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Instrumentation for Basic oral surgery

INCISING TISSUE

Scalpel

- composed of a reusable handle and a disposable, sterile sharp blade.

- the most commonly used handle for oral surgery is the No. 3 handle

(Fig. 6-1).

- The most commonly used scalpel blade for intraoral surgery is the No. 15 blade

(Fig. 6-2).

- The No. 11 bladeis a sharp-pointed blade that is used primarily for making small

stab incisions, such as for incising into an abscess.

- The hooked No. 12 bladeis useful for muco-gingival procedures in whichincisions are made on the posterior aspect of teeth or in the maxillary tuberosity

area.

- Hold in the pen grasp to allow maximal control (Fig. 6-4).

- Mobile tissue should be held firmly in place under some tension.

- When a mucoperiosteal incision is made, the blade should be pressed down

firmly so that the incision penetrates the mucosa and periosteum with the same

stroke.

- Dull blades do not make clean, sharp incisions in soft tissue and therefore should

be replaced before they become overly dull.

ELEVATING MUCOPERIOTEUM

Periosteal elevator

- The instrument that is most commonly used in oral surgery is the No. 9 Molt

periosteal elevator(Fig. 6-5).

- This instrument has a sharp, pointed end (used to begin periosteal reflection and

to reflect dental papillae from between teeth) and a broader, rounded end (used

to continue the elevation of periosteum from the bone).

- can be used to reflect tissue by three methods:

First, the pointed end can be used in a twisting, prying motion to elevatesoft tissue. This is most commonly used when elevating a dental papilla

from between teeth or the attached gingiva around a tooth to be extracted.

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Second method is the push stroke, in which the pointed or the broad end ofthe instrument is slid underneath the periosteum, separating it from the

underlying bone. This is the most efficient stroke and results in the cleanest

reflection of periosteum.

Thirdmethod is a pull stroke. This method is occasionally useful but tendsto shred or tear the periosteum unless it is done carefully.RETRACTING SOFT TISSUE

- The two most popular cheek retractors are :

The right angle Austin retractor(Fig. 6-6) The broad offset Minnesota retractor(Fig. 6-7)

- These retractors can also be used to retract the cheek and a mucoperiosteal flap

simultaneously.- The Seldin retractor(Fig. 6-8) used to retract oral soft tissues. the leading edge

is not sharp but instead is smooth; it should not be used to elevate

mucoperiosteum.

- The No. 9 Molt periosteal elevatorcan also be used as a retractor. Once the

periosteum has been elevated, the broad blade of the periosteal elevator is held

firmly against the bone, with the mucoperiosteal flap elevated into a reflected

position.

- The mouth mirrorcan be used as a tongue or cheek retractor.

- The Weider tongue retractoris a broad, heartshaped retractor that is serratedon one side so that it can more firmly engage the tongue and retract it medially

and anteriorly (Fig. 6-9 , A ).

- A towel clip(see Fig. 6-28) can also be used to hold the tongue (when taking

biopsy). Local anesthesia must be profound where the clip is placed.

GRASPING SOFT TISSUE

-To incise it, stop bleeding or to pass a suture needle.

- The tissue forceps most commonly used for this purpose are the Adson forceps(Figure 6-10, A ). These are delicate forceps with or without small teeth at the

tips, which can be used to hold tissue gently and thereby stabilize it.

- care should be taken not to grasp the tissue too tightly, which will crush the

tissue.

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- longer forceps that have a similar shape are the Stillies forceps. These forceps

are usually 7 to 9 inches long and can easily grasp tissue in the posterior

part of the mouth (Fig. 6-10, B ).

- Angled forceps: the college, or cotton, forceps(Fig. 6-10,B ). they are an excellent instrument for picking up loose fragments of tooth,

amalgam, or other foreign material and for placing or removing gauze packs.

- Locking handles and teeth forceps: Allis tissue forceps (Fig. 6-11 , A and B ) that

will grip the tissue firmly when removing larger amounts of tissue or doing

biopsies, such as in an epulis fissurata. The Allis forceps should never be used on

tissue that is to be left in the mouth because they cause a relatively large amount

of tissue destruction as a result of crushing injury (Fig. 6-11 , C). However, the

forceps can be used to grasp the tongue in a manner similar to a towel clamp.

CONTROLLI NG HEMORRHAGES

-Hemostat (Fig. 6-12 , A) come in a varietyof shapes, may be small and delicate

or larger, and are straightor curved.

- Most commonly used in surgery is acurved hemostat(Fig. 6-12, B).

- A hemostat has long, delicate beaks used to grasp tissue and a locking handle.

- The locking mechanism allows the surgeon to clamp the hemostat onto a vessel

and then let go of the instrument.

- The hemostat is especially useful in oral surgery to remove granulation tissuefrom tooth sockets and to pick up small particles that have dropped into the

wound or adjacent areas.

REMOVING BONE

Rongeurs

- The instrument most commonly used for removing bone in dentoalveolar

surgery is the rongeur forceps. This instrument has sharp blades.-Rongeur forceps have a mechanism incorporated so that when hand pressure is

released, the instrument reopens (Fig. 6- 13, A ).

- The two major designs :

(1) side-cutting forceps

(2) side- and end-cutting forceps(Blumenthal rongeurs) (Figure 6-13, B ).

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- The side- and end-cutting forceps are more practical because they can be

inserted into sockets for removal of interradicular bone, and they can also be

used to remove sharp edges of bone.

- Rongeurs can be used to remove large amounts of bone efficiently and quickly.

- Rongeurs are delicate instruments, so smaller amounts of bone should beremoved in multiple bites, Likewise the rongeurs should never be used to remove

teeth.

Bur and Hand piece

- High-speed, hightorque handpieces with sharp carbide bursremove cortical

bone efficiently. (Fig. 6 -14) .

large bone bur-> when large amounts of bone must be removed, such as intorus reduction.

Fissure bur-> for sectioning of teeth Round bur-> for removal of bone overlying impacted tooth

- The handpiece must not exhaust air into the operative field, to prevent the

occurrence of emphysema.

Mallet and Chisel (Fig. 6 - 15)

- Often used when removing lingual tori.

- The edge of the chisel must be kept sharp.- Two types of chisel :

Mono-bevel -> used mainly for bone cutting. Bi-beveled -> used in the past for sectioning of teeth.

Bone File

- Used for final smoothing of bone before suturing a mucoperiosteal flap

back into position (Fig. 6-16 , A ).

- A double-ended instrument with a small and large end.- Cannot be used efficiently for removal of large amounts of bone.

- removes bone only on a pull stroke (Fig. 6-16, B).

REMOVING SOFT TISSUE FROM BONY CAVITIES

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- Periapical curette ->commonly used for oral surgery is an angled, double-ended

instrument used to remove soft tissue from bony defects (Fig. 6-17 ).

- The principal use is to remove granulomas or small cystsfrom periapical lesions

- Differ from the periodontal curette in design and function.

SUTURING SOFT TISSUE

Needle Holder

- Instrument with a locking handle and a short, blunt beak (Fig. 6-18).

- For intraoral placement of sutures, a 6-inch (15-cm) needle holder is usually

recommended

- The beaks of a needle holder are shorter and stronger than the

beaks of a hemostat (Fig. 6-19).- The face of a beak of the needle holder is crosshatched to permit a positive

grasp of the suture needle. (The hemostat has parallel grooves).

- Holding: The thumb and ring finger are inserted through the rings. The index

finger is held along the length of the needle holder.

Suture Needle

- A small half-circle or three-eighths-circle suture needle (Fig. 6-21, A ).

- The tips: either tapered, or triangular that allow them to be cutting needles (acutting needle will pass through mucoperiosteum more easily than a tapered

needle)

- The cutting portion: extends about one third the length of the needle,

and the remaining portion of the needle is round.

- Care must be taken with cutting needles because they can cut through tissues

lateral to the track of the needle.

- Held: approximately two thirds of the distance between the tip and the base of

the needle (Fig. 6-22).

Suture Material

- Classified by:

Diameter:- The size of suture relates to its diameter and is designated by a series of zeros,

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the larger the number the smaller the diameter.

- The diameter most commonly used in the suturing of oral mucosa is 3-0 (000).

Resorbability: Nonresorbable: silk, nylon, vinyl, and stainless steel.The most commonly used nonresorbable suture in the oral cavity is silk

(ex: 3-0 black silk).

Resorbable: Natural:

- primarily made of gut.

Plaincatgutresorbs quickly in the oral cavity, rarely lastinglonger than 3 to 5 days.

Chromic gut (treated by tanning solutions) lasts longer-upto 7 to 10 days.

Synthetic: Polyglycolic Polylactic acid- long chains of polymers braided into suture material

- resorb slowly, taking up to 4 weeks.

Monofilament or Polyfilament: Monofilament: plain catgutandchromic gut, nylon, and stainless steel. Polyfilament: silk, polyglycolic acid, and polylactic acid.

* Polyfilament sutures are easy to handle and tie and rarely come untied. The cut

ends are soft and nonirritating to the tongue and surrounding

soft tissues. However, they tend to "wick" oral fluids along the suture to the

underlying tissues. This wicking action may carry bacteria along with the

saliva.

*Monofilament sutures do not cause this wicking action

but may be more difficult to tie, tend to come untied, and the

cut ends are stiffer and therefore more irritating to the tongueand soft tissues.

Scissors

Suture scissors: (Fig. 6-23)

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- Usually have short cutting edges, slightly curved long handles with thumb and

finger rings, and serrated blades that make cutting sutures easier.

- The most commonly used suture scissors for oral surgery are the Dean scissors.

Tissue scissors: (Fig. 6-24) Iris scissors-> are small, sharp-pointed, delicate tools used for fine work. Metzenbaum scissors-> are used for undermining soft tissue and for

cutting, they can have either sharp or blunt (rounded) tips.

- They can have straight or curved blades.

- Tissue scissors should not be used to cut sutures because the suture material

will dull the edges of the blades.

HOLDING THE MOUTH OPEN

Bite block (Fig. 6-25)- The bite block is a soft, rubberlike block on which the patient can rest the teeth.

- Bite blocks come in several sizes.

- The bite block must be positioned more to the posterior of the mouth.

- For most adult patients a pediatric-sized bite block is adequate.

Molt mouth prop(side-action mouth prop) (Fig. 6-26)- This mouth prop has a ratchet-type action, opening the mouth wider as the

handle is closed.- Should be used with caution because great pressure can be applied to the teeth

and temporomandibular joint, and injury may occur with injudicious use.

- Useful in patients who are deeply sedated or have mild forms of trismus.

SUCTIONING

- To provide adequate visualization, blood, saliva, and irrigating solutions must be

suctioned from the operative site.

- The surgical suction is one that has a smaller orifice than the typeused in general dentistry (Fig. 6-27, A).

- The Fraser suction (Fig. 6-27, B) has a hole in the handle portion that can be

covered as needed. When hard tissue is being cut under copious irrigation, the

hole is covered so that the solution is removed rapidly. When soft tissue is being

suctioned, the hole can be left uncovered to prevent tissue injury or soft tissue

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obstruction of the suction tip.

HOLDING TOWELS AND DRAPES IN POSITION

- Towel clip(Fig. 6-28) this instrument has a locking handle and finger and thumb

rings. The action ends of the towel clip can be sharp or blunt.

IRRIGATING SOLUTION

- Usually sterile saline or sterile water are used.

- Irrigation is essential:

When a handpiece and bur are used to remove bone, the irrigation coolsthe bur and prevents bone-damaging heat buildup, also increases the

efficiency of the bur by 1-washing away bone chips from the flutes of the

bur and 2-by providing a certain amount of lubrication.

Once a surgical procedure is completed and before the mucoperiosteal flapis sutured back into position, the surgical field should be thoroughly

irrigated.

- A large plastic syringe with a blunt 18-gauge needle (so that it does not damage

soft tissue) and it should be angled for more efficient direction of the irrigating

stream (Fig. 6-29).

EXTRACTING TEETH

Dental Elevators

- These instruments are used to :

luxate teeth (loosen them) from the surrounding bone.- this makes extractions easier

- minimize the incidence of broken roots, teeth, and bone.- facilitates the removal of a broken root

expand alveolar bone.- this facilitates the removal of a tooth that has a limited and obstructed

path for removal.

remove broken or surgically sectioned roots from their sockets.

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- The three major components of the elevator are (Fig. 6-30) :

Handle, generous size. Shank, substantial size and is strong enough to transmit the force from the

handle to the blade.

Blade, is the working tip of the elevator and is used to transmit the force tothe tooth, bone, or both.- Types of Elevators:

-The biggest variation in the type of elevator is in the shape and size of the

blade.

- The three basic types of elevators are:

(1) The straight type

- the most commonly used elevator to luxate teeth (Fig. 6-32, A ).

- the blade has a concave surface on one side that is placed toward the

tooth to be elevated (Fig. 6-32, B ).

- the small straight elevator, No. 301 , is frequently used for beginning the

luxation of an erupted tooth, before application of the forceps.

- larger straight elevators are used to displace roots from their sockets and

are also used to luxate teeth that are more widely spaced or once a

smaller-sized straight elevator becomes less effective.

- the most commonly used large straight elevator is the No. 345.

- the shape of the blade of the straight elevator can be angled

from the shank, allowing this instrument to be used in the

more posterior aspects of the mouth. Ex: the Miller elevatorand thePotts

elevator.

(2) The triangle or pennant-shape type

- the second most commonly used type of elevators (Fig. 6-34).

- come in a variety of types and angulations, but the Cryeris the most

common type.- these elevators are provided in pairs: a leftand a right.

- the triangular elevator is most useful when a broken root remains in the

tooth socket and the adjacent socket is empty.

- the tip of the triangular elevator is placed into the socket, with the

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shank of the elevator resting on the buccal plate of bone. the elevator is

then turned in a wheel-and-axle rotation, with the sharp tip of the elevator

engaging the cementum of the remaining distal root; the elevator is then

turned and the root is delivered.

(3) The pick type

- this type of elevator is used to remove roots.

- two types of pick elevators:

1- the heavy version is the Crane pick(Fig. 6-35). this instrument is used as

a lever to elevate a broken root from the tooth socket. Usually it is

necessary to drill a hole with a bur (purchase point) approximately 3 mm

deep into the root just at the bony crest. The tip of the pick is then inserted

into the hole, and with the buccal plate of bone as a fulcrum, the root is

elevated from the tooth socket.

Occasionally the sharp point can be used without preparing a

purchase point by engaging the cementum or furcation of the tooth.

2- The second type is the root tip pickor apex elevator (Fig. 6-36).

The root tip pick is a delicate instrument that is used to tease small root

tips from their sockets by inserting the tip into the periodontal ligamentspace between the root tip and socket wall.

it should not be used as a wheel-and-axle or lever type of elevators.

Extraction Forceps (From the script)

There are a lot of informations in the book ,I will try to include as much as possible,but my reference

is the script- so u can refer to the book for detailes

-These instruments are used to remove the tooth from the alveolar bone.

-designed in many configurations to adapt to the variety of teeth

Forceps components:

-Basic component are: Handle, Hinge, Beaks (Fig:6-37)

Handlesof the forceps are held differently, depending on the position of the

tooth to be removed.

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Maxillary forceps: are held with the palm underneath the forceps so that the beak

is directed toward the teeth(in a superior direction)-(Fig: 6-38)

Mandibular forceps: are held with the palm on top of the forceps so that the beak

is pointed down toward the teeth.(Fig: 6-39).

-The handles of the forceps are usually straight but may be curved, this providesthe operator with a sense of better fit.

Hinge is like shank of the elevator, it connects the handle to the beak.

-It concentrates the force applied to the handle to the beak.

-there are different styles:

1- American type has hinge in a horizontal direction(Fig:6-37)

2- English type is for a vertical hinge and corresponding vertically positioned

handle( Fig:6-41,A).

English style handle and hinge are used with handle held in vertical direction asopposed to a horizontal direction(Fig:6-41.B)

Beaksare the source of the greatest variation among forceps.

-the beak is designed to adapt to the tooth root near the junction of crown and

root.

One must remember that the beaks of the forceps are designed to be adapted to

the root structure of the tooth and not to the crown of the tooth.

- the beaks of forceps are angled so that they can be placed parallel to the long

axis of the tooth, with the handle in a comfortable position.Beaks for Maxillary Forceps: are parallel to the handle

Beaks for Mandibular Forceps: are perpendicular to the handles.

-The dr. started showing some pictures, you will find them on next pages)

(This is the last thing in the script-for more details refer to the book pages 86-89)

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-Fig6-42:Forceps adapted to maxillary central incisors.

-Fig 6-43: Maxillary forceps adapted to premolars

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-Fig 6-44: forceps adapted to incisor:

-Figure 6-45: Maxillary forceps come in pairs: left and right , these forceps are designed to fit

anatomically around the palatal and the pointed buccal beak fits into buccal bifurcation.

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Mandibular forceps:

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Extra pictures from the book:

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Instrument Tray System:

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