Chapter 4

Surgical Techniques

 

Surgical Removal of Soft Tissue Tumors (Fibroma)

Cutting Instruments

Anesthesia is accomplished by utilizing a "field block." The local anesthetic is injected around the fibroma in the form of a circle. The solution is also deposited under the base of the tumor. (Figs. 1, 2)

The fibroma is grasped with an Allis forceps (Hu-Friedy TFS) at its base. (Fig. 3)

The dissecting scissors (Hu-Friedy, Kelly curved, 6 1/4) are used to make a cut under the base of the tumor. The entire lesion is removed with one or two clean cuts. The scissors must be extremely sharp otherwise tearing of the tissues will occur. The use of a blade in this case is discouraged. (Figs. 4, 5, 6)

The surgical site is sutured with 2-0 gut sutures. (Fig. 7) If there is persistent bleeding, the use of the ACU-SURG* to control hemostasis is indicated. (Fig. 11)

The fibroma is sent for pathological examination. (Fig. 8) There is excellent healing of the tissues one week post-op. (Fig. 9) All of the gut sutures have completely dissolved at this time.

 

* "ACU-SURG": This is a small, portable, DC powered electrosurgical and cauterizing instrument. It has a maximum temp. of 2200 F. Any other DC unit similar to this one would also be recommended in these surgical techniques. AC units can also be used, but in my opinion they are not as convenient, nor as safe.

 

Electrosurgical Instruments

The technique using electrosurgery is similar to the cutting technique except that the ACU-SURG is used to remove the tumor, not the scissors. The electrosurgical cut is also made under the base of the fibroma. Gradual and progressive strokes of the electrosurgical instrument are carried out until the tumor is completely cut. (Figs. 10 to 20) One advantage of this instrument is that there is very little, if any, bleeding associated with the excision because the instrument not only cuts but coagulates as well.

Following removal, 2-0 gut sutures are placed to close the surgical site. (Fig. 21) There is hardly any pain post-operatively utilizing this technique because of the "seal- ing" effect the cautery has on the tissues. The nerve fibers are seared or sealed and patients require very little post-operative analgesics.

The specimen is sent for pathological examination. (Fig. 22) The healing is excel- lent in one week post-op. (Fig. 23)

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Surgical Removal of an Epulis

Cutting Instruments

A #15 blade is used to cut the lesion below its base, in a horizontal direction, on the lingual side. (Figs. 24, 25) An Allis forceps is used to grasp the tumor as the cut is completed. (Figs. 26, 27) If the epulis has extended into the interproximal spaces and is visible on the labial surface, the blade is used to incise the labial portion as far into the interproximal space as possible. The cut is made below the base of the lesion, in a horizontal direction. (Fig. 28)

The curette is used to perform curettage of the lingual, labial and interproximal tissues. Curettage is performed down to the periosteum. (Figs. 29, 30, 31)

ACU-SURG is now used to cauterize any bleeding areas. (Figs. 32, 33, 34)

The specimens are sent for pathological examination. (Fig. 35) The lingual lesion in this case is about 5mm.

The case illustrated is that of a pregnant woman. Pregnancy epuli are very common, and are usually the result of poor or neglected hygiene. There usually is an accompanying gingival or periodontal inflammation with the presence of calculi. However, in some cases, the hygiene may appear to be reasonably good.

Following removal of the lesion, an appropriate assessment of the oral cavity should be accomplished and any periodontal problems treated. If this is neglected, a recurrence of the lesion is possible, especially if any source irritation or infection is still present. 

Surgical Removal of Papillomas

Electrosurgical Instruments

The papilloma illustrated is on the palate, medial to the tuberosity on the right side. (Fig. 36) Anesthesia is accomplished by utilizing a field block. The local anes- thetic is injected around the papilloma in the form of a circle. The local is also deposited under the base of the tumor.

The Allis forceps (Hu-Friedy TFS) is used to grasp the tumor at its base. (Fig. 37)

ACU-SURG is now used as a cutting instrument as well as to accomplish hemostasis. The cut is made at the base of the tumor. (Fig. 38) Slow, sweeping motions with the ACU-SURG are used as the cuts are made. (Figs. 39, 40) Continuous tension on the Allis forceps is applied as the cuts are made. As the instrument cuts the tissue it cauterizes the area as well. Very little, if any, bleed- ing is associated with this method of papilloma removal.

Following removal, the specimen is sent for pathological examination. Excellent healing is evident one week post-op. (Fig. 41)

Surgical Removal of Hyperplastic Tissue

Hyperplastic tissue usually occurs on the edentulous ridges and in the muco-buccal folds. It usually forms because of irritation from ill-fitting dentures. It varies in size and can range from a few mm. to several cm. There are four methods recommended for their removal.

Method #1: Muco-buccal Fold Tissue

Cutting Instruments

The tissue is grasped with an Allis forceps and kept taut using light but steady pressure. (Figs. 42-46)

The dissecting scissors, Hu-Friedy, Kelly curved, 6 3/4, are now used to cut the tissue. The cut is made at the base of the tissue, where it is attached to the mucosa. If the hyperplasia is large, several cuts may be required, guiding the scissors through the tissue. The Allis forceps are always held taut so as to keep tension on the tissue. Loose tissue with no tension exerted on it is difficult to surgically excise. (Figs. 47-50)

If there is bleeding from the underlying mucosa, the bleeding sites are cauterized using the ACU-SURG to accomplish hemostasis. Suturing of the tissue is not recommended, as this tends to interfere with the depth of the sulcus or muco- buccal fold. (Figs. 51-54)

The flanges of the old denture are trimmed and, using a soft tissue acrylic reline, the denture is inserted to serve as a splint.

Once removed, the tissue is sent for pathological examination. (Fig. 55)

 There is excellent healing one to three weeks post-op. (Figs. 56, 57)

Method # 2: Muco-buccal Fold Tissue

Electrosurgical

This method is ideal for cases in which the tissue hyperplasia is small. Anything up to 1 cm would fall into this category. (Fig. 58)

The hyperplastic tissue is held as shown in Method # 1 using the Allis forceps. (Fig. 59)

ACU-SURG is now used as a cutting instrument and for hemostasis. The cut is made at the base of the lesion, while keeping continuous tension on the forceps. As the instrument cuts the tissue electrosurgically, it seals or cauterizes as well, so there's very little, if any, bleeding with this method. The tissue measures about 5 mm. (Figs. 60-64)

The specimen is sent for pathological examination.

The flanges of the old denture are trimmed, a soft reline is prepared and rein- serted immediately. It should be left in place for about 2 days. (Figs. 65, 66) 

 

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Method #3: Hyperplasia of the Edentulous Maxillary Ridge

The Allis forceps is used to grasp and hold the tissue in the cuspid, bicuspid region, on the left side.

Beginning on the left side, the blade is used to make a triangular, V-shaped incision on both the labial and palatal surfaces of the hyperplastic tissue. The base of the triangle is on the surface of the ridge, while the top or apex is adjacent to the crest of the alveolar bone. (Figs. 67-72)

The incisions are carried across the midline to the opposite side to include all of the hyperplastic tissue. The labial incision is completed first followed by the palatal portion.

Both incisions meet at the apex of the triangle. (Figs. 73, 74)

The entire wedge-shaped tissue can now be removed using the Allis forceps. Any tissue that remains attached can be freed using the scissors to make the final cuts. (Figs. 75, 76, 77)

The surgical area is sutured using individual sutures, 2-0 gut. (Figs. 78, 79)

The old denture is relined using soft toner and left in place for at least 2 days.

The tissue is sent for pathological examination.

One week post-op, the healing is excellent (Fig. 80) 

 

Method #4: Hyperplasia of the Mandibular Edentulous Ridge

In the case illustrated, the hyperplastic tissue involves the anterior portion of the mandibular ridge only and can be removed simply by using surgical scissors.

The scissors are used to cut the "flabby" tissue in one piece from right to left. Using scissors instead of a scalpel blade provides more control over the cuts, and avoids removing periosteum which is essential for good, pain-free healing. (Figs. 81-85)

Acu-Surg is now used to cauterize any bleeding areas. (Figs. 85-89)

The old denture is relined with soft toner and left in place for at least 2 days. The tissue is sent for pathological examination.

The tissues are well healed one week post-op. (Fig. 90) 

Surgical Removal of Cysts

Soft Tissue Cysts (Mucocele)

An incision using Blade #15 is made very gently over the top of the cyst, being careful only to incise the oral mucosa and not the cystic lining. (Figs. 91, 92, 93) Using a curved, small hemostat, (curved Kelly that is on the standard tray setup), the cyst is slowly and gently enucleated from the surrounding soft tissue. Using the hemostat helps to dissect and separate the cyst from the surrounding fibrous tissue and muscle attachments. Be careful at all times not to rupture the cyst as the enucleation will then be almost impossible to perform. (Figs. 94, 95) Do not use any sharp instruments such as scissors to enucleate. Use only blunt instruments such as the hemostat and blunt periosteal elevators, if necessary. (Fig. 96) While the dissection is being carried out, the nurse assistant, using gentle thumb in the extraoral submandibular area, applies constant pressure to lift the contents of the sublingual spaces so that the cyst can be more easily visualized. (Figs. 97, 98)

The cyst is held with the hemostat and its remaining attachment is cut with the surgical scissors. (Figs. 99-101)

The surgical site is sutured using 2-0 gut sutures. Silk sutures are not recom- mended. (Fig. 102)

Once removed, the specimen is sent for pathological examination. (Figs. 103, 104) 

Maxillary Labial Frenectomy

This is done to aid in the elimination of a diastema, for orthodontic purposes (Figs. 105, 106). Without the retainer, the diastema between the central incisors recurs.

Using a curved hemostat, insert and grasp the tissue between the frenum and the lip. The hemostat must extend down to the base of the muco-buccal fold.  (Fig. 107)

Using a sharp pair of dissecting scissors, (Hu-Friedy, Kelly curved, 6 1/4), cut the frenum attachment from the inner portion of the lip. The cut must be down to the base of the muco-buccal fold. (Figs. 108-110)

Using a # 15 blade, cuts are now made on both sides of the hemostat, from the base, on either side of the frenum, along the labial surface of the anterior maxilla, to the interproximal space of the two central incisors. These cuts are made down to and including the periosteum. Care must be taken not to denude the mesial surfaces of the incisors. At the completion of these cuts, the frenum will be detached leaving a small groove or trough. (Figs.111-113)

ACU-SURG is used to control bleeding. (Figs. 114-116)

Using a fissure bur #701, a small cut in the labial bone is made in the groove or trough. This fissure bur cut will ensure that the entire attachment of the frenum has been removed. A Miller # 21 curette is also used to scrape the contents of this groove, eliminating any traces or remnants of attachments. (Figs. 117-118)

Again, using blade #15, a circular cut is made in the area of the incisive papillae, on the palate. This cut runs from the palatal surfaces of the central incisors and around the papillae. The cut is made down to and including the periosteum. Using a curved hemostat and the curette, the mucoperiosteum is removed. The curette is then used to "scrape" the bony surface to ensure that most, if not all, of the frenum attachment on the palate is removed. (Figs. 119-121)

Any bleeding of the mucosal tissues is now eliminated by using an electrosurgical instrument, such as "ACU-SURG." (Figs. 122, 123)

2-0 gut sutures are used to close the surgical site on the lip. (Figs. 124, 125)

Healing is excellent 3 months post-op, and there is no further recurrence of the diastema. (Fig. 126)

Mandibular Lingual Frenectomy (Ankyloglossia)

The curved hemostat (Kelly) is used to grasp the frenum at its broad junction and attachment with the tongue. (Figs. 127,128)

The dissecting scissors, Kelly 6 1/4 curved, are used to cut the attachment, by making the cut along the outer surface of the hemostat. Once cut, the portion that is attached to the lingual surface of the mandible will contract and disappear. (Figs. 129, 130) The surgical site on the lower surface of the tongue is now sutured to close this one and the only opening. (Fig. 131) If there is persistent bleeding, hemostasis may be attained using the "ACU-SURG" to cauterize selective sites. In addition, local anesthetic with vasoconstrictor can be used to control hemostasis.

Post-operatively, patients are encouraged to "tongue thrust" for several days, so as to avoid possible reattachment of tissues. This is generally unlikely however, and in one week healing is excellent. (Fig. 132)