Equipment, periodontal therapy, oral surgery principles

Question 1

Dental equipment

Answer 1

Powered equipment on dental trolley

Intra-oral radiography equipment

Lighting

(Magnification)

Table with drainage

Question 2

Powered equipment on dental trolley

Answer 2

High speed handpiece

Low speed handpiece

Three-way syringe

Ultrasonographic scaler

(suction)

Question 3

High speed handpiece

Answer 3

Air-powered turbine operates at 300,000 to 400,000 RPM

Uses friction grip (FG) burs

Used for cutting and shaping tooth/bone

Irrigation spray to reduce keep cool and remove debris

Question 4

Friction grip burs - types

Answer 4

Round (tungsten carbide)

Cross-cut fissure taper (tungsten carbide)

DIamond burs

Question 5

Round friction grip (FG) burs

Answer 5

Variety of sizes

Used for:
§ Removing buccal bone during open extractions
§ Removing coronal remnants during coronectomy
§ Smoothing alveolar bone
§ Small sizes used to create gutters in periodontal ligament space to aid positioning of luxators/elevators

Question 6

Cross-cut fissure taper friction grip burs

Answer 6

Variety of sizes

Used for:
§ Sectioning teeth
§ Coronectomy
§ Buccal bone removal (shank held parallel to tooth root axis)

Question 7

Diamond burs (friction grip burs)

Answer 7

Variety of shapes, sizes, and grit

Round, egg, taper all useful

Less aggressive than tungsten carbide

Used for
§ Smoothing alveolar bone
§ Debriding granulation tissue from alveolus
§ Gingivoplasty

Question 8

Low speed handpiece

Answer 8

High torque, low speed
○ 5000-25000 RPM

Can be fitted straight or contra-angle nose cone

Nose cones gear ratios vary to increase/decrease speed

Most commonly used in general practice with 4:1 reduction gear for polishing

Question 9

Three way syringe

Answer 9

Produces stream of air, water, or spray of air/water

Rinsing away debris, polish etc.

Drying tissues

Question 10

Ultrasonic scaler

Answer 10

Magnetorestrictive or piezoelectric

Tip vibrates at 25,000 - 45,000 Hz

Plaque/calculus removed by mechanical “chipping”, but cavitation effects likely to play a role

Question 11

Suction

Answer 11

Included on some dental machines

Stand alone surgical suction can also be used

Useful for clearing surgical field (e.g. retrieving root remnants)

Range of tips available

Question 12

Lighting for dentistry

Answer 12

Don’t operate in the dark!

Use magnification if available

Adjustable overhead lighting acceptable
○ Will need constant repositioning
○ Difficult to position into caudal oral cavity without surgeon shadow

Head-mounted light source preferable
○ Can be bought cheaply from camping shops
○ Surgical light with loupes ideal

Question 13

Examinatio instruments

Answer 13

Dental probe

Sharp explorer

Mirror

Modified pen grip

Question 14

Dental probe

Answer 14

Blunt end to avoid trauma to soft tissue in sulcus

mm markings - NB different patterns

Check against ruler before starting to chart

Question 15

Sharp explorer

Answer 15

Sharp point for detecting defects in hard tissues

Used perpendicular to tooth surface

Never use on soft tissue

Question 16

Mirror

Answer 16

Make yourself use one

Takes practice but makes charting much quicker and easier

Question 17

Modified pen grip

Answer 17

Used for most dental instruments including scaler and high/low speed handpieces

Use fourth and fifth fingers to stabilise hand

Question 18

Extraction instruments

Answer 18

Scalpel: #15 or #11 - ideally round handle

Dental luxators

Dental elevators

Periosteal elevators

Extraction forceps

Root tip forceps

Thumb forceps

Scissors

Needle holders

Retractors

Question 19

Dental luxators

Answer 19

Fine, sharp tip

Select size which corresponds to root curvature

Inserted into periodontal ligament space and used to cut the ligament fibres

Used with gentle side-to-side rocking motion

Wedge effect helps to expand alveolus (socket)

Must NOT be used with rotational force - easily damaged

Must be sharpened regularly

Question 20

Dental elevators

Answer 20

Select size which corresponds to root curvature

Tip is inserted into periodontal ligament, rotational force applied and held for 10-20 seconds

Periodontal ligament fibres stretch, then tear

Winged design provides increased leverage

Question 21

How to hold luxators/elevators

Answer 21

Handle should fit in the palm
○ Different size handles are now available to fit all hand sizes!

Short finger stop
○ Index finger placed close to sharp tip
○ Essential to avoid iatrogenic damage if instrument slips

Question 22

Periosteal elevators

Answer 22

Used to elevate mucoperiosteal flaps away from the bone

Used in pushing motion with rotation

Keep index finger close to tip to prevent damage if slips

Question 23

Extraction forceps

Answer 23

Small breed size most useful

Only to be used once tooth is mobile following luxation/elevation

Place as far apically as possible

Can use gentle rotational force and hold (as for elevation)

Question 24

Manual scaling instruments

Answer 24

Hand scalers

Calculus forceps

Hand curettes

Question 25

Hand scalers

Answer 25

Must be kept sharp

Used in a pull stroke away from the soft tissues

Only used above the gingival margin (sharp toe and heel would damage delicate soft tissues)

Question 26

Calculus forceps

Answer 26

Can be ised for gross calculus removal

Question 27

Hand curettes

Answer 27

Must be kept sharp

Rounded toe and heal to reduce soft tissue trauma

Used for root planing in areas of attachment loss
§ Closed root planning in pockets of up to 5mm deep
§ Curette introduced into sulcus with face closed
§ Once bottom reached, angle is opened to bring working edge into contact with root surface
§ Overlapping pull strokes used to remove plaque/calculus and smooth the cementum

Question 28

Polishing

Answer 28

Possibly removes microscopic defects in enamel following scaling

Removes residual microscopic deposits of plaque/calculus

Risk of iatrogenic damage minimised by:
○ Light pressure
○ Low speed
○ <3 seconds per tooth
○ Use only fine pumice slurry
○ Use of an oscillating rather than rotary cups

Following polishing sulcus should be irrigated with water or 0.12% chlorhexidine solution

Importance is debatable

Question 29

Principles of oral surgery

Answer 29

Antimicrobials not usually indicated

Halsted’s principles

Oral soft tissues heal rapidly

Most oral wound dehiscence caused by errors in technique

Question 30

Halsted’s principles

Answer 30

Gentle handling of tissue

Meticulous haemostasis

Preservation of blood supply

Strict aseptic technique

Minimum tension on tissues

Accurate tissue apposition

Obliteration of deadspace

Question 31

Gentle handling of tissue

Answer 31

Particularly true for the delicate oral soft tissues

Avoid using forceps as far as possible
§ If must then use atraumatic such as Adson 1x2

Use fingers or stay sutures to reduce crushing damage

Retract soft tissues away from burs with plastic mixing sticks

Question 32

Meticulous haemostasis

Answer 32

Perhaps less important in oral surgery

Blood clot in alveolus important for healing

Avoid diathermy - risk of thermal damage to underlying bone/teeth

Avoid neurovascular bundles - ligation where necessary

Haemostatic agents (e.g. lysostypt)

Question 33

Preservation of blood supply

Answer 33

Use envelope flaps where possible

Rostral vertical incision for triangle flaps

Ensure divergent incisions and wide base for pedicle flaps

Protect neurovascular structures

Do not overtighten sutures

Question 34

Strict aseptic technique

Answer 34

True asepsis not achievable in oral surgery

Routine hand hygiene

Sterile gloves and drapes for major maxillofacial surgery

Rinse mouth with 0.12% CHX

Periodontal prophylaxis BEFORE surgery

Sterilisation of instruments and hand-pieces

Question 35

Minimum tension on tissues

Answer 35

Critical in oral surgery

Utilise large flaps

Elevate periosteum releasing incision

If flap retracts when not held in place there is too much tension

Question 36

Accurate tissue apposition

Answer 36

May need to trim flap or palatal/lingual gingiva to matching shape

Accurate reconstruction of lip frenula

Ensure gingiva cuff maintained around residual teeth

Question 37

Obliteration of dead space

Answer 37

Design flaps so that suture line is supported by healthy underlying bone

Consider filling voids with bone grafting material