basic surgical technique Flashcards
basic principles
risk assessment
aseptic technique
minimal trauma to hard and soft tissues
stages of surgery
anaesthesia access bone removal as necessary tooth division as necessary debridement suture achieve haemostasis POIs post-op medication
surgery principles
maximal access with minimal trauma
bigger flaps heal just as quickly as smaller ones
preserve adjacent soft tissues
consider post-op aesthetics e.g. frenulum, papilla
wide-based incision - circulation
use scalpel in one firm continuous stroke
no sharp angles - incision 90 degrees to gingival margin
adequate sized flap
flap reflection should be down to bone and done cleanly
minimise trauma to dental papillae
no crushing
keep tissue moist
- sterile water/saline irrigation
ensure that flap margins and sutures will lie on sound bone
ensure that wounds aren’t closed under tension - shouldn’t blanch
aim for healing by primary intention to minimise scarring
aims of ST retraction
access to operative field
protection of STs
flap design facilitates retraction
what can you use for ST retraction?
Howarth’s periosteal elevator
rake retractor
Mitchells
how to retract ST flap
care
get elevating instrument under before you start lifting flap - cleanly lift
don’t place retractor on flap - will traumatise it, should be placed under periosteum
envelope/2 sided flap
no anterior mesial relieving incision
can suture through papillae to lingual aspect
crevicular incision
incision in gingival sulcus
what do you use for bone removal and tooth division?
electrical straight handpiece with saline cooled bur
air driven handpieces may lead to surgical emphysema
round/fissure tungsten carbide burs
protection of Sts
smooth action - remove bone from buccal aspect of tooth
uses of elevators
to provide a point of application for forceps
to loosen teeth prior to using forceps
to extract a tooth without the use of forceps
removal of multiple root stumps
removal of retained roots
removal of root apices
elevators - principles of use
mechanical advantage
avoid excessive force
support instrument to avoid injury to pt if instrument slips
ensure applied force is directed away from major structures e.g. antrum, ID canal, mental nerve
always use under direct vision - ensure you can see tip
never 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 use to remove any created bone fragments
why is it important to debride to remove any bone fragments?
inflammation/infection
sharp bone could perforate flap when it is trying to heal
elevator mechanics
wheel and axle
wedge
lever
all 3 actions can be used in combination with each other
elevators points of application
mesial buccal distal superior M/B alternately inferior
types of debridement
physical
irrigation
suction
physical debridement
bone file or handpiece to remove sharp bony edges
Mitchell’s trimmer or Victoria curette to remove soft tissue debris
irrigation
sterile saline into socket and under flap
suction
aspirate under flap to remove debris
check socket for retained apices etc
aims of suturing
reposition tissues cover bone prevent wound breakdown achieve haemostasis encourage healing by primary intention
when would you suture?
don’t routinely suture every extraction socket but would always close STs
non-absorbable sutures
if extended retention periods are required
must be removed post-op
closure of OAF/exposure of canine
e.g. silk, nylon
absorbable sutures
holds tissue edges together temporarily
if removal of suture not possible/desirable
vicryl - breakdown via absorption of water into filaments causes polymer to degrade
?may mean review isn’t required
polyfilament
several filaments twisted together
easier to handle
prone to wicking - oral fluids and bacteria move along the length of the suture and can result in infection
monofilament
single strand pass easily through tissue resistant to bacterial colonisation e.g. 4-0 proline ? maybe not as strong
curve of suture needles
1/2 round is half the circumference of a circle
cross section of suture needles
triangular - tip of triangle on inside - cutting - tip of triangle on outside - reverse cutting round - not used in OS
parts of suture needle
point
body (shaft)
swaged end
general rule for suturing
suture from free tissue to fixed, so from flap to fixed tissue
peri-op haemostasis
LA with vasoconstrictor
artery forceps
diathermy
bone wax
post-op haemostasis
pressure LA infiltration diathermy WHVP Surgicel sutures
why should you avoid relieving incisions in premolar area?
could damage mental nerve at mental foramen
what % of cases is the lingual nerve above the lingual plate?
15-18%
why shouldn’t you do lingual flaps or place lingual retractor for 3rd molar?
sometimes nerve lies above level of bone so can easily damage it
nerves that can be damaged during 3rd molar removal
lingual
IAN - can be predicted
mylohyoid
buccal
PR surgery aims
establish a root seal at the apex of a tooth or at the point of perforation of a lateral perforation
remove existing infection
- curettage, enucleation of cyst
- removal of apical part of root which may have infected lateral canals
flap design for PR surgery
semi-lunar - reduced access - only good for apical lesions - scarring - dysaesthesia - less gingival recession triangular rectangular
bone removal in PR surgery
depends on extent of lesion
try to be conservative and still allow access
PRS - removal of apex
remove 3mm
minimal angle to allow visualisation
try to keep cut at right angles to root to minimise SA
allows curettage
PRS root end prep
US - cleans canal - creates 3mm prep within canal - removes contaminated root filling bur - usually prep outwith confines of canal
PRS wound closure
reosrbable/non-resorbable
replace papilla first
then relieving incision
PRS POI and review
standard POI
review and ROS at one week
post-op radiographs between 1-6wks
further review 3-6m later
PRS reasons for failure
inadequate seal - extra/bifid root - too little apex removed "finning" - seal of incorrect shape - lateral perforation problem - displacement of seal - lateral canals inadequate support - PD pockets, occlusal overload, excessive root resection split roots soft tissue defect over apex post-op
amalgam retrograde seal
historical
ZO/E retrograde seal
cheap easy to use radiopaque bacteriostatic sensitive to moisture may resorb doesn't promote cementogenesis
MTA retrograde seal
moisture resistant promotes cementogenesis v good seal £ long setting time difficult to use
