Oral Surgery in General Practice.

Successful Surgery of the Mouth Follows Fundamental Surgical Principles

The Need for Adequate Knowledge and Equipment in Oral Surgery Practice is Discussed by

Arthur B. Crane, D.D.S., and Harry Kaplan, D.D.S. in

“ORAL SURGERY IN GENERAL PRACTICE.” PART I

 

This is the first of a series of three articles dealing with the problems of surgery met in the average dental practice. Dr. Crane, an outstanding oral surgeon needs no introduction to our readers. His discussions are most instructive and will aid many to overcome difficulties often encountered. The second and third parts will be published in the April and May issues of Nutrition and Dental Health.

Oral Surgery is a branch of dentistry and as such in theory should be thoroughly understood by the general practitioner. It is unwise for beginners to eliminate surgical procedures until they have at least mastered a rudimentary knowledge of surgical technic.

It is necessary in order to become competent in any branch of dentistry to develop a sort of sixth sense, which guides the mind into the proper channels in dealing with intricate problems. For this reason the greater the knowledge and more diversified the experience, the more efficient a man will become in any given branch. Some men are qualified by temperament to carry the responsibility which always follows the surgical invasion of human tissues, and they have also the type of nerves which act quickly in an emergency. These individuals will probably become fascinated by their ability to eliminate disease and aid injured tissues to repair. Others will find the obligations and anxiety constantly preying on their minds.

It cannot be doubted that any dentist who has the mechanical ability to construct an intricate bridge can also perform the most delicate surgical operation provided he is as thoroughly familiar with the anatomy and physiology of the parts as he is with the mechanical and physical aspects of his bridge material, and that he understands the requirements and technic of surgery as well as he understands the features of bridgework.

To times of economic stress it is not unusual for them to attempt to add to their diminishing incomes by ventures into new fields. This tendency is resulting right now in a falling off in the practice of the specialists, because it is leading many general practitioners to attempt the management of cases which were formerly referred. No fault can be found with this procedure providing the general practitioner is capable of rendering an adequate service.

Unfortunately for the general public, however, it would seem that many such practitioners are not taking the trouble to properly equip themselves, either with the knowledge or instruments necessary for satisfactory surgical technic. It is with the hope that some assistance can be given to those in general practice who find it expedient to do surgery, that this paper is written.

The primary requisite for success in the field of surgery is a thorough knowledge of the anatomy and physiology of the various tissues which come within the field. It would consume too much time to go into this phase of the subject deeply, but the knowledge is available and should be thoroughly mastered before the most insignificant operation is undertaken. The knowledge of anatomy and physiology makes the only substantial foundation for the mastery of pathology.

In the majority of cases the important question of how to operate sinks into insignificance, compared to the question whether to operate at all. In order to make such a decision it is necessary that the operator either gain such knowledge from wide observation and study of confine his operating to such simple procedures as are unlikely to involve a serious aftermath.

Diagnosis is a definite discrimination of disease based upon departures from normal and its value is increased directly according to the knowledge, experience, and judgment of the operator. The question of whether to operate can only be determined by correct diagnosis, and this involves not only a thorough knowledge of clinical symptoms, but an ability to determine whether the case would be better handled by some less radical procedure.

The surgery of the mouth is not subject to any unusual laws or magic formulae, but follows the fundamental surgical principles common to all living tissues. It is accordingly most enlightening for anyone who essays to render surgical treatment, to spend as much time as possible in the general operating rooms of good hospitals. This will not only help to develop the indispensable surgical sense but will impress upon the mind the benefit to be derived from a definite plan of procedure and the necessity for anticipating factors which may lead to success or failure.

  1. Scalpel.
  2. Bistoury.
  3. Blunt dissector.
  4. Retractors (tissue).
  5. Flexible and stiff probes.
  6. Assorted bone chisels.
  7. Hypodermic syringe.
  8. Mallet.
  9. Curets.
  10. Thumb forceps.
  11. Bone forceps.
  12. Bone files.
  13. Bone wheels.
  14. Surgical burs.
  15. Straight and curved haemostats.
  16. Surgical scissors.
  17. Needle forceps.
  18. Small half circle needles.
  19. Extracting forceps.
  20. Elevators.
  21. Aspirator points.
  22. Intra-oral spotlight.

Thus when an operation in the mouth is undertaken, the operator will first intelligently plan the sequence of things to be done, then pause as each step is accomplished to determine whether some additional operating is necessary or whether a deviation from the previous conception is desirable. For instance, take the simple operation of extracting a tooth and curetting the periapical area. From preliminary study of the case it may be planned to extract the tooth and then remove the granuloma with the curet. If the granuloma adheres to the tooth root and comes away with it, additional operating might seem to be unnecessary. But if the socket is carefully examined, a lateral communication with a residual area or an apical communication with the antrum may be found, and plan of procedure must be changed accordingly.

One reason that many general practitioners fail to get satisfactory results in surgery is that they have no adequate equipment. This work is of too much importance and carries too much responsibility to be attempted with inefficient instruments.

The instruments in Figure 1 constitute a set which will meet the minimum requirements.

 

 

Prepared Sponges Should be Available

In addition to the equipment just described, special provision must be made to assure a surgically aseptic technic. For this purpose suitable trays must be provided and all necessary sponges, dressings, and instruments must be sterilized prior to the operation. The instruments should be placed on a sterilized tray and be covered with a sterilized towel. Ready made sponges may be purchased but the office assistant can prepare them after slight instruction, which may be obtained from any trained nurse. (Fig. 2.) Usually two types of sponge are advisable: one inch flats and three inch rolled. A sufficient number of both are wrapped in a piece of unbleached muslin, securely folded in, and pinned. For those who have no autoclave, the packages may be treated with live steam until they are thoroughly saturated, after which they may be dried out in the oven of an ordinary gas stove. Towels and aprons should also be sterilized in a similar manner.

As aspirator, on the general principle of the saliva ejector is almost indispensable. However, a saliva ejector is hardly powerful enough for use in surgery. The standard types of air compressors may be connected through a wash bottle to any suction device, by means of non-collapsible rubber tubing. Ordinary surgical aspirator points are too large for use in the minute apertures which must always be cleared out in oral surgery. A small calcium aspirator may be found among the rhinological instruments but Doctor Herman Popkin1 of Trenton, New Jersey, recently suggested the adaptation of the jewelers’ mouth blowpipe for this purpose. The making of these blowpipes is made tapered so that the instrument more readily clears itself of debris. These pipes are of brass which may be readily chromium plated. Before this is done, however, the nozzle tip should be cut off and the remaining end be filed as blunt as possible.

Because of the depth of many surgical fields in the mouth, ordinary window or overhead illumination is frequently inadequate. A small intra-oral spotlight which will focus its rays at the bottom of the mouth socket is almost indispensable, if the full extent of all mouth wounds is to be efficiently examined. The two instruments just mentioned should be used by the assistant and she should be thoroughly instructed in the method of using them so that they are held in positions which do not obscure the vision of the operator.

It often requires a very nice discrimination to determine whether surgical interference is indicated, and if so when. Patients usually present themselves with either swelling or pain, or both. Time does not permit to go into the intricate field of differential diagnosis, but it may be stated as a general principle that any swelling without pain suggest a chronic condition or a tumor formation; while pain with or without swelling is usually a manifestation of an acute inflammation .

Chronic cases may well be deferred until all available information has been obtained. This may involve repeated clinical examinations, radiographic study, tissue section cultures, or even general physical examination. Pain, however, requires immediate treatment for its relief. Its source should be found and its cause removed if possible. If the painful swelling is caused by an accumulation of pus, it is a conservative caution to lance with a long incision, but the pus should not be squeezed out. After the incision, the closed beaks of the haemostatic forceps should be gently insinuated to the bottom of the abscess cavity and then be opened as wide as possible and slowly withdrawn. This will establish a pathway for drainage which should be prevented from closing by the insertion of a sterile piece of rubber dam.

Painful Swellings Should be Watched

Painful swellings which are hard and do not fluctuate or pit on pressure should be treated expectantly. This is best done by the use of continuous hot, moist packs. The technic consists in soaking thick flat sponges of gauze with saturated solution of magnesium sulphate. The sponge should be applied directly over the swollen area and be covered with a hot water bottle or a heating pad protected against moisture, in order to confine the heat. These sponges should be changed frequently enough to insure plenty of moisture.

The patient should be kept quiet and receive adequate supportive and eliminative medication, preferably under the direction of a physician. A couple of days of this treatment will frequently result in the establishment of resolution, which will be indicated by reduction in the size of the swollen area. More often suppuration will soften the swelling and pus will be drawn to a surface making lancing and drainage feasible.

Hard swellings which occupy the floor of the mouth and cause distention under the chin, as well as swellings which gravitate along the boundaries of the sternocleidomastoid muscle are very serious and unless the operator has had experience in dealing with these conditions, it is wise to obtain the assistance of a specialist.

Electrolytic Treatment Aids Alveolar Abscess

Pain unaccompanied by swelling, if it is caused by an incipient alveolar abscess or activity is a residual area may often be controlled by electrolytic treatment. The sponge of the positive pole should be saturated with magnesium sulphate solution and applied directly over the most painful area. The negative sponge may be moistened with salt water and placed in the palm of the patient’s hand. About six to ten milliamperes of current should be used for a period of fifteen to twenty minutes. Relief is often very marked at the conclusion of such a treatment. For home treatment, counter irritation of the gum immediately overlying the painful area with small mustard plasters is sometimes effective. It is also generally very comforting to apply an ice bag, which may be kept on for two hours at a time with an hour interval of rest.

Pain arising from pulp exposure or congested pulp exposure or congested pulp should be relieved by ordinary methods.

Pain arising from pericemental abscess, especially during the incipient stage, is often very obscure. It may be referred to teeth other than the one involved or even to teeth in the opposing jaw. The responsible tooth may ordinarily be found by its tenderness to percussion, its looseness, or by an area of congestion in the alveolar gingiva. The treatment consists in gently exploring the pyorrhea pocket with a blunt flat instrument until the confined pus is released. If the instrument is frequently dipped in Talbott’s iodine solution during the exploration, it will usually suffice for medication.

Pain arising from pericoronal infections about partially erupted third molars, may also be obscure. The same type of exploration as has just been advised should be used under the gum flap until the pus area is discovered. A small piece of sterilized rubber dam or Vaseline gauze should then be inserted under the flap into the pus area in order to insure continued free drainage.

Another obscure pain may arise from an exposed pulp in an upper third molar. Such pain is frequently referred to another tooth on the same side, in either the upper or lower jaw. It is often puzzling to have a patient insist that there is a toothache in a tooth which is normal to every test. Such a situation should immediately suggest a careful examination of the upper third molar.

Having accomplished these preliminary procedures it becomes necessary to determine whether the case is one for surgical interference, and if so to plan the operative procedures. The prime consideration is the question whether the patient will be more benefitted or harmed by immediate surgical interference.

The patient should be questioned to ascertain the general physical condition and if there is indication of serious debilitating disease, he should be referred to his physician for his opinion as to whether preoperative general treatment is advisable. If there is a generalized inflammatory or ulcerated condition of the oral mucous membrane this should be gotten under control prior to the operation. Especial caution is necessary in Vincents infection.

The operation most frequently required is the extraction of teeth. This procedure probably antedates all other surgical operations and for many years it was done in an empirical manner. More recently this operation has been recognized as one that has the potential possibilities of life and death, and therefore is not to be performed in any haphazard manner.

Careful Study Determines Type of Operation

Through careful preliminary study it should be determined if the case is one which is uncomplicated enough for the direct use of forceps or whether the tooth should be removed by the open view method. The decision as to the method of procedure depends upon the condition of the tooth crown, the shape of the tooth root, as indicated in the radiogram and the extent and nature of the periapical disease.

Where the crown of the tooth is not too much undetermined by caries and the root is tapered, the tooth can ordinarily be extracted successfully with the forceps alone. If the crown of the tooth becomes fractured in the attempt to extract with the forceps it is better to immediately proceed to the open view method. In any case, where the crown is badly decayed or the root shows extensive ex-cementosis (Fig. #), or the periapical diseased area is much larger in diameter than the root (Fig. 4), the open view method should be instituted at once.

 

Probably no operation in oral surgery has been subjected to more confusion than the open view method. This operation does not contemplate, as some imagine, the destruction of any considerable amount of alveolar bone, but by the retraction of a sufficiently large flap of soft tissue, enough of the external alveolar plate may be removed to permit the tilting of the root bucally with an elevator. If the root still binds, so that it cannot be delivered, an additional segment of the alveolar plate should be removed and this process continued until the root can be lifted without too much force.

Clean Field of Operation With Aspirator

Cleaning the field with an aspirator, it will now be possible by directing the spotlight into the bottom of the cavity, to determine the nature and extent of the periapical disease. When the visibility is clear, it is a simple matter to be certain that all diseased tissue has been eliminated. The flap may now be sutured back into place and the opening on the alveolar ridge closed, confining the blood clot, with the strong probability that it will organize without unpleasant post-operative sequelae.

Most open-view operations which cause post-operative trouble do so because of a faulty initial incision. The fundamental principle underlying excess is to establish the incision upon a surface of healthy bone at a considerable distance from the operative field. As a general rule the incision should be started at the middle of the gingival margin of the tooth anterior to the one to be extracted. It should be carried forward and downward in a disposal direction until the thicker tissue in the next proximal depression is reached, then it should be brought backward and downwards about the same distance. By blunt dissection, the flap including the periosteum should be stripped from the bone field sufficient exposure is obtained.

                A flap made in this manner will usually have sufficient retention with one suture at the point of the angle and one transalveolar suture at the mesial side of the socket (Fig. 5). Cogwell’s “Dental Oral Surgery”2 contains some instructive illustrations of this and other angular flap incisions.

If the area involved in the periapical disease is too large to be thoroughly evacuated through the tooth socket, an additional opening should be made in the alveolar plate immediately over it, rather than to destroy the entire buccal wall of the tooth socket. After the diseased tissue has been completely removed, the flap may be returned to place and sutured as in an ordinary case.

A precaution worth taking here, as well as in all cases where the apical alveolar plate has been destroyed by the progress of the disease, is to make a counter opening through the gum immediately into this area. Such treatment will permit drainage in the event that pus formation is not stopped by the surgery.

When the upper molar or biscuspid teeth are affected by periapical disease the bone forming the antral floor may be so disintegrated that the slightest pressure on a broken root tip will cause it to slip into the maxillary sinus. The same possibility exists with regard to the inferior dental canal (Fig. 6), in lower bicuspids and molars. In either of these situations it is safer to retract a flap of tissue and expose the root tip through the buccal plate in order that it may be removed by direct traction rather than by a prying motion.

To facilitate the application of forceps or elevators into the bifurcation of multi-rooted teeth, where the alveolar bone is thick and dense at the cervical margin, it is often helpful to incise the adjacent interdental papillae, so that the marginal gum can be retracted enough to allow a small portion of the interfering bone to be removed with the chisel.

                There are numbers of excellent textbooks, illustrated in such a manner that the principles of tooth extraction can readily be learned. But no matter what technic is used, it is of outstanding importance before the blood clot is allowed to form in the socket that all loose or diseased tissue and all foreign particles should be completely eliminated from the field; that all sharp projections of bone should be rounded and that all bone surfaces should be cut back to a point which will readily permit them to be covered with soft tissue or a thick blood clot. The patient should then be kept in the chair, under observation, until a blood clot, which completely fills the socket, has formed.

The use of mouth washes during this period should be discouraged and where bleeding has been inhibited by the suprarenin content of the local anaesthetic, it should be stimulated by massage or even by deeper openings into the adjacent tissue. It often seems that the law of contraries is at work after the extraction of a tooth, for those cases which should bleed often will not, and cases which are bleeding are often difficult to stop. Where excess bleeding is a factor, it is a good plan to place a folded gauze sponge over the tooth socket adding to its bulk until the opposite jaw can hold it in place with considerable pressure. In any case, it is much better not to pack the socket until every other available means of hemorrhage control has been tried.

                                                                                Arthur B. Crane,

                                                                                Harry Kaplan,

                                                                1726 Eye St. N. W., Washington, D. C.

 

REFERENCES

1 Herman Popkin—Personal communication.

2 Cogswell, Wilton, D., D.D.S., F.A.C.D.—Dental Oral Surgery; Outest Printing and Stationery Co.,                                          Colorado Springs, 1932.