What is the best way to hold and use each instrument?
We’re going to start off with the scalpel and with a scalpel, one thing that you want to make sure that you do is, not do what you would do for a spay, for instance where you're doing a continuous incision around those teeth. You want to do little stab incision so with the scalpel you want to hold it about 15 degree angle and go down fairly firmly but not excessively firm to the marginal bone and just continue to make those little stab incisions as you go. I'm going to show you another really quick video that will demonstrate that in this mandibular canine extraction and then once you get up to the large diastema between that premolar in the canine then you can be more consistent with what you would do for a spay. Not do the stab incisions but do a more continuous incision. This will demonstrate that fairly readily.
When we’re starting an incision for a flap over teeth we’re going to make little stab incisions. Note how we're doing that here adjacent to the teeth, just going down to the bone.
One other thing that we want to point out here, the closer we get our fingers to the tip of the instrument, the more control that we have. When you're making those little stab incision you want to make sure that not only do you have your fingers to the tip of the instrument but, you also want to have them against part of the patient. You see that I've got that scalpel between my index finger and my thumb and my middle finger is on the pallet, it’s on the canine, and it's on that third incisor. I've got total control over that scalpel and minimize or eliminate any chance that's going to slip and tear my flap. Especially if you keep that 15 degree angle between the scalpel and the tooth itself. You shouldn't run into that at all.
Let's look at the next phase. Once we've made our incision, to get that flap mobilized we use the periosteal elevator. Here is a molt periosteal elevator. These come in 2 mm and 4 mm ends so, if you flip that over you'll see that you've got a 4 mm end or a 2 mm end on either side. Very convenient. The 2 mm is to be used when you first start. When you first start running into areas between teeth and corners, the small area helps considerably. Then when you go to the removal of the larger portion of the flap, and this video I'm going to show you will show you that, you’ll go to the larger end. That is kind of a milled finish there, you'll see the striations. That is not the side that goes to the patient.
If you turn that over, that is how it goes on the patient.
From a handling standpoint and a ease-of-use standpoint, if you have a pen or pencil, pick that up and kind of get the feel here. You want your index finger on the top of that instrument, again close to the end, and then just cradle that in your palm just like you see there.
Then when you use it on the patient all you need to do is turn it over like this and it's very effective. You can use it very effectively.
I know you’ve probably got questions about these instruments. If you guys stay till the end after that I'm going to give you a link that will let you download our instrument list that we use and that we recommend to all of our students. It's got the products on there, it's got how you contact the people who have those products. I'm happy to share that with you guys at the end.
Let's take a look at a how we actually use that periosteal elevator in this video.
This is the correct use of a periosteal elevator. What we want to do is go the entire periphery of the attached gingiva using that exact same lever technique where we’re not really going apical, we’re pushing down on the bone toward the tooth and then were just twisting to lift that attached gingiva off of the bone.
We're going the entire periphery of the attached gingiva before we start to get any more aggressive. We want a zone where we’ve already exposed that before we start to move more apical and not as much the twisting movement.
This is the safest way to mobilize a flap, you'll see that we get good exposure very quickly in this live patient and also note that my fingers were at the very tip of that instrument during that whole procedure. That gives us maximum control.
I hope that gave you a really good idea about how to use that periosteal elevator. The next phase of this is removing our bone and we do that with a 701-L bur, a cross cut tapered fissure bur.
When we’re using our hand piece with a bur for sectioning or removing bone, we use that modified pen grasp just like you see there, just like we did for the periosteal elevator. Then it's short quick movements to remove the bone, not putting much pressure at all. Just letting the bur do the work, kind of like a painting motion like you observe.
The next step once we’ve removed bone and we’ve got all that vestibular bone gone, sometimes all the way up to the root tip if it’s a tooth that doesn't have much or any periodontal disease. Then we have our little grooves that we create on either side of the tooth in order to place our luxator. Here is how we want to hold that luxator, again it’s in the palm of our hand. We've got our index finger up to the tip and very effective. You have a lot of control over that by using that elevator or luxator like that. Just to clarify an elevator and a luxator nowadays is pretty much the same instrument. A luxator used to be a real thin instrument. It was used just to break down the periodontal ligament between the bone and the tooth. Then a thicker elevator was used to kind of man handle the tooth and get it out of the socket. Now, with our extraction techniques and some of the tips we’re talking about here today, we’re removing more bone. We don't need a really staunch elevator like we used to have. These are all hybrids now where, especially if you see the winged elevators by Miltex like we see here. This is what we use, this is what we recommend. Those are very strong instruments that can be used to luxate and also to elevate.
Once we’ve got that tooth out, one thing that I want to share with you today is a little technique that I don't know that I developed it but, hopefully I’ve showed a lot of people how this works and they’re using this in their practices. This is actually what we call the football technique because we're using a football bur and hopefully this video will clarify what I mean by that.
Once our extractions are complete, generally with periodontal disease or in this case stomatitis with a cat, there’s a lot of granulation tissue, debris, and diseased bone, fimbriated or sharp bone, left and this is the bur that we used to clean all that up and basically we just go in there and paint away everything that's abnormal.
This cat's on his back, we're working on the left maxillary quadrant, and just using that diamond football bur to contour the bone, remove any tissue that's inflamed, and that creates a nice area for closure.