BASIC PRINCIPLES BASIC PRINCIPLES OF OF

SURGERYSURGERY

Basic Sequence wise Steps in Basic Sequence wise Steps in Oral SurgeryOral Surgery

1.1. Pre-operative evaluationPre-operative evaluation2.2. AsepsisAsepsis3.3. Painless Surgery – Type of AnaesthesiaPainless Surgery – Type of Anaesthesia4.4. Gaining Surgical AccessGaining Surgical Access5.5. Control of Hemorrhage during SurgeryControl of Hemorrhage during Surgery6.6. Drainage and Wound debridementDrainage and Wound debridement7.7. Closure of Wounds - Suturing Closure of Wounds - Suturing 8.8. Principle of control & prevention of Principle of control & prevention of

InfectionInfection9.9. Post-operative carePost-operative care * * Edema controlEdema control ** General health & nutrition. General health & nutrition.

The The first step - prior to TREATMENT PLANNING first step - prior to TREATMENT PLANNING AND SURGERY - is the pre-surgical evaluationAND SURGERY - is the pre-surgical evaluation of the of the patient patient

This is carried out by evaluating the patients data that This is carried out by evaluating the patients data that isis

* * recording historyrecording history, , * * clinical examinationclinical examination and and * * relevant investigationsrelevant investigations of the patient. of the patient.

Based on these, a surgical diagnosisBased on these, a surgical diagnosis is arrived at is arrived at and depending on the fitness of the patient, the and depending on the fitness of the patient, the surgeon surgeon is able to decide as to whether surgery is indicated or is able to decide as to whether surgery is indicated or not. not.

Once the surgical diagnosis has been madeOnce the surgical diagnosis has been made, the , the surgeon has 3 main jobs to attendsurgeon has 3 main jobs to attend to ensure a to ensure a successful outcome of the procedure.successful outcome of the procedure.

These are: These are:

IF - indicationsIF - indications

HOW – surgical techniqueHOW – surgical technique

WHEN – timingWHEN – timing

Once these problems are studied, Once these problems are studied, there are 3 there are 3 possible ways the patient can be managedpossible ways the patient can be managed::

By By ObservationObservation With With Conservative treatmentConservative treatment and and Radical managementRadical management

Once it has been decided that Surgical Once it has been decided that Surgical intervention is required – it has to be intervention is required – it has to be decided decided whether the surgery is to be whether the surgery is to be performed in the Dental clinic under performed in the Dental clinic under Local AnaesthesiaLocal Anaesthesia

or or

the patient requires to be admitted to the patient requires to be admitted to the hospital for surgery under General the hospital for surgery under General Anaesthesia.Anaesthesia.

PREOPERATIVE ORDERS / INSTRUCTIONS

Whenever possible telephonic orders Whenever possible telephonic orders should be avoided.should be avoided.

Written orders should be sent with the Written orders should be sent with the patient at his admission to the hospital. patient at his admission to the hospital. There are obvious practical and There are obvious practical and medicolegal implications for this medicolegal implications for this suggestion.suggestion.

Typical pre-operative orders generally Typical pre-operative orders generally included are as follows : included are as follows :

1.1. Admitting diagnosis :Admitting diagnosis :– this is a working – this is a working diagnosis that may be modified or changed diagnosis that may be modified or changed completely by the time of discharge. completely by the time of discharge.

2. 2. Dietary ordersDietary orders:: These should be specific – These should be specific – for example – nothing by mouth, low salt, for example – nothing by mouth, low salt, high protein, soft diet, liquid diet etchigh protein, soft diet, liquid diet etc

3. 3. Physical restrictionsPhysical restrictions:: Be specific for Be specific for example – bed rest, ambulatory, head example – bed rest, ambulatory, head elevated and so onelevated and so on

4. 4. Laboratory requests & special tests:Laboratory requests & special tests:–– if not if not done earlier.done earlier.

5. 5. X’ray tests:X’ray tests: – if not carried out earlier or more – if not carried out earlier or more specific x’rays. specific x’rays.

6. 6. Medications Medications :: AntibioticsAntibiotics – the use of – the use of appropriate antibiotics, if indicated can reduce appropriate antibiotics, if indicated can reduce the incidence of infection & post-operative the incidence of infection & post-operative morbidity.morbidity.

CorticosteroidsCorticosteroids are also useful for reduction of are also useful for reduction of edema & for post-op discomfort. edema & for post-op discomfort.

7. 7. Sedative drugs Sedative drugs :: Drugs to be given the night Drugs to be given the night before surgery should be chosen with care before surgery should be chosen with care following the drug history of the patient. following the drug history of the patient. Barbiturates should be avoided in the very young and the elderly.

8. 8. Special Orders Special Orders :: if any. if any.

Female patients should be asked to remove Female patients should be asked to remove all all

eye and other makeupeye and other makeup before retiring the before retiring the

preceding night.preceding night.

Basic Necessities Required For Basic Necessities Required For SurgerySurgery

The The 2 principal requirements2 principal requirements for surgery are: for surgery are: * * Adequate visibilityAdequate visibility * * AssistanceAssistance*Adequate visibility depends*Adequate visibility depends on 3 things on 3 things a). a). Adequate accessAdequate access in terms of in terms of mouth openingmouth opening & &

surgically created exposuresurgically created exposure b). b). Adequate lightingAdequate lighting c). c). Clear surgical fieldClear surgical field, free of excess blood & other , free of excess blood & other fluidsfluids*A fairly *A fairly trained assistanttrained assistant is a great help during oral is a great help during oral

surgery,and surgery,and he should be familiar with the he should be familiar with the procedure & also anticipate the surgeons needs.procedure & also anticipate the surgeons needs.

BASIC PRINCIPLES OF SURGERY

Basic Principles of Oral SurgeryBasic Principles of Oral Surgery

Having said that,… these principles are:Having said that,… these principles are:

1.1. AsepsisAsepsis2.2. Painless Surgery – Type of AnaesthesiaPainless Surgery – Type of Anaesthesia3.3. Gaining Surgical AccessGaining Surgical Access4.4. Control of Hemorrhage during SurgeryControl of Hemorrhage during Surgery5.5. Drainage and Wound debridementDrainage and Wound debridement6.6. Closure of Wounds - Suturing Closure of Wounds - Suturing 7.7. Principle of control & prevention of Principle of control & prevention of

InfectionInfection8.8. Post-operative carePost-operative care * * Edema controlEdema control ** General health & nutrition. General health & nutrition.

1. 1. PRINCIPLE OF ASEPSIS /ASEPTIC PRINCIPLE OF ASEPSIS /ASEPTIC TECHNIQUE / PREVENTION OF TECHNIQUE / PREVENTION OF CROSS INFECTION CROSS INFECTION

This principle of This principle of ASEPSISASEPSIS ,,is achieved is achieved by adhering to:by adhering to:

A. Disinfection of SurgeryA. Disinfection of Surgery B. Instrument SterlisationB. Instrument Sterlisation C. Instrument disinfectionC. Instrument disinfection D. Maintaining Sterility of D. Maintaining Sterility of

InstrumentInstrument E. Surgical Staff PreparationE. Surgical Staff Preparation F. Observation of OT RoutineF. Observation of OT Routine

A. Disinfection of Surgery

Do not eatDo not eat / / clean utensilsclean utensils in the treatment in the treatment areasareas

Surgery should be such, that Surgery should be such, that floors & walls floors & walls are easily cleanedare easily cleaned

Have Have sinks & soap dispenserssinks & soap dispensers that are that are elbow orelbow or foot controlledfoot controlled

Disinfect walls at regular intervalsDisinfect walls at regular intervals Scrub floors dailyScrub floors daily with phenol product – with phenol product –lysollysol Scrub dust collectingScrub dust collecting on or above chair seat on or above chair seat

levellevel

Waste disposalWaste disposal – – a) a) do not allow saliva or blood soaked material to do not allow saliva or blood soaked material to accumulate on the tray.accumulate on the tray. b) line the b) line the waste receptacle with plastic bag,waste receptacle with plastic bag, when when

full seal full seal and and incinerateincinerate Disinfect allDisinfect all - - supportsupport for for hand piecehand piece, , airwater syringeairwater syringe & &

suction suction - dental chair- dental chair - - control switchescontrol switches( chair, light, ultrasonic scaler)( chair, light, ultrasonic scaler) - - light handlelight handle - - cotton holdercotton holderChemical Solns for Disinfection: : Glutaldehyde 2%,Glutaldehyde 2%, Sodium hypochlorite 5% diluted 1: 100Sodium hypochlorite 5% diluted 1: 100 Iodophor 1:20Iodophor 1:20 (iodine 1 part +70% alcohol 20 (iodine 1 part +70% alcohol 20

parts)parts)

B. Sterlisation of Instruments

Before Before instument sterlisationinstument sterlisation, ensure that the , ensure that the instruments are instruments are presoakedpresoaked & & free of blood free of blood and debrisand debris

Presence of Presence of blood, tissue, oilblood, tissue, oil or other or other material is a material is a BARRIER to steam & heat BARRIER to steam & heat & & may make chemicals ineffective.may make chemicals ineffective.

Therefore before instruments are sterlised Therefore before instruments are sterlised they must be they must be thoroughly scrubbed and thoroughly scrubbed and cleaned by hand / or by ultrasonic cleaner.cleaned by hand / or by ultrasonic cleaner.

After instruments have been cleaned, After instruments have been cleaned, they they must be thoroughly rinsed and drained must be thoroughly rinsed and drained before proceeding with sterlisation.before proceeding with sterlisation.

Any means of sterlisation CHOSEN Any means of sterlisation CHOSEN must be must be RELIABLERELIABLE, , PRACTICALPRACTICAL & & SAFESAFE

3 reliable methods are generally 3 reliable methods are generally available for instrument sterlisation.available for instrument sterlisation.

* * Dry Heat ( oven)Dry Heat ( oven) * * Moist Heat ( steam, autoclave)Moist Heat ( steam, autoclave) * * Ethylene oxide gasEthylene oxide gas

in addition to the in addition to the conventional boiling conventional boiling water sterliser.water sterliser.

C. Disinfection of InstrumentsC. Disinfection of Instruments

Many dental instruments cannot withstand Many dental instruments cannot withstand the extreme temperatures required for heat the extreme temperatures required for heat sterlisation sterlisation therefore therefore where absolute where absolute sterility is not criticalsterility is not critical, then , then ‘Chemical ‘Chemical Sterlisation’ can be performed.Sterlisation’ can be performed.

Chemicals suitable for ‘disinfecting’ Chemicals suitable for ‘disinfecting’ instruments are – instruments are – glutaraldehydeglutaraldehyde (cidex, (cidex, sporacidin) + sporacidin) + iodophorsiodophors (betadine) + (betadine) + formaldehydeformaldehyde + + chlorine compdschlorine compds (chlorax). (chlorax).

Glutaraldehyde is the most commonly usedGlutaraldehyde is the most commonly used..

D. Maintaining Sterility of D. Maintaining Sterility of Instruments Instruments ( Storage) ( Storage)

All items should be All items should be removed from the removed from the sterliser with a sterile cheatle forcepssterliser with a sterile cheatle forceps and placed in the proper storage area.and placed in the proper storage area.

Open tray racks and dental cabinetsOpen tray racks and dental cabinets cannot maintain sterility.cannot maintain sterility.

Unwrapped instruments should be Unwrapped instruments should be placed on and covered by sterile towels.placed on and covered by sterile towels.

Sealed bagsSealed bags / wraps /cassettes/ / wraps /cassettes/ covered covered traystrays provide the necessary protection. provide the necessary protection.

Preferably, the articles should be kept in Preferably, the articles should be kept in containers/cassettes/ racks in which they containers/cassettes/ racks in which they were sterlised until they are ready to be were sterlised until they are ready to be used.used.

Sterlised articles that are stored in the Sterlised articles that are stored in the

disinfecting solution may be contaminated disinfecting solution may be contaminated with pathogenic organism through with pathogenic organism through careless handling.careless handling.

E. Surgical Staff PreparationE. Surgical Staff Preparation

All health care workers should be All health care workers should be IMMUNISEDIMMUNISED, especially against , especially against Hepatitis Hepatitis B - and TuberculosisB - and Tuberculosis

Wear Wear NEAT, CLEANNEAT, CLEAN, simple short sleeved , simple short sleeved CLOSEDCLOSED dental coat.dental coat.

DO NOT WEARDO NOT WEAR clinical clothing outsideclinical clothing outside the clinical setting, because this habit the clinical setting, because this habit takes contamination outside / home.takes contamination outside / home.

NO JEWELRYNO JEWELRY to be worn on wrists or to be worn on wrists or handshands

Keep Keep HAIRHAIR away from treatment areas – away from treatment areas – covercover including facial hair during including facial hair during treatment surgical procedures. WASH treatment surgical procedures. WASH dailydaily

Wear Wear MASKSMASKS – because many diseases – because many diseases are transmitted when no clinically signs are transmitted when no clinically signs are presentare present

* * To be worn during all procedures.To be worn during all procedures.

* * Tie masks before washing handsTie masks before washing hands

* * Change them when dampChange them when damp – as they – as they are no are no

more effectivemore effective

Wear Wear protective protective EYEGLASSESEYEGLASSES with side with side shieldsshields to prevent injury or infection to prevent injury or infection

HAND WASHING HAND WASHING – – to reduce the skin florato reduce the skin flora – the – the mechanical act causes frictionmechanical act causes friction + + washingwashing removes microbesremoves microbes + use of + use of 1% 1% IodineIodine / / chlorhexidinechlorhexidine destroys bacteria. destroys bacteria.

Keep Keep NAILSNAILS short and clean. short and clean.

Routine use of Routine use of GLOVESGLOVES is recommended. is recommended. Wash gloves before removing,Wash gloves before removing, as this as this

reduces the chances of possible reduces the chances of possible contamination of operators hands.contamination of operators hands.

F. Observation of OT RoutineF. Observation of OT Routine

The The sterile instruments, drapes, fluidssterile instruments, drapes, fluids and and dressingsdressings used in oral surgery are used in oral surgery are laid laid upon trolliesupon trollies..

The The instrumentsinstruments are are laid out in the laid out in the sequence they are likely to be used.sequence they are likely to be used.

When pre-packed instruments are not used When pre-packed instruments are not used the required sterlised instruments must be the required sterlised instruments must be handled with a sterile cheatle forceps.handled with a sterile cheatle forceps.

The The surgeon and the assistantsurgeon and the assistant should should wear wear sterile OT gownssterile OT gowns and glovesand gloves, and , and only only those those instruments laid out on the instruments laid out on the trolly should be handled.trolly should be handled.

A A third person or circulating nursethird person or circulating nurse should be present should be present

* to adjust the operating lights * to adjust the operating lights

* position of the patient and * position of the patient and

* other tasks required of him / * other tasks required of him / her.her.

2. PRINCIPLE OF PAINLESS 2. PRINCIPLE OF PAINLESS SURERYSURERY

A. Local Anaesthesia B. General Anaesthesia C. Sedation Techniques D. Day Care Surgry

It is essential that surgery should be It is essential that surgery should be painless WHY ?painless WHY ?..

To prevent To prevent psychological traumapsychological trauma + + physical stressphysical stress to the patient to the patient which which can lead to can lead to shockshock delayed delayed recoveryrecovery..

SurgerySurgery can be performed can be performed under LA, under LA, GA or IV Sedation.GA or IV Sedation.

In oral surgery, it is very essential that In oral surgery, it is very essential that the the GA be given by a specialist in this GA be given by a specialist in this field field

A. LOCAL ANAESTHESIAA. LOCAL ANAESTHESIA LA is LA is suitable for many surgical suitable for many surgical

proceduresprocedures as done in the daily OPD. as done in the daily OPD. It is indicated where It is indicated where

- the patient has - the patient has recently eatenrecently eaten & & does does

not wish to waitnot wish to wait and and

- in certain medical conditions such - in certain medical conditions such as as

Ch. bronchitisCh. bronchitis.. When there is a When there is a single operative sitesingle operative site

and the procedure is and the procedure is likely to take less likely to take less than 45 minutes.than 45 minutes.

Advantages of LAAdvantages of LA

1.1. Safe, efficient, & effective in almost all casesSafe, efficient, & effective in almost all cases

2.2. InexpensiveInexpensive

3.3. Easy to administerEasy to administer

4.4. No monitoring equipment required in healthy No monitoring equipment required in healthy patientspatients

5.5. Patient remains fully concious with intact gag Patient remains fully concious with intact gag reflexreflex

6.6. Outdoor procedure ( convenient for patients)Outdoor procedure ( convenient for patients)

7.7. No pre-operative fasting requiredNo pre-operative fasting required

8.8. Immediate discharge without need for Immediate discharge without need for recovery periodrecovery period

Limitations of LALimitations of LA

1. Unsuitable for uncooperative patients ie 1. Unsuitable for uncooperative patients ie

**small childrensmall children

*patients who are *patients who are afraid of needlesafraid of needles

**anxiousanxious or or very nervous patientsvery nervous patients

2. Only 2. Only suitable for short proceduressuitable for short procedures – less – less than 45 minutesthan 45 minutes

3. 3. Difficult to anaesthetize inflamed tissuesDifficult to anaesthetize inflamed tissues effectively.effectively.

B. GENERAL ANAESTHESIAIndications

When there is When there is acute or subacute acute or subacute infectioninfection, because an LA injection may , because an LA injection may cause a flare up of infectioncause a flare up of infection

When the operation When the operation involves several involves several quadrantsquadrants of the mouth – of the mouth – is lengthyis lengthy – or – or difficultdifficult

for for young childrenyoung children and and nervous patientsnervous patients GA without intubation or inhalation GA without intubation or inhalation

anaesthesia should not be usedanaesthesia should not be used for for procedures lasting more than 5 minutesprocedures lasting more than 5 minutes

Advantages of GAAdvantages of GA

1.1. Excellent for Excellent for nervous & uncooperative nervous & uncooperative ptspts..

2.2. Creates an Creates an excellent operating excellent operating environament for the surgeonenvironament for the surgeon –who does –who does not have to deal with a restless & not have to deal with a restless & constantly moving patientconstantly moving patient

3.3. Complete amnesiaComplete amnesia for the patient for the patient

4.4. Permits virtually Permits virtually unlimited operating unlimited operating timetime

5.5. Caters for Caters for all types of surgical casesall types of surgical cases..

Disadvantages & Limitations of GADisadvantages & Limitations of GA

1.1. Very Very costlycostly

2.2. Patient has to fastPatient has to fast for at least 6 hours for at least 6 hours prior to surgeryprior to surgery

3.3. Requirement ofRequirement of a specialist a specialist anaesthetistanaesthetist

4.4. Post anesthetic recoveryPost anesthetic recovery and and monitoringmonitoring requiredrequired until patient until patient regains full conciousnessregains full conciousness

5.5. Potentially Potentially unsafe for elderly & unsafe for elderly & medically compromisedmedically compromised patients. patients.

C. C. SEDATION TECHNIQUESSEDATION TECHNIQUES

In oral surgery there are 3 methods of In oral surgery there are 3 methods of administering sedationadministering sedation

1.1. OralOral – for nervous patients, – for nervous patients, oral oral benzodiazepenesbenzodiazepenes such as such as diazepam 2-5 mgdiazepam 2-5 mg may be prescribed the night before & then 1 may be prescribed the night before & then 1 hour prior to surgeryhour prior to surgery

2.2. InhalationInhalation – –use of nitrous oxide through nasal use of nitrous oxide through nasal maskmask is acceptable to many pts, however is acceptable to many pts, however adequate sedation is difficult to maintain adequate sedation is difficult to maintain ( relative analgesia)( relative analgesia)

3.3. IntravenousIntravenous – – the most efficient, effective & the most efficient, effective & predictable methodpredictable method of sedation of sedation

Benzodiazepines(diazepam, midazolam) Benzodiazepines(diazepam, midazolam) are the most common sedation agents are the most common sedation agents usedused..

There are There are 3 important considerations 3 important considerations when when sedating a patient.sedating a patient.

1.1. Close monitoring-as for GAClose monitoring-as for GA – all sedated – all sedated pts should be pts should be monitored with aid of pulse monitored with aid of pulse oximetry & BP measurements & ECG oximetry & BP measurements & ECG during surgeryduring surgery..

2.2. Airway protectionAirway protection--sedated pts have sedated pts have reduced gag reflex-so airway must be reduced gag reflex-so airway must be protected with an oral pack behind the protected with an oral pack behind the surgical area.surgical area.

3.3. Flumazenil, is the for Flumazenil, is the for standard reversal standard reversal agent benzodiazepines & must always be agent benzodiazepines & must always be available in case of emergency.available in case of emergency.

D. D. DAY CARE SURGERYDAY CARE SURGERY

------ this is the this is the current conceptcurrent concept - due to - due to shortage of beds/indoor facilities at shortage of beds/indoor facilities at hospitals - hospitals - non critical ptsnon critical pts

Here the pt is intubated for GA and this Here the pt is intubated for GA and this type of surgery is generally suitable / type of surgery is generally suitable / indicated for non critical pts -- indicated for non critical pts -- for for procedures lasting upto 45 minutes or procedures lasting upto 45 minutes or so.so.

The post operative care is supervised by The post operative care is supervised by the nursing staff and then at home.the nursing staff and then at home.

3.3. PRINCIPLE OF ADEQUATE PRINCIPLE OF ADEQUATE ACCESSACCESS

A. Skin IncisionsA. Skin Incisions B. Mucoperiosteal Flaps B. Mucoperiosteal Flaps

C. Bone Removal C. Bone Removal

In this principle, we will talk about…In this principle, we will talk about…

Extra-oral :Extra-oral :

- - Skin incisionsSkin incisions to expose the facial to expose the facial skeleton skeleton

Intra-oral :Intra-oral :

- - Mucoperiosteal flaps & incisionsMucoperiosteal flaps & incisions

- - Bone removalBone removal - methods - methods

- uses of burs- uses of burs

- - Bone cutting InstrumentsBone cutting Instruments & their uses & their uses

INCISIONS AND FLAPSINCISIONS AND FLAPS

Skin incisions were first noted by Skin incisions were first noted by

Dupuytran in l834, who was confronted who was confronted with the corpse of a man who had with the corpse of a man who had stabbed himself with an awl, and stabbed himself with an awl, and found found that the wounds were elliptical rather that the wounds were elliptical rather than round.than round.

In 1861 K Langer, a , a Viennese professor of Viennese professor of anatomyanatomy, studied incisions , studied incisions and punctures wounds in and punctures wounds in cadavers. cadavers.

His results were published His results were published as a schematic as a schematic representation of the lines representation of the lines of greatest skin tension for of greatest skin tension for all regions of the body all regions of the body known as known as Langer's lines.

In 1907, Kocher,In 1907, Kocher, a Swiss surgeon set a Swiss surgeon set forth the principle that :forth the principle that :

‘ ‘ surgical incisions should be made surgical incisions should be made along these Langer Lines of normal along these Langer Lines of normal skin tension; in this way the skin skin tension; in this way the skin would be closed under would be closed under

- least amount of tension and - least amount of tension and

- resultant scar would be - resultant scar would be minimal.’minimal.’

Lines of skin tension as described Lines of skin tension as described by by

von Langer ( 1862 )von Langer ( 1862 )

Anatomical Structures which Influence the surgical approach to the facial bones

The face has a rich The face has a rich arterial supply - arterial supply - the the various arteries freely various arteries freely anastomose with each anastomose with each other & branches of other & branches of the opposite the opposite side,especially in the side,especially in the lips.lips.

Thus Thus wounds of the wounds of the face bleed freely and face bleed freely and heal rapidly.heal rapidly.

The Nerves of the Face The The Facial Facial

nerve(motor)nerve(motor) is shown is shown in blue and the in blue and the Trigeminal (sensory)Trigeminal (sensory) in in black.black.

1.Temporal br.of Facial 1.Temporal br.of Facial & zyomaticotemporal & zyomaticotemporal br.of Trigeminal.br.of Trigeminal.

2. & 3. Zygomatic 2. & 3. Zygomatic branchesbranches

4.Buccal branch4.Buccal branch5.Marginal mandibular 5.Marginal mandibular

br,br,6.Cervical branch 6.Cervical branch

Many oral and maxillofacial procedures involve incisions - a few basic principles are important to remember when giving incisions.

The The 11stst principle principle is that a is that a sharp bladesharp blade of proper size of proper size should be used. should be used.

A A sharp blade allows sharp blade allows incisions to be made incisions to be made cleanlycleanly without damage without damage caused by repeated caused by repeated strokes.strokes.

The The 22ndnd principle principle is is that a that a firm, continues firm, continues strokestroke should be should be used when incising. used when incising.

Repeated, soft Repeated, soft strokes increase the strokes increase the amount of tissue amount of tissue damage and damage and bleedingbleeding, thereby , thereby impair wound impair wound healinghealing..

The The 33rdrd principle principle is is that the surgeon that the surgeon should carefully should carefully avoid cutting vital structures like nerves and blood vessels, when incising.

The surgeon The surgeon should should incise only deeply incise only deeply enough to define the enough to define the next layer,next layer, and and any any vessels or nerves vessels or nerves encountered should encountered should be retracted awaybe retracted away from harms way.from harms way.

The The 44thth principle principle is that is that incisions through incisions through epithelial surfaces that epithelial surfaces that the surgeon plans to the surgeon plans to reapproximate should reapproximate should be made with the blade be made with the blade held perpendicular to held perpendicular to the epithelial layer.the epithelial layer.

This angle produces This angle produces wound edges that are wound edges that are square and therefore square and therefore easier to reorient easier to reorient properly during properly during suturing and less suturing and less susceptible to necrosis.susceptible to necrosis.

The The 55thth principle principle is that is that the incisions in the oral the incisions in the oral cavity should be cavity should be properly placed. properly placed.

It is It is desirable to incise desirable to incise through attached gingiva through attached gingiva and over healthy bone,and over healthy bone, than through unattached than through unattached gingiva and over gingiva and over unhealthy or missing unhealthy or missing bone. bone.

Properly placed incisions Properly placed incisions allow the wound margins allow the wound margins to be sutured over intact to be sutured over intact healthy bone, thereby healthy bone, thereby providing support for the providing support for the healing wound.healing wound.

Some additional pointsSome additional points.. 1.1. During extra-oral surgeryDuring extra-oral surgery, the , the

patients patients head and neck should be in head and neck should be in a straight forward unstrained a straight forward unstrained postureposture so that the landmarks will so that the landmarks will not be distorted.not be distorted.

2. When planning the incision, the 2. When planning the incision, the surgeon surgeon may elect to first draw the may elect to first draw the incision line on the skinincision line on the skin

3. Some surgeons 3. Some surgeons mark out the mark out the incision line with pen and inkincision line with pen and ink while while some, some, cross hatch the skin cross hatch the skin perpendicular to the incision line to perpendicular to the incision line to facilitatefacilitate accurate wound closureaccurate wound closure at at the end of surgery.the end of surgery.

4.4. When operating in vascular areas,When operating in vascular areas, the surgeon the surgeon may may modify the incision technique to reduce modify the incision technique to reduce bleeding bleeding ie use electrosurgery instead of the scalpel.

Another method to reduce bleeding, is the Another method to reduce bleeding, is the injection of vasoconstrictors into the area prior to incision.

5. In 5. In patients undergoing GA underpatients undergoing GA under halogenated halogenated agents, such as agents, such as halothane or enfluranehalothane or enflurane, the , the simultaneous use of simultaneous use of vasoconstrictors like vasoconstrictors like adrenaline may lead to cardiac arrythmias.adrenaline may lead to cardiac arrythmias. Therefore Therefore no adrenaline is to be used without the permission of the anaesthetist..

Skin incisions

Location of some of the commonly used extra-oral incisions in oral & maxillo-facial surgery are

shown in the following diagrams.

Submandibular Submandibular IncisionIncision is used is used for the surgery of for the surgery of the the body and the body and the angle of the angle of the mandiblemandible as well as well as the as the submandibular submandibular gland.gland.

Risdons IncisionRisdons Incision is employed for the is employed for the

surgery of the angle surgery of the angle and ramusand ramus area- it is a area- it is a slightly curved slightly curved incision. incision.

Both with the Both with the Submandibular and Risdons incisions care must be taken to avoid injury to the marginal mandibular branch of the facial nerve

Retromandibular Retromandibular IncisionIncision provides provides access to the ramus, access to the ramus, angle and condylar angle and condylar regionregion.. This incision This incision avoids the branches avoids the branches of the facial nerve, of the facial nerve, facial artery and vein.facial artery and vein.

This approach is used This approach is used for reconstruction of for reconstruction of the TM Joint for the TM Joint for agenesis or ankylosis.agenesis or ankylosis.

Pre-auricular Incision

is made within the skin is made within the skin anterior to the ear. anterior to the ear.

It providesIt provides access to access to the TM Joint.the TM Joint.

Temporary facial nerve Temporary facial nerve weakness involving the weakness involving the temporal or zygomatic temporal or zygomatic branches may occur branches may occur due to stretching of due to stretching of the skin flap.the skin flap.

Gillies Temporal Gillies Temporal approachapproach

is employed is employed for for reduction of the reduction of the fractured zygoma or fractured zygoma or zygomatic arch.zygomatic arch.

It is made in the It is made in the hairline and when hairline and when the hair re-grows it the hair re-grows it is well hiddenis well hidden

Supra - orbital or Brow Incision

is made is made without without shaving the hair shaving the hair and provides and provides access to the access to the lateral bony orbit lateral bony orbit and fronto-and fronto-zygomatic suture.zygomatic suture.

Infra - orbital or Lid Incision (subciliary or infra-orbital)

provides an approach to the inferior orbital region and the fronto - maxillary suture.

Al Kayat - Bramley IncisionAl Kayat - Bramley Incision is a modified preauricular is a modified preauricular approach to the TM Joint andapproach to the TM Joint and zygomatic arch. zygomatic arch. The skin incision is questionThe skin incision is question mark shaped, and the flap somark shaped, and the flap so developed gives excellentdeveloped gives excellent visibility and avoids injury tovisibility and avoids injury tothe branches of the facial the branches of the facial

nervenerve

Alkayat Bramley Alkayat Bramley

incisionincision

Bicoronal ( Bitemporal, Bifrontal)

flap provides better access to the

upper face This is essentially a

continuation of the pre-auricular incision which is carried superiorly across the scalp.

It must remain within the hairline & is important in males.

In children it should not be brought too forward, as the scar tends to drift anteriorly as the child grows.

PRINCIPLE OF ADEQUATE ACCESSPRINCIPLE OF ADEQUATE ACCESS

Mucosal incisions Mucosal incisions & Flaps& Flaps

Many oral surgery procedures involve Many oral surgery procedures involve incisions – therefore it is important to incisions – therefore it is important to remember a few basic principles when remember a few basic principles when giving incisions.giving incisions.

The The 11stst principle principle is that a is that a sharp bladesharp blade of proper size of proper size should be used. should be used.

A A sharp blade allows sharp blade allows incisions to be made incisions to be made cleanlycleanly without damage without damage caused by repeated caused by repeated strokes.strokes.

The The 22ndnd principle principle is is that a that a firm, continues firm, continues strokestroke should be should be used when incising. used when incising.

Repeated, soft Repeated, soft strokes increase the strokes increase the amount of tissue amount of tissue damage and damage and bleedingbleeding, thereby , thereby impair wound impair wound healinghealing..

The The 33rdrd principle principle is is that the surgeon that the surgeon should carefully should carefully avoid avoid cutting vital cutting vital structures like nerves structures like nerves and blood vessels, and blood vessels, when incising. when incising.

The surgeon The surgeon should should incise only deeply incise only deeply enough to define the enough to define the next layer,next layer, and and any any vessels or nerves vessels or nerves encountered should encountered should be retracted awaybe retracted away from harms way.from harms way.

The The 44thth principle principle is that is that incisions through incisions through epithelial surfaces that epithelial surfaces that the surgeon plans to the surgeon plans to reapproximate should reapproximate should be made with the blade be made with the blade held perpendicular to held perpendicular to the epithelial layer.the epithelial layer.

This angle produces This angle produces wound edges that are wound edges that are square and therefore square and therefore easier to reorient easier to reorient properly during properly during suturing and less suturing and less susceptible to necrosis.susceptible to necrosis.

The The 55thth principle principle is that the is that the incisions in the oral cavity incisions in the oral cavity should be properly placed. should be properly placed.

It is It is desirable to incise desirable to incise through attached gingiva through attached gingiva and over healthy bone,and over healthy bone, than through unattached than through unattached gingiva and over unhealthy gingiva and over unhealthy or missing bone. or missing bone.

Properly placed incisions Properly placed incisions allow the wound margins allow the wound margins to be sutured over intact to be sutured over intact healthy bone, thereby healthy bone, thereby providing support for the providing support for the healing wound.healing wound.

Mucosal Incisions and Mucosal Incisions and FlapsFlaps

FlapsFlapsThe The term FLAP indicates a section of soft indicates a section of soft

tissuetissue thatthat

1.1. Is Is outlined by surgical incisionoutlined by surgical incision2.2. Carries its own blood supplyCarries its own blood supply3.3. Allows surgical access to underlying Allows surgical access to underlying

tissuestissues4.4. Can be replaced in the orignal positionCan be replaced in the orignal position

andand5.5. Can be maintained in position with Can be maintained in position with

sutures and is expected to heal.sutures and is expected to heal.

The flap should be a The flap should be a full thickness muco - full thickness muco - periosteal flapperiosteal flap – this means that the flap includes – this means that the flap includes

- - surface mucosa,surface mucosa,

- - submucosasubmucosa & the & the

- - periosteumperiosteum

Importance /Sinificance of Full thickness FlapImportance /Sinificance of Full thickness Flap

Full thickness flaps are necessary because Full thickness flaps are necessary because the the periosteum is the primary tissue periosteum is the primary tissue responsible for bone healingresponsible for bone healing & &

- replacement - replacement of periosteum of periosteum in its in its orignalorignal

position hastens the healing position hastens the healing process.process.

- also- also torn, split and mascerated tissue torn, split and mascerated tissue

heals more slowly than a cleanly heals more slowly than a cleanly reflected, reflected, full thickness flap. flap.

TYPES OF FLAPSTYPES OF FLAPS

A. Full thickness – muco-periosteal flap

Partial thickness flapB. Envelope flap Two sided triangular flap Three sided rhomboid flap Semilunar flapC. Labial, buccal flaps Palatal, lingual flaps

MUCOSAL INCISIONS AND FLAPSMUCOSAL INCISIONS AND FLAPS

The The surgical approach should be so designedsurgical approach should be so designed, to , to * * provide maximum accessprovide maximum access * * minimum traumaminimum trauma. . Certain Certain rules of flap designrules of flap design are. are.1. Avoid severing large vessels and nerves - here your

knowledge of anatomy comes to help2. Place incisions away from the surgical area to

ensure the wound margins rest on sound bone. This avoids

the possibility of collapse of the flap into the bony

defect.3. Design the flap so that there is adequate visibility

without overexposure of bone.

4. The flap should be widest at the base than the apex to maintain proper blood supply and circulation.

[ [ In general,the flap base dimension ( x ) must not be less than the height( y ) and preferably the flap should have x=2y ]

That is how it will have a broad base.

When a releasing When a releasing incision is used to incision is used to reflect a two sided reflect a two sided flap, incision should flap, incision should be designed to be designed to maximise blood maximise blood supply by leaving supply by leaving wide base.wide base.

Design on the left is Design on the left is correct [ B ]correct [ B ]

Design on the right Design on the right is incorrect.is incorrect.

When ‘button hole’ When ‘button hole’ occurs near the free occurs near the free edge of the flap, edge of the flap, blood supply to the blood supply to the flap tissue on the flap tissue on the side away from the side away from the base is compromised.base is compromised.

5. Avoid horizontal and severely/acutely angled vertical

incisions

There should not be sharp angles on the flap. If there is a change in the direction of the incision, it should be in the form of a gentle curve.

Sharp or acute corners tend to slough because of poor circulation - this causes excessive scarring.

6. Maintain the integrity of the interdental papilla.

The papilla at the incision line is allowed to remain wheras the other papilla should be included in the flap.

Vertical incision placed Vertical incision placed

over interdental bone - over interdental bone - maintaing the integrity maintaing the integrity of the interdental of the interdental pappila. pappila.

7. Use sharp instruments to avoid tearing the mucoperiosteum. When a carefully reflected mucoperiosteal flap is repositioned and sutured, there is less tendency

for dehiscence ( flap margin separation ) and scar

formation.

8. Handle the flap very delicately. - forklike retractors or toothed tweezers/ toothed

tissue forceps should not be used to hold the flap. The retractor should be broad and contact the

bone, so that the flap rests passively on it.

9.9. Do not incise close to the gingival margin/ sulcus when using a horizontal or semicircular incision.

Lack of blood supply can cause a severe loss of gingival tissue.

There should be about 4mm of attached gingiva around each tooth.

10. The design of the flap should be such that

when the flap is retracted, it does not interfere with visibility or access.

Elevate / Retract the flap away from the line

of vision.

Three types of properly designed oral soft Three types of properly designed oral soft tissue flapstissue flapsA. Horizontal & one single vertical incision used to create a 2 sided flapB. Horizontal & 2 vertical incisions to create a 3 sided flapC. Single horizontal incision (sulcular) used to create single sided (envelope) flap

Classification of Incisions Classification of Incisions and Flapsand Flaps

1. 1. HorizontalHorizontal - This is rarely used - This is rarely used nowadays because of the natural nowadays because of the natural contours of the maxilla and mandible.contours of the maxilla and mandible.

2. 2. Semilunar ( Curved , Semilunar ( Curved , EllipticalElliptical ) ) - - Not used Not used commonlycommonly, and is used on , and is used on occasions when it is occasions when it is desirable to maintain the desirable to maintain the attached gingiva around attached gingiva around the margin of a the margin of a restoration. A restoration. A disadvantage of the disadvantage of the semilunar incisionsemilunar incision is is that that it often rests on the bony it often rests on the bony defect, causing a greater defect, causing a greater chance of dehiscence and chance of dehiscence and scar formationscar formation. .

A modification that A modification that generally follows the generally follows the bony contour can be bony contour can be used.used.

3. 3. Vertical Vertical - A vertical - A vertical incision incision sometimes called sometimes called the obliquethe oblique, is the , is the most most desirable to usedesirable to use. It may . It may be be single (triangular)single (triangular) or or double (trapezoidal)double (trapezoidal) depending on the access depending on the access requirements.requirements.

The The advantage of the advantage of the vertical incision are that vertical incision are that it provides greater access it provides greater access and visibilityand visibility, affords a , affords a greater view of the greater view of the periodontal defects and periodontal defects and bony fenestrations ( bony bony fenestrations ( bony openings/window) and openings/window) and heals with minimum heals with minimum amount of scar tissue.amount of scar tissue.

4 4 The Ochsenbein-The Ochsenbein-Leubke FlapLeubke Flap - This is a - This is a combination of the combination of the semilunar and vertical semilunar and vertical incisionsincisions and includes and includes some of the some of the advantages of both. advantages of both. This This flap is scalloped flap is scalloped to follow the gingival to follow the gingival contour.contour.

It is of advantage in It is of advantage in cases where there is cases where there is fear that elevation of fear that elevation of the attached gingival the attached gingival will cause shrinkage will cause shrinkage and exposure of the and exposure of the margin of margin of restorations.restorations.

5 5 Envelope FlapEnvelope Flap - - This flap is This flap is mainly mainly used for posterior used for posterior mandibular and mandibular and palatal surgerypalatal surgery. There . There is greater relaxation is greater relaxation of the flap if the of the flap if the incision are made incision are made aroud the necks of all aroud the necks of all the teeth in the the teeth in the quadrant. quadrant. A relaxing A relaxing incision can be added incision can be added at either end of the at either end of the flap if access is not flap if access is not adequate adequate

Wards Incision & flapWards Incision & flap

Y incisionY incision is useful is useful on on the palate for the palate for adequate accessadequate access to to remove the palatal remove the palatal torus.torus.

2 anterior limbs 2 anterior limbs serve as releasing serve as releasing incisionsincisions to provide to provide for greater access.for greater access.

EXPOSURE / REFLECTION EXPOSURE / REFLECTION OF OF

FLAPFLAP The mucoperiosteal flapThe mucoperiosteal flap is is

reflectedreflected with a Howarths with a Howarths periosteal elevator.periosteal elevator.

This is This is first inserted into the first inserted into the buccal/facial sulcusbuccal/facial sulcus where where the periosteum is loosely the periosteum is loosely attached, the first few attached, the first few millimeters at the edge of millimeters at the edge of the flap are the flap are gently freed gently freed along its peripheryalong its periphery..

Thereafter,Thereafter, it is it is reflected,evenly along reflected,evenly along its whole length by a its whole length by a clean movementclean movement with with the Howarths the Howarths periosteal elevator periosteal elevator pressed and kept pressed and kept firmly against the firmly against the bone.bone.

Lifting movements are Lifting movements are to be avoidedto be avoided as they as they tend to tear the tend to tear the tissues.tissues.

a) Start of reflection from vertical a) Start of reflection from vertical incisionincisionb) Reflection of marginal interdental b) Reflection of marginal interdental gingiva by gingiva by directing the periosteal elevator directing the periosteal elevator coronally.coronally.

As said earlier Surgical flaps are made to gain surgical access to an area or to move tissue from one place to the other. These flaps should be so designed so as to prevent the complications of flap surgery such as:

a)a) Flap necrosis: it can be prevented by the - the base of the flap being wider than the

apex - where ever possible, an axial blood supply should be included in the flap - the base of the flap should not be excessively

twisted or stretched as this may compromise

the blood supply of the flap.

b) b) Prevention of wound dehiscence:Prevention of wound dehiscence:

Flap margin dehiscence (separation) Flap margin dehiscence (separation) can can be prevented bybe prevented by

- - approximating the edges of flapsapproximating the edges of flaps over over

healthy bonehealthy bone - by - by handling the edges of the flaps handling the edges of the flaps

gently and kindlygently and kindly - and - and not placing the flap under not placing the flap under

tension.tension.

c) Prevention of flap tearing Soft tissue tearing can be

prevented by - by using sharp instruments - judicious elevation and

retraction and - by relieving incisions

CUTTING OF BONECUTTING OF BONE In oral surgery the cutting of bone to In oral surgery the cutting of bone to

provide ACCESS is done with :provide ACCESS is done with :

burs, burs,

chisels, chisels,

gouges, gouges,

rongeurs, rongeurs,

bone files and bone files and

microsaws.microsaws. The dental surgeon should be able to The dental surgeon should be able to

master the use of each.master the use of each.

1. 1. BURS AND HANDPIECE TECHNIQUEBURS AND HANDPIECE TECHNIQUE

This is the This is the most common methodmost common method employed for employed for removal of bone.removal of bone.

i)i) The The various types of bursvarious types of burs used are used are - surgical bone burs and - surgical bone burs and - tungsten carbide - tungsten carbide these burs have fewer serrationsthese burs have fewer serrations than the than the

conventional steel burs and are conventional steel burs and are less likely to clog.less likely to clog. ii)ii) BursBurs may be may be - long round, - long round, - cylindrical, - cylindrical, - tapered fissure or - tapered fissure or - rosebud shaped.- rosebud shaped. Vulcanite bursVulcanite burs are very useful in surgical are very useful in surgical

extractions extractions for uncovering the superficial aspectfor uncovering the superficial aspect of an unerupted tooth and of an unerupted tooth and for smoothening the for smoothening the socketssockets on completion of operation. on completion of operation.

To avoid overheatingTo avoid overheating the tissues and the tissues and clogging of the burclogging of the bur, , it must be it must be irrigated irrigated with normal salinewith normal saline..

iii)iii) Air turbine drill /Air rotor, should not be used

for bone cutting,, as the air under pressure as the air under pressure may may

be forced deeper into the tissues and be forced deeper into the tissues and produce produce

tissue emphysema, which can be very tissue emphysema, which can be very dangerous.dangerous.

BursBurs can be can be used in 2 waysused in 2 ways, either to , either to

- grind away bone or to - grind away bone or to

- remove blocks of bone.- remove blocks of bone.

Grinding is done with a rosehead /vulcanite Grinding is done with a rosehead /vulcanite or fissureor fissure bur bur with a gentle sweeping with a gentle sweeping motion leaving a smooth margin.motion leaving a smooth margin.

Blocks of bone are removed with fissure Blocks of bone are removed with fissure bursburs to make cuts through the cortex into to make cuts through the cortex into the medulla around an area which can be the medulla around an area which can be lifted out. lifted out.

2. 2. CHISEL AND MALLETCHISEL AND MALLET

Chisel is another Chisel is another method of bone removalmethod of bone removal..

BoneBone can also be can also be removed with a removed with a monobevel monobevel chiselchisel,, wheras wheras it can be it can be sectioned sectioned or or cut cut with a with a bi-beveled chiselbi-beveled chisel (or (or osteotomeosteotome ) )

Chisels are Chisels are available in various widthsavailable in various widths from from 3mm or more. 3mm or more. Tungsten carbide tipTungsten carbide tip on the chisel on the chisel helps to helps to maintain its beveled cutting sharpness.maintain its beveled cutting sharpness.

The The cutting edge of the chisel should be sharpcutting edge of the chisel should be sharp or or it it ‘‘bruisebruise’’ the bone or produce small flakes, the bone or produce small flakes, which will which will tempt the operator in applying tempt the operator in applying excessive forceexcessive force and thereby increase the risk of and thereby increase the risk of jaw fracturejaw fracture..

The surgical The surgical MalletMallet

should be should be evenly balancedevenly balanced

with a with a nylon nylon facing as itfacing as it

imparts less shock imparts less shock //jarringjarring

and is and is less noisyless noisy to the to the

patient.patient.

Chisels can be used either by Chisels can be used either by - hand or - hand or - with a mallet & must be supported against - with a mallet & must be supported against

slipping.slipping.

The The chisel ischisel is usedused to to - plane or smoothen the bone,- plane or smoothen the bone, or or - to cut out blocks of bone- to cut out blocks of bone..

The use of The use of chisels is contraindicatedchisels is contraindicated in older in older patients above 40 yearspatients above 40 years asas the the bone is brittlebone is brittle and the mandible and the mandible may shattermay shatter in different in different directions.directions.

3. Chisels and Burs3. Chisels and Burs

Combined use of chisels & burs can be used Combined use of chisels & burs can be used for either bone cutting or smoothening.for either bone cutting or smoothening.

A rosehead bur A rosehead bur is used is used to drill holes to the to drill holes to the

required depth in the bone, at intervals of 3 required depth in the bone, at intervals of 3 to 5 mm along the planned line of the cut to 5 mm along the planned line of the cut after this after this the holes are joined together with the holes are joined together with a chisel and the cut deepened until the a chisel and the cut deepened until the bone splits.bone splits.

This method is especially This method is especially useful for useful for removing large pieces of bone.removing large pieces of bone.

Chisels are used to Chisels are used to great advantage in great advantage in young patients, where the natural lines of young patients, where the natural lines of cleavage along the cleavage along the 'grain''grain' of bone are of bone are presentpresent. .

In theIn the mandiblemandible these ‘ these ‘grainsgrains’ ’ - run - run vertically in the ascendingvertically in the ascending ramusramus

and and - - parallelparallel to the to the posteriorposterior border border and and

- - horizontally in the bodyhorizontally in the body parallel to the parallel to the

occlusal surface.occlusal surface. In the maxilla there are no true 'grains'In the maxilla there are no true 'grains'

but the plates of bone are easily cutbut the plates of bone are easily cut

The The direction in which the chisel cutsdirection in which the chisel cuts is is determined determined by the angle of the beveled by the angle of the beveled surface.surface.

When used to When used to plane the boneplane the bone, the , the beveled face is placed against the bonebeveled face is placed against the bone and driven at the required depth to and driven at the required depth to shave off successive layers, just like a shave off successive layers, just like a carpenter does. carpenter does.

To To remove blocks of boneremove blocks of bone,, the the beveled beveled surface is usually turned towards the surface is usually turned towards the bone which is to be left bone which is to be left

RONGEUR forceps or RONGEUR forceps or BONE BONE

NIBBLERNIBBLER is the most is the most commoncommon

used instrument forused instrument for * * removing boneremoving bone,, * * bony spursbony spurs, or , or * * trimming the alveolar trimming the alveolar

process process Rongeurs are Rongeurs are * * available in various available in various

sizes, sizes, * * shapes with either either * side cutting or side cutting or * * side and end cutting side and end cutting

bladesblades..

4. Rongeurs and Bone 4. Rongeurs and Bone FilesFiles

Rongeur forcepsRongeur forceps have a have a spring between the spring between the handleshandles so thatso that when pressure is released the when pressure is released the instrument will openinstrument will open..

As rongeurs are delicate instrumentsAs rongeurs are delicate instruments

- only small amounts of bone should be removed small amounts of bone should be removed in in

multiple bites.multiple bites.

- they should- they should not be used to remove large not be used to remove large amount of bone amount of bone inin single bite.single bite.

BONE FILESBONE FILES

- are used for - are used for final final smoothening of bonesmoothening of bone prior to suturing. prior to suturing.

The bone file is The bone file is usually a usually a double ended instrumentdouble ended instrument with a small and large with a small and large end.end.

The teeth of the file are The teeth of the file are arrangedarranged in in such a such a fashion that they remove fashion that they remove bone only on a bone only on a pull pull stroke.stroke.

PushingPushing the bone file the bone file results in results in bruising andbruising and crushingcrushing the bonethe bone and and should be avoided.should be avoided.

5. BONE GOUGES5. BONE GOUGES

are are shaped like shaped like marrow spoonsmarrow spoons and and are are

* * useful for making a useful for making a hole in the thick layer hole in the thick layer of bone overlying a of bone overlying a cyst or other bone cyst or other bone cavitycavity

or for or for

** removing bone removing bone piecemeal from the piecemeal from the buccal aspect of a buccal aspect of a tooth or root to tooth or root to expose it, prior to its expose it, prior to its removal. removal.

6. MICROSAWSThe The microsaws microsaws are are used with special used with special

handpiecehandpiece provided provided alongwith the microelectric system.alongwith the microelectric system.

i) A i) A wide range of sawswide range of saws are available and the are available and the main onesmain ones used are used are

- - sagittalsagittal, , - reciprocating,reciprocating, & & - oscillatingoscillating saws saws ii) These saws are ii) These saws are - slim with safe edge bladeslim with safe edge blade - - provides maximum soft tissue protectionprovides maximum soft tissue protection

& & --permits exact & controlled cutspermits exact & controlled cuts

Micro-electric SystemMicro-electric System

MicrosawsMicrosaws

Foot ControlFoot Control

7. GIGLIS WIRE SAW

ii)) This system consists of wire saw with 2 handles, introducer & guide.

ii) this is used to & fro along its long axis to cut the bone & is usually used to cut the

mandible in hemi -mandibulectomy procedures.

iii) rarely used nowadays since newer & efficient methods have been introduced.

RETRACTION OF TISSUESRETRACTION OF TISSUES

It is the It is the MOST IMPORTANT FUNCTION MOST IMPORTANT FUNCTION PERFORMED BY THE ASSISTANTPERFORMED BY THE ASSISTANT

RetractionRetraction serves 2 objectives serves 2 objectives

a) a) provide free access to the surgeonprovide free access to the surgeon

b) serves b) serves toto protect the tissuesprotect the tissues The tissue layers which are divided by incision The tissue layers which are divided by incision

and dissection are gently held back with and dissection are gently held back with instruments instruments

- - there should be NO there should be NO pullingpulling or or rough handlingrough handling

- - ifif it felt the incision is small, it needs to be it felt the incision is small, it needs to be enlarged.enlarged.

  Therefore, in order Therefore, in order to to perform good surgeryperform good surgery,, it is it is essential to have a essential to have a good vision and good good vision and good accessaccess & for this & for this variousvarious types oftypes of RETRACTORS, RETRACTORS, both extra-oral & intra- both extra-oral & intra- oral, have been designed been designed to to retract theretract the

- - cheekscheeks,,

- tongue and- tongue and

- - mucoperiosteal mucoperiosteal flapsflaps..

Some of the Some of the retractorsretractors are so designed to are so designed to

- retract both theretract both the cheek cheek and mucoperiosteal flapsand mucoperiosteal flaps

simultaneously eg. simultaneously eg. Austins Austins

- Others are - Others are LangenbacksLangenbacks, , Seldins,Seldins,Tongue Tongue depressordepressor, ,

Cats paw.Cats paw.

    The The periosteal elevatorperiosteal elevator is is also also often usedoften used as the as the primary instrument to primary instrument to retract the soft tissueretract the soft tissue

    Mouth mirrorMouth mirror is also a is also a common instumentcommon instument to to retract the tongue, cheek.retract the tongue, cheek.

Remember…Remember… Damage can occur from compressing or Damage can occur from compressing or

cutting the lips or cheek against the teethcutting the lips or cheek against the teeth therefore avoid undue pressure at any one therefore avoid undue pressure at any one point, the point, the lips, tongue and cheek are best lips, tongue and cheek are best held back and retracted by broad bladed held back and retracted by broad bladed instruments.instruments.

The The blade of the retractorblade of the retractor under the under the mucoperiosteal flap mucoperiosteal flap should rest against the should rest against the alveolar bone.alveolar bone.

The The surgeon should pause at intervals to allow surgeon should pause at intervals to allow his assistant to rest and readjust his position.his assistant to rest and readjust his position.

CLEANING FIELD OF OPERATIONCLEANING FIELD OF OPERATION

This This task is also performed by the assistant totask is also performed by the assistant to - - clean the site of operation &clean the site of operation & - - removeremove fluids and debris, fluids and debris, otherwise, the surgeons viewotherwise, the surgeons view will be obscured - will be obscured - or or which if not removed, which if not removed, it it may remain in the may remain in the

tissues to become foreign bodies tissues to become foreign bodies

Large bony fragmentsLarge bony fragments should be should be lifted with lifted with finefine forcepsforceps

Blood, water and fine debris from cutting of Blood, water and fine debris from cutting of hard tissues with a bur can be hard tissues with a bur can be removed by removed by suctionsuction, positioned at a place of dependent , positioned at a place of dependent drainage.drainage.

At intervals sterile water must be At intervals sterile water must be aspirated to prevent blood clotting in the aspirated to prevent blood clotting in the tubing ortubing or

A A spare aspiration tip with a stilettospare aspiration tip with a stiletto should be kept handy and available.should be kept handy and available.

The The suction should not be used as a suction should not be used as a retractor or to explore wounds as it may retractor or to explore wounds as it may damage the tissues and encourage damage the tissues and encourage bleeding,bleeding, - you can use swabs in such - you can use swabs in such situations.situations.

4.4. PRINCIPLE OF CONTROL OF PRINCIPLE OF CONTROL OF HEMORRHAGE DURING SURGERYHEMORRHAGE DURING SURGERY

Local measures to control bleedingLocal measures to control bleeding Hypotensive anaesthesia etc Hypotensive anaesthesia etc

SignificanceSignificance

1. Prevention of excess blood loss is important for maintaining patients oxygen carrying capacity

2. Decreased visibility – even high volume suction cannot keep a surgical field completely dry, especially in the well vascularised oral and maxillofacial region.

3. To avoid formation of hematomas – hematomas cause pressure on wounds decrease vascularity increases wound tension acts as culture medium leading to wound infection.

Methods

1. Digital pressure is very useful for capillary or venous bleeding & as an immediate measure when a large vessel has been cut.

It is applied by compressing the tissues, or the offending vessel, against bone or in certain situations,such as the lip by exerting pressure between index finger and

thumb. The lingual artery may be controlled by drawing the

tongue so that the artery is pressed against the hyoid bone.

The facial artery crosses the lower border of the mandible where digital pressure can be applied.

2. 2. Hemostats or artery forcepsHemostats or artery forceps – –

when a vesselwhen a vessel is cut during operationis cut during operation it must be it must be found found swiftly swiftly andand secured with artery forceps. secured with artery forceps.

For For smaller vesselssmaller vessels after after twisting 2-3 timestwisting 2-3 times the the hemostat may be removed, but on hemostat may be removed, but on larger vessels they larger vessels they must be replaced by ligaturesmust be replaced by ligatures..

3. 3. Ligatures / SuturesLigatures / Sutures..

Direct ligatures of a vessel is performed before Direct ligatures of a vessel is performed before divisiondivision

Artery forceps are placed above and below where the Artery forceps are placed above and below where the cutcut is to be made is to be made and after divisionand after division non resorbable non resorbable ligatures/sutures are firmly tiedligatures/sutures are firmly tied and the and the hemostats hemostats removed.removed.

4. 4. PackingPacking

AAss a temporary measure - a ribbon gauze/ swab a temporary measure - a ribbon gauze/ swab soaked in saline may be packed into the operative or soaked in saline may be packed into the operative or traumatic wound and held under pressure for a short traumatic wound and held under pressure for a short time to arrest hemorrhage.time to arrest hemorrhage.

5. Another method of promoting 5. Another method of promoting haemostasis is by placing haemostasis is by placing vaso-vaso-constrictive substancesconstrictive substances, such, such as as adrenalineadrenaline, 1:1000 in distilled water , 1:1000 in distilled water applied topically to the bleeding wound applied topically to the bleeding wound or by applying procoagulants,or by applying procoagulants, such as such as Thrombin which Thrombin which acts on fibrinogen to acts on fibrinogen to form fibrin form fibrin or Collagenor Collagen in powder form in powder form or as an aqueous solution on gauze.or as an aqueous solution on gauze.

Mechanical Agents, such asMechanical Agents, such as

- fibrin foam,- fibrin foam,

- gelatin foam, - gelatin foam,

- oxidised cellulose and - oxidised cellulose and

- oxidised regenerated foam are - oxidised regenerated foam are substances which form a water wettable substances which form a water wettable meshwork and assist clot formation.meshwork and assist clot formation.

6.6. Electrocoagulation or CauteryElectrocoagulation or Cautery This may be This may be applied directly to the vessels orapplied directly to the vessels or by by passing passing

the current through the artery forceps clamping the the current through the artery forceps clamping the vessel.vessel.

If operating If operating under GAunder GA, the , the anaesthetist should be anaesthetist should be informed that electrocoagulation is to be used - in informed that electrocoagulation is to be used - in case explosive gases are usedcase explosive gases are used for anaesthesia. for anaesthesia.

When using electrocautery - When using electrocautery - ensure that no part of the ensure that no part of the patient touches the mettalic OT table or any other patient touches the mettalic OT table or any other mettalic object, so as to prevent electric burns. mettalic object, so as to prevent electric burns.

7.7. Bone:Bone:

Capillary oozing from the bone surfaces can be controlled Capillary oozing from the bone surfaces can be controlled

- by - by burnishingburnishing the bone with a small instrument the bone with a small instrument

- by application of - by application of hot packshot packs for a few minutes for a few minutes

- application of - application of bone waxbone wax

- arterial bleeding from a bone surface can be - arterial bleeding from a bone surface can be

controlled controlled by compressing, by forcing a wedge of by compressing, by forcing a wedge of

bone against the vessel.bone against the vessel.

8.8. Ligation of External carotid arteryLigation of External carotid artery--

In a major hemorrhage not controlled by local measures, it is at times necessary to ligate the ECA.

The collateral blood supply and the anastomosis is so good in the face that it is often necessary to do this on both the sides, if it is to be effective.

A sufficient blood supply is still maintained by other large vessels supplying the area.

9. Hypotensive Anaesthesia9. Hypotensive Anaesthesia

The use of The use of hypotensive drugshypotensive drugs such as such as hexamethonium & trimetaphen is said to have 2 hexamethonium & trimetaphen is said to have 2 great advantages:great advantages:

- it - it reduces bleedingreduces bleeding - - prevents shockprevents shock

Posture:Posture: gravity acting on the tilted patient results gravity acting on the tilted patient results in blood pooling in the dilated veins, and this leads in blood pooling in the dilated veins, and this leads to decreased venous return and hypotension. to decreased venous return and hypotension. Posture is also used to make the operation site Posture is also used to make the operation site ischemic.ischemic.

The blood pressure is said to be reduced 20 mm The blood pressure is said to be reduced 20 mm Hg for each 2.5 cm of vertical height above heart Hg for each 2.5 cm of vertical height above heart level, solevel, so that when the head is tilted 25* upwards, that when the head is tilted 25* upwards, the cerebral blood pressure is like to be 16mmHg the cerebral blood pressure is like to be 16mmHg less than BP at heart level. less than BP at heart level.

Hypotensive anaesthesia is mainly used in Hypotensive anaesthesia is mainly used in ::

1.1. NeurosurgeryNeurosurgery especially in vascular especially in vascular tumors & aneurysms – hypotension causes tumors & aneurysms – hypotension causes shinkage of the brain.shinkage of the brain.

2.2. Peripheral vascular diseasePeripheral vascular disease

3.3. Removal of Removal of vascular tumorsvascular tumors

4.4. Plastic surgeryPlastic surgery in operations on the nose in operations on the nose & lacrimal apparatus& lacrimal apparatus

5.5. Pelvic floor repair operations Pelvic floor repair operations

6.6. To reduce uncontrollable bleeding during To reduce uncontrollable bleeding during operations.operations.

5) PRINCIPLE OF DEBRIDEMENT AND DRAINAGE

( Toilet of Wounds ) DebridementDebridement DrainsDrains –types –types

DebridementDebridement

Once the surgery / operation is completed, the wound is prepared for closure by careful cleaning to remove all the debris – this debris is a major cause of post operative infection.

What does this mean …it means

1 All pathological tissue, that is - - necrotic tissue, - tooth / tooth follicle/ roots etc, - sinus tract are excised.2 Bony margins are smoothened without any sharp

edges. The bone cavity is saucerised where needed.3. The flaps are trimmed of all necrotic tissue, - tooth chips, bony pieces not attached to the

periosteum are removed from the wound, & - the wound thoroughly irrigated with saline.

Dead space elimination - Dead space elimination - drainagedrainage

Dead space is the area that remains devoid of tissue after closure of the wound.

- It is created as a result of removal of tissue

from the wound or - not suturing in multiple layers. The dead space is usually filled with

hematoma.

Purpose of DrainagePurpose of Drainage…..?…..?

After the operation, the wound needs to be After the operation, the wound needs to be

drained drained to relieve the pressure, especially when they are especially when they are

– – contaminatedcontaminated / / infectedinfected

– – where anwhere an abscess has been incisedabscess has been incised

– – or whenor when immediate closureimmediate closure is made is made over dead over dead

spacespace

Now this dead space may fill with blood or serum andNow this dead space may fill with blood or serum and

later become infected.later become infected.

How to avoid a dead space…..

1.1. Multiple layer suturing from the depth Multiple layer suturing from the depth to the surfaceto the surface

2.2. Use of pressure dressingsUse of pressure dressings for post-op for post-op period up to 18 - 24 hours.period up to 18 - 24 hours.

3.3. Use of surgical packing of the defect-Use of surgical packing of the defect-whenwhen its its not possible to approximate the not possible to approximate the wound marginswound margins

4.4. Use of drainsUse of drains along with pressure along with pressure dressingsdressings - -

Non suction/suction drains. Non suction/suction drains.

Drains - TypesDrains - Types1. Fine superficial drains:1. Fine superficial drains:

- - These areThese are made of piecesmade of pieces of rubber gloveof rubber glove

-- Are used in the wounds of the face Are used in the wounds of the face

toto allow escape of tissue exudatesallow escape of tissue exudates – –

- - usuallyusually removed after 48 hoursremoved after 48 hours..

2. Large superficial drains:2. Large superficial drains:

- - Corrugated rubber drain,

used in dental abscess to keep the wound edges apart to allow free flow of pus.

- Used mainly for extra-oral incision and drainage – &

- Also for large collections of pus drained intra-orally

3. 3. Deep drains:Deep drains:

Tubing-Tubing- with small holeswith small holes cut in its cut in its wall, iswall, is used in deep infections eg used in deep infections eg

- osteomyelitis- osteomyelitis of the jaws or of the jaws or

- to- to drain the antrum through the drain the antrum through the nosenose..

The tube should be of sufficient The tube should be of sufficient diameterdiameter

- to allow free- to allow free passage of fluid & passage of fluid &

- to allow irrigation - to allow irrigation with saline or with saline or

antibiotic solution.antibiotic solution.

4.Vaccum drains:4.Vaccum drains: - These are inserted at a point - These are inserted at a point

remote from the wound by means remote from the wound by means of a sharp stylet.of a sharp stylet.

- The stylet is then withdrawn - The stylet is then withdrawn leaving the tube drain in position.leaving the tube drain in position.

- The tube is then attached to a - The tube is then attached to a plastic bottle from which air has plastic bottle from which air has been removed.been removed.

The advantage of vacuum drain is that The advantage of vacuum drain is that they are inserted away from the they are inserted away from the operative wound, and that negative operative wound, and that negative pressure developed assists removal of pressure developed assists removal of fluidfluid

Some important Points about Drains

1. Drains should be inserted into the cavity at its most dependent point

2. They must be fixed by suture or other device to prevent them from falling out, or being drawn into, the wound.

3. They should be examined daily to ensure that they are patent and working.

4. They are removed when the discharge has ceased, usually 3rd to 7th day

5. Entries must be made in the patients record as to when they were put in and removed.

6. CLOSURE OF WOUNDS

Suturing - principles, and suture materials

GeneralGeneral

Before closure of the incision, the surgeon must ensure that

- bleeding has been controlled, - all swabs, instruments, teeth are accounted for.

Closure is carried out by suturing the wound for which many forms of

- needle holders, - needles and - suture materials are available.

Needle Holder

There are a There are a variety of needle variety of needle holdersholders, but one should , but one should use use the onethe one with which one feels with which one feels comfortable and functional.comfortable and functional.

Generally,Generally, a needle holder of a needle holder of 15 cms length15 cms length with a with a locking locking handlehandle is preferredis preferred..

It is It is held with the thumb and held with the thumb and ring finger through the rings ring finger through the rings and with the index finger and with the index finger along the length of the along the length of the needle holder to provide needle holder to provide stability and control.stability and control.

Needles Made of eitherMade of either stainless steel or or carbon carbon

steel. steel. Manufactured in Manufactured in two basic shapestwo basic shapes either either

straightstraight or or curvedcurved . . Needle points also vary - they generally also vary - they generally

come in either come in either tapered or cutting types.

The The straightstraight cuttingcutting needleneedle is used is used for for skinskin closureclosure in areas with adequate in areas with adequate accessaccess such as abdomen, thoracic or iliac such as abdomen, thoracic or iliac region.region.

In oral & In oral & maxillofacial regionmaxillofacial region straight needles are used for passage of circum are used for passage of circum zygomatic or circum-mandibular wires.zygomatic or circum-mandibular wires.

The The curved needlecurved needle is is generally usedgenerally used for for both skin & mucous membraneboth skin & mucous membrane surgery.surgery.

They are They are manufactured in varying manufactured in varying curvatures,curvatures,such as such as 1/4, 1/21/4, 1/2 & & 5/8 5/8 circle.circle.

The The cuttingcutting needleneedle have sharp edges have sharp edges that that allow the needle to penetrate allow the needle to penetrate toughtough tissues.tissues.

It is It is generally usedgenerally used for for keratinised mucosa,keratinised mucosa, or or subcuticular layerssubcuticular layers where where the tissue is difficult to where where the tissue is difficult to

penetrate.penetrate.

Needles also vary, in their Needles also vary, in their attachments for the suture material.attachments for the suture material.

In the In the swaged needle swaged needle the suture the suture material is inserted into the hollow material is inserted into the hollow during manufactureduring manufacture & the metal is & the metal is compressed around it.compressed around it.

Swagging Swagging simplifies handling & simplifies handling & causes lesscauses less tissue damagetissue damage during during suturing than caused by the ‘eyed’ suturing than caused by the ‘eyed’ needles.needles.

Swaged needle is not re-usableSwaged needle is not re-usable whereas the whereas the ‘eyed’ needle is ‘eyed’ needle is reusablereusable

Suture MaterialsSuture Materials

The basicThe basic purpose of the suturepurpose of the suture … …is to hold the cut tissues is to hold the cut tissues in close approximation until the healing process provides in close approximation until the healing process provides the wound with sufficient strengththe wound with sufficient strength to withstand the stress to withstand the stress without mechanical support.without mechanical support.

SuturesSutures are are available in various sizesavailable in various sizes, varying , varying from 2-0 tofrom 2-0 to extremely fineextremely fine 11-0 suture11-0 suture - the number of zeros in the - the number of zeros in the number, the smaller the diameter of the strand.number, the smaller the diameter of the strand.

5-0, 6-0 are generally used for skin closure5-0, 6-0 are generally used for skin closure in head & neck in head & neck while 3-0 or 4-0 are used intra-orally.while 3-0 or 4-0 are used intra-orally.

Sutures materials may be broadly classified into Sutures materials may be broadly classified into 2 groups – 2 groups – Absorbable Absorbable and and Non - absorbableNon - absorbable

ABSORBABLEABSORBABLE

1.1. Catgut:Catgut: errorneously called catgut – errorneously called catgut – - it is derived from - it is derived from sheepsheep intestinal submucosa intestinal submucosa oror bovine intestinal submucosa.bovine intestinal submucosa.

CatgutCatgut is an is an organic materialorganic material It is It is packed in isopropylpacked in isopropyl alcohol, as a preservativealcohol, as a preservative so so

that it can that it can remain soft & supple & can be easily remain soft & supple & can be easily knotted. knotted.

Catgut absorbs the the alcohol, causingCatgut absorbs the the alcohol, causing it to it to swellswell & & increase in diameterincrease in diameter -it is -it is irritatingirritating to the to the tissuestissues, therefore, it should be removed from the , therefore, it should be removed from the pack and pack and rinsed in saline before use.rinsed in saline before use.

Chromic catgut has the same properties as plain catgut but it has increased strength, because it has been tanned with chromic salts..

2. 2. Collagen:Collagen:

It is It is obtained by grinding of collagen tissue obtained by grinding of collagen tissue from tendons of cattle.from tendons of cattle.

Stronger than catgut,Stronger than catgut, but is but is absorbed earlierabsorbed earlier and and therefore, is therefore, is not used widelynot used widely. .

3. Poly-glycolic acid & poly-lactin:Poly-glycolic acid & poly-lactin:

These are These are synthetic polymerssynthetic polymers & produce & produce very little very little tissue reaction.tissue reaction.

These These sutures remain in the mouth for too long a time sutures remain in the mouth for too long a time (14days) to be used as absorbable sutures(14days) to be used as absorbable sutures

CCan be used as non-resorbable & removed in 5-7days.an be used as non-resorbable & removed in 5-7days.

AnotherAnother problem problem with with this material is that it does notthis material is that it does not slide easilyslide easily - it is recommended that this material - it is recommended that this material should be should be wetted with saline before tyingwetted with saline before tying..

NON – ABSORBABLENON – ABSORBABLE SUTURESSUTURES

SilkSilk

Most popular suture material for intra-oral use for intra-oral use – – is braided & hasis braided & has excellent handling properties.

Made from spun thread of silkwormMade from spun thread of silkworm – – has ahas a smooth surfacesurface and and uniform even fibre structure.

This is a This is a non-resorbable multifilament dyed material easy to seeeasy to see, , is is well tolerated by soft tissueswell tolerated by soft tissues and and tongue,tongue, is is easy to tie and does not come untied and does not come untied easily.easily.

It is inexpensive and produces a moderate tissue It is inexpensive and produces a moderate tissue reactionreaction

It has the lowest tensile strength - and in terms of It has the lowest tensile strength - and in terms of knot handling ability it ranks lowest amongst all knot handling ability it ranks lowest amongst all common suture materials. Therefore at least 3 ties common suture materials. Therefore at least 3 ties should be used for each knot.should be used for each knot.

Available in various sizes, from 1/0 to 7/0 - generally Available in various sizes, from 1/0 to 7/0 - generally 3/0 and 4/0 are used in oral surgery.3/0 and 4/0 are used in oral surgery.

2. 2. NylonNylon::

Is the Is the most popularmost popular skinskin suture material.suture material. Available in braided or mono-filamentAvailable in braided or mono-filament forms.forms.

HasHas tendency to tear through non - keratinised tissue, tendency to tear through non - keratinised tissue, therefore it is not frequently used intra-orally-therefore it is not frequently used intra-orally- tissue tissue reaction is minimalreaction is minimal

NylonNylon, as other synthetic polymer material , as other synthetic polymer material posseses posseses ‘memory’‘memory’ – – when tied the suture remembers that when tied the suture remembers that orignally it was a straight fibre, and knots slip and orignally it was a straight fibre, and knots slip and untie. Therefore,multiple knots are required to maintain untie. Therefore,multiple knots are required to maintain the tie.the tie.

3. 3. Cotton & LinenCotton & Linen::

Cotton sutureCotton suture is made from is made from natural fibres of natural fibres of cotton. cotton. Was commonly used in World War II Was commonly used in World War II when silk was unavailablewhen silk was unavailable

Its Its strength and tissue reaction is similar to silk.strength and tissue reaction is similar to silk. Handling characteristics are inferiorHandling characteristics are inferior..

Linen is somewhat stronger than cotton but Linen is somewhat stronger than cotton but otherwise it has the same characteristics.otherwise it has the same characteristics.

Not commonly used nowadays.Not commonly used nowadays.

4. Dacron polyester/polypropylene/Polyethylene/ Teflon or silicon coated Dacron polyester

These are These are synthetic braided materials, with synthetic braided materials, with minimal tissue reaction.minimal tissue reaction.

These materials exhibit great tensile strength and These materials exhibit great tensile strength and knot holding ability.knot holding ability.

The The teflon / silicon coating eliminates the teflon / silicon coating eliminates the absorption of tissue fluids and thereby reduces the absorption of tissue fluids and thereby reduces the rate of infection.rate of infection.

5. Stainless steel:

Used as monofilament or braidedUsed as monofilament or braided – and are the – and are the strongest and produce a secure knotstrongest and produce a secure knot

Used for Used for - - after cardiothoracic or open heart surgery for after cardiothoracic or open heart surgery for suturing the rib cagesuturing the rib cage or or - - used for scar revision in keloid forming patients.used for scar revision in keloid forming patients. - in oral surgery- in oral surgery they are they are used for tying arch bars / used for tying arch bars / suspension of splints / transosseous wiring in # cases suspension of splints / transosseous wiring in # cases

and not as a suture material and not as a suture material Mettalic sutures Mettalic sutures undergo slow degradation by undergo slow degradation by

corrosion and tissue reaction can occur with increased corrosion and tissue reaction can occur with increased susceptibility to infection.susceptibility to infection.

PRINCIPLES OF SUTURINGPRINCIPLES OF SUTURING

1.1. The needle holder should grasp the needle at The needle holder should grasp the needle at approximately ¾ from the distance of the point.approximately ¾ from the distance of the point.

2.2. The The needle should enter the tissues perpendicular to needle should enter the tissues perpendicular to the surface, as the tissues may be torn if placed the surface, as the tissues may be torn if placed obliquely.obliquely.

3.3. The The needle should be passed through the tissues needle should be passed through the tissues following the curve of the needle. Treating a curved following the curve of the needle. Treating a curved needle as straight will result in tearing of the tissues.needle as straight will result in tearing of the tissues.

Principles of Suturing…..contdPrinciples of Suturing…..contd

4. The 4. The suture should be placed at an equal distance of suture should be placed at an equal distance of 2-3mm from the incision on each side2-3mm from the incision on each side at an equal at an equal depth.depth.

This principle can be modifiedThis principle can be modified when the tissue edges when the tissue edges to be sutured are at different levels;to be sutured are at different levels; then the then the passage of the suture closer to the edge of the lower passage of the suture closer to the edge of the lower side & farther from the edge of the higher side will side & farther from the edge of the higher side will tend to approximate the levels.tend to approximate the levels.

Another methodAnother method involves involves the passage of the suture at the passage of the suture at an equal distance an equal distance from the wound margins on from the wound margins on both the both the sides, but deeper into the tissues of the deeper into the tissues of the lower sidelower side and more and more superficial on the higher sidesuperficial on the higher side. .

Principles of Suturing…..contdPrinciples of Suturing…..contd

5. 5. If one tissue side is free and the other fixed, then the If one tissue side is free and the other fixed, then the needle should be passed needle should be passed from the free to the fixed from the free to the fixed side.side.

6. If one tissue plane is is deeper than the other, the 6. If one tissue plane is is deeper than the other, the needle should be passed needle should be passed from the deeper to to the from the deeper to to the superficial tissues.superficial tissues.

7. 7. Some amount of tissue eversion is desirable in Some amount of tissue eversion is desirable in anticipation of scar contractureanticipation of scar contracture

8. 8. The tissues should not be closed under tension; if The tissues should not be closed under tension; if tension is present tension is present the tissue layer should be the tissue layer should be undermined to relieve it.undermined to relieve it.

Principles of Suturing…..contdPrinciples of Suturing…..contd

9. 9. The suture should The suture should be so tied that it approximates the be so tied that it approximates the tissues and not blanch themtissues and not blanch them..

10. The 10. The knot should NOT be placed on the incision line.knot should NOT be placed on the incision line.

11.Sutures should be placed 3-4 mm apart. Closer11.Sutures should be placed 3-4 mm apart. Closer sutures sutures are placed in areas in areas of underlying muscular are placed in areas in areas of underlying muscular activity eg.tongue.activity eg.tongue.

12. 12. Suturing should be so done as to prevent formation of Suturing should be so done as to prevent formation of ‘dog ears’‘dog ears’

SUTURING METHODSSUTURING METHODS

Interupted Sutures:Interupted Sutures: Most Most commonly usedcommonly used – – is strong & successive sutures is strong & successive sutures

can be placedcan be placed to meet individual requirements to meet individual requirements Each suture is independent of the nextEach suture is independent of the next and the and the

distance between sutures and incision line can be distance between sutures and incision line can be varied.varied.

The loosening of 1 suture will not produce loosening The loosening of 1 suture will not produce loosening of other sutures.of other sutures.

If the wound becomes infected, removal of a few If the wound becomes infected, removal of a few sutures will provide satisfactory treatment.sutures will provide satisfactory treatment.

This technique is preferred in areas of tension or This technique is preferred in areas of tension or where a strong closure is required. where a strong closure is required.

Instrument suturing technique: a) Tissue forceps are used to lift and stabilize the wound margin to allow passage of suture; b) one or two throws of the suture are made around the needle holder; c) the free end of the suture is grasped with the needle holder and passed through the loops; d) with the suture needle held in one hand and the needle holder in the other, the knot is completed and the two ends are drawn apart

A Interrupted skin sutures are placed after deep layers have A Interrupted skin sutures are placed after deep layers have been closed. been closed. B, Eversion of the skin margins should be produced with B, Eversion of the skin margins should be produced with interrupted skin sutures. C, Vertical mattress suture is a interrupted skin sutures. C, Vertical mattress suture is a useful in obtaining the proper eversion of the skin useful in obtaining the proper eversion of the skin margins. margins.

Suturing methods…..contdSuturing methods…..contd

Continuous suture:Continuous suture: This is a This is a rapid method of closure.rapid method of closure. Continuous suturing provides an even Continuous suturing provides an even

distribution of tension over the entire distribution of tension over the entire suture line.suture line.

If the tissues swell in one area, eg a If the tissues swell in one area, eg a hematoma, the remaining sutured area hematoma, the remaining sutured area can provide a degree of slackness and can provide a degree of slackness and help in release of pressure otherwise help in release of pressure otherwise the sutures may have to be removed.the sutures may have to be removed.

This suturing provides a watertight This suturing provides a watertight closure which is closure which is important in intra-oral bone grafting.

Suturing methods…..contdSuturing methods…..contdLocking continuous suture:This has 2 advantages over simple continuous suture1st, the suture aligns perpendicular

to the incision.2nd, the locking prevents continuous

tightening of suture as the wound closure

progresses.

Care should be taken to avoid over tightening

individual locks as excessive pressure may

lead to tissue necrosis.

Suturing methods…..contdSuturing methods…..contd

Mattress sutures:Mattress sutures:

Main Main purpose of mattress suture is to provide morepurpose of mattress suture is to provide more tissue eversion, tissue eversion, either in mucosal or skin margins than either in mucosal or skin margins than occurs with interuppted sutures.occurs with interuppted sutures.

It is also used in areas where wound contraction could It is also used in areas where wound contraction could cause dehiscence or broad scar formation.cause dehiscence or broad scar formation.

Generally used on skin surface such as abdomen and Generally used on skin surface such as abdomen and hips.hips.

Mattress sutures may be either Mattress sutures may be either verticalvertical or or horizontalhorizontal

Suturing methods…..contdSuturing methods…..contd

TheThe VVerticalertical mattress sutures has mattress sutures has the advantage that it runs parallel the advantage that it runs parallel to the blood supply of the flapto the blood supply of the flap

* does not interfere with healingdoes not interfere with healing * is especially designed for skin.* is especially designed for skin.

Interuppted Interuppted HHorizontalorizontal mattress mattress sutures produce broad contact of sutures produce broad contact of wound margins wound margins

Has the disadvantage of Has the disadvantage of constricting blood supply leading constricting blood supply leading to necrosis and dehiscenceto necrosis and dehiscence..

Suturing methods…..contdSuturing methods…..contd

Figure of 8:Figure of 8: This is This is used over extraction used over extraction

sites, where it provides sites, where it provides protection to the surgical protection to the surgical areaarea, , as well as adaption of as well as adaption of gingival papillae around gingival papillae around adjacent teeth.adjacent teeth.

This suture is This suture is also used to also used to keep the pack (whitehead keep the pack (whitehead varnish/benzoin pack ) inside varnish/benzoin pack ) inside the oral wound.the oral wound.

Subcuticular sutureSubcuticular suture In this procedureIn this procedure, the , the

needle penetrates skin needle penetrates skin ahead of the incision & ahead of the incision & exits within the wound.exits within the wound.

Needle is then inserted on Needle is then inserted on the opposite side of the the opposite side of the incision in a continuous incision in a continuous fashion. fashion.

At the end of the incision At the end of the incision the suture is brought out the suture is brought out at a distance from the at a distance from the wound.wound.

By pulling both ends of the By pulling both ends of the suture, the incision is suture, the incision is closed and the suture closed and the suture ends are taped to the skin ends are taped to the skin

Suspension suture (sling) - a type of surgical suturing

used when the flap being repaired is open on the lingual or facial side; surrounds the tooth by passing between the surrounding teeth and gum tissue.

The suture is adjustable and allows for adjustment of the flap for proper healing.

KnotsKnots

A knot is the intertwining of threads for A knot is the intertwining of threads for the purpose of joining them. the purpose of joining them.

The ends of sutures are joined in this The ends of sutures are joined in this manner – to ensure that they do not manner – to ensure that they do not become undone.become undone.

Types of knots :Types of knots : * single or half hitch* single or half hitch * grannys knot* grannys knot * reef knot or square knot* reef knot or square knot * triple throw knot* triple throw knot * surgeons knot* surgeons knot

Reef KnotReef Knot

Triple Throw knotTriple Throw knot

Surgeons KnotSurgeons Knot

Suture RemovalSuture Removal

Normally, intra-oral suture Normally, intra-oral suture in uncomplicated in uncomplicated cases may be removed within 5-7 days after cases may be removed within 5-7 days after placement.placement.

The The suture is held with tissue holding forceps & suture is held with tissue holding forceps & lifted above the surface and cut close to the the lifted above the surface and cut close to the the surface where it enters the tissues.surface where it enters the tissues.

Then when the suture is pulled out , it prevent Then when the suture is pulled out , it prevent contamination from the outer surface to the contamination from the outer surface to the inner tissue.inner tissue.

7. PRINCIPLE OF CONTROL & PREVENTION OF INFECTION

The incidence of The incidence of Post-op Infection can be can be reduced byreduced by:: 1. Careful pre-op preparation1. Careful pre-op preparation 2. Adopting an aseptic technique during surgery2. Adopting an aseptic technique during surgery 3. Minimising trauma during surgery and3. Minimising trauma during surgery and 4. Adequate drainage4. Adequate drainage

Post-operatively Post-operatively the tissues may be protected by use of the tissues may be protected by use of dressings.dressings. The The primary function of dressingsprimary function of dressings is to: is to:       keep the surgical field free of infectionkeep the surgical field free of infection. .       secondly, secondly, support the incisionsupport the incision         protect it from trauma and absorb protect it from trauma and absorb

drainagedrainage. .

1. In the mouth the surgical incisions are not dressed except where there is deficiency of mucous membrane over bone, when packs are used to cover it.

2. Small skin incisions are normally dressed with dry gauze, until the formation of serous exudation has stopped, when they are left uncovered.

3. More extensive wounds & abrassions are covered with ‘tulle gras & dry gauze’ strapped into position with adhesive surgical tape.

4. 4. When a drain has been placedWhen a drain has been placed – a piece of gauze is placed – a piece of gauze is placed around it around it for supportfor support, & to , & to absorbabsorb the discharge.Cotton wool is the discharge.Cotton wool is held over it by a bandageheld over it by a bandage or strapping which should or strapping which should completely cover the dressing.completely cover the dressing.

55. When it is not possible to close the wound primarily . When it is not possible to close the wound primarily Packs Packs are used to are used to

- protect exposed bone or - to prevent skin or mucous membrane from closing over a wound which should heal from its base by granulation. its base by granulation.

Ribbon gauzeRibbon gauze impregnated with BIPP or whitehead varnishimpregnated with BIPP or whitehead varnish is is packed firmlypacked firmly but not tightly but not tightly into theinto the cavitycavity..

When inserted When inserted under GA, packs must be sutured lest they under GA, packs must be sutured lest they become loose & obstruct the airway.become loose & obstruct the airway.

DressingsDressings

Pressure dressing Pressure dressing applied with self applied with self adhesive elastic adhesive elastic bandagebandage

Pressure dressing Pressure dressing applied with tape applied with tape over gauze.over gauze.

Nowadays Nowadays micropore can be micropore can be used as a tape used as a tape minus the gauze.minus the gauze.

Gauze dressing placed over the Gauze dressing placed over the drain for support & to absorb drain for support & to absorb drainage and presure dressing drainage and presure dressing applied over the ramus areaapplied over the ramus area

Antibiotic Therapy:Antibiotic Therapy: In oral surgery, itIn oral surgery, it is is impossible to obtain a impossible to obtain a

sterile fieldsterile field and many and many patients presentpatients present with with acute or chronic inflammatoryacute or chronic inflammatory conditions such conditions such as periodontal disease, pericoronitisas periodontal disease, pericoronitis or or contaminated fractures.contaminated fractures.

There are There are different views on the use of different views on the use of antibiotic therapy, antibiotic therapy, but they should but they should not be a not be a substitutesubstitute for for adherence to aseptic technique. adherence to aseptic technique.

For this reason, manyFor this reason, many oral surgeons prefer to oral surgeons prefer to operate under antibiotic cover, but it should operate under antibiotic cover, but it should not be prescribed routinely. Each casenot be prescribed routinely. Each case must be must be assessed individuallyassessed individually & & bacterial culture & bacterial culture & ABSTABST performedperformed where indicated.where indicated.

POST-OPERATIVE POST-OPERATIVE CARECARE

Post-op instructionsPost-op instructions Physiology of cold & HeatPhysiology of cold & Heat Control of Infection-antibioticsControl of Infection-antibiotics Control of swelling-anti-Control of swelling-anti-inflammatory agentsinflammatory agents

– – corticosteroidscorticosteroids Long term follow up – Long term follow up – significance.significance.

1.1. Post – operative Instructions Post – operative Instructions for cases for cases operated under General operated under General Anaesthesia.Anaesthesia.

Post-operative instructions are given at Post-operative instructions are given at the end of the operation for the the end of the operation for the immediate need of the patients immediate need of the patients to to cover the period of recovery from the cover the period of recovery from the anesthesia until conciousness is regained.anesthesia until conciousness is regained.

The following routine orders for The following routine orders for immediate post-operative care are issued:immediate post-operative care are issued:

a) Take blood pressure& pulse every ½ hour for a) Take blood pressure& pulse every ½ hour for 2 hours, then every hour until constant.2 hours, then every hour until constant.

b) Turn the patient on alternate sides every hour b) Turn the patient on alternate sides every hour to prevent chest complications such as to prevent chest complications such as congestion and atelectasiscongestion and atelectasis

c) Give the patient a medium headrest and c) Give the patient a medium headrest and elevate the head when patient regains elevate the head when patient regains conciousness to prevent coughing. Deep conciousness to prevent coughing. Deep breathing to be encouraged.breathing to be encouraged.

d) After long operations give IV infusion of 5% or d) After long operations give IV infusion of 5% or 10% dextrose in water. If considerable blood 10% dextrose in water. If considerable blood has been lost, a blood transfusion is given.has been lost, a blood transfusion is given.

e) e) Analgesics for painAnalgesics for pain should be prescribed. should be prescribed. MorphineMorphine c contraindicated in head injury & ontraindicated in head injury &

alsoalso if IMFif IMF has been used, since it may has been used, since it may cause relaxation & cause relaxation & allow the tongue to fall allow the tongue to fall backback and cause and cause loss of pharyngeal reflexesloss of pharyngeal reflexes and and obstruction of airway.obstruction of airway.

f) f) Antibiotics therapyAntibiotics therapy should be continued if should be continued if started pre-operativelystarted pre-operatively – it may be given IV – it may be given IV during or immediately postoperatively and during or immediately postoperatively and later continued in a regular manner.later continued in a regular manner.

g) Since the g) Since the post operative orders cancel all post operative orders cancel all pre-operative orders, it is essential to renew pre-operative orders, it is essential to renew the medications one desires to continuethe medications one desires to continue during the post-operative period.during the post-operative period.

g) g) HydrotherapyHydrotherapy may be prescribed in the may be prescribed in the form of form of cold compressescold compresses or packs or packs to to prevent traumatic swellings.prevent traumatic swellings.

A folded towel soaked in ice cold water A folded towel soaked in ice cold water or ice bags may be used - the important or ice bags may be used - the important thing is to apply it immediately.thing is to apply it immediately.

h) h) Fat free fluidsFat free fluids in the form of in the form of waterwater, , teatea, , without milk or cream, orange juice without milk or cream, orange juice may be given – post nausea.may be given – post nausea.

i) i) Good oral hygiene should be maintainedGood oral hygiene should be maintained

in the form of in the form of hot irrigationhot irrigation using using antiseptics. antiseptics.

2. Post-operative instructions – care of mouth after Minor Oral Surgery under LA INSTRUCTIONS TO PATIENTS

1. Do not rinse your mouth for at least six (6) hours after extraction/ surgery.

Do not disturb the blood clots by sucking or putting fingers in the mouth.

Application of ice packs in the first four hours will help to reduce swelling.

2. You may eat and drink after removal of the pack, but hot substances, alcohol and smoking should be avoided for 24 hours

3. Vigorous activity should be avoided for the remainder of the day ie rest.

4.. Be careful not to bite the numbed cheek, lip or tongue.

5. There should be very little bleeding following surgery, but if this persists then again bite firmly on a gauze pad over the wound. If bleeding continues then contact the Dental Surgeon/surgery.

6. Following surgery in the mouth there is local swelling which reaches a maximum in 2-3 days, after which it subsides gradually.

Frequent hot or lukewarm water washes (1/2 teaspoon of salt to a 200ml. glass), helps in the reduction of the swelling, and should begin on the day following surgery and continued over the next 5 days.

7. Post-operative pain should not be severe. If present it should be controlled by the analgesics

prescribed for pain. When necessary the prescribed amount can be taken every four hours, but if pain persists, the patient should report to the Dental Surgeon / Surgery.

8. It is most important to keep the mouth clean following an operation, and toothbrush and toothpaste should be used freely, in addition to mouth-washes.

9. Food and non-alcoholic fluids can be taken freely according to the patient's tolerance.

10. In cases of complication or severe bleeding, treatment is available at the hospital.

PhysiotherapyPhysiotherapy

PhysiotherapyPhysiotherapy in the form of in the form of

* radiant heat* radiant heat

* active and passive stretching* active and passive stretching

* massage, ultrasound and* massage, ultrasound and

* muscle exercises* muscle exercises

are useful in the treatment of infections are useful in the treatment of infections and may be and may be of advantage in the re-of advantage in the re-establishment of function of muscles, establishment of function of muscles, nerves and joints.nerves and joints.

Physiology of Cold & HeatPhysiology of Cold & Heat

COLDCOLD causes causes vaso-constriction of the capillary vessels reduces the blood and lymphatic flow & lowers tissue metabolism locally

Cold in the form of Cold in the form of ice packsice packs or or cold cold compressescompresses is applied is applied as soon as possible as soon as possible after injury or operationafter injury or operation

It should be It should be intermittently appliedintermittently applied to the to the affected part affected part for nofor no longer than 15 to 30 longer than 15 to 30 minutesminutes of of each houreach hour..

Once infection has become established, cold is contra-indicated.

Cold penetrates the tissues to a greater depth Cold penetrates the tissues to a greater depth than heat and is an effective anodyne. than heat and is an effective anodyne.

HEATHEAT causes causes

vasodilationvasodilation – – dilationdilation of the cappilaries of the cappilaries

increases the peripheral blood and lymphatic increases the peripheral blood and lymphatic flowflow and and

accelerates tissue metabolism locally.accelerates tissue metabolism locally.

phagocytosis is aided phagocytosis is aided

the body defence machanism is augmented to the body defence machanism is augmented to fight infection.fight infection.

Heat stimulates the lymphatic drainageHeat stimulates the lymphatic drainage & helps to & helps to localise the infection or bring about resolution.localise the infection or bring about resolution.

However However too much heat may do harm by producing too much heat may do harm by producing extra-cellular edema.extra-cellular edema.

Heat is Heat is applied in the formapplied in the form of of hot water mouth hot water mouth bathsbaths or or gargles, hot packsgargles, hot packs or or poulticespoultices ( not ( not recommended nowadays)recommended nowadays)

Post –operative RoundsPost –operative Rounds All patients in the post-operative state All patients in the post-operative state

must be evaluated completely for any must be evaluated completely for any evidence of complications that affect or evidence of complications that affect or prolong recovery.prolong recovery.

Progress notes during post-op rounds Progress notes during post-op rounds should include:should include:

1. Level of conciousness1. Level of conciousness 2. Patency of airway2. Patency of airway 3. Evaluation of pts cardiorespiratory 3. Evaluation of pts cardiorespiratory

systemsystem 4. TPR & BP4. TPR & BP 5. Skin warmth & colour5. Skin warmth & colour

6. Fluid intake & output6. Fluid intake & output

7. Condition of the wound7. Condition of the wound

8. Survey of the ward MO’s & 8. Survey of the ward MO’s & sisters notessisters notes

9. Attending to patients specific 9. Attending to patients specific complaints.complaints.

Follow –up Follow –up ExaminationExamination

Periodic follow upPeriodic follow up is is

* * beneficial for the patientbeneficial for the patient to assess his to assess his progress progress

* * extremely useful for the clinician to accurately extremely useful for the clinician to accurately

evaluate the treatment and evaluate the treatment and

* * draw valuable conclusions regarding diagnosis draw valuable conclusions regarding diagnosis

and prognosis.and prognosis. The follow up examination in malignant lesions in The follow up examination in malignant lesions in

particularly importantparticularly important – – pts should be carefully pts should be carefully examined for local & metastatic recurrence, first at examined for local & metastatic recurrence, first at very short intervals & later every 2-3 months.very short intervals & later every 2-3 months.

That’s it…… thanks