Oral Surgery Exam 1

Oral Surgery Exam #1 Principles of Asepsis Definitions Sterility = no viable microorganisms Antiseptics = for living tissue Disinfectant = for inanimate objects Sepsis = living tissue breakdown by inflammatory process of microorganisms Sterilization - chemical agents o antiseptics o disinfectants o ethylene oxide gas – instrument sterilization - physical agents o heat  dry  moist • transfers heat better than air • steam has more stored energy • pressurized steam allows for superheating o mechanical dislodgement o radiation DRY MOIST Antimicrobial Effect oxidizes cell proteins denatures cell proteins Time long short Equipment complexity and cost low high Tendency to dull or rust instruments low high Exposure Time (Dry vs. Moist) Heat - general trends (see slide 7 for specific numbers) o need higher dry heat for much longer to achieve same results as steam o e.g.  at 121°C dry heat = 6-12 hours  at 121°C steam = 24 min Gaseous Sterilization – Ethylene Oxide - alkylating agent - flammable (mix w/ 90% CO2 or Freon) - used at room T (for porous, rubber, plastic material that can’t withstand high heat) o Does not melt materials - highly toxic – need long aeration time to de-toxify - NOT practical for dental office

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Instrument Disinfection - Glutaraldehyde (Cidex) o Most commonly used for disinfection - Iodophores (Betadine) o Also can be used on human tissue - Chlorine compounds (Clorox) - Formaldehyde Objectives - Difference b/t sterile technique used in OR and clean technique used in clinic - Be able to perform surgical hand scrub, gown and glove - Be able to set up an instrument tray for dental extractions - Be able to maintain a clean surgical field Sterilization Tests - Color coded packaging o Paper + cellophane - Test areas on package change color on exposure to sterilizing temps or ethylene oxide gas - Special masking tape shows brown lines after sterilization Instrument Set Up - disinfect tray - open outer cassette covering with ungloved hands o Outer layer is not sterile, and therefore can be touched with ungloved hands - open inner cassette covering with sterile gloved hands Gloving - open technique (slides 33-37) o touch only the inner aspect of the folded glove (the cuffed end) o place on one hand o then with that one gloved hand, touch only the outer aspect of the folded glove to place other glove on other hand - closed technique o Pull surgical gown sleeves over hands and put gloves on without touching them with hands  Since the gown is sterile, it can touch the gloves o Not used as much Surgical Site Prep (face, neck and other skin sites) - prepared surgical site to be “painted” with antiseptic sponge sticks (set of 3) o antiseptic agents 2

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 iodophor compounds (Betadine)  chlorhexidine gluconate (Hibiclens) o Start where you are working, and disinfect laterally to the margins  Do this 3 times, with a different sponge each time use sterile gloves proceed from center of sx site to lateral aspects in circular motion discard sponge when lateral margins have been reached repeat prevent irritating antiseptic agents from contact with eyes (cause corneal abrasions) o Protect eyes with eye ointment (Lacri-Lube) protect internal ear with cotton ball open sterile towel and place over preparation site to dry

Scrubbing Mechanisms - mechanical – brush - residual antiseptic agents - iodophor compounds (Betadine) - hexachlorophene (pHisoHex) - chlorhexidine (Hibiclens) Before Scrubbing Hands and Arms - clean under nails and trim them short - cover hair completely - put on mask - remove rings and watch Scrubbing Techniques - time technique is most common o long = 10 min o short = 3 min - stroke technique o 30 strokes per surface  fingers and thumb have 4 surfaces  interwebbing of each finger  ventral, dorsal and lateral surface of hand  4 surfaces of forearm to 2 inches above elbow  rinse both arms keeping hands and arms elevated above waist  allow water to drain off elbow o final rinse  from hands to elbows Drying Technique - nurse or tech will hand sterile towel to right hand

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one end and side of towel: o dry both hands and one arm well – progress up from hand to elbow other end and side of towel: o other arm don’t let towel touch non-sterile items o scrubs o surgical tables

Principles of Surgery Principles of surgery - Following surgical incison/excision, surgeon maximizes the opportunity for healing and restoration of function to occur without complications - general principles o apply to all aspects of surgery - specific principles o apply to certain areas like cancer surgery etc… - 3 main principles o perioperative assessment  ID diseases that may complicate anesthesia • e.g. CV disease, etc…  ID diseases that may compromise surgery or healing • e.g. diabetes, AIDS, hemophelia, pts who have undergone radiation treatment, etc…  ID social habits that may complicate surgery • e.g. smoking, alcoholism, cocaine use etc…  elective surgery • optimize existing conditions (heart disease, diabetes (HbA1c value), chronic renal failure etc..)  non-elective surgery • not always possible to optimize existing conditions • so complications are much higher (trauma, acute infection, obstetrics)  The ability to heal can affect the surgery directly…these potential problems need to be identified early on o access  to adequately visualize problem  to preserve important structures  to allow for handling of complications (bleeding, etc…)  (also a major problem with restorative dentistry)  if access isn’t adequate, stop what you’re doing and make necessary adjustments! • retraction • good assistance • light 4

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Flap/Incision o Must be large enough for good visualization o On skin use resting tension or Langer’s lines o Avoid important structures. o Broad base and good blood supply o In the mouth mucoperiosteal flaps o Avoid excess trauma (gentle tissue handling) • Good suction  RESTING SKIN TENSION LINES • Incisions should be parallel to these • These are naturally occurring wrinkles that are perpendicular to muscles in that region • Scars are more prominent if not made in these o wound healing  pathophysiology • he breezed over this in class and I think he said not to worry about details  classification • primary (clean cut incision) • secondary (open wound, extraction socket) • combined (complex wound)  status • clean wound (e.g. submandibular gland, brain) o no bacteria (brain surgery) • clean/dirty wound (oral cavity) o Lots of intrinsic bacteria is present o Tooth extractions and dental alveolar surgery = clean/contaminated wounds • dirty wound (colon, tooth abscess) o do your best to reduce bacteria (peridex etc..) but still exposed to intrinsic bacteria o don’t REALLY need sterile surgical gloves for oral cavity but we use them anyway – the mouth is the dirtiest area of the whole body Primary Closure and Healing - close inner-most layers of muscle/skin first with as little tension as possible o “train-track” scaring is a result of too much tension - steps o Anesthetize patient o Thoroughly irrigate wound to clean – need hydrostatic forces w/ saline  Use angiocatheter with 60ccs – creates enough force to debride bacteria from wound

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o Remove foreign bodies  Beware of glass – often radiolucent o Achieve hemostasis  If not, a hematoma may occur o Do NOT debride facial tissue excessively o Clean up jagged edges and then close edges by placing sutures at 90° to skin edge (this will be on the exam)  In layers to repair muscle and close dead space  Close from the inside out (evert skin edges)  Approximate anatomical structures  Don’t suture too tightly  Wound eversion requires placing sutures at 90 degrees to the skin edge • Not doing this will cause a scar to pucker in since scar tissue forms at 90 degrees to wound • In mucosa, this is not as important to consider o Train track scarring is a result of sutures being put in areas of tension, or are placed too tight Secondary Closure and Healing - Can’t close these wounds with stitches o Need granulation tissue first, then closure can occur - civil war style closure  “wet to dry” method o soak gauze in saline and wring out to just moist o pack multiple layers inside wound o as gauze dries, it’ll pull bacteria and debris via capillary action out of the wound and into the gauze o gauze must be changed multiple times per day - sometimes form fistulas Complex Wounds - utilize both primary and secondary closure and healing - stitch areas where incision has clean lines and approximate each other without tension - use wet-to-dry gauze method on other areas o area will granulate and then close later on - Wet to dry dressings promotes microdebriment of the wound o Pack gauze, moistened with saline (just barely), in layers into wound o Capillary action of the cotton pulls bacteria/debris into the packing o Packing is changed a couple times a day Avulsive Gunshot to Mandible (slide 26) - FIRST, find and maintain airway - must debride wound of dead tissue before it can be closed… takes several days

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Dog Bite to Child’s Mouth (slide 30) - debride with saline - do an initial stitching to see if there is any missing tissue o most important: make sure commisure is intact - repair muscle layers (any devitalized muscle has to be removed – will be a different color and won’t be bleeding) - remove initial stitches and close from inside out Patient with Pencil in Ear - first image wound and check for major vessels in area - most important: plan for procedure AND for potential emergencies - drains are placed for most neck surgeries o to avoid hematomas o useful with large wounds with gross dead space to suck the tissues together o need to have good oral closure w/ suction drains to prevent salivary contamination o stay in place until they produce less than 20cc/day Patient with Horrible Scar on Lip (slide 37) - wound has been closed improperly - scarring occurred because the wound was under tension and the dead muscle wasn’t excised - only the top layer was closed as opposed to each layer from the inside out Surgery Involving Bone - slow speed drills o if high speeds are used, must be rear-vented so you don’t blow air and debris into the bone o use only surgical drills - good irrigation o bone dust isn’t viable and will infect bone - smooth sharp edges and remove bony spicules separated from periosteum - wash out bone dust o spicules will eventually poke through the mucosa - soft tissue cover if possible Use of Antibiotics - clean wounds o no antibiotics needed in a non-immunocompromised patient o infection is prevented by good aseptic technique and skin prep - clean/dirty wounds o may require antibiotics o if used, new CDC guidelines say 24 hrs instead of a week - dirty wounds

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o require antibiotics antibiotic cover for surgery o principle: high peri-operative blood level of antibiotics during period of bacteremia o 1dose IV 30 min pre-op o 2 doses IV at 6-8 hr intervals o 5 days of antibiotics are NOT indicated  leads to bacterial resistance

Hemostasis - primary o occurs at time of sx o pressure, vasoconstrictors, ties or clips - reactionary o 6-8 hrs later o after local wears off  vasodilation - secondary o 7-10 days after o due to infection “liver clot” -

Drains may be useful in large wounds with gross dead space to “suck” the tissues together and also to prevent the formation of hematoma o Need to have good oral closure with suction drains to prevent salivary contamination

Excessive Healing - despite good would closure, healing may become excessive due to o low grade irritation  infection  foreign body  mobility (bone callus in inadequately fixated fracture  genetic / racial factors - hypertrophic scars o example on slide 49 o scar hasn’t grown out of its initial boundary but it’s raised and larger than it should be - keloid scars o example on slides 50 + 51 o grow beyond the initial boundary of the incision o common in African-Americans o can inject steroids into them to attempt to reduce volume o small ones can be excised and followed with low-dose radiation but in general, nothing can be done o Keloids are typically on people of darker skin

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Hypertrophic scar has more volume of scar tissue, but does not grow outside area of injury Keloids grow well outside of the area they started in

Inflammation and Wound Repair Causes Pathologic – surgeon has little control over this type of tissue damage - caused by bacteria, malignant processes, metabolic processes etc… Traumatic – surgeon can do a lot to either favorably or unfavorably alter this type of tissue damage - PHYSICAL o incision, crushing o extremes of temperature o irradiation o desiccation o obstruction of arterial inflow or venous outflow - CHEMICAL o non-physiologic pH or tonicity o disruption of protein integrity o ischemia due to vascular constriction or thrombosis Wound Healing - The phases significantly overlap and each phase is dependent on the preceding one to occur - three phases: o INFLAMMATORY PHASE o PROLIFERATIVE PHASE o MATURATION AND REMODELING PHASE o RESTORATION OF FUNCTION Inflammatory Phase - main function: remove damaged tissues and eliminate any invading organisms and debris via phagocytosis - release of factors that cause migration and division of cells (proliferative phase) Proliferative Phase - divided into 4 major processes: o angiogenesis  restoration of blood supply to tissues in the wound  new vessels grow from endothelial cells o granulation tissue formation  fibroblasts grow and form a new ECM by excreting collagen and fibronectin  must have a good bed of granulation to allow the new epithelial cells to move in 9

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o epithelialization  epithelial cells proliferate and migrate along ECM until continuity is reestablished  mucosa is replaced on internal surfaces; skin on external surfaces o wound contraction  myoepithelial cells induce wound contracture to bring the wound edges closer together  extremely important in reducing the size of the wound No restoration of blood flow prevents the next stage Proliferation of cells into wound (endothelial and fibroblasts) o Replace blood vessels and ECM respectively Covering of wound with mucosa/skin o Requires granulation tissue to build upon Bringing of damaged tissues together to reduce size of wound

Maturation and Remodeling Phase - collagen is remodeled and realigned along tension lines o restores tensile strength o if in bone, fibroblast connective tissue is replaced w/ new functioning bone o This phase is essential for restoration of function - cells involved in the proliferative phase that are no longer needed undergo apoptosis and are removed o i.e. fibroblasts and endothelial cells o maturation cannot occur without the removal of these cells Inflammatory Phase - begins at the moment of injury and lasts 3-5 days - Damage of tissue results in some degree of hemorrhaging o Must be stopped for healing to begin - vasoconstriction o ruptured cell membranes of injured cells release thromboxanes  vasoconstriction  lasts 5-10 min:  facilitates hemostasis and collects inflammatory cells  brings damaged endothelium and connective tissue to come into contact with platelets and activates them  platelets stick to endothelium – release factors and serve as surface for clotting factors in blood - clotting cascade and vasodilation o Activated platelets release factors which initiate the intrinsic and extrinsic factors  blood clot  platelet factors • inflammatory

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o serotonin, bradykinin, prostaglandins, prostacyclins, thromboxanes, histamine  increase cell proliferation and migration into injured area  cause vasodilation and increase capillary permeability  edema & entry of leukocytes  leukocytes debride wound and neutralize any foreign factors etc… o TBX is released first, then histamine growth factors o PDGF, FGF, TGF o stimulate growth of cells involved in proliferative phase

migration of PMNs o Within 1 hr of wounding o Predominant cell in wound for first 3 days  Phagocytize debris and bacteria  Kill bacteria by releasing oxygen free radicals, secrete proteases that break down damaged tissue o Undergo apoptosis and eventually are removed by macrophages  Important that they die via apoptosis = a non-inflammatory induced death • More inflammation would only make the inflammatory phase continue and hinder the proliferative phase from occurring Macrophages o replace PMNs 2 days after injury o monocytes are attracted to wound – migrate thru blood vessel walls – differentiate into macs by growth factors and chemokines released by platelets and endothelial cells  Continue to phagocytize bacteria and damaged tissue (more effectively than PMNs)  Release proteases which further debride damaged tissue  Release growth factors and cytokines (in the 3rd and 4th days) that are essential for the proliferative phase to occur o Activate adaptive immune system by presenting antigens to helper lymphocytes (CD4) and activating them  This response is necessary to fully remove the insult and end the inflammatory phase  Activates B cells and CD8 cells (for extracellular and intracellular antigens respectively)

Proliferative Phase

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begins 2-3 days after wounding even before inflammatory phase ends under the influence of GFs fibroblasts and endothelial cells enter wound and begin laying down new ECM and blood vessels o endothelial cells enter first because a blood supply is needed before anything else o then fibroblasts migrate and proliferate along fibrinogen and fibronectin (can’t migrate in fluid)

Angiogenesis - under the influence of GFs fibronectin and chemokines produced by platelets and macs w/in the wound, stem cell endothelial cells proliferate and migrate along the fibrin matrix to create new capillaries o critical step – brings oxygen and nutrients to migrating fibroblasts and other cells o tissue appears erythematous due to presence of large # capillaries - to migrate, endothelial cells produce collagenases, metalloproteinases and plasminogen activator to degrade the clot and ECM - low O2 tension and lactic acidosis in wound is essential for platelet and mac production of GFs and chemokines - when O2 tension is restored, production of these factors ceases - fibroblalsts secrete o ECM components: GAGs, glycoproteins, collagen (type III – later to be replaced by type I after wound matures) o GFs for epithelial cell proliferation and migration Collagen Deposition - fibroblasts begin to secret collagen by day 2 or 3 (peaks at 1-3 weeks) - collagen production continues for 2-4 weeks (afterwards, destruction matches its production) - essential for wound strength – before that, only thing holding wound closed is fibrin – fibronectin clot - once maturation begins, fibroblasts undergo apoptosis and decrease in number – signals the end of the proliferative phase and granulation tissue o maturation phase can now begin Epithelialization - Granulation tissue in wound permits re-epithelialization o Skin and mucosa must migrate over the granulation tissue - Epithelial cells migrate and proliferate across wound under surface scab to form a new barrier - Basal keratinocytes arise from wound edges, dermal appendages – hair follicles, sweat and sebaceous glands - They require viable tissue upon which to migrate – hence granulation tissue must fill wound first

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o Granulation tissue persists if wound gets infected  back to inflammatory phase and granulation tissue is broken down – whole process restarts o If there’s inadequate oxygenation, granulation tissue can’t be formed – wound will persist as non-healing ulcers (DIABETICS) To allow proliferation o Protect from outside environment o Remove foreign bodies o Remove dead/dying tissue o Approximate wound edges Migration of keratinocytes over wound is stimulated by lack of contact inhibition and presence of nitric oxide Desmosomes and hemidesmosomes which normally anchor cells to the ECM and each other dissolve and the integrins which attach the cell cytoskeleton to the basement membrane release their attachment Chemokine stimulation then initiates process of migration As keratinocytes migrate new epithelial cells proliferate at wound edges to replace them and provide more cells for advancing epithelial sheet Keratinocytes produce collagenase, metaloproteinases etc.. to dissolve ECM and basement membrane so they can migrate along matrix of granulation tissue Keratinocyte migration continues until cells meet at the middle of the wound to re-establish contact inhibition Desmosomes and hemidesmosomes are re-established and anchorage to basement membrane occurs Basal cells then divide and differentiate in normal fashion

Contraction - 1 wk post-wound fibroblasts begin to differentiate into myofibroblasts  wound begins to contract o Healing tissue in the wound pulls the tissue back together o Reduces the amount of tissue needed in the maturation phase - In full thickness wounds contraction peaks at 5-15 days post-wound – can last several weeks even after epithelialization - Wound size can become 40-80% smaller – reduces amt of tissue that has to be replaced during maturation phase - Myofibroblasts – similar to smooth muscle cells – migrate along fibronectin-fibrin fibers to wound edges o Attach via desmosomes and integrins to collagen and fibronectin of ECM o Contract to pull wound edges together o Dependent on TGF-beta - Contraction stage ends when myofibroblasts stop contracting and undergo apoptosis - Breakdown of provisional matrix  decrease in hyaluronic acid & increase formation of chondroitin sulfate  stops fibroblast proliferation, migration and differentiation - START OF MATURATION PHASE

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Maturation and Remodeling - Collagen production and degradation are equal o Can last a year or more depending on size of wound o Type III collagen is replaced by stronger type I - Collagen fibers are rearranged, cross-linked and aligned along tension lines o Increased tensile strength (only 50-80% or original strength) o Function is not completely regained either - Elastic fibers are not replaced – flexibility of tissues is reduced o Scar tissue is much more rigid – important in cosmetic sx - Vascularity (redness ) decreases - Wound contraction is also undesirable in burns and curved wounds o Skin grafting has been shown to reduce wound contraction -

Tissues returns to normalcy…by 6 months, clinically appears as normal tissue (not histologically though)

Factors that Impair Wound Healing - foreign material - necrotic tissue - ischemia – like in diabetic pts - tension – why we suture wounds – scab are only 5% strength of original tissue Foreign Material - anything host’s immune system considers non-self - BACTERIA: o proliferate, cause infection and produce proteins that destroy host tissue - NON-BACTERIAL FOREIGN MATERIAL o form havens for bacteria, sheltering them from host defenses – promote infection - FOREIGN MATERIAL o often antigenic – increase chronic inflammation (impair proliferative phase) Necrotic Tissue - BARRIER o to in-growth of reparative cells o inflammatory phase needs to be prolonged to remove it - PROTECTED NICHE o for bacterial growth o hematoma formation is excellent nutrient for bacterial growth Ischemia - DEFINITION

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o decreased blood supply thus decreasing delivery of O2 and nutrients to wound  necrosis & lessens delivery of Abs, WBCs and antibiotics  increases chance of infection CAUSES o tight sutures o improperly designed flaps o excessive internal and external pressure o systemic vascular problems

Tension - SUTURES – when used to overcome tension the tissue encompassed will become strangulated and ischemic - EARLY REMOVAL – wound will reopen and excessive scar formation - LATE REMOVAL – wound will spread during remodeling and epithelial tracts form around suture - Fibrin matrix is originally only thing holding wound together (5-10% of tensile strength of tissue) SLIDE 35 He stopped lecturing here – the ppt goes on for another 20 slides… If he doesn’t pick up where he left off next week, I’ll continue these notes and re-post them next week. Exodontia Armamentarium Armamentarium - Forceps – 2 blades, handles for pulling, grasping or compressing o Do not crush a tooth - Elevators – for lifting a depressed part; removing osseous tissue or roots o Pushing rods - Misc Instruments - Extracting teeth is not about excessive force Forceps - Extraction – removes a tooth from alveolar bone o Upper Universal – 150, 150A, 150AS o Straight – 1 (99) o Upper Molar – 53 R & L o Upper 3rd Molar – 210S o Root Tip – 286 o Lower Universal – 151 o Lower Molar – 17 o Lower Molar – 23 (Cowhorn) o Hawk Billed Lower Anterior (Ash) – 4 Extraction Forceps Beak

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Beaks designed for single, double or triple rooted teeth o Grab at the region of the alveolar bone (junction of the crown and root) the closer the beak adaptation to roots, the more efficient the forceps beaks go around crown of tooth and are seated below the CEJ on root surface lower molar forceps – beaks go into furcations o need more force than max molars  greater density of mand bone beaks touch only at the tip o prevents crushing tooth

Extraction Forceps Hinge - connects handle to beaks - transfers and concentrates force applied to handles and beaks - American type – hinge in horizontal direction - English type – hinge in vertical direction Extraction Forceps Handle - serrated surface to prevent slippage - straight or curved - max forceps o palm underneath w/ beaks UP - mand forceps o palm above w/ beaks DOWN - standing in FRONT of pt – OVERHAND grip - standing in BACK of pt – UNDERHAND grip - Forceps are fulcrums o Hold handle as far back away from hinge as possible for most force applied to beaks - Elevation comes from the shoulders, not the wrists - Underhand grip should be used standing behind the patient o Overhand grip can be used standing in front of patient with force coming from shoulder Ash Hawk Billed Lower Anterior - aka “Ash” - For mandibular incisors and premolars o Axis of beaks at 90° o Used after an elevator to twist tooth out o Vertical hinge o Roots of these teeth are fin shaped…cannot be rotated 16

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Great force can be exerted o care must be taken to avoid alveolar fracture

Maxillary Forceps #150 - single rooted teeth (incisors and canines) - beaks curve to meet only at tips - beaks 30° to handle

151 Modifications of #150 Forceps - 150A o parallel beaks that do not touch o for premolars o NOT for incisors (poor adaptation to roots) -

150A 150AS

150AS o same as 150A except they have serrations • Use pedo forceps (150S) for pts who can’t open widely o Ridges prevent slippage

#1 (99) / Straight Forceps - beaks similar to 150 - touch only at tips - parallel to handle - max incisors and canines only

1 (99)

53 R & L - max R and L molars - palatal beak adapts to palatal root (rounded beak) - buccal beak – pointed – fits into furcation between buccal roots - beaks offset from handle - Likely to break a tooth with these o Use these after other failed attempts

53L

#210S 17

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removes conical rooted max 2nd and 3rd molars broad smooth beaks beaks offset from handle 201S

#286 -

for root tips offset molar forceps w/ narrow beaks Narrower beaks fit right into socket may also be used for narrow premolars and mandibular incisors

#151 -

mandibular universal forceps beaks similar to 150 and meet only at tip beaks at 60° angle to handle useful for single rooted teeth can be used for primary teeth, including molars

286

151

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#17 #222 -

mandibular molars pointed tips in center for bifurcations o Beaks engage both furcations beaks at 60° to handle NOT for molars w/ conical or fused roots straight handle (usually)

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similar to #17 BUT beaks are shorter and do NOT have center pointed tips for molars w/ conical or fused roots usually for erupted 3rd molars

222 #23 (Cowhorn) - mandibular molars - 2 heavy pointed curved beaks to fit into bifurcations - removes tooth by squeezing beaks together using buccal and lingual cortical plates as fulcrums - Elevators and forceps in one; o Beaks engage furcations and as you squeeze, the tooth will elevate up o Once the handles come together, rotate and remove tooth o Need a bite block or else you can get a joint hematoma o Only reference point for how close beaks are is the closeness of the handles (cannot see beaks) Bone Cutting Rongeurs • not used to take teeth out - Blumenthal – cuts bone directly o have a reservoir for bone that has been scraped away - Side Cutting – not as efficient o no reservoir; can drop bits of bone down pt’s throat - End Cutting

23 / Cowhorn

Blumenthal Rongeurs

Other Types of Forceps - Tissue Forceps o Adson – with teeth to pick up tissue; can crush Adson o Allis – clamp Forceps  used a lot in neck surgery; not as much in oral surgery  great for grabbing tissue (also crushing tissue)  do NOT use if you’re doing a biopsy b/c it will crush tissue -

Cotton o college pliers

Allis Clamp

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Hemostat Clamps – serrated blades so blood vessels won’t be damaged during clamping o Kelly o straight o curved

Elevators • Forces are more controlled than w/ forceps o Tooth pushers…help to expand the socket o Facilitate the use of forceps • used to luxate teeth prior to use of forceps • make a difficult extraction much easier • expand alveolar bone • can use to remove broken or surgically sectioned roots • elevate tooth against bone, not an adjacent tooth o tip of elevator should be oriented towards the apex of the root to avoid placing forces on adjacent tooth • TYPES: o periosteal o Cryer (East-West, Winter-V) – right and left o Apexo Ejectors – right and left o Crane Pick – Universal Elevator o Straight – 34S and 301 • COMPONENTS o handle – designed to be held comfortably so as to apply sustained controlled force o shank – connects handle to blade; strong o blade – working tipe used to transmit force to tooth a/o bone Straight Dental Elevators - blade has concave surface on one side – used like a shoehorn o #301 – luxates erupted teeth o #34S – displace roots from sockets and luxates teeth more widely spaced o Elevates tooth against bone, not against the adjacent tooth  Tip of elevator needs to be oriented towards apex of root • Avoids pressure on the adjacent tooth o Difficult to do in mandible  Needs to be controlled force o Elevation point is in between the tooth and alveolar bone

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77R Back Action Elevator - blade similar to 301 - offset to permit better access to posterior teeth (has a bend in it) Pick Type: Cryers Elevators - pennant-shaped - come in pairs: Right and Left - useful to remove broken roots adjacent to an empty root socket - tip of blade is placed in empty socket - shank rests on buccal bone and cortical plate - can remove interseptal bone if crown fractures then remove roots Crane Pick Elevator - used as a lever to remove roots - place hole in tooth (purchase point) o Then elevate w/ the crane pick Root Tip Apexo Elevators - used to tease small root tips from sockets - much more delicate than Cryer or Crane Pick - can’t be used as a lever type or wheel and axle elevator - come in pairs: Right and Left - Root has to be elevated, loose or mobile in order to use this o Used to get between root and alveolus Potts Elevators - come in pairs: Right and Left - used mainly to remove maxillary 3rd molars - long with cross-bar handles o generate a lot of force o can fracture maxillary tuberosity - used after a straight elevator; secondary instruments Periosteal Elevator #9 Molt - double ended - pointed end: sharp, used in prying motion to elevate mucoperiosteum from bone (usually interdental papilla) o Elevates the gingival cup and breaks the gingival fibers - rounded end: push stroke once under periosteum to lift it from bone o also used in a pull/scrape stroke to lift mucoperiosteum (greater risk tearing tissue)

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Henahan

Dean Scissors

Miscellaneous Surgical Instruments - mouth mirror - Dean scissors (tissue cutting, suture cutting) - retractors o Henahan – gingival (does not elevate mucoperisoteal flaps) o Austin – gingival Austin o Minnesota o Black – cheek o Wieder – tongue Minnesota - local anesthesia cartridge syringe - bone file - curet Weider o removes growths or other materials from walls of cavities - Bard Parker blade handle – - blade: #15 used for most sx - needle holder bone file - double-ended bone file o removes bony spicules or sharp points o used in a pull direction (not push) o use in a slow motion, not “scrubby-scrub” motion - double-ended spoon curet o removes debris o takes granulation tissue out - needle holder spoon curet needle holder o note: diff from hemostat o points on needle holder are cross-hatched to engage needle in more than one direction - mallet - chisel - surgical suction Surgeon & Assistant Position - surgeons’s back is straight, arms are bent o keep arms closer to body for more dexterity - assistant is offset from the front o impt so no arms are criss-crossed POSSIBLE LIST OF TEST QUESTIONS 1. Ash forceps are for mandibular incisors, premolars and canines. They have their beaks oriented at 90° 2. The underhanded grip is for working behind the patient 3. Use pedo forceps for patients who can’t open their mouths very wide

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4. Centric points on the 53R and L and on the 17 are to engage root furcations 5. #23 (Cowhorn) are forceps + elevator in one – MUST use a biteblock 6. The way you estimate the closeness of beaks is to look at the proximity of the handles 7. Allis clamp is for grabbing tissue – can’t use it for tissue that will be submitted to pathology because it also crushes tissue 8. You have more control of forces with elevators than with forceps 9. The tip of an elevator should be placed towards the apex of the root to avoid putting pressure on adjacent teeth 10. Root-tip elevators are designed to go between the root and alveolus and should be used when the tooth is already partially elevated 11. A possible complication of using a Potts elevator is fracture of the maxillary tuberosity 12. The direction of force when using a bone file is in one direction only: pull – you use it in a push-pull manner but you will only be cutting bone in the pull direction (so only put force in the pull-direction) Extraction Forceps Handle Vertical - creates more force - mandibular teeth - more risk of root tip or crown fracture - Gives apical type pressure Horizontal - STANDING IN FRONT OF PATIENT o Max – Palm Up o Mand – Palm Down - STANDING BEHIND PATIENT o Max – Palm Down o Mand – Palm Up Hinge - transfers and amplifies gripping force from handle to beaks - danger to soft tissue Beaks - adapt to teeth at or below CEJ - roots can be o conical o ribbon shaped o bifurcated o trifurcated - choose beak design that best adapts size and shape of roots - smooth or serrated

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The key to using forceps is to expand the bony alveolus Forceps Movements – in order of how you’d perform them

apical -

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buccal

palatal

rotational

traction

must break the PDL taking teeth out is not about force or yanking forceps are used LAST after elevators apical adaptation is critical errors lead to o tooth fracture o slippage of instrument o injury to adjacent structures o increased difficulty choosing the correct instrument is key Elevation is key o Gentle luxation of teeth is all that is needed Give apical pressure with forceps o Go up and into the alveolus to break the fibers o Try to grab as apical as possible below the CEJ to expand the alveolus

Controlled Forces Mandible - always support lower jaw o standing in front of pt - assistant can help o standing behind pt – DDS can support the jaw with the non-dominant hand - may use a mouth prop - may use pinch-grasp o one finger in buccal vestibule, one between alveolus and tongue Maxilla - pinch-grasp to feel alveolar process during extraction DDS’s Body Position - don’t use wrist – use deltoid and forearm - stand – arms will be at 90° or less o while sitting, arms are bent more acutely than 90° and you lose all leverage - remember you can bend your knees and not just at the waist 24

Forceps for the Extraction of Maxillary Teeth

Anteriors Premolars

Root Shape conical triangular oval

Forceps to Use 1 99-C 150

150-AS

1st & 2nd Molars

trifurcated

89 90

88R & L

53R & L

Erupted 3rd Molars

Root Fragments

trifurcated fused

210-S

pedo 150S 286

Additional Notes -

can use even if there is no clinical crown transmit forces directly in apical direction universal forceps not best suited for trifurcated teeth good for sectioned molars 1st premolars can have buccal and palatal roots – palatal root tends to break – be careful - for crowns; does not move apically as well as 150 - When removing maxillary 1st premolars , remember the palatal root is just as long as the buccal root - Therefore always expand palatal-buccally (more of an emphasis on the buccal movements) - Palatal root more likely to snap off, so go slowly - palatal beak adapts to palatal root rather than entering furcation - The pointed beak is always on the buccal side - “upper cowhorn” - B and P furcation prongs - must use caution to avoid alveolar fracture or tissue damage good adaptation but should be avoided when - caries is extensive - large amalgam - RCT has rendered tooth brittle - beaks similar to 53 - no central point to engage furcation - to remove conical rooted 3rd molars - especially for split roots -

bayonet shaped long slender beaks sometimes for very small premolars

Primary Teeth - 150-S o smaller version of 150

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Forceps for the Extraction of Mandibular Teeth Anteriors & Premolars

Root Shape Ribbon shaped &

Instrument 74, 74-N, 74extra N (aka “Ash”)

151, 151-A 203 1st & 2nd Molars

Bifurcated

23 (cowhorn) 17 151

Erupted 3rd Molars

bifurcated or conical

222

Additional Notes - vertical handle - must continually reposition fulcrum more apically - a lot of torque; can twist crown right off Use a buccal/lingual motion, not rotation - universal forceps - thinner beaks for incisors and root fragments - anything w/ a bifurcation Use a figure 8 motion - pointed beaks - won’t adapt to conical rooted molars - used if root is not bifurcated or when you have split the teeth surgically - beaks 90° to handle - beaks broad and rounded w/o central points (for conical roots w/o furcations)

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Primary Teeth - 151-S • Anteriors use Ash forcep (74) • Has a lot of torque (potential to twist off crown) • Long lever arm allows you to apply a lot of force • Be careful when using these • Rotating force used with ash forcep on canines and premolars • Just buccal-lingual for the mandibular incisors • Use other hand to push down on these to allow more apical grip to the cementum • 151 is universal for anything • 23 can be used with any furcation Elevators and Elevator Techniques Using an elevator is best learned in clinic – this is just to give us a starting point for learning how to use these. Components of an Elevator - handle - shank - blade or tip Two Basic Designs - inclined plane  this is like a wedge - wheel and axle Three Basic Actions - displacement (inclined plane) o blade is inserted into PDL and pushed apically  stretches bone and PDL o be careful when removing root tips near the max sinus – sometimes the roots go thru the sinus floor and it’s easy to push the root INTO the sinus (this is bad) o Stretches the bone (expands it) o Also pushes up the conical roots o Apical pressure at the sinus region can penetrate through the thin bone - lever action o for prying a tooth from the alveolus o edge of blade engages the tooth OR a purchase point o bone is used as a fulcrum – DO NOT USE ADJ TEETH AS FULCRUMS o straight elevators are placed in PDL space o can drill a little groove into the tooth to engage the blade BUT be careful, as this weakens the tooth o Can break teeth doing this (use with caution) Cryer

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-

-

-

o Purchase point can be made with drill in the tooth o Adjacent tooth should not be used as a fulcrum o Cup shaped elevator  Back of instrument is on bone, not tooth o When using the tooth as a purchase point, it is easier to fracture the tooth wheel and axle o elevator tip engages a purchase point in tooth or root o bone is the fulcrum o handle is rotated, transmitting force to tip o most common technique: place elevator in an empty adjacent socket, drive it into the interradicular (or interdental) bone, engage root tip and twist o common “wheel and axle” elevators Cryer pop it out (bifurcated o Good for removing roots tooth) (single or double) o Placed in the adjacent socket, drive through interradicular, engage the other root, and Crane pick (w/ purchase point made w/ drill) Crane Pick

Commonly Used Elevators 34-S and 46 - large, shoehorn straight elevator - most commonly used - displacement 301 - used similarly to the 34-S and 46 BUT for smaller teeth and roots - displacement Back Action Elevator - blade similar to 301 - offset to permit better access to posterior teeth - very narrow Potts Elevators - for removing IMPACTED max 3rd molars - force directed toward palate - elevates tooth distally - need to engage it as apically as possible - Rotation should direct down and backwards o Most common to lose the tooth in the infratemporal fossa if forces are not directed properly  If this does happen, patient put on antibiotics, and let tooth form fibrous capsule to make it easier to pull out later (2-3 weeks)

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Need to do hemicoronal incision to get underneath the zygomatic arch - If the tooth goes backwards, the elevator will stop it - Good retraction is key Crane Pick (#41) - wheel and axle type - most dangerous - most often used w/ a purchase point o point should be at least 3mm apical to CEJ and 3mm deep Cryer (30 and 31 R&L) - wheel and axel type - may be used w/ or w/o purchase point - primarily used to remove roots when there’s an adjacent empty socket - “flag” or “triangle” shaped blades o Go through the intra-radicular bone o Engage the root tip, trying to get it out o Rotate up and out Form Fitters (R&L) - a cross between a cryer and a potts - not often used Cryer - very pointed tip Apexo Elevator (R&L) - wheel and axle type - not designed to be a displacement instrument o may break tips o may dislodge root tip into sinus - great for getting retained root tip fragments o note: not all root tips need to be removed o only remove ones that are associated w/ pathology OR >3-4mm) o Must weigh the pros and cons of removing root tips 

• Maintenance of elevators • To be effective, it must be sharp to engage the root surface • Sharpen periodically • History • First dental chair (1848) Waldo Hanchett • First electric dentist drill (Jan 26, 1875) George Green • False teeth date back as far as 700 BC

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