CHAPTER 3: Principles of
FLAP DESIGN
Surgery
Preventon of fap necrosis
Developing a surgical diagnosis
4 basic Flap Design Principles
- Decisions are made before anesthesia
- Collection of accurate and pertinent data 1. The apex (tipp of a flap should never be wider than
- “evidence based dentistrry the base unless a majoor arterr is present in the base.
Flaps are parallel or converge towards the base to the
Basic Necessites for Surgery apex.
2 Principal Requirements 2. Length of the flap should be no more than twice the
width of the base. (Width of the base > Length of flapp
1. Adequate visibility
a. Adequate access 3. When possible, axial blood supplr should be included
in the base.
- Not onlr requires patientts abilitr to open
mouth widelr, but also mar require surgicallr created 4. Base of the flap should not be excessivelr twisted,
exposure – retraction of tissues, creation of surgical stretched, or grasped with anrthing that mar damage
flaps. the blood vessels because it mar compromise blood
b. Adequate light supplr fading and draining the flap as well as
lrmphatics.
- Light source must be continuallr repositioned
c. A surgical feld ree excess blood and other fuids Preventon of fap dehiscence
- High volume suctioning - Prevented br approximating the edges of the
flap over healthr bone br gentlr handling the edges of
INCISIONS the flap and br not placing the flap under tension.
1. Sharp blade of proper size
Preventon of fap tearing
- Bone and ligament = dull blades more rapidlr
1. Envelope faps
2. Firm contnuous stroke
- Repetitive, tentative stroees = damaged tissue - Created br incisions that produce a one sided
- PREFER: long, continuous stroees flap
- Around the neces of teeth to expose alveolar
3. Avoid cutting vital structures
bone.
- Surgeon must incise onlr deeplr enough to
define next majoor larer 2. Vertcal (Obliquea Releasing Incisions
4. Incisions through epithelial surfaces that the surgeon - Placed one full tooth anterior to the area of anr
plans to reapproximate should be made br the blade anticipated bone removal
held perpendicular to the epithelial surface - Line angle of a tooth or adjoacent interdental
papilla, carried obliquelr apicallr into the atached
5. Incisions must be properly placed
gingiva.
- PREFER: over atached gingiva, over healthr
bone
, 3. Tissue Handling
DEAD SPACE MANAGEMENT
- Tissue forceps must not be pinched together
- An area that remains devoid of tissue afer
too tightlr
closure of wound
- Protect tissues from frictional heat or direct
- Usuallr fills with blood which creates
trauma
hematoma with a high potential for infection
- Tissues should not be allowed to dessicate
(opened wounds must be moistenedp
To eliminate
- Onlr phrsiologic substances should come in
contact with tissue. 1. Suturing tissue planes together to minimiie post-
operative wound
HEMOSTASIS
2. Place pressure dressing over the repaired wound
Uncontrolled bleeding 3. Place paceing into the void until bleeding has stopped
- Decreases visibilitr and remove paceing
- Formation of hematomas – place pressure on 4. Use of drains br themselves or in addition to pressure
wound edges and potentialiie the formation of wound dressings
infections
- Suction Drains – continuallr remove blood until
Means of Promotng ound Hemostasis bleeding stops and tissues bind together
- Non-suction drains – allow anr bleeding to
1. Assistng natural hemostatc mechanisms
drain to the surface rather than to form a hematoma
- Use of fabric sponge and hemostats
- Smaller vessels = 20-30 secs DECONTAMINATION and
- Larger vessels = 5-10 minutes
DEBRIDEMENT
2. By use of heat to cause the ends of blood vessel to
fuse (thermal coagulatona - Decrease bacterial contact br repeatedlr
irrigating the wound during surgerr and closure
- Patient must be grounded - Irrigation – dislodged bacteria, uses
- Cauterr tip and anr metal instrument the sterile/saline water
cauterr tip contacts cannot touch the patient at anr
point other than the bleeding vessel ound debridement
- Removal of anr blood or fluid that has
- Careful removal of necrotic and severelr
accumulated around the vessel to be cauteriied
ischemic tissue and foreign material that would impede
(surgical hemostasis-suture ligationp
wound healing
- Placing vasocontrictive substances such as
- Used for traumaticallr incurred wounds or for
epinephrine or br applring coagulants such as
severe damage
commercial thrombin or collagen on the wound 7
minutes before surgerr begins.
FLAP DESIGN
Surgery
Preventon of fap necrosis
Developing a surgical diagnosis
4 basic Flap Design Principles
- Decisions are made before anesthesia
- Collection of accurate and pertinent data 1. The apex (tipp of a flap should never be wider than
- “evidence based dentistrry the base unless a majoor arterr is present in the base.
Flaps are parallel or converge towards the base to the
Basic Necessites for Surgery apex.
2 Principal Requirements 2. Length of the flap should be no more than twice the
width of the base. (Width of the base > Length of flapp
1. Adequate visibility
a. Adequate access 3. When possible, axial blood supplr should be included
in the base.
- Not onlr requires patientts abilitr to open
mouth widelr, but also mar require surgicallr created 4. Base of the flap should not be excessivelr twisted,
exposure – retraction of tissues, creation of surgical stretched, or grasped with anrthing that mar damage
flaps. the blood vessels because it mar compromise blood
b. Adequate light supplr fading and draining the flap as well as
lrmphatics.
- Light source must be continuallr repositioned
c. A surgical feld ree excess blood and other fuids Preventon of fap dehiscence
- High volume suctioning - Prevented br approximating the edges of the
flap over healthr bone br gentlr handling the edges of
INCISIONS the flap and br not placing the flap under tension.
1. Sharp blade of proper size
Preventon of fap tearing
- Bone and ligament = dull blades more rapidlr
1. Envelope faps
2. Firm contnuous stroke
- Repetitive, tentative stroees = damaged tissue - Created br incisions that produce a one sided
- PREFER: long, continuous stroees flap
- Around the neces of teeth to expose alveolar
3. Avoid cutting vital structures
bone.
- Surgeon must incise onlr deeplr enough to
define next majoor larer 2. Vertcal (Obliquea Releasing Incisions
4. Incisions through epithelial surfaces that the surgeon - Placed one full tooth anterior to the area of anr
plans to reapproximate should be made br the blade anticipated bone removal
held perpendicular to the epithelial surface - Line angle of a tooth or adjoacent interdental
papilla, carried obliquelr apicallr into the atached
5. Incisions must be properly placed
gingiva.
- PREFER: over atached gingiva, over healthr
bone
, 3. Tissue Handling
DEAD SPACE MANAGEMENT
- Tissue forceps must not be pinched together
- An area that remains devoid of tissue afer
too tightlr
closure of wound
- Protect tissues from frictional heat or direct
- Usuallr fills with blood which creates
trauma
hematoma with a high potential for infection
- Tissues should not be allowed to dessicate
(opened wounds must be moistenedp
To eliminate
- Onlr phrsiologic substances should come in
contact with tissue. 1. Suturing tissue planes together to minimiie post-
operative wound
HEMOSTASIS
2. Place pressure dressing over the repaired wound
Uncontrolled bleeding 3. Place paceing into the void until bleeding has stopped
- Decreases visibilitr and remove paceing
- Formation of hematomas – place pressure on 4. Use of drains br themselves or in addition to pressure
wound edges and potentialiie the formation of wound dressings
infections
- Suction Drains – continuallr remove blood until
Means of Promotng ound Hemostasis bleeding stops and tissues bind together
- Non-suction drains – allow anr bleeding to
1. Assistng natural hemostatc mechanisms
drain to the surface rather than to form a hematoma
- Use of fabric sponge and hemostats
- Smaller vessels = 20-30 secs DECONTAMINATION and
- Larger vessels = 5-10 minutes
DEBRIDEMENT
2. By use of heat to cause the ends of blood vessel to
fuse (thermal coagulatona - Decrease bacterial contact br repeatedlr
irrigating the wound during surgerr and closure
- Patient must be grounded - Irrigation – dislodged bacteria, uses
- Cauterr tip and anr metal instrument the sterile/saline water
cauterr tip contacts cannot touch the patient at anr
point other than the bleeding vessel ound debridement
- Removal of anr blood or fluid that has
- Careful removal of necrotic and severelr
accumulated around the vessel to be cauteriied
ischemic tissue and foreign material that would impede
(surgical hemostasis-suture ligationp
wound healing
- Placing vasocontrictive substances such as
- Used for traumaticallr incurred wounds or for
epinephrine or br applring coagulants such as
severe damage
commercial thrombin or collagen on the wound 7
minutes before surgerr begins.
