Feature Article
Vision Keys for Precise Oral Surgery Dr Stephen MacMahon OBE BDS(Syd) FRMS FDSRCS(Eng) BA(Aviation)
Dr. Stephen MacMahon OBE has almost 40 years experience in Minor Oral Surgery. He was a staff member at Westmead Hospital in Oral and Maxillofacial Surgery Department for 20 years, having retired at the end of 2011. During his years at Westmead Hospital, he was actively engaged in teaching undergraduate and post-graduate students in Minor Oral Surgery. For 12 years, he also participated in preparing an undergraduate programme in minor Oral Surgery for Dental Students at the Fiji School of Medicine. He retired from this service five years ago but is a regular examiner to the school. He has been a member of the Dental Team at HMAS KUTTABUL for the past 10 years and continues to treat ADF patients at his rooms. Semi-retirement has given Dr MacMahon more time to finish a manual in Minor Oral Surgery.
Introduction Minor Oral Surgery, or precisely Dento-alveolar surgery, consistently falls into the realms of ‘uncertainty’ for the inexperienced Dental Surgeon. As Dentistry has exited out of the era affectionately referred to as ‘blood and guts’ dentistry, into an era of sophisticated preventive and restorative Dentistry, the art of exodontia and minor oral surgery appears to be pushed back into a minor role in undergraduate training. Hence the new graduate lacks experience when confronted with such tasks, especially when no support is available. Grasping fundamental steps in this surgical discipline, goes a long way in developing a procedure of understanding, which in practice, and when adhered to, makes the outcome a better experience for the operator and patient alike.
Vision keys for precise surgery The ideal outcome of any minor surgical procedure can be outlined as follows: 1. To successfully remove a tooth, fragment or tissue with minimal trauma to the surrounding tissues for rapid healing and low morbidity. 2. To complete the surgery with minimal stress to the patient and also the operator. 3. To maintain a high standard of infection control with the surgery. To achieve this outcome, certain ‘Vision Keys’ need to be adhered to, to get an ideal outcome and can be outlined as follows: 1. Sound Diagnosis and Treatment Planning for both the existing problem and the total patient. 2. Must utilise appropriate consultation and referral. 3. Competence for the surgical procedure. 4. Preparation for emergencies, complications or threat to patient’s safety during the intra-operative and post-operative period.
Diagnosis and Treatment planning Any treatment planning will be determined by the patient’s medical history. A methodical approach to obtaining a medical history is mandatory in the first instance. One can then ask oneself two questions: CADMUS 2012
1. Will the patient’s medical condition compromise the surgery? 2. Will the surgery compromise the patient’s medical condition? Once this information is on board, a thorough dental examination is required. Unless the patient’s dental condition requires urgent management, it is wise to consider caries stabilisation and plaque control prior to surgery. If any of the abutment teeth to the surgical site have deep caries, it is essential to place sedative dressings or pulpal extirpation prior to the planned surgery. This vital step will hopefully avoid any dental interference of the abutment teeth or neighbouring teeth during the healing phase of the surgery. Remember: All surgical cases, whether intended or emergency, must be precisely planned. This step is one of the greatest failings of the inexperienced operator. A plan should be made and adhered to unless by other unforeseen circumstances, an alternate plan needs to be made. Once this discipline has been achieved, the procedure should have a more predictable outcome. Surgical Planning There are 3 stages to surgical planning; 1, ACCESS 2. METHOD OF DELIVERY OF THE TOOTH OR FRAGMENT 3. CLOSURE 1. Access Access to a surgical site is achieved by an incision and reflection of a clean muco-perosteal flap. A flap has to be designed to achieve access for adequate instrumentation to deliver the tooth or fragment. There are a list of rules that need to be considered for flap design: 1. The margins of the flap must rest on sound bone when repositioned to achieve optimum healing. 2. The base of the flap must be broader than its apex to maintain a good blood supply for closure. 3. Two sided flaps are preferable for access and vision. 4. The flap itself must be broad enough for good access. 5. The relieving incision must, in most cases, be on the mesial side of the wound for access and vision. 6. The relieving incision must end in ‘free gingiva’ for adequate reflection.
47