Dept of periodonticsPeriodontal flaps

Presented by, SHIJI MARGARETD.SAPNAD.SARANYAS.SHIFAYA NASRIN CRRI

Definition

“A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility and access to the bone and root surface.

INDICATIONS:

•Irregular bony contours•Deep craters•Pockets on teeth in which a complete removal of root irritants is not clinically possible•Grade II or III furcation involvement •Root resection / hemisection•Intrabony pockets on distal areas of last molars•Persistent inflammation in areas with moderate to deep pockets.

CONTRAINDICATIONS

• Uncontrolled medical conditions such as ‐unstable angina ‐uncontrolled diabetes ‐uncontrolled hypertension ‐myocardial infarction / stroke within 6 months •Poor plaque control•High caries rate•Unrealistic patient expectations or desires

Bone exposure after flap reflection•Full thickness (mucoperiosteal)•Partial thickness (mucosal)

Placement of the flap after surgery•Non displaced flaps•Displaced flaps

Management of the papilla•Conventional flaps•Papilla preservation flaps

Classification of flaps

BASED ON BONE EXPOSURE AFTER REFLECTION

FULL THICKNESS FLAPPeriosteum is reflected to expose the underlying

bone.Indicated in resective osseous surgery.

PARTIAL THICKNESS FLAP

•Split thickness flap.•Periosteum covers the bone.•Indicated when the flap has to be positioned apically.•When the operator does not desire to expose the bone

BASED ON FLAP PLACEMENT AFTER SURGERY•Non displaced flaps:

When the flap is returned and sutured in its original position.

•Displaced flaps:

When the flap is placed apically, coronally or laterally to their original position

DESIGN OF THE FLAP•Split the papilla (conventional flap)

•Preserve it (papilla preservation flap)

MODIFIED WIDMAN FLAP

Presented by Ramfjord and Nissle in 1974

THE ORIGINAL ‘WIDMAN’ FLAP The flap was elevated to expose 2-3 mm of the

alveolar bone. The soft tissue collar incorporating the pocket

epithelium and connective tissue was removed, the

exposed root surface scaled and the bone

recontoured to re-establish a 'physiologic' alveolar

form. The flap margins were placed at the level of the

bony crest to achieve optimal pocket reduction.

THE TERM MODIFIED WIDMAN FLAP Exposure of the interproximal bone and

elimination of infrabony defects by osseous

recontouring is not carried out (No surgical

pocket elimination and apical displacement of

the flap) Incase of esthetic considerations,intracrevicular

incisions starting at the free gingival margins are

used to minimize postsurgical gingival shrinkage. Vertical releasing incisions are usually not used

INDICATIONS: Effective with pocket depths of 5-7 mm

CONTRAINDICATIONS: Lack of or very thin and narrow attached

gingiva can render the technique difficult,

because a narrow band of attached gingiva does

not permit the initial scalloped incision (internal

gingivectomy).

ADVANTAGES:

Root cleaning done with direct vision.Healing by primary intention.Minimal crestal bone resorption.Lack of post operative discomfort.

1) Internal bevel incision should be made

to the alveolar crest starting

0.5 to 1 mm away from

the gingival margin.

PROCEDURE:

1- Modified widman flap2- Undisplaced flap

INTERNAL BEVEL INCISION IN FACIAL AND PALATAL ASPECTS

2) Flap is elevated

3)Crevicular incision is made from the bottom of the pocket to bone

4)Interdental incision sectioning

the base of the papilla

5)Tissue tags and granulation

tissue are removed.

6) Scaling and root planing of exposed root surfaces

7)Suturing done and covered with tetracycline oinment and with a periodontal surgical pack

Post operative results

THE UNDISPLACED FLAP

Most commonly performed type of

periodontal surgery. It differs from the modified Widman flap in

that the soft tissue pocket wall is removed with

the initial incision; thus it considered an

internal bevel gingivectomy.

PROCEDURE

1) The pockets are measured with periodontal

probe and a bleeding point is produced on the

outer surface of gingiva to mark the pocket

bottom

PRE OPERATIVE VIEWS

2) Internal bevel incision in the facial and

palatal aspects

3)Crevicular incision is made and Flap is

elevated

4)Interdental incision is made

5)Triangular wedge of tissues is removed with

curette

6)All tissue tags and granulation tissue are

removed

7)After the scaling and root planing the flap

edge should rest on the root bone junction.

8)Flaps have been placed in their original site

and Sutured.

Post operative results

THE APICALLY DISPLACED FLAP

It can be used for both pocket eradication as well

as widening the zone of attached gingiva.

It can be a full thickness (mucoperiosteal) or a

split thickness (mucosal) flap.

ADVANTAGES:Eliminates periodontal pocket.

Preserves attached gingiva and increases its

width.

Establishes gingival morphology facilitating

good hygiene.Ensures healthy root surface necessary for the

biologic width on alveolar margin and lengthened clinical crown.

DISADVANTAGES:

May cause esthetic problems due to root exposure.

May cause attachment loss due to surgery.

May cause hypersensitivity.

May increase the risk of root caries.

Unsuitable for treatment of deep periodontal

pockets.

Possibility of exposure of furcations and roots,

which complicates post operative supragingival plaque

control.

CONTRAINDICATIONS:

Periodontal pockets in severe periodontal disease.

Periodontal pockets in areas where esthetics is

critical.

Deep intrabony defects.

Patient at high risk for caries.

Severe hypersensitivity.

Tooth with marked mobility and severe attachment

loss.

Tooth with extremely unfavorable clinical crown /

Root ratio.

PROCEDURE for apically displaced flap

1. An internal bevel incision is made, it should be no more than 1mm from the crest of the gingiva and directed to the crest of gingiva.

2. Crevicular incisions are made, followed by initial elevation of the flap; then interdental incision and the wedge of tissue containing pocket wall is removed

3. Vertical incisions are made extending beyond the mucogingival junction.

Full thickness flap elevated by blunt dissection with periosteal elevator

Split –thickness flap elevated using sharp dissection with a bard- parker knife

4.After debridement of the areas

5.Sutures in place

PRE TREATMENT-

POST TREATMENT

PRE-TREATMENT BEFORE OSSEOUS RESECTION

FLAP APICALLY POSITIONED AND SUTURED

POST-TREATMENT

CROWN LENGTHENING BY APICALLY DISPLACED FLAP

CROWN LENGTHENING BY APICALLY DISPLACED FLAP

PRE-TREATMENT

Before debridement After debridement

Incision

Sutures in place

Pre treatment Post treatment

FLAPS FOR REGENERATIVE SURGERY

Two flap designs are available for regenerative surgery:

1. The papilla preservation flap&

2. The conventional flap with only crevicular incisions.

THE PAPILLA PRESERVATION FLAP

Entire papilla is incorporated into one of the flaps.

INDICATIONS:•Where esthetics is of concern.•Where bone regeneration techniques are attempted

CONVENTIONAL FLAP FOR REGENERATIVE SURGERY

In the conventional flap operation, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla, thereby splitting the papilla into a facial half and a lingual or palatal half.

INDICATIONS: When the interdental areas are too narrow to permit the preservation of flap. When there is a need for displacing flaps. The interdental papilla is split beneath the contact point of the two approximating teeth to allow for reflection of buccal and lingual flaps

DISTAL MOLAR SURGERY

Treatment of periodontal pockets on the distal surface of terminal molars is often complicated by the presence of bulbous fibrous tissue over the maxillary tuberosity or prominent retromolar pads in the mandible.

Operations for this purpose were described by Robinsonand Braden

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.

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

Incision designs for surgical procedures distal to the mandibular second molar.

•The incision should follow the areas of greatest attached gingiva and underlying bone.

Distal wedge

Triangular Square , parallel or H-design Linear or pedicle

The size, shape ,thickness and access of the tuberosity or retromolar area determine treatment procedures

TRIANGULAR DISTAL WEDGE:

Triangular wedge incisions are placed creating the apex of the triangle close to the hamular notch and the base of the triangle next to the distal surface of the terminal tooth.

Triangular incision -Using no.12 0r no.15 scalpel blade

Triangular wedge of tissue removal- using scalers ,hoes , or knives

Walls of the wedge are thinned using scalpel blade- for proper adaptation to underlying bone

LINEAR DISTAL WEDGE:

two parallel incisions over the crest of the tuberosity that extend from the proximal surface of the terminal molar to the hamular notch area.

The distance between the two linear incisions is determined by the thickness of the tissues

Two parallel inverse bevel thinning incision –using n0.15 blade

Periosteal elevators are used to raise the flap

Kirkland or orban knives –to remove the wedge of tissue

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

PERIODONTAL PACKS

Periodontal dressing or periodontal packs is a productive materials applied over the wound created by periodontal surgical procedure

minimise postoperative infection aand haemorrahage

Facilitates healing Protects against pai

Zinc –oxide eugenol packs Zno eugenol packs packs based on

reaction of zno & eugenol include –wondr pak

The addition of accelerators such as Zinc acetate gives the dressing a betterworking time.

It is supplied as a liquid and a powder that are mixed prior to use.

Eugenol may produce allergic reaction (reddening of area and burning pain )

Non eugenol packs

Reaction between metallic oxide and fatty acid is basis for coe-Pak

Supplied in two tubes One tube contains oxides of various

metals (Mainly zinc oxide) and lorothidol (a fungicide) and second tube contains non ionized carboxylic acids and chlorothymol (bacteriostatic agents)

Retenton of packs

Mechanically by interlocking in interdental spaces and joining the facial and lingual portion of the pack

Antibacterial properties

Improved healing and patient comfort – incorporating antibiotics

Bacitracin, oxytetracycline , neomycin nitrofurazone(hypersensitivity)

Preparation and application of periodontal dressing

Equal length of the two paste placed on a paper pad

Mixed with a wooden tongue depressor for 2-3 minutes until paste loses its tackiness

Paste is placed in a paper cup of water at room temperature

With lubricated fingers rolled into cylinders and placed on the surgical wound

Strip of pack is hooked around last molar and pressed into place anteriorly

Lingual pack is joined to facial strip at the distal surface of last molar and fitted into place anteriorly

Gentle pressure on the facil and lingual surfaces join the pack interproximally

Continous pack cover the edentulous space

Instructions for patients after surgery

1. The pack should remain in place until it is removed in the office at the next appointment

2. For the first three hours after the operation avoid hot foods to permit the pack to harden

3. Do not smoke

4. Do not brush over the pack

Removal of periodontal pack After 1 week Inserting a surgical hoe along the

margin and exert gentle lateral pressure Pieces of pack- removed with scalers Entire area rinsed with peroxide to

remove superficial debris

Findings at pack removal

Epithelialized but bleed readily when touched

Pockets should not be probed

HEALING AFTER FLAP SURGERY

Immediately after suturing (0 to 24 hours),established by a

blood clot, which consists of a fibrin reticulum with many

polymorphonuclear leukocytes, erythrocytes, debris of

injured cells, and capillaries at the edge of the wound.

One to 3 days after flap surgery,the space between the flap

and the tooth or bone is thinner, and epithelial cells

migrate over the border of the flap

One week after surgery‐The blood clot is replaced by

granulation tissue derived from the gingival connective

tissue, the bone marrow, and the periodontal ligament.

Two weeks after surgery,collagen fibers begin to appear

parallel to the tooth surface. Union of the flap to the tooth is

still weak, owing to the presence of immature collagen fibers,

although the clinical aspect may be almost normal.

•One month after surgery,a fully epithelialized gingival crevice

with a well‐defined epithelial attachment is present. There is a

beginning functional arrangement of the supracrestal fibers.