Technique for Developing a Mucoperiosteal Flap
Several specific considerations are involved in developing flaps for surgical tooth extraction. The first step is to incise the soft tissue to allow reflection of the flap. The no. 15 blade is used on a no. 3 scalpel handle, and it is held it the pen grasp (Fig. 8-9). The blade is held at a slight angle to the teeth, and the incision is made posteriorly to anteriorly in the gingival sulcus by drawing the knife toward the operator. One smooth continuous stroke is used while keeping the knife blade in contact with bone throughout the entire incision (Fig s-1O and 8-11).
The scalpel blade is an extremely sharp instrument but it dulls rapidly when it is pressed against bone, such as when making a mucoperiosteal incision. If more than one flap is to be reflected, the surgeon should change blades between incisions.
If a vertical- eleasing incision is made, the tissue is apically reflected, with the opposite hand tensing the alveolar mucosa so that the incision can .be made cleanly through it. If the alveolar mucosa is not tensed, the knife will not incise cleanly through the mucosa and a jagged incision will result.
Reflection of the flap begins at the papilla. The sharp end of the Woodson elevator or the no. 9 periosteal elevator begins a.reflection (Fig. 8-12). The sharp end is slipped underneath the papilla in the area of the incision and turned laterally to pry the papilla away from the’ underlying bone. This technique is used along the entire extent of the free gingival incision. If it is difficult to elevate the tissue at anyone spot, the incision is probably incomplete, and that area should be reincised. One the entire free edge of the flap has been reflected with the sharp end of the elevator, the broad end is used to reflect the mucoperiosteal flap to the extent desired.
If a three-cornered flap is used the initial reflection is accomplished with the sharp end of the Woodson elevator on the first papilla only. Once the flap reflection is started, the broad end of the periosteal elevator is inserted at the middle corner of the flap and the dissection is carried out with a pushing stroke posteriorly and apically. This facilitates the rapid and atraumatic reflection of the soft tissue flap (Fig. 8-13).
Once the flap has been reflected the desired- amount, the periosteal elevator is used as a retractor to bold the flap in its proper reflected position. To accomplish this effectively the retractor is held perpendicular to the hone tissue while resting on sound bone and not trilpprng soft tissue between the retractor and bone. The periosteal elevator therefore is maintained in its proper position, and the soft tissue flap is held without tension (Fig. 8-14). The Seldin elevator or the Minnesota or Austin retractors can be used in a similar fashion when broader exposure is necessary. The retractor should not .be forced against the soft tissue in an attempt to pull the tissue out of the field. Instead the retractor is positioned in the proper place and he!d firmly against the bone. By retracting in this fashion, the surgeon primarily focuses on the surgical field rather than on the retractor thereby the chance of inadvertently tearing the flap is lessened.