Principles of Flap Design and Suturing Flashcards
What is a surgical flap? What is the purpose of a surgical flap?
Soft tissue flap used to:
Facilitate surgical extractions
Treat pathology (eg apical surgery and periodontal surgery)
To create access for soft tissue and bone augmentation procedures (eg implant surgery)
How does flap design and incorrect technique affect the outcome of treatment?
Correct flap design facilitates adequate exposure and promotes healing
Periosteum plays a vital role in bone healing
Torn and macerated flap heals more slowly
Less bleeding when full thickness flap is elevated
What is full-thickness surgical flaps?
Full-thickness muco-periosteal flaps reflected off bone
How is a mucoperiosteal flap created?
Incision in the gingival sulcus with one smooth continuous stroke, keeping knife blade in contact with bone throughout.
Reflection of flap begins at the papilla with a periosteal elevator pushing mucoperiosteum away from bone with firm continuous pressure.
Retract the mucoperiosteal flap by pressing firmly against bone not against soft tissue
What are the important principles of flap design to consider?
Surgical incision
Blood supply
Access to underlying tissues
Replace in the original position
Maintain with sutures
How should a surgical incision be made if the patient is edentulous?
Incision is made along the crest of the ridge.
What can accidentally be damaged in edentulous patients with extremely resorbed mandibles?
Mental foramen may rest near the top of the residual alveolar ridge so risk of damage to the mental nerve.
How is the mucoperiosteal flap completed?
Incision in the gingival sulcus with one smooth
continuous stroke, keeping knife blade in contact with bone throughout
Reflection of flap begins at a papilla with a periosteal elevator, pushing mucoperiosteum away from bone with firm continuous pressure
Retract mucoperiosteal flap by pressing firmly
against bone, not against soft tissue
How does the incision affect healing post surgery?
Wound heals across the incision. Sharp incision heals more rapidly along the line than torn mucosa.
What locations is an incision good to make?
Make incision over intact bone. Incision unsupported by sound bone results in wound dehiscence and delayed healing
If bucco-cortical plate eroded or surgery removes bone over tooth, incision at least 6-8mm away in area of intact bone
Avoid anatomical structures eg lingual nerve
Use envelope incision or relieving incisions well anterior or posterior to mental foramen
What is the purpose of an oblique vertical relieving incision?
Allows broad base flap to preserve adequate blood supply.
How should vertical relieving incision be carried out?
Should not cross the canine prominence to reduce the tension in suture line and risk of wound dehiscence.
Vertical relieving incision should not be directly on the facial aspect of tooth nor in the papilla as this may result in a soft tissue defect
Why is the base of the flap broader than the free gingival margin?
To preserve blood supply
What is the major blood supply to palatal soft tissue?
Greater palatine artery anterior and middle palate
Lesser palatine artery posterior palate.
How can the flap be made to facilitate access to underlying tissues most optimally?
Adequate sized flap used to facilitate visualisation of area and for insertion of instruments to perform surgery.
Flap held out of surgical field without tension and by retractor resting on intact bone.
What kind of flap is used to access a palatally impacted canine?
An envelope flap
How should flap be positioned at the end of surgery?
Should be positioned back into place and stitched to hold it
Wound healing across the incision
Wound closure should be tension free
What are the types of mucoperiosteal flaps?
Envelope flap
Four-cornered flap (Trapezoid)
Three-cornered flap (triangular)
Semi-lunar incision
What does a four-cornered flap look like?
2 relieving incisions with a broader base than gingival margin.
Envelope incision with 2 relieving incisions.
What does a three-cornered flap look like?
Sulcular incision with a vertical relieving incision
What does a semi-lunar incision looks like?
Avoids marginal attached gingiva.
Flap is moon shaped and doesn’t involve the sulcus.
What is the purpose of suturing?
To hold the flap in position and speed wound healing.
Aids in haemostasis
Holds mucoperiosteal flap over bone.
Can aid in maintaining clot in alveolar bone
Which needles are most commonly used in oral surgery?
3/8 circle and 1/2 circle needles.
What are the types of needle bodies used for suturing?
Round-bodied needles
Conventional cutting needles
Reverse cutting needles (Ideal for tough tissues like skin, tendon sheath or oral mucosa)
Which sutures should be used for oral surgery?
Depends on the type of tissue being repaired
There are absorbable and non-absorbable sutures. Monofilament or braided.
What are the features of the ideal suture?
Ideal suture is the smallest possible suture:
that also provides high uniform tensile strength.
Ability to hold wound securely during healing phase
Can rapidly resorb
Uniform diameter, sterility, pliability, knot security, least amount of tissue reactivity, and predictability.
What are the types of absorbable sutures?
Braided = Vicryl and vicryl rapide
Monofilament = Monocryl, fast absorbing gut, and chromic gut.
What are the types of non-absorbable sutures?
Braided = Ethibond, silk
Monofilament = Ethilon
How are sutures usually placed?
Sutures are usually first placed distal to the last tooth in each interproximal space.
Single interrupted suture can be placed across both papillae of tooth socket.
First insert sutures through the more mobile tissue flap.
When space is restricted use a 3/8 or 1/2 circle needle.
How should the suture be held?
Only needle holders should be used to grasp suture needles.
Suture needle should be inserted and pulled through the tissue in line with the curve of the needle.
Grab the suture needle in center of the needle. Never at its tip or near where the thread is swage to the needle
How should suturing be done? (Technique)
Needle should enter tissue at right angles to tissue.
Do not place sutures closer than 2 - 3mm from flap edges to prevent tearing through the flap during suturing.
When suturing, flaps should be approximated. Pull the suture just tight enough to secure the flap in place
