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diastema. If the tooth is already absent, the incisions are made at the mesial and distal edges of the fistula.
When making flap incisions, adequate pressure should be placed to ensure full thickness of the soft tissue is incised down to the bone. Any vertical incisions should be created slightly divergent as they proceed apically. Divergent incisions allow for adequate blood supply for the newly created pedicle flap. It is important to choose the location of the incisions to ensure that sutured margins will have adequate bony support and will not lie over a defect.
The mucogingival flap is gently elevated off the bone using a periosteal elevator.
Approximately 2-3mm of palatal mucosa is also gently elevated/lifted off the palatal bone so that fresh epithelial edges are created. Any margins of the flap associated with the oronasal fistula should be debrided using a LaGrange scissors or coarse diamond bur to remove 1-2mm of tissue, leaving fresh epithelial edges.
A coarse diamond bur on a high-speed handpiece is used to smooth the edges of the remaining maxillary bone (if necessary) and to remove any epithelial remnants between the fistula and the nasal cavity.
As with any closure in the oral cavity, the key to success is to ensure there is no tension on the incision line. Fenestration of the inelastic periosteum (see previous section on surgical extractions) is performed to increase the mobility of the flap and allow for a tension free closure. This is accomplished by a combination of sharp and blunt dissection with a LaGrange scissors to ensure the overlying mucosa is not damaged.
The gingival flap is then placed over the defect so that
it remains in position without being held. Once this is accomplished (i.e. no tension is present), the flap is ready to be sutured into place.
Placing a subcuticular layer can improve the chances
of healing. A few buried horizontal mattress sutures will help maintain the flap as well as smooth out the incision line. Finally, this layer cannot be licked out by the patient.
Closure is performed as described in previous sections, with the initial sutures placed at the corners of the flap. This will avoid having to resuture the flap if it does not align correctly. This is not necessary if a subcuticular layer has been placed.
The remainder of the flap is then sutured over the defect in a simple interrupted pattern every 2-3 mm using an absorbable suture material.
M. Moran1
1Vets in Business Limited, The Head Honcho, Bridgwater, United Kingdom
Mark Moran, BSc. MBA
Vets in Business Limited Ashcott, TA7 9QS
Somerset, United Kingdom Identifying the opportunities
The key to providing cost effective healthcare is to ensure that a clinic’s principle asset, our veterinary surgeons, are being used productively and supported appropriately. In many clinics experience has shown that veterinary surgeons can spend over half of their time carrying out tasks and duties that could be performed by less qualified, and hence expensive, members of the team.
There are many reasons why this situation occurs, however the most common reason I am given is that it
is just the way we do things here! So how can you tell
if your clinic is using the whole clinic team effectively? The simplest way I have found is to ask them. This
can be achieved by using a simple survey, and/or
using individual confidential interviews. Often using an independent person for this task encourages staff to be more open and honest about their feelings, so long as they are made to feel secure that their comments will be treated in confidence.
Key facts to establish include;
How well do the staff understand the aims, objectives and values of their clinic?
Who do staff go to when they have an issue to resolve? Do staff feel that all of their skills are fully utilised?
Are staff being developed in way that is consistent with the clinic’s goals?
What do staff most enjoy about working at the clinic?
What do they least like, and would change tomorrow if they could?
Your Singapore, the Tropical Garden City

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