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Principles of oral surgery
1.
2.
3. Definition of oral surgery
Developing a surgical diagnosis or pre surgical evaluation
Basic necessities for surgery or pre surgical preparation
Asepsis
Preparation of Patient and Surgeon
Techniques of sterilization
Maintainence of sterility
Surgical staff preparation
Incisions
Principles of flap designing and different types of flaps
Tissue handling
Hemostasis
Suture and suturing techniques
Decontamination and debridement
Edema control
Conclusion
Bibliography
4. Oral and maxillofacial surgery is the specialty of
dentistry which includes the diagnosis, surgical and
adjunctive treatment of diseases, injuries and defects
involving both the functional and esthetic aspects of the
hard and soft tissues of the oral and maxillofacial region
5. The aim of preoperative evaluation is not to screen
broadly for undiagnosed disease but rather to identify
and quantify any comorbidity that may have an impact
on the operative outcome
The context in which preoperative preparation is
conducted ranges from an outpatient office visit to
hospital inpatient consultation to emergency
department evaluation of a patient.
6. Know your patient
Examine your patient and gather patient and scientific
data including the use of consultants.
Look at the data and analyze for hypothesis testing
Consider the alternatives
Is picking up a knife the best thing to do?
To practice evidence based treatment.
8. Sepsis- Breakdown of tissue by action of microbes and
is usually accompanied by inflammation
Antiseptic- Substance that can prevent multiplication
of organism capable of causing infection. Anstiseptics
are applied on living tissues while Disinfectant are
applied on inanimate object.
Sterility- freedom from viable forms of micro
organisms
Sanitization –reduction of number of viable organisms
9. To minimise wound contamintaion by pathogens
because during a surgery, dentist violates the epithelial
surface which is the most important barrier against an
infection
During oral surgical procedures dentist, assistant and
equipment become comtaminated with patients blood
and saliva
10.
11.
12. By using disposable materials:-
Surgical field maintaenance
13. 1. Hand and arm preparation Done by antiseptics with
low toxicity like iodoform, chlorhexidine, and
hexachlorophene
Two techniques are used for
A. Clean technique- used in office based surgeries.
Surgeon wears a clean dress and over it long sleeved
laboratory coat or a surgical scrub
B. Sterile technique- mostly in operating room.
Purpose of it is to minimise the number or micro
organism that can ener the wound site.
14.
15. Use a sharp blade of proper size.
Use firm continuous strokes.
Avoid cutting vital structures
Incise perpendicular to the epithelial surface.
Intraoral incisions should be properly placed.
16.
17. 1. Outlined by a surgical incision
2. Carries its own blood supply
3. Allows surgical access to underlying tissues
4. Can be replaced in the original position
5. Can be maintained with sutures and is expected to
heal
19. 1.Base > Free margin
• to preserve an adequate blood supply
• unless a major artery is present in the base
2.Width of Base > Length of Flap*2
• less critical in oral cavity, but length < width
• a long, straight incision with adequate flap reflection heals
more rapidly than a short, torn incision.
3. An axial blood supply in the base
4. Hold the flap with a retractor resting on intact bone
to prevent tension.
20. The incisions must be made over intact bone
If the pathologic condition has eroded the buccocortical plate,
the incision must be at least 6 or 8 mm away from it.
The incision should be 6 to 8 mm away from the bony defect
created by surgery.
Gently handle the flap's edges
Do not place the flap under tension
Do not cross bony prominences, ex: canine eminence
21.
22. • Is a common problem in procedures using a flap that
provides insufficient access
• A proper long flap heals as quickly as a short flap
• Envelope flaps
– an incision around the necks of several teeth.
– extends 2 teeth anterior and 1 tooth posterior.
If not provide sufficient access…
• Vertical (oblique) releasing incisions:
– extends 1 tooth anterior and 1 tooth posterior.
– started at the line angle of a tooth.
– carried obliquely apically into the unattached gingiva.
– If cross the papilla localized periodontal problems
23.
24.
25.
26. Various types of flaps have been described in oral
surgery, whose name is based mainly upon shape:-
trapezoidal,
triangular,
envelope,
semilunar,
27. The trapezoidal flap is created after a Π shaped incision,
which is formed by a
Horizontal incision along the gingivae, and two oblique
vertical releasing incisions extending to the buccal
vestibule.
Vertical releasing incisions always extend to the
interdental papilla and never to the center of the labial or
buccal surface of the tooth.
This ensures the integrity of the gingiva proper, because if
the incision were to begin at the center of the
tooth,contraction after healing would leave the cervical
area of the tooth exposed.
28. Advantages. Provides excellent access, allows surgery
to be performed on more than one or two teeth,
produces no tension in the tissues, allows easy
reapproximation of the flap to its original position and
hastens the healing process.
Disadvantages. Produces a defect in the attached
gingiva (recession of gingiva).
29. This flap is the result of an Lshaped incision with a
horizontal incision made along the gingival sulcus and
a vertical or oblique incision
The vertical incision begins approximately at the
vestibular fold and extends to the interdental papilla
of the gingiva.
The triangular flap is performed labially or buccally on
both jaws and is indicated in the surgical removal of
root tips, small cysts, and apicoectomies.
30. Advantages. Ensures an adequate blood supply,
satisfactory visualization, very good stability and
reapproximation; it is easily modified with a small
releasing incision, or an additional vertical incision, or
even lengthening of the horizontal incision.
Disadvantages. Limited access to long roots, tension is
created when the flap is held with a retractor, and it
causes a defect in the attached gingiva
31. This type of flap is the result of an extended horizontal
incision along the cervical lines of the teeth. The incision is
made in the gingival sulcus and extends along four or five
teeth.
The tissue connected to the cervical lines of these teeth
and the interdental papillae is thus freed. The envelope
flap is used for surgery of incisors, premolars and molars,
on the labial or buccal and palatal or lingual surface and is
usually indicated when the surgical procedure involves the
cervical lines of the teeth labially (or buccally) and
palatally (or lingually), apicoectomy (palatal root), removal
of impacted teeth, cysts, etc.
32. Advantages. Avoidance of vertical incision and easy
reapproximation to original position.
Disadvantages. Difficult reflection (mainly palatally),
great tension with a risk of the ends tearing, limited
visualization in apicoectomies, limited access,
possibility of injury of palatal vessels and nerves,
defect of attached gingiva
33. This flap is the result of a curved incision, which
begins just beneath the vestibular fold and has a bow
shaped course with the convex part towards the
attached gingiva
The lowest point of the incision must be at least 0.5 cm
from the gingival margin, so that the blood supply is
not compromised. Each end of the incision must
extend at least one tooth over on each side of the area
of bone removal. The semilunar flap is used in
apicoectomies and removal of small cysts and root
tips.
34. Advantages. Small incision and easy reflection, no
recession of gingivae around the prosthetic
restoration, no intervention at the periodontium,
easier oral hygiene compared to other types of flaps
Disadvantages. Possibility of the incision being
performed right over the bone lesion due to
miscalculation, scarringmainly in the anterior area,
difficulty of reapproximation and suturing due to
absence of specific reference points, limited access and
visualization,tendency to tear.
35. Gentle handling of tissue
Meticulous haemostasis
Preservation of blood supply
Strict aseptic technique
Minimum tension on tissues
Accurate tissue apposition
Obliteration of deadspace
Also called as Halsted's principles, or Tenets of
Halsted
36. Is a process which causes bleeding to stop
Methods of promoting wound hemostasis –
1. Natural hemostatic mechanism
2. Use of sponge and applying pressure
3. these two cause stasis of blood and promote
coagulation. Small vessels 20 to 30 sec. larger vessels
5- 10 min. it should be dabbed rather than wiped
4. Use of electric current –fuses the cut ends
5. Sutures
6. Vasoconstrictors like adrenaline: best if placed in the
site 7 minutes before the surgery begins
37. Dead space management: It is any area that remains
devoid of tissue after closure of wound
It usually fills in with blood and can lead to hematoma
formation
It can be eliminated in 4 ways
A. Suturing tissue planes together to minimize post
operative void
B. Place a pressure dressing. This brings the tissue
planes together until either they are bound by fibrin or
pressed by edema or both(takes uptp 12 to 18 hours
38. C. Place a packing in the void and remove when
bleeding stops. Done when surgeon cant tack the
tissue together , eg bony cavity after cyst removal
D.Through use of drains with or without pressure
packs
39. It is a strand of thread that is used to approximate
tissues and to ligate blood vessels
Tools:
1. Needle
2. Suture material
Source: Ratner et al. 2004
43. Selection of suture material should be based on healing
charecteristics of the tissue being approximated
A. Rate of tissue healing. –
suture that looses its tensile strength at same rate as the
tissue gain strength.
Tissue that heal slowly are usually closed with non
absorbable sutures
Rapidly healing tissue with absorbable ones
B.Tissue contamination. – contaminated areas should be
sutured with monofilament materials
44. C. cosmetic results- close and prolonged apposition of
tissue will produce best results
D. Cancer patients- synthetic non absorbable sutures
as the the wound can breakdown.
E. Nutritional status- non absorbable sutures to be
used in undernourished cases as the wound healing
takes longer
48. Needle should be grasped at approximately 1/3° the
distance from eye or 2/3 from point
Needle should enter perpendicular to tissue surface
Needle should pass through the tissue along its curve
Suture should be passed at an equal depth and
distance from incision on both sides
Needle always pass from movable to fixed tissue
Thinner to thicker tissue
Deeper to superficial tissue
49. Tissue must never be closed under pressure. Undermining
of tissue must be done prior to suturing in such cases
Knot should never lie on the incision line
Suture should only be tied only to approximate and not to
blanch
Suture should be placed at a greater depth than the
distance from the incisio, so as to evert the wound margins.
Sutures on the skin are generally removed in 5 days and
intra oral in 7 days. If there is tension while suturing, they
may be kept for 10 days
50. 1. Suture knot slipping
• Inability of the suture to retain until wound healing complete
• Common in absorbable suture
2. Re-infection
• Site for microbial growth causing re-infection
• the need for suture with antimicrobial activity
3. Failure of wound healing
• Improper suturing technique does not allow collagen
formation
51. DECONTAMINATION is done to reduce the bacterial
count and hence reduce risk of infection
Mostly done by irrigastion under pressure. Saline or
antibiotic solutions can be used
DEBRIMENT is careful removal of necrotic and
ischemic tissue and foreign material from injured
tissue that would impede wound healing
Is done where either there is a traumatic injury or
severe tissue damage is done.
52. Edema is accumulation of fluid in interstitial space
because of transudation from damaged vessels and
lymphatic obstruction by fibrin
The degree is determined by :- a. The amount of tissue
damage, b. Looser the connective tissue
Prevention –
A. Application of ice
B. Patient position. Ie patient should keep the head
above the body as much as possible
C. Short term high dose corticosteroids (only if
administerd before tissue damage is done)
Hinweis der Redaktion
Human tissue have genetically determined properties that makes their normal responses to injury predictable, because of this predictability principles of surgery that help optimize wound healing environment have been developed thru basic and clinical research.
These principles are what makes the difference between the early dentist on the left and a surgeon on the right
Examine your patient and gather patient and scientific data including the use of consultants.
and not to use incomplete or poor quality data like poor quality radiographs
Blade No. 10 – with its curved cutting edge is one of the more traditional blade shapes and is used generally for making small incisions in skin and muscles . The No.10 is often utilised in more specialised surgeries such as harvesting the artery during a coronary artery bypass operation, opening the bronchus during thoracic surgery and for Inguinal hernia repair.
Blade No. 11 - is an elongated triangular blade sharpened along the hypotenuse edge and with a strong pointed tip making it ideal for stab incisions. Used in various procedures such as the creation of incisions for chest drains, opening coronary arteries, opening the aorta and removing calcifications in the aortic or mitral valves.
Blade No. 12 - is a small, pointed, crescent shaped blade sharpened along the inside edge of the curve. It is sometimes utilised as a suture cutter but also for arteriotomies ( surgical incision of an artery), parotid surgeries (facial salivary glands), mucosal cuts on a septoplasty (repair of nasal septum) and during cleft palate procedures, ureterolithotomies (calculus removal by incision of the ureter) and pyelolithotomies (surgical incision of the renal pelvis of a kidney for the removal of a kidney stone - also known as a pelviolithotomy ).
Blade No.12D – (sometimes referred to as the 12B in the USA), is a double edged No. 12 blade sharpened along both sides of the crescent shaped curve. It is used extensively within dental surgery techniques.
Blade No. 14 - mostly used in aesthetic procedures that help to rejuvenate the skin's top layers through a method of controlled surgical scraping.
Blade No. 15 - has a small curved cutting edge and is the most popular blade shape ideal for making short and precise incisions. It is utilised in a variety of surgical procedures including the excision of a skin lesion or recurrent sebaceous cyst and for opening coronary arteries.
Blade No.15C - with a longer cutting edge than the traditional No.15 blade. Mostly used by dentists carrying out periodontal procedures.
Blade No.20 - is a large version of the No.10 blade with a curved cutting edge and an unsharpened back edge. Used for orthopaedic and general surgical procedures.
Blade No.21 is a large version of the No.10 blade with a curved cutting edge and an unsharpened back edge. Larger than the No.20 but smaller than the No.22.
Blade No.22 is a large version of the No.10 blade with a curved cutting edge and an unsharpened back edge. Used for skin incisions in both cardiac and thoracic surgrey and to cut the bronchus in lung resection surgery. Larger than the No.20 and No.21.
Blade No.23 has a flat, unsharpened back edge and a curved cutting edge. Used mostly for making long incisions such as an upper midline incision of the abdomen during the repair of a perforated gastric ulcer.
Blade No.24 is slightly larger than the No.23 blade and is more semi circular in shape. Used for making long incisions in general surgery and also in autopsy procedures.
Blade No.36 is a large blade mostly used in general surgery but also in histology procedures.