Instruments for Basic Oral Surgery

INSTRUMENTS FOR BASIC ORAL SURGERY These lectures will introduce the basic and main instruments required to perform routine oral surgical procedures ,these instruments are used for many purposes including both soft and hard tissues (e.g./ Bone , dental procedures):The main instruments include the followings:1- Instruments to incise the tissues . 2- Instruments for elevating mucoperiosteum. 3- Instruments for controlling haemorrhage . 4- Instruments to grasp tissues. 5- Instruments for removing bone includes:a. Rounger forceps( bone cutter, bone nibbler) b. Chisel and mallet. c. Bone file. d. Burs and hand piece. e. Instruments to remove soft tissues from bony defects 6-Instruments for suturing mucosa: a. Needle holder. b. Needle. c. Suture material. d. Scissors. 7- Instruments for retraction of soft tissues. 8. Instruments for irrigation and for providing suction. 1-Instruments to incise tissues: These instruments used to do incision in the soft tissues and this procedure needs scalpel and scalpel handle, the most commonly used handle is number 3 and number 7. The tip of the scalpel handle is prepared to receive a variety of different scalpel blades that can be inserted into a slotted receiver, the most commonly used scalpel blade for intra oral incisions is number 15 , its relatively small and can be used to make incision around teeth and through mucoperiosteum. Another scalpel used to make incisions on the skin extra orally is number 10.. Other commonly used blades for intra oral surgery are number 11 and 12. Blade no. 11 mostly used for making stab incision such as for incising abscess , its pointed triangular in shape , the hooked no. 12 blade is useful for mucogingival procedures especially in the posterior area of the oral cavity , for example maxillary tuberosity or posterior aspects of the upper molar region on the buccal or lingual aspects. 2-Instruments for mucoperiosteum elevation After an incision is made through the mucoperiosteum (mucosa +sub mucosa+ periosteum=mucoperiosteum) The mucosa and periosteum should be reflected from the underlying bone with periosteal elevator. The instrument that is mostly used in our department is Howarth periosteal elevator, this instrument has a sharp pointed end and a broad flat round end. The broad flat round end is inserted into the incision beneath the cut edge of the periosteum to elevate or strip it off the bone , and the sharp end of the elevator used for detachment of muscle insertion or sometimes to complete the incision done by the blade if there is some resistance for the elevation by the flap, many types and sizes of the periosteal elevators are available like Mitchell trimmer Mitchell trimmer is useful in separating through the fibres from around the crown of the unerupted teeth and the neck of erupted teeth. The periosteal elevator can be used to reflect soft tissues by push stroke in which the broad end of the instrument slides underneath the flap separating through the periosteum from the underlying bone and sometimes periosteal elevators are used by a pull stroke or scrap stroke in special locations. 3-Instruments for controlling haemorrhage: When incision is made through the tissues, small vessels may be cut leading to bleeding, to control this bleeding we have instruments Which aid in the stoppage of bleeding called haemostat or artery forceps, this comes in a variety of shapes and sizes, it’s a delicate instrument which may have straight or curved beaks , this instrument has a locking device assisting in the clamping of the blood vessels In addition to its use as an instrument for controlling bleeding its used in oral surgery to evacuate pus from abscesses by inserting the haemostat inside the abscess after an incision is made, also haemostat may be useful in grasping tissues from the tooth socket and pick up small root tips, pieces of calculus, fragments of amalgam or any other small particles that have been dropped in the mouth or wound area. 4-Instruments used to grasp tissues: Here we have : A-Toothed -tissue forceps. B- Allis tissue forceps. These instruments used to hold and stabilize flap during suturing to assist in passing needle through the mucoperiosteal flap, also these instruments, used to hold tissues or grasping tissues in some types of surgical procedures .e.g.\ Taking biopsy. It should be used gently to prevent crushing of the tissues especially in the case of Allis tissue forceps. 5-Instruments for removing bone includes: A-rounger forceps (bone cutter , bone nibbler) B-chisel and mallet. C-surgical burs and hand piece. D-bone file. E-instruments used to remove soft tissues from bony defects Sometimes we need to remove bone to gain access into a lesion like intra-bony cystic lesion, or bony biopsy or to correct an existing bony defect or abnormal bony exostosis or even sometimes to remove a retained root or a sharp bony projection.etc. So we have many tools and instruments to perform such a duty. The use of any one of these instruments depends on the case and preference of the operator, so we have many modalities to perform bone removal. A- Bone rounger: It's also called (bone nibbler) or (bone cutter) it's used to cut bone quickly and efficiently this instrument has sharp blades that are squeezed together by the handles cutting or pinching through the bone, it also has a leaf spring or spring loaded handles to control the opening of the blades, some of these are side cutting others are end cutting. End cutting types are used to cut bone in less accessible areas like inside the tooth socket , these instruments are very useful for trimming of sharp bony projections or removing of a thin plate of compact bone during saucerization of bone cavity. B-Chisel and mallet: This is another method for removing bone especially when large piece of bone need to be removed, we have many sizes and lengths of chisels. Chisel have a sharp monobeveled working end used to cut bone , bibevelede called osteotome , may be used for splitting bone or teeth. Cutting of bone by chisel need to be used by applying force and by the use of mallet,. A mallet with a nylon cover or facing will exert less shock to the patient, also its less noisy. Removal of bone using chisel and mallet mostly done under general anaesthesia. C- Surgical burs and hand piece: It’s a useful method and commonly used to remove bone by rotary means (hand piece) under local anaesthesia, burs are either used to remove bone or to cut a window in the bone, it's also useful in dividing teeth , we have dental steel burs and tungsten carbide burs, carbide burs cut bone more efficiently than steel burs, these burs are-either-round or fissure burs... * large diameter bone burs may be used for removal of wide area of bone or for smoothening of the margins of bony defect, in most cases the use of either size 6 or 8 Bone burs will enable the production of deep narrow slots in the bone, burs can be used with angle or straight hand piece which should have an accepted speed and torque to remove bone efficiently and should always be used with irrigation by distilled water or saline to prevent damage to the bone by heat generation during cutting. *when large amount of bone need to be removed, large bur that resembles an acrylic bur is used. High speed turbine which is used in restorative dentistry must not be used because the air exhausted into the wound may produce tissue emphysema. D- Bone file: This instrument is used for smoothening of bone before suturing of the flap, it's usually double ended instrument with a small and large ends , the working end of the bone file have grooves or slots to work in a pull stroke only, bone file is not used to remove bone its used only for final smoothening .. Notice that its used in a pull stroke one direction only, if pushing movement is used it will lead to crushing of bone and this should be avoided. E-Instruments to remove soft tissues from bony defects: It is called Curette : it's just like excavator , angled , double ended ,of different sizes, the working end is like a spoon, round -oval in shape, its mostly used to remove soft tissues from a bony cavity like :periapical granuloma or cystic lesion from the bone, it also may be used to remove foreign bodies or small pieces or spicules from the bony socket.