FLAP DESIGNS
Acc. To Kruger, Surgical Flap is a soft tissue flap that is incised
and retracted so that the underlying bone can be removed to
expose teeth, roots and pathological tissue.
Broader base PRINCIPLES
Adequate size
Closure over healthy bone
Designed to avoid injury to vital structures
Full thickness mucoperiosteal flap
Vertical releasing incision –
Should cross gingival margin at line angle of
tooth
Not on facial aspect or directly on interdental
papilla
Three-cornered
Two-cornered flap( envelope
flap) flap( triangular flaps)
[Link] 1. Triangular flap with Ward’s
incision
2. Long
2. Triangular flap with Modified
Ward’s incision
3. ‘L’shaped flap
[Link] shaped flap
DIFFERENT TYPES OF FLAP DESIGNS
Berwick’s tongue flap
Comma incision flap
Szmyd flap
Modified szmyd flap
Groove and Moore modifications( 1970)
OTHER FLAP DESIGNS
ENVELOPE FLAPS(MAUREL,1959)
For For deep For deep &
superficial impactio lingually(Ries
Advantages Disadvantage
Broadest base Inadequate access for deep
impactions
Easy to close
Alveolar bone loss
Full coverage of bony cavity
Dehiscence
No risk to vital landmarks
Can ne extended for greater
access
Triangular flap with Ward’s &
Modified Ward’s incision
Ward 1 incision(1956)
Anterior limb- starts from imaginary point from apex of mesial root of 2 nd
molar , continues upwards to DB cusp of 2nd molar.
Intermediate limb-around crevices of 3rd molar upto half the mesiodistal
width of 3rd molar.
Distal /posterior limb-from mid of mesio-distal width of 3 rd molar distally
& laterally to external oblique ridge.
Ward 2 incision(Sir TG ward 1968)-
Anterior limb-from apex of distal root of 1st molar, upwards to MB cuspof
2nd molar
intermediate –curves around cervical portion of 2nd molar upto half of MD
width of 3rd molar.
Distal limb- same as Ward 1.
BAYONET
FLAPS
• Trapezoidal flap.( Cogwell, 1933)
• This flap has three parts: distal or
posterior, intermediate or
gingival( sulcular), and an anterior
part.
• Advantage - Provides a broader base;
better blood supply
• Wider exposure in deep impactions
• Disadvantage -Overextension of this
flap into sulcus may cause oozing of
blood from venous plexus. It can be
avoided by making the anterior limb
more oblique.
‘L’ SHAPED FLAP( MARZOLA,
1975)
(Para marginal flap)
• Similar to ward’s except that vertical releasing
incision is given at 45 degrees angle to axis of
2nd molar
• The posterior limb of the incision extends from a
point just lateral to the ascending ramus of the
mandible into the sulcus. It passes disto-lateral
periodontium by avoiding or including it -
depending upon the proximity of the third molar
with the second molar.
Advantage: prevents pocket formation distal to 2nd
molar
Limitation -Suits only the buccal approach since it
is difficult to raise a lingual flap from this approach.
DESIGN OF DISTO LINGUALLY BASED
FLAP BY BUCCAL COMMA INCISION
-Given by Dr. Nageshwar in 2002
-The incision and flap design seems best suited to
cases in which the third molar is completely
covered with soft tissues.
(JOMS
In cases in which part of the impacted tooth is
visible in the mouth, a small modification is made.
After the incision , a second incision is made from
the distobuccal point on the exposed portion of the
third molar to join the first incision approximately
midway down . This allows excision of a triangular
gingival flap.
Advantage – no distal extension
Base located at distolingual aspect of 2nd molar.
Extends onto buccal shelf of mandible.
Advantage-incision does not lie on bony defect created after 3rd
molar removal.
Basically envelope flap.
Starts medial to external oblique ridge
to middle of distal line angle of 2nd
molar.
Wedge of tissue removed distal to 2nd
molar
Sulcular incision around neck of teeth
Modified SZMYD-vertical incision from
distobuccal line angle of 2nd molar
apically to mucogingival line 2-3 mm.
A pedicle flap design as
described by Goldsmith S, De
Silva R, and Tong D, Lowe R
(2012) incorporates a distal
incision which allows soft tissue
advancement and rotation to
achieve complete closure of the
surgical site over sound bone.
This promotes healing by
primary intention, minimizes
wound dehiscence, loss of the
coagulum or exposure of the
alveolar bone thus decreasing
the risk of dry socket.
J DENT SPECIALITIES.2015;3(1):76-80
incision was placed in the buccal gingival sulcus
from the mesio-buccal line angle of the first molar
to the most distal visible aspect of the third molar.
The releasing incision then extended distally 1 cm
up the external oblique ridge as in buccal envelope
incision.
After removal of the third molar, from the distal
aspect of the incision that was given on the
external oblique ridge was curved towards the
buccal sulcus . This tongue shaped flap is then
pulled and rotated over the extracted socket
allowing primary closure over sound bone.
ADVANTAGE- PRIMARY CLOSURE OVER SOUND BONE
BETTER WOUND HEALING WITH NO DEHISCENCE OR ALVEOLAR
OSTEITIS
STUDIES WITH COMPARISON OF
FLAP DESIGNS
1. Jakse et al(2002) 2. Suarez-Cunqueiro etal(2003)
flap design compared –envelope and Flap designs compared- marginal &
modified triangular; l shaped flap paramarginal
Conclusion- later showed less wound Conclusion- wound dehiscence more
dehiscence as more hematoma
in paramarginal
formation in envelope flap
Probing depth more in marginal flap
at 5-10 days post-op but similar at 3
months post-op.
Kiruloglu et al in 2007
Published in IJOMS
Flap designs compared- modified
SZMYD and triangular flap
Conclusion- modified SZMYD
design showed better primary
periodontal healing.
Erdogan et al- 2011
Published in- Oral& maxillofacial
surgery
Flap designs compared-
triangular& envelope flap in terms
of facial swelling and pain
Conclusion- less facial swelling &
pain with envelope flap design
Koyuncu et al( 2013)
Published in- oral surg oral med
oral pathol oral radiol
Flap designs compared- envelope &
modified triangular
Conclusion- modified triangular flap
had advantage of less post- op pain
& swelling but disadvantage of
alveolar osteitis.
Baquain et al ( 2012)
Published in-IJOMS
Flap designs compared- triangular
& envelope flaps
Conclusion- facial swelling & pain
more with triangular flap design &
probing depth more with envelope
flap design
Different studies have shown different results for outcomes of
various flap designs. Most commonly used flap in all types of
impaction is triangular flap.
Choice of flap design depends on surgeon’s personal
experience, skills & expertise.
CONCLUSION
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