Surgical Techniques Flashcards
what are the basic principles of minor oral surgery
- Risk assessment (good planning, medical history, considering anatomical structures)
- aseptic technique
- minimal trauma to hard and soft tissues
What are the stages of surgery
- Consent
- Surgical pause/ safety checklist
- Anaesthesia
- Access
- Bone removal as necessary
- Tooth division as necessary
- Debridement/wound management
- suture
- Achieve haemostats
- Post-operative instructions
- Post-operative medication
- Follow up
What are the two important points of the surgical technique
- Administering local anaesthetic - it is important that site you’re operating on has adequate anaesthesia
- Lift a mucoperiosteal flap to give surgical access
What are the aims when lifting a flat
- maximal access with minimal trauma
- preserve adjacent soft tissues
- consider post operative aesthetics
what is a mucoperiosteal surgical flap?
- when the periosteum between the bone and mucosa is raised along with the mucosa when creating a flap
What are the aims of surgical access
- wide-based incision
- use scalpel in one firm continuous stroke
- no sharp angles
- adequate flap size
- flap reflection should be done cleanly
- minimise trauma to the dental papillae
- no crushing
- keep tissues moist
- ensure that flap margins and sutures will lie on sound bone
- make sure wounds are not closed under tension
- aim for healing by primary intention to minimise trauma
what are two flap designs
- 3 sided flap
- envelope flap
describe a 3 sided flap for wisdom tooth removal
- distal relieving incision
- crevicular incision around the tooth
- medial relieving incision between 7 and 8
what is important to remember when making a flap for removal of a wisdom tooth
do not make the distal incision too lingual as it risks damage to the lingual nerve
describe an envelope flap for wisdom tooth removal
- distal relieving incision
- a crevicular incision that extends to mid way on the 7 or medial end of 7
what do you do once you have incised the flap?
retract the tissues
what are the aims when retracting soft tissues
- aim to access the operative field
- protect soft tissues
- ensure flap design facilitates retraction
- retract using a howarth’s periosteal elevator or rake retractor
how do you remove bone/ divide teeth or roots
- using an electrical straight handpiece with a saline or sterile water cooled bur
- use round or fissure tungsten carbide burs
what can happen if you use an air driven handpiece to remove bone
can lead to surgical emphysema (air or gas in subcutaneous tissues)
what are the uses of elevators
- provide a point of application for forceps
- extract a tooth without the use of forceps
- remove retained roots
- loosen teeth prior to forceps
- removal of multiple root stumps
- removal of root apices
What is involved in wound management
- debridement and curettage
- suturing
describe the stages of debridement and curettage
- physical: using a bone file or handpiece to remove sharp bony edges. Use a mitchell’s trimmer of victoria curette to remove soft tissue debris
- Irrigation: sterile saline into the socket and under the flap
- Suction: aspirate under the flap to remove debris
- check socket for retained root apices
what do we do when suturing
- approximate tissues
- compress blood vessels
what are the aims of suturing
- reposition tissues
- cover bone
- prevent wound breakdown
- achieve haemostats
- encourage healing by primary intention
Define the ways that sutures can be categorised
- non absorbable
- absorbable
- monofilament
- polyfilament
Describe non absorbable sutures and give examples
- sutures which must be removed postoperatively
- used if extended retention periods are required (closure of OAF)
- Examples are Mersilk, praline and ethilon
Describe absorbable sutures and give examples
- used if the removal of a suture is not possible or desired
- holds the tissues together temporarily
- examples are Vicryl and velosorb
how do absorbable sutures breakdown
Vicryl breakdown via absorption of water into the filaments which causes the polymer to degrade
Describe a monofilament and give examples
- single strand
- pass easily through tissue
- resistant to bacterial colonisation
- proline and ethilon
Describe a polyfilament suture and give examples
- several filaments twisted together
- easy to handle
- can cause wicking (oral fluids and bacteria move along the length of the suture and can result in infection)
- Vicryl, velosorb and mersilk
where would you place sutures on a 3 sided flap
- 1 suture distal, and 2 sutures buccally
where would you place sutures on a envelope flap
- 1 suture distal to 8 and 1 suture distal to 7
How do you control haemostasis perioperatively
- use La with a vasoconstrictor
- Artery forceps
- Diathermy
- Bone wax
how do you control haemostasis post-operatively
- use pressure
- La infiltration
- Diathermy
- Sutures
when removing third molars, what 4 nerves can be damaged
- lingual
- inferior alveolar
- mylohyoid
- buccal
When is the lingual nerve at risk and why
- it is above lingual palate in many patients
at risk when
- incision of flap
- raising buccal and lingual flaps
- retraction of flap
- bone removal
- extraction with forceps
what are the potential complications of lower third molar removal
- pain
- swelling
- bruising
- bleeding
- trismus
- infection
- dry socket
- paraesthesia
why do teeth fracture during surgery?
- thick cortical bone
- root shape
- root number
- hypercementosis
- ankylosis
- caries
- alignment
- poor technique
what should you warn the patient about prior to oral surgery
- explain the procedure
- explain any expected complications
- give the patient an idea of what to expect in lay terms
- if adjacent teeth are close then warn of possible damage
- explain post operative complications
what are the general surgical principles
- maximal access with minimal trauma
- bigger flaps heal just as quickly as smaller flaps
- wide-based incision
- used scalpel in one firm continuous stroke
- no sharp angles
- adequate flap size
- minimize trauma to the dental papillae
- flap reflection should be down to bone and done cleanly (mucoperiosteal flap)
- no crushing
- tissues kept moist
- ensure that flap margins and sutures will lie on sound bone
- make sure wounds are not closed under tension
- aim for healing by primary intention to minimise scarring
Describe the flap technique of extracting a 45 with a fractured crown (root only)
- create a 2 sided flap with a crevicular incision extending from the medial of the 44 (first premolar) to the distal of the 45
- Create a distal relieving incision beginning at the medial of the 6
- Ensure the distal relieving incision extends beyond the junction of the attached and unattached mucosa (not enough access in unattached)
describe the bone removal needed when extracting a 45 with a fractured crown
- easiest area of bone to remove is buccally
- create a gutter between the buccal cortex of bone and the buccal surface of the root, being careful not to drill into the root
describe the suturing required when extracting a 45 with a fractured root
- would likely need 3 sutures
- first suture at the distal papillae
- second suture at the medial papillae
- third suture at the distal relieving incision site
Describe the flap design for extraction of a lower 6 with a broken crown
- a one sided flap with a long crevicular incision extending from the medial of the 4 to the distal of the 7
What are the benefits of a long crevicular incision when removing a lower 6
- less swelling and bruising as a one sided crevicular incision does not extend into the attached gingivae which is more vascular and thus would result in more bleeding
- less likely to damage a nerve as there is no distal relieving incision which may come into contact with a nerve
describe the bone removal needed when extracting a 46 with a fractured crown
- drill buccal bone so that you can see the furcation of the roots
- separate the two roots to create an application point for elevator
- elevate the roots separately
describe the suturing required when extracting a 46 with a fractured root
- suture at mesial papillae of 6
- suture at distal papillae of 6
- suture at papillae between the 4 and 5
