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THE WHOLE TOOTH AND NOTHING BUT THE TRUTH THE FLAP OVER FLAPS Eric M. Davis, DVM, FAVD, Dipl. AVDC
As I think back to my early years as a veterinarian, placing sutures in the oral cavity was rarely called for, perhaps with the rare exceptions of suturing lacerations or occasionally following removal of an oral tumor. In my discussions with veterinary practitioners regarding their approaches to oral disease, oral surgery is still an infrequently performed method of diagnosis or treatment. Yet in my opinion, most oral diseases can only be solved by surgical intervention and can rarely (if ever) be treated by medication alone. For the patient with a "carnasial tooth abscess", chronic periodontal disease, feline chronic gingivostomatitis, etc, I find that many practitioners dispense antibiotics firstand then wait. Of course, the hope is that the swelling, the pain, the odor will go away. It almost never does...it almost always comes back when the pills run out. So when the patient is presented a second time, I will often hear in the history, that a second antibiotic, a "stronger one", was dispensed, again with the same result. Even the misguided concept of "pulse therapy", to treat chronic dental disease has been shown to provide little benefit for the patient other than temporarily decreasing oral malodor. The clinic may be selling pills, but the disease persists and the patient suffers. The only effective way to manage most dental problems is by surgical intervention. So where does one begin?
Surgical incisions in the mouth are used to facilitate dental extractions, to enable thorough cleansing of periodontal pockets, can be used to mobilize tissue to cover defects over bone or teeth, and to remove masses in the oral cavity. As I discussed in the last article, certain surgical principals rise to prominence in oral surgery. First and foremost, oral tissues MUST NOT be closed under tension. In addition, tissue edges should be handled gently, flaps should have wide bases so as to insure that adequate blood flow to the flap is maintained, sutures should not be placed over a void, and tissues to be closed together should have freshly incised edges, preferably beveled. As in other surgery, incisions should be made not only to enable diagnosis and treatment, but with consideration given to how the wound is to be closed. And therein lies the flap over flaps.
Traditionally, most dental text books show placement of vertical releasing incisions at the mesial (rostral) and distal (caudal) edges of a tooth, referred to as "line angles", so as to permit the mucoperiosteum to be reflected away off the underlying alveolar bone. This maneuver would be useful for cleaning the root surfaces of a tooth with a periodontal pocket deeper than 4-6 mm, or to permit sectioning of a tooth for extraction. Once the extraction or root planing is completed, the vertical flap can be replaced and sutured into position using absorbable suture material. Many times, by undermining extensively, or incising the periosteum on the inside aspect of the flap, additional tissue mobility can be achieved to facilitate tension-free closure. 1 Ramsey DT, Marretta SM, Hamor RE, et al. Ophthalmic manifestations and complications of dental disease in dogs and cats. J Am Anim Hosp Assn 1996: 32 (3), 215-234. 2 Smith MM, Smith EM, LaCroix N, Mould J. Orbital penetration associated with tooth extraction. J Vet Dent 2003; 20 (1), 8-17. 3 Holmstrom SE, Fitch PF, Eisner ER. Exodontics. In: Veterinary Dental Techniques for the Small Animal Practitioner, 3rd ed. Philadelphia: WB Saunders, 2004; 291-338.
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