flap designs used for impacted wisdom tooth

1. Different flap designs used for
the management of impacted
third molars
BY
DR/ MOHAMED AMR

2. Types of flaps
Mucosal (partial
thickness)
Mucoperiosteal
( full thickness )

3. Types of mucoperiosteal flaps
Envelope
Tri angular
flap
Conventional
flaps

4. Other variables
Modified tri
angular
Comma
shaped
Vestibular
tongue
shaped
Szmyd &
modified
szmyd
Ward`s &
modified
ward`s
Others

5. Mucoperiosteal flaps
 A. Envelope flap. B. Szmyd flap. C. Triangular flap. D. Modified envelop
flap . E. Modified Szmyd flap . F. Modified triangular flap.

6. Principles of flap designs
1. Incisions should avoid any vital structures like nerves or blood vessels.
2. Incisions far enough away from the surgical site :the wound margins should rest
on sound bone .
3. The base should be wider than the apex for adequate blood supply .
4. A firm pressure upon sharp scalpel should be used so that both mucosa &
periosteal layers of gingiva are incised down to bone .
5. Incision should be of adequate size
6. incision especially in posterior region should be away from lingual aspect of
mandible to avoid lingual nerve
7. Vertical releasing incision should cross free gingival margin at the line angle of
tooth not directly in the papilla nor facial aspect of the tooth .
8. No extension too distally to avoid bleeding from buccal vessels ,
Post operative trismus & temporalis muscle damage , herniation of buccal bad of fat.

7. Factors affecting flap designs
1. Necessary access to the underlying bone & root surface
2. Final position of the flap .
3. Preservation of good blood supply of the flap.

8. Envelope flap

9.  Technique:
1. begins at the anterior border of ramus/ maxillary tuberosity Distal
aspect of lower seven / upper seven .
2. Continue as sulcular incision along cervical lines of last two teeth &ending
at the mesial aspect of first molar
3. No vertical releasing incisions

10. Advantages
1. Good exposure of surgical site
2. Anterior extension of incision
3. Broad base so excellent blood supply
4. Easy closure & re approximation
Dis advantages
1. Due to sulcular incision so we have a
peridontal damage
2. Due to flap reflection we increase
osteoclastic activity so we have high
bone resorption & wound dehiscence
postoperative

11. Tri angular flap

12. Technique
1. Distal incision of seven to anterior border of ramus or max tuberosity
2. Continue as sulcular incision around seven buccally
3. Then vertical incision between six & seven to mucogengival junction

13. Advantages
1. Easy technique
2. Broad base so excellent blood supply
3. Good accessibility easy release of
hematoma first few days postoperative
Dis advantages
1. Periodontal defect
2. Bone resorption

14. Other variables

15. Modified tri angular flap
Advantages :-
1. More conservative
2. Limited flap reflection as decrease osteoclastic activity so decrease bone
resorption
3. Tension free closure
Dis advantages :-
1. Limited reflection ( limited exposure )
2. No anterior extension

16. Comma shaped flap
Technique:-
1. described by nageshwar in 2002 for impacted lower wisdom
2. Incision is made at point below second molar where it is smoothly curved.
3. Up to meet gingival crest at the distobuccal line angle of second molar
4. Then incision is continued as crevicular incision around distal aspect of seven

17. N.B:-
 This flap was made to overcome the problem with conventional incisions:
1. As cut across the insertion of temporalis tendon
2. And flap commonly lie over the bone defect formed after removal of
impacted tooth
Provides
large access
Less periodontal
pocketing distal to
seven
Indicated in
deep
horizontal
impactions

18. Vestibular tongue shaped flap
 Technique:-
1. Described by Berwick , other name para gingival flap ( as anterior releasing
incision located 0.5 CM apical to of the gingival margin of second & first
molar ).
2. Extended on the buccal shelves of mandible
3. With incision line did not lie over bony defect created by removal of impacted
tooth
4. Base at the disto lingual aspect of second molar

19. Ward`s & modified ward`s flap
 Technique :-
1. Anterior incision from distal aspect of second molar downward & forward to the
level of apex of distal root of first molar
2. Sulcular incision around eight then distal incision to cheek
N.B:-
1. Modified ward`s anterior incision is between six & seven downward & forward to
mesial of six
2. Commonly used in completely impacted & no sufficient buccal vestibule .

20. Szmyd flap
1971

21.  Technique:-
1. Small v- shaped incision , made with one point at the distobuccal line angle of
the second molar .
2. One vertical limb following maxillary tuberosity or external oblique ridge .
3. The other avoided gingival sulcus & extended down to the mucogingival
sulcus doesn`t involve papilla of the second molar .
N.B:-
 Easier primary wound
healing than conventionals.
 Less wound dehiscence &
periodontal defect .

22. L -shaped flap
( para marginal flap)
Technique :-
1. incision made away from marginal gingiva by few mm with vestibular
extension by 45 angle
2. Helps in intact marginal attachment distal to second molar
N.B:-
may damage facial vessels

23. Groves & moore flaps
 In 1970 they designed 3 flaps related to the gingival margin of second
molar
 Two of them did not involve gingival margin produced less periodontal
pocketing

24. Lingual flap
 This flap used when lingual approach is used for removal of third molar
 Incision starts at ascending ramus to distobuccal line angle of second molar
 Then sulcular incision around seven buccally and continued lingually to first
molar
N.B :-
lingual nerve damage is the main complication

25. In 1959 Kruger described envelop flap a variation of Thomas vertical flap in
which first part of incision was similar to vertical incision i.e begins medial to
external oblique ridge and extending to distal lower angle of second molar
followed by sulcular incision which was made from distofacial
angle of second molar to mesiofacial angle of first molar.

26. In 1969 Henry described lateral trepanation technique for excision of
developing mandibular third molar and was reported by Kaj and Klamfeldt
as having no late postoperative complications. This technique is based on
the assumption after evaluation, that the third molar would be impacted.
This technique does not appear to be popular

27. In 1979 Killy and Kay advocatd flaps starting along the gingival crevices of
second molar tooth. Healing of gingival crevices from incision has been
unsatisfactory and now rarely used.

28. THE DESIGN OF THE TRIANGULAR INCISION FOR THE JAW ADVOCATED BY MARZOLA. THE
DESIGN OF THE TRIANGULAR INCISION IN THE POSTERIOR MANDIBLE, WITH ITS WITHDRAWAL,
AND AN OBLIQUE INCISION IN THE PAPILLA DISTOBUCCAL THE SECOND MOLAR TO THE BOTTOM
GROOVE (MARZOLA, 1975).

29. THE DESIGN OF THE TRIANGULAR INCISION (MARZOLA, 1975) FOR THE JAW,
AFTER FOLDING THE FLAP PROVIDING AN APPROPRIATE FIELD FOR THE
SURGEON WITHOUT DAMAGING THE ANATOMY OF THE SECOND MOLAR

30. THE DESIGN OF THE TRIANGULAR INCISION (MARZOLA, 1975) FOR THE JAW, AFTER THE FOLDING OF
THE FLAP ENSURES A SUFFICIENT FIELD FOR THE SURGEON WITHOUT DAMAGING THE ANATOMY OF
THE SECOND MOLAR. THE SUTURE IS THEN PERFORMED ONLY ON THAT PORTION WHERE THE
TRIANGLE WAS REMOVED, LEAVING OPEN THE OBLIQUE INCISION, FUNCTIONING AS A PERMANENT
DRAIN IN THE FIRST DAYS AFTER SURGERY, AVOIDING THAT DREADED SWELLING OF THE EARLY DAYS
OF THIS SURGERY

31. BLANCO G, LORA D , MARZOLA C (2017) THE DIFFERENT TYPES OF FLAPS IN THE SURGICAL RELATIONS OF THE THIRD
IMPACTED MOLARS –LITERATURE REVIEW. DENTISTRY 7:425. DOI:10.4172/2161-1122.1000425

32. BLANCO G, LORA D , MARZOLA C (2017) THE DIFFERENT TYPES OF FLAPS IN THE SURGICAL RELATIONS OF THE THIRD
IMPACTED MOLARS –LITERATURE REVIEW. DENTISTRY 7:425. DOI:10.4172/2161-1122.1000425

33.  N.B:-
 Pain , facial swelling , trismus almost seen in most of types of muco periosteal
flaps .
 Tri angular flap ha s a lesser degree of this symptoms than envelope flap .
 Jackse et al . Has a comparison study in disorder of primary wound healing
between conventional flaps & modified triangular flap he found that 56% of pts.
With conventional flaps has dis. In primary wound healing comparing to 10% in
pts . With modified tri angular flap .
 Schofield et al . Reported that flap design was not important in periodontal health
of second molar it`s about the removal of bone distal to seven or not .