Category Archives: Armamentarium for Basic Oral-Surgery

INSTRUMENTS FOR REMOVING SOFT TISSUE FROM BONY DEFECTS

INSTRUMENTS FOR  REMOVING SOFT TISSUE FROM BONY DEFECTS

The periapical curette is an angled, double-ended instrument used to remove soft tissue from bony defects (Fig. 6-20). The principal use is to remove granulomas or small cysts from periapical lesions, but it is also used to remove small amounts of granulation tissue debris from the tooth socket. The periapical curette is distinctly different from. the periodontal curette in design and function.

Bur and Handpiece

Bur and Handpiece

A final method for removing bone is with a bur and hand-piece.This is the technique that most surgeons use when removing bone for surgical removal of teeth. Relatively high-speed hand-pieces with sharp carbide burs remove cortical bone efficiently, Burs such as no. 557 or no. 703 fissure bur or a no. 8 round bur are used. When large amounts of bone must be removed, such as in torus reduction, a large bone bur that resembles an acrylic bur is used.

The handpiece that is used must be completely sterilizable in a steam autoclave. When a hand piece is’ purchased,the manufacturer’s specifications must be checked carefully to ensure that this is possible. The handpiece should have relatively high speed and torque (Fig. 6-19). This allows the bone removal to he done rapidly and allows efficient sectioning of teeth. The hand-piece must not exhaust air into the operative field as do dental drills. Most high-speed turbine drills used for routine restorative dentistry must not be used. The reason is

A, Rongeurs are bone-cutting forceps that have spring-loaded handles. 8, Blumenthal rongeurs are combination end-cutting and side-cutting blades. They are preferred for oral surgery procedures. ·

A, Rongeurs are bone-cutting forceps that have spring-loaded handles. 8, Blumenthal
rongeurs are combination end-cutting and side-cutting blades. They are preferred for oral surgery procedures.
·

that the air exhausted into the wound may be forced into deeper tissue planes and produce tissue emphysema, a potentially dangerous occunence.

Bone File

Bone File

Final smoothing of bone before suturing’ the mucoperiosteal flap back into position is usually performed with a small bone file (Fig. 6-18, A). The bone file is usually a double-ended instrument with a small and large end. It cannot be used efficiently for removal of large amounts of bone therefore it is used only for final smoothing. The teeth of the bone file are arranged in such a fashion that they remove bone only on a pull stroke (Fig.6-18, B). Pushing the bone file results only in burnishing and crushing the bone and should be avoided.

Chisel and mallet

Chisel and mallet

One of the obvious methods of bone removal is to use a surgical chisel and mallet (Fig. 11·17, A-C). Bone is usually removed with a monobevel chisel, and-teeth are usually sectioned with a bibevel chisel. The success of chisel use depends on the sharpness of the instrument. Therefore it is necessary to sharpen the chisel before it is sterilized for the next patient. Some chisels have carbide tips and can be used more than once between sharpenings. A mallet with a nylon facing imparts less shock to the patient is less noisy and is therefore recommended.

INSTRUMENTS FOR REMOVING BONE

INSTRUMENTS FOR REMOVING BONE

Rongeur Forceps

The instrument most commonly used for removing bone is the rongeur forceps. This instrument has sharp blades that are squeezed together by the handles, cutting or pinching through the bone. Rongeur forceps have a leaf spring between the handle so that when hand pressure is released, the instrument will open. This allows the surgeon to make repeated cuts of bone without manually reopening the instrument (Fig. 6-16, A). The two major designs for rongeur forceps are (1) a side-cutting forceps and .(2)the side-cutting and end-cutting forceps (Fig. 6-16, B).

The side-cutting and end-cutting forceps (Blumenthal rongeurs) are more practical for most dentoalveolar surgical procedures that require bone removal. Because they are end-cutting these-forceps can be inserted into sockets for removal of interradicular bone, but they can also be used to remove sharp edges of bone. Rongeurs can be used to remove large amounts of bone efficiently and quickly. Because rongeurs are relatively delicate instruments, the surgeon should not use the forceps to remove large amounts of bone in single bites. Rather, smaller amounts of bone should be removed in each of multiple bites. Likewise the rongeurs should not be used to  Remove teeth, because this practice will quickly dull and destroy the instrument. Rongeurs are usually quite expensive, so care should be taken to keep them in working order

INSTRUMENTS FOR GRASPING TISSUE

INSTRUMENTS FOR GRASPING TISSUE

In performing soft tissue surgery it is frequently necessary to stabilize soft tissue flaps to pass a suture needle. Tissue forceps most commonly used for this purpose are the Adson forceps (pickups) (Fig. 6-13, A). These are delicate forceps with small teeth, which can be used to gently hold tissue and thereby stabilize it. When this instrument is used care should be taken not to grasp the tissue too tightly thereby crushing it Adson forceps are also available Without teeth.

INSTRUMENTS FOR GRASPING TISSUE

INSTRUMENTS FOR GRASPING TISSUE

Figure no. 6-5A, No.9 Molt periosteal elevator is most commonly used in oral surgery. B, A single-ended Molt periosteal elevator with a sharp round end may he used to elevate the mucoperiosteum. C and D, The double-ended Molt periosteal elevator has a large and small end to provide the surgeon the appropriate-size end for the specific task.

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

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

Austin retractor is a right-angle retractor that can be used to retract cheek, tongue, or flaps.

Austin retractor is a right-angle retractor that can be used
to retract cheek, tongue, or flaps.

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

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

Periosteal elevators such as Woodson and no. 9 Molt are useful to retract flaps. Seldin retractor (top) is broader instrument that provides broader retraction and increased visualization

Periosteal elevators such as Woodson and no. 9 Molt are useful to retract flaps. Seldin retractor
(top) is broader instrument that provides broader retraction and increased visualization

Weider retractor is a large retractor designed to retract tongue. Serrated surface helps to engage tongue so that it can be held securely.

Weider retractor is a large retractor designed to retract
tongue. Serrated surface helps to engage tongue so that it can be
held securely.

Weider retractor is used to hold tongue away from surgical field. Austin retractor is used to retract cheek.

Weider retractor is used to hold tongue away from surgical
field. Austin retractor is used to retract cheek.

A, Hemostats (top view) used in oral surgery. B, Curved hemostat (side view).

A, Hemostats (top view) used in oral surgery. B, Curved hemostat (side view).

A, Small, delicate Adson tissue forceps are used to gently stabilize soft tissue for suturing or dissection. 8, The Stillies pickup is longer than the Adson pickup and is used to handle tissue in the more posterior aspect of the mouth ,C The college pliers is an angled forceps that is used for picking up small objects in the mouth or from the Mayo tray stand.

A, Small, delicate Adson tissue forceps are used to gently stabilize soft tissue for suturing
or dissection. 8, The Stillies pickup is longer than the Adson pickup and is used to handle tissue in the
more posterior aspect of the mouth ,C The college pliers is an angled forceps that is used for picking
up small objects in the mouth or from the Mayo tray stand.

When working in the posterior part of the mouth, the Adson forceps may be too short. A longer forceps that has similar shape is the Stillies forceps. This forceps is usually . 7 to 9 inches long and can easily grasp tissue in the posterior part of the mouth and still leave enough of the instrument protruding beyond the lips for the surgeon to control it (Fig. 6-13, B).

Occasionally, it is more convenient to have an angled forceps. Such a forceps is the college, or cotton, forceps (Fig. 6-13, C). Although this forceps is not especially useful for handling tissue, it is an excelent instrument for picking up small fragments of tooth, amalgam, or other foreign material and for placing or removing gauze packs.This instrument is commonly used in tray systems.

In some types of surgery, especially when removing larger amounts of fibrous tissue, such as in an epulis fissuratum, forceps with locking handles and teeth that will grip the tissue firmly are necessary. In this situation the Allis tissue forceps are used (Fig. 6-H, A and B). The locking handle allows the forceps to be placed in the proper position and then to be held by an assistant to provide
the necessary tension for proper dissection of the tissue.The Allis forceps should never be used on ti~sue that is to be left in the mouth, because they cause a relatively large amount of tissue destruction as a result of crushing injury (Fig. 6-14. 0)

Russian tissue forceps are large, round-ended tissue forceps (Fig 6- 15) that are most useful in oral surgery to pick lip teeth that have been elevated from their sockets (Fig.6-15 B). The round end allows a positive grip on 3 tooth or toothth fragment so that it is not likely to slip out of the instrument’s grip, as commonly occurs with the hemostat the Russian forceps are also useful for placing gauze in the mouth when the surgeon is isolating a particular area for surgery.

A, Allis tissue forceps are useful for grasping and holding tissue that will be excised. B, Allis forceps are held in same fashion as needle holder. C, Comparison of Adson beaks (right) With Allis beaks" (left) shows difference in their design and use.

A, Allis tissue forceps are useful for grasping and holding
tissue that will be excised. B, Allis forceps are held in same fashion as needle holder. C, Comparison of Adson beaks (right) With Allis
beaks” (left) shows difference in their design and use.

A, Russian tissue forceps are round-ended pickups. 8, Russian forceps are especially useful for grasping teeth that are loose in the mouth.

A, Russian tissue forceps are round-ended pickups. 8, Russian forceps are especially useful
for grasping teeth that are loose in the mouth.

INSTRUMENTS FOR CONTROLLING HEMORRHAGE

INSTRUMENTS FOR CONTROLLING HEMORRHAGE

When incisions are made through tissue, small arteries and veins are incised causing bleeding that may require more than simple pressure to control. When this is necessary an instrument called a hemostat is used (Fig. 6-12, A). Hemostats come in a variety of shapes, may be relatively small and delicate or larger, and are either straight or curved. The hemostat most commonly used in oral surgery is a curved hemostat (fig. 6-12, /3).

The hemostat has a relatively long delicate beak used to grasp tissue and a locking handle.The locking mechanism allows the surgeon to clamp the hemostat onto a vessel and then let go of the instrument which will remain clamped onto the tissue.

In addition to its use as an instrument for controlling bleeding the hemostat is especially useful in oral surgery to remove granulation tissue from tooth sockets and to pick up small root tips, pieces of calculus, fragments 0f amalgam restorations, and any other small particles that have dropped into the mouth or wound area.

INSTRUMENTS FOR RETRACTING SOFT TISSUE

INSTRUMENTS FOR RETRACTING SOFT TISSUE

It is critical to have good vision and good access to perform good surgery. To this end a variety of retractors have been designed to retract the cheeks, tongue, and mucoperiosteal flaps.

The two most popular cheek retractors are (1) the right-angle Austin retractor (Fig. 6-7) and (2) the offset broad Minnesota retractor (Fig. 6-8). Both of these retractors can retract the cheek and a ucoperiosteal flap simultaneously. Before the flap is create.d, the retractor is held loosely in the cheek, and once the flap is reflected the retractor is placed on the bone and is then used to retract the flap.

In addition to the Austin and Minnesota retractors other retractors are designed more specifically to reflect soft tissue flaps. The Seldin retractor is typical of this kind (Fig. 6-9). Although this retractor may look similar to a periosteal elevator, the leading edge is not sharp but rather is dull and should not be used to reflect mucoperiosteum.The periosteal elevator is often used as the primary instrument to retract soft issue. Once the flap has been reflected the periosteal elevator is positioned 0n bone and held there to reflect the tissue.

The instrument most commonly used to retract the tongue is the mouth mirror. This Is usually part of every basic setup, because it has both the usual use and use as a tongue retractor. The Weider tongue retractor is a broad heart-shaped retractor that is serrated on one side so that it can more firmly engage the tongue and retract it medially and anteriorly (Fig. 6-10). When this retractor is used care must be taken not to position it so far posteriorly that it causes gagging (Fig 6-11).

The towel clip can be used to hold the tongue. When a biopsy procedure is to be performed on the posterior aspect of the tongue, the most positive way to control the tongue is by holding the anterior tongue with a towel , dip local anesthesia must be profound where the clip is placed.

INSTRUMENTS FOR ELEVATING MUCOPERIOSTEUM

INSTRUMENTS FOR ELEVATING MUCOPERIOSTEUM

 After an incision through mucoperiosteum has been made the mucosa and periosteum should be reflected from the underlying bone in a single layer with a periosteal elevator.

The instrument that is most commonly used is the no. 9 Molt periosteal elevator (Fig. 6-5, A), This instrument has a sharp, pointed end and a broader flat end. The pointed end is used to reflect dental papillae from between teeth, and the broad end is used for elevating the tissue from the bone.Some surgeons prefer to use round-ended Molt periosteal elevators. This type of periosteal elevator can be single-ended (Fig. 6-5, m or double-ended (Fig. 6-5, C and D). The cutting edge of the Molt periosteal elevator is thin and sharp, resulting in a clean separation of the periosteum from the bone.

The  periosteal elevator can be used to reflect soft tissue by three methods First, the pointed end can be used in a prying motion to elevate soft tissue. This is most commonly used when elevating a dental papilla. from between teeth. The second method is the push stroke, in which the broad end of the instrument is slid underneath the flap, separating the periosteum from the underlying bone. This is the most efficient stroke and results in the cleanest reflection of the periosteum. The third method is a pull, or scrape, stroke. This is occasionally usefull in some areas but tends to shred or tear the periosteum unless it is done carefully.

The periosteal elevator can also be used as a retractor.Once the periosteum has been elevated, the broad blade of the periosteal elevator is pressed against the bone, with the mucoperiosteal flap elevated into its reflected position.

INSTRUMENTS FOR ELEVATING MUCOPERIOSTUM

INSTRUMENTS FOR ELEVATING MUCOPERIOSTUM

When teeth are to be extracted, the soft tissue attachment around the tooth must be released from the tooth.The instrument most commonly used for this is the no.1 Woodson periosteal elevator (Fig., 6-6). This instrument is relatively small and delicate and can be used to loosen the soft tissue via the gingival sulcus. The pointed end of the no. 9 periosteal elevator can also be used for this purpose.

INSTRUMENTS FOR INCISING TISSUE

INSTRUMENTS FOR INCISING TISSUE

Most surgical procedures begin with an incision. The instrument for making an incision is the scalpel, which is composed of a handle and a disposable, sterile sharp blade. The most commonly used handle is the no. 3 handle, but occasionally the longer, more slender no. 7 handle will be used (Fig. 6-1), The tip of the scalpel handle is prepared to receive a variety of differently shaped scalpel blades that can be inserted onto a slotted receiver

INSTRUMENTS FOR INCISING TISSUE

INSTRUMENTS FOR INCISING TISSUE

The most commonly used scalpel blade for intraoral surgery is the no. 15 blade (fig. 6-2). It is relatively small and can be used to make incisions around teeth and through mucoperiosteum. It is similar in shape to the larger no. 10 blade, which is used for large skin incisions. Other commonly used blades for intraoral surgery are the no. 11 blade and the no. 2 blade. The no. 11 blade is a sharp-pointed blade that is used primarily for making small stab incisions, such as for incising an abscess. The hooked no. 1.2 blade is useful for mucogingival procedures in which incisions must be made on the posterior aspect of teeth or in the maxillary tuberosity area.

The scalpel blade is carefully loaded onto the handle with a needle holder to avoid lacerating the operator’s fingers. The blade is held on the superior edge, where it is reinforced with a small rib, and the handle is held so that the male portion of the fitting is pointing upward (Fig. 6-3, rl). The knife -blade is then slid onto the handle until it clicks into position (Fig. 6-3, B). The knife is unloaded in a similar fashion. The needle holder grasps the most proximal

INSTRUMENTS FOR INCISING TISSUE

INSTRUMENTS FOR INCISING TISSUE

end of the blade (Fig. 6-3, C) and lifts it to disengage it from the male fitting. It is then slid off the knife handle in the opposite direction (Fig. 6-3, D). The used blade is discarded into a proper ‘rigid-sided “sharps” container.
When using the scalpel to make an incision, the surgeon holds it in the pen grasp (Fig. 6-4) to allow maximal control of tile blade as the incision is made. Mobile tissue should be held firmly to stabilize it so that as the incision is made, the blade will incise, not displace, the mucosa. When a mucoperiosteal incision is made, the knife should be pressed down firmly so that the incision penetrates the mucosa and periosteum with the same stroke. Scalpel blade are designed for single-patient use they are dulled verv easilv , when thev come into contact with hard tissue such as bone and teeth, If several Incisions through mucoperteum to bone are required, It may be necessary to use a second blade during a single operation. It is important to remember that dull blades do not make clean,sharp incision of tissue and therefore should be replaced when they become dull.