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====Types of Gingival and Mucogingival Flaps====
====Types of Gingival and Mucogingival Flaps====
An envelope flap is a gingival flap (i.e. not extending apical to the mucogingival junction) created by making a sulcular incision and elevating some of the attached gingiva on the lingual and buccal aspects and no vertical releasing incisions.
An envelope flap is a gingival flap (i.e. does not extend apical to the mucogingival junction) created by making a sulcular incision and elevating some of the attached gingiva on the lingual and buccal aspects with no vertical releasing incisions.
An extended envelope flap is useful for extraction of several adjacent teeth. They are mucogingival flaps, i.e. incisions extend apical to the mucogingival junction. Flaps used for extraction procedures are full-thickness flaps that also include the periosteum.
An extended envelope flap is useful for extraction of several adjacent teeth. <span style="color:#ff0000"> Two types of mucogingival flaps (i.e. incisions extend apical to the mucogingival junction) can be used. Flaps used for extraction procedures are full-thickness flaps that also include the periosteum. BARA DOES THIS MAKE SENSE TO YOU?</span>
*A triangle flap is a mucogingival flap consisting of a sulcular incision and one vertical releasing incision.
*A triangle flap is a mucogingival flap consisting of a sulcular incision and one vertical releasing incision.
*A pedicle flap is a sulcular incision with two vertical releasing incisions, this flap provides the best exposure.
*A pedicle flap is a sulcular incision with two vertical releasing incisions, this flap provides the best exposure.
==Technique for Surgical Extraction of an Upper Canine==
==Technique for Surgical Extraction of an Upper Canine==
#A pre-extraction radiograph of an upper canine tooth shows the length of the root. As a general rule the apex of the canine tooth finishes at the mesial root of the second premolar. This should be taken in to consideration when designing the flap. The flap should enable unimpeded access to the whole root if necessary.
#A pre-extraction radiograph of an upper canine tooth shows the length of the root. As a general rule the apex of the canine tooth finishes at the mesial root of the second premolar. This should be taken in to consideration when designing the flap. The flap should enable unimpeded access to the whole root if necessary.
#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, taking care 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 should 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. The raised flap 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.
#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. 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).
#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 in order 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 repeat 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. 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.
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====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<span style="color:#ff0000">Is this perhaps a bit confusing, since the exceptions are not canines?</<span>.
Care should be taken when placing the vertical releasing incisions and raising the flap to avoid damaging the inferior alveolar blood vessels and nerve exiting the middle mental foramen. A longer releasing incision can be made rostrally creating more of a triangular flap.
Care should be taken when placing the vertical releasing incisions and raising the flap to avoid damaging the inferior alveolar blood vessels and nerve exiting the middle mental foramen. A longer releasing incision can be made rostrally creating more of a triangular flap.
#This is a very large tooth, the roots of which are often adjacent to the mandibular canal.
#This is a very large tooth, the roots of which are often adjacent to the mandibular canal.
#Extraction of a periodontally-sound mandibular first molar tooth is difficult, and may result in iatrogenic fracture. In addition, dilacerated roots may make extraction even more challenging, with an increased risk of root or mandibular fracture.
#Extraction of a periodontally-sound mandibular first molar tooth is difficult, and may result in iatrogenic fracture. In addition, dilacerated roots may make extraction even more challenging, with an increased risk of root or mandibular fracture.
#Create a triangle mucogingival-periosteal flap and remove up to 50 of the buccal alveolar bone using a large round bur in a water cooled high speed hand piece.
#Create a triangle mucogingival-periosteal flap and remove up to 50% of the buccal alveolar bone using a large round bur in a water cooled high speed hand piece.
#Section the tooth into 2 individual roots using a tapered fissure bur
#Section the tooth into 2 individual roots using a tapered fissure bur.
#Using a suitable sized elevator, work around the whole circumference of each root.
#Using a suitable sized elevator, work around the whole circumference of each root.
#Once mobile, use extraction forceps to gently finish the luxation and deliver the tooth.
#Once mobile, use extraction forceps to gently finish the luxation and deliver the tooth.
! Complication !! Cause and Avoidance
! Complication !! Cause and Avoidance
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| Tooth Fracture (crown/root/both) || Incorrect technique – careful use with elevators and luxators
| Tooth Fracture (crown/root/both) || Incorrect technique – careful use with elevators and luxators.
Extraction forceps should not be used before the tooth is adequately loosened.
Extraction forceps should not be used before the tooth is adequately loosened.
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| Oronasal Communication || May be due to infection or iatrogenic damage – avoid excessive force during the extraction.
| Oronasal Communication || May be due to infection or iatrogenic damage – avoid excessive force during the extraction.
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| Jaw Fracture || Pre-operative radiographs should be taken to assess bone loss in advanced periodontal disease
| Jaw Fracture || Pre-operative radiographs should be taken to assess bone loss in advanced periodontal disease.
Incorrect technique (placement of luxators and elevators especially associated with lower canine) must be avoided.
Incorrect technique (placement of luxators and elevators especially associated with lower canine) must be avoided.
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| Haemorrhage || Accidental damage to neurovascular bundle during surgery
| Haemorrhage || Accidental damage to neurovascular bundle during surgery.
Haemorrhage may occur as a result of a root fracture
Haemorrhage may occur as a result of a root fracture.
Pre-existing disease (identified before surgery) if possible.
Pre-existing disease (identified before surgery) if possible.
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| Displaced Tooth Fragments || Avoid downward force in cats as the root fragment may be displaced into the mandibular canal
| Displaced Tooth Fragments || Avoid downward force in cats as the root fragment may be displaced into the mandibular canal.
Avoid excessive force on the palatal root of the upper carnassial in dogs to avoid pushing the root into the nasal turbinates.
Avoid excessive force on the palatal root of the upper carnassial in dogs to avoid pushing the root into the nasal turbinates.
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#In young puppies or persistent deciduous teeth where the root is not being resorbed, raise a small mucoperiosteal flap – a no.11 scalpel blade can be used to make the releasing incisions then a periosteal elevator to raise the flap.
#In young puppies or persistent deciduous teeth where the root is not being resorbed, raise a small mucoperiosteal flap – a no.11 scalpel blade can be used to make the releasing incisions then a periosteal elevator to raise the flap.
#Use a small round bur to remove buccal bone. Care must be taken not to damage the root of the permanent or adjacent teeth
#Use a small round bur to remove buccal bone. Care must be taken not to damage the root of the permanent or adjacent teeth
#Use a small elevator (eg.superslim which is 1.3mm width) to gently luxate the tooth taking care not to position the elevator in a position where the permanent tooth could be damaged. If extracting the mandibular deciduous canines, no instrument should be placed on the lingual (inner) aspect of the tooth as this will damage the permanent developing mandibular canine (lower arrow) and probably also the 3rd incisor (top arrow). If extracting maxillary deciduous canines take care placing any instrument on the mesial (front edge) aspect as the permanent tooth bud develops in front of the deciduous tooth.
#Use a small elevator (eg.superslim which is 1.3mm width) to gently luxate the tooth taking care not to position the elevator in a position where the permanent tooth could be damaged. If extracting the mandibular deciduous canines, no instrument should be placed on the lingual (inner) aspect of the tooth as this will damage the permanent developing mandibular canine <span style="color:#ff0000">(lower arrow)</span> and probably also the 3rd incisor <span style="color:#ff0000">(top arrow)</span>. If extracting maxillary deciduous canines take care placing any instrument on the mesial (front edge) aspect as the permanent tooth bud develops in front of the deciduous tooth.
#Gently rotate and luxate the deciduous tooth. Once there is some mobility, use extraction forceps with a small beak (pattern 76N) in a rotational manner to break down any remaining fibres prior to the tooth being lifted out of the socket.
#Gently rotate and luxate the deciduous tooth. Once there is some mobility, use extraction forceps with a small beak (pattern 76N) in a rotational manner to break down any remaining fibres prior to the tooth being lifted out of the socket.
#Suture the flap closed using a Fine (1 metric) monofilament absorbable suture material with simple interrupted sutures ensuring that there is no tension on the sutures.
#Suture the flap closed using a Fine (1 metric) monofilament absorbable suture material with simple interrupted sutures ensuring that there is no tension on the sutures.
===Crown Amputation for Type 2 Resorptive Lesions (pic21-27)===
===Crown Amputation for Type 2 Resorptive Lesions <span style="color:#ff0000">(pic21-27)</span>===
This technique is used when a tooth is undergoing resorption and there is no normal root structure remaining. This technique can only be used after a diagnosis of type 2 resorptive lesions has been made radiographically.
This technique is used when a tooth is undergoing resorption and there is no normal root structure remaining. This technique can only be used after a diagnosis of type 2 resorptive lesions has been made radiographically.