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 sterili ation - physical agents o heat dry moist transfers heat better than air steam has more stored energy pressuri ed steam allows for superheating o mechanical dislodgement o radiation D!" #$%S& Antimicrobial 'ffect oxidi es cell proteins denatures cell proteins &ime long short '(uipment complexity and cost low high &endency to dull or rust instruments low high Exposure Time (Dry vs. Moist) Heat - general trends )see slide * for specific numbers+ o need higher dry heat for much longer to achieve same results as steam o e,g, at -.-/0 dry heat = 1--. hours at -.-/0 steam = .2 min aseous Sterilization ! Et"ylene Oxi#e - alkylating agent - flammable )mix w3 456 0$. or 7reon+ - used at room & )for porous8 rubber8 plastic material that can9t withstand high heat+ o Does not melt materials - highly toxic need long aeration time to de-toxify - :$& practical for dental office

$nstrument Disinfe%tion - ;lutaraldehyde )0idex+ o #ost commonly used for disinfection - %odophores )<etadine+ o Also can be used on human tissue - 0hlorine compounds )0lorox+ - 7ormaldehyde O&'e%tives - Difference b3t sterile technique used in $! and clean technique used in clinic - <e able to perform surgical hand scrub8 gown and glove - <e able to set up an instrument tray for dental extractions - <e able to maintain a clean surgical field Sterilization Tests - 0olor coded packaging o =aper > cellophane - &est areas on package change color on exposure to sterili ing temps or ethylene oxide gas - Special masking tape shows brown lines after sterili ation $nstrument Set (p - disinfect tray - open outer cassette covering with ungloved hands o $uter layer is not sterile8 and therefore can be touched with ungloved hands - open inner cassette covering with sterile gloved hands loving - open te%"ni)ue )slides ??-?*+ o touch only the inner aspect of the folded glove )the cuffed end+ o place on one hand o then with that one gloved hand8 touch only the outer aspect of the folded glove to place other glove on other hand - %lose# te%"ni)ue o =ull surgical gown sleeves over hands and put gloves on without touching them with hands Since the gown is sterile8 it can touch the gloves o :ot used as much Surgi%al Site *rep (fa%e+ ne%, an# ot"er s,in sites) - prepared surgical site to be @paintedA with antiseptic sponge sticks )set of ?+ o antiseptic agents .

iodophor compounds )<etadine+ chlorhexidine gluconate )Bibiclens+ o Start where you are working8 and disinfect laterally to the margins Do this ? times8 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 =rotect eyes with eye ointment )Cacri-Cube+ protect internal ear with cotton ball open sterile towel and place over preparation site to dry

S%ru&&ing Me%"anisms - mechanical brush - residual antiseptic agents - iodophor compounds )<etadine+ - hexachlorophene )pBisoBex+ - chlorhexidine )Bibiclens+ -efore S%ru&&ing Han#s an# .rms - clean under nails and trim them short - cover hair completely - put on mask - remove rings and watch S%ru&&ing Te%"ni)ues - time techni(ue is most common o long = -5 min o short = ? min - stroke techni(ue o ?5 strokes per surface fingers and thumb have 2 surfaces interwebbing of each finger ventral8 dorsal and lateral surface of hand 2 surfaces of forearm to . 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 Te%"ni)ue - nurse or tech will hand sterile towel to right hand

one end and side of towelD o dry both hands and one arm well progress up from hand to elbow other end and side of towelD o other arm don9t let towel touch non-sterile items o scrubs o surgical tables

Principles of Surgery *rin%iples of surgery - 7ollowing surgical incison3excision8 surgeon maximi es 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 etcE - ? main principles o perioperative assessment %D diseases that may complicate anesthesia e,g, 0F disease8 etcE %D diseases that may compromise surgery or healing e,g, diabetes8 A%DS8 hemophelia8 pts who have undergone radiation treatment8 etcE %D social habits that may complicate surgery e,g, smoking8 alcoholism8 cocaine use etcE elective surgery optimi e existing conditions )heart disease8 diabetes )BbA-c value+8 chronic renal failure etc,,+ non-elective surgery not always possible to optimi e existing conditions so complications are much higher )trauma8 acute infection8 obstetrics+ T"e a&ility to "eal %an affe%t t"e surgery #ire%tly/t"ese potential pro&lems nee# to &e i#entifie# early on o a%%ess to ade(uately visuali e problem to preserve important structures to allow for handling of complications )bleeding8 etcE+ )also a major problem with restorative dentistry+ if access isn9t ade(uate8 stop what you9re doing and make necessary adjustmentsG retraction good assistance light 2

7lap3%ncision o #ust be large enough for good visuali ation o $n skin use resting tension or Canger9s lines o Avoid important structures, o <road base and good blood supply o %n the mouth mucoperiosteal flaps o Avoid excess trauma )gentle tissue handling+ ;ood suction 0EST$1 S2$1 TE1S$O1 3$1ES $n%isions s"oul# &e parallel to t"ese T"ese are naturally o%%urring 4rin,les t"at are perpen#i%ular to mus%les in t"at region S%ars are more prominent if not ma#e in t"ese o 4oun# "ealing pathophysiology he breezed over this in class and I think he said not to worry about details classification primary )clean cut incision+ secondary )open wound8 extraction socket+ combined )complex wound+ status clean wound )e,g, submandibular gland8 brain+ o no bacteria )brain surgery+ clean3dirty wound )oral cavity+ o Cots of intrinsic bacteria is present o Toot" extra%tions an# #ental alveolar surgery 5 %lean6%ontaminate# 4oun#s dirty wound )colon8 tooth abscess+ o do your best to reduce bacteria )peridex etc,,+ but still exposed to intrinsic bacteria o don9t !'ACC" need sterile surgical gloves for oral cavity but we use them anyway the mouth is the dirtiest area of the whole body *rimary 7losure an# Healing - close inner-most layers of muscle3skin first with as little tension as possible o @train-trackA scaring is a result of too much tension - steps o Anestheti e patient o &horoughly irrigate wound to clean need hydrostatic forces w3 saline Hse angiocatheter with 15ccs creates enough force to debride bacteria from wound

o !emove foreign bodies <eware of glass often radiolucent o Achieve hemostasis %f not8 a hematoma may occur o Do :$& debride facial tissue excessively o 0lean up jagged edges and then close edges &y pla%ing sutures at 89: to s,in e#ge (t"is 4ill &e on t"e exam) %n layers to repair muscle and close dead space 0lose from the inside out )evert skin edges+ Approximate anatomical structures Don9t suture too tightly ;oun# eversion re)uires pla%ing sutures at 89 #egrees to t"e s,in e#ge 1ot #oing t"is 4ill %ause a s%ar to pu%,er in sin%e s%ar tissue forms at 89 #egrees to 4oun# $n mu%osa+ t"is is not as important to %onsi#er o Train tra%, s%arring is a result of sutures &eing put in areas of tension+ or are pla%e# too tig"t Se%on#ary 7losure an# Healing - 0an9t close these wounds with stitches o :eed granulation tissue first8 then closure can occur - civil war style closure @wet to dryA method o soak gau e in saline and wring out to just moist o pack multiple layers inside wound o as gau e dries8 it9ll pull bacteria and debris via capillary action out of the wound and into the gau e o gau e must be changed multiple times per day - sometimes form fistulas 7omplex ;oun#s - utili e both primary and secondary closure and healing - stitch areas where incision has clean lines and approximate each other without tension - use wet-to-dry gau e method on other areas o area will granulate and then close later on - ;et to #ry #ressings promotes mi%ro#e&riment of t"e 4oun# o *a%, gauze+ moistene# 4it" saline ('ust &arely)+ in layers into 4oun# o 7apillary a%tion of t"e %otton pulls &a%teria6#e&ris into t"e pa%,ing o *a%,ing is %"ange# a %ouple times a #ay .vulsive uns"ot to Man#i&le )slide .1+ - 7%!S&8 find and maintain airway - must debride wound of dead tissue before it can be closedE takes several days

Dog -ite to 7"il#<s Mout" )slide ?5+ - debride with saline - do an initial stitching to see if there is any missing tissue o most importantD make sure commisure is intact - repair muscle layers )any devitali ed muscle has to be removed will be a different color and won9t be bleeding+ - remove initial stitches and close from inside out *atient 4it" *en%il in Ear - first image wound and check for major vessels in area - most importantD plan for procedure A:D 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 w3 suction drains to prevent salivary contamination o stay in place until they produce less than .5cc3day *atient 4it" Horri&le S%ar on 3ip )slide ?*+ - wound has been closed improperly - scarring occurred because the wound was under tension and the dead muscle wasn9t excised - only the top layer was closed as opposed to each layer from the inside out Surgery $nvolving -one - slow speed drills o if high speeds are used8 must be rear-vented so you don9t blow air and debris into the bone o use only surgical drills - good irrigation o bone dust isn9t 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 (se of .nti&ioti%s - clean wounds o no antibiotics needed in a non-immunocompromised patient o infection is prevented by good aseptic techni(ue and skin prep - clean3dirty wounds o may re(uire antibiotics o if used8 new 0D0 guidelines say .2 hrs instead of a week - dirty wounds

o re(uire antibiotics antibiotic cover for surgery o principleD high peri-operative blood level of antibiotics during period of bacteremia o -dose %F ?5 min pre-op o . doses %F at 1-J hr intervals o I days of antibiotics are :$& indicated leads to bacterial resistance

Hemostasis - primary o occurs at time of sx o pressure8 vasoconstrictors8 ties or clips - reactionary o 1-J hrs later o after local wears off vasodilation - secondary o *--5 days after o due to infection @liver clotA Drains may be useful in large wounds with gross dead space to @suckA the tissues together and also to prevent the formation of hematoma o :eed to have good oral closure with suction drains to prevent salivary contamination

Ex%essive Healing - despite good would closure8 healing may become excessive due to o low grade irritation infection foreign body mobility )bone callus in inade(uately fixated fracture genetic 3 racial factors - "ypertrop"i% s%ars o example on slide 24 o scar hasn9t grown out of its initial boundary but it9s raised and larger than it should be - ,eloi# s%ars o example on slides I5 > Io 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 general8 nothing can be done o 2eloi#s are typi%ally on people of #ar,er s,in

Hypertrop"i% s%ar "as more volume of s%ar tissue+ &ut #oes not gro4 outsi#e area of in'ury 2eloi#s gro4 4ell outsi#e of t"e area t"ey starte# in

Inflammation and Wound Repair 7auses *at"ologi% surgeon has little control over this type of tissue damage - caused by bacteria8 malignant processes8 metabolic processes etcE Traumati% surgeon can do a lot to either favorably or unfavorably alter this type of tissue damage - =B"S%0AC o incision8 crushing o extremes of temperature o irradiation o desiccation o obstruction of arterial inflow or venous outflow - 0B'#%0AC o non-physiologic pB or tonicity o disruption of protein integrity o ischemia due to vascular constriction or thrombosis ;oun# Healing - T"e p"ases signifi%antly overlap an# ea%" p"ase is #epen#ent on t"e pre%e#ing one to o%%ur - three phasesD o %:7CA##A&$!" =BAS' o =!$C%7'!A&%F' =BAS' o #A&H!A&%$: A:D !'#$D'C%:; =BAS' o !'S&$!A&%$: $7 7H:0&%$: $nflammatory *"ase - main functionD remove #amage# tissues an# eliminate any inva#ing organisms an# #e&ris via phagocytosis - release of factors that cause migration and division of cells )proliferative phase+ *roliferative *"ase - divided into 2 major processesD 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 '0# by excreting collagen and fibronectin must have a good bed of granulation to allow the new epithelial cells to move in 4

o epit"elialization epithelial cells proliferate and migrate along '0# until continuity is reestablished mucosa is replaced on internal surfacesK skin on external surfaces o 4oun# %ontra%tion myoepithelial cells induce wound contracture to bring the wound edges closer together extremely important in reducing the si e of the wound :o restoration of blood flow prevents the next stage =roliferation of cells into wound )endothelial and fibroblasts+ o !eplace blood vessels and '0# respectively 0overing of wound with mucosa3skin o !e(uires granulation tissue to build upon <ringing of damaged tissues together to reduce si e of wound

Maturation an# 0emo#eling *"ase - collagen is remodeled and realigned along tension lines o restores tensile strength o if in bone8 fibroblast connective tissue is replaced w3 new functioning bone o &his 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 $nflammatory *"ase - begins at the moment of injury and lasts ?-I days - Damage of tissue results in some degree of hemorrhaging o #ust be stopped for healing to begin - vaso%onstri%tion o ruptured cell membranes of injured cells release t"rom&oxanes vaso%onstri%tion lasts I--5 minD 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 - %lotting %as%a#e an# vaso#ilation o Activated platelets release factors which initiate the intrinsic and extrinsic factors blood clot platelet factors inflammatory

-5

o serotonin8 bradykinin8 prostaglandins8 prostacyclins8 thromboxanes8 histamine increase cell proliferation and migration into injured area cause vasodilation and increase capillary permeability edema L entry of leukocytes leukocytes debride wound and neutrali e any foreign factors etcE o &<M is released first8 then histamine gro4t" fa%tors o =D;78 7;78 &;7 o stimulate growth of cells involved in proliferative phase

migration of *M1s o Nithin - hr of wounding o =redominant cell in wound for first ? days =hagocyti e debris and bacteria Oill bacteria by releasing oxygen free radicals8 secrete proteases that break down damaged tissue o Hndergo apoptosis and eventually are removed by macrophages %mportant that they die via apoptosis = a non=inflammatory in#u%e# #eat" #ore inflammation would only make the inflammatory phase continue and hinder the proliferative phase from occurring Ma%rop"ages o replace =#:s . 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 0ontinue to phagocyti e bacteria and damaged tissue )more effectively than =#:s+ !elease proteases which further debride damaged tissue !elease gro4t" fa%tors and %yto,ines )in the ?rd and 2th days+ that are essential for the proliferative phase to occur o .%tivate a#aptive immune system by presenting antigens to helper lymphocytes )0D2+ and activating them &his response is necessary to fully remove the insult and end the inflammatory phase Activates < cells and 0DJ cells )for extracellular and intracellular antigens respectively+

*roliferative *"ase

--

begins .-? days after wounding even before inflammatory phase ends under the influence of ;7s fibroblasts and endothelial cells enter wound and begin laying down new '0# 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 )can9t migrate in fluid+

.ngiogenesis - under the influence of ;7s fibronectin and chemokines produced by platelets and macs w3in the wound8 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 P capillaries - to migrate8 endothelial cells produce collagenases8 metalloproteinases and plasminogen activator to degrade the clot and '0# - low $. tension and lactic acidosis in wound is essential for platelet and mac production of ;7s and chemokines - when $. tension is restored8 production of these factors ceases - fibroblalsts secrete o '0# componentsD ;A;s8 glycoproteins8 collagen )type %%% later to be replaced by type % after wound matures+ o ;7s for epithelial cell proliferation and migration 7ollagen Deposition - fibroblasts begin to secret collagen by day . or ? )peaks at --? weeks+ - collagen production continues for .-2 weeks )afterwards8 destruction matches its production+ - essential for wound strength before that8 only thing holding wound closed is fibrin fibronectin clot - once maturation begins8 fibroblasts undergo apoptosis and decrease in number signals the end of the proliferative phase and granulation tissue o maturation phase can now begin Epit"elialization - ;ranulation tissue in wound permits re-epitheliali ation o S,in an# mu%osa must migrate over t"e granulation tissue - 'pithelial cells migrate and proliferate across wound under surface scab to form a new barrier - <asal keratinocytes arise from wound edges8 dermal appendages hair follicles8 sweat and sebaceous glands - &hey re(uire viable tissue upon which to migrate hence granulation tissue must fill wound first

-.

o ;ranulation tissue persists if wound gets infected back to inflammatory phase and granulation tissue is broken down whole process restarts o %f there9s inade(uate oxygenation8 granulation tissue can9t be formed wound will persist as non-healing ulcers )D%A<'&%0S+ &o allow proliferation o =rotect from outside environment o !emove foreign bodies o !emove dead3dying tissue o Approximate wound edges #igration 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 '0# and each other dissolve and the integrins which attach the cell cytoskeleton to the basement membrane release their attachment 0hemokine 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 Oeratinocytes produce collagenase8 metaloproteinases etc,, to dissolve '0# and basement membrane so they can migrate along matrix of granulation tissue Oeratinocyte 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 <asal cells then divide and differentiate in normal fashion

7ontra%tion - - wk post-wound fibroblasts begin to differentiate into myofibroblasts wound begins to contract o Bealing tissue in the wound pulls the tissue back together o !educes the amount of tissue needed in the maturation phase - %n full thickness wounds contraction peaks at I--I days post-wound can last several weeks even after epitheliali ation - Nound si e can become 25-J56 smaller reduces amt of tissue that has to be replaced during maturation phase - #yofibroblasts similar to smooth muscle cells migrate along fibronectin-fibrin fibers to wound edges o Attach via desmosomes and integrins to collagen and fibronectin of '0# o 0ontract to pull wound edges together o Dependent on &;7-beta - 0ontraction stage ends when myofibroblasts stop contracting and undergo apoptosis - <reakdown of provisional matrix decrease in hyaluronic acid L increase formation of chondroitin sulfate stops fibroblast proliferation8 migration and differentiation - S&A!& $7 #A&H!A&%$: =BAS'

-?

Maturation an# 0emo#eling - 0ollagen production and degradation are e(ual o 0an last a year or more depending on si e of wound o &ype %%% collagen is replaced by stronger type % - 0ollagen fibers are rearranged8 cross-linked and aligned along tension lines o %ncreased tensile strength )only I5-J56 or original strength+ o 7unction is not completely regained either - 'lastic fibers are not replaced flexibility of tissues is reduced o Scar tissue is much more rigid important in cosmetic sx - Fascularity )redness + decreases - Nound contraction is also undesirable in burns and curved wounds o Skin grafting has been shown to reduce wound contraction &issues returns to normalcyEby 1 months8 clinically appears as normal tissue )not histologically though+

>a%tors t"at $mpair ;oun# Healing - foreign material - necrotic tissue - ischemia like in diabetic pts - tension why we suture wounds scab are only I6 strength of original tissue >oreign Material - anything host9s immune system considers non-self - <A0&'!%AD o proliferate8 cause infection and produce proteins that destroy host tissue - :$:-<A0&'!%AC 7$!'%;: #A&'!%AC o form havens for bacteria8 sheltering them from host defenses promote infection - 7$!'%;: #A&'!%AC o often antigenic increase chronic inflammation )impair proliferative phase+ 1e%roti% Tissue - <A!!%'! o to in-growth of reparative cells o inflammatory phase needs to be prolonged to remove it - =!$&'0&'D :%0B' o for bacterial growth o hematoma formation is excellent nutrient for bacterial growth $s%"emia - D'7%:%&%$:

-2

o decreased blood supply thus decreasing delivery of $. and nutrients to wound necrosis L lessens delivery of Abs8 N<0s and antibiotics increases chance of infection 0AHS'S o tight sutures o improperly designed flaps o excessive internal and external pressure o systemic vascular problems

Tension - SH&H!'S when used to overcome tension the tissue encompassed will become strangulated and ischemic - 'A!C" !'#$FAC wound will reopen and excessive scar formation - CA&' !'#$FAC wound will spread during remodeling and epithelial tracts form around suture - 7ibrin matrix is originally only thing holding wound together )I--56 of tensile strength of tissue+ S3$DE ?@ He stopped lecturing here the ppt goes on for another 20 slides If he doesn t pick up where he left off ne!t week" I ll continue these notes and re#post them ne!t week$ Exodontia Armamentarium .rmamentarium - 7orceps . blades8 handles for pulling8 grasping or compressing o Do not crush a tooth - 'levators for lifting a depressed partK removing osseous tissue or roots o =ushing rods - #isc %nstruments - 'xtracting teeth is not about excessive force >or%eps - 'xtraction removes a tooth from alveolar bone o (pper (niversal ! 1@9+ 1@9.+ 1@9.S o Straight - )44+ o Hpper #olar I? ! L C o Hpper ?rd #olar .-5S o !oot &ip .J1 o 3o4er (niversal ! 1@1 o Cower #olar -* o Cower #olar .? )0owhorn+ o Bawk <illed Cower Anterior )Ash+ 2 Extra%tion >or%eps -ea,

-I

<eaks designed for single8 double or triple rooted teeth o ;rab at the region of the alveolar bone )junction of the crown and root+ the closer the beak adaptation to roots8 the more efficient the forceps beaks go around crown of tooth and are seated below the 0'Q 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

Extra%tion >or%eps Hinge - connects handle to beaks - transfers and concentrates force applied to handles and beaks - .meri%an type hinge in "orizontal direction - Englis" type hinge in verti%al direction Extra%tion >or%eps Han#le - serrated surface to prevent slippage - straight or curved - max forceps o palm underneath w3 beaks H= - mand forceps o palm above w3 beaks D$N: - standing in >0O1T of pt OAE0H.1D grip - standing in -.72 of pt (1DE0H.1D grip - 7orceps are fulcrums o Bold handle as far back away from hinge as possible for most force applied to beaks - 'levation comes from the shoulders8 not the wrists - (n#er"an# grip s"oul# &e use# stan#ing &e"in# t"e patient o Over"an# grip %an &e use# stan#ing in front of patient 4it" for%e %oming from s"oul#er Ash Ha4, -ille# 3o4er .nterior - a,a B.s"C - 7or mandibular incisors and premolars o Axis of beaks at 45/ o Hsed after an elevator to twist tooth out o Fertical hinge o 0oots of t"ese teet" are fin s"ape#/%annot &e rotate# -1

reat for%e %an &e exerte# o %are must &e ta,en to avoi# alveolar fra%ture

Maxillary >or%eps #1@9 - single rooted teeth )incisors and canines+ - beaks curve to meet only at tips - beaks ?5/ to handle

-IMo#ifi%ations of #1@9 >or%eps - 1@9. o parallel beaks that do not touch o for premolars o :$& for incisors )poor adaptation to roots+ 1@9.S o same as -I5A except they have serrations (se pe#o for%eps (1@9S) for pts 4"o %an<t open 4i#ely o 0i#ges prevent slippage

-I5A -I5AS

#1 (88) 6 Straig"t >or%eps - beaks similar to -I5 - touch only at tips - parallel to handle - max incisors and canines only @? 0 D 3 - max ! and C molars - palatal beak adapts to palatal root )rounded beak+ - buccal beak pointed fits into furcation between buccal roots - beaks offset from handle - Cikely to break a tooth with these o Hse these after other failed attempts

- )44+

I?C

#E19S -*

#EFG #1@1 -

removes conical rooted max .nd and ?rd molars broad smooth beaks beaks offset from handle .5-S for root tips offset molar forceps w3 narrow beaks :arrower beaks fit right into socket may also be used for narrow premolars and mandibular incisors mandibular universal forceps beaks similar to -I5 and meet only at tip beaks at 15/ angle to handle useful for single rooted teeth can be used for primary teeth8 including molars -I-

.J1

-J

#1H #EEE mandibular molars pointed tips in center for bifurcations o -ea,s engage &ot" fur%ations beaks at 15/ to handle :$& for molars w3 conical or fused roots straight handle )usually+ similar to P-* <H& beaks are shorter and do :$& have center pointed tips for molars w3 conical or fused roots usually for erupted ?rd molars

-*

... #E? (7o4"orn) - mandibular molars - . heavy pointed curved beaks to fit into bifurcations - removes tooth by s(uee ing beaks together using buccal and lingual cortical plates as fulcrums - Elevators an# for%eps in oneI o -ea,s engage fur%ations an# as you s)ueeze+ t"e toot" 4ill elevate up o On%e t"e "an#les %ome toget"er+ rotate an# remove toot" o 1ee# a &ite &lo%, or else you %an get a 'oint "ematoma o Only referen%e point for "o4 %lose &ea,s are is t"e %loseness of t"e "an#les (%annot see &ea,s) -one 7utting 0ongeurs not used to take teeth out - -lument"al cuts bone directly o have a reservoir for bone that has been scraped away - Si#e 7utting not as efficient o no reservoirK can drop bits of bone down pt9s throat - En# 7utting Ot"er Types of >or%eps - &issue 7orceps o Adson with teeth to pick up tissueK can crush

.? 3 0owhorn

<lumenthal !ongeurs

Adson o Allis clamp 7orceps used a lot in neck surgeryK not as much in oral surgery great for grabbing tissue )also crushing tissue+ #o 1OT use if you<re #oing a &iopsy &6% it 4ill %rus" tissue 0otton o college pliers

Allis 0lamp

-4

Bemostat 0lamps serrated blades so blood vessels won9t be damaged during clamping o Oelly o straight o curved

Elevators >or%es are more %ontrolle# t"an 46 for%eps o Toot" pus"ers/"elp to expan# t"e so%,et o >a%ilitate t"e use of for%eps 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 bone8 not an adjacent tooth o tip of elevator s"oul# &e oriente# to4ar#s t"e apex of t"e root to avoi# pla%ing for%es on a#'a%ent toot" &"='SD o periosteal o 7ryer )'ast-Nest8 Ninter-F+ right and left o .pexo E'e%tors right and left o 7rane *i%, Hniversal 'levator o Straig"t ?2S and ?5 0$#=$:':&S o handle designed to be held comfortably so as to apply sustained controlled force o shank connects handle to bladeK strong o blade working tipe used to transmit force to tooth a3o bone Straig"t Dental Elevators - blade has concave surface on one side used like a shoehorn o #?91 luxates erupted teeth o #?JS displace roots from sockets and luxates teeth more widely spaced o Elevates toot" against &one+ not against t"e a#'a%ent toot" Tip of elevator nee#s to &e oriente# to4ar#s apex of root .voi#s pressure on t"e a#'a%ent toot" o Diffi%ult to #o in man#i&le 1ee#s to &e %ontrolle# for%e o Elevation point is in &et4een t"e toot" an# alveolar &one

.5

HH0 -a%, .%tion Elevator - blade similar to ?5- offset to permit better access to posterior teeth )has a bend in it+ *i%, TypeK 7ryers Elevators - pennant-shaped - come in pairsD !ight and Ceft - 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 7rane *i%, Elevator - used as a lever to remove roots - place hole in tooth )purchase point+ o &hen elevate w3 the crane pick 0oot Tip .pexo Elevators - used to tease small root tips from sockets - much more delicate than 0ryer or 0rane =ick - can9t be used as a lever type or wheel and axle elevator - come in pairsD !ight and Ceft - 0oot "as to &e elevate#+ loose or mo&ile in or#er to use t"is o (se# to get &et4een root an# alveolus *otts Elevators - come in pairsD !ight and Ceft - used mainly to remove maxillary ?rd molars - long with cross-bar handles o generate a lot of force o %an fra%ture maxillary tu&erosity - used after a straight elevatorK secondary instruments *eriosteal Elevator #8 Molt - double ended - pointed endD sharp8 used in prying motion to elevate mucoperiosteum from bone )usually interdental papilla+ o 'levates the gingival cup and breaks the gingival fibers - rounded endD push stroke once under periosteum to lift it from bone o also used in a pull3scrape stroke to lift mucoperiosteum )greater risk tearing tissue+

.-

Benahan

Dean Scissors

Mis%ellaneous Surgi%al $nstruments - mouth mirror - Dean scissors )tissue cutting8 suture cutting+ - retractors o Benahan gingival )does not elevate mucoperisoteal flaps+ o Austin gingival Austin o #innesota o <lack cheek o Nieder tongue #innesota - local anesthesia cartridge syringe - bone file - curet Neider o removes growths or other materials from walls of cavities - <ard =arker blade handle - bladeD P-I used for most sx - needle holder bone file - double-ended bone file o removes bony spicules or sharp points o use# in a pull #ire%tion (not pus") o use in a slo4 motion+ not Bs%ru&&y=s%ru&C motion - double-ended spoon curet o removes debris o takes granulation tissue out - needle holder spoon curet needle holder o noteD diff from hemostat o points on needle holder are cross-hatched to engage needle in more than one direction - mallet - chisel - surgical suction Surgeon D .ssistant *osition - surgeons9s back is straight8 arms are bent o keep arms closer to body for more dexterity - assistant is offset from the front o impt so no arms are criss-crossed *OSS$-3E 3$ST O> TEST L(EST$O1S -, Ash forceps are for mandibular incisors8 premolars and canines, &hey have their beaks oriented at 45/ ., &he underhanded grip is for working behind the patient ?, Hse pedo forceps for patients who can9t open their mouths very wide

..

2, 0entric points on the I?! and C and on the -* are to engage root furcations I, P.? )0owhorn+ are forceps > elevator in one #HS& use a biteblock 1, &he way you estimate the closeness of beaks is to look at the proximity of the handles *, Allis clamp is for grabbing tissue can9t use it for tissue that will be submitted to pathology because it also crushes tissue J, "ou have more control of forces with elevators than with forceps 4, &he tip of an elevator should be placed towards the apex of the root to avoid putting pressure on adjacent teeth -5, !oot-tip elevators are designed to go between the root and alveolus and should be used when the tooth is already partially elevated --, A possible complication of using a =otts elevator is fracture of the maxillary tuberosity -., &he direction of force when using a bone file is in one direction onlyD 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 Han#le Fertical - creates more force - mandibular teeth - more ris, of root tip or %ro4n fra%ture - ;ives apical type pressure Bori ontal - S&A:D%:; %: 7!$:& $7 =A&%':& o #ax =alm Hp o #and =alm Down - S&A:D%:; <'B%:D =A&%':& o #ax =alm Down o #and =alm Hp Hinge - transfers and amplifies gripping force from handle to beaks - #anger to soft tissue -ea,s - adapt to teeth at or below 0'Q - roots can be o conical o ribbon shaped o bifurcated o trifurcated - choose beak design that best adapts si e and shape of roots - smooth or serrated

.?

The key to using forceps is to expand the bony alveolus >or%eps Movements in order of how you9d perform them

api%al -

&u%%al

palatal

rotational

tra%tion

must break the =DC taking teeth out is not about force or yanking forceps are used CAS& after elevators api%al a#aptation is %riti%al errors lead to o tooth fracture o slippage of instrument o injury to adjacent structures o increased difficulty choosing the correct instrument is key 'levation is key o ;entle luxation of teeth is all that is needed ;ive apical pressure with forceps o ;o up and into the alveolus to break the fibers o &ry to grab as apical as possible below the 0'Q to expand the alveolus

7ontrolle# >or%es #andible - 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 vestibule8 one between alveolus and tongue #axilla - pinch-grasp to feel alveolar process during extraction DDS9s <ody =osition - don9t use wrist use deltoid and forearm - stand arms will be at 45/ or less o while sitting8 arms are bent more acutely than 45/ and you lose all leverage - remember you can bend your knees and not just at the waist .2

>or%eps for t"e Extra%tion of Maxillary Teet" !oot Shape conical triangular oval 7orceps to Hse 44-0 -I5 Additional :otes 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 -st premolars can have buccal and palatal roots palatal root tends to break be careful - for crownsK does not move apically as well as -I5 - Nhen removing maxillary -st premolars 8 remember the palatal root is just as long as the buccal root - &herefore always expand palatal-buccally )more of an emphasis on the buccal movements+ - =alatal root more likely to snap off8 so go slowly - palatal beak adapts to palatal root rather than entering furcation - T"e pointe# &ea, is al4ays on t"e &u%%al si#e - @upper cowhornA - < and = furcation prongs - must use caution to avoid alveolar fracture or tissue damage good adaptation but should be avoided when - caries is extensive - large amalgam - !0& has rendered tooth brittle - beaks similar to I? - no central point to engage furcation - to remove conical rooted ?rd molars - especially for split roots bayonet shaped long slender beaks sometimes for very small premolars -

Anteriors =remolars

-I5-AS

-st L .nd #olars

trifurcated

J4 45

JJ! L C

I?! L C

'rupted ?rd #olars

trifurcated fused

.-5-S

!oot 7ragments

pedo -I5S .J1

*rimary Teet" - -I5-S o smaller version of -I5

.I

>or%eps for t"e Extra%tion of Man#i&ular Teet" Anteriors L =remolars !oot Shape !ibbon shaped L %nstrument *28 *2-:8 *2extra : )aka @AshA+ Additional :otes - vertical handle - must continually reposition fulcrum more apically - a lot of tor(ueK can twist crown right off (se a &u%%al6lingual motion+ not rotation - universal forceps - thinner beaks for incisors and root fragments - anything w3 a bifurcation (se a figure F motion - pointed beaks - won9t adapt to conical rooted molars - used if root is not bifurcated or when you have split the teeth surgically - beaks 45/ to handle - beaks broad and rounded w3o central points )for conical roots w3o furcations+

-I-8 -I--A .5? -st L .nd #olars <ifurcated .? )cowhorn+ -* -I'rupted ?rd #olars bifurcated or conical ...

.1

*rimary Teet" - -I--S Anteriors use Ash forcep )*2+ Bas a lot of tor(ue )potential to twist off crown+ Cong lever arm allows you to apply a lot of force <e careful when using these 0otating force used with ash forcep on canines and premolars Qust buccal-lingual for the mandibular incisors Hse other hand to push down on these to allow more apical grip to the cementum -I- is universal for anything .? can be used with any furcation Elevators and Elevator Techniques %sing an elevator is best learned in clinic this is &ust to give us a starting point for learning how to use these$ 7omponents of an Elevator - handle - shank - blade or tip T4o -asi% Designs - inclined plane this is like a wedge - wheel and axle T"ree -asi% .%tions - displacement )inclined plane+ o blade is inserted into =DC and pushed apically stretches bone and =DC o be careful when removing root tips near the max sinus sometimes the roots go thru the sinus floor and it9s easy to push the root %:&$ 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 $! a purchase point o &one is use# as a ful%rum ! D$ :$& HS' ADQ &''&B AS 7HC0!H#S o straight elevators are placed in =DC space o can drill a little groove into the tooth to engage the blade <H& be careful8 as this weakens the tooth o 0an break teeth doing this )use with caution+ 0ryer

.*

o =urchase point can be made with drill in the tooth o Adjacent tooth should not be used as a fulcrum o 0up shaped elevator <ack of instrument is on bone8 not tooth o Nhen using the tooth as a purchase point8 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 rotated8 transmitting force to tip o most common techni(ueD place elevator in an empty adjacent socket8 drive it into the interradicular )or interdental+ bone8 engage root tip and twist o common @wheel and axleA elevators 0ryer pop it out )bifurcated o ;ood for removing roots tooth+ )single or double+ o =laced in the adjacent socket8 drive through interradicular8 engage the other root8 and 0rane pick )w3 purchase point made w3 drill+ 0rane =ick

7ommonly (se# Elevators ?J=S an# JG - large8 shoehorn straight elevator - most commonly used - displacement ?91 - used similarly to the ?2-S and 21 <H& for smaller teeth and roots - displacement -a%, .%tion Elevator - blade similar to ?5- offset to permit better access to posterior teeth - very narrow *otts Elevators - for removing %#=A0&'D max ?rd molars - force directed toward palate - elevates tooth distally - need to engage it as apically as possible - 0otation s"oul# #ire%t #o4n an# &a%,4ar#s o Most %ommon to lose t"e toot" in t"e infratemporal fossa if for%es are not #ire%te# properly $f t"is #oes "appen+ patient put on anti&ioti%s+ an# let toot" form fi&rous %apsule to ma,e it easier to pull out later (E=? 4ee,s)

.J

1ee# to #o "emi%oronal in%ision to get un#erneat" t"e zygomati% ar%" - $f t"e toot" goes &a%,4ar#s+ t"e elevator 4ill stop it oo# retra%tion is ,ey 7rane *i%, (#J1) - wheel and axle type - most dangerous - most often used w3 a purchase point o point should be at least ?mm apical to 0'Q and ?mm deep 7ryer (?9 an# ?1 0D3) - wheel and axel type - may be used w3 or w3o purchase point - primarily use# to remove roots 4"en t"ere<s an a#'a%ent empty so%,et - @flagA or @triangleA shaped blades o ;o through the intra-radicular bone o 'ngage the root tip8 trying to get it out o !otate up and out >orm >itters (0D3) - a cross between a cryer and a potts - not often used 0ryer - very pointed tip .pexo Elevator (0D3) - 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 noteD not all root tips need to be removed o only remove ones that are associated w3 pathology $! R?-2mm+ o #ust weigh the pros and cons of removing root tips #aintenance of elevators &o be effective8 it must be sharp to engage the root surface Sharpen periodically Bistory 7irst dental chair )-J2J+ Naldo Banchett 7irst electric dentist drill )Qan .18 -J*I+ ;eorge ;reen 7alse teeth date back as far as *55 <0

.4