CHAPTER 10 Surgical Procedures
Oral surgery deals with the treatment and ongoing management of irregularities and pathology of the jaw and mouth that require surgical intervention. In the UK, oral surgery is a specialty regulated by the General Dental Council and includes the specialty previously called surgical dentistry. Oral surgery procedures are sometimes termed dento-alveolar surgery (or minor oral surgery) and are commonly undertaken in the dental surgery.
Oral and maxillofacial surgery deals with mouth, jaws, face and neck surgery. In the UK, this specialty is regulated by the General Medical Council. Oral and maxillofacial surgery is sometimes termed major oral surgery, and is undertaken mainly in a hospital. Oral and maxillofacial surgeons can also undertake oral surgery.
Informed consent is required before any operative procedure, especially before surgery. Written informed consent must be obtained from all patients having any surgical procedure. The possible benefits of treatment must be weighed against the risks and always discussed by the person carrying out the procedure. If for some good reason this is not possible, a delegated person with the appropriate expertise should do so.
‘Informed’ consent means that the patient must be fully aware of the procedure, its intended benefits, its possible risks, and the level of these. In particular, patients must be warned carefully and clearly about:
An example of a patient information sheet is given in Box 10.1. To read more about patient consent, see Subchapter 3.2.
Wisdom teeth removal is often necessary because of infection (which causes pain and swelling), decay, serious gingiva (gum) disease, the development of a cyst or because teeth are overcrowded. Wisdom teeth are removed under local anaesthetic (injection in the mouth), sedation or general anaesthetic in hospital, depending on your preference, the number of teeth to be removed and the difficulty of removal.
It is often necessary to make a small incision in the gingiva, which is stitched afterwards. After removal of the teeth, your mouth will be sore and swollen and mouth movements will usually be stiff. Slight bleeding is also very common. These symptoms are quite normal, but can be expected to improve rapidly during the first week. It is quite normal for some stiffness and slight soreness to persist for two to three weeks. Pain and discomfort can be controlled with ordinary painkillers, such as paracetamol, and you might be prescribed antibiotic tablets. A clinician will be available to see you afterwards if you are worried, and will want to check that healing is satisfactory.
Complications are rare, but occasionally wisdom tooth sockets become infected, when pain, swelling and stiffness will last longer than normal. Occasionally patients have tingling or numbness of the lower lip or tongue after lower wisdom teeth removal. This is because nerves to these areas pass very close to the wisdom teeth and may get bruised or damaged. The numbness nearly always disappears after about one month, but very occasionally lasts for a year or more. Jaw fracture is very rare.
These procedures use an electric current to cut or cut and coagulate the tissue. They may be used for extensive oral incisions, or removal of soft tissue, because bleeding from wound edges is reduced.
Artificial cardiac pacemaker: this is a medical device that regulates the heart beat. It is placed in people whose natural heart beat is not fast enough or in those who have a problem with the system that conducts the heart beat from the atria to the ventricles (see Subchapter 4.1). The pacemaker consists of electrodes that are placed in contact with the heart muscles and which send out electrical signals to the heart.
Liquid nitrogen (N2) or nitrous oxide (N2O) is applied to the diseased area. This is done either by spraying it directly or circulating it through a probe called a cryoprobe. The very low temperatures –about –70°C – achieved with liquid N2 make this particularly useful in the management of intractable lesions. Liquid N2 probes and sprays can cause full-thickness skin necrosis, and therefore must be handled very carefully.
Bone and teeth are usually cut with rotating instruments (burs) in a surgical handpiece. This involves the production of heat, so simultaneous cooling by constant running sterile water or sterile saline (irrigation) is important. Air-rotors are less commonly used as they can contaminate wounds unless using a sterile coolant, and occasionally cause surgical emphysema (see Chapter 16). Laser and ultrasonic cutting are uncommonly used. Piezosurgery is a new but expensive technique that cuts only hard tissues, increasingly used in apical and implant surgery as the danger of damage to nerves or arteries or the sinus membrane is less. However, this kind of surgery can generate significant heat, and cutting is slower than with many high-speed drills.
Incisions are usually an integral part of surgery. The wound thus created needs to be closed so that it heals by primary intention. The would is closed usually with cyanoacrylate tissue adhesive or tapes (e.g. Steri-Strip), or sutures (stitches) (Box 10.2). This results in a small line of scar tissue, which is the goal whenever a wound is closed. In some circumstances, an open wound is left to heal by secondary intention. In the mouth it is then protected by a dressing such as Coepak. Wounds in bone are sometimes protected by BIPP (bismuth iodoform paraffin paste), or Whitehead’s varnish (compound iodoform paint).
BOX 10.2 Closing a Wound
The simple interrupted stitch is most commonly used because it allows good approximation of the wound edges, and is easy to place. Various other suturing techniques can be used. The surgeon will often ask the dental nurse to cut the stitch once placed.
|Scalpel blade (Nos 11,12,15)||To cut the flap|
|Scalpel handle (e.g. Swann Morton)|
|Mitchell’s trimmer||To raise the flap|
|Periosteal elevator (e.g. Howarth’s)||To raise the flap and protect soft tissues|
|Surgical handpiece||To remove bone or cut tooth|
|Surgical selection of burs|
|Retractors: flap; cheek; tongue||To retract flap for visibility to operative site, and protect tissues|
|Surgical aspirator||To remove saliva, blood, water and debris|
|Irrigation syringe||To irrigate the site with sterile saline or water|
|Suture||To reposition and fix mucoperiosteal flap|
|Needle holders||To hold the suture needle|
|Rat-toothed tissue dissecting forceps||To hold the flap while suturing|
|Suture scissors||To cut sutures|
|Cotton wool rolls|
Infra-occluded: a tooth whose incisal edge or occlusal surface appears ‘sunken’ in comparison with the rest of the teeth in the arch. So for an upper tooth this would mean the incisal edge or occlusal surface is ‘higher’ than the rest of the teeth, and in the lower teeth it would appear to be lower down. Conversely, teeth can also supra-occlude (over-erupt) in comparison with the rest.
Enforced extractions of deciduous canines or molars are usually balanced by extraction of a contralateral tooth in the same arch. This is to prevent a centre-line shift. Radiographs are usually taken to ensure that there are no other problems (e.g. a midline supernumerary tooth), which may also require attention.
Impaction is usually due to obstruction of the tooth’s path of eruption by soft tissue, bone or adjacent teeth. The teeth most commonly impacted are third molars (‘wisdom’ teeth), followed by canines, second premolars and mandibular second molars. Impacted teeth may erupt ectopically and can cause considerable difficulties for the patient.
Ectopic eruption: when a tooth erupts at an angle or in a location away from its normal position in the dental arch, that is it is displaced or incorrectly positioned. There are several causes for ectopic eruption, of which the most common are lack of available space and trauma.