Basic principles of oral and maxillofacial surgery

CONTENTS
• INTRODUCTION
• BASIC PURPOSE OF SURGERY
• PRINCIPLES OF ORAL SURGERY
• REFERENCES
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Definition
₪Oral maxillofacial surgery is a
“branch of dentistry ,that deals with the
art of diagnosis and treatment of various
diseases, injuries and defects involving the
oro-facial region.”
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Basic purpose of surgery
1. Elimination of disease
2. Prevention of disease
3. Removal of damaged or redundant tissue
4. Improvement of function and aesthetics
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Principles of oral surgery
1. Developing a surgical diagnosis
2. Basic necessities for surgery
3. Aseptic technique
4. Incision planning
5. Flap design
6. Tissue handling
7. Haemostasis
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8. Dead space management
9. Decontamination and debridement
10. Suturing
11. Oedema control
12. Post operative infection control
13. Patient’s general health and nutrition
14. Follow-up
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1. Developing a
surgical diagnosis

• Diagnostic sequences can be divided into 5 levels:
1) History taking
₪ BIOGRAPHIC DATA
₪ CHIEF COMPLAINT
₪ HISTORY OF PRESENT ILLNESS
₪ MEDICAL HISTORY
₪ PAST DENTAL HISTORY
₪ FAMILY HISTORY
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2) Clinical examination
₪ GENERAL EXAMINATION
₪ EXTRA ORAL EXAMINATION
₪ INTRA ORAL EXAMINATION
3) Radiological examination
4) Laboratory investigation
5) Interpretation and final diagnosis
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1)History taking1) History taking
₪ A case history is defined as a planned professional
conversation that enables the patient to communicate
his/her symptoms, feelings, and fears to the clinician so
as to obtain an insight into the nature of the patient’s
illness and his/her attitude to them.
₪ In general, a case history is nothing but an evaluation
of the patient prior to the dental treatment.

₪ A case history is of immense value in the
following ways:
1. To establish the diagnosis.
2. To detect any medical problem
3. Evaluation of other systemic problems
4. Discovery of communicable diseases.
5. Management of emergencies.
6. For effective treatment planning.
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CHIEF COMPLAINT
₪ The chief complaint is established by asking the
patient to describe the problem for which he or she is
seeking help or treatment.
₪ It is recorded in patient’s own words as much as
possible, and no documentary or technical language
should be used.
₪ It is recorded in chronological order of their
appearance, and in the order of their severity.
₪ The chief complaint aids in the diagnosis and
treatment planning and should be given the first
priority.
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COMMON CHIEF COMPLAINTS
1. Pain
2. Burning sensation
3. Bleeding
4. Loose teeth
5. Recent occlusal problems
6. Delayed tooth eruptions
7. Xerostomia
8. Swellings
9. Bad taste
10. Paresthesia and anaesthesia
11. Halitosis
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HISTORY OF PRESENT ILLNESS
₪ Initially, the patient may not volunteer the detailed history of the
problem, so the examiner has to elicit out the additional information
by the possible questionnaire about the symptoms.
₪ The patient’s response to these questions is termed history of
present illness.
₪ The questions can be asked in the manner:
1. when did the problem start?
2. what did you noticed first?
3. did you have any problems or symptoms related to this?
4. what makes the problem worse or better?
5. have any tests been performed before to diagnose this complaint?
6. have you consulted any other examiner for this problem?
7. what have you done to treat this problem?Etc.
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₪In general, the symptoms can be
elaborated under:
1. mode of onset.
2. cause of onset.
3. duration
4. progress and referred pain
5. relapse and remission
6. treatment
7. negative history
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DETAIL HISTORY OF PARTICULAR
SYMPTOM
₪ PAIN:
1. anatomical location (site) 2. origin and mode of onset
3. intensity of pain 4. nature of pain
5. progression of pain 6. duration of pain
7. movement of pain 8. localization behavior
9. effect of functional activity 10. neurological signs
11. temporal behavior
₪ SWELLING:
1. anatomical location (site) 2. duration
3. mode of onset 4. symptoms
5. progress of swelling 6. associated features
7. secondary changes 8. impairment of function
9. recurrence of swelling
₪ ULCER:
1. mode of onset 2. duration
3. associated pain 4. discharge
5. associated diseases
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1)History taking2) Clinical Examination
2) Clinical examination
₪ GENERAL EXAMINATION
₪ EXTRA ORAL EXAMINATION
₪ INTRA ORAL EXAMINATION

GENERAL EXAMINATION
₪BUILT:
₪NOURISHMENT:
₪CONSCIOUSNESS:
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₪ PULSE: it is an important index of severity of the
vascular system and heart abnormalities.
It is useful to record:
₪ Rate: fast or slow (normal rate is 60-100/min)
₪ Rhythm: regular or irregular
₪ Volume: high, normal or low pulse pressure
(normal pulse pressure is 40-60 mm hg)
₪ Tension and force
₪ Character- some vascular diseases may show
different pulse character such as ‘water hammer’
pulse in aortic regurgitation, ‘pulsus paradoxicus’ in
pericardial effusion etc.
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₪ Blood pressure:
₪ It is useful to determine:
-The stroke volume of the heart and stiffness of the arterial
vessels.
-To assess severity of hyper and hypotension and aortic
incompetence.
₪ Normal level of blood pressure is 120/80bmm of hg
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₪ Body temperature
₪ Respiration
₪ Cyanosis
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EXTRA ORAL EXAMINATION
₪ SKIN: skin is looked for:
₪ appearance- any rashes, sores or itching may reveal
a positive history
₪ color- anaemia patients have a pale skin colour,
yellow tint is seen in jaundice patients etc.
₪ texture
₪ signs
₪ pigmentation
₪ edema
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₪ Facial symmetry: facial symmetry is important to note so
as to assess the fullness on both the halves of the face
and to look for any gross disorder that may reveal a
significant history. It is noted as symmetrical or
asymmetrical.
₪ TMJ(Temporomandibular joint): observed for:
₪ symmetry: gross derangement in symmetry may reflect growth
disturbances.
₪ maximum interincisal opening (normal value- 35-50 mm)
₪ any deviation in opening
₪ range of vertical movement
₪ range of lateral movement
₪ Listen for clicking and crepitus sounds
₪ Note for tenderness over joint or masticatory muscles
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₪ Palpation of the joint area:
₪ palpation of the pretragus area: the patient should be requested to
slowly open and close the mouth while the doctor bilaterally palpates
the pretragus depression with his/her index fingers.
₪ intra-auricular depression: it is also performed by inserting a small
finger into the ear canal pressing anteriorly.
₪ palpation is also used to detect the tenderness, clicking and crepitus.
₪ the masseter muscle is examined by simultaneously pressing it both
from inside and outside, termed as bimanual palpation.
₪ the lateral pterygoid muscle is examined by inserting a finger each
behind the maxillary tuberosities, and the medial pterygoid by running
a finger in anteroposterior direction along the medial aspect of
mandible in the floor of the mouth.
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₪ LYMPH NODES: palpation of
lymph node is done to:
 know the position
 number of nodes
 tenderness
 fixity to underlying tissues
₪ Palpation of the lymph nodes
of the neck commonly begins
the most superior nodes and
is worked down to the clavicle
to the supraclavicular nodes.
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₪ The superficial and the deep lymph
nodes of the neck are best examined
from behind the patient, with the
patient’s head inclined forward and
sideways sufficiently to relax the
muscles near the lymph nodes, and
then palpated.
₪ Also look for any distension present
in the superficial veins or any thyroid
enlargement
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₪ EYE
₪Indicator of the anaemia and jaundice
₪Infection of the maxillary teeth may extend to
orbital region – causing swelling of the eyelid and
conjuctivitis.
₪ NOSE
₪Size – should be 1/3rd of total facial height
₪Deviated nasal septum in mouth breathers
₪Saddle nose in congenital syphilis
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₪ SALIVARY GLANDS:
1) PAROTID GLAND
 Check for any swelling over the region.
 In case of parotid abscess, the skin over the area becomes
edematous with pitting on pressure.
 Examine the area for presence of any fistula, and enlargement of
lymph nodes or involvement of facial nerves.
2) SUBMANDIBULAR GLAND
 History of the patient is to be noted: eg swelling with pain at the
time of meals suggests obstruction in submandibular duct.
 Check for any nodal swelling, it may suggest of lymph node
enlargement.
₪ Bimanual palpation- in the open mouth, the physician’s finger
of one hand is placed on the floor of the mouth and pressed as
far as possible. The finger of the other hand is placed on the
exterior at the inferior margin of the mandible. These fingers
are pushed upwards and palpation is achieved.
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INTRA ORAL EXAMINATION
₪ SOFT TISSUES
1. TONGUE: examination should be done to check:
₪ Volume of the tongue: enlarged tongue may be due to
lymphangioma, hemangioma and neurofibroma.
₪ Integrity of the papillae: note the distribution and keratosis of the
papillae
₪ Any cracks or fissures: congenital fissures are mainly transverse
but syphilitic fissures are usually longitudinal.
₪ Any swellings or ulcers:
₪ Mobility of the tongue: check for the impairment of nerve supply
and ankyloglossia.
₪ Note for presence of cyanosis.
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₪ Palpation of the tongue: the tongue should be relaxed and at rest within the
mouth. A protruded tongue may give a false impression because of tensed
muscles.
2. PALATE:
check for:
₪ Clefts, perforations, ulcerations or any swelling
₪ Recent burns or hyperkeratinization
₪ Fistula, tori, papillary hyperplasia etc.
3. LIP: Inspection of lip constitutes:
₪ Lip color, texture and checking of surface abnormalities
₪ Cleft lip
₪ Pigmentation. Eg. Pigmentation of lips occurs in adison’s disease and peutz
jegherts syndrome.
₪ Any presence of neoplasm or chancre or diffuse enlargement of lip.
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4. FLOOR OF MOUTH:
₪ Patient is asked to open his mouth and to keep the tip of the
tongue upward to touch the palate. This will expose the floor of
the mouth. Check for:
₪ Color
₪ Swelling, if any
₪ Any presence of patches.
₪ Ankyloglossia
5. BUCCAL MUCOSA:
the cheek is retracted using a mouth mirror and checked for:
₪ Any ulcer, white patch or neoplasia.
₪ Pigmentation
₪ Observe the opening of stenson’s duct and establish their patency.
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HARD TISSUE EXAMINATION
1. TEETH -
a)NUMBER
b)NOTATION: by any of the three methods of notation:
1) FDI
Primary/Deciduous teeth
Right Left
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Permanent teeth
Right Left
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
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₪ C) Caries assessment: count the total number of caries and the tooth
number is to be noted.
₪ D) Filled teeth
₪ E) Any defected/fractured restoration
₪ F) Attrition, erosion and abrasion:
₪ Attrition is defined as the wear caused by tooth to tooth contact. A certain
amount of attrition is normal called as physiologic attrition.
₪ Erosion: Tooth surface loss caused by chemical or electrochemical action is
termed “corrosion.”
₪ Abrasion: Friction between a tooth and an exogenous agent causes wear
called “abrasion”.
₪ G) Root stumps.
₪ H) Fluorosis: it is an endemic disease in geographic areas where the
content of fluoride ion in the drining water exceeds 2 ppm. Fluorosis is
estimated by the dean’s fluorosis method.
₪ i) Any congenital deformity
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3) Radiological examination

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1)History taking
Conventional Radiography
• A conventional radiography is a 2-Dimensional
projection image of 3-Dimensional object
1) Intraoral radiography
2) Extraoral radiography

Specialized Radiography
A) Tomography
1. Conventional tomography
2. Computed tomography(CT scan)
B) Ultra sonography
C) Magnatic resonance imaging
D) Radio nuclied imaging
E) Sialography
F) Arthrography
G) Angiography
H) CBCT
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XRAY FILMS
Periapical films:
Size 0 For small children (22×35 mm)
Size 1 For anterior adult projections
(24×40 mm)
Size 2 For posterior in adults(most
frequent film) (31×41 mm)
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XRAY FILMS
Bitewing films:
Size 0 For children (posterior)
(22×35 mm)
Size 1 For children (anterior)
(24×40 mm)
Size 2 For adult (posterior) (31×41 mm)
Size 3 For adult (anterior) (27×54 mm)
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XRAY FILMS
Occlusal films:
Size of the film is 57×76 mm
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Conventional Radiography In
Detail
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INTRAORAL RADIOGRAPHY
1) IOPA
INDICATIONS:
1) Detection of periapical infection/inflammation
2) Assessment of periodontal status
3) After trauma to assess the teeth and alveolar bone
4) Assessment of presence and position of unerupted teeth
5) Assessment of root morphology
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6) During endodontic therapy
7) Postoperative assessment
8) Evaluation of apical cyst and other lesions within alveolar
bone
9) Assessment of position and prognosis of implant
VARIOUS TECHNIQUES:
1) Paralleling technique (long cone technique)
2) Bisecting technique (short cone technique)
3) Object localization
1. Right angel to another object
2. SLOB : Same lingual opposite buccal
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1) PARALLELING TECHNIQUE :
• Xray film is supported parallel to the long axis of
tooth and central ray of the xray beam is
directed at right angles to the teeth and film
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2) BISECTING TECHNIQUE :
• It is based on simple geometric principle known
as “the rule of isometry”,which states 2 triangles
are equal if they have two angles and share a
common side.
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3) OBJECT LOCALIZATION :
• To get the three dimensional information
1. Two projections taken at right angles to one another
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2. Tube shift technique (SLOB)
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2. Tube shift technique (SLOB)
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• AREA OF INTEREST IN IOPA :
• Teeth
• Lamina dura
• Alveolar crest
• Periodontal ligament space
• Cancellous bone
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2) BITEWING RADIOGRAPHY
• It is also called inter proximal technique
• Indications:
1) Detection of inter proximal caries
2) Monitoring progression of dental caries
3) Detection of secondary caries below
restoration
4) Evaluating periodontal condition
5) Useful for evaluating alveolar crest and
changes in bone height can be assessed by
comparison with adjacent teeth.
6) Detection of calculus
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• AREA OF INTEREST IN BITEWING RADIOGRAPH:
• Teeth crown portion
• Inter proximal space
• Alveolar crest
• Periodontal ligament space
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3) OCCLUSAL RADIOGRAPH
• TECHNIQUES :
• 1. Maxillary / 2. Mandibular
1. Cross sectional
2. Topographic
1. Anterior
2. Posterior / Lateral
3. Pediatric
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2. Occlusal radiograph
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• INDICATIONS:
1) To locate supernumerary ,unerupted or
impacted teeth
2) To locate foreign bodies in maxilla or mandible
3) To locate and evaluate extent of lesions
4) To evaluate boundaries of maxillary sinus
5) To evaluate facture of maxilla/ mandible
6) To aid in examination who can not open their
mouth more than few milimeter or who can not
tolerate other intraoral methods
7) To locate a retained roots of extracted teeth
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8) To examine area of cleft palate
9) To measure changes in the size and shape of
maxilla and mandible
10) As a midline view when using the parallel
method for determining the baccal and palatal
position of unerupted canines.
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EXTRAORAL RADIOGRAPHY
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EXTRA-ORAL FILMS
TYPES: 1-Screen films 2-Non screen films
INDICATIONS:
1. Patient unable to open mouth
2. View large area of pathology
3. General view of mandible or maxilla
4. View more bones of the face(skull or sinuses)
5. Impacted or un erupted teeth
6. Fractures of jaws & localization of F.B
7. TM joint
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EXTRA-ORAL LANDMARKS
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EXTRA-ORAL
Most commonly used views for maxillofacial imaging:
1) Radiography for the nasal sinuses:
2) Radiography for the maxillary sinuses:
3) Radiography for the mandible
4) Radiography of base of the skull
5) Radiography of zygomatic arch
6) Radiography for temporo mandibular joint
7) Radiography of skull
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Interpretation of radiograph
• Step-1 : Localized the abnormality
• Step-2 : Assess the periphery and shape
• Step-3 : Analyze the internal structure
• Step-4 : Analyze the effects of the lesion on
surrounding structures
• Step-5 : Formulate a radiographic
interpretation
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Specialized Imaging
1) Tomogram
A. Conventional Tomography
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• B. Computed tomography
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Advantages of tomography:
1. Better visualization in various minute
planes
2. Greater geometric precision
3. 3-D view of facial structure
4. Sensitivity to discriminate object with
small density
5. Exact localisation of lesions and their
extent
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2. Ultrasonography
• Principle of echo,by sound waves
• Echo recorded and converted into visual
image
• Limited application in OMFS
• Application in OMFS : Used in diseases of
salivary gland, lymphnodes
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3. MRI
• Application in OMFS:
1. Temporomandibular joint
2. Tumors of nasopharynx , parapharyngeal
area, salivary gland, tongue and
oropharynx
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4.Radionuclide imaging /
scintigraphy
• 99mTechnitium
• Metylene diphosphonate
• 67 Gallium
• Application in OMFS
1. Detect salivary gland disorders
2. Detect silent lesion of bony skeleton
3. Detection of primary malignant lesion
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4. Detection of infection like tuberculosis
5. To evaluate graft uptake
6. To evaluate treatment progress
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5. Sialography
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•fat-soluble contrast agents and
•water- soluble contrast agents

• Indications include:
• In the evaluation of the functional integrity of the salivary
glands
• In case of obstructions
• To evaluate the ductal pattern
• In case of facial swellings, to rule out salivary gland pathology
• In case of intra-glandular neoplasm.
• Containdications include:
• Persons who have allergy to iodine and/or contrast medium.
• Cases where there is acute infection,
• patients with thyroid function tests
• When calculi are located in anterior part of the salivary gland
duct
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6. Arthrography
• Opaque contrast material in joint space
• In TMJ to delineate upper and lower
compartment, Articular disc
• Contraindication:
• Acute infection
• Sensitivity to contrast medium
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7. Angiography
• For studying intracranial and extracranial
vessels
• Contrast medium injected in carotid artery
• Distribution pattern of external carotid artery
• aneurysms
• Arteriovenous malformation
• Vasular tumor
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2. Basic necessities for surgery
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• Main requirement of surgery are
1. Adequate visibility depend on:
– Adequate access
• Comfortable patient
• Proper retraction of tissue by assistance
• High volume suction
– Adequate light source
– Clean surgical field
2. Equipment
3. Assistant
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3. Aseptic technique
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• fundamental and essential principles
of infection control in the clinical and
surgical settings
• Aseptic Techniques are those which:
 Remove/reduce or kill
microorganisms from hands and
objects
 Employ sterile instruments and other
items
 Reduce patients risk of exposure to
microorganisms that cannot be
removed
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• Asepsis technique before and during a surgical procedure to
reduce postoperative infection:
1. Maintaining a Sterile Field
2. Surgical Attire
3. Hand washing, Surgical scrub, sterile gowning & gloving
4. Patients surgical skin preparation
5. Using surgical barriers, including sterile surgical drapes
6. Using safe operative technique
7. Maintaining a safe environment
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OPERATING ROOM ENVIRONMENT CONTROL
The surgical site should be
designed in such a way as to
minimize and control the spread
of infectious organisms
AIM
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1. UNRESTRICTED AREA
2. SEMI RESTRICTED AREA
3. RESTRICTED AREA
OPERATING ROOM COMPLEX DIVIDED INTO
3 AREAS
ACCESS CONTROL
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Scrub sequence
1. Scrub attire
2. Cap
3. Mask
4. Hand Scrub
5. Surgical Gown
6. Glove
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1
2
3
4

Scrub Attire
• Cotton scrub suits
• Shirt tucked into pants
• scrub-shoes and or shoe covers
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Cap
• Caps
– Prevent hair and scurf falling onto sterile field
– Various disposable types
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Mask
• Filters out micro-organisms when breathing
and speaking
• Ideally replaced for each operation
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Hand Scrub
• Reduces flora rather than eliminates
bacterial flora
– Transient flora (from environment)
• Most are harmless
– Resident flora
• Most (95%) are harmless
• Surface , can be removed by scrub
• Deep (glands and follicles) – cannot be removed by
scrub
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Scrubbing solutions should…
• Wide antimicrobial spectrum
• Quick action
• Long residual action
• Effective in organic matter (blood etc)
• Safe ( no irritation/allergy)
• Quick application
• Economical
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Scrub solutions
• Povidone iodine
• Chlorhexidine
• Triclosan
• Alcohol
– Not used as a scrub but may be used after
chlorhexidine
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Povidone iodine “Scrub”
• “Iovone®“
• Iodophore + detergent
• Excellent spectrum
– Bacteria, viruses, fungi
• Some individuals react severely
• Impaired by organic matter
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Chlorhexidine “Scrub”
• “Hibiclens®”
• Broadest spectrum
– Bacteria, viruses, fungi, spores
• Effective in organic matter
• Longer residual activity than povidone
iodine
• Relatively low toxicity
– Occasional sensitivity reactions
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Triclosan
• Newer
• Bacteria
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Alcohol
• 70%
– Note that 100% alchohol is less effective
– Also acts as a degreaser
– Moderate spectrum only
• Notably ineffective against spores
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Scrub preparations
Pump pack Disposable brush
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Scrub Station
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Pedal tap

Before Scrubbing
• Don Cap
• Don Mask
• Jewellery removed
• Fingernails
trimmed/cleaned
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2 Scrub methods
• Count brush strokes,
or
• Count time
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Count strokes
• Also known as the anatomic scrub
• Count 10 brush strokes on each skin
surface of hands and arms (up to just
below elbows). 4 surfaces of
– Fingers
– Palms
– Arms
• Rinse
• Repeat scrub and rinse (4 x)
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Count time
• Also known as the timed scrub
• 1st scrub of day 10 mins
• Between surgeries can do 5 min scrubs
(unless gross contamination has occurred)
e.g.
– Each Fingernail 10 strokes
– Each Finger surface 5 strokes
– Each palm and back of hand 5 strokes
– Each arm surface 5 strokes
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After scrubbing
• Rinse
• Hold hands elevated so
that water does not drip
from elbows to hands
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Drying Hands
• Sterile hand towel provided
– With sterile gown, or
– With sterile surgical pack, or
– In individual pack
• Use one half of towel` for each hand
• Hold hands in front, elbows
below hands
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Gowning 1
• Hold inside at collar
• Chest height
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Gowning 2
• Slip in hands
• Keep bare
hands inside cuffs
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Gowning 3
• Hold ties to the
sides for the
assistant
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Gowning 4
• Assistant ties
at back
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Gloving
Receiving Gloves
• From assistant’s hand, or
• From sterile field
– after assistant has placed onto this
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Receiving Gloves
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Gloving
• Of bare arms (“open”)
– Hands exposed
– Method used when a gown is not required
• Over sleeved sterile gown (“closed”)
– Hands not exposed
– With an Assistant
• “assisted gloving”, fastest method
– Without an Assistant
• Without exposing bare hands from gown, best method
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Open Gloving 1
• With Gown but exposed hands
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Open Gloving 2
• With Gown but exposed hands
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Closed Gloving 1
• Keep bare hand inside cuff
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Closed Gloving 2
• Pick up a glove
by cuff
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Closed Gloving 3
• Rest glove backwards on that same hand,
holding by edge of cuff
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Closed Gloving 4
• Grab cuff with other
hand
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Closed Gloving 5
• Slide second hand into glove without
exposing hand
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Closed Gloving 6
• Pull glove on with first hand, grabbing only
outside of glove through gown
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Closed Gloving 7
• Repeat on other hand but slip gloved
fingers under the cuff
• Avoid handling powdered inside of glove
with gloved fingers
– Glove powder causes severe wound reactions
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Assisted Gloving
• Gloved assistant
holds gloves open
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4. Planning for incision
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• Incision is defined as “A cut or a wound
deliberately made by an operator in the skin
or mucosa using a sharp instrument such as a
surgical blade, cautery,etc. so that underlying
structure can be exposed adequately for
surgical access”
• Principles for incisions:
1. Parallel to the structures without damaging
vital structures.
2. Along the langer’s line so scar formation is
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3.Use a sharp blade of proper size.
4.Use firm continuous strokes.
5.Incise perpendicular to the epithelial surface.
6.Placed on sound bone ,away from surgical
area to prevent dehiscence
7.Pen grasp with proper support and pressure to
produce atraumatic clean incision ,with
predictable depth.
8.Sharp angles tend to produce slough and
scarring
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For better aesthetic results the following
basic concepts are used.
• The incision may be hidden inside an orifice
e.g. oral cavity, nasal cavity.
• Hair bearing areas and hair lines provide
coverage.
• The junction of aesthetic units are useful
e. g. vermilion border, around ala of nose.
• Incisions are put in normal wrinkles, skin
creases etc
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5. Flap design
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Principles of Flap Design
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• Local flap
1. outlined by a surgical incision
2. carries its own blood supply
3. allows surgical access to underlying tissues
4. can be replaced in the original position
5. can be maintained with sutures and is expected
to heal
 Used in oral surgical, periodontic, and
endodontic procedures to gain access.

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• Complications
A. Flap necrosis
B. Flap Dehiscence
C. Flap Tearing
D. Injury to Local Structures

1. Base > Free margin
• to preserve an
adequate blood supply
• unless a major artery is present in the base
2. Width of Base > Length of Flap*2
• less critical in oral cavity, but length < width
• a long, straight incision with adequate flap reflection heals more
rapidly than a short, torn incision.
3. An axial blood supply in the base
4. Hold the flap with a retractor resting on intact bone to
prevent tension.
A. Flap necrosis
6 March 2019 134

1. The incisions must be made over intact bone
2. If the pathologic condition has eroded the
buccocortical plate, the incision must be at least 6 or 8
mm away from it.
3. The incision is 6 to 8 mm away from the bony defect
created by surgery.
4. Gently handle the flap's edges
5. Do not place the flap under tension
6. Do not cross bony prominences, ex: canine eminence
B. Flap Dehiscence
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6 March 2019 136
B. Flap Dehiscence

6 March 2019 137
• Envelope flaps
– an incision around the necks of several teeth.
– extends 2 teeth anterior and 1 tooth posterior.
If not provide sufficient access…
• Vertical (oblique) releasing incisions:
– extends 1 tooth anterior and 1 tooth posterior.
– started at the line angle of a tooth.
– carried obliquely apically into the unattached gingiva.
– If cross the papilla  localized periodontal problems
C. Flap Tearing

6 March 2019 138
• Mandible: lingual n. & mental n.

6 March 2019 139
• Maxilla: greater palatine a. & nasopalatine n./a.

6 March 2019 140
Summary

Types of Mucoperiosteal Flaps
6 March 2019 141
1. Envelope/ sulcular incision
2. Envelope with one releasing incision (three-
corner flap)
3. Envelope with two releasing incisions (four-
corner flap)
4. Semi-lunar incision
5. Y-incision
6. Pedicle flap

6 March 2019 142
2 teeth anterior
1 tooth posterior
1. Envelope/Sulcular flap
Edentulous:
at the crest of the ridge 
removal of a mandibular torus

6 March 2019 143
1 tooth anterior
1 tooth posterior
2. Three-corner flap
Greater access in an apical direction,
especially in the posterior aspect of the
mouth

6 March 2019 144
1 tooth anterior
1 tooth posterior
3. Four-corner flap
rarely indicated

145
4. Semilunar incision
to approach the root apex
avoids trauma to the papillae and gingival margin
useful for periapical surgery of a limited extent.
should not cross major prominences, ex: canine eminence

6 March 2019 146
5. Y-incision
removal of a maxillary
palatal torus

6 March 2019 147
6. Pedicle flap
mobilizes from one area and then rotates
to fill a soft tissue defect in another area.
closure of oroantral communications

6. Tissue handling
6 March 2019 148

• Apart from careful flap design and incision
technique, the careful handling of the tissues
is also necessary for optimal and
uncomplicated healing.
• Excessive crushing, pulling, extremes of
temperature, desiccation and harsh chemicals
damage tissues and these should be avoided.
• Toothed forceps and skin hooks are preferred
to forceps that crush the wound edges.
6 March 2019 149

• Avoid excessive pulling forces to retract
tissue.
• Use copious irrigation when drilling or cutting
bone.
• Protect soft tissue when drilling or cutting.
6 March 2019 150

7. Haemostasis
6 March 2019 151

Hemostasis
• No effort should be spared to minimize
blood loss. Wound hemostasis can be
obtained by:
1. Assist natural clotting processes by applying
pressure on a bleeding vessel or a
hemostat.
2. Use of heat- thermal coagulation.
3. Suture ligation.
4. Pressure on the wound.
5. Use of vasoconstrictors.
6 March 2019 152

8. Dead space management
6 March 2019 153

Dead space management.
• Defined as an area that remains devoid of tissue
after wound closure.
• Dead spaces are usually filled with blood which
delays healing and predisposes to infection.
• Can be managed in 4 ways.
1.Suture all tissue planes.
2.Pressure dressing.
3.Packing.
4.Use of drains.
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9. Decontamination and debridement
6 March 2019 155

Decontamination and debridement.
• Copious irrigation during and after surgery
removes debris and reduce the bacteria count
and minimizes the likelihood of infection.
• Necrotic, foreign and devitalized tissue should
be removed.
6 March 2019 156

Goals
1. Provide an adequate tension of wound
closure without dead space but loose
enough to obviate tissue ischemia and
necrosis.
2. Maintain hemostasis.
3. Permit primary intention healing
4. Reduce postoperative pain
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Goals
5. Provide support for tissue margins until they
have healed and the support no longer
needed
6. Prevent bone exposure resulting in delayed
healing and unnecessary resorption
7. Permit proper flap position
6 March 2019 159

Qualities of the Ideal Suture
Material
1. Pliability, for ease of handling
2. Knot security
3. Sterilizable
4. Appropriate elasticity
5. Nonreactivity
6. Adequate tensile strength for wound
healing
6 March 2019 160

Qualities of the Ideal Suture
Material
7. Chemical biodegradability as opposed to
foreign body breakdown
Postlethwait (1971), Varma et al. (1974), and Ethicon (1985)
6 March 2019 161

Usage
1. Silk and synthetic sutures are employed
most often
2. Gut sutures are used only when retrieval is
difficult, if not impossible.
3. When using gut (plain or chromic) sutures, it
is recommended to soak the package in
warm water. This will remove the kinks and
straighten the suture.
6 March 2019 162

Sutures and Suturing
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing
Plain gut Collagen from Digested + Moderate + + + Plain Rapidly +
healthy by body (Least) + + + + healing
mammals enzymes mucosa
within avoid
70 days suture
removal
Chromic gut Collagen from Digested + Moderate + + + Chromic As above +
healthy by body but less Slower
mammals enzymes than plain absorp-
treated with within gut tion
chromic salts + + + +
6 March 2019 163
Suture materials:

Suture Knot
Coated Copolymer of Hydrolysis + + + Mild + + Braided Subepi- + + + +
Vicryl lactide and 56-70 days coated elial
(Polyglactin glycolide Mucosal
910) coated with surfaces
polyglactin Vessel
370 and ligation
calcium All types
stearate of general
closure
PDS Polyester Slow + + + + Slight + + Mono- Absorbable + +
(polydi- polymer hydrolysis + filament suture with
oxanone) 180 - 210 extended
days wound support
6 March 2019 164
Suture materials:

Suture Knot
Dexon Homopolymer slow + + + Mild + + Braided subepith- + + +
(polygly- of glycolic hydrolysis + + coated elial
colic acid coated after 60 - sutures
acid) with 90 days Mucosal + + + +
polaxamer surfaces
188 Vessel
ligation
Surgical Natural Usually + + Moderate + Braided Mucosal + + + +
silk protein cannot be + + + + (least) surfaces
fiber of raw found after
silk. Treated 2 years
with silicon
protein or wax
Suture materials:
6 March 2019 165

Suture Knot
Nylon Polyamide Degrades at + + + Extremely + + Mono- Skin + +
Duralon polymer a rate of 15- low filament closure
Ethilon 20%per year 0 - +
Nylon Polyamide Degrades at + + + Extremely + + Braided Skin + + + +
Nurolon polymer a rate of 15- low closure
Surgilon 20%per year 0 - + Mucosal
surfaces
Polyester Polyester Nonabsorbable + + + Minimal + + + Braided Cardiova- + + +
Mersilene Polvethylene + scular and
Dacron Terephthalate plastic
Ethibond surgery
General
surgery
Suture materials:
6 March 2019 166

Suture Knot
Prolene Polymer of Nonabsorbale + + + Minimal+ + + Mono- General, + +
(polypro- propylene transient filament plastic,
pylene) acute cardiova-
reaction scular, skin
opthalmology
Gor-Tex Expanded Nonabsorbale + + + Extremely + + Mono- All Types + + + +
polytetrafluoro- low filament of soft-
ethylene 0 - + tissue
approxi-
mation &
cardiova-
scular
surgery
Suture materials:
6 March 2019 167

Suture Knot
Monocryl Poliglecaprone Hydrolysis + + + + Minimal + + + Mono- Soft- Most
25 Copolymer 90 - 120 + filament tissue pliable
of glycolide & days closure Synthetic
caprolactone absorbale
mono-
filament
ever
Suture materials:
6 March 2019 168

Knots
• A suture knot has three components
1. The loop created by the knot
2. The knot itself, which is composed of a
number of tight “throws”, each throw
represents a weave of the two stands
3. The ears, which are the cut ends of the
suture
6 March 2019 169

Principles of Suturing
1. The completed knot must be tight, firm,
and tied so that slippage will not occur
2. To ovoid wicking of bacteria, knot should
not be placed in incision lines
3. Knots should be small and the ends cut
short (2-3mm)
4. Avoid excessive tension to finer gauge
materials as breakage may occur
6 March 2019 171

5. Avoid using a jerking motion, which may
break the suture
6. Avoid crushing or crimping of suture
materials by not using hemostats or
needle holders on them except on the free
end for tying
7. Do not tie suture too tightly as tissue
necrosis may occur. Knot tension should
not produce tissue blanching
6 March 2019 172

8. Maintain adequate traction on one end
while tying to ovoid loosing the first loop
6 March 2019 173

Principles for Suture Removal
1. The area should be swabbed with
hydrogen peroxide for removal of
encrusted necrotic debris, blood, and
serum from about the sutures
2. A sharp suture scissors should be used to
cut the loops of individual or continuous
sutures about the teeth
6 March 2019 174

Principles for Suture Removal
3. It is often helpful to use a No. 23 explorer
to help lift the sutures if they are within
the sulcus or in close opposition to the
tissue
4. A cotton pliers is used to remove the
suture. The location of the knots should
be noted so that they can be removed
first. This will prevent unnecessary
entrapment under the flap
6 March 2019 175

5. Suture should be removed in 7 to 10 days
to prevent epithelialization or wicking
about the suture
6 March 2019 176

Surgical Needles
• Most of surgical needles are fabricated
from heat treated steel
• The surgical needle has a basic design
composed of three parts
1. The eye which is swaged and permits the
suture and needle to act as a single unit to
decrease trauma
6 March 2019 177

Surgical Needles
2. The body which is the widest point of the
needle and is also referred to as the grasping
area. The body comes in number of shapes
(round, oval, rectangular, trapezoid, or side
flattened)
3. The point which runs from the tip to the
maximum cross-sectional area of the body.
The point also comes in a number of different
shapes (conventional cutting, reverse cutting,
side cutting, taper cut,taper, blunt
6 March 2019 178

Needle Holder Selection
1. Use an approximate size for the given
needle. The smaller the needle, the smaller
the needle holder required
2. Needle should be grasped one-quarter to one
half the distance from the swaged area
3. The tip of the jaws of the needle holder
should meet before remaining portion of the
jaws
6 March 2019 181

Needle Holder Selection
4. The needle should be placed securely in
the tips of the jaws and should not rock,
twist, or turn
5. Do not over close the needle holder. It
should close only to the first or second
ratchet. This will avoid damaging the
needle
6. Pass the needle holder so it is always
directed by the operator thumb
6 March 2019 182

Placement of Needle in Tissue
1. Force should always be applied in the
direction that follows the curvature of the
needle
2. Suturing should always be from movable
to a nonmovable tissue
3. Avoid excessive tissue bites with small
needle as it will be difficult to retrieve
them
6 March 2019 184

4. Use only sharp needles with minimal force.
Replace dull needles
5. Never force the needle through the tissue
6. Grasp the needle in the body one-quarter to
one-half of the length from the swaged area.
Do not hold the swaged area; this may bend
or break the needle. Do not grasp the point
area as damage or notching may result
6 March 2019 185

7. Avoid retrieving the needle from the
tissue by the tip. This will damage or dull
the needle
8. Suture should be placed in keratinized
tissue whenever possible
9. An adequate tissue bite is required to
prevent the flap from tearing
6 March 2019 186

Suturing Techniques
1. Interrupted
a- Figure eight
b- Circumferential director loop
c- Mattress-vertical or horizontal
d- Intrapapillary
6 March 2019 187

Suturing Techniques
2. Continues
a- Papillary sling
b- Vertical mattress
c- Locking
6 March 2019 188

Suturing Techniques
• The Choice of technique is generally made
on the basis of a combination of the
individual operator’s preference,
educational background, and skill level, as
well as surgical requirement
6 March 2019 189

Periosteal Suturing
• Generally requires a high degree of
dexterity in both flap management and
suture placement. Small needles (P-3),
fine sutures (4-0 to 6-0) and proper needle
holder are a basic requirement
6 March 2019 190

Periosteal Suturing
• Technique
1- Penetration: The needle point is
positioned perpendicular (90°) to the
tissue surface and underlying bone. It is
then inserted completely through the
tissue until the bone is engaged.
6 March 2019 191

Periosteal Suturing
2- Rotation: The body of the needle is
rotated about the needle point in the
direction opposite to that in which the
needle intended to travel. The needle
point is held lightly against the bone so as
not to damage or dull the needle point
6 March 2019 192

Periosteal Suturing
3- Glide: The needle point is now permitted
to glide against the bone for only a short
distance. Care must be taken not to lift or
damage the periosteum
4- Rotation: As the needle glides against
bone; it is rotated about the body, following
its circumferenced outline. In this way, the
needle will not be pushed through the tissue
resulting in lifting or tearing of the
periosteum
6 March 2019 193

Periosteal Suturing
5- Exit: The final stage of gliding and
rotation is needle exit. The needle is
made to exit the tissue through the gentle
application of pressure from above, thus
allowing the tip to pierce the tissue
6 March 2019 194

Interrupted Sutures
• Indications
1. Vertical incision
2. Tuberosity and retromolar areas
3. Bone regeneration procedures with/without GTR
4. Widman flaps, open flap curettage, repositioned
flaps, or apically positioned flaps where maximum
interproximal coverage is required
5. Edentulous areas
6. Partial or spilt-thickness flap
7. Osseointegrated implants
6 March 2019
196

Interrupted Sutures
• Types
1- Circumferential, direct, or loop
2- Figure eight
3- Vertical or horizontal mattress
4- Interstitial papillary placement
6 March 2019 197

Interrupted Sutures
• Figure eight and Circumferential:
- Suturing is begun on the buccal surface 3-4 mm from
the tip of the papilla so as to prevent tearing of the
thinned papilla
- The needle is first inserted into the outer surface of
the buccal flap and then either through the outer
epithelialized surface (figure eight) or through the CT
under the surface (circumferential)
- The needle is then returned through the embrasure
and tied buccally
6 March 2019 199

Interrupted Sutures
• Mattress sutures:
- Are used for greater flap security and control
- They permit more precise flap placement
especially when combined with periosteal
stabilization
- They also allows for good papillary
stabilization and placement
6 March 2019 201

Interrupted Sutures
• Vertical mattress technique
– Needle is inserted 7-10 mm apical to the tip of
the papilla.
– Passed through the periosteum, emerging again
from the epithelialized surface of the flap 2-3 mm
from the tip of the papilla
– The needle is brought through the embrasure,
where the technique is again repeated lingually
or palatally
– The suture is then tied buccally
6 March 2019 202

Interrupted Sutures
• Horizontal mattress technique
– Needle is inserted 7-8 mm apical and to one side of
the midline of the papilla.
– Emerging again 4-5 mm through the epithelialized
surface on the opposing side of the midline
– The suture may or may not be brought through the
periosteum
– The needle is then passed through the embrasure,
and the suture after being repeated lingually or
palatally is tied buccally
6 March 2019 204

Interrupted Sutures
• Intrapapillary technique
– Recommended for use only with modified
widman flaps and regeneration procedures
– the needle is inserted buccally 4-5 mm from
the tip of the papilla, passed through the
tissue emerging from the tip of the papilla
– This is repeated lingually and tied buccally
6 March 2019 206

Interrupted Sutures
• Sling technique
– It is primarily used for a flap that has been raised
on only one side of a tooth involving one or two
adjacent papillae
– Most often used in coronally and laterally
positioned flaps
– The technique involves use of one of the
interrupted sutures, which either anchored about
the adjacent tooth or slung around the tooth to
hold both papilla
6 March 2019 207

Continuous Sutures
• Advantages
1- Can include as many teeth as required
2- Minimize the need for multiple knots
3- Simplicity
4- Permit precise flap placement
5- The teeth are used to anchor the flap
6- Avoid the need for periosteal sutures
6 March 2019 209

Continuous Sutures
• Disadvantages
– The main disadvantage of continuous suture
is that if the suture breaks, the flap may
become loose or the suture may come untied
from multiple teeth
6 March 2019 210

Continuous Sutures
• Types
1. Independent sling sutures
2. Mattress sutures
a- Vertical
b- Horizontal
3. Continuous locking
6 March 2019 211

Continuous Sutures
• Independent sling suture
– When flap position is not critical
– When buccal periosteal sutures are used for
buccal flap position and stabilization
– When maximum closure is desired
6 March 2019 212

Continuous Sutures
• Technique
– After the initial buccal and lingual tie, the suture
is passed about the neck of the tooth
interdentally and through the lingual flap
– Then again brought interdentally through the
buccal papilla and back interdentally about the
lingual surface of the tooth to the buccal papilla
– Then it is brought about the lingual papilla and
then about the buccal surface of the tooth
– This alternating buccal-lingual suturing is
continued until the suture is tied off with a
terminal end loop 213

Continuous Sutures
• Vertical and horizontal mattress suture
– The technique is similar to that previously
described for the interrupted suture
6 March 2019 215

Continuous Sutures
• Locking suture
– It is indicated primarily for long edentulous
areas, tuberosities, or retromolar areas.
– It has the advantage of avoiding the multiple
knots of interrupted sutures
– If the suture broken, it may completely untie
6 March 2019 216

Continuous Sutures
• Technique
– A single interrupted suture is used to make the
initial tie
– The needle is next inserted through the
underlying surface of the buccal flap and the
underlying surface of the lingual flap
– The needle is then passed through the remaining
loop of the suture, and the suture is pulled
tightly, thus locking it
– This procedure is continued until the final suture
is tied off at the terminal end
6 March 2019 217

11. Oedema control
6 March 2019 219

Oedema control.
• Results from the collection of fluid in the
interstitial spaces due to the transudation from
damaged vessels and lymphatics obstructed by
fibrin.
• More severe in areas with loose connective tissue.
• Oedema is minimized by:
1. Careful and gentle tissue handling
2. Use of ice packs.
3. Short term steroids.
6 March 2019 220

REFERENCES
1. Textbook of Oral Medicine & Diagnosis; Anil Govindrao
Ghom.
2. Textbook of Oral Radiology & Diagnosis; White & Ferroh.
3. Textbook of Oral & Maxillofacial Surgery; Neelima Anil Malik-
4th Ed.
4. Textbook of Oral & Maxillofacial Surgery; S M Balaji.
5. Textbook of Preoperative Health Status Evaluation; James E
Hupp.
6 March 2019 221

Basic principles of oral and maxillofacial surgery

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