Flap Design

Flap Design In endodontic


Objective
The full mucoperiosteal tissue flap raised to perform endodontic surgery should offer access and proximity to the underlying bone and offending root(s) without jeopardizing circulation to the flap or the health of the approximating nonelevated tissues, and without ! miting the surgeon's approach if an unforeseen problem should arise.
Note
Endodontic surgery requires unimpeded access to bone and root. Therefore the surgeon must elevate a full mucoperiosteal flap, which includes the mucosal tissue, the connective tissue, and the periosteum (Figs 1-la and 1-1 b). This differs from the split or par­tial thickness flap more commonly used in periodontal surgery, it is customary for a periodontist to separate the superficial mucosal tis­sue from the underlying connective tissue and thereby leave the periosteal attachment undisturbed (Figs 1-1 c to 1-1 e). Except for a suspected dehiscence, the need to do a free gingival graft, or the performance of a crown-lengthening procedure, a split thickness flap is rarely indicated in endodontic surgery

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Fig 1-1 a                                       Fig 1-1 b


Figs 1-1 a and 1-b The full mucoperiosteal flap includes the mucosa (Al, connec-t ve tissue Bi, and periosteum (Cl. To elevate the full mucoperiosteal flap, the incision must be made to the bone

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Fig 1-1 c                                                                           Fig 1-1 d                            Fig 1-1 e


Figs 1-lc to 1-le The incision for a split thickness or partial thickness flap must separate the mucosa and a seg­ment of the connective tissue (A and Bl from an underlying layer of connective tissue and periosteum IB and Q.

Considerations
The number of teeth involved in the surgery
The length and shape of the roots involved
The presence or absence of pathosis
The dimensions of the pathosis
The amount of attached gingiva
The existence and depth of periodontal pockets
The location of muscle attachments and frenums
The height or depth of the vestibule The location of approximating anatomic struc­tures, such as the neurovascular bundles and the maxillary sinus
The amount of bone covering the site The access required to accomplish the objec­tives
The presence of veneered crowns on the involved or adjacent teeth
Ochsenbein-Luebke
This technique Involves making a scalloped horizontal incision in the attached gingiva that joins two vertical incisions made on each side of the surgical site.
Surgical technique. A vertical incision is made on each side of the proposed surgical site in the trough between the root eminences. These vertical incisions extend from a point 1 to 2 mm short of entering the mucobuccal fold to a point on the attached gingiva approximately 3 to 5 mm above or below the mar­ginal gingiva and the sulcus depth. A scalloped hori­zontal incision following the contour of the gingival margin is made to connect the cervical ends of these vertical incisions {Figs 1-2a and 1-b


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Fig 1-2a                                                                              Fig 1-2b

Figs 1-2a and 1-2b The Ochsenbein-Luebke design connects a scalloped horizontal incision in the attached gin­giva with two aplcally directed vertical incisions. The inci­sions extend from a point 1 to 2 mm short of entering the mucobuccal fold, to a point on the attached gingiva 3 to 5 mm above or below the marginal gingiva and sulcus depth.

Advantages
1. The flap is simple to incise and reflect.
2. The surgical site is readily visualized.
3. Access to the apex of the involved tooth is good.
4. The marginal gingiva is not disturbed, which greatly reduces the potential for gingival reces­sion. This is particularly advantageous in the presence of prosthetic crowns.
5. Existing nonpathologic dehiscences are avoided because the gingival attachment is not dis­turbed.
6. Minimal effort is required to retract the flap.
7. Because the incision has good reference points, the flap is easily repositioned.
8. The patient is able to maintain good oral hygiene during the healing period
Disadvantages
1. Misjudging the size of the lesion may result in the incision(s) crossing the osseous defect.
2. Muscle attachments and frenums present anatomic obstructions that may require modifi­cation of the horizontal component.
3. If the horizontal incision is made too close to the free marginal gingiva, clefting may occur.
4. An unesthetic scar may form.
Intrasulcular flap
A horizontal gingival sulcus incision joined by a sin­gle vertical incision.
Surgical technique. A vertical incision, one to two teeth mesial or distal to the proposed surgical site, is made in the trough between the root eminences (Figs 1-3a and 1-3b). This incision extends from a point 1 to 2 mm short of entering the mucobuc-cai fold to a point at the distal or mesial labial line angle of the selected tooth. From this point, a hori­zontal incision in the gingival sulcus continues to a point two to three teeth to the opposite side of the surgical site. This creates the horizontal com­ponent of a triangle. The suicuiar incision must be firm to bone and free the gingival tissues, includ-i ng the involved papillae

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Fig 1-3a                                                                                            Fig 1-3b

Figs 1-3a and 1-3b The intrasulcular design connects a single vertical fold-to-crest incision (AFB) with a horizontally directed sulcular to-bone incision IB CI along the gingival crest, two to three teeth on the opposite side of the target.

Advantages
1. The possibility of the horizontal incision crossing the osseous defect is eliminated.
2. The crestal exposure facilitates simultaneous periodontal curettage and alveoloplasty.
3. Greater access is afforded for lateral root repair.
4. Flap design is advantageous when treating short roots and/or defects in the coronal third of the root.
5. The flap is easy to reposition because the gin¬giva has basic reference points.
6. The blood supply to the flap is maximal.
Disadvantages
1. Elevation may be more difficult to initiate.
2. Soft tissue clefting or irreversible pocket forma¬tion may result when a dehiscence is uncovered. This may require using guided tissue regeneration techniques prior to closure or referral for postoperative periodontal care.
3. Vertical and horizontal incisions must be long to gain access to the apex of long roots.
4. As the tension of the flap increases, greater retractive forces are required. This can be dam¬aging to the tissues and fatiguing to the opera¬tor.
5. Extension of the vertical incision to ease tension may involve the mucobuccal fold. This often leads to soreness and delayed healing.
6. Gingival tissue detachment may lead to changes in the level of the marginal gingiva (recession), particularly when prosthetic crowns are
i nvolved.
7. Suturing is more difficult.
8. Oral hygiene may be difficult to maintain during the early stages of recovery.
Modified intrasulcular
When a second, tissue-relaxing vertical incision is made at the terminal end of the horizontal leg of the intrasulcular flap design, a rectangular or trapezoidal flap design is created.
Surgical technique. At the terminal point of the hori­zontal incision of a triangular flap, a vertical incision is made extending from the crestai tissue at the mesial or distal line angle of the last tooth to the mucobuc-cai fold. This second vertical incision relaxes the ten­sion on the flap and, when elevated, increases visibility and access to the apex. The length of this second vertical incision is dependent on the amount of relaxation needed (Figs 1-4a and 1-4b).
Advantages
1. Visibility is increased.
2. Access to the surgical site is improved.
3. Tension on the flap is decreased.
4. Repositioning is simplified because the sulcular incisions offer excellent reference points.
5. The crestai exposure facilitates simultaneous peri­odontal curettage and alveoloplasty.
6. There is greater access for lateral root repairs.
7. Flap design is excellent for treating long roots.
Disadvantages
I Elevation is more difficult to initiate.
2. Blood supply to the flap could be at risk, and ischemia and slough are possible sequelae.
3. Soft tissue clefting or periodontal pocket defects could result when a dehiscence is uncovered. This may require the use of tissue regeneration tech­niques prior to closure.
4. Gingival tissue detachments could lead to changes in the level of the marginal gingiva (recession), par­ticularly when prosthetic crowns are involved.
5. Sutunng is more difficult.
6. Maintaining good oral hygiene is difficult during the early recovery stage


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Fig 1-4a                                                                              Fig 1-4b

Figs 1-4aand 1-4b By adding a second vertical inci­sion of any length at the terminus of the crestal intrasulcular design, greater access and less tension can be realized

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