FLAP SURGERY

FLAP SURGERY

^Part 1​

Plan 

Introduction 

1. Definitions
2. Goals
3. Indications 
4. Contraindications 
5. Advantages and disadvantages 

5.1. Advantages

5.2. Disadvantages 

6. Classifications
   1. According to their thickness
   2. According to their repositioning 
7. Types of flaps 

7.3 Full thickness flaps

7.2. Partial thickness flap

7.3. Double thickness flap 

8. Different interventions

Initial preparation

Instrumentation  

Additional reading: New therapeutic strategy: minimally invasive surgery in periodontal regeneration 

Introduction 

Sanitation flaps are one of the therapeutic options available to us to treat periodontitis. 

As the name suggests, the procedure involves cleaning up hidden parts of the tooth (roots and bone) after opening the gum.

This surgical therapy necessarily follows an initial etiological treatment and a careful evaluation of the decision-making criteria. 

• Nowadays, periodontal surgery tends to be more and more conservative and minimally invasive.

1. Definitions 

A periodontal flap is a portion of gum or mucosa that has been surgically detached from the underlying tissues to provide the visibility and direct access necessary for treatment.

Flap procedures are periodontal surgery techniques. They are defined as follows: 

• According to Daniel. A and Bercy. P (1996): “Surgical intervention consists of lifting a tissue flap released by incisions in order to access the underlying root and bone structures.”
• According to Ramfjord .SP and Ash. MM (1993): “A fragment of tissue partially isolated from its original place to serve as a graft in the repair of defects in the body.”

2. Goals 

Periodontics has traditionally seen the development of flap procedures for three reasons: 

• Surgical removal of periodontal pockets. 
• Induction of bone adaptation, reattachment and regeneration in periodontal pockets 
• Correction of infra-bony defects and muco-gingival defects.

3. Indications 

The indications for flap procedures are: 

• Have sufficient accessibility to the root surfaces for proper debridement to be achieved. 
• Active pockets (bleeding, suppuration) more than 5 mm deep that do not respond sufficiently to initial treatment.

• Pocket whose bottom is beyond the mucogingival line. 
• Infra-osseous pocket, 
• Significant thickening of the bony edge, 
• Dental hemisection (furcation involvement) with treatment of adjacent structures. 
• Correction of recessions and increase in height of attached gingiva (by restoring a deflecting architecture of the gingiva facilitating plaque control by the patient).

4. Contraindications 

Contraindications to flap surgery are: 

– Poor patient cooperation. 

– Unfavorable anatomy. 

– Contraindications to periodontal surgery. 

5. Advantages and disadvantages 

5.1. Advantages 

The advantages of flap procedures are: 

• Tissue sparing (completely removes pocket epithelium by incision and preserves existing attached gingiva). 
• Effective root preparation. 
• Visual inspection of lesions. 
• They can be returned to their original place or moved at the end of the operation. 

5.2. Disadvantages 

Aesthetic problems, sensitivity, and cervical caries may appear when the flaps are repositioned apically (the tooth remains slightly exposed).

6. Classifications 

The flaps are classified: 

6.1. According to their thickness 

• Full-thickness flaps (mucoperiosteal): These consist of the periosteum detached from the underlying bone.
• Partial-thickness flaps (mucosal): These are dissected freely over the periosteum, leaving the periosteum with some of the contiguous connective tissue attached to the bone. 

6.2. According to their repositioning 

• Simple flaps (non-repositioned): They are replaced in their initial position at the end of the procedure. These types of flaps allow the elimination of the periodontal pocket. 
• Repositioned (sliding) flaps: They can be moved at the end of the procedure in three directions (apical, lateral, and coronal). These types of flaps allow the correction of certain mucogingival defects.

7. Types of flaps 

7.1. Full thickness flaps 

Also called mucoperiosteal flap, it is the most commonly performed flap in dentistry. 

It consists of detaching the entire gum covering the alveolar bone while keeping the periosteum attached to the latter’s connective tissue. 

Full thickness detachment is more difficult to perform in relation to an area that has received bone filling. 

The bone should not be left exposed at the end of the procedure. The flap must cover the bone completely.

FLAP SURGERY

• Technical

 1. Ensure that the incision path has been made up to bone contact. The incision can be intrasulcular or internally beveled. 

2. Begin the elevation by inserting a stripper into the corner of an incision path. 

3. Maintaining bone contact, advance the detacher, from near to far under the flap. The movement requires a certain amount of force which must be controlled by good support points. 

4. The mucoperiosteal flap gradually peels off, exposing the bone surface. 

7.2. Partial thickness flap

Begin partial thickness dissection at a coronal angle delimited by the incisions made. 

Technical 

1. The incision is either intrasulcular or internally beveled. 
2. As soon as possible, hold the angle of the flap thus created with a claw forceps and curve it so as to visualize the dissection site. 
3. Progress in the apical direction by making incisions from close to close. The blade must be parallel to the bone surface or even slightly convergent.

The main interest of this flap is to create a vascularized connective bed. This bed can be: 

• the recipient site of a displaced graft or flap;
• left raw which results in secondary healing but protects the underlying bone. 

The main risk when implementing this technique is perforation of the vestibular flap. To prevent this, the penetration of the blade must be controlled, and it must be oriented parallel to the bone surface. 

For added safety, the tip of the blade can be angled slightly towards the bone surface

7.3. Double thickness flap 

The double-thickness flap is a flap having a full-thickness portion comprising epithelium, connective tissue and periosteum and a second partial-thickness apical portion comprising only connective tissue and epithelium.

Technical 

1. If the full-thickness flap is already elevated, keep the flap curved and make a periosteal incision through the thickness of the flap. Then dissect step by step to continue elevation. 
2. If the flap was started in partial thickness, incise the periosteum directly above the flap, seeking bone contact with the blade and continue elevation with the detacher. Make sure never to lose bone contact with the detacher.

8. Different interventions

Initial preparation : 

Before any surgical procedure, we use an initial preparation of the patient which determines the success of the treatment. Surgery will only be considered after a positive periodontal reassessment.

Instrumentation : 

– Consultation platform. 

– Syringe for anesthesia with needle and anesthesia cartridge with adrenaline. 

– Bard-Parker scalpel handle with interchangeable blades and Bard-Parker scalpel blades #15, 15c, 11, and 12. 

– Goldman Fox type stripper (Rugine). 

– Instruments for scaling and root planing. 

– Fissure burr, contra angle, bone files. 

– Suture thread, needle holder forceps, and suture scissors. 

– Surgical dressing. 

– Salivary aspiration cannula. 

– Gauze compresses. 

– Physiological serum.

Incisions 

In surgery, an incision is a small cut made by a surgeon with a scalpel on an organ in order to perform an operation inside or beyond it. 

Soft tissue detachment is a method that provides access to the deeper structures of the periodontium which can then be treated under direct visual control. 

The location and shape of the incision affect the healing of soft tissues and also the underlying bone. 

The incision is made to raise a full-thickness or partial-thickness flap. 

The incision must respect the vascular architecture of the surgical site, the oral cavity being a highly vascularized region. 

Characteristics of an incision: 

• A sharp blade of good size should be used; 
• The incision line must be clean and continuous; 
• The practitioner should avoid vital structures when making the incision; 
• The blade should be held in a perpendicular position when making the incision; 
• The incision in the oral cavity should be well placed, preferably at the level of the attached gingiva and on a healthy bony plane. 
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Holding the scalpel 

The scalpel can be held in two ways: 

• Scalpel held like a pen (most common) 
• Scalpel held in palmar pronation 

Incision material 

The blades 

Are sharp instruments used to cut soft tissues. In order to facilitate the procedure, they come in different shapes (blades No. 15, 15C; 12, 11). There are also safety blades. These are blades with a cap that fixes the surgical blade to the handle, effortlessly and safely, without even having to touch the surgical blade. The protective cap covers and protects the blade during fixation, during and after use and during disposal. The blade extractor is integrated.

Blade holder 

• Flat Handle (Most Used) In our practice, flat handle blade holders are the most used. This blade holder handle can be equipped with grooves for a more secure grip with gloved hands. 
• Round handle The round scalpel handle, straight or angled or with tilting (adjustable) head, ergonomic, provides more precision and flexibility during incision, better support points, accepts all standard blades. 
• There are also standard sterile single-use scalpels. These are ready-to-use, single-use, sterile scalpels. They have a carbon stainless steel blade and a thick, ergonomic plastic handle.
• Similarly, there are safety scalpels that are the answer to the potential risks of cuts/pricks during the use and transmission of scalpels during an operation.

Types of incision 

Internal bevel (para-marginal) incision 

When gingival eviction is sought, this incision allows the elimination of a collar of gingiva including the epithelial and connective tissue attachments, as is the case in the Widman flap. It consists of orienting the blade of the coronary scalpel apically at an angle of 10 to 45° relative to the major axis of the tooth, seeking bony contact with the top of the bony crest and following a line parallel to the gingival festoon. 

Intrasulcular incision 

This is the most commonly used incision in periodontal surgery. It tends to preserve the integrity and save the gingival tissue. It is indicated in all flap techniques that do not require gingival eviction. This time, the scalpel blade is introduced into the sulcus and oriented along an axis almost parallel to the major axis of the tooth and its tip must be located at the emergence of the desmodont. The scalpel passes from one tooth to another following the gingival festoon and incising the papillae in line with the dental contact points in order to respect the integrity of the papillae as much as possible. 

Discharge incision 

The discharge incision is an incision that aims to increase the degree of access to the underlying structures and to allow the mobilization of the flap for repositioning. Thus, this incision facilitates the manipulation of the flap by increasing its laxity, avoiding its tearing and limiting the extent of the intrasulcular incisions. In periodontal surgery, the indications are more limited today because “envelope” flaps are preferred, whose vascularization is more favorable. The discharge incision is a straight and vertical incision starting at the end of the intrasulcular or internal bevel incision. It is directed from coronal to apical, respecting the rule of thirds and going beyond the mucogingival line. Do not discharge at the top of the papilla – Risk of not suturing properly and causing papilla retraction. Do not discharge centered at the neck – Risk of gingival recession. 

Sutures 

Suturing is usually the last phase of surgery. It is nonetheless a fundamental act for the smooth running of the post-operative period. During surgical periodontal treatments, sutures are the guarantors of healing. Each point to be performed must be carefully considered and performed. 

The suture allows: 

• bring the edges of a wound closer together, promoting healing, reducing post-operative complications and limiting food contamination. 
• facilitate hemostasis and prevent post-operative hemorrhage. 
• allow the movement and immobilization of a mucosal flap or graft. 
• prevent loss of bone substitute material or hemostatic material. 

The parameters involved in suturing are the choice of the necessary material as well as the techniques to be used according to the different clinical situations. 

Suture material 

The needles 

The function of a needle is to guide the suture to the tissues. 

The properties of a needle: 

• the tip should be sharp and hard.
• the body must combine rigidity and ductility and bend without breaking
• the crimp area should be as malleable as possible to fit tightly onto the wire. 

Suture thread 

The thread is the implantable element. The material that composes the thread gives it its mechanical and biological properties. A good suture thread requires physical characteristics and specific properties such as: 

• good tensile strength, 
• dimensional stability, absence of shape memory,
• good knot security, 
• be flexible enough to prevent mucosal trauma. 

The choice offered to the practitioner is wide. The suture thread can be: 

• absorbable or non-absorbable; 
• monofilament or multi-strand; 
• natural or synthetic. 
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Its choice, between absorbable or non-absorbable, will depend on: 

• of the type of treatment, 
• accessibility to the suture thread. In the posterior area, which is more difficult to access than the anterior area, an absorbable thread is more suitable,
• the availability of the patient, who must return to have the non-absorbable stitches removed, 
• of aesthetic demand. 
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Needle holders 

The needle holder is a surgical instrument made of stainless steel that allows easy handling of suture needles. This surgical instrument is indicated for grasping and guiding the needle during the operation which consists of bringing the edges of a wound together by binding the tissues with a thread. The needle is clamped perpendicular to the needle holder and at the end of its jaws.

The scissors 

Thin and pointed, they must be sharpened so as to cut the wire precisely and easily without shredding it. There are two main types of scissors: 

• scissors for “traditional” surgeries that will be used by passing the thumb and ring finger through the handles. The index and middle fingers will be kept in contact with the body of the scissors to guide and stabilize them. 
• microsurgery scissors that will be grasped between the thumb and index finger. 
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Flap clamp 

The forceps used to grasp the flap are called “dissecting” forceps or “suturing” forceps; they are grasped like a pen and their role is to firmly hold the soft tissues of the flap so that they can be perforated with our needle.

Suture techniques 

There are several suture techniques, each with characteristics that indicate its use. 

Simple O-stitch 

This is the most commonly used stitch, it is simple and quick to perform. Its purpose is to flatten the detached flap. It can be indicated in flaps with little detachment, and also to suture discharge incisions.

“8” point 

The “8” stitch is used for suturing interdental papillae. Indicated when it is impossible to perform an “O” stitch or to bring the edges together after extraction. It has the disadvantage of the risk of delayed healing due to bacterial contamination (thread interposed between the edges).

Mattress Points 

The common objective of all mattress stitches is to allow stronger traction of the flap while minimizing the risk of tearing. They generate optimal adaptation of the edges of the flap and intimate plating of the flap against the underlying bone, subsequently guaranteeing stabilization and resistance to traction forces. 

We distinguish: 

Vertical mattress point is indicated when seeking to hermetically reposition the papillae after eliminating the granulation tissue. It is recommended to use this point in the anterior region given the often narrow interdental space. 

Horizontal mattress stitch It is indicated especially in cases where the interdental space is rather wide, and the attached gingiva is of low height (premolar-molar region). It therefore prevents the collapse of the flap.

Hanging points 

The common goal of suspended stitches is to allow the vestibular flap to be adjusted vertically and, above all, to be maintained in a coronal position by minimizing post-surgical retraction. The suspended stitch goes around the buccal surface of a tooth in order to avoid traumatizing the buccal mucosa.

FLAP SURGERY

Additional reading

New therapeutic strategy: minimally invasive surgery in periodontal regeneration 

Introduction

For 20 years, we have observed that conventional medical techniques are increasingly giving way to less invasive approaches. Reducing surgical trauma, reducing postoperative pain, making scars less and less visible after operations, these are the major challenges that surgeons must face today. 

The ever-increasing understanding of the factors involved in healing has led to the modification of surgical techniques in favor of  minimal surgery protocols. 

Periodontal regeneration has followed this trend. In the treatment of intraosseous lesions, several studies show that with minimally invasive surgery, the improvement of clinical parameters is similar, or even superior, to that of conventional periodontal surgery techniques. 

FLAP SURGERY

Historical

Since 1990, minimally invasive surgery has been defined as the ability to perform surgery with very small incisions and a much smaller operating field than previously possible (Wickham and Fitzpatric, 1990; Hunter and Sackier, 1993). Optical aids – microscopes or loupes – may be used.

It was in 1995 that Harrel first described minimally invasive surgery in the context of periodontal regeneration:  minimally invasive surgery,  or MIS (Harrel and Rees, 1995). Two intrasulcular incisions are made around each tooth bordering the intraosseous lesion and an interdental incision, most often offset palatal or lingual, joins the intrasulcular incisions. The papilla is dissected and small vestibular and palatal/lingual flaps are detached.

A lack of interest in minimally invasive surgery was then noted in the medical literature. Indeed, very few articles were published until 2007, when Cortellini and Tonetti modified MIS by associating it with papillary preservation techniques: this is the  minimally invasive surgical technique  (MIST) (Cortellini and Tonetti, 2007a). This is the starting point for new minimally invasive surgery protocols. These authors were inspired by the concept of the papillary preservation flap (Genon and Bender, 1984; Takei  et al.,  1985). The objective is to guarantee optimal vascularization of the interdental papilla and to avoid postoperative gingival retraction, which is unsightly in the anterior sectors. Indeed, during the elevation of the mucoperiosteal flap, the periosteum is separated from the alveolodental ligament, which induces vascular trauma, particularly at the level of the interdental areas, hence the need to preserve them as much as possible by papillary preservation techniques. The proximal incision is offset to the palatal side to keep the tissue integrity on the vestibular side.

Cortellini  et al.,  establish the outline of the incisions according to the width of the interdental space. If it is greater than or equal to 2 mm, a modified papilla preservation technique (MPPT:  modified papilla preservation technique ) is used (Cortellini  et al.,  1995) to preserve the entire papilla. If it is less than 2 mm, it is impossible to preserve the entire papilla. We then enter the papilla to obtain the greatest possible tissue thickness. This is the modified papilla preservation flap technique (SPPF:  simplified papilla preservation flap ) (Cortellini  et al.,  1999).

Other teams have subsequently conducted clinical trials to study the implementation of biomaterials and the healing achieved. To date, there is only one review of the scientific literature (Cortellini, 2012) on minimally invasive surgery in periodontal regeneration. Paradoxically, this approach is now increasingly used.

FLAP SURGERY

Indications for minimally invasive surgery

After etiological therapy, when deep pockets greater than 6 mm persist in association with an intraosseous lesion, surgical treatment is recommended (Nibali  et al.,  2011). 

The conventional surgical approach indicates a sextant or quadrant approach. Today, an isolated lesion will rather be approached by minimally invasive surgery, which concerns:

• one or more isolated intraosseous lesions: the surgical field is limited to 2 or 3 teeth;
• intraosseous lesions with 1, 2 or 3 walls or combined (Goldman and Cohen, 1958) whose extent is less than half the root height.

The indications for minimally invasive surgery have limitations:

• a very deep lesion will not be approached by minimally invasive surgery; it will require great laxity of the flap with detachment involving several teeth in order to correctly access the bottom of the lesion;
• Likewise, in the case of multiple severe lesions, a  minimum flap  will not be sufficient to treat all of the lesions.

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Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
 

FLAP SURGERY