Periodontal Flap

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Text of Periodontal Flap

Rational and objectivesNikhil Dubey BDS Intern,GDC Raipur

Non surgical periodontal therapy.

Surgical periodontal therapy.

*Why do we do periodontal surgery? *To provide access and direct vision of the root surfaces for thorough debridement. Because in some situation non surgical therapy is not enough to clean the environment.

Surgical periodontal therapy seeks to

Improve the prognosis of teeth.Improve aesthetics.

Purpose of surgical pocket therapy

To eliminate the pathological changes in the pocket walls. To create a stable, easy maintainable state.

May promote periodontal regeneration .

To gain surgical access to deep pockets for adequate cleaning and smoothening of the root surfaces. To facilitate plaque control by reduction or elimination of potential plaque retention areas(correction of morphologic defects).

Objectives, cont.

To provide an environment for an adequate prosthesis. For periodontal regenerative therapy. To correct cosmetic abnormalities.

Indications for periodontal surgery

Areas with irregular bony contours or deep craters. Pockets on teeth in which a complete removal of root irritants is not considered clinically possible. (molars). In cases of grade II or III furcation involvement. Infrabony pockets in distal areas of last molars. Persistent inflammation in areas with moderate to deep pockets may require a surgical approach.

ContraindicationsPatients who do not exhibit good plaque control. Uncontrolled or progressive systemic disease (uncontrolled diabetics,leukemia ect.). Patients taking large doses of corticosteriods may have reduced resistance to stress associated with surgery .. Patients with imminent terminal disease who are debilitated are not candidates for surgery.

Results of pocket therapyConversion of an active pocket to inactive pockets and heal by long junctional epithelium with or without gain of attachment. Pocket elimination or reduction. Improved gingival attachment promotes restoration of bone height, with reformation of periodontal ligament fibers and layers of cementum.

Surgical instruments

Classification of periodontal surgery

Introductory points:Pocket is a pathological deepening of the sulcus. Initially ------Pocket (8mm) Re-evaluation------Pocket(6mm) We need to gain access for thorough cleaning. However, some time we add bone and some time we resects bone.

Classification of periodontal surgery


Procedures. New attachment procedures. Regeneration procedures.

Resective procedures It

is the procedure that means to eliminate or reduce the pocket, by excising or amputating the tissue constricting the pocket wall. (in this case we remove bone).

New attachment procedures It

is the reunion of connective tissue by formation of new cementum with inserting collagen fibers on root surface that has been deprived of its periodontal ligament.

Regeneration proceduresAre surgical procedures aimed at Reproduction or reconstruction of lost or injured periodontium. Aim is to restore the periodontium to the normal physiologic levels. We have new bone and periodontal ligament formation

Resective procedures includes:Gingivectomy, Gingivoplasty. Apically positioned flap without osseous surgery. Apically positioned flap with osseous surgery (Osteoplasty, Osteoctomy). Root resection.

Gingivectomy,GingivoplastyGingivectomy:Excision of soft tissue wall of periodontal pocket. Basic rational is pocket elimination to allow access for root instrumentation. Gingivoplasty:To restore gingival contours.(not commonly used now days). External bevel incision is done to remove excess gingiva and healing is by secondary intention.

Apically positioned flap without osseous surgeryThe idea is to move the gingival margin Apically and not to excise the gingiva. Indications: Deep supra and infra bony pockets. Crown lengthening procedures with minimal attached gingiva. Increase the zone of attached gingiva.

Contra-Indications (Apically positioned flapwithout osseous surgery)

Anatomical reasons:due to location of the pocket.(e.g.. Anterior oblique ridge in the mandible in the 3rd molar area. Esthetic and cosmetic reasons: Anterior area with high lip line. Severely compromised Alveolar bone support.

Apically positioned flap with osseous surgery

We remove bone to have normal architecture by doing Osteoplasty or Osteoctomy.

Indications: Pre-restorative periodontal procedures(exposure of crown). Active pockets with mild or moderate infrabony defects where the base of the pocket is apical to crest of the bone.

Contraindications(Apically positioned flapwith osseous surgery)


limitations,poor crown\root ratio. Presence of excessive tooth mobility.

Definitions Osteoctomy: Removal of some alveolar bone, thus changing the position of crestal bone on tooth surface. Osteoplasty Reshape the bone by thinning it and not to reduce from its height therefore gingiva can adapt nicely.

Root Resection Therapy In

cases of multirooted teeth with infrabony deep pockets and root proximity. In case of furcation grade III. The bone around the area will be thin, therefore affected root can be removed.

Objectives of Resective proceduresPocket elimination or reduction. A physiological gingival contour,tightly adapted to alveolar bone and apical to pre surgical site. A clinically maintainable condition.

Requirements for Resective procedures

Access proper root instrumentation. Access for underlying alveolar crest. Maintain adequate band of attached gingiva. Heal in rapid fashion. Minimize the alveolar crest height. Maintain levels of clinical attachment on a long term basis. Reduce probing on a long term basis.

New Attachment ProceduresClosed curettage. Excisional new attachment procedure (ENAP). Open flap curettage. Modified widman flap procedure.

Closed curettageNot common The idea is to to remove the epithelium that lines the pocket wall. This will promote natural healing process (reattachment). Scientific evidence to prove this is week.

Excisional new attachment procedure (ENAP).

Done extensively in 1960-----1970---. Not common now days. Indicated in localized, mild to moderate Periodontitis, especially interdentally in the anterior region.To eliminate suprabony pockets. Advantage is minimum tissue loss. Disadvantage, is limited vision and it is not applicable in case of deep or irregular pockets

Modified widman flap procedure &Open flap curettageMost common done periodontal surgery. Internal bevel incision. Reflect flap,clean the area. Position the flap back to its original site, therefore have attachment between tissue and root surface. Pocket is reduced.

Grafts, bone grafts, soft tissue grafts. Guided tissue regeneration. Coronal positioned flap. Root surface demineralization (citric acid chemicals). Interdental denudation.

GraftsNot predictable nor overwhelming. Auto grafts (from same person, two step procedures,freeze and dry the bone. Allografts (from same species). Alloplasts (from synthesized materials),an implant from inert material.

Guided tissue regeneration

To guide the right type of cells (periodontal ligament)to attach to root surface, and trying to exclude undesirable cells(epithelium) from attaching to root surface.

Root surface demineralization

Modify the root surface that the right type of cells will attach to it.

Factors influencing the success or failure of all regeneration techniques

Plaque control. Systemic status that affect the periodontium. Traumatic injury to teeth and tissue. Root preparation. Wound closure. Soft tissue approximation. Post operative and long term maintenance.

Criteria for method selection

Characteristics of the pocket: depth,relation to bone,and configuration. Accessibility to instrumentation, including presence of furcation involvements. Existence of mucogingival problems. Response to initial therapy. Plaque control. General health. Diagnosis of the case and previous periodontal treatment. Aesthetic consideration.

Post operative instruction

Pain killer Keep pack in place. Avoid hot food. Use ice pack on the face. Do not brush the area. Use mouth rinse after one day. Do not smoke, follow normal activity, however avoid excessive exertion. Come back to your next appointment.

Surgical versus non surgical treatment of periodontal disease is controversy. Only moderate and sever pockets should be treated surgically. Doing surgery in shallow pocket will result in attachment loss. Gain in attachment will be more after surgery than non-surgery in deep pocket.

Thank you