Surgical Techniques Flashcards
What are the basic principles of surgical technique?
- risk assessment
- good planning
- medical history
- aseptic technique
- minimal trauma to hard and soft tissues
What are the general surgical principles?
- maximal access with minimal trauma
- scalpel used in one firm continuous stroke
- minimal trauma to dental papilla
What are the stages of surgery?
- anaesthesia
- access
- bone removal as necessary
- tooth division as necessary
- debridement
- suture
- achieve haemostasis
- post-operative instruction
- post-operative medication
What is the purpose of flaps?
- allowing access to the area being operated on
- maximal access with minimal trauma
- preserves adjacent soft tissues
What size and shapes should flaps be?
- big
- bigger flaps heal just as quickly as smaller ones
- smaller are more likely to result in tears
- wide based incision
- lots of blood vessels
- reduces chance of necrosis
- no sharp angles
- reduced blood flow to area
What kind of flap should be raised?
- mucoperiosteal
- periosteum must be lifted to reduce trauma caused
What is an envelope flap?
- also called a 2 sided flap
- relieving incision and incision around teeth
Why should trauma to dental papillae be kept to a minimum?
- papilla can shrink after surgery
How should a flap be managed during surgery?
- do not crush the flap
- keep the tissue moist
- irrigate tissue
How should flaps be replaced?
- ensure flap margins and sutures will lie on sound bone
- do not close wounds under tension
- can break open
- must be passive
- tissue should not be blanched when replaced
- aim for healing by primary intention to minimise scarring
- edges of flap heal to each other
How and why should soft tissue be retracted?
- improves access to the operative field
- protects soft tissue
- flap design should facilitate retraction
- Howarth’s periostea elevator
- Bowdler-Henry retractor (rake)
What is a three sided flap?
- mesial and distal relieving incisions
- incision around teeth
- distal relieving incision should not be lingual if on lower arch
- close to lingual nerve
How are teeth divided and bone removed?
- may not be necessary for all cases
- electric straight handpiece
- saline cooled bur
- not turbine hand piece (surgical emphysema)
- 40 revs per minute
- round or fissure tungsten carbide burs
- can divide crowns and roots
- keep as big pieces as possible
What is surgical emphysema?
- when air is forced into the soft tissues during surgery
- can feel crackly
- can spread to neck and chest becoming airway risk
- can become infected and cause sepsis
What are the principles of use for elevators?
- mechanical advantage
- avoid excessive force
- support instrument to avoid injury
- in case of slipping
- ensure applied force is directed away from major structures
- antrum
- inferior alveolar canal
- mental nerve
- floor of mouth
- used under direct vision
- do not use adjacent tooth as fulcrum
- unless also being extracted
- keep sharp and in good shape
- discard if blunt or bent
- establish effective and logical point of application
- careful debridement after use
- remove any bony fragments created
What are elevators used for?
- provide a point of application for forceps
- loosed teeth prior to forceps use
- extract tooth without using forceps
- remove multiple root stumps
- remove retained roots
- remove root apices
What is debridement?
- removal of debris from a socket
- physical debridement
- bone file or handpiece to remove sharp bony edges
- Victoria curette or Mitchell’s trimmer to remove soft tissue
- irrigation
- sterile water or saline to flush bacteria from socket
- also under flap
- suction
- aspirate under flap to remove debris
- check socket for retained apices
What are the aims of suturing?
- repositioning tissues
- covering bone
- preventing wound breakdown
- achieving haemostasis
- encouraging healing by primary retention
What different types of sutures are available?
- absorbable or non-absorbable
- monofilament or polyfilament
What does the number on a suture mean and which ones are most commonly used?
- indicates the size of the thread
- higher the number, thinner the thread
- 3/0 and 4/0 commonly used
What are non-absorbable sutures and what are they used for?
- sutures which do not break down in the mouth
- must be removed postoperatively
- extended retention periods required
- closure of oroantral fistula
- exposure of canine tooth
- Prolene (polypropylene) monofilament
- Mersilk (black silk) multifilament
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
- can result in infection
What are absorbable sutures and what are they used for?
- sutures which break down in the mouth
- removal of suture not required
- may remove need for review
- Velosorb Fast
- hold tissues together temporarily
- vicryl-breakdown via absorption of water into filaments
- polymer degrades
- Monocryl (poliglecaprone 25)
- Vicryl Rapide (polyglactin 910)
What are monofilament sutures?
- single strand
- pass easily through tissue
- resistant to bacterial colonisation
- less wicking
- better aesthetically to reduce scarring
- harder to tie and manipulate than polyfilament
What are the characteristics of suture needles?
- curved
- described as fraction of circumference of a circle
- cross section
- triangular
- round
- not used in oral surgery
How can haemostasis be achieved peri-operatively?
- local anaesthetic with vasoconstrictor
- artery forceps
- rarely used
- diathermy
- cauterisation of soft tissues
- bone wax
- plugs hole
- sticks to glove more than bone
- often has to be removed as not always absorbed
How can haemostasis be achieved post-operatively
- pressure
- biting down on damp gauze
- local anaesthetic with vasoconstrictor
- diathermy
- cauterisation of soft tissues
- white head varnish back
- not used now
- surgicel
- framework for clots to form on
- sutures
What post-op medication is prescribed?
- not routinely prescribed
- antibiotics
- no change to outcome
- increases antibiotic resistance
- analgesics
- paracetamol can be bought by patients
What consideration must be given to the lingual nerve and when is it at risk?
- nerve above the lingual plate in 15-18% of cases
- incision of flap
- raising buccal and lingual flaps
- retraction flaps
- bone removal
- extraction with forceps
What nerves may be damaged during third molar removal?
- lingual
- inferior alveolar
- mylohyoid
- buccal
What is periradicular surgery?
- surgery to establish a root seal at the apex of a tooth or at the point of perforation
What kind of flaps can be used for periradicular surgery?
- semi-lunar
- triangular
- rectangular
What materials can be used for a retrograde seal in periradicular surgery?
- zinc oxide eugenol
- mineral trioxide aggregate
What are the reasons for which periradicular surgery may fail?
- inadequate seal
- too little apex removed
- extra root or bifid root
- displacement of seal
- seal incorrect shape
- inadequate support
- periodontal pockets
- occlusal overload
- excessive root resection
- split roots
- soft tissue defect over apex post operatively
What is anatomical closure?
- tissues heal by secondary intention
- returned to where they previously were
- e.g. retained root socket
What are crevicular incisions?
- incisions in the gingival sulcus
- less scarring
- limited access
- also called one sided flap
What is buccal guttering?
- removal of buccal bone around a tooth
