Basic Oral Surgery Techniques Flashcards
What are the basic principles of oral surgery
risk assessment
aseptic technique
minimal trauma to hard and soft tissues
Why do we do a risk assessment
for good planning so we can consider any local anatomical structures and plan the steps
so we can consider any medications that may impact bleeding and healing in the medical history
What is the environment for oral surgery
- Cross infection control and surgical etiquette is required
* However, a theatre environment is not required
Why is a radiological assessment required
• We need to know what the roots look like and what the local anatomy is and this will help us perioperatively
What are the stages of surgery
- Consent
- Surgical pause/safety checklist
- Anaesthesia
- Access
- Bone removal as necessary
- Tooth division as necessary
- Debridement as necessary
- Suture
- Achieve haemostasis
- Post-operative instructions
- Post-operative medications
- Follow up
What kind of consent is required for oral surgery
written
Need to ensure the px understands what is happening and the risks involved before signing
What does the surgical safety checklist include
developed by WHO and adapted
Check we have the right px, we are operating on the correct side and everything is prepared at the beginning of the procedures
What are the things we aim for with surgical access
maximal access with minimal trauma
preserve adjacent soft tissues
want to remove the mucoperiosteum, not the mucosa alone
What are the main principles of surgical access
- Wide-based incision to allow maintenance of the circulation and perfusion to prevent the tissues from becoming necrotic
- Use a scalpel in one firm continuous stroke so that the mucoperiosteum is lifted
- No sharp angles as we don’t want thin strips of tissue that are at risk of necrosis
- Adequate sized flap
- Flap reflection should be down to bone and done cleanly as the more periosteum that is damaged the more pain
- Minimise trauma to dental papillae
- No crushing
- Keep tissues moist
- Ensure that flap margins and sutures will lie on sound bone as this will allow support to the soft tissues to heal well and prevent wound breakdown
- Make sure wounds are not closed under tension
- Aim for healing by primary intention to minimise scarring as more scarring is associated with secondary intention
What do we do for a 3 sided flap
- Common
- Relieving incisions are made at a distance of one tooth unit each from the tooth treated
- Involves a distal relieving incision, a crevicular incision and a mesial relieving incision
- Don’t go too distal and there is risk of lingual nerve damage
- Follow the external oblique ridge instead
What do we do for an envelope flap
- Pretty much the same as the 3 sided but there is no mesial relieving incision
- The crevicular incision either extends to the midway along the 7 or even further
What does soft tissue retraction allow for
- Allows for access to the operative field
* Allows for protection of the soft tissues
What facilitates retraction
flap design
What instruments are used for soft tissue retraction
• The instruments used for this are Howarth’s periosteal elevator or rake retractor
How do we remove bone
often we do it by ‘guttering’’
What does bone removal allow for
elevation
removal of the crown of the tooth
splitting the tooth
What are the elevators
couplands, warwick james and cryers
What are the principles of use for elevators
○ They give a mechanical advantage
○ Avoid excessive force as there is a risk of jaw fracture
○ Support the instrument to avoid injury to the patient should the instrument slip
○ Ensure applied force is directed away from the major sutures e.g anturm, Id canal and the mental nerve
○ Always use elevators under direct vision
○ Nerve use an adjacent tooth as a fulcrum unless it too is to be extracted
○ Keep elevators sharp and in good shape, discard if blunt or bent
○ Establish an effective and logical point of application
○ Careful debridement after the use of elevators to remove any bone fragments that have been created
What are the uses of elevators
o provide a point of application for forceps
○ To loosen teeth prior to using forceps
○ To extract a tooth without using forceps
○ Removal of multiple root stumps
○ Removal of retained roots
Removal of root apices
What are the 3 basic actions of elevators
wheel and axle
wedge
lever
What is the wheel and axle motion
§ This is when you elevate the tooth to allow the point of the instrument to engage into the tooth and the opposite end sits on some bone and then elevate it out while rotating the wrist
What is the wedge motion
§ In the majority of cases you need to incorporate some wheel and axle
What is the lever motion
§ Avoid if inexperienced
§ Risk of fracturing underlying bone if not done properly
Which action can be used
any
all 3 can be used in combination
What are the points of applications for elevators
○ Mesial ○ Buccal ○ Distal ○ Superior (upper teeth) ○ Mesial/buccal alternately ○ Inferior (lower teeth)
How do we do physical debridement
○ Bone file or handpiece to remove sharp bony edges
○ Use a Mitchell’s trimmer or Victoria curette to remove soft tissue debris
How do we irrigate the socket
○ Sterile saline into socket and under flaps and use suction to remove debris
What is suction for during debridement and curettage
○ Aspirate under flap to remove debris
○ Check socket for retained apices etc
What is suturing done for
• Suturing is done to approximate tissues and compress blood vessels
What is the aims of suturing
○ Reposition tissues ○ Cover bone ○ Prevent wound breakdown ○ Achieve haemostasis ○ Encourage healing by primary intention
What are the types of sutures
○ Non-absorbable
○ Absorbable
○ Monofilament
○ Polyfilament
What are the absorbable sutures made of
synthetic polymer
What are absorbable sutures for
Holds tissue edges together temporarily
Used if the removal of the suture is not possible or desirable
Review may not be required
How are absorbable sutures broken down
○ Vicryl-breakdown occurs via absorption of water into filaments causing the polymer to degrade via hydrolysis
○ The glycolide and lactide copolymer are broken down to glyoclic and lactic acid which are absorbed and metabolised by the body
○ They last for a week or two
What are examples of absorbable sutures
velosorb and vicrylrapide
When are non absorbable sutures used
○ If extended retention periods are required these will be used
○ Must be removed postoperatively
○ Used for closure of an oral antral fistula or exposure of a canine tooth
What are examples of non absorbable sutures
prolene and mersilk
What are monofilament sutures
○ Single strand
What are the advantages of monofilament sutures
Pass easily through tissues
Resistant to bacterial colonisation as its one material rather than the lots seen in poly which is at risk of wicking and moving a lot which can result in infection (not common though)
What are polyfilament sutures
○ Several filaments twisted together
What are examples of monofilament sutures
E.g are prolene and ethilon
What are advantages of polyfilament sutures
○ Easier to handle
What is the disadvantage of polyfilament sutures
Prone to wicking
Oral fluids and bacteria move along the length of the suture and can result in infection
What are examples of polyfilament sutures
Velosorb and mersilk are examples
What are different types of shapes of suture needles1/
straight 1/2 circle (common) 1/2 curve 3/8 circle (common) others exist too
What is the cross sections for suture needles
can be triangular - can be cutting or reverse cutting
round (taper)
How do you hold a suture needle
it has a swaged end, a body and a point
you grab the needle with a needle holder by the swaged end
What are different ways of doing a suture for an 8 (3 sided flap)
1 on distal relieving incision, 2 on mesial reliving incision
1 on distal reliving incision, 1 on mesial reliving vision and 1 distal to 7
How would you do the sutures for a envelope flap on an 8
1 on distal receiving incision and distal to 7
How can haemostasis be achieved peri-operatively
○ LA with vasoconstrictor
○ Artery forceps
○ Diathermy
○ Bone wax
How can haemostasis be achieved post-operatively
○ Pressure ○ LA infiltration ○ Diathermy ○ WHVP ○ Surgicel sutures
What are the 4 nerves than can be damaged in removal of the third molars
lingual
inferior alveolar
mylohyoid
buccal
Why is the lingual nerve at risk
it is above the lingual plate in 15-18% of cases
When is the lingual nerve at risk
□ Incision of flap □ Raising of buccal and lingual flaps □ Retraction of flap □ Bone removal Extraction with forceps
What is analgesia for removal of third molar
○ Ibuprofen
○ Paracetamol
Co-codamo
What are complications of third molar removal
○ Pain ○ Swelling ○ Bruising ○ Bleeding ○ Trismus ○ Infection ○ Dry socket ○ Paraesthesia/anaesthesia of the lip and chin with or without the tongue which can be temporary or permanent
What is peri-radicular surgery
Done for endodontics, it is surgery to the external root surface
When is peri-radicular surgery considered
This type of surgery is considered where previous endo tx has failed and re-root tx is the preferred option
What are the stages of peri-radicular surgery
- LA
- Flap design
- Bone removal
- Curettage
- Apicectomy
- Retrograde prep and filling
- Wound closure
What are the aims of peri-radicular surgery
○ Establish a root seal at the apex of a tooth or at the point of perforation of a lateral perforation
○To remove existing infection
What are the possible flap designs
semi lunar
triangular (2 sided)
rectangular (3 sided)
What is issues with semi lunar flap design
reduced access only good for apical lesions scarring dysesthesia due to transecting nerve fibres less gingival recession
How much bone removal is required for peri-raidulcar surgery
○ Depends one extent of the lesion - there may already be a breach in bone due to the infection
○ Try to be conservative and still allow access
Describe the process of removing the apex in peri-radicular surgery
○ Remove 3mm
○ Minimal angle to allow visualisation
○ Try to keep cut at right angles to root to minimise surface area
○ Allows curettage
What is root end preparation
○ Ultra sonic
§ Cleans canal
§ Creates 3mm preparation within canal
§ Removes contaminated root filling
○ Bur
§ Preparation usually out with confines of canal
§ Don’t use burs for inside the canal
What materials can be used for retrograde seal
amalgam (historical)
zinc oxide/eugenol
MTA
What are the advantages of zinc eugenol /oxide for retrograde seal
§ Cheap
§ Easy to use
§ Radiopaque
§ Bacteriostatic
What are the disadvantages of zinc eugenol /oxide for retrograde seal
§ Sensitive to moisture
§ May resorb
§ Doesn’t promote cementogenesis
What are the advantages of MTA for retrograde seal
§ Moisture resistant
§ Promotes cementogenesis
Very good seal
What are the disadvantages of MTA for retrograde seal
§ Expensive
§ Long setting time
§ Difficult to use
How is wound closure done for peri-radicular surgery
○ Resorbable or non-resorbable sutures
○ 4.0
○ Replace papilla first
Then relieving incision
What are the post-op instructions and review for peri-radicular surgery
○ Standard post op instructions
○ Review and ROS at one week
○ Post-op radiographs between 1-6 weeks
○ Further review 3-6 months later
What are the reasons for failure of peri-radicular surgery
inadequate seal
inadequate support
split roots
soft tissue defect over apex post-op
