Oral Surgery Techniques

Incision Lines

• No oblique incisions are made in:
  • Buccal aspect of lower premolar region (mental nerve)
  • Palatal aspect of maxilla (Greater Palatine Nerve and vessels)
  • Lingual aspect of the mandible (Lingual Nerve)
• Incision lines should include mucous membrane and periosteum in one cut.
• Incision lines should not alter the gingival papillae, and therefore, the gingival papillae should be included within the flap.

Flap Design

• When a releasing incision is used to reflect a two-sided flap, the incision should be designed to maximize blood supply by leaving a wide base.
• The base of the flap should be wider than its free margin to ensure maximum blood supply and enhance healing.
• The flap size should be larger than the expected surgical field to allow:
  • Uncomplicated flap reflection
  • Adequate exposure to the field of surgery
  • Retraction without tension, laceration, and stenosis of the flap
  • The margins of the flap to rest on sound bone on repositioning

Scalpel

• The scalpel is grasped in a pen grip.
• The scalpel should be pulled, not pushed.
• Tissues must be cut at a right angle to the bone.
• One sharp, clean cut down to the bone (mucosa and periosteum) is required.
• Tissues should be stretched during cutting to facilitate a clean cut.

Instrumentation

• The Bard-Parker handle no. 3 can be attached to four types of blades:
  • Blade no. 10: Used for extraoral skin incisions
  • Blade no. 11: Used for stab wound incisions, such as an abscess incision
  • Blade no. 12: Used for incisions in inaccessible areas, such as the maxillary tuberosity
  • Blade no. 15: Used for intraoral surgery

Reflection of the Flap

• Reflection of the flap is done using a mucoperiosteal elevator.
• Good reflection depends on good incision; if not, elevation will be difficult, and strands from periosteum will be found covering the bone surface.
• Mucosa will be separated from periosteum, and repositioning and suturing will be difficult.

Types of Mucoperiosteal Flaps

• 1. Envelope (Marginal or Gingival) flap:
  • Indications: Used mainly in lingual and palatal aspects where oblique incisions are contraindicated
  • Advantages: No oblique incisions, minimal bleeding, minimal postoperative complications
  • Disadvantages: Very limited exposure, possible laceration during reflection
• 2. Pyramidal flap:
  • Indications: The most commonly used type of flap, except where oblique incisions are contraindicated
  • Advantages: Adequate exposure, adequate blood supply, rapid uncomplicated healing
  • Disadvantages: Incision may disturb the gingival tissue, which may result in periodontal pocket formation and bone resorption
• 3. Three lines incision (Trapezoidal flap)
• 4. Semilunar flap

Elevators

• Principles of use:
  • Lever and fulcrum
  • Wedge principle
  • Wheel and axle
• Classifications:
  • 1. Straight elevator
  • 2. Curved elevators: Cryer's elevator, Miller elevator, and curved apexo elevator
  • 3. Cross-bar elevator: Socket applicator, buccal applicator, and Pott's elevator

Wound Debridement

• Debridement of the surgical field involves removing:
  • Spicules of bone
  • Tooth fragments
  • Any foreign body, such as fragments of filling materials
  • Septic granulation tissue using curettes
• Trim any sharp bony edges or bony projections using rongeurs
• Irrigate the field with warm saline or antiseptic solutions to remove fine particles or debris

Wound Closure: Suturing

• Close the wound by means of suturing, which is the approximation of soft tissue to cover the operative field
• Advantages of suturing:
  • Approximate wound margins
  • Promote healing
  • Help in hemostasis
  • Preserve the contour of soft tissues and shape, which helps in constructing adequate prosthetic appliances

Principles of Suturing

• 1. The insertion of the suture needle should be about 2-3mm away from the free edges of the soft tissues to avoid weakening and laceration of those edges
• 2. The suture needle should be of suitable shape and size to be accessible to the sutured area and prevent laceration of the tissues
• 3. Start with the key suture and from the free tissue to the fixed ones
• 4. The sutures should not be placed under tension, as too tight suturing causes strangulation of blood vessels and retards healing
• 5. After ligation of the knots, the suture end is cut at 4-5mm away from the knot
• 6. The needle should pass perpendicular to the tissue
• 7. The needle should pass at an equal depth and distance on both sides of the wound
• 8. On removal, the suture should be cut as near to the mucosa as possible