Coronal Flap Research Articles

U-T Flap for Distal Symes Toe Amputation. A New Flap Adapted to Diabetic Ulcers of the Pulp of the Lesser Toes

The surgical management of diabetic ulcers of the tip of the toes complicated with osteomyelitis of the distal phalanx usually consists of the excision of the bone and soft tissue using a distal Symes toe amputation. This surgery is usually conducted through 2 coronal flaps. When the ulcer is away from the nail or extends further on the plantar side of the pulp, wound closure could be difficult to achieve resulting in wound dehiscence. In addition, the remaining toe is often too short when compared with the neighboring digits. The objective of this surgical technique is to propose a new flap design that could be simple and easy to learn, mainly when dealing with small-to-moderate–sized wounds. The U-T flap is designed to reduce wound complications and yield better esthetics. We found the U-T flap to be a reproducible technique with better outcomes in terms of surgical wound healing and final toe length, after excision of distal infected toes. Level of Evidence: Diagnostic level 5—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Indications and decision making in single and multiple treatment of the anterior sector

Gingival recessions, characterized by apical displacement of the gingival margin and exposure of the root surface, pose both esthetic and functional challenges. This paper reviews the indications and decision making in the management of anterior gingival recessions, a crucial aspect in esthetic and restorative dentistry. Over the years, the evolution of mucogingival surgery towards periodontal plastic surgery has led to the development of various surgical techniques, such as connective tissue grafts and advanced coronal flaps. These techniques aim to provide effective and durable root coverage, adapting to the specific anatomical characteristics of each patient. The selection of the most appropriate surgical technique depends on a detailed evaluation of local anatomical factors and the patient's esthetic expectations. While it is possible to maintain periodontal health with a minimal amount of keratinized gingiva, gingival recessions remain common, especially in individuals with thin periodontal phenotypes. An interdisciplinary approach is essential to ensure outcomes that optimize both periodontal health and esthetics in the long term

Two-Step Periosteal Releasing Incision for Tension-Free Flap Closure After Implant Placement With Simultaneous Guided Bone Regeneration.

We evaluated the effect of periosteal-releasing incisions on flap displacement in anterior maxillary sites following implant placement and simultaneously guided bone regeneration. Thirty patients, each requiring a single dental implant and guided bone regeneration in the maxillary esthetic zone, were recruited. After full-thickness flap elevation, the displacement of the flap was measured under a standardized tension of 1 Ncm. Then, a 2-step periosteal releasing incision was placed in the internal aspect of the flap, and the displacement was remeasured using the same standardized tension. Keratinized tissue width and mucosal thickness at the surgical site were recorded. Patient-reported outcomes were assessed at the 7- and 14-day recall visits. Flap displacement (primary outcome) was calculated before and after periosteal-releasing incisions. Multivariable linear regression models were used to evaluate the influence of mucosal thickness on flap displacement and adjusted for Keratinized tissue width. Primary wound closure was achieved in all patients. The mean difference in flap coronal displacement before and after the periosteal-releasing incisions was 8.2 mm (p < .0001). Adjusted regression models showed no association between mucosal thickness and keratinized tissue width with the amount of flap displacement (p = .770). Patient-reported outcome measures for pain, swelling, and bleeding amounted to 1.28 ± 1.93, 1.36 ± 1.87, and 0.0 ± 0.0 at 7 days and 0.11 ± 0.57, 0.56 ± 1.03, and 0.0 ± 0.0 at 14 days, respectively. Periosteal-releasing incisions using the 2-step procedure described here are a predictable technique to obtain coronal flap displacements >8 mm without increased surgical complications.

Coronal Approach (Cadaver)

For treatment of facial trauma such as a frontal sinus fracture, orbital fractures, or zygoma fractures, the coronal or bi-temporal approach is used. The approach can also be used for superficial temporal artery biopsy. This approach exposes the anterior cranial vault, forehead, and upper and middle regions of the facial skeleton including the zygomatic arch. It provides access to these areas with minimal complications and cosmetically acceptable hidden scars. The subperiosteal or subgaleal planes are commonly used for coronal flap dissection. Here, we present a demonstration of the coronal approach to exposing the upper or middle facial skeleton in a cadaver.

A trans-eyebrow zig-zag approach for frontal bone fractures✰

Frontal bone fractures are amongst the most common facial fractures and surgical management, which has traditionally involved access via a coronal flap, can result in unsightly scarring, alopecia, paraesthesia, facial nerve weakness and temporal hollowing. Alternative approaches include use of endoscopically-assisted surgery, often through the eyebrow, which minimises the risk of unsightly scarring but may also sacrifice access in the process. In this technical note, we discuss a surgical technique for open reduction and internal fixation of fractures of the bone overlying the frontal sinus and supra-orbital rim, which the authors have not found in the literature, which involves the making of a “zig-zag” incision through the eyebrow in a trichophytic manner which reduces the risk of unsightly scarring whilst simultaneously allowing for sufficient surgical access to the fracture site.

Surgical management of frontal bone and naso-orbito-ethmoidal fractures: a 7-year multi-center retrospective review

Frontal and naso-orbito-ethmoidal (NOE) fractures are rare but important injuries due to their anatomical complexity and proximity to vital structures. This study aims to describe the patient factors, procedural factors, and postoperative outcomes in the surgical management of these fractures. Retrospective review of patients aged 18 years or older who were surgically treated for these fractures at two Australian tertiary hospitals (2014-2020). Patient factors (demographics, mechanism of injury, fracture pattern, concomitant injuries); procedural factors (operation timing, surgical approach); and postoperative outcomes (complications, revision surgeries) were recorded. 60 cases were included (41 frontal; 29 NOE; 10 combined). Mean age was 37 (frontal) and 39 years (NOE). Most cases were male (87.8%; 75.9%). The most common mechanism was traffic accidents (29.3%; 34.5%). The most common associated facial fractures were Le Fort fractures (46.3%; 89.7%). The most common associated systemic injuries were brain injuries (36.6%; 34.5%). Mean operation timing was 13 days (frontal) and 11 days (NOE). Coronal flap was most commonly used (68.3%; 82.8%). Postoperative complication rates were 39.0% (frontal) and 37.9% (NOE). Three cases required revision surgeries. Further larger longitudinal studies are required to build knowledge and improve patient outcomes.

Raney Clip Free Coronal Scalp Flap: Case Series

The coronal scalp flap is a useful surgical approach that provides access to the upper and middle third of the skull and can be utilized to repair fractures of the upper and middle face. Intraoperative hemostasis is usually achieved with Raney clips. This case series report discusses the literature on the conventional use of Raney clips during coronal flaps elevation and compares it to the technique used by the Oral and Maxillo-facial department at Memorial Hermann Hospital where use of clips are replaced by an electrosurgical cutting and coagulation device, LigaSure. This technique was used by the department on 21 patients treated at MHH. Use of LigaSure was found to decrease intraoperative bleeding as well as reduce alopecia commonly associated with coronal scalp flaps.

Hard and soft tissue regeneration of severe peri-implantitis defects with the laser-assisted peri-implant defect regeneration technique: 3-year results

PurposeThis retrospective cohort study evaluates the regeneration of severe peri-implantitis deficiencies treated with the laser-assisted peri-implant defect regeneration (LAPIDER) approach within a 3-year follow-up.MethodsTwenty-four implants with severe peri-implantitis in 18 patients were treated according to the LAPIDER technique. In contrast to classic techniques for reconstructive peri-implantitis surgery with a marginal incision, a buccal split-flap preparation avoiding papillae separation was used. After a coronal flap elevation and a laser-assisted peri-implant defect cleaning, connective tissue and autogenous bone grafting was performed. Primary outcomes were the changes of the marginal bone levels (MBL) and the buccal bone thickness. Secondary outcomes included implant survival, peri-implant probing depths (PPD), bleeding on probing (BOP), recession, width of keratinized mucosa (KMW), thickness of keratinized mucosa (KMT), soft tissue esthetics (PES), and implant success.ResultsMBL improved interproximal by 3.10 ± 2.02 mm (p < 0.001), buccal by 3.49 ± 2.89 mm (p < 0.001), and lingual by 1.46 ± 1.98 mm (p = 0.003); buccal bone thickness by 0.55 ± 0.60 mm (p = 0.005), and 1.01 ± 1.25 mm (p = 0.001) at 1 and 3 mm below reference level. Two implants were removed; 22 implants were still in function at a mean follow-up of 36 months. PPD changed from 5.05 ± 1.39 to 3.08 ± 0.71 mm (p < 0.001); recession was reduced from 2.07 ± 1.70 to 0.91 ± 1.13 mm (p = 0.001); KMW increased from 2.91 ± 1.81 to 4.18 ± 1.67 mm (p = 0.006); KMT improved from 1.73 ± 0.50 to 2.44 ± 0.43 mm (p < 0.001); PES changed from 7.7 ± 2.8 to 10.7 ± 1.9 (p < 0.001). 45.8% to 54.2% of the implants met the criteria of implant success.ConclusionsThe favorable results document the proof of principle for the regeneration of severe peri-implant hard and soft tissue deficiencies by the LAPIDER treatment approach.

Coronal Flap Advancement for Treatment of Non-Carious Cervical Lesion Followed by Ceramic Restoration: Case Report

Coronal Flap Advancement for Treatment of Non-Carious Cervical Lesion Followed by Ceramic Restoration: Case Report

Comparative Assessment of Flap-Advancing Techniques in an Ex Vivo Cadaverous Porcine Model.

Since flap advancement is a prerequisite for tension-free primary closure and successful regenerative procedures, the aim of this study was to test the efficacy of six surgical approaches for flap advancement in an ex vivo porcine model. A total of 60 fresh mandibles from pigs were randomized into one of six groups: (1) trapezoidal full-thickness flap design with two vertical releasing incisions (control), (2) trapezoidal flap with linear periosteal scoring, (3) mucosal detachment technique, (4) mucosal detachment with horizontal extension, (5) mucosal detachment with horizontal and vertical extension, and (6) mucosal detachment with horizontal vertical and cutback extension. Coronal advancement of the flap was recorded as the primary variable; the surface area of exposed mucosa and the tear strength were recorded as secondary variables. Homogeneity existed among groups for preoperative keratinized tissue width and tissue thickness. Mucosal detachment with horizontal, vertical, and, cutback extensions achieved the highest amount of advancement. All remaining groups achieved a statistically higher advancement compared with the trapezoidal full-thickness flap (control). Pairwise comparison demonstrated statistical significance between any two groups (P < .001). A positive correlation was noted between exposed mucosa and flap advancement; the advancement increased 0.62 mm for each 10 mm2 of increase in the exposed mucosal surface. Strength at tear stress was the highest in the trapezoidal full-thickness flap (control) and mucosal detachment with horizontal-vertical-cutback incisions (P < .001). Coronal flap advancement was maximized in the mucosal detachment techniques and positively correlated with the area of exposed mucosa.

Reposicionamento coronal do retalho para recobrimento de recessões gengivais múltiplas utilizando matriz de colágeno tridimensional associada às proteínas derivadas da matriz do esmalte – série de casos

Gingival recession is the generic term that means exposure of the teeth root surface. It can cause aesthetic problems, dentin hypersensitivity or even favor the appearance of root caries. Depending on the patients complaint, it can be treated in different ways, such as through direct resin restorations, root desensitization or even surgical root coverage. The latter can be obtained through coronal/lateral repositioning of the flap with or without a connective tissue graft. Currently, the removal of subepithelial connective tissue graft from the patients palate be replaced by 3D collagen matrices, generating satisfactory aesthetic results. The aim of this case series was to evaluate the evolution of root coverage treatment using the protocol for covering multiple gingival recessions with the association of soft tissue substitute and enamel matrix-derivative proteins. Seven systemic healthy adult patients complaining of root exposure sought at our clinic. Coronal flap repositioning associated with soft tissue substitute and enamel matrix-derivative proteins was proposed. All patients were treated with the same surgical technique. At the end of 30 months postoperatively, the patients self-reported satisfactory results, with root coverage close to 85% and total coverage in 50% of the treated teeth, with no complaints of pain, considerable edema and/or hemorrhage in the immediate postoperative period. This protocol used seems to obtain satisfactory results regarding aesthetic complaints or dentin hypersensitivity reported by patients at the beginning of treatment.

Treatment of Implant Labial Soft Tissue Dehiscence with Guided Treatment of Implant Labial Soft Tissue Dehiscence with Guided Bone Regeneration vs Subepithelial Connective Tissue Graft. A Bone Regeneration vs Subepithelial Connective Tissue Graft. A Randomized Clinical Trial

Objective: Background: Implant soft tissue dehiscence is a frequently reported esthetic complication, that more often than not affects the functional integrity of the dental implant with eventual loss of osteointegration. Many treatment modalities with different success rates have been proposed aiming to solve this complication or prolong the survival of the dental implant, of which are guided bone regeneration and soft tissue regeneration around the affected implants. Patients and Methods: This prospective study was carried in the hospital of Future University. 11 Patients (1 Male – 10 Females) with 20 Maxillary implant sites demonstrating soft tissue dehiscence were randomly allocated to either a guided bone regeneration (GBR) group (Control) in which patients received a mixture of autogenous and xenogeneic bone graft substitute covered by a native collagen membrane fixated with titanium tacks over the affected implants or a connective tissue graft and coronal flap advancement (CTG + CAF) group (Intervention) in which patients received a de-epithelialized connective tissue graft harvest from the anterio-lateral hard palate combined with a coronally advanced flap. Recession levels were measured at baseline and at 1,3 and 6 months post operatively, while probing depths and bleeding indices were measured at baseline and 6 months post operatively and patient satisfaction levels were recorded through a visual analogue scale (VAS) questionnaire 6 months post operatively after completion of the follow up period. Results: Out of the 11 patients (1 Male – 10 Females) enrolled in this study, no major post-operative complications were encountered, the most common complication was post-operative swelling and edema that usually peaked 48 hours after surgery, which was more evident in the GBR group. Soft tissue recession levels measured from implant platform to gingival margin was significantly higher at baseline in GBR group compared to CTG+CAF group (P=0.042). While there was no significant difference in soft tissue levels between both groups at 1 month (P=0.362), 3 months (P=0.240) and 6 months (P=0.097). There was no statistically significant difference in VAS mean values between GBR and CTG+CAF groups (P=0.510). Conclusion: Based on the results of our study, we concluded that both treatment modalities provided satisfactory and stable results with major improvements in all clinical outcomes after 6 months compared to baseline measurements, however, GBR provided slightly superior clinical outcomes, compared to CTG + CAF

The Coronal Flap in Oral and Maxillofacial Surgery – A Case Report

The coronal scalp flap is a versatile and aesthetically pleasing approach for access to the cranial vault, cranial base, forehead, nose, upper and middle third of the face, and orbits. In spite of its extensive nature, it is associated with few complications when properly planned. Despite, its versatility of the coronal flap, its use by oral and maxillofacial surgeons is limited especially in Nigeria. A case of surgical remodeling of fibrous dysplasia of the right supra orbital bone region using coronal approach is reported. This article highlighted surgical technique of coronal flap and indications for the use of coronal flap in maxillofacial surgery. Similarly, possible complications of the procedure, prevention and management of such complications were also emphasised. Additionally, it is meant to serve as a guide to young practising surgeons in Nigeria. It is our hope that this will embolden young surgeons in Nigeria to employ its use when indicated.&#x0D;

Buccal Sliding Palatal Pedicle Flap Technique for Wound Closure After Ridge Augmentation.

One standard approach for wound closure after ridge augmentation is coronal flap advancement. Coronal flap advancement results in displacement of the mucogingival junction and reduction of the vestibulum. In the maxilla, a buccal sliding palatal flap can be applied for primary wound closure after ridge augmentation. The dissected part of the palatal connective tissue is left exposed, thus eliminating or reducing the amount of the coronal flap advancement respectively and increasing the amount of keratinized gingiva. In combination with guided soft tissue augmentation, this flap design enables a three-dimensional peri-implant soft tissue augmentation.

Reverse umbrella technique – percutaneous reduction of frontal bone fracture using an intermaxillary fixation screw device

Fractures of the frontal sinus account for approximately 5%–15% of all maxillofacial fractures with a slight male preponderance.1 The standard management involves an access coronal flap for open reduction and internal fixation, but this has some unwanted risks such as scar, alopecia, paraesthesia, and facial nerve weakness.2 We report a safe and effective percutaneous technique for closed reduction of a non-comminuted isolated anterior table fracture of the frontal sinus with the use of intermaxillary fixation (IMF) screws under image intensifier guidance.

A modified surgical approach for hard and soft tissue reconstruction of severe periimplantitis defects: laser-assisted periimplant defect regeneration (LAPIDER)

BackgroundThe main problem in periimplantitis is often the combination of severe periimplant bone loss with a contaminated implant surface and an insufficient soft tissue situation. Classic surgical concepts with crestal access to the bony defect and debridement of the surface most often lead to partial defect regeneration and a soft tissue recession. An incision directly above the pathologic bony lesion is contrary to general surgical treatment rules.AimTo overcome this problem, a new surgical concept was developed which allows to clean the implant surface, reconstruct the bony defect, and improve soft tissue height and thickness without cutting the papilla complex. This publication presents the innovative regenerative treatment approach for severe periimplantitis defects.Material and methodsAfter diagnosis and non-surgical pre-treatment of a severe periimplantitis lesion, the following treatment protocol was applied: horizontal mucosal incision 5 mm apical to marginal mucosa, supraperiosteal preparation in apical direction, cutting through periosteum at the level of the implant apex, subperiosteal coronal flap elevation, exploration and cleaning of the periimplant defect, thorough debridement of the implant surface with the Er:YAG laser, subperiosteal grafting with connective tissue, grafting of the bony defect with autogenous bone chips from the mandibular ramus, and bilayered suturing of periosteum and mucosa. Implant survival, marginal bone levels, periimplant probing depths, recession, and facial mucosa thickness (PIROP ultrasonic measurement) were evaluated in a pilot case at 1-year follow-up examination.ResultsInter-proximal, oral, and buccal marginal bone levels increased significantly to the level of the implant shoulder from pre-operative to 1-year follow-up examination. No signs of suppuration or periimplant infection were present. Probing depths and recession decreased significantly, while the facial mucosa thickness improved from pre-operative to final examination.ConclusionsMarginal bone levels and soft tissue improvement suggest feasibility for the regeneration of severe periimplant hard and soft tissue deficiencies by this new treatment approach. With the use of this concept, the simultaneous implant surface cleansing and improvement of hard and soft tissue seem to be possible and unfavorable postoperative exposition of titanium surface might be prevented. Comparative studies are planned to quantify the effects of this new surgical protocol.

Root Coverage Associated with Acellular Dermal Matrix and L-Prf in Bilateral Unitary Gingival Recessions – Case Report

Gingival recession can be defined as the displacement of the marginal tissue apical to the cemento-enamel junction exposing the root surface of teeth. To restore the displaced tissue, grafts are used mainly to modify the periodontal biotype and reconstruct the gingival tissue and among graft types we mention autogenous, xenogenous and allogeneic. This paper aims to report a case of bilateral root coverage using acellular dermal matrix (ADM) graft and platelet-rich fibrin (L-PRF) membrane. Female patient, 27 years old, non-smoker and no previous medical conditions attended to a college dental clinic in northern Brazil with the main complaint of dental hypersensitivity. On intraoral exam it was observed gingival recessions stage II type 1 in teeth 13 and 23 due to orthodontic treatment. After preoperative exams and oral cavity adequacy, the recommended treatment was root coverage by Zucchelli &amp; De Sanctis technique with autogenous graft. However due to the hard palate thin thickness and the patient's refusal to have a second postoperative area xenogenous and allogeneic were used. During the surgical procedure a coronally advanced flap without relaxing incisions were made and associated with L-PRF membrane in tooth 23 and ADM graft in tooth 13, then the coronal flap was fixed with sutures. We conclude that the use of L-PRF and ADM are viable techniques and with excellent predictability of success; both improved the range of keratinized mucosa and promoted clinical attachment level (CAL) increase.

Fronto-orbital bar access for anterior cranial fossa pathology

Access to the anterior cranial fossa can be achieved strategically using a coronal flap and cranionotomy, and itis easily within the remit of the maxillofacial surgeons armamentarium to provide and access the fronto-orbital region. Using technology piloted in house with 3D printing, we are able to plan and treat patients requiring such surgery with custom made cutting guides where required which promote surgical precision and reduce operating time. Additionally, pre-operative’rehearsal’ on 3D models enables us to better visualise the operative sites and assess the potential intra-operative challenges.

Management of gingival recessions: options and prognostic factors

Surgical coverage of exposed root surfaces is one of the most common treatments in plastic periodontal surgery. The review describes established recession coverage including the application of coronal and lateral advanced flaps, soft tissue grafts as well as their combinations and tunneling procedures. Patient-related, defect-orientated and technique-based factors will be addressed that mainly influence the success of root coverage and, therefore, should be considered in pre-surgical treatment planning. An indication scheme presents differential indications of the most important techniques depending on clinical parameters.

Differences in effectiveness of membrane fixation using periosteal vertical mattress and simple sling suture techniques in infrabony pocket treatment

Guide tissue regeneration (GTR) is the treatment of infrabony pockets for soft and hard tissue regeneration. Membrane is used as a barrier and prevents apical migration of the cells in epithelial tissues. Membrane fixation is one of the procedures in GTR treatment because resorbed membrane is less stable. Simple sling suture technique for membrane fixation has 1 anchorage, located in coronal flap, while periosteal vertical mattress suture technique has 2 anchorages in periosteum, making it more stable. This study aimed to study the differences in the effectiveness of membrane fixation using periosteal vertical mattress suture and simple sling suture techniques in terms of probing depth, relative attachment loss, and alveolar bone height in the treatment of infrabony pockets. The samples were divided into 2 groups. The first group was open flap debridement (OFD) with demineralized freeze dried bone allograft (DFDBA) application and membrane fixation with simple sling suture, while the second group was OFD with DFDBA application and membrane fixation with periosteal vertical mattress suture, observed on day 0, 30th day, and 90th day. The results of the study showed significant differences in the probing depth and relative attachment loss (except from the 30th day to the 90th day), and there were no significant differences in the alveolar bone height from the baseline to the 90th day, between the group of membrane fixation using simple sling suture and that of periosteal vertical mattress suture techniques on flap surgery. This study concluded that membrane fixation in the treatment of infrabony pocket with periosteal vertical mattress suture technique is more effective in reducing the probing depth and relative attachment loss, but there is no difference in increasing the alveolar bone height when compared to simple sling suture technique.