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Journal of Oral Science & Rehabilitation No. 1, 2018

F l a p d e t a c h m e n t a n d r e t r a c t i o n i n p e r i a p i c a l s u r g e r y Introduction In periapical surgery, and after planned inci- sion, the flap is raised and separated from the bone. In this regard, a full-thickness or muco- periosteal flap (comprising mucosa, connec- tive tissue and periosteum) is detached with the aim of securing sufficient access to the bone and adequate elimination of the diseased periapical tissue. It is important to detach the periosteum from the bone together with the flap in order to minimize bleeding during sur- gery, reduce inflammation and pain in the postoperative period, and facilitate healing.1, 2 Once the flap has been raised, it is retracted in order to keep the bone surface visible and accessible, and to avoid damage to either the flap or the surrounding tissue during the oper- ation.1 The present study aims to review all of the aspects to be taken into account during the detachment and retraction of the flap in periapical surgery. Flap detachment The surgical incisions delimit a flap comprising attached gingival tissue, free alveolar mucosa and a fibromucous or periosteal layer that must preserve its vitality and recover its physiologi- cal functions after being repositioned. Flap detachment should be performed firmly and gently, taking care to minimize trauma.2 This requires a well-defined full-thickness incision with adequate placement of the periosteotome on the bone. During the process, it is useful to revise the incision with a fine dissector (Fig. 1) in order to eliminate any connective tissue or periosteal fibers that have not been dissected by the scalpel. Detachment has a series of par- ticularities, depending on the type of flap involved. S u b m a r g i n a l i n c i s i o n f l a p After a well-defined full-thickness incision, detachment is carried out with a periosteo- tome held like a pencil and placed at the junc- tion between the horizontal and vertical inci- sions, with the concave surface, of the instrument facing the bone (Figs. 2A & E). The periosteotome is kept in continuous contact with the bone surface in order to avoid flap tearing or fenestration caused by possible irregularities, such as bone crest exostosis. The instrument is then gradually displaced hori- zontally, along the incision line, in the apical direction. The flap is raised sufficiently to expose the bone overlying the periapical lesion (Figs. 2F & H). Fig. 1 N e u m a n n i n t r a s u l c u l a r i n c i s i o n f l a p After completing the incision through the gin- gival sulcus, the papillae are carefully sepa- rated one by one with the help of a fine dissec- tor. The papillae should detach easily if the sulcular incision has correctly sectioned the gingival fibers and their lingual prolongation (Figs. 3A–D). The periosteotome is then posi- tioned at the angle formed by the vertical and horizontal incisions (Fig. 3B). It must be taken into account that in the pres- ence of periodontal disease the bone crest is blunted or flattened, and greater resistance to detachment in the apical direction may be expe- rienced. In some cases, this is wrongly taken to indicate the presence of a fibrous insertion or resistant insertion of the periosteum, an atypical cementoenamel junction, or an erosive margin (noncarious neck lesion). A series of particular- ities can be found, depending on the presence of anatomical anomalies or alterations associ- ated with the prior surrounding disease during detachment. Identification of fibrous or epithelial tracts In the presence of a long-standing fibrous or epithelial tract, the pathological tissue of the lesion may have become integrated into the mucosa and submucosa, and in this case the flap is first raised from the surrounding tissue. With the flap kept tense, the scalpel blade is then positioned parallel to the bone surface, and the flap is detached without perforating the mucosa. The tearing of frenula or muscle insertions poses no esthetic or functional prob- lem, and these elements should be raised as part of the flap. Once the fistular or fibrous tract has been dissected, raising of the flap is continued (Figs. 4A–E). Bone exostosis The soft tissue overlying zones characterized by large bone volumes is very thin and can easily be perforated during detachment. In such cases, it is important to work with a sharp periosteo- tome, keeping it in continuous contact with the bone surface.1 Fig. 1 Preoperative digital panoramic radiograph with preoperative computed tomography scans. Journal of Oral Science & Rehabilitation Volume 4 | Issue 1/2018 25

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