Oral surgery introduction



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The Curette
The curette is like a large spoon excavator and is used in the same manner to:
1) remove debris from the socket,
2) clean out old or incomplete blood clots,
3) remove chronic granulation tissue from around necks of adjacent teeth.
It is not necessary to use it routinely after every extraction, but it should be at hand. Use it when the crown, roots or bone have been broken into small pieces and have fallen into the socket.
The curette can be used to remove dental granulomas or small cyst membranes at the bottom of a socket, HOWEVER that is beyond the scope of this course. You need to discuss with a Stomatologist is you think there may be some pathology present.

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Periapcial curette is a double-ended, spoon-shaped instrument used to remove soft tissue from bony defects.

Bite Blocks
For Mandibular Extractions, bite blocks are very useful and necessary to prevent stress on the

TMJ. By having the patient’s jaw supported on the bite block, the joints will be protected.


A, Rubber bite block is used to hold mouth open in position chosen by patient. B, The sides of the bite block corrugated to provide a surface for the teeth to engage.

Surgical Suction


A, Typical surgical suction has small diameter tip. Suction tip has hole in side to prevent tissue injury because of exscess suction pressure. B, Fraser suction tip has blade in handle to allow operator more control over amount of suction power. Wire stylet is used to clean tip when bone or tooth particles plug suction.

Periosteal Elevator

Reflects soft tissue by:


1. Prying Motion
• commonly used when elevating a dental papilla from between teeth
2. Push Stroke
• the end of the instrument is slid along the neck of the tooth, pushing it until it touches bone. This helps to separate the Periodontal Ligament from the tooth.





No. 1 Woodson periosteal elevator is used to loosen soft tissue from teeth before extraction.

Retractors






Minnesota retractor is an offset retractor used for retraction of cheeks and flaps.


ORAL SURGERY 25

PREOPERATIVE CHECK LIST
Patient - comfortable and reassured

- suitably anaesthetized (test for profound anaesthesia)

- informed consent

- all information at hand, e.g. records, radiographs etc.


Equipment - light properly placed

- suction

- instruments - both at hand and necessary

- medication and post-op instructions


Operator - preoperative assessment done

- operation planned

- contingency plan

- radiograph reviewed


Light
It is very important to have good illumination on the surgical site. You can’t remove what you can’t see!

POSTOPERATIVE CHECK LIST
Toilet of - rid site of debris; pack with Gelfoam, if required, and/or gauze 2X2 sponges to

the Wound assist in the clotting of the bleeding site
Suture - if necessary, the objective is to place edges of wound as close to apposition as possible and prevent displacement of tissue, maintain cleanliness of site, assist in establishing clot and stop bleeding.
Check up - before dismissing check for bleeding, suture tension, make sure post-op instructions are understood and handed out, analgesics provided or recommended including dosage, precautions, side effects, etc.
Follow up - contact next day or after a few days – good public relations. Make appointment for suture removal if necessary.
Charting - make brief accurate notes listing name, type and amount of anesthetic, number and kind of sutures, difficulties encountered, e.g., retained roots; date and sign, as the chart is a legal document as well as a professional document. It must be clear, concise, complete and consistent.


PATIENT AND OPERATOR POSITION





Operator prepared by wearing protective eyeglasses, mask, and gloves. Surgeons should have short or pinned-back hair and should wear clinic clothing that is changed daily or sooner if soiled. Patient should have full, waterproof drape.

A, If operator’s hair is long, it should be tied so that it stays in place and does not drape into surgical field. B, As alternative, dentist’s hair can be placed under surgical cap.







C, Long and uncontrollable hair that drapes into surgical field is unacceptable.





A gauze partition can be placed in the mouth to help guard against loss of tooth or tooth fragments into the oral pharynx.

Maxillary Extraction
Standing
• Chair should be tipped back so that the maxillary occlusal plane is at an angle of about

60 degrees to the floor.

• The height of the patient’s mouth should be at or slightly below the operator’s elbow level.
Sitting
• Patient is positioned as low as possible so that the mouth is level with the operator’s elbow.










Patient positioned for maxillary extraction: tilted back so that maxillary occlusal plane is at about 60-degree angle to floor. Height of chair should put patient’s mouth slightly below surgeon’s elbow.

Extraction of teeth in maxillary right quadrant. Note that surgeon turns patient’s head toward self.














Extraction of anterior maxillary teeth. Patient looks straight ahead.

Patient with head turned slightly toward surgeon for extraction of maxillary left posterior teeth.






Mandibular Extractions
Standing
• Patient should be positioned upright.

• The occlusal plane is parallel to the floor when the mouth is opened.

• The chair should be lower so that the surgeon’s arm is inclined downward to approximately 120- degree angle at the elbow.

• Use a bite block.


Sitting
• Operator’s hand and arm position is similar to that used for standing position.

• Patient is placed more upright.

• Mandibular occlusal plane of mouth when open is nearly parallel to the floor.

• Opposite hand helps support the mandible.

• Use a bite block.








For mandibular extractions, patient is more upright, so that mandibular occlusal plane of opened mouth is parallel to floor. Height of chair is also lower to allow operator’s arm to be straighter.

For extraction of mandibular anterior teeth, surgeon stands at side of patient, who looks straight ahead.

Patient with head turned toward surgeon for removal of mandibular teeth.

When English style of forceps is used for anterior mandibular teeth, patient’s head is positioned straight.








For extraction of mandibular posterior teeth, patient turns slightly toward surgeon.




In seated position, patient is positioned as low as possible so that mouth is level with surgeon’s elbow.

Behind-the-patient approach for extraction of posterior right mandibular teeth. This allows surgeon to be in comfortable, stable position.

Behind-the-patient approach for extraction of posterior left mandibular teeth. Hand is positioned under forceps.


For extraction of maxillary teeth, patient is reclined back approxi- mately 60 degrees. Hand and forceps position are same as for standing position.







For removal of mandibular posterior teeth, patient’s head is turned toward surgeon.

For extraction of mandibular teeth, operator’s hand and arm position is similar to that used for standing position. Patient is placed more upright so mandibular occlusal plane of open mouth is nearly parallel to floor. Surgeon’s opposite hand helps support mandible.









For removal of anterior teeth, surgeon moves to position behind patient, so that mandible and alveolar process can be supported by surgeon’s opposite hand.





The behind-the-patient’s position can be used for removal of mandibular posterior teeth. Hand is positioned under forceps for maximum control.


When English style of forceps is used, a behind-the-patient position is preferred.


DIAGNOSIS AND TREATMENT PLANNING

Before carrying out any surgical procedure, a careful study of the problem must be made. This study will include:


1) a medical history of the patient's health, both past and present.
2) a careful preoperative study of the patient including the patient’s description of the complaint, a thorough clinical examination and diagnostic quality x-rays of the problem.
3) a plan for the extraction as well as for any emergency that might be encountered.
4) a plan for postoperative care.
This study should be backed up by theoretical and practical (clinical) knowledge obtained in oral anatomy and medical/dental evaluations.
Once a decision has been made to extract a tooth (see Dental Evaluation) and the medical history is clear (see Medical Evaluation) one may proceed to the technical aspects of the surgical procedure. One must always be fully aware of the structures and systems involved to completely care for the patient before, during and after the treatment (see Oral Anatomy).
Constant reference must always be made to the above-mentioned disciplines.
As a therapist, you are expected to perform uncomplicated extractions; however, if complications should arise during the course of an extraction, or postoperatively, which otherwise may have been unexpected, then one must be able to adequately care for those eventualities. If it is not possible to easily deal with the situation, the patient should be referred to a dentist or oral and maxillofacial surgeon.
Remember that you are the expert at the scene!

Radiographs
As a standard procedure, pre-op radiographs should be obtained prior to proceeding. The only exception would be:
deciduous teeth – mobile and about to normally exfoliate.
Radiographs for surgery should indicate:
1) roots – size, number, curvature (e.g. dilaceration)
2) proximity to other structures (e.g. maxillary sinus, mandibular canal, unerupted tooth)
3) pathology associated with tooth (e.g. cyst, granuloma, cementoma)
These points will ultimately assist you in deciding whether or not to proceed with an extraction or whether it should be referred to a dentist or oral and maxillofacial surgeon.
Radiographs will also provide visual proof and legal protection in the event of postoperative arguments.

Prescribed or treatment-planned surgery is authorized by the examining dentist; however, 90% of surgical cases will be of the emergency (unauthorized) kind. In emergency cases the following points must be satisfied before proceeding:


1) medical history is clear;
2) systemic involvement has been controlled;
3) tooth in question is pulpally or periodontally involved beyond the care that a therapist can provide;
4) patient does not wish endodontic or periodontal services of a stomatologist;
5) extraction is the only viable alternative;
6) extraction will be uncomplicated;
7) a diagnostic quality pre-op radiograph is available;
8) informed consent obtained.

Clinical Evaluation of Teeth for Removal
1. Access to Tooth
The first factor to be examined in pre-operative assessment is the extent to which the patient can open his or her mouth. REFER the patient if they cannot open mouth wide enough.
Check the location and position of the tooth to be extracted such as tooth alignment and crowded or malposed teeth (may present difficulty).
2. Mobility of Tooth
Greater than normal mobility is frequently seen with periodontal disease. Less than normal mobility should be carefully assessed for the presence of hypercementosis or ankylosis of the roots.
Ankylosis is often seen with primary molars that are retained and have become submerged and occasionally in nonvital teeth that have had RCT many years before the extraction. REFER the patient if the tooth is ankylosed.

A B



A, Tooth with severe periodontal disease with bone loss and wide periodontal ligament space. This kind of tooth is easy to remove. B, Retained mandibular second primary molar with an absent succedaneous tooth. It is submerged, and likelihood for ankylosed roots is high.


3. Condition of the Crown
Assess the following:
• presence of large carious lesions

• presence of large amalgam restorations

• large accumulation of calculus





Teeth with large carious lesions are likely to fracture during extraction, which makes extract-ion more difficult.
For teeth with large carious lesions and large amalgam restorations because of weakness in the crown. Apply the forceps as far apically as possible so as to grasp the root of single rooted teeth or engage the furcation of multirooted teeth.
Large accumulation of calculus (gross deposits) should be removed with a scaler or ultrasonic cleaner before extraction. The deposits interfere with the placement of the forceps in the appropriate fashion, and fractured calculus may contaminate the empty socket once the tooth is extracted.

Conditions of Adjacent Teeth
Large amalgams or RCT – keep this in mind when elevators and forceps are used to mobilize and remove the indicated tooth. Use elevators with extreme caution because fracture of the restoration may occur. Inform patient of the possibility of damage before the surgical procedure.









Teeth with large amalgam restorations. These are likely to be fragile and to fracture when extraction forces are applied.

Mandibular first molar. If it is to be removed, surgeon must take care not to fracture amalgam in second premolar with elevators or forceps.




Radiographic Examination of Tooth
Periapical – provides the most accurate and detailed information concerning the tooth, its roots, and the surrounding tissue.
Panoramic – used frequently, but their greatest usefulness is for impacted teeth as opposed to erupted teeth. Not generally available for dental therapists.
The radiograph should be mounted in the ADA standardized method. View the radiograph as if you are looking at the patient from the front. The raised dot on the film faces the observer.








Properly exposed radiographs for extraction of mandibular first molar.



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