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Impacted teeth Congenitally missing teeth

Most commonly affected: Most commonly affected:

1. Mandibular third molars 1. Maxillary and mandibular third molars
2. Maxillary third molars 2. Mandibular second premolars
3. Maxillary canines 3. Maxillary lateral incisors

Extractions

Indications Contraindications

● Severe caries ● Poorly controlled medical conditions

● Endodontic ○ Diabetes, end-stage renal disease, angina, bleeding disorder, etc.
○ Internal root resorption ● Immunocompromised or immunosuppressed
● Periodontal ○ Leukemia, lymphoma, high doses of steroids
○ Severe attachment loss ● History of head & neck radiation
● Orthodontic ○ Increased risk of osteoradionecrosis
○ Severe crowding ● History of bisphosphonates
● Cracked teeth ○ Increased risk of medication-related osteonecrosis of the jaw (MRONJ)
● Ankylosed teeth, complicated impactions, or supernumerary teeth ○ Not an absolute contraindication, dependent on type & duration of bisphosphonates
○ Surgical procedures should be conservative

Extraction procedure

Basic steps Third molars

1. Sever soft tissue attachment with periosteal elevator ● Extraction will eliminate periodontal problems, alleviate pain, allow cleaning of
2. Luxate tooth to expand socket second molars
3. Deliver tooth with forceps ● Maxillary third molars should be delivered distobuccally
4. Curette socket, smooth bone, irrigate
Primary closure
Forceps ● Physical closure of a wound at the end of surgery
● Seat as apically as possible, place along lingual surface, then buccal ● Not necessary in non-surgical extractions, as it damages mucosal tissue
● Deep into sulcus, along long axis of the tooth
● Toward the center of resistance Secondary closure
● Most initial movements are buccal, then lingual (due to thinner buccal plate) ● Wound left open at the end of surgery
● Rotary movement for single-rooted teeth ● Will heal via granulation, contraction
● Apical pressure to expand socket
Post-op instructions
Surgical extractions ● Gauze pressure
● Consider for long or divergent roots, endo-treated, crown fracture, retained roots ● Soft diet
● Often requires full-thickness flap (buccal flap to avoid lingual nerve damage) ● No negative pressure
● Removal of buccal bone to create trough ● No smoking
● Removal of interradicular or cortical bone ● Salt water rinse after 24 hours
● Sectioning of tooth
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Extractions

Complications

1. Subperiosteal abscess 4. Nerve injury

● Infection under the periosteum due to trapped necrotic bone or tooth ● Common with extraction of mandibular third molars, IAN block
● Treatment: irrigate to remove bone or tooth ● Refer to OMFS if they do not have normal sensation after one month

2. Oro-antral communication (sinus exposure) 5. Tooth displacement

● Common with maxillary first molars ● Maxillary sinus: maxillary first and second molars
● <2 mm: monitor, suture ● Infratemporal fossa: maxillary third molars
● 2-6 mm: antibiotic, antihistamine, analgesic, nasal spray, suture ● Submandibular space: mandibular third molars
● >6 mm: flap surgery to close
6. Bleeding
3. Alveolar osteitis ● Risk increases for patients on blood thinners or with bleeding disorders
● “Dry socket”, dislodged blood clot, extremely painful ● Treatment: gauze pressure, sutures, hemostatic agents (gelfoam, topical thrombin)
● Multifactorial: associated with oral contraceptive use, smoking, and using straws
● Treatment: anesthetize, irrigate, dry socket paste with eugenol, pain control

Flap design

Flap considerations
● Wide base, incision over intact bone, vertical
releases at line angles
● Avoid vital structures such as arteries, nerves, and
thin tissue

0 vertical releases 1 vertical release

2 vertical releases For apicoectomy of maxillary anterior teeth Down the midline of the palate for torus removal
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Grafting

● Performed after some extractions to preserve ridge

● Performed independently to restore bony defects or gain ridge thickness

Type and source Osteoconductive Osteoinductive Osteogenic

Provides scaffold for new bone Presence of signals to encourage tissue growth Capable of growing tissue

Autograft: same individual + + +

Allograft: same species + +/- -
Alloplastic: synthetic or natural materials, + - -
not from living source

Xenograft: other species (bovine, porcine) + - -

Implants

● Most commonly used implant is endosteal

Implant components

Implant body Cover screw Healing abutment Impression coping

● Inserted into osteotomy ● Soft tissue is closed over screw ● Used in single stage implant placement, ● Inserted into implant body when taking
● Made of titanium, highly biocompatible ● Second stage surgery needed to uncover emerges from the soft tissue conventional impression
● Various diameters and lengths screw after healing ● Contours tissue for restoration ● Coping is different based on closed tray
or open tray technique

Scan body Implant analogue Abutment and screw Implant crown

● Used when taking digital impression for ● Used by lab when pouring cast to ● Can be custom or stock, 1 piece or 2 ● Cement-retained: good for esthetic zones
implant crown replicate position where implant has been pieces because no screw hole
placed ● Connects the implant body to the ● Screw-retained: presence of access hole,
restoration easier to remove

Indications and contraindications Measurements for placement

Indications 1 mm: from buccal/lingual plate,

● Replace missing tooth inferior border of mandible, maxillary
sinus, nasal cavity
Contraindications
● Inadequate vertical or horizontal bone thickness 1.5 mm: from adjacent natural teeth
● Uncontrolled medical conditions or immunocompromised
2 mm: from IAN
● History of head & neck radiation or bisphosphonate use
● Bruxism 3 mm: from adjacent implants
● Children and adolescents
5 mm: from mental nerve

Common width of implant: 4 mm

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Implants

Stability Bone quality

Primary stability: biomechanical stability of the implant when it is first placed
Secondary stability: osseointegration of the implant into the bone, long-term healing
● Osseointegration describes a direct histologic connection between the bone and
implant
Ordered most dense to least dense:
● Type I: anterior mandible (best primary stability)
● Type II: posterior mandible (best osseointegration)
● Type III: anterior maxilla
● Type IV: posterior maxilla (worst prognosis for implants)

Trauma & surgery

Traumatic injuries Orthognathic surgery

Midface fractures
Le Fort I - For retrusive maxilla,
Le Fort I: - Horizontal across osteotomy: vertical maxillary excess
maxilla - Le Fort I fracture created
- Only maxillary bone to move upper jaw forward
involved or upward

Le Fort II:
- Pyramidal across
midface Bisagittal split - For retrusive or protrusive
- Involves orbits and osteotomy mandible
nasal bones (BSSO): - Splitting of the mandible to
set it back or bring it
forward
Le Fort III: - Most common
complication is nerve
- Complete craniofacial damage (IAN)
disjunction
- Involves zygomatic
arch Distraction - Appliance provides
osteogenesis: gradual traction that allows
for bone deposition
Mandibular fractures - Osteotomy phase →
From most common to least common: latency phase → distraction
condyle > angle > symphysis phase

Simple: Closed to the oral cavity

Compound: Open to the oral cavity (breaks skin)
Greenstick: Partial thickness fracture
Comminuted: Fractured in multiple pieces
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Trauma & surgery

Trauma to permanent teeth

Concussion Subluxation Avulsion Extrusion

Tooth has sore PDL Tooth has increased mobility Separation of tooth from alveolus Tooth is displaced coronally
No splinting required Flexible splint, 2 weeks Reimplant clean tooth in socket Flexible splint, 2 weeks
Storage mediums: milk > Hank’s balanced
salt solution > saliva > saline
Flexible splint, 2 weeks

Lateral luxation Intrusion Alveolar fracture Root fracture

Tooth is displaced laterally Tooth is displaced apically Alveolar bone fractured, Root fractured horizontally
Flexible splint, 4 weeks Flexible splint, 4 weeks usually with lateral luxation Flexible splint for 4 weeks,
Rigid splint, 4 weeks but 4 months if it is in cervical ⅓

Biopsy

Cytology/brush Fine needle aspiration Incisional Excisional

● Scrape lesion with brush, tongue ● Aspirate contents with needle and ● Incise deep narrow wedge of lesion, ● Remove the entire lesion, extending to
depressor syringe extending to normal tissue normal tissue
● For large areas with dysplastic change ● For radiolucent or fluid-filled lesions ● For lesions > 1 cm, suspected malignant ● For lesions < 1 cm, suspected benign
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Wound healing

Stage Time frame Physiologic process

Hemostasis Minutes to hours ● Vasoconstriction

● Blood clot stabilization through clotting factor release and thrombus formation

Inflammation Hours to 7 days ● Infiltration of neutrophil granulocytes, macrophages, lymphocytes

● Migration of keratinocytes
● Microbe removal and phagocytosis of debris

Proliferation 1 to 6 weeks ● Migration and proliferation of endothelial cells, fibroblasts, and epithelial cells
● Formation of granulation tissue and re-epithelization via keratinocytes
● Angiogenesis
● Wound contraction
● Collagen synthesis and deposition

Maturation/remodeling Six weeks to years ● Continued deposition of collagen

● Secretion of growth factors, matrix metalloproteinases

TMJ

Disc displacement Opening patterns Other pathology

With reduction: articular disc is displaced anterior to
condylar head, “click” as condyle pops over disc on
opening/closing
Without reduction: articular disc is displaced anteriorly and
condyle cannot reduce back into fossa, resulting in a “lock”
of condyle in place → ipsilateral deviation
Deflection: at maximum opening, jaw moves toward
the side that is stuck
Deviation: at maximum opening, jaw moves toward
one side and then goes back to the midline
Dislocation: condyle is displaced out of position in the fossa,
anterior to the articular eminence → requires manual
manipulation to move the condyle back into place
Ankylosis: trauma, surgery, or infection causes the mandible
to become fused to the fossa; can be a fibrous or bony fusion
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TMJ

Nonsurgical treatment Surgical treatment

● Counseling ● Arthrocentesis: flush out superior joint space

● Medical therapy: NSAIDs, steroids, analgesics, muscle relaxants ● Arthroscopy: instrument superior joint space
● Physical therapy ● Arthroplasty: disc repositioning surgery
● Occlusal splint ● Discectomy: disc repair or removal
● Condylotomy: vertical ramus osteotomy
● Total joint replacement

Medical emergencies

General steps = SPORT Airway obstruction Anaphylactic shock Asthma

1. Stop treatment ● Signs/sx: difficulty breathing, hands ● Severe allergic reaction ● Difficulty breathing due to constriction of
2. Position the patient properly around neck ● Signs/sx: rash, difficulty breathing, low bronchioles
3. Oxygen ● Tx: Clear throat of foreign objects, check BP, nausea, vomiting ● Signs/sx: wheezing
4. Reassure the patient for breathing, chin tilt, back blows, ● Tx: albuterol, epinephrine, antihistamine, ● Tx: albuterol inhaler
5. Take vitals Heimlich maneuver oxygen, EMS ● Avoid triggers of asthma attacks
● Prevention is key → throat pack ● Prevention is key → accurate health
history

Angina Myocardial infarction Epinephrine overdose Hyperventilation

● Chest pain due to ischemia of heart
tissue
● Tx: oxygen, nitroglycerin (NTG), aspirin
○ NTG → wait 5 min → NTG → wait
5 min → aspirin, EMS
○ Position patient upright
● Ischemia of heart tissue with necrosis
● Occlusion of major coronary vessel
● Signs/sx: chest pain, difficulty breathing,
nausea/vomiting, pain (jaw, neck, arm)
● Tx: MONA: morphine, oxygen,
nitroglycerin, aspirin, EMS
○ Position patient upright
● Due to intravascular injections of local
anesthetic with epinephrine
● Signs/sx: increased BP and HR
● Tx: beta blockers
● Prevent by calculating proper dose of
local anesthetic, aspirate during injection
● Breathing uncontrollably, too much O2
and not enough CO2
● Signs/sx: dizzy, weak, lightheaded
● Tx: sit upright, decrease O2 intake by
breathing through one nostril or pursed
lips, relaxation techniques
● Only condition where supplemental O2
is outright contraindicated

Diabetic complications Seizure Stroke Syncope

● Hypoglycemic: sweating, pale, irritable,
hungry, sleepy
○ Conscious tx: glucose tab, juice
○ Unconscious tx: IV dextrose, IM
glucagon, EMS
● Hyperglycemic: dry mouth, thirsty,
headache, blurred vision, weak
○ Tx: activate EMS
● Abnormal brain electrical activity
● Signs/sx: uncontrollable jerking, staring,
temporary loss of consciousness or
awareness
● Tx: remove objects from mouth, do not
restrain, benzodiazepine
○ Grand mal: dilantin, phenytoin
○ Status epilepticus: valium,
diazepam
● Blocked blood supply to brain or burst ● Fainting, most common emergency
blood vessel ○ Vasovagal syncope: anxiety related
● Signs/sx: facial droop, arm drift, slurring ○ Orthostatic hypotension: blood
speech pressure decreases upon standing
● Tx: administer O2, EMS up
● Signs/sx: reduced HR and BP, loss of
consciousness
● Tx: Supine or left lateral decubitus
(pregnant) position, ammonia