Instrumentation_sutures Flashcards
WOODSON NO. 1
- For interdental papillas, attached gingiva,
crestal periodontal fibers
MOLT NO. 9
(2)
- Pointed end for interdental papilla
- Broad end for free alveolar mucosa
elevation and flap retraction
- Push stroke
- Most common technique used, especially when combined with rolling/lifting component
- Rolling/lifting
- Good for interdental papilla
- Pull stroke
- Not used too often as it tends to tear and shred periosteum
Seldin retractor
(2)
- Great for tongue retraction, and flap retraction
- Not used as a periosteal elevator (blunt ends)
Minnesota retractor
(2)
- Cheek, flap retractor
- Workhorse of retractors in OMS
RETRACTING
- Wieder retractor, a.k.a. “Sweetheart” retractor
CONTROLLING HEMORRHAGE
* Hemostat
(4)
- Crile, Kelly, Halstead (a.k.a. “mosquito”)
- Straight or curved
- Handle with locking device once vessel is clamped
- Also used for removing granulation tissue or small root tips
CONTROLLING HEMORRHAGE
* Burnisher
- Any flap instrument for compressing bone around a nutrient vessel
ADSON FORCEPS
(4)
- Three teeth opposed
- Stabilize tissue while passing suture needle
- Not good for grasping needle
- Used on skin
BROWN FORCEPS
(4)
- Multiple serrated tips
- Grasping keratinized mucosal edges
- Good for grasping needle
- Not for skin or fine tissue
GRASPING TISSUE
* Allis tissue forceps
(2)
- Grasping and manipulating large portions of tissue that are going to be removed from the
body - I.E. epulis fissuratum, lesions, bone
- Not for grasping tissue that will remain
- Too much trauma from beaks
REMOVING BONE
* Rongeurs
(4)
- Most commonly used for alveoloplasties
- Will crush/cut lips if not paying attention
- A relatively atraumatic means of removing bone
- Quick cut, does not create heat like a handpiece and bur
Rongeurs
Types:
(2)
- Side cutting
- End cutting (Blumenthal Rongeurs)
REMOVING BONE
* Chisel and Mallet
(5)
- Cleanest means of removing bone
- Can create traumatic forces to TMJ/jaw without proper support
- Mallet: occasionally with nylon face to decrease noise/trauma
- Unibevel - bone removal
- Bibevel - splitting teeth
REMOVING BONE
* Bone file
(3)
- Used for final smoothing of small areas of sharpness
- Pull stroke is the action stroke
- Crosscut or parallel grooves
REMOVING BONE
* Handpiece:
(4)
- MUST NOT EXHAUST AIR INTO OPERATIVE FIELD
- Electric vs Nitrogen powered
- Completely sterilizable
- High speed and torque
AIR EMPHYSEMA
(4)
- Air-driven handpiece during surgical extraction
- Possible for air embolus
- Possibly requires airway protection
- ABX to prevent secondary infection
- Resolves 3-7 days
- Air-driven handpiece during surgical extraction
(2)
- Sudden edema
- Crepitus to area
- Possible for air embolus
(1)
- Air forced through venous system
REMOVING BONE
* Burs
(4)
- Carbide
- One time use, then throw away
- # 6 or #8 for bone removal or grooves
- # 702 or #703 for sectioning teeth/contouringalveolus/troughing
- # 703 has larger radius versus #702
REMOVING BONE
(3)
- Surgical handpiece must be done under copious irrigation
- Will generate heat and kill superficial bone
- Thermal necrosis occurs at 47°C
REMOVING SOFT TISSUE FROM BONY DEFECTS
(3)
- Curettes
- Hemostats
- Rongeurs
SUTURING MUCOSA
* Needle holder
- 6” or 15 cm
- Grasping surface on beak is crosshatched (prevent
needle spinning) - As opposed to hemostats which are parallel
- Needle prone to spin
- Iris scissors
- Tissue cutting only, do not use for suture cutting
- Dean angled scissors
(2)
- Tissue and suture cutting
- Serrated
Bite block
(2)
- Passively placed
- Decreases stress on TMJs
Molt mouth prop
(2)
- Ratcheting system to remain open
- Can severely damage TMJs and teeth
Surgical suction
(2)
- Small orifice
- Some with wire stylet used to clean tip
DENTAL ELEVATORS
* Uses:
(3)
- Luxate teeth, NOT to remove teeth
- Minimizes root fractures
- Requires a fulcrum point
DENTAL ELEVATORS
* Types:
(3)
- Straight
- Flag/Cryer
- Pick
DENTAL ELEVATORS
* Crane pick/Cogswell:
- Elevate roots or teeth applied to a purchase point
- MAGIC STICK!! (E-92)
- Offset shank to aid in luxation force
DELIVERING TEETH
* Forceps
- Primary instrument for tooth delivery
EXTRACTION FORCEPS
* Maxillary Forceps
(2)
- Beaks parallel to handle
- Palm under handle
EXTRACTION FORCEPS
* Mandibular forceps
(2)
- Beaks almost perpendicular to handle
- Palm on top of handle
EXTRACTION FORCEPS
(3)
- Beaks adapt to root structure
- Beak aligned parallel to long axis of tooth
- Acts as a wedge to expand alveolar bone
MAXILLARY FORCEPS
* #150
(2)
- Universal!
- Single rooted vs multi
rooted
MANDIBULAR FORCEPS
* #151
(2)
- Universal
- Single and multi rooted
MANDIBULAR FORCEPS
(2)
- # 13, Ash, aka Charlene
- Conical rooted teeth, turning motion effective
- # 23, Cowhorn, aka Michael Jordan(3)
- Molars
- Beaks enter bifurcation
- Tooth is elevated by squeezing handles and
using pumping motion
MANDIBULAR FORCEPS
* #17
- Molar
What does ‘suture’ mean?
- Any strand of material that is utilized to ligate blood vessels or approximate tissues
Primary purpose of suturing
(3)
- Position and secure surgical flaps to their anatomic position
- Promote optimal healing
- Hemostasis
THE “IDEAL”SUTURE
- Sterile
- All-purpose
- composed of material that can be used in any surgical procedure
- Causes minimal tissue injury or tissue reaction
- ie, nonelectrolytic, noncapillary, nonallergenic, noncarcinogenic
- Easy to handle
- Holds securely when knotted
- ie, no fraying or cutting
- High tensile strength
- Favorable absorption profile
- Resistant to infection
ESSENTIAL SUTURE CHARACTERISTICS
(5)
- Sterility
- Uniform diameter and size
- Pliability for ease of handling and knot security
- Uniform tensile strength by suture type and size
- Freedom from irritants or impurities that would elicit tissue reaction
Initial response (4-7 days)
(2)
- Invokes inflammatory response
- PMNL, mononuclear cells, fibroblasts
After 4-7 days
* Dependent on type of suture used
(2)
- Plain gut elicits intense response with macrophages and PMNLs
- Non-absorbable elicits less intense, relatively acellular response
All sutures passing through mucous membrane or skin provide a “—” down which
bacteria can gain access to underlying tissue
wick
How to avoid/limit wicking:
(2)
- Use monofilament material if possible
- Remove suture as early as possible
Suture removal:
* 3-5 days →
* 5-7 days →
* 5-10 days →
skin of head and neck
intraoral sites
body/extremities
SUTURE TYPES
* According to structure
(1)
* According to behavior in tissue
(1)
* According to origin
(1)
- Monofilament vs multifilament
- Resorbable vs nonresorbable
- Natural vs synthetic
MONOFILAMENT
(4)
- Suture made of single filament
- Less inflammatory response
- Less wicking
- Requires more ties to assure an
adequate knot
BRAIDED
(4)
- Multifilament
- Greater inflammatory response
- Greater wicking
- Fewer ties for adequate knot
ABSORBABLE
(4)
- Plain Gut
- Chromic Gut
- Monocryl (Poliglecaprone 25)
- Vicryl (Polyglactin 910)
NON-ABSORBABLE
(4)
- Silk
- Nylon
- Prolene (Polypropylene)
- Steel
Gut sutures were derived from the
submucosal layer of ovine (sheep) small intestine or the serosallayer of bovine (cow) small intestine
Plain gut:
(3)
- Tissue treated with aldehyde solution
- Tensile strength maintained for 7-10 days
- Absorption complete within 70 days
Chromic gut:
(3)
- Treated with chromium salt
- Tensile strength maintained for 10-14 days
- Absorption complete within 90 days
ABSORBABLE SUTURE
* Tissue reaction is due to
* Breakdown accomplished by
* Do not place under stresses tissue where
* Used:
non-collagenous material
proteolytic enzymatic digestive process
extended approximation is needed
general soft tissue approximation
Monocryl (Poliglecaprone 25):
(3)
- Monofilament copolymer of glycolide and e-caprolactone
- Tensile strength 50-60% at 7 days, 20-30% at 14 days, and lost at 21 days
- Absorption complete at 91-119 days
Vicryl (Polyglactin 910):
(3)
- Braided multifilament coated with copolymer of lactide and glycolide
- Tensile strength of 75% at 14 days, 50% at 21 days
- Absorption complete at 56-90 days
Absorbed by — – minimal tissue reaction
* Used:
hydrolysis
General soft tissue approximation
Not used where extended tissue approximation is required
Surgical silk:
(2)
- Braided raw silk spun by silkworms (organic protein called fibroin)
- Sometimes coated with beeswax or silicone to ease handling/placement
Surgical silk:
* Absorbed by proteolysis at — years, can cause acute tissue reaction, and eventual encapsulation by fibrous connective tissue
* Eventually pushed out by body if left in
* Tensile strength remains at – year
* Contraindicated in pts with
* Used:
2
1
silk sensitivities
General soft tissue approximation (vermillion border – pts enjoy better as gut suture ends are sharp on tissue)
Nylon:
(2)
- Monofilament (Ethilon) polyamide polymer
- Braided (Nurolon) coated with silicone
Nylon:
* Progressive hydrolysis may result in
* Minimal tissue reaction, should not be used where
* — makes it useful in retention and skin closure
loss of tensile strength (81% at 1 years, 72% at 2 years, 66%
at 11 years)
permanent retention of tensile strength is
required
Elasticity
Prolene (Polypropylene):
(2)
- Monofilament of isostatic crystalline stereoisomer of a liner propylene polymer (permitting
little or no saturation)
Prolene (Polypropylene):
* Does not adhere to tissues and is useful as a
* — tissue reaction
* Not subject to degradation or weakening, and maintains
* Used:
“pull-through” suture (subcuticular closure)
Minimal
tensile strength for up to 2 years
high tension areas (fascia), contaminated wounds, skin closures
- Sutures were originally manufactured ranging in size from #1 to #6
(3)
- # 1 being the smallest
- A #4 suture would be roughly the diameter of a tennis racquet string.
- The manufacturing techniques, derived at the beginning from the production of musical strings,
did not allow thinner diameters.
Size refers to the
diameter of the suture strand and is denoted as zeroes.
The more zeroes characterizing a suture size, the
smaller the resultant strand diameter
* 4-0 or 0000 is larger than 5-0 or 00000
The smaller the suture, the
less tensile strength of the strand.
COMPONENTS OF SURGICAL NEEDLE
(3)
- Attachment end
- Body
- Point
- Attachment end
(2)
- Swaged end permanently attached to material
- Eyed →need to thread suture material
Chord length
- Straight line distance between the point of
the curved needle and swage
Needle length
- Distance between point to end along needle
Radius
- Distance between center of the circle to
body of needle
Diameter
- Gauge or thickness of the needle
Cutting
(3)
- Needle body is triangular
- Sharpened cutting edge on inside
- Easy to tear through tissue if too forceful
Reverse cutting
(2)
- Needle body is triangular, inverted
- Less tear through
Taper
(2)
- Rounded needle body
- Limited tear through
SUTURING TECHNIQUE
- Grasp needle with holder below the swage
- Ratchet one to two “clicks”
- Insert needle 90° to tissue
- Turn wrist to continue to pass through tissue
- Attempt to not grasp needle point with instrument
- Will dull tip and tear through tissue with continued use
- Pass through loose tissue first, then though stable tissue
- Grasp tissue gently (do not crush wound edges)
Now there should be two ends to the suture through the tissue
(2)
- One with the needle at end
- One without needle, considered the tail
In non-dominant hand, secure/hold the suture needle
(1)
- Make sure to hold securely in hand that needle does not touch
nonsterile environment or patient’s facial anatomy
Place empty instrument in between suture ends
* Should be over the
incision line
SURGICAL KNOT
- First throw is forward and a “double”
- Second throw or Reverse throw is single and
“squares” the knot - Finish with another squared knot:
- Single forward throw and single reverse throw
SIMPLE INTERRUPTED SUTURE
- Maintains strength and tissue position if
one portion fails - Requires more time and suture material
- Has minimal holding power against stress
HORIZONTAL MATTRESS SUTURE
- Tension suture
- Rapid
- Minimizes number of sutures needed
- Less suture material used
FIGURE OF EIGHT SUTURE
(3)
- Tension suture
- Brings tissue into good apposition
- Good to secure socket dressings
SIMPLE CONTINUOUS SUTURE
(5)
- Easy for linear long span wounds
- Involves one diagonal pass and one
perpendicular pass - Uses less material vs multiple interrupted
- Provides minimal tension-holding
- Prone to failure if one portion fails
- Easy for linear long span wounds
- I.e. alveoloplasty full thickness
mucoperiosteal flap approximation
LOCKING CONTINUOUS SUTURE
(3)
- Greater tissue stability vs simple running
- Uses more suture material vs simple
running - More stable in the event of a partial failure
or breakage
