Category Archives: Principles of Surgery

Surgical Procedure

Surgical Procedure

The following eleven steps, with modifications as appropriate,make up the typical approach: (1) flap design, (2) incision and reflection, (3) access to the apex, (~) curettage,(5) root end resection, (6) root end preparation and filling,  17) radiographic verification, (8) flap replacement and suturing, (9) postoperative instructions, (10) suture removal, and (11) long-term evaluation. This sequence IS shown in Hg. 17-13 on page 393.
Flcu) design. A properly designed and carefully reflected flap will result in good access and uncqrnplicated healing.” The basic principles of flap design should be followed; these are detailed in Chapter 8. Although several 11

possibilities exist, the three most common incisions are (l) submarginal curved (i.e., semilunar), (2) submarginal, and (3) full mucoperiosteal (i.e. sulcular). The submarginal and full mucoperiosteal incision will have either a three-corner (i.e., triangular) or four-corner. (i.e., rectangular) design. ‘.Semilun ar incision. This rs a Slightly curved halfmoonhorizontal incision in  the alveolar mucosa (PIg. 17-14 on page 394). Although the location  llows easy reflection, access to the peri radicular structures is restricted. Other disadvantages to thrs incision include excessivehemorrhage, delayed  healing, and scarring; this design is contraindicated for endodontic surgery. Submarginal incision. The horizontal component is in attached ~ingiva with one or two ‘accompanying vertical incisions (Fig. 17.-15 on Rage 394). Generally the incision is scalloped in the horizontal line, with obtuse
angles at the corners. It is’ used most succe-ssfully in the maxillary anterior region or, occasionally, with maxillary premolars with crowns. ‘Because of the design, prerequisites are at least 4 rom of attached gingiva and good peri- _
odontal health. The major advantage is esthetics. Leaving the gingiva intact around the margins of crowns is less likely to
result in bone resorption with tissue recession and crown margin exposure. Compared with the semilunar inci-111

FIG. 17-7 A, Irretrievable material in mesial and lingual canals anu <If.'lca'pathos.s. B, CH1~ls are retreated but there is Iailu-e C, Treatment is root end resection to level 01 gutta-percha In the Iresl<l' and lingual aspects, D, After 2 years, healing is complete.

FIG. 17-7 A, Irretrievable material in mesial and lingual canals anu <If.’lca’pathos.s. B, CH1~ls are
retreated but there is Iailu-e C, Treatment is root end resection to level 01 gutta-percha In the Iresl<l’
and lingual aspects, D, After 2 years, healing is complete.

ion, the submarginal provides less risk of incising over a bony defect and provides better access and visibillty. dvantages include hemorrhage along the cut mar- !l 0 the surgical site and occasional healing by scarornpared with the full mucoperiosteal sulcular (ol’erio lncision. This is an incision into the gingival sulcus, extending to the gingival crest (rig. ] 7-16 on page 39-+), This procedure includes elevation of interdental papilla, free ningi,’al margin, attached gingl\’a, and alveolar mucosa. One or two vertical iPlaxlI1g incisions may >e used, creating a three- or /lJ’.l-corner design,

FIG. 17-8 A, Overfill of injected obturating material has resulted in pain and paresthesia as a result of damage to inferior alveolar nerve. B, Corrected by retreatment, then .apicectomy, curettage, and a root end amalgam fill.

FIG. 17-8 A, Overfill of injected obturating material has resulted in pain and paresthesia as a result
of damage to inferior alveolar nerve. B, Corrected by retreatment, then .apicectomy, curettage, and a
root end amalgam fill.

 

 

BIBLIOGRAPHY

BIBLIOGRAPHY

Cohen  lk, Diegelmann RF, Lindblad WJ: Wound healing: bio-  chemical and clinical aspects, Philadelphla, 1992, WB Saunders.

Leaper DJ. !larding KG: Wounds: biology and mallagemetlt, Odbrd, 19~8~th:rord University Press

PATIENT GENERAL HEALTH AND NUTRITION

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 cellularprocesses. Numerous medical conditions lmpalr :a
patient’s ability to resist infection and heal wounds. . These include conditions that establish a. Qtabolic state of metabolism, that impede oxygen or nutnent delivery to tissues, and that require administration of drugs or physical agents that interfere with immunologi( or wound-healing cells. Examples of diseases that induce a catabolic metabolic state Include poorly controlled  insulin-dependent diabetes mellitus, end-stage renalor
hepatic disease, and malignant diseases. Conditions that interfere with the delivery of oxygen or nutrients to wounded tissues include severe chronl.Cobstructive pulmonary disease (COPD). poorly compensated congestive heart failure (hypertrophic cardiomyopathy) and
addictions, such as ethanolism. Diseases requiring \ht administration of drugs that interfere with hot  trehses or wound-healing capabilities include autoimmune discrease  for which long-term corncosteroid therapy is given
and malignancies for which cytotoxic agents and irradiation are used.

T’he surgeon can help Improve the patient’s chances of ‘having normal heathy of  elective surgical wound by evaluating and optimizing the patient’s general health status before surgery. 11>[ malnourished patients, this include improving the nutritional status so that the patients is in  position  nitrogen balance and an anabolic metabolic state.

EDEMA CONTROL

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 help determine the degree of postsurgical edema. First, the greater
the amount of tissue injury, the greater the amount of edema. Second, the more loose connective tissue that is contained in the injured region, the more edema is present. For example, attached gingiva has little loose connective
tissue, so it exhibits little tendency toward edema; however, the lips and floor of the mouth contain large amounts of loose connective tissue and can swell
significantly.

The dentist can control the amount of postsurgical edema by performing surgery in a manner that minimizes tissue damage. Some believe that ice applied to a freshly wounded area decreases vascularity and thereby
diminishes transulation. However, no controlled study has verified the effectiveness of this practice. Patient positioning in the early postoperative period is also used to decrease edema by having the patient try to keep the
head elevated above the rest of the body as much as possible during the first few postoperative days. Short-term, high-dose systemic corticosteroids can be administered to the patient and have an impressive ability to lessen inflammation and transulation (and thus edema). However, corticosteroids are useful for edema control only if administration is begun before tissue is damaged.

DECONTAMINATION AND DEBRIDEMENT

DECONTAMINATION AND DEBRIDEMENT

Bacteria invariably contaminate all wounds that are open to the external or oral environment. Because the risk of infection rises with the increased size of an inoculum, one way to lessen the chance of wound infection is to decrease the bacterial count. This 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. 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. In general, debridement is used only during care of traumatically incurred wounds or for severe tissue damage caused by a pathologic condition.

Dead Space Management

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 reapproxlmating all tissue planes during closure. Dead space in J wound usually fills with blood, which creates a hematoma with a high potential for infection.

Dead space can be eliminated in four ways. The first is by suturing tissue planes together to minimize the postoperative void. A second method is to place a pressure dressing over the repaired wound. The dressing ‘compresses tissue planes together until they are either bound
hy fibrin or pressed together by surgicaledema (or both). This usually takes about 12 to 18 hours. The third way to iminate dead space is to place packing into the void it bleeding has stopped and then remove the packing.
i technique is usually used when the surgeon is II hie to tack tissue together or to place pressure dressin (e.g., when bony cavities are present). The packing rna erial is usually impregnated ~’ith an antibacterial medication to lessen the chance of infection. The .fourth means of preventing dead space is through the use of drains, either by themselves or in addition to pressure
dressings. Suction drains continually remove any blood.

that accumulates in a wound until the bleeding stops and the tissues bind together and eliminate dead space. Nonsuction drains allow any bleeding to drain to the surface rather than to form a hematoma (Fig. 3-5).

Means of Promoting Wound Hemostasis

Means of Promoting Wound Hemostasis

Wound hemostasis can be obtained in five ways. The first is by assisting natural hemostatic mechanisms. This is usually accomplished by either using a fabric sponge to place pressure on bleeding vessels or placing a hemostat on a vessel. Both methods cause stasis of blood in vessels which promotes coagulation. A few small vessels generally  require pressure for only 20 to 30 seconds, whereas larger vessels require 5 to 10 minutes of continuous pressure. The surgeon  assistants should dab rather than wipe the wound with sponges to remove extra vasated blood. Wiping is more likely to reopen vessels that are already plugged by clotted blood.

A’second means of obtaining hemostasis is by the use of heat to cause the ends of cut vessels to fuse closed tthermal coagulation). 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 witfi an electrocauteryztjp, Three conditions should be created for proper use of thermal coagulation.
First, the patient must be grounded, to allow the current to enter the body. Second, 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 third necessity for thermal coagulation is the removal of any blood or fluid that has accumulated around the vessel to be cauterized. Fluid acts as an energy sump and thus prevents a sufficient amount
of heat from reaching the vessel to cause closure.

The third means of providing surgical hemostasis is by suture ligation. If a sizable vessel is already severed, each end is grasped with a hemostat. The surgeon then ties a nonabsorbable suture around the vessel. If a vessel can be dissected free of surrounding connective tissue before it is cut, two hemostats can be placed on the vessel, with enough .space left between them to cut the vessel. Once the vessel is severed, sutures are tied around each end and the hemostats removed.

The fourth means of gaining hemostasis is by placement, of a pressure dressing over the wound. This creates pressure on the small vessels that were cut, promoting coagula

FIG. 3-5 Example of nonsuction drain. This is a Penrose drain and is made of flexible, rubberized material that can be placed into wound during closure or after incision. and drainage of abscess to prevent premature sealing of wound before blood or pus collections can drain to surface. Draining material runs both along and through Penrose drain. In this illustration, suture has been tied to drain and drain is' ready for insertion into wound. Needled end of suture will be used to attach drain to wound edge to hold drain in place.

FIG. 3-5 Example of nonsuction drain. This is a Penrose drain and
is made of flexible, rubberized material that can be placed into
wound during closure or after incision. and drainage of abscess to
prevent premature sealing of wound before blood or pus collections
can drain to surface. Draining material runs both along and through
Penrose drain. In this illustration, suture has been tied to drain and
drain is’ ready for insertion into wound. Needled end of suture will
be used to attach drain to wound edge to hold drain in place.

tion. Care must be taken not to apply so much pressure as to compromise wound vascularity. Most bleeding from dentoalveolar surgery can be controlled by this means. The fifth method of promoting hemostasis is by placing vasoconstrictive substances, such as epinephrine, in’
the wound or by applying procoagulants, such as commercial thrombin or collagen, on the wound. Epinephrine serves as a vasoconstrictor most effectively when placed in the site of desired vasoconstriction at lease 7
minutes before surgery begins .

 

HEMOSTASIS

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 wellvascularized oral and maxillofacial regions. Another problem bleeding causes is’ the formation of hematomas. Hematomas place pressure on wounds, decreasing vascularity; they increase tension on the wound edge and they act as culture media, potentiating the development of a wound infection.

FIG. 3-3 Three types of properly designed oral soft tissue flaps. A, Horizontal" and single vertical inci- $ions used to create two-sided flap. B. Horizontal and two vertical incisions used to create three-sided' flap. C, Single horizontal incision Used to create single-sided (envelope) flap

FIG. 3-3 Three types of properly designed oral soft tissue flaps. A, Horizontal” and single vertical inci-
$ions used to create two-sided flap. B. Horizontal and two vertical incisions used to create three-sided’
flap. C, Single horizontal incision Used to create single-sided (envelope) flap

F!G. 3·4 instruments used to minimize darnaqe while. holding soft tissue. Top, finely toothed tissue forceps (pickups); botom, soft tissue  skin) hook.

F!G. 3·4 instruments used to minimize darnaqe while. holding soft tissue. Top, finely toothed tissue forceps (pickups); botom, soft tissue skin) hook.

TISSUE HANDING

TISSUE HANDING

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, desiccation, or the use of unphysiologic chemicals easily damage tissue. Therefore the surgeon should use care whenever touching tissue. When tissue forceps are used, they should not be pinched together too tightly; rather, the}’ should be used to delicately hold the tissue. When possible, toothed forceps or tissue hooks should be used to hold tissue (Fig. 3-4). In addition, tissue should not be overaggressively retracted to gain greater surgical access, This

F!G. 3-2 A, Principles of flap design. In general, flap base dimension (x) must not be less than height dimension (y), and preferably flap should have x = 2)'. 8, When releasing, incision is used to reflect a two-sided flap; incision should be designed to maximize flap blood supply by leaving wide base. Design on left is correct; design on right is incorrect. C, When "buttonhole" occurs near free edge of flap, blood supply to flap tissue on side of hole away from flap base is compromised.

F!G. 3-2 A, Principles of flap design. In general, flap base dimension (x) must not be less than height
dimension (y), and preferably flap should have x = 2)’. 8, When releasing, incision is used to reflect a
two-sided flap; incision should be designed to maximize flap blood supply by leaving wide base.
Design on left is correct; design on right is incorrect. C, When “buttonhole” occurs near free edge of
flap, blood supply to flap tissue on side of hole away from flap base is compromised.

includes’ not pulling excessivelyon the cheeks or tongue during surgery.When bone is cut, copious amounts of irrigation should be used to decreasethe amount of bone damage from heat.’ Soft tissues should also be protected from . frictional heat or, direct trauma from drilling equipment.Tissues should not be allowed to desiccate; open wounds should be frequently moistened or covered with a damp sponge. Finally, only physiologic substances should come in contact with. living .tissue. For example, tissue forceps used to place a specimen into formalin during a biopsy procedure should not be returned to the wound until any contaminating formalin is thoroughly removed. The surgeon who handles tissue gently is rewarded with grateful patients whose wounds heal with fewer complications.

 

Prevention of Flap Tearing

Prevention of Flap Tearing

Tearing of a flap is a common complication 0f  the next  perienced 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 .Envelope flaps are those created by incisions that produce
a one-sided flap, An example is an incision made around, the necks of several teeth to expose the alveolar bone without any vertical incisions. However, if aI1 envelope flap goes not provide sufficient access, another incision should be made to prevent it from tearing (Fig. 3-3). Vertical
(oblique) releasing incisions should generally be placed one full tooth anterior, to the area of any anticipated bone removal. The incision is generally started at the line angle of a tooth or in the adjacent inter dental
papilla and carried obliquely apically into the unattached gingiva. It is uncommon to need more than one releasing incision when using a flap to gain oral surgical access.