 Definition of oral surgery

 Developing a surgical diagnosis or pre surgical evaluation

 Basic necessities for surgery or pre surgical preparation
 Aseptic technique
 Preparation of Patient and Surgeon
 Techniques of sterilization
 Maintainence of sterility
 Surgical staff preparation
 Incisions
 Principles of flap designing and different types of flaps
 Tissue handling
 Hemostasis
 Suture and suturing techniques
 Decontamination and debridement
 Edema control
 Conclusion
 Bibliography
 Oral and maxillofacial surgery is the specialty of
dentistry which includes the diagnosis, surgical and
adjunctive treatment of diseases, injuries and defects
involving both the functional and esthetic aspects of the
hard and soft tissues of the oral and maxillofacial region
 The aim of preoperative evaluation is not to screen
broadly for undiagnosed disease but rather to identify
and quantify any comorbidity that may have an impact
on the operative outcome
 The context in which preoperative preparation is
conducted ranges from an outpatient office visit to
hospital inpatient consultation to emergency
department evaluation of a patient.
 Know your patient
 Examine your patient and gather patient and scientific
data including the use of consultants.
 Look at the data and analyze for hypothesis testing
 Consider the alternatives
 Is picking up a knife the best thing to do?
 To practice evidence based treatment.
It depends on:-
>Adequate access
>Adequate light
>Clean surgical field
 TERMINOLOGIES-
 Sepsis- Breakdown of tissue by action of microbes and
is usually accompanied by inflammation
 Antiseptic- Substance that can prevent multiplication
of organism capable of causing infection. Anstiseptics
are applied on living tissues while Disinfectant are
applied on inanimate object.
 Sterility- freedom from viable forms of micro
organisms
 Sanitization –reduction of number of viable organisms
 To minimise wound contamintaion by pathogens
because during a surgery, dentist violates the epithelial
surface which is the most important barrier against an
infection
 During oral surgical procedures dentist, assistant and
equipment become comtaminated with patients blood
and saliva
 By using disposable materials:-
 Surgical field maintaenance
 1. Hand and arm preparation Done by antiseptics with
low toxicity like iodoform, chlorhexidine, and
hexachlorophene
 Two techniques are used for
 A. Clean technique- used in office based surgeries.
Surgeon wears a clean dress and over it long sleeved
laboratory coat or a surgical scrub
 B. Sterile technique- mostly in operating room.
Purpose of it is to minimise the number or micro
organism that can ener the wound site.
 Use a sharp blade of proper size.
 Use firm continuous strokes.
 Avoid cutting vital structure
 An incision should not cross an underlying bony
defect
 Incise perpendicular to the epithelial surface.
 Intraoral incisions should be properly placed.
1. Outlined by a surgical incision
2. Carries its own blood supply
3. Allows surgical access to underlying tissues
4. Can be replaced in the original position
5. Can be maintained with sutures and is expected to
heal
Flap necrosis
Flap Dehiscence
Flap Tearing
Injury to Local Structures
1. Base > Free margin
• to preserve an adequate blood supply
• unless a major artery is present in the base
2. Width of Base > Length of Flap*2
• less critical in oral cavity, but length < width
• a long, straight incision with adequate flap reflection heals
more rapidly than a short, torn incision.
3. An axial blood supply in the base
4. Hold the flap with a retractor resting on intact bone
to prevent tension.
The incisions must be made over intact bone
If the pathologic condition has eroded the buccocortical plate,
the incision must be at least 6 or 8 mm away from it.
The incision should be 6 to 8 mm away from the bony defect
created by surgery.
Gently handle the flap's edges
Do not place the flap under tension
Do not cross bony prominences, ex: canine eminence
• Is a common problem in procedures using a flap that
provides insufficient access
• A proper long flap heals as quickly as a short flap
• Envelope flaps
– an incision around the necks of several teeth.
– extends 2 teeth anterior and 1 tooth posterior.
 If not provide sufficient access…
• Vertical (oblique) releasing incisions:
– extends 1 tooth anterior and 1 tooth posterior.
– started at the line angle of a tooth.
– carried obliquely apically into the unattached gingiva.
– If cross the papilla  localized periodontal problems
 Various types of flaps have been described in oral
surgery, whose name is based mainly upon shape:-

 trapezoidal,
 triangular,
 envelope,
 semilunar,
 The trapezoidal flap is created after a Π shaped incision,
which is formed by a
 Horizontal incision along the gingivae, and two oblique
vertical releasing incisions extending to the buccal
vestibule.
 Vertical releasing incisions always extend to the
interdental papilla and never to the center of the labial or
buccal surface of the tooth.
 This ensures the integrity of the gingiva proper, because if
the incision were to begin at the center of the
tooth,contraction after healing would leave the cervical
area of the tooth exposed.
 Advantages. Provides excellent access, allows surgery
to be performed on more than one or two teeth,
produces no tension in the tissues, allows easy
reapproximation of the flap to its original position and
hastens the healing process.
 Disadvantages. Produces a defect in the attached
gingiva (recession of gingiva).
 This flap is the result of an Lshaped incision with a
horizontal incision made along the gingival sulcus and
a vertical or oblique incision
 The vertical incision begins approximately at the
vestibular fold and extends to the interdental papilla
of the gingiva.
 The triangular flap is performed labially or buccally on
both jaws and is indicated in the surgical removal of
root tips, small cysts, and apicoectomies.
 Advantages. Ensures an adequate blood supply,
satisfactory visualization, very good stability and
reapproximation; it is easily modified with a small
releasing incision, or an additional vertical incision, or
even lengthening of the horizontal incision.
 Disadvantages. Limited access to long roots, tension is
created when the flap is held with a retractor, and it
causes a defect in the attached gingiva
 This type of flap is the result of an extended horizontal
incision along the cervical lines of the teeth. The incision is
made in the gingival sulcus and extends along four or five
teeth.
 The tissue connected to the cervical lines of these teeth
and the interdental papillae is thus freed. The envelope
flap is used for surgery of incisors, premolars and molars,
on the labial or buccal and palatal or lingual surface and is
usually indicated when the surgical procedure involves the
cervical lines of the teeth labially (or buccally) and
palatally (or lingually), apicoectomy (palatal root), removal
of impacted teeth, cysts, etc.
 Advantages. Avoidance of vertical incision and easy
reapproximation to original position.
 Disadvantages. Difficult reflection (mainly palatally),
great tension with a risk of the ends tearing, limited
visualization in apicoectomies, limited access,
possibility of injury of palatal vessels and nerves,
defect of attached gingiva
 This flap is the result of a curved incision, which
begins just beneath the vestibular fold and has a bow
shaped course with the convex part towards the
attached gingiva
 The lowest point of the incision must be at least 0.5 cm
from the gingival margin, so that the blood supply is
not compromised. Each end of the incision must
extend at least one tooth over on each side of the area
of bone removal. The semilunar flap is used in
apicoectomies and removal of small cysts and root
tips.
 Advantages. Small incision and easy reflection, no
recession of gingivae around the prosthetic
restoration, no intervention at the periodontium,
easier oral hygiene compared to other types of flaps
 Disadvantages. Possibility of the incision being
performed right over the bone lesion due to
miscalculation, scarringmainly in the anterior area,
difficulty of reapproximation and suturing due to
absence of specific reference points, limited access and
visualization,tendency to tear.
 Gentle handling of tissue
 Meticulous haemostasis
 Preservation of blood supply
 Strict aseptic technique
 Minimum tension on tissues
 Accurate tissue apposition
 Obliteration of deadspace

 Also called as Halsted's principles, or Tenets of

Halsted
 Is a process which causes bleeding to stop
 Methods of promoting wound hemostasis –
1. Natural hemostatic mechanism
2. Use of sponge and applying pressure
3. these two cause stasis of blood and promote
coagulation. Small vessels 20 to 30 sec. larger vessels
5- 10 min. it should be dabbed rather than wiped
4. Use of electric current –fuses the cut ends
5. Sutures
6. Vasoconstrictors like adrenaline: best if placed in the
site 7 minutes before the surgery begins
 Dead space management: It is any area that remains
devoid of tissue after closure of wound
 It usually fills in with blood and can lead to hematoma
formation
 It can be eliminated in 4 ways
 A. Suturing tissue planes together to minimize post
operative void
 B. Place a pressure dressing. This brings the tissue
planes together until either they are bound by fibrin or
pressed by edema or both(takes uptp 12 to 18 hours
 C. Place a packing in the void and remove when
bleeding stops. Done when surgeon cant tack the
tissue together , eg bony cavity after cyst removal
 D.Through use of drains with or without pressure
packs
 It is a strand of thread that is used to approximate
tissues and to ligate blood vessels
 Tools:
1. Needle
2. Suture material

Source: Ratner et al. 2004

 Natural
Origin
Synthetic

Absorbable
Sutures Absorption
Nonabsorba
ble

Multifilame
nt
Fiber
construction
Monofilame
nt
 Physical
 Tensile Strength, Dimension, Knot-pull strength, Knot
security, Stiffness
 Handling
 Knot-tie down, First throw hold, Tissue drag, Package
memory, Suppleness
 Biological
 Tissue reaction, Absorption, Biocompatibility, Tensile
strength loss
 Selection of suture material should be based on healing
charecteristics of the tissue being approximated
A. Rate of tissue healing. –
suture that looses its tensile strength at same rate as the
tissue gain strength.
Tissue that heal slowly are usually closed with non
absorbable sutures
Rapidly healing tissue with absorbable ones
B.Tissue contamination. – contaminated areas should be
sutured with monofilament materials
 C. cosmetic results- close and prolonged apposition of
tissue will produce best results
 D. Cancer patients- synthetic non absorbable sutures
as the the wound can breakdown.
 E. Nutritional status- non absorbable sutures to be
used in undernourished cases as the wound healing
takes longer
 Are of two types :- a. Eyed
b. Eyeless
 Needle should be grasped at approximately 1/3° the
distance from eye or 2/3 from point
 Needle should enter perpendicular to tissue surface
 Needle should pass through the tissue along its curve
 Suture should be passed at an equal depth and
distance from incision on both sides
 Needle always pass from movable to fixed tissue
 Thinner to thicker tissue
 Deeper to superficial tissue
 Tissue must never be closed under pressure. Undermining
of tissue must be done prior to suturing in such cases
 Knot should never lie on the incision line
 Suture should only be tied only to approximate and not to
blanch
 Suture should be placed at a greater depth than the
distance from the incisio, so as to evert the wound margins.
 Sutures on the skin are generally removed in 5 days and
intra oral in 7 days. If there is tension while suturing, they
may be kept for 10 days
1. Suture knot slipping
• Inability of the suture to retain until wound healing complete
• Common in absorbable suture

2. Re-infection
• Site for microbial growth causing re-infection
• the need for suture with antimicrobial activity

3. Failure of wound healing

• Improper suturing technique does not allow collagen
formation
 DECONTAMINATION is done to reduce the bacterial
count and hence reduce risk of infection
 Mostly done by irrigastion under pressure. Saline or
antibiotic solutions can be used
 DEBRIMENT is careful removal of necrotic and
ischemic tissue and foreign material from injured
tissue that would impede wound healing
 Is done where either there is a traumatic injury or
severe tissue damage is done.
 Edema is accumulation of fluid in interstitial space
because of transudation from damaged vessels and
lymphatic obstruction by fibrin
 The degree is determined by :- a. The amount of tissue
damage, b. Looser the connective tissue
 Prevention –
 A. Application of ice
 B. Patient position. Ie patient should keep the head
above the body as much as possible
 C. Short term high dose corticosteroids (only if
administerd before tissue damage is done)
 A surgeon can help improve patients chances of having
normal healing of an elective surgical wound by
evaluating and optimizing the patient general health
status before surgery.