Instruments in major oral and maxillofacial surgery

A surgical instrument is a specially designed tool or device for performing specific actions and carrying out desired effects during surgery or operations.

1. Instrumentation in Maxillofacial Surgery Presenter – Dr. Kamini Dadsena. Moderator – Dr. Rohit Chandra. Department OF PLASTIC SURGERY Max Hospital Patparganj

2. Instruments A. Instrument for gaining surgical asepsis and art preparation Cheatle’s forcep Swab holder Towel clip B. Instrument for gaining surgical access - Scalpel (Blade handle, Blade) Dissecting scissors C. Instrument for reflection of mucoperiosteum flap – Periosteal elevator/ strippers Cleft palate Rasparatory D. Instrument for Retraction – Langenbeck Retractor C shaped retractor Austin retractor Cat’s paw retractor Seldin’s retractor Obwegessor’s retractor Skin hook Tongue depressor Cheek retractors

3. Instruments E. Suction apparatus - Suction tubing Suction tip F. Instrument for wound debridement – Curette Bone scoop Lister’s sinus forcep Drains G. Instrument for holding tissues and materials – Needle holder Artery forceps Kocher’s artery forceps Allis forceps Tissue holding forcep Babecock’s forcep Bone holding tissue forcep H. Instrument for management of fractures / osteotomies – Hayton – William’s forcep Rowe’s disimpaction forcep Walsham’s forcep Asche’s forcep Nasal rasp Bone awl Rowe’s modification & Bristow’s zygomatic elevator Smith’s bone spreader

4. Instruments Instrument for bone removal – Bone Rongeur Chisel & Mallet Osteotome Gigli’s saw Bone file Bone gouge Handpiece & bur J. Miscellaneous instruments – Mouth prop Mouth gag Instruments for trauma and osteotomies Instruments for cleft surgery

5. Instrument for gaining surgical asepsis

6. Cheatle’s Forceps Used for picking up sterile instruments from trays and linen from drums. Stored in a container containing antiseptic solution .

7. Swab Holder Uses : To hold swab/sponge and scrub/clean the skin/ mucosa in the area of operative field. To swab the throat in unconscious patients under GA To hold tongue and give anterior traction ….

8. Towel Clips Two types: Pinchter type (Jones) Forceps type ( Beckhaus ) Uses To hold drapes stabilize suction tubes, motor cables, tongue etc.

9. Instrument for gaining surgical access

10. Scalpel Bard Parker blade handle Various sizes available, most commonly used one is No.3 – blade 10, 11, 12, 15 No.4 (similar but bigger ) -- blade 22, 23 No.7 (longer and more slender ) - blade 15

11. Scalpel Commonly used No.10 – Skin incision No.11 – Sharp pointed, for stab incision No.12 – Hooked, for mucogingival procedures No.15 –for intraoral use No 20- for skin incision in orthopaedic and gen surgery No 22- for skin incision in cardiac and thoracic surgery

12. Dissecting Scissors Iris scissor- fine work Metzenbaum scissor Mayo curved heavy duty dissecting scissors

13. Dissecting Scissors Micro scissor- Scissor with spring action ( provides fast cutting and dissection )

14. Suture Cutting Scissors They have long delicate handles and a short blade with cutting edge and striations . Can be straight / curved angulated / non angulated Heath’s suture cutting scissor

15. Instrument for reflection of mucoperiosteum flap

16. Periosteal Elevators Used in “push” stroke .

17. Molt’s No. 9 Periosteal Elevator Uses Pointed end : to release dental papilla around teeth (by prying motion). Broad end : for elevating the mucoperiosteal flap from bone (by push stroke). Can be used as soft tissue retractor

18. Obwegeser’s Howarth’s

19. Joseph periosteal elevator 19

20. Cleft palate Rasparatory Broad, flat elevator used to elevate mucoperiosteum while mobilizing the flaps for cleft palate repair .

21. Instruments for Retraction

22. Langenbeck Retractor Common types are Standard (edge of the blade points towards handle) Reverse (edge of the blade points away from the handle), edge of the blade can take support to retract tissues

23. Langenback Retractor Uses To retract incised edges. To retract soft tissue mass. To allow visualisation of deeper tissues

24. C - Shaped Retractor Mostly used in abdominal surgeries .

25. Deaver retractor 25 Used to hold abdominal wall during abdominal and thoracic surgery.

26. Austin’s Retractor Short right angled retractor used for retracting cheek, tongue and mucoperiosteal flaps. Working end - forked

27. Kilners Cat’s Paw Retractor Used for retracting small amount of soft tissues. Care should be taken not to apply excessive force.

28. Obwegessor’s Ramus Retractor Similar to Langenback except that the edge of the blade is forked forming V shaped notch so as to engage the anterior border of ramus of mandible. Uses : During sagittal split osteotomy During coronoidectomy

29. Channel Retractor Used to engage the inferior border of the mandible on the buccal side to assist in the osteotomy and also to protect the facial vessels and nerves.

30. Tongue Depressor Uses : To depress tongue during endotracheal intubation and extubation To depress and move it anteriorly to check for airway obstruction To retract the tongue during surgical procedure

31. Skin Hook Types Single prong – Gillies Double prong - Kilner Uses – To hold and retract skin edges during cutting , dissection and suturing. To retract small amount of soft tissues

32. Vein Hook ( Desmarre’s ) Used to retract vessels during dissection (especially for major vessels during neck dissection)

33. Nerve Hook (Dandy’s) A small instrument with a broad curve at the tip, tip is relatively blunt. Used in neurectomy procedures for nerve identification and in nerve repositioning procedures.

34. Copper Malleable A universal kind of retractor made of copper, can be molded into any shape according to the need .

35. Self Retaining Retractors ( Weitlaner ) An instrument with long curved blades. Blades have multiple prongs. Ratchet to hold tissue apart

36. Suction apparatus

37. Suction Tip ( Fraizer , Yankauer ) To maintain a clean field by sucking away blood, flushing solutions, debris, cystic fluid, pus and secretions. No 3 and 4 are commonly used Yankauer – rigid hollow tube made up of metal or disposable plastic with a curve at the distal end to facilitate removal of thick pharyngeal secretions

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39. Instrument for suturing

40. Needle Holder Working tip has cross hatched serrations with a single vertical serration to grip the needle. The handle has a catch. Usually a 6 inch needle holder is used.

41. INSTRUMENTS FOR SUTURING MUCOSA

42. Instruments for haemostasis 42

43. Artery Forceps Can be straight / curved large / medium / small Mosquito are small curved artery forceps which have smaller finer tips

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45. Artery Forceps Uses To achieve hemostasis by catching blood vessels (by crushing / ligating / cauterizing) To drain an abscess ( by Hilton’s method). As tissue forceps for holding subcutaneous tissue and aponeurosis (but not skin or nerves). To pick up necrotic tissues, granulation tissues, foreign bodies, bone fragments

46. Kocher’s toothed Artery Forceps Uses Specially designed to hold the coronoid process during coronidectomy procedures. Can be used like other bone holding forceps for stabilization of bony fragments

47. Instruments for holding tissues 47

48. Adson’s Tissue Forceps Delicate forceps, used to hold tissues during process of dissection / suturing. Two types Plain / non toothed-, used to hold delicate structures Toothed –to hold tough structures like skin, coarse muscle and fascia

49. Babcock’s Tissue Forceps Instrument with broad flared blades with fenestrations and without teeth . More delicate and less traumatic than Allie’s forcep . Used to hold enlarged lymph nodes or any glandular tissue or appendix

50. Allis Tissue Forcep A forceps with locking handle, blades have delicate teeth . Uses To hold and retract tissues (generally for tissues that will be excised). To provide tension during tissue dissection. Should never be used to hold the skin directly .

51. Crocodile Bone Holding Forcep Used to hold the bony fragments during manipulation (fracture reduction and fixation / osteotomy / resection procedures). When it comes without catch in the handle , called as Sequestrum holding forcep , used to hold sequestrum

52. Instrument for bone removal

53. Bone Rongeur Forcep This forcep has curved handles with spring action. The tip of the blade is angulated forward towards the handle and has a concave inner surface. The beaks are sharp. They can be Both side and end cutting Only side cutting (Blumenthal)

54. Bone Cutter shape of the blade is different and have a side cutting action only . Uses To cut sharp bony margins following surgical procedures .

55. Chisel They have a heavy round / square handle and long flat working tip. Unibevelled To smoothen the bone bevel is kept facing the bone whereas to cut the bone it is kept facing away from the bone. Available in various sizes of working tips .

56. Osteotome Similar to chisel but --- bibeveled . It splits bone rather than cutting or chipping it. Uses Various osteotomy procedures. Removal / Recontouring of bone. Biopsy of bony lesions

57. Pterygoid Osteotome It is designed in completing osteotomy between the maxillary tuberosity and pterygoid plates in LeFort I osteotomy procedures. Curved end Placed between tuberosity and pterygoid plates of sphenoid bone Advantages Narrow tip to minimize encroachment upon BFP Narrow shank to minimize threat of tearing mucoperiosteal flap Sharp edge with reverse bevel to aid better seating of osteotome

58. Pterygoid Osteotome

59. Mallet Similar to hammer, made up of steel / lead / wood. Used for giving controlled taps on the chisel / osteotome . To be effective the mallet should be used with a loose free swinging movements of the wrist.

60. Bone Gouge It has a round handle and a blade that has sharp working tip that is concave on inner side. Working tip is half round and has a long working area. Uses To make a window in anterior border of maxillary sinus.(in Caldwell Luc) To remove cancellous bone graft material / irregular pieces of bone.

61. Gigli’s Wire Saw It has 2 components Wire saw It is made by twisting a few pieces of wire together so that it acquires a sharp barbed cutting edge. Handles At the end of the wire there is a ring to which the hook of the handles can be fitted .

62. Handpiece & Bur It is a quicker method of bone removal. Micromotor straight Handpiece The handpiece should have relatively high speed (35-40000 rpm) and torque which allows rapid bone removal. Burs stainless steel / carbide and available in different shapes and length.

63. Surgical Saw In handpieces speed of 10,000 – 1 lakh cpm can be achieved . Different kinds of saws available for various type of osteotomy. Sagittal saw moves side to side (5 - 6° arc), used for wedge / transverse osteotomy. Oscillating saw oscillates (5 - 6° arc), used for curved / straight osteotomy. Reciprocating saw moves to and fro (2.4mm), used for short / long osteotomy .

64. Instrument for wound debridement

65. Curette (Lucas) An exploratory instrument with spoon shaped working tip, used to scrape soft tissues from bony defects. The working end may be in the plain as the shank or at an angulation for adequate access. It can be single / double ended. Always held in “thumb and palm” grasp and used in “pull (scrape)” stroke . Uses To enucleate cyst /granulomas / intra osseous tumours / cystic neoplasms .

66. Volkmann’s Bone Scoop Similar to curette but concavity of the working edge is more pronounced. Uses To collect the contents from sinus tract / fistula / chronic abscess cavity. To scrape bony cavities due to cystic / tumorous / osteomyelitic lesions. To scoop out cancellous bone for grafting procedures. To introduce graft material or antiseptic powder into the surgical area.

67. Lister’s Sinus Forcep It has long narrow blades which are serrated transversely for only ½ an inch at the tip. Tip is rounded and bulbous. Instrument does not have a catch. Uses To open an abscess by Hilton’s method. To dissect out sinus / fistulous tract in soft tissues. To hold a small piece of gauze between blades to clean a cavity.

68. Instruments For Mangament Of Fractures / Osteotomies

69. Hayton Williams Forceps 2 widely divergent curved beaks that engage the maxilla behind the tuberosity. Used for mid – palatal fractures.

70. Rowe’s Maxillary Disimapction Forceps Pair of this instrument for disimpacting maxilla in LeFort fractures Consists of a straight unpadded blade and a curved padded blade. The unpadded blade is passed up a nostril and padded blade grips the palate. The operator stands behind the patient and manipulates the fragment into position.

71. Asche’s Nasal Septum Forcep Used to reduce and align fractures of the nasal septum. Blades are passed on either side of the septum and vomer and perpendicular plate of ethmoid bone.

72. Walsham’s Nasal Bone Forcep For reduction of nasal fractures It has 2 blades – small blade is inserted into the nose and larger is applied externally to grip the side of the nose up to the medial canthus and parallel to frontal process of maxilla.

73. Zygomatic Elevator Bristow’s elevator – flat instrument of sufficient rigidity and inserted into the same plane to reduce zygomatic arch fracture .

74. Rowe’s modification – through Gille’s temporal approach. The instrument has a blade and oval handle similar to Bristow’s pattern as well as a lifting handle which is attached by a strong hinge with a positive stop near the origin of the other handle. 74

75. Stacey zygomatic bone hook 75

76. Trocar It is a sharp, pointed instrument with a sleeve or cannula. Used to gain entry into the surgical site through percutaneous approach to avoid skin incision and scar. Example – transbuccal approach to ramus of mandible.

77. Nasal Septum Osteotome It is used to fracture the anterior nasal spine and separate the nasal septum from maxilla during LeFort I or premaxillary osteotomy procedures .

78. Smith Spreader It has 3 blades that are separated by spring action when the handles are compressed. Used to separate bony fragments after completion of the osteotomy cuts mainly used to check separation of fragments during downward fracture of maxilla / SSO procedure.

79. Bone Awl Long slender instrument provided with an eyelet at tip through which the wires are pushed in for transosseous wiring. Used for placement of circum -mandibular wiring or can be passed around the zygomatic arch/ piriform as in maxillary suspension procedures.

80. Instruments for cleft palate 80

81. Dingman’s Retractor

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91. Instruments for skin grafting 91

92. Skin Graft Set Contains following instruments Dermatome Wooden plank, used to stretch skin during harvesting and to keep graft over it for manipulation. Spreader, used to stretch the harvested graft over wooden plank.

93. Dermatome It is a surgical instrument used to produce thin slices of skin from the donor site. Manual / electrical Manual – hand held knives ( Humby’s ; Modified Watson knife) possess adjustment facility. Electrical dermatome – operated by air pressure (Brown / Zimmer dermatome)

94. Instruments For Bone Grafting BONE TREPHINE Specially designed instrument used to obtain small diameter trephines of bone for grafting Has 3 parts Barrel with stands. Piston (working tip has saw) Stylet

95. Instruments for opening mouth 95

96. INSTRUMENTS FOR HOLDING THE MOUTH OPEN Soft, rubberlike block- patient rests teeth Patient opens to comfortably wide position- block inserted: holds in the position Protects patient’s TMJ, while mandibular teeth

97. Heister’s Jaw Stretcher & Fergusson’s Mouth Prop Used to forcibly open the mouth Indications: Trismus due to infection, muscle spasm, hemarthrosis of TMJ following surgery Post operative active jaw physiotherapy after TMJ ankylosis , OSMF .

98. References Textbook of oral and maxillofacial surgery – Neelima A Malik Peterson’s Contemporary Oral & Maxillofacial surgery – James Hupp , Edward Ellis Rowe & William’s Maxillofacial injuries Textbook of Oral and Maxillofacial Surgery – Daniel M Laskin Internet

99. Thank You 99