Oral Surgery Techniques

Study Notes

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.

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

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 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.

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
1. 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
1. Three lines incision (Trapezoidal flap)
1. Semilunar flap

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

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

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

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