Changes

#Vertical releasing incisions are made between the upper canine and lateral incisor rostrally and at the mesial line angle of the second premolar. The blade is also run in the gingival suclus around the tooth, being careful not to perforate through the gingiva. The vertical releasing incisions should extend beyond the mucogingival junction (the junction between attached gingiva and the alveolar mucosa). The vertical releasing incisions can be slightly divergent to allow adequate blood supply to the flap. The vertical releasing incisions should also be made so that there is bone support for the sutured wound and not lie over a void.  

#Vertical releasing incisions are made between the upper canine and lateral incisor rostrally and at the mesial line angle of the second premolar. The blade is also run in the gingival suclus around the tooth, being careful not to perforate through the gingiva. The vertical releasing incisions should extend beyond the mucogingival junction (the junction between attached gingiva and the alveolar mucosa). The vertical releasing incisions can be slightly divergent to allow adequate blood supply to the flap. The vertical releasing incisions should also be made so that there is bone support for the sutured wound and not lie over a void.  

#A sharp periosteal elevator is used to raise a full thickness mucoperisoteal flap. The elevator is positioned at an angle to the bone –if too flat, accidental perforation of the flap can occur. The tissue is tightly adhered at the mucogingival junction and care must be taken not to perforate the flap here. The flap raised should give good exposure to the alveolar bone overlying the tooth root.  

#A sharp periosteal elevator is used to raise a full thickness mucoperisoteal flap. The elevator is positioned at an angle to the bone –if too flat, accidental perforation of the flap can occur. The tissue is tightly adhered at the mucogingival junction and care must be taken not to perforate the flap here. The flap raised should give good exposure to the alveolar bone overlying the tooth root.  

#Using a high speed water cooled round bur, create a gutter on either side of the canine tooth root. Some overlying buccal bone can be removed to adequately see the mesial and distal edge of the tooth root. The gutters should be half the width of the tooth root and extend up to 2/3 of the length of the root. The gutters are then connected on the buccal aspect so that the bone plate overlying the root is removed together with the root. (pic17)

#Using a high speed water cooled round bur, create a gutter on either side of the canine tooth root. Some overlying buccal bone can be removed to adequately see the mesial and distal edge of the tooth root. The gutters should be half the width of the tooth root and extend up to 2/3 of the length of the root. The gutters are then connected on the buccal aspect so that the bone plate overlying the root is removed together with the root.  

#A dental elevator is positioned in the groove created on either the mesial or distal aspect of the tooth. (pic18) Elevators should not be used on the palatal aspect of the upper canine tooth to avoid iatrogenic oronasal communication. The elevator should be rotated slowly to tear the periodontal ligament attachment. Tension should be held for about 10 seconds to allow the ligament to tear. Move the elevator to the opposite groove and repeated the motion. Repeat until the tooth starts to loosen. When the tooth is loose, position the extraction forceps as far apically as possible and rotate the tooth along its long axis, pulling gently at the same time. (pic19) The extracted tooth should be checked to ensure that the whole root has been extracted (a post op radiograph should be taken if any doubt).

#A dental elevator is positioned in the groove created on either the mesial or distal aspect of the tooth. Elevators should not be used on the palatal aspect of the upper canine tooth to avoid iatrogenic oronasal communication. The elevator should be rotated slowly to tear the periodontal ligament attachment. Tension should be held for about 10 seconds to allow the ligament to tear. Move the elevator to the opposite groove and repeated the motion. Repeat until the tooth starts to loosen. When the tooth is loose, position the extraction forceps as far apically as possible and rotate the tooth along its long axis, pulling gently at the same time. The extracted tooth should be checked to ensure that the whole root has been extracted (a post op radiograph should be taken if any doubt).

#The empty socket should be debrided if there is any granulation tissue or debris. Check the socket for any loose bone fragments. The edges of the socket should then be smoothed using either a diamond coated bur or with ronguers. The extraction site can be lavaged with lactated ringers solution to remove any remaining debris. The air-water syringe on the dental machine should not be used as air may cause an embolism or emphysema and water is cytotoxic to connective tissue cells.  

#The empty socket should be debrided if there is any granulation tissue or debris. Check the socket for any loose bone fragments. The edges of the socket should then be smoothed using either a diamond coated bur or with ronguers. The extraction site can be lavaged with lactated ringers solution to remove any remaining debris. The air-water syringe on the dental machine should not be used as air may cause an embolism or emphysema and water is cytotoxic to connective tissue cells.  

#The flap is then replaced and sutured in position using a monofilament absorbable suture material, using a simple interrupted suture pattern. (pic20) The flap should be sutured with no tension. Releasing incisions can be made in the periosteum on the underside of the flap to release tension if necessary. Care must be taken not to perforate the flap.  

#The flap is then replaced and sutured in position using a monofilament absorbable suture material, using a simple interrupted suture pattern. The flap should be sutured with no tension. Releasing incisions can be made in the periosteum on the underside of the flap to release tension if necessary. Care must be taken not to perforate the flap.  

====Applying the Principles to the Lower Canine Tooth====

====Applying the Principles to the Lower Canine Tooth====

The basic principles described above are used for the mandibular canine with the following exceptions –

The basic principles described above are used for the mandibular canine with the following exceptions –

Dental elevators should not be placed directly mesially and distally but rather on the mesiolingual and distolingual aspects of the tooth. This is to avoid fracture of the rostral mandible.

Dental elevators should not be placed directly mesially and distally but rather on the mesiolingual and distolingual aspects of the tooth. This is to avoid fracture of the rostral mandible.

==Extraction of the Maxillary Fourth Premolar Tooth==

==Extraction of the Maxillary Fourth Premolar Tooth==