basic surgical technique

Question 1

basic principles

Answer 1

risk assessment
aseptic technique
minimal trauma to hard and soft tissues

Question 2

stages of surgery

Answer 2

anaesthesia
access
bone removal as necessary
tooth division as necessary
debridement
suture
achieve haemostasis
POIs
post-op medication

Question 3

surgery principles

Answer 3

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

Question 4

aims of ST retraction

Answer 4

access to operative field
protection of STs
flap design facilitates retraction

Question 5

what can you use for ST retraction?

Answer 5

• Howarth’s periosteal elevator
• rake retractor
• Minnesota retractor

Question 6

how to retract ST flap

Answer 6

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

Question 7

envelope/2 sided flap

Answer 7

no anterior mesial relieving incision

can suture through papillae to lingual aspect

Question 8

crevicular incision

Answer 8

incision in gingival sulcus

Question 9

what do you use for bone removal and tooth division?

Answer 9

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

Question 10

uses of elevators

Answer 10

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

Question 11

elevators - principles of use

Answer 11

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

Question 12

why is it important to debride to remove any bone fragments?

Answer 12

inflammation/infection

sharp bone could perforate flap when it is trying to heal

Question 13

elevator mechanics

Answer 13

wheel and axle
wedge
lever
all 3 actions can be used in combination with each other

Question 14

elevators points of application

Answer 14

mesial
buccal
distal
superior
M/B alternately
inferior

Question 15

types of debridement

Answer 15

physical
irrigation
suction

Question 16

physical debridement

Answer 16

bone file or handpiece to remove sharp bony edges

Mitchell’s trimmer or Victoria curette to remove soft tissue debris

Question 17

irrigation

Answer 17

sterile saline into socket and under flap

Question 18

suction

Answer 18

aspirate under flap to remove debris

check socket for retained apices etc

Question 19

aims of suturing

Answer 19

reposition tissues
cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention

Question 20

when would you suture?

Answer 20

don’t routinely suture every extraction socket but would always close STs

Question 21

non-absorbable sutures

Answer 21

if extended retention periods are required
must be removed post-op
closure of OAF/exposure of canine
e.g. silk, nylon

Question 22

absorbable sutures

Answer 22

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

Question 23

polyfilament

Answer 23

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

Question 24

monofilament

Answer 24

single strand
pass easily through tissue
resistant to bacterial colonisation
e.g. 4-0 proline
? maybe not as strong

Question 25

curve of suture needles

Answer 25

1/2 round is half the circumference of a circle

Question 26

cross section of suture needles

Answer 26

triangular
 - tip of triangle on inside - cutting
 - tip of triangle on outside - reverse cutting
round
 - not used in OS

Question 27

parts of suture needle

Answer 27

point
body (shaft)
swaged end

Question 28

general rule for suturing

Answer 28

suture from free tissue to fixed, so from flap to fixed tissue

Question 29

peri-op haemostasis

Answer 29

LA with vasoconstrictor
artery forceps
diathermy
bone wax

Question 30

post-op haemostasis

Answer 30

pressure
LA infiltration
diathermy
WHVP
Surgicel
sutures

Question 31

why should you avoid relieving incisions in premolar area?

Answer 31

could damage mental nerve at mental foramen

Question 32

what % of cases is the lingual nerve above the lingual plate?

Answer 32

15-18%

Question 33

why shouldn’t you do lingual flaps or place lingual retractor for 3rd molar?

Answer 33

sometimes nerve lies above level of bone so can easily damage it

Question 34

nerves that can be damaged during 3rd molar removal

Answer 34

lingual
IAN - can be predicted
mylohyoid
buccal

Question 35

PR surgery aims

Answer 35

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

Question 36

flap design for PR surgery

Answer 36

semi-lunar
 - reduced access
 - only good for apical lesions
 - scarring
 - dysaesthesia
 - less gingival recession
triangular
rectangular

Question 37

bone removal in PR surgery

Answer 37

depends on extent of lesion

try to be conservative and still allow access

Question 38

PRS - removal of apex

Answer 38

remove 3mm
minimal angle to allow visualisation
try to keep cut at right angles to root to minimise SA
allows curettage

Question 39

PRS root end prep

Answer 39

US
 - cleans canal
 - creates 3mm prep within canal
 - removes contaminated root filling
bur
 - usually prep outwith confines of canal

Question 40

PRS wound closure

Answer 40

reosrbable/non-resorbable
replace papilla first
then relieving incision

Question 41

PRS POI and review

Answer 41

standard POI
review and ROS at one week
post-op radiographs between 1-6wks
further review 3-6m later

Question 42

PRS reasons for failure

Answer 42

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

Question 43

amalgam retrograde seal

Answer 43

historical

Question 44

ZO/E retrograde seal

Answer 44

cheap
easy to use
radiopaque
bacteriostatic
sensitive to moisture
may resorb
doesn't promote cementogenesis

Question 45

MTA retrograde seal

Answer 45

moisture resistant
promotes cementogenesis
v good seal 
£
long setting time
difficult to use