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Welcome to the University of Michigan Dentistry Podcast Series promoting oral health care
worldwide.
[silence]
With the help of a simulated patient we would like to demonstrate treatment planning and
instrumentation in oral surgery. The establishment of the treatment plan depends on the diagnosis
that must be firmly established before we begin anything in the way of surgical therapy
because surgery is final. This is no remaking or redoing what we carry out for this patient
so consequently a great deal of time must be spent to make sure that the diagnosis upon
which you base your treatment plan is one that is tenable and sound. Patients will come
to oral surgery clinic with their records as we have seen before. The records will include
an extraction slip; a recommendation for the removal of teeth or other surgical procedures.
But in this situation this is a communications document it relays one man's impression to
another. And you must be sure that you do not follow this as a dictate but only use
it as a guide to the area that requires your diagnosis and your treatment plan for which
you are responsible. There is an opportunity for misunderstanding in the relay of this
information and request. There can be human errors in marking the wrong teeth. There can
be other misunderstandings about overall treatment plans that deal with many of the variations
in restoration and prosthetic dentistry. So one must be sure that is used correctly and
whenever there is any question about the diagnosis or which tooth is to be removed, it is well
for you to thoroughly go over your own findings and then call either the man who referred
the patient and get any misunderstanding resolved without troubling the patient or if there
is need for consultation from another clinical department within the school make sure you
call the representative from that department so that can be evaluated and you can approach
without anything that is equivocal in the nature of the diagnosis. In the treatment
planning the radiographs for the given surgical procedure are of importance. The radiographs
give us details as to the morphology of the roots, the density of the adjacent bone, the
proximity of regional vulnerable anatomy and pathology will dictate the pathways to which
teeth can be removed and will therefore provide us with information for technical efficiency.
For the premedication of the patient we would start with possibilities of additional adjunct
to patient control. After all, it is the rapport that we establish with our patient that is
essential. So, informed consent, assurance on their part that they are aware of what's
to be done for them and then an area of confidence that you establish with them is most important.
You must be able to control your patient before you can carry out any work for them. These
aspects of control begin with a psychological establishment of rapport with your patient
and they may in certain instances require additional adjunct to patient control.
The IV solution used in the oral surgery clinic consists of lactated ringers with 5% dextrose.
The tubing is initially primed to eliminate any air bubbles in the system. The IV tray
that we will have in each of the operatory will contain a tourniquet, an omboard as well
as the tape to fix the angiocath or butterfly. The, we have sponges to cleanse the site of
the venopuncture and we will have the butterfly 23-gauge, 23 butterfly as well as a 22-gauge
angiocath to perform the venopuncture. Whenever conscious sedation is utilized in the clinic
a pulse oximeter is absolutely necessary to monitor the oxygen saturation of the patient
throughout the entire procedure. Another anxiety service that we have for the patients is an
analgesic machine. Demonstrated here is a wall-mounted unit. This wall-mounted unit
will consist of a mouth piece, the tubing to deliver the gases, a re-breathing bag as
The supply of oxygen nitrous oxide is for this machine is delivered from a central point.
Rooms without a wall mount unit can be supplied with a portable unit. The portable unit is
the same unit as the wall mount. It will have a nose piece, tubing, the re-breathing bag
as well as an oxygen-nitrogen monitor. The units will have their own gases, oxygen as
well as the nitrous oxide and these gauges demonstrate in here, demonstrate the amount
of oxygen as well as nitrous oxide in the reserve, in reserve in these tanks. These
gauges must register above zero.
We will find again one who is prepared we hope now psychologically as well as physically
for what we hope to carry out. Anesthesia will be administered utilizing local anesthesia.
We have again scrubbed so our gloved hands are clean and we would be able to proceed
with the local administration of the local anesthetic. In the administration of local
anesthesia and in the work that is carried out in surgery it is well to segment the areas
of procedure for example if we were going to work in the mandibular arch and in the
maxillary arch on this patient we obviously could not work in both of those areas simultaneously.
And therefore we would administer the local anesthesia to the mandibular arch and then
carry out that work and as we were completing that work then we would proceed with the administration
of the anesthesia in the maxillary arch and then go back and finish the work in the lower
and then by the time we're ready to work in the maxillary arch the anesthesia is at its
appropriate level. So it's not only for keeping the local anesthetic just ahead of your work
for maximum effectiveness but also the aspect of the volumes of local anesthesia that are
administered. We don't want to administer a large volume of multiple injections all
within a short space of time because when we do this we increase the potential for toxic
reactions to local anesthesia. The instruments for a specific procedure are built upon a
basic set and they should be thought of from the beginning of the first incision to the
placement of the last suture.
The instruments required to complete the surgical procedures are listed on this chart that you
are now observing. This chart will be posted on the wall above the instrument cabinet in
each of the operatories. The instruments in the top compartment are individually wrapped
because they have been sterilized. They will be removed from this cabinet with a sterile
but clean surgical glove. The left bank of drawers will have a writing platform where
you will find a surgical manual to assist in the clinic. There will be a blood pressure
monitor.
There will be extra sterile towels that can be utilized in the surgical procedure as necessary
and post-operative instructions.
A transfer forcep is provided to transfer the sterile sponges to the bracket tray.
It is also used to transfer the anesthetic solution, the needle, as well as the Q-tips.
The surgical blades as well as the sutures and the viascription may be removed with a
sterile but clean glove because these have been individually packeted and the transfer
forcep is then repositioned in the container provided in the face of cabinet.
The bracket tray should be arranged in an orderly fashion and we will look at that for
the moment. It will have the instruments arranged in the sequence that we plan to utilize them
from beginning of the procedure to the end.
The handpiece will be draped with a sterile sleeve.
The blood products will be collected in a disposable container beneath the mayor stand.
In working on the mandibular arch we would like the patient so positioned that she is
comfortable that the head and the cervical spinal column is generally in a comfortable
position. When her mouth is open, the mandibular-occlusal plane should be horizontal, parallel with
the floor. Just open widely if you will, please. Actually in this instance it's not quite horizontal
as you can see she's a little too far back and so we would elevate the chair slightly
bringing her up a little bit and then she should be positioned also so that when this
field, when her mouth is open and we're working on this field…
The level of the operating field should be so placed that your hand level is lower than
your elbow. In that manner, you can work directly and you won't be at an awkward angle. So in
the mandibular arch then, the patient's mouth open, the mandibular-occlusal plane should
be parallel to the floor. A little later on, we will demonstrate that in the maxillary
arch, the occlusal plane of the maxillary teeth should be perpendicular to the floor.
And the patient then will be tipped way back. Let us attempt to demonstrate here a few of
the positions of the operator and the assistant as we go through the access to the several
areas of the mouth.
Our surgical assistant Ms. Itzo will begin lubrication of the commissures of the mouth.
In surgery often we retract the corners of the mouth and cheek rather excessively and
unless the mouth is well lubricated the lips may crack and so for the patient's comfort
we begin in this manner. We will attempt to show the several positions of patient, operator,
and assistant as we go into the several areas of the oral cavity for surgical procedure.
Ms. Itzo has the suction here and this will be helpful in clearing the field as we approach
the area for access. We've had the patient positioned so when she opens the mandibular
occlusal plane is horizontal and parallel with the floor. The exposure of the field
comes by way of retraction of the cheek. Patients will tend to want to cooperate with you and
when you retract in the direction in this instance toward the patient's left her natural
tendency is to comply and turn her head toward the direction of the retraction. You should
explain to your patient that this is not what you want them to do but rather to turn slightly
toward you and to retain that position even though we are pulling their cheek in that
direction. This will keep your field exposed so that you're able to operate.
After the anesthesia has been administered, we will frequently use a curette to test for
soft tissue anesthesia utilizing it in the free-gingival margin area and applying it
to test for the lack of any sensation. You can prepare the patient that they will feel
some pressure and perhaps hear some noise as instruments are applied but that they will
not feel anything that is sharp. We intentionally avoid the terms of pain and hurt as we again
are trying to retain elements of rapport when operating on the patient. You always prepare
your patient for everything they'll experience. Do not surprise them as you proceed and as
you start to apply pressures. Here we are using the 15 blade in the manner that is shown
going in to the gingival sulcus and we would divide the epithelial attachment to keep the
blade in contact with the tooth as we go into the embrasure. That would be followed by the
use of the periosteal elevator. The small end of the periosteal elevator and utilizing
a rest finger on the teeth we would then go in to the base of the papilla. Go down to
alveolar crest of bone and reflect the flap out. If we then wish to mobilize teeth, we
would use a dental elevator and this 77-R elevator is an appropriate one that would
then go into the area of access from which the flap had been reflected so that we would
not bruise any of the tissues. We never use this instrument unless the free-gingival margin
flap is retracted away because the bone must be used as the fulcrum and not the gingival
tissue. After we have obtained preliminary mobilization of the tooth in question we would
then apply the forceps. The forceps are designed so that the beaks of the forcep should be
in the same long axis of the roots of the teeth. Consequently the lower forcep has a
more or less right angle position to the beaks as compared with the handles whereas the maxillary
forcep tends to have a more linear relationship between beaks and handles of the forceps.
The forceps are grasped well down on the handles, and they are grasped in this manner so that
you don't have anything that is awkward in the neuromuscular relationship of manipulation
of the tooth. If you engage the handles in a backward or some awkward position of this
nature you will not have sufficient control over the manipulation of the tooth. Teeth
tend to be resistant to mobilization and as you start the mobilization it requires a good
deal of force. As the tooth begins to luxate you use less and less force until again at
the time that the tooth is ready to deliver, it is just literally lifted out of the socket
after you have it sufficiently mobilized.
In the traction that's required to break down the periodontal membrane and expand the alveolus
to lift the tooth from the socket, it is necessary to support the jaw so that the mandible is
secure while the tooth is being mobilized from it. In that effort then one can use the
opposite hand, placing the thumb on the occlusal surfaces of the teeth on the opposite side,
a finger at the inferior border of the mandible and then the beaks can be applied to the tooth
in question. We're quite careful in the application of the beak watching where it goes so we don't
engage gingival tissue so we only engage the tooth. We'll slide the lingual beak down carefully
and watch it go into the sulcus and then we would close the forceps slightly and slide
the beaks down in the buccal.
Then we would support the mandible securely, inform the patient that they will feel a good
deal of pressure for the moment and then we would begin the luxation of the tooth with
the forceps. In conical shaped roots, we can add to the buccal-lingual motion an element
of torsion in any single rooted tooth it tends to have a conical root configuration.
Another method for the support of the mandible so the patient can use their own muscles of
mastication to support the jaw while we're using forces of elevators and forceps is the
use of a rubber bite block shown here. The patient is instructed of its use, they are
shown the bite block. They're told that this is to be put on the other side of their mouth.
They are asked to close on it in order to support the jaw so we'll do that at the moment.
We'll secure it well. Ask the patient to close and we can expose the field again and then
as we're utilizing an elevator say in the back part of the mouth, if we were going to
place this elevator in this matter and rotate we'd tell the patient to bite down firmly
at that particular time when we're exerting force when using an elevator that tends to
have a sharp blade.
Another method to safe-guard the patient against the potential abuse and accident of these
instruments is to place your finger on the lingual aspect opposite where you'll be placing
this elevator force. Then in the event of an inadvertent slip up in this matter it is
obvious that you're gonna stop instead of burying that instrument in the soft tissues
of tongue or floor of the mouth. These then are methods in which the mandible can be supported.
In connection with the use of the rubber bite block, it's well to keep in mind that intermittently
the patient can bite down and by using the elevators of the mandible firmly support the
jaw so that you move the tooth and not the jaw. However, this position if maintained
for a protracted period of time is uncomfortable, muscles will go into spasms so that intermittently
the prop should be removed, the patient allowed to close and whenever we ask the patient to
close we will always if we have an operative field open, a socket that is open and a flap
that is reflected back. We will always take a sponge and ask the patient to close down
if you will while we are either changing our instruments, selecting a new instrument or
in any way involved in the delay from the actual work in that field.
The position of the operator in general should be as forward and direct as possible. We utilize
direct vision in all operative fields and very rarely do we use any reflected image
in oral surgery. In the mandible there are some instances where in the anterior midline
procedures, the position of the operator can be from the rear. In that instance the patient
is lowered, the operator gets behind the patient, the chair is tipped back slightly, so that
when she opens the operator has once again the advantage of direct vision of this particular
field and can manipulate again with forceps or other instruments quite readily from this
posture.
As the assistant retracts the cheek, it is well to keep in mind that the position of
the head must be maintained and light must be established into the field so that often
the suction tip can be used to retract the lower lip downward to allow more light to
gain access to the field while the mirror is being used to retract the cheek. We would
reverse this situation on the right side, the retraction would be made in this manner.
The patient would turn away from the operator. The assistant would reach around behind and
take the mirror with her right hand and in this manner we could again work directly on
this side.
So we have demonstrated the access around the circumference of the mandibular arch and
now we'll turn our attention to the maxillary arch and we will change the position of the
patient so that we can obtain access to the maxillary field.
The patient has been repositioned for the approach to the maxillary arch. We will note
that she has been tipped way back so that when her mouth is open, the maxillary occlusal
plane is perpendicular to the floor. Then with the operator positioned laterally he's
able to bend directly forward and have full direct vision of the maxillary field. In retracting
the cheek for the maxillary field one will remember that the buccinator muscle is put
on the stretch when the mouth is open. So if the patient is open to a maximum range
the cheek is tight and you cannot retract it well. So for retraction in the maxillary
arch we'll want the patient's jaws partially closed together. That will keep the buccinator
somewhat relaxed and then we can retract laterally. Just like that. And we'll also be able to
retract in this manner and uh, if the patient again is instructed to keep toward the operator
and not to follow the force of the traction, of the retractors of the cheek then we'll
keep the field in view. In the approach to this region, we could apply instruments in
the same manner that we did in the mandibular arch, the curette applied to the buccal and
to the palatial gingival margins. We could apply all of the other instruments in the
same manner that we demonstrated in the mandibular arch and in the case of forceps we will note
that the upper forcep as the beaks again in line in this number 150 forcep in line with
the handles. The handles are grasped with the handles well-placed downward in the palm
and the beaks are slide around the neck of the tooth in this manner. Now as we apply
forces to the maxilla it is our hope to control the position of the head so that when the
forces are applied to the tooth, the tooth is moved and the head is not moved. Therefore
if you will place your finger on the buccal surface and your thumb on the palatial surface
you will be able to so engage the alveolar process that you can support it and you'll
have an index of how much pressure you are using as you attempt to luxate the tooth.
The tooth is never pulled or there is never any traction exerted until complete mobility
has been obtained. As a matter of fact, when the first pressures are used there's actually
a force toward the apex rather than any traction exerted on the tooth. Once then mobilized
again, the same sequence of muscle groups beginning with the forearm and winding up
with the wrist so that the final delivery of the tooth is a gentle one and not one that
is sudden or violent.
The approach to the opposite side is achieved in the same manner asking the patient again
to turn away from you, you maintain your direct vision and position. The approach is made
with the retraction of the cheek with the mouth partially closed again and we have an
approach that is feasible to the maxilla on the right side. So it is these positions that
will allow us to gain access to the maxillary arch. In the palatal region occasionally for
impacted teeth and other pathology in the palate hyper-extension and maximum opening
would be required. These then are the several approaches to the different quadrants of the
oral cavity and we mentioned when we were speaking about anesthesia that we would divide
up the work. For example if we going to prepare a mouth with multiple extractions we would
confine the work to one side of the mouth at a time. This means that the patients would
still have the opposite side of the mouth for mastication and if there were problems
with hemostasis why the patient would be able to control post-operative bleeding episodes
because only one side of their mouth would be involved. As we were demonstrating earlier,
if for any reason you leave the field you always place a sponge over the operative field
and have the patient close on it.
Throughout the procedure for the division of tissue removal of bone and teeth we would
use suction to keep the field clear. However, in the closures we would use intermittent
pressure with sponges in order to avoid that. In the alveolar plasty we would use with the
rongeur forceps that are used to contour that and the filing of the bone done with a double-ended
bone file as we are finally contouring the bone beneath the flaps and the soft tissue
flaps are trimmed so that there are no excesses and the pathology is removed, trimmed with
scissors, and then the sutures are placed, the sutures applied in a manner which you've
been previously instructed utilizing 3-0 silk on this particular suture needle. The needle
is grasped just with the tips of the needle holder and that gives control to the needle
point as it penetrates the tissue in this curve cutting needle. When the final sutures
have been placed and incidentally before you close, before you insert any sutures an instructor's
check is required. This is necessary to make sure that the contouring of the ridge is satisfactory.
So when that has been obtained you'll proceed with the closure and the insertion of the
last sutures, a pack is placed over the operative field, a moistened pack so that it does not
adhere to the mucus membranes.
Throughout the procedure the bracket tray should be maintained in as orderly a sequence
as is possible. It is this neatness in arranging of instruments that is part of the assistant's
role.
Following the procedure the doctor's notes will document the diagnosis, the anesthesia,
the procedure, complication if any, post-operative instructions, any medication prescribed to
the patient, the disposition on the patient on discharge, and revisit as needed.
This must require the signature of the instructor and will be dated. All patients leaving the
oral surgery clinic will have in their possession a post-operative instruction sheet. This instruction
sheet must be reinforced orally by the students.
A suggested dietary menu is also provided with this instruction sheet.
And extra sponges to assist with hemostasis are also provided.
The departmental code as well as the surgical procedure code are posted on the walls of
the clinic. Each patient will present to the oral surgery clinic with a bill-in sheet,
the bill-in sheet will include 'C' for completion, the procedure code will be prefixed with a
'U' to designate an undergraduate student. It will also list the tooth number and the
appropriate fee. The student must provide his, provide the letters, this sheet must
have the signature of the instructor assigned to the case.
With this we hope we have oriented you as to the approach to the patient and the treatment
planning and the application of instruments in the oral surgery clinic.
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