Surgical extractions: Oral surgery gum tissue flaps.

Some surgical extractions will require the dentist to create a "tissue flap." The idea is that when this gum tissue flap is reflected (pealed back) it allows the dentist access to both the tooth and bone tissue that lie underneath. As its name implies, a tissue flap has an outline where even though it can be reflected it is still substantially attached to other undisturbed areas of gum tissue.

The normal course of events is one where a flap is created and reflected. Whatever bone removal is needed is accomplished and the tooth is removed. The gum tissue flap is then returned to its original position and sutured (stitched) in place. As opposed to the hypothetical situation where bone and its overlying gum tissue might be removed together, the fact that a tissue flap is repositioned so it covers back over most of the extraction site provides a significant benefit for the healing process.

How are the tissue flaps used with oral surgery created?

When preparing to "lay" a flap, a dentist or oral surgeon will first use a local anesthetic ("novocaine") to numb up the tooth extraction site and nearby tissues. They will then use a scalpel to cut the flap. The outline of the flap will be scored with the blade of the scalpel, cutting directly through the gum tissue down to the bone. Since the patient is numb, no pain will be felt. The patient will, however, feel the pressure of the scalpel on their jawbone.

Once the outline has been scored, the dentist will reflect the flap (peal it back from the bone). One edge of the flap will lie directly where the patient's gum tissue and teeth meet. Somewhere along this edge the dentist will insert their tissue "elevator" (periosteal elevator). This is a tool that looks like a small (somewhat pointed) flat-bladed screwdriver. As it is pushed underneath the outline of the flap, the gum tissue will peal back thus exposing the underlying bone and tooth. Since the patient is numb, no pain will be felt. They will, however, feel the pressure of the elevator being worked along their jawbone.

At this point the flap has been completed. The dentist or oral surgeon may now perform whatever procedure is required (bone removal, tooth sectioning) as a part of the tooth extraction process.

Why was the flap that was created so big?

When compared to the width of the space where the patient's tooth has been extracted, a tissue flap may look like it involves a comparatively large area. If so, it's because there are a couple of design factors that the dentist or oral surgeon must take into consideration when making a tissue flap.

Since the whole idea of creating a tissue flap is one of visibility and access, the flap must be large enough that it fills these needs. If the flap is too small, the dentist will tend to pull and stretch the gum tissue, thus creating more tissue trauma than if the flap had simply been designed large enough in the first place.

Additionally, the dentist will need a firm base over which to suture (stitch) the flap back into place. This means that the edges of the flap must extend over and rest upon undisturbed bone. And finally, the flap must provide for an adequate blood supply for its movable portion. For this reason, the base portion of a flap will always be broader in length than its free edge.