Minor Oral Surgical Principles (NXPowerLite) / Orthodontic Courses by Indian Dental Academy

Minor Oral Surgery Principles
&
Exodontia

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

Principles of minor oral
surgery
Diagnosis and treatment planning
Basic necessities for surgery.
Pain and anxiety control
Aseptic technique
Incisions
Flap design
Tissue handling
Hemostasis
Means of promoting wound hemostasis
Removal of bone
Delivery of the tooth, root or other lesion
Decontamination and debridement
Principle of drainage
Dead space management
Suturing principles and methods
Post surgical care of wound and edema
control
Patient general health & nutrition.

DEVELOPING A SURGICAL DIAGNOSIS
AND TREATMENT PLANNING
The decision to perform surgery should be the culmination of
several diagnostic steps.
The initial step
Presurgical evaluation: collection of accurate and pertinent
data.
- Patient interviews
- Physical
- Laboratory and
- Imaging examination

Patient information and data should be
organized into a format to reach a proper
diagnosis and form a decision concerning
surgery which is either indicated as not.

Surgeons should be thoughtful observers,
should note all aspects of its outcome to
advance their surgical knowledge and to
improve future surgical results.
BASIC NECESSITIES FOR SURGERY
Two principles requirements are
Adequate visibility

Assistance

Adequate visibility: This depends on 3 things
Adequate access

Adequate light

A surgical field free of blood and others
fluids

Adequate access

Patients ability to open their mouths wide but
also require surgically created exposure.

Retraction of tissues away from the operative
field provides much of the necessary access.

Proper retraction also protects tissues from
accidental injury e.g., cutting instruments.
Bowdler Henry rake retractor.
Wards double ended 3
rd
molars
Lacks tongue depressor
Kilners cheek retractor
Lasters retractor for upper 3
rd
molar
Instruments for retraction
Adequate light
Background illumination colour
corrected fluorescent lamps 400-500
lux intensity.

Main sealing mounted lamp (luminare)
high intensity.
- Focused at the centre of the surgery
40,000-100,000 lux.
- Periphery of the surgery - 8,000
15,000 lux.

A surgical field free of fluids
High volume suctioning with a small tip
Wet gauges
Cotton and
Sponge

Competent assistance:
A trained and competent assistants provides
invaluable help during surgical procedures.

The assistant should be sufficiently familiar
with the procedures being performed to
anticipate surgeons needs.
Pain and anxiety control

Local anaesthesia

Sedation

General anaesthesia

Principle of Asepsis
Asepsis is the exclusion of micro-organisms from the
operative field to prevent them entering the wound.
Preoperative surgical scrub
4% chlorhexidine
10% Povidine Iodine

Patients preparation
Detergents 10% povidine iodine in 10%
alcohol.
0.5% chlorhexidine
Alcoholic solution
Mouth wash
Povidine iodine
Chlorhexidine
INCISIONS
An incision can be described as a sharp wound
produced by a surgical scalpel.

Basic principles of incisions

1
st
principle - A sharp blade of the proper size
should be used.

Bone and ligamental tissues dull blades more
rapidly than does buccal mucosa.

2
nd
principle: is that a firm, continuous
stroke should be used when incising.

Long continuous strokes are preferable to
short interrupted ones.

Mucoperiosteal incision should be firm
that penetrates the mucosa and
periosteum with the same stroke.

3
rd
principle: The surgeon should be careful to
avoid cutting vital structures while incising.

No patients microanatomy is exactly the same.
Avoid unintentional cutting of large vessels or
nerves.
For e.g., Incision in the mandibular buccal sulcus
and lingual area - prevent the inadvertent cutting
of facial and lingual vessels.

4
th
principle: Incision
through epithelial
surfaces should be
made with the blade
held perpendicular to
the epithelial surface.
5
th
principle: Incisions in the oral cavity should
be properly placed.
E.g., Over healthy bone, wound edges should
be at least 6-8mm away from the defect.
Incision should lie at the
line angles of the teeth
and not at the facial
surfaces nor in the
papilla.
Instruments to incise tissue
Scalpel composed of handle + sharp
blade
Handle Scalpel blade
Scalpel motion made by moving
hand and rest and not by moving
entire forearm.
Scalpel is help in a pen-grip and
handle in supported against slipping.
Flap design:
Surgical flaps are made to gain surgical access
to an area or to move tissue from one place to
another.
The term flap indicates a section of soft tissue.
Basic principles of flap designs
- Prevent - flap necrosis
- flap dehiscence
- flap tearing

Principles of flap design:

Base of the flap should be wider
than apex.

The length of the flap should
be no more than twice the
width of the base.

Axial blood supply should be
included in the base of the
flap.

The presence of a sinus
must be taken into account
when flaps are designed.

The base of the flap should not be
excessively twisted or stretched.

Flap must have adequate size to provide
necessary access and visualization of the
required area.

Flaps should be a full thickness flap i.e.,
mucoperiosteal flap.

The margins of the flap should be at least 6-
8mm away from any present / future defect
that will remain after surgery.

Flaps should be designed to avoid any injury
to local vital structure in the area of surgery
i.e., lingual and mental nerves.

Releasing incision should be used only when
necessary and not routinely.

Overextension of a flap in the vertical
dimension should be avoided.

Types of mucoperiosteal flaps
Envelope flap
Three cornered flap
Four cornered flap
Semilunar flap
Y-shaped incision flap Pedical flap
Tissue Handling
The difference between an acceptable and
an excellent surgical outcome rests on how
the surgeons handle the tissue.
Toothed forceps or tissue hooks.

Tissue should not be retracted over
aggressively.

When bone is cut, copious amount of
irrigation is used.

Soft tissues - protected from frictional heats
or direct trauma from drilling equipments.
Tissues - moistened or covered with a damp
sponge prevent desiccation.
Only physiologic substances should come in
contact with living tissue.

The surgeon who handles tissue gently is
rewarded with wounds that heal with fewer
complications and grateful patients www.indiandentalacademy.com
Hemostasis
Prevention of excessive blood loss during
surgery is important for preserving a patients
oxygen carrying capacity.

Decreased visibility that uncontrolled
bleeding creates.

Hematomas : Place pressure on wounds
Decrease vascularity.
Increase wound tension.
Acts as culture media potentially the
development of a wound infection
Means of obtaining hemostasis:
Assisting natural hemostatic mechanisms.
Electro-coagulation.
Suture ligation.
Pressure packing.
Vasoconstructive substances.
Use of Hemostatic agents
- Turpentine or tannic acid
- Thrombin and Russell viper venom
- Oxidized regenerated cellulose (Surgicel)

Bleeding from bone

Burnishing the bone with a small
instrument.
Applying hot packs.
Bone wax.
Driving a chisel into the bone.

Removal of Bone
The aim is to expose and to remove bony
overlying the tooth, root and other underlying
pathology.
Techniques of bone removal:
a. Bur technique.
b. Chisel and mallet technique.
Bur technique
IT is precise, efficient and useful
technique.
It should be always used with copious
amount of saline irrigation to avoid
thermal trauma (necrosis of bone).
Round bur
Straight fissure bur
Chisel and mallet technique
Historical importance and rarely used.
Less bone necrosis than bur technique.
Can cause inadvertent fracture of the bone.
Jaw bone should be supported while using
this technique.
Quick, clean method for removing young
elastic bone provided the instrument is sharp
and used skillfully.
Contraindicated in sclerotic bone and in thin
atrophic mandible.

Technique

Vertical stops / cuts should be placed.

The bevel of chisel should be towards
the bone which has to be sacrificed.
Delivery of tooth root / lesion

After the necessary bone removal the
delivery of the tooth, root or lesion
should be effected.

Granulation tissue, by cystic lining or
lesion should be removed.

Debridement / decontamination:

Careful cleansing to remove the debris.
Pathological tissue such as tooth follicle or
sinus tracts, is excised.
Sharp bony edges are filed.
Flaps are trimmed of all necrotic tissues or
tags.
Tooth chips and loose pieces of bone are
removed.
Thorough irrigation.
Dead space management
Dead space is the area that remains
devoid of tissue after closure of the wound.
Created - removal of tissues in depth
- not suturing in multiple layers
This dead space is usually filled with blood
or serum and subsequently become
infected.

Means of eliminating dead spaces
Multiple layer suturing
Pressure dressing
Surgical packing of the defect
Drains
- Fine superficial drains
- Larger superficial drains
- Deep drains (tube drains)
- Vacuum drains
Suturing:

Edema control
Edema is an accumulation of fluid in the
interstitial space because of transudation from
damaged vessels and lymphatic obstruction by
fibrin.
Two variables:
- Amount of tissue injury.
- Amount of loose connective tissue.
Controlled by
- Minimizing tissue damage
- Ice application
- Systemic corticosteroids
Patient general health and nutrition:
Wound healing depends on
Patients ability to resist inflammation
Provide essential nutrients
Thank you
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