Instruments

As Dr. Rasha Rahahleh said, please concentrate on this lecture, they will show us the instruments that we will be talking about in the clinics, you really need to see them!

The first group of instruments is about incising tissue, for oral surgery you need to make flap, so for making this flap you need to incise tissue properly. The instrument that is used to incise tissue is called scalpel, it is composed of two parts : - The scalpel handle, it can be disinfected so it can be used once and once again. - The blade, it is disposable, used for one time then discarded.
The scalpel

There are different types of blades that are used in oral surgery : No.15, the most common one, it is small to be adapted for teeth, mucoperiosteal around the teeth, it is small so easily placed around the teeth. No.10, it is used for large incision, not used intra-orally. No.11, the pointed one, for incision of abscess thats why it has a pointed end. No.12, the curved one, used in perio not in oral surgery, for mucogingival incisions.
No.12 No.11 No.10 No.15

This is how we load and unload the blade, never touch the blade with your finger because it might injure your finger, so for safety purposes we load and unload it using needle holder . For loading, hold the blade from its superior edge by needle holder then slide it along the slot(slot of the handle), that is how it will be fixed on the handle. For unloading , hold the blade from its inferior edge then unload it and slide it along the slot. We will show you that in the clinics. You only need to know that you must load and un load it using needle holder not by fingers.

Pen grasp for holding the scalpel, like holding a pen and then make the incision, you have to hold the mucosa firmly while incising it because it is mobile tissue, so that the incision will be clear from mucosa, you have to incise with one cut not multiple so that bleeding will be optimized, as we said mucosa and periosteum together so that we reach the bone, hold the scalpel and make incision all inside the bone(mucosa and periosteum) in one clear cut. Pen grasp

When the procedure is very long you have to change the blade many times, because the blade becomes dull and when it is dull it will traumatize the tissue.

Instruments for elevating mucoperiosteam, after you have done your incision now you need to elevate mucoperiosteum or expose the tooth, so for elevating mucoperiosteal we use : Mucoperiosteal elevator or periosteal elevator, of course it is done as one layer mucosa and periosteal in a single layer, you have to reach the bone when you put it underneath the flap then reflect it, the most commonly used periosteal elevator in oral surgery is #9, it is called molt periosteal elevator, it has a pointed end and broad end here, the pointed end is used first, underneath dental papilla to reflect it and detach it from underlying bone. First detach the dental papilla from the teeth by the narrow end and then by the broad end at the end of the flap. No.9 molt

Of course you have to reflect enough amount of the flap, if you reflect the flap as a small piece then you will not be able to see, so reflect the flap widely , you need to have good vision, you cannot remove what you are not able to see. This is another type for reflecting mucoperiosteal, it is not very common, this is a small pen it is rounded and small, actually it is used for detachment. at the clinics we do detachment by tweezers There are three methods by which elevating the flap used for reflecting soft tissues : prying motion, insert the elevator(the pointed end) beneath the dental papilla and elevate it, this will detach the dental papilla from the teeth.

 Push stroke, by the broad tip of the elevator, put the elevator beneath the whole flap then push it under the flap that is why it is called push stroke and then reflect the flap. This is also a very common method for reflecting the flap. pull/scrap is hard to put in the tissue because you pull the tissue from the bone, it is really harmful, you might tear the gingiva and mucosa, it is not really recommended unless you are experienced surgeon. As beginner surgeon only use prying motion.

Instruments for retracting soft tissues, after you reflect the flap, now your flap is free from bone, so you have to stabilize it in its place, there are instruments for retracting soft tissues and stabilizing it away from your field in order to see properly(good vision and good access), these instruments retract the cheek, tongue and flap that you are already made. Examples for cheek retracting instruments : Right angled Austin retractor, for retracting the cheek. Minnesota retractor also it is common, you will see it at the clinics. Austin and Minnesota, most common cheek retractor because they retract the flap as well, it is easier because you retract the cheek and the flap with one instrument Seldin, uncommon retractor, some surgeon prefer using them because they are long handled, long enough to be away from the cheek while holding it.

austin

Seldin

So again periosteal elevator for the bone, that the flap not trapped between the elevator and the bone so it will be crushed, so make sure that your flap is away from and not trapped between the bone and your instrument. Again periosteal elevator is very common used for retracting the flap from the broad end, stabilized in the bone and reflect it with the flap. The Seldin retractor although it is similar to periosteal retractor, its edges are round not sharp, we use it for retracting the flap you cannot elevate or reflect the flap with this instrument, it looks like periosteal elevator but you cannot use it as

perioteal elevator, it will harm the tissue because the edges here are not sharp, they are round so it will not reflect the flap properly, only used for retracting the flap.

There are tongue retractors, the tongue may come on your way while you are doing your surgery, so you need to retract it to have good access and vision. The mouth mirror is the most commonly used instrument, that you already use in cons department, it is used for retracting cheek and tongue as well but sometimes you need to retract something bigger as a large tongue so you use weider tongue retractor. Weider tongue retractor, it looks like a heart, it is big to retract the tongue, it is serrated so that it can stabilize the tongue while retracting it and not to be moved, be careful with this retractor because it is big and if you put it posteriorly you may induce gagging reflex to your patient, be careful not to put it too far postriorly. It is used especially in third molar surgery you must keep the tongue away from your field so you can do your surgery properly. Weider

 Towel clip it is not for retracting the tongue, however it can be used for retracting it, it hold the tongue like a scissor anteriorly, put the clip, hold it and push it away. This tongue clip is useful when u do biopsy for the posterior third of the tongue, tongue retractor hold worse but it is grooved so it will not give enough field for biopsy, so when you need to do biopsy for posterior third of the tongue, this is the ideal instrument to do it however it is very painful, that is why you have to give very good local anesthesia on the place where you are putting this instrument on because it is really painful. Towel clip

Instruments for grasping soft tissues, oral cavity is full of soft tissue(mucosa, mucoperiosteal), these instruments are need while you are incising on soft tissue or to stop bleeding from an artery or vein. There are four types : The Adsons forceps, it is small and delicate, used for holding soft tissues that you want to keep them in the mouth not to remove them like for biopsy, actually it is used when you want to make a suture you can hold the flap with this forceps and you insert the suture in the flap, it can be of two types : With teeth Without teeth The one which is with teeth has sharp point edges, easy to hold the tissue by it, but it may crush the tissue ,so the one which is without teeth is better to be used.

Adsons forceps

 The Stillies forceps, it is used for posterior areas, similar to Adsons forceps but it is larger so easier to reach posterior areas that Adson will not reach

The cotton players(the tweezers) it is not really used for holding tissue for suturing for example, it is used for removing granulation tissue, may be from the socket, it has an angle which goes inside the socket easily or it may be used for removing amalgam restoration or broken fragment of the tooth, this angle facilitates reaching different areas like inside the socket.

Cotton player stillies

Allis tissue forceps, it is common, used when you have large amounts of tissues to be removed for a biopsy or a tumor, you see the teeth here, these teeth to hold the tissue firmly, so again for holding tissue that you need to get rid of from the patients mouth not for holding tissue that will stay in it like holding a flap, because it has teeth and that will cause injury

to the tissue. Cyst, tumor and fibrous tissue all of them should be removed. It has a working handle that help you to hold it firmly and grasp the fibrous tissue. Allis

This is the correct way for holding forceps, the thumb is here, the ring finger is here, the middle one is here to stabilize it and the index is here to direct it.

Instruments for controlling hemorrhage, sometimes while you are doing your surgery, you will have hemorrhage from an artery, vein or capillary, so you need an instrument to control hemorrhage to be able to see and your vision will not be impaired. Usually pressure is enough, light pressure on the bleeding capillary leads to stop bleeding but sometimes bleeding might not stop so in such case you need an instrument that called hemostat. Hemostat has very long tipped beaks, see the beak it is long and delicate, it can also be used for removing granulation tissue or to pick up small fragment of the tooth or restoration(just like the player), it has locking handle so if there is an

artery or vein that is bleeding, just hold it and keep it locked, you do not have to hold it all the time. hemostat

Instruments for removing bone, sometimes you have to remove bone for some reasons.. Impacted tooth inside bone, then you need to remove the bone to reach the impacted tooth. Bony lesions like torus mandibularis or torus palatinus Sharp edges of bone remain after doing extraction The instruments are : Rongeur forceps, we have two types depending on where the cutting edges are Cutting edges on the sides, it is not really common

 Cutting edges on both the sides and the tip(Blumenthal rongeurs), the one that we use in surgery because it is easier, it can be used at the tip of the socket to remove ineterradicular bone because it has cutting edges on the tip. Rongeur forceps can be used for removing large amounts of bone but it has to be used in multiple bites not only one bite; each bite you close and remove small amount of bone. It is never used for extraction of teeth because the blade on the cutting ends will become dull and will not remove bone efficiently, if you remove tooth by it the tooth might slipped from it and swallowed or aspirated by the patient. Only for removing of bone. Rongeur

Blumenthal rongeur

 Bur and handpiece, this is the handpiece that we use in surgery, not like that you use in cons, specific for surgical removal of bone. Fissure bur for sectioning of teeth. Acrylic bur looks like that we know but here it used for removing tori(paltenus, mandibularis).

Round bur for removal of bone overlying impacted tooth. The important feature in these hanpieces that they do not incorporate air with them, that is why you cannot use carbide handpiece for surgical procedures because it might inforce air deeply and cause a condition called emphysema , that is why it is important that only these handpieces are used for removal of bone. These handpieceses also can be used for sectioning of teeth, such as molars you divide them into 2-3 parts and remove every part by its own. Of course it should be of high speed and high torque like carbide bur so it can remove cortical bone efficiently and section teeth quickly so you will end up quick and fast procedure.

Handpiece must be sterilizable, make sure when buy it from the manufacturer that it is sterilizable because you use it for many patients and it must not exhaust air into the operative field so it will not cause emphysema.

Bur and handpiece

Mallet and Chisel It isn't really common to used, Bur and handpiece are easier to used, the mallet and chisel are often used when removing lingual tori. , Chisel > there is mono and bi bevel Mono-bevel > it used mainly for bone cutting u will find chisel beveled from one side and straight from the other

Bi-beveled > used in the past when they want section teeth but now this is very unlikely . Mallet> is look like a hummer . **We put a chisel in the bone and lock by the mallet , in fact it a little traumatic to the patient so this is very unlikely to use .

Bone File
Bone File > Final smoothing of bone before suturing a mucoperiosteal flap , the bone file cannot be used efficiently for removal of large amounts of bone; therefore, it is used only for final smoothing - It come with serration with one cutting side and , the other side doesn't cut >> so it work only in pull stroke

Pushing this type of bone file against bone results only in burnishing and crushing the bone, and should be avoided ,,only in pull stroke way

Removing Soft Tissue From Bony Cavities

periapical curette >> The curette commonly used for oral surgery is an angled, double-ended instrument used to remove soft tissue from bony defects . The principal use is to remove granulomas or small cysts from periapical lesions, but the curette is also used to remove small amounts of granulation tissue debris from a tooth socket. Note ,, that the periapical curette is distinctly different from the periodontal curette in design and function.

Suture Soft Tissue

Once a surgical procedure has been completed, the mucoperiosteal flap is returned to its original position and is held in place by sutures. the needle holder is the instrument used to place the sutures.

Needle Holder
The needle holder is an instrument with a locking handle and a short, blunt beak. For intraoral placement of sutures, a 6-inch ( l6-cm) needle holder is usually recommended .

The beaks of a needle holder are shorter and stronger than the beaks of a hemostat . The face of a beak of the needle holder is crosshatched to permit a positive grasp of the suture needle. The hemostat has parallel grooves on the face of the beaks, thereby decreasing the control over needle and suture. Therefore the hemostat is a poor instrument for suturing.

**What make the needle holder differ than any other instrument (such as the
hemostate)? a) groove b) beak To control the locking handles properly and to direct the long needle holder, the surgeon must hold the instrument in the proper fashion : The thumb and ring finger are inserted through the rings. The index finger is held along the length of the needle holder to steady and direct it. finger aids in controlling the locking mechanism. The index finger should not be put through the finger ring because this will result in dramatic decrease in control

Needles
The needle used in closing mucosal incisions is usually a small half-circle or three-eighths-circle suture needle. The needle is curved to allow it to pass through a limited space, where a straight needle cannot reach, and passage can be done with a twist of the wrist, Suture needles come in a large variety of shapes, from very small to very large. . The tips of suture needles are either :: - tapered tip - triangular tips that allow them to be cutting needles (which commonly used) . Taperd needles have a round cross section ,, a Care must be taken with cutting needles because they can cut through tissues (brushing) rather go inside it ,therefore ,, It isn't really common to used in oral surgery

Techniques for placing sutures :

The curved needle is held approximately two thirds away from the tip ,, This allows enough of the needle to be exposed to pass through the tissue one third from suturing material,, this allowing the needle holder to grasp the needle in its strong portion to prevent bending of the needle

Suture Material
Many types o f suture materials are a available , The materials are classified by diameter, restorability , and whether they are monofilament or polyfilament.

a) Size: the size of suture relates to its diameter and is designated

by a series of zeros . As 0 , 01 , 02 , 03 ,04 >> the larger the number the smaller the needle 04<03<02<01<0 A larger size suture is 2-0, or O and Smaller sizes are designated, for example, 4-0, 5-0 and 6-0 Sutures of very fine size. The diameter most commonly used in the suturing of oral mucosa is 3-0 Sutures of size 3-0 are large enough to withstand the tension placed on them intraorally ( mucoperiosteal ) and strong enough for easier knot tying with a needle holder compared with smaller-diameter b) Resorbability : Sutures may be resorbable or nonresorbable. Non resorbable > the most commonly used non resorbable suture in the oral cavity is silk ,, Nylon, vinyl, and stainless steel are rarely used in the mouth. **Natural Resorbable > sutures are primarily made of gut. Although the term catgut is often used to designate this type of suture, gut actually is derived from the surface of sheep intestines.

Plain catgut resorbs quickly in the oral cavity, rarely lasting longer than 2 to3 days. Gut that has been treated by tanning solution (chromic acid) and is therefore called chromic gut lasts longer-up to 7 to 10 days. **Several synthetic resorbable> These are materials that are long chains of polymers braided into suture material. Examples : are polyglycolic acid and polylactic acid. these materials are slowly resorbed, taking up to 4 weeks before they are resorbed, Such long-lasting resorbable sutures are rarely indicated in the oral cavity for basic oral surgery. c) monofilament or polyfilament > Monofilament sutures are sutures such as plain and chromic gut, nylon, and stainless steel, Polyfilament sutures are silk, polyglycolic acid, and polylactic acid. **We used Polyfilament because it easy to tie and well tolerated by the patient's soft tissues and the cut ends are usually soft and nonirritating to the tongue and surrounding tissue. However, because of the multiple filaments, they tend to "wick" oral fluids along the suture to the underlying tissues, this wicking action may carry bacteria along with saliva while Monofilament sutures do not cause this wicking action but may be more difficult to tie, tend to come untied, and the cut ends are stiffer and therefore more irritating to the tongue and soft tissues. **As result sutures that are holding mucosa together usually stay no longer than 5 to 7 days, so the wicking action is a little clinical importance.

Scissors
They are two types : a) Suture scissors: scissors usually have short cutting edges because their sole purpose is to cut sutures , these scissors have slightly curved handles and serrated blades that make cutting sutures easier in posterior area . **The most commonly used suture scissors for oral surgery are the

Dean scissors. b) Dissecting scissors : are designed for cutting soft tissue Now dissecting scissors are two types :: 1)Iris >> are small, sharp-pointed, delicate tools used for fine work. We used removing Avery fine sutures from the skin .

2) Metzenbaum Scissors >> used for undermining soft tissue and for separations the layer from each other .

Instrument For Holding Mouth Open

We use it when we need to do long time surgery either under general or Local anesthesia , They are two types : 1) Rubber Bite Block :: The bite block is a soft, rubberlike block on which the patient can rest the teeth in the serration area. it will open the mouth and ease the pain over the joint ** It necessary to support the mandible to prevent stress on the temporomandibular , Supporting the patient's jaw on a bite block will protect the joints so the patient will be more comfortable.

**This type of mouth prop mainly with patient under a local anesthesia ( consciousness ) or useful in patients who have mild forms of trismus.

2) Molt Mouth Prop >> This mouth prop has a ratchet-type action, it has a reverse action it will opening the mouth wider as the handle is closed and closing the mouth as the handle is opened . This type of mouth prop should be used with caution because great pressure can be applied to the teeth and temporomandibular joint, and injury may occur with injudicious use.

**This type of mouth prop is mainly used with patient under General anesthesia (loss of consciousness) or useful in patients who are deeply sedated patient

SUCTINING
To provide adequate visualization, blood, saliva, and irrigating solutions must be suctioned from the operative site. The Fraser suction > surgical suction is one that has a smaller orifice than the type used in general dentistry to more rapidly ( effectively) evacuate fluids from the surgical site by creating a negtive pressure to maintain adequate visualization.

Holding Towels And Drapes In Position

Mainly used with patient under General anesthesia When drapes are placed around a patient, they can be held ( stabilize) together with a towel clip. . **When this instrument is used, the operator must exercise extremely not to hold the patient's skin under this towel .

IRRIGATING
**When a headpiece and bur are used to remove bone, it is essential that the area be irrigated with a steady stream of irrigating solution, usually sterile saline or sterile water. The irrigation cools the bur and prevents bone-damaging heat buildup. **The irrigation also increases the efficiency of the bur by washing away bone chips from the flutes of the bur and by providing a certain amount of lubrication. ** Once a surgical procedure is completed and before the mucoperiosteal flap is sutured back into position, the surgical field should be thoroughly irrigated **A large plastic syringe with a blunt 18-gauge needle is commonly used for irrigation, although the syringe is disposable, .

EXTRACTING TEETH
One of the most important instruments used in the extraction procedure is the dental elevator:

 These instruments are used to luxate teeth (loosen them) from the surrounding bone, Loosening teeth before the application of the dental forceps makes extractions easier In addition to their role in loosening teeth from the surrounding bone, dental elevators are also used to expand alveolar bone. Finally, elevators are used to remove broken or surgically sectioned roots from their sockets. Any elevator consists of three components :: 1) Handle :: The handle of the elevator is usually of generous size, so it can be held comfortably in the hand to apply substantial but controlled force, In some situations, cross bar or T-bar handles 2) Shank 3) Blade

Types of Elevators
The biggest variation in the type of elevator is in the shape and size of the blade, the three basic types of elevators are: ( 1 ) the straight type: The straight elevator is the most commonly used elevator to luxate teeth or displace roots from their sockets .

(2) the triangle or pennant-shape type: these elevators are provided in pairs: a left and a right, The triangular elevator is most useful when a broken root remains in the tooth socket and the adjacent socket is empty., The elevator is turned in a wheel-and-axle rotation., **The Cryer is the most common type.

(3) The pick type: This type of elevator is used to remove roots. ** The heavy version of the pick is the Crane pick , this instrument is used as a lever to elevate a broken root from the tooth socket. Usually it is necessary to drill a hole with a bur , the tip of the pick is then inserted into the hole,, (we will talked about it later on)

**The second type of pick is the root tip pick or apex elevator The root tip pick is a delicate instrument that is used to tease small root tips from their sockets , It must be emphasized that this is a thin instrument and should not be used as a wheel-and-axle or lever type of elevator like the Cryer elevator or the Crane pick.

 The root tip pick is used to tease (mobile) the very small root end of a tooth by inserting the tip into the periodontal ligament space between the root tip and socket wall.

Extraction Forceps
The extraction forceps are instruments used for removing the tooth from the alveolar bone The basic components of dental extraction forceps are handle, hinge, and beaks.

Handle : The handles of the forceps are held differently, depending on the position of the tooth to be removed. - Maxillary forceps are held with the palm underneath the forceps so that the beak is directed toward the teeth. - Mandibular forceps used held with the palm on top of the forceps so that the beak is pointed down toward the teeth. Beaks : The beaks of the extraction forceps are the source of the greatest variation among forceps. The beak is designed to adapt to the tooth root near the junction of the crown and root. One must remember that the beaks of the forceps are designed to be

adapted to the root structure of the tooth and not to the crown of the tooth. The beaks of forceps are angled so that they can be placed parallel to the long axis of the tooth, with the handle in a comfortable position, therefore the beaks of maxillary forceps are usually parallel to the handles, while the beaks of mandibular forceps are usually set perpendicular to the handles.

The doctor starts to show some a picture:

forceps adapted to maxillary central incisor

Maxillare foreceps adapted to premolar

. Maxiller foreceps adapted to molar , the molar forceps come in pairs: a left and a right, these forceps are designed to fit anatomically around the palatal and the pointed buccal beak fits into the buccal Bifurcation

Root tip foreceps, for broken molar roots, narrow premolars, lower incisors

forceps adapted incisor mandibular

Mandible forceps adapted to molar

SURGICAL EXTRACTION TRAY

BIOPSY TRAY

POSTOPERATIVE TRAY

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Done by : Malak abu-aqulah & Rahaf Al-ibrahem