3. General surgical procedures - incisions, suturing, sewing materials, curettage, drainage, puncture. Flashcards
Primary purpose of surgical incisions
Gain access intraorally or extraorally, to site that is the object of the surgery
Role retractors play in surgical procedures
- Pull the tissues aside to visualize the tissues exposed=>
- Allows better access to the surgical site
How length of surgical incisions managed
- No longer than necessary
- Skin or mucosal incision the shortest
- Incisions in deeper layers longer to allow the surface to be slid from side to side=>
- maximal access without increasing the surface incision length
Types of blades are commonly used for incisions in oral and maxillofacial surgery
- The #15 blade with its rounded tip is most popular
- # 11 blade with its pointed tip
- # 12C blade with its smaller rounded tip are also used for specific procedures
Recommended technique for making an incision
- One single firm movement using the palm of the hand as support for the scalpel handle=>
- To avoid undesirable instability
Alternative methods for making incisions besides using a scalpel
- Electrosurgery or a laser
- Combined instruments like a scalpel blade with electrosurgery capacity
Drawbacks of electrosurgical cutting
- Produces bloodless field=> at the expense of surface cauterization=>
- More wound breakdown, scarring, and wound contracture
- Unsuitable for esthetic areas
Where skin incisions around the face placed for the best esthetic results
- In established skin creases
- Future skin creases (in young patients)
- Or in the relaxed skin tension lines
Relaxed skin tension lines
Run at right angles to the direction of underlying musculature
Precautions taken when making facial incisions to minimize scarring
- Follow relaxed skin tension lines
- Avoid crossing natural crease lines at right angles
- Consider underlying nerves, particularly branches of the facial nerve
How incisions be made on the oral mucosa
Full thickness over the mandible and maxilla, going down to the bone
Characteristics and indications of a straight vertical incision
- Most esthetic result with minimal scarring
- Indicated for obtaining access to deeper lesions
- Tunneling procedures
- Minimally invasive intraoral procedures, though access is limited
When a straight horizontal incision in the buccal sulcus indicated and its drawback
- Management of periapical pathology
- Impacted teeth
- Tumors, and sinus procedures
- Produces more scarring than a vertical incision.
Intrapapillary/sulcular/gingival margin incision and its potential problems.
- Uses a scalpel at a reverse bevel
- Sections interdental papillae and some supracrestal fibers
- Excellent access with minimal scarring
- Potential problems => Issues around crowns and bridges, gingival recession, root exposure, and occasional gingival problems
Purpose of releasing incisions at each end of a gingival margin incision
- Releasing incisions( should be divergent)=> protect the vascularity of the flap and minimize visible scarring
- especially when placed further back in the oral cavity
Winter type incision for third molars
- Extends down the external oblique ridge to the disto-buccal line angle of the second molar=>
- Continues around the gingival margin of the first and second molar
- Good access but can be difficult to suture and may cause gingival recession
- An alternative=> releasing incision terminating around the posterior edge of the first molar to avoid a small arteriole
Double Y-type incision and when it is indicated
- For Palatal torus removal
- Good blood supply for the palatal mucosa and allows excellent access for removal with drills and chisels
- Can be followed by sharp or blunt dissection to avoid damaging important structures
Primary goal of suturing following a surgical incision
- Close the wound, ensuring the best apposition of tissues and minimal scarring
Alternatives to traditional suturing
Stapling and the use of tissue adhesives.
Instruments commonly used for suturing
Needle holders, tissue forceps, and scissors
Main categories of sutures based on their resorption properties
- Resorbable or non-resorbable
- Resorbable sutures dissolve over time
- Non-resorbable sutures need to be removed
Monofilament sutures
- Tend to stay cleaner
- Leave fewer suture marks on tissues
- Harder to knot=>more likely to become unknotted
- Can irritate the tongue and cheeks
Multifilament Sutures
- Easier to knot
- Lie flat, and are less irritating
- Harder to keep clean
- Tend to “wick,” attracting moisture and bacteria
- Some synthetic sutures combine the benefits of both by being coated multifilaments
Catgut suture, and its properties
- Made from sheep intestine, 🐑
- Proteinaceous product
- Plain Catgut
- Chromic Catgut
Plain Catgut
- Monofilament
- Resorbs in 5-7 days via enzymatic action,
- Often causes inflammatory response
Chromic Catgut
- Treated with chromic acid to improve handling properties=>
- Reduce inflammatory response
- Resorbs in about 2 weeks
- Considered ideal for many intraoral suturing needs
- Potential concerns regarding prion disease transmission
Polyglycolic Acid and Polyglactin Sutures
- Synthetic
- Resorb in about 6 weeks through hydrolysis
- Monofilament, multifilament or coated multifilament
Polydioxanone (PDS) and polyglyconate sutures used for
- Synthetic
- Resorb in about 120 days 🕰️
- used where long-term resorption is beneficial=>alar cinch sutures for LeFort orthognathic surgery
- Monofilament, multifilament, coated multifilament
Characteristics and uses of silk sutures
- Natural product from silkworms
- Non-resorbable
- Always braided
- Easy to knot
- Lies flat
- Needs removal
- Prone to food sticking and wicking=> infection if not kept clean.
On the skin, they leave suture marks if not removed after a few days
Properties and occasional uses of cotton sutures
- Natural
- Non-resorbable
- Multifilament
- knots easily
- Occasionally used on the mucosa and tends to wick
Advantages of nylon and polypropylene sutures
- Synthetic
- Monofilament
- Non-resorbable
- Extremely fine, non-irritant
- often used in microsurgery and skin suturing
- Polypropylene is especially benign for skin=>minimal suture marks
Common characteristics and variations of surgical needles
- Come ready-swaged to the suture
- Vary in length
- Diameter of a circle
- Some in other shapes like a J shape
Round-bodied needle and its typical use
Non-cutting and is generally used on friable internal organs
Cutting needle and its application
- Triangular in cross-section
- One edge sharpened to cut through tissues
- Necessary for mucosa, skin, and some fascial layers of the head and neck
Difference between a forward-cutting and a reverse-cutting needle?
- Forward-Cutting Needle=> The cutting edge is on the inside of the circle
- Reverse-Cutting Needle=>The cutting edge is on the outside of the circle=>
- Cuts away from the direction the needle is passed=>
- Preferred in most oral surgical procedures to prevent cutting through the tissues too often
Taper cut needle
- Combines a reverse-cutting tip with a round-bodied portion
- Makes initial incision with the cutting tip
- Passes through tissues with the round-bodied part=>minimal damage
How suture tied once it has been passed through tissues
- Tied in a knot
- Done with an instrument or by hand
- A monofilament suture requires more knots than a braided suture to prevent it from becoming untied.
Process of tying a secure surgical knot
- Start with a double overhand or double thumb knot=> prevents slipping
- Follow with another thumb knot=> If tied in the same direction=>it forms a surgeon’s knot (secure)
* =>If tied in the opposite direction, it forms a granny knot (adjustable). - The final knot converts the previous knot to a reef or square knot to prevent loosening.
Simple interrupted sutures, and recommended density
- Common sutures with each stitch tied separately
- Around three sutures per centimeter of length is a good balance=>
- Minimize stitch marks and infection while preventing a widened scar
Horizontal and vertical mattress sutures
- Horizontal Mattress Sutures: Used for watertight closure
- Vertical Mattress Sutures: Provide watertight closure and everted suture line=>
- Ideal for suturing over dead spaces like cyst cavities or oroantral fistulas
Continuous locking and non-locking sutures
- Non-Locking Sutures: Often used on the skin for better cosmetic results.
- Locking Sutures: Used in the oral cavity for better closure and waterproofing
- The risk with continuous sutures=>one part breaks=>suture line can fail
- Interrupted sutures =>doesn’t compromise the entire line
Curettage, and how it is performed
Use of an instrument to remove tissue by scraping or scooping
Dental procedure in which curettage used
- Teeth affected by periodontitis. Specifically
- Gingival curretage=>removes soft tissue lining of the periodontal pocket with a curet=>
- leaves only a gingival connective tissue lining.
Goal of gingival curettage
- Promote new connective tissue attachment to the tooth=>
- Removal of pocket lining and junctional epithelium
Primary purpose of drainage by incision in the case of pus-producing infections
Resolve the infection by incising the abscess cavity and draining the pus.
Pus components, and why its drainage is important
- Dead leukocytes (neutrophils) and causative bacteria
- Drainage reduces tissue tension=>
- Improves local blood supply
- Changes the local environment by increasing oxygenation=»>
- Resolve the infection
How a clinician detects an abscess
- Carefully palpate swollen areas to detect fluctuance=>
- Indicates abscess formation
When an abscess should be incised
- When pus has accumulated within the cavity
- Infections usually start with cellulitis=>
- Soft, doughy, and diffuse swelling=>
- May not respond to surgery
Considerations for anesthesia during incision and drainage of an abscess
- Conventional local infiltration=>superficial and well-localized abscesseS
- Greater volumes of anesthetic=>extensive infection=>
- Inferior alveolar nerve block, sedation, or general anesthesia
inflammation creates an acidic environment, slowing the onset of action and reducing effectiveness
Why aspiration of pus prior to incision recommended, and how it should be performed
- Sterile syringe with a large-gauge needle is for pus accumulation
- Localize the abscess=> collect pus for bacteriologic examination
- Mucosa or skin disinfected before aspiration to avoid contamination
Precautions taken to avoid damaging important structures during incision
- Avoid damage to salivary gland ducts and nerves
- Placed parallel to the facial nerve branches
- Consider structures like the marginal mandibular branch of the facial nerve and mental nerve
- Avoid damaging greater palatine artery and lingual artery
Where incision made to minimize cosmetic and functional issues
- Placed in esthetically acceptable areas
- Intraoral incisions minimal and careful to avoid future functional problems
How an incision made to maximize drainage efficiency
- Should encourage gravity drainage
- Made with blunt dissection to minimize injury to vital structures
- Ensure adequate opening of the abscess cavity.
Role irrigation plays in the treatment of large abscesses
Irrigation with saline helps reduce residual contamination in large abscesses
How drains managed post-insertion
- Shortened over the next few days to ensure complete drainage
- Removed when drainage stops to avoid delaying the normal wound healing process.
