Mucoperiosteal Flaps

Presented by

DELIGHT Isabela

OGWAL K. Emmannuel

KAMUGISHA Moses

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 Mucoperiosteal flaps are surgical technique commonly
Introduction used in oral and maxillofacial surgery, periodontics,
and implantology.

They involve elevating a flap of soft tissue underlying

structures to gain access to the surgical site.

The flap can then be repositioned to provide adequate

soft tissue coverage and promote healing.

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 A flap is a unit of tissue transferred from one site (donor
Flaps site) to another (recipient site) while maintaining its own
blood supply.

Flaps are of different shapes and forms . They range from

simple advancements of skin to composites of many
different types of tissue. These composites need not
consist only of soft tissue but may contain skin, muscle,
bone, fat or fascia.

The commonly used in oral surgery is the muco-periosteal

flap
Oral surgical flap by definition is the portion of the mucoperiosteal tissue that
is surgically detached from the underlying bone for better access and visibility.

• The term flap indicates a section of soft tissue that;

• Is outlined by a surgical incision
• Carries its own blood supply
• Allows surgical access to underlying tissues
• Can be replaced in original position
• Can be maintained with sutures and is expected to heal

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Mucoperiosteal Differentiate Flaps from Grafts
● While a flap is transferred with its blood supply
flaps intact, a graft is a transfer of tissue without its own
blood supply. Therefore, survival of the graft depends
entirely on the blood supply from the recipient site
while the flap does not.

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Principles of flap Regardless of the flap design used, certain principles
should be followed while incising and reflecting the
design gingiva.

1. Incision should be made with a firm, continuous

stroke.

2. Incision should not cross underlying bony defects

that existed prior to surgery, or would be produced
by the surgery.
3. Vertical incisions are made in the concavities
between bony eminences.
4. Termination of vertical incision at the gingival crest
must be at the line angle of the tooth.

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Principles of flap 5. Vertical incision should not extend beyond
the depth of the muco-buccal fold and the
design base of the flap must be as wide as the width of the free
edge (supra-periosteal vessels running vertically should
not be transected)
6. Periosteum must be reflected as an integral part of the
fl ap

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Requirements of a Flap
➔ Accessibility: The flap design should provide adequate access to the surgical
site to allow for proper visualization, instrumentation, and manipulation
during the procedure. The flap should be designed to expose the necessary
structures without causing excessive trauma to the surrounding tissues.
➔ Preservation of blood supply: Blood supply is crucial for the survival of the
flap and the success of the surgical procedure. The flap should be designed
to preserve the blood supply to the flap and the surrounding tissues.
➔ Soft tissue preservation: The soft tissues, including the mucosa and gingiva,
should be preserved as much as possible during flap design. The flap should
be designed to minimize tissue damage, reduce scarring, and maintain the
integrity of the surrounding soft tissues.

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Requirements of a Flap
➔ Adequate visibility: The flap design should provide adequate visibility of the surgical
site to allow for proper identification and treatment of the affected structures. The flap
should be designed to expose the necessary structures while maintaining the integrity
of the surrounding tissues.

➔ Minimal tension : The flap design should minimize tension on the surrounding tissues
to avoid tissue necrosis and impaired wound healing. The flap should be mobilized in
a way that reduces tension on the flap and the surrounding tissues.

➔ Closure: The flap should be designed to allow for adequate closure of the wound
without causing excessive tension on the surrounding tissues. The closure should be
designed to minimize dead space, reduce the risk of infection, and promote wound
healing.

➔ Postoperative care: Postoperative care is an essential component of successful oral

surgery. The flap design should consider the postoperative care required for the
patient, including proper wound care, pain management, and follow-up appointments
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 There are full mucoperiosteal flaps and limited

Classification of mucoperiosteal flaps.

1. Full mucoperiosteal flaps:

Intraoral flaps a. Triangular (one vertical releasing

incision).
b. Rectangular (two vertical releasing
incision).
c. Trapezoidal (broad based rectangular).
d. Horizontal - Envelop (no vertical
releasing incision)
2.Limited mucoperiosteal flaps:
a. Submarginal curved (Semilunar)
b. Submarginal scalloped (Ochsenbein-
Luebke)

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Sulcular full thickness flaps(full mucoperisoteal
flap)
Triangular flap
● This fl ap is the result of an L- shaped incision with a horizontal
incision made along the gingival sulcus and a vertical or oblique
incision.

● The vertical incision begins approximately at the vestibular fold and

extends to the interdental papilla of the gingiva. The triangular flap is
performed labially or buccally on both jaws and is indicated in the
surgical removal of root tips, small cysts, and apicoectomies.

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Advantages
● Ensures an adequate blood supply, satisfactory
visualization, very good stability and reapproximation
● It is easily modified with a small releasing incision, or an
additional vertical incision, or even lengthening of the
horizontal incision.
Disadvantages
● Limited access to long roots, tension is created when
the flap is held with a retractor, and it causes a defect in
the attached gingiva.

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Rectangular flap
● Formed by an intrasulcular, horizontal incision and two
vertical releasing incisions.
● Main advantage is increase in surgical access to root
apex.
● Usually used for mandibular anteriors, multiple teeth
and teeth with long roots.
Disadvantages include;
o Difficult reapproximation of flap margins and
wound closure.
o Difficult post surgical stabilization
o Greater chance for postsurgical flap
dislodgement.
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Trapezoidal flap
● The trapezoidal flap is formed by a horizontal incision
along the gingivae, two oblique vertical releasing
incisions extending to the buccal vestibule.
● The vertical releasing incisions always extend to the
interdental papilla and never to the centre of the labial or
buccal surface of the tooth. This is because if the
incision were to begin at the centre of the tooth,
contraction after healing would leave the cervical area of
the tooth
exposed.
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Advantages
● Provide excellent access
● Allows surgery to be performed on more than one or two
teeth
● Produces no tension in tissues, allows easy reapproximation
of the flap to its original position and hastens the healing
process

Disadvantages
● Produces a defect in the attached gingiva (recession of the
gingiva)
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Envelope flap(Horizontal flap)
● This type of flap is the result of an extended horizontal incision along
the
cervical lines of the teeth.

● The incision is made in the gingival sulcus and extends along four or fi ve
teeth. The tissue connected to the cervical lines of these teeth and the
interdental papillae is thus freed.
● The envelope flap is used for surgery of incisors, premolars and molars,
on the labial or buccal and palatal or lingual surface and is usually
indicated when the surgical procedure involves the cervical lines of
teeth.

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Advantages

● Avoidance of vertical incision

● Reapproximation to original position

Disadvantages

● Difficult reflection (mainly palatally)

● Great tension with a risk of the ends tearing
● Limited visualization in apicoectomies
● Limited access
● Possibility of injury of palatal vessels and
nerves

● Defect of attached gingiva 22

Flaps resulting from Y-shaped Incision

● An incision is made along the midline of the palate, as well as two

anterolateral incisions, which are anterior to the canines.

● Indicated in surgical procedures involving the removal of small

exostoses

Flaps resulting from X-shaped Incision

● This is an extension of the Y- shaped incision. More posterolateral

incisions are made, which are necessary for adequate access to the
surgical field.

● This type of flap is designed such that major branches of the greater
palatine artery are not severed. Is indicated in larger exotoses.
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Semilunar flap

Its a horizontal incision with a dip towards the incisal aspect in the
centre of the flap, resembling a half-moon.
The lowest point of the incision must be atleast 0.5cm from the gingival
margin, so that the blood supply is not compromised.
Each end of the incision must extend atleast one tooth over on each side
of the area of bone removal.
It is indicated for apicoectomies and removal of small cysts and root tips

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Advantage
● utilized for incision and drainage procedure
● Small incision with east reflection
● No recession of gingiva
● Easier oral hygiene.
Disadvantage

• It is not generally recommended for periradicular sugery because

inadequate of inadequate visual and operative access reference
points

• Difficulty of reapproximation and suturing due to absence of specific

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.

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Submarginal scalloped rectangular (leubke- ochsenbein)

● The flap design calls for a scalloped incision in the middle of the attached
gingiva.

● Therefore attached gingiva around the crown margin will remain intact.
● The purpose of the scalloped horizontal incision is to provide a guide for the
correct repositioning of the elevated flap for suturing.

● The vertical incision is parallel.

● Mesial or mesiodistal vertical releasing incisions permit adequate access to
the surgical site without violating the integrity of the attached gingiva
around the tooth or crown.

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● The junction where the horizontal scalloped incision in the attached
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gingiva meets the vertical incision is rounded to promote smoother

and faster healing.
Advantages.
● The marginal or interdental gingiva are not
involved
● It does not expose the crestal bone.
Disadvantages
● excessive bleeding,
● possibility of flap shrinkage,
● Delayed healing and scar formation 29
Intraoral Locoregional flaps

Tongue flap
● Tongue is a highly vascular organ.
● The anterior based, posterior based or lateral flaps can be
raised based on the proximity of flap to the defect.
● They are commonly used in anterior palatal fistula and
oral submucous fibrosis.

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Palatal Flap
● Palatal flaps are axial flaps based on the greater palatine artery
useful in closure of small palatal defects, oroantral fistulae.
● After rotation, the flap is placed over the orifice of the socket, the
wound margins are debrided, and the flap is sutured with the
buccal tissues.
● They may be used as pedicled finger flaps or island flap.

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Buccal Flap
•This is a typical trapezoidal flap created
buccally, corresponding to the area which is to
be covered

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 References

1. Andersson, L., 2014. Essentials of Oral and Maxillofacial Surgery.

2. D., F., 2007. Oral Surgery. Springer Berlin Heidelberg.

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