Soft tissue management: flap design, incision, tissue elevation, and tissue retraction

Abstract

The ultimate goal in surgical endodontics is not only the eradication of periapical pathosis but also preservation of periodontal conditions using suitable surgical techniques. Acceptable treatment outcomes are no longer possible without consideration of esthetic consequences for all involved dentoalveolar structures. During surgical endodontics the cortical bone is exposed by incising, elevating, and reflecting a full‐thickness tissue flap. Certain basic principles must be considered before deciding on the type of incision and flap design. Thorough knowledge of regional anatomical structures in conjunction, as well as prevailing periodontal conditions affect and must be considered when making the proper decision on how and where to reflect the mucoperiosteal tissues. Various modes of incision can be selected, including horizontal, sulcular, submarginal, and vertical releasing incisions. The variety of flaps reflects the number of variables to be considered before choosing an appropriate flap design. While many flap designs have been suggested over the years, some have become obsolete and new techniques have emerged. It is critical that incisions and tissue elevations and reflections are performed in a way that facilitates healing by primary intention. This can be obtained by complete and sharp incision avoiding severing or traumatizing the tissues during elevation; it is equally important to prevent drying of tissue remnants on the root surface and drying of the flap during the procedure. The introduction of microsurgery to surgical endodontics attempts to minimize trauma and to enhance surgical results. Because of the combination of magnification and more delicate instruments, improved and careful tissue handling has become possible. Additional improvements in flap design and soft tissue manipulation are considered key elements in enhanced biological and esthetic outcomes of marginal soft tissues.

Soft tissue management: suturing and wound closure

“…Tissue flap designs should allow the maintenance of optimal and sufficient blood supply to all parts of the mobilized and immobilized portions of the soft tissues (1). With prolonged duration of the surgical procedure, especially when a high degree of hemostasis has been achieved, there is a risk of drying out of the tissues.…”

“…In principle, a tissue flap consists of gingival and mucosal tissues as well as periosteum. Various modes of incisions can be selected prior to tissue elevation and reflection (1). The prime objective of periapical surgery is to provide conditions such that healing and repair or regeneration can occur.…”

Comparative Study Between Two Flaps—Trapezoidal flap (TZF) and Ocshenbein-Leubke Flap (OLF) in Periapical Surgeries

“…Good access and visibility of the surgical field is one of the principle requirements of periapical surgery and the manipulation of the soft tissues must be performed without compromising the requirements for optimal access to the periapical region and perfect visibility of the involved apical structures [3,4].Although the results of comparison were statistically insignificant; OL flap was found to be adequate in 9 patients as compared to 7 patients of the TZ flap group. In a similar study visibility was assessed by the operator's personal experience during holding of flap by assistant, facilitation of visibility during cutting bone and assistance in lip retraction and it was found that OL flap is much better in all the respects [4].…”

“…In a similar study visibility was assessed by the operator's personal experience during holding of flap by assistant, facilitation of visibility during cutting bone and assistance in lip retraction and it was found that OL flap is much better in all the respects [4].…”

Surgical endodontics: past, present, and future

“…Flap designs have been somewhat modified to provide enhanced outcomes (12,(140)(141)(142)(143)(144)(145)(146). However, the ultimate response will be highly dependent on the endodontic surgeon, the choice of flap design based on the anatomy of both the soft and hard tissue, the extent of pathosis when present, attention to detail during the surgical procedure, and management during wound closure (147).…”