4. Introduction
Last decade, demand on endodnotic surgery has
been increased.
Point of view Endodontic macro surgery.
The evolution to microsurgery.
7. Soft tissue access
◦The term Flap indicates a section of
soft tissue that is outlined by a surgical
incision.
8. Certain basic principles must be considered before
deciding on the type of incision and flap design:
1. Regional anatomical structures.
2. Recognition of the position of the root within the
mandible or the maxilla.
3. Periodontal conditions play an essential role in the
decision making process.
Principles of Flap design
9. 4. Type and quality of restorations in special reference
to the position of the restoration margin to the
gingiva need to be determined and are critical to the
esthetic outcome.
5. Evaluation of the size and position of the expected
periradicular pathology in relation…..
10. Flap Design
◦ In order to design a mucoperiosteal flap successfully for
oral surgery there are number of points that must be
considered:
Broad
base
Adequat
e size
Anatomical
considerati
on
Margins
on sound
bone
Relieving
incisions
11. • Broad base
Mormann and Ciancio The circulation changes
observed suggested that flaps receive their major
blood supply from their apical aspect
12. Adequate size
• the flap must be large enough to
allow the surgeon to visualize the
tooth in question and adjacent teeth
fully.
• Small flap causes difficulty for the
surgeon and tension on the flap,
resulting in excessive tissue 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.
13. Anatomical consideration
Anatomical structures that must be taken into consideration when designing a flap
are explained according to the area of flap placement.
Mandible
There are nerves which should be considered when planning surgery in mandible:
Mental nerve
Lingual nerve
16. The greater palatine nerve and vessels
• majority of palatal surgeries are done using an envelope flap
around necks of teeth, the neurovascular bundle are reflected with
the flap without much difficulty.
• vertical relieving incision done at the anterior end of the flap, as
posterior relieving incision will severe the greater palatine vessel
causing risk bleeding.
Nasopalatine nerve
• If the anterior part of the palate needs to be reflected, then this
neurovascular bundle can be safely cut at the level of the foramen.
• The resultant bleeding can be easily controlled with pressure and
the nerve can regenerate.
17.
18. Margins on sound bone
1. the incision should rest on sound bone once
the surgery is complete.
2. The surgeon should anticipate the
approximate amount of bone that will need to
be removed so that this can be taken into
account when designing the flap.
3. If the incision does not lie on a sound bone,
then this will result in delayed healing and a
higher chance of wound breakdown.
20. Avoid incision lines over radicular
eminences such as canines and maxillary
first bicuspids.
Avoid incisions across major muscle
attachment.
Extent of horizontal incisions should be
adequate to provide access with minimal
soft tissues trauma.
21. Extent of vertical incisions should be sufficient to allow the
tissue retractor to seat on solid bone leaving the apex well
exposed.
Junction between horizontal and vertical incision lines
should either include or exclude the involved interdental
papilla.
Flaps should include the full thickness of the
mucoperiosteum.
22. Avoid horizontal and severly angled vertical incisions. The
supraperiosteal vessels assume a vertical course parallel to
long axis of teeth. Collagen fibers of the gingival mucosa
(gingival ligament)are vertically oriented as well. These
severely angled incisions shrink excessively during surgery
as a result of contraction of cut collagen fibers and
severance of gingival blood vessels. It often results in
placing excessive tension during suturing , tearing out of
the nutrition and subsequent scar formation as a result of
healing by secondary intention.
23.
24.
25.
26. Flap designs and Incisons:
◦ The wide variety of flap designs reflects the number of variables to be
considered before choosing an appropriate flap. As conditions vary with
each individual patient and specific situation, there will always be a need
to select the best flap design for every single case.
27. The choice of flap designs should allow maintenance
of optimal blood perfusion during surgery.
This implies using a design where vertical releasing
incisions run vertical, parallel to the tooth axis and to
supraperiosteal blood vessels in the mucosa and
gingiva, resulting in minimal vascular disruption.
The flap design plays an important role as to how much
recession will occur postoperatively.
28. • Paramedian rather than mid-
axial releasing incisions are
recommended to minimize
recession risks (Mormann).
29. The incision line should begin in a 90-degree
angle to the outer contour of the marginal
gingiva as shown and marked with a green line.
This rule applies to any type of incision, to
avoid thinning out of tissues and allowing
sufficient blood supply to reach the area,
promoting better healing(Velvart)
The tissue margin
comprises unsupported
epithelial cells without
the epithelial base cells,
which are responsible for
formation of a
multilayered seal of
epithelial cells.
30. single straight incision
directed to the crestal bone.
The pointed tissue ending will
necrotize at its very end,
creating a small, but visible
defect and a recession. This
type of incision is simple to
perform, but will result in a
poor healing result. (peters)
the incision line should
begin and ends in a 90-
degree angle to the outer
contour of the marginal
gingiva as shown and This
rule applies to any type of
incision, to avoid thinning
out of tissues and allowing
sufficient blood supply to
reach the area, promoting
better healing.
31. Classification:
I. Full mucoperiosteal flaps:
a) Triangular (single vertical releasing
incision)
b) Rectangular (double vertical releasing
incisions)
c) Trapezoidal (broad base rectangular)
d) Horizontal (no vertical releasing
incision)
e) Papilla-base.
II. Limited mucoperiosteal flaps:
a) Submarginal scalloped rectangular
(luebke – ochsenbein)
b) Submarginal curved (semi- lunar)
32. I- Full mucoperiosteal flaps:
The entire soft tissue overlying the cortical bone plate is reflected.
The advantage of these flaps is keeping intact supraperiosteal vessels.
33. a) Triangular flap:
Two incisions; horizontal and vertical.
Vertical releasing incision.
Horizontal incision intrasulcular
gingival incision.
34. Advantage
• Rapid
healing
• Ease of
closure
Disadvantage
• Limited
surgical
access
indications
• Maxillary
incisor region.
• Maxillary and
mandibular
posterior teeth.
• The most
recommended
flap for
posterior
mandibular
region
35. Not recommended for:
Teeth with long roots (maxillary canines)
Mandibular anterior teeth due to the lingual
inclination of their roots.
37. Advantag
e
• Good
surgical
access.
disadvanta
ge
• Difficult re-
approximation
of margins.
• Difficult post
surgical
stabilization.
• Great
potential for
post surgical
indication
• Mandibular
anterior.
• Maxillary
canines.
• Multiple
teeth.
Not
indicated
• Mandibular
posterior
teeth.
38. c) Trapezoidal flap:
Two vertical releasing incisions which join a
horizontal intrasulcular incision at obtuse
angles.
39. Advantage
• It creates a
broad-based
flap.
• It was assumed
that this
provide a
better blood
supply.
disadvantage
• More bleeding
due to
disruption of
more of the
vertically
oriented blood
vessels.
• Shrinkage,
pocketing or
clefting of soft
tissue due to
severing of
more collagen
fibers.
• Wound healing
by secondary
intention.
Not indicated
• periradicular
surgery.
40. d) Horizontal (envelope)
flap:
A horizontal, intrasulcular
incision with no vertical
releasing incision.
It has a very limited application
due to the limited surgical
access.
42. E) Papilla-base Flap:
A horizontal incision at the papillary base extending
intrasulcular toward the crestal bone. At least one vertical
incision is established.
The key point of the PBI is to avoid thinning of the split flap
Peters and velvart stated that Papilla base flaps have allowed
virtually recession free healing after endodontic surgery.
43. II. Limited mucoperiosteal
Flaps:
◦ They have a submarginal (subsulcular) horizontal, or horizontally
oriented, incision, and does not include marginal or interdental
tissues. Therefore in this type of flaps more vertically oriented
blood vessels and collagen fibres are severed.
44. A) Submarginal scalloped rectangular (luebke –
ochsenbein) Flap:
A modification of the rectangular flap.
It provides the advantages of the rectangular
and semilunar flaps.
The horizontal incision is placed in the
attached gingival.
The horizontal incision is scalloped following the
contour of marginal ginigva above the free
gingival groove. Vreeland and Tidwell
modified the submarginal incision by placing a
scalloped horizontal incision 1 to 2 mm below
the gingival margin
45.
46. Advantage
•Does not involve
marginal or
interdental
gingivae.
•Crestal bone is not
exposed.
•Adequate surgical
access.
Disadvantage
•Disruption of
vertically oriented
blood vessels
producing more
bleeding.
•Severing vertically
oriented collagen
fibres producing
flap shrinkage.
•Difficult
reapproximation.
•Delayed healing.
•Scar formation.
indications
• Maxillary incisor
region.
• Maxillary and
mandibular posterior
teeth.
• The most
recommended flap for
posterior mandibular
region
47. B) Submarginal curved (Semilunar) Flap:
A curved incision in the alveolar
mucosa and attached gingival.
Incision begins at the alveolar mucosa
extending into attached gingival and then
curves back into the alveolar mucosa,
resembling a half moon.
48. Advantage
Does not disturb the
gingival margin and
interdental papillae.
disadvantage
Poor surgical access.
Poor wound healing due to disruption
of blood supply to un-flapped tissues.
Difficult wound closure.
Postsurgical scarring.
49. Considerations in palatal surgery:
Palatal approach is difficult limited
visibility and accessibility.
Indicated flap designs:
1. Horizontal (envelope).
2. Triangular.
50. The horizontal intrasulcular incision extends
mesially to:
Envelope flap palatal midline.
Triangular flap mesial to the first
premolar.
Extends distally as far as needed to give
accessibility.
51. Triangular flap:
Vertical releasing incision extends from a point
near midline and join the anterior extent of the
horizontal incision mesially.
Vertical palatal incisions are safe in premolar
area, or mesial to it.
Greater palatine artery branches rapidly as it
courses anteriorly.
52. Indications of palatal flaps:
1. Surgical procedures in palatal roots of
molars and premolars such as
apicectomy, amputation, or
perforation repair.
1. Repair of perforations or resorption
defects of palatal surfaces of anterior
teeth.
53. Incisions
Flap design and surgical exposure should be
planned before initial incision is made.
SCALPEL:
Handle- No. 3, No.7
Differently shaped
Disposable, sterile sharp
blade:
54. 1. No.15 or 15c
• most commonly used
• Relatively small
• Around teeth through
mucoperiosteum ,
blades with rounded
end (BB 369, Aesculap,
Tuttlingen, Germany)
2.5mm.
55. 2. No.10-
similar to No.15
Large skin incisions
3.No. 11
•Small stab incisions
•Sharp, pointed
•Incising an abscess
4.No.12
•Hooked
•Mucogingival procedures
•Posterior aspect of teeth/ maxillary
tuberosity
56. •Pen Grasp: Allow maximal control
•Hold mobile tissue firmly
•Press down firmly
57. LASERS.
◦ The term Laser is the acronym for “Light Amplification by
Stimulated Emission of Radiation”.
◦ CO2 laser with wavelength of 10,600nm
58. Photobiology Of Lasers
Photochemical
Biostimulation - Stimulatory effects of laser on
biochemical and molecular processes that normally occur in
tissues such as healing and repair.
Photodynamic Therapy – induce reactions in tissues
for the treatment of pathologic condition.
Tissue fluorescence - used as a diagnostic method
to detect light reactive substance in tissue.
59. Photo thermal interactions
Photo ablation – removal of tissue by
vaporization and super heating of tissue
fluids , coagulation, and hemostasis.
Photocoagulation
Laser heats the tissues to 60 deg C for a
limited time leading to coagulation of the
tissues with minimal alteration in the
appearance of tissue structure.
60. Photomechanical
•Photo disruption - breaking apart of
structures by laser light.
•Photoaccoustic interaction- involve
removal of tissue with shock wave
generation.
61. • Marginal gingiva is very delicate:
1.do not begin reflection in the horizontal
incision.
2.Attached supracrestal tissues are clinically
very important.
Damaging these tissues apical epithelial
downgrowth causing:
Increased sulcular depth and loss of soft
tissue attachment level.
62. Submarginal flaps:
1. Reflection should not begin
also in the horizontal incision.
2. Reflecting forces may
damage wound edges,
delay healing, and causes
scar formation.
64. Flap Reflection:
• It should begin in the vertical
incision few millimeters apical to its
junction with the horizontal incision.
• Once this part is lifted from cortical
plate a periosteal elevator is inserted
between it and the bone with its
sharp side toward bone.
65. • The elevator is then moved coronally so
that;
The marginal and interdental gingivae
as well as the wound edge are separated
without direct application of dissectional
forces.
• By doing so all direct reflective forces
are applied to periosteum and bone only.
• The horizontal sulcular incision may be
made with a scalpel.
67. Flap Retraction:
Retractor should rest
on sound cortical bone.
If retractor rests on
the base of reflected
tissues damage
of microcirculation and
delayed healing occur.
Groove technique.
68. Time of retraction:
General rule: the longer the flap is
retracted the greater the post surgical
complications
Because of:
Reduced vascular flow.
Tissue hypoxia.
Frequent flap irrigation with sterile saline to prevent
dehydration.
Limited mucoperiosteal flaps more susceptible to
dehydration.
Therefore, they require more frequent irrigation.
69. After reflecting a mucogingival
flap, scaling of root-attached
tissues and tissue tags on cortical
bone should be avoided to allow
rapid reattachment and
protection against bone
resorption.
70. SURGICAL SITE CLOSURE
After irrigation with saline solution to remove debris,
the wound edges are reapproximated carefully to allow
primary intention healing.
Compression of the repositioned flap with a saline-
moistened piece of gauze is necessary to create a thin
fibrin layer between flapped tissue and cortical bone
Replacement of a thin blood clot with parallel fibrin
fibers by new fibrous tissue results in collagen adhesion.
72. The Term suture describes any type of material utilized to approximate
tissues or skin, in another meaning it means to sew.
The primary objective of suturing in dental field is to position and secure
flaps in order to promote healing.
73. Goals of suturing
1. Provide an adequate tension of wound
closure without dead space.
2. Maintain hemostasis.
3. Permit primary intention healing
4. Reduce postoperative pain .
5. Prevent bone exposure resulting in
delayed healing and unnecessary
resorption.
6. Permit proper flap position.
78. •The reverse
cutting point has
two opposing
cutting edges and
third cutting edge
on the outer
curvature of the
needle.
79. •The tapered point is used primarily on soft, easily penetrated
tissues . it leaves small hole and can be used in soft tissue
surgery.
The blunt point has a rounded end which does not cut through
the tissue .
80.
81. IDEAL SUTURE Material
Tensile st: adequate material strength will prevent suture
breakdown & use of proper knots for the material used will
prevent untying or knot slippage.
Tissue biocompatibility: sutures made from
organic material will evoke a higher tissue
response than synthetic sutures.
tissue reaction α amount & size of suture material.
82. •Low capillarity: multifilament type soak up tissue fluid by
capillary action providing a rich medium for microbes
increasing chances of inflammation & infection.
•Good handling& knottingproperties: ease of tying & a
thread type that permits minimal knot slippage also
influence thread selection.
•Sterilizationwithoutdeterioration of properties: most
sutures available in packages are sterilized by dry heat &
ethylene oxide gas.
•
83. •Non allergic, non electrolytic
and non carcinogènic
• Its use should be possible in any
operation.
• Low cost
85. According to their behavior in
tissue:
Absorbable
Cat Gut
Chromic Cat
Gut
Collagen
POLYGLACTI
N910(VICRYL)
VICRYLplus
ANTIBACTERIAL
Non absorbable
Natural:
Silk
Cotton
Synthetic
Nylon
Polyprop
ylene
89. Gut / cat gut
Oldest known absorbable suture.
Galen referred to gut suture as early as 175 A.D.
Derived from sheep intestinal sub mucosa or
bovine intestinal serosa.
When placed intra orally sutures are digested in 3-
5days.
90. CHROMIC CATGUT
Coated with thin layer of chromium salt
solution to minimize tissue reaction,
increase TS, slow the absorption rate,
better knot security, and ease of
handling.
It is monofilament and is available in the
plain form as well as “tanned” in
chromic acid. The tanning process
delays the digestion by white blood cell
lysozymes.
91. COLLAGEN SUTURE
◦ Natural, absorbable, monofilament
◦ Obtained by homogenous dispersion of
pure collagen fibrils from the flexor
tendons of cattle.
◦ TS - < 10% after 10 days.
◦ Disadvantage of premature absorption.
92. SYNTHETIC ABSORBABLE
POLYGLACTIN 910 (VICRYL)
Synthetic suture
Monofilament/multifilament
Lactide has hydrophobic qualities→delaying loss
of TS
TS - 14 – 21 days, strongest material.
Absorption –60-90days.
93. Minimal tissue reactivity and can be
used in infected tissues
Coated with polyglactin 370 and calcium
stearate which allows easy passage
through tissues as well as easier knot
placement.
94. VICRYL plus ANTIBACTERIAL SUTURE
◦ Handles and performs same as normal vicryl.
◦ In vitro studies shown that triclosan on VICRYL plus
creates a zone of inhibition around the suture.
95. Non absorbable sutures
Silk
Braided or twisted
Advantage:
Ease of handling – more for braided
Good knot security
made non capillary in order to withstand action of body fluids & moisture.(wax
or silicon coated)
Cost effective
Disadvantage:
nonabsorbable silk sutures are easy to tie and handle but are no longer
recommended as they accumulate plaque, allow rapid bacterial colonization and
are uncomfortable to remove because of ingrowth of tissue
96. COTTON
◦ Natural, multifilament, non absorbable
◦ From stable Egyptian cotton fibers
◦ good knot security
◦ Not good in presence of contaminated wounds or
infection
◦ Rarely used nowadays as it is weak.
97. Nylon
◦ Used for skin closure.
◦ Causes tissue irritation when used intra-orally.
◦ Very hard material.
98. Polypropylene
They are non-absorbable, sterile surgical
suture composed of an isotactic crystalline
steroisomer of polypropylene, a synthetic linear
polyolefin. The suture is pigment blue to
enhance visibility.
High tensile strength.
Monofilament.
It has good plasticity and it expands with tissue
swelling to accommodate the wound.
Disadvantage:
High memory, poor knot security and lack of
elasticity.
99. Is a unique, microporous, nonabsorbable monofilament
made of expanded polytetrafluoroethylene (ePTFE), the
same proven material used in other Gore Medical Products.
This unique material offers the benefits of both
monofilament and multifilament sutures with the excellent
material properties of PTFE including:
•Soft and supple for excellent handling and minimizing the
irritation caused by knots
•No out of package memory
•White color is highly visible in the surgical field
•Minimal biological tissue response with cellular ingrowth.
•Monofilamnet.
GORE-TEX®
100. Lilly GE, Armstrong , When comparing
histological tissue response of different suture
materials, monofilament sutures (e.g. nylon,
gut, steel, PTFE, PROLENE and chromic gut)
produced smaller inflammatory reaction than
multifilament materials (e.g. silk, siliconized
silk, polyester, teflonized polyester, cotton, or
linen)
101. • To avoid necrosis of papillae by
inserting too much suture
material, # 6 – 0 to # 8 – 0 suture
sizes are recommended in micro-
surgical techniques(Blatz MB,
Lindemann)
103. Efforts are made to minimize scar formation and
recessions after surgical procedures.. Microsurgery alone
will not accelerate epithelial healing rates, but through
perfect tissue adaptation of wound edges, it can create
smaller distances for epithelial migration during the
healing process.
104. A) interrupted suture, (B) anchor suture, (C)
sling suture, and (D) vertical mattress suture
107. •Rapid soft tissue healing is a result of reduced tissue
trauma and enhanced wound closure during microsurgical
procedures. To achieve these goals several measures are
necessary:
Accurate
Treatment
planning
• Patient
related
factors
• Flap design
• Operator
skills
Minimal tissue
trauma
• Incision
• Micro-
instruments
and
materials.
109. • Epithelial streaming as a sheet or as fingers is
observed after 2 days, eventually resulting in a
multilayered seal(Wirthlin MR, Hancock EB ).
Because of early epithelial bridging, suture
removal is therefore advocated after 2 to 3
days . Initial resistance to rupture forces is
attributed to regeneration of epithelial
attachment to tooth surfaces(Wirthlin) .
110. • Other authors do not recommend suture
removal before 4-5 days, as stainable
collagen content in granulation tissue, which
determines tensile wound strength, is only
present after 4 days(Torabinejad).
111. • More and more variables of wound healing,
including patient nutritional status, bacterial
infection, wound care and available tissue
oxygen, are being researched. Consequently,
novel therapies are evolving, such as growth
factor therapy.
112. Papilla Preservation/Protection
◦ Complete and predictable restoration of lost
interdental papillae is one of the biggest
challenges .
◦ Therefore, it is imperative to maintain the
integ- rity of the papilla during surgical
procedures.
