Oral Surgery

L4&L5 Examination, Investigations and Treatment Plan 3rd Year

Dr Amera Alkaisi

Clinical Examination

After careful history taking, thorough clinical examination is followed.

The clinical examination is basis of developing an accurate diagnosis and successful

treatment plan.

A comprehensive examination enables the examiner to identify

1. The nature of the complaint that promotes the patient to visit the dental clinic or to
discover a disease, which is unknown to an apparently well patient.

2. It is the diagnostic assessment of the patient‘s status.

3. Relies on the clinician’s primary senses with the aid of simple instruments.
Diagnosis consist of :
1. General physical examination of the patient
2. Local examination of the lesion
Methods of clinical examination
1. Inspection
2. Palpation
3. Percussion
4. Probing
5. Auscultation

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 • Inspection
It is the technique of examination which uses the visual sense.
Start examination by looking at the patient as a whole then move to the area of complain.
To determine if there are any sign that aids in diagnosis of the case. Any change in color,
swelling, ulcer …etc.

• Palpation
Palpation is the examination method that relies on the sense of touch.
In which the hands and fingers are used to gather information by touch, it is applied
depending upon the area to be examined. Used to detect the following:
1.Temperature
2. Tenderness
3. Size, surface
4. Edge
5. Consistency
6. Fluctuation
7. Compressibility
Use your finger to fell the consistency and texture of the swelling if it is hard or fluctuant,
the temperature and dimension. To feel the mobility of the teeth and tender spot.

• Percussion
It is the striking of the tissues (soft or hard) with fingers or an instrument. Ex Handle of the
mirror
• It is used to evaluate tenderness and pain.
• Striking the tissues and the examiner listens to the resulting sound or watches the
patient’s reaction.
• Localize tenderness and pain more exaggerated in acute rather than chronic cases.

Three characteristics are noted:

Tenderness to percussion, tooth movement and sound.

Percussion
• Greater tenderness to precession in an apical direction suggests apical
periodontitis.
• Greater tenderness to percussions in a lateral direction suggests lateral
periodontitis of gingival origin.

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 • Probing
Is the palpation with an instrument & is one of the most important
It is a diagnostic techniques used in Dentistry

1. Examination of carious lesion

Ø The dental probe , Explorer, which is sharp ended, curved or angulated, Decay is
detected by repeatedly pressing and withdrawing the explore tip at each site of
suspected decay.
Ø A carious lesion is identified by the sensation known as a “catch” when the explorer
resists the withdrawals force.
2. Testing local anesthesia.
3. Examination of gingival and periodontal tissues
Blunt end graduated periodontal probe is used to determine the sulcus/pocket depth
and the presence of bleeding in periodontal disease.
4. Exanimation of parotid & submandibular salivary gland ducts
Lacrimal probe is used
5. To identify or determine the extent of a narrow tract or cavity.

6. Fistulous tracts can be probe with Gutta Percha points to determine the origin of
fistula

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 • Auscultation

Auscultation is the diagnostic process of listening to sounds made by various body parts.
Abnormal temporomandibular joint sound is often heard while the patient opens and closes
the mouth using stethoscope. It is rarely used in dentistry

• Transillumination

Is the use of light source to examine the ability of tissue to absorb or reflect the light.
It is especially used for paranasal sinus examination.
The examination of the maxillary and frontal sinuses by allowing light to pass through it in a
completely darkened room.
1. For examination of the maxillary sinuses: the light source is placed in the mouth
and the lips are closed.
2. For the frontal sinuses the light is placed in the upper part of the orbit with the
eyelids closed. A healthy sinus air filled transmits the light, diseased sinus, filled with
fluid, pus, solid mass or thickened mucosa, will appear opaque.
3. The significance of transillumination, used only for detection of diseases extend from
teeth to the maxillary sinuses or vise versa.
4. Transillumination is of great value in detection of interproximal caries in anterior
teeth by the use of light cure equipment.

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Clinical examination includes
A. Extraoral examination
Objectives
l. 'To evaluate any 'general abnormalities & in particular those of head & neck
region
2. To look for signs & symptoms of the patient that could influence diagnosis and
Treatment
This examination includes
Ø General examination
Start with general evaluation is, look at the patient
1. If he looks well or ill, or is pale or flushed.
2. Observe patient posture, GAIT (Manner of walking), these abnormalities are related to
neuromuscular disabilities
3. Check for any cyanosis, clubbing, lymphadenopathy & edema
4. Check vital signs, Pulse, blood pressure, temperature, and respiratory rate should be
noted. Then move to maxillofacial area.

Ø Examination of the skin

ü Look for appearance, any rashes ,sores, itching
ü Color, anemic patient have a pale skin color, yellow in jaundice
ü Texture, sign , pigmentation, edema
Ø Examination of the face
ü Observe facial form, gross asymmetries of face includes diffuse swellings,
traumatic injuries, and congenital deformities.
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 ü If there is any swelling, the size, the shape and consistency must be noted. If it
is tender firm or soft, it's color, hot or cold…etc .
ü Examine the lymph nodes, the facial, sublingual, submandibular and
cervical lymph nodes, should be palpated, any enlargement or tenderness
these lymph nodes may enlarged due to dental infection
ü Examination of paranasal sinuses pressure in inferior orbital region may be
tender which indicate acute maxillary sinusitis.
ü Examine the eye, if there is exophthalmos or ptosis, pale conjunctiva indicate
anemia , sclera should be examined
ü The ear should be examined.
ü Examine salivary glands, parotid, submandibular and sublingual for

Dryness, Enlargement, quantity of secretions

ü Any limitation of mouth opening or deviation of the midline of the mandible,

palpable clicking during movement of the temporomandibular joint.

Examination of temporomandibular joint

Observed for:
¨ Symmetry: gross derangement in symmetry may reflect growth disturbances.
¨ Maximum interincisal opening (normal is 35-50 mm), any deviation in opening
¨ Range of vertical movement
¨ Range of lateral movement
¨ Listen for clicking and crepitus sounds tenderness over joint or masticatory muscles
¨ Palpation of TMJ
¨ Palpation of pre tragus area
¨ Intra auricular palpation
¨ Auscultation, it is used to study the movement of TMJ and also used for examination of
venous malformation

Palpation of pre tragus area

The examiner can be positioned either in front of or behind the patient.
Patient is asked to slowly open and close the mouth palpating with index finger,
placed in the pre tragus depression.

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Intra auricular palpation
• Performed by inserting small finger into the ear canal and pressing anteriorly.
• While palpating with this methods check whether condyle moves symmetrically with
the rotation and translation phase.

Examination of the neck

Examine the neck for any swelling, thyroid gland, lymphnodes

Examination of lymphnode
Lymph nodes are oval or bean-shaped structures found along lymphatic vessels that drain
body parts.
• They act as filter for foreign particles, dead tissue, cancer cells and
microorganisms .
• Human body have approximately 600-800 LN, 300 of them in head and neck.
• Normally, they are non tender, soft and cannot be felt even though they are
present.
• Tender on palpation, mobility should be noted.
ü In acute stages LN are tender but not palpable
• In chronic stages LN are enlarge in size and palpable
• Know the position ¨ number of nodes ¨ tenderness ¨ fixity to underlying
tissues
• Consistency of lymph nodes
ü Soft in consistency, Inflammatory
ü Firm, syphilis
ü Elastic and rubbery Hodgkin’s disease
ü Matted lymph nodes Periodontitis, Tuberculosis, Acute
lymphadenitis.
ü Stony hard Carcinoma
Lymphadenopathy: is a disease process that involves changing in numbers, consistency,
size and fixation to adjacent tissues.

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 The causes of lymphadenitis are, infection, idiopathic -autoimmune
diseases and cancer.

B. Intra oral examination

Instruments for dental examination
1. Dental Mirror
2. Dental probe
3. Tweezer
Methods of examination
1. Inspection- of the buccal and labial sulcus, the tongue, palate, pharynx and floor of the
mouth duct of salivary glands must be seen palpated, if there is pus discharge
2. Palpation by hand to detect consistency of the lesion
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3. Tenderness, percussion, instrumentation
4. Vitality test using cold or hot method use probe to examine tooth in question. check if the
tooth is tender to percussion
Methods of palpation

1. Bimanual
It is the manipulation of the tissues using two hands or two fingers of both hands. It
is used for examination of cheeks, floor of the mouth and to detect the presence of
salivary gland stones.

2. Bidigital

Is done by pressing the structure to be examined between examiner’s thumb & index
finger. Done for evaluation of nodules, lip etc

Using two fingers of one hand. qUsed usually for lips and buccal mucosa

3. Bilateral
Used to compare symmetrical structures. EX, TMJ, Muscles of Mastication, Lymph
nodes, Two lobes of Thyroid gland

Intraoral examination
Objectives
1. To detect soft tissue abnormalities.
2. To evaluate the status of the teeth and hard tissue

Intraoral examination, includes systematically checking, lips, labial and buccal

mucosa, floor of the mouth, tongue, hard and soft palate, oropharynx, muscle of
mastication, (Lateral & Medial pterygoid, masseter and temporalis),Teeth. Gingiva.
Orifice of the ducts of the Parotid and Sub mandibular glands.

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1. Intra oral examination should start with the extent of mouth opening which is
described in term of patients finger width, ex 2, 3, 4 fingers
2. Check, if there is any deviation during mouth opening
3. Look for oral hygiene (good, fair, poor, very poor)
4. Reflect the lips and check with mouth mirror to check the vestibules and floor of the
mouth
5. Examine the orifice of salivary glands, if it is enlarged, any redness or discharge.
6. Examine dorsal, ventral and lateral surfaces of the tongue for presence or absence of
papillae, fissure, ulcer, growth, induration and anterior and lateral movements.
7. Hard and soft palate examined for any swelling, ulcer, sinus and perforation.
8. Mucosa checked for presence of tobacco irritation, leucoplakia and pigmentation
9. The gingiva examined for stippling, color and size of inter dental papilla
10. Presence of calculus, any sinus, any retained roots
11. Check for the presence any pocket or periodontal disease.

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Teeth examination

• Check for: Size, Color, structural changes of teeth, Eruption status of teeth,
Retained deciduous teeth, Any trauma to tooth
• The primary examination technique for evaluating the teeth include:
Visual inspection, Probing, Percussion Transillumination
• Examination of carious tooth requires good light source, mirror, sharp
explorer, air syringe are the most basic tools required
• Check the occlusion:
Class I: Mesio buccal cusp of the maxillary Ist molar occludes in the buccal
groove of mandibular Ist permanent molar.
Class II: Distobuccal cusp of upper first molar occludes in the buccal groove
of lower first permanent molar.
Class III: Mesiobuccal cusp of maxillary first permanent molar occludes in
interdental space between mandibular first & second molar.
• Check for the presence of tooth attrition, is physiologic wearing away of a
tooth as a result of tooth to tooth contact, as in mastication.
• Check for abrasion : Friction between tooth & an exogeneous agent
• Check for erosion, is irreversible loss of dental hard tissue by a chemical
process
• Check for mobility of the teeth
• Check the vitality of the teeth
• Test for percussion

Attrition Abrasion Erosion

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Investigations
¨ Hematological investigations
¨ Urine analysis
¨ Biochemical investigations
¨ Radiological investigations
¨ Histopathological investigations
¨ Microbiological investigations
¨ Sialography, Cephalometry, OPG, MRI, CT scan etc

A. Radiographic investigation
Used to give information of the hidden hard and soft tissue.
Preoperative clinical assessment maybe supplemented some times by' preoperative
radiographs. Both pre and post-operatively is necessary,
It show curved root, large cyst, caries exposure of the pulp
Ø Intraoral
Periapical, occlusal, Bitewing views

Periapical Bitewing occlusal

Ø Extraoral
OPG, PA view of skull and jaws, AP view, TMJ views
Special investigations like:
Sialography MRI CT Scan and CBCT

PA OPG
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B. Blood pressure determination
C. Vitality test
1. Hot application, hot instrument
2. Cold application ethyl chloride
3. Electrical pulp tester, to check the tooth response
D. Laboratory test, test for bleeding, blood sugar. Biopsy used to confirm the diagnosis.

Routinely used Hematological investigations include

§ Total red blood count

§ Hb concentration
§ Red cell indices
§ Total white cell count
§ Differential white cell count
§ ESR
§ Bleeding and coagulations disorder
§ Partial thromboplastin time.

Urinalysis

Glycosuria ¨ Ketonuria ¨ Bilirubin or urobilinogen ¨ Proteinuria ¨ Haematuria

Skin testing
¨ Patch tests ¨ Intradermal injections ¨ Prick test ¨ Modified prick test ¨ Scratch test

Aspiration
Withdrawal of fluids from body cavity.
o Aspirate used for cultures and sensitivity tests to identify the pathogen
o E.g. Heamangioma bluish blood is aspirated.
o Yellowish white fluid “pus” (associated with painful fluctuant swelling) abscess.
o Yellowish white fluid pus with “sulphur granule” Actinomycosis

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 BIOPSY

Biopsy is used to confirm the diagnosis

1. Incisional: to take a small piece of the lesion for histopathological examination
2. Excisional; to take the whole lesion for histopathological examination

Indication for preoperative radiograph

1. History of difficult extraction

2. A tooth abnormally resist forceps extraction
3. Any tooth in close relation to the maxillary sinus or inferior dental nerve or mental
nerve.
4. All third molars or misplaced teeth.
5. Pulpless teeth because they are very brittle
6. Any tooth subject to trauma because fracture of the root or alveolar bone may be
present.
7. Any partially erupted or unerupted teeth
8. Any isolated teeth or over erupted teeth.
9. Any tooth with abnormal crown or defect eruption

Treatment plan
Treatment plane must be designed to suit patient general and medical condition.

This depend on:

• Thorough preoperative assessment of any difficulties which may occur

• Advantage and disadvantage of the various methods of treatment.
• Local or general anesthesia better to be use with premedication or without…etc.
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