INDICATIONS

To access site for effective treatment
- Extraction site
  - Flap design is discussed in this chapter; additional extraction steps discussed in Chapter 8
- Periodontal surgery of deep pockets (greater than 5 mm)

EQUIPMENT

15c scalpel blade (see Fig. 7-1a)
Periosteal elevator (Molt #2 and/or #4) (see Fig. 7-1a)
Tissue forceps
Small scissors (see Fig. 7-1b)

Figure 7-1 (a) 15C scalpel blade, scalpel handle, Molt #2 periosteal elevator, Molt #4 periosteal elevator. (b) Thumb forceps, needle holders, and small, sharp scissors.

PROCEDURE

Adequate pain management: preoperative, multimodal, local blocks, and preoperative dispensing
Appropriate antimicrobial selection
Flaps for extraction
- General concepts
  - Adequate exposure is necessary to facilitate extraction procedure and flap closure afterward
  - Full-thickness mucoperiosteal flap is typically used
  - Flap should extend through attached gingiva, past the mucogingival line, into the alveolar mucosa, typically just past the edge of the tooth, in the interdental area (Fig. 7-2)
  - Freshen the edge of the gingival margin with the blade by removing 1 mm before the flap is elevated (Fig. 7-3)
  - Introduce the blade tip into the sulcus around the tooth to release the junctional epithelium at the base of the sulcus (Fig. 7-4)
  - Elevate flap with periosteal elevator, to the level of the alveolar mucosa (Fig. 7-5, a–c)
  - Gently elevate or stretch the palatal or lingual gingiva as well (Fig. 7-5, d)
  - Release tension on flap by excising periosteal layer on underside of flap (Fig. 7-6, a): pull up on flap with forceps, gently excise periosteal fibers until release is apparent (Fig. 7-6, b); do not go through full thickness
  - After the extraction, close flap with absorbable suture, simple interrupted sutures
- Maxillary canines
  - Make mesial (rostral) incision directly up (see Fig. 7-2)
  - Make distal incision angled caudally, following the direction of the root (Fig. 7-7)
    - Note: While there may be concerns about a distal incision interfering with blood supply to the flap, extensive personal experience has shown this not to be the case, particularly with broad-based flaps
  - It is essential on this tooth to provide release by excising periosteal fibers, especially if an oronasal fistula is present
- Maxillary fourth premolar
  - Mesial (rostral) incision is typically sufficient to release the flap; a distal incision may damage salivary ducts (see Figs. 7-4 and 7-5, b)
  - At closure, the corner of the mesial incision edge will rotate to fit into the space of the palatal root (Fig. 7-8)
- Mandibular canine
  - Start incision at distal aspect of canine for 2–3 mm, following the linguodistal direction of the root (Fig. 7-9)
  - At the caudal extent of the first incision, make buccal and lingual releasing incisions in a Y-pattern (Fig. 7-10, a); avoid cutting through the frenulum (fold of mucosa on buccal aspect) (Fig. 7-10, b)
  - Additionally, an incision at the mesial (rostral) aspect of the tooth can be made for additional release (Fig. 7-11, a and b)
  - Elevation of the lingual mucosa gives access for bone removal and elevation (Fig. 7-11, c)
- Mandibular first molar
  - Make mesial and distal incisions (Fig. 7-12)
  - Once the tooth is extracted, gently elevate the lingual gingival margin sufficiently to provide release for adequate closure (see Fig. 7-5, d)
- Envelope flaps: for minor extractions that need minimal access, use the periosteal elevator to gently stretch out the gingival margins, without a releasing incision, and that can later be sutured at closure (Fig. 7-13)
Flaps for periodontal surgery
- If a periodontal pocket is greater than 5 mm, closed root planing will be challenging and ineffective, so a gingival flap will expose the site for adequate treatment
- As compared with extractions with interdental releasing incisions, the gingival margin around the tooth to be periodontally treated should be preserved
  - Releasing incision should be made at the adjacent tooth, at the “line angle” (Fig. 7-14)
    - Halfway between the outside aspect of the tooth and the midpoint of the root—the line angle
    - Not interdentally
    - Not at the furcation
    - Not directly over the midpoint of the root
  - When there is interdental gingiva (col, papilla) between teeth and the flap is to be made across several teeth, incise the interdental gingiva lingual or palatal to the teeth, not directly over the height of the papilla (Fig. 7-15)
  - Specially designed flaps, such as a crescent-shaped flap at the palatal aspect of a maxillary canine, will expose the site for effective treatment of deep infrabony pockets that have not yet progressed to a oronasal fistula
    - Attention to the palatal artery to preserve it within the flap is optimum
  - Elevate with periosteal elevator only as much as is needed to expose the area to be treated
    - One exception is to elevate through the attached gingiva to the level of the alveolar mucosa if the flap is to be sutured so the gingiva is placed further apically down the root (apically repositioned flap [ARF]—a procedure used to minimize soft tissue pocket depth and maximize contact between the remaining attached gingiva and bone)
Closure of flaps
- Small, absorbable suture material used in a simple interrupted pattern is typically best
- In dogs, a small reverse cutting needle will help get through the tough gingiva best
- In cats, a small taper needle may cause less trauma, especially in inflamed tissues
- With the palatal or lingual mucosa also elevated, pass needle/suture through this tissue first, then through buccal mucosal flap

Figure 7-2 Releasing incisions are full thickness, extending through the attached gingiva, past the mucogingival junction into the alveolar mucosa above (right maxillary canine).