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Dentoalveolar 93

https://t.me/med1917

RADIOGRAPHIC ZONES OF EDENTULOUS MAXILLA AND THEIR MANAGEMENT

e following classication 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 (allon 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 aer – 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

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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 deection 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 inammatory 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 classication 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 classication 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

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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):

●

>5cm

●

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 benet 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, 1mm increase in length means 3× increase in diculty; less than 5mm LA is ok, more than 5mm needs sedation or GA

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Dentoalveolar 97

https://t.me/med1917

WINTER CLASSIFICATION FOR IMPACTED THIRD MOLARS

e following classication 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 diculty 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: Aclinicopathological 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: Apilot study. J Adv Med Educ Prof. 2017;5(2):67–72.

Braånemark PI, Hansson BO, Adell R, etal. 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. Aclassiﬁcation 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: Areview 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.

t.me/Dr_Mouayyad_AlbtousH

https://t.me/med1917

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 65years old or more/mechanism/neurology, multiregion trauma

●

If just neck pain but none of the preceding, get three view cervical spine X-rays in 1hour

DOI: 10.1201/9781003156895-12 99

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100 Classiﬁcations and Lists in Oral and Maxillofacial Surgery

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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 dened 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. AGCS score of less than 8 warrants emergency intubation.

●

Severe – GCS 3–8

●

Moderate – GCS 9–12

●

Mild – GCS 13–14

●

Minor – GCS 15

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Critical Conditions (Perioperative and Emergency Care) 101

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MANAGEMENT OF ANTICOAGULANTS AND ANTIPLATELETS IN SURGERY

e following describes how and when to stop specic 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:

●

24hours (48hours if high risk)

●

Restart at 6–12hours if low-risk surgery

●

Restart at 48hours if high-risk surgery

●

What if a patient on warfarin needs emergency surgery?

●

5 mg vitamin K and wait 6hours, 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: congestiveheart 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 aer:

usually stop 24hours before, restart at 48hours if highrisk

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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 aer

●

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 tiroban aer stopping clopidogrel (Glp 2b/3a receptor inhibitor)

●

If not recent ACS/stent, do not stop if low bleeding risk (ifhigh bleeding risk, can stop clopidogrel as in preceding)

●

How does tranexamic acid work?

●

Inhibits plasminogen (antibrinolytic)

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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