Armamentarium

ARMAMENTARIUM IN ORAL AND MAXILLOFACIAL SURGERY

PROF. OTASOWIE D. OSUNDE

  • BDS, PhD, FWACS, FAOCMF

  • DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

  • UNIVERSITY OF CALABAR - CALABAR

OUTLINES

  • INTRODUCTION

  • ELEVATORS

  • EXTRACTION FORCEPS

  • BONE CUTTING INSTRUMENTS

  • SOFT STAINLESS STEEL WIRE

  • MISCELLANEOUS INSTRUMENTS: TISSUE FORCEPS, RETRACTORS, CHEATLE FORCEPS, DRAINS, ETC

  • LASER

  • CONCLUSION

INTRODUCTION

  • Armamentarium: Comprises all the instruments, equipment, and materials used in the practice of oral and maxillofacial surgery.

  • Scope of oral and maxillofacial surgery includes:

    • Dentoalveolar surgery

    • Head and Neck Infections

    • Cranio-Maxillofacial Trauma (soft and hard tissues)

    • Cysts and Benign Tumors of the Mouth and Jaws

    • Malignant Tumors of the maxillofacial region

    • Cleft lip and Palate Surgery

    • Orthognathic Surgery (surgical correction of jaw deformities)

    • Reconstructive Maxillofacial Surgery

    • Aesthetic Maxillofacial Surgery

    • Maxillary Sinus Surgery

    • TMJ pathology including TMJ Surgery

    • Preprosthetic and Implant Surgery

    • Craniofacial Distraction Osteogenesis

ELEVATORS

  • Periosteal Elevator: e.g., MOLT, HOWARTH

    • Function: Detach the periosteum from bone post-incision or detach gingival tissues around the tooth neck before forceps application.

    • Features: Double-ended with one round, blunted end and one pointed end.

    • Tray Setup: Used for most surgical procedures, such as extractions, gingivoplasty, alveoplasty, cyst removal.

DENTAL ELEVATORS

  • Purpose: Luxate teeth from the socket prior to extraction forceps, expand the bony socket.

  • Components: Handle, Shank, and Blade.

  • Classification:

    • Straight or Gouge Type

    • Triangular Type

    • Pick Type

WORK PRINCIPLES OF DENTAL ELEVATORS

  • Three applicable work principles:

    1. Lever Principle: Commonly used; the elevator acts as a lever (first degree) with the fulcrum between effort and load, enhancing mechanical advantage.

    2. Wedge Principle: Elevator forces between root and bone, parallel to the long axis of the tooth.

    3. Wheel and Axle Principle: A modified lever principle; effort applied to wheel circumference raises the axle, effectively lifting weight.

  • In practice, these principles work in combination during tooth extraction.

WORKING RULES IN THE USE OF ELEVATORS

  1. Never use adjacent tooth as a fulcrum.

  2. Never use buccal and lingual plates as fulcrum.

  3. Utilize finger guards to protect soft tissues against slippage.

  4. Support the shank with the index finger to control applied forces.

  5. Elevate from the buccal side; the concave or flat surface must face the tooth/root aimed for elevation.

STRAIGHT ELEVATORS

  • Usage: Common for luxating teeth.

  • Function: Loosen tooth or root from bony socket before forceps placement.

  • Features: Straight handle, single rounded working end (concave surface on one side).

  • Examples: Coupland, Straight Warrick James.

  • Tray Setup: Tooth and root extraction.

CRYER’S ELEVATOR

  • A straight elevator with a triangular blade.

  • Working End: Angulated with convex and flat surfaces, flat is the working side.

  • Types: Comes as left and right.

  • Works Based On: Lever and wedge principles.

  • Uses: Extraction of retained roots of mandibular molars.

COUPLAND ELEVATOR

  • Manufacturer: G. Hartzell & Son, Germany.

  • Material: Stainless steel.

CRYER ELEVATORS

  • Manufacturer: G. Hartzell, stainless steel, USA.

EXTRACTION FORCEPS

  • Function: Designed to deliver the tooth from the socket.

  • Features: Each forcep comprises two handles, a joint, and two beaks.

  • Clinical Application:

    • For mandibular teeth, beaks applied along the long axis below the cemento-enamel junction.

    • For maxillary teeth, beaks applied above the cemento-enamel junction.

    • Ensure a firm grip prior to movements.

MAXILLARY EXTRACTION FORCEPS

  • Design: Handles and beaks are at 180 degrees.

  • Maxillary Anterior Forceps:

    • Beaks are identical, closed, straight, flat, and broad.

    • Uses: Extraction of maxillary incisors and canines.

    • Basic Forces:

    • Maxillary central incisors: Labial movements, mesial rotation.

    • Maxillary lateral incisors: Combined rotational and labio-palatal movements.

    • Maxillary canines: Combined rotational and labio-palatal movements.

MAXILLARY PREMOLAR FORCEPS

  • Design: Identical, broad, open, concave inner beaks.

  • Usage: Extraction of maxillary first and second premolars.

  • Basic Forces:

    • First premolars: Bucco-palatal movements (tooth delivery buccally).

    • Second premolars: Rotational and bucco-palatal movements (tooth delivery in buccal or palatal direction).

MAXILLARY MOLAR FORCEPS

  • Design: Left and right forceps with non-identical beaks.

  • Operation: Pointed beak engages between mesio-buccal and disto-buccal roots; rounded beak engages palatal root above the cemento-enamel junction.

  • Basic Forces:

    • First and second molars: Bucco-palatal movements (tooth delivery buccally).

    • Third molars: Buccal movements, distal rotation.

MAXILLARY ROOT FORCEPS

  • Maxillary Anterior Root Forceps: Identical, straight, slender, closed beaks.

  • Maxillary Posterior Root Forceps: Similar to anterior type but curved for posterior access.

  • Bayonet Forceps: Pointed, angulated, closed identical beaks of varying lengths for removing retained maxillary root stumps.

MANDIBULAR EXTRACTION FORCEPS

  • Design: Beaks and handles at right angles.

  • Mandibular Anterior Forceps:

    • Identical, short, broad, closed beaks for extracting anterior teeth (incisors and canines).

    • Basic Forces:

    • Central and lateral incisors: Labio-lingual in combination with rotational movements (tooth delivered labially).

    • Canines: Labio-lingual in combination with rotational movements (tooth delivered labially).

MANDIBULAR PREMOLAR FORCEPS

  • Identical, broad, open beaks longer than anterior forceps.

  • Used for extraction of first and second mandibular premolars.

  • Basic Forces: Extraction using bucco-lingual and mesio-distal movements (tooth delivered in the buccal direction).

MANDIBULAR MOLAR FORCEPS

  • Identical, broad open beaks with pointed tips; tooth delivered using bucco-lingual movement.

MANDIBULAR ROOT FORCEPS

  • Identical, closed slender beaks longer than lower premolar forceps; for extracting retained roots of all mandibular teeth.

BONE CUTTING INSTRUMENTS

  • Rongeurs Forceps:

    • Features: Sharp, angulated beak with a concave inner surface; can be side cutting, end cutting, or a combination.

    • Design: Long, curved handles with spring action for increased gripping force.

    • Use: Remove large amounts of bone in multiple small bites.

CHISEL

  • Type: Uni-bevelled instrument for cutting bone.

  • Structure: Heavy round handle and a flat sharp working tip.

  • Uses:

    • Remove chips of bone during third molar extraction.

    • Split teeth in difficult extractions.

    • Smoothen rough bony surfaces (to plane bone).

  • Working Rule: The bevel faces the bone for planing, and away from the bone for cutting.

OSTEOTOME

  • Similar to chisels but with a bi-bevelled working end.

  • Uses: Osteotomy procedures, biopsy of bony lesions, bone removal or recontouring.

  • Mallet: Similar to a hammer, used for controlled taps on chisels, osteotomes, or bone gouges.

Other bone cutting instruments: Gigli saw, power drills.

MISCELLANEOUS INSTRUMENTS

  • Retractors: For retracting soft tissues, cheeks, tongue, or flaps during surgery. Examples include Langebeck’s retractor, Austin’s retractors, ramus retractors, tongue depressors.

  • Tissue Holding Forceps: For holding tissues during surgery. Examples: Allis’ Tissue holding forceps, Babcock’s forceps.

  • Toothed and Non-toothed Tissue Holding Forceps:

    • Plain forceps (non-toothed) for delicate tissues (e.g., peritoneum, delicate muscles, blood vessels, nerves).

    • Toothed forceps for tougher structures.

  • Utility in Suturing: Toothed forceps hold needles during suturing.

SOFT STAINLESS STEEL WIRE

  • Diameter: 0.5mm.

  • Forms and Uses:

    1. Eyelet Wires: For inter-maxillary fixation (IMF).

    2. Tie-Wires: To link eyelets together.

    3. Inter-osseous Wiring: For open fixation of fractures.

    4. Inter-dental Wiring: Approximate fracture segments and fixation of luxated teeth post-trauma.

    5. Suspension Wires: Used less frequently due to the emergence of bone plates in maxillofacial trauma.

    • Examples: Fronto-Mandibular suspension wire, Circum-mandibular suspension wire, Circum-zygomatic suspension wire.

INDICATIONS FOR IMF

  1. Maxillofacial Trauma

  2. Cosmetic reasons

  3. Stabilization post-mandibulectomy

CONTRA-INDICATIONS

  • Medical conditions such as:

    1. Epilepsy

    2. Chronic obstructive airway diseases

    3. Asthma

    4. Psychiatric patients

    5. Pregnancy

    6. Children

MISCELLANEOUS INSTRUMENTS (CONTINUED)

  • Cheatle’s Forceps: For picking sterile instruments.

  • Towel Clips: Used for holding drapes.

  • Scalpel: Comprising a blade and a handle; commonly used sizes are 10, 11, 12, 15.

  • Dissecting Scissors: For soft tissue dissection.

  • Sinus Forceps: For draining abscess/cellulitis with a long shank and blunt ends.

  • Needle Holders: For holding needles during suturing.

  • Haemostatic Forceps: For clipping blood vessels.

LASER (Light Amplification by Stimulated Emission of Radiation)

  • Function: To remove soft tissue with minimal discomfort and bleeding; also exhibits bacteriocidal effects, enhancing wound healing.

  • Applications:

    • Frenectomy

    • Excision of lesions

    • Gingivoplasty

    • Crown lengthening

    • Root canal therapy

  • Clinical Applications: Important safety precautions

    • Laser beam is hazardous to eyes and skin; protective goggles are mandatory for patient, operator, and assistant.

    • Non-shiny instruments are preferable to avoid reflection.

    • Smoke plume forms during tissue vaporization; use high-volume evacuation during the procedure.

CONCLUSION

  • A thorough knowledge of the various instruments available in oral and maxillofacial surgery is fundamental to effective practice.

  • Improper instrumentation can lead to inefficiencies and complications, emphasizing the need for proper understanding and usage of surgical armamentarium.