Flap
design
Seminar Elective Year 6
Flap
The term flap indicates
Soft tissue that is outlined by a surgical
incision
Carries its own blood supply
Allows surgical access to underlying tissues
Can be replaced as required in its original
position
Maintained with sutures and is expected to
heal.
Flap
Design a mucoperiosteal flap
successfully for oral surgery there are nu
mber of points that must be considered
Broad base
Adequate size
Anatomical consideration
Margins on sound bone
Relieving incisions
Broad base
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Healing of flap with adequate blood supply
The base should be broader than the free
edge
If this is not adhered the flap can undergo
ischemic necrosis.
Adequate access to the operating field.
Adequate size
Gain access to underlying hard tissue
Small flap causes difficulty for the surgeon and
tension on the flap, resulting in excessive tiss
ue trauma
A general rule for the size of a flap is to start
one tooth behind the tooth to be operated and
continue to one tooth in front.
Anatomical consideration
(Mandible)
Mental nerve
The anterior relieving
incision should be placed
mesial to the first premol
ar. The nerve lies within the
buccal soft tissues and there
fore will be retracted intact
with the flap.
Care must be taken during
the procedure not to cause c
rush injury to the nerve by e
xcessive pressure with the fl
ap retractor.
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Anatomical consideration
(Mandible)
Lingual nerve
Incisions should be made buccally to prevent
severing the nerve
Inferior alveolar nerve
This nerve is of great importance during the
planning of surgical removal of teeth. While remo
ving root pieces in the apical third of molar teeth
care should be taken not to put excessive force.
Anatomical consideration
(Maxilla)
The greater palatine nerve and vessels
Majority of palatal surgeries are done using an
envelope flap around the necks of the teeth
If vertical relieving incision is required, then this must
be done at the anterior end of the flap, as posterior
relieving incision will severe the greater palatine vessel
Anatomical consideration
(Maxilla)
Nasopalatine nerve
The resultant bleeding can be easily controlled
with pressure and the nerve can regenerate.
Margins on sound bone
The incision should be rest on sound
bone
If the incision does not lie on a sound
bone, then this will result in delayed he
aling and a higher chance of wound bre
akdown.
Relieving incisions
This decision will depend on the amount of
reflection required to gain adequate access to s
urgical field
The incision should be made obliquely, so the
base of the flap is broader than the free edge
The incision should also not divide interdental
papillae
It is also important not to cross bony
prominences, if done flap will be under tension,
which could lead to dehiscence
Surgical removal
lower 3rd molar
Material & Method
Inclusion criteria :
Bilateral symmetrical impacted
mandibular 3rd molar.
Absence of acute local inflammation or
pathology.
Exclusion criteria : systemic disease,
pregnancy, smokers and patients on me
dications (influence the surgical procedur
e or wound healing).
Using a randomized split mouth design.
Surgical procedures
The same theatre, operator, surgical instruments,
rotary ,material and irrigation devices.
Sedation: IV 0.03 mg/kg of midazolam
8 mg of dexamethasone and 1 g co-amoxicalv IV
Local anesthesia : 2% lidocaine with 1:100,000
adrenaline by local infiltration and inferior alveolar
nerve block.
Envelope flap, Triangular flap
The tooth was removed, the socket was inspected,
dental follicular tissue was curetted.
The socket was irrigated with normal saline.
Surgical procedures
The flap was repositioned and sutured with 4-0
silk.
Postoperative instruction and medication: a nonsteroidal analgesic 5 days and mouth wash.
Variables were recorded preoperatively on the
day of surgery.
Recorded 2 days, 7 days and 14 days
postoperatively.
Recorded one final probing depth after a mean of
22 weeks(median 17 weeks)
Material & Method
Trimus
Maximum inter-incisal opening
Facial swelling
Tragus soft tissue pogonion
Tragus lateral corner of mouth
Lateral corner of eye angle of
mandible
Pain
Periodontal
examination of
2nd molar
VAS 0-10 (no pain to excruciating pain)
Plaque index, bleeding index, probing
depth
Result
Pain
No
significant
difference
Swelli
ng
Trism
us
Triangular flap
More swelling in
day 2 and 7
No significant
difference after
day 14
Triangular flap
More limit mouth
opening after 7
days
Triangular flap
More swelling in
day 2
No significant
difference
Result
Plaque
accumulat
e
No
significa
nt
differen
ce
Periodonta
l bleeding
No
signific
ant
differen
ce
Probing
depth at
distal of
2nd molar
Alveolar
osteitis
Envelop
e flap
Increase
pocket
depth in
day 7,
14 and
in final
Envelop
e flap
Higher
incidenc
e but not
statistica
lly
significa
nt
Discussion
Envelope flap
Advantages :
Good exposure of the surgical site and
the sulcular incision can be extended ant
eriorly
Broad base, blood supply is excellent
The design facilitates easy closure and
reapproximation.
Envelope flap
Disadvantages :
Damage to the periodontal ligament
Increased osteoclastic activity when
raising a mucoperiosteal flap with potenti
al local bone loss
Higher risk of wound dehiscence in the
postoperative period compared with the
modified triangular flap
Triangular flap
Advantages :
More conservative owing to
a lesser degree of tissue refl
ection
Simple to close and allows
for relatively tension-free cl
osure
Disadvantages :
Cannot be readily extended
Triangular flap
Anterior releasing component induce
inflammation in muscle of mastication
, muscle irritation and buccal tissue
edema
Greater facial swelling and trismus
Discussion
No significant correlation between duration and
postoperative swelling
Greater pain score with longer operation time
