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What is smoker melanosis mechanism?
- melanocytes stimulated by polycyclic amines (nicotine, benzpyrine) for protection
- reverse smokers where melanocytes lost have depigmented red mucosa
What is the clinical/histo feature of smoker melanosis?
- pigmentation in anterior facial gingiva
- histo: increased melanin in basal layer sim to melanotic macule
When should smoker's melanosis be biopsied?
unexpected pigmentation location: hard palate or increased density (surface elevation)
How do drugs discolor oral cavity?
- stimulate melanocytes
- deposition of metabolites
What does mincocycline do to oral cavity?
- discolor bone/teeth
- dark green bone through oral mucosa -> linear band above the facial attached gingiva near mucogingival juntion and broad zone discoloration of hard palate.
How long do records have to be kept?
- 7-10 years (vary states)
- pediatric: until majority
What is least reliable ID method?
natural, accidental, suicide, homicide
What are some dental ID marks?
- anatomic, restorative, pathological components.
- patern of palatal ridge, ridges on lip surface and radiographic outline of max & frontal sinuses.
- ID markings on removable prosthesies
What are the steps of the postmortem exam?
- tools: long-handled pruners, 8-10" knife
- Photos: head/face, occlusal planes, unusual pathology, restorative
- impressions & resection: not necessarily required, use 10% formalin
How do you examine oral cavity in rigor mortis body?
- use reciprocating (stryker) saw or osteotome and mallet to create LeFort I maxilla fracture
- place above inferior nasal spine and malar process to enure apices aren't transected.
- cut high on rami to avoid damage to impacted thirds
What is the national organization for disaster management?
- NDMS: national disaster medical system: establish morgue, ID and dispose remains to funeral via 10 regional DMORTs (disaster morturary operational response team)
- dental team: assemble antemortem, interpret, postmort
What are the ellis classifications?
- I: enamel
- II: dentin
- III: pulp
- IV: root
What are modified WHO trauma classes?
- Luxation: perio
- Hard dental: enamel, crown, root (complicated implies endo)
- Supporting bone:intrusion, socket, jaw fractures, alveolar (DA)
- gingiva & oral mucosa: contusion(no epithelial break), abrasion, laceration
What is a contusion?
no epithelial break
What are luxation injuries?
- extrusive/lateral/intrusive luxation
What malocclusion are most at risk for trauma?
Angle Class II, Div 1 are 3x more prone
What is the Ellis III fracture in WHO?
Complicated Crown Fracture (hard tissue)
What are the risk factors for trauma?
- 25-30% prevalence
- <20 yrs (8-12 especially MIXED dentition)
Where are open apices typically found?
- normal (w/o pulp & periradicular disease) developing roots of immature teeth
- necrotic pulp: before root growth is complete, dentin stops and growth arrested
- dev anomalies: dens in dente
What is apexogenesis?
vital pulp therapy: promoting root groth to lenth and maturation of apex
What is the sequlae of trauma?
- Pulp necrosis: uninfected via coagulation/ischemia or liquefaction (infection)
- Pulp canal obliteration: accelerated deposition of hard tissue along the pulp canal walls
- external inflammatory root resporption
What is external inflammatory root resorption?
- result of removal of injured periodontal ligament tissue next to the root surface by macrophages and osteoclasts
- results in a saucer-shaped cavity on the root surface mostly involving cementum.
- resorption cavity will subsequently be fully or partially repaired by new cementum with insertion of new Sharpey’s fibers.
What are the steps of examination?
- radio: esp resorptive and calcific changes
- photographs: esp for abuse & litigation
- follow up: varied recall 1 week, 2 week, 6 weeks, 3, 6 12 months, then yearly, pulp vitality
- subjective: chief complaint, med/dent hx
- objective: pulp tests, radio, bite test, cracked tooth, refrerred pain
What are presentations of vertical root fractures?
- perio pockets
- uniformly widened lamina dura
What are the diagnostic tests for teeth?
- pulpal: CO2, Ice, EPT
- color: gray v yellow
- transillumination: fractures
What is concussion?
- supporting structures w/o loosening
- marked reaction to percussion
- good prognosis: 100% open, 95% closed
What is subluxation?
- LOOSE not displaced
- good prognosis: 100% open, 90% closed(>1yr)
What is extrusive luxation?
- partial OUTWARD displacement
- ok prognosis: 90% open, 50-40% closed
What is lateral luxation?
- displacement other than axial w/ communication or fracture of alveolar socket
- ok pulp prognosis (worse than extrusive): 90% open, 25% closed
- pulp survival higher though than extrusive for open apices
What is intrusive luxation?
- displacement into alveolar bone w/ communication or fracture of alveolar socket
- poor prognosis: 40% open, 0% closed
What is avulsion?
- complete displacement out of socket (Exarticulation)
- worst pulp prognosis 30 % open, 0% closed
- PDL healing: 40% open, 20% closed
- Must be reinserted quickly (<30 mins) and wet stored (socket, saline, saliva, milk)
what are the most common oral injuries?
- 1. dental
- 2. soft tissue
- 3. bone fractures
How long does it take mature teeth to regain vitality after injury?
What is the treatment for reversible pulpitis?
apexgenisis: vital pulp therapy
What is the treatment for irreversible pulpitis (necrotic pulp)?
- Closed apex: RCT
- Open: apexification: Root end closure & obturation or Regenerative endo
What is apexification?
root end closure to induce root end formation (apical calcific barrier) when pulp is necrotic
What is the order of occurrence for facial bone fractures in children?
Alveolar, nasal, mandible, zygomatic & orbit, maxillary
What are the common locations of mandibular fractures in children?
condyle, symphisis (& contralateral condyle)
What are clinical features of mandibular fractures?
submandibular swelling, ecchymoses, lacerations, anterior open bite
What are tx for mandibular fractures?
- closed reduction: wiriing jaw (MMF), splint
- open reduction: direct surgical reaaprox (ORIF), wire or rigid fixation
- fixate much shorter time for children
What are the complications of pediatric facial bone fractures?
- non-union rare
- infection: raare
- TMJ ankylosis
- growth arrest (asymmetry)
Who is the OMFS godfather?
What are MCC of OMF injury?
What are the various severities of mandibular fractures?
- greenstick: young bend, not break
- simple: not displaced
- compound: displaced
- communited: multiple fracture lines & fragments
What are the most common areas of mandibular fractures?
- body (41%), angle (23%), condyle (18%), parasympheseal (9%), alveolar process (3%), coronid (0.4%)
- parasympheseal/ sympheseal- in the region btw the canines
- sympheseal = midline
- weak points: condyl, ramus, mental foramen
What is a favorable vs. unfavorable displacement of fracture?
- favorable: muscles tend to draw bony fragments together
- unfavorable: displaced by muscle forces
Explain the midfacial fractures:
- dentoalveolar fracture: only involving bone investing roots of teeth
- Le Fort 1: horizontal maxillary fracture, running through entire maxilla above apices of teeth; posteriorly, it crosses the pterygoid plate
- Le Fort 2: pyramidal fracture, crossing inferior orbital nerve & nasal & lacrimal bones, medial wall of the orbit
- Le Fort 3: the most serious, where entire midface has separated from base of the skull
- zygomatic complex- zygomatic bone articulates w maxillary & temporal bone
- orbital- fracture of thin orbital floor
- nasoethmoidal- anything affecting the nasal zone & ethmoidal region
What are the perhospital care steps?
- secure airway
- hemostasis: direct pressure, swab
- stabilization: barton bandage, bridle wire
What is the normal nasal bridge width?
half of interpupillary
What is racoons' eyes indiciative of?
- basilar skull fracture
- may present later
What is battles sign?
mastoid bruising (posterior basilar skull base injury)
How is CSF tested?
- filter paper: separates from blood -> ring, double ring or halo
- test for glucose or beta-2 transferrin
What is the preffered high PPV test for CSF?
What does anterior open bite suggest in trauma?
- bilateral condylar or angle fractures
- posterior and inferior displacemnt of facial bones (lefort III)
What is the key nerves for midface trauma?
IAN and Infraorbital
what is telecanthus?
increased distance between medial anthi(corners of eye)
What are presentations of nasoehtmoidal fractures?
- widened nasal bridge
- periorbital edema
- subconjunctival hemmorhage
What are presentations of orbital fractures?
- diplopia: double vision
- enopthalmus: posterior displacement of eyeball
What is the best way to palpate the zygoma?
intraoral: buccal uper molars to ID displacement or collapse of arch
What are the best imaging techniques for the face?
- upper: axial/coronal CT, skull, waters
- midface: axial/coronal CT, waters,, bumental, posteroanterios occlusal
- mandible: pano mandible series, elongated towne.
- use lateral oblique if pano isn't available
What view should be used if panoramic is not available for lower facial trauma?
What is the ring bone rule?
one fracture or dislocation implies another
What is a imaging sign of a midfacial fracture?
- opacification or increased fluid levels in maxillary sinus
- tear drop: orbital floor fracture