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Flap Design in Implant Dentistry Iyad Abou-Rabii DDS. OMFS. MSc. PhD

Flap Design in Implant Dentistry

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Page 1: Flap Design in Implant Dentistry

Flap Design in Implant Dentistry

Iyad Abou-RabiiDDS. OMFS. MSc. PhD

Page 2: Flap Design in Implant Dentistry

Introduction

• Establishing non tension primary closure over implantand bone-grafted sites begins with proper soft tissuemanagement.

Page 3: Flap Design in Implant Dentistry

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.

Page 4: Flap Design in Implant Dentistry

IMPORTANCE OF ADEQUATE TISSUECLOSURE

• Trapezoid Shape

• Full thickness flaps shouldbe reflected cleanly

• No tension

Page 5: Flap Design in Implant Dentistry

Filleting The Flap

A trapezoidal design allowsthe operator to surgicallyfillet the underlyingperiosteum

Page 6: Flap Design in Implant Dentistry

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

Page 7: Flap Design in Implant Dentistry

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.

Page 8: Flap Design in Implant Dentistry

Maxillary buccal tissue managementwith crestal incision through tissue

• The buccal periosteumcan be relieved using acurved blade in theapical-horizontaldirection.

Page 9: Flap Design in Implant Dentistry

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

Page 10: Flap Design in Implant Dentistry

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

Page 11: Flap Design in Implant Dentistry

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

Page 12: Flap Design in Implant Dentistry

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.

Page 13: Flap Design in Implant Dentistry

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.

Page 14: Flap Design in Implant Dentistry

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.

Page 15: Flap Design in Implant Dentistry

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

Page 16: Flap Design in Implant Dentistry

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.

Page 17: Flap Design in Implant Dentistry

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.

Page 18: Flap Design in Implant Dentistry

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

Page 19: Flap Design in Implant Dentistry

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.

Page 20: Flap Design in Implant Dentistry

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

Page 21: Flap Design in Implant Dentistry

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

Page 22: Flap Design in Implant Dentistry

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

Page 23: Flap Design in Implant Dentistry

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

Page 24: Flap Design in Implant Dentistry

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

Page 25: Flap Design in Implant Dentistry

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.

Page 26: Flap Design in Implant Dentistry

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.

Page 27: Flap Design in Implant Dentistry

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

Page 28: Flap Design in Implant Dentistry

Double closure tissue management forthe premaxillary receptor site

• A full thickness reflection is then made to expose both crestaland palatal bony surfaces

Page 29: Flap Design in Implant Dentistry

Double closure tissue management forthe premaxillary receptor site

• The re¬maining buccalperiosteum is nowcarefully reflected toexpose the nasal spineand nares floor

Page 30: Flap Design in Implant Dentistry

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.

Page 31: Flap Design in Implant Dentistry

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

Page 32: Flap Design in Implant Dentistry