**2. Third molar surgery**

#### **2.1 Background**

The flap design has considerable effects on primary wound healing in lower third molar surgery [1]. When the conventional sulcular flap design is used, 56% of the patients develop a disorder in primary wound healing [1]. The envelope flap is fixed anteriorly with intersulcular sutures. Notably, dehiscence can take place inconspicuously and unnoticed by the patient and may heal secondarily. The secondary wound healing can cause wedge-shaped defects of the gingiva distal to the second molar or can lead to a loss of attachment distal to the second molar. This periodontal complication after lower third molar surgery has been investigated by several studies [2–5]. Dehiscence occurs in only 10% of cases of triangular flap design [1], and the triangular flap design decreases tension in the area distal to wound closure compared with the envelope flap technique. The vestibular triangular flap can be easily moved to the lingual, ensuring a wound closure that is almost tension-free. The mesial vestibular relieving incision, which is only adapted coronally by a single suture, allows depletion of the postoperative hematoma during masticatory movements. On the first postoperative day, a present hematoma is easy to relieve by spreading and compression. The advantage is that the release area has bone support. Such postoperative morbidity has important medical-legal and economic implications. Many surgical approaches, such as those with the use of surgical drains, different wound closure techniques, and various flap designs, have been tried to minimize the complications [6].

Advantages

defects

margins

Limitations

to wound dehiscence

second molar

triangular flap [8].

a hematoma. Advantages

**197**

area of the second molar [1]

• Dehiscence to the second molar [7]

• Good exposure during surgery

*Flap Techniques in Dentoalveolar Surgery DOI: http://dx.doi.org/10.5772/intechopen.91165*

• Mesial cut could be extended if cystic surgery or endosurgery is required

• The envelope flap provides adequate soft tissues, covering for any bone

• The envelope flap has a wider base, assuring vascularity up to the wound

• Inducing loss of the alveolar bone distal to the second molar probably due

• The envelope flap leads to a total loss of the attached gingiva in this area after the operation, thus causing pocket formation and loss of attachment in the

• Hypersensitivity in the area of the distally exposed root surface of the

**2.3 Triangular flap design and modification (buccally based triangular flap)**

This technique was described by Szmyd [6]. The incision is conducted from the mandibular ramus to the distobuccal crown edge of the second molar, followed

For suturing, the same suturing technique is used distally (envelop), whereas the perpendicular incision is only adapted with a single coronally placed suture. The main aim is exact repositioning of the gingival margin in the area of the second molar. The loose adaption in the apical portion allows easy relief of

• This flap can be easily moved to the lingual, ensuring a wound closure that is

by a perpendicular incision obliquely into the mandibular vestibulum, with a length of about 10 mm. In contrast, the modified incision extends over the mucogingival borderline, and the periodontium of the second molar is only touched

at the dentofacial edge (**Figures 2** and **3**). The flap is lingually based on the

• A suitable choice for compromised cases of nicotine exposure

• Reduces the incidence of wound dehiscence

almost tension-free [8]

• Alveolar osteitis and soft tissue abscess are severe complications

• Sulcular incision may lead to periodontal damage

#### **2.2 Envelope flap**

An envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus is a widely used technique for lower third molar surgery (**Figure 1**).

The envelope flap is closed with two or three single button sutures distal to the second molar, with special attention to an exact repositioning in the area of the gingival margin. In addition, the flap is adapted with interdental sutures between the first and the second molars.

**Figure 1.** *Envelope flap for the removal of the third molar.*

Advantages

**2. Third molar surgery**

been tried to minimize the complications [6].

lower third molar surgery (**Figure 1**).

*Envelope flap for the removal of the third molar.*

the first and the second molars.

The flap design has considerable effects on primary wound healing in lower third molar surgery [1]. When the conventional sulcular flap design is used, 56% of the patients develop a disorder in primary wound healing [1]. The envelope flap is fixed anteriorly with intersulcular sutures. Notably, dehiscence can take place inconspicuously and unnoticed by the patient and may heal secondarily. The secondary wound healing can cause wedge-shaped defects of the gingiva distal to the second molar or can lead to a loss of attachment distal to the second molar. This periodontal complication after lower third molar surgery has been investigated by several studies [2–5]. Dehiscence occurs in only 10% of cases of triangular flap design [1], and the triangular flap design decreases tension in the area distal to wound closure compared with the envelope flap technique. The vestibular triangular flap can be easily moved to the lingual, ensuring a wound closure that is almost tension-free. The mesial vestibular relieving incision, which is only adapted

coronally by a single suture, allows depletion of the postoperative hematoma during masticatory movements. On the first postoperative day, a present hematoma is easy to relieve by spreading and compression. The advantage is that the release area has bone support. Such postoperative morbidity has important medical-legal and economic implications. Many surgical approaches, such as those with the use of surgical drains, different wound closure techniques, and various flap designs, have

An envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus is a widely used technique for

The envelope flap is closed with two or three single button sutures distal to the second molar, with special attention to an exact repositioning in the area of the gingival margin. In addition, the flap is adapted with interdental sutures between

**2.1 Background**

*Oral Diseases*

**2.2 Envelope flap**

**Figure 1.**

**196**


Limitations


#### **2.3 Triangular flap design and modification (buccally based triangular flap)**

This technique was described by Szmyd [6]. The incision is conducted from the mandibular ramus to the distobuccal crown edge of the second molar, followed by a perpendicular incision obliquely into the mandibular vestibulum, with a length of about 10 mm. In contrast, the modified incision extends over the mucogingival borderline, and the periodontium of the second molar is only touched at the dentofacial edge (**Figures 2** and **3**). The flap is lingually based on the triangular flap [8].

For suturing, the same suturing technique is used distally (envelop), whereas the perpendicular incision is only adapted with a single coronally placed suture. The main aim is exact repositioning of the gingival margin in the area of the second molar. The loose adaption in the apical portion allows easy relief of a hematoma.

Advantages


**3. Flap techniques for canine exposure or removal**

adjacent teeth, infections, and cystic changes.

*Flap Techniques in Dentoalveolar Surgery DOI: http://dx.doi.org/10.5772/intechopen.91165*

treated using a closed technique.

eruption of canine.

**199**

**3.2 Labially impacted canine techniques**

Canines are among the most commonly impacted teeth after the third molar teeth. Different causes have been suggested and investigated in literature [9]. The impacted canines need to be either exposed or removed to avoid some possible complications. Untreated canines may cause tooth malalignment, root resorption of

The location of an impacted canine will determine the access for surgical exposure or removal. About one-third of the impacted maxillary canines are positioned labially or within the alveolus, while two-thirds are located palatally [10]. Kokich [11, 12] suggested that the following four criteria related to tooth position within the alveolar bone housing need to be carefully evaluated before exposing the impacted

1.The first criterion looks at the labial-palatal position of the impacted canine. When there is labial impaction, the treatment of choice is an open technique (gingivectomy or apically positioned flap). While impaction in the midalveolus requires an open or closed technique, a palatal impaction is usually

gingivectomy open technique can be conducted. If the crown is located at the MGJ level, an apically repositioned flap is used. When the crown is apical to

2.The second criterion evaluates the impaction position relative to the mucogingival junction (MGJ) in an apical-coronal dimension. When the majority of the impacted crown is positioned coronal to the MGJ, the

3.The third criterion involves the evaluation of the amount of keratinized gingiva (KG) mainly with facial impactions. When there is an abundance of KG, the impacted canine is positioned relatively close to the MGJ, and a gingivectomy procedure is recommended. However, if there is inadequate KG,

4.The fourth criterion evaluates the mesial-distal position of the canine relative to the lateral incisor. If the canine crown is positioned distal to the mesial aspect of the lateral incisor, an open technique is performed. If the crown is positioned mesial to the lateral incisor, a closed technique for the pataltal

Labial canine impaction is usually difficult to approach because aesthetic outcomes of final soft-tissue healing are a challenge. An inappropriate surgical technique or flap design may lead to compromised aesthetic results [12]. During the process of uncovering a labially impacted maxillary canine, mucogingival problems, such as an immersed clinical crown, limited keratinized gingiva, gingival recession, and scarring, may occur if an inappropriate surgical intervention is employed [13]. In addition, the vertical and horizontal locations of the impacted canine also greatly affect orthodontic tooth movements and soft-tissue responses. Therefore, it is

an apically repositioned flap or closed technique is suggested.

the MGJ, a closed technique is generally utilized.

**3.1 Background**

canine:

**Figure 2.** *Triangular flap for the removal of the third molar.*

**Figure 3.** *Modified triangular flap for removal of the third molar.*

#### Limitations

