002: My Take On Soft Tissue Flap Design
Dr. Kirk opens this episode by sharing that he frequently receives questions about soft tissue flap design, especially regarding impacted third molar removal. He will focus today's show on covering his approach to flap design fundamentals and specifics for accessing lower and upper third molars.
Russell first explains his background in learning flap design during dental school under Dr. Charlie Shannon. A key concept Russell learned was that incisions heal side-to-side rather than end-to-end. This taught him the importance of making incisions adequately long to create flaps with enough access and minimal tension. Russell says finding the ideal incision length takes experience but making flaps too short leads to complications.
Flap Design Fundamentals
Russell breaks flap design into four main types:
Envelope Flap
This is Russell's workhorse flap for most procedures. When created properly, the envelope flap provides good visibility and access without excessive soft tissue trauma. It involves reflecting a full-thickness flap off the associated bone.
3-Corner Flap
Adding a vertical releasing incision to one end of an envelope flap creates a 3-corner flap for additional access. This converts the envelope into a triangular flap.
4-Corner Flap
Two vertical releasing incisions from an envelope flap makes a rectangular 4-corner flap for maximum access.
6-Corner Flap (Dr. Sclar technique)
For large bone graft coverage, Russell learned a technique from Dr. Anthony Sclar involving a 4-corner flap with additional angled releases at the base through mucosa only. This provides passive advancement over large bone grafts.
Russell emphasizes some key principles when creating releasing incisions:
- Make the flap base wider than the apex for ample blood supply.
- Consider scoring the periosteum at the flap base for passive flap movement.
By thoughtfully incorporating vertical releases or periosteal scoring, the workhorse envelope flap can be adapted to provide the access needed for most procedures.
Lower Third Molar Flap Design
When removing lower third molars, Russell uses the following flap design:
- Make a crestal incision off the distal of the second molar, wrapping around the neck of the second molar onto the buccal.
- Release the papilla between the first and second molars.
This envelope flap allows access to lower third molars without further releases.
However, in some cases the keratinized tissue near the retromolar pad impedes visibility and access. Russell's trick is to make a periosteal incision at a 45-degree angle in this area without going full thickness. This provides substantial gain in access with minimal trauma.
Russell avoids full-thickness vertical releases on the lower as this single periosteal incision provides ample access in most cases. The flap typically lays back passively without suturing.
Upper Third Molar Flap Design
For upper thirds, Russell uses the following flap design:
- Make a crestal incision from the tuberosity area to the distal of the second molar. Continue with a sulcular incision around the second molar while releasing the papilla between the first and second molar.
- Reflect a full-thickness flap using a periosteal elevator.
Occasionally, the incision may need to extend more distally near the hamular notch if the third molar is trapped in soft tissue. This allows full access to deliver the tooth without catching in the soft tissue pocket and potentially tearing the flap.
Beyond this envelope flap, Russell finds no further releases are necessary on the upper as access is readily obtained.
Conclusion
In summary, Russell uses simple and reliable flap designs like the envelope flap that can be augmented with selective releasing incisions or periosteal scoring as needed. While many complex flaps exist, Russell has found these basic options work extremely well for him in most cases.
However, Russell is very interested to hear from other dentists on their preferred flap techniques and welcomes suggestions or insights his colleagues have learned over the years. This exchange of ideas can help the community continually improve their surgical skills.
Listeners can email Russell with questions or flap design tips at [email protected]. He will be sure to review submissions and respond within 48 hours. Russell thanks listeners for joining him on another episode, and looks forward to continuing the conversation.
