Oral surgery introduction



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ORAL SURGERY

INTRODUCTION

Dental therapists gain positive recognition within the community through an understanding of their limits, proper diagnosis, skillful technique and appropriate pre and post surgical treatment. The resulting relief from pain and infection invariably earns the dental therapist a real sense of gratitude from the thankful patient.


There should be no surprises in your approach to and completion of a surgical procedure. Complications may arise but you must have the knowledge and skills to deal efficiently and effectively with them.
Remember, preplanning is important in oral surgery and so is a systematic and organized approach to the procedure. Make each movement a planned and thoughtful one. Always be in control of the situation, anticipate, visualize and understand!


REASONS FOR ORAL SURGERY
Every surgical procedure must be balanced, weighing the benefits against the detriments. There is no such thing as routine oral surgery. The purpose of the surgery must be to:
• eliminate disease

• relieve pain

prevent future disease

• remove damaged or redundant tissue



• improve aesthetics or function
A correct treatment plan is dependent on your knowledge and skills in diagnosis and how well you know your patient. Your treatment plan should not only include accepted and practical methods of treatment but also be responsive to the realities of your patients in such areas as economics, time factors, social responsibilities and the ability to obtain further specialized services such as prosthetics, endodontics, etc.
Remember, it is better to over estimate the possible difficulties of the surgical outcome and its effects thus leading to relief and gratitude when things turn out better than expected. Underestimating the problems that the patient might have leads to embarrassment, distress and perhaps litigation. In other words never promise more than you can deliver and prepare your patient for all eventualities. ALWAYS HAVE A WELL-INFORMED PATIENT.
The guiding principle in all health care procedures with patients is DO NO HARM”.

A FEW PRINCIPLES OF EXTRACTION
Surgical instruments are designed to expand the bony socket of the tooth, thereby loosening the tooth for easier removal. A tooth is never ‘pulled out by brute force’.

Elevators
Elevators come in a wide variety of shapes and sizes. Like all surgical instruments they are “functionally designed” to efficiently do specific jobs well. These instruments are forms of levers operating on the principle of the wedge, the inclined plane and the sharp pick. The straight elevator is used to maneuver between the tooth, the gingival cuff, and the alveolar process in order to sever the periodontal attachment and gently expand the alveolar crest at the cervical area. In order to adapt to the tooth surface and fit into the space, the blade is slightly gouge shaped and sharp.
The Cryer elevator represents the second major type of elevator design. They have sharp, pennant shaped blades. They are used in a rotating manner to elevate roots, broken tooth segments and interseptal bone.
Elevators generally have large handles that fit within the palm of the hand. Controlled, gentle forces are very important when using elevators, as they are sharp and potentially very dangerous instruments.
Small Large Right Left






Forceps
Forceps come in a wide variety of shapes. The beaks of the forceps are designed to firmly grasp the tooth gingivally to the cervical line or as far apically as possible. The handle design enables a comfortable grasp and a firm grip, improved access and increased leverage to luxate the tooth and thereby expand the socket and loosen the tooth.
What are extraction forceps?
An instrument resembling a pair of tongs used for grasping teeth in order to luxate (loosen and extract them from the alveolus (socket).
1. Definitions
Universal Forceps – the forceps may be used on either side of the same dental arch.
Anatomical Forceps – forceps with beaks that are formed so that they are well adapted to the anatomy of specific root(s) (concavities and furcations)
2. Characteristics of Forceps
a) handles are designed for palm grasp
b) one handle may have an additional hook or curve to assist in leverage by providing a place for the little finger.
c) tips of the beak are placed on the roots of the teeth (on cementum), therefore, the tips of the beaks are designed to correspond to the shape of the roots (concave, convex or furcations)
3. Forceps Classified in Two General Groups
a) those constructed for the removal of upper teeth (maxillary forceps)
b) those for the removal of lower teeth (mandibular forceps)
4. How to Identify Forceps
Forceps can be identified by Angle of Beaks





THE ORAL SURGICAL INSTRUMENT KIT
* Please know the design and function of each instrument.


Elevators
straight elevator – small straight elevator – large Cryer elevator – left Cryer elevator – right


Forceps
maxillary universal straight anterior

maxillary universal curved anterior and bicuspid maxillary right molar forceps

maxillary left molar forceps

maxillary right semi cowhorn maxillary left semi cowhorn


mandibular universal anterior and bicuspid

mandibular universal Hawksbeak anterior and bicuspid (Mead 3)

mandibular universal molar mandibular universal cowhorn molar
primary forceps

maxillary universal primary molar mandibular universal primary molar



Other Surgical Instruments
Rongeurs

Curette


Bone file

SURGICAL ELEVATORS





(40, 46, 1)





(34S)

(31)
(30)



MAXILLARY FORCEPS


Maxillary Curved Universal Anterior and Bicuspid

(Also used for Primary Maxillary Anteriors) (150)

Maxillary Straight

Universal Anterior (99C)











MAXILLARY MOLAR FORCEPS

Maxillary Left Molar (53L, 18L)

Maxillary Right Molar (53R, 18R)

MANDIBULAR FORCEPS

Mandibular Universal Anterior and Bicuspid

(Also used for Primary Anteriors) (151, 203)








Mandibular Universal Hawksbeak Anterior and Bicuspid

(Also used for Primary Anteriors) (MD3)





Mandibular Universal Molar (79, 17)


PRIMARY FORCEPS





(MD2) (40)
(76S, 150S)

ORAL SURGERY 9

OTHER SURGICAL INSTRUMENTS





Rongeurs





Curette

Elevators
Dental elevators are used for the following:
• to luxate teeth (loosen them) from the surrounding bone. Loosening teeth before the application of forceps can frequently make a difficult extraction easier. Luxation of teeth before forceps application facilitates the removal of a broken root should it occur.
• for expanding alveolar bone
• to remove broken or surgically sectioned roots from their sockets
There are 2 basic types.
straight or gouge
triangle or pennant-shaped (Cryer elevator is provided in pairs, left or right)


Three major components of an elevator are handle, shank, and blade.


A, Straight elevator is most commonly used elevator. B and C, Blade of straight elevator is concave on its working slide.










Triangular-shaped elevators (Cryers) are pairs of instruments and are therefore used for specific roots.

Crossbar handle is used on certain elevators. This type of handle can generate large amounts of force and therefore must be used with caution.






ORAL SURGERY 11

Extraction Forceps
There are two types of extraction forceps.
1. American – horizontal hinge
2. English – vertical hinge






Basic components of extraction forceps are handle, hinge, and beak.





Straight handles are usually preferred, but curved handles are preferred by some surgeons.






A, English style of forceps have hinge in vertical direction.

B, English style forceps are held in vertical direction.


Maxillary Forceps
The maxillary forceps are held with the palm underneath the forceps. The beak is directed in a superior position. When using this forceps, the front-of-patient approach is the only operator/patient position used.


Forceps used to remove maxillary teeth are held with palm under handle.


Mandibular Forceps
There are two operator/patient approaches; front-of-patient and behind-the-patient. With the front-of-patient approach, the palm is located on top of the forceps with the beak pointing downward. Using the behind-the-patient approach, the palm is located under the forceps with beak pointing downward.


A, Forceps used to remove mandibular teeth are held with palm on top of forceps. B, Firmer grip for delivering greater amounts of rotational force can be achieved by moving thumb around and under handle.





Straight handles are usually preferred, but curved handles are preferred by some surgeons.


A, Superior view of no. 150 forceps. A, Superior view of no. 150A forceps.

B, Side view of no. 150 forceps adapted B, No. 150A forceps have parallel beaks to maxillary incisor. hat do not touch. C, Adaptation of

no. 150A forceps to maxillary premolar.



A, Superior view of the no. 1 forceps. B, Side view of the no. 1 forceps. C, No. 1 forceps adapted to incisor.



A, Superior view of the no. 53L forceps. B, Side view of no. 53L forceps. C, Right, NO. 53L; Left, no. 53R.

D and E, No. 53L adapted to maxillary molar.

.









A, Superior view of no. 210S forceps. B, Side view of no. 210S forceps. C, No. 210S adapted to maxillary molar.

A, Superior view of no. 286 forceps. B, Side view of no. 286 forceps. C, No. 286 adapted to broken root.





No. 150S (bottom) is smaller version of no. 150 forceps and is used for primary teeth.



A, Superior view of no. 151 forceps. B, Side view of no. 151 forceps. C and

D, No. 151 adapted to mandibular incisor.


A, No. 151A forceps have beaks that A, Side view of English style of forceps. are parallel and do not adapt well to B, Forceps adapted to lower premolar. roots of most teeth. B, No. 151A forceps

adapted to lower premolar tooth. Note lack of close adaptation of tips of beak to root of tooth.




A, Superior view of no. 17 molar forceps. B, Side view of no. 17 molar forceps. C and D, No. 17 adapted to lower molar.


A, Side view of no. 222 forceps. B, No. 222 forceps adapted to lower third molar.
16 ORAL SURGERY

The Rongeurs and Bone File
The rongeurs and bone file are used to smooth any ragged edges of bone that may cause discomfort by irritating the tongue, lips etc., or impair healing. Ragged edges of bone are usually the result of the buccal or lingual cortical plate breaking during an extraction, or the regular or irregular bone as caused by chronic periodontal disease. They are also used in removing any interseptal bone that is higher than the surrounding alveolar bone.
If a portion of the alveolar plate is broken off, the area should be felt with the finger to determine if there are any jagged or sharp edges of bone. If present, the rongeurs are used to snip off these jagged projections. It is used in the same manner as scissors. The bone file is then used to smooth off the freshly cut bone and any small remaining projections. The bone file is used in a drawing motion towards the operator.


Rongeur Forceps
The rongeur forceps have sharp blades that are squeezed by the handles, cutting or pinching through the bone.
There are two major designs.
1. Side-cutting
2. Side-cutting/end-cutting
Do not use to remove large amounts of bone in single bites.




A, Rongeurs are bone-cutting forceps that have spring-loaded handles. B, Blumenthal rongeurs are combination end-cutting and side-cutting blades. They are preferred for oral surgery procedures.
Bone File
The bone file is a double-ended instrument with a small and large end. It is used only for final smoothing.
They remove bone only on a pull stroke due to the arrangement of the teeth on the file. CAUTION: Pushing on the bone file results only in burnishing and crushing the bone and should be avoided.




A, Double-ended bone file is used for smoothing small, sharp edges or spicules of bone. B, Teeth of bone file are effective only in pull stroke.




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