
Treatment with IV bisphosphonates increases the risk of osteonecrosis of the jaw
Note: Cardiac disease, such as coronary artery disease, uncontrolled hypertension, and cardiac decompensa-
tion can complicate exodontia. Usually a postinfarction patient is not subjected to oral surgery within 6
months of his infarction. However, emergency procedures can be performed, provided the patient's physician
has been consulted.
Important:
1. Infected maxillary molars and mandibular molars will usually drain into the buccal space which lies be-
tween the buccinator muscle and overlying skin and superficial fascia.
2. The submaxillary space, which lies inferior to the mylohyoid muscle, is primarily infected by the
mandibular first, second, and third molars.
misc.
The most common site for oral cancer is the:
buccal mucosa
tongue and floor of the mouth
palate
attached gingiva
159
misc.
The universal sign of laryngeal obstruction is:
mydriasis
stridor (crowing sounds)
sweating
tachycardia
160
stridor (crowing sounds)
***Stridor is a high-pitched, noisy respiration, like the blowing of the wind. It demands im-
mediate attention. It is caused by partial obstruction of the airway at the level of the larynx or
trachea.
Because total airway obstruction usually occurs during inspiration, there is usually adequate
oxygen left in the cerebral blood to permit up to 2 minutes of consciousness. If the obstruc-
tion is not recognized and managed and if oxygen is not delivered to the victim's lungs, blood,
and brain, permanent neurologic damage occurs within 3 to 5 minutes.
Noninvasive Procedures for Obstructed Airway:
Back blows, manual thrusts, Heimlich maneuver, chest thrust, and finger sweep
Invasive Procedures for Obstructed Airways:
*** These procedures should only be performed by persons trained in these techniques
andonly if proper equipment is available.
Tracheotomy: Is used more for long-term airway maintenance and not for emergency
airways
Cricothyrotomy: Is 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 cricothyrotomy may be lifesaving in an anaphylactic reaction in which a pa-
tient shows signs of laryngeal obstruction. If a patient shows signs of laryngeal obstruction,
that is, stridor (crowing sounds), epinephrine should be given and oxygen administered. If a
patient loses consciousness and appears to be unable to breathe, an emergency cricothyro-
tomy may be required to bypass the laryngeal obstruction.
tongue and floor of the mouth
The most common sites of oral cancer are the tongue and the floor of the mouth. The other com-
mon sites are the buccal vestibule, buccal mucosa, gingiva, and rarely, the hard and soft palate. This
cancer is extremely malignant and, even if there is slight delay it spreads to lymph nodes of the neck.
Squamous cell carcinoma (epidermoid carcinoma) is the most common form of oral cancer. Oral
SCC usually presents as an indurated ulcer with poorly defined borders. The lesion is characteris-
tically painless, unless inflammation from superinfection or chronic mechanical irritation is pres-
ent. An indolent clinical presentation in the form of a small superficial ulceration, leukoplakia, or
erythroplakia is also likely, especially in the early stages of development.
Remember: SCC usually affects the lower lip, and it rarely the upper lip. This occurrence has
been attributed to greater exposure of the lower lip to sunlight. Lip carcinoma commonly presents
as an ulcer. In many cases, a keratin crust covers the ulcer. The rest of the lip vermilion may show
actinic changes.
Important: Carcinoma in situ is an epithelial dysplasia that includes all the layers of the epithe-
lium 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 structures, then true in-
vasive squamous cell carcinoma has evolved.
The degree of histologic differentiation best describes the degree of malignancy of a tumor. Ma-
lignant neoplasms are histologically classified as (1) well differentiated (2) moderately differenti-
ated, or (3) poorly differentiated (anaplastic) tumors. From a histologic point of view, poorly
differentiated tumors have the highest degree of malignancy.
1. The salivary glands, blood vessels, lymphatics, muscle, bone, and other connective tis-
Notes sue can also give rise to primary malignancies of the head and neck.
2. Cancer of the breast, prostate, lung, kidney, thyroid, hematopoietic system, and colon
can metastasize to the head and neck region.
misc.
Pericoronitis is acute inflammation of the tissue overlying and surrounding a
partially erupted or erupting tooth. The most commonly involved tooth is a:
maxillary third molar
maxillary second molar
mandibular third molar
mandibular second molar
161
misc.
Bleeding that consists of pinpoint dots of blood is called . Larger flat
areas where blood has collected under the tissue, up to a centimeter in
diameter, are called . A very large area is called a/an .
purpura, petechiae, ecchymosis
petechiae, ecchymosis, purpura
ecchymosis, purpura, petechiae
petechiae, purpura, ecchymosis
162
mandibular thi rd molar See picture below
The clinical picture is that of a markedly red, swollen, suppurative 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 on the inflamed tis-
sue during mastication. There may be trismus of the masticator muscles on the affected side.
Involvement of the cervical nodes, fever, and malaise are common. If this occurs, antibiotic
therapy is indicated.
The principal etiologic factors in pericoronitis are food debris and bacterial waste products
that have accumulated under the soft tissue flap, overlying a partially erupted tooth. This tis-
sue is often traumatized during mastication, which further exacerbates the situation.
Satisfactory emergency treatment is as follows:
1. 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 rinse with warm saline hourly.
3. Prescribe a soft diet and instruct the patient to refrain from chewing on the affected side
of the mouth.
4. Repeat treatment daily until the inflammatory reaction subsides.
Important: The maxillary third molar is the most frequent contributing factor to pericoro-
nal infections found around mandibular third molars. Always examine the maxillary third
molar, it may be supererupted or malaligned.
petechiae, purpura, ecchymosis
Postoperative ecchymosis is a result of trauma to the underlying blood vessels. Blood es-
capes from the vascular tree and accumulates in the tissues. It is common after extrac-
tions in elderly patients due to the fragility of the vessel walls. All patients should be
warned that it may occur following extractions. Note: Sometimes the patient will com-
plain of a diffuse, nonpainful, yellowish discoloration of the skin. Moist heat often speeds
the resolution of postoperative ecchymosis.
Most common adverse effects of radiation therapy on the oral and paraoral tissues:
Rampant caries Difficulty in swallowing
Radiation mucositis Varying degree of trismus
Xerostomia Radiation dermatitis
Important: Osteoradionecrosis does not develop unless the patient's oral condition is
not optimized before radiation therapy, and postirradiation dental procedures are per-
formed without proper precautions.
Note: Hyperbaric oxygen therapy must be considered if surgery is to be performed on
an irradiated mandible.
Remember:
Petechiae - <2 mm
Purpura -2-10 mm
Ecchymosis - >10 mm
misc.
Thrombocytopenia (low platelet count) that is less than is an absolute
contraindication to elective surgical procedures because of the possibility of
significant bleeding.
- 50,000/mm
3
75,000/mm
3
100,000/mm
3
125,000/mm
3
163
Which of the following
. erythroplasia
ulceration
duration
slow growth
bleeding
induration
fixation
misc.
characteristics raise the suspicion of malignancy?
164
copyrighte2013-2014-Dental Decks
ORALS^RGERY&PAIN CONTROL
50,000/mm
3
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 (TIT)
Disseminated intravascular coagulation (DIC)
Marrow invasion or aplasia
Hypersplenism
Drugs
Cirrhosis
Transfusions
Viral infections (infectious mononucleosis)
1. Normal platelet count is 150,000 - 450,000.
Notes 2. Emergency procedures may be done with as 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, inhibiting platelet ag-
gregation for their 7 to 10 day life span. Because approximately 10% of platelets
are replaced each day, it takes an average of 2-3 days for bleeding time to nor-
malize, but most experts recommend allowing 7 days without aspirin before sur-
gery. Other NSAIDs will alter platelet function only temporarily.
erythroplasia
ulceration
duration
bleeding
induration
fixation
Characteristics of lesions that raise the suspicion of malignancy:
Erythroplasia: lesion is totally red or speckled red and white
Ulceration: lesion is ulcerated or is an ulcer
Duration: more than two weeks
Rapid growth
Bleeding: Bleeds on gentle manipulation
Induration: lesion and surrounding tissue is firm to the touch
Fixation: feels attached to adjacent structures
A red but not ulcerated area on mucous membrane is called erythroplasia. The texture may be
normal or roughened. Size is variable, some being so small as to virtually escape detection, whereas
large areas are conspicuous to casual inspection. There are usually no symptoms. Being neither el-
evated nor depressed, they present as quiet, unpretentious lesions. The border may be sharp or
blend imperceptibly into surrounding normal mucosa. It must constantly be kept in mind that early
carcinoma frequently appears as an area of erythroplasia. There are certain areas of the oral mucosa
that seem more prone to develop malignancy. Additionally, oral cancer is more often seen in those
over age 40. Because of this, an area of erythroplasia in a cancer-prone area in a patient past 40 is
highly suspicious for malignancy and should be biopsied on the day it is seen. This is especially true
for those lesions with a duration exceeding 2 weeks.
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 influ-
ence the actual extent of the tumor. Regional spread to the neck lymph nodes occurs by the lym-
phatic route.
misc.
Which of the following is the most common technique used for mandibular
advancement?
> the step osteotomy
> mandibular ramus sagittal split osteotomy
the vertical ramus osteotomy
the vertical body osteotomies
165
misc.
The prototypic neuropathic facial pain is:
postherpetic neuralgia
. burning mouth syndrome
trigeminal neuralgia
temporal arteritis
166
> mandibular ramus sagittal split osteotomy
The mandibular ramus sagittal split osteotomy has be-
come one of the most commonly performed mandibular
orthognathic procedures. The mandible is split sagittally
and can either be used to advance the mandible (in the
case ofretrognathia,) or to set back the mandible (in
treating prognathiaj. It is the standard procedure used
today. Note: The position of the condyle is unchanged
during correction of mandibular prognathism or retrog-
nathism.
Vertical ramus osteotomy: can be used to set
the mandible posteriorly. Used for the correction
of prognathism.
Vertical body osteotomies: procedures that involve
extracting mandibular teeth bilaterally (usually bicuspids).
Apiece of bone is also removed from the mandible and you
slide everything back. Used for prognathism.
The step osteotomy: may be indicated in cases of
mandibular prognathism, retrognathism, asymmetry, and
apertognathia. By performing bilateral step-shaped cuts
in the body of the mandible, the lower jaw is divided into
three separate, independently moveable pieces.
Note: Maxillary surgeries are referred to as Le Fort I osteotomies. The maxilla can be moved forward
and down more easily than it can be moved up or back. Distraction osteogenesis (DO) involves cutting
an osteotomy to separate segments of bone and the application of an appliance that will facilitate the grad-
ual and incremental separation of bone segments. Used for patients with cleft lip and palate as well as
other deformities of the facial skeleton.
' trigeminal neuralgia
Classifications of Orofacial Pain
Pain Type
Somatic (increased stimulus yields increase in pain)
Neuropathic (pain independent of stimulus intensity)
Psychogenic
Atypical
Source
Musculoskeletal (TMJ, periodontal, muscles)
Visceral (salivary glands, dental pulp)
Damage to pain pathways (TN, trauma, stroke)
Intrapsychic disturbance (conversion reaction,
psychotic delusion, malingering)
Facial pain of unknown cause/diagnosis pending
Neuropathic pain:
Trigeminal neuralgia: prototypic neuropathic fascial pain; Typically there is a trigger point and
the pain presents as electrical, sharp, shooting, and episodic (seconds to minutes in duration). Most
commonly seen in patients over 50 years of age. Carbamazepine (Tegretol) is still the mainstay of
treatment.
Odontalgia secondary to deafferentation (atypical odontalgia): occurs as a result of trauma or
surgery (root canal or extraction). Results from damage^to the afferent pain transmission system.
Postherpetic neuralgia: is a potential sequela of a herpes zoster infection. Pain is described as burn-
ing, aching, or electric shock-like. Treated with antidepressants, anticonvulsants, or sympathetic
blocks. Ramsay Hunt syndrome is a herpes zoster infection of the sensory and motor branches of CN
VII and CN VIII.
Neuromas: may occur after nerve injury. This area (neuroma) can become very sensitive to stimuli
and cause chronic neuropathic pain.
Burning mouth syndrome: is most commonly seen in postmenopausal females. Chief complaints
are pain, dryness, and burning of the mouth and tongue. Some complain of altered taste sensation. Half
of patients get better without treatment during a 2-year period.
Chronic headache: categorized as being either migraine, tension-type, or cluster
Temporal arteritis (giant cell arteritis): is the most common form of vasculitis that occurs in adults.
Almost all patients are over the age of 50. Commonly causes headaches, joint pain, facial pain, fever,
and difficulties with vision, and sometimes permanent visual loss in one or both eyes. Often difficult
to diagnose.
tmj
What is the best way to palpate the posterior aspect of the mandibular
condyle?
intraorally
externally over the posterior surface of the condyle with the mouth open
through the external auditory meatus
any of the above
167
tmj
The most common direction in which the articular disc in the TMJ can be
displaced is:
laterally
medially
posteriorly
anteromedially
168
externally over the posterior surface of the condyle with the mouth open
The temporomandibular joint should be evaluated for tenderness and noise. When checking for joint
noises (clicking and crepitus), the joint is palpated laterally (in front of the external auditory meatus)
while the patient opens and closes the mandible.
Tenderness can be assessed by palpating the lateral aspects of the joints when the mouth is closed and
during opening of the mouth. The joint should also be palpated for tenderness while the patient opens
maximally, and the fingertip should be positioned slightly posterior to the condyle to apply force to
determine if there is inflammation of the retrodiscal tissue.
Note: By placing fingertips in the patient's external auditory meatus, this technique can produce false
joint sounds during mandibular function because of pressure against the thin ear canal cartilage.
Remember: (1) The posterior aspect of the condyle is rounded and convex, whereas the
anteroinferior aspect is concave. (2) The condyles are not symmetrical nor identical
Temporomandibular disorders:
Myofascial pain disorder (MPD): most common cause of masticatory pain and compromised func-
tion. The symptoms are diffuse and poorly localized in the preauricular region, often involving the
muscles of mastication. The pain and tenderness develop as a result of abnormal muscle function and
hyperactivity. It can be the result of disc displacement disorders or degenerative arthritis.
Disc displacement disorders: are seen with and without reduction (the return of the normal disc-
to-condyle relationship). See card 170.
Systemic arthritic conditions: include rheumatoid arthritis, systemic lupus, and pseudogout. Pa-
tients with these conditions usually have other clinical systemic signs and symptoms.
Chronic recurrent dislocation: occurs when the mandibular condyle translates anterior to the ar-
ticular eminence and requires mechanical manipulation to achieve reduction. It is associated with
pain and muscle spasm.
Ankylosis: can occur intracapsularly or extracapsularly, and can be fibrous or bony. Bony ankylo-
sis results in more limitation of motion. Trauma is the most common cause of ankylosis. These pa-
tients have a severely restricted range of motion that may be accompanied by pain.
anteromedially
In a healthy temporomandibular joint (TMJ), the articular disc is seated on the condyle and is held in place by
the collateral ligaments (also called "discal ligaments") that are attached to the medial and lateral poles of
the condyle. Attached to the anterior portion of the articular disc are muscle fibers from the lateral pterygoid
muscle.
When the collateral ligaments become elongated or torn, they become loose which allows the lateral ptery-
goid muscle to pull the articular disc out of place. When this occurs, it is called a disc displacement. Because
of the anteromedial direction of the lateral pterygoid muscle, the articular disc is usually displaced antero-
medially.
Note: When the articular disc is displaced anteromedially to the condyle, a click sound is usually demon-
strated when the mouth is opened and the condyle moves past the thick posterior band of the articular disc.
There can also be a clicking sound when the mandible moves to the opposite side as the condyle again moves
past the thick posterior band of the articular disc. Often another click will be demonstrated when the mouth is
subsequently closed and the condyle moves from the thin central area of the disc and then past the thicker pos-
terior band as the articular disc once again becomes displaced. A crepitation sound (also known as "crepitus "
multiple scraping or grating sounds) is usually associated with a degenerative process (osteoarthritis) of
the condyle, the dull thud is usually associated with a self-reducing subluxation of the condyle, and tinnitus
is described as ear ringing.
Nonsurgical therapy for TMJ dysfunction:
Patient education: parafunctional habits (e.g., nail and pencil biting) and stress can be associated with
myofascial pain disorder (MPD). These habits or stress should be dealt with by a trained professional.
Medications: for TMJ disorders include NSAIDs, steroids, narcotic and nonnarcotic analgesics, antide-
pressants, and muscle relaxants.
Physical therapy: treatment may include biofeedback, ultrasound, transcutaneous electrical nerve stim-
ulation (TENS), massage, thermo-treatment, exercise, and iontophoresis.
Occlusal splints: can be classified as either autorepositioning (for muscle or joint pain when no specific
anatomically based pathologic entity can be identified) or anterior repositioning. The anterior reposition-
ing splint protrudes the mandible into a forward position, hypothetically recapturing the normal disc-to-
condyle relationship. Occlusal modification may be accomplished via equilibration, full mouth
reconstruction, orthodontics, and orthognathic surgery.
Arthrocentesis: for patients with internal derangement. A few milliliters of saline or lactated ringer solu-
tion are injected into the superior joint space.
tmj
Which surgical approach is the best to expose the TMJ?
preauricular
submandibular
both are the same
16!
tmj
What clinical sign is considered pathognomonic for the first stage of intern
derangement of the articular disc?
ringing in the ears
reciprocal clicking
muscle inflammation
headaches
17
preauricula
Surgical approaches to the TMJ:
Preauricular: the best incision to expose the TMJ. A perpendicular incision is made just anterior
the external ear parallel to the superficial temporal artery. The incision extends from one inch abo
the zygomatic arch to the lower extremity of the ear. The condyle is approached from behind. Not
With this approach, care must be taken not to damage either the facial nerve or the vessels that ricr.
supply this area.
Submandibular approach (Risdon approach): this is one standard surgical approach to the ram
of the mandible and neck of the condyle. It is not the best approach for procedures within the jo:
space itself.
Patients with pain and dysfunction whose signs and symptoms do not respond satisfactorily to nonsi
gical therapy within 3 months may be candidates for surgery, particularly if they are diagnosed with a
vanced internal derangement caused by ankylosis, rheumatoid arthritis, or severe degenerati
osteoarthritis. Patients with no improvement in range of motion and mouth opening despite conservati
treatment are also candidates for surgical therapy.
Surgical treatments:
Arthroscopy allows direct visualization of the anatomic structure of the TMJ, biopsy of patholoj
tissue, and removal of osteoarthritic fibrillation tissue, as well as direct injection of steroid into i
flamed synovial tissues.
Disc repositioning surgery (open arthroplasty): is used in patients with painful, persistent clickii
popping, and closed lock. The disc is mobilized and a posterior wedge may be removed, with suti
ing used to reposition the disc in a better anatomic position.
Disc repair or removal (discectomy): is indicated when the disc is severely damaged. Results vi
widely as to whether it is a viable option for patients. Replacement materials have been problemat
so there is a tendency to favor autogenous materials (i.e., temporalis muscle and fascia).
Condylotomy: is accomplished by performing an intraoral vertical ramus osteotomy. It has been us
for the treatment of internal derangement with and without reduction and chronic dislocation.
Total joint replacement: is indicated in the severely pathologic joint, as seen in rheumatoid arth
tis, severe degenerative joint disease, ankylosis, and neoplasia. Costochondral bone graft reconstn
tion is the most common autogenous material used.
reciprocal clickini
The most common form of pain and discomfort associated with TMJ disorders is masticatoi
myalgia or myofascial pain. This is a disorder characterized by pain and masticatory mu
cle spasm and limited jaw opening. The condition is characterized by a unilateral dull, achii
pain which increases with muscular use.
Internal derangement of the articular disc:
First stage: reciprocal clicking is considered pathognomonic. In the first stage of interr
derangement, clicking begins suddenly and spontaneously or after an injury. The noise
often loud and may be audible to others, but it is rarely associated with severe pain.
Second stage: the second stage of disc derangement is reciprocal clicking with inte
mittent locking. The typical patient complains that the jaw becomes locked and there
usually, but not always, severe pain over the affected joint.
Third stage: is associated with limited opening and has been termed closed lock. A lb
ited opening of <27 mm and severe pain over the affected joint are characteristic findinj
Note: In contrast to the second stage, few patients are able to unlock or relocate their clos
lock and restore normal function.
Fourth stage: the final stage is characterized by an increase in opening and crepitus c
curring within the joint during movement due to degenerative changes in the disc and art
ular surfaces. Note: This stage appears to be less painful than previous stages, because t
neurovascular tissue is no longer impinged between the condyle and the glenoid fossa.
The occurrence of TMJ pain caused by rheumatoid arthritis depends on the severity of 1
systemic disease. Most studies show that about one-third of the patients with rheumatoid arth
tis will experience pain in the joint at some time, with nearly 60% of patients suffering fn
bilateral joint dysfunction. Note: The target tissue of rheumatoid arthritis is the synovial me
brane. Progression in the TMJ follows a general scheme with exudation, cellular infiltratit
and pannus formation. The articular surfaces of the temporal and condylar components ;
destroyed, the disc becomes grossly perforated, and the subchondral bone is resorbed.
preauricular
Surgical approaches to the TMJ:
Preauricular: the best incision to expose the TMJ. A perpendicular incision is made just anterior to
the external ear parallel to the superficial temporal artery. The incision extends from one inch above
the zygomatic arch to the lower extremity of the ear. The condyle is approached from behind. Note:
With this approach, care must be taken not to damage either the facial nerve or the vessels that richly
supply this area.
Submandibular approach (Risdon approach): this is one standard surgical approach to the ramus
of the mandible and neck of the condyle. It is not the best approach for procedures within the joint
space itself.
Patients with pain and dysfunction whose signs and symptoms do not respond satisfactorily to nonsur-
gical therapy within 3 months may be candidates for surgery, particularly if they are diagnosed with ad-
vanced internal derangement caused by ankylosis, rheumatoid arthritis, or severe degenerative
osteoarthritis. Patients with no improvement in range of motion and mouth opening despite conservative
treatment are also candidates for surgical therapy.
Surgical treatments:
Arthroscopy allows direct visualization of the anatomic structure of the TMJ, biopsy of pathologic
tissue, and removal of osteoarthritic fibrillation tissue, as well as direct injection of steroid into in-
flamed synovial tissues.
Disc repositioning surgery (open arthroplasty): is used in patients with painful, persistent clicking,
popping, and closed lock. The disc is mobilized and a posterior wedge may be removed, with sutur-
ing used to reposition the disc in a better anatomic position.
Disc repair or removal (discectomy): is indicated when the disc is severely damaged. Results vary
widely as to whether it is a viable option for patients. Replacement materials have been problematic,
so there is a tendency to favor autogenous materials (i.e., temporalis muscle and fascia).
Condylotomy: is accomplished by performing an intraoral vertical ramus osteotomy. It has been used
for the treatment of internal derangement with and without reduction and chronic dislocation.
Total joint replacement: is indicated in the severely pathologic joint, as seen in rheumatoid arthri-
tis, severe degenerative joint disease, ankylosis, and neoplasia. Costochondral bone graft reconstruc-
tion is the most common autogenous material used.
reciprocal clicking
The most common form of pain and discomfort associated with TMJ disorders is masticatory
myalgia or myofascial pain. This is a disorder characterized by pain and masticatory mus-
cle spasm and limited jaw opening. The condition is characterized by a unilateral dull, aching
pain which increases with muscular use.
Int ernal derangement of the articular disc:
First stage: reciprocal clicking is considered pathognomonic. In the first stage of internal
derangement, clicking begins suddenly and spontaneously or after an injury. The noise is
often loud and may be audible to others, but it is rarely associated with severe pain.
Second stage: the second stage of disc derangement is reciprocal clicking with inter-
mittent locking. The typical patient complains that the j aw becomes locked and there is
usually, but not always, severe pain over the affected joint.
Thi rd stage: is associated with limited opening and has been termed closed lock. A lim-
ited opening of <27 mm and severe pain over the affected joint are characteristic findings.
Note: In contrast to the second stage, few patients are able to unlock or relocate their closed
lock and restore normal function.
Fourth stage: the final stage is characterized by an increase in opening and crepitus oc-
curring within the joint during movement due to degenerative changes in the disc and artic-
ular 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 occurrence of TMJ pain caused by rheumatoid arthritis depends on the severity of the
systemic disease. Most studies show that about one-third of the patients with rheumatoid arthri-
tis will experience pain in the joint at some time, with nearly 60% of patients suffering from
bilateral joint dysfunction. Note: The target tissue of rheumatoid arthritis is the synovial mem-
brane. 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.
anat
The arises from the anterior surface of the external carotid artery
and then passes near the greater cornu of the hyoid bone.
submental artery
inferior alveolar artery
> lingual artery
anat
The buccinator and superior pharyngeal constrictor muscles of the pharynx are
attached to each other at the:
mastoid process
epicranial aponeurosis
genial tubercles on the internal surface of the mandible
10
lingual artery
It loops upward and then passes deep to the posterior border of the hyoglossus muscle to
enter the submandibular region. The loop of the artery is crossed superficially by the hy-
poglossal nerve. The lingual artery supplies structures of the floor of the mouth and the
posterior and inferior surface of the tongue. Major branches include the :
Suprahyoid artery: supplies the suprahyoid muscles
Dorsal lingual artery: supplies the tongue, tonsils, and soft palate
Sublingual artery: supplies the floor of the mouth, mylohyoid muscle, and sublin-
gual gland
Deep lingual artery: supplies the tongue
Important: The lingual artery does not accompany the corresponding 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 of the mandible. The inferior alveolar nerve passes lateral to the sphenomandibu-
lar ligament. The submandibular duct is crossed twice by the lingual nerve. If the lingual
nerve is cut after the chorda tympani joins, there will be loss of both taste and tactile sen-
sation.
Note: The lateral pterygoid muscle forms the roof of the pterygomandibular space.
O n eooh side, the P - O ^ - T ^ E ^ ^ ^ S S *
riorly to attach to the posterior end of the n , l m y l o
b u C
e i n a t o r
passively increased.
The pterygomandibular raphe is noted in the oral cavity as the pterygomandibular fold
1. The buccinator muscle is pierced by the needle when performing an inferior
"
0t CS
f-rt^ndofof the temporalis muscle and the superior pharyngeal con-
be incised.
drugs
A sedative dose of a barbiturate should be expected to produce:
respiratory depression
mi nor analgesia
decreased BMR
all of the above effects
1
89
exo
All of the following are true statements concerning the principles of suturing
technique EXCEPT one. Which one is the EXCEPTION!
the needle should be perpendicular when it enters the tissue
sutures should be placed at an equal distance from the wound margin (2-3 mm) and at
equal depths
sutures should be placed from mobile tissue to thick tissue
sutures should be placed from thin tissue to thick tissue
sutures should not be overtightened
sutures should be 2-3 mm apart
90
ORALSURGERY & PAIN CONTROL^
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
Have anticonvulsant effects
Mechanism of action of barbiturates:
Barbiturates inhibit depolarization of neurons by binding to the GABA receptors, which
enhances the transmission of chloride ions.
Characteristics of barbiturates:
Well absorbed orally, distributed widely throughout the body
Metabolized in the liver to inactive metabolites that are excreted in the urine
Therapeutic uses of barbiturates:
Anesthesia: influenced by duration of action. Thiopental is an ultra short-acting barbitu-
rate used IV to induce surgical anesthesia. Note: After IV administration, the last tissue to
become saturated as a result of redistribution is fat (as compared to liver, brain, and mus-
cle tissue)
Anticonvulsant: phenobarbital used in long-term management of tonic-clonic seizures,
status epilepticus, and eclampsia
Anxiety: can be used as mild sedatives to relieve anxiety and insomnia
Drug interactions: CNS depressants, alcohol, and opioid analgesics enhance the CNS de-
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 from the lethal dose (this is known as a small therapeutic window).
Note: The barbiturates can produce fetal damage when administered to a pregnant woman.
*** j
m s
j
s
f
a
i
s e;
sutures should not be overtightened or closed under tension.
The interrupted suture is the most common suture method. Because each suture is in-
dependent, this procedure offers strength and flexibility in placement. Due to this advan-
tage, 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 of this pattern
of sutures. (See figure #1 below)
Advantages of a continuous pattern or method (See figure #2 below):
Ease and speed of placement
Distribution of tension over the whole suture line
A more watertight closure than the interrupted pattern or method
Figure #1 Figure #2
exo
For impacted mandibular third molars, place the following in their correct
order from the least difficult to most difficult to remove.
vertical
horizontal
distoangular
mesioangular
103
Which two major forces are
exo
used for routine tooth extractions?
. rotation
pulling
pushing
luxation
104
mesioangular - 43% of mandibular impactions
horizontal - 3% of mandibular impactions
vertical - 38% of mandibular impactions
distoangular - 6% of mandibular impactions
Important: This is the exact opposite of impacted maxillary third molars, where the
mesioangular impactions (12%) are the most difficult and the vertical (63%) and dis-
toangular impactions (25%) are the easiest to remove.
Surgical principles for removing impacted teeth:
1. Adequate exposure (adequate-sizedflap): an envelope flap is most often used, but
releasing incisions are common. Note: The base portion of the flap should always be
wider than the apex portion of the flap to maintain adequate blood supply to the re-
leased soft tissues.
2. Bone removal: a trough of bone on the buccal aspect of the tooth down to the cer-
vical line should be removed initially; more bone removal may be required depending
on the particular tooth. Important: Bone is rarely, if ever, removed on the lingual as-
pect of the mandible because of the likelihood of damaging the lingual nerve.
3. Tooth sectioning: sectioning of the tooth may also be needed. This is most often
performed 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 of the soft tis-
sue flaps completes the procedure.
rotation
luxation
Luxation is the loosening of the tooth in the socket by progressive severing of the periodon-
tal ligament fibers. Patience and controlled force are needed, not brute strength. The force
should be applied as low down the root as possible when extracting teeth. You should support
the jaw with your other hand and have a thumb and finger on either side of the tooth being ex-
tracted. Note: Rotation forces can be used on single rooted teeth. Teeth are extracted by lux-
ation forces perpendicular to the long axis of the tooth, not by pulling along the long axis. The
fulcrum is as close to the apex of the tooth as possible.
Remember: The beak of the extraction forcep is designed so that most of the pressure ex-
erted during an extraction is transmitted to the root of the tooth.
Important: When using dental elevators, one should always have respect for the forces gen-
erated. Due to the large amount of leverage, dental elevators can generate tremendous forces
during normal use and have potential to cause iatrogenic damage.
Note: A Class II lever is used during tooth extractions (seepictures below)
Class I Lever Class II Lever Class III Lever
Effort
L m
f
A
i 1 j...,.,, , ,,i | Fulcrum - J .
Fulcrum
or or
Pivot Point Pivot Point
Effort
Pivot Point
implants
Currently, the most popular used implants are:
bladeform implants
subperiosteal implants
transosseous implants
rootform implants
^ % r-k M I * .i . ._ copyngnt 2C
ORAL SURGERT&PATNCONTROL
143
copyright@2013-2014-Dental Decks
misc.
To prevent infective endocarditis in patients at risk for such infections,
the American Heart Association (AHA) frequently issues guidelines for
prophylactic antibiotic coverage during dental procedures. In accordance
with the most recently revised AHA guidelines, which of the following are
acceptable antibiotic options for the prevention of infective endocarditis?
i cephalexin
amoxicillin
> clarithromycin
> erythromycin
azithromycin
clindamycin
144
root form implants
Dental implants are divided into three categories based on their relationship to the oral tis-
sues:
1. Endosseous implants are implants that are surgically inserted into the jawbone. They are
the most frequently used implants today. They are further subdivided into root form and blade
(plate) form.
2. Subperiosteal implants are frameworks 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 the jawbone. However, these implants actually penetrate the entire jaw so that they
actually emerge opposite the entry site, usually at the bottom of the chin. Note: Their primary
indication is in the very atrophic mandible where root form implants may further compromise
the strength of the jaw.
Remember: Osseointegrated implants are anchored directly to living bone. This determination
is made by radiographic and light microscopic analysis. Only endosseous and transosseous im-
plants are considered true osseointegrated implants.
Root form implants: cylindrical in shape, can be smooth, threaded, perforated, and solid or hol-
low, vented, coated, or textured. They are available in various widths (3.2 mm to 7 mm) and
lengths (8 mm to 18 mm). Typically made of titanium. Treatment with root form implants is di-
vided into three phases; surgical, healing and prosthetic. Note: These implants are the most pop-
ular.
Blade implants (also known as plate form implants): are flatter in appearance and are utilized
when there is insufficient width of bone but adequate depth. They are available in single and
two-stage forms. Typically made of titanium.
Two basic types of implant placement:
1. Submerged: requires a second surgical procedure (two-stage) to uncover the fixture.
2. Nonsubmerged: does not require a second surgical procedure (one-stage).
cephalexin
amoxicillin
clarithromycin
azithromycin
clindamycin
In adults, the new antibiotic regimen recommended for the prevention of infective endo-
carditis is:
Amoxicillin: 2.0 grams, 30-60 minutes prior to the procedure (four 500-mg
tablets)
For those patients allergic to penicillin,
Clindamycin: 600 mg, 30-60 minutes to the procedure (four 150-mg tablets)
The guidelines for children are:
Amoxicillin: 50 mg/kg, 30-60 minutes prior to the procedure
For those patients allergic to penicillin,
Clindamycin: 20 mg/kg, 30-60 minutes prior to the procedure
These new guidelines involve a number of changes from the previous set of guidelines:
Only one antibiotic dosage is required
The recommended antibiotic for penicillin-allergic patients is clindamycin not eryth-
romycin
Prophylaxis is no longer required for many dental procedures
Alternatives for patients who are allergic to penicillin and who cannot take clin-
damycin include cephalexin, clarithromycin, and azithromycin.

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The gold standard test for primary adrenal failure is the:

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