Oral Surgery Lecture 4 – 02/01/08

Needle Design We use a reverse cutting needle We use a reverse cutting needle less tendency to cut through the mucosa less tendency to cut through the mucosa

Suture Size Size matters: Size matters: 3-0 and 4-0 intraoral 3-0 and 4-0 intraoral 5-0 and 6-0 extraoral 5-0 and 6-0 extraoral 11-0 microscope use required 11-0 microscope use required

Two Choices on Sutures Absorbable Absorbable Used at Pacific Used at Pacific Gut Gut Monofilamentous Monofilamentous Stick out Stick out Irritate the patient Irritate the patient Less forgiving Less forgiving Hard to tie Hard to tie Wicking problem Wicking problem Absorb in 2-3 days Absorb in 2-3 days

Two Choices on Sutures Non-Absorbable Non-Absorbable Used at Pacific Used at Pacific Silk Silk Polyfillamentous Polyfillamentous More wicking potential because of multiple strands More wicking potential because of multiple strands More comfortable to patient because it lays down flat when cut More comfortable to patient because it lays down flat when cut You control length of in-mouth time You control length of in-mouth time Immunocompromised patients because they take longer to heal and gut will resorb too soon Immunocompromised patients because they take longer to heal and gut will resorb too soon

Two Absolute Indications for Gut Over Silk Any patient needing prophylaxis for anything Any patient needing prophylaxis for anything For patients that don’t have to come back for post-op (or can’t come back due to whatever reason). For patients that don’t have to come back for post-op (or can’t come back due to whatever reason).

What we use in clinic In clinic we use “swedge” needles In clinic we use “swedge” needles Swank or swedge means that the thread of the needle fits into the hull of the needle itself Swank or swedge means that the thread of the needle fits into the hull of the needle itself When pulled through tissue there is no change in diameter When pulled through tissue there is no change in diameter Problem with swedge / swanks Problem with swedge / swanks Needle is a weak link because it is hollow Needle is a weak link because it is hollow Break needle if you grab it w/holder Break needle if you grab it w/holder

What Knot Do I Use? Everything we use here is based on the square knot: Everything we use here is based on the square knot: Spin twice around the needle and tie the knot, spin once around needle holder and tie the knot Spin twice around the needle and tie the knot, spin once around needle holder and tie the knot If you screw up a square knot: If you screw up a square knot: You get a granny knot You get a granny knot

Other Sutures Vertical matress Vertical matress Oral-antral perforations Oral-antral perforations Continuous / locking continuous Continuous / locking continuous Long spans Long spans Figure of eight Figure of eight Hold something in a socket Hold something in a socket

Suture Removal DON’T DRAG THE KNOT through the mucosa. DON’T DRAG THE KNOT through the mucosa. Cut flush under the knot Cut flush under the knot Grab the knot and pull the cut side through Grab the knot and pull the cut side through

Flap Design Full thickness is preferred Full thickness is preferred But you knew that… But you knew that… Rules: Rules: Cut to bone Cut to bone Incisions heal edge to edge, not from the corners to the middle, so… Incisions heal edge to edge, not from the corners to the middle, so… If more access is needed If more access is needed Extend envelope more Extend envelope more Drop a releasing incision Drop a releasing incision

More on Flap Design Releasing incision Releasing incision Make sure the base of the flap is wider than the margin so adequate blood supply will remain in flap for healing Make sure the base of the flap is wider than the margin so adequate blood supply will remain in flap for healing Vertical incision Vertical incision Make it at least one tooth distal and mesial from the surgical area Make it at least one tooth distal and mesial from the surgical area Make sure releasing incisions are over areas with supporting bone beneath so that the sutures will have support!

Anatomy Poop your pants Poop your pants If you cut the greater palatine artery If you cut the greater palatine artery Lots of collateral innervation Lots of collateral innervation At the long buccal nerve, so you can cut it. At the long buccal nerve, so you can cut it. No releasing incisions on the lingual of mandible No releasing incisions on the lingual of mandible Avoid the facial artery and lingual nerve Avoid the facial artery and lingual nerve Damaged by the Minnesota retractor Damaged by the Minnesota retractor Mental nerve Mental nerve

Envelope Flap Easy and more esthetic healing (perio people use this frequently). Easy and more esthetic healing (perio people use this frequently).