Half way in to a tricky extraction you hear a voice…”Maybe now is a time to raise a flap?”
You ignore this voice and keep sweating with the luxator in hand, because it has been far too long since you raised a flap and you dread the nurse’s reaction.
If this is you, then we got you. I brought on Consultant Oral Surgeon Dr. Sami Stagnell to share his tips and pearls in Oral Surgery, specifically WHEN and HOW to raise cleaner flaps, as well as what types of flaps to consider for each situation and when NOT to consider extending beyond an envelope flap.
Protrusive Dental Pearl: Nice and Clean Extraction Sites – Use the spoon end of Mitchell’s trimmer to clean the surgical site for 30 secs to 2 minutes.
Highlights of this episode:
- 1:27 Protrusive Dental Pearl: Nice and Clean Extraction Sites
- 13:43 How to gain confidence in raising a flap
- 21:51 Envelope Flaps
- 30:09 Guidelines regarding relieving incisions
- 37:32 Raising a nice clean flap
- 41:45 Guidelines in lifting the papilla
- 44:56 Blades – 15 vs 15C vs 12 blade
Improve your Oral Surgery Sectioning with this speed-increasing electric handpiece at Incidental Limited. And get 5% OFF their entire products with the code ‘onions‘!
Check out the Oral Surgery Course that Dr. Sami Stagnell will be launching in 2023.
If you enjoyed this episode, check out Make Extractions Less Difficult: Regain Confidence by Sectioning and Elevating Teeth
Click below for full episode transcript:Opening Snippet: /Sami/ So the first word you said was purposeful. And that is it like you're doing everything with direction and purpose and meaning. You're doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you're putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don't want to sort of have to try and repair if they don't want it. /Jaz/ What instrument are you using to raise the papilla and beyond?
Hello, Protruserati. I’m Jaz Gulati and welcome back to another episode of The Protrusive Dental Podcast. This time, Oral Surgery specifically how to raise cleaner flaps and the principles of raising flaps in oral surgery, for exodontia. I’m joined today by Dr. Sami Staggnell. I know you will love his humor, and his humility. He’s a really humble guy. He’s a consultant oral surgeon, but he’s so down to earth. So I know you’ll enjoy all the tips and pearls he’ll share with you. The main themes that we’ll cover in this episode are like, when should we raise a flap like I’ve been in the past struggling with a difficult extraction, I’m thinking, it is now the best time to raise the flag? Or should I just keep going? Should I keep luxating, elevating and maybe the truth will come out? Or should I really start getting my handpiece in and start raising a flap, I mean, nowadays, I’m raising less and less flaps, I mean, I probably section 80 to 90% of all molars, and I do it flapless. So it’s something that I’m having to do less and less. But obviously, for third molars, I’m raising flaps. And so I had lots to learn from Sami as well, in terms of how to make my own flaps cleaner and nicer. We’re going to revise the different types of flaps and when to consider an envelope and when to extend beyond an envelope. And also, we talked a little about blades, are all blades build equally? Are there any that you should be avoiding? It was a surprise that he taught me today, which I’ll be sharing with you as well.
The Protrusive Dental Pearl, it only has to be oral surgery related. So one way I feel I have zero evidence for this maybe it exists, but I haven’t read it, is how to reduce dry sockets. I was taught by this oral surgeon in Singapore, a very simple thing, like I think most oral surgeons do this and they pass this on to us when they will make learning from them as students. And I guess we fall into bad habits and we don’t do it, is once you’ve removed the tooth, do you actually clean the site, even if you haven’t raised the flap? And so something like Mitchell’s trimmer, you know that spoon end of Mitchell’s trimmer? My nurse knows, Zoe knows that after an extraction, I’ll always ask for it. So when we started working together a few years ago, she was surprised at how every time I was doing the extraction, I was asking for Mitchell’s trimmer. And then now she knows it’s part of the kit when I do an extraction. So every time I take a tooth out whether I’m raising a flap or not, I’ll use a spoon end of a Mitchell’s trimmer, and scrape, scrape, scrape. What am I scraping? I’m scraping the adjacent papilla you know there’s plaque there, right? That’s causing inflammation, that’s not a optimal healing environment, I’m going to scrape the inside of the socket, I’m gonna get rid of any potential debris, any granulation tissue, I’m just giving it a good clean for, you know, 30 seconds to two minutes if I find that it was one I had a section and then maybe there could be some bits of amalgam in there, you never know. So make your surgical sites clean and nice using something like a spoon end of a Mitchell’s trimmer. And using this, I’ve had like two or three dry sockets the whole year. So now it’s August and eight months, I’ve had three dry sockets, so it’s not like I’m immune to them. But I do feel since I started doing this a few years ago, I get less and less. So now let’s join the real expert in oral surgery, which is Dr. Sami Stagnell. I’ll catch you in the outro.
Sami Stagnell, welcome to The Protrusive Dental Podcast. How are you my friend? [Sami]
I’m very good, Jaz. Thanks for having me, man. [Jaz]
I’m so buzzing for this. Oral surgery is always a popular topic when it comes to Protruserati, we had some great ones in the past. And we’re gonna delve deeper into flaps. But before we get into that, tell us a little about yourself. Where are you in your training pathway? What kind of work really, what part of oral surgery that you love to do? What’s your niche within that? [Sami]
Yeah, for sure. Training is a long term thing, isn’t it? But as far as training goes, I’m a specialist now. So I got through specialty training about five, six years ago. I’m also a consultant. So I work at Eastern hospital two days a week, the rest of the time I manage things between general practice. So doing IMS type work, so specialty referral and through the NHS as well as balancing private referrals as well. And then subspecialty interest in implantology. So I spent most of the last 10 years building that as my niche. So traditionally a lot of oral surgeons would sort of just put implants where the bone is, but I have a background with a Master’s, restorative masters and a few other bits and pieces up my sleeve. So yeah, a few tricks to sort of help make me a sort of better implantology. But that’s effectively the sort of the general day to day so yeah, it’s quite good fun mixing it up general oral surgery and implantology [Jaz]
Do you restore your implant as well? [Sami]
Yeah, I still do. Absolutely. And I think I’ve always, I’ve never given an up totally. I’ve got a prosthodontist who I absolutely love, and she’s amazing. She makes me look good in so many ways. But I definitely think you’d have to keep your hand in and I know, Pynadath George, who’s sort of been on your podcast before. He’s one of those people who inspires me in so many ways and I do look up to him a lot. And he’s a polymath, and I sort of, I’ve always been comfortable in that zone and I think until in the last few years, took a while for people to get okay with people being polymaths and I think as an oral surgeon as someone who does the surgical side you’ve got to understand the restorative and the the outcome orientated aspect of it because otherwise it’s moot. It’s completely lost, I think. [Jaz]
It raises an interesting point. I mean, firstly, I respect so much from an oral surgery background, that you respect the fact that is restoratively driven. That’s amazing. That’s the way it should be. But when it comes to Implantology, as a non specialty, there is no specialty of implantology, there’s no specialist in implantologist, really, it’s a made up term. When we have people with perio background claiming that okay, you know, we are the drill experts in implants, then you have the restorative folks, prosthodontic folk and the oral surgery, how can you get it and even GDPs who do implants, I guess what I’m trying to ask is how can we be more integrated in our approach, when all these different sub specialties are dabbling in implants? [Sami]
You have hit the nail on the head with that question. I am totally on board with how that question gets asked. Because I think it’s asked often by the wrong people in the wrong circumstances it’s often asked is how can we control implantology? And it tends to be like you say, specialty specific people who are asking that question rather than people ask them holistically. And one of my other sort of sideline jobs is I’m a council member on the College of General Dentistry and we rent things like the training standards and implant dentistry that are due for review. And it’s a question we constantly ask ourselves, how do we improve that? How do we change? How people approach implantology because when I got into this about 12 years ago, when I placed my first implants as a undergrad, I was quite lucky over to do that as part of my sort of general upcoming as a dentist. You know, I got taught by a prosthodontist, who’s daughter now is also a prosthodontist, as well, who I work with on the younger itI and [Sami]
Must be Emily Abraham? [Sami]
It was yes. Well spotted. Yes. [Jaz]
Another Sheffield alumni. [Sami]
Yes, Sheffield. Absolutely, though, the Sheffield group. So I think it’s one of the few things in dentistry, that means you actually makes you have to be raise your game and everything. I think implantology doesn’t give you any leeway. Like you can choose other specialty areas. And even just if you’re just doing basic Oral Surgery minor or surgery, you can get away with sort of understanding, is the teacher restorative, is it not? You can tread lightly around the edges and sort of get vaguely whether or not it is or isn’t. But implantology, the deeper you get, the more your knowledge base has to grow, the wider your sort of scope for it has to be. And I think there are lots of people claiming stake in it. But in the UK, we’re the only country in Europe that has specialties in the way that we do almost there’s not as many specialties as many other European countries. And I’ll be corrected on that if I got that wrong. But if you go to someone like Germany, people orthodontics and surgery, you go to Austria, so I spent a year doing ITL fellowship in Austria. And there’s no specialties, it’s simply an oral surgeon by virtue of the fact that you work in the oral surgery department. So when I was out there for a year, all the faculty were mixed on one floor, so everyone had their offices that we shared with prosthodontists, perio guys, the was the president for the European Federation of Perio was in the office opposite view, which was amazing. So I spend a lot of time with those guys raising my perio game. So I do connective tissue grafts, I’ll sort of assess phenotypes, I think about the current conditions and things because that was so important. And what they brought to the table was crucial. And I watched these teams, everyone handed off to everyone, everyone knew where their cutoff was. And everyone knew, right, this isn’t for me. Now I’ve got a handle on. And it just meant that no, but there wasn’t infighting, and it’s somewhere I really want to get us in the UK because I think there is so much to be learned from that sort of background, from that way of thinking. And that’s much more open and collaborative approach to it. And then the only people that are going to benefit other patients. And then when they were not going to run out of work, we still place relatively few implants as a country. So there’s loads of work to be gleaned. We just need to approach it the right way, I think. [Jaz]
Thanks for explaining that. But did I catch you right that you placed your first, technically you place your first implant as an as an undergrad? [Sami]
Yeah, I was a fifth year. So Neoss was running an undergraduate program in King’s at the time, because I think the founders of Neoss were partly related to King’s. So when I was a fourth year, there was sort of an option out there to sort of get involved in implants. Now, I’ll take this story back even further. And I try not to bore your listeners. But a lot of people asked me when I sort of got into dentistry what I wanted to do Dentistry, I wanted to do it from a young age, no family or anything. I just my dentist didn’t hurt me. I went to the doctor for jobs, but my dentist was always nice. And then when I did work experience, I ended up doing my work experience with Andrew Darwin, who is sort of one of the gods [Jaz]
Oh, my goodness [Sami]
In anhtology. So 16 year old me on Harley Street has no clue about oral surgery, has no clue about dentistry. It’s just been told all the standard Spiel stuff that you get at the UCaaS sort of forms and all the rest of it. And I’ve walked in and I spent a week with these guys, and it blew my mind, absolutely blew my mind and I sort of knew that oral surgery of some kind. I was like, if this is dentistry This is then I’m in you know, sign me up now because I’m all on. And by the time I then got to 40 I sort of, I was toying with the idea of do I maybe do medicine as well and maxfax and I think you know, at that stage of your career, you sort you’re flooded with ambition and enthusiasm and you sort of you haven’t had enough clarity, have seen enough things yet to make good decisions. But this opportunity came up to, you know, who wants to try and do implants. And because it wasn’t really a mainstay thing in dentistry, even like 15 years ago, it was happening, but it wasn’t sort of something that undergrads were really talking about. Most people were trying to busy fill their quotas with composites and root canals, let alone trying to get anything else done. And I sort of me being something I struggle with saying no to things. So I was like, yes, struggling. So I then had to go to Prof Abraham, who sort of would work up the case with me, and I had to present him do all of that other stuff. So my finals case process, I placed two implants. And it was one of the nurses working in King’s at the time, it was her dad, I got to do the implants on so yeah, so it was already [Sami]
That is so cool. You talked about quotas. And you know, when dentists are trying to do their one quota for that molar root canal, you went ahead and place two implants. I love that. And I think it’s so important to appreciate everyone’s origin story. And I repeat this theme time and time again, with every guest, I might spend a few minutes finding out how you fell in to where you are in the world at the moment in your journey. And I think it’s so relevant that, hey, you had that experience with Andrew Darwin in Harley Street, you met some people who took you under their wing to help you go above and beyond to help you as an undergrad. And you showed that interest. And then that spiraled into where you are today. So amazing, I hope people find some value from that journey and can can model it and look up to it. So don’t be, undergrad all over the world, don’t be upset that you didn’t place an implant. That’s the norm. But appreciate that When opportunity comes knocking, take it where you can. And if you already have an interest from before, then then go with it. So I’m glad you shared that. [Sami]
I’ll add to that, if you don’t mind. Like I think you know, I was listening to a podcast really recently that was talking, you know, some people talking about luck. Luck is simply preparedness for when opportunity arises. Like you’ve just said, that opportunity comes you jump on board. And I think at the early stages of career, you’ve got to take those steps, you’ve got to take those leaps. And you’ve got to put in the mileage because all of a sudden, one day, kids come along, mortgage comes along, the world approaches you in a different way. And you may not have the energy and the enthusiasm. But if you can be inspired by what you’re doing, it makes a heck of a difference. And you’ll sort of find the drive. And often it’s motivation comes from seeing the results. And it’s simply being able to dedicate the time and the discipline to dedicate yourself to some of the ventures to begin with and understanding patients in those early formative years. I think so many people want to jump into implants, and I see young people come to it all the time. And hopefully this segues on to what we’re gonna talk about today. But people come and go, I want to do implants. Okay, great. How many surgical did you do? They’re like none. I’m like, Oh, my. Okay, no, no, no, do not pass go and like so what years have you done? Have you done any surgical? Have you spent any time in the hospital? No, but I’m on an implant MSc and I’m like, The only people winning here are the universities like they are the ones taking money. And I’m not, that’s not a go at the universities because the universities have phenomenal teachers but you’re not you haven’t seen enough composites fail. You haven’t managed enough patients, who didn’t enjoy their perio treatment, you haven’t screwed up making immediate dentures like you haven’t done enough of the stuff that will make you good at the rest of it later down the line. So take inspiration, but be patient. And that’s a really tricky balance, especially in today’s Go, go go sort of lifestyle. [Jaz]
Sami, that is real talk right there. And I love the way this podcast started because it was very warm and fuzzy and uplifting and the story and now we just hit them hard with a real talk. I love that. Let’s because people now are getting little bit nervous because we’re into the podcast now. And we haven’t mentioned the word ‘mucoperiosteal’ yet so there we are, we mentioned it now. So let’s move on. Let’s talk about flaps, my friend. So the first question I have for you really is I am not afraid anymore to raise a flap like go back four or five years ago maybe then the thought of raising a flap was very much like okay, it’s been half an hour, the tooth’s not budging. I look at my nurse, I’m sweating and like okay, get me the blade. And then that means to her, okay, there’s no, I’m not having a lunch today, basically. So that was the kind of sort of background. A lot of dentists are like that okay, I’ve run out of options here. And I don’t want to refer in the middle of an extraction. So let me remember what they taught me in fourth year of undergrad and try and pull up some sort of flap and drill some bone and figure it out. Now whilst I had better mentors and stuff, and now I’m very happy to Section teeth and that for me, and we’ve covered this before as well, sectioning teeth, for me was so important in getting higher success rate and confidence and now things don’t faze me as much and having those failures behind me, those painful faces behind me that taught me valuable lessons. And even when I was at Guy’s hospital doing an oral surgery post, I saw an upper canine humble a consultant, Oral Surgeon. So that showed to me that actually, sometimes when you have these patchy areas, the way explain it to me you have these patchy areas of ankylosis and you can’t predict that sometimes and those are just gonna be really difficult. So don’t you know don’t be too upset if you can’t get it out because chances are if you’re struggling, most people would struggle [Sami]
You won’t ever know. And I remember seeing this as an NHS as well. Watching a maxfax consultant who I absolutely like, put on a pedestal. And I watched him walk into an EMT theater where they were doing a cancer operation to take out some pre molars and he spent 45 minutes doing it. I’ve watched as a registrar, one of the like, the greatest surgeons I’ve ever worked with who’s at cleft maxillofacial surgery, he made everything look easy. And, you know, we walked away after an hour and a half doing four wisdom teeth, and he just turned to me was like, Well, that was like glass bottles in a concrete bed. I was like, Yeah, and I was assisting, I wasn’t even doing it. And I was sweating. And it’s totally that this having respect for the foundation, I think. But it’s the tightrope between fear and respect. And a lot of that, and the difference is experience. The difference is simply putting yourself out there, but most people, they don’t see it as a means to an end with oral surgery, they don’t see a means to an end with surgical extractions. You’re doing you know, when you started doing verti preps, and you might do crown lengthening, you’ve got an outcome because you’ve got a bigger thing that comes after all of that, you’ve got something else that supersedes it. Whereas in oral surgery is just getting the tooth out and I say just, but actually, you know, the thing that causes most fear and problems for most patients, most of their bad experiences are root canals and bad extractions. So surely, if the PRA, ever the PR exercise needed to be had in dentistry, it’s about good root canals and good extractions. You know, people come in and like the other dentist had any on my chest, I’m not that agile for one. And secondly, I don’t know, a single person teaching that technique, the sort of amount the patient style of removal of tooth. And, but when I speak to most people, and then especially on the implant courses that I teach on, where are people getting hung up on with raising flaps with approaching these is they don’t think far enough ahead. So the biggest start of stumbling block is often planning for the unexpected. So I have a plan A, but I have B, C, and D, hopefully in the background somewhere, that means that we’re not going to get stuck somewhere, we’re not going to come unstuck. And if we do, I’ve talked the patient through it, I’m not keeping it from the patient either. And I think again, it was a medical legal lecture, I went to the British Association of Oral Surgery conference a few years back, and there was a barrister talking, he was like, people need to stop getting worried about owning risk, because it’s not your risk to own, it’s for patients don’t. So if a tooth is risky, if there is a three that’s going to be ankylotic and different, difficult. I just talk people through my experience, I will normally tell people look, this is how I expect it to go. These are some of the things that can happen, the 30 seconds of telling people that tends to mean that you’re just sharing your experience. And if it happens, then they just look at you like you’re sort of you had your crystal ball on you could tell the future. And if it doesn’t, then they just think you’re good anyway. So you know, telling them after it’s just an excuse, that was always the way it was told to me, you know, just for warn. I think a friend of mine, Richard Moore, who runs an oral surgery podcast, he just did one on complications as well, which is worth a listen to for any of your listeners as well. And Judith, his colleague, I forgot his surname now who is a friend and colleague of his as well trained Richard initially used the phrase forearm is forewarned, and I think that is such an important that hope I got that away, right. That is such an important phrase. But I think listeners will hopefully get it that you can make assessments but people don’t treatment plan with oral surgery, so they just in their head go the tooth going to come out. But they don’t think about the anatomy, they don’t think about if I’m going to raise a flap where I’m gonna have to put it, do I have all the kit ready, I get the nurses to get stuff out at the start of a session. Because the nurse, 10 quick turnarounds, between getting things up, because you can adlib for 20 seconds, we’re just gonna get some more kit out, we’re just gonna make this a little bit quicker, we’re going to try and speed things up because it’s not playing ball. So I want to make sure that we go the right way with this as quickly as possible, versus trying to talk holiday plans for 20 minutes with whilst the nurse remembers which where water tubing goes in and the like. And all you do is sweat more and feel worse and then just that hiatus ruins your momentum. But it’s that’s the experience factor. And I think the more people do it, the more comfortable they get raising a flap and I think you’ll see that now like you say you’ve raised a lot of flaps, you’ve done a lot of these now. So you start, I put luxator on to tooth and I’ll tell straightaway whether or not I’m going to bother trying to just continue luxating or not, I’ll sort of use feel and in the same way that you’re sort of apply a certain tactility and experience to cram perhaps or looking at aesthetics and assessing whether they’re right or not. And actually now we’re going to do something different, but people aren’t used using that experience, and then it becomes a vicious circle. The more you avoid it, the less likely you are to do it. And you just keep going and then 10 years down the line you refer everything out and it’s actually it’s not that’s not a practice bill. [Jaz]
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You’re so right. And I love those communication gems you shared. I love the humor there. And in case you are multitasking and you missed it, the whole glass bottles and the concrete. I love that. What a great analogy, what a great visualizations about some of the trickiest teeth that we’ve had to remove. So yeah, I mean, I am not so worried anymore. So just reflecting back on my journey in evolution in oral surgery as a GDP. But when I, even when I am raising a flap, quite often my go to flap is an envelope flap. So if you don’t mind, Sami just explaining to those maybe younger grads, what an envelope flap is. And I just want to know, in your practice, when you are raising as part of your let’s say, Plan A, you’re going to do a flapless maybe and then plan B if you need to raise a flap you will do this kind of flap, what percentage of times are you ending up doing? So we’re talking non wisdom teeth here, we’re talking anything but wisdom teeth, What percentage of times would you just raise an envelope flap? [Sami]
Yeah, so I think envelope flaps are the way so those watching the video, I’m gonna apologize for telling my back and those listening, I’m just gonna tell you that and I’m drawing some badly drawn teeth at the moment and a broken root. And so, you know, assume typically this is sort of in that sort of four or five region or sort of the lateral that sort of breaks off, you know, after post core crowns tooth. Envelope flap is just what we traditionally typically called the single sided flap. So it’s that first incision, where you sort of use your blade to gently sort of trace the outline of usually the adjacent teeth, you can take it crestally, so sort of if you’re looking from it, top down, and, you know, the incision is in the midline, along the crest. And I often think that it’s quite useful putting fingers either side. So if you’re holding the buccal and palatal or the lingual and the labial, you get a feel for where your distance is. So you can place your blade in the right place. And often, a lot of people look like a sushi chefs, when they’re sort of doing this the way they’re sort of trying to sort of filet things and you’re like, Well, hang on. No, no, no, no, just raise the flap. And it’s almost I think it comes from this tentative nature of wanting to do it properly. But all you do is traumatize the flap. Unless you’re a periodontist raising a split thickness, flap, go to bone, go down to firm contact, be is sincere and sort of direct with the movements that you’re making. Because.. [Jaz]
Be purposeful [Sami]
Yeah, that’s it perfect word. And then that’s it. Because if you’re not, all you’re doing is traumatizing tissues, the more trauma there is the more bleeding, bruising, swelling, soreness, discomfort people are going to get later. So that all forms part of what you’re doing. But typically, for most procedures, I think probably for 60 to 80% of stuff an envelope works. Because often you can get enough reflection. And the other thing with raising flaps is you want to start and give yourself enough leeway because a lot of people will do flap, and then go, right I was taught two sided at dental school or whatever it is. And like they’ll do their flap. Now something else breaks or now you have to take away more bone. Now, you know, for example, if this had a big perio defect on that tooth and the tooth in front, whatever, all of a sudden, you’ve now put your flap on compromised that area that’s never going to support it when you put your… [Jaz]
Your relieving incision [Sami]
hen you put periosteum Well, you do a couple of things. One is you damaged tissues around adjacent teeth. And I think again, in an era of aesthetics, if you’ve got nicely done crowns, you know, this is why I get my prosthodontist provisional crowns on anything that we’re operating around for months before we get to the final things. So we can connect with tissue graft to do whatever it is that we need to do to make things look nice because if those margins are going to change at all, and I’m responsible for that change, the last thing you want to do is in on really nice looking crown and the same for some of the older population. You already have great margins and already fed up with that, but don’t want to go and replace some of the stuff. Why make that situation worse for them. So often you can maintain those flap margins quite nicely reposition that replace things to where they are, because that’s it, you’re starting with the money, this all has to go back to where it was when you started, if you’ve got solid bone, and is this concept of a periosteal cuff. Maxfax guys used to talk to me a lot about this, and they never understood it until they had loads of infections. And they often try and give themselves like a 5 to 10 mil cuff of margin. In some cases, I think that’s too much. And you’re probably encroaching on their anatomy. And actually, I think we can be a bit more minimally invasive of the concept stands. And again, it comes from autogenous, grafting and Frank Zastrow, who took the quarry bone split technique a little bit further, he talks about this, and I think it’s because you get this periosteal attachment to bone natural will stick to natural, you will get that and here is the Hemi desmosomes or behavior that you want to sort of reconnect to tissues, you’re not going to get that if it’s on the mind, but more so again, it comes back to the planning, if that’s going to break or I’m going to need to take away more bone and then all of a sudden I’m in a difficult situation, start minimal, give yourself freedom to extend but no way you’re going to take it to. And I think that’s [Jaz]
So it’s a perfect good thing to start with an envelope and just follow the adjacent gingival margins, you know buccally usually, and then as and when your plan changes, you may then need to put a relieving incision make it a two sided three sided as appropriate. But as you said, 60 to 80% time when you are raising a flap and just out of interest, what percentage of your referral cases for like in an upper first molar or lower pre molar, some tricky extractions that you might get, What percentage of times I even raising a flap? [Sami]
Very few. Because sort of failed extraction. But often like people have done the same thing, again and again, you can always predictably do. People look at you like you’re 30 When you sort of tell them, Did you put your applicator here? Did it then break like this? Did you then look at the fast handpiece in the long diamond. And people look at you like were you in the room. And you’re like No, but people do these things predictably. And often it’s because of the fear takes over. So the bad behaviors creep in. And then like no one will know if I just picked up the fast handpiece. Or I’ll just you know, I’ll just dribble some water from the three in one and the acrylic bur, we’ll see if that works. And might, because people cut corners because they haven’t set up, they haven’t got themselves ready or prepared. They didn’t anticipate it would break. And no one is perfect. Stuff still goes wrong on me. But it’s how you carry yourself in it. And I think you know that candor of being able to say to a patient, look, this isn’t going how we expected it to be. Hold fire, we’re going to reset and we’re going to restart. And we’ll come back to and often just having the authority about yourself and the confidence to say it’s not going right. So what I’m going to do is this. And you talk about referring and often like I think people are either afraid to refer because they think that we sit in our ivory towers as consultants just casting in Shame on those who send in? No, we don’t, because we’ve all been there. But there are some things we know that are avoidable. And often I think you get the fear stories, then people come in and go oh, my dentist said I needed to be asleep for this. And it probably didn’t. If you the dentist just lead with actually I’m not confident or comfortable doing this. I’m going to end and I say to patients my backup because I say to patients And I said to my colleagues all the time that being a GDP is probably the hardest job and it ends up on my doorstep. It’s only going one place in the bin. So I got a really easy job. Because I only do one thing. Being a GDP is probably one of the hardest jobs you can do hands down, I think. So if you turn around and say to your patients that your GP isn’t going to try and manage your dodgy ticker, are they going to send you to a cardiologist, I’m not going to manage this too, because actually, it’s outside my skill set. And you may need someone who can manage it, if it goes wrong. Most people are fine with that, and they will respect you for it. So don’t feel bad to say that to people. But I think it’s their sort of when people skirt around the subject. But in terms of, you know, again, I say this to the juniors who come through training. And I don’t say it to sound arrogant, but the difference between me and one of the juniors is 10,000 teeth, because I’ve spent the last 10 years you know, 5 to 10 years doing it. So in that time, I’ve amassed enough screw ups. You know, Michael Jordan talks about his failures quite openly, like he made, he missed several 1000 shots, he screwed up a number of games, it’s the same thing for me, I’ve done the mistakes enough times to know how it feels often when those broken teeth end up in my chair if I put a luxator on it. I have a sense of fear that other people won’t do in the same way that you will look at a splint Jaz and know whether it’s badly adjusted probably without even putting articulating paper. Because you’ve seen enough of that and you’ve done enough for them and that’s all that it comes down to in the same way that some people will be great and GDP is great with Invisalign. They’ll look at a case and straight off the bat go no you need fixed. Go see this guy and that’s just experience. That’s all it comes down to. But again, I go back to the point, if you do avoid it, you’ll never get that experience but for most stuff, you can avoid it. And then again, like if you’re going to add in throw in distal relieving through the motor, you know, chuck it further back, chuck the distal relieving incision. [Jaz]
Let’s just make really tangible for those listening in case they’ve forgotten exactly what we have on the board at the moment. So we’ve got, let’s say, we’ve got a canine, premolar root, second premolar, and molar and then the first molar is broken, it’s subgingival we’re going to be raising an envelope flap and now somebody’s going to suggest it. Okay, when might we need to extend that to a relieving incision? [Sami]
Yes, I’ll put the relieving incision distally always to start with, because I think in the lower arch, it’s less of a problem, scarring is less of a problem. Because people you know, nobody has a high lower lip line, you know, very few people show off gingiva in the bottom to be honest, then you end up with recession problems. So, again, most people have thin phenotypes anteriorly, around lower central incisors. So that’s always going to be a tougher place to manage those. So, you know, stick those distal relieving incisions in there rather than mesial ones. And often, again, the longer that envelope, the initial envelopes, if you’re taking a one, two up to two and a half units, then you’ve got enough, you don’t always need to take a papilla. And I think that’s one of the things that most people are sort of fallible for. So you know, I’ll sort of drawing the papilla on my shonky drawing, yeah. But for those listening [Jaz]
Just to make it clear, I mean, you’d start, I’ll usually start off with the envelope first and see where you go. You then would add the relieving as and when required? [Sami]
Yeah, totally. That’s all it is, like, you know, see what you can see, if you can’t see enough, what are you going to need to see more? And if that’s going to fail? Or what are the light again? So going back to the idea that if I can’t see at this stage, where am I going to get caught out? And where am I going to need? What am I going to need to see? So say, around lower premolars, you may well need to see them in terms of if you’re really getting down that low, hopefully not. But if you need to see it and protect it, then you know, it means you’re relieving incision may be a benefit just past the canine. So you avoid the anteriors you can you know you can include that, you can avoid the papilla. So the sort of sparing type flap, so you basically imagined an oblique incision, next to sort of one of these lower incisors, sort of angling the blade at almost like a 45 degree angle down to the bone at the level of the papilla. So you sort of leave the papilla intact, because between the two and the three, and then you can take the rest of that incision down and that will often spare because it’ll have blood supply from the labial aspect as well. [Jaz]
So that’s one principle, don’t cut in the middle of a pillar, either either include the entire pillar, or would you say it’s okay to stop short of the pillar? [Sami]
I think you can stop short of it. Because often like and you’ll see this, this has come more from the perio guys than anything else. So say you’re around the tooth, say imagine you’re on that lower four or five spaces again. So you’re sort of round the three in and then you’ll include the papilla, and then as you just compose the ability to then go to the midline of the tooth. And then when you’re sort of because again, you’re thinking forward to when you’re going to repair that as well like how am I going to put that back together? So do I have the right sutures for this? Am I going to be able to reconnect keratinized tissue to create nice tissue mucogingival junction to mucogingival Junction, use anatomical landmarks and make sure you safeguard those anatomical landmarks because again, it’s all starting with the end in mind. So you thinking forwards to what am I going to send this patient away with? And what am I going to have to deal with later when they come back? If they need a new crown? If they’re going to have, what’s the next stage? If it’s just having a tooth out, you know, are they going to walk away with scars or deficits around crown margins those things? [Jaz]
Well, I think the reason I mentioned some of those points there is just to give some principles and foundations to dentists who are revisiting refreshing Oral Surgery flaps and I think what this podcast can’t be because you really need to be go to a proper courses. Okay, this is a two side, this is a three side, this is how you raise it. That’s wasn’t the plan. But the plan for just a main message I guess we want to send is a mistake that I would have made many years ago is okay, I’m gonna raise a flap now the flight or flight responses is inside me. Again, the whole sweating, find the blade 20 minutes are talking holidays, the blade comes, you’re gonna miss lunch, and then automatically you go for okay, I was, the only flap I remember from dental school is a three sided flap. So let me just go and raise a three sided flap. And that’s a common mistake that GDPs might still be making nowadays. And I just want to save everyone for everyone from that. Maybe start with an envelope first. Get some training, get some refresher course under your belt, start with an envelope first and then see if you need to extend it and I think some of those foundations you covered well, good there anything else want to add to that before we talk about how to make the flap cleaner? [Sami]
Yeah, I think the two things that I add into what you just said are Yes, go on courses, get some mentoring and I think mentoring is becoming something that we’re shying less and less away from we’ve got more and more comfort with getting someone else on board to come and give us a hand and watch us do some cases. And you know I know some absolute you know pillars in the industry who will still get their mates and they’ll still pick up the phone to and you know, I have no qualms over going next door and speaking someone’s I’m still a new consultant in the grand scheme of things, I’m still very junior in my career. And just because I have the name badge doesn’t mean they know everything. And at some point, I have to be able to go, you know what, it’s not safe. Actually, I want to just sense check what I’m doing. And that’s, you know, that’s consciously incompetent. And that’s the safest you can probably be because you know, your boundaries, you know what your standards are, don’t be afraid, I think to go and ask for help, get some mentoring. And if you say to your patients, look, you’re a bit more complex, I want to bring in a colleague who can help me I’m sort of training up to make sure that I’m better at these cases, again, very few people mind because you’re open and honest. And if they don’t like it, then we’ll find them refer them anyway. So save yourself the headache, and because they’re probably not the patients you want to try and manage when it goes wrong anyway. And the other thing is instrumentation people go cheap, you know, people will spend 1000s on the weirdest stuff, like apps, like, they’ll buy a scanner that they use twice, or something like that, you know, and then then I’m not really buying to digital, but it’s the same thing at surgery, people won’t spend two, three grand on a decent surgical deck, you know, again, if you’re going to get into implants, you do those other things that will pay dividends. Same goes for things like Piezo, yeah, I use my Piezo for more than just taking teeth out, I do it for all the implantology work that I do as well. And so it’s got multiple uses, and blog rabbits in my line of work, it’s great. I’m not saying go out and buy a Piezo, but they’re a great addition. But a good surgical day. Good hand pieces that work that are going to get looked after that are gonna get oil. And then again, you don’t need the hue, you know, the top of the line, finest, you know, hand instruments, but you can get really decent sort of German made ones for not very much money. And again, like Hu-Friedy, Zepf, devemed, like there’s some great lines out there that, yeah, they’re a bit more of a premium, but they don’t fall apart. I’ve used cheap and cheerful and that stuff last minute. And by the time you’ve bought it for the eighth time, you spent what you would have. And actually you would have had something that worked much nicer fell better on your hands didn’t constantly like lose grip, didn’t lose teeth, didn’t drop Needles, Scissors that cut, you know, stuff like that was just like, again, because you’re there hacking away. It’s like you’re trying to start a campfire. Just it again, it’s the small things that just make the whole thing miserable. It’s marginal gains, but from a different viewpoint, I think. [Jaz]
Brilliant. Now, when we come to raising a clean flap, any top tips that you can give that okay, we’re gonna be raising either two sided or maybe an envelope flap. We don’t want messy flaps, it looks like a dog’s dinner, it looks like a facial trauma injury. Any tips I can give on raising a nice clean flap, full thickness mucoperiosteal. [Sami]
So the first word you said was purposeful. And that is it like you’re doing everything with direction and purpose and meaning. You’re doing it for a reason. So get your blade down to bone, to hard tissue, be confident in where you’re putting that blade and know where you are, raise the papillae first. So I tend to sort of raise the outer edges and round the margins because those are the bits that tear. And those the bits that you then don’t want to sort of have to try and repair if they don’t want it [Jaz]
What instrument are you using to raise the papilla and beyond? [Sami]
So often enough of the very least, the Mitchell’s trimmer does wonders. But it’s something that if you don’t have one of those sort of medium sized excavator works, because actually that the shape of that will get right under the papillae, you can put them in contact with a bone just peel up edges ever so slowly, and that works really nicely as well. Or a curette is a sort of more spoon like version of an excavator, isn’t it. Again, you can get dedicated papilla elevators, things like that. And those are, again, reduce for instruments. General Medical has a really big range. And I’ll pick up the general medical guys because they’re very good for the substance. And the so you can use any range of things. And again, like typically the ones that are fine, and we’ll have it sort of like a sharp or fine point on them that you can get between the teeth, you can sort of really put that sort of arrow head type almost configuration in underneath the papilla, just try and gently sort of like flick it up and flick it open. And then as you sort of work your way down the flap, you sort of the width of the instrument can get wider because as you get into the meat of the flap, what you’re potentially doing is tearing, if you’ve got a very small fine instrument from that you’re putting a lot of pressure through a very large space, because the periosteum will give eventually and so then you can sort of key help that your flaps and things and so again, that’s more repair work that you don’t want to sort of do unnecessarily so, and keeping these instruments in contact with bone, not on the flap because so Pynadath George again is great at this. We’ve had long conversations about it. I think you talked about it in the local aesthetic podcasts he did with you. So listeners can rewind to that one. But he talks about hydrodissection. And giving yourself enough time for [Jaz]
Man, that’s changed our practice in terms of when I’m doing with wisdom teeth, I love that so much. [Sami]
But it’s so i And again, like, when I’ve got many trainees with me, they sort of look at me really funny when I sort of walk in numb up, and then go and make coffee. And then I was he gone. And because like, I’m going back to rethink and look at the scans and look at the x rays and replan make sure that I’m happy in my head with everything. But I’m letting the local get to work, because it’ll take 10 minutes for the adrenaline to get to work and to create that vasodilation and give you that sort of cleaner field that you need for them to be comfortable. And then you can come back and redeliver more anesthetic. In that time, the team will prep the patient, get them ready. So when I walk in and scrub in, I just get started. And actually it saves time, because again, it’s small talk that you don’t really need to make with them. And it can feel almost awkward. And if they’ve been given that time to go numb when you get started, they’re properly numb. And they have a bit of time to forget. And sometimes I’ll do it. If I’m dealing with sedation, it’s like numb them as I’m as they’re sort of getting started as they give the first bolus of the dazzle and so tends to be a very patchy haze. And then the anesthetist will get them really comfortable. So by the time I come back again, they’re properly sedated, we’re good to go. So yeah, using good local and good local technique is a big part of it. And that helps with the cleanness of the flap because I definitely think you can see a difference. And we’ve seen it, you see it across oral surgery. Now is so vascular, but whether it’s orthognathic or otherwise good time for your local to work makes a huge difference with how you can then handle flaps. [Jaz]
The right instrumentation, being purposeful, keeping your instrument on the bone, like you said and correct LA techniques is a good summary of that. But it’s want to just hone in on one point we’ll go to next question, the intrument. Let’s say we’re going to use a medium size excavator, can you just guide the dentists who may be visualizing this, if we liken that excavator to a spoon, that spoon is now going on to papilla, are you using the outside of the spoon? Are you using the inside of the spoon when you’re actually lifting up the papilla? So I curbside or the? The convex side or the concave side? [Sami]
So I’ll often use the convex side against bone when I’m lifting the papilla first, because you’re almost trying to scoop under it, you’re trying to sort of gently lift and flick it forward, and then spin it around and get a toe, or there’s sort of a tip of that spin down onto bone and sort of gently sort of tunneling. And what I tend to find as well as most people will stick into one area of lifting that flap. And that’s when they get tears and things because the rest of the flaps not mobilizing. So sometimes it’s worth going around to other areas of the flap and seeing what will start to raise and what will start to move because as you start to get more mobility in the flap, you’ll get more of it raise. And I’ll often use tissue forceps. So the same as you would be doing for when you’re suturing. I’ll use those to sort of hold up leading into the flap, again, it’s about control. So making sure that you’ve got control over where that flap’s going. And as you sort of hold it, and you gently apply some pressure and pull, you can get your elevator down onto that bone and squirrel in underneath it. And that will again help to sort of push up to raise it. So you gently working your way around it and taking some time. And I think people underestimate, you know, again, it’s knowing where your patients there. So some of the perio patients, if we’re doing sort of clearances and then coming back to them for full arch work or whatever. Some of those patients have got such inflamed tissues that by the time it all heals, it’s really scarred up. It’s really tethered. It’s very rare. And again, even in the ones that are sort of you look at the ones who have been wearing dentures for years and flabby ridges, similar sort of stuff, these are sort of quite traumatized tissues. So sometimes it can be quite hard. So don’t underestimate how difficult that can be to raise the flap because no tooth extractions necessarily the same. And that will sort of have an implication what’s underneath and again, it goes you know, if you’re raising a flap and you’ve say you’re raising the flap, and there was a socket there, you know, I talked about putting your blade down quite decisively. But often what scares people is they put the blade and suddenly it drops into where the socket was. But again, that’s where it you know, I mentioned earlier on putting your fingers either side, or where the pallet is in, say that buccal bone is. Knowing where that midpoint is okay, fine, you’re going to be safe, but it’s okay to go to bone and to use again, you can use a caret to try and scoop something out. There’s Danny Boozer from Bern, he talks often about you know, if you’re doing an early placement with an implant, for example, you’re raising that flap, that’s tissues really immature. So taking that out of the socket moving it bucally, he calls it the free gingival flap, because you know you’re not taking it from anywhere else, you’ve got that tissue and it adds to the bulk buccally as well. So use that tissue if you can, if you need to. [Jaz]
Brilliant. And the last thing I want to cover through the wrap up is, talk us about it, I mean, I think we can do a whole another episode on suturing that kind of stuff, but that’s we’re just focused on armamentarium, the blade. Is there just the one for GDP? Is it just a 15? And can you just talk about 15C versus 15 Normal? And and How about one more thing, which I actually people have asked me for is, you know that I usually call it the putty knife, but it’s actually a blue sterile blade that comes in a packaging. I use it for my putties. But the first time I worked in this practice [Sami]
Do you mean the 12? Like a sickle? [Jaz]
No, that’s what I use for composite. I mean, an actual, it’s actually 15 blade on a plastic handle, right? It’s sterilized, got an expiry date on it. But first time I was reblading for this practice, the nurse handed me this, I’m like, No, I want it on a metal blade. And I want the blade open from a package and stuck on. Now and that got me thinking Hang on a minute it. Am I just being very old school? Are dentists actually using this disposable blade, which I use for putties? Is that acceptable? I don’t know. [Sami]
I use them. Because again, not everywhere has them. And it’s, I think it’s being versatile. And again, sometimes like, I’ll be honest, they’re not the most comfortable. I prefer round handled blades. And unlike a certain feel to like the pen type ones, I find that the feedback is much better. And I can be more dexterous with them, I can sort of change the angles in a nicer way. I don’t shy away from them. I think if it just gets you going and doing it again, then great. They don’t make 15C thing [Jaz]
Sure, No one’s ever taught me to use that. I was just unsure. And I don’t want to do the wrong thing. So you know, already. You’re raising a flap you wanna do it well, so I was like, no, no, get me the proper surgical kit out. Let me use the blade I’m used to using but it’s good to hear, have that reassurance that if you have that pre-sterilized number 15, Blue, that’s usually the one I use light blue in color. You can use that right? [Sami]
Yeah, you can definitely I mean, there’s the you know, the people will use them in a&e will use them all over. Like, it’s not wrong to use it. But again, like, you know, to go out and buy a nice scalpel handle will set you bet like 30 to 50 quid. You know, I know people who spend more on coffee in a month, you know, I just think there’s that, you know, if that makes your life easier to just buy one. And then you can use any blade you want as well, because they’re all universal, sort of, like, sort of fittings. So just, you know, there’s no, you can shortcut it. And if you want to get used to get out of this, so what and some practices if you work in lots of practices, and some might have different things. But again, if you’re moving around working lots of practices, you might want to start investing in your own kit anyway. So I think, yeah, the scalpel blades, 15 C is my preference, because I think it’s a fine blade, it’s the same shape as a 15, just a smaller width. So it has a smaller cutting to the length on it. And the smaller tip, so it’s just shrunk down 15. And I prefer those, I feel like you are in a much more finer way you’re managing the flap and a much finer way and raising that nicer. So that’s my preference. I started using, I’ve now gotten forgotten the number whether it’s at 11 or 12. I think 11 is the sharp pointy one. And 12 is this sort of curved, sickle one whatever I’ve got. [Jaz]
Super curved [Sami]
Yeah, and they’re quite useful. Because again, if you start getting into like implantology, and you’re doing lingual flaps to sort of raise for bone grafting, you can’t get in there otherwise. And same for things like taking connective tissue from the tuberosity sometimes are quite useful on the palate, if you ever do things like ectopic canines and flaps there. So it’s worth having a pack like I seem to collect packets of sort of blades and things and then you can get into Microblading sorts of stuff. But again, that’s more sort of adventurous. I think 15 C will cover you for the vast majority of stuff. And I think that that’s totally okay, just get started with that. [Jaz]
Well, I learned something new today that you can use that blue blade, and I will apologize to my nurse when I get there from an afternoon shift of it as the first thing I do. So thanks so much for sharing that with me. And honestly, you gave so many communication gems. You’re very funny. I enjoy your humor today. Please tell us where we can follow you on Instagram. You mentioned about implant courses. Please tell us about your involvement with that. Tell us how we can reach out with you. [Sami]
Yeah, thanks so much. And like you said, the armamentarium side, I think we could keep going to I’ll hold you to this and I’ll invite myself back. We’ll do another one if you want. But in terms of reaching out, you can follow me on Instagram @mr_ oral_surgery. So Mr. Oral Surgery And I’m on Twitter as well @samistagnell and also you can heckle me there and on LinkedIn as well. And as for courses, I am in the midst of setting up some new oral surgery courses, I’m going to be doing them with a few colleagues of mine. And we’re looking at developing, mentoring network because everything we’ve talked about today is sort of the real struggle. And you can go and implant courses. But the feedback that I’ve had from a lot of this senior guys the big names in implantology is that most people aren’t doing the basics. So for me my tagline you heard it here first is you know being better at basics. That’s what I want people to be. I want people to get the simple stuff, right and then progress and then grow and elevate themselves from there. But just come back like you said before, touch base, mentor, refresh. You can do that umpteen times and you’ll never sort of tired from it. And again, learning it from a few different people which is why we want we’re building this mentor network because we appreciate the fact that there are more than one way to skin the cow or there’s more than one way to elevate molar. So I think you want to hear it from a few different people and find what works in your hand. So you get comfortable with that. As for implant courses at the moment, predominantly, I’m teaching on the Paul Tipton year one course, which is really good. So definitely recommend that. And I contribute to a few others here and there. So if you follow me online, you’re sort of [Jaz]
definitely well, I’ll put the link to to follow you on Instagram and LinkedIn. But also, if we need to know when you have any links, so you can send to me, Sami I’m gonna stick them in the show notes, so people can just quickly click on, that’d be great. I really enjoyed our chat today. And I think we’ve got what we wanted out because it’s unrealistic to explain through a podcast format all the different types of flap, but I think people will walk away just thinking bit more about the plan for oral surgery. The fact that knows even just learning you as an oral surgeon, the percentage of time that you actually using a flap and when using flap, what’s the main go to flap, I think that’s going to hold a lot of value for a lot of people. And then just little nuances about blade, which I discovered today. Thank you so much for that. And the communication stuff you shared today was really valuable. Thanks so much for your time today. [Sami]
That’s a real pleasure. I think my absolute takeaway is going to be just plan, you plan for everything else. Don’t stop planning in this plan, the complications, plan your approach, plan your escape, and those are things that are going to sort of make things more comfortable, because when it happens, it’s not a complete unknown. So there’s definitely but Jaz, thanks so much for having me on. I’ve really enjoyed it. It’s been really good chatting. [Jaz]
It’s been really fun. Thank you.
Well, there we have it guys, you can use that blue blade after all, and I shouldn’t have corrected my nurse. So there we are. Now I know. And I hope you found value from that it was great that those who were watching, you managed to see him draw. For those who are listening, I’m sorry that it was a little bit of a visual episode that we didn’t get to explain certain elements of it. But you can always go back on YouTube to check out exactly those parts where he’s drawing certain things. I think that might be helpful for you. If you enjoyed listening to this episode, if it was helpful to you, please do give it a rating on your app, whichever app you listen to, or if you’re watching YouTube, do hit that subscribe and a thumbs up button. Leave a comment any questions you want. I always do get the guests to come and support you guys on YouTube. Or sometimes if I know the answer, I’ll always try and help you out. Thanks so much and I’ll catch you in the next one.