Oral and General Surgery Facts

PAIN
In Gate Control theory  Larger nerve fiber impulses INHIBIT the impulses of the
smaller ones

In Tracheostomy,
1. Indicated in Ludwigs Angina in cases oedema of the glottis
2. Entry through 2nd – 4th Tracheal rings (entry through 1st ring  tracheal stenosis and
through 5-7th is very difficult)
3. In elective Tracheostomy, entry should be made  “below the cricoid”

Entry at “Cricothyroid membrane” is made in Cricothyroidotomy  Is a life saving

procedure when endotracheal intubation ISNOT possible

BONY UNDERCUTS IN MAXILLA

1. Severe bony undercuts  Remove both undercuts so no undercut exists

2. Severe bilateral tuberosity undercuts (Patient with Maxillary “CD”)  Remove
tissue only on one side if possible

Flap design for removing maxillary tuberosity undercuts,

1. A wedge is done first
2. Incision made at the crest of the ridge
3. Incision may extend to PM and Canine area

 Most tuberosity reductions before denture construction  requires  Primarily soft

tissue / Fibrous tissue removal
 If RM pad and Tuberosity contacts  Surgically reduce tuberosity
 Principal problem of removing / reducing tuberosity  Formation of OAF
 Tuberosity # during extraction  Leave it and Stabilize if needed [DONOT lift
mucoperiosteum to see the size]

Congestive Heart Failure

 Diseased myocardium unable to deliver cardiac output needed by body.
 Symptoms: Orthopnoea, Nocturnal dyspnoea, pedal edema
 Supine position is AVOIDED. Patients must be kept in UPRIGHT POSITION ***

General Medicine
 Broncheictasis Dialation of bronchi???
 Pulmonary emphysema Alveoli distended
 Coronary Heart Diseases: Angina, MI, Heart Failure, Card. Arrhythmias, Sudden
death

Pterygo-mandibular space (PM)

Boundaries:
Laterally  Medial of Ramus
Medially  Lateral of Medial Pterygoid
Posteriorly  Deep portion of parotid
Anteriorly  Pterygomandibular raphe
Roof  Lateral Pterygoid muscle (******)
Contents:
Lingual n
Mandibular n
Mylohyoid n

Drainage:
PM into Pre-tracheal and Retro pharyngeal
SM and SL into Lateral / Para-Pharyngeal (Lateral Pharyngeal communicate with SM
and SL antero-inferiorly)

Signs and symptoms:

1. Moderate to severe trismus (???)
2. Deviated uvula to the unaffected side
3. Anterior bulge of half of soft palate and tonsillar pillar
4. Pain

Masticator space
1. Sub-Massetric space (Muscles of mastication – Mass, MP, LP, Temporalis insertion)
2. PM space (Predominant)
3. Superficial Temporal
4. Deep Temporal
1. Trismus is characteristic
2. Masticator space (technically PM space)  Supero-posteriorly Parotid and
Infero-posteriorly Lateral Pharyngeal

Para-mandibular space
1. Submandibular
2. Submental
3. Sublingual

Teeth and Space infections

 Lower anteriors  Sub mental
 Lower PM’s and 1st Molar  Sub lingual (Root apices above MH line)
 *** EXAM Mandibular 1st molar  Buccal vestibular space***********
 Lower 2nd and 3rd molar  Sub mandibular (Root apices below MH line)
 Pericoronal infection from Lower 3rd molar  Lateral Pharyngeal
 Max Laterals and Palatal root of Max Molars  Palatal abscess

Missing Roots
 DB root of maxillary 3rd molar may ONLY be found in Maxillary sinus / between PO
and buccal plate
  Missing mandibular root may be displaced into  Mandibular canal / Through
lingual cortical plate [X Cannot be located adjacent to masseter]
 Maxillary impactions, most likely to be displaced into ANTRUM / IT Fossa with
incorrect techq  DISTO-ANGULAR

CPR Facts
 Victim is unresponsive  Lie him in SUPINE position
 Primary airway hazard for unconscious  Tongue
 First step in CPR  Establish responsiveness (*)
 Triple manoeuvre for airway maintenance  Open-Release airway, Head-Chin lift, Jaw
thrust
 Early signs of OXYGEN WANT  Cyanosis, ↑ Pulse and Tachycardia
 Important signs of AIRWAY OBSTRUCTION  Stertorous breathing, Pronounced
retraction of chest spaces, Hands over throat (Universal sign)
 External Cardiac Compressions
o Lower half of sternum
o Compressions  60-80 / min in adults and 100 / min in children
[*****Even if that is performed by TWO RESCUERS]
o Compression-relaxation cycle  60 / minute repetitions
o Sternum depressed approx 1½ to 2 inches
 An important assessment  should see PUPILLARY CONSTRICTION
 Complications  **** Incorrect compressions over Xiphoid process  LIVER
damage
 Artificial ventilation – exhaled air cycle  5 / sec
 Interruptions in cardiac compressions result in  reduction in blood flow and BP
becoming zero
 In most medical emergencies, the easiest techq to open victim’s airway  TILT his
head back

****** Required Cardiac Compressions  60-80 / min in adults and

100 / min in children [*****Even when that is performed by TWO
RESCUERS]
****** Artificial ventilation – required exhaled air cycle  5 / sec
****** Proper rate of rescue breathing  12 times / min [Adults]

Nerve blocks / Needles

Muscles Involved
 Muscle encountered during aspiration of pus from PM space intra-orally 
Buccinator
 Muscle penetrated during IAB  Buccinator
 In IAB, trismus is usually due to needle injury to Medial Pterygoid
 Incorrect Infra-orbital block  Quadratus Labii Superioris encountered
 MOST difficult tooth to anesthetize by infiltration alone  Maxillary 1st Molar [MB
Root]

Absent Subjective Symptoms

 PSA and Buccal blocks

Lingual nerve
 Sensory fibres to Tongue  Floor  Lingual surface of mandible
 Should be protected when manipulating MYLOHYOID ridge
 Extra-oral techq’s
 Mandibular block  Needle direction to Lat. Pterygoid Plate POSTERIOR
 Maxillary block  Needle direction to Lat. Pterygoid Plate ANTERIOR

*** Teeth that can be removed after IAB and Lingual block  All lowers anterior to 2nd
PM
*** Mandibular canal location  Between first and second PM’s, below root apices
*** Extra-oral Infra-orbital block DOES NOT block sphenopalatine n
***Nerves anesthetized for Max Laterals  Nasopalatine & Superior alveolar

Hypovolemic Shock
 Hypotension
 Tachycardia
 Low pulse pressure

N2O - O2 Sedation
 Main route of elimination  Lungs
 CONTRA_INDICATIONS:
o Hemoglobinopathies
o Emphysema
o Emotional instability
o URT obstruction
 Common side effects:
o Nausea
o Diffusion Hypoxia
o Behavioural problems (***)
*** Low blood solubility
***Absorbed and excreted in LUNGS
***Readily diffuses into alvelolar membrane
***Sedative doses of N2O  depress bone marrow & WBC after prolonged use
*** In a central N2O system, the main pressure reduction device is located between
 pressure gauge and analgesia machine

Local Anesthesia
** nerve membrane stablization action  prevents Na ions influx
*****LA produce anesthesia by  preventing Na ions influx****
***LA efficacy is REDUCED in the presence of Acute Infection and Inflammation
[Has NO bearing with AB administration]
** Initial repolarization is due to  efflux of K ions to outside
*****MOST alarming respiratory condition during patient sedation  Apnoea
 Syncope questions [ Select airway / O2 if available]
 Syncope worsening, pulse and respiration becomes weak and cyanotic  support
respiration with oxygen through an open airway
 Patient under syncope fails to regain consciousness even after supine position and
ammonia inhalation  Check pulse and support respiration through patent airway
*** Oxygen is strongly indicated in short, convulsive attacks as a result of a toxic reaction
***Supporting respiration with Oxygen also indicated Overdose of DIAZEPAM

***Primary cause of toxic manifestation of adrenaline  INTRAVASCULAR injection

***Most common post-op OUTPATIENT complication of GA  ATELECTASIS
*** Anesthetic agent best suited in comparison to Intra-oral types  Endotracheal
intubation with pharyngeal packs
***Conscious sedation  Patients retain reflexes [Not in GA]
***Unconscious sedation  Neurolept Analgesia
*** Area LAST depressed by GA agent  MEDULLA

Fractures
 Most common site for dental fractures  Maxillary incisors
 Lefort II paresthesia’s are generally distributed over “Infra-orbital” nerve
  Paresthesias following fratures  MOST common  Zygomaticomaxillary complex
[IO nerve]
 Piercing IAN with 27 guage needle mild temporary paresthesia of lower lip
 Paresthesia of lower lip  may be due to  removal of mandibular 3rd molar
 Loss of sensation of lowerlip
 Metastatic tumour of mandible
 CNS Tumour [Pontine]
 Fracture in Mndibular 1st molar region
 Mental Anesthesia  # body / angle
 Facial paralysis most common in Condylar neck #
 ***Oral surgical procedures generally require  Medical H  Physical
examination  CBC  Urinalysis
 Principles of fracture management  RFI
 MOST pathognomonic features of mandibular fractures 
SL Hematoma/ecchymoses  Deranged Occlusion (most common)
 Facial paralysis most common in Condylar neck #
 Most COMMON pathognomonic sign of a mandibular fracture 
MALOCCLUSION

Cleft Palate
 25% alone
 Females
 Inability of palatal shelves to fuse during 9th week in utero
 Prevents normal speech and swallowing [SpeechInability of soft palate to close
airflow to Nasopharynx]
 Rx:
 Surgical repair of palate
 Orthognathic surgery [deficient midface]
 Ortho Rx [MO]
 Speech therapy

Sagittal Osteotomy [Rx of]

 Mandibular retrusion
 Mandibular protrusion
 Apertognathia
***Sagittal split method is advantageous than Transoral vertical subcondylar osteotomy
as it ALONE may be used to correct either prognthism or retrognathism
***Orthognathic surgery  aims to  ↑ perio prognosis, ortho results, restorative results
along with esthetics and patient satisfaction

Psychogenic Reaction
 Nausea
 Pallor and cold perspiration
 Widely dialated pupils, eyes rolled up
 Brief convulsion

Biopsy care
 General practitioner should avoid performing biopsy for
 Large bluish/reddish lesion that blanches [Hemangioma]
 Large suspected cancerous lesion
  Isolated pigmented lesion [non-amalgam]

General Questions
 Followup care and discharge instructions are recorded, written and
explained orally but not the responsibility of the nurse
 Dictation following an operation, NEED NOT include  a detailed
RECOVERY room record
 Purpose of taping the eyes shut prior to draping a patient  prevent
corneal abrasion

***Radicular cyst, 1.5 cm in diameter, beneath a non-vital and non-functional molar

 Needs reflection of gingival flap
***Question on difficulty of extraction, comparison Choose a non-pathological, fully
erupted, non-traumatic tooth [May even be max 1st PM]
*** Albumin has NO ROLE in Hemostasis
***Paranasal sinuses are absent in NASAL bones
***Depressing Automnomic NS is NOT an acceptable way of controlling pain
***Hemostasis on cold application  Transient vasoconstriction
***Bibevelled chisels are used to split teeth [Osteotomes]
***Most accurate body temperature  RECTAL
*** Ideally extraction suturing NEED NOT require Continuous/absorption types
***Bacteriological specimen is better collected during ACUTE STAGE of the disease
***AB are prescribed ONLY in the presence of systemic symptoms
 FEVER, TRISMUS etc
***Universally used Oral Surgical Blade  # 15

*** Skin graft vestibuloplasty prevents recurrence by  Forming a barrier to

reattachment of muscle to periosteum
*** Lymphatic infection better detected by “Cervical region palpation”