Surgical Incisions and Flaps

The following fundamental rules apply to every surgical procedure, concerning the incision and flap: The incision must be carried out with a firm, continuous stroke, not interrupted strokes. During the incision, the scalpel should be in constant contact withbone. Repeated strokes at the same place,many times, impair wound healing. Flap design and incision should be carried out in such a way that injury of anatomic structures is avoided, such as: the mental neurovascular bundle, palatal vessels emerging from the greater palatine
foramen and incisive foramen, infraorbital nerve, lingual nerve, submandibular duct, parotid duct, hypoglossal venous plexus, buccal artery (of concern
when incision of an abscess of the pterygomandibular space is to be performed), facial nerve and facial artery and vein, which are of concern basically for the drainage of abscesses performed withextraoral incisions.
Vertical releasing incisions should begin approximately at the buccal vestibule and end at the interdental papillae of the gingiva. Envelope incisions and semilunar incisions, which are used in apicoectomies and removal of root tips, must be at least 0.5 cm from the gingival sulcus.
The elliptic incision, which is used for the excision
of various soft tissue lesions, comprises two convex incisions joined at an acute angle at each end, while the depth of the incision is such that there is no tension when the wound margins are coapted and sutured.
The width of the flap must be adequate, so that the operative field is easily accessible, without creating tension and trauma during manipulation.
The base of the flap must be broader than the free gingival margin, to ensure adequate blood supply and to promote healing.
The flap itself must be larger than the bone deficit so that the flap margins, when sutured, are resting on intact, healthy bone and not over missing or unhealthy
bone, thus preventing flap dehiscence and tearing.
The mucosa and periosteum must be reflected together. This is achieved (after a deep incision)when the elevator is continuously kept and pressed firmly against the bone.
When the incision is not made along the gingival sulcus, for esthetic reasons, and especially in people with broad smiles, the scar that will result must betaken into consideration, particularly on the labial surface of the front teeth.
During the surgical procedure, excessive pulling and crushing or folding of the flapmust be avoided, because the blood supply is compromised and healing is delayed.
Types of Flaps
Various types of flaps have been described in oral surgery, whose name is based mainly upon shape. The basic flap types are: trapezoidal, triangular, envelope, semilunar, flaps created by and incisions, and pedicle flaps.

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