Basic Surgical Technique Flashcards
What can happens if tooth breaks during a simple XLA?
procedure can turn surgical
What is important if we consider a surgical extraction?
our own limitations - don’t do any surgical procedures we haven’t done before or haven’t done in years
What are the 3 basic principles of MOS?
Risk assessment
aseptic technique
minimal trauma to hard and soft tissues
What is risk assessment?
this is when we plan the surgery and how we plan to carry it out, the order of surgery and exactly what we want to do
med history - any medications that would affect surgery
What is aseptic technique?
the mouth is full of MOs however we want to create an environment where we dont introduce any new MOs that can lead to infection
What will minimal trauma to hard and soft tissues lead to?
Lower complications, less post op pain, bruising and swelling
What environment is minor oral surgery carried out in?
doesn’t have to be in theatre environment but we have large light, large room, surgical gown, cap and sterile gloves
we must use aseptic technique and minimise trauma to soft and hard tissues
What are the 12 stages of surgery?
- consent - written and verbal
- surgical safety checklist
- anaestheisa
- access
- bone removal
- tooth division if needed
- debridement and wound management
- suture
- achieve haemostats
- post op instructions
- post op meds
- follow up
What GDC standard is about consent?
3rd standard states we must obtain valid consent
must obtain verbal and written consent when tx involves conscious sedation or GA
What sort of consent do we get in oral surgery?
Written and verbal consent for surgical and non surgical procedures (we have a consent form that details and risks of tx and pt signs this)
What is a surgical safety checklist?
We use modified WHO guideline checklist for minor oral surgery
It includes sign in - who is treating pt, who pt is and what site were working on, pts tx plan, mh, allergies, radiographs
surgical pause
sign out
What must we do to gain surgical access?
Lift a mucoperiosteal flap
What is a mucoperiosteal flap?
flap of mucosal tissue, including the underlying periosteum, reflected from the bone during oral surgery
Do big flaps heal slower than smaller flaps?
No both take same time
What do we want in terms of flaps?
Maximal access with minimal trauma (wide flaps to allow access - will heal same rate as small flaps)
Where is the periosteum?
Between bone and mucosa is a connective tissue known as periosteum
How do we properly lift a flap?
We must lift the mucosal tissue and periosteum (if we leave periosteum attached to the bone this is wrong)
What if when we lift a flap we leave periosteum attached to bone?
This is wrong - for a mucoperisoteal flap we must raise mucosa and periosteum
When gaining surgical access why do we make a wide based incision?
we want to ensure the flap maintains good circulation/perfusion to prevent flap going necrotic and dying
What do we want to make sure we incise for flaps?
Mucosa and periosteum - we do this with one continuous firm stroke
What does a small thin flap have higher risk of?
necrosis and death
What must we ensure flap margins lie on?
Sound bone
flap margins on sound bone allows what?
support to the soft tissue and means they can heal properly preventing any wound breakdown
When we close wounds what is important?
that wound is tension free as if there is tension there will be breakdown of wound
What type of healing to we aim for?
healing by primary intention to minimise scarring
What happens if we cause more damage to periosteum?
More bruising and post op pain we get
What is a 3 sided flap?
This is where we make 3 incisions :
- distal relieving incision
- crevicular incision
- medial relieving incision
What 3 incisions do we make for 3 sided flaps?
medial RI
Crevicular incision
distal RI
what must we be careful with distal relieving incisions?
That it isn’t too lingually placed as it can risk the lingual nerve
What should distal RI be?
more buccal and follow external oblique ridge of mandible
What is an envelope flap?
This is a flap where we make two incisions
- distal ri
crevicular RI that extends to tooth infront
What incisions do we Make when making an envelope flap?
DISTAL RI
CREVICULAR RI (extending to tooth infront)
Once we incise the flap what must we do?
lift flap back to provide access to operative field
What dow e use to lift flap back?
Howarth’s periosteal elevator
rake retractor
What must we then remove after lifting a flap?
bone
What do we use to remove bone?
electrical straight handpiece with sterile water cooled bur
Why do we not use air driven handpieces in oral surgery?
leads to surgical emphysema which is where gas or air is driven underneath mucosa or skin leading to many problems - may need hospital admission or antibiotics
What burs do we use to remove bone or divide teeth to protect the teeth?
tUNGESTEN OR CARBIDE BURS
What is a buccal gutter?
This is where we make an incision around he lower 8 to allow us to elevate the tooth or remove crown and split roots
What can we use elevators for?
To deliver roots and sometimes teeth - loosen teeth by widening pdl and mobilise roots
What are the 3 types of elevators?
couplands
Warwick James
cryers
What are couplands elevators?
3 sizes – narrowest to widest (1,2,3) and are used to split multi rooted teeth and are inserted between the bone and tooth roots to elevate them out the socket
How do we identify right from left cryer?
old them to ceiling facing upwards and pointy bits should point at each other
What do elevators do?
Give us mechanical advantage to remove teeth and roots and avoid excessive force which can lead to mandible fracture
What are the 6 uses of elevators?
provide point of application for forceps
loosen teeth using forceps
extract tooth without forceps
removing Muti rooted stimos
removing retained roots
removing root apices
What are point of applications of elevators?
Mesial
Distal
Buccal
Superior
What is the most common motion when using elevators?
When and axle rotation movement
How do we rotate elevators?
rotate the first to allow instrument to engage the tooth
What movement should we avoid using?
Lever movement
What must we do once procedure is finished?
clean and irrigate wound
What are the 3 methods of debridement?
physical
irrigation
suction
What is physical debridement?
this is where we use a bone file or headpiece to remove any sharp bony edges
victorias curette or Mitchells trimmer to remove soft tissue debris
What do we use to remove any sharp bony edges?
bone file
handpiece
What do we use to remove soft tissue debris?
victorias curette
Mitchell’s trimmer
What is irrigation debridement?
This is where we put sterile saline into socket and under flap
What is suction debridement?
tHIS IS WHERE we aspirate under flap to remove debris and check socket for retained apices
When do we use sutures?
when we have lifted a flap and need to approximate tissues
if we want to compress BVs and gain haemostatic control
What is the aim of sutures?
Reposition tisses
cover bone
prevent wound breakdown
achieve haemostasis
encourage healing by primary intention
What are the two types of stitches?
Absorbable
Non absorable
and these can be monofilament or polyfialment
What are non resorbable stitches?
Ones that dont dissolve and are used if needed for extended periods of time
What are some examples of non-resorbale stitches?
Mersilk
Prolene
EThlon
What are non absorbable sutures used for?
Closure of OAF
Closure of exposed canine
What are absorbable stitches?
These are sutures that dissolve after a period of time and hold tissue edges together temporarily
How do absorbable stitches work?
break down via hydrolysis
polymer degrades and is metabolised by body
How long do absorbable sutures last?
1-2 weeks
What are some examples of absorbable sutures?
Vicryl
velsorb fast
What are the two types of suture filaments?
Monofilament
Polyfilament
What are monofilament sutures?
Single strand suture that passes easily through tissue and are resistant to bacterial colonisation
What are some examples of
monofilament sutures?
praline
ethlon
What is a polyfilament suture?
This is where there is several filaments twisted together (many strands) and the are easier to handle than monofilament suturs
What is the issue with polyfilament sutures?
Prone to wicking which an allow oral fluids and bacteria to move along length of suture and result in infection
Examples of polyfilmatent sutures?
vicryl
mersilk
What two shapes of suture needles do we use?
1/2 circle
3/8 circle
What size and length of suture needles do we have?
various
What is the cross section of a suture needle like?
Triangular
round
How does triangular cross section suture needle work?
If the tip of triangle is on the inside then suture passes through tissues easy with minimal trauma (however concerns we can tear suture through when tying off so some do reverse cutting with tip of triangle on outside)
How do we hold a suture needle?
Grade suture needle with needle holder 1/3rd from wedged end and have body then point at top
What are the main types of sutures?
interrupted
horizontal matress
continuous
vertical matress
How do we suture a 3 sided flap?
suture across DRI
2 sutures across MRI
OR
1 SUTURE IN MRI
1 SUTURE IN DRI
1 SUTURE DISTAL TO 7 ONCE 8 HAS GONE
How do we suture envelope incision?
One suture distal to 7
one on MRI
How can we achieve haemostasis?
la with vasoconstrictor
artery forceps to clamp any large bleeding vessels
diathermy
bone wax if bleed from bone
pressure
sutures
When removing lower 3rd molars what nerves can be damaged?
IAN
Buccal
lingual
Mylohyoid
What must we inform pts with wisdom tooth removal?
Potential nerve damage
Where is lingual nerve in 15-18% of cases?
Above lingual plate and means we are at risk so we would want to do surgical extraction
Complications of wisdom tooth removal?
Pain
Swelling
Bruising
Bleeding
Trismus
Infection
Dry Socket
Paraesthesia/anaesthesia
What is mucocele excision?
soft tissue procedure to remove sac of saliva created in response to trauma of lower lip or damage to minor salivary glands
How do we excise a mucocele?
• WE USE BLUNT DISSECTION RATHER THAN SCALPEL TO AVOID RISKING ANY NERVE ENDINGS BEING DAMAGED
What is preri-radicular surgery?
periradicular surgery is surgery to the external root surface. Examples of periradicular surgery include apicoectomy, root resection, repair of root perforation or resorption defects, removal of broken fragments of the tooth or a filling material, and exploratory surgery to look for root fractures.
How do we design flap for peri-radicular surgery?
triangular flap - 2 sides
rectangular flap - 3 sides
How do we do peri-radicular surgery?
- The amount of bone removal depends on the extent of the lesion – try be conservative and still allow access - if infection is evident then we may not need to do any bone removal but in some cases we thin the bone
- Then we remove the apex (3mm with fissure bur) at a minimal angle to allow visualisation and try to keep cut at RAs to root to minimise the surface area
- Then we curettage
- We take the ultrasonic to clean canal, creates 3mm prep within canal and removes contam root filling
- We use a bur to prep usually out with confines of canal
the retrograde seal with MTA
close with sutures
