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ARMAMENTARIUM

Definition of armamentarium is the collection of equipment and methods used in the practice of

medicine.

SURGICAL INSTRUMENTS

Oral surgery is that specialty of the dental profession concerned with diagnosis, surgical and

adjunctive treatment of disease, injuries, and defects of the jaws and associated structures.

Because of the nature of this specialty and the equipment used, the oral surgery service is often

established in a less traveled area of the clinic. Patients undergoing surgical treatment should be

isolated from patients receiving routine dental treatment.

ASEPSIS AND CLEANLINESS

Because surgical procedures expose susceptible areas of tissues to invasion by bacterial

organisms, strict attention must be paid to cleanliness and aseptic techniques. All instruments,

equipment, dressings, and medication must be carefully sterilized and protected from any

contamination that might later be introduced into a surgical site. Possible sources of

contamination must be minimized through continual attention and adherence to cleanliness of

area, equipment, and personnel. Any time we deal with open wounds, proper sterilization and

handling of instruments cannot be over emphasized.

Before using these instruments, they should be properly sterilized and maintained in a sterile

condition throughout the operation. The sterile instrument forceps should always be used when

transferring sterile instruments from one point to another. A sterile towel should be under all

instrument setups. When the operation is completed, the instruments should be washed
thoroughly. If they are not to be sterilized immediately, they should be thoroughly dried to

prevent rusting.

THE DENTAL ASSISTANT AS AN ASSISTANT IN ORAL SURGERY

In addition to some general clinical duties, the dental assistant in oral surgery performs a number

of specialized duties. The nature of many of his duties will depend upon his capabilities, the

technical procedures followed by the dentist, and the ways in which the dentist wishes his

assistant to participate. The effective assistant is the one who takes an interest in his work and

tries to become familiar with instruments, equipment, procedures, and techniques. He establishes

rapport with patients, maintains personal and area cleanliness and appearance, and anticipates

and carries out the dentist's needs so that unnecessary delays are avoided. Thorough familiarity

with instruments and materials used for specific operative procedures is of particular importance

in the oral surgery section. One reason for this is that surgical setups are commonly prepared,

packed, and autoclaved ahead of time. From an examination of the patient's record, the

experienced oral surgery assistant can usually determine what instruments and materials will be

required for the operation and have them ready when needed. Many oral surgeons perform

certain operations in a surgical operating room of a hospital, often using general anesthesia. The

dental assistant may be expected to perform preparatory procedures, assist in surgery, and clean

the operating room after surgery. Therefore, he must be familiar with pertinent basic and local

hospital operating room procedures.


Based on the sterile factor :

A steriled instrument that have direct contact to body


Critical instruments Eg : blade, scissors

Instrument that not used to penetrates to tissue but only touch the mucosa
Semi-critical instruments Eg : mouth mirror

Instrument that not used in the surgery


Non-critical instruments Eg : lamp, chair controller

Sterilization of the instrument can be done by using :-

1. Autoclave

2. Pemanasan kering

3. Sterilisasi kimia

Instruments used in oral surgery

Instruments for anaesthesia, airway maintenance

Instruments for gaining surgical asepsis

Instruments for gaining surgical access

Instruments for reflection of mucoperiosteal flap

Instruments for retraction

Instruments for holding

Suction apparatus

Instruments for bone removal

Instruments to hold the bone

Instruments for wound debriment

Instruments for management of fracture or osteomies

Miscellanous instruments
1.Instruments for anaesthesia,airway maintenance

1. Laryngoscope

2. Endotracheal tube

3. Cricothyrotomy set

4. Tracheostomy set

2. Instruments for gaining surgical asepsis

Cheatle forceps

The function is used to pick up sterile instruments from a

tray.It is a long angulated instrument that Stored in a

container with antiseptic solution

Swab Holding Forceps

This is also an instrument with long handles but straight

beaks which are fenestrated in the ends.It is used for holding

the swab dipped in an antiseptic solution and paint the surgical

area with antiseptic.


Towel Clips

Instruments used to hold the patients drapes in place. It is also used to clip on the suction tubes,

drills on to the drapes to hold them in place.

It can also be used to hold tongue and retract it forward in an unconscious patient.. it has two

type : Backhouse towel clip and Pincher type

3. Instruments for gaining surgical access

Surgical scapels

Surgical scalpels are used to cut soft tissue and incise localized abscesses. A surgical knife is

comprised of a handle and interchangeable blades. Four sizes and shapes of detachable blades

and three types of handles are available.

.figure 3 : Surgical knife handle and blades.


Blade handles

Common : number 3 and beaver style

Has a receiving slots for the blade

Blades Bard Packer (BP) blades

number 11 blade - for stab incision for drainage of an abscess.

number 12 blade - for placing crevicular incision for periodontal procedures.

number 10 blade - for skin incisions

Number 15 blade for carrying out surgeries in mucogingival areas and others
Dissecting scissors

Dissecting scissors can be used for incising soft tissue flaps, excising pathological soft tissue and

can be used for blunt dissection into the deeper layers. Deans suture cutting scissors are used for

cutting suture materials. Dissecting scissors usually have narrower blades than a suture cutting

scissors and may be straight or curved, sharp ended or blunt ended scissors.

4.Instruments for reflection of mucoperiosteal flap

Root elevators

Root elevators are instruments designed to loosen or remove roots, root fragments, or teeth. As

with forceps, a variety of designs are available to suit different teeth, techniques, and locations in

the mouth.

a. Stout A Elevator. This elevator's nib is flat on one side and rounded on the other. The nib has

straight tapering walls and a rounded end


Figure 7 : Stout A elevator.

b. Straight Elevator Number. 34-S. This elevator is straight and shaped like a gouge . In cross-

section its nib is crescent-shaped. It is one of the most commonly used elevators.

Figure 8 : Straight elevator number 34-S.

c. Straight Elevator Number 301. This elevator is similar in shape to but smaller than number 34-

Figure 9 :. Straight elevator number 301.

d. Apical Fragment Root Elevators. These are used to remove apical root fragments
Figure 10 :. Miller root elevators numbers 73 and 74.

Figure 11 : Apical fragment root elevators.

Periosteal elevators

Periosteal elevators are used to separate and raise periosteum from the surface of the bone and

retract the tissue flap .

a. Woodson Plastic Instrument Number One. This is a restorative instrument often used as a

periosteal elevator in oral surgery.


b. Spatula Number Seven. This wax instrument also is often used as a periosteal elevator. It is

blunt on one end and pointed on the other.

c. Molt Periosteal Elevator Number Nine. This elevator has a curved, blunt blade at each end.

d. Seldin Periosteal Elevator Number 22. This elevator has a flat handle with a small blade at

each end. The blades are angled and shaped to give easy access to all locations in the mouth. All

edges are rounded slightly to avoid needless injury to the tissues.

Figure 12 :. Periosteal elevators.

5.Instruments used for retraction

The main function is to hold back or retract organ or tissue to gain exposure to operative site. It

is includes :-

1. Tissue retractor

2. Tongue and cheek retractor

3. Langenbeck retractor

4. Cats paw retractor

5. Autins retractor

6. Obwegessors ramus retractor

7. Skin hook
8. Chin retractor

9. Alar retractor

10. Tongue depressor

Langenbeck retractor

It is in L shaped with long handle. It is used for retraction of soft tissues and incision edges to

have a better visibility of deeper structures . It comes in different sizes depending upon length of

the handle and width of the blade

Tongue Depressor

it is also a L shaped retractor without handle. It has broad, flat rounded blade.. the function is

used for the retraction and depression of the tongue to improve visibility of the posterior

pharyngeal wall and the tonsillar region.it is also be used for cheek retractors.
Austins Retractor

Also an L shaped retractor without handle. It is used basically for the retraction of small

intraoral flaps as in case of removal of an impacted tooth

Cats paw retractor

The end of the instruments resembles a cats paw. It is used for retraction of small amount of soft

tissues
Obwegessors ramus retractor

The shape is similar to langenbecks except fesor the V

shape end. Helpful to engage the anterior border of ramus

and to retract soft tissues

Skin hook

Alar retractor

Used to retract the ala of the nose during rhinoplasty

Chin retractor

In case genioplasty
6.Instruments used for holding

1. Needle holder

2. Haemostat

3. Kochers artery forceps

4. Tissue forceps

5. Adsons tissue holding forceps

6. Allis tissue holding forceps

7. Dressing holder

8. Sponge forceps

9. Instruments forceps

Dressing forceps

Dressing forceps have the appearance of large tweezers. They are used to handle sterile dressings

inside the mouth.

Figure 21 :. Dressing forceps.

Sponge forceps

Sponge forceps are large and doughnut-shaped nibs. They are used to handle sterile dressings or

linen outside the mouth.


Figure 22 :. Sponge forceps.

Instrument forceps

Instrument forceps have prong-like nibs resembling a knife and fork. They are used to handle

sterile instruments.

Figure 23 :Instrument forceps.

Hemostats

Hemostats are small forceps designed to stop the flow of blood by clamping blood vessels. A

hemostat is used for holding material and tissue.


Figure 24: . Hemostats.

Needle holders

Needle holders are forceps resembling straight hemostats. Each jaw has a groove on its inner

surface, which is used to hold and manipulate the suture needle during suturing.

Figure 25 : Suture needle holder.

Kochers artery forceps

It is used to grasp heavy tissue. It have straight or curved end and may

used as clamp

Other name : Ochsner


Adsons tissue holding forceps

It can be either toothed or non-toothed. Toothed : have serration at tip which help a better grasp

and Non-toothed : do not have serration. The function is to stabilize the soft tissue flaps during

suturing. Small blood vessel can be held with it

Allis tissue holding forceps

Used when a larger amount of fibrous tissues have to be removed and have locking handles and

teeth that will grip the tissues firmly


7.Instruments for bone removal

1. Rongeurs

2. Chisel

3. Osteotome

4. Mallet

5. Bone file

6. Hand piece and burs

Osteotome

This is an instrument used for splitting bone. It has bi-bevelled edge and comes in various sizes

depending on the width of cutting edges and the length of the instruments. Used to perform

osteotomy cuts and in certain cases may also be used to split impacted teeth to facilitate removal.
Rongeur forceps

Rongeur forceps are cutting instruments designed to cut and contour bone (figure 3-18). Springs

located between their handles separate their beaks when closing pressure is not being applied.

The dentist may ask for a single rongeur.

a. Rongeur number 1A is both a side and end cutting instrument.

b. Rongeur number 4A is a side cutting rongeur.

Figure 30 : Rongeur forceps.

Bone files

Bone files are made in various sizes. They are used to smooth the edges of bone. Seldin bone file

number 11 is double-ended, with the file surface at one end being larger than the file surface at

the other end.

Figure 31 :. Bone file.

Bone chisels
Bone chisels are used to remove bone or section teeth. Some are designed for use with a hand

mallet. Another type is driven by a special handpiece, as an engine-driven oral surgical mallet.

Chisels must be kept sharp to be effective.

a. Stout chisels numbers 1, 2, and 3 are straight bone chisels used with a hand mallet. They differ

in the size of their blades.

b. Chisel points used with the engine-driven surgical mallet are made in different shapes,

designed for various surgical procedures. These include two bone removing points, one unibevel

and one bibevel, one gouge and two tooth elevator points.

Surgical mallets

The oral surgical hand mallet is a double-headed mallet resembling a gavel or wood mallet. The

engine-driven oral surgical mallet (impactor) fits on the arm of the dental engine like a straight

handpiece. It is equipped with five detachable impactor points.

Figure 32 :. Surgical mallets.

Surgical burs

Specially designed surgical burs (figure 3-21) are used by many oral surgeons to remove bone

and to groove teeth for controlled sectioning. They are made for both the straight and contra-
angle handpiece. Steel bur number 41 is available for AHP or SHP. The tungsten carbide bur is

available for SHP only. To avoid excessive heat while cutting, sterile water should be dripped

over the bur.

Figure 33 :. Surgical burs.

8.Instruments for wound debriment

Surgical Curettes

Curettes are instruments designed to remove extraneous material from tooth sockets and other

spaces in the alveolar bone. Their nibs are spoon- shaped and their shanks are angled to reach

different areas of the mouth. Standard curettes include Molt curettes 1, 2, 4, (anterior) and 5L,

6R, 9L, 10R (posterior)

Figure 34 :. Curettes.
Bone scoop (Volkmanns scoop)

Similar to surgical curretes Used for debriding contents from an abscess cavity,sinus or fistula

tract an to scoop out bones.

Listers sinus forceps

Used for probing and forcing an entry into an abscess sac or for stretching an opening into an

abscess by Hiltons operation. It helps in

draining of abscess

9. Miscellanous instruments

1. Mouth prop

2. Bite block

3. Mouth gag

4. Foleys self-retaining catheter

5. Ryles tube

6. Infant feeding tube

7. Trocar

8. Surgical diarthermy

9. cryosurgery
Mouth prop

A device for maintaining the jaws of a dental patient in an open state. It used when the operator

need to open the mouth larger.

Suture needles

Many different types of suture material can be attached to different shapes and sizes of needles.

Suture needles are use to carry suture material through soft tissue which, when tied, will hold

tissue parts together for initial healing.

Figure 37 :. Suture material and needle.


Gingival retractors

Gingival retractors are used to hold gingival flaps back and out of the way to expose operative

areas. Thoma gingival retractors 1 and 2 are two-pronged, fork-like retractors. Instruments

designed for other purposes, such as periosteal elevators are also used as retractors.

Irrigating syringe

Irrigating syringes are used to wash pus, debris, and other extraneous material from tooth

sockets, cavities, or inflamed gingival flaps. The tip is usually metal and should be blunt. If a

syringe with a glass barrel is used, particular care must be exercised; the glass barrel could

shatter if it is hit with a surgical bur.

Figure 38. Irrigating syringes.

Dental aspirator

The dental aspirator is an electrically operated vacuum suction unit used to maintain a clear

operating field by removing blood, bone chips, debris, and other materials. The unit is fitted with

a tube running from a vacuum bottle, which ends in a handle and suction tip. The handle fitted
with a suction tip is controlled by the oral surgery assistant in the removal of extraneous material

from the surgery site.

Figure 39 . Dental aspirators.

Surgical instrument stand

Figure 40 : Surgical instrument stand.


INSTRUMENT SETUPS AND PROCEDURES

Procedures commonly used in the oral surgery section will be discussed in the following

paragraphs of this lesson. See Appendix A for the listing of the instruments in a typical surgical

setup.

PREPARATION TO RECEIVE THE PATIENT

Preparation to receive a patient begins with the cleanup and sterilization of instruments used

during the treatment of the preceding patient. All evidence of treatment of that patient should be

removed. Traces of blood should be removed from the dental unit and instrument trays. The

cuspidor, aspirator bottles, handles, tips, and tubes should be cleaned. Instruments should be

scrubbed and either sterilized or set aside for sterilization. Linens, headrest covers, and bracket

table covers should be replaced. The dental chair should be lowered and set in an upright

position, with the bracket table and operating lamp pushed back, out of the way. The next

patient's records and radiographs should be set out for the dentist to examine. A basic

examination setup should be placed on the bracket table. Instrument setups, sterile towels, and

dressings (as indicated by the dentist) should be on hand and their need anticipated.

PREOPERATIVE TREATMENT

In some cases, the dentist may wish the next patient to have some form of medication before

surgery and may have the patient come in early for this purpose. The dental assistant may be

expected to make a record of patients requiring such medication, notifying the dentist of the

patient's arrival, reminding him of the need for medication, and recording the medications given.
The oral surgery assistant should be familiar with the uses, doses, and effects of these and other

drugs important in the practice of oral surgery.

Instrument Setups.

Uncomplicated extraction.

Figure 41. Instruments and materials for uncomplicated extraction.

Surgical extraction and bone removal.

Figure 42. Instruments and materials for surgical extraction and bone removal.
SURGICAL SETUPS

1. Basic setup

a. Forceps holding air

b. Instrument forceps (in jar)

c. Periosteal elevator - Molt #9

d. Root elevators - 34S and 301

e. Extracting forceps - appropriate one

f. 2" x 2" gauze sponges

2. Supplementary items determined by procedure, as well as preference of the dentist.

a. Oral surgical burs

b. Surgical knife

c. Apical fragment root elevators - paired for posterior

d. Curettes - paired for posterior

e. Rongeur

f. Surgical scissors

g. Suture material

h. Suture scissors

i. Bone file

j. Gingival retractors

k. Oral surgical mallet

l. Oral surgical chisel


m. Dental surgical burs

n. Apical fragment root elevators

o. Iodoform impregnated gauze