Principles of oral surgery.. (nx power lite) /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Principles of maxillofacial surgery
Painless surgery
Asepsis & sterilisation
Adequate access
Arrest of haemorrhage
Debridement & drainage
Closure of wounds
Post operative care

Painless surgery
Pre-medication
Anaesthetic considerations
Local
Local and sedation
General

Goals of Pre medication
Sedation
Amnesia
Analgesia
Drying of airway secretions
Prevention of autonomic reflex responses
Reduction of gastric secretions
Antiemetic effects
Reduction of anaesthetic requirements
Facilitation of smooth induction of anaesthesia

Selection of appropriate drugs
Considerations Psychological condition
Physical status
Age
Surgical procedures & its duration
Out patient or in patient procedure
Elective or emergency

Common pre-operative drugs
Drug
Diazepam
Midazolam
Pentobarbitol
Morphane
Meperdine
Atropine
(Anticholinergic)
Scopolamine
Metoclopramide
(Antiemetic)

Route
Oral
I.M.
Oral, I.M.
I.M.
I.M.
I.M., I.V.

Dose
5 to 20 mg.
3 to 7 mg.
50 to 200 mg.
5 to 15 mg.
5 to 15 mg.
0.3 to 0.6 mg

I.M.,I.V.
Oral, I.M.,I.V.

0.3 to 0.6 mg
5 to 20 mg.


Painless surgery
Local Anaesthesia Majority of the minor oral surgical procedures
Are carried out under local anaesthesia


Painless surgery
Local anaesthesia with sedation In apprehensive patients minor surgical procedures
are carried out under local anaesthesia combined
with intra-venous sedation using Diazepam 5 to 20 mg
Midazolam 3 to 7 mg

Indications for general anaesthesia
Acute infections
Surgery in several parts of the mouth
Prolonged surgery
Technically difficult surgery
Extremes of age
Very nervous patients

Asepsis & sterilisation
Asepsis
Method of surgery designed to prevent
introduction of infection into a wound
at the time of operation
Sterilisation
Removal or disinfection of all micro
organisms including bacterial spores
and virus

Sources of infection during surgery
Patient himself
Operator
Instruments & materials used
Operating area


Minimising infection from the patient
Attention to oral hygiene
Oral prophylaxis
Chlorhexidine mouth washes
Preparation of the mouth prior to surgery


Minimising infection from the operator
Wearing mask & head cap
Keeping finger nails short & clean
Removing rings, watches, bangles
Scrubbing the hands
Wearing sterile gloves


Preventing infection from instruments

Using only sterilised instruments and
materials during surgery


Methods of sterilisation
Moist heat -

autoclave

Dry heat

hot air oven

-

Boiling water
Chemicals
Gamma radiation

What is the reliable method of Sterilisation?
Moist heat (autoclave)
Types

-

high vaccum

-

Downward displacement

Temperature required - 121° c
Pressure

- 15 to 20 pounds

Time

- 15 to 20 mts.

Mode of action - coagulation of proteins

Hot air oven sterilisation
Temperature

-

160 to 183° c

Time

-

one hour

Mode of action

Due to oxidation


Minimising iatrogenic infection

Clean environment
Regular microbiological monitoring of facilities


Access

Oral cavity

Mucoperiosteal flaps

Face

Skin incisions


Access - intra oral

Principles of muco periosteal flaps
Visibility
Vascularity
Healing

Access – intra oral
Muco periosteal flap
Flap consisting mucosa and periosteum
Design
Visibility
Large enough to provide adequate access
Viability
Broad base with narrow margin to provide
proper blood supply
Healing: Line of incision should be placed on
sound bone www.indiandentalacademy.com


Labial Approach


Palatal Approach

Incisions for caldwell-luc operations


Degloving incision for maxilla


Degloving incision for mandible


Access – extra oral

Submandibular incision

Risdon incision

Weber-fergusson incision


Temporal incision (Gillies)


Bicoronal incision


Skin incisions around the eye
Lateral Eyebrow
Medial Eyebrow
Temporal
(Gillies)

Medial Canthus

Subciliary
(Blepharoplasty)
Infraorbital


Access
Removal of bone
Bone is removed either by using surgical
burs or chisel


Access
Instruments for bone removal
1. Chisel
2. Osteotome
3. Gouge
4. Ronguers
5. Bone file

Control of haemorrhage
Mechanism of haemostasis
Vasoconstriction
Platelet aggregation
Clot formation
Clot stabilisation
Clot retraction

Arrest of haemorrhage- Methods used by surgeons
Soft tissue –
Digital pressure
Pressure packs
Use of haemostat
Ligation of blood vessels
Electro cautery
Bone –
Burnishing
Hot pack
Use of bone wax
Absorbable haemostatic agents

Debridement of wound
Removal of
Devitalised tissue
Granulation tissue
Bone pieces
Hanging bone margins
Trimming of flap margins
Proper irrigation

Drainage of wounds to prevent haematoma
Drains –
Corrugated rubber
Polythene tube


Closure of wounds - reasons for suturing
To get close approximation of wound margins
To ensure healing by primary intension
To minimise wound contamination
To control post-operative haemorrhage


Closure of wounds -types of sutures
Interrupted suture
Most commonly used to close
mucoperiosteal flaps and skin
Advantages
Better in mobile areas
Alternate sutures can be removed

Closure of wounds
Mattress suture - horizontal
Tissues under tension
To get slight eversion of wound margins
To prevent scar contraction
To control post extraction bleeding
Does not cut through tissues
Used for sectioned muscles

Closure of wounds
Mattress suture - Vertical
Tension in tissues
Eversion of wound margins
Better adaptation
Where healing is expected to be delayed
Control of haemorrhage

Closure of
wounds

Sub cuticular

To prevent dead space and for
cosmetic reasons
Continuous suture
Closing subcutaneous tissues
Long mucosal & skin incisions
Sectioned muscle
Disadvantage - only two knots if
one knot breaks failure of suturing

Closure of wounds
Suture materials - Requirements
Adequate tensile strength
Knot retension
No tissue reaction
Absorbability
Ease of handling

Closure of
wounds
Suture materials - Classification
Natural
Non absorbable
Synthetic
Absorbable

Natural
Synthetic

Silk
Linen
Cotton
Polyamides
Polyesters
Catgut
Polyglycolic acid
Polyglactin 910


Suture Materials

- Black braided silk

Most commonly used in minor oral surgery 3.0
Advantages
Knot retension is good
Reasonable tensile strength
Non capillary
Cut ends are not irritant to soft tissues
Easily seen and to handle
Obtained from the cocoon of the silkworm larve

Suture materials -Cat gut
Prepared from submucosal layer of small
intestines of sheep
Chronic gut is treated with chromium salts
Plain cat gut absorbed in 7 to 10 days, chronic
in 21 to 28 days by proteolytic degradation
Synthetic absorbable materials are
absorbed by hydrolysis
Polyglycolic acid is hydroxyacetic acid
Polyglactin is hydroxyacetic acid and Lactic acid

Suture material
Disadvantages of cat gut Early loss of tensile strength
Poor knot retension
Results in local oedema
Cannot be used in infected areas
Cut ends are irritating to tissues
Cat gut is almost replaced by synthetic materials due
to their minimal tissue reactions and strength

Post Operative care
Pain
Infection
Bleeding
Diet
Sutures
Review


Post operative pain

Pain Mechanisms
Peripheral tissue injury
Transmission through the nerves
Perception within the brain


Post operative pain

Target areas for pain control
Blockade of Prostaglandin synthesis
Intervening peripheral nerve conduction
Suppression of higher sites in CNS


Post operative pain
Strategies Mild pain - Pre and post operative NSAIDS,
Regular LA agent
Moderate pain – Pre and post operative NSAIDS
Long acting LA agent.
Severe pain – Pre and post operative NSAIDS
Long acting LA agent
Centrally acting analgesics (codine)

Antibiotic Prophylaxis
Who needs it?
Patients with impaired host defense.
Patients undergoing surgical procedures where the
risk of infection is small but consequences are very
serious e.g., infective endocarditis.
Patients undergoing surgical procedures which have
a high rate of infections (normal host defense
mechanisms), but the nature of surgery vulnerable
to infection.

Use of antibiotics
Guidelines
No routine use of post operative antibiotics
Acute infections

Penicillin group

Subacute infection

Penicillin and Metranidazole

Chronic infection

Metranidazole


Antibiotic prophylaxis
What should be the duration of administration?
A study conducted using three different antibiotic
regimens suggested that a single dose of preoperative
antibiotic is Sufficient for prophylaxis when surgery is
completed within 3 hours. Antibiotic coverage should
extend for operations of longer duration.
No value of antibiotic after the operation.


Antibiotic prophylaxis

Has timing any influence?
Administration of antibiotic immediately prior
to surgical Incision should be effective prophylaxis
for surgical wound infections.


Antibiotic combinations
Advantages
Broad Spectrum coverage
Poly microbial infections
Enhancement of antimicrobial effect
Decreased emergence of resistant strains


Antibiotic combinations
Disadvantages
Antagonism
Increased colonization with resistant organisms
Increased toxicity
Increased cost


Swelling or Oedema
Physiology of cold and heat
Cold application immediately
after Surgery
Warmth after oedema
has occured

Prevents oedema
Resolves oedema

Use of antiinflammatary agents

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Principles of oral surgery.. (nx power lite) /certified fixed orthodontic courses by Indian dental academy

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