PRESENTATION BY: DR SAIMA

N NAKAPOLO
BDS, 4TH YEAR
PART.1
 PRINCIPLES OF FLAP
DESIGN,DEVELOPMENT AND
MANAGEMENT
1.DESIGN PARAMETERS FOR SOFT
TISSUE FLAP
 Soft tissue flap:Is a surgical procedure in which the soft tissues(gums) are
separated from the alveolar bone temporarily and folded back to allow the dentist
to reach the alveolar bone and the teeth root/s.
Indications
Gingival flap surgery is used to treat gum disease (periodontitis). It may be
recommended for people with moderate or advanced periodontitis
Anatomic problems
Procedural accidents
Retrieval of materials in the root canal
Horizontal apical root fracture
Biopsy
Corrective surgery
Surgical extraction(open extraction)
1. Broad base
adequate blood supply
The base of the flap should be broader than the free edge(free margin) to ensure that all areas contained within
the flap have a source of uninterrupted blood supply. If this is not adhered to, then areas within the flap, or entire
flap itself can undergo ischemic necrosis.

2. Adequate size
To provide necessary visualization of the area.
For the insertion of instruments required to perform the surgery e.g. retractor
For an envelope
flap to be of adequate
size, the length of the
flap in the
anteroposterior
dimension usually
extends two teeth
anterior and one tooth
posterior to the area of
surgery .
3. Flaps for tooth removal should be full-thickness mucoperiosteal
flaps.
This means that the flap includes the surface mucosa, the submucosa,
and the periosteum

4. The incisions that outline the flap must be made over intact bone
that will be present after the surgical procedure is complete.

If the pathologic condition has eroded the buccocortical plate, the incision should be at least 6 or 8 mm away
from it in an area of intact bone. In addition, if bone is to be removed over a particular tooth, the incision must
be sufficiently distant from it so that after bone is removed, the incision is 6 to 8 mm away from the bony defect
created by surgery. If the incision line is unsupported by sound bone, it tends to collapse into the bony defect,
which results in wound dehiscence and delayed healing
5. Anatomical consideration
Mandible:
Mental nerve-location can depend on the age and race
-The mental nerve emerges via the mental foramen, which is situated either in the interdental space between the
apices of the lower first and second premolar teeth, or a position apical to the second premolar.
Lingual nerve-In the third molar region, it is only covered by a thin layer of mucous membrane.
 Maxilla
The greater palatine nerve and vessels
Nasopalatine nerve and vessels
6. Relieving incisions
Releasing incisions are used only when necessary and not routinely.
When vertical-releasing incisions are necessary, only a single vertical incision is usually needed, which is usually
at the anterior end of the envelope component. This decision will depend on the amount of reflection required
to gain adequate access to surgical field.
 2.Types of Mucoperiosteal Flaps
The most common incision is the sulcular incision which, when not combined with releasing incision,
produces the envelope flap
vertical releasing flaps:
three-cornered flap (Triangular flap)
four-cornered flap(Trapezoidal flap)
Semi-lunar incision
The Y incision
Pedicle flap
3.Developing a Mucoperiosteal Flap

Steps:

1.Incision of gingival sulcus:

incise the gingival sulcus, using the No.15 blade and a No.3 Scalpel handle.
The knife is angled slightly away from the tooth and incises soft tissue, including the
periosteum, at crestal bone.
The incision is started posteriorly and is carried anteriorly, with care taken to incise completely
through the interdental papilla.
2. Reflection of the flap
is begun by using the sharp end of the periosteal elevator to pry away the interdental papilla
3.Retraction of the mucoperiosteal flap

Periosteal elevator is used to retract mucoperiosteal flap.

The elevator is placed perpendicular to the bone and held in place by pressing
firmly against the bone, not by pushing it apically against soft tissue.
 4. Refraction of the mucoperiosteal
flap

Once the entire free edge of the flap has been reflected with the sharp end of the elevator, the
broad end is used to retract the mucoperiosteal flap to the extent desired, taking care to
keeping the edge of the elevator on bone and under the periosteum.
If more than one flap is to be reflected, the surgeon should consider changing blades between
incisions.
The scalpel handle is held in a pen grasp for maximal
control and tactile sensitivity
4.Principles of Suturing

Functions of sutures
The most important: To coapt wound margins (to hold the flap in position and
approximate the opposing wound edges)
Aid in homostasis
Overlaying tissues should never be sutured tightly in an attempt to gain
hemostasis in bleeding tooth socket.
Sutures help to hold a soft tissue flap over the bone.
Sutures may aid in maintaining a blood clot in the alveolar socket
A special suture such as a figure-of-eight suture can provide a barrier to clot
displacement.
 Suturing materials required
needle holder -The needle holder of choice is 15 cm (about 6 inches) in length and has a locking handle
o The needle holder is held with the thumb and ring finger through the rings and with the index finger along the
length of the needle holder to provide stability and control

suture material.
Scissors
 The suture needle usually used in the mouth is a small three eighths to one
half circle with a reverse cutting edge.
The cutting edge helps the needle pass through the tough mucoperiosteal
flap tissue.
 How to suture?

1.Reposition the envelope flap into its correct location

2.Place sutures through the papillae only (usually facial),starting with mobile
tissues first. Avoid placing sutures across empty tooth sockets

3.The needle is regrasped with the needle holder and is passed through the
attached tissue of the lingual papilla.
When passing the needle through tissue, the needle should enter the surface
of the mucosa at the right angle, to make the smallest possible hole in the
mucosal flap
The minimal amount of tissue between the suture and the edge of the flap
should be 3 mm.
 4.Tie the sutures with an instrument tie(the suture should not be tied too
tightly or too loose)
The knot should be positioned so that it does not fall directly over the incision
line because this causes additional pressure on the incision.
In most situations in which the oral mucosa is being sutured, the
ends of the suture should be left no longer than a centimeter
 Types of sutures used
1. The simple interrupted suture- is the one most commonly used in the oral cavity.

Advantages
These sutures can be placed quickly,
Tension on each suture can be adjusted individually.
If one suture is lost, the remaining sutures stay in position

Disadvantage
The knots can easily collect debris
 2.horizontal mattress suture
A suture technique that is useful for suturing two adjacent papillae with a single suture
3.The figure-of-eight suture
the figure-of-eight suture-holds the two papilla in position and puts a cross over the top of the socket that
may help hold the blood clot in position.

Advantages
aid in hemostasis
This suture is usually performed to help maintain a piece of oxidized cellulose in the tooth socket
 4.Continuous sutures
-used for long incisions

Advantages
can be used to efficiently accomplish the closure.
When using this technique, a knot does not have to be made for each suture, which makes it quicker to suture
a long-span incision and leaves fewer knots to collect debris

Disadvantage
if one suture pulls through, the entire suture line becomes loose.
The non-resorbable sutures are removed after 5-7 days
PART 2
PRINCIPLES AND TECHNIQUES FOR
OPEN EXTRACTIONS
Indications for Open Extraction
1. after initial attempts at forceps extraction have failed
2. If the preoperative assessment reveals that the patient has thick or especially dense bone,
particularly of the buccocortical plate, surgical extraction should be considered.
3. Occasionally, the dentist treats a patient who has very short clinical crowns with evidence of
severe attrition
4. Hypercementosis (mostly in old people)
5. Roots that are widely divergent(especially maxillary first molar roots)
6. Roots that have severe dilaceration or hooks
7. Expanded Maxillary sinus that include the roots of the maxillary molars.
8. Teeth that have crowns with extensive caries, especially root caries
9. large amalgam restorations
10. crowns that have already been lost to caries and that present as retained roots
11. Teeth that have fractured at the cervical line and, therefore, exist only as a root.

Advantages
less traumatic(prevention of excessive bone loss)
Is quicker, more straightforward extraction
 Technique for Open Extraction of
Single-Rooted Tooth
1. provide adequate visualization and access by reflecting a sufficiently large mucoperiosteal flap.
2.determine the need for bone removal.
BUT: the surgeon may attempt to reseat the extraction forceps under direct visualization and, thus, achieve a
better mechanical advantage and remove the tooth with no surgical bone removal at all.

(
 grasp a bit of buccal bone under the buccal beak of the forceps to obtain a better mechanical advantage and grasp
of the tooth root. This may allow the surgeon to luxate the tooth sufficiently to remove it without any additional
bone removal
 3.use the straight elevator, pushing it down the
periodontal ligament of the tooth
Caution: The index finger of the surgeons hand must
support the force of the elevator so that the total
movement is controlled and no slippage of the
elevator occurs.

4.proceed with surgical bone removal over the area of the

tooth(a bur is used to remove the bone along with ample
irrigation)
 If the tooth root is solid in bone, buccal bone can be
removed and a purchase point can be made for the
insertion of the elevator. the purchase point hole
should be about 3 mm in diameter and deep enough to
allow the insertion of an instrument.(A heavy elevator
such as a Crane pick)

A triangular elevator such as the Crane pick is then

inserted into the purchase point and the tooth is then
elevated from its socket
4. The bone edges should be checked; if sharp, they should be smoothed with a
bone file.
5. the entire surgical field should be thoroughly irrigated with copious amounts
of sterile saline.
Special attention should be directed toward the most inferior portion of the
flap (where it joins the bone) because this is a common place for debris to
settle, especially in mandibular extractions.
6. Soft tissue is repositioned to its original position and sutured with 3-0 black
silk or chromic sutures
Thank you!!!