PERIODONTALFLAPS

DRJEBIN,MDS.,D.ICOI

DEF:
Aperiodontalflapisasectionofgingivaand/ormucosasurgicallyseparatedfromthe underlyingtissuestoprovidevisibilityandaccesstotheboneandrootsurface.

INDICATIONS: Irregularbonycontours Deepcraters Pocketsonteethinwhichacompleteremovalofrootirritantsisnotclinicallypossible GradeIIorIIIfurcationinvolvement Rootresection/hemisection Intrabonypocketsondistalareasoflastmolars Persistentinflammationinareaswithmoderatetodeeppockets. CONTRAINDICATIONS: Uncontrolledmedicalconditionssuchas unstableangina uncontrolleddiabetes uncontrolledhypertension myocardialinfarction/strokewithin6months Poorplaquecontrol Highcariesrate Unrealisticpatientexpectationsordesires

CLASSIFICATIONOFFLAPS
Classifiedbasedon: Boneexposureafterflapreflection Fullthickness(mucoperiosteal) Partialthickness(mucosal) Placementoftheflapaftersurgery Nondisplacedflaps Displacedflaps Managementofthepapilla Conventionalflaps Papillapreservationflaps

BASEDONBONEEXPOSUREAFTERREFLECTION FULLTHICKNESSFLAP Periosteumisreflectedtoexposetheunderlyingbone. Indicatedinresectiveosseoussurgery.

Contraindications : Areawheretreatmentforosseousdefectwithmucogingivalproblemisnotrequired. Thinperiodontaltissuewithprobableosseousdehiscenceandosseousfenestration. Areawherealveolarboneisthin.

PARTIALTHICKNESSFLAP Splitthicknessflap. Periosteumcoversthebone. Indicatedwhentheflaphastobepositionedapically. Whentheoperatordoesnotdesiretoexposethebone.

BASEDONFLAPPLACEMENTAFTERSURGERY

Nondisplacedflaps: Whentheflapisreturnedandsuturedinitsoriginalposition.

Displacedflaps: Whentheflapisplacedapically,coronallyorlaterallytotheiroriginalposition

DESIGNOFTHEFLAP

Splitthepapilla(conventionalflap)or Preserveit(papillapreservationflap).

BASEDONMANAGEMENTOFTHEPAPILLA CONVENTIONALFLAP

The interdental papilla is split beneath the contact point of the two approximating teeth to allow reflection of buccal and lingual flaps.

Theconventionalflapisusedwhen Theinterdentalspacesaretoonarrow Whentheflapistobedisplaced.

Conventionalflapsincludethe TheModifiedWidmanflap, Theundisplacedflap, Theapicallydisplacedflap,and Theflapforregenerativeprocedures.

PAPILLAPRESERVATIONFLAP

The papilla preservation flap incorporates the entire papilla in one of the flaps

Twobasicflapdesigns,thosewithandthosewithoutverticalreleasingincisions: EnvelopeFlap: Aflapthatisreleasedinalinearfashionatthegingivalmarginbuthasno verticalreleasingincision(s). PedicleFlap: Iftwoverticalreleasingincisionsareincludedintheflapdesign. TriangularFlap: Ifoneverticalreleasingincisionisincludedintheflapdesign.

Envelope Flap

Pedicle Flap

Triangular Flap

Themajorbloodsupplytoaflapisatitsbaseandtravelsinanapicaltocoronal direction. Recommendedflaplength(height)tobaseratioshouldbenogreaterthan2:1

INCISIONS

Horizontalincisions. Verticalincisions.

HORIZONTALINCISIONS Horizontalincisionsaredirectedalongthemarginofthegingivainamesialoradistal direction. Twotypesofhorizontalincisionshavebeenrecommended: A)Theinternalbevelincision,whichstartsatadistancefromthegingivalmarginandis aimedatthebonecrest,and B)Thecrevicularincision,whichstartsatthebottomofthepocketandisdirectedtothe bonemargin. C)Inaddition,theinterdentalincision isperformedaftertheflapiselevated.

INTERNALBEVELINCISION

1st incision 1 incision Reverse bevel incision 11 or 15 surgical scalpel used Starts at a distance from the gingival margin aiming at the bone crest.

Removespocketlining. Producesasharpthinflap margin. Startsfromadesignatedareaon thegingivaandisdirectedtoan areaatornearthecrestofthe bone.

V ari ous l oc ati ons and

angles of internal bevel incision

CREVICULAR INCISION

Also known as second

incision Made from the base of the pocket to the crest of the bone This incision, together with the initial reverse bevel incision, forms a V-shaped wedge ending at or near the crest of bone

PROCEDURE: 1) Beak-shaped #12D blade is used 2) Periosteal elevator inserted into the initial internal bevel incision 3) Flap separated from the bone

INTERDENTAL INCISION

Also known as third incision To separate the collar of gingiva that is left around the tooth Incision made facially lingually & interdentally connecting the 2 segments. Orbans knife is used

VERTICAL INCISIONS

Can be used on one or both ends of the horizontal incision Must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced Vertical incisions in the lingual and palatal areas are avoided

This incision should be made at the line angles to prevent splitting of a papilla or incising directly over a radicular surface.

ELEVATION OF THE FLAP Blunt dissection with periosteal elevator

For reflection of full thickness flap

Sharp dissection with surgical scalpel (#11 or #15)

For reflection of partial thickness flap

AflapthatincludesonlygingivaltissueisreferredtoasaGINGIVALFLAP. Aflapthatextendsbeyondthemucogingivaljunctiontoincludealveolarmucosa,is aMUCOGINGIVALFLAP.

FLAPRETRACTION Retractionshouldbepassivewithoutanytension. Forceshouldnotbenecessarytokeeptheflapretracted. Theedgeoftheretractoralwaysbekeptonbone.

Continuousflapretractionforlongperiodsisalsoisnotadvised.Suchapracticewill desiccatethesofttissueandbonecausingadelayinwoundhealing.

Whentheflapisretracted,thesurgicalassistantshouldfrequentlyirrigatethesurgicalfield withsterilesaline,tokeepthetissuesmoistened,toreducecontamination,andtoimprove visibility.

OPENFLAPDEBRIDEMENT

provideaccesstorootsurfacesandmarginalalveolarbone.

FLAPPOSITIONING surgicalflapsmayberepositioned,apicallypositioned,coronallypositionedor laterallypositioned

Anapicallypositionedflapisonethatisapicallydisplacedfromitsoriginalposition tothelevelofthealveolarcrestorabout1mmcoronaltothecrest. Thecoronallypositionedflapisadvancedcoronaltoitsoriginalposition.

FLAPTECHNIQESFORPOCKETTHERAPY Increaseaccessibilitytorootdeposits Eliminateorreducepocketdepthbyresectionofthepocketwall Exposetheareatoperformregenerativemethods

FLAPTECHNIQUES Themodifiedwidmanflap Theundisplacedflap Thepalatalflap Theapicallydisplacedflap Flapsforregenerativesurgery Thepapillapreservationflap Conventionalflapforregenerativesurgery Distalmolarsurgery

THEORIGINALWIDMANFLAP ByLeonardWidman (1918) Widmandescribedamucoperiostealflapdesignedtoremovethepocketepitheliumand theinflamedconnectivetissue,therebyfacilitatingoptimalcleaningoftherootsurfaces. ADVANTAGES: Lessdiscomfortforthepatient,sincehealingoccurredbyprimaryintention. Itwaspossibletoreestablishapropercontourofthealveolarboneinsiteswithangular bonydefects.

STEP 1

STEP 2

STEP 3

STEP 4

THEMODIFIEDWIDMANFLAP
RamfjordandNissle (1974) ThemodifiedWidmanflap.

Themaingoalsoftheprocedureincludeoptimummechanicalsubgingivalroot planingwithdirectvision.

INDICATIONS: Especiallyeffectivewithpocketdepthsof57mm. CONTRAINDICATIONS: Lackoforverythinandnarrowattachedgingivacanrenderthetechniquedifficult,because anarrowbandofattachedgingivadoesnotpermittheinitialscallopedincision(internal gingivectomy).. osseoussurgicalprocedure

ADVANTAGES:

Rootcleaningwithdirectvision. Tissuefriendly. Healingbyprimaryintention. Minimalcrestalboneresorption. Lackofpostoperativediscomfort.

STEP 1 STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

THEUNDISPLACEDFLAP Currently,itisthemostcommonly performedtypeofperiodontalsurgery. ItdiffersfromthemodifiedWidmanflapinthatthesofttissuepocketwallisremovedwith theinitialincision;thusitmaybeconsideredaninternalbevelgingivectomy.

Pre-operative Facial & Lingual Views

Internal Bevel Incisions Facial & Palatal Aspects

Flap Elevated Showing Osseous Defects

Osseous surgery has been performed

Flaps Placed In Their Original Site And Sutured

Post Operative Results

PARTIALTHICKNESSPALATALFLAPSURGERY

DevelopedbyStaffileno andimprovedbyCornetal. eliminationofperiodontalpocketswherethickpalataltissuesoccur.

ADVANTAGES: Flapthicknessmaybeadjusted. Palatalflapmaybeadaptedtotheproperposition. Betterpostoperativegingivalmorphologyispossiblewithathinflapdesign. Treatmentsmaybecombined(osseousresectionandwedgeprocedure). Rapidhealing. Easymanagementofpalataltissue. Minimaldamagetopalataltissue.

Outline of primary incision

Primary incision

Thin primary flap preparation.

. Secondary incision

Secondary flap removal

Suture

THEAPICALLYDISPLACEDFLAP
Itcanbeusedforbothpocketeradicationaswellaswideningthezoneofattachedgingiva. Itcanbeafullthickness(mucoperiosteal)orasplitthickness(mucosal)flap.

ADVANTAGES: Eliminatesperiodontalpocket. Preservesattachedgingivaandincreasesitswidth. Establishesgingivalmorphologyfacilitatinggoodhygiene. Ensureshealthyrootsurfacenecessaryforthebiologicwidthonalveolarmarginand lengthenedclinicalcrown.

DISADVANTAGES: Maycauseestheticproblemsduetorootexposure. Maycauseattachmentlossduetosurgery. Maycausehypersensitivity. Mayincreasetheriskofrootcaries. Unsuitablefortreatmentofdeepperiodontalpockets. Possibilityofexposureoffurcationsandroots,whichcomplicatespostoperative supragingivalplaquecontrol. CONTRAINDICATIONS: Periodontalpocketsinsevereperiodontaldisease. Periodontalpocketsinareaswhereestheticsiscritical. Deepintrabonydefects. Patientathighriskforcaries. Severehypersensitivity. Toothwithmarkedmobilityandsevereattachmentloss. Toothwithextremelyunfavourableclinicalcrown/Rootratio.

Facial And Lingual Preoperative Views

Facial And Lingual Flaps Elevated

After Debridement Of The Areas

Sutures In Place

Healing After 1 Week

Healing After 2 Months

Preoperative

Postoperative

PRE-TREATMENT

BEFORE OSSEOUS RESECTION

AFTER OSSEOUS RESECTION

FLAP APICALLY POSITIONED AND SUTURED

POST-TREATMENT

FLAPSFORREGENERATIVESURGERY

Twoflapdesignsareavailableforregenerativesurgery: Thepapillapreservationflap & Theconventionalflapwithonlycrevicularincisions.

AdequateinterdentalspaceInterdentalspaceisverynarrow PapillapreservationflapConventionalflapwithonlycrevicularincisions

THEPAPILLAPRESERVATIONFLAP

Entirepapillaisincorporatedintooneoftheflaps. INDICATIONS: Whereestheticsisofconcern. Whereboneregenerationtechniquesareattempted.

CONVENTIONALFLAPFORREGENERATIVESURGERY Intheconventionalflapoperation,theincisionsforthefacialandthelingualorpalatal flapreachthetipoftheinterdentalpapilla,therebysplittingthepapillaintoafacialhalf andalingualorpalatalhalf. INDICATIONS: Whentheinterdentalareasaretoonarrowtopermitthepreservationofflap. Whenthereisaneedfordisplasingflaps.

DISTALMOLARSURGERY Treatmentofperiodontalpocketsonthedistalsurfaceofterminalmolarsisoften complicatedbythepresenceofbulbousfibroustissueoverthemaxillarytuberosityor prominentretromolarpadsinthemandible. OperationsforthispurposeweredescribedbyRobinson andBraden

Impaction Of A Third Molar Distal To A Second Molar

Little Or No Bone Distal To The Second Molar.

Often Leads To A Vertical Osseous Defect Distal To The Second Molar.

A typical incision design for a surgical procedure distal to the maxillary second molar.

Incisiondesignsfor surgicalproceduresdistal tothemandibularsecond molar. Theincisionshouldfollow theareasofgreatest attachedgingivaand underlyingbone.

TRIANGULARDISTALWEDGE:
Triangularwedgeincisionsareplacedcreatingtheapexofthetriangleclosetothehamularnotch andthebaseofthetrianglenexttothedistalsurfaceoftheterminaltooth.

LINEARDISTALWEDGE:
Thelineardistalwedgeincorporatestwoparallelincisionsoverthecrestofthetuberositythatextend fromtheproximalsurfaceoftheterminalmolartothehamularnotcharea. Thedistancebetweenthetwolinearincisionsisdeterminedbythethicknessofthetissues

DISTAL POCKET ERADICATION PROCEDURE WITH THE INCISION DISTAL TO THE MOLAR

SCALLOPED INCISION AROUND THE REMAINING TEETH

FLAP REFLECTED AND THINNED AROUND THE DISTAL INCISION

FLAP IN POSITION BEFORE SUTURING. IT SHOULD BE CLOSELY APPROXIMATED

FLAP SUTURED BOTH DISTALLY AND OVER THE REMAINING SURGICAL AREA

HEALINGAFTERFLAPSURGERY
Immediatelyaftersuturing(0to24hours), establishedbyabloodclot,whichconsistsofa fibrinreticulumwithmanypolymorphonuclearleukocytes,erythrocytes,debrisofinjured cells,andcapillariesattheedgeofthewound. Oneto3daysafterflapsurgery, thespacebetweentheflapandthetoothorboneis thinner,andepithelialcellsmigrateovertheborderoftheflap Oneweekaftersurgery Thebloodclotisreplacedbygranulationtissuederivedfromthe gingivalconnectivetissue,thebonemarrow,andtheperiodontalligament.

Twoweeksaftersurgery, collagenfibersbegintoappearparalleltothetooth surface.Unionoftheflaptothetoothisstillweak,owingtothepresenceof immaturecollagenfibers,althoughtheclinicalaspectmaybealmostnormal. Onemonthaftersurgery, afullyepithelializedgingivalcrevicewithawelldefined epithelialattachmentispresent.Thereisabeginningfunctionalarrangementof thesupracrestalfibers.

THANKU