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ORAL SURGERY Part 1: Principles of Surgery Indications for Dental Extractions 1) Severe caries 2) Pulpal necrosis irreversi!

le pulpitis "#ere en$o can%t !e $one &) Severe perio $' () Ort#o$ontic purposes )*a'+ *an$+ 1P, an$ &r$ *olars) -) ,alpose$ teet# .) /rac0e$ teet# 1) Preprost#etic e'tractions 2) 3*pacte$ teet# 4) Supernu*erary teet# 15) 6eet# assoc+ " pat#ology 11) Pre7ra$iation t#erapy )8uestiona!le teet# s#oul$ !e e'tracte$) Contraindications to Dental Extractions 1) Severe uncontrolle$ *eta!olic $iseases )$ia!etes) 2) En$7stage renal $isease &) A$vance$ car$iac con$itions )unsta!le angina9 uncontrolle$ :6;9 recent ,3) 7s#oul$ "ait . *ont#s after /A<G surgery to #ave elective e'tractions () Leu0e*ia an$ ly*p#o*a )s#oul$ treat $isease !efore e'tractions) -) :ea$ an$ nec0 ra$iation )can lea$ to osteora$ionecrosis) 7pts treate$ " #yper!aric o'ygen prior to e'tractions .) Pericoronitis )cellulitis) aroun$ *an$+ &r$ *olars 7s#oul$ treat tissue infection !efore e'traction )anti!iotics9 irrigation9 an$ re*oving *a'+ & r$ *olar) 1) Acute infectious sto*atitis an$ *alignant $iseases 2) 6reat*ent " 3= !isp#osp#onates9 c#e*o9 anticoagulants9 an$ steroi$s 4) Pregnancy in 1st an$ &r$ tri*ester 15) Severe !lee$ing $isor$ers )#e*op#ilia9 t#ro*!ocytopenia) Forces Used in Routine Extractions 1) Lu'ation: loosening of toot# !y progressive severing of P>L 7force applie$ perpen$icular to long a'is of toot# 2) Rotation: use$ only on single7roote$ teet# Indications for Surgical Extractions 1) 3nitial atte*pts at forceps e'traction #ave faile$ 2) Pt appears to #ave #eavy $ense !one &) Ol$er pts $ue to loss of elastic !one () S#ort clinical cro"ns " severe attrition )!ru'is*) -) :yperce*entosis or "i$ely $ivergent roots .) E'tensive $ecay or cro"n loss Positioning of Dentist When Extracting Teeth 1) ,a'illary teet#: stan$ in front of or to si$e of pt 7pt%s upper ?a" s#oul$ !e at sa*e #eig#t as $entist%s s#oul$er 2) ,an$+ teet#: stan$ $irectly to si$e of or !e#in$ pt 7pt positione$ so occlusal plane of *an$i!le is parallel to floor an$ c#air as lo" as possi!le Extracting Primary Teeth 7pri*ary $irection of lu'ation s#oul$ !e to lingual ! c t#ese teet# are *ore lingually positione$ 7opposite of a$ults

Sequence of Extractions 1) ,a'illary teet# !efore *an$i!ular teet# 2) Posterior teet# !efore anterior teet# Im acted Teeth 7i*pacte$ teet# are ones t#at $on%t erupt into arc# in e'pecte$ ti*e 7teet# !eco*e i*pacte$ ! c a$?acent teet#9 $ense overlying !one9 or e'cessive soft tissue prevents eruption 7ina$e8uate arc# lengt# is *ost co**on reason teet# fail to erupt 7i*pacte$ teet# are retaine$ for pt%s lifeti*e unless surgically re*ove$ 7*ost co**on i*pacte$ teet# are *an$+ &r$ *olars9 *a'+ &r$ *olars9 an$ *a'+ canines 7unerupte$ teet# inclu$e !ot# i*pacte$ teet# an$ teet# in process of erupting 7e*!e$$e$ teet# is use$ interc#angea!ly " i*pacte$ teet# )E*!e$$e$ teet# @ 3*pacte$ teet#) 7i*pacte$ *a'+ &r$ *olars can !e $isplace$ into: 1) infrate*poral space 7re*ove$ via #e*ostat 2) *a'illary sinus 7re*ove$ via /al$"ell7Luc approac# 7*an$+ &r$ *olars can !e $isplace$ into: 1) su!*an$+ space )*ost li0ely) 2) 3A canal &) cancellous !one space Cald!ell"#uc Procedure 7opening *a$e into *a'+ sinus !y incision into canine fossa a!ove *a'+ P, roots 7after toot# root re*oval9 figure72 suture *a$e9 anti!iotics9 nasal spray9 an$ $econgestant given 7palatal root of *a'+ 1st *olar is *ost often $islo$ge$ into sinus Reasons to Extract Im acted Teeth 1) Prevention of perio $' in a$?acent teet# 2) Prevention of caries &) Prevention of pericoronitis () Prevention of root resorption of a$?acent teet# Contraindications to Extracting Im acted Teeth 1) E'tre*es of age )preteen or over &- yrs ol$) 2) /o*pro*ise$ *e$ical status &) Li0ely $a*age to a$?acent structures Classifications of Im acted Teeth 1) Angulation a) ,esioangular )least $ifficult for *an$+ an$ *ost $ifficult for *a'+9 *ost co**on) !) :oriBontal c) =ertical $) >istoangular )*ost $ifficult for *an$+ an$ least $ifficult for *a'+) 7*ost *an$+ &r$ *olars angle$ to lingual 2) Pell an$ Gregory /lassification a) Relations#ip to anterior !or$er of ra*us i) /lass 1: nor*al position anterior to ra*us ii) /lass 2: #alf of cro"n is "it#in ra*us iii) /lass &: entire cro"n is "it#in ra*us !) Relations#ip to occlusal plane i) /lass A: toot# at sa*e plane as ot#er *olars ii) /lass <: occlusal plane of &r$ *olar is !t" occlusal plane an$ cervical line of 2n$ *olar iii) /lass /: &r$ *olar is !elo" cervical line of 2n$ *olar -) Prevention of o$ontogenic cysts an$ tu*ors .) 6reat*ent of pain of une'plaine$ origin 1) Prevention of ?a" fractures 2) Aacilitation of ort#o t't

Factors that $a%e Im action Surgery #ess Difficult 1) ,esioangular i*paction 1) Large follicle 2) /lass 1 ra*us position 2) Elastic !one &) /lass A $ept# 4) Separate$ fro* 2n$ *olar () Roots 1 & to 2 & for*e$ )2 & is !est) 15) Separate$ fro* 3A nerve -) Ause$9 conic roots 11) Soft tissue i*paction .) Ci$e P>L Factors that $a%e Im action Surgery $ore Difficult 1) >istoangular 1) 6#in follicle 2) /lass & ra*us position 2) >ense9 inelastic !one &) /lass / $ept# 4) /ontact " 2n$ *olar () Long9 t#in roots 15) /lose to 3A canal -) >ivergent9 curve$ roots 11) /o*plete !ony i*paction .) ;arro" P>L Princi les of Surgical Extractions 1) E'posure 7surgeon *ust #ave a$e8uate visi!ility of surgical site )*a0e flap) 7incision s#oul$ !e *a$e over soun$ !one 7envelope flap is *ost often use$9 !ut can also use releasing incisions 7vertical releasing incisions s#oul$ !e *a$e at line angle of toot#9 never on facial aspect or splitting papilla 7!ase of flap )vesti!ule) s#oul$ al"ays !e "i$er t#an ape' )crest) to *aintain !loo$ supply to soft tissues 2) <one re*oval 7!etter to re*ove !one " !ur t#an to fracture it t#roug# forceful e'traction 7troug# of !one on !uccal $o"n to cervical line s#oul$ !e re*ove$ initially9 an$ *ore if nee$e$ $epen$ing on position an$ root *orp#ology &) 6oot# sectioning 7sectioning toot# *ay !e nee$e$ to avoi$ e'cess !one re*oval or in?ury to vital structures 7*an$+ &r$ *olars are teet# *ost often nee$e$ to !e sectione$ () 3rrigation of "oun$ 7copious irrigation i*pt to avoi$ leaving !one spicules or toot# frag*ents !elo" soft tissue flap Com lications of Extractions 1) 6earing of *ucosal flap 2) Puncture "oun$s in palate9 tongue9 etc+ 7control !lee$ing an$ allo" #ealing !y secon$ary intention &) Oral7antral co**unication 7*anage " figure 2 suture over soc0et9 anti!iotics9 an$ nasal spray 7if very s*all9 ?ust let !loo$ clot for* 7if very large9 t#en close " flap proce$ure 7co*plications: c#ronic oroantral fistula an$ *a'+ sinusitis () Root fracture -) 6oot# $isplace*ent a) *a'+ *olar into *a'+ sinus )palatal root of *a'+ 1st , *ost co**on) !) *a'+ &r$ *olar into infrate*poral fossa c) *an$+ *olar roots force$ into su!*an$i!ular space $) toot# lost into orop#aryn' )*ay cause air"ay o!struction9 s#oul$ ta0e to ER for c#est '7rays) .) 3n?ury to a$?acent teet# 1) Alveolar process fractures )*a'+ tu!erosity) 7if tu!erosity f's co*pletely off9 t#en s*oot# s#arp e$ges of !one an$ suture soft tissue 7if f'ns !ut still intact9 t#en *anually reposition an$ sta!iliBe " sutures 7tu!erosity f' *ost often occurs on lone7stan$ing *olars or e'traction of last *olar in arc# 2) 6rau*a to inferior alveolar nerve )*an$+ &r$ *olars)

4) E'cessive !lee$ing a) in?ury to 3A artery !) arteriolar !lee$ fro* elevating flap c) pt%s #e*ostasis )"arfarin9 #e*op#ilia9 von Cille!ran$%s9 c#ronic liver $eficiency) 15) 3nfections )rare) 11) >ry soc0et )localiBe$ alveolar osteitis) 7occurs in &D of *an$+ &r$ *olar e'tractions 12) Air e*p#yse*a )fro* nonsurgical #an$pieces) Dry Soc%et 7cause$ !y increase$ fi!rinolytic activity9 causing loss of !loo$ clot in e'traction site 7s*o0ing an$ oral contraceptives #ave !een in$icate$9 as "ell as rinsing9 #ot li8ui$s 7*ost co**on in *an$i!ular *olars )*ost co**on co*plication seen after *an$+ *olar e'traction) 7signs: "orsening t#ro!!ing pain9 ra$iating pain9 !a$ o$or an$ taste9 poor #ealing e'traction site 7treat*ent: irrigation " saline9 se$ative $ressing )eugenol) c#ange$ every 2 $ays until asy*pto*atic9 an$ analgesics )no anti!iotics nee$e$) Extraction Ti s 7se8uence of e'traction s#oul$ !e *a'illary !efore *an$i!ular an$ posterior to anterior 7first force applie$ s#oul$ !e apical 7<7L forces are less effective in *an$+ posterior teet# $ue to $ense !one 7nor*al saline s#oul$ !e use$ for irrigation ! c it is isotonic 7$istille$ "ater is #ypotonic an$ can cause cell lysis &l'eolo lasty 7in$icate$ in any area t#at *ay cause $ifficulty in $enture construction Tori Remo'al 7only nee$ to !e re*ove$ for $enture fa!rication 7palatal tori re*oval: 1) *a0e stent pre7op 2) $ou!le7Y incision *a$e over *i$line of torus &) osteoto*e use$ to re*ove in s*all portions 7s#oul$ not re*ove en *asse ! c can enter into nose !y re*oving palatine !one () large !ur use$ to s*oot# area -) close "oun$ " #oriBontal *attress suture an$ place stent to prevent #e*ato*a $andi(ular Ridge Surgery for Com lete Dentures 7*ay nee$ to e'cise la!ial lingual frenu*9 *ylo#yoi$ ri$ge9 or e'ostoses 7$o not re*ove genial tu!ercles9 even if large9 ! c t#ey are attac#*ent for supra#yoi$ *uscles 7tongue "oul$ t#en !e flacci$ Soft Tissue Surgery 7soft tissue *ay nee$ to !e re*ove$ re*o$ele$ for $entures 1) ,an$+ retro*olar pa$ 2) ,a'+ tu!erosity &) E'cessive alveolar ri$ge tissue () 3nfla**atory fi!rous #yperplasia -) La!ial lingual frenu*

Princi les of Suturing 1) ;ee$le s#oul$ !e perpen$icular "#en entering tissue 2) Sutures s#oul$ !e place$ at e8ual $istance fro* "oun$ *argin )27&**) an$ at e8ual $ept#s &) Sutures s#oul$ !e place$ fro* *o!ile to non*o!ile tissue () Sutures s#oul$ !e place$ fro* t#in tissue to t#ic0 tissue -) Sutures s#oul$ not !e overtig#tene$ or close$ un$er tension .) Sutures s#oul$ !e 27&** apart 1) Suture 0not s#oul$ !e on t#e si$e of t#e "oun$ 7suturing usually not necessary on single7toot# e'traction unless severe !lee$ing or gingiva torn 7if !lee$ing persists for long ti*e9 #ave t#e* !ite on tea !ag ! c tannic acid pro*otes #e*ostasis Sutures 7as suture $ia*eter $ecreases9 strengt# $ecreases 7siBe 5 suture is average siBe 7a$$ing 5%s *eans t#ey are getting s*aller )(75 s*aller t#an &75) 7assigning positive nu*!ers *eans suture siBe increases )29 &9 -9 etc) 7s*allest $ia*eter suture t#at is sufficient to 0eep "oun$ close$ s#oul$ !e use$ 7&75 an$ (75 *ost co**on in $ental surgery 7can !e resor!a!le or nonresor!a!le 1) resor!a!le: gut9 polyglactin )vicryl)9 polyglycolic aci$ )$e'on)9 poly$i'anone 7plain gut *a$e for* s#eep intestine an$ rapi$ly $igeste$ 7c#ro*ic gut is c#ro*itiBe$ to !e *ore resistant to proteolytic enBy*es 2) nonresor!a!le: nylon9 sil09 polypropylene 7*ust !e re*ove$ in -71 $ays Interru ted 's Continuous Suture Techniques 1) 3nterrupte$: eac# suture is in$epen$ent 7offers strengt# an$ fle'i!ility in place*ent 7if one suture co*es loose9 integrity of re*aining sutures not co*pro*ise$ 7$isa$vantage: re8uires *ore ti*e 2) /ontinuous: *any sutures place$ t#at are connecte$ 7ease an$ spee$ of place*ent 7$istri!utes tension over "#ole suture line 7gives *ore "atertig#t closure t#an interrupte$ pattern Dead S ace 7any area t#at re*ains $evoi$ of tissue after closure of "oun$ 7create$ !y re*oving tissues in $ept#s of "oun$ or not reappro'i*ating tissue planes $uring closure 7$ea$ space usually fills in " !loo$ to for* #e*ato*a " #ig# potential for inf'n 7can eli*inate $ea$ space !y: 1) closing "oun$ in layers 2) apply pressure $ressings &) use $rains () place pac0ing into voi$ until !lee$ing stops Wound )ealing 1) Pri*ary intention: occurs in closely appro'i*ate$ "oun$ e$ges 7lo"er ris0 of inf'n an$ *ini*al scar for*ation 2) Secon$ary intention: occurs "#en large gap !t" incision e$ges 7re8uires larger a*t of epit#elial *igration9 collagen $eposition9 contraction9 an$ re*o$eling 7slo"er #ealing an$ *ore scar for*ation )granulation tissue) 7granulation tissue is "ea0er t#an original tissue 7factors t#at i*pair "oun$ #ealing: foreign *aterial9 necrotic tissue9 isc#e*ia9 tension9 syste*ic con$itions

Stages of Wound )ealing 1) 3nfla**atory stage: fro* ti*e of in?ury to 27- $ays 7#e*ostasis )vasoconstriction9 clot for*ation) an$ infla**ation )vaso$ilation9 p#agocytosis) 7neutrop#ils an$ ly*p#ocytes pre$o*inate 2) Proliferative stage: 2 $ays to & "ee0s 7epit#elialiBation9 angiogenesis9 granulation tissue for*ation9 an$ collagen $eposition 7fi!ro!lasts pre$o*inate &) Re*o$eling ,aturation stage: & "ee0s to 2 years 7collagen fi!ers increase tensile strengt# an$ contraction occurs Stages of )emostasis 1) =ascular p#ase: vasoconstriction 2) Platelet p#ase )Pri*ary #e*ostasis): platelet an$ collagen interaction lea$ing to platelet plug &) /oagulation p#ase )Secon$ary #e*ostasis): casca$e of coagulation factors () Repair process: gro"t# of fi!ro!lasts an$ s*oot# *uscle9 fi!rinolysis of clot )o! to &chie'e )emostasis 1) Pressure 2) Sutures &) Electrocautery () 6#ro*!in -) /ellulose s#eet )Surgicel) .) Gelatin sponge )Gelfoa*) 1) <one "a' )Parafin <ees"a') 2) 6ran'ena*ic aci$ 4) ,icrofi!rillar collagen

Dental Im lants 7factors t#at nee$ to !e consi$ere$: 1) Pri*ary sta!ility 2) A*ount of !one &) Anato*ic structures )sinus9 ot#er teet#9 3A nerve) 7loss of teet# for e'ten$e$ ti*e can lea$ to ri$ge resorption )esp+ *an$+) an$ ri$ge aug*entation *ay !e nee$e$ )!one grafting) 7co**on sites for autogenous !one grafts inclu$e: 1) iliac crest &) anterior corte' of c#in )s*all areas of !one) 2) ri! () lateral corte' of ra*us e'ternal o!li8ue ri$ge 7allogenic grafting also possi!le 7PA; an$ /6 scan s#oul$ !e use$ in i*plant t't planning "*ost popular type of i*plants use$ are root"form im lants *one &ugmentation Surgery 1) ,a'+ sinus grafts to aug*ent *a'+ alveolar ri$ge 2) <one grafts a) Autograft: transplante$ fro* one region to anot#er in sa*e person 7gol$ stan$ar$ for !one regenerative properties !) Allograft: 6ransplante$ fro* one in$ivi$ual to genetically non7i$entical person on sa*e species 7freeBe7$rie$ !one is *ost co**on allogenic graft c) Eenograft: transplante$ fro* one species to a $ifft species 7s*o0ers9 alco#olics9 uncontrolle$ $ia!etes9 or uncontrolle$ syste*ic $' are poor can$i$ates for !one grafting $) 3sograft: transplante$ fro* in$ivi$ual of sa*e species "#o is genetically relate$ to recipient e) Alloplastic graft: inert9 *an7*a$e synt#etic *aterial &) Gui$e$ 6issue Regeneration: *e*!ranes use$ to #in$er *igration of fi!rous /6 "#ile supporting gro"t# of !one () Alveolar $istraction osteogenesis: #as goal of lengt#ening *an$i!le 15712** 7!one frag*ents *ove$ p#ysiologically an$ ne" !one for*s in $istraction Bone 75+-71** incre*ents of *ove*ent per $ay " 1** *ove*ent not to !e e'cee$e$ in 2( #rs -) ,an$i!le aug*entation: aug*entation of atrop#ic *an$+ in$icate$ in pt " less t#an 2** !one #eig#t Ty es of Im lant Integration

1) Osseointegration: $irect an$ f'nal connection !t" living !one an$ i*plant surface 7*ost pre$icta!le long7ter* sta!ility 2) Ai!ro7osseous integration: /67encapsulate$ i*plant "it#in !one 7-5D success rate over 15 yrs &) <iointegration: ac#ieve$ via !ioactive *aterials )#y$ro'yapatite or !ioglass) 7$evelop !one faster t#an noncoate$ i*plants9 !ut little $ifference seen after one year +sseointegration 7$irect a$aptation of !one to $ental i*plant 7$efine$ #istologically as !eing evi$ent at lig#t *icroscope level 7i*plant success criteria $efine$ as: 1) i*plant i**o!ile clinically 2) no peri7i*plant ra$iolucency present &) *ean vertical !one loss less t#an 5+2** annually () no pain or inf'n -) i*plant place*ent $oesn%t in#i!it place*ent of cro"n prost#esis Contraindications to Im lant Placement 1) Uncontrolle$ $ia!etes () <isp#osp#onate t#erapy 2) 3**unoco*pro*ise$ -) <ru'is* &) Anato*ic consi$erations .) 6o!acco use )relative contrain$ication) 7also contrain$icate$ to place i*plants i**e$iately after e'traction toot# " active inf'n )"ait 2 "ee0s) &natomic #imitations to Im lant Placement 1) <uccal plate )5+-**) .) 3nteri*plant $istance )&**) 2) Lingual plate )1**) 1) 3A canal )2**) &) ,a'+ sinus )1**) 2) ,ental nerve )-**) () ;asal cavity )1**) 4) 3nferior !or$er of *an$i!le )1**) -) 3ncisive canal )avoi$ *i$line *a'+) 15) A$?acent toot# )5+-**) 7nee$ 15** of !one #eig#t to place i*plant 7i*plants place$ in anterior *a'illa #ave #ig#est failure rate Stages of Im lant Placement 1) 3*plant place*ent 7can use surgical stent to ac#ieve proper angulation an$ parallelis* 7cooling saline spray use$ $uring !one prep an$ i*plant place*ent to 0eep !one te*p+ un$er (1 $egrees / )11. A) 2) :ealing a!ut*ent place*ent &) Prost#etic restoration of i*plant Im lants Restoring Edentulous $axilla 7at least (72 i*plants place$ at least 15** $ept# to ac#ieve cross7arc# sta!iliBation of prost#esis Im lants Restoring Edentulous $andi(le 1) 6issue7!orn prost#esis: place$ over 27( i*plants 2) 3*plant7!orn prost#esis: place$ over - i*plants9 all place$ in anterior *an$i!le anterior to *ental fora*en

Part 2: 6rau*a Surgery Tooth Fractures 1) /ro"n craBe crac0 )infraction): no loss of toot# structure 2) :oriBontal or vertical cro"n fracture: can !e confine$ to ena*el9 or inclu$e $entin an$ or pulp &) /ro"n7root fracture: *ay or *ay not involve pulp a) ,ore t#an 1 & root involve$: e'tract !) Less t#an 1 & root involve$: R/6 c) Pri*ary teet#: e'tract () :oriBontal root fracture: locate$ in apical9 *i$$le9 or cervical coronal t#ir$ a) /oronal: re*ove seg*ent an$ perfor* R/6 !) Apical *i$$le: rigi$ splint for 27& *ont#s -) /oncussion: in?ury to toot#7supporting structure causing sensitivity to percussion !ut no *o!ility $isplace*ent 7no t't nee$e$ .) Su!lu'ation: in?ury to toot# supporting structures resulting in *o!ility !ut no $isplace*ent 7splint for 1715 $ays 1) 3ntrusion: $isplace*ent of toot# into soc0et 7often assoc+ " co*pression fracture of soc0et 7splint for 1( $aysF *ay nee$ to a"ait re7eruption or re8uire ort#o$ontic e'trusion 7no t't for intru$e$ pri*ary teet#9 ?ust let t#e* re7erupt 2) E'trusion: partial $isplace*ent of toot# out of soc0et 7splint for 1( $ays 4) La!ial or lingual $isplace*ent: alveolar "all fractures pro!a!le 15) Lateral $isplace*ent: $isplace*ent of toot# in *esial or $istal $irection 7alveolar "all fractures pro!a!le 11) Avulsion: co*plete $isplace*ent of toot# fro* its soc0et 7*ay #ave alveolar "all fracture 7replant an$ splint 1715 $ays 7$o not replant pri*ary teet# 12) Alveolar process fracture 7re$uce $entoalveolar seg*ent an$ rigi$ splint )arc# !ar) for (7. "ee0s Facial Fractures 7facial fractures s#oul$ al"ays !e consi$ere$ after car acci$ents9 fig#ts9 falls9 or sports acci$ents 7signs of facial fracture inclu$e: 1) pain -) a!nor*al *o!ility of !one 4) *alocclusion 2) contour $efor*ity .) nu*!ness )/; =7&) 15) step $efect &) ecc#y*osis 1) crepitation 11) *o!ility of *an$i!le seg*ents () laceration 2) #e*ato*a ecc#y*osis of AO, 7"#en t#ere is lip laceration " fracture$ toot#9 al"ays ta0e soft tissue ra$iograp# to $etect any !ro0en frag*ents of toot# *aterial 7t't goals of *a'illofacial fractures: control #e*orr#age9 restore occlusion9 re$uction an$ sta!iliBation of fracture$ seg*ents 7fat e*!olis* is *ost often a se8uelae of fractures 7#ig#est inci$ence of fractures occurs in *ales !t" 1-72( yrs ol$ fro* trau*a ,ygomatic &rch Fractures 7!est visualiBe$ !y su(mental 'ertex 'ie! 7co*plications: parest#esia )*ost co**on) sinus #e*ato*a9 i*paire$ ocular *uscles

$andi(le Fractures 7can al*ost al"ays !e seen on PA; ra$iograp#9 !ut s#oul$ !e visualiBe$ in at least t"o ra$iograp#s 7PA;9 6o"nes9 P7A s0ull9 lateral o!li8ue 7*alocclusion is *ost pat#ogno*ic sign of *an$+ f' 7*an$i!le is 2n$ *ost co**on fracture$ facial !one an$ -5D are *ultiple fractures 7*ost co**on sites for *an$i!le fractures: 1) /on$yle: 24D -) Alveolar process: &D 2) Angle: 2-D .) Ra*us: 2D &) Sy*p#ysis: 22D 1) /oronoi$: 1 () <o$y: 1.D 7fracture of con$yle "ill result in $eviation on opening to fracture$ si$e fro* trau*a to ipsilateral lateral pterygoi$ *uscle 7fractures can !e classifie$ as: 1) Si*ple )close$): no co**unication " e'ternal environ*ent 2) /o*poun$ )open9 co*ple'): co**unication " e'ternal environ*ent )s0in9 *ucosa9 or P>L) 73nfection co**on &) /o**inute$: fracture$ in *ultiple pieces () Greenstic0: one si$e of !one is !ro0en an$ ot#er is !ent 7*ost often seen in c#il$ren ! c !one *ore elastic -) Pat#ologic: occurre$ at "ea0ene$ site $ue to pre7e'isting $isease .) Aavora!le: not $isplace$ !y forces of *uscles of *astication 1) Unfavora!le: $isplace$ !y forces of *uscles of *astication 7line of fracture $eter*ines "#et#er *uscles "ill !e a!le to $isplace fracture$ seg*ents 7!ilateral *an$i!le fractures *ay result in posterior $isplace*ent of tongue causing air"ay o!struction 7conte*porary t't for *an$+ f's t#at are $isplace$ an$ *o!ile is "it# open re$uction an$ internal fi'ation " titaniu* plates an$ scre"s 7ot#er *et#o$s of repair inclu$e lingual splinting )pe$o pts) an$ inter*a'illary fi'ation )"ire ?a"s close$) 7prolonge$ i**o!iliBation of con$ylar f's "ill lea$ to an0ylosis of 6,G so con$ylar f's s#oul$ only !e i**o!iliBe$ for 2 "ee0s + en 's Closed Reduction for $andi(ular Fractures 1) Open re$uction: involves $irect e'posure an$ re$uction of f' t#oug# surgical incision 2) /lose$ re$uction: e'ternal fi'ation $evices an$ inter*a'illary fi'ation $idface Fractures 7*i$face f's !est evaluate$ " /6 scans of face 7!ot# a'ial an$ coronal orientations nee$e$ to fully evaluate fractures 7can involve *a'illa9 Bygo*a9 nose9 an$ or!its 7or!ital floor fracture is ter*e$ H!lo"out fractureI 7zygomaticomaxillary complex (tripod) fractures are *ost co**on *i$face f' )(5D) 7*a'illary fractures classifie$ as: 1) LeAorte 3 )transverse *a'illary): separation of *a'illa only "it# intact nasofrontal co*ple' 7signs: *alocclusion )o en (ite)9 !uccal vesti!ule ecc#y*osis )-uerin.s sign)9 epista'is 2) LeAorte 33 )pyra*i$al): separation of *a'illa an$ nasal co*ple' fro* cranial !ase )*o!ile nasofrontal co*ple') 7signs: *alocclusion )open !ite)9 periori!tal e$e*a9 su!con?unctival #e*orr#age9 parest#esia of infraor!ital nerve &) LeAorte 333 )craniofacial $ys?'n): co*plete separation of *i$face at level of naso7or!ital7 et#*oi$ co*ple' )*o!ile nasofrontal an$ *alar co*ple'es) 7*a?or sign is r#inorr#ea fro* /SA lea0ing into nasal cavity 7also #ave restricte$ *an$+ *ove*ent

() Jygo*atico*a'illary co*ple' fracture )J,/): c#ee0 !one f' " flattening of *alar process 7Bygo*atic arc# f' #as HCI $efor*ity on su!*ental verte' ra$iograp# an$ /6 scan 7*a'illa9 or!it9 an$ Bygo*atic f's re8uire rigi$ internal fi'ation 7isolate$ Bygo*atic f's can often !e re$uce$ " *inor surgery an$ " o use of plates an$ scre"s 7Gillies approac#: long elevator inserte$ t#roug# superficial te*poral fascia to pop Bygo*atic arc# !ac0 into position 7si*ple nasal fractures are repaire$ " internal an$ e'ternal splints 7nasal !one fracture is *ost co**on facial fracture *one )ealing 1) Pri*ary !one #ealing: $irect atte*pt !y corte' to re7esta!lis# itself 2) Secon$ary !one #ealing: involves classical stages of f' #ealing 7p#ases of !one #ealing: 1) :e*orr#age: !loo$ clot organiBation an$ proliferation of vessels occurs in first 15 $ays 2) /allus for*ation: pri*ary callus for*e$ in 15725 $ays an$ secon$ary callus for*s in 257.5 $ays &) A'nal reconstruction: *ec#anical forces cause :aversian syste*s to line up accor$ing to stress lines 7e'cess !one is re*ove$ an$ s#ape of !one *ol$e$ 7ta0es 27& yrs to co*pletely refor* f' Ina ro riate *one )ealing 1) >elaye$ union: satisfactory #ealing t#at re8uires greater t#an nor*al . "0 perio$ 2) ;on7union: failure of f' seg*ents to unite properly &) ,al7union: $elaye$ or co*plete union in i*proper position Reasons for Fractures /ot )ealing 1) 3sc#e*ia 2) E'cessive *o!ility &) 3nterposition of soft tissue () 3nfection Part &: Ort#ognat#ic Surgery E'aluating /eed for +rthognathic Surgery 7pts evaluate$ accor$ing to nor*al facial proportions 7vertically9 face is $ivi$e$ into e8ual t#ir$s 7#oriBontally9 face is $ivi$e$ into e8ual fift#s &ngle Classifications of +cclusion 1) Angle class 3: nor*al $ental occlusion " straig#t )ort#ognat#ic) profile 2) Angle class 33: *an$+ 1st *olars an$ canines are in posterior position relative to *a'+ counterparts 7face appears posteriorly convergent )retrognat#ic) &) Angle class 333: *an$+ 1st *olars an$ canines are in anterior position relative to *a'+ counterparts 7face appears anteriorly convergent )prognat#ic) Imaging for +rthognathic Surgery 7lateral cep#s are *ain i*aging use$9 alt#oug# PA;s9 A7P cep#s9 an$ PAs are ta0en as nee$e$ 7cep#alo*etric analysis #elps $eter*ine "#ic# ?a" is involve$ pri*arily in $efor*ity9 $irection of gro"t# of ?a"s9 an$ *ost i$eal proce$ure for pt

Diagnoses of Dentofacial Deformities 1) ,a'+ #yper #ypoplasia 2) ,an$+ #yper #ypoplasia &) Anterior open !ite )apertognat#ic) () =ertical *a'+ e'cess )*a'+ too long " gu**y s*ile) -) :oriBontal transverse $iscrepancy )pt #as posterior cross!ite) .) ,acrogenia )c#in too !ig) or *icrogenia )c#in too s*all) 1) /ant )vertical asy**etry) $axillary Surgery 7referre$ to LeAorte 3 osteoto*ies 7*a'illa can !e *ove$ for"ar$ an$ $o"n *ore easily t#an up or !ac0 7*a'illa can also !e sectione$ into t"o or t#ree seg*ents to !etter position t#e occlusion $andi(ular Surgery 7*ost often $one using one of t"o osteoto*ies: 1) Sagittal split osteoto*y: ra*us is $ivi$e$ !y #oriBontal osteoto*y on *e$ial aspect an$ vertical osteoto*y on lateral aspect 7lateral an$ *e$ial aspects t#en separate$ an$ *an$+ a$vance$ or set !ac0 2) =ertical ra*us osteoto*y: ra*us cut vertically an$ *an$+ positione$ for"ar$ or !ac0 7*an$i!le can !e *ove$ anteriorly to correct retrognat#ia )class 33) or posteriorly to correct prognat#ia )class 333) 7c#in can !e *ove$ using a genial osteoto*y )genioplasty) to correct *acrogenia or *icrogenia Distraction +steogenesis 7involves cutting an osteoto*y to separate seg*ents of !one an$ application of an appliance t#at "ill facilitate t#e gra$ual an$ incre*ental separation of !one seg*ents "#ic# "ill fill in "it# ne" !one Cleft #i and Palate 7cleft L3P *ore co**on in *ales 7/L is $efect in fusion of lateral an$ *e$ial nasal processes 7cleft PALA6E *ore co**on in fe*ales 7/P is lac0 of fusion !t" palatal s#elves 7*ost co**only foun$ on Asians an$ least co**on in AA 7/L P surgery follo"s rule of 15s: surgery perfor*e$ "#en c#il$ is at least 15 "ee0s ol$9 "eig#s at least 15 l!s9 an$ #as at least 15 g $L :! Part (: Aacial Pain an$ ;europat#ology Physiology of Pain 1) 6rans$uction: activation of A7$elta an$ /7fi!ers to spinal cor$ or !rain ste* 2) 6rans*ission: pain info in /;S is sent to t#ala*us an$ corte' for processing of sensory e*otional aspects &) ,o$ulation: li*its rostral flo" of pain info fro* spinal cor$ an$ trige*inal nucleus to #ig#er cortical centers 7acute pain lasts & *ont#s or less 7c#ronic pain is pain lasting longer t#an (7. *ont#s Classification of +rofacial Pain 1) So*atic pain: increase$ sti*ulus lea$s to increase$ pain a) *usculos0eletal pain )6,G9 perio9 *uscular) !) visceral )salivary glan$9 pulp) 2) ;europat#ic pain: pain in$epen$ent of sti*ulus activity 7$a*age to pain pat#"ays )trige*inal neuralgia9 trau*a9 stro0e) &) Psyc#ogenic pain: cause$ !y intrapsyc#ic $istur!ance 7conversion r'n9 psyc#otic $elusion9 *alingering () Atypical pain: facial pain of un0no"n cause

Trigeminal /euralgia 0Tic Douloureaux1 7a trigger point e'ists "#ere pain typically presents as electrical9 s#arp9 s#ooting sensation 7triggere$ !y "in$9 tactile9 or t#er*al sti*ulation 7pain is episo$ic )secon$s to *inutes) follo"e$ !y refractory perio$ 7usually unilateral 7no *otor or sensory $eficits present 7treat*ent: 1) anticonvulsant $rugs: ga!apentin9 car!a*aBepine 2) surgically: *icrovascular $eco*pression )Ganetta proce$ure)9 ga**a 0nife ra$iosurgery &) /onservative: nig#t guar$9 soft $iet9 *otion e'ercises9 *oist #eat9 *assage9 ;SA3>s &ty ical +dontalgia 0+dontalgia Secondary to Deafferentation1 7occurs as result of trau*a or surgery )R/6 or e'traction) 7t#ese result in $a*age to afferent pain trans*ission syste* 7propose$ *ec#anis*s: 1) perip#eral #yperactivity at surgical site 2) /;S #yperactivity secon$ary to c#anges in 2n$7or$er nerve in trige*inal nucleus Posther etic /euralgia 7se8uelae of #erpes Boster inf'n 7pain is !urning9 ac#ing9 or electric s#oc07li0e 7treat*ent: 1) anticonvulsants 2) anti$epressants &) sy*pat#etic !loc0s 7Ra*say7:unt syn$ro*e: #erpes Boster inf'n of sensory an$ *otor !ranc#es of /; =33 an$ =3339 resulting in facial paralysis9 vertigo9 $eafness9 an$ cutaneous eruption of e'ternal au$itory canal /euromas 7can occur after a nerve in?ury 7pro'i*al section of transecte$ nerve for*s sprouts fille$ " Sc#"ann cells 7!eco*es very sensitive to sti*uli an$ can cause c#ronic neuropat#ic pain *urning $outh Syndrome 7pts co*plain of pain9 $ryness9 !urning of *out# an$ tongue9 an$ altere$ taste 7*ost co**on in post*enopausal fe*ales 7t#oug#t to !e secon$ary to $efect in pain *o$ulation 7sy*pto*s of -5D of pts resolve " o t't in 27yr perio$ 7#or*one t#erapy9 anticonvulsants9 an$ anti$epressants ;O6 useful Chronic )eadaches 1) ,igraine a) Onset: acute !) Location: unilateral c) Sy*pto*s: nausea9 vo*iting9 p#otop#o!ia9 p#onop#o!ia $) Pain: t#ro!!ing e) >uration: prolonge$ f) >iagnostic test: c#ec0 for #' of sy*pto*s g) Prior #' of #ea$ac#es: yes 2) /luster a) Onset: acute !) Location: unilateral c) Sy*pto*s: r#inorr#ea9 lacri*ation of ipsilateral si$e $) Pain: s#arp9 sta!!ing e) >uration: &5 *ins to 2 #rs f) >iagnostic test: #istory of sy*pto*s g) Prior #' of #ea$ac#es yes

&) 6ension a) Onset: c#ronic !) Location: glo!al an$ unilateral c) Sy*pto*s: *ultiso*atic co*plaints $) Pain: ac#ing e) >uration: $aily f) >iagnostic test: none g) Prior #' of #ea$ac#es: yes () 6e*poral Arteritis a) Onset: acute or c#ronic !) Location: localiBe$ c) Sy*pto*s: "eig#t loss9 poly*yalgia9 fever9 vision pro!le*s9 ?a" clau$ication $) Pain: severe t#ro!!ing pain e) >uration: prolonge$ f) >iagnostic test: eryt#rocyte se$i*entation rate test )ESR)9 ten$er te*poral arteries g) Prior #' of #ea$ac#es: no 7can lea$ to !lin$ness on affecte$ si$e if not treate$ 8uic0ly /er'e In2uries 1) Anest#esia: loss of sensation 2) Parest#esia: a!nor*al sensation )!urning9 tingling9 etc+) &) :yperest#esia: increase in sensitivity () >ysest#esia: painful sensation to nor*al sti*ulus -) ;eurapra'ia: *il$ in?ury " no a'onal $a*age )spontaneous recovery "it#in ( "ee0s) .) A'onot*esis: a'onal $a*age !ut intact en$oneural an$ perineural s#eat# 7Callerian $egeneration occurs $istal to in?ury 7Potential for recovery in 17& *ont#s 1) ;eurot*esis: co*plete severance of a'on "it# a gap create$ 7no recovery e'pecte$ " o surgery Part -: 6e*poro*an$i!ular >isor$ers T$3 7classifie$ as gingly*oart#ro$ial ?oint " !ot# translational an$ rotational *ove*ent 7synovial ?oint 7anato*y: 1) 6,G: articulation !t" con$yle of *an$i!le an$ s8ua*ous portion of te*poral !one 2) Articular surface of te*poral !one: f'nal aspect of 6,G *a$e of $ense fi!rous /6 a) concave portion: articular fossa )glenoi$ *an$i!ular fossa) !) conve' portion: articular e*inence )tu!ercle) &) Articular $isc: $ense fi!rocartilagenous /6 )avascular an$ aneural) 7separates ?oint into inferior an$ superior ?oint spaces 7anterior posterior !an$s: t#ic0 )post+ !an$ t#ic0er an$ attac#e$ to retro$iscal tissues) 7inter*e$iate Bone: t#in )center of $isc) () Retro$iscal tissues: loose /6 t#at is vascular an$ innervate$ $yofascial Pain Disorder 7*ost co**on cause of *asticatory pain 6,G pain an$ co*pro*ise$ f'n 7$iffuse9 poorly localiBe$ pain in preauricular region9 often involving *uscles of *astication 7pain an$ ten$erness result fro* a!nor*al *uscle f'n an$ #yperactivity9 as "ell as spas* an$ $ysf'n 7parafunctional #a!it *ay !e etiologically relate$ )"ear facets often seen) 7if pt #as nocturnal parafunctional #a!it9 sy*pto*s are "orse in *orning 7can also !e result of $isc $isplace*ent $isor$ers an$ $egenerative art#ritis 7is stress7relate$ $isor$er )increase$ stress causes increase$ *uscle tension !ru'is*)

Disc Dis lacement Disorders 7assoc+ " synovial infla**ation 7$isc $isplace*ent is en$ result of infla**ation an$ c#ronic ?oint overloa$ing 7$isc *ost often $isplace$ in anteromedial direction 1) >isc $isplace*ent " re$uction: $isc returns to nor*al $isc7to7con$yle relations#ip 7nor*al interincisal opening " o $eviation can !e seen 7opening clic0 correspon$s to con$yle *oving over posterior portion of anteriorly $isplace$ $isc )re$uction) 7secon$ clic0 occurs "#en ?a" is close$ an$ $isc fails to *aintain its nor*al re$uce$ relations#ip to con$yle 2) >isc $isplace*ent " o re$uction: $isc $oesn%t return to nor*al position 7results in li*ite$ range of *otion an$ ipsilateral $eviation on opening 7no popping or clic0ing o!serve$ &) 3nternal $erange*ent: a!nor*al relations#ip of articular $isc to *an$+ con$yle an$ fossa 7posterior !an$ of $isc is anteriorly $isplace$ in front of con$yle as $isc translates anteriorly9 posterior !an$ re*ains in front of con$yle lea$ing to infla**ation of retro$iscal tissue causing $ecrease$ pro$uction of synovial flui$ an$ $ecrease$ *o!ility Degenerati'e 3oint Disease 0DID1 1) Osteoart#ritis 2) Syste*ic Art#ritic /on$itions a) Syste*ic lupus )SLE) !) R#eu*atoi$ art#ritis c) /rystalline art#ropat#ies )calciu* pyrop#osp#ate $e#y$rate )pseu$ogout)) &) 6,G an0ylosis 7*ost co**only cause$ !y trau*a Chronic Recurrent Dislocation 7occurs "#en *an$+ con$yle translates anterior to articular e*inence 7assoc+ " pain an$ *uscle spas* 7re8uires *ec#anical *anipulation to ac#ieve re$uction 7"#en pro!le* !eco*es c#ronic )*ultiple recurrences)9 <oto' t't to lateral pterygoi$ an$ surgery *ay !e nee$e$ &n%ylosis 7pt presents " severely restricte$ range of *otion an$ li*ite$ interincisal opening " pain 7!ony an0ylosis results in *ore li*itation of *otion t#an fi!rous an0ylosis 7trau*a is *ost co**on cause of an0ylosis9 !ut surgery9 ra$iation t#erapy9 an$ inf'n can also cause it /onsurgical Thera y for T$D 7t't o!?ectives are to $ecrease pain sy*pto*s an$ i*prove f'n 7in cases of an0ylosis an$ severe sy*pto*atic $egenerative ?oint $isor$ers9 surgery *ay !e rig#t c#oice 7nonsurgical t#erapy inclu$es: 1) Patient e$ucation counseling: prevent paraf'nal #a!its9 re$uce stress9 etc+ 2) P#ysical t#erapy: !iofee$!ac09 ultrasoun$9 electrical nerve sti*ulation9 *assage9 e'ercise 7results in increase$ circulation to affecte$ region &) P#ar*acot#erapeutic intervention: ;SA3>s9 steroi$s9 narcotics analgesics9 anti$epressants9 *uscle rela'ants () Occlusal consi$erations: e8uili!ration9 prost#etics9 ort#o9 ort#ognat#ic surgery9 an$ splints a) Autorepositioning splints: use$ for *uscle an$ ?oint pain "#en no specific anato*ic cause can !e foun$ 7"or0 !y re$ucing intra7articular pressure 7allo"s for no "or0ing or !alancing interferences " full arc# contact !) Anterior repositioning splint: protru$es *an$i!le into for"ar$ position9 recapturing nor*al $isc7to7con$yle relations#ip

Surgical Treatments for T$D 1) Art#rocentesis: !enefits pts " internal $erange*ent 7nee$les place$ into superior ?oint space an$ saline in?ecte$ to re$uce infla*e+ *e$iators 7t#oug#t to $isten$ ?oint capsule9 release a$#esions9 an$ re*ove c#e*ical *e$iators assoc+ " ?oint pat#ology 2) Art#roscopy: place*ent of t"o cannulas to allo" access for intracapsular instru*entation of superior ?oint space 7lysis of a$#esions9 steroi$ in?'n9 an$ *otoriBe$ s#aving of osteoart#ritic fi!rillation tissue &) >isc repositioning surgery )Open art#oplasty): $isc is *o!iliBe$ an$ posterior "e$ge *ay !e re*ove$ an$ $isc repositione$ into *ore $esira!le position 7use$ in pts " painful9 persistent clic0ing7popping an$ close$ loc0 () >isc repair re*oval )>iscecto*y): in$icate$ "#en $isc is severely $a*age$ 7if $isc is re*ove$9 it can !e replace$ " autogenous *aterials )te*poralis *uscle9 fat9 articular cartilage) or prost#etics -) /on$yloto*y: acco*plis#e$ !y perfor*ing an intraoral vertical ra*us osteoto*y 7allo"s soft tissues to passively reposition t#e con$yle an$ $isc into *ore f'nally neutral position .) 6otal ?oint replace*ent: in$icate$ in severely pat#ologic ?oints )r#eu*atoi$ art#ritis9 $eg+ Goint+ >'9 an0ylosis9 neoplasia) 7costoc#on$ral !one graft reconstruction is *ost co**on autogenous *aterial use$ 7totally prost#etic ?oints can also !e *a$e 7s#oul$ A=O3> occlusal a$?ust*ents9 prost#etic restorations9 ort#o t't9 an$ ort#ognat#ic surgery & roaches to Ex ose T$3 1) Pre7auricular incision: perpen$icular incision anterior to e'ternal ear 7is !est "ay to e'pose 6,G 2) Su!*an$i!ular approac# )Ris$on approac#): stan$ar$ approac# to ra*us an$ nec0 of con$yle 7not !est "ay to approac# ?oint space Part .: O$ontogenic 3nfections $icroorganisms Causing +dontogenic Infections 7poly*icro!ial infections 1) Anaero!ic )1-D) a) Gra* neg+ ro$s: *ost )<acteroi$es9 Auso!acteriu*) !) Gra* pos+ cocci )Strep) 2) Aero!ic )2-D) a) Gra* pos+ cocci )*ost) Strep9 Stap# Pathologic $echanism 7#ig#ly virulent Strep species initiate infectious process in $eep tissues 7cellulitis t#en occurs )aero!ic)9 follo"e$ !y proliferation of anaero!ic organis*s )for* a!scess) 7aero!ic organis*s consu*e t#e o'ygen9 *a0ing environ*ent *ore favora!le for anaero!es 7$isease progresses !y follo"ing pat# of least resistance9 often t#roug# !one corte' an$ inva$ing fascial space )*ost often enter vesti!ular space) 7can $rain spontaneously an$ result in asy*pto*atic9 c#ronic $raining fistula Fascial S ace Infections 1) =esti!ular -) Su!*an$i!ular 2) <uccal .) Su!*ental &) /anine 1) ,asticator )pterygo*an$+9 *asseteric9 superficial $eep te*poral) () Su!lingual 2) Lateral p#aryngeal 7t#ese are referre$ to as potential spaces9 ! c in #ealt#y state t#ere is no real spaceF a!scess for*ation causes cavities in t#ese fascial planes 7spaces are contiguous " eac# ot#er an$ as a!scess sprea$s9 *ore spaces can !eco*e involve$ 7canine an$ $eep te*poral space inf'ns can result in cavernous sinus t#ro*!osis via op#t#al*ic veins 7lateral p#aryngeal space inf'ns can sprea$ to *e$iastinu* 7!ot# s#oul$ !e consi$ere$ life7t#reatening e*ergencies

#ud!ig.s &ngina 7!ilateral inf'n of su!*an$i!ular9 su!lingual9 an$ su!*ental spaces 7can lea$ to !loc0age of air"ay Six Treatment Princi les for +dontogenic Infections 1) >eter*ine severity of inf'n 2) Evaluate state of pt%s #ost $efense *ec#anis*s &) >eter*ine "#et#er pt s#oul$ !e treate$ !y general $entist or specialist () 6reat inf'n surgically 7re*ove source of inf'n an$ $eco*press $rain purulence 7goal is to get a$e8uate $rainage so sprea$ of inf'n can !e !roug#t un$er control 7speci*en for culture an$ sensitivity s#oul$ !e o!taine$ -) Support pt *e$ically 7air"ay *anage*ent9 #y$ration9 electrolytes9 anti!iotics9 analgesics .) /#oose an$ prescri!e appropriate anti!iotics 7Pen =K is preferre$ $rug for o$ontogenic inf'ns 7if allergic9 t#en clin$a*ycin or clarit#ro*ycin are goo$ 7narro" spectru* agents are !etter t#an !oar$ spectru* for o$ontogenic inf'ns ! c alter nor*al flora less 7!acterici$al agents !etter t#an !acteriostatic Indications for &nti(iotic Use 1) Rapi$ly progressing s"elling () Aascial space involve*ent 2) >iffuse s"elling -) Severe pericoronitis &) /o*pro*ise$ #ost $efenses .) Osteo*yelitis 7pseu$o*e*!ranous colitis )/+ $ificile) can result fro* anti!iotic use of a*o'icillin9 clin$a*ycin9 an$ cep#alosporins 7treat " vanco*ycin or *etroni$aBole +steomyelitis 7infla**ation of *e$ullary portion of !one 7osteo*yelitis sprea$s via inf'n9 infla**ation9 an$ isc#e*ia 7*ost co**on initiating causes are o$ontogenic inf'ns an$ trau*a 7inf'n !egins in *e$ullary space of cancellous !one9 t#en sprea$s to cortical !one9 periosteu*9 an$ soft tissues 7occurs *ore often in i**unoco*pro*ise$ an$ in *an$i!le over *a'illa 7causative agents are si*ilar to o$ontogenic inf'ns )Strep9 anaero!ic cocci an$ gra*7 ro$s) 7treat*ent $one !y $e!ri$e*ent an$ anti!iotics /ecroti4ing Fasciitis 7rapi$ly progressing inf'n of s0in an$ fascia " #ig# *ortality rate )&57-5D) 7cause$ !y group7A strep or /+ perfringens 7treate$ " surgical $e!ri$e*ent an$ anti!iotics Ca'ernous Sinus Throm(osis 7retrogra$e inf'n fro* !ac0flo" of *aterial $raine$ fro* face 7/; 3339 3=9 =719 an$ =3 involve$ Sinusitis 1) Acute )less t#an 1 *ont#) 7S+ pneu*onia9 :+ influenBae9 ,+ catarr#alis 2) /#ronic )over & *ont#s) 7results fro* o!struction of sinus $rainage 7$ia!etics *ay $evelop *ucor*ycosis )fungal inf'n) &) 6't: a*o'icillin or aug*entin )a*o'icillinLclavulanate)9 anti#ista*ines9 or surgery to esta!lis# $rainage () /o*plications of sinusitis: or!ital cellulitis9 cavernous sinus t#ro*!osis9 *eningitis9 osteo*yelitis

&nimal *ite Infections 7cause$ !y Pasteurella *ultici$a 7t't " a*picillin or a*o'icillin Part 1: <iopsies *io sy Technique 7!loc0 anest#esia preferre$ ! c in?ection into lesion can $istort t#e arc#itecture an$ *a0e $iagnosis $ifficult 1) Suction: use lo" volu*e suction "rappe$ in gauBe so not to aspirate t#e speci*en 7#e*ostasis is i*pt so a #ig# volu*e suction isn%t nee$e$ 2) 3ncision: use s#arp scalpel to avoi$ e'cessive $a*age to tissue an$ ac#ieve clearly $efine$ *argins &) Laser: car!on $io'i$e laser in super7pulse$ *o$e is accepta!le if #e*ostasis concerns are significant 7a fine perip#eral Bone of necrosis $oes occur " laser () :an$ling tagging: if suspect *alignancy9 a tissue tag s#oul$ !e use$ to #elp i$entify orientation 7tissue s#oul$ !e place$ in 15D for*alin in volu*e 25' t#at of speci*en -) Recor$s: !iopsy $ata s#eet *ust !e fille$ out inclu$ing pt #' an$ clinical fin$ings +ral *rush Cytology 1) Uses: $etecting cancerous an$ precancerous lesions 2) ,et#o$: cytology !rus# place$ over lesion an$ rotate$ -715 ti*es to o!tain cells fro* all & epit#elial layers 7cells transferre$ to glass sli$e an$ fi'ative place$ an$ sent to la! 7one of & categories assigne$: a) ;egative: no evi$ence of atypical cells or carcino*a !) Positive: $efinitive evi$ence of atypical cells or carcino*a c) Atypical: a!nor*al epit#eliu* 7all positive an$ atypical fin$ing s#oul$ un$ergo $efinitive scalpel !iopsy &s iration *io sy 0Fine /eedle &s iration1 1) Uses: lo" *or!i$ity an$ #ig# $iagnostic accuracy for *ost lesions 7also use$ to $eter*ine if lesion is vascular or not !efore surgical e'ploration 2) ,et#o$: special syringe an$ nee$le use$ to collect cells fro* clinically or ra$iograp#ically i$entifie$ *ass Incisional *io sy 1) Uses: "#en lesion is large )M1c*)9 poly*orp#ic9 suspicious for *alignancy9 or in #ig# *or!i$ity area 2) ,et#o$: portion of lesion is incise$ an$ *ust !e o!taine$ in a representative area of t#e lesion9 avoi$ing areas of necrosis an$ in a$e8uate $ept# to *a0e $efinitive #istological $iagnosis Excisional *io sy 1) Uses: for s*aller lesions )N1c*) t#at appear !enign or on s*all vascular an$ pig*ente$ lesions 2) ,et#o$: entails re*oval of entire lesion an$ a peri*eter of surroun$ing uninvolve$ tissue )ard Tissue5Intraosseous *io sy Techniques 1) ,ucoperiosteal flaps are al"ays use$ for intraosseous lesions an$ s#oul$ !e full7t#ic0ness9 over soun$ !one9 an$ allo"ing (7-** *argins 2) All ra$iolucent lesions s#oul$ !e aspirate$ to *a0e sure t#ey are not vascular &) Osseous "in$o" create$ to re*ove lesion for !iopsy () After lesion is re*ove$9 1** of a$?acent osseous tissue s#oul$ !e curettage$ in all $irections )andling of Excised S ecimen 7s#oul$ i**e$iately !e place$ in 15D for*alin solution t#at is at least 25' volu*e of speci*en *io sying an Ulcer 7s#oul$ "ait 1( $ays )2 "0s) to !iopsy an oral ulcer9 ! c t#ey s#oul$ #eal "it#in 1( $ays

Part 2: Surgical ,anage*ent of /ysts an$ 6u*ors +'er'ie! 7goals of surgical *anage*ent are era$ication of pat#ology an$ est#etic functional re#a!ilitation 7cysts can !e classifie$ as fissural an$ o$ontogenic 7o$ontogenic 0eratocysts ten$ to act *ore aggressively an$ #ave #ig#er recurrence rates t#an fissural cysts an$ cysts of o$ontogenic infla**atory origin 7cysts of ?a" are treate$ " eit#er: 1) Enucleation &) Stage$ enucleation an$ *arsupialiBation 2) ,arsupialiBation () Enucleation an$ curettage Enucleation 1) >escription: s#elling out lesion " o rupture 2) 3n$ications: use$ "#en it can safely !e $one " o sacrificing a$?acent structures &) Pros: is a $efinitive t't an$ easier postop "oun$ care () /ons: *ay "ea0en ?a" an$ $a*age a$?acent structures $arsu iali4ation 1) >escription: surgical "in$o" *a$e9 follo"e$ !y $eco*pression an$ evacuation 2) 3n$ications: $one if enucleation "oul$ $a*age a$?acent structures or it "oul$ !e unsuccessful &) Pros: si*ple an$ *ay spare vital structures () /ons: $ifficult "oun$ care an$ so*e pat#ologic tissue *ay !e left Staged Enucleation and $arsu iali4ation 1) 3n$ications: $one if cyst is not totally o!literate$ after initial *arsupialiBation #eals Enucleation and Curettage 1) >escription: s#elling out lesion " o rupture9 follo"e$ !y 172** curettage of a$?acent !one 2) 3n$ications: OK/s or any cyst t#at recurs after enucleation &) /ons: *ay recur an$ *ore $estructive to a$?acent structures $alignant Tumors of 3a! 7*ost co**on are epi$er*oi$ carcino*as )S//) 7salivary glan$s9 !loo$ vessels9 ly*p#atics9 *uscle9 !one9 an$ ot#er /6 can give rise to pri*ary *alignancies of #ea$ an$ nec0 7cancer of !reast9 prostate9 lung9 0i$ney9 t#yroi$9 #e*atopoietic syste*9 an$ colon can *etastasiBe to #ea$ an$ nec0 7"#en a pri*ary cancer of #ea$ nec0 is $iagnose$9 clinical staging s#oul$ !e perfor*e$ prior to $efinitive t't 7can inclu$e /6 scans9 PE6 scan9 c#est '7rays9 an$ en$oscopy 7co*!o of surgery9 ra$iation9 an$ c#e*o are *o$alities use$ to treat pri*ary cancers of #ea$ nec0 Reconstruction 7opti*ally $one !efore perfor*ing any $efinitive t't 7can range fro* no reconstruction " "oun$ *anage*ent an$ secon$ary #ealing to co*ple' reconstruction " place*ent of en$osseous i*plants Sialolithiasis 7salivary glan$ stones 7*ost often affects su!*an$i!ular glan$ )2-D) 7causes pain an$ s"elling "#ic# "orsens "#en saliva flo" is sti*ulate$ 7glan$ can !eco*e infecte$9 causing purulence9 eryt#e*a9 AO, e$e*a9 an$ ly*p#a$enopat#y

Part 4: Local Anest#esia #ocal &nesthetics 7$rugs "#ic# reversi!ly !loc0s t#e con$uction of nerve i*pulses 7$ental concern is sensory nerve !loc09 !ut *otor nerves can !e !loc0e$ in #ig# conc+ 7local anest#etics !loc0 so$iu* c#annels 7all LAs are *a$e of a lipop#ilic aro*atic ring lin0e$ to a #y$rop#ilic a*ino group 7!on$ is eit#er an ester or a*i$e !on$ "#ic# $eter*ines class of LA Classes of #ocal &nesthetics 1) A*i$es: *eta!oliBe$ !y *icroso*al P7(-5 enBy*e in liver a) li$ocaine !) *epivicaine c) !upivicaine 7a*i$es #ave letter H3I follo"e$ !y7HcaineI in na*e 2) Esters: *eta!oliBe$ !y pseu$oc#olinesterase in plas*a a) novocaine !) procaine c) !enBocaine $) tetracaine 7esters are far *ore co**on to #ave allergic r'n Dosages for #ocal &nesthetics mg/carp max dose (mg/kg) max dose (mg) 2% lido (xylocaine) 36 4.5 300 2% lido w/ 1:100k 36 500 3% mepi!icaine (car"ocaine) 54 5.5 400 2% mepi!icaine w/1:20k 36 5.5 400 4% prilocaine (#i$anes$) 2 % 600 4% prilocaine w/ 1:200k 2 % 600 0.5% "&pi!icaine w/ 1:200k ('arcaine) ( 1.3 (0 1.5% e$idocaine w/ 1:200k ()&ranes$) 2 5.5 400 4% ar$icaine w/ 1:100k (*ep$ocaine) 6% 500 7*a' a*t of 2D li$o " 1:1550 epi to #ealt#y 1-5 l! *an is (11 *g )1& carps) 7eac# 1+2cc carp of 2D li$o " 1:1550 epi contains 25*g cc li$ocaine9 &. *g li$ocaine9 an$ 5+512 *g epi Clar%.s Rule for Pediatric #& Dosing 7*a' pe$o $ose@ )"eig#t of c#il$ in l! 1-5)')*a' a$ult $ose) 7conversion of l! to 0g is 2+2 l! 0g Contents of 6 Car ule of 78 #ido !5 696::% E i 1) &. *g li$o 2) 5+512 *g epi Differential /er'e *loc%ade 0Critical #ength Conce t1 7$iff+ nerve !loc0a$e is *a' $istance an action potential can H?u*pI $o"n a nerve 7in *yelinate$ nerve9 local anest#etic *ust !loc0 a *ini*u* successive nu*!er of no$es of Ranvier to !loc0 t#e action potential of nerve 7sensations $isappear an$ reappear in a $efinite or$er: 1) Pain )first to $isappear an$ last to reappear) 2) 6e*perature )col$9 t#en "ar*) &) 6ouc# () Pressure -) ,otor 7s*all9 un*yelinate$ nerve fi!ers )pain9 te*p9 autono*ics) *ore sensitive to LA t#an larger9 *yelinate$ fi!ers

$echanism of &ction of #ocal &nesthetics

7"#en in?ecte$ into tissue9 LA e'ists in !ot# ioniBe$ an$ non7ioniBe$ for*s 7non7ioniBe$ for* penetrates tissue rea$ily ! c lipop#ilic aro*atic ring passes t#roug# nerve s#eat# an$ *e*!rane 7re7e8uili!ration !t" ioniBe$ an$ non7ioniBe$ for*s occurs "it#in nerve cell 7ioniBe$ for* t#en in#i!its nerve *e*!rane%s ;aL c#annels9 preventing inflo" of ;aL to prevent for*ation of action potentials 7inf'n causes tissue to !eco*e aci$ic9 resulting in increase$ ioniBe$ for* of LA at e'pense of non7ioniBe$ for* 7t#is prevents passage of LA t#roug# nerve *e*!rane9 $ecreasing effectiveness 7LA can !e *i'e$ " so$iu* !icar!onate to al0aliniBe t#e solution to $ecrease pain upon infiltration an$ increase effectiveness 7LA "or0 !est at p: a!ove 1 ! c $rop in P: s#ifts LA to ioniBe$ for* Pharmaco%inetics of #ocal &nesthetics 7re$istri!ution of LA affecte$ !y: 1) $iffusion a"ay fro* site of action 2) vascularity of in?ection site )increase$ !loo$ flo" causes s#orter $uration of action) &) increase$ protein !in$ing increase$ lipi$ solu!ility )increase$ $uration of action) 7$uration of LA is $irectly proportional to protein !in$ing an$ lipi$ solu!ility 7t#e lo"er t#e pKa of LA9 t#e faster t#e onset Systemic Toxicities of #ocal &nesthetics 7LA to'icity $ue to elevate$ plas*a levels of LA $ue to intravascular in?'n or over$ose 7c#il$ren an$ el$erly are at *ost ris0 for LA to'icity 1) ,il$ to'icity: circu*oral nu*!ness9 tac#ycar$ia9 :6;9 tinnitus9 *etallic taste9 tal0ative9 appre#ension9 e'cita!ility9 slurre$ speec#9 $iBBiness9 $isoriente$ 2) ,o$+ to'icity: tre*or9 #allucination9 #ypotension9 !ra$ycar$ia9 $ecrease$ car$iac output &) Severe to'icity: seiBure9 car$iac an$ resp+ $epression9 co*a9 $eat# 7seiBures are *ost co**on si$e effect fro* syste*ic a!sorption of to'ic a*t of LA () Allergic Responses: ester LA #ave #ig# inci$ence )-D)9 a*i$e LA #ave lo" inci$ence )N1D) 7p-aminobenzoic acid (PABA) in esters in$uce allergic r'n 7if pt allergic to !ot# esters an$ a*i$es9 can give <ena$ryl )$ip#en#y$ra*ine) 7metabisulfate is an antio'i$ant "#ic# protects vasoconstrictor fro* o'i$ation an$ #as lo" allergenicity 7methylparaben is !acteriostatic preservative t#at can cause allergic r'n as "ell 7responsi!le for rare allergic r'n in a*i$e LA -) ,et#e*oglo!ine*ia: con$ition uni8ue to receiving $oses of prilocaine over .55*g 7*et#e*oglo!in can%t !in$ carry o'ygen 7signs: $ecrease$ pulse7o'9 cyanosis9 c#ocolate7colore$ !loo$ 7treate$ " *et#ylene !lue !y 3= Trismus 7cause$ !y 3A in?'n $irecte$ into *e$ial pterygoi$ *uscle 7causes spas* of *uscle 7*anage*ent: apply #ot9 *oist to"els to site for 25 *ins every #our9 analgesics9 an$ gra$ual opening closing of *out# ;asoconstrictors 7vasoconstrictors increase t#e $uration of LA action )pri*ary) 7$ecrease syste*ic to'icity !y $ecreasing rate of syste*ic a!sorption )secon$ary) 7re$uces !lee$ing !y $ecreasing !loo$ flo" into operative area )only infiltrations9 not nerve !loc0s) 7re$uce rate of vascular a!sorption !y causing vasoconstriction 7#elp *a0e anest#esia *ore profoun$ !y increasing conc+ of LA at nerve *e*!rane 7vasoconstrictors act at alp#a receptors to constrict arterioles Drug Interactions !5 ;asoconstrictors

1) Anti$epressants )tricyclic an$ polycyclic) 7increase$ sensitivity to Epi 2) ;onspecific !eta7!loc0ers )propranolol) 7en#ance perip#eral alp#a71 a$renergic effects )increase$ <P " o tac#ycar$ia) &) ,a' $oses a) #ealt#y pt: 255 ug Epi !) /ar$iovascular pt: (5 ug Epi Pregnancy and #ocal &nesthetics 1) /lass /: a) !upivicaine c) articaine !) *epivicaine $) Epi 2) /lass <: a) li$ocaine !) prilocaine c) eti$ocaine )no longer on *ar0et) Trigeminal /er'e 7/; = 7is !ot# sensory an$ *otor nerve 7originates in pons 7& !ranc#es: 1) Opt#al*ic nerve )=1): nasociliary9 supraor!ital9 lacri*al9 frontal9 supratroc#lear9 an$ infratroc#lear nerves 2) ,a'illary nerve )=2): Bygo*atic9 PSA9 ,SA9 ASA9 infraor!ital9 greater palatine9 an$ nasopalatine nerves &) ,an$i!ular nerve )=&): auriculote*poral9 lingual9 !uccal9 an$ 3A *ental nerves /eedle Dimensions 1) Lengt# a) S#ort nee$le: 25** !) Long nee$le: &2** 2) >ia*eter a) &5 gauge: 5+&** !) 21 gauge: 5+(** c) 2- gauge: 5+-** 7positive aspiration is $irectly correlate$ to nee$le gauge 7larger gauge nee$les $on%t $eflect as often 7larger gauge nee$les $on%t !rea0 as often )41D of nee$le !rea0s involve &5 gauge nee$les) 7pts can%t tell t#e $ifference !t" 2-9 219 an$ &5 gauge nee$les Posterior Su erior &l'eolar 0PS&1 *loc% 1) Area of anest#esia: *a'+ &r$ *olar to *a'+ 1st *olar 7$oesn%t anest#etiBe palatal tissue )possi!ly $oes for ,< of *a'+ 1st *olar) 2) 6ec#ni8ue: go in $istal to *alar process (- $egrees to *esio$istal plane an$ to !uccolingual plane 7insert nee$le 1-** in $ept# &nterior Su erior &l'eolar 0&S&1 *loc% 0Infraor(ital /er'e *loc%1 1) Area of anest#esia: *i$line of *a'illa to ,< of *a'+ 1st *olar 7affects ASA9 ,SA9 inferior palpe!ral9 lateral nasal9 an$ superior la!ial nerves 7$oesn%t anest#etiBe palatal tissue 2) 6ec#ni8ue: nee$le penetrates over *a'+ 1st P, 1-** $eep an$ lateral to !uccal vesti!ule 7nee$le touc#es !one as en$point an$ 1*L of anest#etic is in?ecte$ slo"ly 7pressure applie$ for 2 *inutes -reater Palatine *loc%

1) Area of anest#esia: fro* canine to posterior aspect of #ar$ palate9 as "ell as fro* gingival *argin to *i$line of palate 7greater palatine fora*en locate$ #alf"ay !t" gingival *argin an$ *i$line palate -** anterior to ?'n of #ar$ an$ soft palates 2) 6ec#ni8ue: initially use topical an$ pressure anest#esia )25 secon$s *ini*u*) an$ penetrate at location of greater palatine fora*en at $ept# of !one )O-**) /aso alatine *loc% 1) Area of anest#esia: palatal tissue fro* canine to canine )pre*a'illa area) 2) 6ec#ni8ue: topical an$ pressure anest#esia initially9 t#en insert nee$le tip (- $egrees to palatal soft tissue at ?'n of palate an$ incisive papilla at $ept# of !one $ental /er'e *loc% 0Incisi'e *loc%1 1) Area of anest#esia: soft tissue on !uccal fro* pre*olars to *i$line lip9 c#in9 periosteu*9 an$ !one 2) 6ec#ni8ue: insert nee$le in $ept# of !uccal vesti!ule opposite *an$+ P, at -** $ept# 7use P carpule $andi(ular *loc% 0I& *loc%1 1) Area of anest#esia: pulps an$ !uccal soft tissue of *an$+ teet# )e'cept area innervate$ !y !uccal nerve)9 lip9 c#in9 periosteu*9 an$ !one in area 2) 6ec#ni8ues a) 6ra$itional ):alstea$) *et#o$ 7penetrate 171+- c* a!ove an$ parallel to *an$i!ular occlusal plane9 approac#ing fro* contralateral pre*olars 7nee$le en$point s#oul$ !e -5D of *esio$istal lengt# of ra*us 7a$vance nee$le until #it !one9 "it#$ra" 1**9 aspirate9 an$ in?ect Q carp 7"it#$ra" nee$le 1571-**9 aspirate9 an$ in?ect rest to #it lingual nerve 7save tiny !it for long !uccal !loc0 if nee$e$ !) A0inosi 6ec#ni8ue 7anest#etiBes 3A9 lingual9 an$ !uccal nerves 7useful in uncooperative c#il$ren an$ pts " tris*us 7nee$le inserte$ parallel to *a'+ occlusal plane at level of *a'+ !uccal vesti!ule 7penetrate #alf $istance of ,> lengt# of ra*us )2-**) 7no !ony en$point )en$s ?ust superior to lingula) 7#u! of nee$le s#oul$ !e opposite *esial aspect of *a'+ 2n$ *olar c) Go"7Gates 6ec#ni8ue 7anest#etiBes 3A9 lingual9 long !uccal9 auriculote*poral9 an$ *ylo#yoi$ nerves 7#ave pt open as "i$e as possi!le to rotate an$ translate con$yle for"ar$ 7palpate con$yle an$ retract c#ee0 7!egin fro* contralateral canine an$ penetrate at >< cusp of *a' 2n$ *olar 7insert nee$le 2-7&5** until contact !one9 "it#$ra" slig#tly 7in?ect anest#etic9 "#ic# is not near nerve9 !ut aroun$ 1c* superior to it in superior aspect of pterygo*an$i!ular space Part 15: /onscious Se$ation &S& Physical Status Classifications 1) PS 3: nor*al9 #ealt#y pt 2) PS 33: *il$ syste*ic $isease &) PS 333: severe syste*ic $isease t#at is not incapacitating () PS 3=: severe syste*ic $isease t#at is constant t#reat to life -) PS =: *ori!un$ pt "#o "ill $ie " o operation .) PS =3: !rain7$ea$ pt "#ose organs are !eing re*ove$ for $onor purposes

-uedel.s Signs5Stages of &nesthesia

1) A*nesia an$ analgesia: preservation of protective refle'es 7stage en$s " loss of consciousness 7conscious se$ation falls un$er t#is stage 2) >eliriu* an$ e'cite*ent: involuntary *ove*ents9 o!tun$e$ refle'es9 irregular !reat#ing occurs 7stage en$s " onset of total anest#esia 7nausea an$ vo*iting co**on in t#is stage )*ay lea$ to aspiration of vo*it) &) Surgical anest#esia: can !e lig#t9 *e$iu* )i$eal for invasive surgery)9 an$ $eep 7s0eletal *uscles rela' an$ !reat#ing !eco*es regular () ,e$ullary paralysis pre*orte*: very $eep anest#esia " loss of car$iovascular f'n " i**inent $eat# stages 1 an$ 2 co*!ine$ are ter*e$ induction stage of anest#esia /eurole t &nesthesia 7co*!ine$ a$*inistration of: 1) ;euroleptic agent )>roperi$ol) 2) ;arcotic analgesic &) ;itrous o'i$e 7#as slo" in$uction of anest#esia9 !ut return to consciousness is 8uic0 after ;2O re*ove$ Inhalation &nesthetics 7in#alation anest#esia upta0e $epen$ent on: 1) Solu!ility a) <loo$ solu!ility: $ecrease$ !loo$ solu!ility@rapi$ in$uction an$ recovery ti*e !) Lipi$ solu!ility: increase$ lipi$ solu!ility@increase$ potency 2) Alveolar !loo$ flo" &) >ifference in partial pressure !t" alveolar gas an$ venous !loo$ $alignant )y erthermia 7in#erite$ con$ition t#at *ost often occurs "#en e'pose$ to in#alation anest#etics 7in#alation agents cause increase$ *uscle *eta!olis* "#ic# can lea$ to $eat# 7treate$ " 155D o'ygen9 cooling proce$ures9 an$ a$*inistration of dantrolene $inimum &l'eolar Concentration 7a*t of $rug necessary to prevent *ove*ent in -5D of pts su!?ecte$ to stan$ar$iBe$ sti*ulus at 1 at* *lood"-as Partition Coefficient 7$iff !t" partial pressures of gas an$ !loo$ in$icate$ #o" 8uic0ly agent crosses pul*onary *e*!rane into !loo$strea* 7#ig#er value9 #ig#er t#e solu!ility Pro erties of Inhalation &nesthetics 1) Gas p#ase: nitrous o'i$e 7;O is least potent of in#alation anest#etics 2) =olatile li8ui$ p#ase: isoflurane9 #alot#ane9 $esflurane9 sevoflurane9 enflurane /itrous +xide 7colorless9 nonirritating gas " *il$ o$or an$ taste 7is potent analgesic9 !ut "ea0 general anest#etic 7"or0s on /;S )reticular activating syste* an$ li*!ic syste*) 7first sy*pto* is tingling of #an$s 7re8uires *ini*u* of &5D o'ygen $elivery 7no !iotransfor*ation 7e'crete$ unc#ange$ !y lungs 7is in#alation anest#etic " fastest onset of action 7si$e effects: #ea$ac#e9 nausea vo*iting )*ost co**on)9 let#argy9 $iffusion #ypo'ia 7;2O s#oul$ !e avoi$e$ in pts " /OP> !ut is fine in ast#*atic pts Diffusion )y oxia

7nitrous o'i$e fro* !loo$strea* $iffuses into alveoli in lungs for eli*ination an$ *i'es " in#ale$ roo* air t#at contains 25D o'ygen9 resulting in #ypo'ia 7prevente$ !y a$*inistering #ig# conc+ o'ygen $uring recovery perio$ of nitrous se$ation +ccu ational Ris% from /itrous +xide 7prolonge$ e'posure to ;O can result in: 1) <one *arro" suppression: *egalo!lastic ane*ia9 leucopenia 2) ;eurological $eficits: perip#eral neuropat#y9 pernicious ane*ia Part 11: 3= an$ Enteral Se$ation Procedure for I; Sedation 7usually $one " 21 gauge nee$le place$ into median ce halic 'ein 7avoi$ entering !rac#ial artery9 "#ic# causes !urning at site9 !lotc#y ar*9 an$ "ea0 pulse *ar(iturates 7act as se$atives an$ #ypnotics 7are potent anest#etics9 !ut "ea0 analgesics 7act !y $epressing /;S activity !y $ecreasing rate of GA<A $issociation at its receptor 7increases duration of c#lori$e c#annel opening to $ecrease neuronal firing 7t#is prolongs t#e in#i!itory effect of GA<A in reticular activating syste* )RAS) 7are very lipi$7solu!le "#ic# results in very rapi$ onset of actionF "#y t#ey are use$ for in$uction of anest#esia ! c pro$uce unconsciousness in less t#an &5 secon$s 7agents: 1) 6#iopental )Pentot#al): ultra7s#ort acting agent 7 #as #ig# lipi$ solu!ility so crosses <<< 8uic0ly 2) ,et#o#e'ital: ultra7s#ort acting &) P#eno!ar!ital: long7acting agent *en4odia4e ines 7act as an'iolytics9 anticonvulsants9 antispas*o$ics9 se$atives9 an$ a*nesics 7act !y en#ancing !in$ing of GA<A to GA<A receptors 7increases frequency of c#lori$e c#annel opening to $ecrease neuronal firing 7availa!le in oral an$ 3= for*s 7ris0 of respiratory $epression an$ co*a is less for !enBos t#an !ar!iturates 7agents: 1) S#ort7acting: triaBola* ):alcion) an$ *i$aBola* )=erse$) 2) 3nter*e$iate7acting: alpraBola* )Eana') &) Long7acting: $iaBepa* )=aliu*)9 loraBepa* )Ativan)9 c#lor$iaBepo'i$e )Li!riu*) 7flumenazil is use$ to reverse effects of !enBos !y co*peting at GA<A receptor )antagonist) 7effect lasts only 25 *inutes9 so !e"are of re7se$ation 7presence of propylene glycol in 3= *i'ture for !enBos can cause p#le!itis )irritation infla**ation of vein) Pro ofol 0Di ri'an1 73= se$ative agent t#at is #ig#ly lipop#ilic 7goo$ for outpatient anest#esia $ue to its rapi$ in$uction an$ recovery an$ lo" inci$ence of nausea vo*iting 7nic0na*es H,il0 of A*nesiaI

<etamine

7is ;,>A receptor agonist an$ s#ort7acting 7pro$uces dissociati'e anesthesia )$issociation !t" t#ala*us an$ li*!ic syste*) 7pt appears a"a0e9 !ut is unconscious an$ $oesn%t feel pain 7is 8uic0 for* of anest#esia goo$ for s#ort proce$ures 7is car$iovascular sti*ulant 7can cause postop $isorientation an$ #allucinations 7often use$ in c#il$ren an$ young a$ults Chloral )ydrate 7/;S $epressant use$ in c#il$ren 7active *eta!olite is tric#loroet#anol 7#as onset of &5 *ins to 1 #r an$ lasts for (72 #ours 7to'icity causes #ypotension9 resp+ $epression9 #ypot#er*ia9 car$iac arr#yt#*ia9 an$ co*a 7contrain$icate$ in #epatic an$ renal i*paire$ pts + ioids 7narcotics t#at act as agonists on *u9 $elta9 0appa9 an$ sig*a receptors in /;S 7provi$e analgesia an$ eup#oria 7availa!le in oral an$ 3= for*s: 1) Aentanyl: 3=9 oral 2) Sufentanil: 3= &) Alfentanil: 3= () ,orp#ine: 3=9 oral -) /o$eine: oral .) ,eperi$ine )>e*erol): 3=9 oral 7naloxone is *u7receptor agonist t#at reverses effect of opioi$s + ioid &d'erse Effects 1) Pruritis )fro* #ista*ine release) 2) ;ausea vo*iting &) Urinary retention () /onstipation -) ,iosis .) Resp+ $epression + ioid Withdra!al 1) :6; .) Restlessness 2) Piloerection9 c#ills 1) ,y$riasis &) S"eating 2) Lacri*ation an$ r#inorr#ea () ;ausea vo*iting 4) 3nso*nia -) A!$o*inal cra*ping 7opioi$ "it#$ra"al is not life7t#reatening li0e alco#ol or !enBo "it#$ra"al is

Com lications of Sedation

1) ,alignant #ypert#er*ia: prevents release of calciu* fro* sarcoplas*ic reticulu* of s0eletal *uscle9 lea$ing to persistent contraction 7rigi$ity9 fever9 tac#ycar$ia9 #ypo'ia 7triggere$ !y succinylc#oline an$ :alot#ane 7treate$ " >antrolene 2) P#le!itis: infla**ation of superficial veins t#at can occur after insertion of 3= 7 pain9 ten$erness9 in$uration9 eryt#e*a 7treate$ " elevating li*!9 *oist #eat9 ;SA3>s &) Laryngospas*: forceful9 involuntary spas* of laryngeal *uscles cause$ !y oral flui$s triggering laryngeal refle' $uring lig#ter stages of anest#esia 7prevente$ !y using p#aryngeal !arrier an$ tonsil suction 7treate$ " positive pressure o'ygen7supple*ente$ ventilation " face*as0 7if still persists9 use succinylc#oline or last resort cricot#yroto*y 7*ost co**on co*plication of office7!ase$ anest#esia is loss of air"ay 7*ost co**on $ental e*ergency is syncope Synco e 7transient loss of consciousness cause$ !y transient cere!ral #ypo'ia 7t't: 1) place pt in supine position " feet slig#tly elevate$ )6en$elen!urg position) 2) Esta!lis# air"ay !y c#in left an$ a$*inister 155D o'ygen &) ,onitor vital signs ;ital Signs 1) 6e*perature: nor*al oral te*p is 42+. A or &1 / 2) :eart rate: nor*al range is .5725 !p* &) <loo$ pressure: nor*al is 125 25 () Respiratory rate: nor*al range is 12712 !reat#s *in Cardio ulmonary Resuscitation 0CPR1 7A</>s 1) Air"ay: #ea$ tilt or ?a" t#rust )if nec0 trau*a suspecte$) 2) <reat#ing: is respiration a!sent ina$e8uate9 *ust provi$e rescue !reat#ing 7!ag7valve *as0 7ventilation rate: 1 !reat# every -7. secon$s )15712 !reat#s *in) 7c#il$ rate is one !reat# every & secon$s )25 !reat#s *in) &) /irculation: c#ec0 pulse an$ if a!sent9 initiate c#est co*pressions 7co*pression to ventilation ratio is &5:2 () >efi!rillation 7ti*e interval fro* first $efri!rillation is *ost i*pt factor in $eter*ining survival 7for every 1 *in $elay !t" $efri!+ an$ collapse $ecreases survival !y 15D Shoc% 7syn$ro*e in "#ic# t#ere is ina$e8uate cellular perfusion o'ygen for *eta!olic $e*an$s of tissues 7reduced cardiac out ut is *ain factor in all types of s#oc0 7c#aracteriBe$ !y: 1) increase$ vascular resistance () *yocar$ial isc#e*ia 2) tac#ycar$ia )increase$ :R) -) *ental status c#ange &) a$renergic response )s"eating) Stages of Shoc% 1) /o*pensatory: co*pensatory *ec#anis*s atte*pt to *aintain perfusion to vital organs 7increase$ :R an$ perip#eral resistance 2) Progressive: *eta!olic aci$osis &) 3rreversi!le: organ $a*age occurs an$ survival not possi!le Categories of Shoc%

1) :ypovole*ic: pro$uce$ !y re$uction in !loo$ volu*e 7cause$ !y #e*orr#age9 $e#y$ration9 vo*iting9 $iarr#ea9 an$ flui$ loss fro* !urns 2) /ar$iogenic: circulatory collapse fro* pu*p failure of left ventricle 7cause$ !y *assive *yocar$ial infarction &) Septic: $ue to severe inf'n 7cause$ !y gra*7 en$oto'ins () ;eurogenic: results fro* severe in?ury trau*a to /;S -) Anap#ylactic: occurs " severe allergic r'n Com lete *lood Count 1) :e*atocrit: percentage of R</s in "#ole !loo$ 7*en: (57-(DF "o*en: &17(1D 2) 6otal C</s: nor*al is -5557159555F $ental inf'n is 1-95557259555 &) :e*oglo!in: *en is 1(712F "o*en is 1271. () 6otal R</s *leeding Times 1) <lee$ing ti*e: 174 *inutes 2) Prot#ro*!in ti*e )P6): 1171. secon$s &) Partial t#ro*!oplastin ti*e )P66): &27(. secon$s 7"arfarin increases P6 an$ P66 Concern For Insulin"De endent Dia(etics 7*a?or concern is hy oglycemia Sym toms of Dehydration 1) Oliguria 2) Rise in !o$y te*p &) 3ncrease in :R an$ car$iac output () >ecrease in !loo$ pressure -) Severe cell $ysf'n *reathing Terms 1) Apnea: transient cessation or a!sence of !reat#ing 2) :ypercapnea: e'cess /O2 in arterial !loo$ &) :ypocapnea: !elo" nor*al /O2 in arterial !loo$ () >yspnea: $ifficulty !reat#ing -) Respiratory arrest: per*t cessation of !reat#ing -) :yperapnea: a!nor*ally $eep an$ rapi$ !reat#ing .) :yperventilation: increase$ pul*onary ventilation in e'cess of *eta!olic re8uire*ents 7results in loss of /O2 fro* !loo$ 1) :ypoventilation: un$erventilation in relation to *eta!olic re8uire*ents 7results in increase$ levels of /O2 in !loo$ 2) Atelectasis: occurs "#en *ucus foreign o!?ect o!structs airflo" in !ronc#us9 causing collapse of lung tissue into airless state 7prolonge$ atelectasis lea$s to pneu*onia 4) Pneu*ot#ora': occurs "#en air lea0s into pleural space causing lung to recoil fro* c#est "all Treating Patients on Dialysis 7s#oul$ treat t#e* t#e day after $ialysis