480

Tîie Irlernatiora/ Joumal ot Pericdonlit5 S Restorative Dentistry


Periodontal Reconstructive
Flaps - Classification and
Surgical Considerations
Odsd Bahal, BD5, MSD'
Mark Handskmon. DDS'
Periodontal recanstructive flaps have
been previously classified accarding
to flap types' or their intended direc-
tion.^ This classificotion and termi-
nology has been canfusing^ end, in
aur opinion, unclear. This has resulted
from the introduction of mismatched
elements of the flap design, direction
of transfer, geometry, number, and
varied angles af rototion. Ta classify
the uniqueness of flap design and ta
allow the placement of all flaps into
a specific category, it is suggested
that information from the general and
plostic surgery literature be adapted
to periodontics.
Private Practice, 416 North Bedford Dnve,
Suite 404, Beverly Hills, California 90210.
481
Rationale for classification
All periodontol reconstructive flaps
share two similar characteristics:
1. They ore all randam pattern flaps
(cutaneaus flaps).'-^ They receive
their name because of their mode
of blood supply, which arises from
segmentai ond axial arteries.
These vessels perforate the bese
of the flap via musculocutaneous
arterioles ¡Fig 1|.
2. All are local flaps, because they
are adjacent to the defect. This
gives them improved ability to
match the texture, color, and thick-
ness of the surrounding tissues.
Mechanism of classification
These flops can be seporated by the
direction of transfer and geametry.
Mode of transfer
1. Rotational. All rotational flops
share the common characteristic
of movement around a pivot
point. The rodius of the arc af ro-
tation is the line of greotest ten-
sion. The greater the ratation, the
greater the actual shortening of
the flap (Fig 2¡.
2, Advancement. Advanced flops
reach their final site without rota-
tian or any lateral mavement.
They con consist of one or more
pedicles. The advanced flap con-
sists of two straight-line, vertical in-
cisions with or without 100- to
110-degree back cuts (Fig 3).
These incisions bring the wound
edges together into their new po-
sition and coordinate their motion.
• 11. Number 6, 1991
 482

Both the advanced flap and the

rotation flop con be further classified
according to the geometry of the
flap.

Geometry

1, Transpositional, A rectangular
segment of gingiva and mucosa
is used.
2- Rotational, A semicircular seg-
ment of gingivo or mucosa is
used.

It is our opinion that this clossifi-

cation, which is based on occepted
general surgical principles ond further
modified to accurately descnbe the
reconstructive pericdontol flap, can
Fig I The random paltem flap is supplied by a network of vesseis that perforate
ossist the surgeon in visualization of the base of the Hop vio muscuiocutaneous arterioles. ¡Adapted from McGregor and
presurgical designs and ensure op- Margan'./
timal reconstructive efforts. No other
subdivisions are needed The sim-
plicity of this classification precludes
further esoteric division.

Fig 2 The rotational fiap moves araund
a pivot point The greater the rotation, the
greater the shortening of the flap.
Fig 3 The odvonced flop design is
based on two vertical incisions with or
without 100- to 110-degree backcuis. This
allows flap advancement ond closure
without tension.

The IntemaHonol Journol ol Penodontics & Reslorotive Dentislry


Surgical considerations
Flap survival
Prior to the surgical procedure, the
surgeon should consider all possible
designs before choosing the specific
one to be used.' Specific thought
should be given to all factors that
may increase flap survival.' When a
flap is needed, it should be meticu-
lously planned and should stort at
the recipient site. The dimensions
should be outlined and a pattern
drawn. All phases of flop transfor-
mation should be considered, includ-
ing possible shortening of the flap
and the desired angles and vectors
of movement.* The final pattern
should be lorger than the orea to be
reconstructed. Specific attention
should be given to the length of the
puffern to ovoid tension or kinking of
the flap.
Atroumofic technique
All flaps are sen/ed by a network of
blood and lymphatic vessels. The
crushing effect of surgical instruments
causes vessel changes and provides
substance for organisms to multiply
and create further tissue damage.'*
Therefore, atraumatic and gentle sur-
gical techniques should be practiced
throughout the surgical procedure.
Hot sponges hove been used to pro-
mote coagulation. However, they in-
crease capillary bleeding' and
should not be used in atraumatic sur-
gery. FHot sponges will further in-
crease tissue damage, because the
temperature will rise to as much as
óó^C, ond the incidence of wound
infection will increase.'" This infection
is probably the result of increased
tissue necrosis.
The initial phase of atraumatic sur-
gery consists of on outline of the re-
cipient and donor sites as well as the
transfer phases. The outline is drawn
with méthylène blue while the surgical
area is under tension. This stretching
effect will prevent false cuts and al-
low accurate incisions. When the out-
line crosses Iwo dissimilar surfaces,
for example, gingiva and mucosa,
the surgeon should place the mu-
cosa under tension and commence
incisions from the less firm surface,
from mucosa to gingiva.
Wound closure
Sutures couse a foreign body reac-
tion. Since the goal of suturing is to
close the wound and control the
placement of the wound edges, the
relationship between the sutures and
wound edges is important Engaging
a larger portion of tissue brings seg-
ments of tissue under constriction and
reduces the control of the position of
the wound edges.""'^ The optimal
time for suture removal is when the
tensile strength of the heoling wound
exceeds the strength of the suture
and is sufficient to maintain the ap-
proximation vi^thout assistance. The
tension on the sutures should be
carefully examined, because it will be
increased by the postoperative swell-
ing and thus reduce circulation and
couse further edge separation.
483
Sutures are classified according to
their reaction within the tissue: ab-
sorbable or nonabsorbable. They
can be further divided according to
their strength, ability to retain the knot,
pliability, wicking oclion, and tissue
reaction. A variation in edge ap-
proximation exists whenever uneven
flap margins are present.
Sutures alone will not provide op-
timal approximotion of the wound
edges. The uneven margin should be
further undermined and the thicker
edge should be advanced toward
the thinner side. Suturing of the peri-
osteum presents with a specific clin-
ical decision. The knot should be
pulled deeper into the wound. This
can be achieved by suturing to invert
the wound edges (as with a horizon-
tal mattress suture) which will further
create a vector that displaces the
knot more deeply.
Volume I I , Number 6, 1991
 484
Flop necrosis
Flap necrosis is disastrous when re-
constructive efforts ore being execut-
ed. It occurs most commonly be-
couse of inodequote blood supply
and moy increase both soft ond hard
tissue loss ot the surgical site.
The blood supply of the flap is
determined at the time of initiol ma-
nipulation."'^ Therefore, it is essentiol
to increose the tolerance of the fiap
to the initiol ischémie episode,'* which
peoks ot 48 hours, Vosculority from
the recipient site" increases after that
period.
Many techniques hove been used
in plastic surgery to enhonce the flop
survival, including cooling of flops'^
ond the use of vosodilotors" ond
other drugs. All such techniques have
been unsuccessful or unpredictable.
It is known from clinicol experience in
generol ond plostic surgery that a
flap raised in two or more stoges is
more likely to survive than a flap per-
formed in one stage. This is called
the "delay phenomenon."^" Al-
though the exact mechonism is not
known, this empirical finding should
be evoluated in cun-ent reconstructive
periodontol procedure.
may jeopodize vosculority. Pressure
on tfie medium-sized orterioles and
capillaries can be external or internal,
Internol pressure, usuolly the result of
internol bleeding or a surgical he-
The InternQtioroi Jouinai of Periodantics & Restorahve Dentislry
Maintenance af blood supply
During the surgicol procedure and
the immediate postoperotive period,
added core should be exercised in
maintaining existing vasculor potterns
and avoiding tension, pressure, and
kinking. Gentle manipulation, close
approximation, ond control of bleed-
ing aid in avoiding hematoma. Color
chonges within the flop should be
observed, becouse they moy be cor-
related to survival length" (Figs 4 to
7¡. Potterson'' observed three color
changes: white flops indicóte empty
capillaries and short sun/ivol; pink
flops indicóte the presence of blood
in tfie capillories and intermediate
survival; and o blue flap indicates
congested capillaries and the greot-
est length of sunjival.
It is our experience that similar col-
or chonges ore found in the rotation-
al and advanced flap used in peri-
odontal reconstruction. Clinically, if
pressure is opplied to the flap after
tronsfer, bleeding will occur. If the
pressure is releosed ond the original
color returns, the flop will most likely
survive. Similar blonching is often
seen along the line of greatest ten-
sion. This should be reduced by fur-
ther dissection, mobilization, ond
gentle manipulotion. Kinking will oc-
cur more frequently in the transposi-
tional flop, in the mandibular incisor
oreo, and when a shallow vestibule
reduces the degree of loterol mobi-
lizotion,
Externol pressure to the flop should
be provided for 5 minutes. However,
pressure over o prolonged period
motomo, can be as detrimentol ta
the vasculorily of the flap as external
pressure from a rigid periodontol
dressing. Careful dissection and
gentle manipulotion ore necessGiy to
ovoid the development of exagger-
ated swelling.
Surgicol hemostasis
Vasoconstrictors moy be detrimentol
to flop survival, and the vascularity of
the flop con be improved by reduc-
ing the amount of vos a can striction
used during the surgicol procedure."
It has been shown experimentally
thot doses of epinephrine exceeding
1:100,000 used in combinatian with
lidocaine moy increose flop necro-
sis.^^ It was further illustroted that
an epinephrine concentrotion of
1:100,000 will provide surgical he-
mostasis similor to that pravided by
higher doses and will reduce the
likelihood of necrosis,'''
Bleeding should be controlled
through ligotion of smoll- ond me-
dium-sized orterioles or wth a high-
frequency, high-omperage electro-
surgicol unit. Cotton pellets impreg-
nated with lidocoine ond epinephrine
¡1:200,000 to 1:800,000) or liquid co-
caine (4% to 5%j can be used to
control superficial and surfoce bleed-
ing.
 485

Figs 4 to 7 Color changes observed within o flop ot various stages of healing. White flops indicate empty capillaries and short
sunivol; pink flaps indicate the presence of blood in the capillaries ond intermedióte survivol; and a blue flap indicates cagested
capillaries ond the greatest length of survival.

n . Number 6, 1991
48Ó

Plastic properties of oral tissues

The oral mucosa have limited elas-

ticity. When the incisions are made
and a flap is elevated, tissue shrink-
age occurs. Clinically, the mucasa
will shririk to a greater extent than
gingiva. The flap, however, can be
stretched to or beyond its original
size. The surgeon should be coreful
not to extend beyond the elastic limits
af the flap to avaid stretching blood
vessels or overthinning of the flap
over bony deformities.

Posfoperative infection
Postoperotive infections must be
treated as soon as possible. Such
complications primarily occur be-
cause of excessive tissue trauma.^'-"
Risk of infection is greoter following a
reconstructive procedure because of
the reduced vascularity subsequent
to flop elevation. Such infections
should be treated aggressively with
antibiotics and drainage.

Summary
A simplified classification of peri-
odontal flaps has been offered. The
design of periodontal flaps requires
careful planning, logicol design, and
meticulous execution. When all the
foctors discussed are given adequate
consideration, surgical morbidity is
decreased, and wound healing is not
compromised.

ol of Periodonticí & Restoralive Denlislty


References
1. Friedmon N: Mucogingivoi surgery.
7"exDeni J1957;75:35S,
2, HaliWB: Pure MucagingivaiProblems.
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re 11, Number 6, 1991