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Journal of Oral Science & Rehabilitation No. 3, 2017

Fig. 1 Clinical view before the trapezoidal submarginal flap for periapical surgery of tooth #11. Fig. 2 Detachment of the trapezoidal submarginal flap. Fig. 3 Intraoperative view after ostectomy and resection of the apex of tooth #11. F l a p d e s i g n i n p e r i a p i c a l s u r g e r y Introduction Types of flaps Two factors are important for securing optimum functional and esthetic outcomes in periapical surgery: flap design and the suturing technique used. Flap design in periapical surgery should be adequate for the planned surgical procedure, offering good access to the zone surrounding the affected apexes without altering the circu- lation in either the mobilized or nonmobilized soft tissue.1 A number of factors must be taken into account in preparing the flap: the location and extent of the apical lesion, the periodontal con- dition of the affected tooth and of the adjacent teeth, the condition of the surrounding anatom- ical structures, and the presence and quality of prosthetic restorations in contact with the gin- gival margin.1 The flap should encompass at least one tooth on either side of the affected tooth. Acute flap angles are to be avoided. A narrow corner is difficult to trim and suture and can suffer ischemia and become detached, favoring the formation of scars. A full-thickness flap including mucosa, sub- mucosal connective tissue and periosteum should be raised. The interdental papilla should not be divided (sectioned) and should be either totally included within or separate from the flap. The incisions are to be sufficiently extensive to ensure that the retractor rests on bone and does not compress part of the flap. Classically, the most commonly used type of flap in periapical surgery has been the trapezoidal or triangular Neumann flap, with an intrasulcular incision and two vertical releasing incisions. However, owing to the improvements in surgical techniques and suture materials, oral surgery has become more conservative and delicate, and the Luebke–Ochsenbein flap with submarginal incisions is now more widely used. 1 . S u b m a r g i n a l i n c i s i o n f l a p ( L u e b k e – O c h s e n b e i n f l a p ) A horizontal incision is made in the attached gingival tissue about 3–4 mm above the gingival margin, with two vertical releasing incisions on either side of the flap located one or two teeth distal to where the lesion is located (Figs. 1–3). This type of flap is easy to detach, but can leave a postsurgical scar if the repositioning sutures are not performed adequately.2 The Luebke–Ochsenbein flap is less aggres- sive with the gingival tissue than an intrasulcu- lar incision flap, and it is easy to make the incision slightly triangular or angled in order to secure precise repositioning (Figs. 4–6). It is particu- larly useful in patients with fixed prosthesis restorations, since correct application of the technique results in less recession of the gingi- val margin3, 4 and interdental papillae.5 Fig. 1 Fig. 2 Fig. 3 Journal of Oral Science & Rehabilitation Volume 3 | Issue 3/2017 57

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