Minor Oral Surgery Seminar

• The soft tissue flap gives access to the surgical site; it's also expected to heal following the procedure and must be designed to avoid any significant anatomical structures.
• When planning the flap design you should consider: the size of the flap and the number of sides (both of which will influence access to the surgical site). The flap must be large enough to allow you to visualise the whole surgical site which often includes not only the tooth for removal but also the surrounding bone. If the flap is too small it is more likely that you will have difficulty visualising the surgical site and may traumatise the flap trying to reflect it adequately.
• In minor oral surgery flaps are classified according to the number of sides they have (1, 2, or 3 sides). Relieving incisions (present on 2 and 3 sided flaps) will also affect access to the surgical site by influencing the how much the flap may be reflected. When using a buccal approach (which is the approach you will take for all your cases in 4th year), increasing the number of sides will generally increase the reflection possible. It is important to ensure that the relieving incision does not encroach on any significant anatomical structures.
• Example of flap design in minor oral surgery:

  • 1 sided flap (envelope flap)

  
• Example of flap design in minor oral surgery:

  • 2-sided flap

  
• Example of flap design in minor oral surgery:

  • 3-sided flap

  
• The instruments you use to facilitate raising the flap:

  • Scalpel
  • Warwick James elevator (Molt no. 9)
  • Howarths periosteal elevator
  • Mitchells trimmer
• Incising and raising the flap (part 1): Start by incising the flap with the scalpel using your plan as a guide. Hold the blade in a pen grip and press firmly. It's important that you pass through all the soft tissue layers (mucosa, submucosa and periosteum). Failure to do so will result in difficulty raising the flap from the bone. When incising the flap make sure that you include any interdental papilla with the flap.
• Incising and raising the flap (part 2): Once incised, the flap is raised. It's helpful to initially free the interdental papilla - can be done with a curved Warwick James elevator/the small end of the ash. The remaining soft tissue flap is raised from the bone with a periosteal elevator, such as the ash, Howarths or Mitchells. The key aspect of this stage of the process is identifying the plane between the soft and hard tissues. Once this process has begun it may be helpful to retract the raised section of the flap with a Howarths while you continue to raise the flap with the ash or Mitchells.
• Incising and raising the flap (part 3): When the flap has been raised in its entirety, it's retracted with a rake retractor. The retractor should rest on underlying bone to avoid flap trauma by placing the flap under undue tension. Following completion of surgery, the flap should be repositioned & is expected to heal. Making sure the flap has a broad base will ensure an adequate blood supply - will reduce risk of flap necrosis. This may be achieved by flaring the relieving incisions. Ensuring the flap margins are repositioned onto sound bone is also desirable, so flap is well supported.
• Bone removal is often indicated to facilitate the surgical extraction. There are a number of reasons for removing bone and it is important to be clear about what you are aiming to achieve before you start because removing bone inappropriately may hinder the extraction (for example too much bone removal may remove a potential point of application).
• Reasons for undertaking bone removal:

  • To reveal the tooth
  • To provide a point of application for an elevator
  • To provide access to a furcation of a tooth prior to sectioning
  • To relieve an impaction
• Bone removal is carried out using a surgical handpiece and a rosehead (round) bur. The surgical handpieces in the department have a line attached directly to the handpiece in order to provide irrigation with saline while they're in use, thereby preventing the bone from overheating.
• Be aware that the surgical burs used for bone removal are longer than those in other areas of dentistry. It is really important to protect the soft tissues from the rotating bur while in use in order to prevent trauma. In terms of positioning, you should usually aim to work down the long axis of the tooth.
• It will often be necessary to section a tooth prior to extracting it in a surgical situation. In particular, when you are extracting multi-rooted teeth or where a tooth is impacted. In the case of multi-rooted teeth it is advisable to begin sectioning the tooth at the level of the furcation.
• Sectioning is carried out using a fissure bur. We advise that you use the fissure bur to create a deep groove initially, then use an elevator (such as a Couplands 1) to propagate the fracture. This approach ensures that the tissues adjacent to the tooth in question are protected. The position adopted for sectioning will depend on a number of factors but is often perpendicular to the long axis of the tooth. When sectioning a tooth, again, you should be mindful of protecting the soft tissues.
• The tooth is removed either whole or in sections using a choice of elevators or forceps. Where elevators are used, they apply a slow and deliberate force to the tooth/root and require a fulcrum (usually bone). Used in this way, elevators facilitate removal of the tooth by guiding it along its natural path of withdrawal, which will be influenced by the shape of the tooth. Take care not to apply excessive force, in particular avoid using the elevator as a class 1 lever (crowbar motion) as this will increase the risk of fracture.
• Once the tooth has been removed, smooth off any sharp edges of bone with a Mitchells or bur then make sure that any debris/loose bony fragments are removed from both the socket and underneath the flap. You should then use saline to irrigate before closing the wound.
• When you reposition the soft tissue flap you need to ensure that any relieving incisions are realigned and following this that the repositioned flap is stabilised. Start by repositioning the edges of the relieving incision (if the flap is 2 sided). There are no set numbers of sutures you must use, sometimes one is enough.
• You will use the resorbable suture material vicryl on your oral surgery clinical attachment MOS block. The needle has an inside cutting edge. Take care when passing the needle through the tissues because if you pull the needle towards yourself it may tear the mucosa. Be mindful of managing your needle while knot tying. Use single interrupted sutures secured with a surgeon's knot. Following placement vicryl takes 4-6 weeks to resorb.