BASIC ORAL SURGERY
Incisions
-Most surgical procedures begin with an incision
Done with a blade holder and the surgical blade
(#10, #11, #12 and #15)
The proper way of loading the blade to the blade holder (bard
parker handle) is with the pen grasp for maximum control
Dupuytran (1884)
-Skin tension was first noted
-He observed that wounds are elliptical instead of
round
Karl Langer, Ritter von Edenberg (1861)
-Made a schematic representation of the incision of
greatest normal skin tension for all regions of the
body known as the “Langer lines” or “cleavage lines”
The Langer lines run parallel to the skin creases and
perpendicular to the action of the underlying muscles
Emil Theodore Kocher (1907)
-Recognised the surgical importance of Langer’s
tension lines and advised that surgical incisions
follow these lines
The incisions made parallel to the Langer lines generally heal
better and produce less scarring
Skin would be dosed under the least amount of tension and
the resulting scar would be minimal
Basic necessities of surgery
1. Adequate visibility
a. Adequate access
b. Adequate light
c. Surgical field is free of excess blood and other
fluids (suction)
2. Adequate assistance
Principle of an incision (Larry Peterson)
1. A sharp blade of the proper size should be used
2. A firm continuous stroke should be made when
incising
3. The surgeon should carefully avoid cutting vital
structures when incising
4. Incisions made through epithelial surfaces which the
surgeon plans to re-approximate should be made
with the blade held perpendicular to the epithelial
surface
5. Incisions in the oral cavity should be properly placed
I. Extraoral incisions
Principles of extraoral incisions
1. The blade should be held perpendicular to the
epithelial surface
Oblique incisions will result in a bias cut
2. Blade should be passed in one stroke over the pre-
determined length for the incision
Avoid irregularities in the wound ridge
3. The skin is slightly tensed by finger pressure to
provide uniform resistance of the passage of the
blade
Seven types of extraoral incisions
i. Submandibular incision
-Only done if the submandibular gland is involved
Used in surgical procedures wherein access to the body and
the angle of the mandible is necessary
The mandibular ramus and the condylar process are
accessible if the incision is extended posteriorly
ii. Risdon incision
-A slightly curved incision that involves the
mandibular angle and ramus
Both the submandibular and risdon incisions must be made
with care to avoid injury to the marginal mandibular branch of
the facial nerve
iii. Retro-mandibular incision
-Provides access to the mandibular ramus, angle and
condylar process
Required for the accomplishment of TMJ reconstruction for
agenesis or ankylosis in young persons
Advantage: avoids severing the branches of the facial nerve,
facial artery and vein
iv. Pre-auricular
-Provides access to the TMJ
Made within the skin crease anterior to the ear
Usually results in injury to the temporal and zygomatic
branches of the facial nerve
v. Gillies approach
-Access to the zygoma or zygomatic arch
Used for the reduction of a fractured zygoma (zygomatic arch)
Made within the hairline (completely hidden when the hair
regrows)
vi. Brow incision
-Provides access to the lateral bony orbit and the
zygomaticofrontal suture
vii. Lid incision
-Provides access to the inferior bony orbit and the
zygomaticomaxillary suture
II. Intraoral incisions
Principles of intraoral incisions (Daniel Laskin)
1. Incisions should not be made over the operative site
but rather in the adjacent undisturbed areas so there
would be adequate support of the tissues thereby
enhancing rapid vascularisation and healing to the
area
2. Incisions should be placed in areas wherein major
nerves and blood vessels are not intersected unless
necessary
May result in paraesthesia or excessive bleeding
Maintenance of adequate blood supply is of prime
importance (incisions should be made parallel to any
major blood vessel)
3. Incisions should not be made over thinned mucosa,
those found of bony exostoses or other bony
prominences
Because there is less blood supply to the area
Tissues are difficult to manipulate resulting in
tearing, dehiscence and poor wound healing
4. Incisions around teeth should be made in the gingival
crevice( sulcus)
The blade is run parallel to the long axis of the tooth
5. Maintain the integrity of the interdental papillae
-Destruction of the papillae results in
a. Necrosis and subsequent gingival recession
b. Interdental space exposure leading to
periodontal problems
Types
Horizontal incision (simple straight incision)
-Created in a mesial or distal direction
Made either in the crest of the alveolar ridge or along the
necks of the teeth (gingival sulcus)
Vertical incision (releasing incision)
-Created at one end or both ends of the horizontal
incision
Decreases tension over the incision line (tearing)
Flaps
-Made to gain surgical access to an area or move
tissue from one place to another
A surgical section of the gingivae surgically separated from
underlying tissue to provide visibility and access to the
underlying bone and root surfaces
Done with the periosteal elevator (molt #9)
Preventing complications of flap surgery
I. Flap necrosis
-Can be prevented if the surgeon attends to four basic
principles
1. The apex of the flap should never be wider than
the base, unless a major artery is present
2. Generally, the length of the flap should be no
more than twice the width of the base
3. When possible, an axial blood supply should be
included in the base of the flap
4. The base of flaps should not be excessively
twisted, stretched or grasped with anything that
might damage the vessels (these manoeuvres
may compromise the blood supply feeding and
drainage)
II. Flap dehiscence
-Dehiscence exposes underlying bone, produces pain,
bone loss and increases scarring
Sutures that are too tight cause ischemia of the flap margin
and result in tissue necrosis, with tearing of the suture
through the tissue
Thus sutures that are too tightly tied result in wound
dehiscence more frequently than sutures that are loosely tied
May be prevented by
1. Approximating the edges of the flap over healthy
bone by gently handling the flaps edges
2. Not placing the flap under tension
III. Flap tearing
-It is preferable to create a flap at the onset of
surgery that is large enough for the surgeon to avoid
either tearing the flap or interrupting surgery to
change it
A properly repaired long incision heals just as quickly
as a short one
Types
1. Unrepositioned flap – a flap is returned to its original
position
2. Repositioned flap – a flap is positioned apically or
coronally
Classification
I. Full thickness flap (mucoperiosteal flap)
-All of the soft tissue is reflected including the
periosteum to expose the underlying bone
-Commonly used in oral surgery
Layers
a. Surface mucosa
