CASE HISTORY, ARMAMENTARIUM &

CHAIR SIDE POSITIONING

Moderator Presented by:

Dr. K. Gopalkrishnan Mohit Bindal
 CONTENTS
Case history
Armamentarium
Introduction
Armamentarium
Tray systems
Chair side positioning
Introduction
Position of chair
Position of patient
Position of operator
Role of supporting hand
Lighting
Conclusion
References
Case history

3
 Case history

 Relevance ?
 Establishes communication

 Documentation

 Helps us develop a rapport with patient

 Understand the general medical condition

 Past experience

 Arrive at a diagnosis

 Plan treatment
 Case history

STANDARD FORMAT FOR RECORDING RESULTS OF HISTORY AND

PHYSICAL EXAMINATIONS

 Biographic Data
 Chief Complaint

 HOPI

 Past medical history

 Past dental history

 Social and family medical history

 Review of systems

 Clinical examination (intra/extra oral)

 Laboratory and radiographic imaging/ examinations

 Case history

BIOGRAPHIC DATA
 Name of patient
 Age

 Sex

 Residence

 Registration no.

 Occupation
 Case history

CHIEF COMPLAINT

 Complaints are recorded in patients own words

 With duration

 In chronological order if more than one complaint

 If complaints start simultaneously, list them in order of severity

 Also ask whether patient was perfectly fine before the period
mentioned by the patient
 Case history

HISTORY OF PRESENT ILLNESS

Commences from the beginning of the first symptom to the time of examination.
Includes :

i. Mode of onset – sudden or gradual, with cause of onset if present

ii. Duration

iii. Progress of the disease

iv. Treatment which the patient might have received

 Case history

PAST MEDICAL HISTORY

 Major systemic disease

 Duration & treatment

 Allergy

 Previous hospitalizations

 H/o of blood transfusion

 Pregnancy & lactating mother

 Case history

PAST DENTAL HISTORY

 Previous dental t/t

 Past experience

 Complications
 Case history

SOCIAL AND FAMILY MEDICAL HISTORY

 Marital status

 Social & economic status

 Residential area

 Hereditary diseases
 Case history

REVIEW OF SYSTEMS
 Case history

ROUTINE REVIEW OF HEAD, NECK, AND MAXILLOFACIAL REGIONS

Nose,
Sinuses,
TMJ area

Head
Eyes Constit Oral
Ears utional

Neck
 Case history

INSPECTION
 Head and face: General shape, symmetry, hair distribution
 Ear: Normal reaction to sounds

 Eye: Symmetry, size reactivity of pupil, color of sclera and conjunctiva,

movement, test of vision
 Nose: Septum, mucosa, patency

 Mouth:Teeth, mucosa, pharynx, lips, tonsils

 Neck: Size of thyroid, jugular distention

 Case history

PALPATION

Paranasal:
TMJ: Pain over
Crepitus, sinuses
tenderness

Oral: Salivary
glands, floor
Neck: lymph
of mouth, lips,
nodes
muscles of
mastication
 Case history

PERCUSSION

Oral: Teeth

Paranasal:
Resonance
over sinus
(difficult to
assess)
 Case history

AUSCULTATION

• TMJ: Clicks, crepitus

• Neck: Carotid bruits

 Case history
LABORATORY INVESTIGATIONS
 Case history

RADIOGRAPHIC IMAGING
 ARMAMENTARIUM
 Instruments for local anesthesia
 Instruments for incising tissue

 Instruments for elevating mucoperiosteum

 Instruments for retracting soft tissue

 Instruments for controlling hemorrhage

 Instruments for grasping tissue

 Instruments for removing bone

 Instruments for removing soft tissue from bony defects

 ARMAMENTARIUM CONTD..
 Instruments for suturing mucosa
 Instruments for holding mouth open

 Instruments for providing suction

 Instruments for transferring sterile instruments

 Instruments for holding towels and drapes in position

 Instruments for irrigation

 Dental elevators

 Extraction forceps

 Instrument tray systems

DIAGNOSTIC INSTRUMENTS
LOCAL ANESTHETIC INSTRUMENTS
SYRINGE

Non disposable
•Disposable

•Safety syringe
COMPUTER –CONTROLLED LOCAL ANESTHETIC DELIVERY SYSTEMS
Reduces pain
Reduces stress
for operator &
pts
Predictable
injection site
location

Cost
Additional
armamenterium
 CARTRIDGE
 Glass cylinder with L/A & other
ingredients
 1.8ml/ 1.7ml/2.2ml
 NEEDLE
 Single piece of tubular metal ;plastic
/metal syringe adaptor & needle hub

 25/ 27/ 30 gauge

barrel

Needle
shaft

bevel hub
plunger
 ADDITIONAL ARMAMENTARIUM
 Topical antiseptic
 Topical anesthetic

 Applicator sticks

 Cotton gauze

 Hemostat
 INSTRUMENTS FOR INCISING TISSUES
Most surgical procedures begin with incision

No. 7 Handle
No. 3 Handle
Longer, more sender
Commonly used
 BLADES
Small stab incision

Mucogingival
Used for large Incisions on procedures
skin incision posterior aspect
of teeth

Small-incision
around teeth &
through
mucoperiosteum
 LOADING & UNLOADING BLADE

Correct way to load the scalpel blade on the handle Unloading of blade
 Using a Scalpel

Held in pen grasp

Maximal control of blade
Mobile tissue should be held firmly to stabilize it
Knife pressed down firmly in mucoperiosteal incisions
 INSTRUMENTS FOR ELEVATING MUCOPERIOSTEUM
 Most commonly used molt no. 9 periosteal elevator

 Sharp end – reflect dental papilla from between teeth

 Broad end – elevating tissue from bone

• Some surgeons prefer Round ended Molt periosteal elevator

 No. 1 Woodson periosteal elevator

 Small and delicate

 Release soft tissue around tooth
 Methods of reflecting the periosteum from the flap
 Prying motion; pointed end used to reflect the dental papilla

 Push stroke; uses the broad end and the most efficient stroke to reflect the
periosteum from underlying bone

 Pull stroke; Scrape stroke (most likely to tear the mucosa)

Howarth’s Periosteal Elevator
Designed to strip mucoperiosteum from bone
Used in pen grasp

Freer’s Elevator
oUsed for reflecting the gingiva surrounding the
tooth before extraction
oEasy to use
oHas thin ends

Desmotomes
Are either straight or curved
Straight - used for the
anterior teeth of the upper jaw
Curved - for the rest of the teeth of the
upper & all of the teeth of the lower jaw.
 INSTRUMENTS FOR RETRACTING SOFT TISSUE
 Provide good vision and access
 To retract cheek, tongue &
mucoperiosteal flaps

C – shaped retractors

 For retraction of the cheek

Cheek Retractor
 For retraction of cheeks & lips
 Austin’s
retractor
Minnesota retractor
Periosteal elevator is often used to retract soft tissue

Seldin Retractor

•Designed specifically to retract soft tissue flaps

•Looks similar to periosteal but end is dull
 LANGENBECK RETRACTOR

 “L” shaped retractor with long

handle.
 Used for retraction of the edges of a
flap for improved visualization of the
deeper layer and structures
 It comes in different sizes
depending upon length of the
handle and width of the blade.
Instruments used to retract tongue
 Mouth mirror

 Weider retractor
 Broad, heart shaped
 Serrated on one side to
firmly engage tongue & retract it medially & anteriorly
 Tongue Depressor
 It has broad, flat rounded blade.

 Towel clip
 Biopsy in posterior aspects of tongue
 L.A. should be given in the area of placing towel clip
 Skin Hook
 Undesirable trauma to the skin during surgical procedures may be reduced to a
minimum
 There will be a decreased incidence of wound infections and inflammations - better
wound healing and more desirable cosmetic results
 INSTRUMENTS FOR CONTROLLING HEMORRHAGE
 small arteries & veins are cut, requiring more than simple pressure
 Instrument used : Hemostat

Different Sizes Straight or Curved

Face of hemostat has parallel

grooves
 Hemostat has long delicate beak – grasp tissue

 Locking handle – allows surgeon to let go of instrument once the vessel is clamped

Uses of hemostat:
 Controlling bleeding

 Remove granulation tissue from tooth sockets

 Pick up small root tips, pieces of calculus, fragments of amalgam restorations or any
other small particles that have dropped into mouth or wound area
 Electro cautery/thermal cautery
 Current passed through a resistant metal wire electrode

 Heated electrode is then applied to tissue to achieve hemostasis

 Applied across the lesion until slightly pink to pale coagulation occurs

 Electrocoagulation uses

monopolar or bipolar electrodes

Monopolar electrocautery
Parts :
 High frequency AC generator (over 20,000Hz)
 Regulator
 Foot control
 Active electrode
 Indifferent electrode
 The patient is part of the electrical circuit

 Interchangeable tips such as loops, fine tips, and needle

tips.
Bipolar electrocautery
 Both active and return electrodes are incorporated into a single
handheld instrument
The current passes between the tips of the two electrodes and affects
only a small amount of tissue
Precautions :

 Avoid point contact with indifferent electrode

 Avoid placement of indifferent electrode near bony ridges

 Ether, cyclopropane used for GA – risk of sparking

 Operator should wear rubber footwear

 Avoid contact of the tip with metal instruments

 INSTRUMENTS USED TO DRAIN THE ABCESS

Lister sinus forceps

 Uses

 To open an abcess By Hiltons methods to break the

loculae
 To hold the small gauze to clean the cavity
 To disect out sinus, fistulous tract in soft tissues
 INSTRUMENTS FOR GRASPING TISSUE

During soft tissue surgery it is frequently

For working in posterior part of mouth –
necessary to stabilize soft tissue flaps
Stillies Forceps
Tissue forceps commonly used – Adson
• Shape similar to Adson
forceps
• Longer(7-9 inches)
 Allis Tissue Forceps
 Removing large amounts of fibrous tissue

 Has locking handles & teeth

 Used only on tissues to be dissected

Russian forceps
•Round ended tissue forceps
•Used to pick teeth that have been elevated from socket
•For placing gauze in mouth
 BABCOCK’S FORCEPS

•Broad, flared ends with smooth tips.

•Used to atraumatically hold viscera , mucosa, lymph nodes.
 INSTRUMENTS FOR REMOVING BONE
Rongeur Forceps
 Most commonly used
 Sharp blades – squeezed together by the handles
 Cutting or pinching through the bone
 Have leaf spring between handle – opens on release of hand pressure
 Two designs :

Side cutting Forceps Mandible

Maxilla
Blumenthal Rongeurs
 Chisel & Mallet
 Used to remove bone

 Monobevelled

 Success depends on sharpness of instrument

 Mallet with nylon facing

 Imparts less shock

 Less noisy

 Recommended
Osteotome
 Bone splitting instrument
 Bibevelled

Osteotomy cuts: orthgnathic surgery

/refracturing maluinted #

Osteoplasty/ bone reconturing

 Bone File

 Final smoothening of bone before suturing

 Double ended – small & large end

 Remove bone only in pull stroke

Bur and handpiece

 This is the technique that most surgeons use while

removing bone for surgical removal of teeth

 Relatively high speed handpieces with sharp carbide

burs remove cortical bone efficiently

 Handpiece must not exhaust air into the field

No.557 No.703 No.8 round bur

 INSTRUMENTS FOR REMOVING SOFT TISSUE FROM BONY
DEFECTS
Periapical Curette
 Angled, double ended

 Remove

 Granulomas
 Small cysts
 Granulation tissue from socket
 INSTRUMENTS FOR SUTURING MUCOSA
Needle Holder
 Has locking handle & short stout beak

 Intraoral – 6 inch needle holder recommended

 COMPARISON BETWEEN NEEDLE HOLDER & HEMOSTAT

Needle Holder Hemostat

 Beak is shorter & stronger  Long delicate beak

 Face of the beak is cross hatched to permit  Has parallel grooves
a positive grip
 Correct position of the fingers to hold needle holder
 Thumb & ring finger inserted through the rings

 Index finger held along the length to steady & direct it

 Second finger aids in control & locking mechanism

 Scissors:
 Various types of scissors are used in oral surgery, depending on the surgical
procedure

Suture scissors

Suture scissors have relatively long handles and are held

the same way as the needle holder
Dean scissors

Have sharp cutting edges

 SOFT TISSUE SCISSORS
•Iris scissors &Metzenbaum scissors.

•Straight or curved blades.

•Iris : small, sharp pointed,delicate.

•Metzenbaum :undermining soft tissues &

cutting; blunt nosed tips.

•Don’t cut sutures : dull the edges- less

effective & more traumatic

•Iris: very fine skin sutures

 INSTRUMENTS FOR HOLDING MOUTH OPEN
Rubber bite block

 Bite blocks - it is a rubber block on

which the patient can rest his teeth.

 If wider opening is required, bite

block is positioned more to the
posterior of the mouth.
 SIDE ACTION ADJUSTABLE MOUTH PROPS

 Molt mouth prop or the side action

mouth prop- is used by the operator
to open the mouth wider if
necessary

 Has rachet type action, opening the

mouth wider when the handle is
closed
 MOUTH GAG
 Forcefully open mouth :trismus
 Broad,serrated blades: rest on occlusal surface of molars: instrument opened:
slow, gradual force
 Keep mouth open : procedures under G/A.
 INSTRUMENTS FOR PROVIDING SUCTION
 To provide good visualization, blood,
saliva, and irrigating solutions must
be suctioned from the operating site
The surgical suction has a smaller orifice to facilitate suctioning of tooth
sockets when needed

The Fraser suction has a hole in

the handle portion that can be
covered as the requirement
dictates.

Plastic suction tips are also available

 INSTRUMENTS FOR TRANSFERRING STERILE INSTRUMENTS
 The transfer forceps are heavy forceps used to move instruments from one
sterile area to another
 These forceps are usually right angled forceps with heavy jaws, so
instruments such as extraction forceps can be moved from one area to
another and small items can be handled without dropping them
 INSTRUMENTS USED FOR PREPARING THE SURGICAL FIELD
Swab holder
 Long blades, expanded at ends, forming an oblong tip

 Uses
 To hold a swab and clean the area of operation

 To swab the throat in unconscious patient or pt under GA

 To press on the tonsillar bed to arrest haemorhage

 To hold the tongue in an unconscious patient

 INSTRUMENTS FOR HOLDING TOWELS AND DRAPES IN
POSITION
 Towel clip:
 Hold together, drapes placed around a
patient
 Stabilizes suction tubes, micromotor etc.

 Hold & retract tongue: unconscious

patient.
 Locking handle+ finger & thumb rings

 Sharp/ blunt action ends

 Curved points –penetrate towels

&drapes
 INSTRUMENTS FOR IRRIGATION
 Bone removal: steady steam of  Large plastic syringe +blunt 18
irrigation-sterile saline. gauge needle
 Cools the bur

 Prevents bone- damaging heat build

up
 Increases efficiency of bur:

 Washes away bone chips

 Lubrication

 Completion of procedure: before

suturing
 DENTAL ELEVATORS
One of the most important instruments used in extraction procedure is the
dental elevator.

Parts of elevator
 INDICATIONS

 To reflect mucoperiosteal membrane

 To luxate and remove teeth which cannot be engaged by the beaks of forceps.

 To remove roots, fractured or carious teeth

 To loosen teeth prior to application of forceps

 To split teeth which have grooves cut in them

 To remove intraradicular bone

Elevators should be used with carefully because of dangers of :

 Damaging or even extracting the adjacent tooth

 Fracturing the maxilla or mandible
 Fracturing the alveolar process
 Plunging the point of the instrument into the soft tissue, with possible
perforation of blood vessels and nerves
 Penetrating the maxillary antrum or forcing a root or a third molar into the
maxillary antrum
 Forcing the apical third of the lower third molar into the mandibular canal
or through the lingual plate into the pterygomandibular space
 Rules while using elevators
 Never use adjacent teeth as fulcrum

 Never use buccal plate at gingival line as fulcrum

 Never use lingual plate at gingival line as fulcrum

 Always use finger guards to protect the patient

 Be certain that the forces applied by the elevator are under control & that the elevator
tip is exerting pressure in the correct direction
 When cutting through interseptal bone, take care not to engage the root of an adjacent
root, thus inadvertently forcing it through alveolus
Working principles of elevators :
 The lever principle
 The wedge principle
 The wheel and axle principle
or a combination of two or more of these principles.

The Lever Principle

•Most commonly used
•First class lever
•The position of the fulcrum is between the
effort (E) and the resistance (R)
Formula of levers :
effort x effort arm = load x load arm
 In order to gain a mechanical advantage,
the effort arm > load arm
 Effort arm =3/4
 Load arm = 1/4

 Inputforce x effort arm = output force x load arm

 MECHANICAL ADVANTAGE=
output force = effort arm = 3
input force load arm
The Wedge Principle

 The wedge in its simple form is a movable inclined plane which overcomes a large
resistance at right angles to the applied effort

 Wedge elevator is forced between root of tooth & bone parallel to long axis of tooth
 The effort is applied to the base of the plane, and the resistance has its effect on the slant
side
 The sharper the angle of the wedge the less effort required to make it overcome a given
resistance
Formula for Wedge :
Effort x Length = Resistance x Height

MECHANICAL ADVANTAGE =
Resistance = Length = 10 = 2.5
Effort Height 4
h = 4mm
l = 10mm
 Straight & Apex elevators work on this principle
 WHEEL AND AXLE PRINCIPLE
 The wheel and axle is a simple  Formula for wheel & axle :
machine Effort x Radius of Wheel = Resistance x
 Modified form of lever Radius of Axle
 The effort is applied to the MECHANICAL ADVANTAGE R = Rw
circumference of a wheel which = 42 = 4.6 E Ra
turns the axle so as to raise a weight 9

Rw = 42mm
Ra = 9mm
Coupland elevator

Cryers elevator
Warwick James Apexo elevator
 Crane pick

Winters Crossbar

Root tip pick

 EXTRACTION FORCEPS
 These instruments are used for removing the tooth from the alveolar bone
 Components :
 Beaks
 Hinge
 Handle

 The handles of the forceps are held differently, depending on the position of the tooth to be removed
 Two different styles of forceps :
 The American type
 The British type

 The beak is designed to adapt to the tooth root at the junction of the crown and root.

 The width of the beaks also vary based on the teeth they are to be used on
 MAXILLARY FORCEPS
 Single-rooted: incisors,canines,premolars
 3-rooted:molars

 Maxillary universal forceps: no.150

Maxillary Premolar forceps no. 150 A Upper molar forceps no.53
Upper Third Molar Forceps Bayonet Forceps

Upper Cowhorn Forceps no.88

Mandibular Anterior Forceps no.150 Mandibular Molar Forceps no.17

Mandibular 3rd molar forceps Lower Cowhorn Forceps

 PHYSICS FORCEPS
The Physics Forceps are a unique type of extraction system that provides:
 Predictable and efficient extractions in less than four minutes

 Atraumatic extractions where the bone preserved

 Elimination of root tip fractures

 Eliminated the need for elevating a flap

 Very little operator movement (or strength) necessary

 Light constant pressure applied to the tooth - chemical changes in the PDL - release of
the Sharpey’s fibers
 Once the tooth releases, it can be removed simply with a rongeur or even fingers

 Utilizes the biomechanics of a first class lever

 Each instrument has a beak and bumper where the beak does all the work and the
bumper is a fulcrum or a pivot point
Physics forceps are available as a set of four

The Pedodontic set of Physics are similar to the Standard set of Physics Forceps
They are much smaller (approximately 30%)
Surgical extraction kit
 CHAIR SIDE POSITIONS
 The positions of the patient, chair,
and operator are critical for
successful completion of the
extraction
Correct position:
 Comfortable for both the patient and surgeon
 Allows the surgeon to have maximal control of the force that is being delivered to the
patient's tooth
 Allows the surgeon to keep the arms close to the body and provides stability and
support
 Allows the surgeon to keep the wrists straight enough to deliver the force with the arm
and shoulder and not with the hand
 Allows the force delivered to be controlled in the face of sudden loss of resistance from
a root or bone fracture.
 POSITION OF CHAIR

For a maxillary extraction

 Chair should be tipped backward so that the
maxillary occlusal plane is at an angle of about 60
degrees to the floor

 Chair height should be adjusted so that site of

operation is about 8cm (3 inch) below shoulder
level of operator
For a mandibular extraction
 More upright position

 The occlusal plane is parallel to the floor

 Chair height should be adjusted so that

the tooth to be extracted is about
16cm(6 in.) below the level of operator's
elbow
POSITION OF PATIENT
 According to Mason (1988), lying the
patient down in the supine position
at this late stage of pregnancy may
cause "Supine Hypotensive
Syndrome”
 Hunter & Hunter (1997) describe this
is a result of 'impaired venous return
to the heart resulting from
compression of inferior vena cava by
the uterus.
POSITION OF OPERATOR
 THE SUPPORTING HAND
 Reflecting the soft tissues of the cheeks, lips, and tongue to provide adequate
visualization of the area of surgery
 To protect the tissues & other teeth

 To stabilize the patient's head

 Supporting and stabilizing the lower jaw

 Supports the alveolar process and provides tactile information

 To feel any slipping of the forceps on the tooth or any tendency of adjacent teeth to
move, or alveolar bone to fracture
NOTE : When working on the maxilla, the free fingers of the supporting hand should be
kept close
 THE SUPPORTING HAND

Upper Right Upper Anterior Upper Left

Lower Right Lower Anterior Lower Left

 LIGHT

 Good illumination of the operative

field is an absolute essential for the
successful extraction of teeth
 CONCLUSION

 It is said that eyes do not see what mind does not know.

 A thorough knowledge of basic instruments, their usage & the

various chair side positions forms an integral part for the
successful completion of any surgical procedure
 REFERENCES

 Contemporary Oral and Maxillofacial Surgery -Peterson

 Oral and Maxillofacial surgery (vol 1)
-Daniel M. Laskin
 Oral and Maxillofacial surgery (vol 1)
-W. Harry Archer
 Oral Surgery
- Fragiskos
 The extraction of teeth( 2nd edition)
-Geoffery L Howe
 Principles of Oral & Maxillofacial Surgery (5th Edition)
- U.J. Moore
 Thank you. . .

NEXT WEEK :TOPIC;INTRODUCTION ,HISTORY & SCOPE OF OMFS

BY PRAVESH SINGH