BASIC PRINCIPLES OF SURGERY

Basic Sequence wise Steps in Oral Surgery

1. 2. 3. 4. 5. 6. 7. 8. 9.

Pre-operative evaluation Asepsis Painless Surgery Type of Anaesthesia Gaining Surgical Access Control of Hemorrhage during Surgery Drainage and Wound debridement Closure of Wounds - Suturing Principle of control & prevention of Infection Post-operative care * Edema control * General health & nutrition.

The first step - prior to TREATMENT PLANNING AND SURGERY - is the pre-surgical evaluation of the patient This is carried out by evaluating the patients data that is * recording history, * clinical examination and * relevant investigations of the patient. Based on these, a surgical diagnosis is arrived at and depending on the fitness of the patient, the surgeon is able to decide as to whether surgery is indicated or not.

Once the surgical diagnosis has been made, the surgeon has 3 main jobs to attend to ensure a successful outcome of the procedure. These are: IF - indications HOW surgical technique WHEN timing Once these problems are studied, there are 3 possible ways the patient can be managed: By Observation With Conservative treatment and Radical management

Once it has been decided that Surgical intervention is required it has to be decided whether the surgery is to be performed in the Dental clinic under Local Anaesthesia

or
the patient requires to be admitted to the hospital for surgery under General Anaesthesia.

PREOPERATIVE ORDERS / INSTRUCTIONS

Whenever possible telephonic orders should be avoided. Written orders should be sent with the patient at his admission to the hospital. There are obvious practical and medicolegal implications for this suggestion. Typical pre-operative orders generally included are as follows :

1. Admitting diagnosis : this is a working diagnosis that may be modified or changed completely by the time of discharge. 2. Dietary orders: These should be specific for example nothing by mouth, low salt, high protein, soft diet, liquid diet etc 3. Physical restrictions: Be specific for example bed rest, ambulatory, head elevated and so on

4. Laboratory requests & special tests: if not done earlier.

5. Xray tests: if not carried out earlier or more specific xrays. 6. Medications : Antibiotics the use of appropriate antibiotics, if indicated can reduce the incidence of infection & post-operative morbidity. Corticosteroids are also useful for reduction of edema & for post-op discomfort.

7. Sedative drugs : Drugs to be given the night before surgery should be chosen with care following the drug history of the patient. Barbiturates should be avoided in the very young and the elderly. 8. Special Orders : if any. Female patients should be asked to remove all eye and other makeup before retiring the preceding night.

Basic Necessities Required For Surgery

The 2 principal requirements for surgery are: * Adequate visibility * Assistance *Adequate visibility depends on 3 things a). Adequate access in terms of mouth opening & surgically created exposure b). Adequate lighting c). Clear surgical field, free of excess blood & other fluids *A fairly trained assistant is a great help during oral surgery,and he should be familiar with the procedure & also anticipate the surgeons needs.

BASIC PRINCIPLES OF SURGERY

Basic Principles of Oral Surgery

Having said that, these principles are:
1.
2. 3. 4. 5. 6. 7.

8.

Asepsis Painless Surgery Type of Anaesthesia Gaining Surgical Access Control of Hemorrhage during Surgery Drainage and Wound debridement Closure of Wounds - Suturing Principle of control & prevention of Infection Post-operative care * Edema control * General health & nutrition.

1.

PRINCIPLE OF ASEPSIS /ASEPTIC TECHNIQUE / PREVENTION OF CROSS INFECTION

This principle of ASEPSIS ,is achieved by adhering to: A. B. C. D. E. F. Disinfection of Surgery Instrument Sterlisation Instrument disinfection Maintaining Sterility of Instrument Surgical Staff Preparation Observation of OT Routine

A. Disinfection of Surgery

Do not eat / clean utensils in the treatment areas Surgery should be such, that floors & walls are easily cleaned Have sinks & soap dispensers that are elbow or foot controlled Disinfect walls at regular intervals Scrub floors daily with phenol product lysol Scrub dust collecting on or above chair seat level

Waste disposal a) do not allow saliva or blood soaked material to accumulate on the tray. b) line the waste receptacle with plastic bag, when full seal and incinerate Disinfect all - support for hand piece, airwater syringe & suction - dental chair - control switches( chair, light, ultrasonic scaler) - light handle - cotton holder Chemical Solns for Disinfection: Glutaldehyde 2%, Sodium hypochlorite 5% diluted 1: 100 Iodophor 1:20 (iodine 1 part +70% alcohol 20 parts)

B. Sterlisation of Instruments

Before instument sterlisation, ensure that the instruments are presoaked & free of blood and debris Presence of blood, tissue, oil or other material is a BARRIER to steam & heat & may make chemicals ineffective. Therefore before instruments are sterlised they must be thoroughly scrubbed and cleaned by hand / or by ultrasonic cleaner. After instruments have been cleaned, they must be thoroughly rinsed and drained before proceeding with sterlisation.

Any means of sterlisation CHOSEN must be RELIABLE, PRACTICAL & SAFE

3 reliable methods are generally available for instrument sterlisation. * Dry Heat ( oven) * Moist Heat ( steam, autoclave) * Ethylene oxide gas

in addition to the conventional boiling water sterliser.

C. Disinfection of Instruments

Many dental instruments cannot withstand the extreme temperatures required for heat sterlisation therefore where absolute sterility is not critical, then Chemical Sterlisation can be performed. Chemicals suitable for disinfecting instruments are glutaraldehyde (cidex, sporacidin) + iodophors (betadine) + formaldehyde + chlorine compds (chlorax). Glutaraldehyde is the most commonly used.

D. Maintaining Sterility of Instruments ( Storage)

All items should be removed from the sterliser with a sterile cheatle forceps and placed in the proper storage area. Open tray racks and dental cabinets cannot maintain sterility. Unwrapped instruments should be placed on and covered by sterile towels.

Sealed bags / wraps /cassettes/ covered trays provide the necessary protection. Preferably, the articles should be kept in containers/cassettes/ racks in which they were sterlised until they are ready to be used. Sterlised articles that are stored in the disinfecting solution may be contaminated with pathogenic organism through careless handling.

E. Surgical Staff Preparation

All health care workers should be IMMUNISED, especially against Hepatitis B and Tuberculosis Wear NEAT, CLEAN, simple short sleeved CLOSED dental coat. DO NOT WEAR clinical clothing outside the clinical setting, because this habit takes contamination outside / home. NO JEWELRY to be worn on wrists or hands

Keep HAIR away from treatment areas cover including facial hair during treatment surgical procedures. WASH daily Wear MASKS because many diseases are transmitted when no clinically signs are present * To be worn during all procedures. * Tie masks before washing hands * Change them when damp as they are no more effective

Wear protective EYEGLASSES with side shields to prevent injury or infection

HAND WASHING to reduce the skin flora the mechanical act causes friction + washing removes microbes + use of 1% Iodine / chlorhexidine destroys bacteria. Keep NAILS short and clean.

Routine use of GLOVES is recommended. Wash gloves before removing, as this reduces the chances of possible contamination of operators hands.

F. Observation of OT Routine
The sterile instruments, drapes, fluids and dressings used in oral surgery are laid upon trollies.

The instruments are laid out in the sequence they are likely to be used. When pre-packed instruments are not used the required sterlised instruments must be handled with a sterile cheatle forceps.

The surgeon and the assistant should wear sterile OT gowns and gloves, and only those instruments laid out on the trolly should be handled.

A third person or circulating nurse should be present * to adjust the operating lights * position of the patient and * other tasks required of him / her.

2. PRINCIPLE OF PAINLESS SURERY

A. B. C. D.

Local Anaesthesia General Anaesthesia Sedation Techniques Day Care Surgry

It is essential that surgery should be painless WHY ?. To prevent psychological trauma + physical stress to the patient which can lead to shock delayed recovery. Surgery can be performed under LA, GA or IV Sedation. In oral surgery, it is very essential that the GA be given by a specialist in this field

A. LOCAL ANAESTHESIA LA is suitable for many surgical procedures as done in the daily OPD. It is indicated where - the patient has recently eaten & does not wish to wait and - in certain medical conditions such as Ch. bronchitis. When there is a single operative site and the procedure is likely to take less than 45 minutes.

Advantages of LA
1. 2. 3. 4.

5.
6. 7.

8.

Safe, efficient, & effective in almost all cases Inexpensive Easy to administer No monitoring equipment required in healthy patients Patient remains fully concious with intact gag reflex Outdoor procedure ( convenient for patients) No pre-operative fasting required Immediate discharge without need for recovery period

Limitations of LA

1. Unsuitable for uncooperative patients ie *small children *patients who are afraid of needles *anxious or very nervous patients 2. Only suitable for short procedures less than 45 minutes 3. Difficult to anaesthetize inflamed tissues effectively.

B.

GENERAL ANAESTHESIA

Indications
When there is acute or subacute infection, because an LA injection may cause a flare up of infection When the operation involves several quadrants of the mouth is lengthy or difficult for young children and nervous patients GA without intubation or inhalation anaesthesia should not be used for procedures lasting more than 5 minutes

Advantages of GA
1. 2.

3. 4.

5.

Excellent for nervous & uncooperative pts. Creates an excellent operating environament for the surgeon who does not have to deal with a restless & constantly moving patient Complete amnesia for the patient Permits virtually unlimited operating time Caters for all types of surgical cases.

Disadvantages & Limitations of GA

1. 2.

3. 4.

5.

Very costly Patient has to fast for at least 6 hours prior to surgery Requirement of a specialist anaesthetist Post anesthetic recovery and monitoring required until patient regains full conciousness Potentially unsafe for elderly & medically compromised patients.

C. SEDATION TECHNIQUES
In oral surgery there are 3 methods of administering sedation 1. Oral for nervous patients, oral benzodiazepenes such as diazepam 2-5 mg may be prescribed the night before & then 1 hour prior to surgery 2. Inhalation use of nitrous oxide through nasal mask is acceptable to many pts, however adequate sedation is difficult to maintain ( relative analgesia) 3. Intravenous the most efficient, effective & predictable method of sedation

Benzodiazepines(diazepam, midazolam) are the most common sedation agents used.

There are 3 important considerations when sedating a patient. 1. Close monitoring-as for GA all sedated pts should be monitored with aid of pulse oximetry & BP measurements & ECG during surgery. 2. Airway protection-sedated pts have reduced gag reflex-so airway must be protected with an oral pack behind the surgical area. 3. Flumazenil, is the for standard reversal agent benzodiazepines & must always be available in case of emergency.

D. DAY CARE SURGERY

--- this is the current concept - due to shortage of beds/indoor facilities at hospitals - non critical pts Here the pt is intubated for GA and this type of surgery is generally suitable / indicated for non critical pts -- for procedures lasting upto 45 minutes or so. The post operative care is supervised by the nursing staff and then at home.

3.

PRINCIPLE OF ADEQUATE ACCESS

A. Skin Incisions

B. Mucoperiosteal Flaps C. Bone Removal

In this principle, we will talk about

Extra-oral : - Skin incisions to expose the facial skeleton Intra-oral : - Mucoperiosteal flaps & incisions - Bone removal - methods - uses of burs - Bone cutting Instruments & their uses

INCISIONS AND FLAPS

Skin incisions were first noted by Dupuytran in l834, who was confronted with the corpse of a man who had stabbed himself with an awl, and found that the wounds were elliptical rather than round.

In 1861 K Langer, a Viennese professor of anatomy, studied incisions and punctures wounds in cadavers. His results were published as a schematic representation of the lines of greatest skin tension for all regions of the body known as Langer's lines.

In 1907, Kocher, a Swiss surgeon set forth the principle that : surgical incisions should be made along these Langer Lines of normal skin tension; in this way the skin would be closed under - least amount of tension and - resultant scar would be minimal.

Lines of skin tension as described by von Langer ( 1862 )

Anatomical Structures which Influence the surgical approach to the facial bones

The face has a rich arterial supply - the various arteries freely anastomose with each other & branches of the opposite side,especially in the lips. Thus wounds of the face bleed freely and heal rapidly.

The Nerves of the Face The Facial nerve(motor) is shown in blue and the Trigeminal (sensory) in black. 1.Temporal br.of Facial & zyomaticotemporal br.of Trigeminal. 2. & 3. Zygomatic branches 4.Buccal branch 5.Marginal mandibular br, 6.Cervical branch

Many oral and maxillofacial procedures involve incisions a few basic principles are important to remember when giving incisions.

The 1st principle is that a sharp blade of proper size should be used. A sharp blade allows incisions to be made cleanly without damage caused by repeated strokes.

The 2nd principle is that a firm, continues stroke should be used when incising. Repeated, soft strokes increase the amount of tissue damage and bleeding, thereby impair wound healing.

The 3rd principle is that the surgeon should carefully avoid cutting vital structures like nerves and blood vessels, when incising. The surgeon should incise only deeply enough to define the next layer, and any vessels or nerves encountered should be retracted away from harms way.

The 4th principle is that incisions through epithelial surfaces that the surgeon plans to reapproximate should be made with the blade held perpendicular to the epithelial layer. This angle produces wound edges that are square and therefore easier to reorient properly during suturing and less susceptible to necrosis.

The 5th principle is that the incisions in the oral cavity should be properly placed. It is desirable to incise through attached gingiva and over healthy bone, than through unattached gingiva and over unhealthy or missing bone. Properly placed incisions allow the wound margins to be sutured over intact healthy bone, thereby providing support for the healing wound.

Some additional points.

1. During extra-oral surgery, the patients head and neck should be in a straight forward unstrained posture so that the landmarks will not be distorted. 2. When planning the incision, the surgeon may elect to first draw the incision line on the skin 3. Some surgeons mark out the incision line with pen and ink while some, cross hatch the skin perpendicular to the incision line to facilitate accurate wound closure at the end of surgery.

4. When operating in vascular areas, the surgeon may modify the incision technique to reduce bleeding ie use electrosurgery instead of the scalpel. Another method to reduce bleeding, is the injection of vasoconstrictors into the area prior to incision.

5. In patients undergoing GA under halogenated agents, such as halothane or enflurane, the simultaneous use of vasoconstrictors like adrenaline may lead to cardiac arrythmias. Therefore no adrenaline is to be used without the permission of the anaesthetist.

Skin incisions
Location of some of the commonly used extra-oral incisions in
oral & maxillo-facial surgery are shown in the following diagrams.

Submandibular Incision is used for the surgery of the body and the angle of the mandible as well as the submandibular gland.

Risdons Incision is employed for the surgery of the angle and ramus area- it is a slightly curved incision. Both with the Submandibular and Risdons incisions care must be taken to avoid injury to the marginal mandibular branch of the facial nerve

Retromandibular Incision provides access to the ramus, angle and condylar region. This incision avoids the branches of the facial nerve, facial artery and vein. This approach is used for reconstruction of the TM Joint for agenesis or ankylosis.

Pre-auricular Incision is made within the skin anterior to the ear. It provides access to the TM Joint. Temporary facial nerve weakness involving the temporal or zygomatic branches may occur due to stretching of the skin flap.

Gillies Temporal approach is employed for reduction of the fractured zygoma or zygomatic arch. It is made in the hairline and when the hair regrows it is well hidden

Supra - orbital or Brow Incision is made without shaving the hair and provides access to the lateral bony orbit and frontozygomatic suture.

Infra - orbital or Lid Incision (subciliary or infra-orbital) provides an approach to the inferior orbital region and the fronto - maxillary suture.

Al Kayat - Bramley Incision is a modified preauricular approach to the TM Joint and zygomatic arch. The skin incision is question mark shaped, and the flap so developed gives excellent visibility and avoids injury to the branches of the facial nerve

Alkayat Bramley incision

Bicoronal ( Bitemporal, Bifrontal) flap provides better access to the upper face This is essentially a continuation of the pre-auricular incision which is carried superiorly across the scalp. It must remain within the hairline & is important in males. In children it should not be brought too forward, as the scar tends to drift anteriorly as the child grows.

PRINCIPLE OF ADEQUATE ACCESS

Mucosal incisions & Flaps

Many oral surgery procedures involve incisions therefore it is important to remember a few basic principles when giving incisions.

The 1st principle is that a sharp blade of proper size should be used. A sharp blade allows incisions to be made cleanly without damage caused by repeated strokes.

The 2nd principle is that a firm, continues stroke should be used when incising. Repeated, soft strokes increase the amount of tissue damage and bleeding, thereby impair wound healing.

The 3rd principle is that the surgeon should carefully avoid cutting vital structures like nerves and blood vessels, when incising. The surgeon should incise only deeply enough to define the next layer, and any vessels or nerves encountered should be retracted away from harms way.

The 4th principle is that incisions through epithelial surfaces that the surgeon plans to reapproximate should be made with the blade held perpendicular to the epithelial layer. This angle produces wound edges that are square and therefore easier to reorient properly during suturing and less susceptible to necrosis.

The 5th principle is that the incisions in the oral cavity should be properly placed. It is desirable to incise through attached gingiva and over healthy bone, than through unattached gingiva and over unhealthy or missing bone. Properly placed incisions allow the wound margins to be sutured over intact healthy bone, thereby providing support for the healing wound.

Mucosal Incisions and Flaps

Flaps
The term FLAP indicates a section of soft tissue that
1.

2.
3. 4.

5.

Is outlined by surgical incision Carries its own blood supply Allows surgical access to underlying tissues Can be replaced in the orignal position and Can be maintained in position with sutures and is expected to heal.

The flap should be a full thickness muco - periosteal flap this means that the flap includes - surface mucosa, - submucosa & the - periosteum

Importance /Sinificance of Full thickness Flap

Full thickness flaps are necessary because the periosteum is the primary tissue responsible for bone healing & - replacement of periosteum in its orignal position hastens the healing process. - also torn, split and mascerated tissue heals more slowly than a cleanly reflected, full thickness flap.

TYPES OF FLAPS
A. Full thickness muco-periosteal flap Partial thickness flap B. Envelope flap Two sided triangular flap Three sided rhomboid flap Semilunar flap C. Labial, buccal flaps Palatal, lingual flaps

MUCOSAL INCISIONS AND FLAPS

The surgical approach should be so designed, to * provide maximum access * minimum trauma. Certain rules of flap design are. 1. Avoid severing large vessels and nerves - here your knowledge of anatomy comes to help 2. Place incisions away from the surgical area to ensure the wound margins rest on sound bone. This avoids the possibility of collapse of the flap into the bony defect. 3. Design the flap so that there is adequate visibility without overexposure of bone.

4. The flap should be widest at the base than the apex to maintain proper blood supply and circulation.

[ In general,the flap base dimension ( x ) must not be

less than the height( y ) and preferably the flap should have x=2y ] That is how it will have a broad base.

When a releasing incision is used to reflect a two sided flap, incision should be designed to maximise blood supply by leaving wide base. Design on the left is correct [ B ] Design on the right is incorrect.

When button hole occurs near the free edge of the flap, blood supply to the flap tissue on the side away from the base is compromised.

5.

Avoid horizontal and severely/acutely angled vertical incisions There should not be sharp angles on the flap. If there is a change in the direction of the incision, it should be in the form of a gentle curve. Sharp or acute corners tend to slough because of poor circulation - this causes excessive scarring.

6. Maintain the integrity of the interdental papilla.

The papilla at the incision line is allowed to remain wheras the other papilla should be included in the flap.

Vertical incision placed over interdental bone - maintaing the integrity of the interdental pappila.

7. Use sharp instruments to avoid tearing the mucoperiosteum. When a carefully reflected mucoperiosteal flap is repositioned and sutured, there is less tendency for dehiscence ( flap margin separation ) and scar formation. 8. Handle the flap very delicately. - forklike retractors or toothed tweezers/ toothed tissue forceps should not be used to hold the flap. The retractor should be broad and contact the bone, so that the flap rests passively on it.

9. Do not incise close to the gingival margin/ sulcus when using a horizontal or semicircular incision. Lack of blood supply can cause a severe loss of gingival tissue. There should be about 4mm of attached gingiva around each tooth.

10. The design of the flap should be such that when the flap is retracted, it does not interfere with visibility or access. Elevate / Retract the flap away from the line of vision.

Three types of properly designed oral soft tissue flaps A. Horizontal & one single vertical incision used to create a 2 sided flap B. Horizontal & 2 vertical incisions to create a 3 sided flap C. Single horizontal incision (sulcular) used to create single sided (envelope) flap

Classification of Incisions and Flaps

1. Horizontal - This is rarely used nowadays because of the natural contours of the maxilla and mandible.

2. Semilunar ( Curved , Elliptical ) - Not used commonly, and is used on occasions when it is desirable to maintain the attached gingiva around the margin of a restoration. A disadvantage of the semilunar incision is that it often rests on the bony defect, causing a greater chance of dehiscence and scar formation. A modification that generally follows the bony contour can be used.

3. Vertical - A vertical incision sometimes called the oblique, is the most desirable to use. It may be single (triangular) or double (trapezoidal) depending on the access requirements. The advantage of the vertical incision are that it provides greater access and visibility, affords a greater view of the periodontal defects and bony fenestrations ( bony openings/window) and heals with minimum amount of scar tissue.

4 The OchsenbeinLeubke Flap - This is a combination of the semilunar and vertical incisions and includes some of the advantages of both. This flap is scalloped to follow the gingival contour. It is of advantage in cases where there is fear that elevation of the attached gingival will cause shrinkage and exposure of the margin of restorations.

5 Envelope Flap - This flap is mainly used for posterior mandibular and palatal surgery. There is greater relaxation of the flap if the incision are made aroud the necks of all the teeth in the quadrant. A relaxing incision can be added at either end of the flap if access is not adequate

Wards Incision & flap

Y incision is useful on the palate for adequate access to remove the palatal torus. 2 anterior limbs serve as releasing incisions to provide for greater access.

EXPOSURE / REFLECTION OF FLAP The mucoperiosteal flap is reflected with a Howarths periosteal elevator.

This is first inserted into the buccal/facial sulcus where the periosteum is loosely attached, the first few millimeters at the edge of the flap are gently freed along its periphery.

Thereafter, it is reflected,evenly along its whole length by a clean movement with the Howarths periosteal elevator pressed and kept firmly against the bone. Lifting movements are to be avoided as they tend to tear the tissues.

a) Start of reflection from vertical incision b) Reflection of marginal interdental gingiva by directing the periosteal elevator coronally.

As said earlier Surgical flaps are made to gain surgical access to an area or to move tissue from one place to the other. These flaps should be so designed so as to prevent the complications of flap surgery such as: a) Flap necrosis: it can be prevented by the - the base of the flap being wider than the apex - where ever possible, an axial blood supply should be included in the flap - the base of the flap should not be excessively twisted or stretched as this may compromise the blood supply of the flap.

b) Prevention of wound dehiscence:

Flap margin dehiscence (separation) can be prevented by - approximating the edges of flaps over healthy bone - by handling the edges of the flaps gently and kindly - and not placing the flap under tension.

c) Prevention of flap tearing Soft tissue tearing can be prevented by - by using sharp instruments - judicious elevation and retraction and - by relieving incisions

CUTTING OF BONE

In oral surgery the cutting of bone to provide ACCESS is done with : burs, chisels, gouges, rongeurs, bone files and microsaws. The dental surgeon should be able to master the use of each.

1. BURS AND HANDPIECE TECHNIQUE

This is the most common method employed for removal of bone. i) The various types of burs used are - surgical bone burs and - tungsten carbide these burs have fewer serrations than the conventional steel burs and are less likely to clog. ii) Burs may be - long round, - cylindrical, - tapered fissure or - rosebud shaped. Vulcanite burs are very useful in surgical extractions for uncovering the superficial aspect of an unerupted tooth and for smoothening the sockets on completion of operation.

To avoid overheating the tissues and clogging of the bur, it must be irrigated with normal saline. iii) Air turbine drill /Air rotor, should not be used for bone cutting, as the air under pressure may be forced deeper into the tissues and produce tissue emphysema, which can be very dangerous.

Burs can be used in 2 ways, either to - grind away bone or to - remove blocks of bone. Grinding is done with a rosehead /vulcanite or fissure bur with a gentle sweeping motion leaving a smooth margin. Blocks of bone are removed with fissure burs to make cuts through the cortex into the medulla around an area which can be lifted out.

2. CHISEL AND MALLET Chisel is another method of bone removal.

Bone can also be removed with a monobevel chisel, wheras it can be sectioned or cut with a bi-beveled chisel (or osteotome )

Chisels are available in various widths from 3mm or more. Tungsten carbide tip on the chisel helps to maintain its beveled cutting sharpness.
The cutting edge of the chisel should be sharp or it bruise the bone or produce small flakes, which will tempt the operator in applying excessive force and thereby increase the risk of jaw fracture.

The surgical Mallet should be evenly balanced with a nylon facing as it imparts less shock /jarring and is less noisy to the patient.

Chisels can be used either by - hand or - with a mallet & must be supported against slipping. The chisel is used to - plane or smoothen the bone, or - to cut out blocks of bone. The use of chisels is contraindicated in older patients above 40 years as the bone is brittle and the mandible may shatter in different directions.

3. Chisels and Burs

Combined use of chisels & burs can be used for either bone cutting or smoothening. A rosehead bur is used to drill holes to the required depth in the bone, at intervals of 3 to 5 mm along the planned line of the cut after this the holes are joined together with a chisel and the cut deepened until the bone splits. This method is especially useful for removing large pieces of bone.

Chisels are used to great advantage in young patients, where the natural lines of cleavage along the 'grain' of bone are present. In the mandible these grains - run vertically in the ascending ramus and - parallel to the posterior border and - horizontally in the body parallel to the occlusal surface. In the maxilla there are no true 'grains' but the plates of bone are easily cut

The direction in which the chisel cuts is determined by the angle of the beveled surface. When used to plane the bone, the beveled face is placed against the bone and driven at the required depth to shave off successive layers, just like a carpenter does. To remove blocks of bone, the beveled surface is usually turned towards the bone which is to be left

4. Rongeurs and Bone Files

RONGEUR forceps or BONE NIBBLER is the most common used instrument for * removing bone, * bony spurs, or * trimming the alveolar process Rongeurs are * available in various sizes, * shapes with either * side cutting or * side and end cutting blades.

Rongeur forceps have a spring between the handles so that when pressure is released the instrument will open. As rongeurs are delicate instruments - only small amounts of bone should be removed in multiple bites. - they should not be used to remove large amount of bone in single bite.

BONE FILES

- are used for final smoothening of bone prior to suturing.

The bone file is usually a double ended instrument with a small and large end. The teeth of the file are arranged in such a fashion that they remove bone only on a pull stroke. Pushing the bone file results in bruising and crushing the bone and should be avoided.

5. BONE GOUGES

are shaped like marrow spoons and are * useful for making a hole in the thick layer of bone overlying a cyst or other bone cavity or for * removing bone piecemeal from the buccal aspect of a tooth or root to expose it, prior to its removal.

6. MICROSAWS The microsaws are used with special handpiece provided alongwith the microelectric system. i) A wide range of saws are available and the main ones used are - sagittal, - reciprocating, & - oscillating saws ii) These saws are - slim with safe edge blade - provides maximum soft tissue protection & -permits exact & controlled cuts

Micro-electric System

Microsaws

Foot Control

7. GIGLIS WIRE SAW saw with 2 handles, introducer & guide. ii) this is used to & fro along its long axis to cut the bone & is usually used to cut the mandible in hemi mandibulectomy procedures. iii) rarely used nowadays since newer & efficient methods have been introduced.
i) This system consists of wire

RETRACTION OF TISSUES

It is the MOST IMPORTANT FUNCTION PERFORMED BY THE ASSISTANT Retraction serves 2 objectives a) provide free access to the surgeon b) serves to protect the tissues The tissue layers which are divided by incision and dissection are gently held back with instruments - there should be NO pulling or rough handling - if it felt the incision is small, it needs to be enlarged.

Therefore, in order to perform good surgery, it is essential to have a good vision and good access & for this various types of RETRACTORS, both extra-oral & intra- oral, have been designed to retract the - cheeks, - tongue and - mucoperiosteal flaps.

Some of the retractors are so designed to - retract both the cheek and mucoperiosteal flaps simultaneously eg. Austins - Others are Langenbacks, Seldins,Tongue depressor, Cats paw.

The periosteal elevator is also often used as the primary instrument to retract the soft tissue Mouth mirror is also a common instument to retract the tongue, cheek.

Remember

Damage can occur from compressing or cutting the lips or cheek against the teeth therefore avoid undue pressure at any one point, the lips, tongue and cheek are best held back and retracted by broad bladed instruments. The blade of the retractor under the mucoperiosteal flap should rest against the alveolar bone. The surgeon should pause at intervals to allow his assistant to rest and readjust his position.

CLEANING FIELD OF OPERATION

This task is also performed by the assistant to - clean the site of operation & - remove fluids and debris, otherwise, the surgeons view will be obscured or which if not removed, it may remain in the tissues to become foreign bodies Large bony fragments should be lifted with fine forceps Blood, water and fine debris from cutting of hard tissues with a bur can be removed by suction, positioned at a place of dependent drainage.

At intervals sterile water must be aspirated to prevent blood clotting in the tubing or A spare aspiration tip with a stiletto should be kept handy and available. The suction should not be used as a retractor or to explore wounds as it may damage the tissues and encourage bleeding, - you can use swabs in such situations.

4.

PRINCIPLE OF CONTROL OF HEMORRHAGE DURING SURGERY

Local measures to control bleeding Hypotensive anaesthesia etc

Significance
1.

Prevention of excess blood loss is important for maintaining patients oxygen carrying capacity Decreased visibility even high volume suction cannot keep a surgical field completely dry, especially in the well vascularised oral and maxillofacial region. To avoid formation of hematomas hematomas cause pressure on wounds decrease vascularity increases wound tension acts as culture medium leading to wound infection.

2.

3.

Methods
1. Digital pressure is very useful for capillary or venous bleeding & as an immediate measure when a large vessel has been cut. It is applied by compressing the tissues, or the offending vessel, against bone or in certain situations,such as the lip by exerting pressure between index finger and thumb. The lingual artery may be controlled by drawing the tongue so that the artery is pressed against the hyoid bone. The facial artery crosses the lower border of the mandible where digital pressure can be applied.

2. Hemostats or artery forceps when a vessel is cut during operation it must be found swiftly and secured with artery forceps. For smaller vessels after twisting 2-3 times the hemostat may be removed, but on larger vessels they must be replaced by ligatures.

3. Ligatures / Sutures.
Direct ligatures of a vessel is performed before division
Artery forceps are placed above and below where the cut is to be made and after division non resorbable ligatures/sutures are firmly tied and the hemostats removed.

4. Packing
As a temporary measure - a ribbon gauze/ swab soaked in saline may be packed into the operative or traumatic wound and held under pressure for a short time to arrest hemorrhage.

5. Another method of promoting haemostasis is by placing vaso-constrictive substances, such as adrenaline, 1:1000 in distilled water applied topically to the bleeding wound or by applying procoagulants, such as Thrombin which acts on fibrinogen to form fibrin or Collagen in powder form or as an aqueous solution on gauze.

Mechanical Agents, such as - fibrin foam, - gelatin foam, - oxidised cellulose and - oxidised regenerated foam are substances which form a water wettable meshwork and assist clot formation.

6. Electrocoagulation or Cautery
This may be applied directly to the vessels or by passing the current through the artery forceps clamping the vessel. If operating under GA, the anaesthetist should be informed that electrocoagulation is to be used - in case explosive gases are used for anaesthesia.

When using electrocautery - ensure that no part of the patient touches the mettalic OT table or any other mettalic object, so as to prevent electric burns.

7. Bone:
Capillary oozing from the bone surfaces can be controlled - by burnishing the bone with a small instrument - by application of hot packs for a few minutes - application of bone wax - arterial bleeding from a bone surface can be controlled by compressing, by forcing a wedge of bone against the vessel.

8. Ligation of External carotid arteryIn a major hemorrhage not controlled by local measures, it is at times necessary to ligate the ECA. The collateral blood supply and the anastomosis is so good in the face that it is often necessary to do this on both the sides, if it is to be effective.

A sufficient blood supply is still maintained by other large vessels supplying the area.

9. Hypotensive Anaesthesia

The use of hypotensive drugs such as hexamethonium & trimetaphen is said to have 2 great advantages: - it reduces bleeding - prevents shock Posture: gravity acting on the tilted patient results in blood pooling in the dilated veins, and this leads to decreased venous return and hypotension. Posture is also used to make the operation site ischemic. The blood pressure is said to be reduced 20 mm Hg for each 2.5 cm of vertical height above heart level, so that when the head is tilted 25* upwards, the cerebral blood pressure is like to be 16mmHg less than BP at heart level.

Hypotensive anaesthesia is mainly used in :

Neurosurgery especially in vascular tumors & aneurysms hypotension causes shinkage of the brain. Peripheral vascular disease Removal of vascular tumors Plastic surgery in operations on the nose & lacrimal apparatus Pelvic floor repair operations To reduce uncontrollable bleeding during operations.

1.

2. 3. 4.

5. 6.

5) PRINCIPLE OF DEBRIDEMENT AND DRAINAGE ( Toilet of Wounds )

Debridement Drains types

Debridement
Once the surgery / operation is completed, the wound is prepared for closure by careful cleaning to remove all the debris this debris is a major cause of post operative infection.

What does this mean it means 1 All pathological tissue, that is - necrotic tissue, - tooth / tooth follicle/ roots etc, - sinus tract are excised. 2 Bony margins are smoothened without any sharp edges. The bone cavity is saucerised where needed. 3. The flaps are trimmed of all necrotic tissue, - tooth chips, bony pieces not attached to the periosteum are removed from the wound, & - the wound thoroughly irrigated with saline.

Dead space elimination - drainage

Dead space is the area that remains devoid of tissue after closure of the wound. - It is created as a result of removal of tissue from the wound or - not suturing in multiple layers. The dead space is usually filled with hematoma.

Purpose of Drainage..?
After the operation, the wound needs to be drained to relieve the pressure, especially when they are contaminated / infected where an abscess has been incised or when immediate closure is made over dead space

Now this dead space may fill with blood or serum and later become infected.

How to avoid a dead space..

1.

2.

3.

4.

Multiple layer suturing from the depth to the surface Use of pressure dressings for post-op period up to 18 - 24 hours. Use of surgical packing of the defect-when its not possible to approximate the wound margins Use of drains along with pressure dressings Non suction/suction drains.

Drains - Types
1. Fine superficial drains: - These are made of pieces of rubber glove - Are used in the wounds of the face to allow escape of tissue exudates - usually removed after 48 hours.

2. Large superficial drains:

- Corrugated rubber drain, used in dental abscess to keep the wound edges apart to allow free flow of pus. - Used mainly for extra-oral incision and drainage & - Also for large collections of pus drained intra-orally

3. Deep drains: Tubing- with small holes cut in its wall, is used in deep infections eg - osteomyelitis of the jaws or - to drain the antrum through the nose.
The tube should be of sufficient diameter - to allow free passage of fluid & - to allow irrigation with saline or antibiotic solution.

4.Vaccum drains: - These are inserted at a point remote from the wound by means of a sharp stylet. - The stylet is then withdrawn leaving the tube drain in position. - The tube is then attached to a plastic bottle from which air has been removed.
The advantage of vacuum drain is that they are inserted away from the operative wound, and that negative pressure developed assists removal of fluid

Some important Points about Drains

1.

2.

3.

4.

5.

Drains should be inserted into the cavity at its most dependent point They must be fixed by suture or other device to prevent them from falling out, or being drawn into, the wound. They should be examined daily to ensure that they are patent and working. They are removed when the discharge has ceased, usually 3rd to 7th day Entries must be made in the patients record as to when they were put in and removed.

6. CLOSURE OF WOUNDS

Suturing - principles, and suture materials

General

Before closure of the incision, the surgeon must ensure that - bleeding has been controlled, - all swabs, instruments, teeth are accounted for.

Closure is carried out by suturing the wound for which many forms of - needle holders, - needles and - suture materials are available.

Needle Holder

There are a variety of needle holders, but one should use the one with which one feels comfortable and functional. Generally, a needle holder of 15 cms length with a locking handle is preferred. It is held with the thumb and ring finger through the rings and with the index finger along the length of the needle holder to provide stability and control.

Needles

Made of either stainless steel or carbon steel. Manufactured in two basic shapes either straight or curved . Needle points also vary - they generally come in either tapered or cutting types. The straight cutting needle is used for skin closure in areas with adequate access such as abdomen, thoracic or iliac region. In oral & maxillofacial region straight needles are used for passage of circum zygomatic or circum-mandibular wires.

The curved needle is generally used for both skin & mucous membrane surgery. They are manufactured in varying curvatures,such as 1/4, 1/2 & 5/8 circle.
The cutting needle have sharp edges that allow the needle to penetrate tough tissues. It is generally used for keratinised mucosa, or subcuticular layers where where the tissue is difficult to penetrate.

Needles also vary, in their attachments for the suture material. In the swaged needle the suture material is inserted into the hollow during manufacture & the metal is compressed around it. Swagging simplifies handling & causes less tissue damage during suturing than caused by the eyed needles. Swaged needle is not re-usable whereas the eyed needle is reusable

Suture Materials

The basic purpose of the suture is to hold the cut tissues in close approximation until the healing process provides the wound with sufficient strength to withstand the stress without mechanical support. Sutures are available in various sizes, varying from 2-0 to extremely fine 11-0 suture - the number of zeros in the number, the smaller the diameter of the strand. 5-0, 6-0 are generally used for skin closure in head & neck while 3-0 or 4-0 are used intra-orally.

Sutures materials may be broadly classified into 2 groups Absorbable and Non - absorbable
ABSORBABLE
1.

Catgut: errorneously called catgut - it is derived from sheep intestinal submucosa or bovine intestinal submucosa. Catgut is an organic material It is packed in isopropyl alcohol, as a preservative so that it can remain soft & supple & can be easily knotted.

Catgut absorbs the the alcohol, causing it to swell & increase in diameter -it is irritating to the tissues, therefore, it should be removed from the pack and rinsed in saline before use.

Chromic catgut has the same properties as plain catgut but it has increased strength, because it has been tanned with chromic salts.

2. Collagen:

It is obtained by grinding of collagen tissue from tendons of cattle. Stronger than catgut, but is absorbed earlier and therefore, is not used widely.

3. Poly-glycolic acid & poly-lactin:

These are synthetic polymers & produce very little tissue reaction. These sutures remain in the mouth for too long a time (14days) to be used as absorbable sutures Can be used as non-resorbable & removed in 5-7days. Another problem with this material is that it does not slide easily - it is recommended that this material should be wetted with saline before tying.

NON ABSORBABLE SUTURES

Silk

Most popular suture material for intra-oral use is braided & has excellent handling properties. Made from spun thread of silkworm has a smooth surface and uniform even fibre structure. This is a non-resorbable multifilament dyed material easy to see, is well tolerated by soft tissues and tongue, is easy to tie and does not come untied easily.

It is inexpensive and produces a moderate tissue reaction It has the lowest tensile strength - and in terms of knot handling ability it ranks lowest amongst all common suture materials. Therefore at least 3 ties should be used for each knot. Available in various sizes, from 1/0 to 7/0 - generally 3/0 and 4/0 are used in oral surgery.

2. Nylon:

Is the most popular skin suture material. Available in braided or mono-filament forms. Has tendency to tear through non - keratinised tissue, therefore it is not frequently used intra-orally- tissue reaction is minimal Nylon, as other synthetic polymer material posseses memory when tied the suture remembers that orignally it was a straight fibre, and knots slip and untie. Therefore,multiple knots are required to maintain the tie.

3. Cotton & Linen:

Cotton suture is made from natural fibres of cotton. Was commonly used in World War II when silk was unavailable Its strength and tissue reaction is similar to silk. Handling characteristics are inferior. Linen is somewhat stronger than cotton but otherwise it has the same characteristics. Not commonly used nowadays.

4. Dacron polyester/polypropylene/Polyethylene/
Teflon or silicon coated Dacron polyester

These are synthetic braided materials, with minimal tissue reaction. These materials exhibit great tensile strength and knot holding ability. The teflon / silicon coating eliminates the absorption of tissue fluids and thereby reduces the rate of infection.

5. Stainless steel:

Used as monofilament or braided and are the strongest and produce a secure knot Used for - after cardiothoracic or open heart surgery for suturing the rib cage or - used for scar revision in keloid forming patients. - in oral surgery they are used for tying arch bars / suspension of splints / transosseous wiring in # cases and not as a suture material Mettalic sutures undergo slow degradation by corrosion and tissue reaction can occur with increased susceptibility to infection.

PRINCIPLES OF SUTURING
1.

The needle holder should grasp the needle at approximately from the distance of the point. The needle should enter the tissues perpendicular to the surface, as the tissues may be torn if placed obliquely. The needle should be passed through the tissues following the curve of the needle. Treating a curved needle as straight will result in tearing of the tissues.

2.

3.

Principles of Suturing..contd
4. The suture should be placed at an equal distance of 2-3mm from the incision on each side at an equal depth. This principle can be modified when the tissue edges to be sutured are at different levels; then the passage of the suture closer to the edge of the lower side & farther from the edge of the higher side will tend to approximate the levels. Another method involves the passage of the suture at an equal distance from the wound margins on both the sides, but deeper into the tissues of the lower side and more superficial on the higher side.

Principles of Suturing..contd
5. If one tissue side is free and the other fixed, then the needle should be passed from the free to the fixed side. 6. If one tissue plane is is deeper than the other, the needle should be passed from the deeper to to the superficial tissues. 7. Some amount of tissue eversion is desirable in anticipation of scar contracture 8. The tissues should not be closed under tension; if tension is present the tissue layer should be undermined to relieve it.

Principles of Suturing..contd
9. The suture should be so tied that it approximates the tissues and not blanch them. 10. The knot should NOT be placed on the incision line.

11.Sutures should be placed 3-4 mm apart. Closer sutures are placed in areas in areas of underlying muscular activity eg.tongue. 12. Suturing should be so done as to prevent formation of dog ears

SUTURING METHODS
Interupted Sutures: Most commonly used is strong & successive sutures can be placed to meet individual requirements Each suture is independent of the next and the distance between sutures and incision line can be varied. The loosening of 1 suture will not produce loosening of other sutures. If the wound becomes infected, removal of a few sutures will provide satisfactory treatment. This technique is preferred in areas of tension or where a strong closure is required.

Instrument suturing technique: a) Tissue forceps are used to lift and stabilize the wound margin to allow passage of suture; b) one or two throws of the suture are made around the needle holder; c) the free end of the suture is grasped with the needle holder and passed through the loops; d) with the suture needle held in one hand and the needle holder in the other, the knot is completed and the two ends are drawn apart

A Interrupted skin sutures are placed after deep layers have been closed. B, Eversion of the skin margins should be produced with interrupted skin sutures. C, Vertical mattress suture is a useful in obtaining the proper eversion of the skin margins.

Suturing methods..contd
Continuous suture: This is a rapid method of closure. Continuous suturing provides an even distribution of tension over the entire suture line. If the tissues swell in one area, eg a hematoma, the remaining sutured area can provide a degree of slackness and help in release of pressure otherwise the sutures may have to be removed. This suturing provides a watertight closure which is important in intra-oral bone grafting.

Suturing methods..contd
Locking continuous suture: This has 2 advantages over simple continuous suture 1st, the suture aligns perpendicular to the incision.
2nd, the locking prevents continuous tightening of suture as the wound closure progresses.
Care should be taken to avoid over tightening individual locks as excessive pressure may lead to tissue necrosis.

Suturing methods..contd
Mattress sutures:

Main purpose of mattress suture is to provide more tissue eversion, either in mucosal or skin margins than occurs with interuppted sutures. It is also used in areas where wound contraction could cause dehiscence or broad scar formation.
Generally used on skin surface such as abdomen and hips. Mattress sutures may be either vertical or horizontal

Suturing methods..contd

The Vertical mattress sutures has the advantage that it runs parallel to the blood supply of the flap * does not interfere with healing * is especially designed for skin. Interuppted Horizontal mattress sutures produce broad contact of wound margins Has the disadvantage of constricting blood supply leading to necrosis and dehiscence.

Suturing methods..contd
Figure of 8: This is used over extraction sites, where it provides protection to the surgical area, as well as adaption of gingival papillae around adjacent teeth. This suture is also used to keep the pack (whitehead varnish/benzoin pack ) inside the oral wound.

Subcuticular suture

In this procedure, the needle penetrates skin ahead of the incision & exits within the wound. Needle is then inserted on the opposite side of the incision in a continuous fashion. At the end of the incision the suture is brought out at a distance from the wound. By pulling both ends of the suture, the incision is closed and the suture ends are taped to the skin

Suspension suture (sling) a type of surgical suturing used when the flap being repaired is open on the lingual or facial side; surrounds the tooth by passing between the surrounding teeth and gum tissue. The suture is adjustable and allows for adjustment of the flap for proper healing.

Knots

A knot is the intertwining of threads for the purpose of joining them. The ends of sutures are joined in this manner to ensure that they do not become undone. Types of knots : * single or half hitch * grannys knot * reef knot or square knot * triple throw knot * surgeons knot

Reef Knot

Triple Throw knot

Surgeons Knot

Suture Removal

Normally, intra-oral suture in uncomplicated cases may be removed within 5-7 days after placement. The suture is held with tissue holding forceps & lifted above the surface and cut close to the the surface where it enters the tissues.

Then when the suture is pulled out , it prevent contamination from the outer surface to the inner tissue.

7. PRINCIPLE OF CONTROL & PREVENTION OF INFECTION

The incidence of Post-op Infection can be reduced by: 1. Careful pre-op preparation 2. Adopting an aseptic technique during surgery 3. Minimising trauma during surgery and 4. Adequate drainage Post-operatively the tissues may be protected by use of dressings. The primary function of dressings is to: keep the surgical field free of infection. secondly, support the incision protect it from trauma and absorb drainage.

1.

In the mouth the surgical incisions are not dressed except where there is deficiency of mucous membrane over bone, when packs are used to cover it.
Small skin incisions are normally dressed with dry gauze, until the formation of serous exudation has stopped, when they are left uncovered. More extensive wounds & abrassions are covered with tulle gras & dry gauze strapped into position with adhesive surgical tape.

2.

3.

4. When a drain has been placed a piece of gauze is placed around it for support, & to absorb the discharge.Cotton wool is held over it by a bandage or strapping which should completely cover the dressing.
5. When it is not possible to close the wound primarily Packs are used to - protect exposed bone or - to prevent skin or mucous membrane from closing over a wound which should heal from its base by granulation. Ribbon gauze impregnated with BIPP or whitehead varnish is packed firmly but not tightly into the cavity. When inserted under GA, packs must be sutured lest they become loose & obstruct the airway.

Dressings

Pressure dressing applied with self adhesive elastic bandage

Pressure dressing applied with tape over gauze. Nowadays micropore can be used as a tape minus the gauze.

Gauze dressing placed over the drain for support & to absorb drainage and presure dressing applied over the ramus area

Antibiotic Therapy:

In oral surgery, it is impossible to obtain a sterile field and many patients present with acute or chronic inflammatory conditions such as periodontal disease, pericoronitis or contaminated fractures. There are different views on the use of antibiotic therapy, but they should not be a substitute for adherence to aseptic technique. For this reason, many oral surgeons prefer to operate under antibiotic cover, but it should not be prescribed routinely. Each case must be assessed individually & bacterial culture & ABST performed where indicated.

POST-OPERATIVE CARE

Post-op instructions Physiology of cold & Heat Control of Infection-antibiotics Control of swelling-anti-inflammatory agents corticosteroids Long term follow up significance.

1.

Post operative Instructions for cases operated under General Anaesthesia.

Post-operative instructions are given at the end of the operation for the immediate need of the patients to cover the period of recovery from the anesthesia until conciousness is regained. The following routine orders for immediate postoperative care are issued:

a) Take blood pressure& pulse every hour for 2 hours, then every hour until constant. b) Turn the patient on alternate sides every hour to prevent chest complications such as congestion and atelectasis

c) Give the patient a medium headrest and elevate the head when patient regains conciousness to prevent coughing. Deep breathing to be encouraged. d) After long operations give IV infusion of 5% or 10% dextrose in water. If considerable blood has been lost, a blood transfusion is given.

e) Analgesics for pain should be prescribed.

Morphine contraindicated in head injury & also if IMF has been used, since it may cause relaxation & allow the tongue to fall back and cause loss of pharyngeal reflexes and obstruction of airway. f) Antibiotics therapy should be continued if started preoperatively it may be given IV during or immediately postoperatively and later continued in a regular manner.

g) Since the post operative orders cancel all pre-operative orders, it is essential to renew the medications one desires to continue during the post-operative period.

g) Hydrotherapy may be prescribed in the form of cold compresses or packs to prevent traumatic swellings. A folded towel soaked in ice cold water or ice bags may be used - the important thing is to apply it immediately. h) Fat free fluids in the form of water, tea, without milk or cream, orange juice may be given post nausea. i) Good oral hygiene should be maintained in the form of hot irrigation using antiseptics.

2. Post-operative instructions care of mouth after Minor Oral Surgery under LA

INSTRUCTIONS TO PATIENTS

1. Do not rinse your mouth for at least six (6) hours after extraction/ surgery. Do not disturb the blood clots by sucking or putting fingers in the mouth. Application of ice packs in the first four hours will help to reduce swelling. 2. You may eat and drink after removal of the pack, but hot substances, alcohol and smoking should be avoided for 24 hours

3. Vigorous activity should be avoided for the

remainder of the day ie rest. 4. Be careful not to bite the numbed cheek, lip or tongue. 5. There should be very little bleeding following surgery, but if this persists then again bite firmly on a gauze pad over the wound. If bleeding continues then contact the Dental Surgeon/surgery.

6. Following surgery in the mouth there is local swelling

which reaches a maximum in 2-3 days, after which it subsides gradually. Frequent hot or lukewarm water washes (1/2 teaspoon of salt to a 200ml. glass), helps in the reduction of the swelling, and should begin on the day following surgery and continued over the next 5 days. 7. Post-operative pain should not be severe. If present it should be controlled by the analgesics prescribed for pain. When necessary the prescribed amount can be taken every four hours, but if pain persists, the patient should report to the Dental Surgeon / Surgery.

8. It is most important to keep the mouth clean following an operation, and toothbrush and toothpaste should be used freely, in addition to mouth-washes. 9. Food and non-alcoholic fluids can be taken freely according to the patient's tolerance. 10. In cases of complication or severe bleeding, treatment is available at the hospital.

Physiotherapy

Physiotherapy in the form of * radiant heat * active and passive stretching * massage, ultrasound and * muscle exercises are useful in the treatment of infections and may be of advantage in the re-establishment of function of muscles, nerves and joints.

Physiology of Cold & Heat

COLD causes vaso-constriction of the capillary vessels reduces the blood and lymphatic flow & lowers tissue metabolism locally

Cold in the form of ice packs or cold compresses is applied as soon as possible after injury or operation It should be intermittently applied to the affected part for no longer than 15 to 30 minutes of each hour. Once infection has become established, cold is contraindicated. Cold penetrates the tissues to a greater depth than heat and is an effective anodyne.

HEAT causes vasodilation dilation of the cappilaries increases the peripheral blood and lymphatic flow and accelerates tissue metabolism locally. phagocytosis is aided the body defence machanism is augmented to fight infection. Heat stimulates the lymphatic drainage & helps to localise the infection or bring about resolution. However too much heat may do harm by producing extracellular edema. Heat is applied in the form of hot water mouth baths or gargles, hot packs or poultices ( not recommended nowadays)

Post operative Rounds

All patients in the post-operative state must be evaluated completely for any evidence of complications that affect or prolong recovery. Progress notes during post-op rounds should include: 1. 2. 3. 4. 5. Level of conciousness Patency of airway Evaluation of pts cardiorespiratory system TPR & BP Skin warmth & colour

6. Fluid intake & output 7. Condition of the wound 8. Survey of the ward MOs & sisters notes 9. Attending to patients specific complaints.

Follow up Examination

Periodic follow up is * beneficial for the patient to assess his progress * extremely useful for the clinician to accurately evaluate the treatment and * draw valuable conclusions regarding diagnosis and prognosis. The follow up examination in malignant lesions in particularly important pts should be carefully examined for local & metastatic recurrence, first at very short intervals & later every 2-3 months.

Thats it thanks