Upload
iyad-abou-rabii
View
1.454
Download
32
Embed Size (px)
Citation preview
Flap Design in Implant Dentistry
Iyad Abou-RabiiDDS. OMFS. MSc. PhD
Introduction
• Establishing non tension primary closure over implantand bone-grafted sites begins with proper soft tissuemanagement.
Points to consider
Zola states five basic points to consider in the design of asoft tissue flap for intraoral surgery:
1. anatomy,
2. access,
3. replacement,
4. closure,
5. blood supply.
IMPORTANCE OF ADEQUATE TISSUECLOSURE
• Trapezoid Shape
• Full thickness flaps shouldbe reflected cleanly
• No tension
Filleting The Flap
A trapezoidal design allowsthe operator to surgicallyfillet the underlyingperiosteum
What about the Knot
1. Suture knot begins with twoforward loops.
2. one forward loop.
3. one reverse loop.
4. single forward loop.
A completed granny-square-granny knot.
1
43
2
Maxillary buccal tissue managementwith crestal incision
• Used when small to moderate bone expansionor grafting is required
A full thickness crestal incisionbetween the maxillary lateral incisorteeth.
Maxillary buccal tissue managementwith crestal incision through tissue
• The buccal periosteumcan be relieved using acurved blade in theapical-horizontaldirection.
Maxillary buccal tissue managementwith crestal incision through tissue
• If the implant healingscrew or grafting materialis still evident visually atthe buccal-lingual tissueinterface then verticalincisions through theproximal tissue, includingthe papillae, are used.
• If the wound margins stilldo not approximate, thevertical incision is thencarried into the alveolarmucosa
Maxillary buccal tissue managementwith crestal incision through tissue
• The needle is pulledcompletely through the lingualtissue and reentered into thebuccal tissue papillae in alingual to buccal direction
• An interrupted suture knot istied next to the proximal tooth
• The same type of interruptedsuture knot is tied next to theadjacent tooth.
• Single interrupted sutures areplaced every 3– 4 mm to closethe incision on the crest of theridge
Maxillary buccal tissue managementwith crestal incision through tissue
• The needle is pulledcompletely through the lingualtissue and reentered into thebuccal tissue papillae in alingual to buccal direction
• An interrupted suture knot istied next to the proximal tooth
• The same type of interruptedsuture knot is tied next to theadjacent tooth.
• Single interrupted sutures areplaced every 3– 4 mm to closethe incision on the crest of theridge
Maxillary buccal tissue managementwith crestal incision through tissue
• Vertically incised attached gingivaltissue is sutured immediately afterplacing the proximal-crestal sutures.
• Passing the needle through tissueon both sides of the vertical incisionline can simultaneously result intorn tissue and compromiseesthetics.
• The needle is pulled through theincision line and then reinserted intothe bound tissue of the adjacenttooth.
Mandibular buccal tissuemanagement with crestal incision
• a full thickness flap iselevated
• the periosteal elevatorshould be forcibly pressedagainst the bone.
• The tissue should bereflected in an anterior toposterior direction.
• During tissue elevation, thesurgeon’s thumb is used toresist the pressure of theelevator.
Tissue closure of mandibularposterior edentulous area
• If the tissue lies passivelyover the implant coverscrews and/or bone graftingmaterials, the operator canbegin suturing.
• If flap tension is present,then a no. 12 Bard Parkercurved scalpel is used toplace 1-mm-deep horizontalrelieving incisions in theperiosteum/tissue interface.
Tissue closure of mandibularposterior edentulous area
• Suturing begins along thedistal surface of the mostanterior tooth
• the knot is securely closedwithout tissue tension
• A horizontal mattresscontinuous suture is now usedto close the tissue in ananterior to posterior direction
• To prevent premature opening,a few interrupted suturesshould be placed along thecontinuous suture line
Tissue management and flap designfor sinus grafting procedures
• initial incision begins withdirecting a straight scalpelinto the distal-crestal aspectof the fibrous maxillarytuberosity and continuesanteriorly along the alveolarcrest for 3–5 mm.
• The incision then traversesthe palatal incline of themaxillae in an anterior–superior direction to avoidthe greater palatineforamina and its contents.
Tissue management and flap designfor sinus grafting procedures
• initial incision begins withdirecting a straight scalpelinto the distal-crestal aspectof the fibrous maxillarytuberosity and continuesanteriorly along the alveolarcrest for 3–5 mm.
• The incision then traversesthe palatal incline of themaxillae in an anterior–superior direction to avoidthe greater palatineforamina and its contents.
Tissue management and flap designfor sinus grafting procedures
• The scalpel continues thispath until it is within 4 mmof the palatine process ofthe maxillae.
• At this point, the incisionalters into an anterior onlydirection and continues tothe cuspid apex.
• Once reached, the blade isturned toward the disto-lingual aspect of the cuspid
Tissue management and flap designfor sinus grafting procedures
• At this point, the incisionalters into an anterior onlydirection and continues tothe cuspid apex.
• Once reached, the blade isturned toward the disto-lingual aspect of thecuspid where it enters thesulcus.
Tissue management and flap designfor sinus grafting procedures
• The intrasulcular incisioncontinues facially around thecuspid to include the mesialcuspid papillae where itterminates.
• Beginning in the mesialcuspid papillae, a verticalreleasing incision is directedtoward the root of thecentral incisor, therebycreating the desiredtrapezoid flap
Tissue management for the ramusdonor site
• The surgery begins with a fullthickness incision that bisectsthe pterygo-mandibular raphae.
• A straight scalpel is angledtoward the buccal to avoid thelingual nerve.
• The incision continuesanteriorly onto the ridge crestfor approximately 15 mm
Tissue management for the ramusdonor site
• The blade is then reversed so thecutting edge is facing superiorlyand placed into the distal of theincision, where it continues in abucco-lateral direction forapproximately 15 mm.
• A periosteal elevator is used toreflect the raphae tissue towardthe lingual. The buccal fullthickness flap is then reflected tosufficiently expose the externaloblique ridge and ramus areas
Tissue management for the chin donorsite
• Using a straight scalpel, a horizontal incision ismade 2–3 mm below the in-ferior border of thebuccal attached gingivae.
• The incision extends from cuspid eminence tocuspid eminence
Tissue management for the chin donorsite
• A no. 9 periosteal elevator is used in an inferiordirection to elevate a full thickness flap to theinferior bor¬der of the mandible.
• The dissection then proceeds laterally to exposethe mental nerve bundles
Tissue management for the chin donorsite
• Using a straight scalpel, ahorizontal incision is made 2–3mm below the in-ferior border ofthe buccal attached gingivae.
Double closure tissue management forthe premaxillary receptor site
• Proper flap design includes atrapezoidal shape .
• The dissection begins with twofull thickness vertical incisionsthat include the proximalpapillae
• A split thickness horizontalincision is made approximately2 mm inferior to themucobuccal fold connecting itto the two vertical incisions.
Double closure tissue management forthe premaxillary receptor site
• The split thickness dissection is continued until it reachesattached gingivae.
• At this level, a horizontal incision is made through theperiosteum, uniting it with the two vertical incisions
Double closure tissue management forthe premaxillary receptor site
• A full thickness reflection is then made to expose both crestaland palatal bony surfaces
Double closure tissue management forthe premaxillary receptor site
• The re¬maining buccalperiosteum is nowcarefully reflected toexpose the nasal spineand nares floor
Double closure tissue management forthe premaxillary receptor site
• the periosteum is suturedto the lingual full thick-ness flap in order not toshorten the lingual flap.
Double closure tissue management forthe premaxillary receptor site
• The remaining flap is now brought to the buccal over the top ofthe sutured periosteal flap and sutured into position buccally