Oral surgery is that specialty of the dental profession concerned with diagnosis, surgical and adjunctive treatment of disease, injuries, and defects of the jaws and associated structures. Because of the nature of this specialty and the equipment used, the oral surgery service is often established in a less traveled area of the clinic. Patients undergoing surgical treatment should be isolated from patients receiving routine dental treatment.

3-2. ASEPSIS AND CLEANLINESS

Because surgical procedures expose susceptible areas of tissues to invasion by bacterial organisms, strict attention must be paid to cleanliness and aseptic techniques. All instruments, equipment, dressings, and medication must be carefully sterilized and protected from any contamination that might later be introduced into a surgical site. Possible sources of contamination must be minimized through continual attention and adherence to cleanliness of area, equipment, and personnel. Any time we deal with open wounds, proper sterilization and handling of instruments cannot be over emphasized.

Before using these instruments, they should be properly sterilized and maintained in a sterile condition throughout the operation. The sterile instrument forceps should always be used when transferring sterile instruments from one point to another. A sterile towel should be under all instrument setups. When the operation is completed, the instruments should be washed thoroughly. If they are not to be sterilized immediately, they should be thoroughly dried to prevent rusting.

3-3. THE DENTAL ASSISTANT AS AN ASSISTANT IN ORAL SURGERY

In addition to some general clinical duties, the dental assistant in oral surgery performs a number of specialized duties. The nature of many of his duties will depend upon his capabilities, the technical procedures followed by the dentist, and the ways in which the dentist wishes his assistant to participate. The effective assistant is the one who takes an interest in his work and tries to become familiar with instruments, equipment, procedures, and techniques. He establishes rapport with patients, maintains personal and area cleanliness and appearance, and anticipates and carries out the dentist's needs so that unnecessary delays are avoided. Thorough familiarity with instruments and materials used for specific operative procedures is of particular importance in the oral surgery section. One reason for this is that surgical setups are commonly prepared, packed, and autoclaved ahead of time. From an examination of the patient's record, the experienced oral surgery assistant can usually determine what instruments and materials will be required for the operation and have them ready when needed. Many oral surgeons perform certain operations in a surgical operating room of a hospital, often using general anesthesia. The dental assistant may be expected to perform preparatory procedures, assist in surgery, and clean the operating room after surgery. Therefore, he must be familiar with pertinent basic and local hospital operating room procedures.

3-4. GENERAL

The most frequently performed procedure in oral surgery is the extraction of teeth. A large proportion of oral surgery instruments are designed and used for the extraction of teeth and tooth roots and the associated removal and contouring of alveolar bone. Commonly used oral surgery instruments and equipment are discussed in this lesson.

The instrument and materials setups illustrated in this lessonare typical and may be varied as necessary.

3-5. EXTRACTION FORCEPS

a. General. Extraction forceps are used in the removal of teeth. Variations in these instruments are caused by differences in root shape, size, number, alignment of the tooth, and location in the mouth. Except for those designed for some specific operations, forceps generally follow certain basic principles. They are distinguished by the angles of the beaks, the notches on the beaks, the contour, and the number engraved on the forceps.

b. Maxillary Anterior Forceps.

(1) Forceps number 65 is a bayonet-shaped forceps with pointed nibs used primarily to remove crowded maxillary incisors and root fragments (figure 3-1).

Figure 3-1. Forceps No. 65.

(2) Forceps number 150S is an S-shaped forceps designed for maxillary anterior and bicuspid teeth and roots (figure 3-2). The Universal Forceps number 150A also is S-shaped and used to extract all maxillary teeth.

Figure 3-2. Forceps No. 150S.

(3) Forceps number 286 is a bayonet-shaped forceps (figure 3-3). It is used primarily for extracting maxillary anterior teeth and roots. It may be used for bicuspids.

Figure 3-3. Forceps No. 286

(4) Forceps #1 (Winter) is no longer in the Medical Supply Catalog, but you may see it in clinics.

c. Maxillary Posterior Forceps.

(1) Forceps number 150S may also be used for maxillary bicuspids.

(2) Forceps numbers 53R and 53L are bayonet-shaped forceps designed for maxillary first and second molars. Number 53R is designed for teeth on the right side of the maxillary arch, number 53L for teeth on the left side (figure 3-4).

Figure 3-4. Forceps numbers 53R and 53L.

(3) Forceps number 210 has a hooked handle. It is a bayonet-shaped forceps designed for maxillary third molars (figure 3-5).

Figure 3-5. Forceps number 210.

d. Mandibular Anterior Forceps.

(1) Forceps number 151S is a canoe-shaped universal forceps used to extract all mandibular anterior teeth (figure 3-6).

Figure 3-6. Forceps number. 151S.

(2) Forceps number 203 is used for extracting mandibular anterior teeth, bicuspids, and roots (figure 3-7).

Figure 3-7. Forceps number 203.

e. Mandibular Posterior Forceps.

(1) Forceps numbers 151S, and 203, as noted above may be used for mandibular bicuspids. See figures 3-6 and 3-7.

(2) Forceps number 15 has a hooked handle (figure 3-8). It is designed for mandibular first and second molars.

Figure 3-8. Forceps number 15.

(3) Forceps number 222 has L-shaped beaks. It is designed for mandibular third molars (figure 3-9).

Figure 3-9. Forceps number. 222.

(4) Forceps number 217 has cow horn-shaped beaks and a hooked handle (figure 3-10). It is designed for mandibular molars.

Figure 3-10. Forceps number 217.

(5) Forceps number 16 is generally obsolete, but you may see it in clinics.

3-6. ROOT ELEVATORS

Root elevators are instruments designed to loosen or remove roots, root fragments, or teeth. As with forceps, a variety of designs are available to suit different teeth, techniques, and locations in the mouth.

a. Stout A Elevator. This elevator's nib is flat on one side and rounded on the other. The nib has straight tapering walls and a rounded end (figure 3-11).

Figure 3-11. Stout A elevator.

b. Straight Elevator Number. 34-S. This elevator is straight and shaped like a gouge (figure 3-12). In cross-section its nib is crescent-shaped. It is one of the most commonly used elevators.

Figure 3-12. Straight elevator number 34-S.

c. Straight Elevator Number 301. This elevator is similar in shape to but smaller than number 34-S (figure 3-13).

Figure 3-13. Straight elevator number 301.

d. Apical Fragment Root Elevators. These are used to remove apical root fragments (figures 3-14 and 3-15).

Figure 3-14. Miller root elevators numbers 73 and 74.

Figure 3-15. Apical fragment root elevators.

3-7. PERIOSTEAL ELEVATORS

Periosteal elevators are used to separate and raise periosteum from the surface of the bone and retract the tissue flap (see figure 3-16).

a. Woodson Plastic Instrument Number One. This is a restorative instrument often used as a periosteal elevator in oral surgery.

b. Spatula Number Seven. This wax instrument also is often used as a periosteal elevator. It is blunt on one end and pointed on the other.

c. Molt Periosteal Elevator Number Nine. This elevator has a curved, blunt blade at each end.

d. Seldin Periosteal Elevator Number 22. This elevator has a flat handle with a small blade at each end. The blades are angled and shaped to give easy access to all locations in the mouth. All edges are rounded slightly to avoid needless injury to the tissues.

Figure 3-16. Periosteal elevators.

3-8. CURETTES

Curettes are instruments designed to remove extraneous material from tooth sockets and other spaces in the alveolar bone. Their nibs are spoon- shaped and their shanks are angled to reach different areas of the mouth. Standard curettes include Molt curettes 1, 2, 4, (anterior) and 5L, 6R, 9L, 10R (posterior) (figure 3-17).

Figure 3-17. Curettes.

3-9. RONGEUR FORCEPS

Rongeur forceps are cutting instruments designed to cut and contour bone (figure 3-18). Springs located between their handles separate their beaks when closing pressure is not being applied. The dentist may ask for a single rongeur.

a. Rongeur number 1A is both a side and end cutting instrument.

b. Rongeur number 4A is a side cutting rongeur.

Figure 3-18. Rongeur forceps.

3-10. BONE FILES

Bone files are made in various sizes. They are used to smooth the edges of bone. Seldin bone file number 11 (figure 3-19) is double-ended, with the file surface at one end being larger than the file surface at the other end.

Figure 3-19. Bone file.

3-11. BONE CHISELS

Bone chisels are used to remove bone or section teeth. Some are designed for use with a hand mallet. Another type is driven by a special handpiece, described in paragraph 3-12 as an engine-driven oral surgical mallet. Chisels must be kept sharp to be effective.

a. Stout chisels numbers 1, 2, and 3 are straight bone chisels used with a hand mallet. They differ in the size of their blades.

b. Chisel points used with the engine-driven surgical mallet are made in different shapes, designed for various surgical procedures. These include two bone removing points, one unibevel and one bibevel, one gouge and two tooth elevator points.

3-12. SURGICAL MALLETS

The oral surgical hand mallet (figure 3-20) is a double-headed mallet resembling a gavel or wood mallet. The engine-driven oral surgical mallet (impactor) fits on the arm of the dental engine like a straight handpiece. It is equipped with five detachable impactor points.

Figure 3-20. Surgical mallets.

3-13. SURGICAL BURS

Specially designed surgical burs (figure 3-21) are used by many oral surgeons to remove bone and to groove teeth for controlled sectioning. They are made for both the straight and contra-angle handpiece. Steel bur number 41 is available for AHP or SHP. The tungsten carbide bur is available for SHP only. To avoid excessive heat while cutting, sterile water should be dripped over the bur.

Figure 3-21. Surgical burs.

3-14. SCISSORS

Utility scissors (figure 3-22) are ordinary scissors usually made of stainless steel and used for miscellaneous cutting. Suture scissors have curved, small blades and are used to cut suture material in the mouth. Tissue (saw-tooth) scissors have long curved handles and short serrated jaws suitable for cutting soft tissue.

Figure 3-22. Scissors.

3-15. SURGICAL KNIVES

Surgical knives (figure 3-23) are used to cut soft tissue and incise localized abscesses. A surgical knife is comprised of a handle and interchangeable blades. Four sizes and shapes of detachable blades and three types of handles are available.

Figure 3-23. Surgical knife handle and blades.

3-16. SUTURE NEEDLES

Many different types of suture material can be attached to different shapes and sizes of needles. Suture needles are use to carry suture material through soft tissue which, when tied, will hold tissue parts together for initial healing.

Figure 3-24. Suture material and needle.

3-17. GINGIVAL RETRACTORS

Gingival retractors are used to hold gingival flaps back and out of the way to expose operative areas. Thoma gingival retractors 1 and 2 are two-pronged, fork-like retractors. Instruments designed for other purposes, such as periosteal elevators (figure 3-16), are also used as retractors.

3-18. IRRIGATING SYRINGE

Irrigating syringes (figure 3-25) are used to wash pus, debris, and other extraneous material from tooth sockets, cavities, or inflamed gingival flaps. The tip is usually metal and should be blunt. If a syringe with a glass barrel is used, particular care must be exercised; the glass barrel could shatter if it is hit with a surgical bur.

Figure 3-25. Irrigating syringes.

3-19. DENTAL ASPIRATOR

The dental aspirator (figure 3-26) is an electrically operated vacuum suction unit used to maintain a clear operating field by removing blood, bone chips, debris, and other materials. The unit is fitted with a tube running from a vacuum bottle, which ends in a handle and suction tip. The handle fitted with a suction tip is controlled by the oral surgery assistant in the removal of extraneous material from the surgery site.

Figure 3-26. Dental aspirators.