Category Archives: Armamentarium for Basic Oral-Surgery

INSTRUMENTS FOR IRRIGATION

INSTRUMENTS FOR IRRIGATION

When a handpiece and bur are used to remove bone, it is essential that the area be irrigated with a steady stream of irrigating solution, usually sterile saline. THe irrigation cools the bur and’ prevents bone-damaging heat buildup. The irrigation also ncreases the efficiency of the bur by washing away bone chips from the flutes of the bur and by providing a certain amount of lubrication. In addition, once a surgical procedure iscompleted and before the mucoperiosteal flap is sutured back into position, the surgical field should be irrigated thoroughly with saline. A large plastic syringe with a blunt 18-gauge needle is used for irrigation purposes. Although the syringe is disposable, it can be sterilized multiple times before it must be discarded. The needle should be blunt and smooth so that it does not damage soft tissue, and it should be angled for more efficient direction of the irrigating stream (Fig. 6-34, A and B).

INSTRUMENTS FOR HOLDING TOWELS AND DRAPES IN POSITION

INSTRUMENTS FOR HOLDING TOWELS AND DRAPES IN POSITION

When drapes are placed around a patient, they must be held together with a towel clip (Fig, 6-33). This instrument has a locking handle and finger and thumb rings.The action ends of the towel clip are sharp, curved points that penetrate the towels and drapes. When this instrument is used the operator must take extreme caution not to pinch the patient’s underlying skin.

A,Typical surgical suction has small-diameter tip. 8, Fraser suction-tip has blade in handle to allow operator more control over amount of suction power. Suction tip has hole in side to prevent tissue injury caused by excess suction pressure. Wire stylet is used to clean tip when bone or tooth particles plug suction.

A,Typical surgical suction has small-diameter tip. 8, Fraser suction-tip has blade in handle to allow operator more control over amount of suction power. Suction tip has hole in side to prevent
tissue injury caused by excess suction pressure. Wire stylet is used to clean tip when bone or tooth particles
plug suction.

INSTRUMENTS FOR TRANSFERRING STERILE INSTRUMENTS

INSTRUMENTS FOR TRANSFERRING STERILE INSTRUMENTS

The transfer forceps are heavy forceps used to move instruments from one sterile area to another (Fig. 6-32,A), These forceps are usually right-angled forceps with heavy jaws, so instruments such as extraction forceps can be. moved from one area to another and small items can be handled without dropping them (Fig. 6-32, B and C). The transfer forceps are stored in a container that is usually filled with a bactericidal solution, such as glutaraldehyde, The container must be emptied and new solution placed at least every other day. The container should be thoroughly washed and autoclaved at least once per week.

INSTRUMENTS FOR PROVIDING SUCTION

INSTRUMENTS FOR PROVIDING SUCTION

To provide adequate visualization, blood, saliva, and. irrigating.solutions must be suctioned from the operative site. The surgical suction is one that has a smaller orifice then the type used in general dentistry so that the tooth sockets can be suctioned in case a root tip is fractured and adequate visualization is necessary. Many of these suctions are designed with several orifices so that the soft tissue will not become aspirated into the suction hole and cause tissue injury (Fig. 6-31, A).

The Fraser suction has a hole in the handle portion that can be covered as the requirement dictates. When hard tissue is being cut under copious irrigation, the hole is covered so that the solution is removed rapidly. When soft tissue is being suctioned, the hole is uncovered to prevent tissue injury (Fig. 6-31, B).

INSTRUMENTS FOR HOLDING MOUTH OPEN

INSTRUMENTS FOR HOLDING MOUTH OPEN

When performing extractions of mandibular teeth, it is necessary to support the mandible to prevent stress on the temporomandibular joints (TMJs) By having the patient’s jaw supported on a bite block, the joints wilt be protected. The bite block is just what the name implies (Fig. 6·29, A and 8). It is a rubber block on which the patient can rest the teeth. The patient opens the mouth to a comfortably wide position, and the rubber bite block is inserted, which holds the mouth in the desired position. Should the surgeon need the mouth to open wider the patient must open widely and the bife block must be positioned more to the posterior of the mouth.

The side-action mouth prop or Molt mouth prop (Fig. 6-3) can be used by the operator to open the mouth wider if necessary, This mouth prop has a ratchet-type action opening the mouth wider as the handle is closed. This type of mouth prop should be used with-caution, because great pressure can be applied to the teeth and TMJ, and injury may occur with injudicious use. This type of mouth prop is useful in patients who are deeply sedated.

Whenever a bite block or side-action mouth prop is used, the surgeon should take care to avoid opening the mouth too widely, because it may cause stress on the jaw joint. Occasionally, this may result in stretch injury to the joint, necessitating additional treatment. When long procedures are being performed it is a good idea to periodically remove the prop and allow the patient to move the jaw and rest the muscles for a short time.

Side-action, or Molt mouth prop can be used to open patient's mouth when patient is unable to cooperate, such as during sedation

Side-action, or Molt mouth prop can be used to open patient’s mouth when patient is
unable to cooperate, such as during sedation

SCISSORS

SCISSORS

The final instruments necessary for placing sutures are suture scissors (Fig. 6-26). Suture scissors usually have relatively long handles and thumb and finger rings. They are held in the same way as the needle holder. The suture scissors usually have short cutting edges because their sale purpose is to cut sutures (Fig. 6-27). The most commonly used suture scissors are the Dean scissors. These have slightly curved handles and serrated blades that make cutting sutures easier.

An additional type of scissors is designed for soft tissue.The two major types of tissue scissors a.re (1) the Iris scissors and (2) the Metzenbaum scissors (Fig. 6-28). The Iris scissors are small, sharp-pointed delicate tools used for fine work. The Metzenbaum scissors are blunt-nosed scissors used for undermining soft tissue, as well as for cutting. Tissue scissors such as the Iris or Metzenbaum scissor should not be used to cut sutures, because the suture material will dull the edges of the blades and make them less effective for cutting tissue. The exception is when removing very fine sutures placed in skin incisions in the face. Scissors with thin pointed tips such as an Iris may be useful.

Soft tissue scissors are of two designs: Iris scissors (top) are small, sharp-pointed scissors. Metzenbaum scissors (bottom) are longer, delicate, blunt-nosed scissors.

Soft tissue scissors are of two designs: Iris scissors (top) are small, sharp-pointed scissors.
Metzenbaum scissors (bottom) are longer, delicate, blunt-nosed scissors.

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

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

SUTURE MATERIAL

SUTURE MATERIAL

Many types of suture materials are available. The materials are classified by size, resorbability, and whether or not they are monofilament or polyfilament.

The size of suture is designated by a series of zeros. The size most commonly used in ‘the suturing of oral mucosa is 3-0 (000). A larger size suture would be 2-0, or O. Smaller sizes would be 4-0, 5-0, and 6-0 sutures. Sutures of very fine size such as 6-0, are usually used in cohspicuous places on the- skin, such as the face because smaller

A, Comparison of needles used in oral surgery. Top is P- 3 needle, which is usually 4-0 size suture. Middle is FS-2 needle, and bottom is X-l. All are cutting needles. B, Tip of needle used to suture mucoperiosteum is triangular in cross section to make it a cutting needle. C, Suture may be threaded through needle eye or can be purchased already swaged onto needle.

A, Comparison of needles used in oral surgery. Top is P-
3 needle, which is usually 4-0 size suture. Middle is FS-2 needle, and
bottom is X-l. All are cutting needles. B, Tip of needle used to suture
mucoperiosteum is triangular in cross section to make it a cutting
needle. C, Suture may be threaded through needle eye or can be
purchased already swaged onto needle.

Needle holder grasps curved needle two thirds of the distance from tip of needle.

Needle holder grasps curved needle two thirds of the
distance from tip of needle.

 sutures usually cause less scarring Sutures of size 3-0 are large enough to prevent tearing through mucosa, are strong enough to withstand the tension placed on them intraorally, and are strong enough for easy knot tying with a needle holder.

Sutures may be resorbable or nonresorbable. Nonresorbable suture materials include such types as silk, nylon, and stainless steel. The most commonly used nonresorbable suture in the oral cavity is silk. Nylon and stainless steel are rarely used in the mouth. Resorbable sutures are primarily made of gut. Although the term catgut is often used to designate this type of suture, gut actually is derived from the serosal surface of sheep intestines. Plain catgut resorbs relatively quickly in the oral cavity, rarely lasting longer’ than 5 days. Gut that has been treated by tanning solutions (chromic acid) and is therefore called chromic gilt lasts longer-up to 10 to 12 days. Several synthetic resorbable sutures are also available.These are materials that are long chains of polymers braided into suture material. Examples are polyglycolic acid and polylactic acid .’ These materials are slowly resorbed, taking up to 4 weeks before they are resorbed. Such long lasting resorbable sutures are rarely Indicated in the oral cavity.

Finally, sutures are classified based on whether or not they are monofilament or polyfilament. Monofilament sutures arc sutures such as both plain and chromic gut nylon, and stainless steel. Polyfilament sutures are silk,polyglycolic acid, and polylactic acid. Sutures .that are made of braided material are easy to handle and tie and rarely. come untied. The cut ends are usually soft and
nonirritating to the tongue and surrounding soft tissues.However because of the multiple filaments, they tend to “wick” oral fluids along the suture to the underlying tissues,this working action may carry bacteria along with the saliva Monofilament sutures do not Cause this wicking action but may be more difficult to tie tend to come untied and are stiffer and therefore more irritating to the tongue and soft tissues.

Suture scissors have long handles and short blades: Blades may he angled slightly in either of two directions.

Suture scissors have long handles and short blades: Blades may he angled slightly in either
of two directions.

Suture scissors should be held in same fashion as needle holder.

Suture scissors should be held in same fashion as needle holder.

The most commonly used suture for the oral cavity is 3-o black silk. The size 3-0 has the appropriate amount of strength; the polyfilament nature of the silk makes it easy to tie and easily tolerated by the patient’s soft tissues. The black-color makes the suture easy to see when the patient returns for suture’ removal. Sutures that are holding mucosa together usually stay no longer than 5 to 7 days, so the wicklng action is of little clinical importance. (fcchntques for suturing and knot tying are presented in-Chapter 8.)

NEEDLE

NEEDLE

The needle used in closing mucosal incisions is usually a small half-circle or three eighths-circle-suture needle. It is curved to allow the needle to pass through a limited space, where a straight needle could not reach. Suture needles come in a large variety of shapes, from very small to very large (Fig. 6-24, A). The tips of suture needles are either tapered, such as a sewing needle, or they have triangular tips that allow them to be cutting needles (Fig. 6- 24, B). A cutting needle will pass through mucoperiosteum more easily than the tapered needle. The cutting portion of the needle extends about one third the length of the needle, arid the remaining portion of the needle is round. The suture can be threaded through the eye of the needle or can be purchased already swaged on by the manufacturer (Fig. 6-24, C). If the dentist chooses to load his or her own needles for the sake of economy, needles that have eyes like those in typical sewing needles) must be used. If the dentist chooses to use the disposable needles,
then the suture will be swaged onto the needle. Needles that have eyes are larger at the tip and may cause slightly increased tissue injury compared with the swaged on needles.

The curved needle is held approximately two thirds of the distance between the tip and the end of the needle (Fig. 6-25). This allows enough of the. needle to be exposed to pass through the tissue, while allowing the needle holder to grasp the needle in its strong portion to prevent bending of the needle. Techniques for placing sutures are discussed in Chapter 8.

NEEDLE HOLDER

NEEDLE HOLDER

The needle holder is an instrument with a locking handle and a short, stout beak. For intraoral placement of sutures, a 6-inch (15-cm) needle holder is usually recommended (Fig. 6-21). The beak of the needle holder is shorter and stronger than the beak of the hemostat (Fig.6-22, A). The face of the beak of the needle holder is crosshatched to permit a positive grasp of the suture needle and suture. The hemostat has parallel grooves on the face of the beaks, thereby decreasing the control over needle and suture. Therefore the hemostat should not be used for suturing (Fig. 6-22, B).

To properly control the locking handles and to direct the relatively long needle holder, the surgeon must hold the instrument in the proper fashion (Fig. 6-23). The thumb and ring finger are inserted through the rings. The index finger is held along the length of the needle holder to steady and direct it. The second finger aids in controlling the locking mechanism. The index finger should not be put through the finger ring because this will result in dramatic decrease in control.

A, Surgical chisel and mallet can be used for removing bone and sectioning teeth. B, Additional chisels are straight unibevel chisel, curved unibevel chisel, or straight bibevel chisel. C, A close-up view of the chisel working end shows the bibevel end, the straiqht unibevel end, and the curved unibevel end.

A, Surgical chisel and mallet can be used for removing bone and sectioning teeth.
B, Additional chisels are straight unibevel chisel, curved unibevel chisel, or straight bibevel chisel.
C, A close-up view of the chisel working end shows the bibevel end, the straiqht unibevel end, and
the curved unibevel end.

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

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

Typical moderate-speed, high-torque, sterilizable hand piece with 703 bur

Typical moderate-speed, high-torque, sterilizable hand piece with 703 bur

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

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

Needle holder has locking handle and short, stout beak.

Needle holder has locking handle and short, stout beak.

A, Hemostat (top) has longer, thinner beak compared with needle holder (bottom) and therefore should not be used for suturing. B, Face. of shorter beak of needle holder is crosshatched to ensure positive grip on needle (left). Face of hemostat has parallel grooves that do not allow a firm grip on needle (right).

A, Hemostat (top) has longer, thinner beak compared with needle holder (bottom) and
therefore should not be used for suturing. B, Face. of shorter beak of needle holder is crosshatched
to ensure positive grip on needle (left). Face of hemostat has parallel grooves that do not allow a
firm grip on needle (right).

Needle holder is held by using thumb and ring finger in rings (top) and first and second finger to control instrument (bottom).

Needle holder is held by using thumb and ring finger in rings (top) and first and second
finger to control instrument (bottom).

INSTRUMENTS FOR SUTURING MUCOSA

INSTRUMENTS FOR SUTURING MUCOSA

Once a surgical procedure has been completed, the mucoperiosteal flap is returned to its original position and held in place by sutures. The needle holder is the instrument used to place the sutures.