Incision Designs & Suturing Techniques In Oral Surgery Part 1

Dr.Basheer Muhammed Jafar Salman

Lecturer- Oral Surgery B.D.S, M.Sc

1 Email: bsalman@sharjah.ac.ae

Objectives ( part 1, 2 ): Define the incision and the flap Identify the principles of designing the flap Outline different types of the flaps used in oral surgery Understand the advantages, disadvantages of different designs of the flap Discuss the different types of suture material Discuss different types of suture needle Mention different types of suturing techniques

Further reading Fragiskos D. Fragiskos (2007): Oral Surgery. Springer Hupp (2008), Contemporary Oral and Maxillofacial Surgery. Alsevier 2

Definitions
Incision:
A cut into a body tissue or organ, especially one made during surgery by using a scalpel.

Flap:
A section of soft tissue that: 1- Outlined by a surgical incision. 2- Carries its own blood supply. 3- Allows access to underlying tissues. 4- Can be replaced into the original position. Flap reflected Incision Incision

Principles of Incision Designs

1- The incision must be carried out with a firm, continuous strokes, not interrupted strokes, the scalpel should be in constant contact with bone since repeated strokes at the same place impair wound healing.

Firm, continuous cut

2- Incision design should be carried out in such a way that injury of anatomic structures is avoided, such as: the mental nerve, palatal vessels, lingual nerve, submandibular duct, parotid duct.

Mental nerve 4

Principles of Incision Designs

3- The extension of the flap must be adequate (one or two teeth on either side of area of bone removal), so that the operative field is easily accessible, without creating tension and trauma during manipulation. 4- The base of the flap must be broader than the free gingival margin, and width of the base should be greater than the length, to ensure adequate blood supply and to promote healing.
Base

The flap extends one tooth on either side Blood supply direction

Base of the flap greater than the height (x= 2y)

Base of the flap must be broader than free margin (apex)

Principles of Incision Designs

5- The flap itself must be larger than the bone deficit so that the flap margins, when sutured, are resting on intact, healthy bone and not over missing or unhealthy bone, thus preventing flap dehiscence (opening) and tearing. Flap margin should rest on intact bone not defect 6- The mucosa and periosteum must be reflected together. This is achieved by a deep incision & the periosteal elevator is kept pressing firmly against the bone. Flap reflection 7- During the surgical procedure, excessive pulling or folding of the flap must be avoided, because the blood supply is compromised and healing is delayed.

Improper handling of the flap

Excessive pulling and folding of flap should be avoided

Necrotic sloughing

Types of Flaps
1- Trapezoidal Flap ( 3 sided flap)
A- It is created by a horizontal incision along the gingivae, and two vertical (oblique) releasing incisions extending to the buccal vestibule. B- The vertical incisions always extend to the interdental papilla and never to the center of the labial or buccal surface of the tooth. C- The trapezoidal flap is suitable for extensive surgical procedures. Advantages: 1- Provides excellent access. 2- Allows surgery to be performed on more than one tooth. 3- Produces no tension in the tissues when the flap retracted. Disadvantages: Produces a defect in the attached gingiva (recession of gingiva).

Types of Flaps
2- Triangular Flap ( 2 sided flap )
It is created by a horizontal incision made along the gingival sulcus and a vertical (oblique) incision extending from buccal vestibule to the interdental papilla of the gingiva.

Advantages: 1- Ensures an adequate blood supply. 2- Good access. 3- It is easily modified by adding vertical incision, or even lengthening of the horizontal incision.

Disadvantages: 1- Limited access to long roots 2- Tension is created when the flap is held with a retractor. 3- It causes a defect in the attached gingiva.

Types of Flaps
3- Envelope Flap (single sided, gingival flap)
A- This type of flap is created by a horizontal incision along the gingival sulcus of the teeth and extends along four or five teeth. B- If the patient is edentulous, the incision is made along the crest of the ridge. C- This design is primarily used in surgical procedures involving the palate in cases of removal of impacted teeth (impacted canine, premolars or supernumerary teeth). Advantages: 1- Avoidance of vertical incision. 2- Ensures an adequate blood supply. 3- Easy reapproximation to original position. 4- Could be modified by adding vertical incision, or even lengthening of the horizontal incision. Disadvantages: 1- Difficult reflection (specially palatally). 2- Great tension during retraction with an increased risk of flap tearing. 3- Limited access 4- Defect of attached gingiva. 9 Gingival flap for exposure of palatally positioned premolar

Types of Flaps
4- Semilunar Flap
A- This flap is created by a curved incision beneath the fold of the vestibule that extend at least one tooth over on each side of the area of bone removal. B- The lowest point of the incision must be at least 0.5 cm from the gingival margin, so that the blood supply is not compromised. C- The semilunar flap is used in apicoectomies and removal of small cysts and root tips. Advantages: 1- Small incision. 2- Easy reflection. 3- No intervention with the periodontium (no gum recession around the prosthetic restoration). 4- Easier oral hygiene control compared to other types of flaps. Disadvantages: 1- The incision may be made over the bone lesion due to miscalculation. 2- Limited access and visualization. 3- Tendency to tear 10
0.5 cm to ensure the blood supply

Semilunar flap for apicoectomy of upper central incisor

Flap Designs for Specific Cases

The Elliptic Incision ( in biopsy procedures)

A- It is used for the excision of various soft tissue lesions. B- It consists of two convex incisions joined at an acute angle at each end.

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Flap Designs for Specific Cases

Flap Resulting from shaped Incision:

This type of flap is indicated in surgical procedures of the palate mainly for the removal of bony exostoses (torus palatinus).

Buccal Flap & Palatal Flap

This type is indicated for closure of an oroantral communication (fistula).

Buccal Flap 12

Palatal Flap

Oro-antral fistula

Thank You
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