ORAL SURGERY

Part 1: Principles of Surgery

Indications for Dental Extractions
1) Severe caries
2) Pulpal necrosis/irreversible pulpitis where endo can’t be done
3) Severe perio dx
4) Orthodontic purposes (max./mand. 1PM and 3rd molars)
5) Malposed teeth
6) Cracked teeth
7) Preprosthetic extractions
8) Impacted teeth
9) Supernumerary teeth
10) Teeth assoc. w/ pathology
11) Pre-radiation therapy (questionable teeth should be extracted)

Contraindications to Dental Extractions

1) Severe uncontrolled metabolic diseases (diabetes)
2) End-stage renal disease
3) Advanced cardiac conditions (unstable angina, uncontrolled HTN, recent MI)
-should wait 6 months after CABG surgery to have elective extractions
4) Leukemia and lymphoma (should treat disease before extractions)
5) Head and neck radiation (can lead to osteoradionecrosis)
-pts treated w/ hyperbaric oxygen prior to extractions
6) Pericoronitis (cellulitis) around mand. 3rd molars
-should treat tissue infection before extraction (antibiotics, irrigation, and removing max. 3rd
molar)
7) Acute infectious stomatitis and malignant diseases
8) Treatment w/ IV bisphosphonates, chemo, anticoagulants, and steroids
9) Pregnancy in 1st and 3rd trimester
10) Severe bleeding disorders (hemophilia, thrombocytopenia)

Forces Used in Routine Extractions

1) Luxation: loosening of tooth by progressive severing of PDL
-force applied perpendicular to long axis of tooth
2) Rotation: used only on single-rooted teeth

Indications for Surgical Extractions

1) Initial attempts at forceps extraction have failed
2) Pt appears to have heavy dense bone
3) Older pts due to loss of elastic bone
4) Short clinical crowns w/ severe attrition (bruxism)
5) Hypercementosis or widely divergent roots
6) Extensive decay or crown loss

Positioning of Dentist When Extracting Teeth

1) Maxillary teeth: stand in front of or to side of pt
-pt’s upper jaw should be at same height as dentist’s shoulder
-height of chair - level of patient’s mouth is slightly below the surgeon’s elbow (James Hupp)
2) Mand. teeth: stand directly to side of or behind pt
-pt positioned so occlusal plane of mandible is parallel to floor and chair as low as possible
-height of chair - lower to allow operator’s arm to be straighter (James Hupp)

Extracting Primary Teeth

-primary direction of luxation should be to lingual b/c these teeth are more lingually positioned
-opposite of adults
Sequence of Extractions
1) Maxillary teeth before mandibular teeth
2) Posterior teeth before anterior teeth

Impacted Teeth
-impacted teeth are ones that don’t erupt into arch in expected time
-teeth become impacted b/c adjacent teeth, dense overlying bone, or excessive soft tissue prevents eruption
-inadequate arch length is most common reason teeth fail to erupt
-impacted teeth are retained for pt’s lifetime unless surgically removed
-most common impacted teeth are mand. 3rd molars, max. 3rd molars, and max. canines
-unerupted teeth include both impacted teeth and teeth in process of erupting
-embedded teeth is used interchangeably w/ impacted teeth (Embedded teeth = Impacted teeth)
-impacted max. 3rd molars can be displaced into:
1) infratemporal space -removed via hemostat
2) maxillary sinus -removed via Caldwell-Luc approach
-mand. 3rd molars can be displaced into:
1) submand. space (most likely)
2) IA canal
3) cancellous bone space

Caldwell-Luc Procedure
-opening made into max. sinus by incision into canine fossa above max. PM roots
-after tooth/root removal, figure-8 suture made, antibiotics, nasal spray, and decongestant given
-palatal root of max. 1st molar is most often dislodged into sinus

Reasons to Extract Impacted Teeth

1) Prevention of perio dx in adjacent teeth 5) Prevention of odontogenic cysts and tumors
2) Prevention of caries 6) Treatment of pain of unexplained origin
3) Prevention of pericoronitis 7) Prevention of jaw fractures
4) Prevention of root resorption of adjacent teeth 8) Facilitation of ortho txt

Contraindications to Extracting Impacted Teeth

1) Extremes of age (preteen or over 35 yrs old)
2) Compromised medical status
3) Likely damage to adjacent structures

Classifications of Impacted Teeth

1) Angulation
a) Mesioangular (least difficult for mand. and most difficult for max., most common)
b) Horizontal
c) Vertical
d) Distoangular (most difficult for mand. and least difficult for max.)
-most mand. 3rd molars angled to lingual
2) Pell and Gregory Classification
a) Relationship to anterior border of ramus
i) Class 1: normal position anterior to ramus
ii) Class 2: half of crown is within ramus
iii) Class 3: entire crown is within ramus
b) Relationship to occlusal plane
i) Class A: tooth at same plane as other molars
ii) Class B: occlusal plane of 3rd molar is btw occlusal plane and cervical line of 2nd molar
iii) Class C: 3rd molar is below cervical line of 2nd molar
Factors that Make Impaction Surgery Less Difficult
1) Mesioangular impaction 7) Large follicle
2) Class 1 ramus position 8) Elastic bone
3) Class A depth 9) Separated from 2nd molar
4) Roots 1/3 to 2/3 formed (2/3 is best) 10) Separated from IA nerve
5) Fused, conic roots 11) Soft tissue impaction
6) Wide PDL

Factors that Make Impaction Surgery More Difficult

1) Distoangular
2) Class 3 ramus position
3) Class C depth
4) Long, thin roots
5) Divergent, curved roots
6) Narrow PDL
7) Thin follicle
8) Dense, inelastic bone
9) Contact w/ 2nd molar
10) Close to IA canal
11) Complete bony impaction

Principles of Surgical Extractions

1) Exposure
-surgeon must have adequate visibility of surgical site (make flap)
-incision should be made over sound bone
-envelope flap is most often used, but can also use releasing incisions
-vertical releasing incisions should be made at line angle of tooth, never on facial aspect
or splitting papilla
-base of flap (vestibule) should always be wider than apex (crest) to maintain
blood supply to soft tissues
2) Bone removal
-better to remove bone w/ bur than to fracture it through forceful extraction
-trough of bone on buccal down to cervical line should be removed initially, and more if needed
depending on position and root morphology
3) Tooth sectioning
-sectioning tooth may be needed to avoid excess bone removal or injury to vital structures
-mand. 3rd molars are teeth most often needed to be sectioned
4) Irrigation of wound
-copious irrigation impt to avoid leaving bone spicules or tooth fragments below soft tissue flap

Complications of Extractions
1) Tearing of mucosal flap
2) Puncture wounds in palate, tongue, etc.
-control bleeding and allow healing by secondary intention
3) Oral-antral communication
-manage w/ figure 8 suture over socket, antibiotics, and nasal spray
-if very small, just let blood clot form
-if very large, then close w/ flap procedure
-complications: chronic oroantral fistula and max. sinusitis
4) Root fracture
5) Tooth displacement
a) max. molar into max. sinus (palatal root of max. 1st M most common)
b) max. 3rd molar into infratemporal fossa
c) mand. molar roots forced into submandibular space
d) tooth lost into oropharynx (may cause airway obstruction, should take to ER for chest x-rays)
6) Injury to adjacent teeth
7) Alveolar process fractures (max. tuberosity)
-if tuberosity fxs completely off, then smooth sharp edges of bone and suture soft tissue
-if fxns but still intact, then manually reposition and stabilize w/ sutures
-tuberosity fx most often occurs on lone-standing molars or extraction of last molar in arch
8) Trauma to inferior alveolar nerve (mand. 3rd molars)
9) Excessive bleeding
a) injury to IA artery
b) arteriolar bleed from elevating flap
c) pt’s hemostasis (warfarin, hemophilia, von Willebrand’s, chronic liver deficiency)
10) Infections (rare)
11) Dry socket (localized alveolar osteitis)
-occurs in 3% of mand. 3rd molar extractions
12) Air emphysema (from nonsurgical handpieces)

Dry Socket
-caused by increased fibrinolytic activity, causing loss of blood clot in extraction site
-smoking and oral contraceptives have been indicated, as well as rinsing, hot liquids
-most common in mandibular molars (most common complication seen after mand. molar extraction)
-signs: worsening throbbing pain, radiating pain, bad odor and taste, poor healing extraction site
-treatment: irrigation w/ saline, sedative dressing (eugenol) changed every 2 days until asymptomatic, and
analgesics (no antibiotics needed)

Extraction Tips
-sequence of extraction should be maxillary before mandibular and posterior to anterior
-first force applied should be apical
-B-L forces are less effective in mand. posterior teeth due to dense bone
-normal saline should be used for irrigation b/c it is isotonic
-distilled water is hypotonic and can cause cell lysis

Alveoloplasty
-indicated in any area that may cause difficulty in denture construction

Tori Removal
-only need to be removed for denture fabrication
-palatal tori removal:
1) make stent pre-op
2) double-Y incision made over midline of torus
3) osteotome used to remove in small portions
-should not remove en masse b/c can enter into nose by removing palatine bone
4) large bur used to smooth area
5) close wound w/ horizontal mattress suture and place stent to prevent hematoma

Mandibular Ridge Surgery for Complete Dentures

-may need to excise labial/lingual frenum, mylohyoid ridge, or exostoses
-do not remove genial tubercles, even if large, b/c they are attachment for suprahyoid muscles
-tongue would then be flaccid

Soft Tissue Surgery

-soft tissue may need to be removed/remodeled for dentures
1) Mand. retromolar pad
2) Max. tuberosity
3) Excessive alveolar ridge tissue
4) Inflammatory fibrous hyperplasia
5) Labial/lingual frenum
Principles of Suturing
1) Needle should be perpendicular when entering tissue
2) Sutures should be placed at equal distance from wound margin (2-3mm) and at equal depths
3) Sutures should be placed from mobile to nonmobile tissue
4) Sutures should be placed from thin tissue to thick tissue
5) Sutures should not be overtightened or closed under tension
6) Sutures should be 2-3mm apart
7) Suture knot should be on the side of the wound
-suturing usually not necessary on single-tooth extraction unless severe bleeding or gingiva torn
-if bleeding persists for long time, have them bite on tea bag b/c tannic acid promotes hemostasis

Sutures
-as suture diameter decreases, strength decreases
-size 0 suture is average size
-adding 0’s means they are getting smaller (4-0 smaller than 3-0)
-assigning positive numbers means suture size increases (2, 3, 5, etc)
-smallest diameter suture that is sufficient to keep wound closed should be used
-3-0 and 4-0 most common in dental surgery
-can be resorbable or nonresorbable
1) resorbable: gut, polyglactin (vicryl), polyglycolic acid (dexon), polydixanone
-plain gut made form sheep intestine and rapidly digested
-chromic gut is chromitized to be more resistant to proteolytic enzymes
2) nonresorbable: nylon, silk, polypropylene
-must be removed in 5-7 days

Interrupted vs Continuous Suture Techniques

1) Interrupted: each suture is independent
-offers strength and flexibility in placement
-if one suture comes loose, integrity of remaining sutures not compromised
-disadvantage: requires more time
2) Continuous: many sutures placed that are connected
-ease and speed of placement
-distributes tension over whole suture line
-gives more watertight closure than interrupted pattern

Dead Space
-any area that remains devoid of tissue after closure of wound
-created by removing tissues in depths of wound or not reapproximating tissue planes during closure
-dead space usually fills in w/ blood to form hematoma w/ high potential for infxn
-can eliminate dead space by:
1) closing wound in layers
2) apply pressure dressings
3) use drains
4) place packing into void until bleeding stops

Wound Healing
1) Primary intention: occurs in closely approximated wound edges
-lower risk of infxn and minimal scar formation
2) Secondary intention: occurs when large gap btw incision edges
-requires larger amt of epithelial migration, collagen deposition, contraction, and remodeling
-slower healing and more scar formation (granulation tissue)
-granulation tissue is weaker than original tissue
-factors that impair wound healing: foreign material, necrotic tissue, ischemia, tension, systemic conditions
Stages of Wound Healing
1) Inflammatory stage: from time of injury to 2-5 days
-hemostasis (vasoconstriction, clot formation) and inflammation (vasodilation, phagocytosis)
-neutrophils and lymphocytes predominate
2) Proliferative stage: 2 days to 3 weeks
-epithelialization, angiogenesis, granulation tissue formation, and collagen deposition
-fibroblasts predominate
3) Remodeling/Maturation stage: 3 weeks to 2 years
-collagen fibers increase tensile strength and contraction occurs

Stages of Hemostasis
1) Vascular phase: vasoconstriction
2) Platelet phase (Primary hemostasis): platelet and collagen interaction leading to platelet plug
3) Coagulation phase (Secondary hemostasis): cascade of coagulation factors
4) Repair process: growth of fibroblasts and smooth muscle, fibrinolysis of clot

How to Achieve Hemostasis

1) Pressure 6) Gelatin sponge (Gelfoam)
2) Sutures 7) Bone wax (Parafin/Beeswax)
3) Electrocautery 8) Tranxenamic acid
4) Thrombin 9) Microfibrillar collagen
5) Cellulose sheet (Surgicel)

Dental Implants
-factors that need to be considered:
1) Primary stability
2) Amount of bone
3) Anatomic structures (sinus, other teeth, IA nerve)
-loss of teeth for extended time can lead to ridge resorption (esp. mand.) and ridge augmentation may be
needed (bone grafting)
-common sites for autogenous bone grafts include:
1) iliac crest 3) anterior cortex of chin (small areas of bone)
2) rib 4) lateral cortex of ramus/external oblique ridge
-allogenic grafting also possible
-PAN and CT scan should be used in implant txt planning
-most popular type of implants used are root-form implants

Bone Augmentation Surgery

1) Max. sinus grafts to augment max. alveolar ridge
2) Bone grafts
a) Autograft: transplanted from one region to another in same person
-gold standard for bone regenerative properties
b) Allograft: Transplanted from one individual to genetically non-identical person on same species
-freeze-dried bone is most common allogenic graft
c) Xenograft: transplanted from one species to a difft species
-smokers, alcoholics, uncontrolled diabetes, or uncontrolled systemic dx are poor candidates for
bone grafting
d) Isograft: transplanted from individual of same species who is genetically related to recipient
e) Alloplastic graft: inert, man-made synthetic material
3) Guided Tissue Regeneration: membranes used to hinder migration of fibrous CT while supporting
growth of bone
4) Alveolar distraction osteogenesis: has goal of lengthening mandible 10-12mm
-bone fragments moved physiologically and new bone forms in distraction zone
-0.5-1mm increments of movement per day w/ 1mm movement not to be exceeded in 24 hrs
5) Mandible augmentation: augmentation of atrophic mand. indicated in pt w/ less than 8mm bone height
Types of Implant Integration
1) Osseointegration: direct and fxnal connection btw living bone and implant surface
-most predictable long-term stability
2) Fibro-osseous integration: CT-encapsulated implant within bone
-50% success rate over 10 yrs
3) Biointegration: achieved via bioactive materials (hydroxyapatite or bioglass)
-develop bone faster than noncoated implants, but little difference seen after one year

Osseointegration
-direct adaptation of bone to dental implant
-defined histologically as being evident at light microscope level
-implant success criteria defined as:
1) implant immobile clinically
2) no peri-implant radiolucency present
3) mean vertical bone loss less than 0.2mm annually
4) no pain or infxn
5) implant placement doesn’t inhibit placement of crown/prosthesis

Contraindications to Implant Placement

1) Uncontrolled diabetes 4) Bisphosphonate therapy
2) Immunocompromised 5) Bruxism
3) Anatomic considerations 6) Tobacco use (relative contraindication)
-also contraindicated to place implants immediately after extraction tooth w/ active infxn (wait 8 weeks)

Anatomic Limitations to Implant Placement

1) Buccal plate (0.5mm) 6) Interimplant distance (3mm)
2) Lingual plate (1mm) 7) IA canal (2mm)
3) Max. sinus (1mm) 8) Mental nerve (5mm)
4) Nasal cavity (1mm) 9) Inferior border of mandible (1mm)
5) Incisive canal (avoid midline max.) 10) Adjacent tooth (0.5mm)
-need 10mm of bone height to place implant
-implants placed in anterior maxilla have highest failure rate

Stages of Implant Placement

1) Implant placement
-can use surgical stent to achieve proper angulation and parallelism
-cooling saline spray used during bone prep and implant placement to keep bone temp. under 47
degrees C (116 F)
2) Healing abutment placement
3) Prosthetic restoration of implant

Implants Restoring Edentulous Maxilla

-at least 4-8 implants placed at least 10mm depth to achieve cross-arch stabilization of prosthesis

Implants Restoring Edentulous Mandible

1) Tissue-born prosthesis: placed over 2-4 implants
2) Implant-born prosthesis: placed over 5 implants, all placed in anterior mandible anterior to mental
foramen
 Part 2: Trauma Surgery
Tooth Fractures
1) Crown craze/crack (infraction): no loss of tooth structure
2) Horizontal or vertical crown fracture: can be confined to enamel, or include dentin and/or pulp
3) Crown-root fracture: may or may not involve pulp
a) More than 1/3 root involved: extract
b) Less than 1/3 root involved: RCT
c) Primary teeth: extract
4) Horizontal root fracture: located in apical, middle, or cervical/coronal third
a) Coronal: remove segment and perform RCT
b) Apical/middle: rigid splint for 2-3 months
5) Concussion: injury to tooth-supporting structure causing sensitivity to percussion but no
mobility/displacement
-no txt needed
6) Subluxation: injury to tooth supporting structures resulting in mobility but no displacement
-bleeding from gingival crevice
-splint for 7-10 days
7) Intrusion: displacement of tooth into socket
-often assoc. w/ compression fracture of socket
-splint for 14 days; may need to await re-eruption or require orthodontic extrusion
-no txt for intruded primary teeth, just let them re-erupt
8) Extrusion: partial displacement of tooth out of socket
-splint for 14 days
9) Labial or lingual displacement: alveolar wall fractures probable
10) Lateral displacement: displacement of tooth in mesial or distal direction
-alveolar wall fractures probable
11) Avulsion: complete displacement of tooth from its socket
-may have alveolar wall fracture
-replant and splint 7-10 days
-do not replant primary teeth
12) Alveolar process fracture
-reduce dentoalveolar segment and rigid splint (arch bar) for 4-6 weeks

Facial Fractures
-facial fractures should always be considered after car accidents, fights, falls, or sports accidents
-signs of facial fracture include:
1) pain 5) abnormal mobility of bone 9) malocclusion
2) contour deformity 6) numbness (CN V-3) 10) step defect
3) ecchymosis 7) crepitation 11) mobility of mandible segments
4) laceration 8) hematoma/ecchymosis of FOM
-when there is lip laceration w/ fractured tooth, always take soft tissue radiograph to detect any broken
fragments of tooth material
-txt goals of maxillofacial fractures: control hemorrhage, restore occlusion, reduction and stabilization of
fractured segments
-fat embolism is most often a sequelae of fractures
-highest incidence of fractures occurs in males btw 15-24 yrs old from trauma

Zygomatic Arch Fractures

-best visualized by submental vertex view
-complications: paresthesia (most common) sinus hematoma, impaired ocular muscles
Mandible Fractures
-can almost always be seen on PAN radiograph, but should be visualized in at least two radiographs
-PAN, Townes, P-A skull, lateral oblique
-malocclusion is most pathognomic sign of mand. fx
-mandible is 2nd most common fractured facial bone and 50% are multiple fractures
-most common sites for mandible fractures:
1) Condyle: 29% 4) Body: 16% 7) Coronoid: 1%
2) Angle: 25% 5) Alveolar process: 3%
3) Symphysis: 22% 6) Ramus: 2%
-fracture of condyle will result in deviation on opening to fractured side from trauma to ipsilateral
lateral pterygoid muscle
-fractures can be classified as:
1) Simple (closed): no communication w/ external environment
2) Compound (open, complex): communication w/ external environment (skin, mucosa, or PDL)
-Infection common
3) Comminuted: fractured in multiple pieces
4) Greenstick: one side of bone is broken and other is bent
-most often seen in children b/c bone more elastic
5) Pathologic: occurred at weakened site due to pre-existing disease
6) Favorable: not displaced by forces of muscles of mastication
7) Unfavorable: displaced by forces of muscles of mastication
-line of fracture determines whether muscles will be able to displace fractured segments
-bilateral mandible fractures may result in posterior displacement of tongue causing airway obstruction
-contemporary txt for mand. fxs that are displaced and mobile is with open reduction and internal fixation
w/ titanium plates and screws
-other methods of repair include lingual splinting (pedo pts) and intermaxillary fixation (wire jaws
closed)
-prolonged immobilization of condylar fxs will lead to ankylosis of TMJ so condylar fxs should
only be immobilized for 2 weeks

Indication for intraoperative maxillomandibular fixation (MMF) (FTS)

-intraoperative fixation
-temporary fragment stabilization in emergency case prior to definitive treatment
-fixation of avulsed and alveolar crest fragments
-use as a tension band

Open vs Closed Reduction for Mandibular Fractures

1) Open reduction: involves direct exposure and reduction of fx though surgical incision
2) Closed reduction: external fixation devices and intermaxillary fixation

Indication of open reduction (FTS)

-Displaced unfavorable fractures of body/angle/para-symphysis
-concomitant fractures of the craniofacial skeleton
-malunion
-nonunion
-contraindications to MMF
-displaced bilateral condylar fracture with midface fractures
-edentulous maxilla opposite a mandibular fracture

Indication of closed reduction (FTS)

-nondisplaced favorable fractures
-grossly comminuted fractures
-fractures with extensive soft tissue injury
-edentulous mandible fractures
-pediatric mandible fractures
-condylar fractures
Indication for removal of teeth in line of fracture (FTS)
-gross mobility
-periapical pathology
-significant periodontal disease
-fractured roots
-partially erupted 3rd molars with pericoronitis or associated cyst

Surgical Approaches for Open Reduction of Mandible (FTS)

-symphysis and para-symphysis – intra-oral vestibular approach
-stepwise incision through mucosa first, followed by incision through mentalis muscles &
periosteum
-2-layer wound closure for muscle and mucosa
-body and angle fracture of mandible
-I/O approach -Trans-buccal incision
-E/O approach -Risdon Approach (Submandibular)

Surgical Approach to Mandibular Condylar Fractures (FTS)

-Pre-auricular (high condylar fracture)
-Retromandibular
-Submandibular aka Risdon Approach (low condylar fracture)

Midface Fractures
-midface fxs best evaluated w/ CT scans of face
-both axial and coronal orientations needed to fully evaluate fractures
-can involve maxilla, zygoma, nose, and orbits
-orbital floor fracture is termed “blowout fracture”
-zygomaticomaxillary complex (tripod) fractures are most common midface fx (40%)
-maxillary fractures classified as:
1) LeForte I (transverse maxillary): separation of maxilla only with intact nasofrontal complex
-signs: malocclusion (open bite), buccal vestibule ecchymosis (Guerin’s sign), epistaxis
2) LeForte II (pyramidal): separation of maxilla and nasal complex from cranial base (mobile
nasofrontal complex)
-signs: malocclusion (open bite), perioribtal edema, subconjunctival hemorrhage,
paresthesia of infraorbital nerve
3) LeForte III (craniofacial dysjxn): complete separation of midface at level of naso-orbital-
ethmoid complex (mobile nasofrontal and malar complexes)
-major sign is rhinorrhea from CSF leaking into nasal cavity
-also have restricted mand. movement

4) Zygomaticomaxillary complex fracture (ZMC): cheek bone fx w/ flattening of malar process

-zygomatic arch fx has “W” deformity on submental vertex radiograph and CT scan
-maxilla, orbit, and zygomatic fxs require rigid internal fixation
-isolated zygomatic fxs can often be reduced w/ minor surgery and w/o use of plates and screws
-Gillies approach: long elevator inserted through superficial temporal fascia to pop
zygomatic arch back into position
-simple nasal fractures are repaired w/ internal and external splints
-nasal bone fracture is most common facial fracture

Surgical Approach for Zygomaticomaxillary complex fracture (OMFT)

-Temporal Approach – Gillies
-Maxillary Vestibular Approach
-Supra-orbital Eyebrow Approach
-Upper Eyelid Approach AKA Blepharoplasty/Upper Eyelid Crease/Supra-tarsal Fold Approach
-Lower Eyelid Approach – Sub-tarsal, Sub-ciliary
-Transconjunctival Approach
-Coronal Approach – Bi-coronal, Hemi-coronal
Bone Healing
1) Primary bone healing: direct attempt by cortex to re-establish itself
2) Secondary bone healing: involves classical stages of fx healing
-phases of bone healing:
1) Hemorrhage: blood clot organization and proliferation of vessels occurs in first 10 days
2) Callus formation: primary callus formed in 10-20 days and secondary callus forms in 20-60
days
3) Fxnal reconstruction: mechanical forces cause Haversian systems to line up according to stress
lines
-excess bone is removed and shape of bone molded
-takes 2-3 yrs to completely reform fx

Inappropriate Bone Healing

1) Delayed union: satisfactory healing that requires greater than normal 6 wk period
2) Non-union: failure of fx segments to unite properly
3) Mal-union: delayed or complete union in improper position

Reasons for Fractures Not Healing

1) Ischemia
2) Excessive mobility
3) Interposition of soft tissue
4) Infection

Radiographs for Maxillofacial Trauma

1)Mandibular Fracture
-Panoramic, Posterior Anterior skull view
-CT Scan - Axial, coronal, sagittal
-CBCT
-Condyle Fracture - CT scan, lateral oblique, TMJ view
2) Maxillary Fracture
-Panoramic, PNS view (Water's View)
-Zygoma - Submento-vertex View - jug handle
-Nasal Bone
- Lateral nasal view
- PNS view
- Orbital fracture
- CT scan - coronal, sagittal view – tear drop sign
- PNS view - orbital wall very thin, may not appreciate
3) Panfacial fracture- CT scan
-If no CT scan - OPG, PA, Submento-vertex View, PNS
4)Frontal Bone - Lateral skull, CT scan
 Part 3: Orthognathic Surgery

Evaluating Need for Orthognathic Surgery

-pts evaluated according to normal facial proportions
-vertically, face is divided into equal thirds
-horizontally, face is divided into equal fifths

Angle Classifications of Occlusion

1) Angle class I: normal dental occlusion w/ straight (orthognathic) profile
2) Angle class II: mand. 1st molars and canines are in posterior position relative to max. counterparts
-face appears posteriorly convergent (retrognathic)
3) Angle class III: mand. 1st molars and canines are in anterior position relative to max. counterparts
-face appears anteriorly convergent (prognathic)

Imaging for Orthognathic Surgery

-lateral cephs are main imaging used, although panaromic, A-P cephs, and PAs are taken as needed
-cephalometric analysis helps determine which jaw is involved primarily in deformity, direction of growth
of jaws, and most ideal procedure for pt

Diagnoses of Dentofacial Deformities

1) Max. hyper/hypoplasia
2) Mand. hyper/hypoplasia
3) Anterior open bite (apertognathic)
4) Vertical max. excess (max. too long w/ gummy smile)
5) Horizontal transverse discrepancy (pt has posterior crossbite)
6) Macrogenia (chin too big) or microgenia (chin too small)
7) Canting (vertical asymmetry)

Maxillary Surgery
-referred to LeForte I osteotomies
-maxilla can be moved forward and down more easily than up or back
-maxilla can also be sectioned into two or three segments to better position the occlusion

Mandibular Surgery
-most often done using one of two osteotomies:
1) Sagittal split osteotomy: ramus is divided by horizontal osteotomy on medial aspect and vertical
osteotomy on lateral aspect
-lateral and medial aspects then separated and mand. advanced or set back
2) Vertical ramus osteotomy: ramus cut vertically and mand. positioned forward or back
-mandible can be moved anteriorly to correct retrognathia (class II) or posteriorly to correct prognathia
(class III)
-chin can be moved using a genial osteotomy (genioplasty) to correct macrogenia or microgenia

Distraction Osteogenesis
-involves cutting an osteotomy to separate segments of bone and application of an appliance that will
facilitate the gradual and incremental separation of bone segments which will fill in with new bone

Imaging for Distraction Osteogenesis (Sem 9)

-Panoramic Radiographs
-Posterior Anterior skull view
-Lateral Cephalometric
-Paranasal Sinus view (Water’s View)
-maxillary occlusal - for palatal sagittal split osteogenesis
Cleft Lip and Palate
-cleft LIP more common in males
-CL is defect in fusion of lateral and medial nasal processes
-cleft PALATE more common in females
-CP is lack of fusion btw palatal shelves
-most commonly found on Asians and least common in AA
-CL/P surgery follows rule of 10s: surgery performed when child is at least 10 weeks old, weighs at least
10 lbs, and has at least 10 g/dL Hb

Imaging for cleft lip and palate (Sem 9)

-Alveolar Bone Grafting - Panoramic, Maxillary Occlusal, IOPA, CBCT
Orthognathic X-rays – lateral cephalometric
 Part 4: Facial Pain and Neuropathology
Physiology of Pain
1) Transduction: activation of A-delta and C-fibers to spinal cord or brain stem
2) Transmission: pain info in CNS is sent to thalamus and cortex for processing of sensory/emotional
aspects
3) Modulation: limits rostral flow of pain info from spinal cord and trigeminal nucleus to higher cortical
centers
-acute pain lasts 3 months or less
-chronic pain is pain lasting longer than 4-6 months

Classification of Orofacial Pain

1) Somatic pain: increased stimulus leads to increased pain
a) musculoskeletal pain (TMJ, perio, muscular)
b) visceral (salivary gland, pulp)
2) Neuropathic pain: pain independent of stimulus activity
-damage to pain pathways (trigeminal neuralgia, trauma, stroke)
3) Psychogenic pain: caused by intrapsychic disturbance
-conversion rxn, psychotic delusion, malingering
4) Atypical pain: facial pain of unknown cause

Trigeminal Neuralgia (Tic Douloureaux)

-a trigger point exists where pain typically presents as electrical, sharp, shooting sensation
-triggered by wind, tactile, or thermal stimulation
-pain is episodic (seconds to minutes) followed by refractory period
-usually unilateral
-no motor or sensory deficits present
-compression on trigeminal neuralgia by superior cerebellar artery
-treatment: 1) anticonvulsant drugs: gabapentin, carbamazepine
2) surgically: microvascular decompression (Janetta procedure), gamma knife radiosurgery
3) Conservative: night guard, soft diet, motion exercises, moist heat, massage, NSAIDs

Prescription:
-Tab Carbamazepine 200mg BID
-Tab Gabapentin 300mg TID

Atypical Odontalgia (Odontalgia Secondary to Deafferentation)

-occurs as result of trauma or surgery (RCT or extraction)
-these result in damage to afferent pain transmission system
-proposed mechanisms:
1) peripheral hyperactivity at surgical site
2) CNS hyperactivity secondary to changes in 2nd-order nerve in trigeminal nucleus

Postherpetic Neuralgia
-sequelae of herpes zoster infxn
-pain is burning, aching, or electric shock-like
-treatment: 1) anticonvulsants
2) antidepressants
3) sympathetic blocks
-Ramsay-Hunt syndrome: herpes zoster infxn of sensory and motor branches of CN VII and VIII, resulting
in facial paralysis, vertigo, deafness, and cutaneous eruption of external auditory canal

Neuromas
-can occur after a nerve injury
-proximal section of transected nerve forms sprouts filled w/ Schwann cells
-becomes very sensitive to stimuli and can cause chronic neuropathic pain
Burning Mouth Syndrome
-pts complain of pain, dryness, burning of mouth and tongue, and altered taste
-most common in postmenopausal females
-thought to be secondary to defect in pain modulation
-symptoms of 50% of pts resolve w/o txt in 2-yr period
-hormone therapy, anticonvulsants, and antidepressants NOT useful

Chronic Headaches
1) Migraine
a) Onset: acute
b) Location: unilateral
c) Symptoms: nausea, vomiting, photophobia, phonophobia
d) Pain: throbbing
e) Duration: prolonged
f) Diagnostic test: check for hx of symptoms
g) Prior hx of headaches: yes
2) Cluster
a) Onset: acute
b) Location: unilateral
c) Symptoms: rhinorrhea, lacrimation of ipsilateral side
d) Pain: sharp, stabbing
e) Duration: 30 mins to 2 hrs
f) Diagnostic test: history of symptoms
g) Prior hx of headaches yes

3) Tension
a) Onset: chronic
b) Location: global and unilateral
c) Symptoms: multisomatic complaints
d) Pain: aching
e) Duration: daily
f) Diagnostic test: none
g) Prior hx of headaches: yes
4) Temporal Arteritis
a) Onset: acute or chronic
b) Location: localized
c) Symptoms: weight loss, polymyalgia, fever, vision problems, jaw claudication
d) Pain: severe throbbing pain
e) Duration: prolonged
f) Diagnostic test: erythrocyte sedimentation rate test (ESR), tender temporal arteries
g) Prior hx of headaches: no
-can lead to blindness on affected side if not treated quickly

Nerve Injuries
1) Anesthesia: loss of sensation
2) Paresthesia: abnormal sensation (burning, tingling, etc.)
3) Hyperesthesia: increase in sensitivity
4) Dysesthesia: painful sensation to normal stimulus
5) Neurapraxia: mild injury w/ no axonal damage (spontaneous recovery within 4 weeks)
6) Axonotmesis: axonal damage but intact endoneural and perineural sheath
-Wallerian degeneration occurs distal to injury
-Potential for recovery in 1-3 months
7) Neurotmesis: complete severance of axon with a gap created
-no recovery expected w/o surgery
 Part 5: Temporomandibular Disorders
TMJ
-classified as ginglymoarthrodial joint w/ both translational and rotational movement
-synovial joint
-anatomy:
1) TMJ: articulation btw condyle of mandible and squamous portion of temporal bone
2) Articular surface of temporal bone: fxnal aspect of TMJ made of dense fibrous CT
a) concave portion: articular fossa (glenoid/mandibular fossa)
b) convex portion: articular eminence (tubercle)
3) Articular disc: dense fibrocartilagenous CT (avascular and aneural)
-separates joint into inferior and superior joint spaces
-anterior/posterior bands: thick (post. band thicker and attached to retrodiscal tissues)
-intermediate zone: thin (center of disc)
4) Retrodiscal tissues: loose CT that is vascular and innervated

Myofascial Pain Disorder

-most common cause of masticatory pain/TMJ pain and compromised fxn
-diffuse, poorly localized pain in preauricular region, often involving muscles of mastication
-pain and tenderness result from abnormal muscle fxn and hyperactivity, as well as spasm and dysfxn
-parafunctional habit may be etiologically related (wear facets often seen)
-if pt has nocturnal parafunctional habit, symptoms are worse in morning
-can also be result of disc displacement disorders and degenerative arthritis
-is stress-related disorder (increased stress causes increased muscle tension/bruxism)

Disc Displacement Disorders

-assoc. w/ synovial inflammation
-disc displacement is end result of inflammation and chronic joint overloading
-disc most often displaced in anteromedial direction
1) Disc displacement w/ reduction: disc returns to normal disc-to-condyle relationship
-normal interincisal opening w/o deviation can be seen
-opening click corresponds to condyle moving over posterior portion of anteriorly displaced disc
(reduction)
-second click occurs when jaw is closed and disc fails to maintain its normal reduced relationship
to condyle
2) Disc displacement w/o reduction: disc doesn’t return to normal position
-results in limited range of motion and ipsilateral deviation on opening
-no popping or clicking observed
3) Internal derangement: abnormal relationship of articular disc to mand. condyle and fossa
-posterior band of disc is anteriorly displaced in front of condyle as disc translates anteriorly,
posterior band remains in front of condyle leading to inflammation of retrodiscal tissue causing
decreased production of synovial fluid and decreased mobility

Degenerative Joint Disease (DID)

1) Osteoarthritis
2) Systemic Arthritic Conditions
a) Systemic lupus (SLE)
b) Rheumatoid arthritis
c) Crystalline arthropathies (calcium pyrophosphate dehydrate (pseudogout))
3) TMJ ankylosis
-most commonly caused by trauma

Chronic Recurrent Dislocation

-occurs when mand. condyle translates anterior to articular eminence
-assoc. w/ pain and muscle spasm
-requires mechanical manipulation to achieve reduction
 -when problem becomes chronic (multiple recurrences), Botox txt to lateral pterygoid and surgery
may be needed

Ankylosis
-pt presents w/ severely restricted range of motion and limited interincisal opening w/ pain
-bony ankylosis results in more limitation of motion than fibrous ankylosis
-trauma is most common cause of ankylosis, but surgery, radiation therapy, and infxn can also cause it

Nonsurgical Therapy for TMD

-txt objectives are to decrease pain symptoms and improve fxn
-in cases of ankylosis and severe symptomatic degenerative joint disorders, surgery may be right
choice
-nonsurgical therapy includes:
1) Patient education/counseling: prevent parafxnal habits, reduce stress, etc.
2) Physical therapy: biofeedback, ultrasound, electrical nerve stimulation, massage, exercise
-results in increased circulation to affected region
3) Pharmacotherapeutic intervention: NSAIDs, steroids, narcotics/analgesics, antidepressants,
muscle relaxants
4) Occlusal considerations: equilibration, prosthetics, ortho, orthognathic surgery, and splints
a) Autorepositioning splints: used for muscle and joint pain when no specific anatomic
cause can be found
-work by reducing intra-articular pressure
-allows for no working or balancing interferences w/ full arch contact
b) Anterior repositioning splint: protrudes mandible into forward position, recapturing
normal disc-to-condyle relationship

Surgical Treatments for TMD

1) Arthrocentesis: benefits pts w/ internal derangement
-needles placed into superior joint space and saline injected to reduce inflame. mediators
-thought to distend joint capsule, release adhesions, and remove chemical mediators
assoc. w/ joint pathology
2) Arthroscopy: placement of two cannulas to allow access for intracapsular instrumentation of superior
joint space
-lysis of adhesions, steroid injxn, and motorized shaving of osteoarthritic fibrillation tissue
3) Disc repositioning surgery (Open arthoplasty): disc is mobilized and posterior wedge may be removed
and disc repositioned into more desirable position
-used in pts w/ painful, persistent clicking-popping and closed lock
4) Disc repair/removal (Discectomy): indicated when disc is severely damaged
-if disc is removed, it can be replaced w/ autogenous materials (temporalis muscle, fat, articular
cartilage) or prosthetics
5) Condylotomy: accomplished by performing an intraoral vertical ramus osteotomy
-allows soft tissues to passively reposition the condyle and disc into more fxnally neutral position
6) Total joint replacement: indicated in severely pathologic joints (rheumatoid arthritis, deg. Joint. Dx,
ankylosis, neoplasia)
-costochondral bone graft reconstruction is most common autogenous material used
-totally prosthetic joints can also be made
-should AVOID occlusal adjustments, prosthetic restorations, ortho txt, and orthognathic surgery

Approaches to Expose TMJ

1) Pre-auricular incision: perpendicular incision anterior to external ear
-is best way to expose TMJ
2) Submandibular approach (Risdon approach): standard approach to ramus and neck of condyle
-not best way to approach joint space
 Part 6: Odontogenic Infections
Microorganisms Causing Odontogenic Infections
-polymicrobial infections
1) Anaerobic (75%)
a) Gram neg. rods: most (Bacteroides, Fusobacterium)
b) Gram pos. cocci (Strep)
2) Aerobic (25%)
a) Gram pos. cocci (most) Strep, Staph

Pathologic Mechanism
-highly virulent Strep species initiate infectious process in deep tissues
-cellulitis then occurs (aerobic), followed by proliferation of anaerobic organisms (form abscess)
-aerobic organisms consume the oxygen, making environment more favorable for anaerobes
-disease progresses by following path of least resistance, often through bone cortex and invading fascial
space (most often enter vestibular space)
-can drain spontaneously and result in asymptomatic, chronic draining fistula

Fascial Space Infections

1) Vestibular 5) Submandibular
2) Buccal 6) Submental
3) Canine 7) Masticator (pterygomand., masseteric, superficial/deep temporal)
4) Sublingual 8) Lateral pharyngeal
-these are referred to as potential spaces, b/c in healthy state there is no real space; abscess formation
causes cavities in these fascial planes
-spaces are contiguous w/ each other and as abscess spreads, more spaces can become involved
-canine and deep temporal space infxns can result in cavernous sinus thrombosis via ophthalmic veins
-lateral pharyngeal space infxns can spread to mediastinum
-both should be considered life-threatening emergencies

Ludwig’s Angina
-bilateral infxn of submandibular, sublingual, and submental spaces
-can lead to blockage of airway

Six Treatment Principles for Odontogenic Infections

1) Determine severity of infxn
2) Evaluate state of pt’s host defense mechanisms
3) Determine whether pt should be treated by general dentist or specialist
4) Treat infxn surgically
-remove source of infxn and decompress/drain purulence
-goal is to get adequate drainage so spread of infxn can be brought under control
-specimen for culture and sensitivity should be obtained
5) Support pt medically
-airway management, hydration, electrolytes, antibiotics, analgesics
6) Choose and prescribe appropriate antibiotics
-Pen VK is preferred drug for odontogenic infxns
-if allergic, then clindamycin or clarithromycin are good
-narrow spectrum agents are better than board spectrum for odontogenic infxns b/c alter normal
flora less
-bactericidal agents better than bacteriostatic

Indications for Antibiotic Use

1) Rapidly progressing swelling 4) Fascial space involvement
2) Diffuse swelling 5) Severe pericoronitis
3) Compromised host defenses 6) Osteomyelitis
-pseudomembranous colitis (C. dificile) can result from antibiotic use of amoxicillin, clindamycin, and
cephalosporins
 -treat w/ vancomycin or metronidazole

Osteomyelitis
-inflammation of medullary portion of bone
-osteomyelitis spreads via infxn, inflammation, and ischemia
-most common initiating causes are odontogenic infxns and trauma
-infxn begins in medullary space of cancellous bone, then spreads to cortical bone, periosteum, and soft
tissues
-occurs more often in immunocompromised and in mandible over maxilla
-causative agents are similar to odontogenic infxns (Strep, anaerobic cocci and gram- rods)
-treatment done by debridement and antibiotics

Necrotizing Fasciitis
-rapidly progressing infxn of skin and fascia w/ high mortality rate (30-50%)
-caused by group-A strep or C. perfringens
-treated w/ surgical debridement and antibiotics

Cavernous Sinus Thrombosis

-retrograde infxn from backflow of material drained from face
-CN III, IV, V-1, and VI involved

Sinusitis
1) Acute (less than 1 month)
-S. pneumonia, H. influenzae, M. catarrhalis
2) Chronic (over 3 months)
-results from obstruction of sinus drainage
-diabetics may develop mucormycosis (fungal infxn)
3) Txt: amoxicillin or augmentin (amoxicillin+clavulanate), antihistamines, or surgery to establish drainage
4) Complications of sinusitis: orbital cellulitis, cavernous sinus thrombosis, meningitis, osteomyelitis
Animal Bite Infections
-caused by Pasteurella multicida
-txt w/ ampicillin or amoxicillin
 Part 7: Biopsies
Biopsy Technique
-block anesthesia preferred b/c injection into lesion can distort the architecture and make diagnosis difficult
1) Suction: use low volume suction wrapped in gauze so not to aspirate the specimen
-hemostasis is impt so a high volume suction isn’t needed
2) Incision: use sharp scalpel to avoid excessive damage to tissue and achieve clearly defined margins
3) Laser: carbon dioxide laser in super-pulsed mode is acceptable if hemostasis concerns are significant
-a fine peripheral zone of necrosis does occur w/ laser
4) Handling/tagging: if suspect malignancy, a tissue tag should be used to help identify orientation
-tissue should be placed in 10% formalin in volume 20x that of specimen
5) Records: biopsy data sheet must be filled out including pt hx and clinical findings

Oral Brush Cytology

1) Uses: detecting cancerous and precancerous lesions
2) Method: cytology brush placed over lesion and rotated 5-10 times to obtain cells from all 3 epithelial
layers
-cells transferred to glass slide and fixative placed and sent to lab
-one of 3 categories assigned: a) Negative: no evidence of atypical cells or carcinoma
b) Positive: definitive evidence of atypical cells or carcinoma
c) Atypical: abnormal epithelium
-all positive and atypical finding should undergo definitive scalpel biopsy

Aspiration Biopsy (Fine Needle Aspiration)

1) Uses: low morbidity and high diagnostic accuracy for most lesions
-also used to determine if lesion is vascular or not before surgical exploration
2) Method: special syringe and needle used to collect cells from clinically or radiographically identified
mass

Incisional Biopsy
1) Uses: when lesion is large (>1cm), polymorphic, suspicious for malignancy, or in high morbidity area
2) Method: portion of lesion is incised and must be obtained in a representative area of the lesion, avoiding
areas of necrosis and in adequate depth to make definitive histological diagnosis

Excisional Biopsy
1) Uses: for smaller lesions (<1cm) that appear benign or on small vascular and pigmented lesions
2) Method: entails removal of entire lesion and a perimeter of surrounding uninvolved tissue

Hard Tissue/Intraosseous Biopsy Techniques

1) Mucoperiosteal flaps are always used for intraosseous lesions and should be full-thickness, over sound
bone, and allowing 4-5mm margins
2) All radiolucent lesions should be aspirated to make sure they are not vascular
3) Osseous window created to remove lesion for biopsy
4) After lesion is removed, 1mm of adjacent osseous tissue should be curettaged in all directions

Handling of Excised Specimen

-should immediately be placed in 10% formalin solution that is at least 20x volume of specimen

Biopsying an Ulcer
-should wait 14 days (2 wks) to biopsy an oral ulcer, b/c they should heal within 14 days
 Part 8: Surgical Management of Cysts and Tumors
Overview
-goals of surgical management are eradication of pathology and esthetic functional rehabilitation
-cysts can be classified as fissural and odontogenic
-odontogenic keratocysts tend to act more aggressively and have higher recurrence rates than
fissural cysts and cysts of odontogenic inflammatory origin
-cysts of jaw are treated w/ either:
1) Enucleation 3) Staged enucleation and marsupialization
2) Marsupialization 4) Enucleation and curettage

Enucleation
1) Description: shelling out lesion w/o rupture
2) Indications: used when it can safely be done w/o sacrificing adjacent structures
3) Pros: is a definitive txt and easier postop wound care
4) Cons: may weaken jaw and damage adjacent structures

Marsupialization
1) Description: surgical window made, followed by decompression and evacuation
2) Indications: done if enucleation would damage adjacent structures or it would be unsuccessful
3) Pros: simple and may spare vital structures
4) Cons: difficult wound care and some pathologic tissue may be left

Staged Enucleation and Marsupialization

1) Indications: done if cyst is not totally obliterated after initial marsupialization heals

Enucleation and Curettage

1) Description: shelling out lesion w/o rupture, followed by 1-2mm curettage of adjacent bone
2) Indications: OKCs or any cyst that recurs after enucleation
3) Cons: may recur and more destructive to adjacent structures

Malignant Tumors of Jaw

-most common are epidermoid carcinomas (SCC)
-salivary glands, blood vessels, lymphatics, muscle, bone, and other CT can give rise to primary
malignancies of head and neck
-cancer of breast, prostate, lung, kidney, thyroid, hematopoietic system, and colon can metastasize to head
and neck
-when a primary cancer of head/neck is diagnosed, clinical staging should be performed prior to definitive
txt
-can include CT scans, PET scan, chest x-rays, and endoscopy
-combo of surgery, radiation, and chemo are modalities used to treat primary cancers of head/neck

Reconstruction
-optimally done before performing any definitive txt
-can range from no reconstruction w/ wound management and secondary healing to complex reconstruction
w/ placement of endosseous implants

Sialolithiasis
-salivary gland stones
-most often affects submandibular gland (85%)
-causes pain and swelling which worsens when saliva flow is stimulated
-gland can become infected, causing purulence, erythema, FOM edema, and lymphadenopathy
 Part 9: Local Anesthesia
Local Anesthetics
-drugs which reversibly blocks the conduction of nerve impulses
-dental concern is sensory nerve block, but motor nerves can be blocked in high conc.
-local anesthetics block sodium channels
-all LAs are made of a lipophilic aromatic ring linked to a hydrophilic amino group
-bond is either an ester or amide bond which determines class of LA

Classes of Local Anesthetics

1) Amides: metabolized by microsomal P-450 enzyme in liver
a) lidocaine b) mepivicaine c) bupivicaine
-amides have letter “I” followed by-“caine” in name
2) Esters: metabolized by pseudocholinesterase in plasma
a) novocaine b) procaine c) benzocaine d) tetracaine
-esters are far more common to have allergic rxn

Dosages for Local Anesthetics

mg/carp max dose (mg/kg) max dose (mg)
2% lido (xylocaine) 36 4.5 300
2% lido w/ 1:100k 36 7 500
3% mepivicaine (carbocaine) 54 5.5 400
2% mepivicaine w/1:20k 36 5.5 400
4% prilocaine (Citanest) 72 8 600
4% prilocaine w/ 1:200k 72 8 600
0.5% bupivicaine w/ 1:200k (Marcaine) 9 1.3 90
1.5% etidocaine w/ 1:200k (Duranest) 27 5.5 400
4% articaine w/ 1:100k (Septocaine) 68 7 500
-max amt of 2% lido w/ 1:100k epi to healthy 150 lb man is 477 mg (13 carps)
-each 1.8cc carp of 2% lido w/ 1:100k epi contains 20mg/cc lidocaine, 36 mg lidocaine, and 0.018 mg epi

Clark’s Rule for Pediatric LA Dosing

-max pedo dose= (weight of child in lb/150)x(max adult dose)
-conversion of lb to kg is 2.2 lb/kg

Contents of 1 Carpule of 2% Lido w/ 1:100k Epi

1) 36 mg lido
2) 0.018 mg epi

Differential Nerve Blockade (Critical Length Concept)

-diff. nerve blockade is max distance an action potential can “jump” down a nerve
-in myelinated nerve, local anesthetic must block a minimum successive number of nodes of Ranvier to
block the action potential of nerve
-sensations disappear and reappear in a definite order:
1) Pain (first to disappear and last to reappear)
2) Temperature (cold, then warm)
3) Touch
4) Pressure
5) Motor
-small, unmyelinated nerve fibers (pain, temp, autonomics) more sensitive to LA than larger, myelinated
fibers
Mechanism of Action of Local Anesthetics
-when injected into tissue, LA exists in both ionized and non-ionized forms
-non-ionized form penetrates tissue readily b/c lipophilic aromatic ring passes through nerve
sheath and membrane
-re-equilibration btw ionized and non-ionized forms occurs within nerve cell
-ionized form then inhibits nerve membrane’s Na+ channels, preventing inflow of Na+ to prevent
formation of action potentials
-infxn causes tissue to become acidic, resulting in increased ionized form of LA at expense of non-ionized
form
-this prevents passage of LA through nerve membrane, decreasing effectiveness
-LA can be mixed w/ sodium bicarbonate to alkalinize the solution to decrease pain upon infiltration and
increase effectiveness
-LA work best at pH above 7 b/c drop in PH shifts LA to ionized form

Pharmacokinetics of Local Anesthetics

-redistribution of LA affected by:
1) diffusion away from site of action
2) vascularity of injection site (increased blood flow causes shorter duration of action)
3) increased protein binding/increased lipid solubility (increased duration of action)
-duration of LA is directly proportional to protein binding and lipid solubility
-the lower the pKa of LA, the faster the onset

Systemic Toxicities of Local Anesthetics

-LA toxicity due to elevated plasma levels of LA due to intravascular injxn or overdose
-children and elderly are at most risk for LA toxicity
1) Mild toxicity: circumoral numbness, tachycardia, HTN, tinnitus, metallic taste, talkative, apprehension,
excitability, slurred speech, dizziness, disoriented
2) Mod. toxicity: tremor, hallucination, hypotension, bradycardia, decreased cardiac output
3) Severe toxicity: seizure, cardiac and resp. depression, coma, death
-seizures are most common side effect from systemic absorption of toxic amt of LA
4) Allergic Responses: ester LA have high incidence (5%), amide LA have low incidence (<1%)
-p-aminobenzoic acid (PABA) in esters induce allergic rxn
-if pt allergic to both esters and amides, can give Benadryl (diphenhydramine)
-metabisulfate is an antioxidant which protects vasoconstrictor from oxidation and has low
allergenicity
-methylparaben is bacteriostatic preservative that can cause allergic rxn as well
-responsible for rare allergic rxn in amide LA
5) Methemoglobinemia: condition unique to receiving doses of prilocaine over 600mg
-methemoglobin can’t bind/carry oxygen
-signs: decreased pulse-ox, cyanosis, chocolate-colored blood
-treated w/ methylene blue by IV

Trismus
-caused by IA injxn directed into medial pterygoid muscle
-causes spasm of muscle
-management: apply hot, moist towels to site for 20 mins every hour, analgesics, and gradual
opening/closing of mouth

Vasoconstrictors
-vasoconstrictors increase the duration of LA action (primary)
-decrease systemic toxicity by decreasing rate of systemic absorption (secondary)
-reduces bleeding by decreasing blood flow into operative area (only infiltrations, not nerve
blocks)
-reduce rate of vascular absorption by causing vasoconstriction
-help make anesthesia more profound by increasing conc. of LA at nerve membrane
-vasoconstrictors act at alpha receptors to constrict arterioles
Drug Interactions w/ Vasoconstrictors
1) Antidepressants (tricyclic and polycyclic)
-increased sensitivity to Epi
2) Nonspecific beta-blockers (propranolol)
-enhance peripheral alpha-1 adrenergic effects (increased BP w/o tachycardia)
3) Max doses
a) healthy pt: 200 ug Epi
b) Cardiovascular pt: 40 ug Epi

Pregnancy and Local Anesthetics

1) Class C:
a) bupivicaine c) articaine
b) mepivicaine d) Epi
2) Class B:
a) lidocaine
b) prilocaine
c) etidocaine (no longer on market)

Trigeminal Nerve
-CN V
-is both sensory and motor nerve
-originates in pons
-3 branches:
1) Opthalmic nerve (V1): nasociliary, supraorbital, lacrimal, frontal, supratrochlear, and
infratrochlear nerves
2) Maxillary nerve (V2): zygomatic, PSA, MSA, ASA, infraorbital, greater palatine, and
nasopalatine nerves
3) Mandibular nerve (V3): auriculotemporal, lingual, buccal, and IA/mental nerves

Needle Dimensions
1) Length
a) Short needle: 20mm
b) Long needle: 32mm
2) Diameter
a) 30 gauge: 0.3mm
b) 27 gauge: 0.4mm
c) 25 gauge: 0.5mm
-positive aspiration is directly correlated to needle gauge
-larger gauge needles don’t deflect as often
-larger gauge needles don’t break as often (97% of needle breaks involve 30 gauge needles)
-pts can’t tell the difference btw 25, 27, and 30 gauge needles

Posterior Superior Alveolar (PSA) Block

1) Area of anesthesia: max. 3rd molar to max. 1st molar
-doesn’t anesthetize palatal tissue (possibly does for MB of max. 1st molar)
2) Technique: go in distal to malar process 45 degrees to mesiodistal plane and to buccolingual plane
-insert needle 15mm in depth

Anterior Superior Alveolar (ASA) Block (Infraorbital Nerve Block)

1) Area of anesthesia: midline of maxilla to MB of max. 1st molar
-affects ASA, MSA, inferior palpebral, lateral nasal, and superior labial nerves
-doesn’t anesthetize palatal tissue
2) Technique: needle penetrates over max. 1st PM 15mm deep and lateral to buccal vestibule
-needle touches bone as endpoint and 1mL of anesthetic is injected slowly
-pressure applied for 2 minutes
Greater Palatine Block
1) Area of anesthesia: from canine to posterior aspect of hard palate, as well as from gingival margin to
midline of palate
-greater palatine foramen located halfway btw gingival margin and midline palate 5mm anterior to
jxn of hard and soft palates
2) Technique: initially use topical and pressure anesthesia (20 seconds minimum) and penetrate at location
of greater palatine foramen at depth of bone (~5mm)

Nasopalatine Block
1) Area of anesthesia: palatal tissue from canine to canine (premaxilla area)
2) Technique: topical and pressure anesthesia initially, then insert needle tip 45 degrees to palatal soft tissue
at jxn of palate and incisive papilla at depth of bone

Mental Nerve Block (Incisive Block)

1) Area of anesthesia: soft tissue on buccal from premolars to midline lip, chin, periosteum, and bone
2) Technique: insert needle in depth of buccal vestibule opposite mand. PM at 5mm depth
-use ½ carpule

Mandibular Block (IA Block)

1) Area of anesthesia: pulps and buccal soft tissue of mand. teeth (except area innervated by buccal nerve),
lip, chin, periosteum, and bone in area
2) Techniques
a) Traditional (Halstead) method
-penetrate 1-1.5 cm above and parallel to mandibular occlusal plane, approaching from
contralateral premolars
-needle endpoint should be 50% of mesiodistal length of ramus
-advance needle until hit bone, withdraw 1mm, aspirate, and inject ¾ carp
-withdraw needle 10-15mm, aspirate, and inject rest to hit lingual nerve
-save tiny bit for long buccal block if needed
b) Akinosi Technique
-anesthetizes IA, lingual, and buccal nerves
-useful in uncooperative children and pts w/ trismus
-needle inserted parallel to max. occlusal plane at level of max. buccal vestibule
-penetrate half distance of MD length of ramus (25mm)
-no bony endpoint (ends just superior to lingula)
-hub of needle should be opposite mesial aspect of max. 2nd molar
c) Gow-Gates Technique
-anesthetizes IA, lingual, long buccal, auriculotemporal, and mylohyoid nerves
-have pt open as wide as possible to rotate and translate condyle forward
-palpate condyle and retract cheek
-begin from contralateral canine and penetrate at DB cusp of max 2nd molar
-insert needle 25-30mm until contact bone, withdraw slightly
-inject anesthetic, which is not near nerve, but around 1cm superior to it in superior
aspect of pterygomandibular space

Part 10: Conscious Sedation

ASA Physical Status Classifications
1) PS I: normal, healthy pt
2) PS II: mild systemic disease
3) PS III: severe systemic disease that is not incapacitating
4) PS IV: severe systemic disease that is constant threat to life
5) PS V: moribund pt who will die w/o operation
6) PS VI: brain-dead pt whose organs are being removed for donor purposes
Guedel’s Signs/Stages of Anesthesia
1) Amnesia and analgesia: preservation of protective reflexes
-stage ends w/ loss of consciousness
-conscious sedation falls under this stage
2) Delirium and excitement: involuntary movements, obtunded reflexes, irregular breathing occurs
-stage ends w/ onset of total anesthesia
-nausea and vomiting common in this stage (may lead to aspiration of vomit)
3) Surgical anesthesia: can be light, medium (ideal for invasive surgery), and deep
-skeletal muscles relax and breathing becomes regular
4) Medullary paralysis/premortem: very deep anesthesia w/ loss of cardiovascular fxn w/ imminent death
stages 1 and 2 combined are termed induction stage of anesthesia

Neurolept Anesthesia
-combined administration of:
1) Neuroleptic agent (Droperidol)
2) Narcotic analgesic
3) Nitrous oxide
-has slow induction of anesthesia, but return to consciousness is quick after N2O removed

Inhalation Anesthetics
-inhalation anesthesia uptake dependent on:
1) Solubility
a) Blood solubility: decreased blood solubility=rapid induction and recovery time
b) Lipid solubility: increased lipid solubility=increased potency
2) Alveolar blood flow
3) Difference in partial pressure btw alveolar gas and venous blood

Malignant Hyperthermia
-inherited condition that most often occurs when exposed to inhalation anesthetics
-inhalation agents cause increased muscle metabolism which can lead to death
-treated w/ 100% oxygen, cooling procedures, and administration of dantrolene

Minimum Alveolar Concentration

-amt of drug necessary to prevent movement in 50% of pts subjected to standardized stimulus at 1 atm

Blood-Gas Partition Coefficient

-diff btw partial pressures of gas and blood indicated how quickly agent crosses pulmonary membrane into
bloodstream
-higher value, higher the solubility

Properties of Inhalation Anesthetics

1) Gas phase: nitrous oxide
-NO is least potent of inhalation anesthetics
2) Volatile liquid phase: isoflurane, halothane, desflurane, sevoflurane, enflurane

Nitrous Oxide
-colorless, nonirritating gas w/ mild odor and taste
-is potent analgesic, but weak general anesthetic
-works on CNS (reticular activating system and limbic system)
-first symptom is tingling of hands
-requires minimum of 30% oxygen delivery
-no biotransformation
-excreted unchanged by lungs
-is inhalation anesthetic w/ fastest onset of action
-side effects: headache, nausea/vomiting (most common), lethargy, diffusion hypoxia
-N2O should be avoided in pts w/ COPD but is fine in asthmatic pts
Diffusion Hypoxia
-nitrous oxide from bloodstream diffuses into alveoli in lungs for elimination and mixes w/ inhaled room
air that contains 20% oxygen, resulting in hypoxia
-prevented by administering high conc. oxygen during recovery period of nitrous sedation

Occupational Risk from Nitrous Oxide

-prolonged exposure to NO can result in:
1) Bone marrow suppression: megaloblastic anemia, leucopenia
2) Neurological deficits: peripheral neuropathy, pernicious anemia

Part 11: IV and Enteral Sedation

Procedure for IV Sedation
-usually done w/ 21 gauge needle placed into median cephalic vein
-avoid entering brachial artery, which causes burning at site, blotchy arm, and weak pulse

Barbiturates
-act as sedatives and hypnotics
-are potent anesthetics, but weak analgesics
-act by depressing CNS activity by decreasing rate of GABA dissociation at its receptor
-increases duration of chloride channel opening to decrease neuronal firing
-this prolongs the inhibitory effect of GABA in reticular activating system (RAS)
-are very lipid-soluble which results in very rapid onset of action; why they are used for induction of
anesthesia b/c produce unconsciousness in less than 30 seconds
-agents:
1) Thiopental (Pentothal): ultra-short acting agent
- has high lipid solubility so crosses BBB quickly
2) Methohexital: ultra-short acting
3) Phenobarbital: long-acting agent

Benzodiazepines
-act as anxiolytics, anticonvulsants, antispasmodics, sedatives, and amnesics
-act by enhancing binding of GABA to GABA receptors
-increases frequency of chloride channel opening to decrease neuronal firing
-available in oral and IV forms
-risk of respiratory depression and coma is less for benzos than barbiturates
-agents:
1) Short-acting: triazolam (Halcion) and midazolam (Versed)
2) Intermediate-acting: alprazolam (Xanax)
3) Long-acting: diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Librium)
-flumenazil is used to reverse effects of benzos by competing at GABA receptor (antagonist)
-effect lasts only 20 minutes, so beware of re-sedation
-presence of propylene glycol in IV mixture for benzos can cause phlebitis (irritation/inflammation of vein)

Propofol (Diprivan)
-IV sedative agent that is highly lipophilic
-good for outpatient anesthesia due to its rapid induction and recovery and low incidence of
nausea/vomiting
-nicknames “Milk of Amnesia”
Ketamine
-is NMDA receptor agonist and short-acting
-produces dissociative anesthesia (dissociation btw thalamus and limbic system)
-pt appears awake, but is unconscious and doesn’t feel pain
-is quick form of anesthesia good for short procedures
-is cardiovascular stimulant
-can cause postop disorientation and hallucinations
-often used in children and young adults

Chloral Hydrate
-CNS depressant used in children
-active metabolite is trichloroethanol
-has onset of 30 mins to 1 hr and lasts for 4-8 hours
-toxicity causes hypotension, resp. depression, hypothermia, cardiac arrhythmia, and coma
-contraindicated in hepatic and renal impaired pts

Opioids
-narcotics that act as agonists on mu, delta, kappa, and sigma receptors in CNS
-provide analgesia and euphoria
-available in oral and IV forms:
1) Fentanyl: IV, oral
2) Sufentanil: IV
3) Alfentanil: IV
4) Morphine: IV, oral
5) Codeine: oral
6) Meperidine (Demerol): IV, oral
-naloxone is mu-receptor agonist that reverses effect of opioids

Opioid Adverse Effects

1) Pruritis (from histamine release)
2) Nausea/vomiting
3) Urinary retention
4) Constipation
5) Miosis
6) Resp. depression

Opioid Withdrawal
1) HTN 6) Restlessness
2) Piloerection, chills 7) Mydriasis
3) Sweating 8) Lacrimation and rhinorrhea
4) Nausea/vomiting 9) Insomnia
5) Abdominal cramping
-opioid withdrawal is not life-threatening like alcohol or benzo withdrawal is
Complications of Sedation
1) Malignant hyperthermia: prevents release of calcium from sarcoplasmic reticulum of skeletal muscle,
leading to persistent contraction
-rigidity, fever, tachycardia, hypoxia
-triggered by succinylcholine and Halothane
-treated w/ Dantrolene
2) Phlebitis: inflammation of superficial veins that can occur after insertion of IV
- pain, tenderness, induration, erythema
-treated w/ elevating limb, moist heat, NSAIDs
3) Laryngospasm: forceful, involuntary spasm of laryngeal muscles caused by oral fluids triggering
laryngeal reflex during lighter stages of anesthesia
-prevented by using pharyngeal barrier and tonsil suction
-treated w/ positive pressure oxygen-supplemented ventilation w/ facemask
-if still persists, use succinylcholine or last resort cricothyrotomy
-most common complication of office-based anesthesia is loss of airway
-most common dental emergency is syncope

Syncope
-transient loss of consciousness caused by transient cerebral hypoxia
-txt: 1) place pt in supine position w/ feet slightly elevated (Tendelenburg position)
2) Establish airway by chin left and administer 100% oxygen
3) Monitor vital signs

Vital Signs
1) Temperature: normal oral temp is 98.6 F or 37 C
2) Heart rate: normal range is 60-80 bpm
3) Blood pressure: normal is 120/80
4) Respiratory rate: normal range is 12-18 breaths/min

Cardiopulmonary Resuscitation (CPR)

-ABCDs
1) Airway: head tilt or jaw thrust (if neck trauma suspected)
2) Breathing: is respiration absent/inadequate, must provide rescue breathing
-bag-valve mask
-ventilation rate: 1 breath every 5-6 seconds (10-12 breaths/min)
-child rate is one breath every 3 seconds (20 breaths/min)
3) Circulation: check pulse and if absent, initiate chest compressions
-compression to ventilation ratio is 30:2
4) Defibrillation
-time interval from first defribrillation is most impt factor in determining survival
-for every 1 min delay btw defrib. and collapse decreases survival by 10%

Shock
-syndrome in which there is inadequate cellular perfusion/oxygen for metabolic demands of tissues
-reduced cardiac output is main factor in all types of shock
-characterized by:
1) increased vascular resistance 4) myocardial ischemia
2) tachycardia (increased HR) 5) mental status change
3) adrenergic response (sweating)

Stages of Shock
1) Compensatory: compensatory mechanisms attempt to maintain perfusion to vital organs
-increased HR and peripheral resistance
2) Progressive: metabolic acidosis
3) Irreversible: organ damage occurs and survival not possible
Categories of Shock
1) Hypovolemic: produced by reduction in blood volume
-caused by hemorrhage, dehydration, vomiting, diarrhea, and fluid loss from burns
2) Cardiogenic: circulatory collapse from pump failure of left ventricle
-caused by massive myocardial infarction
3) Septic: due to severe infxn
-caused by gram- endotoxins
4) Neurogenic: results from severe injury/trauma to CNS
5) Anaphylactic: occurs w/ severe allergic rxn

Complete Blood Count

1) Hematocrit: percentage of RBCs in whole blood
-men: 40-54%; women: 37-47%
2) Total WBCs: normal is 5000-10,000; dental infxn is 15,000-20,000
3) Hemoglobin: men is 14-18; women is 12-16
4) Total RBCs

Bleeding Times
1) Bleeding time: 1-9 minutes
2) Prothrombin time (PT): 11-16 seconds
3) Partial thromboplastin time (PTT): 32-46 seconds
-warfarin increases PT and PTT

Concern For Insulin-Dependent Diabetics

-major concern is hypoglycemia

Symptoms of Dehydration
1) Oliguria
2) Rise in body temp
3) Increase in HR and cardiac output
4) Decrease in blood pressure
5) Severe cell dysfxn

Breathing Terms
1) Apnea: transient cessation or absence of breathing
2) Hypercapnea: excess CO2 in arterial blood
3) Hypocapnea: below normal CO2 in arterial blood
4) Dyspnea: difficulty breathing
5) Respiratory arrest: permt cessation of breathing
5) Hyperapnea: abnormally deep and rapid breathing
6) Hyperventilation: increased pulmonary ventilation in excess of metabolic requirements
-results in loss of CO2 from blood
7) Hypoventilation: underventilation in relation to metabolic requirements
-results in increased levels of CO2 in blood
8) Atelectasis: occurs when mucus/foreign object obstructs airflow in bronchus, causing collapse of lung
tissue into airless state
-prolonged atelectasis leads to pneumonia
9) Pneumothorax: occurs when air leaks into pleural space causing lung to recoil from chest wall

Treating Patients on Dialysis

-should treat them the day after dialysis