Minor oral surgical principles /certified fixed orthodontic courses by Indian dental academy

Minor Oral Surgery Principles
&
Exodontia
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Principles
surgery

of

minor

oral

 Diagnosis and treatment planning
 Basic necessities for surgery.
 Pain and anxiety control
 Aseptic technique
 Incisions
 Flap design
 Tissue handling
 Hemostasis
 Means of promoting wound hemostasis
 Removal of bone

 Delivery of the tooth, root or other lesion
 Decontamination and debridement
 Principle of drainage
 Dead space management
 Suturing principles and methods
 Post surgical care of wound and edema
control
 Patient general health & nutrition.


DEVELOPING A SURGICAL DIAGNOSIS AND
TREATMENT PLANNING
The decision to perform surgery should be the culmination of
several diagnostic steps.
The initial step
Presurgical evaluation: collection of accurate and pertinent
data.
- Patient interviews
- Physical
- Laboratory and
- Imaging examination

 Patient information and data should be
organized into a format to reach a proper
diagnosis and form a decision concerning
surgery which is either indicated as not.
 Surgeons should be thoughtful observers,
should note all aspects of its outcome to
advance their surgical knowledge and to
improve future surgical results.


BASIC NECESSITIES FOR SURGERY
Two principles requirements are
 Adequate visibility
 Assistance
Adequate visibility: This depends on 3 things
 Adequate access
 Adequate light
 A surgical field free of blood and others
fluids

Adequate access
 Patients ability to open their mouths wide but
also require surgically created exposure.
 Retraction of tissues away from the operative
field provides much of the necessary access.
 Proper retraction also protects tissues from
accidental injury e.g., cutting instruments.

Instruments for retraction







Bowdler Henry rake retractor.
Ward’s double ended 3rd molars
Lack’s tongue depressor
Kilner’s cheek retractor
Laster’s retractor for upper 3rd molar

Adequate light
 Background illumination – colour
corrected fluorescent lamps – 400-500
lux intensity.
 Main sealing mounted lamp (luminare)
– high intensity.
- Focused at the centre of the surgery
– 40,000-100,000 lux.
- Periphery of the surgery - 8,000 –
15,000 lux.

A surgical field free of fluids
 High volume suctioning with a small tip
 Wet gauges
 Cotton and
 Sponge
Competent assistance:
 A trained and competent assistants provides
invaluable help during surgical procedures.
 The assistant should be sufficiently familiar
with the procedures being performed to
anticipate surgeons needs.

Pain and anxiety control
• Local anaesthesia
• Sedation
• General anaesthesia


Principle of Asepsis
Asepsis is the exclusion of micro-organisms from the
operative field to prevent them entering the wound.
Preoperative surgical scrub
4% chlorhexidine
10% Povidine Iodine
Patients preparation
Detergents – 10% povidine iodine in 10%
alcohol.
– 0.5% chlorhexidine
– Alcoholic solution
Mouth wash
Povidine iodine
Chlorhexidine

INCISIONS
An incision can be described as a sharp wound
produced by a surgical scalpel.
Basic principles of incisions
1st principle - A sharp blade of the proper size
should be used.
Bone and ligamental tissues dull blades more
rapidly than does buccal mucosa.

2nd principle: is that a firm, continuous
stroke should be used when incising.
Long continuous strokes are preferable to
short interrupted ones.
Mucoperiosteal incision should be firm
that penetrates the mucosa and
periosteum with the same stroke.

3rd principle: The surgeon should be careful to
avoid cutting vital structures while incising.
No patients microanatomy is exactly the same.
Avoid unintentional cutting of large vessels or
nerves.
For e.g., Incision in the mandibular buccal sulcus
and lingual area - prevent the inadvertent cutting
of facial and lingual vessels.


4th principle: Incision
through
surfaces

epithelial
should

be

made with the blade
held perpendicular to
the epithelial surface.


5th principle: Incisions in the oral cavity should
be properly placed.
E.g., Over healthy bone, wound edges should
be at least 6-8mm away from the defect.

Incision should lie at the
line angles of the teeth
and not at the facial
surfaces nor in the
papilla.


Instruments to incise tissue
Scalpel – composed of handle + sharp
blade

Handle

Scalpel blade

Scalpel motion made by moving
hand and rest and not by moving
entire forearm.

Scalpel is help in a pen-grip and
handle in supported against slipping.


Flap design:
Surgical flaps are made to gain surgical access
to an area or to move tissue from one place to
another.
The term flap indicates a section of soft tissue.
Basic principles of flap designs –
- Prevent

- flap necrosis
- flap dehiscence
- flap tearing


Principles of flap design:
Base of the flap should be wider
than apex.
 The length of the flap should
be no more than twice the
width of the base.
 Axial blood supply should be
included in the base of the
flap.
 The presence of a sinus
must be taken into account
when flaps are designed.

 The base of the flap should
excessively twisted or stretched.

not

be

 Flap must have adequate size to provide
necessary access and visualization of the
required area.
 Flaps should be a full thickness flap i.e.,
mucoperiosteal flap.
 The margins of the flap should be at least 68mm away from any present / future defect
that will remain after surgery.

 Flaps should be designed to avoid any injury
to local vital structure in the area of surgery
i.e., lingual and mental nerves.
 Releasing incision should be used only when
necessary and not routinely.
 Overextension of a flap in the vertical
dimension should be avoided.

Types of mucoperiosteal flaps

Envelope flap

Three cornered flap



Four cornered flap

Semilunar flap



Y-shaped incision flap

Pedical flap


Tissue Handling
The difference between an acceptable and
an excellent surgical outcome rests on how
the surgeons handle the tissue.
 Toothed forceps or tissue hooks.
 Tissue should
aggressively.

not

be

retracted

over

 When bone is cut, copious amount of
irrigation is used.

 Soft tissues - protected from frictional heats
or direct trauma from drilling equipments.
 Tissues - moistened or covered with a damp
sponge – prevent desiccation.
 Only physiologic substances should come in
contact with living tissue.

The surgeon who handles tissue gently is
rewarded with wounds that heal with fewer
complications and grateful patients

Hemostasis
 Prevention of excessive blood loss during
surgery is important for preserving a patients
oxygen carrying capacity.
 Decreased visibility
bleeding creates.

that

uncontrolled

 Hematomas : Place pressure on wounds
 Decrease vascularity.
 Increase wound tension.
 Acts as culture media potentially the
development of a wound infection

Means of obtaining hemostasis:
 Assisting natural hemostatic mechanisms.
 Electro-coagulation.
 Suture ligation.
 Pressure packing.
 Vasoconstructive substances.
 Use of Hemostatic agents
- Turpentine or tannic acid
- Thrombin and Russell viper venom
- Oxidized regenerated cellulose (Surgicel)

Bleeding from bone
 Burnishing
instrument.

the

bone

with

 Applying hot packs.
 Bone wax.
 Driving a chisel into the bone.


a

small

Removal of Bone
 The aim is to expose and to remove bony
overlying the tooth, root and other underlying
pathology.
Techniques of bone removal:
a. Bur technique.
b. Chisel and mallet technique.


Bur technique
 IT is precise, efficient and useful
technique.
 It should be always used with copious
amount of saline irrigation to avoid
thermal trauma (necrosis of bone).
 Round bur
 Straight fissure bur


Chisel and mallet technique
 Historical importance and rarely used.
 Less bone necrosis than bur technique.
 Can cause inadvertent fracture of the bone.
 Jaw bone should be supported while using
this technique.
 Quick, clean method for removing young
elastic bone provided the instrument is sharp
and used skillfully.
 Contraindicated in sclerotic bone and in thin
atrophic mandible.

Technique
 Vertical stops / cuts should be placed.
 The bevel of chisel should be towards
the bone which has to be sacrificed.


Delivery of tooth root / lesion
• After the necessary bone removal the
delivery of the tooth, root or lesion
should be effected.
• Granulation tissue, by cystic lining or
lesion should be removed.


Debridement / decontamination:
 Careful cleansing to remove the debris.
 Pathological tissue such as tooth follicle or
sinus tracts, is excised.
 Sharp bony edges are filed.
 Flaps are trimmed of all necrotic tissues or
tags.
 Tooth chips and loose pieces of bone are
removed.
 Thorough irrigation.

Dead space management
Dead space is the area that remains
devoid of tissue after closure of the wound.
Created - removal of tissues in depth
- not suturing in multiple layers
This dead space is usually filled with blood
or

serum

infected.

and

subsequently


become

Means of eliminating dead spaces
Multiple layer suturing
Pressure dressing
Surgical packing of the defect
Drains
- Fine superficial drains
- Larger superficial drains
- Deep drains (tube drains)
- Vacuum drains

Suturing:
Edema control
Edema is an accumulation of fluid in the
interstitial space because of transudation from
damaged vessels and lymphatic obstruction by
fibrin.
Two variables:
- Amount of tissue injury.
- Amount of loose connective tissue.
Controlled by
- Minimizing tissue damage
- Ice application
- Systemic corticosteroids

Patient general health and nutrition:
Wound healing depends on
 Patients ability to resist inflammation
 Provide essential nutrients


Thank you

Minor oral surgical principles /certified fixed orthodontic courses by Indian dental academy

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Minor oral surgical principles /certified fixed orthodontic courses by Indian dental academy