Surgical Endodontics

Soft tissue management: flap design, incision, tissue elevation, and tissue retraction
Velvart, Peters, Endodontic Topics, 2005 Vol. 11 - Soft tissue management: flap design, incision, tissue elevation, and tissue retraction

Biology of the gingiva

The gingiva is one of four components of the periodontium, which further comprises of periodontal ligament, alveolar bone, and cementum. Each of these structures is distinct in its location and tissue architecture, but they function together as a single unit. Gingival epithelium The gingival epithelium can be divided into three different types based on their location and composition (14) (Fig. 2). NEXT PAGE

Fig. 2. Schematic drawing of gingival histology; SE, sulcular epithelium; JE, junctional epithelium; OE, oral epithelium; PL, periodontal ligament; AB, alveolar bone; CT, connective tissue.

The oral epithelium extends from the mucogingival junction to the tip of the gingival crest. CONTD The sulcular epithelium is located between the gingival crest and the most coronal portion of the junctional epithelium. The junctional epithelium extends from the base of the gingival sulcus to a level approximately 2 mm coronal from the alveolar bony crest. In a healthy situation without attachment loss, the junctional epithelium reaches the cemento-enamel junction. The junctional epithelium is closely adapted to the tooth surface to fulfill sealing and attachment functions.

Oral gingival epithelium The oral epithelium is a stratified squamous keratinized epithelium, and four different cell layers can be identified (Fig. 3).
Fig. 3. Histology of the gingival epithelium/connective tissue interface. SB, stratum basale; SS stratum spinosum, SG, stratum granulosum; SC, stratum corneum. Note the marked extensions and depressions forming the rete ridges (courtesy Dr J. Gutmann).

The cells of the stratum basale lie in close contact with the basement membrane, which separates the epithelium from the subjacent connective tissue. These rather small cells multiply continuously and as they mature into keratinizing cells, they form the stratum spinosum. The cells of the spinous layer are largest in size and form the thickest layer of all epithelial cells. Contd Closer to the surface, the cells become flattened (stratum granulosum), whereas in the most superficial layer (stratum corneum) the cells are flat and closely aligned, often without nuclei. The oral epithelium also contains Langerhans cells, also known as dendritic cells; they are mostly located in the stratum spinosum. These cells play an important role during the inflammation process as they bind and process antigens to the local lymph nodes and present them to macrophages and lymphocytes (17). Generally speaking, the oral epithelium, which is between 0.2 and 0.3 mm in thickness, has a largely protective function (18). Oral sulcular epithelium The sulcular epithelium makes up the lining of a gingival sulcus. A healthy sulcus extends to a depth of 0.5 mm. The sulcular epithelium is structurally similar to the oral epithelium. The epithelial/connective tissue interface in the sulcus area forms rete pegs, which become elongated when inflammation is present. In contrast to the junctional epithelium, the sulcular epithelium is less permeable and not extensively infiltrated by polymorphonuclear leukocytes. It has mostly protective functions. Junctional epithelium The junctional epithelium is distinctly different from sulcular and oral epithelium in both its origin and structure. In its most apical portion, the junctional epithelium forms but few cell layers. The thickness of the junctional epithelium increases gradually to 1530 layers at the border to the sulcular epithelium. The cells of the stratum basale multiply rapidly and the reproduced cells tend to align themselves parallel to the long axis of the tooth and exfoliate into the gingival sulcus. The interface between the junctional epithelium and connective tissue is almost straight. Migrating polymorphonuclear leukocytes are present throughout the junctional epithelium. This migration process increases considerably during the development of an inflammatory process. In addition to polymorphonuclear leukocytes, T lymphocytes are then present (19). In contrast to other oral epithelia, where cells are in close apposition to each other and little extracellular space exists, the junctional epithelium displays gaps between cells. These gaps are presumably responsible for the permeability of the junctional epithelium. The 5

intercellular matrix not only functions as an adhesive between cells but also aids adhesion to tooth surfaces and to the basement membrane separating the epithelium and the connective tissue. Moreover, the intercellular matrix plays an important role in regulating diffusion of water, nutrients, and toxic materials through the epithelium (20, 21). The junctional epithelium is responsible for the formation of the epithelial attachment to the tooth surface. Likewise, it provides a barrier and communicates aspects of host defense against bacterial infection (22). Epithelial cells have been recognized as metabolically active and capable of reacting to external stimuli by synthesizing a number of cytokines, growth factors, and enzymes (14, 23, 24). Gingival connective tissue Fibroblasts, another major cellular component of connective tissue, are of mesenchymal origin; they rarely form cell-to-cell contacts but rather attach to the surrounding matrix of collagens and other glycoproteins. Fibroblasts synthesize the extracellular matrix of connective tissue and take part in the regulatory process; they may respond to a variety of stimulants through production of cytokines, enzymes, enzyme inhibitors, or matrix macromolecules. These enzymes allow the regulation of matrix degradation for remodeling or turnover purposes (25). Accordingly, fibroblasts are sensitive to changes in the matrix, growth factors, or cytokines. In case of an injury they are able to chemotactically migrate and attach to various substrates. Once at the site of the trauma, fibroblasts commence matrix synthesis. The major component of the matrix are collagenous proteins. The collagen fibers are organized in a distinct architectural pattern. They have been classified according to their location, origin and insertion, such as dentoalveolar, transgingival, interseptal, circular fibers, etc. Connective tissue consists of 5560% supragingival fibers, which attach gingiva to teeth and provide the basis for its firmness and biomechanical resistance during mastication (14).

Anatomy
The gingival tissue reaches from the papilla to the mucogingival junction, where it joins the alveolar mucosa (11, 14). The height of the gingiva from the mucogingival junction to the gingival margin is highest on the labial aspect of the maxillary incisors and decreases in height in distal areas (30). The papilla, an esthetically and functionally an important structure, is the tissue between two adjacent teeth. It is considered to be roughly pyramidal and triangular in shape (31). The embrasure contor and the specific anatomy of adjacent crowns determine the shape of the papilla (1416, 32). 6

Depending on the width of neighboring crowns and contact point areas, the papilla has one, or for most teeth, two peaks lingually and buccally, joined by a concave col (Fig. 4) (11, 15, 16, 33). In a mesio-distal direction, the midsection of the col slopes toward each tooth CONTD Fig. 4. Schematic diagram of a cross-section of the interdental papilla. L, lingual; B, buccal, red area junctional epithelium; AB, alveolar bone; DGF, dentogingival fibers; TSF, transseptal fibers; DPF, dentoperiosteal fibers; AGF, alveolargingival fibers (courtesy Dr J. Gutmann).

On these slopes, the epithelium gradually changes its appearance toward the characteristics of the epithelial cuff (epithelial attachment). The width of the col between the buccal and lingual papilla and the depth of concavity in the col area increase gradually from anterior to posterior teeth (16). The papilla usually fills the entire interproximal space between neighboring teeth. Another important anatomical consideration is the supply of blood vessels to alveolar mucosa and gingiva.

There are four interconnected pathways of blood supply: 1. 2. 3. 4. the subepithelial capillaries of the gingiva and alveolar mucosa, the vascular network within the periosteum, the intraseptal arteries in the bone marrow, and the plexus of the periodontium.

The periosteal and the periodontal plexus communicate directly through Volkmann's canals without participation of the vessels of the bone marrow; thus, unified histological responses to surgical wounding are observed (34) (Fig. 5). Fig. 5. Schematic drawing of gingival blood vessels.

The gingiva and periosteum are blood supplied mainly through supraperiosteal vessels, which run roughly parallel to the teeth's long axis, branch, and subdivide in the lamina propria of the gingiva and form the vascular network on the periosteum (3436).

To a lesser degree, rami perforantes of the intraseptal arteries penetrating the interdental bone and the periodontal ligament vessels supply the gingiva with blood, the vessels finally ending in loops termed the gingival plexus in the tips of connective tissue papillae (11, 14, 3740). CONTD The multiple interconnections between different plexus through numerous anastomoses and collateral pathways of circulation establish adequate blood supply, if single vessels are severed surgically (3436, 39, 40).

Flap design
When designing a tissue flap, various modes of incision can be selected, including horizontal, sulcular, submarginal, and vertical releasing incisions. The tissue flap in its entirety can be a full-thickness or a combination of a full- and a split-thickness flap. Consequently, a number of flap designs exist and are discussed in the literature, including specific rules and recommendations (3, 50 53). The variety of flap designs reflects a number of variables to be considered. It is critical that tissue incisions, elevations, and reflections are performed in a way that facilitates healing by primary intention. This goal can be obtained, firstly, by using a complete and sharp incision of the tissues, secondly, by avoiding severing and trauma of the tissue during elevation, and, finally, by preventing drying of tissue remnants on the root surface and drying of the reflected tissues during the procedure (3). Semilunar flap Triangular flap Rectangular and trapezoidal flap Submarginal flap (OchsenbeinLuebke)

Papilla-base flap
The papilla-base flap was suggested to prevent recession of the papilla. This flap consists of two releasing vertical incisions, connected by the papilla-base incision and intrasulcular incision in the cervical area of the tooth. The name is derived from the preparation of the 9

papilla base using a microsurgical blade. The size of the blade should not exceed 2.5 mm in width. Controlled and minute movement of the surgical blade within the small dimensions of the interproximal space is crucial. CONTD The papilla-base incision requires two different incisions at the base of the papilla. A first shallow incision severs the epithelium and connective tissue to the depth of 1.5 mm from the surface of the gingiva (Fig. 22, blue line). The path is a curved line, connecting one side of the papilla to the other. The incision begins and ends perpendicular to the gingival margin (Fig. 29). In the second step, the scalpel retraces the base of the previously created incision while inclined vertically, toward the crestal bone margin. The second incision results in a split-thickness flap in the apical third of the base of the papilla (Figs 22 and 23). From this point on apically, a full-thickness mucoperiosteal flap is elevated. Although the papilla-base flap achieved very predictable healing results, this technique is challenging to perform. Atraumatic handling of the soft tissues is of utmost importance in order to obtain rapid healing through primary intention. The epithelium of the partial-thickness flap has to be supported by underlying connective tissue; otherwise, it will necrose and lead to scar formation. On the other hand, excessive thickness of the connective tissue layer of the split flap portion could compromise the survival of the buccal papilla left in place. Fig. 22. Schematic drawing of incision types. The red line represents a single straight incision directed to the crestal bone margin as used for the papilla preservation technique in periodontal application. The green and blue lines delineate the two incisions needed for the papilla base incision. The first shallow incision placed at the lower end of the papilla in a slight curved line, perpendicular to the gingival margin (blue line). A second incision, directed to the crestal bone margin from the base of the previously created incision, is placed (green line). The result is a split-thickness flap on the base of the papilla .

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Fig. 23. Elevated split-thickness flap showing the papilla-base incision and major part of the papilla unaltered and apical to the crestal bone level of a full-thickness flap.

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The ideal thickness of the partial-thickness flap has not been studied. Epithelium thickness varies between 111 and 619 m with a mean of 364 m (61). The recommended thickness of free gingival grafts was reported to be 12 mm (62, 63). Based on the gingival

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graft studies, a thickness of 1.5 mm was chosen for the split-thickness flap in the papilla-base incision. The selected thickness resulted in excellent healing results (64).

Strategies and procedures

The choice of flap designs should allow the maintenance of optimal and sufficient blood supply to all parts of the mobilized and nonmobilized portions of the soft tissues. This implies specifically that vertical releasing incisions should run vertical, parallel to the long axis of the teeth and supraperiosteal blood vessels in the gingiva and mucosa. Paramedian releasing incisions are recommended to minimize the risk of recession (39). The initial portion of the vertical incision should be placed perpendicular to the marginal course of the gingiva toward the mid section of the papilla and gradually turning the incision parallel to the tooth axis (Fig. 25). Adequate micro-configuration of the gingival margins will minimize any potential recession of the tissues.

Fig. 25. Vertical releasing incisions. (A) Incorrect straight vertical incision creates compromised tissue area with insufficient blood supply, which will eventually necrose. (A) dashed line indicates the desired incision course. Reprinted with permission from (7). (B) Correct placement of the releasing incision perpendicular to the marginal contour of the gingiva shown in a schematic diagram (B), reprinted with permission from (3). (C) Clinical example of a correctly placed incision. CONTD

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In order to enhance regeneration of the bone and periodontal ligament over the resected root surface, certain cells have to be prevented from repopulating the bony defect (73). When the integrity of the periosteum has been maintained, it will serve as a barrier against the connective tissue cells, so that these cells cannot invade the bone cavity during the healing process and prevent a complete bone fill. Scaling of root attached tissue and tissue tags on the cortical bone should be avoided to allow rapid reattachment and protection against bone resorption (37, 55, 74). After reflecting the mucogingival tissues, a retractor must be placed securely on sound bone to prevent compression or crushing of the soft tissue (Fig. 26). Excessive trauma from retraction may cause increased swelling and delayed healing. As a practical measure to avoid tissue slipping under the retractor, a fine groove is made with a small round bur in which the retractor can be positioned (3).

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