The following eleven steps, with modifications as appropriate,make up the typical approach: (1) flap design, (2) incision and reflection, (3) access to the apex, (~) curettage,(5) root end resection, (6) root end preparation and filling, 17) radiographic verification, (8) flap replacement and suturing, (9) postoperative instructions, (10) suture removal, and (11) long-term evaluation. This sequence IS shown in Hg. 17-13 on page 393.
Flcu) design. A properly designed and carefully reflected flap will result in good access and uncqrnplicated healing.” The basic principles of flap design should be followed; these are detailed in Chapter 8. Although several
possibilities exist, the three most common incisions are (l) submarginal curved (i.e., semilunar), (2) submarginal, and (3) full mucoperiosteal (i.e. sulcular). The submarginal and full mucoperiosteal incision will have either a three-corner (i.e., triangular) or four-corner. (i.e., rectangular) design. ‘.Semilun ar incision. This rs a Slightly curved halfmoonhorizontal incision in the alveolar mucosa (PIg. 17-14 on page 394). Although the location llows easy reflection, access to the peri radicular structures is restricted. Other disadvantages to thrs incision include excessivehemorrhage, delayed healing, and scarring; this design is contraindicated for endodontic surgery. Submarginal incision. The horizontal component is in attached ~ingiva with one or two ‘accompanying vertical incisions (Fig. 17.-15 on Rage 394). Generally the incision is scalloped in the horizontal line, with obtuse
angles at the corners. It is’ used most succe-ssfully in the maxillary anterior region or, occasionally, with maxillary premolars with crowns. ‘Because of the design, prerequisites are at least 4 rom of attached gingiva and good peri- _
odontal health. The major advantage is esthetics. Leaving the gingiva intact around the margins of crowns is less likely to
result in bone resorption with tissue recession and crown margin exposure. Compared with the semilunar inci-
ion, the submarginal provides less risk of incising over a bony defect and provides better access and visibillty. dvantages include hemorrhage along the cut mar- !l 0 the surgical site and occasional healing by scarornpared with the full mucoperiosteal sulcular (ol’erio lncision. This is an incision into the gingival sulcus, extending to the gingival crest (rig. ] 7-16 on page 39-+), This procedure includes elevation of interdental papilla, free ningi,’al margin, attached gingl\’a, and alveolar mucosa. One or two vertical iPlaxlI1g incisions may >e used, creating a three- or /lJ’.l-corner design,