CLINICAL GUIDELINE

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Incision Techniques and Flap

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Designs for Apical Surgery ss e n c e
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in the Anterior Maxilla

Thomas von Arx, PD Dr med dent
Department of Oral Surgery and Stomatology
School of Dental Medicine
University of Bern
Bern, Switzerland

Giovanni E. Salvi, PD Dr med dent

Department of Periodontology
School of Dental Medicine
University of Bern
Bern, Switzerland

Correspondence to: Dr T. von Arx

Department of Oral Surgery and Stomatology, School of Dental Medicine,
University of Berne, Freiburgstrasse 7, CH-3010 Bern, Switzerland;
phone: +41 31 632 25 66; fax +41-31 632 98 84; e-mail: [email protected].

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Abstract ub

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Apical surgery is often a last resort, and is margin, and the patient’s esthetic de-
ss e n c e
fo r
used to surgically preserve a tooth with a re- mands. The outcome with respect to soft
current lesion of endodontic origin when tissue healing following apical surgery will
conventional re-treatment is neither indicat- further depend on anatomical and surgical
ed nor clinically or financially feasible. Inci- aspects, such as the biotype of the gingiva,
sion type and flap design are important fac- maintenance of vascular supply, marginal
tors to consider when outlining the surgical bone structure, technique of flap elevation
area: the first must ensure optimal access to and retraction, duration of surgery, and
the root end and the second must allow vis- wound closure. It is important to address
ibility. A variety of factors must be consid- soft tissue healing with the patient during
ered when choosing a specific incision planning of apical surgery because, in
technique, particularly in the anterior maxil- solving the endodontic problem, a gingival
la. These include status of the marginal pe- recession may have been created.
riodontium, location and extent of the peri-
apical lesion, presence of a restoration (Eur J Esthet Dent 2008;3:110–126.)

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The main objective of apical surgery is to Considering these aspects, incision ub and

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prevent re-infection of the periradicular tis- flap design are challenging steps in apical tio
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sues through surgical access to the root surgery, particularly in the esthetic (maxil-
ss e n c e
fo r
end, resection of the apical portion of the lary) zone. A number of criteria must be re-
affected root, and hermetic obturation of spected when choosing the type and out-
the cut root end. This retrograde root canal line of the flap2:
filling should form a barrier to inhibit egress I Periodontal condition of affected and ad-
of irritants from the confines of the affected jacent teeth: in conjunction with surgical
root, thereby enabling healing of the tis- periodontal therapy, previously used re-
1
sues surrounding the root . The decision to sective incision techniques have been
perform apical surgery is mainly based on replaced by papilla preservation tech-
the issues listed in Table 1. niques, in particular in the anterior max-
In the anterior maxilla, esthetics must be illa3.
carefully evaluated. The patient should be I Location and extent of the apical lesion
informed about possible alteration of soft must be considered in order to allow
(and hard) tissues following any kind of proper access, inspection and manage-
surgical procedure. Typical changes seen ment of the lesion. Also, the incision lines
after apical surgery include: should be placed on sound bone to en-
I Recession of facial gingiva: might lead able primary healing.
to longer teeth (clinical crown), dishar- I Adjacent anatomical structures: In the
mony of the scalloped gingival contour, anterior maxilla, the location of the upper
or exposure of a discolored root surface labial frenulum must be taken into con-
or restoration margin. sideration when performing incisions in
I Recession of papillae: shorter papillae the central area.
may lead to disharmony of the soft tis- I Restoration margins: the quality and lo-
sues, but may also create esthetically cation of the restoration margin, and the
disturbing “black” interdental triangles, type and surface of the restorative ma-
which may be accompanied by prob- terial, if inadequate, may result in site-
lems such as phonetics or food im- specific periodontal attachment loss4,5.
paction. I Biotype of the gingiva: patients with thin
I Scarring: soft tissue scarring is a fre- biotype gingiva tend to demonstrate soft
quent finding following surgical interven- tissue recession following soft tissue sur-
tions in soft tissues. Inappropriate tissue gery, whereas thick biotype cases react
handling (severing of mucoperiosteum with pocket formation6–8.
during flap elevation, inadequate wound
closure), flap shrinkage (dehydration),
healing complications (wound infection,
wound dehiscence), and patient-inher-
ent factors (keloid-type healing) may
lead to esthetically disturbing scar tissue
formation.

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Table 1 Issues to consider when evaluating cases referred for apical surgery. ub

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Function The affected tooth is of functional importance (prosthetic pillar and/or opposing tio
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dentition).
ss e n c e
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Restoration The existing restoration is of acceptable quality, or in case of severe destruction, the
planned restorative treatment is feasible and technically and financially reasonable.

Periodontium Any of the following findings might negatively affect the outcome of apical surgery:
deep pocket probing depth, angular (vertical) bony defect, advanced gingival
recession, furcation involvement.

Endodontium Conventional retreatment must be evaluated before apical surgery. Main indications for
surgery from an endodontic perspective include technical problems, such as blocked
canals (screw, post, separated instruments), anatomical issues (isthmuses, accessory
or lateral canals), or pathological features (non-healing cystic lesions or irregular
tumor-like bone lesions).

Access Difficulties in accessing the root-end area might preclude from performing apical
surgery. Access might be problematic in mandibular molars, or in palatal roots of
maxillary molars.

Patient factors Although mentioned as the last point, patient factors such as general health,
compliance, financial aspects, and esthetic demands will often determine the
therapeutic approach.

Anatomy
A thorough knowledge of the oral anatomy
is essential for flap procedures. At the facial
aspect (the standard approach for apical
surgery in the anterior maxilla), the kera-
tinized gingiva and the non-keratinized
mucosa meet at the muco-gingival line (lin-
ea girlandiformis) (Fig 1). Usually, the kera-
tinized gingiva is broader in the anterior
than the posterior areas of the jaws. The
keratinized gingiva can be divided into the Fig 1 Healthy anterior soft tissues: the free gingiva (1)
free gingiva (covering the sulcus) and the can be seen as a small glossy band at the cervical area
attached gingiva (covering the bone), with of the teeth; the attached gingiva (2) is characterized by
a more matt appearance; also note the course of the
the gingival groove separating the two. The
blood vessels within the alveolar mucosa (3).
interdental gingiva forms the papilla. The
papilla has a facial and lingual/palatal por-
tion, with the non-keratinized col area locat-
ed in between.

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Microsurgery ub

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Apical surgery, or as it is nowtcalled,
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ess capical
en e
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microsurgery or endodontic microsurgery,
combines the magnification and illumina-
tion provided by a surgical operating mi-
croscope with the use of microinstru-
ments11. The microscope does not improve
access to the surgical field, but it creates a
much better view of the surgical field. With
respect to soft tissue handling (eg, placing
correct incision lines in gingival and peri-
odontal structures, and subsequent wound
closure), apical surgery is comparable to
(plastic) periodontal microsurgery, for
which the use of a surgical microscope has
been strongly recommended to optimize
mucogingival outcome12.

Fig 2 Schematic illustration of the vascular supply of

Flap outline
the marginal periodontium: (1) supraperiosteal vessels,
(2) alveolar bone vessels, (3) periodontal vessels. A full mucoperiosteal flap is usually raised
to gain surgical access in apical surgery.
The procedure includes a horizontal inci-

Vascular supply sion and one or two vertical (or slightly di-
vergent) release incisions. The horizontal
Recent studies have shown that vascular incision is normally extended one tooth
territories also exist in the oral cavity9. In the mesially and distally of the tooth to be treat-
anterior maxilla, the facial soft tissues re- ed, thereby creating a broad flap basis and
ceive their vascular supply bilaterally from ensuring adequate blood supply. Flap out-
(1) the superior labial artery (a branch of the lines include triangular, rectangular, and
facial artery) and (2) the infraorbital artery (a trapezoidal shapes. The number and direc-
branch of the maxillary artery). Within the at- tion of the release incisions determine the
tached gingiva, blood vessels are primarily flap shape. In cases of small lesions, a tri-
vertically oriented, and the use of acutely angular flap may be adequate, whereas in
angulated incisions has been discour- larger lesions an additional release incision
10
aged . The blood supply of the gingiva is creating a rectangular or trapezoidal flap
provided by supraperiosteal vessels, alve- provides better access and prevents ten-
olar bone vessels, and periodontal vessels sion of the flap margins.
(Fig 2). It is essential to realize that any inci-
sion of the marginal soft tissues may inter-
fere with the blood supply to these tissues.

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Incision ub

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A sharp blade is used to cut the soft tissues
ss e n c e
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in one stroke. Particularly in the alveolar
mucosa, it is important to cut down to the
bone to avoid severing the soft tissues
when elevating the flap. A round scalpel
handle is helpful for guiding the blade. With
a small blade it is possible to follow the
contour of the tooth or to create a scalloped
incision. However, thin and delicate blades
tend to become blunt when hitting the un- Fig 3a Don’t begin the flap elevation from the mar-
derlying bone. There are no studies evalu- ginal tissues (avoid applying reflective forces to the del-
icate marginal periodontium).
ating the effect of different blades on heal-
ing following periodontal or apical surgery.

Flap elevation
Dissection and elevation of a flap is a com-
paratively traumatic step. Caution must be
exercised not to sever the flap, in particular
the periosteum. Severing the flap increas-
es the risk of intra- and postoperative
bleeding, and may provoke post-surgical
swelling and pain. The elevation procedure
should always begin from the release inci- Fig 3b Insert the elevator from the release incision,
creating a tunnel between the bony surface and the
sion, as the surgeon first mobilizes the alve-
mucoperiosteum.
olar mucosa and then directs the elevating
instrument toward the attached gingiva
and the cervical area (Fig 3). Avoiding the
application of excessive force to the mar-
ginal bone will help to diminish damage to
the delicate marginal periodontium. During
surgery, squeezing of the mucoperiosteum
by retractors must be avoided under all cir-
cumstances. Several options are available:
(1) placing a retraction suture in the flap
and using a hemostat to secure the suture,
(2) placing a piece of gauze between the
retractor and the tissue, or (3) cutting a
Fig 3c Then shift the instrument towards the margin-
small groove apical to the bony crypt to al tissues, gently elevating the flap from the crestal
serve as a resting place for the retractor13. bone and root surface.

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Surgery and wound closure ub

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Root- and bone-attached tissue
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been shown to improve healing of the dis-
sectional wound, and preservation of these
tissues is essential. Unless periodontal tis-
sues are inflamed, curettage of root and
bone surfaces is not indicated or recom-
mended14. In addition, dehydration of ex-
posed root and bone surfaces must be
avoided. When using agents for hemor-
Fig 4a Submarginal incision (SMI), sol- rhage control, contact with flap margins and
id red line = triangular flap, dotted red line the cervical area must be prevented. Al-
= option for rectangular/trapezoidal flap,
though flap shrinkage may be observed
dotted black line see Figs 4e and 4f.
during apical surgery, periosteal release in-
cisions are not routinely recommended for
coronal flap advancement due to the risk of
post-surgical hematoma, swelling, and
pain. Following flap repositioning, primary
wound closure is accomplished with multi-
ple interrupted sutures. The use of a surgi-
cal microscope is strongly recommended
for correct and tension-free flap adaptation,
in particular when fine (6-0 or finer) suture
materials are used. Non-resorbable, polymer
monofilaments (polypropylene/polyamide)
3
Fig 4b Papilla base incision (PBI), solid
are preferable. Needles should be of a ⁄8
red line = triangular flap, dotted red line = 13,15
option for rectangular/trapezoidal flap, dot-
circle and have a triangular cross-section .
ted black lines see Figs 4g and 4h.

Flap designs recommend-

ed in the anterior maxilla
Flaps including papilla, such as the facial
intrasulcular incision or palatal papilla-
preservation incision, should be avoided
in the anterior maxilla, unless simultane-
ous periodontal surgery is indicated
(marginal periodontitis, apico-marginal
lesion). Other reasons to use the intrasul-
cular incision include the presence of a
Fig 4c Papilla-saving incision (PSI), sol-
id red line = trapezoidal flap, dotted black
fistula or root perforation close to the gin-
line see Fig 4h. gival margin.

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d e f g h

Fig 4 (d to h) Schematic illustration of soft tissue components: (1) free gingiva, (2) attached gingiva, (3) alve-
olar mucosa. (e) Cross-section of the submarginal incision at the facial tooth aspect: A perpendicular incision
is made within the attached gingiva at a minimal distance of 2 mm apical to the free gingiva. The blood supply
of the marginal tissue is maintained by alveolar bone and periodontal vessels. Solid red line = incision, dotted
red line = blunt flap elevation. (f) Cross-section of the submarginal incision at the facial tooth aspect: Placing the
incision too close to or within the free gingiva will completely cut off the blood supply of the marginal tissue, even-
tually leading to recession or necrosis. Solid red line = incision, dotted red line = blunt flap elevation. (g) Cross-
section of the papilla base incision (PBI) at the mid-papilla aspect: The PBI consists of two incisions: a perpen-
dicular incision of the epithelium, and a beveled incision of the subepithelial connective tissue, enabling a partial
flap configuration in this area. Solid red line = incision, dotted red line = blunt flap elevation. (h) Cross-section
of the papilla base incision and the papilla-saving incision at the facial aspect: The incision is placed along the
tooth axis into the sulcus. Tissue tags often remaining on the cervical root surface should not be removed unless
inflamed. Solid red line = incision, dotted red line = blunt flap elevation.

Under healthy periodontal conditions, the from the base of the sulcus (Fig 4e). Plac-
following incision techniques are recom- ing the incision too close or into the free
mended for apical surgery in the anterior gingiva (Fig 4f) may eventually lead to
maxilla: the submarginal incision (SMI), necrosis of the thin facial tissue cuff by cut-
the papilla base incision (PBI), and the ting off the blood supply. In the anterior
papilla-saving incision (PSI) (Fig 4). maxilla, usually one release incision is suf-
ficient for the surgical approach. Flap ele-
vation is initiated from the release incision
SMI (Fig 5) and never from the submarginal incision.
Scarring of the horizontal incision frequent-
The horizontal incision is a scalloped inci- ly occurs and must be discussed with the
sion within the attached gingiva and fol- patient, in particular in patients with high lip
lowing the gingival contour. Caution must lines. In patients with a narrow band of at-
be exercised to place the incision onto the tached gingiva (width < 4 mm), this incision
bony surface and at least 2 mm apically technique is contraindicated.

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Fig 5a A 23-year-old female patient was referred by Fig 5b Preoperative

her endodontist for apical surgery of the maxillary left radiograph.
central incisor. The patient had persistent pain follow-
ing root canal treatment. She had sustained a dental
trauma 10 years earlier, with subsequent pulp canal
obliteration.

Fig 5c A submarginal incision with a distal release in- Fig 5d Postoperative

cision was carried out for surgical access. In this case, radiograph.
an adhesive composite was used for root-end sealing
following apicoectomy.

Fig 5e Wound closure was accomplished with mul- Fig 5f Sutures were removed 4 days after apical sur-
tiple interrupted single sutures using non-resorbable gery. A slight edematous reaction can be seen in the
6-0 monofilament polyamide suture material. adjacent soft tissues.

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Fig 5g The 1-year follow-up shows no scar forma- Fig 5h 1-year follow-
tion, with only a fine line along the former incision line. up radiograph.

Fig 5i The surgical challenge was to maintain the perfect esthetics in this high lip line case (picture taken at
1-year follow-up).

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Fig 6a A 49-year-old female patient was referred for Fig 6b Preoperative radiograph.
apical surgery of the maxillary left first premolar. The pa-
tient complained about persistent pain following root-
canal treatment.

Fig 6c A papilla base incision was chosen for surgi- Fig 6d Wound closure was accomplished with mul-
cal access. Note that the premolar had three roots (two tiple interrupted single sutures using non-resorbable
buccal and one palatal). An adhesive composite was 6-0 monofilament polyamide suture material.
used for root-end sealing following apicoectomy.

PBI13 (Fig 6) low) incision is made perpendicular to the

surface of the gingiva, reaching approxi-
This incision has two horizontal compo- mately 0.5–1 mm into the tissue. Then the
nents. On the facial aspect of the tooth, the blade is directed tangentially towards the
incision is placed intrasulcularly, whereas alveolar bone for a bevelled incision at the
in the interdental area, a curved incision is base of the papilla, allowing elevation of a
placed at the base of the papilla. To ensure split flap in this area. A vertical release in-
wound adaptation and healing, a com- cision is placed at the line angle of the ad-
bined partial-full flap is raised in the area jacent tooth, and flap elevation is initiated
of the papilla base (Fig 4g). The first (shal- from the vertical release incision.

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Fig 6e Postoperative radiograph. Fig 6f The sutures were removed 8 days following
apical surgery. Note slight recession at the mesial line
angle of the first premolar.

Fig 6g The 1-year follow-up shows recession-free Fig 6h 1-year follow-up radiograph.
healing (compare with Fig 6a). No scar is discernible
in the areas of the papilla bases, but a slight scar is vis-
ible in the region of the former mesial release incision.

PSI (Fig 7) of the periapical lesion. Repositioning and

suturing of the flap must be carried out
This incision comprises two curved or di- carefully to avoid subsequent recession of
vergent incisions within the keratinized gin- the facial gingiva.
16
giva of the affected tooth . Incisions are
continued within the alveolar mucosa. Flap
elevation should start from the alveolar Discussion
mucosa and not from the attached gingi-
va. Caution must be exercised not to place When planning apical surgery, the sur-
the incisions too close to the expected site geon is strongly advised to discuss possi-

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Fig 7a A 40-year-old male patient was referred for Fig 7b Preoperative

apical surgery of the maxillary left central incisor, which radiograph.
was symptomatic.

Fig 7c Intraoperative situation following wound clo- Fig 7d Postoperative

sure with the papilla-saving incision. Multiple interrupt- radiograph.
ed single sutures were made using non-resorbable
6-0 and 7-0 monofilament polyamide suture material.

Fig 7e Clinical situation 5 days following surgery, at Fig 7f The 1-year follow-up demonstrates no further
the time of suture removal. recession of the facial gingiva compared to the preop-
erative situation (see Fig 7a).

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Fig 7g The higher magnification shows scar forma- Fig 7h 1-year follow-
tion at the mucogingival line and within the alveolar mu- up radiograph.
cosa, but no scar is visible within the attached gingiva.

ble adverse effects on the soft tissues with Harrison and Jurosky14 investigated the
the patient, in particular problems that may mucoperiosteal tissue responses to inci-
occur in the anterior maxilla. Surgery may sional wounds occurring with intrasulcular
solve the periapical hard tissue problem triangular and submarginal rectangular
but create a new soft tissue problem. Pros flap designs in monkeys over a period of
and cons of the different incision and flap 4 weeks. Little difference was found in the
designs must be carefully evaluated, but temporal and qualitative healing respons-
should always respect anatomical land- es to the incisional wounds for the two flap
marks such as the location and extent of designs, but the submarginal rectangular
the lesion and the morphology and vascu- incisions showed greater intersample vari-
lar supply of the marginal soft tissues. ations in the first 4 postoperative days. In
Soft tissue healing has been investigated both vertical and horizontal components of
in experimental studies in animals. Kramper the incisional wounds, epithelial closure
et al17 evaluated the clinical and histological occurred rapidly, with epithelial barrier for-
features of wound healing with three com- mation occurring between 48 and 96
mon types of surgical flap designs in apical hours, and with aggregation of collagen
surgery. The flap designs – including a fibers taking place between 24 and 72
semilunar incision of the alveolar mucosa, hours. Taking into consideration this rapid
a SMI of attached gingiva, and an intrasul- healing of the incisional wound, removing
cular incision of the attachment apparatus sutures within 3 to 4 days after apical sur-
and papillae – were performed in dogs and gery has been suggested2.
observed at intervals of up to 60 days. In- Selvig and Torabinejad18 examined
flammatory changes persisted longer in the wound healing after mucoperiosteal sur-
semilunar and intrasulcular incisions and gery with an intrasulcular and vertical-re-
retarded wound healing. Loss of alveolar leasing incision (triangular flap) in cats. Tis-
bone occurred with the intrasulcular inci- sue reactions were studied histologically
sion. Visible scarring was found with the for up to 2 weeks. At 3 days post-surgery,
submarginal and semilunar incisions. the incisional wound was bridged with an

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epithelial layer of 2 to 3 cells in thickness, bilization of one adjacent papillaPbut
ub using

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and at 1 week epithelialization of the the PBI in the other interproximal space. At
tio
the one-year follow-up, PBI tsites
otn

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wound surface appeared complete. Heal- ess showed
e nc e
fo r
ing of gingival connective tissue appeared no papilla shrinkage, whereas the papilla
essentially complete at 2 weeks. The au- height in ISI sites diminished by 1 mm. The
thors suggested waiting at least 4 days authors concluded that PBI allows pre-
before removing sutures, because the ten- dictable recession-free healing of the inter-
sile strength of the surgical wound ap- dental papilla.
peared to be directly related to the colla- von Arx et al21 evaluated periodontal
gen content of the healing tissue, which changes following apical surgery, and re-
showed a rapid increase beginning ap- lated changes to the type of incision and
proximately the fourth day after creation of to the type of restoration present at the gin-
the wound. Further, healing was found to gival margin. Significant differences were
be most rapid in areas where the wound found for changes in levels of gingival
bed consisted of soft connective tissue, margin and clinical attachment when com-
such as in the region of the free gingiva paring the ISI and the SMI. For example,
and in areas with intact periosteal fibres. ISI demonstrated a mean recession of
Reattachment of flap tissues to a denuded 0.42 mm at buccal sites, whereas SMI
bone surface appeared to be considerably yielded a gain of 0.05 mm at the one-year
delayed compared with healing of the gin- follow-up. No statistically significant influ-
gival incisional wound. The slowest rate of ence of the presence and type of restora-
tissue repair occurred in the alveolar mu- tion margins or the smoking habit of the
cosal region. patient could be demonstrated.
Few clinical studies have evaluated From a clinical point of view, all incisions
changes of marginal soft tissues following in soft tissues will lead to scar formation to
apical surgery. Jansson et al19 assessed a certain degree. As documented with the
changes in periodontal pocket depth and three cases, scar formation appears to be
clinical attachment level at one year follow- more pronounced in the alveolar mucosa
ing apical surgery, comparing root-end re- compared with the gingiva. Unless the pa-
sected (test) teeth with control teeth in the tient has a very high lip line, displaying a
surgical area and with contra-lateral con- significant portion of the supporting soft tis-
trol teeth. A full thickness mucoperiosteal sues, scarring of the alveolar mucosa is
flap with vertical releasing incisions was re- seldom an esthetic problem. In contrast,
flected, exposing the area around the test gingival recession (and subsequent expo-
tooth and the two adjacent teeth. While sure of root dentine or restoration margins)
probing depth did not change across the may severely compromise esthetics, even
three groups, loss of clinical attachment in a medium lip line situation. As a conse-
was more pronounced in root-end resect- quence, attempts to prevent gingival re-
ed teeth compared to control teeth. cession are more important than preven-
20
Velvart et al compared changes of tion of scar formation in the esthetic zone.
papilla height one year after surgery with With regard to the horizontal placement
baseline height, performing a marginal in- of the incision, the clinician must balance
trasulcular incision (ISI) with complete mo- the pros and cons of the SMI. With this

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 VON ARX/SALVI

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technique, it is paramount to maintain the Conclusions ub

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blood supply to the unreflected tissue22. tio
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Necrosis and subsequent breakdown of I Apical surgery may be associated with
ss e n c e fo r
this delicate marginal tissue band would changes in the soft tissues (ie, recession
have a devastating esthetic result. Alterna- of papillae and gingiva, or scar tissue
tively, the PBI should be considered when formation).
the width of the attached gingiva is inade- I When apical surgery is planned, in par-
quate in the esthetic area. The PBI will pre- ticular in the anterior maxilla (esthetic
serve the height of the papilla, as has been zone), the patient must be informed
20
shown by Velvart et al . However, the risk about potential consequences related
of midfacial gingival recession remains21. to a specific incision and flap design.
Similarly, the PSI carries a risk of midfacial I The choice of incision and flap design
gingival recession. Therefore, the PSI is must be based on gingival morphology,
only recommended in cases presenting location and extent of the periapical le-
with attached gingiva of inadequate width, sion, and the current status of the peri-
in combination with narrow and thin adja- odontium.
cent papillae. I Proper soft tissue handling (flap eleva-
With regard to release incisions, place- tion and retraction, soft tissue manage-
ment close to the midline (frenulum) ment during surgery, wound closure) is
should be avoided. In treatment of central essential to prevent further damage and
or lateral incisors, placement of release in- adverse outcomes of gingival wound
cisions is suggested at distal line angles of healing.
the adjacent distal tooth. In treatment of ca-
nines or first premolars, however, release
incisions at mesial line angles of adjacent Acknowledgments
mesial teeth improve access to the apical
area. The use of two release incisions is We thank Ueli Iff, Medical Illustrator, School of Dental
seldom necessary in the esthetic area. Medicine, University of Bern, for excellent cooperation
and the schematic illustrations.
Some authors advocate placing release
incisions exclusively at the mesial aspect
of a flap, thereby avoiding cutting through
vessels that travel from posterior to anteri- References
9
or . However, no clinical study has evalu- 1. von Arx T. Failed root canals: the case for api-
ated the effect of the location of release in- coectomy (periradicular surgery). J Oral Maxillo-
fac Surg 2005;63:832–837.
cisions on the healing outcome in apical
2. Velvart P, Peters CI. Soft tissue management in
surgery. The PSI, with two release incisions endodontic surgery. J Endod 2005;31:4–16.
in the anterior maxilla, carries an esthetic 3. Krähenmann MA, Lang NP, Salvi GE. Flap
designs for tissue preservation in periodontal
risk (Fig 7), and the use of alternative inci- therapy (in German). Parodontologie
sions should be carefully evaluated. 2006;17:19–23.
4. Padbury A, Eber R, Wang HL. Interactions
between the gingiva and the margin of restora-
tions. J Clin Periodontol 2003;30:379–385.

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VOLUME 3 • NUMBER 2 • SUMMER 2008
 CLINICAL GUIDELINE

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ub M.

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5. Broadbent JM, Williams KB, 11. Kim S, Kratchman S. Modern 18. Selvig KA, Torabinejad
Thomson WM, Williams SM. endodontic surgery concepts
lica
Wound healing after muco-
Dental restorations: a risk fac- and practice: a review.
t
periosteal surgery in the cat.ion
t ot

n
tor for periodontal attachment J Endod 2006;32:601–623. e ss e n c e
J Endod 1996;22:507–515.
fo r
loss? J Clin Periodontol 12. Burkhardt R, Hürzeler MB. Uti- 19. Jansson L, Sandstedt P, Laft-
2006;33:803–810. lization of the surgical micro- man AC, Skoglund A. Rela-
6. Eger T, Müller HP, Heinecke A. scope for advanced plastic tionship between apical and
Ultrasonic determination of periodontal surgery. Pract Peri- marginal healing in periradicu-
gingival thickness. Subject odontics Aesthet Dent lar surgery. Oral Surg Oral
variation and influence of tooth 2000;12:171–180. Med Oral Pathol Oral Radiol
type and clinical features. 13. Velvart P, Peters CI, Peters OA. Endod 1997;83:596–601.
J Clin Periodontol Soft tissue management: flap 20. Velvart P, Ebner-Zimmermann
1996;23:839–845. design, incision, tissue eleva- U, Ebner JP. Comparison of
7. Müller HP, Heinecke A, tion, and tissue retraction. long-term papilla healing fol-
Schaller N, Eger T. Masticatory Endod Topics 2005;11:78–97. lowing sulcular full thickness
mucosa in subjects with differ- 14. Harrison JW, Jurosky KA. flap and papilla base flap in
ent periodontal phenotypes. Wound healing in the tissues endodontic surgery. Int Endod
J Clin Periodontol of the periodontium following J 2004;37:687–693.
2000;27:621–626. periradicular surgery. I. The 21. von Arx T, Vinzens-Majaniemi
8. Müller HP, Eger T. Masticatory incisional wound. J Endod T, Bürgin W, Jensen SS.
mucosa and periodontal phe- 1991;17:425–435. Changes of periodontal
notype: a review. Int J Peri- 15. Burkhardt R. New aspects in parameters following apical
odontics Restorative Dent plastic-periodontal surgery (in surgery: a prospective study of
2002;22:172–183. German). Schweiz Monatsschr three incision techniques. Int
9. Kleinheinz J, Büchter A, Kruse- Zahnmed 1999;109:639–649. Endod J 2007;40:959–969.
Lösler B, Weingart D, Joos U. 16. Borchard R, Erpenstein H. Sur- 22. Velvart P, Peters CI, Peters OA.
Incision design in implant den- gical incisions and tissue man- Soft tissue management: flap
tistry based on vascularization agement in periodontology (in design, incision, tissue eleva-
of the mucosa. Clin Oral German). Parodontologie tion, and tissue retraction.
Implants Res 2004;15:121–133. Endod Topics 2005;11:78–97.
2005;16:518–523. 17. Kramper BJ, Kaminski EJ,
10. Gutmann JL, Harrison JW. Sur- Osetek EM, Heuer MA. A com-
gical access: soft tissue man- parative study of the wound
agement. In: Gutmann JL, Har- healing of three types of flap
rison JW (eds). Surgical design used in periapical sur-
endodontics. Pacific: Medico gery. J Endod 1984;10:17–25.
Dental Media International
1998:153–182.

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