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Instruments

As Dr. Rasha Rahahleh said, please concentrate on this lecture, they will show us the

instruments that we will be talking about in the clinics, you really need to see them!

The first group of instruments is about incising tissue, for oral surgery you need to

make flap, so for making this flap you need to incise tissue properly. The

instrument that is used to incise tissue is called scalpel, it is composed of two

parts :

- The scalpel handle, it can be disinfected so it can be used once and once

again.

- The blade, it is disposable, used for one time then discarded.

The scalpel

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There are different types of blades that are used in oral surgery :

No.15, the most common one, it is small to be adapted for teeth,mucoperiosteal around the teeth, it is small so easily placed around the

teeth.

No.10, it is used for large incision, not used intra-orally. No.11, the pointed one, for incision of abscess thats why it has a pointed

end.

No.12, the curved one, used in perio not in oral surgery, for mucogingivalincisions.

No.12

No.11

No.10

No.15

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This is how we load and unload the blade, never touch the blade with your finger

because it might injure your finger, so for safety purposes we load and unload it

using needle holder.

For loading, hold the blade from its superior edge by needle holder then slide it

along the slot(slot of the handle), that is how it will be fixed on the handle.

For unloading , hold the blade from its inferior edge then unload it and slide it

along the slot. We will show you that in the clinics.

You only need to know that you must load and un load it using needle holder not

by fingers.

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Pen grasp for holding the scalpel, like holding a pen and then make the incision,

you have to hold the mucosa firmly while incising it because it is mobile tissue, so

that the incision will be clear from mucosa, you have to incise with one cut not

multiple so that bleeding will be optimized, as we said mucosa and periosteum

together so that we reach the bone, hold the scalpel and make incision all insidethe bone(mucosa and periosteum) in one clear cut.

Pen grasp

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When the procedure is very long you have to change the blade many times,

because the blade becomes dull and when it is dull it will traumatize the tissue.

Instruments for elevating mucoperiosteam, after you have done your incision

now you need to elevate mucoperiosteum or expose the tooth, so for elevating

mucoperiosteal we use :

Mucoperiosteal elevator orperiosteal elevator,of course it is done as one layer

mucosa and periosteal in a single layer, you have to reach the bone when you put

it underneath the flap then reflect it, the most commonly used periosteal elevator

in oral surgery is #9, it is called molt periosteal elevator, it has a pointed end and

broad end here, the pointed end is used first, underneath dental papilla to reflect

it and detach it from underlying bone. First detach the dental papilla from the

teeth by the narrow end and then by the broad end at the end of the flap.

No.9 molt

Of course you have to reflect enough amount of the flap, if you reflect the flap as

a small piece then you will not be able to see, so reflect the flap widely , you need

to have good vision, you cannot remove what you are not able to see.

This is another type for reflecting mucoperiosteal, it is not very common, this is a

small pen it is rounded and small, actually it is used for detachment. at the clinics

we do detachment by tweezers

There are three methods by which elevating the flap used for reflecting softtissues :

prying motion, insert the elevator(the pointed end) beneath the dentalpapilla and elevate it, this will detach the dental papilla from the teeth.

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Push stroke, by the broad tip of the elevator, put the elevator beneath thewhole flap then push it under the flap that is why it is called push stroke

and then reflect the flap. This is also a very common method for reflecting

the flap.

pull/scrap is hard to put in the tissue because you pull the tissue from thebone, it is really harmful, you might tear the gingiva and mucosa, it is not

really recommended unless you are experienced surgeon.

As beginner surgeon only use prying motion.

Instruments for retractingsoft tissues, after you reflect the flap, now your flap is

free from bone, so you have to stabilize it in its place, there are instruments for

retracting soft tissues and stabilizing it away from your field in order to see

properly(good vision and good access), these instruments retract the cheek,

tongue and flap that you are already made.

Examples for cheek retracting instruments :

Right angled Austinretractor, for retracting the cheek. Minnesotaretractor also it is common, you will see it at the clinics.

Austin and Minnesota, most common cheek retractor because they retract

the flap as well, it is easier because you retract the cheek and the flap with

one instrument

Seldin, uncommon retractor, some surgeon prefer using them because theyare long handled, long enough to be away from the cheek while holding it.

austin

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Seldin

So again periosteal elevator for the bone, that the flap not trapped between the

elevator and the bone so it will be crushed, so make sure that your flap is away

from and not trapped between the bone and your instrument. Again periosteal

elevator is very common used for retracting the flap from the broad end,

stabilized in the bone and reflect it with the flap.

The Seldin retractor although it is similar to periosteal retractor, its edges are

round not sharp, we use it for retracting the flap you cannot elevate or reflect the

flap with this instrument, it looks like periosteal elevator but you cannot use it as

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perioteal elevator, it will harm the tissue because the edges here are not sharp,

they are round so it will not reflect the flap properly, only used for retracting the

flap.

There are tongue retractors, the tongue may come on your way while you are

doing your surgery, so you need to retract it to have good access and vision.

The mouth mirroris the most commonly used instrument, that you alreadyuse in cons department, it is used for retracting cheek and tongue as well

but sometimes you need to retract something bigger as a large tongue so

you use weider tongue retractor.

Weidertongue retractor, it looks like a heart, it is big to retract the tongue,it is serrated so that it can stabilize the tongue while retracting it and not to

be moved, be careful with this retractor because it is big and if you put it

posteriorly you may induce gagging reflex to your patient, be careful not to

put it too far postriorly. It is used especially in third molar surgery you must

keep the tongue away from your field so you can do your surgery properly.

Weider

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Towel clipit is not for retracting the tongue, however it can be used forretracting it, it hold the tongue like a scissor anteriorly, put the clip, hold it

and push it away.

This tongue clip is useful when u do biopsy for the posterior third of the tongue,

tongue retractor hold worse but it is grooved so it will not give enough field for

biopsy, so when you need to do biopsy for posterior third of the tongue, this is

the ideal instrument to do it however it is very painful, that is why you have to

give very good local anesthesia on the place where you are putting this

instrument on because it is really painful.

Towel clip

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Instruments for grasping soft tissues, oral cavity is full of soft tissue(mucosa,

mucoperiosteal), these instruments are need while you are incising on soft tissue

or to stop bleeding from an artery or vein.

There are four types :

The Adsonsforceps, it is small and delicate, used for holding soft tissuesthat you want to keep them in the mouth not to remove them like for

biopsy, actually it is used when you want to make a suture you can hold the

flap with this forceps and you insert the suture in the flap, it can be of two

types :

With teeth Without teeth

The one which is with teeth has sharp point edges, easy to hold the tissue by it,

but it may crush the tissue ,so the one which is without teeth is better to be used.

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Adsons forceps

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The Stilliesforceps, it is used for posterior areas, similar to Adsons forcepsbut it is larger so easier to reach posterior areas that Adson will not reach

The cotton players(the tweezers) it is not really used for holding tissue forsuturing for example, it is used for removing granulation tissue, may be

from the socket, it has an angle which goes inside the socket easily or it

may be used for removing amalgam restoration or broken fragment of the

tooth, this angle facilitates reaching different areas like inside the socket.

Cotton player

stillies

Allistissue forceps, it is common, used when you have large amounts oftissues to be removed for a biopsy or a tumor, you see the teeth here,

these teeth to hold the tissue firmly, so again for holding tissue that you

need to get rid of from the patients mouth not for holding tissue that will

stay in it like holding a flap, because it has teeth and that will cause injury

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to the tissue. Cyst, tumor and fibrous tissue all of them should be removed.

It has a working handle that help you to hold it firmly and grasp the fibrous

tissue.

Allis

This is the correct way for holding forceps, the thumb is here, the ring finger is

here, the middle one is here to stabilize it and the index is here to direct it.

Instruments for controlling hemorrhage, sometimes while you are doing your

surgery, you will have hemorrhage from an artery, vein or capillary, so you need

an instrument to control hemorrhage to be able to see and your vision will not be

impaired. Usually pressure is enough, light pressure on the bleeding capillary

leads to stop bleeding but sometimes bleeding might not stop so in such case youneed an instrument that called hemostat.

Hemostat has very long tipped beaks, see the beak it is long and delicate, it can

also be used for removing granulation tissue or to pick up small fragment of the

tooth or restoration(just like the player), it has locking handle so if there is an

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artery or vein that is bleeding, just hold it and keep it locked, you do not have to

hold it all the time.

hemostat

Instruments for removing bone, sometimes you have to remove bone for some

reasons..

Impacted tooth inside bone, then you need to remove the bone to reachthe impacted tooth.

Bony lesions like torus mandibularis or torus palatinus Sharp edges of bone remain after doing extraction

The instruments are :

Rongeurforceps, we have two types depending on where the cuttingedges are

Cutting edges on the sides, it is not really common

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Cutting edges on both the sides and the tip(Blumenthal rongeurs), theone that we use in surgery because it is easier, it can be used at the tip

of the socket to remove ineterradicular bone because it has cutting

edges on the tip.

Rongeur forceps can be used for removing large amounts of bone but it has

to be used in multiple bites not only one bite; each bite you close and

remove small amount of bone.

It is never used for extraction of teeth because the blade on the cutting

ends will become dull and will not remove bone efficiently, if you remove

tooth by it the tooth might slipped from it and swallowed or aspirated by

the patient. Only for removing of bone.

Rongeur

Blumenthal rongeur

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Bur and handpiece, this is the handpiece that we use in surgery, not likethat you use in cons, specific for surgical removal of bone.

Fissure bur for sectioning of teeth. Acrylic bur looks like that we know but here it used for removing

tori(paltenus, mandibularis).

Round bur for removal of bone overlying impacted tooth.The important feature in these hanpieces that they do not incorporate air

with them, that is why you cannot use carbide handpiece for surgical

procedures because it might inforce air deeply and cause a condition called

emphysema , that is why it is important that only these handpieces are

used for removal of bone.

These handpieceses also can be used for sectioning of teeth, such as molars

you divide them into 2-3 parts and remove every part by its own.

Of course it should be of high speed and high torque like carbide bur so it

can remove cortical bone efficiently and section teeth quickly so you will

end up quick and fast procedure.

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Handpiece must be sterilizable, make sure when buy it from the

manufacturer that it is sterilizable because you use it for many patients and

it must not exhaust air into the operative field so it will not cause

emphysema.

Bur and handpiece

Mallet and Chisel

It isn't really common to used, Bur and handpiece are easier to used, the mallet and

chisel are often used when removing lingual tori.

,Chisel > there is mono and bi bevel

Mono-bevel> it used mainly for bone cuttingu will find chisel beveled from one

side and straight from the other

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but now this is verysection teeth> used in the past when they wantbeveled-Bi

unlikely .

Mallet> is look like a hummer .

**We put a chisel in the bone and lock by the mallet , in fact it a little traumatic

to the patient so this is very unlikely to use .

Bone File

Bone File >Final smoothing of bone before suturing a mucoperiosteal flap , the

bone file cannot be used efficiently for removal of large amounts of bone;

therefore, it is used only for final smoothing

- It come with serration with one cutting side and ,

the other side doesn't cut >> so it work only in pull stroke

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Pushing this type of bone file against bone results only in burnishing and crushing

the bone, and should be avoided,,only in pull stroke way

Removing Soft Tissue From Bony Cavities

periapical curette >>The curette commonly used for oral surgery is an angled,double-ended instrument used to remove soft tissue from bony defects .

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

but the curette is also used to remove small amounts of granulation tissue debris

from a tooth socket.

Note ,, that the periapical curette is distinctly different from the periodontal

curette in design and function.

Suture Soft Tissue

Once a surgical procedure has been completed, the mucoperiosteal

flap is returned to its original position and is held in place by sutures. the needle

holder is the instrument used to place the sutures.

Needle Holder

The needle holder is an instrument with a locking handle and

a short, blunt beak. For intraoral placement of sutures,a 6-inch

( l6-cm) needle holder is usually recommended .

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The beaks of a needle holder are shorter and strongerthan the

beaks of a hemostat . The face of a beak of the needle

holder is crosshatchedto permit a positive grasp of the suture

needle. The hemostat has parallel grooveson the face of the

beaks, thereby decreasing the control over needle and suture.Therefore the hemostat is a poor instrument for suturing.

**What make the needle holder differ than any other instrument (such as thehemostate)? a) groove b) beak

To control the locking handles properly and to direct the

long needle holder, the surgeon must hold the instrument in

the proper fashion :

The thumb and ring finger are inserted through the rings. The index finger is held along the length of the needle holder to steady and

direct it.

finger aids in controlling the locking mechanism. The index finger should not be put through the finger ring because this will

result in dramatic decrease in control

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Needles

The needle used in closing mucosal incisions is usually a small

half-circle or three-eighths-circlesuture needle.

The needle is curved to allow it to pass through a limited space, where a straight

needle cannot reach, and passage can be done with a twist of the wrist, Suture

needles come in a large variety of shapes, from very small to very large.

.

The tips of suture needles are either::

- tapered tip

- triangular tips that allow them to be cutting needles (which commonly used) .

Taperd needles have a round cross section ,, a Care must be taken with cutting

needles because they can cut through tissues (brushing) rather go inside it

,therefore ,, It isn't really common to used in oral surgery

Techniques for placing sutures :

The curved needle is held approximately two thirds awayfrom the tip ,, This allows enough of the needle to be exposed to pass

through the tissue

one third from suturing material,, this allowing the needle holder to graspthe needle in its strong portion to prevent bending of the needle

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Suture Material

Many types o f suture materials are a available , The materials are

classified by diameter, restorability , and whether they are

monofilament or polyfilament.

a) Size: the size of suture relates to its diameter and is designated

by a series of zeros .As 0 , 01 , 02 , 03 ,04 >> the larger the number the smaller the needle

04

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Plain catgut resorbs quickly in the oral cavity, rarely lasting longer than 2to3

days. Gut that has been treated by tanning solution (chromic acid)and is

therefore called chromic gut lasts

longer-up to 7 to 10 days.

**Several synthetic resorbable> These are materials that are long

chains of polymers braided into suture material.

Examples : are polyglycolic acid and polylactic acid. these materials are slowly

resorbed, taking up to 4 weeksbefore they are

resorbed, Such long-lasting resorbable sutures are rarely indicated

in the oral cavity for basic oral surgery.

c) monofilament or polyfilament > Monofilament sutures aresutures such as plain and chromic gut, nylon, and stainless

steel, Polyfilament sutures are silk, polyglycolic acid, and

polylactic acid.

**We used Polyfilamentbecause it easy to tie and well tolerated by the patient's

soft tissues and the cut ends are usually soft and nonirritating to the tongue and

surrounding tissue. However, because of the multiple filaments, they tend to

"wick" oral fluidsalong the suture to the underlying tissues, this wicking action

may carry bacteria along with saliva whileMonofilament sutures do not causethis 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 tongue and soft tissues.

**As result sutures that are holding mucosa together usually stay

no longer than 5 to 7 days, so the wicking action is a little

clinical importance.

Scissors

They are two types :

a) Suture scissors: scissors usually have short cutting edges because their sole

purpose is to cut sutures , these scissors have slightly curved handles and

serrated blades that make cutting sutures easier in posterior area .

**The most commonly used suture scissors for oral surgery are the

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Dean scissors.

b) Dissecting scissors : are designed for cutting soft tissue

Now dissecting scissors are two types ::

1)Iris >> are small, sharp-pointed, delicate tools used for fine work.

We used removing Avery fine sutures from the skin.

2) Metzenbaum Scissors>> used for undermining soft tissue and

for separations the layer from each other

.

Instrument For Holding Mouth Open

We use it when we need to do long time surgery either under general or Local

anesthesia , They are two types :

1) Rubber Bite Block ::The bite block is a soft, rubberlike

block on which the patient can rest the teeth in the serration area. it will open themouth and ease the pain over the joint

** It necessary to support the mandible to prevent stress on the

temporomandibular , Supporting the patient's jaw on a bite block

will protect the joints so the patient will be more comfortable.

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**This type of mouth prop mainly with patientunder a local anesthesia (

consciousness ) or useful in patients who have mild forms of trismus.

2) Molt Mouth Prop >> This mouth prop has a ratchet-type action, it has a

reverse action it will opening the mouth wider as the handle is closed and closing

the mouth as the handle is opened . This type of mouth prop should be used with

caution because great pressure can be applied to the teeth and

temporomandibular joint, and injury may occur with injudicious use.

**This type of mouth prop is mainly used with patient under General anesthesia

(loss of consciousness) or useful in patients who are deeply sedated patient

SUCTINING

To provide adequate visualization, blood, saliva, and irrigating

solutions must be suctioned from the operative site.

The Fraser suction> surgical suction is one that has a smaller orifice than the type

used in general dentistry to more rapidly ( effectively) evacuate fluids from the

surgical site by creating a negtive pressure to maintain adequate visualization.

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Holding Towels And Drapes In Position

Mainly used with patient under General anesthesia

When drapes are placed around a patient, they can be held ( stabilize)

together with a towel clip..

**When this instrument is used, the operator must exercise extremely not to

hold the patient's skin under this towel .

IRRIGATING

**When a headpiece and bur are used to remove bone, it is

essential that the area be irrigated with a steady stream of

irrigating solution, usually sterile saline or sterile water. The

irrigation cools the bur and prevents bone-damaging heat

buildup.

**The irrigation also increases the efficiency of the bur

by washing away bone chips from the flutes of the bur and by

providing a certain amount of lubrication.

** Once a surgical procedure is completed and before the mucoperiosteal flap is

sutured back into position, the surgical field should be thoroughly irrigated

**A large plastic syringe with a blunt 18-gaugeneedle is commonly used for

irrigation, although the syringe is disposable, .

EXTRACTING TEETH

One of the most important instruments used in the extraction

procedure is the dental elevator:

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These instruments are used to luxate teeth (loosen them)from thesurrounding bone, Loosening teeth before the application of the dental forceps

makes extractions easier

In addition to their role in loosening teeth from the surrounding bone, dentalelevators are also used to expand alveolar bone. Finally, elevators are used to remove broken orsurgically sectioned roots from

their sockets.

Any elevator consists of three components ::

1) Handle ::The handle of the elevator is usually of generous size, so it can be

held comfortably in the hand to apply substantial but controlled force, In some

situations, cross bar or T-bar handles2)Shank

3) Blade

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 straight elevator is the most commonly used

elevator to luxate teeth ordisplace roots from their sockets.

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(2) the triangle or pennant-shape type:these elevators are provided in

pairs: a left and a right, The triangular elevator is most useful when a broken root

remains in the tooth socket and the adjacent socket is empty., The elevator isturned in a wheel-and-axle rotation.,

**The Cryer is the most commontype.

(3) The pick type:This type of elevator is used to remove roots.

** The heavy version of the pick is the Crane pick , this instrument is used as a

lever to elevate a broken rootfrom the tooth socket.

Usually it is necessary to drill a hole with a bur , the tip of the pick is

then inserted into the hole,,(we will talked about it later on)

**The second type of pick is the root tip pick or apex elevator

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

from their sockets, It must be emphasized that this is a thin instrument andshould not be used as a wheel-and-axle or lever type of elevator like the Cryer

elevator or the Crane pick.

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The root tip pick is used to tease (mobile) the very small root end of a toothby inserting the tip into the periodontal ligament space between the root tip

and socket wall.

Extraction Forceps

The extraction forceps are instruments used for removing the

tooth from the alveolar bone

The basic components of dental extraction forcepsarehandle, hinge, and beaks.

Handle :The handles of the forceps are held differently, depending

on the position of the tooth to be removed.

- Maxillary forcepsare held with the palm underneaththe forceps so that the

beak is directed toward the teeth.

-Mandibularforcepsused held with the palm on topof the forceps so that the

beak is pointed down toward the teeth.

Beaks :The beaks of the extraction forceps are the source of the

greatest variation among forceps. The beak is designed to adapt

to the tooth root near the junction of the crown and root. One

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

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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, therefore the beaks

of maxillary forceps are usually parallel to the handles, while the beaks ofmandibular forceps are usually set perpendicular to the handles.

The doctor starts to show some a picture:

forceps adapted to maxillary central incisor

Maxillare foreceps adapted to premolar

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.

Maxiller foreceps adapted to molar, the molar forceps come in pairs: a left and

a right, these forceps are designed to fit anatomically around the palatal and the

pointed buccal beak fits into the buccal

Bifurcation

Root tip foreceps, for broken molar roots, narrow premolars, lower incisors

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forceps adapted incisor mandibular

Mandible forceps adapted to molar

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SURGICAL EXTRACTION TRAY

BIOPSY TRAY

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POSTOPERATIVE TRAY

" , , , , "

Done by : Malak abu-aqulah & Rahaf Al-ibrahem