INCISIONS AND FLAPS

INCISIONS AND FLAPS

Definition Flap is a small incision made in mucosa and periosteum under local anaesthesia to gain access to the area for raising the mucoperiosteum to perform dentoalveolar surgeries.

Rules of flap design.

Avoid severing large vessels and nerves. Place margins far away from surgical areas to ensure wound margins over sound bone. This also gives room for any adjustments and avoids collapse of flap into the bony defect. Design the flap for adequate visibility without over exposure of bone.

 Base of flap should be the widest portion There should be no sharp angles on the flap. Sharp corners tend to slough due to poor circulation . Vertical or oblique incisions should not be made over root eminence. It is best to incise in trough between adjacent teeth.

 Maintain integrity of interdental papilla . The papilla at incision line is allowed to remain whereas other papilla should be included in flap. Use sharp instruments. Always include the point of the blade during incision as it allows the bone contour & any irregularities to be followed easily.

 Be gentle with the flap. The retractor should be broad and designed to contact bone so the flap rests on it passively.

Do not incise close to gingival sulcus when using a horizontal or semilunar incision. 2-3mm of attatched gingiva should be left around each tooth . To avoid tearing the mucoperiosteum , incision should be made in one pass bone deep & with firm & continuous stroke.

 Incise in the attatched gingiva for semilunar flap.

Elevate the flap away from the line of vision to provide adequate exposure to the surgical area.

Types of flaps in intraoral incisions

1. ENVELOPE FLAP

2. TWO-SIDED TRIANGULAR FLAP

3. THREE-SIDED TRAPEZOIDAL FLAP

4. SEMILUNAR/ELLIPTICAL/CURVED FLAP
5. OCHSENBEIN-LUBKE FLAP 6. PEDICAL FLAP

ENVELOPE FLAP
This is made by extended horizontal incision in the gingival sulcus along the cervical lines of the teeth.

INDICATIONS- Surgical procedures including cervical lines labially (buccally) and palatally (lingually), apicoectomy (palatal root), removal of impacted teeth and cysts.

 ADVANTAGES-Avoidance of vertical incision &

easy reapproximation to original position.

DISADVANTAGES-Difficult reflection (mainly

palatally), great tension with the risk of ends

tearing, limited visualization in apicoectomy,

limited access, possibility of injury to palatal

nerves and vessels, defect of attached gingiva.

TWO-SIDED TRIANGULAR FLAP

This is made by an L-shaped incision on the side of an envelope flap preferably divergent towards vestibular sulcus extending to interdental papilla of gingiva.

INDICATIONS-Surgical removal of root tips, cysts & apicoectomies.

 ADVANTAGES-Ensures adequate blood supply, good visualization, good stability and

reapproximation, easily modified by additional

vertical incision or lengthening horizontal

incision.
DISADVANTAGES-Limited access to long roots,

tension is created when flap is held with a

retractor, may cause defects in attatched gingiva.

THREE-SIDED TRAPEZOIDAL FLAP

It is made by giving an second vertical incision to the horizontal incision for better access. The oblique incision always extends to interdental papilla. This ensures integrity of the gingiva.

INDICATIONS-Extensive surgical procedures requiring adequate access.

 ADVANTAGES-Provides excellent access,

produces no tension on the tissues, allows

easy reapproximation of the flap to its original

position and hastens healing.

DISADVANTAGES-Produces defect in attatched

gingiva (recession of gingiva).

 In case of missing teeth and edentulous

arches, horizontal incision is made over the

alveolar crest whereas vertical incision is

carried out in the same way.

 This flap is made by a curved incision beginning from the vestibular fold & has a bow-shaped course. The lowest point should be atleast 0.5mm from the gingival margin.

SEMILUNAR FLAP

INDICATIONS-Surgeries requiring periapical exposure, apicoectomies, removal of cysts & root tips.

 ADVANTAGES-Small incision & easy reflection, no recession of gingiva, no intervention at periodontium, easier oral hygiene. DISADVANTAGES-Possibility of incision being performed right over bone lesion, scarring in anterior regions, difficulty in reapproximation

and suturing, limited access & visualization,

tendency to tear.

OCHSENBEIN-LUBKE FLAP
It is a combination of both vertical & semilunar incisions. The flap is scalloped to follow gingival architecture.

INDICATIONS- For those cases where there is a fear that elevation of attatched gingiva will lead to shrinkage & exposure of margins of restoration.

 ADVANTAGES-Sparing of marginal gingiva, easy lip retraction & most adequate visibility, non-exposure & minimal loss of crestal bone, ease of reapproximation of flap & suturing, good esthetic results. DISADVANTAGES-Difficulty in reapproximation of attatched gingiva.

 This type of flap is based on & along a particular blood vessel like Greater palantine artery in the palate.

PEDICLE FLAP

INDICATIONS-Mainly used for closure of oroantral communications, reconstruction for malignant defects.

 Three types of pedicle flaps used for closure of oroantral communication are1. Buccal flap

2. Palatal flap 3. Pedicle bridge flap

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