Principles of Minor Oral Surgery
This chapter describes the principles involved in minor oral surgery.
After reading this chapter you should have an understanding of the principles involved in the successful practice of minor oral surgery.
As mentioned in Chapter 2, the successful practice of any form of surgery begins by taking a thorough history, reaching the correct diagnosis and formulating an appropriate treatment plan. Arriving at a diagnosis may involve performing pre-operative special tests such as radiography and pulp testing. Treatment planning includes the choice of anaesthesia.
It is imperative that the surgeon has a thorough knowledge of the anatomy of the area of interest. Surgery should be aseptic and as atraumatic as possible. The operator must have the appropriate instrumentation. Suggested instruments are listed in Table 3-1 and shown in Fig 3-1.
|Suggested instrumentation for minor oral surgery|
|Scalpel handle and blades (11 and 15)|
|Periosteal elevators (Howarth’s)|
|Tissue retractors (Bowdler Henry/cheek/tongue)|
|Surgical handpiece and burrs|
|20ml syringes for irrigation|
|Curettes (Mitchell’s trimmer)|
|Artery clips (Mosquito)|
|Suture holders and sutures (resorbable and non-resorbable)|
|Dental elevators (straight (Couplands) and curved (Warwick James/Cryers))|
|Dental extraction forceps|
It is worth considering the steps involved in the removal of a buried root as an aid to discussing the principles. These steps are:
gaining informed consent
localisation of the root
operative pain control
curettage and debridement
post-operative pain control
This was discussed in Chapter 1. When performing surgical procedures it is good practice to obtain written consent. Written informed consent is essential when conscious sedation is used.
This is achieved by clinical examination, both visual and by palpation. In addition radiographs are needed. Radiographs are useful because they:
aid in localisation
show any associated pathology
indicate the quality of surrounding bone
demonstrate the proximity of important structures.
Occasionally, it may be necessary to take different radiographs to locate the root using parallax. Such views may be two different intra-oral periapical films or panoramic and occlusal views.
It is imperative that pain control is excellent if surgery is to be performed. As mentioned in Chapter 1, the mainstay for minor oral surgery is local anaesthesia with or without sedation. If pain control is unsatisfactory the procedure cannot be performed to the best standards. Excellent local anaesthesia has benefits at both ends of the syringe. The patient feels no pain and the clinician can work with reduced stress. The use of sedation can be helpful for some patients. However, sedation must not be used as a measure to counter poor local anaesthesia. This topic is discussed further in Chapter 4.
The incision should be made with a sharp disposable blade. If a number of incisions are involved the blade should be changed. The blade normally used in intra-oral surgery is the number 15 (Fig 3-2). A number 11 blade may be used on occasion (Fig 3-2).
The scalpel handle should be held like a pen and the incision made at 90° to the surface. When making an incision for a mucoperiosteal flap the incision is made down on to bone. This is important, as it means that when the flap is raised the bone is directly exposed and there is no soft tissue attached. Pressing the scalpel on to bone during the incision can blunt the blade. This is why the blade should be changed when there are multiple incisions.
The design is such that the flap:
has an adequate blood supply
avoids damage to important structures
allows adequate visibility
allows atraumatic reflection
has its edges on sound bone at the end of the procedure
can be replaced at the end of surgery without tension.
Many flaps have vertical />