Incision Sharp blade change if necessary Continuous stroke reduce tissue tearing Protect the vital structures Surgeon must focus on the blade while cutting Blade must be perpendicular on the surface ID: 921384
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Slide1
4) Access
Incision
Flap design
Slide2Incision
Sharp blade (change if necessary)
Continuous stroke (reduce tissue tearing).
Protect the vital structures.
Surgeon must focus on the blade while cutting.Blade must be perpendicular on the surface.Incision line must be on health gingiva and bone (never place the incision over the defect area).
Slide3Wrist movement rather than hand.
Blade always perpendicular on the tissue.
Steady stroke and movement.
Pen grasp.
Slide4Flaps
Full thickness mucoperiosteal flap
Partial thickness flaps.
Slide5Slide6Flap
Tissue reflected to provide access to surgical site.
Three major point with flap design:
Design to prevent flap necrosis.Design to prevent flap dehiscence.Design to prevent flap tearing.
Slide7Prevention of flap necrosis:
4 basic principles must be followed
Apex (tip) never wider than the base.
If 3 sided flap the releasing should be parallel or converged from the base to apex.
Length should be no more than twice the width of the base. Preferably the width is greater.Base of the flap should never be twisted or grasped excessively.
Slide8Base wider than apex
Length (y) no more than twice the width of the base (x)
Slide9Blood from vestibule towards the teeth .
The supply should always be available.
Slide10Prevention of flap dehiscence.
Usually achieved by approximation of flap on healthy bone.
Do not place the flap under tension.
Dehiscence will prevent healing by primary intention (which we want to achieve), healing will be by secondary intention (will include bone exposure, pain) healing will by time with granulation tissue which will create scarring.
Slide11Prevention of Flap tearing
Long flap heal the same as short flap (do not attempt to make short flap if you need more access).
Well designed flap according to the surgical procedure will reduce the risk of tearing.(choose your flap wisely; envelop, 2 sided, 3 sided)
Gentle handling.
Slide125) Hemostasis
Control bleeding during surgery
Good visualization.
Too much bleeding increase the risk of hematoma.
HematomaPlace pressure on the wound.
Decrease vascularity.
Potential space for micro-organisms and infection.
Slide13Hemostasis
Pressure
Small vessels can be controlled by applying pressure for about 20-30 seconds
Large vessels require pressure 5-10 mins continuous
DO NOT WIPE [that will remove the clot]. Dab the bleeder do not wipe it.
Slide14Hemostasis
Heat
(thermo-coagulation)
Electrical current (electro-cautery)
Must be applied to the bleeder vessel OTHERWISE it will cause burn.
Clean field with controlled fluid accumulation such as saliva and blood.
Slide15Hemostasis
Ligation
Ligate the bleeding vessel by using suture.
Slide16Slide17Hemostasis
Pressure dressing (with hemostatic material or without).
Periodontal pack
Hemostatic agents (bone wax,
surgicel®).The most effective is
Tranexamic acid (5% mouth rinse)
Slide18Dead space
:
any area that remains devoid of tissue after closure of the wound.
Created (usually due to blood accumulation within space created by the surgery; that will create hematoma which is potential risk for infection)
Remove too much tissue in depth of the wound.
Poor re-approximation of wound planes and edges.
Slide19Elimination of dead space.
Suture all the planes of the wound.
Apply pressure [depending on the size of the space].
Packing the wound with dressing material which will provide pressure and antibacterial properties.
Drain; if large space is created a drain should be place into the space to prevent fluids and blood accumulation.
Slide20Edema
is an accumulation of fluid in the interstitial space because of transudation from damaged vessels and lymphatic obstruction by fibrin
Degree of edema depends on 2 variables:
The amount of tissue injury
The looser the connective tissue.
Slide21How to manage edema
Reduce tissue damage and better tissue handling.
Corticosteroids (especially if given before tissue damage (pre-op)) [4 -8 mg dexamethasone I.M. or I.V.]
Ask the patient to keep his head above the level of the body in the post-op period.
Post-op Ice application (debatable: no control study to confirm its effectiveness)
Slide226) Prevention of wound infection
Before closure good irrigation to the surgical site will decrease the bacterial count.
Gentle tissue handling and good suturing will decrease the risk of contamination.
Remove all debris and sharp bone to ensure good closure.
Wound debridement; remove any necrotic tissue. All necrotic tissue must be removed before closure. If large space and suture not possible then closure must be achieved with a surgical pack.
Slide237) Patient support
Good medical history
Depending on the operation; we can decide the type of antibiotics and pain killers that we must use.
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