Oral Surgery & Local Anesthesia II

 Lecture 1:
 Armamentarium:
- The basic oral surgery is the first topic that must be
discussed to a dental student before going into the
world of oral surgery.
 Oral surgery: surgical procedures related
only to the oral cavity
 Oral & Maxillofacial surgery: surgical
procedures related to the oral cavity, face, and
neck
- Armamentarium of oral surgery definition:
 Defined as the main instruments used to
preform minor oral surgery
- The word “Surgery”:
 Is a planned trauma to the body
 OR defined as creation of wound that is
done according to specific principles
 The most important thing in surgery is the
closure or “Healing” of wound. This means
that we want to stick to specific principles
during creation of surgical wound or trauma to
optimize the healing result
 The “ideal healing” is no scar formation but
unfortunately it is not possible to have zero
scar after surgical intervention. So, in order to
minimize the scar formation, we must optimize
the healing of the wound plus minimize the
 post-surgery complications which is done by
sticking to the primary principles of surgery
- Instruments used in oral surgery:

1) Soft Tissue Incising Instrument:

 Blade holder also termed as “Scalpel”

 Used to hold the scalpel blades
 Used to perform an incision in the soft tissue to get
an access to the underlying tissue
 Most commonly used blade holder is the number 3
scalpel
 2) Scalpel Blades:

 Are the blades that are placed on the scalpel

 The blades are the ones to contact the soft tissue and
create a cut
 Can be called “surgical blades”
 Scalpel blades have different designs and each one
has a number
 Most commonly used blade is number 15
 Blade 15 is the “little sister” of blade 10. The
difference between them is the size and their use
 15 is the most common one because it is used to
create an incision and cut the oral mucosa. The oral
mucosa is a delicate tissue
 10 is used to cut the skin. The skin is tougher than
the oral mucosa, therefore blade 10 is larger and
sharper
 Blade number 11 is less used and it has a pointed
end
 Blade 11 is used for abscess drainage using the
pointed tip to stab the abscess
 Blade 12 is used mostly by periodontists which is
sickle shaped and used mostly for gingival
procedures. However, it could be used for the same
procedure of number 15.

 Safe blade handling:

o Holding the scalpel is the same as holding the

handpiece “pen grasp”
o Loading of the blade is done by opening the end of
the blade cover and pulling the blade out using the
needle holder
o After that, load the blade into the scalpel by sliding
it into its slot until we hear a “click” sound. The
click sound indicates that the blade is now stable on
the scalpel
o Removal of blade from the scalpel is also done using
the needle holder by grabbing the end of the blade
and pulling it out of the scalpel.
o Throw the blade into the sharp box
o The main principle of blades is the more we use it,
the duller it becomes which means less cutting
efficiency. The more the strokes of the blade, the
more the dull it become (less sharp)
o Never hold the blade using your hands
o Using needle holder to grab the blade prevents any
self-injury

3) Molt Periosteal Elevator:

 After incision into the soft tissue, we will see the
periosteum. Sometimes we cut both the mucosa and
the periosteum
 Periosteum is a tough layer covering the bone;
therefore, we have to elevate it and reflect it away in
order to do full thickness flap
 A flap is a piece of soft tissue outline by surgical
incisions used to get access to underlying tissue. A
flap has its own blood supply and hence there are
important flap incision principles that must be
followed to maintain blood flow to the flap or else
necrosis can occur.
 Flaps should be returned to its own original position
 In order to expose the underlying bone after creating
a flap (mucosa and periosteum), we should use an
instrument to elevate and reflect the periosteum and
mucosa away and it is called the number 9 molt
periosteal elevator
 Periosteal elevator has two ends:
A) A small and sharp end
B) A large and blunt end
 Small and sharp end:
o is used to elevate the tight parts such as
the interdental papilla and gingival
margin. These parts must be elevated
slowly to avoid trauma. The elevation and
reflection should be done in non-invasive
and planned procedure because any
aggressive motion could lead to tearing of
 mucosa (because the mucosa is a soft and
delicate tissue).

o The motion of small and sharp end is

called the prying motion which is
inserting the small end below the
interdental papilla and gingival sulcus and
then start the twisting or wedging motion
towards the bone. This prying motion will
elevate the interdental papilla and
gingival sulcus away from bone

 After elevating and reflecting the gingival

sulcus and interdental papilla, we want to reach
deeper and elevate the attached gingiva which
is done by using the larger end of the periosteal
elevator

 Large and blunt end:

o Is used after the small and sharp end has
elevated the interdental papilla and
gingival sulcus in order to elevate the
attached gingiva and expose the bone.
o Using the large and end blunt, two strokes
will be done:
 1) Push stroke: after elevating the interdental
papilla and gingival sulcus, we use the large end
and push towards the bone. This push stroke
will make the large end reach between the
mucosa + periosteum and the bone
2) Pull stroke: after the push stroke, we then do the
pull stroke which is to pull the large end away
from bone. The pull stroke is done to reach the
full thickness flaps

 Flaps are two types:

1) Full thickness flaps
2) Partial thickness flaps

 The large and blunt part of the periosteal elevator

has a concave side and a convex side. We always do
the push stroke using the convex part facing the
mucosa and periosteum
 4) Retractors:
 The main necessity in oral surgery procedures are
accessibility and visibility. Visibility is obtained by
making the area blood free by having proper
suctioning, proper hemostasis, and profound
knowledge of anatomy. Accessibility of my
instruments is obtained by using retractors
 One of the most important instruments in oral
surgery are retractors which provide accessibility.

 Retractors come in different shapes and functions:

1) Austin retractor:

 Also called “Right Angle Retractor”. Named

according to the university the created this
retractor
 Used mostly in posterior region of the mouth
2) Minnesota retractor:

 Also known as “Offset retractor” because it

doesn’t have a specific angle. Named
according to the university that created this
retractor
 Mostly used in anterior regions
3) Weider Tongue retractor:

 The tongue retractor has right angle and a

heart shape that is serrated (irregularities)
which provides proper catch and control to
the tongue and hence avoid slipping of the
tongue.
 As the name says, it is used to retract the
tongue
4) Seldin retractor:

 Similar in shape to the periosteal elevator

 It is an instrument that has two ends that are
wide and blunt
 Cannot be used to reflect flap, but is used for
retraction of loose tissues.

 Note: Retraction should be light and not

invasive or else ulcers, swelling, or trauma can
occur to the site of pressure especially to the
corner of the mouth
5) Soft Tissue Handling:

 After opening up a flap, we have to handle

the soft tissue
 Soft tissue forceps is called Adson soft tissue
forceps

 Adson Forceps

 Soft tissue forceps are:

 A)Toothed forceps: creates a better catch
to the soft tissue, but we must be careful
to not over-pinch the tissue with the
toothed forceps otherwise perforation of
tissue will occur
B) Non-toothed forceps
 A longer type of forceps that is used for
posterior areas called Stillies Forceps

 Stillies Forceps
 Cotton plier or college plier that looks like a
tweezer which has a lock on it. It is used to
pull out any sharp and foreign objects

 Cotton plier

 Allis tissue forceps which looks like a

needle holder, it has a “fork-like” end. Allis
tissue forceps is used to excise soft tissues.
Example: we use allis tissue forceps to
excise a biopsy of cyst.
  Allis Tissue
Forceps

 Allis tissue forceps shouldn’t be used to

handle tissue because the end of this forceps
will crush and damage the soft tissue.
6) Bleeding control:
 For bleeding control, we use an instrument
called “Hemostat” or “Artery Forceps” or
“Mosquito”

 Hemostat or
Artery forceps
or Mosquito

 It has a locking handle and looks like a

scissor
 Called mosquito because the active part
(end) of the tip is long, slender, and high
focus
  Two designs:
A) Straight end
B) Curved end: for better manipulation and
control
7) Needle Holder:

 The difference between needle holder and

hemostat:
1) The end of the needle holder is short and
wider, while the end of hemostat is long and
slender
2) The inside of a hemostat has parallel
grooves, while the needle holder has
irregular grooves and cross-hatching

 If we take a cross-section of the suture needle,

we will find two designs
1) Non-cutting needles:
o Has a round cross-section
 2) Cutting needles
o Has a triangular cross-section
o The triangular part is also two parts:
A) Cutting
B) Reverse cut: which is a reverse
triangle which means the tip of the
triangle is facing downwards.
 The reverse cutting needle is important and
used in suturing the mucoperiosteum. It will be
very hard to use non-cutting or cutting needle
to suture the mucoperiosteum (especially the
periosteum because it’s a tough tissue). Hence,
we use reverse cutting needle to suture the
mucoperiosteum
- The most commonly used
suture size according to books
is 3.0
- By practice, 3.0 and 4.0 are
most commonly used
- Silk is the most common type
of suture used
 Therefore, we say the most
common type used is 3.0
black silk suture with
reverse cutting needle
- Size of needle could be ½
circle or 3/8 circle
 Lecture 2:
- Armamentarium continued:
8) Bone removal instruments:

 Bone removal is a very important part in oral

surgery especially because we are dealing with
the alveolar bone

1) Rongeur:
  Similar shape to dental forceps but
the Rongeur has a spring in the
middle to re-open it automatically
 The Rongeur has cutting blades
 Two types of rongeur:
A) Side cutting: has cutting blades
on its sides only
B) End-and-side cutting: has
cutting blades on both end and
side
 The advantage of rongeur is that it
allows us to cut large pieces of
bone in a shorter time span
 Must be used in multiple small
bite and never do large bites
otherwise unplanned bone
removal (traumatic) will occur to
the bone
2) Chisel & Mallet:
  Requires extra-caution when used
 Chisel:
A) Uni-bevel blade
B) Bi-bevel blade
 Chisel is more dangerous than
rongeur, because the chisel will be
placed on the bone, and using the
mallet to hit the chisel and remove
bone. Therefore, it must be used
with more caution
 Chisel & Mallet mostly was seen
in sinus lifting surgeries in the past
(indirect lifting). It is no longer
used to due invention of advanced
surgical instruments
3) Surgical drill:

 Most commonly used because of

the easy manipulation
 Electrical driven is preferred than
air driven
 Some handpieces made special for
bone have inward air driven
system (away from the site of
surgery). The purpose is to avoid
air on bone which can cause tissue
emphysema (air accumulation in
deep fascia spaces)
 Copious irrigation and cooling is a
must to avoid necrosis. Bone is
very sensitive to heat generation
(normally, the bone temperature is
47 Celsius), hence without
copious irrigation, necrosis will
occur to the bone
 Recently, the electrical surgical
drills nowadays (especially in
implant surgeries) have high and
fixed torque to achieve the desired
result
4) Bone file:

 Used for smoothening of sharp bone

edges
 Closing a flap on sharp bone edges will
cause bone spicules or irregularities
which can lead to an osteoplasty
surgery later on, hence smoothening of
sharp bone edges using bone files is a
necessity
 Motion of bone file is pull stroke only
to remove edges. Never do push and
pull stroke, because it causes polishing
 and burnishing instead of removing
edges
9) Periapical curette:

 Looks similar to spoon excavator but

larger in size
 Has two ends
 Periapical curette is used for curettage of
any soft tissue pathologies inside bone
such as abscess, granuloma, cysts,
 Used to remove any soft tissue
pathologies inside bone

10) Soft tissue cutting:

  Iris scissor is the scissor used for cutting
soft tissue

11) Mouth prop and gag:

 Bite blocks are rubber materials that has
two ends which are placed on the occlusal
surfaces of upper and lower teeth
 Used to keep patients mouth open during
procedure
 Mouth prop is the same design as the bite
block but has a lock and mostly used in
surgeries under general anesthesia
 The problem with mouth prop is that it
can affect the TMJ and masticatory
muscles which can lead to their
overstretching and hence pain.

Bite Block Mouth Prop

12) Surgical suction:

 Surgical suction has a narrow tip

 Close to the surgical suction tip, there is a
small opening that can be closed using
finger. This opening is created to reduce
the negative pressure of suctioning.
Example: during surgical procedure, the
tip was closed by a bone part and
disallowed the fluid to get sucked by the
surgical suction. In this case, place your
finger on the opening and this will reduce
the negative suction, forcing the bone part
to drop.
  Sometimes, there is no need to use close
the opening with finger if a very small
piece has entered the surgical suction.
Instead, we use what we call a “Stylet
Wire” which cleanses the tip of the
suction
13) Towel clip:

 Used to hold sterile towels during surgical

procedures in GA.
 The sterile towels cover every part of the
body except the surgical sites
 The site of surgery should be sterilized by
scrubbing it with iodine or other
chemicals
- Extraction instruments:
14) Straight elevators:

 All elevators have three parts:

1) Blade
2) Shank
3) Handle
 The handle in elevators is much larger
than the blade to get the perfect
transmission of power
 Hold the elevator by gripping the handle,
and the index placed on the shank
 Crossbar angled elevator: is held by
gripping the handle and the tip passed
between your fingers

 The crossbar angled elevator has a high

risk of fracturing the tooth and bone if any
 angulation was incorrect. Only specialists
use this instrument
 Straight elevators have different sizes:
size 1, size 2, size 3.

15) Angled or curved elevators:

 Angled elevators are two types:
1) Crane Pick elevator:
o Such as the cryer
o Are larger in sizes than root tip
pick elevators
o Can be used to remove remaining
roots
o Crane pick elevator has different
designs such as:
A)Triangular tip crane-pick
(Cryer)
B) Angled crane-pick
2) Root Tip Pick elevator:
o Also called the “apexo” elevator
o Can look like a normal curved
elevator or can look similar to the
curette
o Used to remove the small pieces
 Angled Crane
Pick Elevator

Cryer 

Root Tip Pick elevator 

also called Apexo
  Root Tip Pick
which looks like
curette

16) Upper and lower extraction forceps:

 Hold the forceps on the palm
 The 3 parts of forceps are:
A)Handle
B) Hinge
C) Beak
 The handle of the forceps is larger than
the other parts to get the perfect
transmission of force from shoulder to
the fingers
 Extraction doesn’t need a superpower,
it’s only a matter of proper application of
instruments and proper delivery of
controlled force
 Extra force can lead to fracture of teeth
or even fracture of bone

17) Maxillary extraction forceps

 Maxillary extraction forceps for upper
molars have a beak which has a flat side and
a toothed (pointed) side. The toothed side
 should be placed in the buccal furcation and
the flat side should be placed on the palatal
side
 Upper maxillary forceps have a curve which
eases the accessibility to the tooth. The curve
also plays an important role in which it
provides a major principle:
o In maxillary forceps, the beak of
forceps should be parallel to the long
axis of the tooth before starting any
movement
 For extracting upper wisdoms, a specific
forceps is used called “Universal Forceps”
or “Bayonet”. The bayonet doesn’t have
toothed beaks at all, because most of the
upper wisdom teeth do not have any
furcation
 Cow-Horn Forceps also called “Cat-Paw
Forceps” is a forceps that contains horn-like
projections and is used for extracting heavily
destructed molars. This forceps has two
sides on the beak:
1) A side with a single horn: placed on the
buccal furcation
2) A side with a double horn: placed on the
palatal root
18) Mandibular extraction forceps
 The mandibular extraction forceps have
two designs:
A)English style: we see this in our
university AAUP
B) American style
 The Cow-Horn or Cat-Paw forceps for
mandibular molars have only two horns,
one for the buccal and one for the lingual,
unlike the maxillary molars which have
three thorns
 Upper Anterior Forceps

 Upper Premolar Forceps

 Upper Molar Forceps

 Upper Bayonet

 Cow-Horn Upper
 Lower Anterior
Forceps

 Lower Premolar
Forceps

 Lower Molar
Forceps
  Cow-Horn
Lower Forceps

 Adult vs
Pediatric
extraction forceps
19) Basic extraction tray
20) Surgical extraction tray
21) Biopsy surgical tray
22) Postoperative tray

 The tray system:

 There are autoclavable cassettes specific
for each procedure to be done in the
clinic/operating room. This means there is
a cassette for basic extraction, a cassette
for surgical extraction, a cassette for
biopsy, and a cassette for postoperative
treatment.
 For example, when we want do take a
surgical biopsy, then we will take out the
cassette for surgical biopsy which
contains the instruments required for
taking biopsy, and then place all the
instruments on the tray