NBDE II Oral Surgery Cram Notes 10/14

NDBE II - ORAL SURGERY CRAM NOTES

Adrenal Cortex

Pt on small doses (Predisone 5mg/day) will have suppression when they have been on it for 1 month
Pt on Prednisone (20-30mg/day = 100mg Cortisol/day) have suppression after 1 week
Short term tx of high dose steroids will NOT alter adrenal cortical function

May take 1 year to regain adrenal cortical function if one suppressive doses of steroids

Signs of Adrenal Crisis

- lightheaded, dizziness, weakness, sweating, abdominal pain, N&V, loss of consciousness

Tx: of Adrenal Crisis

- Hydrocortisone IM
- IV fluids for hypotension

Normal daily secretion of cortisol is 20mg, when stressed out 200mg

If pt taking >=20mg Prednisone a day, consider supplementation

Also consider if taken acute dose higher then Prednisone 10-20mg/day within last 2 weeks

If currently taking steroids, double dose on day of surgery, and possibly the next day if in a lot of pain
If < 2 weeks after steroid therapy discontinued, double daily maintenance dose on day of surgery
If > 2 weeks after steroid therapy discontinued, none needed

Anterior Pituitary releases ACTH to cause adrenal cortex to release glucocorticoids.

If stressed, anterior pituitary releases  ACTH, thus  steroid output
If  steroids circulating, ant. Pituitary  ACTH, thus atrophy of adrenal cortex

Cushings Syndrome – prolonged exposure of high levels of cortisol

Anatomy

Parasympathetic secretomotor fibers from CN VII via CORDA TYMPANI n. & LINGUAL n. to Submandibular ganglion.

Innervation of Tongue

Ant 2/3
Sensory - CN V-3 - lingual n.
Taste – CN VII (FACIAL n.) via chorda tympani n.
Motor – CN XII hypoglossal n.

Post 1/3
Taste & Sensation – CN IX – glossopharyngeal n.
Motor – CN XII – hypoglossal n.

Lingual n. = floor of mouth

= md lingual gingival
= ant. 2/3 of tongue sensory

Aurticulotemporal n. = TMJ
= Auricle
= External auditory meatus

Long Buccal n. = cheek

= Md buccal gingival
NBDE II Oral Surgery Cram Notes 10/14
Innervation of Palate
Sensory
Ant. 1/3 – Incisive foramen has NASOPALATINE n.
Post. 2/3 – Greater Palatine foramen – GREATER PALATINE n.
Soft Palate – Lesser Palatine foramen – LESSER PALATINE n.

Motor
TENSOR VELI PALATINI m. innervated by CN V-3, all other muscles are CN X (vagus n.)

CN V-1: Opthalmic branch – Sensory

- cornea, skin of scalp, forehead, eyelids, nasal cavity

CN V-2: Maxillary branch – Sensorry

- skin over maxilla, upper teeth and gingival, mx sinus

CN V-3: Md branch – Sensory & Motor

- Sensory: skin over md, lower teeth and gingival, TMJ, floor of mouth, ant tongue
- Motor: Muscles of Mastication (Masseter m, Temporalis m., Lat. Pterygoid m., Med. Pterygoid m.)

Blood Supply
External carotid a.  Maxillary a.  pharyngeal a.
 descending palatine a. (soft palate/gingiva/hard palate)
 ptergoid canal a.
 Sphenopalatine a.
 Infraorbital a.
 post. Sup. Alveolar a.
 mid. Sup. Alv. A.
 ant. Sup. Alv. A.
 Inf. Alv. A.
 mental branch
 incisive branch
 muscles of mastication

I nfratem poral Fossa

Boundaries:
Posterior to Mx
Inferior to greater wing of sphenoid
Medial to coronoid process and ramus
Lateral to layer pterygoid plate

Communicates w Pterygopalatine fossa via pterygomaxillary fissure

Communicates w Orbit via inferior orbital fissure

Contents:
Lateral pterygoid m.
Medial pyerygoid m.
Lower part of temporalis m.
Maxillary a.
Pterygoid venous plexus
Md nerve
Otic ganglion
Chorda tympani
NBDE II Oral Surgery Cram Notes 10/14

P terygopalatine Fossa
- below and behind orbit
- no lateral wall, on lateral side is pterygomaxillary fissure
- contents:
o Mx n.
o Mx a.
o PSA n.
o Zygomatic n.
o Ganglionic branches

Carotid Sheath
Contains:
Carotid a.
Internal jugular v.
Vagus n.
Deep cervical lymph nodes

Location:
Lateral boundary of retropharyngeal space
Deep to sternocleidomastoid m.
To base of skull
To first rub

Facial v.  retromandibular v.  internal jugular v.  subclavian v.  brachiocephalic v.  superior vena cava

M ylohyoid m .
- innervated by CN V-3
- function: elevates hyoid bone, base of tongue, floor of mouth
- inferior to sublingual gland

Masticator Space
Made up of
1. Masseteric
2. Pyerygomandibular
3. Temporal space
- all bound by muscles and fascia of mastication.
- Infections usually are dental related, or needle tract infections
- Infection in this area is dominated by trismus, pain and swelling

Tongue
Motor Innervated CN Hypoglossus
- if damaged unilaterally – result is ipsilateral atrophy of tongue

Muscles of Tongue
Intrinsic
1. Transverse
2.
3.

Extrinsic
1. Genioglossus – protrudes tongue
2. Hyoglossus -
3. Styloglossus -

Taste Buds
NBDE II Oral Surgery Cram Notes 10/14
Circumvallate Papilla
- surrounded by Von Ebner’s glands (release serious mucous to rinse away food from papilla)

Facial N erve
Exits via STYLOMASTOID FORAMEN
4 components
1. Brancial Motor: muscle of facial expression, post. Belly of diagastric, stylohyoid m., stapedius m.
2. Visceral Motor: parasympathetic to lacrimal, submd, and sublingual glands, other mucous membranes in
nasopharynx, hard and soft palate
3. Special sensory: taste to ant 2/3 of tongue
4. general sensory: skin of concha, auricle and behind ear.

Sinus
Frontal sinusitis – forehead pain
Ethmoid Sinusitis – paid btw eyes, bridge of nose
Maxillary Sinusitis – pain in midface, mx post. Teeth, cheek
Sphenoid Sinusitis – pain behind eyes or at the back of the head.

Maxillary Sinus innervated by PSA, MSA, ASA and infraorbital n.

Lingual a.
- branches off external carotid a.
- lingual a. branches into 4.
1. suprahyoid a.
2. dorsal lingual a. – dorsum of tongue
3. sublingual a. – floor of mouth and sublingual gland.
4. deep lingual a. – ant. 2/3 of tongue

Pterygomandibular space

Contents:
1. Inf. Alv. N.
2. Inf. Alv. A.
3. lingual n.

Pterygomandibular Raphe – insertion point of buccinator m. & superior constrictor m.

The pterygomandibular raphé (pterygomandibular ligament) is a tendinous band of the buccopharyngeal fascia,
attached by one extremity to the hamulus of the medial pterygoid plate, and by the other to the posterior end of the
mylohyoid line of the mandible.
• Its medial surface is covered by the mucous membrane of the mouth.
• Its lateral surface is separated from the ramus of the mandible by a quantity of adipose tissue.
• Its posterior border gives attachment to the superior pharyngeal constrictor muscle.
• Its anterior border attaches to the posterior edge of the buccinator.

Lymphatic Drainage

Parotid/EAM/lateral eye lid/middle ear  Parotid Lymph Nodes  Deep Cervical Lymph Nodes

Front scalp/nose/cheek/lips (not center)/teeth(not md centrals)/ant 2/3 tongue/floor of mouth/gingival

submandibular lymph nodes  deep cervical lymph nodes

Tip of tongue/floor on mouth beneath tongue/md incisors/center of lower lip/chin  submental lymph nodes
submandibular & deep cervical lymph nodes

Salivary Glands
NBDE II Oral Surgery Cram Notes 10/14
1. Sublingual Gland
- majority mucous cells
- floor of mouth close to mid-line
- mylohyoid m. supports sublingual gland inferiorly
- small mucous ducts – RIVIAN ducts
- innervated by CN VII via CHORDA TYMPANI n. & CN V-3 via LINGUAL n. (synapse in sublingual ganglion)
- vascular supply: SUBLINGUAL a. (branch off lingual a. from external carotid a.)

2. Parotid
- parasympathetic innervation by CN IX – glossopharyngeal n. (passes through foramen ovale)
- meets with CN V-3 and preganglionic synapse in OTIC GANGLION
- combine w auriculotemporal n. and go to gland
- largest gland and purely serous,
- blood supply from external carotid a., maxillary a., superficial temporal a.

3. Submandibular

Anaesthesia

Induction – Stage 1 and 2 of GA

Depth of anaesthesia depends on tension (partial pressure) of agent on brain

- rates of induction/recovery depend on rate of change of tension

Maintenance – process of keeping pt in surgical anaesthesia

Recovery – delivery of anaesthesia is stopped, and anaesthetic has been eliminated from the body

The most resistant part of the brain to anesthetic is the medulla oblongata

MAC (minimum alveolar concentration) – alveolar [ ] of anaesthetic at which 50% of population is unresponsive to
standard surgical stimulus

Optimum Site for IV sedation for outpatient = Median Cephalic Vein (lateral to antecubital fossa)

Inhalation Anaesthetics = Enflurane, Halothane, Isoflurane, Sevoflurane, Desflurane, NO2 (gas)

The first 5 are volatile liquids

All inhalation agents can cause Malignant Hypothermia

Speed of Induction of anaesthetic effect depends on:

1. Solubility (MOST IMPORTANT)
2. Inspired gas partial pressure
3. ventilation rate
4. pulmonary blood flow
5. Arteriovenous [ ] gradient

Dissociative Anaesthesia – Ketamine

- produces a trancelike state for 10-30min
- the pt’s eyes stay open but they are dazed
- as medication wears off, the pt may have intense dreams

Malignant Hypothermia
- sudden rapid rise in body temperature
-  CO2,  sympathetic NS activity

Causes of MH
1. all potent inhalational agents
2. All depolarizing muscle relaxants (succinylcholine)
NBDE II Oral Surgery Cram Notes 10/14
Tx of MH
1. Dantrolene
2. 100% O2
3. Cooling procedures

Psychogenic Reaction (i.e. fainting) – caused by psychological factors rather then physical factors (i.e. drugs)
Somatogenic Reaction – a reaction from an organic pathophysiologic cause

Local Anaesthetics
Max Lidocaine = 7mg/kg (480mg MAX)

Neuroleptic Anaesthesia
= Neuroleptic + Narcotic + NO2
= neurolept ANALGESIA + unconsciousness

Neuroleptic ANALGESIA is conscious and can respond = neuroleptic + narcotic

Neuropletic Anaesthesia = neurolept + NO2, pt is unconscious

Syncope
- pt symptoms = warmth, nausea, palpitations, dizzy, weak
- Signs = sweating, tachycardia,  PVR
- Blood pools in periphery,  cerebral blood flow
- Compensatory mechanisms kick in, but fail and lead to Vagally mediated bradycardia
- Place pt supine, monitor vitals, O2 by nasal cannula
- Watch for tongue obstruction, head tilt & chin lift

Trismus from LA is from puncturing Medial Pterygoid m.

Tx – hot compress, analgesics, stretching

Geudel’s Stages of Anaesthesia

Stage 1 – Amnesia & Analgesia – anaesthesia  loss of consciousness, all reflexes present
Stage 2 – Delirium & Excitement – loss of cosciousness  onset of total anaesthesia, not a stable stage
Stage 3 – Surgical Anaesthesia – regular breathing, total loss of consciousness, signs of resp and cvs failure potential. 4
planes within this stage
Stage 4 – Premortem – Signals danger – pupils are maximally dilated, skin is cold, BP very low, eyes non-reactive to
bright light when functional circulation to the brain has stopped

Laryngospasm
- when blood/saliva collects near vocal cords, pt goes into spasm, vocal cords close,
- tx: O2, and succinylcholine – skeletal muscle relaxant

Propylene Glycol in IV fluids can cause Phlebitis

PHLEBITIS: irritation/inflammation of a vein. Causes pain, tenderness, edema, erythema,

SHOCK
- inadequate cellular perfusion and inadequate O2 delivery for the metabolic demands of the tissues, resulting primarily
from CO
1. Compensatory Stage - HR, PVR
2. Progressive Stage – metabolic acidosis, compensatory mechanisms don’t work
3. Irreversible (refractory stage) – organ damage, death is immanent

Types of Shock
1. Hypovolimeic shock -  blood volume,
2. Cardiogenic shock – circulatory collapse, pulp failure of the left ventricle, due to big MI
3. Septic shock – from severe infection, endotoxins of G- bacteria
4. Neurogenic shock – severe trauma/injury to CNS
5. Analphylactic shock – severe allergic reaction
NBDE II Oral Surgery Cram Notes 10/14
LA MOA
- inhibit excitation of nerve by blocking conduction. Reversibly binding and inactivating sodium channels
- site of action is lipoprotein sheath of nerve
- small myelinated nerves which propagate pain are affected first, then touch, proprioception, skeletal muscle
tone.

Loss of Function from LA

1. Pain
2. Temp
3. Touch
4. Deep Pressure
5. Skeletal muscle tone
NOTE: regaining of function is in opposite order. Thus pain is first to be lost and last to come back
Pain fibers are A delta and C fibers. They fire rapidly and APs last long. They are the first to be blocked by LA.

LA physiologic activity depends on their

1. Lipid Solubility: potency is dependent on lipid solubility,  lipid solubility = faster nerve penetration
2. Diffusibility: of LA through tissue influences speed of action onset
3. Affinity for protein binding: related to duration of action,  protein binding =  duration
4. % ionization at physiologic pH: non-ionized form (base) diffuses across nerve membrane and works
5. vasodilating properties

Lidocaine toxicity
- sedative effect on brain (CNS)  drowsiness & slurred speech  unconsciousness  coma
- other LA initial toxicity is usually excitatory before inhibitory
- if pt goes into convulsions, O2 + Diazepam IV

Amide LA – metabolized in Liver

Esther LA – metabolized in blood plasma via pseudocholinesterase  PABA

Biopsies

Technique
1. Anaesthesia – blocks where possible, if using infiltration – 1cm away from lesion
2. Tissue stabilization – fingers/clamps
3. Hemostasis – gauze (avoid high vol. suction)
4. Incision – with sharp scalpel
5. Extent of tissue – include some normal tissue
6. Handling of tissue – use a traction suture, avoid forceps
7. specimen care – put in 10% formalin solution right away

Methods of Biopsy
1. Need/Aspiration –
2. Open biopsy – organ exposed and tissue sample taken
3. Closed biopsy – use of a visualization device to locate lesion, requires smaller incision for access

Indications to Biopsy
1. Non-healing oral ulcer > 2 weeks
2. pigmented lesions
3. tissue associated with paresthesia
4. lesion that suddenly enlarges

Always aspirate a lesion if it is compressible, pulsable, blue, a beat (bruit) is heard, central bone lesions

Diseases/Conditions

Hemophilia A – Factor VIII deficiency, sex-linked recessive trait

NBDE II Oral Surgery Cram Notes 10/14
Hemophilia B – Factor IX deficiency
Hemophilia C – Factor XI deficiency

Characteristics of Hemophilia
1.  PTT
2. normal PT
3. normal bleeding time

Rheumatic Fever
- result of Group A beta hemolytic Step infection
- results in valve damage to heart (esp mitral valve)

COPD = emphysema or chronic bronchitis

- if airflow obstruction is chronic, progressive, and fixed then COPD

Emphysema = barrel chested = pink puffer

- from distal air spaces becoming enlarged, and lungs are hyperinflated
- lungs loose elasticity, thus hard to exhale

Chronic Bronchitis = Blue Bloater

- inflamed bronchi, thus hard for air to flow, heavy mucous/phlegm, 3 months of year x 2 years
Atelectasis – obstruction in bronchi, leading to lung collapse
Pneumothorax – air leaks into pleural space, lung recoils from chest wall.

Acidosis – blood has too much acid,  pH of blood (7.3), pt CNS is depressed, disoriented, coma
- severe acidosis occurs during CPR

Alkalosis – blood has too much base,  blood pH, overexitable nervous system, results in tetany

Metabolic Acidosis -  blood pH,  HCO3,

- causes: diabetic, lactic acidosis, severe dehydration, some drugs (ASA, methanol)

Respiratory Acidosis -  blood pH,  CO2 in blood due to  lung function (i.e.  resp rate)

Tx of Acidosis – give HCO3

Metabolic Alkalosis -  blood pH,  HCO3,

Causes: diuretics, cushings, hyperaldosteronism, hypoparathryoidism

Respiratory Alkalosis -  blood pH,  CO2 in blood due to rapid & deep breathing,
Causes: anxiety, pain, fever,  blood O2, hypoxia, pregnancy, hyperthyroidism, ASA OD

Tx of Alkalosis: ammonium chloride

Extractions

Forces used during tooth extraction: Rotation & Luxation

Class II lever is used during tooth extraction

 Pivot Point/Fulcrum Effort

NBDE II Oral Surgery Cram Notes 10/14

Oral Antral Communication

If small – no additional surgical tx

If moderate size (2-6mm) – figure-8 suture over tooth socket
If large size (>7mm) – close with a flap procedure

Post op Instructions
- avoid blowing nose for 7 days
- sneeze through mouth
- avoid vigorous rinsing
- soft diet for 3 days

Rx: Otravin (decongestant), Antibiotics (Amoxil), Sudafed (systemic decongestant).

If small non-infected root tip (2-3mm) is displaced into sinus then just leave it
If it is large piece or whole tooth, then you must do a Caldwell-Luc approach to remove it.

Stages of Wound Healing

1. Inflammatory Stage: vascular & cellular phase – PMNs and lymphocytes, macrophages are important
2. Proliferative Stage: fibroblastic stage: collagen and new blood vessels are produced
3. Maturation Stage: remodeling stage: collagen fibers continue to  tensile strength

2 methods of wound healing

1. Primary Intention: re-epithelialization and collagen formation allowing the wound to be sealed in 24 hours.
2. Secondary Intention: involves re-epithelialization via migration from the wound edges, collagen deposition in the CT,
contracture, and remodeling. Site fills in with granulation tissue, healing is slower, leaves scar and depression.

Flaps
- broad base
- finish coronally at the line angle of a tooth, not on the buccal surface

Dry-Socket
- increased fibrinolytic activity causes lysis of blood clot
- caused by smoking, premature mouth rinsing, possibly birth control
- signs/symptoms: pain, bad taste, bad odour, poorly healing socket, throbbing pain
- tx: irrigate with warm saline gently, place eugenol dressing (replace q48h), analgesics prn, no need for
antibiotics
- don’t curette socket, it will delay healing and possibly spread inflammatory condition.

Contraindications to Extractions
Local Factors Systemic factors
Acute infection w uncontrolled cellulites Uncontrolled DM
Acute Pericoronitis Uncontrolled CVD
Acute infectious stomatitis Severe bleeding disorder
Malignant disase Uncontrolled leukemias
Irradiate jaws Debilitating disease
ANUG Pts on certain meds (immunosuppressants, steroids,
cancer tx)

Exo of Primary Maxillary molars – deliver lingually, palatal root less likely to break

If Mx tuberosity comes out with tooth, smooth out remaining bone

If mx tuberosity fractured, but intact, then reposition and stabilize with sutures
Most commonly occurs during exo of 7 or 8

Submandibular Space
- bounded by oral mucosa and tongue anterior and medially
NBDE II Oral Surgery Cram Notes 10/14
- superficial layer of deep cervical fascia laterally
- hyoid bone inferiorly
- makes up the sublingual and submaxillary space, divided by the mylohyoid m.

Submental Space
- medial part of the submaxillary space
- drains the lower lip, tip of tongue, md incisors and canine

Sublingual Space
- superior part of submandibular space, contains sublingual gland

5 Phases of Healing of an Exo Site

1. Hemorrhage and Clot Formation
2. Organization of clot by granulation tissue
3. Replacement of granulation tissue by CT and epithelialization of site
4. Replacement of CT by fibrillar bone
5. Recontouring of the alveolar bone and bone maturation

When exo Mx teeth – occlusal plane to surgeons shoulder, stand infront or to the side

When exo Md teeth – occlusal plane parallel to floor when open and at level of elbow, stand behind or to the side

Fracture Healing
Primary Bone Healing – direct attempt by the cortex to re-establish itself after break
Bone on either sides of cortex must unite to reestablish mechanical continuity
Bone resorbing cells on one side of fracture tunnel and re-establish new haversian systems providing pathways for
penetration of blood vessels.

Secondary Bone Healing

1. Hemorrhage – early inflammatory – occurs first and is associated with clot organization and proliferation of
blood vessels. (Days 1-10)
2. Callus formation – repair – primary callus is formed Days 10-20, secondary callus forms days 20-60
3. Functional reconstruction – late remodeling – mechanical forces are important in this phase. Haversian systems
are lined up according to stress lines, excess bone is removed, takes 2-3 years

Endosteal proliferation – occurs within bone

Periosteal proliferation – occurs within the CT covering of all bones (periosteum)

Signs and Symptoms of Condylar Fracture

- malocclusion
- lower lip numbness
- mobility, pain, bleeding at fracture site

Tx
Open – direct exposure and reduction via surgical incision,
Closed – external fixation devices, IMF, 3-6 weeks,

Most common mid-face fracture = Zygomaticomaxillary complex fracture

Le Fort 1 – horizontal fracture in the maxillae above the maxillary teeth  OPEN BITE
Le Fort 2 – maxilla separated from facial skeleton, separated bone is pyramidal in shape including palate and maxillary
teeth.  periorbital edema, eccymosis, subconjuctival hemorrhage, nose bleeds
Le Fort 3 – horizontal fracture where entire maxilla and one or more facial bones are separated from upper face 
restricts md movement

First step to tx is to establish proper occlusion.

4 Reasons Fractures DOESN’T HEAL

NBDE II Oral Surgery Cram Notes 10/14
1. Ischema – poorly vascularized bone
2. Excessive Mobility  pseudoarthrosis/pseudo joint may occur
3. Interposition of soft tissue  occurs between fracture ends
4. Infection  compound fractures likely to be infected

Inappropriate Healing
1. Delayed-union  satisfactory healing needs > 6 weeks
2. Non-union  failure of fracture segments to unite properly, due to infection, improper immobilization,
interposition of soft tissue
3. Mal-union  can be delayed or complete union in an improper position, due to improper immobilization and or
reduction

Types of Fractures
1. Greenstick – fracture that only extends only through the cortical portion of the bone without complete fracture
of the bone.
2. Simple – divides a single bone into two distinct parts with no external communication
3. Compound – fracture communicates without outside environment, infection is common
4. Comminuted – multiple fractures in a bone,

Muscles of the Mandible

Group 1 – Masseter, medial Pterygoid, Temporalis
- elevate md,
- upward displacement of the proximal segment

Group 2 – digastric, mylohyoid, geniohyoid, lateral Pterygoid

- depress md
- displace distal fracture inferiorly and posteriorly

Group 3 – lateral Pterygoid

- if condylar neck fracture, moves condyle forward

Md Fracture
Most frequent – Body > Angle > Condyle > symphysis > ramus > coronoid process – least frequent

Types of Closed Reduction

1. Barton Bandage – simplest form, usually temporary
2. Intermaxillary fixation – wiring teeth together, with wiring, arch bars and splints
3. External Skeletal fixation – screws through skin into bone, and the screws held together EO w acrylic splint
4. Direct intraosseous wiring – method of open reduction, holes drilled into bone, and wires threaded through and
tightened.

Phases of Hemostasis
1. Vascular Phase – vasoconstriction of damaged vessels, occurs immediately
2. Platelet Phase – platelets in vessels become stick, mechanically plug the cut vessels, occurs in seconds
3. Coagulation Phase – blood lost outside coagulates via extrinsic and common pathways,
- blood in vessels coagulates through intrinsic and common pathways
- slower phase

Methods to obtain Hemostasis

1. Assisting natural hemostatic mechanism – cotton sponge with pressure or clamp vessel with hemostat
2. use heat on cut vessels
NBDE II Oral Surgery Cram Notes 10/14
3. suture ligation of vessel
4. pressure dressing over wound (most common)
5. vasoconstrictors (epi)

First Aid

In adult, give 1 breath q5-6s, = 10-12 breaths/min

In infant give 1 breath q3s = 20 breaths/min

What is first step in CPR = establish pt is unresponsive

Call EMS as soon as adult is unresponsive
Call EMS after 1 min of CPR on infant/child

1. Call 911
2. Blow – tilt head, chin lift, check breathing, give 2 breaths
3. Pump – 30 pumps on chest 2 inches down,
4. continue 2-3 until EMS arrives

ABC of CPR
A = Airway, head tilt/chin lift,
B = Breathing - check breathing 5-10s, if not breathing, give 2 breaths, if breath doesn’t go in, give Heimlich
maneuver)
C = Circulation – check pulse 5-10s,
If pulse, give 2 breaths q5-6s,
If no pulse, 15 compressions + 2 breaths, check pulse every minute

Treatment of Cysts
Marsupialization – cyst is deroofed and cystic lining is made continuous with the oral cavity, cyst sac is opened and
emptied
- do this when close to vital structures or cyst is very large

Enucleation – total removal of cystic lesion, tx of choice where possible

Bleeding Tests

INR – International Normalized Ratio

- PT ratio, normal pt not on any meds has INR = 1, INR > 5 don’t do anything to them

PTT – partial thromboplastin time – checks intrinsic system

- basic test for hemophiliac, normal value = 25-36s
Bleeding Time – normal value = < 9min
Platelet Count – 150,000 – 450,000, minimal 50,000 count

Taking BP
If using a small cuff, produces falsely elevated readings
If using a big cuff, produces falsely low readings

GRAFTS

Allogenic Bone
- comes in 3 forms
1. Fresh Frozen – not used due to concern of disease transmission
2. Freeze-Dried (FDBA) – osteoconductive, not osteogenic or osteoinductive, usually placed with autogenous
grafts
3. Demineralized Freeze-Dried (DFDBA) – lacks mechanical strength, osteoconductive and osteoinductive. Exposes
BMP, thus induces bone formation

Osteogenesis – ability to form new bone in a graft by transplanting viable osteoblasts

Osteoconduction – ability of the graft to allow vascular and cellular invasion by the host site.
NBDE II Oral Surgery Cram Notes 10/14
Osteoinduction – ability of the graft to stimulate differentiation of mesenchymal cells into osteoblasts at recipient site.

Autogenous/Autograft – bone from the same person from one part of the body to another part in the same body.
3 types of graft autogenous grafts
1. Cortical – able to withstand early mechanical forces, need more time to revascularize, from cranial vault, iliac crest,
ribs, md symphysis
2. Cancellous graft -  healing rate, from ant/post. Iliac crest, inability to provide mechanical stability
3. corticocancellous graft – don’t increase osteogenesis as much as cancellou grafts due to the layer of relative non-
porous cortical bone. Rib, skull, ilium

Isograft – tissue surgically transplanted from an individual of the same species AND genetically related to recipient.

Greatest osteogenic potential is from autogenous cancellous graft with hemopoietic marrow

Osseointegration – the direction connection between living bone and a load-bearing endosseous implant at the light
microscopic level.

Criteria for Success of an Implant

1. clinical immobility under load-bearing conditions
2. symptom free
3. minimal loss of crestal bone
4. no peri-implant radiolucency
5. success rate of 85% after 5 years, and 80% after 10 years

Misc Implant Info

- for implant success you need adequate transfer of force and biocompatibility
- implant handpiece has low speed and high torque
- use Superfloss to clean implant
- if implant is mobile, remove, debride socket, socket preservation technique with resorbable membrane
- you need 10mm of bone to place an implant
- 2mm of bone between implant apex and mandibular nerve
- titanium and titanium alloy are material of choice for implants
- best time to improve keratinized tissue around an implant is at stage II surgery
- GTR may be used to eliminate a boney defect around an implant
- Don’t burn bone around implant (no higher then 116°F or 40? C

Misc Oral Surg

Petechia – pin point bleeding/bruising

Purpura – bruising < 1cm
Ecchymosis – large are of bruising
- occurs from trauma to underlying blood vessels

Platelet count – normal range is 150,000-450,000

Don’t do any procedure if below 50,000
10,000-20,000 may bleed spontaneously
emergency procedure may be done under guidance of hematologist if 30,000

Area of erythroplasia (non ulcerate red lesion on mucous membrane), if in pt, in a high cancerous area over 40years,
then biopsy immediately. Especially if lesion has been there for > 2 weeks

Osteomyelitis
- inflammatory process within trabecular bone (medullary), involves marrow spaces
- often caused by S. aureus
- in adults OM in vertebrae/pelvis
- in kids end of long bones
NBDE II Oral Surgery Cram Notes 10/14
- 2 major types

1. Suppurative OM
a. Acute: md>mx, due to  blood supply in md, thus  chance of OM
b. Chronic
c. Infantile
2. Non-Suppurative OM
a. Chronic sclerosing (focal and diffuse)
b. Garre’s OM: periosteal thickeiing and peripheral reactive bone formation, boney hard non-tender
swelling, associated with a painful carious tooth
c. Actinomycotic OM

Vital Signs
1. BP – 120/80
2. Pulse – 72 bpm
3. Respiration Rate – 12-15
4. Temp – most accurate rectally (37.7C), orally (37C)

Antibiotic Prophylaxis for BE

Adults Children
Amoxil 2g po 1 hr prior Amoxil 50mg/kg (upto 2g) po 1 hr prior
Clindamycin 600mg po 1 hr prior Clindamycin 20mg/kh (upto 600mg) po 1 hr prior.