General Procedures in Oral Surgery

General Procedures in Oral Surgery


Welcome to the University of Michigan Dentistry
Podcast Series promoting oral health care worldwide. [silence] With the help of a simulated patient we would
like to demonstrate treatment planning and instrumentation in oral surgery. The establishment
of the treatment plan depends on the diagnosis that must be firmly established before we
begin anything in the way of surgical therapy because surgery is final. This is no remaking
or redoing what we carry out for this patient so consequently a great deal of time must
be spent to make sure that the diagnosis upon which you base your treatment plan is one
that is tenable and sound. Patients will come to oral surgery clinic with their records
as we have seen before. The records will include an extraction slip; a recommendation for the
removal of teeth or other surgical procedures. But in this situation this is a communications
document it relays one man’s impression to another. And you must be sure that you do
not follow this as a dictate but only use it as a guide to the area that requires your
diagnosis and your treatment plan for which you are responsible. There is an opportunity
for misunderstanding in the relay of this information and request. There can be human
errors in marking the wrong teeth. There can be other misunderstandings about overall treatment
plans that deal with many of the variations in restoration and prosthetic dentistry. So
one must be sure that is used correctly and whenever there is any question about the diagnosis
or which tooth is to be removed, it is well for you to thoroughly go over your own findings
and then call either the man who referred the patient and get any misunderstanding resolved
without troubling the patient or if there is need for consultation from another clinical
department within the school make sure you call the representative from that department
so that can be evaluated and you can approach without anything that is equivocal in the
nature of the diagnosis. In the treatment planning the radiographs for the given surgical
procedure are of importance. The radiographs give us details as to the morphology of the
roots, the density of the adjacent bone, the proximity of regional vulnerable anatomy and
pathology will dictate the pathways to which teeth can be removed and will therefore provide
us with information for technical efficiency. For the premedication of the patient we would
start with possibilities of additional adjunct to patient control. After all, it is the rapport
that we establish with our patient that is essential. So, informed consent, assurance
on their part that they are aware of what’s to be done for them and then an area of confidence
that you establish with them is most important. You must be able to control your patient before
you can carry out any work for them. These aspects of control begin with a psychological
establishment of rapport with your patient and they may in certain instances require
additional adjunct to patient control. The IV solution used in the oral surgery clinic
consists of lactated ringers with 5% dextrose. The tubing is initially primed to eliminate
any air bubbles in the system. The IV tray that we will have in each of the operatory
will contain a tourniquet, an omboard as well as the tape to fix the angiocath or butterfly.
The, we have sponges to cleanse the site of the venopuncture and we will have the butterfly
23-gauge, 23 butterfly as well as a 22-gauge angiocath to perform the venopuncture. Whenever
conscious sedation is utilized in the clinic a pulse oximeter is absolutely necessary to
monitor the oxygen saturation of the patient throughout the entire procedure. Another anxiety
service that we have for the patients is an analgesic machine. Demonstrated here is a
wall-mounted unit. This wall-mounted unit will consist of a mouth piece, the tubing
to deliver the gases, a re-breathing bag as well as a monitor. This is a fail-safe system.
Fail-safe in the sense that, in the word that it will not operate without oxygen. The supply of oxygen nitrous oxide is for
this machine is delivered from a central point. Rooms without a wall mount unit can be supplied
with a portable unit. The portable unit is the same unit as the wall mount. It will have
a nose piece, tubing, the re-breathing bag as well as an oxygen-nitrogen monitor. The
units will have their own gases, oxygen as well as the nitrous oxide and these gauges
demonstrate in here, demonstrate the amount of oxygen as well as nitrous oxide in the
reserve, in reserve in these tanks. These gauges must register above zero. We will find again one who is prepared we
hope now psychologically as well as physically for what we hope to carry out. Anesthesia
will be administered utilizing local anesthesia. We have again scrubbed so our gloved hands
are clean and we would be able to proceed with the local administration of the local
anesthetic. In the administration of local anesthesia and in the work that is carried
out in surgery it is well to segment the areas of procedure for example if we were going
to work in the mandibular arch and in the maxillary arch on this patient we obviously
could not work in both of those areas simultaneously. And therefore we would administer the local
anesthesia to the mandibular arch and then carry out that work and as we were completing
that work then we would proceed with the administration of the anesthesia in the maxillary arch and
then go back and finish the work in the lower and then by the time we’re ready to work in
the maxillary arch the anesthesia is at its appropriate level. So it’s not only for keeping
the local anesthetic just ahead of your work for maximum effectiveness but also the aspect
of the volumes of local anesthesia that are administered. We don’t want to administer
a large volume of multiple injections all within a short space of time because when
we do this we increase the potential for toxic reactions to local anesthesia. The instruments
for a specific procedure are built upon a basic set and they should be thought of from
the beginning of the first incision to the placement of the last suture. The instruments required to complete the surgical
procedures are listed on this chart that you are now observing. This chart will be posted
on the wall above the instrument cabinet in each of the operatories. The instruments in
the top compartment are individually wrapped because they have been sterilized. They will
be removed from this cabinet with a sterile but clean surgical glove. The left bank of
drawers will have a writing platform where you will find a surgical manual to assist
in the clinic. There will be a blood pressure monitor. There will be extra sterile towels that can
be utilized in the surgical procedure as necessary and post-operative instructions. A transfer forcep is provided to transfer
the sterile sponges to the bracket tray. It is also used to transfer the anesthetic
solution, the needle, as well as the Q-tips. The surgical blades as well as the sutures
and the viascription may be removed with a sterile but clean glove because these have
been individually packeted and the transfer forcep is then repositioned in the container
provided in the face of cabinet. The bracket tray should be arranged in an
orderly fashion and we will look at that for the moment. It will have the instruments arranged
in the sequence that we plan to utilize them from beginning of the procedure to the end. The handpiece will be draped with a sterile
sleeve. The blood products will be collected in a
disposable container beneath the mayor stand. In working on the mandibular arch we would
like the patient so positioned that she is comfortable that the head and the cervical
spinal column is generally in a comfortable position. When her mouth is open, the mandibular-occlusal
plane should be horizontal, parallel with the floor. Just open widely if you will, please.
Actually in this instance it’s not quite horizontal as you can see she’s a little too far back
and so we would elevate the chair slightly bringing her up a little bit and then she
should be positioned also so that when this field, when her mouth is open and we’re working
on this field… The level of the operating field should be
so placed that your hand level is lower than your elbow. In that manner, you can work directly
and you won’t be at an awkward angle. So in the mandibular arch then, the patient’s mouth
open, the mandibular-occlusal plane should be parallel to the floor. A little later on,
we will demonstrate that in the maxillary arch, the occlusal plane of the maxillary
teeth should be perpendicular to the floor. And the patient then will be tipped way back.
Let us attempt to demonstrate here a few of the positions of the operator and the assistant
as we go through the access to the several areas of the mouth. Our surgical assistant Ms. Itzo will begin
lubrication of the commissures of the mouth. In surgery often we retract the corners of
the mouth and cheek rather excessively and unless the mouth is well lubricated the lips
may crack and so for the patient’s comfort we begin in this manner. We will attempt to
show the several positions of patient, operator, and assistant as we go into the several areas
of the oral cavity for surgical procedure. Ms. Itzo has the suction here and this will
be helpful in clearing the field as we approach the area for access. We’ve had the patient
positioned so when she opens the mandibular occlusal plane is horizontal and parallel
with the floor. The exposure of the field comes by way of retraction of the cheek. Patients
will tend to want to cooperate with you and when you retract in the direction in this
instance toward the patient’s left her natural tendency is to comply and turn her head toward
the direction of the retraction. You should explain to your patient that this is not what
you want them to do but rather to turn slightly toward you and to retain that position even
though we are pulling their cheek in that direction. This will keep your field exposed
so that you’re able to operate. After the anesthesia has been administered,
we will frequently use a curette to test for soft tissue anesthesia utilizing it in the
free-gingival margin area and applying it to test for the lack of any sensation. You
can prepare the patient that they will feel some pressure and perhaps hear some noise
as instruments are applied but that they will not feel anything that is sharp. We intentionally
avoid the terms of pain and hurt as we again are trying to retain elements of rapport when
operating on the patient. You always prepare your patient for everything they’ll experience.
Do not surprise them as you proceed and as you start to apply pressures. Here we are
using the 15 blade in the manner that is shown going in to the gingival sulcus and we would
divide the epithelial attachment to keep the blade in contact with the tooth as we go into
the embrasure. That would be followed by the use of the periosteal elevator. The small
end of the periosteal elevator and utilizing a rest finger on the teeth we would then go
in to the base of the papilla. Go down to alveolar crest of bone and reflect the flap
out. If we then wish to mobilize teeth, we would use a dental elevator and this 77-R
elevator is an appropriate one that would then go into the area of access from which
the flap had been reflected so that we would not bruise any of the tissues. We never use
this instrument unless the free-gingival margin flap is retracted away because the bone must
be used as the fulcrum and not the gingival tissue. After we have obtained preliminary
mobilization of the tooth in question we would then apply the forceps. The forceps are designed
so that the beaks of the forcep should be in the same long axis of the roots of the
teeth. Consequently the lower forcep has a more or less right angle position to the beaks
as compared with the handles whereas the maxillary forcep tends to have a more linear relationship
between beaks and handles of the forceps. The forceps are grasped well down on the handles,
and they are grasped in this manner so that you don’t have anything that is awkward in
the neuromuscular relationship of manipulation of the tooth. If you engage the handles in
a backward or some awkward position of this nature you will not have sufficient control
over the manipulation of the tooth. Teeth tend to be resistant to mobilization and as
you start the mobilization it requires a good deal of force. As the tooth begins to luxate
you use less and less force until again at the time that the tooth is ready to deliver,
it is just literally lifted out of the socket after you have it sufficiently mobilized. In the traction that’s required to break down
the periodontal membrane and expand the alveolus to lift the tooth from the socket, it is necessary
to support the jaw so that the mandible is secure while the tooth is being mobilized
from it. In that effort then one can use the opposite hand, placing the thumb on the occlusal
surfaces of the teeth on the opposite side, a finger at the inferior border of the mandible
and then the beaks can be applied to the tooth in question. We’re quite careful in the application
of the beak watching where it goes so we don’t engage gingival tissue so we only engage the
tooth. We’ll slide the lingual beak down carefully and watch it go into the sulcus and then we
would close the forceps slightly and slide the beaks down in the buccal. Then we would support the mandible securely,
inform the patient that they will feel a good deal of pressure for the moment and then we
would begin the luxation of the tooth with the forceps. In conical shaped roots, we can
add to the buccal-lingual motion an element of torsion in any single rooted tooth it tends
to have a conical root configuration. Another method for the support of the mandible
so the patient can use their own muscles of mastication to support the jaw while we’re
using forces of elevators and forceps is the use of a rubber bite block shown here. The
patient is instructed of its use, they are shown the bite block. They’re told that this
is to be put on the other side of their mouth. They are asked to close on it in order to
support the jaw so we’ll do that at the moment. We’ll secure it well. Ask the patient to close
and we can expose the field again and then as we’re utilizing an elevator say in the
back part of the mouth, if we were going to place this elevator in this matter and rotate
we’d tell the patient to bite down firmly at that particular time when we’re exerting
force when using an elevator that tends to have a sharp blade. Another method to safe-guard the patient against
the potential abuse and accident of these instruments is to place your finger on the
lingual aspect opposite where you’ll be placing this elevator force. Then in the event of
an inadvertent slip up in this matter it is obvious that you’re gonna stop instead of
burying that instrument in the soft tissues of tongue or floor of the mouth. These then
are methods in which the mandible can be supported. In connection with the use of the rubber bite
block, it’s well to keep in mind that intermittently the patient can bite down and by using the
elevators of the mandible firmly support the jaw so that you move the tooth and not the
jaw. However, this position if maintained for a protracted period of time is uncomfortable,
muscles will go into spasms so that intermittently the prop should be removed, the patient allowed
to close and whenever we ask the patient to close we will always if we have an operative
field open, a socket that is open and a flap that is reflected back. We will always take
a sponge and ask the patient to close down if you will while we are either changing our
instruments, selecting a new instrument or in any way involved in the delay from the
actual work in that field. The position of the operator in general should
be as forward and direct as possible. We utilize direct vision in all operative fields and
very rarely do we use any reflected image in oral surgery. In the mandible there are
some instances where in the anterior midline procedures, the position of the operator can
be from the rear. In that instance the patient is lowered, the operator gets behind the patient,
the chair is tipped back slightly, so that when she opens the operator has once again
the advantage of direct vision of this particular field and can manipulate again with forceps
or other instruments quite readily from this posture. As the assistant retracts the cheek, it is
well to keep in mind that the position of the head must be maintained and light must
be established into the field so that often the suction tip can be used to retract the
lower lip downward to allow more light to gain access to the field while the mirror
is being used to retract the cheek. We would reverse this situation on the right side,
the retraction would be made in this manner. The patient would turn away from the operator.
The assistant would reach around behind and take the mirror with her right hand and in
this manner we could again work directly on this side. So we have demonstrated the access around
the circumference of the mandibular arch and now we’ll turn our attention to the maxillary
arch and we will change the position of the patient so that we can obtain access to the
maxillary field. The patient has been repositioned for the
approach to the maxillary arch. We will note that she has been tipped way back so that
when her mouth is open, the maxillary occlusal plane is perpendicular to the floor. Then
with the operator positioned laterally he’s able to bend directly forward and have full
direct vision of the maxillary field. In retracting the cheek for the maxillary field one will
remember that the buccinator muscle is put on the stretch when the mouth is open. So
if the patient is open to a maximum range the cheek is tight and you cannot retract
it well. So for retraction in the maxillary arch we’ll want the patient’s jaws partially
closed together. That will keep the buccinator somewhat relaxed and then we can retract laterally.
Just like that. And we’ll also be able to retract in this manner and uh, if the patient
again is instructed to keep toward the operator and not to follow the force of the traction,
of the retractors of the cheek then we’ll keep the field in view. In the approach to
this region, we could apply instruments in the same manner that we did in the mandibular
arch, the curette applied to the buccal and to the palatial gingival margins. We could
apply all of the other instruments in the same manner that we demonstrated in the mandibular
arch and in the case of forceps we will note that the upper forcep as the beaks again in
line in this number 150 forcep in line with the handles. The handles are grasped with
the handles well-placed downward in the palm and the beaks are slide around the neck of
the tooth in this manner. Now as we apply forces to the maxilla it is our hope to control
the position of the head so that when the forces are applied to the tooth, the tooth
is moved and the head is not moved. Therefore if you will place your finger on the buccal
surface and your thumb on the palatial surface you will be able to so engage the alveolar
process that you can support it and you’ll have an index of how much pressure you are
using as you attempt to luxate the tooth. The tooth is never pulled or there is never
any traction exerted until complete mobility has been obtained. As a matter of fact, when
the first pressures are used there’s actually a force toward the apex rather than any traction
exerted on the tooth. Once then mobilized again, the same sequence of muscle groups
beginning with the forearm and winding up with the wrist so that the final delivery
of the tooth is a gentle one and not one that is sudden or violent. The approach to the opposite side is achieved
in the same manner asking the patient again to turn away from you, you maintain your direct
vision and position. The approach is made with the retraction of the cheek with the
mouth partially closed again and we have an approach that is feasible to the maxilla on
the right side. So it is these positions that will allow us to gain access to the maxillary
arch. In the palatal region occasionally for impacted teeth and other pathology in the
palate hyper-extension and maximum opening would be required. These then are the several
approaches to the different quadrants of the oral cavity and we mentioned when we were
speaking about anesthesia that we would divide up the work. For example if we going to prepare
a mouth with multiple extractions we would confine the work to one side of the mouth
at a time. This means that the patients would still have the opposite side of the mouth
for mastication and if there were problems with hemostasis why the patient would be able
to control post-operative bleeding episodes because only one side of their mouth would
be involved. As we were demonstrating earlier, if for any reason you leave the field you
always place a sponge over the operative field and have the patient close on it. Throughout the procedure for the division
of tissue removal of bone and teeth we would use suction to keep the field clear. However,
in the closures we would use intermittent pressure with sponges in order to avoid that.
In the alveolar plasty we would use with the rongeur forceps that are used to contour that
and the filing of the bone done with a double-ended bone file as we are finally contouring the
bone beneath the flaps and the soft tissue flaps are trimmed so that there are no excesses
and the pathology is removed, trimmed with scissors, and then the sutures are placed,
the sutures applied in a manner which you’ve been previously instructed utilizing 3-0 silk
on this particular suture needle. The needle is grasped just with the tips of the needle
holder and that gives control to the needle point as it penetrates the tissue in this
curve cutting needle. When the final sutures have been placed and incidentally before you
close, before you insert any sutures an instructor’s check is required. This is necessary to make
sure that the contouring of the ridge is satisfactory. So when that has been obtained you’ll proceed
with the closure and the insertion of the last sutures, a pack is placed over the operative
field, a moistened pack so that it does not adhere to the mucus membranes. Throughout the procedure the bracket tray
should be maintained in as orderly a sequence as is possible. It is this neatness in arranging
of instruments that is part of the assistant’s role. Following the procedure the doctor’s notes
will document the diagnosis, the anesthesia, the procedure, complication if any, post-operative
instructions, any medication prescribed to the patient, the disposition on the patient
on discharge, and revisit as needed. This must require the signature of the instructor
and will be dated. All patients leaving the oral surgery clinic will have in their possession
a post-operative instruction sheet. This instruction sheet must be reinforced orally by the students. A suggested dietary menu is also provided
with this instruction sheet. And extra sponges to assist with hemostasis
are also provided. The departmental code as well as the surgical
procedure code are posted on the walls of the clinic. Each patient will present to the
oral surgery clinic with a bill-in sheet, the bill-in sheet will include ‘C’ for completion,
the procedure code will be prefixed with a ‘U’ to designate an undergraduate student.
It will also list the tooth number and the appropriate fee. The student must provide
his, provide the letters, this sheet must have the signature of the instructor assigned
to the case. With this we hope we have oriented you as
to the approach to the patient and the treatment planning and the application of instruments
in the oral surgery clinic. You have been listening to a presentation
from the University of Michigan’s School of Dentistry which is dedicated to supporting
open learning and open educational resources. This recording is licensed under the creative
comments. It may be reused and redistributed for nonprofit use. Please attribute materials
to the University of Michigan’s School of Dentistry and redistribute under this same
license. For more information on how this and other University of Michigan School of
Dentistry recordings may be used visit www.dent.umich.edu/license.

Author: Kevin Mason

20 thoughts on “General Procedures in Oral Surgery

  1. How are we supposed to deal with increasing questions concerning aniline? I'm not sure about the ethical aspect but I've been laughing those questions off as being absurd. Besides, I've got too much money invested
    Int'l ARIAN Commerce Co.. Does anyone know of any oncology drug manufacturers who are out to make a killing? As long as we are injecting aniline for a profit, why not go all the way. Right?God, I love making so much money. Don't you? If you don't get them way, get em the other way.

  2. Get real! Rubber gloves are for problem pediatric patients only. Gloves always provide an excellent seal when placing the hand over the nose and mouth as you cut off the air supply of a problem child. Let the other kids see too! That keeps them in line when its their turn.Time is money! If you're interested, Int'l ARIAN Commerce Co stocks are priced right! They provide us analine! Oh yeah, does anyone know of any oncology drug manufacturers who are out to make a killing? Get it? HA HA HA

  3. There giving me one at USC in Los Angeles and im not going to like at all.But well my parents are doing this for my own good

  4. @Msilikenachos Oh, I thought you meant a metal chain being used to pull the tooth out of the mouth. I remember them using rubber/plastic chains to move teeth. My mistake.

  5. Sterility was more lax in the 70s/80s. With all this sterile, anti-bacterial everything it's no wonder every kid is allergic to something. Allergies to foods were rare in the days when people didn't sterilize everything they touched.

  6. No doubt the MD knows what he's doing, and talking about, but he would absolutely put me to sleep as he talks. If I was at school there, I would flunk over sleeping through the lectures.

  7. anesthesia gives a amnesia feeling. The first time i got my 3 wisdom tooth pulled, it felt like 5 mins passed, but really 2 hours went by. However beware of the nauseous feeling, it'll make you throw up like crazy.

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