ABSTRACT
Healing following apical surgeries depend t a large extent on the soft tissue
flap design. Different flap designs have been advocated and used,
depending on the location and size of the peri-radicular lesion.
A new flap design, which used sub-marginal straight incision was compared
with intra-sulcular rectangular/triangular flap and scalloped, sub-marginal
flap. Post - Operative healing was compared for swelling, alternation of
colour, recession of marginal gingival and extent of scarring.
It was found that sub-marginal straight horizontal incision showed better
healing with lesser scarring. It is concluded that the new flap design can
provide an alternative.
Key words: Soft tissue healing, periapical surgery, flap design, muco-gingival flap
• Termination of vertical incision at the • Possible delayed healing, scarring and flap
gingival crest must be at the line angle of shrinkage may be seen6.
the tooth. • Difficult to visualize and treat periodontal
• Vertical incision should not extend beyond defects and root fracture.
the depth of the muco-buccal fold.
The purpose of this study was to evaluate
• Base of the flap must be as wide as the the clinical features of healing of two
width of the free edge (supraperiosteal conventional surgical flaps i.e. triangular or
vessels running vertically should not be rectangular with intrasculcular incision and
transected). submarginal scalloped flap when compared with
• Periosteum must be reflected as an integral a new experimental flap design.
part of the flap.
A new experimental flap, anticipated to be
Some disadvantages exist with benefits of more beneficial in terms of helaing, was
the traditionally and widely used rectangular designed. This is a mucogingival flap, but the
flap in which the incision is given in the horizontal incision is straight, unlike scalloped
intrasulcular area3. Though it allows enhanced in Ochsenbein-Luebke flap.
surgical access and excellent visibility yet it
The possible advantages are :
has certain disadvantages such as :
• Single, clean incision.
• More difficult to incise and reflect
• Flap provides sufficient access and visibility
• Possibility of gingival recessoion to the pathosis.
• Flap re-approximation, wound closure, • Less soft tissue trauma
suturing and post-surgical stabilization is
• Easy reapproximation with better chances
difficult.
of healing by primary intention
• Severely angled flap deprives unreflected
• Minimal tension of the sutures
tissues of some of its blood supply.
• Recession free healing
Submarginal scalloped flap is formed by
scalloped horizontal incision in attached Material and Methods
gingival with vertical releasing incisions.
A total of 15 patients coming to the
Scaplloping corresponds to the contour of the
Department of Endodontics with periradicular
marginal gingiva. There must be an adequate
pathosis where endodontic surgery was
band of attached gingiva present (3-5 mm).
indicated were selected for the study.
This requires a very careful analysis of
Mandibular molars were not chosen for the
attachment level along the entire length of the
study as this area does not allow for the incision
horizontal incision. It is advantageous, that it
to be placed within the attached gingival.
does not involve marginal or interdental gingiva
and therefore does not expose crestal bone, The subjects were randomly distributed into
as a result of which the gingival recession is 3 groups of 5 cases each as follows:
minimized4. But its disadvantages are5:
Types of incision
• Unable to extend flap, if needed.
Group I Triangular/rectangular (intrasulcular)
• Disruption of blood supply to marginal
gingival tissues, must rely on collateral Group II Submarginal scalloped
circulation (which may not exist-resulting Group III Experimental flap
in sloughing of marginal gingiva).
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Wadhwani KK and Garg A Healing of soft tissue...
Patients’ informed consent was taken. incisions were given at the end of the horizontal
Adequate anaesthesia of the area to be incision. Then the periosteal elevator was used
operated was obtained. For incision, sharp No. to gently raise the flap (Fig. 1c)
15C blade was used. All the patients included
During the procedure, constant irrigation
in this study were free of any systemic disease
with physiologic saline was done to prevent
so that there could be no variable in healing
dehydration of flap. Apical curettage /
pattern with different systemic disease.
apicectomy was performed. Before
In Group I, the intrasulcular horizontal reapproximation of the flap, a wet gauge was
incision with two vertical relaxing incision was placed for few minutes to minimize hematoma
given. The horizontal incision began in the and to enhance reattachment of flap to the
gingival suclus and was extended through the underlying bone.
fibres of gingival attachment to the crestal bone.
Suturing of the flap was done using 4-0
Care was taken to ensure that the interdental
silk suture. Interrupted, interdental sutures
papilla was incised through mid col area,
were given for horizontal incision of full
incising the fibres of epithelial attachment to
thickness flap and single interrupted suture was
crestal bone. The vertical incisions were placed
given in vertical incision and horizontal incision
at the line angles of the teeth adjacent to the
of submarginal flap. These sutures were
involved teeth, pressing firmly enough to ensure
removed after 5 days.
that the scalpel was cutting down to the cortical
bone. Then the periosteal elevator was used to Results and Discussion
gently elevate the periosteum and its superficial
tissues from the cortical plate (Fig. 1a) The healing was evaluated clinically after
5 days and 15 days post-operatively. Criteria
In Group II, the submarginal scalloped flap for postoperative healing used were;
design was used. The scalloped incision was
given in the attached gingiva following the • Presence or absence of swelling
contour of marginal gingiva, above the free • Alteration of colour
gingiva groove. Incision was given through the • Recession of marginal gingival
gingiva and periosteum to cortical bone using
• Extent of scarring
firm pressure and a single smooth stroke.
Vertical incisions were placed at each of the Group I
terminal ends of the horizontal incisions. Then
The inflammatory changes of redness and
the flap was reflected carefully (Fig 1b).
swelling were more severe during the early
In group III, cases were chosen in which, wound repair with intrasulcular incision.
teeth required either cervical restoration or Recesion of the marginal gingiva was observed
crown. Here the straight firm continuous in two cases of intrasulcular incision. Their
incision was given in the attached gingiva, apical return to normal appearance was delayed when
to free gingival groove. The vertical relaxing compared with submarginal incision wounds,
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Endodontology, Vol. 16, 2004