5th book Suction & Retractors in OMFS.pdf

i
Suctions & Retractors in
Oral & Maxillofacial
Surgery
Dr. Rahul VC Tiwari
Dr. Anil Managutti
Dr. Pranav Parashar
Dentomed Publication House,
Amritsar, Punjab

ii
Published
By
Dentomed Publishing House
14 GGS, Majitha Road,
Amritsar-143001, Punjab,
India,
Phone: 09501544877
Author: Dr. Rahul VC Tiwari, Dr. Anil Managutti, Dr. Pranav Parashar
All rights reserved. No part of this book may be reproduced in any form or by
any means, including photocopying or utilized by any information storage and
retrieval system without written permission from copyright owner.
Although care has been taken to confirm the accuracy of information
presented; the authors, editors and publisher is not responsible for any
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The publisher has made every effort to trace copyright holders for borrowed
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publication and apologize if permission and acknowledgements to publish in
this form have not been given.
Suctions & Retractors in Oral & Maxillofacial Surgery- First Edition 2021
978-81-950328-1-5
Price: Rs. 1500/-
e- Type setting at: Crystal Software, Pvt. Ltd., Amritsar
Copyright© 2021 Dentomed Publishing House, Amritsar, Punjab, India
www.dentomedpub.com

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PREFACE
Oral and Maxillofacial Surgery is a comprehensive reference for all trainees and
specialists in oral and maxillofacial surgery, oral surgery, and surgical dentistry. This
landmark new resource draws together current research, practice and developments in
the field, as expressed by world authorities. The book’s aim is to cover the full scope
of oral and maxillofacial surgery, incorporating recent technical and biological
developments within the specialty. It provides a uniquely international and
contemporary approach, reflecting the exciting developments of technique and
instrumentation within this surgical field, built on technical innovation and medical
and dental research. Oral and Maxillofacial Surgery coalesces impressively broad and
deep coverage of this surgical specialty into a cohesive and readable resource,
identifying commonalities and shedding light on controversies through reasoned
discussion and balanced presentation of the evidence. The Editors are joined by over
50 international experts, offering a truly global perspective on the full spectrum of
issues in oral and maxillofacial surgery. The book’s coverage extends from basic
principles such as patient evaluation, dental anesthesia, wound healing, infection
control, and surgical instruments, to coverage of the complex areas of dentoalveolar
surgery, oral pathologic lesions, trauma, implant surgery, dentofacial deformities,
temporomandibular joint disorders, and salivary gland disorders. Where relevant, the
book provides separate coverage of topics where practice differs significantly from
region to region, such as general anesthesia.
Dr. Rahul VC Tiwari
Dr. Anil Managutti
Dr. Pranav Parashar

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About Author
Dr. Rahul VC Tiwari is a Dentist, Oral & Maxillofacial Surgeon & Scientific Writer
with 7 years of experience. He is from Kondagaon, Bastar, Chhattisgarh where he
completed his schooling. Further he completed Bachelor of Dental Surgery from
Saraswati Dhanwantari Dental College Hospital & Research Institute, Parbhani,
Maharashtra & achieved 3rd rank in College. Then Masters of Dental Surgery in Oral
& Maxillofacial Surgery from Sibar Institute of Dental Sciences, Guntur, Andhra
Pradesh & achieved 1st rank in OMFS in College. Later Fellowship in Orthognathic
Surgery from Jubilee Mission Medical College Hospital & Research Institute ,
Thrissur, Kerala & achieved All India 1st rank in Association of Oral & Maxillofacial
Surgeons of India Fellowship Exam. He is also pursuing Doctor of Philosophy in Oral
& Maxillofacial Surgery from Narsinbhai Dental College & Hospital, Sankalch&
Patel University, Visnagar, Gujarat. He has work experiences in Medical College,
Dental College & Corporate Hospitals. He is a Scientific Writer for Writing
Assistance with more than 250 Indexed Publications. He is author of 6 Professional
Books published worldwide. He is Reviewer & Editorial Board Member for around
25 National & International Indexed Journals. He is a Life Member of International
Association of Oral & Maxillofacial Surgeons, Association of Oral & Maxillofacial
Surgeons of India & Indian Dental Association. He is also a National Service Scheme
Volunteer authorized form Government of India. His name is registered in India Book
of Records for his Academic Excellence.

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Dr. Anil Managutti is acclaimed Oral and maxillofacial surgeon and Implantologist
with 19 years of experience. He is presently working as Prof. & HOD in the
department of Oral and maxillofacial surgery at Narsinhbhai Patel Dental College and
Hospital, Sankalchand Patel University [SPU], Visnagar, Gujarat India. He is dean
external affairs to Sankalchand Patel University. He is P.G Guide and PhD supervisor
in SPU .He has done his B.D.S & M.D.S from K.L.E. Institute Of Dental Sciences
Belgaum, Karnataka . He has worked in tertiary center of traumatology at Rajshree
Chhatrapati Shahu maharaja Medical College Kolhapur. He has done fellowship in
oral Implantology. Under his guidance the dept. of OMFS, NPDCH was awarded
certificate excellence at 8th
INTERNATIONAL DENTALSTUDENTS & 2nd
DENTAL SURGEONS CONGRESS2016 as Best department of ORAL &
MAXILLOFACIAL SURGERY. DENASIA INTERNATIONAL DENTAL
CONFERENCE 2016 awarded him as ‘BEST ACADEMICIAN OF THE YEAR’ in
2016. He has more than 60 national and international publications to his credit. He is
invited guest speaker to many associations and private organizations. He has
organized national and international seminars and workshops and was spart of
organizing committee of them.

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Dr. Pranav Parashar is a renowned, established oral and maxillofacial surgeon,
experienced academician, and enthusiastic researcher with an immense experience of
11 years, after his post graduation. He is from Indore, Madhya Pradesh, where he did
his schooling and under graduation (Bachelors in Dental Surgery), from College of
Dental Sciences & Hospital, Indore. Then he did his masters in dental surgery
(Masters in Dental Surgery) in oral and maxillofacial surgery from Rama Dental
College, Hospital & Research Centre, Kanpur, Uttar Pradesh. He has been associated
with various private corporate hospitals as visiting consultant and has a flourishing
private clinic in Indore. He is presently working as Professor in N.S.C.B Medical
College & Hospital, Jabalpur, Madhya Pradesh, and before this he was working with
Index Medical College & Hospital & research Centre, Indore, Madhya Pradesh. He
has several awards for his presentations in speciality and state conferences. Also he
has about 15 research and case report publications, in many established national and
international journals. He is a life member of Association of Oral & Maxillofacial
Surgeons of India (AOMSI), and Indian Dental Association (IDA). He has mentored
various courses and also chaired various sessions at national & international
conferences.

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DEDICATION
This Book is dedicated to
My family and teachers

Contents
INTRODUCTION...................................................................................................................................1
SUCTION...............................................................................................................................................5
Objective of suction.............................................................................................................................5
Safety considerations:..........................................................................................................................6
Know When and Why to Suction.........................................................................................................7
Basic Suctioning Techniques...............................................................................................................7
Emergency Suctioning.........................................................................................................................8
Choose the Right Dental Suction Device..............................................................................................8
INSTRUMENTS FOR SUCTIONING ................................................................................................9
Types...............................................................................................................................................9
Various types of suction tips available: ..............................................................................................16
Modifications of Surgical Suction Tip Geometry for Flow Optimisation: Influence on Suction-Induced
Noise Pollution..................................................................................................................................17
RETRACTORS.....................................................................................................................................23
SURGICAL RETRACTORS TYPES AND USAGE .........................................................................26
Importance of Surgical Retractors......................................................................................................26
Materials ...........................................................................................................................................27
Types of Retractors............................................................................................................................28
Self Retaining Retractors...................................................................................................................29
Hand Held Retractors ........................................................................................................................29
Varieties............................................................................................................................................31
Retractors used for nasal surgeries .....................................................................................................33
Retractors used for orbit surgeries......................................................................................................36
Retractors used for maxillofacial trauma............................................................................................37
Retractors used for orthognathic and plastic surgery...........................................................................38
Assortments commercially available retractors and their specification................................................39
Description and Use...........................................................................................................................53
Army-Navy and three Parker retractors..............................................................................................56
Modified Laster’s retractor ................................................................................................................66
Alexis ring retractor...........................................................................................................................67

Modified retractor for use in sectioning the inferior alveolar nerve.....................................................72
Tongue retractors...............................................................................................................................73
OptragateH oral retractor ...................................................................................................................79
Mouth Gags and their evolution ........................................................................................................88
Introduction.......................................................................................................................................88
History ..............................................................................................................................................88
Features of an ideal mouth gag:.......................................................................................................88
Lane mouth gag: ..............................................................................................................................90
Rose mouth gag:...............................................................................................................................91
Doyen Jenson Mouth gag:...............................................................................................................92
Ferguson’s mouth gag: ....................................................................................................................93
Ferguson’s mouth gag......................................................................................................................94
Gags with spring catch:...................................................................................................................95
Coleman mouth gag.........................................................................................................................95
Mouth gags with tongue blade: ......................................................................................................97
Whitehead mouth gag:.....................................................................................................................98
Mouth Gags with slotted tongue blades: ........................................................................................98
Boyle’s Davis mouth gag:..............................................................................................................99
Doughty mouth gag: .....................................................................................................................101
Dott mouth gag................................................................................................................................103
Gag with closed frame:.................................................................................................................104
Thompson’s modification of Dingman mouth gag: ...................................................................105
Mouth gag with adjustable split alveolar bar: .............................................................................106
Gag with long hooks: ...................................................................................................................107
Mouth gags with sliding stem:.....................................................................................................107
References .......................................................................................................................................109

1
INTRODUCTION
Fear of visiting the dentist and undergoing oral surgery can make patients reluctant to seek dental
care and increase their discomfort when they do. Many Americans suffer from some form of
dental anxiety. Oral surgery to treat cavities, infections, broken teeth, and jaw and gingival health
issues are among the most common medical procedures.
Although most procedures are performed on an outpatient basis, dental surgery can also be an
emergency procedure in the event of an obstructive injury to the teeth or jaws, a serious
infection, or an injury that complicates other conditions. Whether performing dental suction in an
office, in a hospital, or in an emergency setting, the right technique can lower the risk of
complications and ease patient anxiety.
Dental health issues are among the most prevalent health afflictions facing Americans. Nearly
half of Americans have gum disease. Ninety percent have had at least one cavity, and about 1 in
4 have untreated cavities. Untreated oral health issues can lead to serious health
problems, including cardiovascular disease. This means that dentists are on the front lines of the
fight for better public health, and oral surgery does a lot more than produce a pretty smile.
Dental suction devices are a routine part of oral surgery, whether a dentist is filling a tooth,
draining an abscess, or undertaking a more complex operation, such as removing wisdom teeth.
Dentists and dental assistants may use a wide range of dental suction techniques depending on
the specific procedure, but the importance of suction is hard to overstate.

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Some of the most important roles of dental suction in oral surgery include:
Preventing Aspiration and Choking
Dental surgery often requires that numerous objects, such as gauze and dental instruments, enter
the patient’s mouth. This makes it impossible for a patient to safely swallow during procedures
for which they are awake, such as routine cavity treatment. Dental suctioning removes excess
saliva. It can also prevent patients from inadvertently aspirating or choking on dental
instruments, toothpaste, dental medications, or other routine components of oral surgery.
Ensuring Patient Comfort
Not being able to swallow during routine procedures can be stressful for patients. Dental suction
prevents drooling, and ensures that the patient does not feel an overwhelming need to swallow. It
also offers reassurance that, should anything obstruct the airway, the dental team can quickly
remove it. This can help ease anxiety, making dental procedures less stressful for patients.
Removing Secretions
Every patient naturally salivates during dental procedures. Removing excess oral secretions does
more than just ensure patient comfort. It also makes it easier for the dentist to operate. Pooling
saliva can obstruct the dentist’s view and make it more difficult to grasp or treat teeth. By
quickly removing secretions, dental suction devices help dentists work more quickly and
efficiently.
Treating Airway Emergencies
Airway emergencies can happen even during routine procedures. A patient might have an
unexpected allergic reaction to latex, novocaine, or another drug. Or, the patient may vomit or

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bleed, and aspirate their own fluids. Accidental ingestion of foreign bodies during dental
anesthesia is a leading cause of death during dental procedures. It is also highly preventable with
the right suction machine. Dental staff can use suction machines to quickly clear the airway of
vomit, dental equipment, and other debris.
When a patient undergoes emergency dental care for a traumatic injury (or other reasons), dental
suction is especially important. This is because the patient may not be able to fast prior to general
anesthesia, increasing their risk of vomiting and aspiration. A dental team that is mindful of these
risks and prepared to act quickly can ensure that the patient receives excellent dental care while
minimizing any risk of serious complications.

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SUCTION
In medicine, devices are sometimes necessary to create suction. Suction may be used to clear
the airway of blood, saliva, vomit, or other secretions so that a patient may breathe. Suctioning
can prevent pulmonary aspiration, which can lead to lung infections. In pulmonary hygiene and
the oral procedures, suction is used to remove fluids from the airways, to facilitate breathing and
prevent growth of microorganisms. Small suction-providing devices are often called aspirators.
In surgery suction can be used to remove blood from the area being operated on to allow
surgeons to view and work on the area. Suction may also be used to remove blood that has built
up within the skull after an intracranial hemorrhage.
Suction devices may be mechanical hand pumps or battery or electrically operated mechanisms.
In many hospitals and other health facilities, suction is typically provided by suction regulators,
connected to a central medical vacuum supply by way of a pipeline system. The plastic,
rigid Yankauer suction tip is one type of tip that may be attached to a suction device. Another is
the plastic, nonrigid French or whistle tip catheter
Objective of suction
The purpose of oral suctioning is to maintain a patent airway and improve oxygenation by
removing mucous secretions and foreign material (vomit or gastric secretions) from the mouth
and throat (oropharynx).
Oral suction is the use of a rigid plastic suction catheter, known as a yankauer, to remove
pharyngeal secretions through the mouth (Perry et al., 2014). The suction catheter has a large
hole for the thumb to cover to initiate suction, along with smaller holes along the end, which
mucous enters when suction is applied. The oral suctioning catheter is not used for tracheotomies

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due to its large size. Oral suctioning is useful to clear secretions from the mouth in the event a
patient is unable to remove secretions or foreign matter by effective coughing. Patients who
benefit the most include those with CVAs, drooling, impaired cough reflex related to age or
condition, or impaired swallowing (Perry et al., 2014).
Safety considerations:
 Avoid oral suctioning on patients with recent head and neck surgeries.
 Use clean technique for oral suctioning.
 Know which patients are at risk for aspiration and are unable to clear secretions because
of an impaired cough reflex. Keep supplies readily available at the bedside and ensure
suction is functioning in the event oral suctioning is required immediately.
 Know appropriate suctioning limits and the risks of applying excessive pressure or
inadequate pressure.
 Avoid mouth sutures, sensitive tissues, and any tubes located in the mouth or nares.
 Avoid stimulating the gag reflex.
 Always perform a pre- and post-respiratory assessment to monitor patient for
improvement.
 Consider other possible causes of respiratory distress, such as pneumothorax, pulmonary
edema, or equipment malfunction.
 If an abnormal side effect occurs (e.g., increased difficulty in breathing, hypoxia,
discomfort, worsening vital signs, or bloody sputum), notify appropriate health care
provider.

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Know When and Why to Suction
Suctioning is almost always necessary to remove excess saliva and fluids during a dental
procedure. Suctioning also maintains a clean oral cavity and can prevent choking and
aspiration. For some dental procedures, it is important to isolate individual teeth in addition to
suctioning the mouth. A dental dam or cotton roll may be appropriate. Dry-angle absorption,
which uses a triangular absorbent pad, may also be helpful.
You must also suction patients when:
 They cannot swallow or clear the airway on their own.
 Equipment or a tooth breaks, posing an immediate risk of aspiration or choking.
 The patient expresses discomfort from accumulating saliva or other fluids.
Basic Suctioning Techniques
The following dental suction techniques ensure a safe and comfortable procedure for the
patient:
 Talk to the patient about the procedure before beginning, especially if the patient suffers
from dental anxiety.
 For routine dental procedures, discuss the treatment plan with the dentist before
beginning. This is doubly important if the dentist will be treating several areas of the
mouth because you and the dentist will have to work around one another.
 Position suctioning equipment so that it does not suction oral tissue such as the gums or
tongue.
 Avoid obstructing the dentist’s mirror or line of sight. Do not touch any of the dentist’s
equipment with the suction tip. This may require frequent changes of position.

8
 Do not directly suction the middle of the patient’s throat, because this can cause pain,
choking, and gagging.
 Monitor for broken teeth, damaged equipment, and any other risk factors for choking and
aspiration. Promptly responding to an unexpected emergency can prevent choking.
 Position the high-volume evacuation (HVE) attachment opposite the dentist’s handpiece.
It should be lateral and very close to the aerosol-producing instrument—usually just 1-2
centimeters away.
As with any medical procedure, it’s important to reassure the patient, especially when there are
unusual noises or the patient coughs or gags.
Emergency Suctioning
Even a simple dental procedure can become an emergency, especially when a patient has health
risk factors such as a history of anaphylactic reactions. Emergency responders and dental teams
should be prepared to promptly intervene when a patient has difficulty breathing because of
anaphylaxis, aspiration, or unexpected vomiting. Suction Assisted Laryngoscopy and Airway
Decontamination (SALAD) can prove life-saving in a patient who is actively vomiting or
bleeding following a dental trauma or other emergency. This strategy works best with a DuCanto
catheter, which boasts a large diameter and curved tip for rapid airway decontamination.
Choose the Right Dental Suction Device
The right suction device delivers consistent suction, uses an attachment that is an appropriate
size for the patient and the procedure, and lowers the risk of complications and discomfort. The
right portable suction device allows you to care for patients in any setting and is compatible with
a wide range of attachments.

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INSTRUMENTS FOR SUCTIONING
 Adequate visualization: blood, saliva, irrigating solutions suctioned
 Surgical suction: smaller orifice than usual- rapid evacuation of fluids
 Several designs of orifice: soft tissue not aspirated & injured
Types
1. Fraser suction:
 Hole in the handle
 Hard tissue cut; hole covered to remove the solution rapidly
 Soft tissue suctioned: hole uncovered to prevent injury
2. High Volume Suction Tip
 Large bore tubes with slight angulation- end
 Autoclavable stainless steel/ plastic
 Disposable plastic tubes
 Suck out large volumes of irrigation fluids, blood clots & debris
3. Saliva Ejector
 Low volume suction tip
 Disposable plastic- different designs

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 Flexible- bent & adapted under tongue
 Buccal vestibule: partially retracts cheek
Steps Additional Information
1. Assess patient need for suctioning
(respiratory assessment for signs of hypoxia),
risk for aspiration, and inability to protect own
airway or clear secretions adequately, which
may lead to upper airway obstruction.
Baseline respiratory assessment, including an
O2 saturation level, can alert the health care
provider to worsening condition.
Signs and symptoms include obvious excessive
secretions; weak, ineffective cough; drooling;
gastric secretions or vomit in the mouth; or
gurgling sounds with inspiration and
expiration. Pooling of secretions may lead to
obstruction of airway. Suctioning is required
with alterations in oxygen levels and with
increased secretions.
2. Explain to patient how the procedure will
help clear out secretions and will only last a
few seconds. If appropriate, encourage patient
to cough.
This allows patient time to ask questions and
increase compliance with the procedure.
Minimizes fear and anxiety.
Encourage the patient to cough to bring

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secretions from the lower airways to the upper
airways.
3. Position patient in semi-Fowler’s position
with head turned to the side.
This facilitates ease of suctioning.
Unconscious patients should be in the lateral
position.
4. Perform hand hygiene, gather supplies, and
apply non-sterile gloves. Apply mask if a body
fluid splash is likely to occur.
Wash hands
Apply non-sterile gloves
This prevents the transmission of
microorganisms.
Supplies include a suction machine or suction
connection, connection tubing, non-sterile
gloves, yankauer, water and a sterile basin,
mask, and clean towel.
Suctioning may cause splashing of body fluids.

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5. Fill basin with water. Water is used to clear connection tubing in
between suctions. Fill basin with enough water
to clear the connection tubing at least three
times.
Fill sterile container with sterile water
6. Attach one end of connection tubing to the
suction machine and the other end to the
yankauer.
This prepares equipment to function
effectively.
Suction container

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7. Turn on suction to the required level. Test
function by covering hole on the yankaeur with
your thumb and suctioning up a small amount
of water.
Suction levels for adults are 100-150 mmHg on
wall suction and 10-15 mmHg on portable
suction units. Always refer to hospital policy
for suction levels.
8. Remove patient’s oxygen mask if present.
Nasal prongs may be left in place. Place towel
on patient’s chest.
Always be prepared to replace the oxygen if
patient becomes short of breath or has
decreased O2 saturation levels.
The towel prevents patient from coming in
contact with secretions.
9. Insert yankauer catheter and apply suction
by covering the thumb hole. Run catheter
along gum line to the pharynx in a circular
motion, keeping yankauer moving.
Encourage patient to cough.
Movement prevents the catheter from
suctioning to the oral mucosa and causing
trauma to the tissues.
Insert yankauer and
apply suction by covering the thumb hole
Coughing helps move secretions from the
lower airways to the upper airways.

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Apply suction for a maximum of 10 to 15
seconds. Allow patient to rest in between
suction for 30 seconds to 1 minute.
10. If required, replace oxygen on patient and
clear out suction catheter by placing yankauer
in the basin of water.
Replace oxygen to prevent or minimize
hypoxia.
Clear suction tubing
with water
Clearing out the catheter prevents the
connection tubing from plugging.
11. Reassess and repeat oral suctioning if
required.
Compare pre- and post-suction assessments to
determine if intervention was effective.
12. Reassess respiratory status and
O2 saturation for improvements. Call for help
if any abnormal signs and symptoms appear.
This identifies positive response to suctioning
procedure and provides objective measure of
effectiveness.
13. Ensure patient is in a comfortable position This promotes patient comfort.

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and call bell is within reach. Provide oral
hygiene if required.
14. Clean up supplies, remove gloves, and
wash hands. Document procedure according to
hospital policy.
Cleanup prevents the transmission of
microorganisms. Documentation provides
accurate details of response to suctioning and
clear communication among the health care
team.

16
Various types of suction tips available:

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Modifications of Surgical Suction Tip Geometry for Flow Optimisation: Influence on
Suction-Induced Noise Pollution
Suction devices for clearing the surgical field are used by surgeons during almost every type of
surgical procedure to obtain a better view of the surgical field. The suction device may also be
used as a hook, for dissection, and removal of excess tissue. There are different types of suction
devices for different types of surgical procedures. As disposables, they are cheap and effective,
although not yet optimized regarding their noise emissions. Tissue adhesion of the suction head
to delicate tissues is a well-known problem, especially during forced suction, and can result in
severe tissue damage. To prevent this, several rows of supplementary holes were introduced in
commercially available suction tubes. The fact that this leads to massive noise increases,
however, has been accepted up to now, although it is well known that forced suction at the
liquid-air boundary results in a massive increase of noise emissions with levels up to 120 dB(A).
Loud noise is a significant stressor in the operation theatre (OT). This is aggravated during
emergencies with massive bleeding, where it is important to rapidly achieve a clear and dry
surgical field to stop blood loss as fast as possible. In contradiction to that, it has been shown that
quiet working environments help us to work more efficiently and reduce the rates of error.
Furthermore, loud suction noises near the inner ear may result in permanent hearing loss in
patients undergoing surgery in the ear and temporal head area. It is not evident why the most
often used tool in the OT has not been optimized yet.

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Figure 1: Suction tips of different models: standard models A and B are industrially
manufactured disposable articles of daily use, and new models 1, 2, and 3 are our newly
developed prototypes.
Conventional suction devices have a series of side holes to avoid tissue adhesion. However, these
additional holes can cause air admixture during suctioning at the liquid-air boundary. Since parts
of the additional holes are located above the liquid level, air is sucked in and leads to flow
interruptions and considerable turbulences within the multiphase flow.
Physical Aspects.
The interrupted flow is caused by immiscible blood and air with different viscosities. The flow is
also turbulent in most cases (such as the Reynolds number is more than 2500 in standard model
A at a flow rate of 250 ml/min). Flow stoppages and turbulence lead to audible vibrations. The
sound pollution of suctioning increases up to 120 dB(A) (100 cm), sound levels in suction
devices peaked with smaller diameter (2 mm) between 4 and 6 kHz, with wider diameter (4 mm)
around 3 kHz, although the diameter was positively correlated with sound energy, all perceived

20
as noise. Noise is defined as “unwanted or undesirable sound” as well as “wrong sound in wrong
place at wrong time” for it may cause annoyance and decrease in work efficiency. In physics, it
is regarded as random, fluctuating, inharmonious wave forms.
Aspects of Noise Pollution.
The impact of noise on human performance depends on the type of noise and the task to be
performed. Especially during critical periods and tasks, it may reduce mental efficiency and
short-term memory. Although there is a wide variability in individual sensitivity to noise, a
normal healthy adult may tolerate about 50–55 dB(A) sound relatively well. The World Health
Organization (WHO) “Guidelines for community Noise” suggests that sound levels in hospital
should not exceed 35 dB(A). Studies have shown that noise in the OT is even louder during
critical components of the case and is related to equipment and staff, resulting in negative impact
on patient safety. It is said that the most important source of noise in the OT is the use of
particular surgical tools. Noise in health care settings has increased during the last 50 years. At
frequencies of 2.0–8.0 kHz (especially 3.0–4.5 kHz), the human ear has a higher sensitivity (the
Fletcher–Munson curves of equal volume levels ISO 226: 2003), and sounds are perceived as
being 10–20 dB louder than those outside this range, at same intensity. Furthermore, in this
frequency range, essential parts of speech information are located, impeding communication
within the OT team. Persistent, high levels of noise are known to lead to health problems. Noise
is regarded as a general stressor and a pervasive and influential source of stress, which may
affect the cardiovascular system. The volume level and the frequency of noise (sound quality)
can have negative repercussions on the ability to concentrate, and it may represent a significant
source of distraction, although this is not unequivocal. High levels of sound pollution may
therefore influence outcome of surgical procedures and provoke human errors; inexperienced

21
subjects are more prone to negative noise impact than experienced ones, particularly during
difficult tasks. Higher levels of noise were correlated directly with higher surgeons stress
response (physiological and selfreported), as well as levels of surgical errors, putting patients at
increased risks for postoperative complications, although the causal relation between noise and
complications is hard to prove. The US Agency for Healthcare Research and Quality mandates a
“high-level priority” to reduce noise-induced distraction in the OT to improve patient safety,
although, so far, little reliable and systematic information exists of the sound levels in the
operating room environment. Due to its inherently complex structure, errors can be catastrophic
for patients and health care institutions alike. Noise levels during operations have been correlated
with surgical site infection (SSI), attributed to noise-induced distraction leading to lapses in
compliance with aseptic principles. As a result, it is advantageous for surgeons and patients to
use a continuous quieter suction device. Usually, sound pressure levels refer to a measuring
distance of 1 m. The dimensions of the noise measuring stand (silent room) allow low-reflection
measurements at a distance of 10 cm. In order to compare the SPL measured here with standard
1-m measurements, a correction must be made (minus 6 dB for every doubled distance). The
closer the noise to the hearing organ itself is, the opposite effect is to be considered (increase of
the sound pressure by 6 dB at half the distance). Suction noise near the inner ear (>100 dB(A),
especially in children during ear and neurosurgical procedures, has been described to result in
lasting hearing loss. However, tracheal suctioning in children (4–10 kHz, peak 96 dB) has not
lead to measurable restrictions in hearing capacity/capability. In a prospective study, Nelson et
al. could not demonstrate lasting hearing loss due to ear canal suctioning, and Katzke et al.
confirmed this finding. However, noise-induced hearing impairment may be more common than
normally assumed, as the deterioration of hearing is hard to detect in the high frequency range. In

22
our study, frequencies above the audible range (>16 kHz) were recorded. These high-frequency
flow stoppages in particular are responsible for hemolysis and malactivation of leukocytes and
platelets, although the exact mechanisms for the damage of blood cells are controversial. The
foaming or admixing of air (“aeration”) can adversely affect the integrity of the blood cells by
direct oxygen contact. By reduction of air admixtures, membrane damage, oxidation of various
blood components, and the formation of radicals can be avoided or reduced. Gentle and thus
quiet suction would protect blood cells. The louder the suction noise, the greater the vibrations
stress on the blood cells. Budde et al. have shown that avoiding turbulence (audible as a noise)
reduces blood cell damage. The technical solution for this is the Turbulence Controlled Suction
System developed by Friedrich et al. Further studies have to show the impact of suction cup
geometry in this relation.
Other Aspects.
Air admixtures can also cause infection problems. In animal experiments, it has been shown that
bacterial air contamination can be transported with the suction of secondary air. That means that
infectious complications may result from increased air mixing. However, the other modified
models, 1 and 3 do not show significant changes in the proportion of extracted air. Nevertheless,
the high-frequency vibrations are significantly reduced here as well. -e new model 2 is very quiet
(p < 0.001) and has shown a low level of aeration (p < 0.001). Loudness in health care units
disturbs communication, concentration, and increases stress. Engelmann et al. describe
significant effects due to a noise reduction program in a pediatric operation theatre. Through
comparative measurements in the critical care environment, White and Zomorodi did show that
there is a greater need for a viable solution. Since not all noise sources can be controlled,
Friedrich et al. developed the silent operating theatre optimisation system (SOTOS), a novel

23
closed but flexible communication tool in noisy environment. Our working group has shown that
it is possible to reduce flow-induced noise and air admixture using a polypragmatic approach.
Turbulence Controlled Suction System (TCSS) adjusts the rotational speed of the roller pump
system via a vibration sensor in the suction handle. We can assume that the combination of
TCSS and optimized suction head geometry should further reduce the noise level. The protective
effect on integrity of blood cells has also been shown.
The flow-induced noise is correlated to the suction tip geometry. Parameters of the suction tip
relevant to stream-flow can be improved. The optimized suction heads are significantly quieter,
as shown in our experimental results. Such optimization may reduce noise-related hearing loss
und reduce stress during surgery, as it leads to a more quiet operation theatre. A noise-optimized
suction device can improve the performance of the surgical team, reduce complications, improve
the quality of collected blood, reduce the need for allogenic transfusion and organ damage, and
finally increase patient safety. Further studies and advanced techniques, such as computational
fluid dynamics simulation, are necessary to continue the optimization on suction heads for
various applications.

25
RETRACTORS
A retractor is a surgical instrument used to separate the edges of a surgical incision or wound,
or to hold back underlying organs and tissues so that body parts under the incision may be
accessed. The general term retractor usually describes a simple handheld steel tool possessing a
curved, hooked, or angled blade and fitted with a comfortable handle, that when in place
maintains the desired position of a given region of tissue. These simple retractors may be
handheld, clamped in place, or suspended at the end of a robotic arm. Retractors can also be self-
retaining and not need to be held once inserted by having two or more opposing blades or hooks
which are separated via spring, ratchet, worm gear or other method. The term retractor is also
used to describe distinct, hand-cranked devices such as rib spreaders (also known as thoracic
retractors, or distractors) with which surgeons may forcefully drive tissues apart to obtain
exposure. For specialized situations such as spinal surgery, retractors have been fitted both with
suction and with fiberoptic lights to keep a surgical wound dry and illuminated. Surgical
retractors probably originate with very basic tools used in the Stone Age.[1]
Branches or antlers
of various shapes were used to dig and extract food from the ground. As the use of tools evolved,
a variety of instruments came about to substitute for the use of hooked or grasping fingers in the
butchering of meat or dissection of bodies. The use of metals in tool making was of great
importance. A variety of Roman metal instruments of the hook and retractor family have been
found by archeologists. These instruments would generally be called hooks if the end was as
narrow as the handle of the instrument. If the end was broad, it would be called a retractor. Also
arising from this group of tools were other related tools for displacing (elevators and spatulas)
and scooping (spoons and curettes).

26
In 4th century CE, Indian physician Susruta used surgical tools such as retractors. In a
description of the procedure of tonsillectomy from the 7th century CE, Paul of
Aegina documents the use of a tongue spatula to keep the tongue out of the way while a form of
tonsil hook is used to bring the tonsil forward for excision. In 1000 CE Abu al-Qasim al-
Zahrawi, also known as Albucasis or Abulcasis, described a variety of surgical instruments
including retractors in his famous text Al-Tasrif. Vesalius described a variety of hooks and
retractors in the 16th century. Jan Mikulicz-Radecki's invention of a hinged rib spreading
retractor in 1904 prompted a flurry of development of retractors in the early 20th century,
culminating in 1936 in our modern device based on the design of Enrique Finochietto.[2]
SURGICAL RETRACTORS TYPES AND USAGE
Surgical Retractors
A retractor is a surgical instrument that is used to hold back underlying organs and tissues, so
that body parts under the incision may be accessed without any fear of damage to the organs
lying at the above levels. Surgical retractors have a wide variety and retractors come under
various shapes, sizes and strength.
Importance of Surgical Retractors
During the dissection/inspection, a surgeon needs an exposure best as possible while inflicting a
minimum of trauma to the surrounding tissue. The handles of the retractor may be hook-shaped,
notched, or ring-shaped to give the holder a firm grip without tiring. The blades of the
retractors are at a right angle to the shaft. The blades can be smooth, raked, or hooked.

27
Materials
Surgical retractors require a very high-grade stainless steel as they hold internal organs during an
operation. A common material used in the making of retractors is superior grade stainless steel.
Stainless steel is preferred because of its strength and its ability to be sterilized. The retractors
are therefore extremely hard. However, there are some drawbacks of stainless steel retractors like
they become very slippery when they come into contact with blood and other body fluids which
can lead to tissue damage during operation. Moreover, stainless steel is also thermally highly
conductive which also results in tissue injury as it quickly absorbs heat from the tissue with
which it comes in contact. Another disadvantage is that they have reflective surfaces which
produce glare under the high-level illumination which is very common during surgical
procedures.
To overcome these drawbacks, polymeric materials are used in the making of surgical retractors.
Such polymeric materials include
 Polyetherimide
 Polyimide and
 Thermosetting materials
It is to be noted that any material of construction of surgical retractors is that
 It must be sterilizable
 It must be autoclavable
to allow for the necessary sterilization process so they may be reused for multiple, successive
surgical procedures.

28
Types of Retractors
 Cheek retractor
 Dental mirror
 Lip retractor
 Mouth prop
 Tongue retractor
Figure 2: Cheek retractor
There are two types of retractors on the basis of their functionality.
 Self-retaining retractors
 Handheld retractors

29
Self Retaining Retractors
Self-retaining retractors do not need an assistant to hold them in place. self-retaining retractors
hold tissue apart and lock it in place. Rib Spreaders come in this category. They hold the ribs
apart during the abdominal surgery when the required organ is located inside the rib cage.
Followings are the commonly used retractors
 Balfour Baby Retractors 9cm
 Balfour Retractors 18cm
 Gosset Retractors 3 sided
 Gosset Retractors 2 sided
Hand Held Retractors
They can be hand-held retractors. The handheld retractors require an assistant to hold them but
the self-retaining ones don’t once they are adjusted in position. The correct method of using a
hand-held retractor is that it must be held by its handle properly so as to produce maximum
exposure of the surgical area, maximum leverage, and steady retraction.
Ex: kirschner with frame + blades

30
Varieties of Surgical Retractors
Each type of surgical retractors have specific properties as per the usage. For instance:
Tissue Retractor: During a surgery, the tissue retractors hold tissue flaps away from the
treatment site. This provide better visibility, reach and undisturbed working. Some retractors
may have fork like prongs. This allows the handling of the tissue without causing much damage.
Cheek Retractor: These retractors are designed to hold and retract the cheeks, tongue, or a
portion of the mucosa during surgical procedures. The retractors are made of metal or plastic,
and may be large, curved, or angled.
 Senn retractor is simple.
 The deaver is more exotic.
 The hohmann is orthopedic retractor.
 Army-navy is a bladed retractor.
 Rake retractors are forked.
Common self retaining retractors are weitlaner and gelpi. Also use adsons and balfours.
Kinds of Retractors
Depending on the various body parts which need to be operated, there are different names given
to retractors such as follows:
 Lung Retractor
 Abdominal Retractor
 Skin Retractor
 Eyelid Retractor
 Canny Ryall Retractor
 Scalp Retractor

31
 Pin Retractor
 Vertical Retractor
 Cone Retractor
 Arterial Retractor
 Fan Blade Retractor
 Vaginal Retractor
 Laminectomy Retractor
 Thyroid Retractor
 Nerve Root Retractor etc.
 Common Surgical Retractors in
use
 The following is a list of surgical
retractors in current use
 Lahey Retractor
 Senn Retractor
 Blair (Rollet) Retractor
 Rigid Rake
 Flexible Rake
 Ragnell Retractor
 Linde-Ragnell Retractor
 Davis Retractor
 Volkman Retractor
 Mathieu Retractor
 Jackson Tracheal Hook
 Crile Retractor
 Meyerding Finger Retractor
 Little Retractor
 Love Nerve Retractor
 Green Retractor

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Varieties
Various sizes and shapes available
1. Kilner cheek retractor
Functions
 Retraction of cheek
 Aids in visibility
 Protection of tissues
Figure 3: Kilner cheek retractor
2. Austin retractor
Functions
 Retraction of cheek and tongue

33
Figure 4
3. Bowdler Henry rake retractor
Functions
 Retraction of periodontal flap during surgical procedures
Figure 5

34
4. Minnesota retractor
Functions
 Retraction of the cheek and tongue
Figure 6: Minnesota retractor
5. Howarths periosteal elevator
Functions and features
 Retraction
 To separate the tissue from the bone
 One working end is a pointed tip and the other is rounded with sharp edges
Figure 7: Howarths periosteal elevator

35
Retractors used for nasal surgeries
6. Aufricht Nasal Retractor
 Double-ended retractor designed for rhinoplasty procedures
 2 blunt prongs
 45mm wide
 7" overall length
Figure 8: Aufricht Nasal Retractor
7. Anderson Double-ended Retractor
 One end features a saddle style blade
 Other end features double ball prongs
 7 1/4" overall length
Figure 9: Anderson Double-ended Retractor
8. Sheen Nasal Retractor
 Used in rhinoplasty procedures
 Angled
 7mm blade
Figure 10: Sheen Nasal Retractor

36
Retractors used for orbit surgeries
9. Desmarres Lid Retractors
 Designed for ophthalmology procedures
 Retracts the upper or lower eye lid away from the cornea
 Curved, saddle style blade
 Available in four blade sizes
o 12mm small (60-05-11E)
o 14mm medium (60-05-12E)
o 16mm large (60-05-13E)
o 18mm x-large (60-05-14E)
10. Desmarres Fenestrated Lid Retractors
 Designed for ophthalmology procedures
 Retracts the upper or lower eye lid away from the cornea
 Curved, saddle style blade
 Fenestrated blades
 Available in four blade sizes
o 12mm small (60-05-21E)
o 14mm medium (60-05-22E)
o 16mm large (60-05-23E)
o 18mm x-large (60-05-24E)

37
Retractors used for maxillofacial trauma
11. Biggs Face Lift Retractors
o 7"
o Designed for face lift procedures
o Curvature of instrument maximizes view
of the surgical field
o 2" fenestrated blade
o 3 1/2 from tip of blade to curve
12. Cronin Cheek Retractor
 Retracts buccal facial checks for optimum
viewing of the oral operating field
 Used during plastic and oral maxillofacial
procedures
 Ergonomic handle with finger grip reduces
fatigue
 20mm x 45mm round, flat blade
 6" overall length

38
Retractors used for orthognathic and plastic surgery
13. Freeman Face Lift Retractors
o Used for plastic surgery procedures including face lifts
and breast reconstruction
o Rake style prongs provide even skin retraction
o The small version includes thumb hook
 Available in three sizes:
 Large 7" long x 1 1/2" wide (APR-509)
 Petite 7" long x 7/8" wide (APR-519)
 Small 4" long x 1" wide with thumb ring (APR-
518)
14. Goldman Knife Guide and Retractor
 6 3/4"
 Double-ended
 2 ball tips
 Features an angled knife guide
a. Right Angle (67-20-51E-R)
b. Left Angle (67-20-51E-L)

39
Assortments commercially available retractors and their specification

52
At present, many types of self-retaining retractors are available. The most widely used is the
Balfour retractor, which consists of two opposing blades that can be spread directly apart 180
degrees from each other. After these blades have been placed in an incision and spread, a third
blade can be attached to pull at 90 degrees from the two main blades. This type of retractor finds
its main use in abdominal surgery, such as exploratory laparotomy, gastrectomy, and pelvic
procedures. Its limitations include the fixed relation of the blades to each other, the maximal
number of blades that can be used at one time (three), and the limited shapes and depths of the
blades available for it. The Balfour retractor is helpful in holding the sides of the abdominal
incision apart, although in many cases an additional hand-held retractor is needed for this
purpose; however, any deeper retraction that is needed, as in holding organs aside, requires the
use of additional assistant-held retractors.
Also in general use are several types of self-retaining retractors having two blades, each attached
to the end of a scissors-like apparatus with a ratchet catch to hold the desired position
(Weitlaner). These are used mostly in minor surgery and in some types of neck surgery. They
hold the skin edges apart but are limited by the fixed blade and the fixed relation of the blades to
each other. The most helpful type of self-retaining retractor currently available is the ring type
(Brunschwig, Wilkinson, Wexler, and others). A large flat metal ring is placed around the
incision and to this ring are attached various blades. The number of blades varies; the Wilkinson
comes with four blades, the Wexler with five, and the Brunschwig with seven. The advantages of
this type are its capacity to hold aside the deeper structures and to give more complete retraction
of the abdominal wall. It is used for longer, more complicated abdominal procedures requiring
prolonged retraction, such as periaortic node dissection. Although these retractors are more
versatile than those previously described, they are limited by the fixed depth of the blades

53
available to fit them and the fixed relation of the blades to the ring and to each other. Some have
attempted to overcome this limitation by producing a malleable blade to fit their retractor set or
by using various types of adjustable hinges in attaching one blade of the set to the ring. These
retractor sets are expensive, costing about $400.
They are sold as the complete set, which includes one ring, blades, and the specialized clamps
for attaching them. There is a nearly complete lack of interchangeability among blades (a
Wilkinson blade will not fit a Wexler retractor and vice versa). The high price of such limited
purpose retractor sets restricts their use to larger hospitals and centers where the volume of
complicated surgery justifies their cost. This is unfortunate because the surgeon in a smaller
hospital who has an occasional complicated abdominal procedure to perform is the one who most
needs their help.
Description and Use
In an attempt to gain the advantages of the ring type self-retaining retractor while adding to its
versatility, three flat rings were fabricated from 16 gauge stainless steel. (See Figure 1 for
measurements.)
Clamps were fashioned very simply from small shackles; these are available in galvanized iron at
most hardware stores and in stainless steel or bronze at a well equipped boating store. The
crossbar of the shackle is replaced by a thumbscrew of the appropriate thread placed 180 degrees
from the original crossbar. This, in essence, makes a small C clamp which is then used to attach
any of the commonly available flat retractors (such as Parker, Roux, malleable, and Deaver) to
the ring. (Figure 2.) One with a concave cross section to the shaft (such as the Richardson) also
attaches easily to the ring with this clamp. (Figure 3.) If desired, the clamp can be modified

54
slightly by cutting a shallow groove inside the jaw opposite the thumbscrew at 45 degrees to the
long axis of the clamp. This can be accomplished in a few minutes using a medium-sized round
file.
In this configuration, by turning the clamp upside down, it will also attach any round- or oval-
shafted retractor (such as a rake) to the ring. In operation, this retractor retainer, with the
appropriately chosen hand-held type of retractor, forms a set that is used in a manner similar to
the previously described ring retractor sets. The opposing pull of the retractor blades on the walls
of the incision fixes the ring in position in a semirigid. The rigidity of this position can be
augmented by increasing the amount of pull on each retractor blade or by adding more blades.
This rigidity of position enables one to use a single blade to retract some deeper structure without
adding another deep blade on the other side of the ring. Versatility and ready adaptability of this
retractor retaining system are among its main advantages. The surgeon can more nearly obtain
the desired exposure for the planned operation using this ring and clamp set since he has at his
disposal all of the widths and depths available in the various hand-held retractors of the operating
suite. He can attach as many of these to the ring as he needs, and by adding one or more
malleable retractors, he can obtain an infinite number of angles for the retraction of deeper
structures simply by bending the retractor to the point where retraction is needed.
The use of this efficient ring self-retaining retraction system frees the assistants from most
retractor-holding chores and makes them available for other useful jobs such as tying sutures,
aiding dissection, and clamping blood vessels. A reduction in the number of assistants necessary
for any given operation is an extension of this advantage. The choice of ring sizes makes this
system useful in pediatric surgery, oral surgery, certain types of minor surgical procedures, as
well as abdominal surgery. superiorly and the blade from a Davis type mouth gag inferiorly.

55
The advantages of versatility and adaptability were well demonstrated in this case since two
short lengths of small spring were attached to the ring (one on each side using four very small
clamps) and were used as suture holders in the fashion of a Dingman mouth gag. Being able to
fix a movable structure (the sides of the uvula in this case) in space by the use of “guy wire”
sutures that are affixed to the suture-holding springs is a great aid to subsequent suturing. The
use of these spring suture holders on the ring has also been found to be quite advantageous in
vascular surgery. Appendectomies and inguinal hernioplasties are common operations in which
self-retaining retractors are rarely used. Since these procedures are generally performed with
minimal assistance, adequate exposure can be a problem.
With a small or medium ring, this retracting system has been most useful in these cases, and thus
another advantage is the extension of the benefits of self-retaining retraction to types of surgery
in which it has not generally been used in the past. The small ring with three blades from a
mouth gag or three narrow malleables is quite useful as a vaginal retractor. The postpartum
laceration that extends to the cervix can easily be repaired without the need for assistants to hold
the required exposure. This ring and clamp set is easily as helpful as any of the ring retractor sets
on the market and does as well as a mouth gag for cleft palate repairs. In addition, it extends the
advantages of self-retaining retraction to a widened variety of surgical procedures. The three
rings can be made to order at any well that can be a struggle even with two good assistants. The
clamps vary in price from $50 to $2.50 the shape needed and attaching it to the ring with apiece,
depending on the size and material.
By bending a large malleable retractor to set a sturdy clamp, the liver can be retracted efficiently
in most cases, eliminating the need for a second The rings presently in use were cut from a solid
assistant and making everyone’s job easier. The small ring has been used to advantage in

56
alternative is to have strips of the appropriate width section of the midportion of the tongue,
using two cut from the same material, overlap the corners, and spot weld them. (Figure 1, insert.)
Army-Navy and three Parker retractors.
It has worked well in repair of a cleft palate, The clamps can be made from any size shackle.
using two small two-pronged rakes (rubber-shod) Those presently in use range from very small
ones (l$$ X 3/a inch in outside dimensions) to larger, sturdier ones whose arms are l/4 inch in
diameter (these are about 2 X 1% inches in outside dimensions). These can be rethreaded with a
hand tap to fit any size machine screw. A flat type thumbscrew can also be used. In use at
present on the largest clamp, in place of a standard thumbscrew, is a T bolt made by brazing a 2
inch length of 3he inch diameter steel rod across the head of a machine screw. Therefore, for an
outlay of $70, a ring and clamp set is possible that may be combined with the hand-held
retractors available in even the most rudimentary operating suite, to obtain a utility that cannot be
matched by any number or combination of self-retaining retractors presently available.
Self-retaining retractors are a great aid in surgery since they assist in obtaining and maintaining
the exposure necessary to accomplish the goal of surgery. The purpose of this retractor-retaining
ring and clamp set is to increase the versatility of the self-retaining retractor and to make its
advantages more generally available by a drastic reduction in cost. This is accomplished by using
a simple, easily obtained clamp that can be adapted to the retractors presently available in any
operating suite in combination with any of the three ring sizes to produce a self-retaining
retractor that can easily accommodate variables such as the size of the patient and the type of
operation.

57
Figure 8. Measurements of the three rings fabricated from 16 gauge stainless steel.
Figure 9 Flat retractor.

58
Figure 10 Cotwave upper surface handle.
Figure 11 Round handles

59
Figure 12. Medium ring with four malleable retractors for use in abdominal surgery
Figure 13. Small ring with two rubber-shod rakes and a tongue blade retractor for cleft palate
repair.

65
Modified Laster’s retractor
The Laster’s upper third molar and cheek retractor is a useful instrument in the armamentarium
of the oral and maxillofacial surgeon or oral surgeon performing dentoalveolar surgery in the
posterior maxilla. Developed by Dr Zvi Laster in the 1970s, the instrument was based on a
Howarth’s nasal raspatory in combination with a cheek retractor. Not only does the instrument
provide broad retraction of soft tissues, its reflective shape provides optimal illumination of the
surgical site. It has also been suggested for use to enhance access when removing lingual bony
lesions such as large mandibular tori. The curved handle, held with the little finger, allows
multiple instruments to be held by the same hand at one time such as an osteotome. However, if
not being used for this purpose the grip of the instrument is commonly observed as
demonstrated. The authors note that the instrument handle, when gripped for a long procedure,
can contribute to fatigue of the operator’s hand. After discussions with the hospital’s Central
Sterilisation Service Department the instrument was modified with a longer flat handle. Note the
more relaxed grip. The authors noticed a significant improvement in comfort when using the
modified handle and recommend it especially for operators who stand on the contralateralside
during surgery

66
Fig. 14. Grip of a Laster’s retractor - this grip used for long procedures can lead to fatigue
Fig. 15. Original Laster’s (top) side by side with modified Laster’s (bottom)

67
Fig. 16. Modified Laster’s with more relaxed and comfortable grip.

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Alexis ring retractor
The Alexis wound protector and retractor (Applied Medical Resources Corporation, Rancho
Santa Margarita, USA) is a single-use, cylinder-shaped device made of 2 semi-rigid polymer
rings attached by a flexible polymer membrane. To obtain quick and easy retraction, the flexible
internal ring is manipulated into the oral cavity and the stiffer external ring is rolled in a 4-
handed technique to tighten the membrane until the 2 rings are adjacent to each other, one inside
and the other outside the mouth (Fig. 2). Once in place the rigid, self retaining, and
circumferential retraction improves vision and access. To gain access to the oral cavity, surgeons
routinely use a bite block to separate the jaws and a Kilner cheek retractor to retract the lips. Use
of the Alexis retractor eliminates the need for a bite block so there is more intraoral space. It also
enables greater lateral retraction of the tongue, which improves access to the soft tissues of the
mouth, in particular the posterior or posterior lateral aspect of the floor of the mouth, buccal
mucosa, and tongue.
The Alexis retractor is useful in edentulous patients where bite blocks are cumbersome, take up
space, and may not adequately separate the jaws. It protects the lips from iatrogenic damage
from other instruments, and as it is made from plastic, will not conduct charge from unipolar
instruments unlike traditional metal retractors. As it is self-retaining it releases the assistant to
aid in the operation. However, it does restrict access to the anterior buccal mucosa.

69
Fig. 17. The small, rigid Alexis ring retractor comprises 2 semi-rigid polymer rings attached by a
flexible polymer membrane (published with the patient’s consent).

70
Fig. 18. The flexible inner ring is manipulated into the oral cavity and the stiffer external ring is
rolled in a 4-handed technique to tighten the polymer membrane until the 2 rings are adjacent
(published with the patient’s consent).

71
Fig. 19. The considerable improvement in access is clear when comparing standard access using
Kilner retractors and bite blocks (A) with the Alexis retractor (B) in the same patient (published
with the patient’s consent).

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Modified retractor for use in sectioning the inferior alveolar nerve
In the management of trigeminal neuralgia there are various options, including (rarely) section of
the inferior alveolar nerve. Access to this nerve at the lingula is limited and it is difficult to
obtain a clear view and at the same time protect the surrounding tissues. Two retractors may be
required, which compromises the control of the surrounding Fig. 1 tissues particularly for a
single operator. The instrument that was designed allows a clear view and easy access, reduces
the number of retractors required, protects the soft tissues, and is comfortable to hold. It is
capable of defining the nerve branch, and places the nerve under tension, which aids recognition
and dissection of the nerve bundle and accompanying vessels.
TECHNIQUE
For access to the inferior alveolar nerve was use a standard incision, as for a sagittal split
mandibular osteotomy, followed by careful raising of the medial ramal soft tissue by
subperiosteal dissection distally towards the lingula. Once the lingula is identified the soft tissue
is lifted above and below the projection by a Howarth’s periosteal elevator, which is slid into
place. The nerve is exposed and the modified retractor is positioned to allow the nerve trunk to
fall into the groove between the blades of the instrument. The nerve is now well exposed and the
blades of the instrument stretch the inferior dental bundle, retract the adjacent tissues, and hold
the tongue back to a safe position.

73
Figure 20: Modified retractor

74
Tongue retractors
The tongue is a muscular organ in the oral cavity that is very important for speech, mastication,
taste and swallowing. Surgical procedures involving manipulation or surgery to the tongue may
cause severe discomfort and difficulty to patients postoperatively. Retraction of the tongue is
necessary in several operations. The main indications for retracting the tongue are surgery to the
tongue itself and accessing several sites of the middle and posterior thirds of the tongue as well
as other sites of the oral cavity.
Methods of retracting the tongue found in the literature include using a single suture piercing the
tongue through and through, using a gauze to grasp it by hand, utilizing tools such as the dental
mouth mirror and the Weider tongue retractor, or even piercing it with a towel clip. A new self-
retaining retraction method was also recently proposed by McAnerney et al. Siegmund et al.
even suggested the use of a common stainless-steel soup spoon. The downside with some of
these is the injuries caused on the lingual mucosa by the retraction instruments as well as the
damage caused to the tongue itself. This is associated with postoperative pain and a longer
healing period.
On the other hand, using tongue retractors or gauzes does not provide firm retraction and the
tongue which can easily slip out of the surgeon’s or the assistant’s grasp. Technique This method
can be used with the patient under general anesthesia or local anesthesia, provided there is
excellent patient cooperation and the surgery is relatively short in duration.
In order to retract the tongue with our proposed technique, the following common surgical
materials are required: (1) a single, non-resorbable, strong suture, preferably silk 2/0 or 1/0 and
(2) a common type nasogastric tube. Preparation requires that a small piece (approximately 1–2

75
cm in length) in the middle of the Levin tube is cut off, resulting in a small cylindrical piece of
relatively soft plastic. This piece is then cut in half parallel to the tube long axis, resulting in two
separate semicylindrical pieces. One piece is then pierced on one side by the suture, which then
is placed through the tongue until it passes through to the other side. With the suture through the
tongue, and holding the one piece of the Levin against the other side of it, the needle of the
suture is then used to pierce the second piece of the Levin on one side. The needle is then turned
180 degrees and passes through the same second piece on the other side and then passes through
the tongue again, and when it exits, it goes through the first piece on the Levin, but this time on
the other side of its initial entry. The needle is then cut off, and the two ends of the suture are tied
together, ensuring that the two pieces of the Levin tube are firmly immobilized against both sides
of the tongue. The remaining suture is cut to the desired length and tied again to ease handling of
the tongue by the surgeon. The whole technique resembles a mattress suture, but with two pieces
of semicylindrical plastic protecting the tongue from the single suture injuries (Figs. 1, 2, 3, 4, 5).
It can be used in all operations involving the tongue, most notably in the resection of lingual
carcinomas, carcinomas of the posterior alveolar ridge and benign and malignant tumors of the
maxilla and palate. It provides an easy, stable and non-traumatic way to retract, mobilize and
hold the tongue, and so far, it has never caused our patients major postoperative pain, swelling or
discomfort. The addition to the simple suture technique of the nasogastric tube acting as a shield
protects the tongue from dehiscence and unnecessary trauma. One could point out that piercing
the tongue in two rather than one spot is associated with a higher risk of injuring a blood vessel
or nerve, but in our experience, it is not the needle of the suture that traumatizes the lingual
mucosa, but the ripping caused by the constant in-and-out slipping of the suture used in the
single suture retraction technique

76
Fig. 21 Common Levin tube used for protecting the tongue from tearing forces of the suture
Fig. 22 Cutting the tube in half for each side of the tongue

77
Fig. 23 The resulting pieces that will act as ‘‘bumpers’’
Fig. 24 Application of the retracting suture with the protective elastic bands

78
Fig. 25 Atraumatic tongue retraction

79
OptragateH oral retractor
OptragateH is a soft, latex free oral retractor made from EvopreneH a polymer of Styrol-Ethylen-
Butylen-Styrol (Ivoclar Vivadent Ltd, Compass Building, Feld Spar Close, Enderby, Leicester
LE19 4SE, Leicestershire, UK). It consists of a flexible, oval inner frame around which the
EvopreneH sheet is draped as a continuous apron to cover the lips. Although primarily marketed
for improving access for routine dental procedures, it also provides an excellent, comfortable soft
tissue retraction device for the purpose of orthodontic bonding. OptragateH is available in 3
sizes, Junior, Small and Regular (Figure 1). The author has found that the small retractor is the
most versatile size, fitting approximately 90% of patients, whilst the large retractor is suitable for
larger adult mouths and the junior retractor for children below 10 years of age. The retractors can
be sourced directly from the manufacture and a number of dental supply companies. They are
supplied in boxes of 80 of a single size or a variety pack of 40 each of regular and large. They
have an extended shelf life with an expiry date of up to 2 and half years. Benefits for orthodontic
bonding Ease of placement The retractor is easy to place within seconds, and written and
diagrammatic instructions are provided. Figure 2a–g shows the stepwise placement of a junior
version of the retractor. It is important that the inner frame is pushed fully into the depth of the
sulcus to hold it in place and to cover the lips completely. Comfort and retraction The retractor is
flexible in three dimensions, offering comfort for long periods of retraction such as full arch
bondings. There is also excellent retraction and visibility for both direct and indirect bonding as
far back as the second molars (Figure 3a,b). The flexibility of the retractor means that the patient
can move their jaws freely with the retractor in-situ, and it allows for appropriate positioning of
the lower jaw to facilitate optimum access during bonding. Once the teeth are bonded the
retractor can be left in-situ to facilitate initial archwire placement (Figure 4). Soft tissue

80
protection The positioning of the apron part of the retractor across the soft tissues of the lips and
commisures of the mouth provides a robust protective barrier. This offers protection for the lips
from acid etchant and self-etch prime (SEP) during tooth preparation, protecting from acid burns
and white patches respectively. During effective
Figure 26: OptragateH is available in 3 sizes Junior, Small and Regular
mixing of the two components of SEP it is possible for SEP to be pushed along the shank of the
brush with inadvertent placement on the soft tissues. With the complete coverage of the lips
afforded by the OptragateH retractor, this problem is prevented (Figure 5a,b). Moisture control
Coverage of the upper and lower lips intra-orally provides a waterproof barrier from the large
number of minor salivary glands present in the lips. The patient can also move their lips
comfortably without the risk of contamination of a prepared tooth. The saliva collects beneath
the apron, being trapped in the pouch created between the lips and the retractor. Care must be
taken when removing the retractor to wipe away any pooled saliva. The retractor can be used
with other methods of moisture control, such as absorbent buccal shields and saliva ejectors, for
an effective dry field for direct and indirect bonding. Cross-infection Each retractor comes
individually packed and CE marked and is hermetically sealed for single use only. It therefore

81
offers an alternative to standard plastic retractors that must undergo decontamination between
patients. Use of single-use items is encouraged by the British Dental Association, whose written
guidance on infection control states ‘Equipment that is described as single use should be used
wherever possible.’1 From a patient perspective, it provides a clear message when removed from
its sealed packet that the device is specific to the individual for a single episode and strongly
reinforces a practice cross infection message. This represents a significant improvement
compared to some of the plastic retractors that can degrade and look aesthetically poor after
repeated decontamination. A sterile version is soon to be made available for use in surgical
procedures. Potential issues with routine use Cost Retractors are supplied in boxes of 80 units
and cost between 50 and 80 pence (equivalent 80 cents–1$ 35 cents or 0.6–0.8 Euro) depending
upon the supplier used and number ordered. However, this cost can be partly offset by the need
to buy standard plastic retractors and effectively decontaminate them. Fit If sized incorrectly or
placed in individuals with lax soft tissues, the retractor can spring out of the mouth during the
bond up process, ruining the dry field. However, experience with sizing and placement makes
this a rare occurrence. Disposal Data sheet advice from the manufacturers advises disposal as
clinical waste by incineration and so they are perhaps somewhat less eco-friendly than a reusable
retractor. Conclusion OptragateH provides a single use, cost effective, protective, comfortable
method of soft tissue retraction for orthodontic bonding.

82
The Development of a New Medical Instrument: Modified Tongue Depressor
n the oropharyngeal region examinations, the abeslang (tongue depressor) used to create a wider
field of vision and press down the tongue to make the pharynx easier. In order to look under the
tongue, the depressor is redesigned so that it can be examined under the tongue and transformed
into a retractor by creating an angle in the body of the present invention. This technique is
intended to be used in conjunction with new technology surgical procedures. Our invention
consists of the stem (1), the body (2), the end (3) the notch (4), and the angle (5) in the angled
model. This model is more effective than the routine tongue depressors and will not make any
difference regarding cost. It will also allow the use of new surgical techniques while at the same
time ensuring the exclusion of language in operations.
FIELD OF THE INVENTION
The invention relates to the field of medicine in the area of the oropharyngeal region to provide
ease of examination and sublingual region surgery is to provide the excitation. In oropharyngeal
region examinations, abeslang is used to create a wider field of vision and to make the pharynx
easier to appear. However, it is not possible to obtain a clear vision by removing the language
from the region during the examination of the regions under the language. The tongue ligament
is also referred to in the literature as ankyloglossia or hypertrophy lingual frenulum. In the
disease, there is a fibrous band that restricts the language movements between the base of the
mouth and the tongue and may cause absorption disorders in children who are fed to speech
disorders and breastfeeding from time to time.1 This fibrous tape is treated surgically, and
excision, excision with electrocautery, radiofrequency, ablation surgery and laser surgery and
excision methods are used during surgery.2,3,4,5 During the surgery, the retractor of the tongue

83
was used as the retractor for many years. Grooved tongue tie director is a retractor designed for
this purpose (Medicon, Tuttlingen, Germany) was designed to not allow the use of technology.
PURPOSE OF THE INVENTION
In the oropharyngeal region examinations, it was aimed to assist the surgery by the exclusion of
the tongue by providing the exclusion of the tongue during the examination of the sub-lingual
regions and the tongue bonding operations. The invention includes polyvinyl chloride (PVC),
wood, plastic, composite, and so on. Because it will be produced from the materials that do not
conduct electricity and will allow the handle to be held more strongly radiofrequency, cautery
surgery, ablation surgery will facilitate the use of technology such as thermal welding. The
angled models of the invention will promote vision in patients with a large tongue which are
difficult to exclude. The pre-notch tongue which can be manufactured at various angles of the
invention grasps the root of the tongue and enables the movements of the tongue to be guided by
the person performing the examination or performing the surgery. There are two figures; Figure
1 describes flat, Figure 2 detailed angled model. Description of Figure 1: 1. Side view of the flat
form of the invention. 2. Top view of the flat form of the invention. 3. Three-dimensional (3D)
view of the flat shape of the invention. 4. Detail view of the notch portion of the flat form of the
invention. 5. Side view of an angled structure of the invention. 6. Top view of an angled
structure of the invention. 7. Three-dimensional (3D) view of an angled form of the invention. 8.
Detail view of the notch portion of the angled shape of the invention.
Description of references in Figure 2: 1. Handle 2. Body 3. Fly 4. Notch (notch angle) 5. Body
angle The invention is made of PVC, plastic, wood or composite material compatible with
human tissues. The device comprises a handle, body, tip, notch (notch angle), and in some

84
embodiments, a body. The invention is used by hand from the back. For this purpose, surgical
use is made of sterile disposable or re-sterilized.
THE APPLICATION OF THE INVENTION TO THE INDUSTRY
This model, which is more effective than the language presses used in the routine examination,
will not make any difference regarding cost. Also, it allows the use of technology such as
radiofrequency, cautery surgery, ablation surgery, thermal welding, while providing language
retraction in tongue bond operations. Advantages: 1) Prevents the front of the image from being
closed during surgery due to the angle provided. 2) During the examination and surgery with
normal tongue pressure, patient braking can not be controlled because the process becomes
difficult. It prevents the patient from playing the base of the mouth by pressing the brake device
between the device (Figs. 1 and 2). With this advantage, the duration of examination and surgery
is reduced in patients with cooperative difficulties and in children. 3) The sterile material can be
used in surgery. 4) Material is not metal, allows the patient to intervene surgery without cautery
burn.

85
FIGURE 27:. From left to right; normal abeslang; modified board abeslang; Flat designed
abeslang; angled designed abeslang are photographed.

86
FIGURE 28. Use of abelangs on the author is photographed herein. The advantage of using
modified abeslang can be seen on the author as dominating the base of the mouth.

88
Mouth Gags and their evolution
Introduction
Mouth gags are instruments that help in keeping the jaws of the patient open enabling the
surgeon to perform oral cavity and oropharyngeal surgeries. These mouth gags have
undergone numerous modifications to make the life of surgeons that much easier while
performing intraoral surgeries. The original idea of keeping both the jaws apart was
borrowed from Dentists. They had many instruments that could keep the jaws apart.
Further more an ideal mouth gag should keep the tongue away from the field of surgery
while exposing the area in question adequately. The mouth gag when applied should not
cause compression over the endotracheal tube through which oxygen and anesthetic gases
will be transferred to the lungs of the patient during the surgical procedure. Different
types of mouth gags were designed to suit varying requirements of the surgeons and the
anesthetists.
History
In medieval times mouth gags were used as torture instruments. They went by the name
“Kiefer” / “Mundsperre”. Torture using mouth gags were lawful under Roman Law and
was recognized as a legitimate torture tool. These gags were later used for intra oral
examinations and surgical procedures involving the oral cavity.
Features of an ideal mouth gag:
1. It should provide adequate exposure of all parts of the oral cavity to facilitate the
surgeon to perform intraoral surgeries.
2. It should be easy to apply

89
3. It should be self retaining allowing the surgeon to have both the hands free to perform
the desired surgical procedure.
4. It should be easy to apply in all types of anatomical and other variants that could be
caused by the disease.
5. It should enable safe anesthesia by not causing compression / kinking of the
endotracheal tube.
6. It should hold back the tongue from falling into surgeon’s field
7. It should not slide or slip
There is no single mouth gag that can be satisfactorily used by all surgeons. Hence
various modifications are available even though the concept is the same.
Some of the commonly used mouth gags include: Mouth gags without tongue blade:
These gags simply act as just mouth openers. These gags invariably will not hold the
tongue away from surgeon’s field. A tongue stitch should be provided to hold the
tongue from falling into the surgeon’s field of vision. These gags were initially used for
examination of oral cavity and by anesthetists during intubation.

90
Lane mouth gag:
This mouth gag keeps the mouth open. It does not have a tongue blade and hence a tongue
stitch needs to be provided to prevent tongue falling and occluding the airway. This
type of mouth gag is commonly used in pediatric practice to keep a child’s mouth open.
This mouth gag has two prongs which can be used to hold the mouth open. The distance
between these prongs can either be increased or decreased by using the screws provided
for this purpose.
Figure 29: Lane Mouth Gag

91
Rose mouth gag:
This mouth gag also does not have a tongue blade. Its main function is just to hold the
jaws apart to ensure that oral cavity is kept open. Unlike Lane mouth gag it does not have
a screw mechanism to adjust jaw opening, instead it is provided with a ratchet. A
surgeon by just bringing together the handles of the gag can increase the distance between
the prongs. The ratchet mechanism has its own advantages. Surgeon can widen the oral
cavity by using only one hand to stabilize the gag.
Figure 30: Rose Mouth Gag

92
Doyen Jenson Mouth gag:
This gag also does not have a tongue blade. Its main function is to keep the mouth of the
patient open and to prevent bite injury to the examiner’s fingers.
Figure 31: Doyen Jenson mouth gag
This mouth gag also works on ratchet principle. The blades of this gag can be separated
by bringing the finger limbs together. The position of the blade is maintained due to the
presence of ratchet mechanism.
Mason modified this mouth gag to help anesthesiologist to deliver gases to the lungs. In
this modification the blades of the mouth gag was provided with metal tubes through
which gases can be insufflated.

93
Ferguson’s mouth gag:
Hewitt modified Ferguson’s mouth gag by adding two tubes to the gag to deliver
chloroform vapor.
Figure 32: Ferguson’s mouth gag

94
Ferguson’s mouth gag
The main advantage of this mouth gag is that its handle does not affect surgical field.
Hewitt’s modification of Ferguson’s mouth gag
Gags provided with additional source of light:
Major difficulties faced by the surgeon while operating inside the oral cavity is:
1. Narrow space
2. Inadequate light
The oral cavity space can be somewhat increased by application of mouth gag. Lighting
can be improved by providing light at the end of the mouth gag blades. Modification is
available in Hewitt’s mouth gag model where a small Cecil leaf light is which could
illuminate using battery power is attached to one of the limbs of the mouth gag. With
the advancement in lighting systems like fibreoptics the currently available models are
provided with fibreoptic lighting systems.

95
Gags with spring catch:
It was Coleman in 1861 who developed a mouth gag based on the principle of forceps
with a subtle difference where the handles do not cross each other at the hinge. Attached
to one of the handles is a spring catch which helps in keeping the blades fixed at any
required distance from each other.
Figure 33: Ferguson’s mouth gag
Coleman mouth gag
The extremities of this mouth gag are covered on their outer surface by India rubber
guards. While using the instrument, the handles are opened and the blades are brought
together and introduced between the teeth at the back of the mouth. The patient’s mouth
can be opened by compressing the handles of the mouth gag. The spring catch maintains
the position of the blades.

96
William Robert Ackland’s modification of Ferguson’s mouth gag:
William Robert Ackland a British Dentist added grooved jaws to Ferguson’s mouth gag.
These grooves were designed to fit against the teeth of the patient. These grooves ensured
that the mouth gag securely held itself in place keeping the mouth open.
Mouth gags with sheet spring retention:
Many forceps type mouth gags were designed and used. Of course they showed minor
differences. It was Black in 1921 who described a forceps type mouth gag with sheet
spring to keep the jaws closed while inserting the mouth gag. Ring type retention system
was used.
Figure 34:Black Mouth gag with sheet spring retention system

97
Mouth gags with tongue blade:
In these type of mouth gags the tongue blade serves as lingual retractor. Thomas Smith
1868 first incorporated a tongue depressor to a mouth gag.
This type of mouth gag had a small tongue blade just to prevent tongue fall. It is
provided with a pair of rings which when tightened will increase the distance between the
blades thereby keeping the mouth open.
Figure 35: Image showing Thomas Smith Mouth gag

98
Whitehead mouth gag:
This is another type of mouth gag combined with a tongue blade. This was designed by
Whitehead.
Figure 36: Whitehead mouth gag
Mouth Gags with slotted tongue blades:
These gags needed external support to hold them in position. The support was in the form
of M stand / Draffin bipod. Initially suspension apparatus designed by Thacker -
Neville was used. Since it was too unwieldy other smaller support systems were
pereferred.
This modification became essential with the advent of endotracheal anesthesia. The
tongue blade of all mouth gags had a tendency to compress endotracheal tube
compromising ventilation. One important modification that became popular was the
provision of a slot in the tongue blade to facilitate the housing of endotracheal tube
without causing compression. This modification was first designed by Davis. The slot

99
that was cut in the tongue blade extended approximately for 2/5 of the length of the
tongue blade. At the distal end of the blade a short shallow trough would be provided.
Similar modifications were suggested by Doughty in 1957.
Boyle’s Davis mouth gag:
This mouth gag is commonly used to expose the oral cavity and oropharynx during
tonsillectomy. Advantages of Boyle Davis Mouth gag:
1. Provides excellent exposure of oropharyngeal structures including palatine tonsils
2. It can be stabilized using a M jack or Draffin pod allowing the surgeon to have both
hands free
3. The mouth gag and tongue blades can easily be dismantled and reassembled hence
tongue blades of various sizes can be used as per the requirement of the size of patient’s
mouth.
Uses of this mouth gag include:
1. Tonsillectomy
2. Adenoidectomy
3. UPPP and other soft palatal surgical procedures
4. Surgical procedures involving the hard palate
Disadvantages:

100
1. This type of mouth gag cannot be used for tongue surgeries because the tongue blade
would completely hide the tongue.
2. This mouth gag could injure teeth and lips if not applied with care
3. Excessive mouth opening using this mouth gag would cause tempormandibular joint
dislocation.
figure 37:Image showing Boyle Davis mouth gag and tongue blades
Figure 38:Image showing Thacker - Neville mouth gag

101
Doughty mouth gag:
Andrew Doughty was credited with the designing of Doughty mouth gag. He split the
tongue blade of the classic Boyle Davis mouth gag so that the endotracheal tube can be
held in the groove without any danger of compression to the tube.
Figure 39: Doughty mouth gag showing slot in the tongue blade that could accommodate
the endotracheal tube without the danger of compressing it
Figure 40: Sommerland and Mehendale in the year 2000 suggested a number of
modifications of tongue blade of Dott mouth gag in order to facilitate cleft palate repair.
This was done to suit the small infants who underwent these procedures frequently. The

102
highly reflective surface of the tongue blade was given a matt finish to eliminate the
glare.
The two flanges at the base of tongue blade was removed thereby eliminating a pressure
source on the lower lip. Sommerland modification of tongue blade on the right side where
the flanges at the base of the tongue blade has been removed
Agarwal and Panda modified Dott's mouth gag by placing two parallel bars over the
lingual surface of the tongue blades. This rather simple modification really prevented
compression of the endotracheal tube.
Figure 41:Image showing Panda’s modification of tongue blade

103
Dott mouth gag:
Norman Dott of Edinburg constructed a mouth gag. This gag is actually the precursor of
all popular mouth gags of today. It is shaped like a "C" with one side open. It consists
of two parts. The upper part is provided with jaw hooks and the lower is the sliding part
with the tongue blade. This gag is easy to apply and still more easy to maintain.
Figure 42: Dott mouth gag
Even though it has its own similarities to Boyle Davis mouth gag, this was
independently developed by Dott. This is a classic example of open frame mouth gag.

104
Gag with closed frame:
It was in 1962 Dingman and Gabb modified the C shaped open frame Dott mouth gag
into a rectangular and closed frame gag. The tongue blade supports the gag inferiorly and
also held the endotracheal tube close to the tongue. To this rectangular frame side
retractors were mounted on universal joints. These side retractors hooked the lips at their
angle and pulled them laterally. Major drawback of this otherwise popular mouth gag is
the lack of adaptability and cannot be used in the presence of irregularities in the
alveolus.
Figure 43: Image showing Dingman type mouth gag

105
Thompson’s modification of Dingman mouth gag:
In order to overcome the lack of adaptability of Dingman mouth gag in the presence of
irregular alveolus Thompson opened up the closed frame of Dingman mouth gag. This
was done by removing the central segment of the cephalad side of the rectangular frame.
This provided more space for the surgeon to work in the anterior portion of the palate.
This was very helpful in performing cleft palate repair.
Figure 44: Image showing Thompson’s modification of Dingman mouth gag

106
Mouth gag with adjustable split alveolar bar:
This type of mouth gags would be very useful during cleft palate repair surgical
procedures. Many of the severe grade cleft palate patients have abnormal spacing
between the maxillary alveolar arches. It will be really difficult to fit both alveolar hook
retractors of Dingman type mouth gag in these patients. To over come this difficulty
Millard and Slepyan introduced the Miami device. This gag had ope frame in the
cephalad end similar to the Thompson’s mouth gag. The jaw hooks were made
independently adjustable. The swivel hook retractors were made removable and hence
suitable sized retractors can be inserted to make the mouth gag more versatile.
Figure 45: Image showing Miami modification of Dingman type mouth gag

107
Gag with long hooks:
This type of mouth gag improved oral cavity visibility. It was Rao and Peter who
suggested this modification. The basic structure of the gag was more or less similar to
Dingman mouth gag. The length of the hooks that fitted into the alveolus and teeth was
increased. This increase in the length of the hooks displaced the horizontal bar superiorly
thereby improving access to the anterior portion of the palate. The entire frame
assembly was more curved allowing for sliding and fitting into the more distal
dentitions. This again improved exposure to the anterior portion of the palate.
Mouth gags with sliding stem:
Major problem with the mouth gags already described is that they cannot be used to
perform surgeries on the tongue. This is because the tongue blade invariably hindered
access to the tongue. In this type of mouth gag the tongue blade is done away with. The
lower part of this modified mouth gag consists of a sliding stem which is combined with
jaw holding adjustable device.
Figure 46: Mouth gag with sliding stem

108
The fact that there are numerous modifications documented and undocumented to the
established mouth gags indicate no one gag is perfect for performing surgeries inside the
oral cavity. A large number of modifications and variants of the existing mouth gags are
available. It is for the surgeon to decide which one would fit the surgical requirements.

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