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Incision Designs & Suturing Techniques

InOral Surgery

Part 1Dr.Basheer Muhammed Jafar Salman

Lecturer- Oral SurgeryB.D.S, M.Sc

Email: bsalman@sharjah.ac.ae

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Objectives ( part 1, 2 ):

Define the incision and the flap

Identify the principles of designing the flap

Outline different types of the flaps used in oral surgery

Understand the advantages, disadvantages of different designs of the flap

Discuss the different types of suture material

Discuss different types of suture needle

Mention different types of suturing techniques

Further readingFragiskos D. Fragiskos (2007): Oral Surgery. Springer Hupp (2008), Contemporary Oral and Maxillofacial Surgery. Alsevier

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DefinitionsIncision:A cut into a body tissue or organ, especially one made during surgery by using a scalpel.

Flap:A section of soft tissue that:

1- Outlined by a surgical incision.

2- Carries its own blood supply.

3- Allows access to underlying tissues.

4- Can be replaced into the original position.

IncisionIncision

Flap reflected

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1- The incision must be carried out with a firm, continuous strokes, not interrupted strokes, the scalpel should be in constant contact with bone since repeated strokes at the same place impair wound healing.

2- Incision design should be carried out in such a way that injury of anatomic structures is avoided, such as: the mental nerve, palatal vessels, lingual nerve, submandibular duct, parotid duct.

Principles of Incision Designs

Firm, continuous cut

Mental nerve

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3- The extension of the flap must be adequate (one or two teeth on either side of area of bone removal), so that the operative field is easily accessible, without creating tension and trauma during manipulation.

4- The base of the flap must be broader than the free gingival margin, and width of the base should be greater than the length, to ensure adequate blood supply and to promote healing.

Blood supply direction

Base of the flap must be broader than free margin (apex)

Principles of Incision Designs

Base of the flap greater than the height (x= 2y)

The flap extends one tooth on either side

Base

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5- The flap itself must be larger than the bone deficit so that the flap margins, when sutured, are resting on intact, healthy bone and not over missing or unhealthy bone, thus preventing flap dehiscence (opening) and tearing.

6- The mucosa and periosteum must be reflected together. This is achieved by a deep incision & the periosteal elevator is kept pressing firmly against the bone.

7- During the surgical procedure, excessive pulling or folding of the flap must be avoided, because the blood supply is compromised and healing is delayed.

Flap margin should rest on intact bone not defect

Excessive pulling and folding of flap should be avoided

Principles of Incision Designs

Improper handling of

the flap

Necrotic sloughing

Flap reflection

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1- Trapezoidal Flap ( 3 sided flap)

A- It is created by a horizontal incision along the gingivae, and two vertical (oblique) releasing incisions extending to the buccal vestibule.

B- The vertical incisions always extend to the interdental papilla and never to the center of the labial or buccal surface of the tooth.

C- The trapezoidal flap is suitable for extensive surgical procedures.

Advantages:1- Provides excellent access.2- Allows surgery to be performed on more

than one tooth.3- Produces no tension in the tissues when the

flap retracted.

Disadvantages:Produces a defect in the attached gingiva (recession of gingiva).

Types of Flaps

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2- Triangular Flap ( 2 sided flap )

It is created by a horizontal incision made along the gingival sulcus and a vertical (oblique) incision extending from buccal vestibule to the interdental papilla of the gingiva.

Advantages:1- Ensures an adequate blood supply.2- Good access.3- It is easily modified by adding vertical

incision, or even lengthening of the horizontal incision.

Disadvantages:1- Limited access to long roots2- Tension is created when the flap is held with

a retractor.3- It causes a defect in the attached gingiva.

Types of Flaps

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A- This type of flap is created by a horizontal incision along the gingival sulcus of the teeth and extends along four or five teeth.

B- If the patient is edentulous, the incision is made along the crest of the ridge.

C- This design is primarily used in surgical procedures involving the palate in cases of removal of impacted teeth (impacted canine, premolars or supernumerary teeth).

Advantages:1- Avoidance of vertical incision.2- Ensures an adequate blood supply.3- Easy reapproximation to original position.4- Could be modified by adding vertical incision,

or even lengthening of the horizontal incision.

Disadvantages:1- Difficult reflection (specially palatally).2- Great tension during retraction with an

increased risk of flap tearing.3- Limited access4- Defect of attached gingiva.

Gingival flap for exposure of palatally positioned premolar

Types of Flaps3- Envelope Flap (single sided, gingival flap)

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4- Semilunar Flap

A- This flap is created by a curved incision beneath the fold of the vestibule that extend at least one tooth over on each side of the area of bone removal.

B- The lowest point of the incision must be at least 0.5 cm from the gingival margin, so that the blood supply is not compromised.

C- The semilunar flap is used in apicoectomies and removal of small cysts and root tips.

Advantages:1- Small incision.2- Easy reflection.3- No intervention with the periodontium

(no gum recession around the prosthetic restoration).4- Easier oral hygiene control compared to other

types of flaps.

Disadvantages:1- The incision may be made over the bone lesion

due to miscalculation.2- Limited access and visualization.3- Tendency to tear

Semilunar flap for apicoectomy of upper central incisor

Types of Flaps

0.5 cm to ensure the blood supply

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The Elliptic Incision( in biopsy procedures)

A- It is used for the excision of various soft tissue lesions.

B- It consists of two convex incisions joined at an acute angle at each end.

Flap Designs for Specific Cases

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Flap Resulting from - shaped Incision:

This type of flap is indicated in surgical procedures of the palate mainly for the removal of bony exostoses (torus palatinus).

Buccal Flap & Palatal Flap

This type is indicated for closure of an oroantral communication (fistula).

Buccal Flap Palatal Flap

Flap Designs for Specific Cases

Oro-antral fistula

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Thank You