Stages of minor oral surgery
All minor oral surgery operations follow a similar sequence of stages, which is the basis of a systematic approach . Like any other surgery, the sequence follows the anatomical tissue planes – first inwards until the objective is achieved, and then outward until the wound is repaired.
Stages of the operation sequence
- Bone removal – access
– point of elevation
– removal of obstruction
- Tooth section
The first procedure is the placement of a suitable retractor so as to display the operation site and hold the lips, cheeks and tongue out of the way. The Kilner cheek retractor will control both lips and cheek, provided it is held at the correct angle so as to pouch out the cheek. The tongue is best controlled by ignoring it – conscious efforts by the patient are seldom helpful. When the retractor is in place, a final check should be made on the relative positions of the patient, the operator, the assistant, and the light.
The shape of the incision has to be planned with the needs of both exposure and closure in mind. A long incision heals as easily as a short one, and so exposure should be generous. While the mental nerve is the only significant structure at risk, thoughtful placement of incisions can reduce haemorrhage by avoiding unnecessary section of muscles or small constant vessels. Most incisions can be made on to the underlying bone, and this ensures separation of both mucosal and periosteal layers in the one cut. The scalpel should be held in a pen grip and the hand should be steadied, if possible, by using a suitable rest for the fingers. Incisions may sometimes be conveniently extended with tissue scissors.
The mucoperiosteal flap is reflected with a periosteal elevator, such as a Howarth’s. Two elevators can be used to advantage at this stage – one working and the other aiding retraction in the subperiosteal plane. Adequate undermining of the wound margins is required in order to mobilize the flap. Generous reflection is the key to adequate vision, and wide exposure reduces
traction trauma to the wound edges.
Removal of bone is usually required and, in the interest of vision and to reduce trauma from excessive elevating force, should be generous. This is most conveniently achieved by using a bur in a slow- to moderate-speed handpiece. Handheld chisels are useful in `peeling off thin layers of bone, and rongeurs are ideal when the blades can be placed either side of the piece of bone to be removed. Bone files are seldom required since sharp edges can be `nibbled off. Excessive smoothing is unnecessarily traumatic and time wasting. Although generous in extent, bone removal must be calculated to achieve an end, and never be blindly destructive. The main objectives should be the achievement of access, the establishment of a point of application for an elevator (or forceps), and the removal of the obstruction to movement of the tooth or root. It may be that all these objectives may be reached simultaneously, but in any event they should be considered in that order. Slots or gutters around teeth or roots should be deep and narrow so as to preserve a fulcrum for leverage. Additionally the shape of the tooth must be borne in mind, both when clearing
the cardinal points of the crown and in allowing for curvature and angulation of the roots.
Division of a tooth into a number of simpler, or more favourably shaped, segments may resolve the conflicts of the paths of withdrawal, or relieve
impaction. This is best achieved by piercing the surface with a round bur, which is then sunk to the estimated width of the tooth, and the round `shaft’ converted into a slot with a fissure bur. Tungsten carbide tipped burs are essential for efficient cutting. The depth of all cuts should be judged so as to remain within tooth substance, and to avoid damage to the neighbouring structures. Final
separation is achieved by levering within the slot with a flat elevator until the tooth cracks apart. In order to avoid propagating the crack through the
bone, it is safer to gain even limited movement of the tooth within the socket before section.
When all necessary bone removal and tooth section is complete, the tooth or root is delivered, usually by leverage with an elevator. The successful delivery of the tooth is a cause of some satisfaction, and is usually greeted with relief by the patient, but this does not represent the end of the operation!
The socket, or other bony defect, should be examined for the presence of debris – pieces of enamel, amalgam, calculus or loose chips of bone all seem to delay healing until exfoliated. Soft tissue tags can be removed with discretion, although there is no evidence that they cause any harm. Excessive irrigation is unnecessary and washes away adherent clotted blood, which is the best dressing material available.When bleeding is controlled, and the wound is
clean, it is ready for closure.
Most minor oral surgical wounds are sutured so as to replace the flap in the optimum position for healing. The object is not to pull the edges together to form a tight seal, but rather to support them in position and prevent displacement in the early phase of healing.
On completion of suturing, the tension of retraction should be released and the wound reexamined for any gaping. A short period of pressure, applied by biting gently on a damp swab, will ensure the final cessation of haemorrhage.
During this time, the patient’s postoperative instructions may be discussed.
A return appointment must be offered before the patient is discharged. Seven days is usually the most convenient interval, but postponement for a few extra days is of no consequence.
Brief, but accurate, operation notes must be made to record the procedure used, and to note any variation from the usual technique.