Suture Selection Guidelines

• Use finest suture that provides adequate strength
• Match absorption time to tissue healing time
• Consider patient comfort and compliance
• Antibacterial sutures for high-risk patients

Handling Tips

• Monofilament sutures: Handle gently, use more knots
• Braided sutures: Better handling but may harbor bacteria
• Wet sutures: Some synthetics handle better when moistened

Removal Guidelines

• Facial sutures: 3-5 days
• Intraoral sutures: 7-10 days
• Areas under tension: 10-14 days
• Absorbable sutures: May dissolve or require removal if not absorbed

Complications Prevention

• Proper technique: Avoid excessive tension
• Appropriate size: Neither too fine nor too heavy
• Sterile handling: Prevent contamination
• Patient education: Post-operative care instructions

Emergency Airway Cart

Basic Equipment

• Bag-mask ventilators: Multiple sizes
• Oropharyngeal airways: Full size range
• Laryngoscope: Multiple blade sizes
• Endotracheal tubes: Complete size range
• Stylets: Malleable introducers

Advanced Equipment

• Video laryngoscope: Improved visualization
• LMA: Multiple sizes and types
• Bougie: Gum elastic introducer
• Fiber-optic scope: Awake intubation
• Surgical airway kit: Cricothyroidotomy/tracheostomy

Medications

• Sedatives: Midazolam, propofol
• Paralytics: Succinylcholine, rocuronium
• Vasopressors: Epinephrine, phenylephrine
• Reversal agents: Naloxone, flumazenil

Microsurgical Repair Principles

• Timing: Primary repair (immediate) vs secondary repair (delayed)
• Tension-free approximation: Essential for successful repair
• Precise fascicular alignment: Critical for functional recovery
• Microsurgical technique: 8-0 to 10-0 non-absorbable sutures

Epineural Suturing

• Indication: Pure sensory nerves (like inferior alveolar nerve)
• Technique: Sutures placed through epineurium only
• Advantages:
  • Simpler technique
  • Less surgical trauma
  • Shorter operative time
  • Adequate for sensory function
• Suture material: 8-0 or 9-0 nylon or polypropylene
• Number of sutures: 2-4 sutures typically sufficient

Perineural/Group Fascicular Suturing

• Indication: Mixed motor/sensory nerves
• Technique: Individual fascicles or fascicular groups sutured separately
• Advantages:
  • More precise fascicular alignment
  • Better functional outcomes for motor nerves
  • Reduced cross-innervation
• Disadvantages:
  • More complex technique
  • Longer operative time
  • Greater surgical trauma
• Requirements: High magnification, specialized training

Fascicular Suturing

• Indication: Large mixed nerves with identifiable fascicles
• Technique: Individual fascicle-to-fascicle repair
• Use: Primarily for major peripheral nerves outside oral cavity

Mandibular Tori

Mandibular tori are bony growths that occur on the mandible, typically on the lingual aspect of the alveolar ridge. While they are often asymptomatic, there are specific indications for their removal, particularly when they interfere with oral function or prosthetic rehabilitation.

Indications for Removal

1. Interference with Denture Construction:

   • Mandibular tori may obstruct the proper fitting of full or partial dentures, necessitating their removal to ensure adequate retention and comfort.

2. Ulceration and Slow Healing:

   • If the mucosal covering over the torus ulcerates and the wound exhibits extremely slow healing, surgical intervention may be required to promote healing and prevent further complications.

3. Interference with Speech and Deglutition:

   • Large tori that impede normal speech or swallowing may warrant removal to improve the patient's quality of life and functional abilities.

Surgical Technique

1. Incision Placement:

   • The incision should be made on the crest of the ridge if the patient is edentulous (without teeth). This approach allows for better access to the torus while minimizing trauma to surrounding tissues.
   • If there are teeth present in the area, the incision should be made along the gingival margin. This helps to preserve the integrity of the gingival tissue and maintain aesthetics.

2. Avoiding Direct Incision Over the Torus:

   • It is crucial not to make the incision directly over the torus. Incising over the torus can lead to:
     • Status Line: Leaving a visible line on the traumatized bone, which can affect aesthetics and function.
     • Thin Mucosa: The mucosa over the torus is generally very thin, and an incision through it can result in dehiscence (wound separation) and exposure of the underlying bone, complicating healing.

3. Surgical Procedure:

   • After making the appropriate incision, the mucosal flap is elevated to expose the underlying bone.
   • The torus is then carefully removed using appropriate surgical instruments, ensuring minimal trauma to surrounding tissues.
   • Hemostasis is achieved, and the mucosal flap is repositioned and sutured back into place.

4. Postoperative Care:

   • Patients may experience discomfort and swelling following the procedure, which can be managed with analgesics.
   • Instructions for oral hygiene and dietary modifications may be provided to promote healing and prevent complications.

5. Follow-Up:

   • Regular follow-up appointments are necessary to monitor healing and assess for any potential complications, such as infection or delayed healing.

• Primary site of LA action: Amygdala (limbic system).
• pKa of lignocaine: 7.8.
• Pregnancy supine hypotension: Due to IVC compression.
• Pregnant patient position: Left lateral decubitus.
• Corticosteroids in pregnancy: FDA Category C.
• Ketamine action site: Thalamocortical junction.
• Atracurium & cisatracurium metabolism: Hoffman elimination.
• Neuralgia treatment: Carbamazepine arrests Na⁺ channels in inactive state.