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PBL 3 - Coggle Diagram

- - - - Based on the Winter classification: mesioangular
      - Based on Pell and Gregory classification: Class I and Class A
        
        Class I: There is sufficient space available between the anterior border of the ascending ramus & the distal aspect of the 2nd molar for the eruption of the 3rd molar.
        
        Class II: The space available between the anterior border of the ramus & the distal aspect of the of the 2nd molar is less than the mesio-distal width of the crown of the 3rd molar. It denotes that the distal portion of the 3rd molar crown is covered by bone of the ascending ramus.
        
        Class III: The 3rd molar is totally embedded in the bone of the anterior border of the ascending ramus because of the absolute lack of space. It is obvious that Class 3 teeth present more difficulty in removal as a relatively large amount of bone has to be removed and there is a risk of damaging the ID nerve or fracturing the mandible (or both).
        
        Relative depth of third molar
        
        Class A: The occlusal plane of the impacted tooth is at the same level as the occlusal plane of the 2nd molar. (The highest portion of impacted 3rd molar is on a level with or above the occlusal plane).
        
        Class B: The occlusal plane of the impacted tooth is between the occlusal plane & the cervical margin of the 2nd molar. (The highest portion of impacted 3rd molar is below the occlusal plane but above the cervical line of the of 2nd molar).
        
        Class C: The impacted tooth is below the cervical margin of the 2nd molar. (The highest portion of impacted 3rd molar is below the cervical line of the of 2nd molar).
  - - - Asymptomatic and pathology-free impacted third molars need not be removed but would advice periodic review.
      - Non-intervention avoids risks and may preserve potentially functional teeth and the bony ridge
      - Deeply impacted third molars in patients with no history or evidence of pertinent local or systemic pathology should not be removed.
    - - involves the raising and protection of soft tissue flaps and bone removal with either chisel or bur with water cooling irrigation
      - The whole tooth should be removed and wound toilet completed. Any suspected pathological material should be sent for a histopathology report
      - The surgical procedure to be carried out depends on the following:
        
        status of the tooth
        
        type of impaction
        
        surrounding structures (e.g. relationship of the inferior dental and lingual nerves)
      - Indication
        
        Infection
        
        Caries
        
        Periodontal disease
        
        Pathology
- - - - If present, either removal of soft tissue or
        occlusal adjustment
    - - Cap amoxicillin 500mg TDS 5/7 + Tab metronidazole 400 mg TDS 5/7
      - amoxicillin and clavulanic acid 625 mg BD 5/7 + Tab metronidazole 400 mg TDS 5/7
      - Penicillin allergy
        Tab erythromycin 500 mg QID 5/7
    - - Operculectomy
      - Surgical removal of impacted tooth
  - - - lingual nerve
      - Inferior alveolar nerve
      - long buccal nerve
      - mylohyoid nerve
  - - - Muscles of mastication - that elevate mandible and closes mouth
        
        Masseter
        
        medial pterygoid
      - nerve supply
        
        Lingual nerve - need to be cautious when doing surgical removal of mandibular third molar
        
        Inferior alveolar nerve - Supplying the teeth of lower jaw, it emerges through mental foramen to supply skin of face
        
        Buccal nerve - sensory nerve that supplies skin over cheek and mucous membrane lining cheek
        
        Mylohyoid nerve - branch of inferior alveolar nerve, supplies mylohyoid muscle
  - - - Based on trigger 1: states that overlying operculum slightly, inflamed and vestibular sulcus on buccal tooth 48 was raised
        
        Might caused by trauma from tooth 18 biting to operculum of tooth 48
- - - - Neurapraxia
        
        Mildest injury caused by compression of the nerve.
        
        Recover once cause is removed.
      - Axonotmesis
        
        More severe blunt injury causing axon degeneration but intact connective tissue
        
        Near perfect recovery once caused is removed.
      - Neurotmesis
        
        Completely divided nerve involving all layers of connective tissue caused by laceration or ischemia.
        
        Need surgical intervention. Recovery is never perfect.
    - - Second Degree
        
        axonal injury with subsequent degeneration and regeneration caused by traction or compression
        
        Recovery
        
        2-4 months or 8-10 months
      - Third Degree
        
        damaged axon with intact perineurium and epineurium layers typically caused by traction or compression
        
        Recovery
        
        2-5 months or ~10 months
      - First Degree
        
        conduction block, rapid and virtually complete return of sensation or function and no degeneration of axon.
        
        Good prognosis
      - Four Degree
        
        disruption of the axon, endoneurium and perineurium with preservation of the discontinuity of the epineurium resulting in severe fascicular disorganization.
        
        Poor prognosis
      - Fifth Degree
        
        severe disruption of connective tissue components of the nerve trunks with compromised sensory and functional recovery.
        
        Poor prognosis
  - - - Most will heal within 6 months
  - - - Buccal
      - Sublingual
      - Submandibular
        
        For this patient, the tooth was displaced to the right submandibular area.
      - Submental
    - - Masseter
      - Pterygomandibular
      - Temporal
        -superficial
        -deep
        -infra
- - - - Pericoronitis (definitive diagnosis)
        
        He might experienced lymphadenopathy that causes swelling on his right jaw
        
        inability to close the jaws.
        
        Can exhibit long periods of chronic inflammation without symptoms
        
        affected area is erythematous and edematous
        
        often associate with lymphadenopathy, fever, leukocytosis and malaise
        
        An inflammatory process that arises within the tissues surrounding the crown of a partially erupted tooth
      - Facial cellulitis
        
        Ludwig's angina develop from spread an acute infection from the lower molar teeth
        
        massive unilateral swelling but may spread to contralateral neck.
        
        Can cause restricted neck movement, dysphagia, dysphonia, dysarthria, drooling, and sore throat
        
        Fever, chills, leukocytosis, and an elevated sedimentation rate may be seen
        
        no obvious present of pus
        
        unlikely that this could be the definite diagnosis as this is related to acute infection.
      - Sialadenitis
        
        Inflammation of salivary gland
        
        -usually bilateral swelling but can be unilateral
        
        the affected gland is swollen and painful, and the overlying skin may be warm and erythematous.
        
        associated with low-grade fever and trismus
        
        periodic swelling and pain occur within the affected gland (during mealtime)
        
        he did not mention that his swelling happen during his mealtime
      - Mumps
        
        An infection caused by the Paramyxovirus family.
        
        Unilateral swelling
        
        Low grade fever, headache, malaise, anorexia and myalgia.
        
        Common site: Parotid, submandibular and sublingual gland
        
        He did not complain of common viral infection symptoms throughout the course of swelling.
        
        He also did not complain of increased pain when chewing.
      - Ameloblastoma
        
        Benign intraosseous progressively growing epithelial odontogenic neoplasm
        
        Painless buccolingual conrtical expansion.
        
        Increased size can cause paraesthesia, pain, facial deformity and limited mouth opening.
        
        Associated with unerupted third molar
        
        Patient's course of swelling ha sonly been for 3 days. Fairly impossible for Ameloblastoma to grow large in a short amount of time.