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Dentoalveolar 93
https://t.me/med1917
RADIOGRAPHIC ZONES OF EDENTULOUS
MAXILLA AND THEIR MANAGEMENT
e following classication is used to aid in planning and carrying out implant treatment in the edentulous maxilla.
1. Half-canine to half-canine
2. Half-canine to distal of 4
3. Distal of 4 posteriorly
●
Bone in 1–3 – traditional implants
●
Bone in 1 and 2 only – angled conventional implants (all on
4) with implant-supported or -retained prosthesis
●
Bone in 1 only – anterior conventional, posterior zygomatics (allon 4) with implant-supported prosthesis
●
No bone in any zones – quad zygoma or on-lay everything
RCS (ENGLAND) GUIDELINES ON IMPACTED
CANINES
e following guidelines are used to assist surgeons in decision
making regarding the management of impacted canines.
●
Age 10–13, not severely displaced, extract C (maintain space if
needed) and wait 12 months
●
Otherwise, expose if orthodontically feasible (not in midline,
above apices or horizontal)
●
Buccal teeth need bond and chain, palatal not necessary,
down to orthodontist preference
Modifications:
●
If patient does not want to proceed and no pathology – monitor
●
If patient needs treatment of permanent canine for resorption
of adjacent teeth (except laterals), but no further treatment
aer – extract permanent canine (if laterals resorbing, ideally
replace them with canines)
●
If patient wants treatment but is unwilling to wear braces –
transplantation (if root more than three-quarters formed,
needs RCT at 10 days)
t.me/Dr_Mouayyad_AlbtousH
94 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
RCS (ENGLAND) GUIDELINES FOR SURGICAL
ENDODONTICS
e following guidelines set out objective indications that would
warrant surgical endodontic therapy. e aim of endodontic
treatment is to disinfect the pulp space followed by sealing this
space to prevent recontamination.
●
Unable to do conventional root canal therapy (RCT)
●
Failed RCT (repeating is detrimental/have a good coronal seal)
●
Cyst needs biopsy of apex
●
Root perforation/apical one-third fracture
●
Unsuitable for prolonged/multiple RCT phases
Contraindicated if
●
Unrestorable
●
Advanced periodontal disease
●
Close to nerve
●
Inadequate access
●
Unusual bone or root form
ROOD AND SHEHAB CLASSIFICATION FOR
INFERIOR ALVEOLAR NERVE (IAN) INJURY RISK –
RADIOGRAPHIC SIGNS AND INDICATIONS OF CONE
BEAM COMPUTERISED TOMOGRAPHY (CBCT)
e following signs have been proposed to establish the relationship between the IAN and the third molar root observed on panoramic radiography.
A. Root darkening
B. Rood deection
C. Root narrowing
D. Dark line in apex
E. Loss of white line
F. Inferior alveolar nerve narrowing
G. Inferior alveolar nerve diversion
High (19%) risk of nerve injury if proceed. NB: OPG has high negative
predictive value, so if none of these ndings is low risk; if ndings are
present, positive predictive value is poor so need CBCT to fully assess.
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Dentoalveolar 95
https://t.me/med1917
STAGES OF PERICORONITIS
Pericoronitis is an intraoral inammatory process due to infection of the gingival tissue surrounding or overlying an erupting or
partially erupted tooth. e stages are depicted in the following.
1. Pericoronal
2. Submucosal
3. Fascial plane
SIEBERT’S CLASSIFICATION OF ALVEOLAR
BONE LOSS
Alveolar ridge defects may occur due to injury, trauma or normal healing post-extraction. e following classication is used
to classify alveolar bone loss.
1. Horizontal (bucco-lingual tissue loss)
2. Vertical (apico-coronal tissue loss)
3. Combined (both bucco-lingual and apico-coronal tissue loss)
WALDRON AND MUSTOE’S CLASSIFICATION
OF PRIMARY INTRAOSSEOUS ODONTOGENIC
CARCINOMA (‘SCC IN BONE WITH NO ULCER
AND NO DISTANT PRIMARY AT DIAGNOSIS OR
6 MONTHS AFTERWARDS’)
Primary interosseous carcinoma is an uncommon neoplasm.
e following classication is used to classify from where the
tumours can arise.
1. From cyst
2. Ameloblastic
a. Metastasising malignant ameloblastoma
b. Ameloblastic carcinoma
3. De novo
4. Mucoepidermoid
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96 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
Other types:
●
Clear cell odontogenic carcinoma – clear cytoplasm with
strands of hyalinised tissue (from mucoepidermoid, renal cell
or Pindborg tumour)
●
Ghost cell odontogenic carcinoma, secondary to Pindborg or
Gorlin’s cyst (may also be mistaken for craniopharyngioma)
●
Ameloblastic brosarcoma – benign epithelial part but malignant mesenchymal part
Criteria for giant cell tumour versus lesion
(minor criteria):
●
>5cm
●
Recurrent
●
Rapid + tooth involvement + cortical thinning
WHARFE AND OTHER ASSESSMENTS
TO DETERMINE DIFFICULTY FOR LOCAL
ANAESTHETIC (LA) VERSUS GENERAL
ANAESTHETIC (GA)
e following guidelines are used to aid in decision making
regarding which patients may benet from LA versus GA in third
molar extraction.
●
W – Winter (disto-angular)
●
H – height of mandible
●
A – angulation of second molar
●
R – root (long thin divergent)
●
F – follicle (thin)
●
E – exit path (obstructed)
●
Plus – Pell and Gregory 3C
●
Winter’s lines – red line perpendicular from amber bone
level line, 1mm increase in length means 3× increase in
diculty; less than 5mm LA is ok, more than 5mm needs
sedation or GA
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Dentoalveolar 97
https://t.me/med1917
WINTER CLASSIFICATION FOR IMPACTED
THIRD MOLARS
e following classication is based on the inclination of the
impacted wisdom tooth (third molar) to the long axis of the second molar. It is used to determine the diculty of removal of
these molars.
●
Mesio-angular 44%
●
Vertical 38%
●
Disto-angular 6%
●
Horizontal 3%
●
Linguo-angular/bucco-angular/inverted are rare
FURTHER READING
Ackermann GL, Altini M, Shear M. The unicystic ameloblas-
toma: Aclinicopathological study of 57 cases. J Oral Pathol.
1988;17(9–10):541–6.
Akram A, Fuadfuad MD, Malik AM, Nasir Alzurfi BM, Changmai
MC, Madlena M. Comparison of the learning of two nota
tions: Apilot study. J Adv Med Educ Prof. 2017;5(2):67–72.
Braånemark PI, Hansson BO, Adell R, etal. Osseointegrated
implants in the treatment of the edentulous jaw. Experience
from a 10-year period. Scand J Plast Reconstr Surg Suppl.
1977;16:1–132.
Cawood JI, Howell RA. Aclassification of the edentulous jaws. Int
J Oral Maxillofac Surg. 1988;17(4):232–6.
Ellis GE, Davey KW. The classification and treatment of inju-
ries to the teeth of children. 5th ed. Chicago, IL: Year Book
Medical; 1970.
National Institute for Health and Care Excellence guidelines for
the removal of wisdom teeth. In: Greenwood MC, Corbett
IP, eds. Dental emergencies. 1st ed. Oxford: Blackwell
Publishing Ltd; 2012. https://onlinelibrary.wiley.com/doi/
pdf/10.1002/9781118702895.app5
-
t.me/Dr_Mouayyad_AlbtousH
98 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
Husain J, Burden D, McSherry P, Morris D, Allen M. National
clinical guidelines for management of the palatally ectopic
maxillary canine. Br Dent J. 2012;213(4):171–6.
Karthik K, Sivakumar, Sivaraj, Thangaswamy V. Evaluation of
implant success: Areview of past and present concepts. J
Pharm Bioallied Sci. 2013;5(Suppl 1):S117–9.
Lekholm U, Zarb GA. Patient selection and preparation. In:
Branemark PI, Zarb GA, Albrektsson T, eds. Tissue integrated
prostheses: Osseointegration in clinical dentistry. Chicago, IL:
Quintessence Publishing Company; 1985: 199–209.
Pell GJ, Gregory GT. Impacted mandibular third molars:
Classification and modified technique for removal. Dent Dig.
1933;39:330–8.
Reeder MM, Felson B, Bradley WG. Reeder and Felson’s gam-
uts in radiology, comprehensive lists of roentgen differential
diagnosis. New York: Springer; 1993.
Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic
lesions of the mandible: Clinical and radiologic-histopathologic review. Radiographics. 1999;19(5):1107–24.
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12
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Critical Conditions
(Perioperative and
Emergency Care)
COMPUTERISED TOMOGRAPHY (CT) OF
CERVICAL SPINE INDICATIONS
e indications for CT of cervical spine in a trauma patient are
discussed next.
Within one hour if:
●
Glasgow Coma Scale (GCS) < 13 initially, intubated, X-rays
inadequate/unclear/impossible
●
Suspicion plus 65years old or more/mechanism/neurology,
multiregion trauma
●
If just neck pain but none of the preceding, get three view
cervical spine X-rays in 1hour
DOI: 10.1201/9781003156895-12 99
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100 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
GODRINSKY AND HOLYOKE SEVEN
SPACES
Potential routes of cervicofacial infection spread and neck space
infections.
1. Platysma-investing fascia
2. Investing fascia – infrahyoid fascia
2a. Infrahyoid muscles
3. Pretracheal/retrovisceral
4. Prevertebral – alar fascia [i.e. between retropharynx and
prevertebral fascia (route into mediastinum)]
4a. Prevertebral-investing fascia (above clavicles)
5. Prevertebral
GLASGOW COMA SCALE (MOVE)
e Glasgow Coma Scale (GCS) is a method for assessing the
impairment of conscious level in response to a dened stimulus.
Scores range from 3–15, with 3 being the most severe.
●
Movement (6 – obeys, 5 – localises, 4 – withdraws, 3 – exor,
2 – extensor, 1 – none)
●
Verbal (5 – alert, 4 – confused, 3 – inappropriate, 2 – incomprehensible sounds, 1 – none)
●
Eye (4 – spontaneously open, 3 – voice, 2 – pain, 1 – none)
HEAD INJURY SEVERITY
e severity of head injury and its impact on prognosis are
related to the GCS of the patient following injury. AGCS score of
less than 8 warrants emergency intubation.
●
Severe – GCS 3–8
●
Moderate – GCS 9–12
●
Mild – GCS 13–14
●
Minor – GCS 15
t.me/Dr_Mouayyad_AlbtousH
Critical Conditions (Perioperative and Emergency Care) 101
https://t.me/med1917
MANAGEMENT OF ANTICOAGULANTS
AND ANTIPLATELETS IN SURGERY
e following describes how and when to stop specic anticoagulants prior to surgery and how to go about reversal if required.
●
When to stop warfarin before elective surgery:
●
5 days before the day of surgery
●
When to stop direct oral anticoagulants (DOACs) before elective surgery:
●
24hours (48hours if high risk)
●
Restart at 6–12hours if low-risk surgery
●
Restart at 48hours if high-risk surgery
●
What if a patient on warfarin needs emergency surgery?
●
5 mg vitamin K and wait 6hours, or four-factor prothrombin complex concentrate (Octaplex)
●
What if a patient on DOACs needs emergency surgery?
●
Tranexamic acid helps
●
Reverse Apixaban/Rivaroxaban with Andexaret
●
Reverse Dabigatran with Idarucizumab
●
Who needs bridging therapy with low molecular weight heparin (LMWH) in elective surgery?
●
Venous thromboembolism (VTE) within 3 months/highrisk VTE patients (e.g. multiple VTEs)
●
Atrial brillation (AF) patients with
– Cerebrovascular accident (CVA) in last 3 months
– CVA in past with three or more risk factors of conges-
tive cardiac failure/hypertension/age > 75/diabetes
– CHADS2 score of 5 or greater (With this risk scoring
tool, one point is awarded for the presence of each of:
congestiveheart failure, hypertension, AF, diabetes
mellitus, age ≥ 75 and two further points are awarded if
there is a history of either CVA or transient ischaemic
attack [TIA], thus providing a total combined score)
●
Mechanical heart valve
– Bridging LMWH – when to stop before/restart aer:
usually stop 24hours before, restart at 48hours if
highrisk
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102 Classifications and Lists in Oral and Maxillofacial Surgery
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●
Should aspirin be stopped?
●
No, unless high bleeding risk, in which case stop 3 days
before and restart 7 days aer
●
What about those on dual antiplatelet therapy?
●
If recent acute coronary syndrome (ACS)/stent, don’t stop
unless necessary
●
If bleeding risk is high, postpone surgery; if have to operate, stop clopidogrel 5 days prior
●
If particularly high thrombotic risk and high bleeding risk,
consider bridging with tiroban aer stopping clopidogrel
(Glp 2b/3a receptor inhibitor)
●
If not recent ACS/stent, do not stop if low bleeding risk
(ifhigh bleeding risk, can stop clopidogrel as in preceding)
●
How does tranexamic acid work?
●
Inhibits plasminogen (antibrinolytic)
MANAGING CAROTID INVOLVEMENT
e following passage describes how to manage a patient with a
head and neck cancer that involves the carotid artery and may
potentially result in carotid blowout and catastrophic bleeding.
●
Multidisciplinary team (MDT) discussion
●
Conservative/interventional radiology?
●
Acute bleed in a dying patient, conservative management
needs a concrete ‘Emergency plan’
●
Dark towels
●
Suctioning equipment
●
Brisk bleeding indicates use of 5–10 mg midazolam
●
Reassurance, instructions regarding contacting next
of kin
●
UK head and neck guidelines suggest the following:
●
If a sentinel bleed, manage with endovascular stenting if
possible
●
If acute blowout, apply pressure/remove clips if expanding
haematoma, emergent clamping and if possible reconstruct
as high morbidity without carotid
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