This is the 4th script of surgery, for the lecture of Principles of surgery.

The reference for this script was the record of the lecture and the book ,in addition to some extra information and pictures to enhance your understanding. This lecture contains many points that may mislead you, by the end of the script there are some flowcharts that summarize the most important points without details, you can use them to arrange your information. The reference from the book is chapter 3.

Principles Of Surgery

Human tissues have genetically determined properties that make their responses to injury fairly predictable. Depending on this predictability, principles of surgery that help to optimize the wound-healing environment have evolved through time and through basic and clinical research. DEVELOPING A SURGICAL DIAGNOSIS Most of the important decisions concerning a maxillofacial surgical procedure should be made long before the administration of anesthesia. The decision to perform surgery should be the culmination of several diagnostic steps. In the analytic approach the surgeon first identifies the various signs and symptoms and relevant historical information; then, using available data and logical reasoning, the surgeon establishes the relationship between the individual problems. Lets say we have a patient that requires wisdom tooth extraction. and lab tests. differential diagnosis. In our minds we should always have a set of diagnoses for the condition we have. For example the patient is complaining of pain at the pre auricular area ; it might be due to wisdom, TMJ or submandibular tumor etc .. most probable to the least. Each diagnosis is excluded one by one to reach the definitive diagnosis.

The initial step in the presurgical evaluation is:

1-the collection of accurate and pertinent data: This is accomplished through patient interviews; physical, laboratory,and imaging examinations; and the use of consultants when necessary. Patient interviews and physical examinations should be performed in an unhurried, thoughtful fashion. The surgeon should not be willing to accept incomplete data, such as a poor-quality radiograph, especially when it is probable that additional data might change decisions concerning surgery. For a good analysis, data must be organized into a form that allows for hypothesis testing; that is, the dentist should be able to consider a list of possible diseases and eliminate those unsupported by the data. By using this method, along with the knowledge of which diseases have a probability of being present, the surgeon is usually able to reach a decision about whether surgery is indicated. 2- Clinicians also must be thoughtful observers. Whenever a procedure is performed, they should note all aspects of its outcome to advance their surgical knowledge and to improve future surgical results. This procedure should also be followed whenever a clinician is learning about a new technique. In addition, a clinician should practice evidence-based dentistry by evaluating the purported results of any new technique by weighing the scientific merit of studies used to investigate the technique.Frequently, scientific methods are violated by the unrecognized introduction of a placebo effect, observer bias, patient variability, or use of inadequate control groups.

BASIC NECESSITIES FOR SURGERY Little difference exists between the basic necessities required for oral surgery and those required for the proper performance of other aspects of dentistry. The two principal requirements are (1) adequate visibility and (2) assistance. Although visibility may seem too obvious to mention as a requirement for performing surgery, clinicians often overlook it. Adequate visibility depends upon the following three factors: (1) adequate access, (2) adequate light, and (3) a surgical field free of excess blood and other fluids. -Adequate access requires: the patient's ability to open the mouth widely. Retraction of tissues( such as the lips , cheeks and tongue) away from the operative field provides much of the necessary access. (Proper retraction also protects tissues from being accidentally injured, for example, by cutting instruments.) Improved access also may require surgically created exposure the creation of surgical flaps, which are discussed later in this script.

-Adequate light is another obvious necessity for surgery. However, clinicians often forget that many surgical procedures place the surgeon or assistant in positions that block chair-based light sources. To correct this problem, the light source must continually be repositioned, or the surgeon or assistant must avoid obstructing the light or use a headlight. -A surgical field free of fluids is also necessary for adequate visibility. High volume suctioning with a relatively small tip can quickly remove blood and other fluids from the field. -As in other types of dentistry, a properly trained assistant provides invaluable help during oral surgery. The assistant should be sufficiently familiar with the procedures being performed to anticipate the surgeon's needs. It is extremely difficult to perform good surgery with no or poor assistance. -Aseptic technique includes minimizing wound and surgical field contamination by pathogenic microbes and , this can be done by using antiseptic and disinfectant solutions , wearing aprons and gloves, and placing the sterilized instruments on the sterile sheet.

Operative techniques
1) Each surgical procedure is started by: 1) doing an incision then2) retraction of soft tissue flap to gain access and some surgeries require removal of bone then 3) delivery of the tooth or root then4) debridement and irrigation is done to smoothen sharp bony edges then 5) suturing and 6)post operative care of the patient.

Incision
Few basic principles are important to remember when performing incisions. Which are: 1- a sharp blade of the proper size should be used. *The blade used is fixed on an instrument , this instrument is called the scalpel. In oral surgery the scalpel used is number 3 scalpel.

(number 3 scalpel)

(scalpel with blade fixed on it)

*The rate at which a blade dulls ( becomes not sharp) depends on the resistance of tissues through which the blade cuts.Bone and ligamental tissues dull blades more rapidly than does buccal mucosa. Therefore the surgeon should change blades whenever the knife does not seem to be incising easily. *These are some types of blades used in oral surgery:

Blade number 11: used to do an incision in an abscess to drain it.

Blade number 15: most commonly used

Blade number 10: similar to number 15 blade but larger, usually used by general surgeons to do excisions extraorally.

Blade number 12: used to do an incision in the posterior area of the oral cavity, especially in the maxillary tuberosity region ( curved)

2-Use a single firm continuous stroke when incising. Repeated incisions are not allowed because they cause damage to blood vessels and soft tissue which increases bleeding and may complicate our surgical treatment. *holding the scalpel is done using the pen grasp, for more control and tactile sensitivity, and only the wrist should be moved not the whole forearm. 3-the surgeon should carefully avoid cutting vital structures when incising. Thats why you should know anatomy of the head and neck specially the oral cavity. And the surgeon must incise only deeply enough to define the next layer . In general we can say that: a- incisions in the buccal area of the lower premolar should not be done to avoid injuring the mental nerve ( for example if I want to do an incision to remove an impacted lower second premolar , the vertical releasing incision should be distal to the tooth away from the mental nerve area) b-Incisions in the lower wisdom teeth area lingually should not be done to avoid injuring the lingual nerve which is covered only by soft tissue in this area. c-when using a scalpel the surgeon's focus must remain on the blade to avoid accidentally cutting structures such as the lips or cheeks of the patient when inserting and removing the blade to and from the mouth. 4- incisions through epithelial surfaces that the surgeon plans to reapproximate should be made with the blade held perpendicular to the epithelial surface ( 90 degrees) . This angle produces squared wound edges that are both easier to reorient properly during suturing and less susceptible to necrosis of the wound edges as a result of ischemia, any oblique incision will cause undermining of the edges which will compromise the blood supply and subsequently interfere with wound healing. 5- incisions in the oral cavity should be properly placed.

It is more desirable to incise through attached gingiva and over healthy bone. ( for example: 1- in the upper maxilla area, in the first incision which is the vertical releasing incision, we should not cross the canine eminence because this will cause dehiscence and separation of the flap margin later on because its a prominent area, 2- for a more esthetic outcome , the incision should not be done on the mid portion of the dental papilla, it should be either including it or mesial or distal to it but not in its middle ) Properly placed incisions allow the wound margins to be sutured over intact, healthy bone that is at least a few millimeters away from the damaged bone, thereby providing support for the healing wound. Incisions placed near the teeth for extractions should be made in the gingival sulcus, unless the clinician feels it is necessary to excise the marginal gingiva or to leave the marginal gingiva untouched..

Flap Design
Surgical flaps are made to:1- gain surgical access to the field , for example in order to extract an impacted wisdom tooth I have to make a flap to gain access to it. 2- Or to move tissue from one place to another. ** Several basic principles of flap design such as : 1-making the flap with an adequate size and 2- a full thickness flap passing through mucosa, submucosa, and periosteum must be followed to prevent the complications of flap surgery, which are:1- flap necrosis, 2-dehiscence, and 3-tearing.

1- flap necrosis
Flap necrosis can be prevented if the surgeon attends to four basic principles. First, the apex (tip) of a flap should never be wider than the base, unless a major artery is present in the base. Flaps should have sides that diverge ) (moving from the apex to the base in order not to compromise the blood supply of the flap.

Because the source of blood supply to the flap is the periosteum which is found in the area where the base of the flap is, so suppose that we do a flap that has a base narrower than the apex, in this case all the parts of the flap contained within the borders of the base will have blood supply but the edges will not, and since the base is the only blood supply source , these edges will not be supplied and have necrosis , look at the figure below.
base

apex

This is a wrong flap design, the red area will have blood supply while the edges in black will not which will lead to necrosis and delay wound healing.

This is the right Flap with the base wider than the apex, and blood supply reaches the whole Flap.

Second, generally the flap base dimension (x) must not be less than height dimension (y), and preferably flap should have x = 2y, the width is always larger than the length. For example if x=1cm , then y should be 0.5 cm

Third, when possible, an axial blood supply should be included in the base of the flap, for example a flap in the palate should be based toward the greater palatine artery . An example on this is the cases of oroantral communication which is a common
complication, that may occur during an attempt to extract the upper back teeth or roots.,

many techniques are used to close this communication like1) buccal advancement flap and 2) palatal rotational flap. but we dont do a vertical releasing incision for closure because we may hurt the greater palatine artery. In the palatal rotational flap, We do two incisions that are long enough and rotate the flap to close the fistula, by this the greater palatine artery will be included in the flap, see the picture below.

Fourth, the base of flaps should not be excessively twisted, stretched, or grasped with anything that might damage vessels, because these maneuvers can compromise the blood supply feeding and draining the flap. The reason that may require the use of over retraction is: inadequate flap size, so your flap should be big enough from the beginning .

2-Flap dehiscence

Flap margin dehiscence is the separation between flap margins after suturing And it is prevented by: 1) approximating the edges of the flap over healthy bone, 2)by gently handling the flap's edges,3) and by not placing the flap under tension which may lead to necrosis. Dehiscence exposes underlying bone, producing pain, bone loss, and increased scarring. For example if I have a bony lesion and I want to do a flap to remove it, I go 5-8 mm away from the lesion and do the incision, so that later on suturing of the flap happens on healthy bone and flap dehiscence is prevented.

Incisions should be 5-8 mm away from the area of surgery

3-Flap Tearing
Tearing of a flap is a common complication of the inexperienced surgeon who attempts to perform a procedure

using a flap that provides insufficient access. Because a properly repaired long incision heals just as quickly as a short one, it is preferable to create a flap at the onset of surgery that is large enough for the surgeon to avoid either tearing it or interrupting surgery to enlarge it.

TISSUE HANDLING The difference between an acceptable and an excellent surgical outcome often rests on how the surgeon handles the tissues. The use of proper incision and flap design techniques plays a role; however, tissue also must be handled carefully. Excessive pulling or crushing, extremes of temperature ( like drilling in the bone without using copious amounts of irrigation), desiccation, or the use of unphysiologic chemicals ( like using hydrogen peroxide instead of normal saline for irrigation by mistake) easily damage tissue . In addition, tissue should not be over aggressively retracted to gain greater surgical access, Therefore the surgeon should use care whenever touching tissue.

HEMOSTASIS
Prevention of excessive blood loss during surgery is important for preserving a patient's oxygen-carrying capacity. However, maintaining meticulous hemostasis during surgery is necessary for other important reasons. One is the decreased visibility that uncontrolled bleeding creates. Even high volume suctioning cannot keep a surgical field completely dry, particularly in the well-vascularized oral and maxillofacial regions. Another problem bleeding causes is the formation of hematomas ( collection of blood inside tissues). Hematomas place pressure on wounds, decreasing vascularity; they increase tension on the wound edges; and they act as culture media, potentiating the development of a wound infection.
Techniques for Promoting Wound Hemostasis (the process that stops bleeding):

1) by assisting natural hemostatic mechanisms. This is usually accomplished by placing pressure on bleeding vessels which causes stasis of blood in vessels, and promotes coagulation. A few small vessels generally require pressure for only 10 to 30 seconds, whereas larger vessels require 10 to 20 minutes of continuous pressure.

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2) the use of heat to cause the ends of cut vessels to fuse closed (thermal coagulation). this is done by using a device called Microcautery , Heat is usually applied through an electrical current that the surgeon concentrates on the bleeding vessel by holding the vessel with a metal instrument, such as a hemostat, or by touching the vessel directly with an electrocautery tip.

Principles during Thermal Coagulation

the patient must be grounded, to allow the current to enter the body. the cautery tip and any metal instrument the cautery tip contacts cannot touch the patient at any point other than the site of the bleeding vessel. Otherwise the current may follow an undesirable path and create a burn. the removal of any blood or fluid that has accumulated around the vessel to be cauterized because Fluid acts as an energy sump and thus prevents a sufficient amount of heat from reaching the vessel to cause closure.

3)by suture ligation. 4)placement of a pressure dressing over the wound. This creates pressure on the small vessels that were cut, promoting coagulation. 5)Placing vasoconstrictive substances, such as epinephrine, in the wound or by applying procoagulants, such as commercial thrombin or collagen, on the wound.

Dead Space Management

Dead space in a wound is any area that remains devoid of tissue after closure of the wound. Dead space is created by either removing tissue in the depths of a wound or by not reapproximating all tissue planes during closure. Dead space in a wound usually fills with blood, which creates a hematoma with a high potential for infection.

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1) suturing tissue planes together to minimize the postoperative void 2) place a pressure dressing over the repaired wound. The dressing compresses tissue planes together until they are either bound by fibrin or pressed together by surgical edema (or both). 3) place packing into the void until bleeding has stopped and then remove the packing.( packing means the filling of a wound or cavity with gauze, sponges, pads, or other material;) The packing material is usually impregnated with an antibacterial medication to lessen the chance of infection

Dead space can be eliminated in four ways

4) the use of surgical drain, which is a device, such as a tube, sutured into the opening of
a wound or dental cavity to facilitate discharge of fluid or purulent material, as It makes a path for blood to run through, so instead of accumulating inside blood goes outside through this channel.

DECONTAMINATION AND DEBRIDEMENT Decontamination is easily accomplished by repeatedly irrigating the wound during surgery and closure. Irrigation dislodges bacteria and other foreign materials and rinses them out of the wound. Irrigation can be achieved by forcing large volumes of fluid under pressure on the wound using a syringe. Although solutions containing antibiotics can be used, most surgeons simply use sterile saline or sterile water. Wound debridement is the careful removal from injured tissue of necrotic, foreign, and severely ischemic material that would impede wound healing.
EDEMA CONTROL

Edema is an accumulation of fluid in the interstitial space because of transudation from damaged vessels, and lymphatic obstruction by fibrin .

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Variables that help determine the degree of postsurgical edema

Amount of tissue injury

Amount of CT in the injured region

the greater the amount of tissue injury, the greater the amount of edema

the more loose connective tissue that is contained in the injured region, the more edema is present. **For example attached gingiva has little loose CT, so it exhibits little tendency toward edema. While the lips , cheeks,and FOM contain large amounts of loose CT and can swell significantly

**Edema is a common complication after surgical extractions, but sometimes it may also happen after simple extractions if the extraction was traumative. ** The dentist can control the amount of postsurgical edema by performing surgery in a manner that minimizes tissue damage. **also ice packs can be used, we ask the patient in the first day of surgery to put ice from 5-10 minutes every 3-4 hours, which can decrease the vascularity in that area and decrease edema. **We can use medications, mainly high dose short term corticosteroids.In general we use Dexamethasone which is an anti inflammatory drug which has the ability to decrease edema.

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PATIENT GENERAL HEALTH AND NUTRITION Proper wound healing depends on: a patient's ability to resist infection, to provide essential nutrients for use as building materials, and to carry out reparative cellular processes. Numerous medical conditions impair a patient's ability to resist infection and heal wounds. These include conditions that 1establish a catabolic state of metabolism, 2-that impede oxygen or nutrient delivery to tissues,3- and that require administration of drugs or physical agents that interfere with immunologic or wound-healing cells. ** Examples of diseases that induce a catabolic metabolic state include: 1) poorly controlled insulin-dependent diabetes mellitus, 2) end-stage renal or hepatic disease, 3) and malignant diseases. **Conditions that interfere with the delivery of oxygen or nutrients to wounded tissues include: 1) severe chronic obstructive pulmonary disease (COPD), 2) poorly compensated congestive heart failure (hypertrophic cardiomyopathy), 3) drug addictions, such as ethanolism. ** Diseases requiring the administration of drugs that interfere with host defenses or wound-healing capabilities include: 1) autoimmune diseases for which long-term corticosteroid therapy is given 2)malignancies for which cytotoxic agents and irradiation are used. The surgeon can help improve the patient's chances of having normal healing of an elective surgical wound by evaluating and optimizing the patient's general health status before surgery. For malnourished patients, this includes improving the nutritional status so that the patient is in a positive nitrogen balance and an anabolic metabolic state.

This is the end of the lecture, the following charts include the main points of some topics.

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Operative Techniques

incision

Flap

tooth or root delivery

debridement and irrigation

suturing

patient post operative care

Incision principles

sharp blade of proper size used

single firm continuous stroke

avoid cutting vital structures

blade held perpendicul ar to epithelium

incision properly placed

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flap necrosis prevention principles

the base wider than the apex

width of the flap base larger than the length

axial blood supply included in the base

avoid over retraction of the flap

Promoting wound hemostasis techniques

placing pressure

thermal coagulation

suture ligation

pressure dressing

vasoconstrictive substances

Best Of Luck Dear Colleagues Nagham Ayman Rabi

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