Lec. Oral surgery DR.

Kardo Mustafa

PRINIPLES OF SURGERY

DEVELOPING A SURGICAL DIAGNOSIS

Most of the important decisions concerning a maxillofacial surgical procedure

should be made long before the administration of anesthesia.

The initial step in the pre-surgical evaluation is the collection of accurate and
pertinent data. This is accomplished through patient interviews; physical,
laboratory, and imaging examinations; and the use of consultants when necessary.

The dentist should be able to consider a list of possible diseases and eliminate
those unsupported by the data. By using this method, along with the knowledge of
which diseases have a probability of being present, the surgeon is usually able to
reach a decision about whether surgery is indicated.

BASIC NECESSITIES FOR SURGERY

Little difference exists between the basic necessities required for oral surgery and
those required for the proper performance of other aspects of dentistry. The two
principal requirements are (1) adequate visibility and (2) assistance.

Adequate visibility depends upon the following three factors: (1) adequate access,
(2) adequate light, and (3) a surgical field free of excess blood and other fluids.

1- Adequate access not only requires the patient's ability to open the mouth
widely, but it also may require surgically created exposure. Retraction of
tissues away from the operative field provides much of the necessary access.
(Proper retraction also protects tissues from being accidentally injured, for
example, by cutting instruments.) Improved access is also gained by the
creation of surgical flaps.

2- Adequate light is another obvious necessity for surgery. However, clinicians

often forget that many surgical procedures place the surgeon or assistant in
positions that block chair-based light sources. To correct this problem, the
light source must continually be repositioned, or the surgeon or assistant
must avoid obstructing the light or use a headlight.

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3- A surgical field free of fluids is also necessary for adequate visibility. High-
volume suctioning with a relatively small tip can quickly remove blood and
other fluids from the field.

As in other types of dentistry, a properly trained assistant provides invaluable help

during oral surgery. The assistant should be sufficiently familiar with the proce-
dures being performed to anticipate the surgeon's needs.

ASEPTIC TECHNIQUE

Aseptic technique includes minimizing wound contamination by pathogenic

microbes.
This includes:
a- Preparation of the patient.
b- Preparation of the surgeon (medical staff), and assistant.
c- Sterilization of instruments and aseptic condition of theatre or dental clinic.

INCISIONS

Many oral and maxillofacial surgical procedures necessitate incisions. A few basic
principles are important to remember when performing incisions:

1- A sharp blade of the proper size should be used. A sharp blade allows
incisions to be made cleanly, without unnecessary damage caused by
repeated strokes. The rate at which a blade dulls depends on the resistance of
tissues through which the blade cuts. Bone and ligament tissues dull blades
more rapidly than does buccal mucosa. Therefore the surgeon should change
blades whenever the knife does not seem to be incising easily.

2- A firm, continuous stroke should be used when incising. Repeated, tentative

strokes increase both the amount of damaged tissue within a wound and the
amount of bleeding, thereby impairing wound healing. Long, continuous
strokes are preferred to short, interrupted ones.

3- The surgeon should carefully avoid cutting vital structures when incising.
No patient's microanatomy is exactly the same. Therefore to avoid
unintentionally cutting large vessels or nerves, the surgeon must incise only
deeply enough to define the next layer. Vessels can be more easily
controlled before they are completely divided, and important nerves can

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usually be freed from adjacent tissue and retracted away from the area to be
incised.

4- Incisions through epithelial surfaces that the surgeon plans to re-approximate

should be made with the blade held perpendicular to the epithelial surface.
This angle produces squared wound edges that are both easier to reorient
properly during suturing and less susceptible to necrosis of the wound edges
as a result of ischemia.

5- Incisions in the oral cavity should be properly placed. It is more desirable to

incise through attached gingiva and over healthy bone than through
unattached gingiva and over unhealthy or missing bone.

FLAP DESIGN

Surgical flaps are made to gain surgical access to an area or to move tissue from
one place to another. Several basic principles of flap design must be followed to
prevent the complications of flap surgery: flap necrosis, dehiscence, and tearing.

Prevention of Flap Necrosis

Flap necrosis can be prevented if the surgeon attends to four basic principles.

1- The apex (tip) of a flap should never be wider than the base, unless a major
artery is present in the base. Flaps should have sides that either run parallel to
each other or, preferably, converge moving from the base to the apex of the
flap.

2- Generally the length of a flap should be no more than twice the width of the
base.

3- When possible, an axial blood supply should be included in the base of the
flap. For example, a flap in the palate should be based toward the greater
palatine artery.

4- The base of flaps should not be excessively twisted, stretched, or grasped with
anything that might damage vessels, because these maneuvers can compromise
the blood supply feeding and draining the flap.

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Prevention of Flap Dehiscence

Flap margin dehiscence (separation) is prevented by approximating the edges of

the flap over healthy bone, by gently handling the flap's edges, and by not placing
the flap under tension. Dehiscence exposes underlying bone, producing pain, bone
loss, and increased scarring.

Prevention of Flap Tearing

Tearing of a flap is a common complication of the inexperienced surgeon who

attempts to perform a procedure using a flap that provides insufficient access.
Because a properly repaired long incision heals just as quickly as a short one, it is
preferable to create a flap at the onset of surgery that is large enough for the
surgeon to avoid either tearing it or interrupting surgery to enlarge it.

TISSUE HANDLING

Excessive pulling or crushing, extremes of temperature, desiccation, or the use of

unphysiologic chemicals easily damage tissue. Therefore the surgeon should use
care whenever touching tissue. When tissue forceps are used, they should not be
pinched together too tightly; rather, they should be used to delicately hold the
tissue. When possible, toothed forceps or tissue hooks should be used to hold
tissue. In addition, tissue should not be over aggressively retracted to gain greater
surgical access.

HEMOSTASIS

Prevention of excessive blood loss during surgery is important for preserving a

patient's oxygen-carrying capacity. However, maintaining meticulous hemostasis
during surgery is necessary for other important reasons. One is the decreased
visibility that uncontrolled bleeding creates. Even high- volume suctioning cannot
keep a surgical field completely dry, particularly in the well- vascularized oral and
maxillofacial regions. Another problem bleeding causes is the formation of
hematomas. Hematomas place pressure on wounds, decreasing vascularity; they
increase tension on the wound edges; and they act as culture media, potentiating
the development of a wound infection.

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Means of Promoting Wound Hemostasis

Wound hemostasis can be obtained in five ways:

1- Is by assisting natural hemostatic mechanisms. This is usually accomplished
by either using a fabric sponge to place pressure on bleeding vessels or placing
a hemostat on a vessel. Both methods cause stasis of blood in vessels, which
promotes coagulation. A few small vessels generally require pressure for only
20 to 30 seconds, whereas larger vessels require 5 to 10 minutes of continuous
pressure. The surgeon and assistants should dab rather than wipe the wound
with sponges to remove extravasated blood. Wiping is more likely to reopen
vessels that are already plugged by clotted blood.

2- By the use of heat to cause the ends of cut vessels to fuse closed (thermal
coagulation). Heat is usually applied through an electrical current that the
surgeon concentrates on the bleeding vessel by holding the vessel with a metal
instrument, such as a hemostat, or by touching the vessel directly with an
electrocautery tip.

3- By suture ligation. If a sizable vessel is already severed, each end is grasped

with a hemostat. The surgeon then ties a nonabsorbable suture around the
vessel. If a vessel can be dissected free of surrounding connective tissue before
it is cut, two hemostats can be placed on the vessel, with enough space left
between them to cut the vessel. Once the vessel is severed, sutures are tied
around each end and the hemostats removed.

4- By placement of a pressure dressing over the wound. This creates pressure on

the small vessels that were cut, promoting coagulation.

5- By placing vasoconstrictive substances, such as epinephrine, in the wound or

by applying procoagulants, such as commercial thrombin or collagen, on the
wound. Epinephrine serves as a vasoconstrictor most effectively when placed
in the site of desired vasoconstriction at least 7 minutes before surgery begins.

DECONTAMINATION AND DEBRIDEMENT

Bacteria invariably contaminate all wounds that are open to the external or oral
environment. Because the risk of infection rises with the increased size of an
inoculum, one way to lessen the chance of wound infection is to decrease the
bacterial count. This is easily accomplished by repeatedly irrigating the wound
during surgery and closure. Irrigation dislodges bacteria and other foreign
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materials and rinses them out of the wound. Irrigation can be achieved by forcing
large volumes of fluid under pressure on the wound. Although solutions containing
antibiotics can be used, most surgeons simply use sterile saline or sterile water.

Wound debridement is the careful removal from injured tissue of necrotic, foreign,
and severely ischemic material that would impede wound healing. In general,
debridement is used only during care of traumatically incurred wounds or for
severe tissue damage caused by a pathologic condition.
Care must be taken not to apply so much pressure as to compromise wound
vascularity.

Principle of drainage:
Wounds need to drain freely after operation where they are contaminated or
infected, where an abscess has been incised, or where immediate closure is made
over a dead space which may fill with blood or serum and subsequently become
infected.

Fine superficial drains: these are made of pieces of rubber glove and are used in
wounds of the face to allow escape of the tissue exudates. They are usually
removed after 48hrs.

Larger superficial drains: corrugated rubber is used in the dental abscess to keep
the wound edges apart and allow thick puss to flow freely. Though chiefly used for
extraoral incisions and drainage, they are necessary for large collections of puss
drained intraoral.

Deep drains: tubing, sometimes with the small holes cut in its walls, is used in
osteomyelitis of the jaws or to drain the antrum through the nose, the tubes must be
of sufficient diameter to ensure the free passage of fluid and to allow irrigation
with saline or antibiotic solutions.

Dead Space Management

Dead space in a wound is any area that remains devoid of tissue after closure of the
wound. Dead space is created by either removing tissue in the depths of a wound
or by not reapproximating all tissue planes during closure. Dead space in a wound
usually fills with blood, which creates a hematoma with a high potential for
infection.

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Dead space can be eliminated in four ways.

1- Suturing tissue planes together to minimize the post- operative void.

2- Place a pressure dressing over the repaired wound. The dressing com-
presses tissue planes together until they are either bound by fibrin.

3- Place packing into the void until bleeding has stopped and then removes the
packing. This technique is usually used when the surgeon is unable to back
tissue together or to place pressure dressings (e.g., when bony cavities are
present). The packing material is usually impregnated with an antibacterial
medication to lessen the chance of infection.
4- Use of drains, either by themselves or in addition to pressure dressings.

EDEMA CONTROL

Edema occurs after surgery as a result of tissue injury. Edema is an accumulation

of fluid in the interstitial space because of transudation from damaged vessels and
lymphatic obstruction by fibrin. Two variables help determine the degree of
postsurgical edema.
First: the greater the amount of tissue injury, the greater the amount of edema.
Second: the more loose connective tissue that is contained in the injured region,
the more edema is present. For example, attached gingiva has little loose
connective tissue, so it exhibits little tendency toward edema; however, the lips and
floor of the mouth contain large amounts of loose connective tissue and can swell
significantly.

The dentist can control the amount of postsurgical edema by:

1- Performing surgery in a manner that minimizes tissue damage.
2- Some believe that ice applied to freshly wounded area decreases vascularity
and thereby diminishes transudation.
3- Patient positioning in the early postoperative period is also used to decrease
edema by having the patient try to keep the head elevated above the rest of
the body as much as possible during the first few postoperative days.
4- Short-term, high-dose systemic corticosteroids can be administered to the
patient and have an impressive ability to lessen inflammation and
transudation (and thus edema). However, corticosteroids are useful for
edema control only if administration is begun before tissue is damaged.

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PATIENT GENERAL HEALTH AND NUTRITION

The surgeon can help improve the patient's chances of having normal healing of an
elective surgical wound by evaluating and optimizing the patient's general health
status before surgery. For malnourished patients, this includes improving the
nutritional status so that the patient is in a positive nitrogen balance and an
anabolic metabolic state.