dentistry oral and maxillofacial surgery

1. A LEXA NDR IA UNIVER SITY – FAULTY OF
DENTISTRY
ORAL AND MAXILLOFACIAL SURGERY-1
PRINCIPLE OF ORAL
SURGERY
BY:
DR :Dalia Omar Ibrahim Ahmed

2. PRINCIPLES ARE :
8- Instruments of removal of bone1- Diagnosis and treatment
Planning
9-debridement and wound closure and
dead space managements
2- Preoperative Patient and operator
preparation and surgical position
10-suturing principles and methods3-Basic requirement for surgery.
11-Hemostasis and means of
promoting wound hemostasis
4-Pain and Anxiety control
12- Post-surgical care of wounds5- Principles of making an Incisions.
13- Monitoring patient general health
and nutrition
6- Principles of Flap design & Types of
surgical flaps
7-Tissue handling principles and flap
reflection

3. 1-SURGICAL DIAGNOSIS AND TREATMENT
PLANNING
The decision to preform surgery is preceded by some diagnostic steps
1-Presurgical evolutions :
Collection of accurate data through:
a. Patient interview b. Radiological and laboratory assessment
c. General physical assessment.
these data should be organized in to a format to reach a proper diagnosis
weather the surgical intervention in indicated or not.

5. 2 - P R E O P E R A T I V E PA T I E N T A N D D E N T I S T
P R E PA R A T I O N A N D S U RG I C A L P O S I T I O N
P R E O P E R A T I V E O P E R A T O R P R E PA R A T I O N
1. Hand and arm preparation Done by antiseptics with low toxicity like
Iodoform, Chlorhexidine, and hexachlorophene
Two techniques are used for :
A. Clean technique- used in office based surgeries..
Surgeon wears a clean dress and over it long sleeved laboratory coat or a
surgical scrub
B. Sterile technique- mostly in operating room..
Purpose of it is to minimize the number or micro organism that can enter the
wound site.

7. OPERATOR POSITIONS
The operator should stand as nearly erect as possible
distributing his weight on both feet during his prolonged
standing in order to avoid abnormal strain at the weight-
bearing joints also the operator must paralyze the level of his
elbow to the level of the patient oral cavity

8. OPERATOR POSITIONS
1- The operator should stand on the front and right side of the dental chair
when extracting upper and lower teeth on the LEFT side
2- When extracting lower teeth on right side the operator stand on the
RIGHT side of the dental chair and when extracting lower left teeth operator
should stand on the LEFT side
3- Its more convenient to tilt the chair a little backward for more accessibility
4- If operation on the lower jaw it should be placed parallel to the room
floor
5- If operating in the upper jaw it should be placed 45 degree with the room
floor

10. PREOPERATIVE PATIENT
PREPARATION
Pre-operative preparation: Physical examination, medical examination, or clinical
examination and pre-surgical X-rays
Staging for surgery (Operative) : Hair is present at the surgical site, it is shaved. if
operating extraorally on male patient then the surgical site is swabbed off by Antiseptic
such as Iodine.
Surgical staging intra-orally : All calculus must be removed from the teeth by scaling the
tooth to be extracted is dried by dry sterile cotton or gauze then the oral cavity is rinsed by
an antiseptic such as chlorhexidine the tooth is dried by dry sterile cotton the swabbed by
2% Iodine in alcohol on small cotton pellet

11. Two basic requirements :
1- adequate visibility. depend on:
a. adequate access. b. adequate light c. dry surgical field. ( high suction ,cotton, gauge)
obtain good access by :
1- patients ability to properly open there mouth .
2- retraction of the tissues away from the surgical fields will provide adequate access and will
also protect the tissue from accidental injuries
2-Competent assistance the assistance should be familiar with the surgical procedure being
preformed to anticipate the surgeon needs.
3-BASIC REQUIREMENT
FOR SURGERY.

12. 5-PAIN AND ANXIETY
CONTROL
1- local anesthesia
2- General Anesthesia
3- sedation

13. PRINCIPLES OF MAKING
AN INCISIONS
Incision is :sharp wound produced by surgical scalpel
Instruments to incise tissue : THE SCALPLE
the scalpel is a tool composed of handle + sharp blade
When making an incision the scalpel is held in a pen grasp and moved
only by the hand and rest not the entire arm. .

14. No.11
Stab incision to
drain an abscess
No.12
Inaccessible site ex
retro-molar area and
gingival incision to cut
sutures
No.15
Intra oral incision

15. NO. 10
Extra-oral incision
NO. 20
Puncture or cut
NO.21
Making incision on skin and
muscle
NO.22
Skin incision
NO.23
Long incision
NO.24
Long incision

17. 5-PRINCIPLES OF MAKING
AN INCISIONS
1- use sharp blade of proper size .
2-the scalpel stroke should be continues and firm .
3- the surgeon should be carful and with knowledge of the anatomical land
marks not to injure a vital structure ex. Nerves or artery
4-the blade should be perpendicular to the EPITHELAIL surfaces

18. 5-PRINCIPLES OF MAKING
AN INCISIONS
5- the edges of the incision should be at least 6mm -8mm away from the defect
6- incision should be placed properly:
-over healthy bone - on the line angle of the tooth crown not on the facial surface
nor the dental papilla

19. 6- PRINCIPLES OF FLAP DESIGN &
TYPES OF SURGICAL FLAPS
1- The incision should be designed to avoid injury to the vessels and nerves
in the region
2- The incision must include the mucosa and the underlying periosteum in
one sharp clean cut until the bone is reached to avoid tearing and laceration
of the tissues during reflection of the flap
3-The flap base should be broader then the free margin to maintain
maximum blood supply to the flap tissue

20. 6- PRINCIPLES OF FLAP DESIGN &
TYPES OF SURGICAL FLAPS
4-The flap should large enough to fulfill the fallowing:
a.To expose ALL the operation area
b.To be able to be retracted without causing tension on the tissues
and to avoid laceration and delayed healing
c.To cover all the operative field after surgery , with the edges of the
flap resting on sound bone at the adjacent border this will prevent the
flap from falling in to a bony defect created by the surgery

21. 6- PRINCIPLES OF FLAP DESIGN &
TYPES OF SURGICAL FLAPS
5- The gingival margins of the teeth standing in the flap should be incised vertically
so that the flap could be detached from the bone without laceration
6-The flap should be repositioned to cover the field of the surgery and sutured
without tension to avoid strangulation of the blood vessels which will delay healing
7- The oblique (vertical ) releasing incision should not alter the contour of the
dental papilla ex. It should be cut mesial or distal to the to prevent necrosis of the
soft tissue and the underlying alveolar bone it should extends 1 tooth anterior and 1
tooth posterior
.

22. 8-The flaps preformed in edentulous alveolar ridge for alveolectomy
must be trimmed of their excess to cover the alveolus without
overlapping at their edges to avoid flappy ridge formation which can
interfere with prosthetic appliances e.g. dentures

23. TYPES OF
MUCOPERIOSTEAL FLAPS
1- Pyramidal flaps
2- Semilunar flaps
3- Gingival flaps

24. 1- PYRAMIDAL FLAPS
Three incision line flapTwo incision line flap
It is made by making oblique cuts (2
vertical releasing incision) and one
gingival incision
It is indicated for exposure of large
surgical area
Ex. Molar region with cystic
involvement
Made by cutting one oblique line
(vertical) with one gingival line
(horizontal)
It is adequate for removal of small
teeth
ex front teeth , premolars ,
tooth fragments ex. Remaining one
root

25. Disadvantage of the pyramidal
flap
Advantage of the pyramidal
flap
1-Disturbance of the gingival
tissue attachment by cutting the
gingival incision which can retard
healing.
This disadvantage can be
overcome by
a. Preforming sharp clean cut to
the gingival tissues
b. Neat retraction to avoid tissue
laceration which will bring
adequate re-adaptation of these
tissue after surgery
1- Provides adequate exposure
2-Affords discovery of destroyed
or necrotic bone
3- Allow resting of the flap on
sound bone during closure of the
surgical field .

26. 2- SEMILUNAR FLAPS
This type of flaps avoids disturbance to the gingival attachment the incision is
made at least 1cm away from the gingival margins to avoid laceration of the
gingival attachments

27. REQUISTIES OF THE
SEMILUNAR FLAP
It is the requirements of all mucoperiosteal flaps with two extra points
1- The incision is cut so that the convex side toward the gingival margins this
allows adequate exposure of the field of the operation site and maintain adequate
blood supply to the flap the flap cut in this manner gives abase broader then its free
margins
2- the incision is made at least 1cm away from the gingival margins to avoid
laceration of the gingival attachments

29. INDICATION OF
SEMILUNAR FLAP
1-Removal of small root fragment embedded in the alveolus away from the gingival
margins
2-Apicectomy because it is not necessary to expose the alveolar to bone the gingival
margins
disadvantagesAdvantages
-Inadequate for exposure large surgical field
-Areas of destroyed alveolar bone may exist under the
periosteum beyond the incision lines of the flap not
discovered and removed leading to recurrent infection
Avoids disturbance
to the gingival
attachment

30. 3- GINGIVAL FLAPS
Requisites :
1-The gingival tissue around the cervical margins is sharply incised before
retraction of the mucoperiosteum with the periodontal elevator
2- The gingival incision must be of adequate distance mesio-distally in order to
allow retraction of the flap without tension
Indications:
For exposure of shallow portions of Alveolar bone plate such as gaining access to
the neck of the teeth .

31. Advantages :
1- Avoids oblique incisions prevents
retarded healing and minimizes bleeding
2-Avoids disturbance of large area of
the mucoperiosteum thus minimizes the
post- operative complication of pain ,
edema and retarded healing
3- GINGIVAL FLAPS ADVANTAGES

32. 7-TISSUE HANDLING PRINCIPLES
AND FLAP REFLECTION
 Halsted's principles, also known as Tenets of Halsted, are the basic
principles of surgical technique regarding tissue handling.
 · Gentle handling of tissue.
 · Using of hemostasis.
 · Sharp anatomical dissection to prevent damage.
 · Strict aseptic technique.
 · Avoid tension on tissues.
 · Importance give rest to the tissue after surgery.
 · Obliteration of dead space

33. FLAP REFLECTION
Periosteal elevator : used to reflect the flap

34. FLAP REFLECTION
PERIOSTEAL ELEVATOR
Double ended with one round, blunted end and one pointed end The
pointed end is used to begin the periosteal reflection and to reflect dental
papillae from
between teeth, and the broad, rounded end is
used to continue the elevation of the periosteum
from bone.
Used for most surgical procedures

35. 8- INSTRUMENTS OF
REMOVAL OF BONE
The alveolar bone investing the tooth to be extracted must be reduced or
removed so that we can gain access to the structure also to reduce
resistance around the tooth bone should be excised to provide point of
forceps or elevator application and also to create space in which the
tooth or root maybe displaced
several instruments are used to remove bone they are surgical chisels ,
surgical burs , bone cutting forceps Rongeur , surgical air turbine.

36. METHODS OF BONE
REMOVAL
Surgical chisel and mallet :
Chisel technique
A. Mallet driven chisel
B. Hand chisel (bone Gouge osteotome )
C. Electric automatic chisel( impactor)

37. A. MALLET DRIVEN CHISEL
Technique
Unibeveled chisels are used for removal of alveolar bone
the chisel is held by the operator left hand with it's blade contracting the
alveolar bone about 45 degree oblique to determine the depths of the bone
to be removed by making an oblique cut
Then the direction of the chisel is made horizontal for the bone removal in
segments( flakes ) the chisel is driven by blows of a metal Mallet held in the
right hand few steady blows are given at a time

39. B.HAND CHISEL (BONE
GOUGE )
Works by hand pressure of the operator
Indication:
In Soft bone
Disadvantage:
1 - it is difficult to use in area of dense bone
2 - difficult to control
3 - heavy pressure might cause it's sleeping and injuring the tissue

40. B. HAND CHISEL (BONE
GOUGE )

41. C. ELECTRIC AUTOMATIC
CHISEL (IMPACTOR)
Consist of a number of variables shapes and size of
chisel blades. The suitable blade is mounted on a
special hand piece by the dental engine. Chisel blade
cuts automatically by applying pressure against the
bone when the pressure is released that chisel stops
cutting

43. ADVANTAGES OF CHISEL
TECHNIQUE
1 - Clean and smooth cutting made by the chisel prevents complication and ensure proper
healing
2- Practical and safe when operating on the general anesthesia where electrically driven surgical
burs might cause combustion and explosion with some aesthetic gases used in GA
3 Automatic chisel possesses the following advantages :
A . variable patterns of chisel blades supplied with this apparatus makes it suitable to remove
bone easily by selecting the proper blades that suits the area
B. Safe and easy control of the chisel as it works only on applying pressure against the bone and
stops automatically when the pressure is released and being driven the electric engine don't need
much skill by the operator

44. DISADVANTAGES
1- Chisels cause great alarm to the patient
2- Chisel is contraindicated for bone removal in the maxilla because the maxillary
bone is thin and weak the chisel might cause fracture of the bone over the maxillary
sinus or maxillary tuberosity
3- Hand chisel is not practical for removal extremely dense and hard areas of the
alveolar bone
4- Electrically driven automatic chisel is contraindicated with some general anesthesia
gases to avoid the dangers of Sparks generated and explosion
5- Mallet driven chisel needs great skill and training by the operator to avoid damage
to the tissues

46. 2- SURGICAL BURS
TECHNIQUE :
Variety of shapes and sizes are used for bone removal. Fissure and round
surgical burs are used
The bur works on a straight or contra- angle hand pieces by the dental
engine.
It is essential that the bur is Sharp and flushed continuously during use
with sterile normal saline solution to prevent overheating to keep its
cutting edges from becoming clogged with bone or tooth substance and
to keep the operative site clean and visible .

47. 2- SURGICAL BURS
TECHNIQUE
Constant use of the suction and good retraction of the flaps should be
taken in mind during the process of bone removal to prevent it's injury
by the bur . Bone maybe removed with bur either by simply cutting it
away using a large round or fissure bur No.8-10 or by the use of
"postage stamp " method
in the last technique a row of holes is made with round bur and joined
together with either fissure bur or chisel cuts

48. SURGICAL BURS

49. SURGICAL BURS
Advantages of surgical burs:
1- Not alarming to the patient
2- Indicated in the maxilla as it's a safe method
3- practical in removal of areas of heavy dense bone especially the mandible
4- easy control and use.
Disadvantages of surgical burs
1-generation of excessive amounts of heat if the burs not properly flushed
continuously during use with sterile normal saline solution
2- its contra Indicated to be used with some general anesthetic gases when
operating under GA

50. RONGEUR FORCEPS
its for is she trimming bone edges after extraction
of the tooth or root to trim the sharp edges of the
alveolar plate and also cutting projecting bony
septa in the socket of extracted teeth

51. TYPES AND USES OF
RONGEUR FORCEPS :
1- Site cutting Rongeur : with blades having sharp cutting side it's suitable for
trimming sharp edges of the alveolar plate , this type of Rongeur is sometimes
called a bone shear
2- End cutting Rongeur : designed with cutting end blades which cut bone at their
tips . This type is suitable for cutting projecting bony septa in the sockets of
extracted teeth
3- End and side cutting Rongeur: the blades are designed to cut at their sides and
tips which makes this type of Rongeur more practical

55. BONE FILE : SMOOTHING
OF SHARP BONE EDGES

56. 9-DEBRIDEMENT AND WOUND
CLOSURE:
It is a careful removal of pathological necrotic and ischemic tissues and
foreign body ex tooth & bone chips.
After the operation is done the field should be irrigated with normal
Saline or Antiseptic solution to remove any fine particles or debris
closure of the wound by means of suturing promotes healing and
prevents complications because an open wound is subjected to entrance
of saliva loaded with food debris and bacteria suturing also prevents
post operative hemorrhage

57. DEAD SPACE
MANAGEMENT
It is an area that remained devoid of tissue after closure of the
wound which usually become infected.
it is created by
-Deep tissue removal .. to eliminate….placement of a surgical
packing and dressing .
-Not proper suturing of the wound … to eliminate…. multi layer
suturing

58. DEAD SPACE
MANAGEMENT

59. 11-SUTURING PRINCIPLES AND
METHODS

60. PRINCIPLES OF
SUTURING:
1- The needle holder is held with a thump and a ring fingers , the index
finger rest on the shaft for stability and control
2- The needle is grasped at approximately three quarters over the distance
from the tip
3- The needle should enter the tissue at right angle
4- The needle should be passed through the tissue the needle following the
curve of the needle

61. PRINCIPLES OF
SUTURING:
5- The suture needle suitable in shape and size to be accessible to the
surgical area and prevent laceration of the tissues
6- The insertion of the suture needle about 2 to 3 millimeters away from
the free edges over the soft tissue to be sutured to avoid weakening and
laceration of those images
7- If one tissue is mobile and the other is fixing the needle should be
passed from the mobile to the fixed side

62. PRINCIPLES OF
SUTURING
8- Should not be placed under tension
9- After ligation of the knot the suture is cut at 4 to 5 millimeters far from
the knot
10- The knots should be positioned to one side of the incision

63. PRINCIPLES OF
SUTURING
11- Sutures should be placed approximately 2 to 3 millimeters apart in case of
extraction wounds they are placed in the interdental papillae not in the middle of
the socket
12- The suture material should not be dance heavier than the sutured tissue in
order to prevent necrosis of this tissue which might be caused thick suture
material . To dance suture material lead to Deep scarring of the tissue with the
complications of infection and secondary hemorrhage

64. SUTURING
ARMAMENTARIUM
1 - Needle holder
There are different types off needle holders but the most common used one
have a locking handle and short beaks and or about 6 inches (15 cm) long

65. 2- SUTURE NEEDLE
It is supplied in different shapes and sizes for the accessibility to the sutured area and avoid
complication , The selection of the needle depend on field application
patterns of suture needle according to the accessibility :
1 - Straight suture needle skin suturing
2-Curved suture needles For intra-oral deep suture The most common used. It is easier
to use in small space there are various curved needles 1/4 circle, 3/8 circle1/2 circle, 5/8
circle
3- In the oral cavity the most frequently used needle are 3/8 or 1/2 circle.

68. PATTERNS OF SUTURE NEEDLES
ACCORDING TO CROSS SECTION
1- Round circular needles (traumatic)
Its round in cross-section it might be straight or curved half circle for more
accessibility to the sutured area. It is adequate for suturing fragile tissue as
mucous membrane and oral mucosa with its advantage Of easy penetration of
the tissue without cutting or laceration

69. PATTERNS OF SUTURE NEEDLES
ACCORDING TO CROSS SECTION
2 - Cutting edge (A traumatic) suture needles:
The needle has sharp cutting edge (sides) has a triangular cross section
also it is maybe it's straight, curved or half circle to be accessible to the
sutured area . pressure is needed to make the needle penetrate the tissues
easy and sharp penetration through the dense tissues such as the Oral
mucoperiosteum prevent laceration IF this type is used on the delicate
tissues such as lips mucosa or thin epithelium it can cause excessive cut
and laceration to the tissues

70. SWAGE AND EYED NEEDLES:
A. Swage needles
1. Pre-packed and pre-sterilized
2 . Needle attached to the suture material
3. It is the most favorable for intra oral use
4. less tissue trauma
B. Eyed Needles
1. Reusable may have burs that could
weaken the suture material

71. TYPES OF SUTURE
1. Interrupted suture
The most commonly used in there dental alveolar surgery
2. Continuous suture
A. Simple B. Locked
3. Mattress sutures, used to event the wound edges
A. Vertical B. Horizontal
4. Figure of eight suture

73. 11-HEMOSTASIS
methods to promote wound hemostasis
1-Apply pressure using sponge this will cause the stasis of the blood and
promote natural coagulation process.
Small vessels 20-sec -30 sec Large vessels 10 min -15 min
‫الكي‬2-Electro-coagulation will fuses the wound edges
-3-Vasoconstrictor like adrenaline placed in the surgical site 5min -10 min
before surgery .
Other hemostatic agents :
Tannic acid , Thrombin , Oxidized regenerated cellulose (surgical
4- Suture ligation .
5-Hemostat used to stop the bleeding

75. BONE HEMOSTASIS
The bone wax is smeared across the bleeding edge of the
bone, blocking the holes and causing immediate hemostasis

76. 12- POST-SURGICAL CARE OF
WOUNDS
wound post-operative care:
1-the wound should be kept clean to prevent wound infection
2-Pain control medication is given for patients comfort
3-Anti Inflammatory in given to Avoid wound inflammation
4- post surgical Supplements ex Vitamin K,. Iron is given to
Accelerate healing of the wound .