Basic Surgical Technique Flashcards
Basic principles of Surgery
- Risk assessment involving good planning and MH
- Aseptic technique
- Minimal trauma to hard and soft tissues
- Surgeon should be performed efficiently
- Plan stages before embarking on procedure
What are the stages of Surgery?
- Anaesthesia
- Access
- Bone removal as necessary
- Tooth division as necessary
- Debridement
- Suture
- Achieve haemostasis
- Post-operative instructions
- Post-operative medication
What do you do if the procedure is out of your depth?
- Refer
- Know own limitations
How to gain surgical access?
- Wide-based incision- circulation
- Use scalpel in one firm continuous stroke
- No sharp angles
- Adequate sized flap
- Flap reflection should be down to bone and done
cleanly - Minimise trauma to dental papillae
- No crushing
- Keep tissue moist
- Ensure that flap margins and sutures will lie on
sound bone - Make sure wounds are not closed under tension (otherwise will break open)
- Aim for healing by primary intention to
minimise scarring
How to lift muco-periosteal flap?
- Lift mucosa and periosteum
- Strip it back until you see bone
Why do we use Soft tissue retraction?
- Access to operative field
- Protection of soft tissues
- Flap design facilitates retraction
- Howarth’s periosteal elevator or rake retractor
- Should be done with care
What is a 3 sided flap?
- Mesial incision
- Incision following buccal margin
- Distal incision
What is an envelope flap?
- AKA 2 sided flap
- Buccal incision along abutment tooth and tooth extracting
- Distal incision
What to do if you need to use bone removal in order to remove tooth?
- Electrical straight handpiece with saline
cooled bur - Air driven handpieces may lead to surgical
emphysema ( can be life threatening ) - Round or fissure tungsten carbide burs
- Protection of soft tissues
Steps not done in every case but in some
What is surgical emphysema?
- Can be life threatening as can cause sepsis
- Presence of gas in subcutaneous soft tissues
- Detected clinically by swelling of affected area and crepitus on palpation
Where do you remove bone if needed?
- Create a gutter of buccal bone next to tooth
- If it doesn’t come out then need to divide the tooth
- Start with crown
- Then divide roots
What are the principles of use for Elevators?
- Mechanical advantage
- Avoid excessive force
- Support the instrument to avoid injury to the
patient should the instrument slip - Ensure applied force is direct away from major
structures eg. antrum, ID canal, mental nerve - Always use elevators under direct vision
- 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 the use of elevators to remove any bone fragments that have been created
What is the motion used for elevators?
- Wheel and axle
- Wedge
- Lever
- Used in combo with each other
- Avoid excessive force
What are some uses of elevtaors?
- 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
What are the points of application of elevevators?
- Mesial
- Buccal
- Distal
- Superior (upper teeth)
- Mesial/buccal alternately
- Inferior (lower teeth)
What are the 3 methods for Debridement?
Physical
– 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
What are the aims of suturing?
- Approximate tissue (get back tissue to where it was)
- Compress blood vessels
- Reposition tissues
– Cover bone
– Prevent wound breakdown
– Achieve haemostasis
– Encourage healing by primary intention
What are some different types of Sutures?
- Non-absorbable
- Absorbable
- Can be polyfilament or monofilament
When are non-absorbable sutures used?
- If extended retention periods are required
– Must be removed postoperatively
– Closure of OAF or exposure of canine tooth
What are polyfilament sutures?
– Several filaments twisted together
– Easier to handle
– Prone to wicking
- Oral fluids and bacteria move along the length
of the suture and can results in infection
When are absorbable sutures used?
– 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 is not required (usually review needed though)
What is a monofilament suture?
– Single strand
– Pass easily through tissue
– Resistant to bacterial colonisation
What are some different suture needles?
Curved
– ½ round is half the circumference of a circle
Cross section
– Triangular
- Tip of triangle on inside-cutting
- Tip of triangle on outside-reverse cutting*
– Round
- Not used in oral surgery
3/8 circle and 1/2 circle most used in oral surgery
How to hold a suturing needle?
- Point is pointy bit that goes into tissue first
- Body (shaft) is where held by tweezers
- Swaged end is where thread attaches to needle
What are the peri-operative points to achieve Haemostasis?
- LA with vasocontrictor (put more in if struggling with haemostasis)
– Artery forceps
– Diathermy
– Bone wax
What are post-operative points to achieve Haemostasis?
– Pressure
– LA infiltration
– Diathermy
– WHVP (not used anymore)
– Surgicel (most common)
– Sutures
Post op medications
- Medications not given as often as trying to reduce antibiotic resistance
- Don’t tend to prescribe analgesics due to low prices and patient can buy themselves
Why do you need to be careful of Lingual nerve during oral surgery?
- Nerve is above lingual plate in 15-18% cases
It is at risk during
– Incision of flap
– Raising of buccal and lingual flaps
– Retraction of flap
– Bone removal
– Extraction with forceps
What nerves do you need to be careful of during removal of third molars?
– Lingual (more commonly affected)
– Inferior alveolar (more commonly affected)
– Mylohyoid
– Buccal
What are some complications of lower third molars?
- Pain
- Swelling
- Bruising
- Trismus
- Paraesthesia/anaesthesia-lip/tongue
Factor these into consent process and get them to sign notes
What analgesia is useful for third molar removal?
– Ibuprofen
– Cocodamol
– Paracetemol
- Chlorohexidine can also be given
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
- Curettage, enucleation of cyst
- Removal of apical part of root which may have
infected lateral canals
What are the different flap designs?
Semi-lunar
– Reduced access
– Only good for apical lesions
– Scarring
– Dysaesthesia
– Less gingival recession
Triangular
Rectangular
What materials do you use for a retrograde seal?
- Zinc Oxide/eugenol
Qualities of Retrograde seal?
– Cheap
– Easy to use
– Radiopaque
– Bacteriostatic
– Sensitive to moisture
– May resorb
– Doesn’t promote cementogenesis
What are the steps for removal of apex?
- Remove 3mm
- Minimal angle to allow visualisation
- Try to keep cut at right angles to root to minimise surface area
- Allows curettage
