Flap SurgeryPresenter: R2 鄭瑋之 Instructor: Dr. 陳娟娟 2012/11/14

Purpose

1. To gain access to deeper periodontal structures with direct vision.

2. Relocation of the frenulum3. Maintenance of the attached tissue4. Pocket elimination and regeneration

Indications

• Pockets > 5mm persisting after phase I therapy• Bony pockets and interdental craters• Bony lesions in the furcations• Need for surgical crown lengthening• When to open up a flap? complicated

morphology like:– Deep and narrow pocket– Difficult to achieve the correct angle

Contraindications

• Shallow, supraalveolar pockets– subgingival scaling/rootplaning

• Esthetically sensitive areas• Fibrous thickened gingiva

– gingivectomy more favorable morphology

Comparison of open vs. closed

Instruments

Instruments

Small elevators for mobilization of the mucoperiosteal flap

Instruments

Principles of Flap Design

• Local flap1. outlined by a surgical incision2. carries its own blood supply3. allows surgical access to underlying tissues4. can be replaced in the original position5. can be maintained with sutures and is expected

to heal Used in oral surgical, periodontic, and

endodontic procedures to gain access.

Principles of Flap Design

• ComplicationsA. Flap necrosisB. Flap DehiscenceC. Flap TearingD. Injury to Local Structures

Principles of Flap Design

1. Base > Free margin• to preserve an adequate blood supply• unless a major artery is present in the base

2. Width of Base > Length of Flap*2• less critical in oral cavity, but length < width• a long, straight incision with adequate flap reflection

heals more rapidly than a short, torn incision.

3. An axial blood supply in the base4. Hold the flap with a retractor resting on intact

bone to prevent tension.

A. Flap necrosis

Principles of Flap Design

1. The incisions must be made over intact bone2. If the pathologic condition has eroded the

buccocortical plate, the incision must be at least 6 or 8 mm away from it.

3. The incision is 6 to 8 mm away from the bony defect created by surgery.

4. Gently handle the flap's edges5. Do not place the flap under tension6. Do not cross bony prominences, ex: canine eminence

B. Flap Dehiscence

Principles of Flap DesignB. Flap Dehiscence

Principles of Flap Design

• Envelope flaps– an incision around the necks of several teeth.– extends 2 teeth anterior and 1 tooth posterior.

If not provide sufficient access…• Vertical (oblique) releasing incisions:

– extends 1 tooth anterior and 1 tooth posterior.– started at the line angle of a tooth.– carried obliquely apically into the unattached gingiva.– If cross the papilla localized periodontal problems

C. Flap Tearing

Principles of Flap Design

• Mandible: lingual n. & mental n.

D. Injury to Local Structures

Principles of Flap Design

• Maxilla: greater palatine a. & nasopalatine n./a.

D. Injury to Local Structures

Basic Incisions

• Can be sulcular, crestal, or inverse bevel

Basic Incisions

Full thickness

(mucoperiosteal)

a: sulcularb: crestalDepending on

the amount of attached tissue present

Basic Incisions

Split/partial thickness

(mucosal)

In areas of thin bony plates andfor mucogingival procedures

Basic Incisions

Modified flap(mucoperiosteal)

1. gingivectomyIncision for pocket reduction

Requires adequate attached keratinized gingiva

On the palate, enlarged tissue, or with limited access

2. inversebeveledincision to the crest of bone.

Comparison of full- vs. partial-

Types of Mucoperiosteal Flaps

1. Envelope/sulcular incision2. Envelope with one releasing incision (three-

corner flap)3. Envelope with two releasing incisions (four-

corner flap)

Full-thickness mucoperiosteal flap

Types of Mucoperiosteal Flaps

2 teeth anterior 1 tooth posterior

1. Envelope/Sulcular flap

Types of Mucoperiosteal Flaps

1 tooth anterior 1 tooth posterior

2. Three-corner flap

Greater access in an apical direction, especially in the posterior aspect of the mouth

Types of Mucoperiosteal Flaps

1 tooth anterior1 tooth posterior

3. Four-corner flap

rarely indicated

Common Periodontal Flap

1. Inverse bevel incision 0.5~2mm, extending to the alveolar crest. Thins gingival tissue and permits compete closure of the interdental osseous defects postoperatively.

2. Flap reflection. Full thickness mucoperiosteal flap is reflected to permits visualization.

3. Crevicular incision between the hard tooth and the diseased pocket epi., to the depth of the junctional epi.

4. Horizontal incision carried along the alveolar crest

5. Root planing with direct vision

6. Complete coverage of interdental defects

1. Sulcularly, crestally, or full-thickness flap labially positioned inverse beveled incision to bone

2. Flap completed, reflected off bone3. Flap is apically positioned and sutured

A: The internal bevelled, scalloped incision is used for pocket elimination through apical repositioning of the flap.

B: The flappositioned apically for pocket elimination.

1. Crestal incision with blade, partial-thickness flap parallel to long axis of tooth

2. Flap raised by sharp dissection, periosteum retained over bone3. Flap is apically positioned at or below alveolar crest

1. No alveolar mucosa is present on the palate to permit apical positioning.

2. Pocket elimination by palatal flap that just covers the contours of the bone to eliminate osseous defects.

3. Requires skill and experience.

Osteoplasty

Osseous grooving, peprmits better adaption of flaps to facilitate plaque removal alter healing

Osteoplasty

Osteoplasty

Suturing for Flap Surgery

Simple Loop Modification of Interrupted

Figure 8 Modification of Interrupted

Vertical mattress suture

Horizontal mattress suture

Single Interrupted Sling

Reference

1. Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD, JD, FACS and Myron R Tucker, DDS

2. Peterson's principles of oral and maxillofacial surgery, Michael Miloro,G. E. Ghali,Peter Larsen,Peter Waite

3. An atlas of minor oral surgery: principles and practice, David A. McGowan

4. Manual of minor oral surgery for the general dentist, Karl R. Koerner5. Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA,

DDS, MSD6. Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak7. Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition,

EDWARD S. COHEN, DMD

Thanks for your attention!