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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

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