Board Review – Oral Surgery

Roseman University of Health Sciences

College of Dental Medicine

L. Kris Munk DDS, MS

Dentoalveolar Surgery
Caries
Pulpal necrosis when endo is not an option
Severe Periodontal disease
Orthodontic prescription
Malposed teeth
Cracked teeth
Impacted teeth
Pre-prosthetic extractions
Supernumerary teeth
Pre-radiation therapy patients
Pre-bisphosphonate therapy patients

Indications to Remove Teeth

Severe uncontrolled diabetes
End-stage renal disease
Unstable advanced cardiac disease
Leukemia and lymphoma
Hemophilia or platelet disorders
Head and neck radiation
IV bisphosphonate treatment (MRONJ)
Pericoronitis (oral & maxillofacial surgeon)
Acute infectious stomatitis or malignancy

Relative Contraindications to
Remove Teeth – Medical Consults
Relationship of
associated vital
structures
Configuration of
roots
Condition of
surrounding bone
Mechanical
principles involved
in tooth extraction

Radiographic Examination
After initial attempts at forceps extraction
have failed
Dense bone
Older patients (less elastic bone)
Short clinical crowns
Hypercementosis
Extensive decay or crown loss
Dilacerated roots
Proximity to vital structures

Indication for Surgical Extractions

An impacted tooth is one that fails to
erupt into the dental arch within the
expected time.
Adjacent teeth, dense bone, or excessive
soft tissue prevents it from erupting
Mandibular 3rd molars, maxillary 3rd
molars, maxillary canines are the most
commonly impacted teeth

Impacted teeth
Impacted Teeth
Unerupted teeth
includes both
impacted teeth and
teeth that are in the
process of erupting

Unerupted Teeth
The term embedded teeth is used
occasionally to describe impacted teeth.
Inadequate arch length is the primary
reason that teeth fail to erupt
The most common teeth to become
impacted are the third molars because
they are the last to erupt

Embedded Teeth
Prevention of periodontal disease of adjacent
teeth
Prevention of dental caries
Prevention of pericoronitis
Prevention of root resorption of adjacent teeth
Prevention of odontogenic cysts and tumors
Treatment of pain of unexplained origin
Prevention of jaw fractures
To facilitate orthodontic treatment

Indication to Remove Impacted

Teeth
Extremes of age
Compromised
medical history
Likely damage to
adjacent structures

Contraindication to Remove
Impacted Teeth
Angulation –

◦ Mesioangular (least difficult)

◦ Horizontal
◦ Vertical
◦ Distoangular (most difficult)

Classification of Impacted Teeth

Relationship to the Anterior Border of the
Ramus

◦ Class 1 – normal position anterior to the ramus

◦ Class 2 – ½ of the crown is within the ramus
◦ Class 3 – entire crown in embedded within the
ramus

Pell and Gregory Classification

Relationship to the Occlusal Plane

◦ Class A – tooth at the same plane as the other

molars
◦ Class B – occlusal plane of the 3rd molar is
between the occlusal plane and the
cervical line of the 2nd molar
◦ Class C – the 3rd molar is below the cervical
line of the 2nd molar

Pell and Gregory Classification

Pell and Gregory Classification
Mesioangular position
Pell and Gregory Class 1 Ramus
Pell and Gregory Class A Depth
Roots 1/3 – 2/3 formed
Fused conical roots
Wide periodontal ligament
Large follicle
Elastic bone
Separated from 2nd molar
Separated from IA Nerve
Soft tissue impaction

Factors Making Extractions Less

Difficult
Distoangular position
Pell and Gregory Class 2 or 3 ramus
Pell and Gregory Class B or C depth
Long, thin roots
Divergent, curved roots
Narrow periodontal ligament
Thin follicle
Dense, inelastic bone
Contact with 2nd molar
Close to the IA Nerve
Complete bony impaction

Factors Making Extractions More

Difficult
Exposure
◦ Adequate visual
access
◦ Appropriate soft
tissue flap design
with base wider than
apex

Surgical Principles
Bone Removal –
down to cervical
line
Teeth sectioning –
controlled
deconstruction
Wound irrigation
and debridement

Surgical Principles
 • Tearing flaps – tears should be repaired
• Puncture wounds - Leave puncture wound open
• Oral-antral communications - Figure 8 suture,
sinus precautions, antibiotics, nasal spray
• Root fracture
• Tooth displacement –
• maxillary sinus
• infratemporal fossa (Maxillary 3rd’s)
• Mandibular roots into submandibular space or IA
canal
• Tooth lost in oropharynx
• Patient must be transported to an ER for chest and
abdominal radiographs

Complications
Injury to adjacent teeth
◦ Fracture of teeth or restorations
◦ Luxation of adjacent teeth
Alveolar process and tuberosity fractures
Nerve injuries – IA, lingual (sensation and
taste)
◦ Consider referral for microneurosurgical evaluation
Bleeding
Infections
Alveolar osteitis (Dry Socket)

Complications
Alveoloplasty may be indicated for the
removal of any area that may cause
difficulty in denture construction of in the
patient’s satisfaction with the prosthesis.

◦ Buccal alveoloplasty
◦ Crestal alveoloplasty
◦ Intraseptal alveoloplasty

Alveoloplasty
Exostoses and
palatal tori are
overgrowths of
bone on the lateral
surfaces of the
alveolar ridges or in
the palate.

Torus Palatinus
Similar to Torus
Palatinus, Torus
Mandibularis always
grows on the lingual
surface of the
mandible, near the
bicuspid teeth. Buccal
exostosis grows on the
buccal surface of the
maxilla or mandible.

Torus Mandibularis
Mandibular retromolar pad
Maxillary tuberosity
Excessive alveolar ridge tissue
Inflammatory fibrous hyperplasia
Labial and lingual frenum

Soft Tissue Surgery

State of the Art for replacement of lost
dentition
Made of titanium
Principles of success
◦ Primary stability
◦ Quality and quantity of bone
◦ Anatomical structures
 Sinus
 Adjacent teeth
 IA and mental nerves

Implant Surgery
Quality and quantity of bone
◦ Denser cortical bone has a higher implant
success rate than loose, soft cancellous bone

Bone Types

Implant Surgery
Autograft - Autogenous bone from patient
Allograft – cadaver bone processed to
ensure sterility; osteoconductive but not
osteoinductive (Scaffolding for growth)
Xenograft – genetically different species,
i.e. bovine bone
Bone Morphogenetic protein (BMP) –
induce bone formation and enhance graft
healing

Implant Surgery - Grafting

Distraction osteogenesis (DO) – a biologic
process of new bone deposition and
formation between osteotomized bone
surfaces that are separated by gradual
traction.

Implant Surgery
Maintains height and width of ridge after
tooth removal
Depends on atraumatic extraction – best
if buccal and lingual plates are intact
Thoroughly debride extraction site of
granulation tissue
Allograft or Xenograft material placed in
socket and covered with collagen
membrane

Socket Preservation
Trauma Surgery
Mandible Fractures
Radiographs - panoramic
Radiographs - Townes
Radiograph – Waters View
Posterior – Anterior Skull View
Lateral Oblique View
ORIF (Open Reduction Internal Fixation) –
displaced and mobile fractures

CR-MMF (Closed Reduction

Maxillo/Mandibular Fixation) or
Intermaxillary Fixation – non-displaced
with teeth and occlusion

Mandible Fractures - Treatment

CR-MMF – ORIF –
Closed Reduction Open
Maxillomandibular Reduction/Internal
Fixation Fixation

Mandibular Fractures
Midface Fractures
Le Fort Fractures
 Definition:
• Horizontal fracture of
the maxilla at the
level of the nasal
fossa
• Allows motion of the
maxilla while the
nasal bridge remains
stable

Maxillary LeFort I Fractures

 Definition:
• Pyramidal fracture of
the maxilla, the
nasal bones, and the
medial aspect of the
orbits

Maxillary LeFort II Fractures

 Definition:
• Fractures through
the Maxilla, Zygoma,
Nasal bones,
Ethmoid bones, and
the base of the skull

Maxillary LeFort III Fractures

Evaluation of a patient with a dentofacial
deformity is guided by the principle of
balance and symmetry. Orthognathic
surgery is performed to correct severe
skeletal discrepancies that prevent
appropriate dental occlusion and most often
is done in conjunction with orthodontics.

Orthognathic Surgery
Normal Facial Proportions
Angle Class I – normal dental occlusion with a
straight (orthognathic) profile.
Angle Class II – mandibular first molars and
canines are in a posterior position relative to
the maxillary counterparts, and the face
appears posteriorly convergent (retrognathic).
Angle Class III – mandibular first molars and
canines are in an anterior position relative to
the maxillary counterparts, and the face
appears to be anteriorly convergent
(prognathic).

Angle Classifications
Angle Classifications
Lateral cephalograms
are the main images
used in treatment
planning for
orthognathic surgery.
Panoramic, anterior-
posterior radiographs,
and periapical
radiographs are taken
as needed.

Imaging
Cephalometric Analysis
Maxillary hyperplasia
Maxillary hypoplasia
Mandibular hyperplasia
Mandibular hypoplasia
Apertognathia (anterior open bite)
Vertical maxillary excess (maxilla too long)
Horizontal traverse discrepancy (posterior
crossbite)
Macrogenia (large chin)
Microgenia (small chin)

Possible Diagnoses
Le Fort I Osteotomies (maxillary
surgeries)
Bilateral Split Osteotomy (BSSO)
Vertical Ramus Osteotomy
Genioplasty
Distraction Osteogenesis

Surgical Options
Surgical Options
Pathology of dental structures
Muscles
Joints
Blood vessels
Salivary glands
Sinuses
Eyes, ears
Central nervous system
Peripheral nervous system

Facial Pain and Neuropathology

Physiologic aspect – must have:

◦ Transduction (activation of A-delta and C fibers

to the spinal cord or brainstem)
◦ Transmission (pain information in the CNS sent
to the thalamus and cortical centers for
processing of sensory and emotional aspects)
◦ Modulation (limitation of rostral flow of pain
information from the spinal cord and trigeminal
nucleus to higher centers)

Facial Pain and Neuropathology

Facial Pain and Neuropathology
Facial Pain and Neuropathology
Neuropathic Pain – Trigeminal Neuralgia
◦ Trigger point
◦ Electric, sharp shooting, episodic
◦ Patients> 50 years old
◦ Treated with anticonvulsant drugs and
microvascular decompression
Odontalgia – endo or extraction
◦ damage to afferent pain transmission system;
◦ treated with analgesics
Postherpetic Neuralgia – burning, itching
◦ treated with anticonvulsants and antidepressants

Facial Pain and Neuropathology

Neuromas – nerve injury leading to
sprouts filled with Schwan cells
Burning Mouth Syndrome
◦ postmenopausal women
◦ Pain, dryness, burning of the mouth
◦ 50% resolve within 2 yrs. without therapy
Migraines
Temporal Arteritis

Facial Pain and Neuropathology

Facial Pain and Neuropathology
Temporomandibular Disorders
 The articular disk
is positioned
between the
condyle of the
mandible and the
glenoid fossa. It
is made up of
dense collagen.

Anatomy of the TMJ Joint

 The posterior attachment is
a system of collagen and
elastic fibers. The
retrodiscal tissues are
vascular and highly
innervated. As a result,
the retrodiscal tissue is
often a major component
to the pain of TMJ
dysfunction.

Anatomy of the TMJ Joint

TMJ Dysfunction
Myofacial Pain Disorder (MPD)
Disk Displacement Disorders
Degenerative Joint Disease (DJD)
Systemic Arthritic Conditions
Chronic Recurrent Dislocation
Ankylosis
Neoplasm
Infections

Temporomandibular Disorders
Myofacial Pain Disorder
◦ most common cause of masticatory pain and
compromised function
◦ Diffuse, poorly localized pain in the preauricular
region
◦ Often involves muscles of mastication
◦ Abnormal muscle function and hyperactivity
◦ Parafunctional habits (clenching, bruxism)
◦ Could be related to DJD and arthritis
◦ Wear facets and nocturnal habits
◦ Symptoms often worse in the morning

Temporomandibular Disorders
Withreduction – return of the normal disc-to-
condyle relationship
◦ Normal interincisal opening without deviation
◦ Opening click corresponds to the condyle moving
over the posterior area of the anteriorly displaced
disk
◦ Closing click (reciprocal click) occurs when the jaw
is closed and the disc fails to maintain its normal
reduced relationship to the condyle
Without reduction – no return of the normal
disc-to-condyle relationship
◦ Limited range of motion
◦ Ipsilateral deviation on opening

TMJ Disc Displacement

  Medications – NSAID’s, Celebrex, muscle relaxants,
antidepressants
 Counselling
 Botox
 Physical therapy – TMJ school, TENS
 Occlusal modification
 Splint therapy
 Arthrocentesis – lavage and lysis
 Surgery
◦ Arthroscopy
◦ Disk repositioning surgery
◦ Disk repair or removal (Discectomy)
◦ Partial joint replacement
◦ Total joint replacement

Therapies
Odontogenic Infections
The bacteria that cause odontogenic infection
are most commonly part of the indigenous
bacteria that normally live on or in the host.
 These bacteria are primarily aerobic gram-
positive cocci, anaerobic gram-positive cocci,
and anaerobic gram-negative rods.
When these bacteria gain access to deeper
underlying tissues, as through a necrotic
dental pulp or through a deep periodontal
pocket, they cause odontogenic infections.

Odontogenic Infections
Odontogenic Infections
The predominant
aerobic bacteria in
odontogenic
infections are the
Streptococcus
viridans group of
bacteria:
◦ S. anginosus
◦ S. intermedius
◦ S. constellatus

Aerobic Organisms
The anaerobic bacteria found in odontogenic
infections include a variety of species.
Anaerobic gram-positive cocci are found in
about 65% of cases, usually Streptococcus
and Peptostreptococcus.
Anaerobic gram-negative rods are cultured
in about 75% of the infections. The
Prevotella, Porphyromonas and
Fusobacterium organisms are often present.

Anaerobic Organisms
Odontogenic Infections
Odontogenic
infections seem to
pass through four
stages:
◦ Inoculation stage
◦ Cellulitis stage
◦ Abscess stage
◦ Resolution stage

Odontogenic Infections
 In the first 3 days
of symptoms, a
soft, mildly tender,
doughy swelling
appears.

Inoculation Stage
 After 3 to 5 days,
the swelling
becomes hard, red,
indurated, and
acutely tender as
the infecting mixed
flora stimulates the
intense
inflammatory
response.

Cellulitis Stage
 At 5 to 7 days after
the onset of
swelling, the
anaerobes begin to
predominate,
causing a liquefied
abscess in the
center of the
swollen area.

Abscess Stage
 When the abscess
drains spontaneously
through skin or
mucosa, or it is
surgically drained,
the immune system
destroys the infecting
bacteria, and the
processes of healing
and repair ensue.

Resolution Stage
  Principle 1: Determine the Severity of the
Infection

◦ Complete history – CC, HPI

◦ Physical examination
 general appearance -general malaise, sick,
dehydrated
 vital signs (temperature > 101)
 evaluation of spaces (vestibular, buccal, sublingual,
canine, submandibular, lateral pharyngeal
 palpation of swelling (doughy, indurated,
fluctuance)

Treatment Principles
  Remember, mild swelling represents the earliest
inoculation stage of infection which is most easily
treated.
 Cellulitis is an acute, painful infection with more
swelling and diffuse borders. Cellulitis has a hard
consistency on palpation and contains no visible pus.
Cellulitis may be a rapidly spreading process in
serious infections.
 An acute abscess is a more mature infection with
more localized pain, less swelling, and well-
circumscribed borders. The abscess is fluctuant on
palpation because it is a pus-filled tissue cavity.
 A chronic abscess is usually slow growing and less
serious than cellulitis.

Treatment Principles
 Principle
2: Evaluate the Patient’s
Defense Mechanisms
◦ Compromised Host Defenses
 Poorly controlled diabetes
 Alcoholism
 Malnutrition
 End-stage renal disease
 HIV/AIDS
 Lymphomas and Leukemias
 Cancer chemotherapy
 Corticosteroids
 Organ transplantations

Treatment Principles
 Principle
3: Should the patient be referred to an
Oral & Maxillofacial Surgeon

◦ Difficulty breathing
◦ Difficulty swallowing
◦ Dehydration
◦ Trismus (opening < 20 mm)
◦ Swelling extending beyond the alveolar process
◦ Temperature > 100 degrees
◦ Severe malaise and sick appearance
◦ Compromised host defenses
◦ Need for general anesthesia

Treatment Principles
  Principle 4: Treat the Infection Surgically

◦ The primary principle of management of

odontogenic infections is to perform surgical
drainage and to remove the cause of the infection.
◦ The primary goal in surgical management of
infection is to remove the cause of the infection,
which is most commonly a necrotic pulp or deep
periodontal pocket.
◦ A secondary goal is to provide drainage of
accumulated pus and necrotic debris.
◦ The dentist has the following surgical options:
 endodontic treatment
 extraction, with or without I & D (incision and
drainage)

Treatment Principles
Incision and Drainage (I&D)
 Obtaining a specimen for culture and sensitivity (C&S)
testing should be considered.
After the site of surgery has been anesthetized, the surface
mucosa is disinfected with a solution such as providone-
iodine (Betadine) and/or dried with sterile gauze.
A large-gauge needle, usually 18 gauge, is used for
specimen collection.
The needle is then inserted into the abscess or cellulitis, and
1 or 2 mL of pus or tissue fluid is aspirate.
The specimen is then inoculated directly into aerobic and
anaerobic culturettes, which are sterile tubes containing a
swab and bacterial transport medium.
The surgeon should request, in writing, a gram stain, aerobic
and anaerobic cultures, and antibiotic sensitivity testing.

Cultures
  Inoculation-stage infections, that initially appear as
edema with a soft, doughy, diffuse, mildly tender
swelling, do not typically require I & D.
 Whenever an abscess is diagnosed, the surgeon must
drain it. Failure to do so may result in worsening of
the infection and failure of the infection to resolve,
even if antibiotics are given. Even if the tooth cannot
be immediately opened or extracted, an I & D should
be considered.
 The decision to drain a cellulitis is made based on the
location and intensity of the infection. Usually with a
cellulitis there is no accumulation of pus to drain.

Treatment Principles
  Principle 5: Support the Patient Medically

◦ Be aware of systemic medical conditions

◦ Beware of dehydration
◦ Address pain
◦ Follow up antibiotics

Treatment Principles
Principle 6: Choose the Appropriate Antibiotic

◦ The clinician may decide that no antibiotic is

necessary. Antibiotics are not necessary in every
case.
◦ In other situations, broad-spectrum or even
combination antibiotic therapy may be indicated
based on:
 the seriousness of the infection.
 whether or not adequate surgical treatment can be
achieved.
 The state of the host’s defenses.

Treatment Principles
  Contrary to widely held opinion, extraction of a tooth
in the presence of infection does not promote the
spread of infection. Several studies have shown that
removal of a tooth in the presence of infection
hastens the resolution and minimizes the
complications of the infection, such as time out of
work, hospitalization, and the need for extraoral I&D.
 Prompt removal of the offending tooth (or teeth) in
the presence of infection is to be encouraged; a prior
period of antibiotic therapy is not necessary.

Treatment Principles
 Indications for Therapeutic Use of
Antibiotics:

◦ Swelling extending beyond the alveolar process

toward deep fascial spaces
◦ Cellulitis
◦ Trismus
◦ Lymphadenopathy
◦ Temperature > 101 degrees
◦ Severe pericoronitis
◦ Osteomyelitis

Treatment Principles
 Situations Where Use of Antibiotics may not
be indicated:

◦ Patient demand
◦ Severe pain
◦ Toothache
◦ Periapical abscess
◦ Alveolar Osteitis (Dry socket)
◦ Multiple extractions in a patient who is not
immunocompromised
◦ Mild pericoronitis
◦ Drained alveolar abscess

Treatment Principles
 Effective Orally Administered
Antibiotics That are Useful for
Odontogenic Infections:

◦ Penicillin
◦ Amoxicillin
◦ Clindamycin
◦ Azithromycin
◦ Metronidazole

Treatment Principles
The antibiotics mentioned above (except
metronidazole) are effective against aerobic
and facultative streptococci, and oral
anaerobes.

Metronidazole is effective only against

obligate anaerobic bacteria, but the
effectiveness of this antibiotic class in
odontogenic infections has been shown in a
prospective study.

Treatment Principles
 Odontogenic infections are caused by a
highly predictable group of bacteria, and the
antibiotic sensitivity of these organisms is
well known and consistent.

A recent systematic review of randomized

clinical trials comparing penicillin or
amoxicillin with newer antibiotics found that
when appropriate dental surgery was done,
none of newer antibiotics had a significantly
greater clinical cure rate than amoxicillin or
penicillin.

Empirical Antibiotic Therapy

 Principle
7: Post-op Evaluation and
Assessment

◦ After surgery and antibiotic therapy, the

patient should be carefully monitored for
response to treatment and complications.
◦ In most situations, the patient should be
asked to return to the dentist 2 to 3 days
after completion of the original therapy,
but daily evaluation may also be indicated.

Treatment Principles
Potential Spaces
Deep Fascial Spaces
Buccal Space
Sublingual Space
Submandibular Space
Inflammation of the medullary portion of
the bone
Most common initiating causes are
odontogenic infections and trauma
Relatively rare and is more common in
the mandible than in the maxilla
secondary to the difference in blood
supply
Treatment is medical (antibiotics) and
surgical (debridement and/or resection)

Osteomyelitis
 Preciously called BRONJ (Bisphosphonate-related
Osteonecrosis of the Jaw) and ARONJ
(Antiresorptive agent Related Osteonecrosis of
the Jaw)
 Now referred to as MRONJ (Medication Related
Osteonecrosis of the Jaw)
 Bisphosphonate medications (and others) inhibit
osteoclastic activity resulting in decreased bone
resorption
◦ Used to treat bony diseases such as multiple
myeloma, Paget’s disease and metastatic
diseases

MRONJ
Diagnosis: non-
healing bony
exposure in jaws for
at least 8 weeks
and current or
previous
bisphosphonate use
without history of
radiation therapy to
the jaws.

MRONJ
Oral medications – used to treat
osteoporosis
IV medications – used to treat bone
metastasis and hypercalcemia resulting
from malignancy
MRONJ has a greater association with IV
bisphosphonate medications

MRONJ
Before initiating bisphosphonate therapy,
patients should have a thorough dental
evaluation and plan to extract teeth that
are non-restorable or with guarded
prognosis, to remove tori, and to perform
alveoloplasty.
The goal is to reduce factors that can
initiate MRONJ.

MRONJ – Patient Management

< 3 years on bisphosphonates – no
treatment adjustments necessary
> 3 years on bisphosphonates – 3 month
drug holiday. If possible, consider
endodontics before extractions

MRONJ – Patient Management

Position Paper – AAOMS 2014
Four types of
biopsies:

 Cytology
 Aspiration
 Incisional
 Excisional

Biopsies - Types
Cytology – used in detecting cancerous
and precancerous lesions
◦ Cytology brush is placed over the lesion and
rotated 5 – 10 times to obtain cells from all 3
epithelial layers
◦ Cells are transferred to a glass slide where a
fixative is placed
◦ Specimen is dried and sent to a laboratory
◦ Possible results: negative, positive, or atypical
◦ All positive and atypical findings should
undergo scalpel biopsy

Biopsies - Cytology
• Aspiration - uses a special syringe and
needle to collect cells from a mass

• Relatively low morbidity and high diagnostic

accuracy
• Determines if lesion is solid, cystic, or vascular
• Indicated in any intraosseous lesion before
surgical exploration
• May also be indicated in deep soft tissue
lesions

Biopsies - Aspiration
Incisional biopsies
are used:
◦ when lesion is > 1 cm
◦ Polymorphic
◦ suspicious for
malignancy
◦ in an anatomical area
with high morbidity.

Biopsies - Incisional
 Excisional biopsies are
used:
◦ For smaller lesions (<1
cm)
◦ Vascular lesions
◦ Pigmented lesions
◦ Removal of entire lesion
and a perimeter of
surrounding uninvolved
tissue

Biopsies – Excisional
 Most intraosseous lesions are of odontogenic
origin
 Aspirate radiolucent lesions first (solid, cystic,
vascular)
◦ If vascular, consider arteriogram
 Good surgical technique with FTMPF over sound
bone
 Avoid neurovascular structures
 1 mm of adjacent osseous tissue should be
removed by curettage in all directions

Biopsies – Hard Tissue

Goals

◦ Eradication of the pathologic entity

◦ Esthetic functional rehabilitation
 Patient expectation
 Physical and emotional tolerances
 Indications for grafting
 Soft tissue management
 Dental rehabilitation

Surgical Management of Cysts and

Tumors
Fissural cyst - derived from epithelial
remnants entrapped along the fusion line
of embryonal processes
Odontogenic - cysts that are formed from
tissues involved in odontogenesis (tooth
development).
◦ Odontogenic Keratocysts act aggressively and
have higher recurrence rates

Classification of cysts
 Enucleation - removal of a mass, structure or
contents from its supporting tissues
 Marsupialization - the surgical technique of
cutting a slit into an abscess or cyst and
suturing the edges of the slit to form a
continuous surface from the exterior surface
to the interior surface of the cyst or abscess.
 Enucleation and curettage - Removal of tissue
with a curette from the wall of a cavity or
another surface.

Treatment Option of cysts

Enucleation
Curettage
Resection
◦ Marginal
◦ Partial Thickness
◦ Total
◦ Composite

Treatment Options - Tumors

Epidermoid Carcinomas (squamous cell) are most
common
Salivary tissue
Blood vessels
Lymphatics
Metastatic tumors
◦ Breast
◦ Prostate
◦ Lung
◦ Kidney
◦ Thyroid
◦ Hematopoietic system
◦ Colon

Malignant Tumors
Thorough History and Physical
Physical examination
CT Scans
Pet (positron emission tomography) Scans
Chest radiographs
Panendoscopies

Staging Malignant Tumors

Surgery
Radiationtherapy
Chemotherapy
Combination

Treatment Options - Malignancies

Complete anesthesia occurs when three
consecutive nodes of Ranvier are blocked
This is the “critical length” principle
Increasing the length of the nerve
exposed to the local anesthetic may
increase success
◦ That is why we may add a Gow-Gates injection
to a Halstead IA injection

Local Anesthesia
Sensations disappear and reappear in a
definite order

◦ Pain
◦ Temperature
◦ Touch
◦ Pressure

Local Anesthesia
Increased blood flow near an injection site
means shorter duration of anesthesia
Increased protein binding characteristics of
the local anesthetic means increased lipid
solubility which means increased duration of
action (Marcaine)
Duration of action is directly proportional to
protein binding and lipid solubility
The lower the pKa of a drug (closer to
physiologic pH) the faster the onset of action.

Local Anesthesia
Mild to Moderate toxicity
◦ Talkativeness
◦ Apprehension
◦ Excitability
◦ Slurred speech
◦ Dizziness
◦ disorientation
Severe toxicity
◦ Seizures
◦ Respiratory depression
◦ Coma
◦ Death

Local Anesthesia - Toxicity

Allergic Reaction
◦ Esters have the highest incidence
◦ Amides have the lowest incidence
◦ Before 1985, allergies were likely due to
methylparaben
◦ For patients allergic to amides and esters,
Benadryl may be an alternative (the package
insert for Benadryl specifically warns against
this)
◦ Metabisulfite is an antioxidant present with
vasoconstrictors

Local Anesthesia - Toxicity

Methemoglobinemia - is a blood disorder
in which an abnormal amount of
methemoglobin -- a form of hemoglobin --
is produced. Hemoglobin is the protein in
red blood cells that carries and distributes
oxygen to the body.

◦ Prilocaine > 600 mg (for a 70 kg adult)

◦ Articaine (Septocaine) is the second most
common local anesthetic to cause this

Local Anesthesia - Toxicity

When used for an IA block,
All local anesthetics have been
demonstrated to have equal efficacy;
there is no one local anesthetic that has
been shown to be superior.
Bupivacaine (Marcaine) is the most potent
local anesthetic packaged for dentistry
Prilocaine (Citanest) and Articaine
(Septocaine) are the least potent

Local Anesthesia
 Drug pKa MRD (mg/kg) MRD (mg)
Articaine 4% 7.7 7 --
Bupivacaine . 8.1 -- 90
5%
Lidocaine 2% 7.7 7 500
Mepivacaine 7.6 6.6 400
3%
Prilocaine 4% 7.8 8 600

Local Anesthesia
Needles
◦ 30 gauge = .3 mm in outside diameter
◦ 27 gauge = .4 mm in outside diameter
◦ 25 gauge = .5 mm in outside diameter

 97% of broken needles are 30 gauge needles

 Studies show that patients cannot tell the
difference between 25 gauge, 27 gauge and 30
gauge needles

Local Anesthesia Techniques

Maxillary Nerve Blocks
◦ PSA
◦ MSA (infiltration?)
◦ ASA (same as infraorbital nerve block but with
2 minutes of applied pressure)
◦ Greater Palatine
◦ Nasopalatine

Nerve Blocks - Maxilla

Mental
 Incisive (same as mental nerve block but with 2
minutes of applied pressure)
 Inferior Alveolar Nerve Block
 Traditional(Halstead)
 Vazirani-Akinosi
 Gow-Gates

Nerve Blocks - Mandible