OS instrumentation

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emm64
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223613
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OS instrumentation
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2013-06-12 17:21:49
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OS instrumentation
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OS instrumentation
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  1. incising tissue: 
    • Scalpel
    •  Most common use: #3 handle (more slender, longer #7 is used sometimes) with #15 blade (for incision
    • around teeth and through mucoperiosteum)
    •  Blade inserted with needle holder  no laceration
    •  Pen grasp onto the scalpel  maximal control!
    •  Dull edge → no clean sharp incision but tears the tissue!!!
  2. 2. Instruments for elevating mucoperiosteum: 
    • periosteal elevator
    •  Reflect mucosa and periosteum in a single layer!
    •  Most common: #9 Molt periosteal elevator!
    • (i) Sharp, pointed end: reflect dental papillae from teeth
    • (ii) Broad end: elevating tissue from bone
    •  3 methods of reflecting soft tissue
    • (i) Pointed end used to pry  elevate soft tissue → for dental papilla from inbetween teeth
    • (ii) Push stroke with broad end from underneath the periosteum → MOST efficient stroke/cleanest reflection
    • (iii) Pull/scrape stroke → shred or tear the periosteum unless done carefully
  3. Instruments for retracting soft tissue
    • a. Cheek retractor:
    • NOTE: 1 & 2 retract both cheek and mucoperiosteal flap
    • 1) Right-angle Austin retractor
    • 2) Offset broader Minnesota retractor
    • 3) Seldin retractor: only soft tissue flap but not mucoperiosteum (bc not sharp)
    • b. Tongue retractor
    • 1) Most common: Mouth mirror
    • 2) Weider tongue retractor: more firmly engage tongue and retract more anteriorly and medially
    •  Careful not to push tongue too far back and cause gagging reflex!
    • 3) Towel clip (especially for biopsy of posterior aspect of tongue!) → must be anesthesized!!!
  4. Instruments for controlling hemorrhage 
    • → for simple pressure control: Hemostat!
    •  Most common: curved hemostat!
    •  Locking mechanism allows to clamp to vessel
    •  Also used for: removing granulation tissue from tooth sucket, picking up small root tips, calculus, amalgam
    • restorations…
  5. Instruments for grasping tissue:
    • a. Adson forceps to stabilize soft tissue flaps to pass a suture needle!
    • b. Stillies forceps: for posterior part of the mouth!
    • c. Sometimes cotton forceps if needs to be angled!
    • d. Allis tissue forceps: when need locking handles and with teeth grips
    •  NEVER to be used for tissue that will stay in the mouth since this will destroy the tissue by crushing it!
    • e. Russian forceps: for grasping teeth that are loose in the mouth!
  6. 6. Instruments for removing bone
    • a. Roungeur Forceps
    •  Most commonly used to remove bone!
    •  With spring-loaded handle  repeated cuts of bone without manually opening the instrument
    •  2 Types: side cutting or end cutting or Blumenthal roungeur (side and end cutting)
    •  smaller amounts of bone in multiple times
    •  do not remove teeth with Roungeur forceps
    • b. Chisel and Mallet
    •  Bone with monobevel and teeth with bibevel chisels
    •  Mallet with nylon facing impart to ↓ noise
    • c. Bone File
    •  Final smoothing of bone before suturing the mucoperiosteal flap back into position
    •  File only on pull stroke!
    • d. Bur and Handpiece
    •  MOST used by surgeons to remove bone or teeth!
    • 2
    •  Must not exhaust air into operative field as do dental drills!!! → bc air may be forced into deeper tissue
    • planes and produce tissue emphysema (potentially dangerous occurance!)
  7. Instruments for removing soft tissue from bony defects: 
    • periapical curette!
    •  To remove granuloma or small cysts from periapical lesions or tooth sucket!
  8. Instruments for suturing mucosa
    • a. Needle holder (locking handle and a short, stout beak)
    •  Beak is shorter and stronger than that of hemostat
    •  Face of beak is crosshatched  positive grasp of the suture needle and suture!
    •  Intraoral placement of suture → 6 in needle holder!
    •  Held by using thumb and ring finger in rings and first and 2nd fingers to control instrument!
    • b. Needle
    •  For mucosal suture: ½ or 3/8 circle suture needle! → allow the needle to pass through a limited space
    •  Tapered tip or triangular tips (cutting tips  easily pass mucoperiosteum!)
    •  Suture can be either threaded or already swaged by manufacturer
    •  Curved need held about 2/3 distance between tip and end of needle!
    • c. Suture Material (dpend on size, resorbability and monofilament vs polyfilament)
    •  Oral mucosa: commonly 3-0 (or 000)
    • (i) Larger size suture would be 2-0 or 0
    • (ii) Smaller size: 4-0, 5-0, 6-0 → maybe in face bc smaller suture cause less scarring
    •  3-0:
    • (i) large enough to prevent tearing through mucosa
    • (ii) strong enough to withstand tension intraorally
    • (iii) strong enough for easy knot tying with needle holder
    •  Resorbable vs. non-resorbable
    • (i) Non: silk, nylon, stainless steel
    • (ii) Resorbable 1° made of gut!
    • a) aka: catgut but mainly sheep intestine → lasts about 5 days
    • b) chromic gut lasts 10-12 days bc treated with tanning solution (chromic acid)
    • NOTE: some are synthetically made resorbable!!! : long chains of polymers braided into suture material
    • → lasts about 4 weeks!  not indicated in oral cavity!
    • Example: polyglycolic acid and polylactic acid!
    •  Monofilament vs polyfilament
    • (i) Monofilament: plain, chromic gut, nylon and stainless steel
    • a) No wicking action
    • b) More difficult to tie, tend to become untied
    • c) Stiffer  more irritating to soft tissue
    • (ii) Polyfilament: skilk, polyglycolic acid, polylactic acid
    • a) Easier to handle and tie and rarely come untied
    • b) Cut ends are soft and nonirritating to tongue
    • c) “wick” oral fluids along the suture to tissues which may carry bacteria along with saliva!!!
    • NOTE: MOST COMMON USED IN ORAL CAVITY IS 3-0 black silk!!!
    •  Strong enough
    •  Easily tie and tolerated by pt
    •  Black makes it easy to see for suture removal
    •  Since suture no longer than 5-7 days, wicking action is of little clinical importance!
    • d. Scissors: to cut sutures!
    •  Most common: Dean scissors!: slightly curved handles and serrated blades
    •  Others: Iris and Metzenbaum scissors
  9. Instruments for holding mouth open: 
    • especially for mandibular extractions, must prevent stress on TMJ
    • a. Bite block: rubber block that pt rests their teeth
    •  If must open wider, bite block positioned more posteriorly
    • b. Side-action mouth prop or Molt mouth prop→ used by operator to open mouth wider if necessary!
    •  Caution since ↑ pressure on teeth and TMJ
    •  Only for pts that are deeply sedated
    • NOTE: always caution not to open too widely bc stress on TMJ and if it’s a long surgery, periodically remove and allow TMJ
    • to relax!
  10. Instruments for providing suction: for adequate visualization
    • a. Surgical suction: smaller orifice than operative suction for tooth socket!
    • 3
    • b. Fraser suction : holde in the handle portion that can be covered as required
    • 1) Hard tissue suction: hole is covered under copious irrigation
    • 2) Soft tissue: uncovered to prevent tissue injury
  11. Instruments for transferring sterile instruments: 
    • Transfer forceps
    •  Can move large and small items without dropping them
    •  Stored in container filled with bactericidal solution (glutaraldehyde)
    •  Must be emptied and replaced at least every other day and autoclaved at least once per week
  12. Instruments for holding towels and drapes in position: 
    • Towel clip
    •  Locking handle & finger and thumb rings
    •  Ends: sharp, curbed points  penetrate towel and drapes
    •  Caution not to pinch the pt’s underlying skin
  13. Instruments for irrigation: 
    • large plastic syringe with blunt 18-gouge needle (blunted and smoothed and angled!!)
    • NOTE: when handpiece and bur is used to remove bone, need steady stream of irrigating solution: usually sterile saline
    •  to cool bur and prevent bone-damaging heat buildup!
    •  ↑efficiency of bur by washing away bone chips from flutes of bur and for lubrication
  14. Dental elevators: 
    • to luxate teeth (loose them) from surrounding bone 
    •  minimize incidence of broken roots and teeth
    •  facilitate removal of broken root later if it happens
    •  expand alveolar bone
    •  also used to remove broken or surgically sectioned roots from sockets (especially roots!!!)
    • a. Components
    • 1) Handle
    •  Large  substantial but controlled force
    •  May use with crossbar or T-bar → careful bc ↑↑amount of force is generated!
    • 2) Shank: connects handle to blade
    • 3) Blade: working tip that is used to transmit for to tooth, bone or both
    • b. Types (biggest variateion: shape and size of blade)
    • 1) Straight or gouge type: luxate teeth (MOST COMMONLY USED)
    •  Concave on one side  used like shosehorn
    •  Blade: can be angled from shank  allow use in posterior region of mouth (ex: Miller and Potts elevator)
    • 2) Triangle or pennant-shape type: when broken root remains in tooth and adjacent socket is empty
    •  Provided in pairs (left and right) for specific roots
    •  Most common: Cryer
    • 3) Pick type: to remove roots
    •  Crane pick: heavy instrument for removing root after drilling a hole with a bur (3mm into root)
    •  Root tip pick/ apex elevator: small root tip fragments from their socket (VERY THIN instrument  must
    • tease not lever!)
  15. Extraction Forceps: remove tooth from alveolar bone
    • a. Components
    • 1) Handle: adequate size  enough pressure and leverage to remove required tooth + serrated surface  no slippage
    •  Held differently depending on position of tooth to be removed
    • (i) Maxillary: palm underneath forceps
    • (ii) Mandibular: palm on top of forceps  beak down
    • 2) Hinge: connects handle to beak
    •  Transfers and concentrates force applied to handles to beak
    •  Types
    • (i) American type: hinge in horizontal direction
    • (ii) English: vertical hinge  vertically positioned handle
    • 3) Beaks: greatest variations
    •  Adapts to tooth ROOT STRUCTURE at the CEJ  different beaks for 1,2, 3 rooted teeth   chance of
    • root fracture!
    •  Closer beak adapts to tooth roots, more efficient extraction and less chance for complications
    •  Width of beak depending on type of teeth removing
    •  Beaks are angles  parallel to long axis of tooth
    • (i) Maxillary beak: usually parallel to the handle (offset a little for comfort)
    • (ii) Mandibular beak: usually perpendicular to handles
    • b. Maxillary forceps
    • 4) Considered single rooted teeth: Maxillary incisors, canine, premolar (even though 1PM bifurcates since only care
    • about root near CEJ)
    •  Remove with maxillary universal forceps (usually #150 for anterior and #150A for premolars)
    • NOTE: #150S (smaller version) for all primary maxillary teeth!!!
    •  Straight forceps #1 is easier for maxillary incisors
    • 2) Considered 3 roots for maxillary molars (1 palatal root and buccal bifurcation)
    •  Molar forceps in pairs: Right and Left
    • (i) #53: Design to fit around palatal beak, pointed buccal beak into buccal bifurcation and offset for good
    • positioning
    • (ii) #88 (a.k.a.; upper cowhorn forceps): longer, more accentuated, pointed beak formation
    • NOTE: ESPECIALLY USUFUL FOR MAXILLARY MOLARS WITH DECAYED CROWNS, BUT MAY
    • CRUSH ALVEOLAR BONE
    • (iii) when have single conical root for some reason: #210: broad, smooth beak with offset
    • (iv) Removing broken roots/ narrow premolars/lower incisor: #286 (a.k.a.: root tip forceps)
    • c. Mandibular forceps
    • 1) Considered single rooted teeth: Anteriors and premolars
    •  Lower universal forceps: #151 (similar to 150 but beak pointed inferiorly) for anteriors and #151A for PM
    •  English-style vertical hinge forceps sometimes for mandibular single rooted teeth   force generation  
    • fracture rate
    • 2) 2-rooted teeth for molars: B and L bifurcation
    •  ONLY single molar forceps (no R and L)
    •  Mostly #17: straight handled and oblique beaks and bilateral pointed tips for bifurcations
    •  #222 for conically shaped roots of mandibular molars (no bifurcation  3rd molar) since no pointed tips
    •  #23 (a.k.a.: cowhorn forceps): two pointed heavy beaks that uses B/L cortical plates as fulcrum   risk of
    • fracture of alveolar bone
    •  #151S for all mandibular primary teeth
  16.  Typical extraction pack with (required forceps lateral added)
    • 1. Local anesthesia syringe
    • 2. Needle
    • 3. Local anesthesia cartridge
    • 4. Woodson elevator
    • 5. Periapical curette
    • 6. S/L straight elevator
    • 7. Cotton pliers
    • 8. Curved hemostat
    • 9. Towel clip
    • 10. Austin retractor
    • 11. Suction
    • 12. Gauze
  17. Surgical Extraction tray
    • : for incision, reflection of soft tissue, removal of bone, section of teeth, retrieval of roots, debridement and suturing
    • 1. basic
    • 2. needle holder
    • 3. suture
    • 4. scissors
    • 5. periosteal elevator
    • 6. blade handle
    • 7. blade
    • 8. Adson tissue forceps
    • 9. bone file
    • 10. tongue retractor
    • 11. root tip pick
    • 12. Russian tissue forceps
    • 13. Cryer elevator
    • 14. Roungeur
    • 15. handpiece and bur
  18. Biopsy tray: for incision and dissection and closure of wound
    • 1. Basic
    • 2. Blade handle and blade
    • 3. Needle holder and suture, suture scissors
    • 4. Metzenbaum scissors
    • 5. Allis tissue forceps
    • 6. Adson tissue forceps
    • 7. Curved hemostat
  19. Postoperative tray: to irrigate surgical site and remove sutures
    • 1. Scissors
    • 2. College pliers
    • 3. Irrigation syringe
    • 4. Applicator sticks
    • 5. Gauze
    • 6. Suction
  20. Maxillary forceps
    • 150: anterior
    • 150A: premolars
    • 150S: primary
    • #1 forceps: primary incisors
    • 53: 3 root molars
    • 88: cowhorn, molars
    • 210: molars single conical root
    • 286: both max/mand broken roots, narrow premolars
  21. Mandibular forceps
    • 151: anterior
    • 151A: premolars
    • english, vertical: single rooted
    • 17: dobuble rooted
    • 222: molars
    • 23: cowhorn, molars

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