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FLAP TECHNIQUES FORPOCKET ELIMINATION
Guided By:-
Dr. Prashant Bhusari
Prof. & Guide
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Instruments used in flap surgery.
Treatment decisions for soft & hard tissue pockets in flap surgery.
Flap techniques for pocket elimination.
Flap techniques for reconstructive & regenerative surgery.
Suturing techniques.
Periodontal dressing.
Post surgical care.
Healing following flap surgery.
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Introduction
The type of periodontal surgery & how
many sites should be included is made
after the initial cause-related measures
has been evaluated.
The time lapse between this initial cause-
related phase of therapy and this
evaluation may be 1 to 6 months. This
time lapse has following advantages:-
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1. Removal of calculus & plaque will reduce the
inflammatory cell infiltrate in the gingiva (edema,
hyperemia, flabby tissue consistency) so thatassessment of the true gingival contour & pocket depths
possible.
2. Reduction of gingival inflammation makes the softtissue more fibrous & firmer facilitates surgical handling
of the soft tissue so that bleeding is reduced.
3. A proper assessment of the prognosis has beenestablished. The effectiveness of the patients home
care, can be properly evaluated. Lack of effective self-
performed infection control mean patient should be
excluded from surgical treatment.
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The first surgical technique used in periodontal therapy
were described as means of gaining access to diseased
root surfaces. Such access could be accomplished
without excision of the soft tissue pocket (open-viewoperations).
Later, procedures were described by which the
diseased gingiva was excised (gingivectomyprocedures)
The concept that not only inflamed soft tissue but also
infected and necrotic bone had to be eliminated calledfor the development of surgical techniques by which the
alveolar bone could be exposed and resected (flap
procedures).
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A Periodontal flap is defined as, a section of the
gingiva and or oral mucosa, surgically elevatedfrom the underlying tissues to provide visibility of the
bone and root surface. (Carranza 1996)
Flap is a piece of tissue parity severed from its placeof origin for use in surgical grafting and repair of
body defects. (Ramfjord)
A flap is a segment of gingiva and adjoiningalveolar mucosa raised from the underlying tissues
by surgical meansGrant.
Surgery has been defined as the act and art oftreating diseases or injuries by manual operation.
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History of Periodontal Flap
The history begins with Athens, Rome &extending to Vienna in late 19thcentury &
the Berlin in the early 20thcentury.
The Berlin group was originally led by menlike Partsh (1900) & Sachs (1913) but was
dominated by Robert Neumann for the
Radical surgical treatment for pyorrhoea
In the 1920s, a controversy concerning the
priority of periodontal flap surgery invoved
(Cieszynski 1926, Widman 1923,
Neumann 1923). Each claiming to have
been first to publish of flap design.
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Carl partsh (1855-1932) known to this days for Partsh
incision which is a curved incision with the convexity
toward the crown of the tooth.
After 1907, Partsch recommended for the first time that
the flap be sutured.
Most of the progress in periodontal surgery in this periodcame from Germany & other European countries & was
associates with three names: Robert Neumann, Leonard
Widman & A. Cieszinski.
The surgical treatment Neumann proposed in 1912 but
in 1920 mucoperiosteal flap procedure is well described
by Neummann in his 3rdedition.
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Widman in 1916 appears to have been the first to describe flap
surgery for pocket elimination, although Cieszinski in a
discussion in 1914 referred to periodontal flap surgery foraccess for scaling, removal of granulation tissue and reduction
of pocket depth. However no description of the methodology
was given.
The English translation of Widmansarticle in 1918 gave a
detailed description of a mucoperiosteal flap design, which
leaves a collar of epithelium and inflamed connective tissues
around the necks of the teeth from the gingival margin to thebone.
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Widman in a modification of his original technique is the first
person to describe the reverse bevel incision, although it had
been alluded to previously by cieszynski.
Zentler described in 1918 the use of a crevicular
mucoperiosteal flap for access to remove infected bone and
infected granulomatous tissue. The method is very similar to
what Neumann described in 1920.
During the 1930s and 1940s, gingivectomy become the most
popular method of surgical pocket elimination, but as pointed
out by Schluger in 1949, this operation did not offer anacceptable solution for the elimination of intrabony pockets and
craters and for pockets extending apically beyond the attached
gingiva.
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Schluger recommended doing a gingivectomy first andthen a mucoperiosteal flap to expose the alveolar crest
and part of the alveolar process.
Later Schlugersapproach was modified to the push
back and the pouch operations with an extensive
exposure of the alveolar process and a mucobuccal fold
extension following surgical remodeling of the bone forpocket elimination.
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A new approach to surgical elimination of the periodontal
pocket extending beyond the mucogingival line was
proposed by Nabers in 1954. He used essentially theNeumann flap approach with a crevicular mucoperiosteal
flap and trimming of the inside of the gingival margin of the
flap.
This method was modified by Ariando and Tyrell to include
two instead of the one vertical releasing incision as
suggested by Nabers. Later Nabers modified the procedureby recommending Widmansreverse bevel incision as the
initial approach to the flap design and Friedman suggested
calling this procedure the apcially repositioned flap.
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Main objectives of flap surgery
Surgical elimination or reduction of periodontal pockets.
To induce reattachment and bone regeneration in
periodontal pockets.
To correct gingival, mucogingival defects and deficiencies.
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Flap for pocket therapy
1. Original Widman flap.
2. Neumann flap.
3. Undisplaced flap.
4. Kirkland flap.
5. Modified Widman flap .
6. Apically positioned flap.
7. Palatal flap
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Flap for reconstructive and regenerative
surgery :
Distal wedge procedure.
Papilla preservation flap :-
1. Modified papilla preservation.
2. Simplified papilla preservation.
3. Minimally Invasive Surgical Technique (MIST).
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Flaps to correct gingival and mucogingival
defects and deficiencies :
Pedicle graft procedures
Rotational flap procedures (e.g. Laterally sliding flap,
Double papilla flap, Oblique rotated flap)
Advanced flap procedures (e.g. Coronally repositioned
flap, Semilunar coronally repositioned flap).
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Other objectives of Flap Surgery
Creating accessibility for proper professional scaling and
root planning.
Establishing a gingival morphology which facilitates the
patients self performed plaque control.
To correct gingival contour that interferes with oral hygiene.
To establish drainage for gingival or periodontal abscess.
To prepare for restorative dentistry.
To improve the esthetic appearance of the tissue
overgrowth.
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Objectives of flaps used for Pocket Therapy
Increase accessibility to root deposits.
Eliminate or reduce pocket depth by resection of the
pocket wall.
Expose the area to perform regenerative methods.
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Classification of Flap
Bone exposure after flap reflection.
Placement of the flap after surgery.
Management of the papilla.
Presence / absence of releasing
incisions.
Depending on the direction of transferand geometry (Bahat and
Handelsman 1991).
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Bone exposure after flap reflection.
Full thickness (mucoperiosteal)
All the soft tissue, including the periosteum, isreflected to expose the underlying bone.
Partial thickness (mucosal) flaps /split thickness flap
It includes only the epithelium and a layer of theunderlying connective tissue. The bone remains
covered by a layer of connective tissue, including theperiosteum
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Full thickness or mucoperiosteal flap:- Anincision generally is made in or near thegingival sulcus region and carried apically
toward the crest of the bone from which pointthere is total reflection of all soft tissue from thesurface of the alveolar process.
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By contrast the split thickness or mucosal flap isprepared by initiating an incision at or near the gingivalsulcus region and proceeding apically through the
connective tissue past the crest of the alveolar bone soas to leave a layer of periosteal connective tissueintact, covering the vestibular surface of the alveolarprocess.
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In the full thickness flap-the resorptive activity at the six
to eight-day period affects the entire layers ofcircumferential lamellae and a portion of thehaversian systems that are immediately subjacent tothose lamellae, so it is a distinct quantitative differenceas to the amount of bone that is resorbed.
Twenty-one day period, where now definiteosteogenesis is characteristic of the alveolar processassociated with the split thickness flap, it is at this timethat one can observe that very little change that tookplace by resorption at the crest of the process andonly some on the vestibular surface.
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There are many more osteoclasts and osteoblasts inaction during their respective times of activity with the fullthickness flap. This again is related to the degree ofdamage or trauma by surgery.
Reflecting a split thickness flap achieves thinness withbody and permits its reapposition at the gingival marginregion with it being better contoured and much moreadaptable than the heavy-bodied full thickness
mucoperiosteal flap .
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Placement of the flap after surgery
Undisplaced or Nondisplaced Flaps :- when the flap isreturned & sutured in its original position.
Displaced flaps :- when the flap placed apically,coronally or laterally to its original position.
Palatal flap cannot be displaced because of absence of unattached gingiva.
Importance of Apically displaced flap:-
Apically Displaced flaps have the important advantage of preserving theouter portion of the pocket wall and transforming it into attached gingiva soit fulfills 2 objectives :-
1. Pocket Elimination
2. Width of Attached gingiva increase.
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Management of the papilla
Conventional Flap :- Interdental papilla is split beneaththe contact point of the two approximating teeth toallow reflection of buccal & lingual flap.
used :-
1. interdental space is too narrow.
2. when the flap is to be displaced.
Conventional flaps include:
The modified Widman flap,
The undisplaced flap,
The apically displaced flap,
The flap for regenerative procedures.
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Papilla Preservation Flaps :- itincorporates the entire papilla in oneof the flap by means of crevicularinterdental incison to sever the
connective tissue attachment & ahorizontal incision at the base of thepapilla, leaving it connected to one ofthe flaps .
/ b f l i i i i
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Presence / absence of releasing incisions
Flap with releasing incisions Envelope flap
(with Vertical incision) ( without Vertical incision)
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Advantages Disadvantages
Flap with Vertical
incision
Used if the osseous defect is
very deep or of it is isolated to
one or two teeth
Delayed healing
Limit the surgical field to only
those teeth that are
pathologically involved
Greater post operative
pain and bleeding
Flap can be move to another
position without causing
excessive tension
Cannot be given in palatal
as well as lingual area
Envelop flap Quicker to heal and are
associated with less postoperative pain and bleeding
Limit access to the bony
tissues
Used in situations where
esthetics is a major
consideration
Cannot be easily moved or
repositioned to other
locations
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Depending on the direction of transfer and
geometry
Rotational flap
Advancement flap
Rotational Flap e.g.
Lateral Positioned Flap
Advancement Flap e.g.
Coronally Advanced Flap
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Indications
Accessibility for proper scaling and rootplanning.
Establishment of a morphology of the
dentogingival area conductive to plaquecontrol.
Pocket depth reduction.
Correction of gross gingival aberrations
Shift of the gingival margin to a position
apical to plaque retaining restorations.
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Contraindications
Patient cooperation :- Till the patient achieved
adequate plaque control the surgery must be delayed
which is assessed in the pre-surgical phase & in
general most of the systemic disease under control by
medication which are also not contraindicated for
surgery after physician concern.
Cardiovascular Diseases :
1. Arterial hypertensionnormally does not preclude
periodontal surgery. The patients medical history should
be checked for any previous untoward reaction to local
anesthesia. Local anesthetics free from or low in
adrenaline may be used and an aspirating syringe should
be adopted to safeguard against intravascular injection.
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2. Angina Pectoris :Does not influence the periodontal
surgery. Premedication's with sedatives and use of local
anesthetics low in adrenaline are recommended.
3. Myocardial Infarctionpatients should not be subjected to
periodontal surgery with in 6 months following hospitalization
until well after cardiac rehabilitation.
4. Anticoagulant therapy have the potential for bleeding
after surgical procedures. This include patients taking Aspirin
as a prophylaxis for heart disease and such patients should
stop taking Aspirin temporarily before undergoing periodontalsurgery. Adjustments of the anticoagulants drug therapy
usually needs to initiated 2-3 days prior to the dental
appointment. Aspirin & NSAIDs should not be used post-
operatively pain control since they increase bleeding
tendency & tetracycline is contraindiated.
5 Rheumatic Endocarditis congenital heart lesions and
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5. Rheumatic Endocarditis, congenital heart lesions and
heart and vascular implants involve risk of transmission of
bacteria to heart tissue and vascular implants during the
transient bacteremia. Treatment of patients with these
conditions should be preceded by antiseptic mouth rinsing(0.2% Chlorhexidine) and an appropriate antibiotic should
be prescribed and administered a few hours before.
Blood Disorders :
Patients suffering from acute leukemias, agranulocytosis,
and lymphogranulomatosis must not be subjected to
periodontal surgery. Anaemias in mild and compensated forms do not preclude
surgical treatment. More severe and less compensated
forms may entail lowered resistance to infection and
increased propensity for bleeding.
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Hormonal Disturbances :
Diabetes Mellitusis often associated with delayed wound
healing and lowered resistance to infection andpredisposition for atherosclerosis. Well compensated
patients may be subjected to periodontal surgery provided
precautions are taken with dietary and insulin routines.
Adrenal function may be impeded in patient receiving large
doses of corticosteroids over an extended period. These
conditions involve reduced resistance to physical and
mental stress and the doses of corticosteroid may have tobe altered during and after the period of periodontal surgery.
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Neurological Disorders :
1. Multiple sclerosis and Parkinsons Disease :may in
severe cases, make ambulatory periodontal surgeryimpossible. Paralesis, impaired muscular function, tremor
and uncontrollable reflexes may necessitate treatment under
general anesthesia.
2. Epilepsyis often treated with phenytoin which in
approximately 50% of cases may mediate the formation of
gingival hyperplasia. These patients may, without special
restrictions, be subjected to periodontal surgery for correctionof the hyperplasia.
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Organ Transplantation:
Prophylactic antibiotics are recommended in transplant
patients taking immunosuppressive drugs, and the patients
physician should be consulted before any periodontal therapy
is performed. In addition, antiseptic matrix rinsing (0.2%
Chlorhexidine) should proceed the surgical treatment.
Smoking :
Although smoking negatively affects wound healing (Siana et
al 1989), it may not be considered a contraindication for
surgical periodontal treatment. The clinician should be
aware, however, that less resolution of probing pocket depthand smaller improvements in clinical attachment may be
observed in smokes than in non-smokers. (Preber &
Bergstorm 1990)
General Surgical Considerations
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General Surgical Considerations Procedural selection should be based on the following :
1. Simplicity
2. Predictability3. Efficiency
4. Underlying osseous topography
5. Anatomic and physical limitations (e.g. small mouth,
gagging, mental foramen)
All incisions should be bold, clean, smooth and definite. An
uneven ragged incision requires more healing time.
An incision should be on bone or tooth surface & on healthy
tissue adjacent to the lesion otherwise it hampers the
operative site due to profuse bleeding.
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Flap design should allow for adequate access and visibility.
Flap design should prevent unnecessary bone exposure withresultant possible loss and dehiscence or fenestration
formation.
Where possible, primary intention procedures are preferredto those of secondary intention.
The base of a flap should be as wide as the coronal aspect to
allow for adequate vascularity.
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Tissue tags should be removed to allow for rapid healing and
to prevent regrowth of granulation tissue.
Adequate flap stabilization is necessary to prevent
displacement, unnecessary bleeding, hematoma formation,
bone exposure and possible infection.
All flaps should be designed for maximum utilization and
retention of keratinized gingival tissue so as to maintain a
functional zone of attached keratinized gingiva and prevent
needless secondary procedures.
PERIODONTAL SURGICAL INSTRUMENTS
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PERIODONTAL SURGICAL INSTRUMENTS
(Armamentarium) : Periodontal surgery is
accomplished with numerousinstruments. Periodontal surgical
instruments are classified as
follows (Carranza and Newman
1996)
Excisional and incisional
instruments:-
1. Surgical blades e.g. Bard
Parker blades (39 mm) No.11, 12,
12D, 15, 15c.
2. Interdental knives e.g. Orban
Knive No.1-2.
Surgical curettes and sickles e.g.
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g g
Prichard curette, Kirkland surgical
instruments.
Periosteal elevators e.g. No.24 G
and Goldman Fox No.14.
Surgical chisels and Hoes.
Surgical files e.g. Schluger and
Sugarman files.
Scissors and Nippers e.g. Goldman
Fox No.16 and Castroveijo scissors
N dl h ld
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Needle holders e.g.
conventional and Castroveijo
needle holders.
Hemostats and tissue
forceps.
Soft tissue and Bonerongeurs.
Surgical burs.
Local anesthetic syringe.
Irrigating syringe.
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Apprehension :
Medication with a tranquilizer, barbiturate or antihistaminicmay be indicated. It may be given at the time of surgery.
Intramuscular or IV administration of scopalamine or
meperidineantihistamine and meperidine - diazepamcombinations are widely used. Some practitioners use intense
oxide analgesia.
If premedication for sedation is used in the office, it should beadministered 30-48 minutes before local anesthetic injections
S l ti C it i f Fl T h i
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Selection Criteria for Flap Technique
The selection of a technique for treatment of a particular
lesion is based on a number of considerations.
1. Characteristics of the pocket :-
a. Depth
b. Relations to the underlying bone
c. Configuration
2. Accessibility to instrumentation including presence of
furcation involvement.
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3. Existence of mucogingival problems.
4. Response to phase I therapy.
5. Patient cooperation and ability to perform effective oral
hygiene.
6. Age of the patient and general health.
7. Overall diagnosis of the case.
8. Esthetic considerations.
9. Previous periodontal treatment.
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Treatment decisions for soft & hard tissue
pockets in flap surgery
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Incisions used in Flap Surgery
Incisions used for the conventional flaps are classified as :
Horizontal incisions
1. Internal bevela. Scalloping
b. Linear
2. Crevicular
3. Interdental
Vertical Incisions
Horizontal Incision
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Horizontal Incision
Internal Bevel incision or reverse bevel or inverse bevel incision:-
It starts at a distance from the gingival margin & is aimed at the bone
crest. The portion of the gingiva that is left around the tooth containsthe epithelium of the pocket lining and the adjacent granulomatous
tissue.
It is the incision from which the flap will be reflected to expose theunderlying bone and root.
It accomplishes three important objectives (Carranza and Newman
1996).
1. It removes the pocket lining.
2. It conserves the relatively uninvolved outer surface of the gingiva
which, if apically positioned, converts to attached gingiva.
3. It produces a sharp and thin flap margin for adaptation to the bone
tooth junction.
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The starting point on the gingiva is determined by whether
the flap will be apically displaced or not. It is called first
incision because it is the initial incision in the reflection of the
periodontal flap and the reverse bevel as the bevel is in areverse direction from that of the gingivectomy incision.
The principle of the reverse bevel incision was thought to
have arisen early in the 1900s but the person who actually
introduced it is controversial as Neumann (1912), Cieszynski
(1914) and Widman (1917); all used it. When utilizing
reverse bevel procedures, both scalloped and linear incisionshave been described.
The scalloped incision is s ch that it follo s the conto rs of
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The scalloped incision is such that it follows the contours of
the gingival margins at varying distances form the margin
depending on how much tissue is to be removed.
After the flap is reflected and the surgical corrective
procedures completed, the flap is usually replaced or
repositioned so that the marginal soft tissue covers the
marginal and interdental bone and hence minimized thehealing by secondary intention.
The linear incision does not follow the contours of the
gingival margins and hence does not provide any interdentalsoft tissue coverage for bone when the flap is replaced or
repositioned, and therefore osseous tissue is left exposed
interdentally and healing in these areas is by secondary
intention only.
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Indications :-
1. Original widman flap.
2. Modified Widman flap.
3. Apically repositioned flap.
4. Undisplaced flap.
Instruments :-
Surgical scalpel blade No. #11 or #15
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Crevicular or sulcuar incision (second incision) :
This starts form the base of the pocket to the crest of the bone.
This, along with the first incision, forms a V-shaped wedge
ending at or near the crest of the bone; this wedge of tissuecontains most of the inflamed and granulomatous areas that
constitute the lateral wall of the pocket, as well as the junctional
epithelium and the connective tissue fibers that still persist
between the bottom of the pocket and the crest of the bone.
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Indicatios :-
1. when preservation of gingiva is critical,as in esthetic area. E.g kirkland flap
2. when minimum keratinized tissue.
Instruments :-
The incision is carried around the entire
tooth. The beak shaped No.12 B blade isusually used for this incision.
Ad t
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Advantages :
It is the easiest to perform and is accomplished by placing
the scalpel blade into the gingival sulcus and severing boththe epithelial and connective tissue attachments from the
tooth. It is followed by a full thickness flap, which is
relatively easy to reflect and suture.
It can be used when the surgeon is extracting a tooth or a
root fragment, placing a dental implant or performing an
apicoectomy.
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Disadvantage :
The epithelial lining is incorporated into the flap and then
sutured back onto the root when the flap is closed. This
might be acceptable as long as the gingival attachment is
healthy, but if a periodontal pocket is present and the
sulcular epithelium is diseased, a sulcular incision is
contraindicated.
I t d t l Thi d i i i
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Interdental or Third incision
To separate the collar of gingiva that is left around the tooth .
The orbans knife is used for this incision.
The incision is made not only around the facial & lingual
radicular area but also interdentally, connecting the facial &
lingual segments, to free the gingiva completely around thetooth.
Orbans Knife
Incisions Description Indications Instruments
V ti l R l i P di l t 1 T i S l l bl d 11
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Vertical or Releasing Perpendicular to
gingival margin at the
line angles of teeth
1. To increase access.
2. To allow apical or
coronal positioning of
flap
Scalpel blades no. 11
or 15
Thinning Internal or undermining
incision extending from
gingival margin toward
the base of the flap to
decrease the bulk of
the connective tissueon the underside of the
flap
1. Palatal flap
2. Distal wedge
procedure
3. Internal bevel
gingivectomy
4. Bulky papilla
Scalpel blade no. 12 or
15
Cutback Small incision made at
the apical aspect of a
releasing incision &directed towards the
base of the flap
Pedicle flap that are
laterally positioned
Scalpel bladed no. 11
or 15
Periosteal releasing Incision at the base of
the flap severing the
underlying periosteum
To release flap tension
allowing coronal
advancement of the
flap
Scalpel blade no. 15
Original widman flap
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g p
A Swedish dentist Leonard widman in 1918 first time use a
flap procedure for pocket elimination.
In his article The Operative treatment of pyorrhea alveolaris
He described a mucoperiosteal flap design aimed at removing
the pocket epithelium & the inflamed connective tissue,
thereby facilitating optimal cleaning of the root surface.
He introduced the reverse bevel scalloping type of gingival
incision in 1916 as modification of Neumanns periodontal flap
surgery.
This procedure was aimed at reattachment and readaptation
of the pocket walls rather than just the surgical eradication of
the outer walls of the pocket.
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Indications :
Moderate to deep periodontal pockets.
As a surgical treatment of pyorrhea alveolaris.
Advantages :
Excellent direct vision.
Good access to all root surfaces and furcation.
Flap repositioning possible.
Reestablishment of bony contours possible in sites withangular bony defects.
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Disadvantages :
Root exposure.
Post operative pain and edema.
Superficial resorption of exposed bone.
Bony exposure in interproximal areas.
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Technique for original widman flap
Sectional releasing incisions were first made todemarcate the area scheduled for surgery.
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Neumann Flap
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Neumann Flap
Robert Neumann developed principle of periodontal flap
surgery between 1914 and 1916
Crevicular incision to the bone margin & Vertical incisionnot
bisecting the interdental papilla.
Separation of flap was done then elevated to gain clear view
of the entire field of operation, all granulation tissue & calculus
were removed & bone margin smoothened with the chisels &
burs to reshape the normal topography.
The margin of the flap was then trimmed & scalloped with the
scissors to reach exactly the bone margin and sutured using
straight & curved needle & silk thread.
Diff b t O i i l id &
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Difference between Original widman &
Neumann Flap
Original widman Flap Neumann Flap
No Lingual / palatal
Both buccal & lingual flap
should be reflected
Only buccal flap should
be reflected
Area for surgery Three tooth at a time Sextant
Type of incision Reverse bevel Intracrevicular
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UNDISPLACED FLAP
One of the most commonly performed type of pdl surgery.
Soft tissue pocket wall is removed with the initial incision; thus it
may be considered an internal bevel gingivectomy.
surgically remove the pocket wall.
To avoid mucogingival problem -important to determine :
enough attached gingiva will remain after removal of the pocket wall.so pocket
depth and location of MGJ is important.
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Stage I :- pockets - measured with the pdl probe, and a bleeding point is produced
on the outer surface of the gingiva to mark the pocket bottom.
Internal bevel incision is made after the scalloping of the bleeding marks on the
gingiva.
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Stage II :- The initial, internal bevel incision is made after the scalloping of the
bleeding marks on the gingiva.
The incision is usually carried to a point apical to the alveolar crest, depending on thethickness of the tissue.
The thicker the tissue, the more apical is the ending point of the incision.
Stage III :- The second or crevicular incision is made from the bottom of the pocket to
detach the connective tissue from the bone.
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Stage IV :- flap is reflected with a periosteal elevator (blunt dissection) from the
internal bevel incision. Usually there is no need for vertical incisions because the
flap is not displaced apically.
Stage V :- The interdental incision is made with an interdental knife, separating
the connective tissue from the bone.
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A continuous sling suture is used to secure the facial and the lingual or palatal
flaps. This type of suture, using the tooth as an anchor, is advantageous toposition and hold the flap edges at the root-bone junction.
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Advantages :
1. Improved accessibility for instrumentation.
2. Removes the pocket wallreducing or eliminating the
pocket .
Disadvantage :
1. Poor esthetics
2. Root exposuresensitivity and caries
M difi d Fl O ti
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Modified Flap Operation
In 1931 Kirkland described a surgical procedure to be
used in the treatment of PeriodontalPus Pockets.
This procedure was called as Modified Flap Operation,and is basically an access flap for proper root
debridement & no attempt was made to reduce the pre-
operative depth of the pockets.
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Ad antage of Modified Flap
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Advantage of Modified Flap
1. Useful in anterior region of the dentition for the
esthetic regions, since root surface was not exposed.
2. Potential for bone regeneration in intrabony defects.
In contrast to the original Widman flap as well as theNeumann flap, the modified flap operation did not
include :-
(1) Extensive sacrifice of non-inflamed tissues.
(2) Apical displacement of the gingival margin.
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Modified Widman Flap
Ramfjord & Nissle (1974) described the modifiedWidman flap technique.
Also recognized as the open flap curettage technique.
Original Widman flap technique included both apical
displacement of the flaps and osseous recontouring
(elimination of bony defects) to obtain proper pocket
elimination, the modified Widman flap technique is notintended to meet these objectives
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Indications for the Modified Widman Flap
Adequate width of attached gingiva.
Deep Pockets.
Intrabony Pockets.
Need to minimize recession, as in the anterior regions.
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Initial incision is made parallel to the long axis of the tooth .
If pockets are deeper than 3 mm-incision is placed -1mm away from the
gingival margin to ensure removal of all crevicular epithelium .
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Second incision i.e crevicular incision is made around the neck of the toothfrom bottom of the crevice to the alveolar crest.
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Third incisionmade in the horizontal direction to separate the soft tissue
collar of root surface s from the bone
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Following proper debridement and curettage of angular bone defects,
the flaps are carefully adjusted to cover the alveolar bone and sutured
Advantage of Modified Widman Flap
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Advantage of Modified Widman Flap
Access & visualization of the root surfaces.
The possibility of obtaining a close adaptation of the soft
tissues to the root surfaces.
The minimum of trauma to which the alveolar bone and
the soft connective tissues are exposed.
Less exposure of the root surfaces, which from an
esthetic point of view is an advantage in the treatment of
anterior segments of the dentition.
Preservation of gingival width.
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Minimal or no inflammationin the area of connectivetissue adaptation indicating that the active pathologic
aspect of the pocket is eliminated acting as a source of
irritation.
f f
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Disadvantages of Modified Widman Flap
Postoperative soft tissue craters.
Residual probing depth in the presence of intrabony
defects.
New attachment is unpredictable.
Unstable junctional epithelial attachment long term.
There will be some post operative tissue shrinkage once
healing occurs.
Comparison of the Original andM difi d Wid Fl P d
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Modified Widman Flap Procedures
Original Widman Flap Modified Widman Flap
For Pocket Elimination Gain access to the roots and the
alveolar crest
Collar of tissue attached to theteeth torn with curettes
Collar excised with sharp knives(Second incision) and removedwith curettes
High flap reflection i.e. raisedbeyond the apex of tooth
Minimal flap reflection i.e.Mucoperiosteal flap is raised only 2 to
3 mm from the alveolar crest
Flaps do not cover interproximalbone
Close interproximal flapadaptation because exageratedpalatal scalloping of the flaps
Bone remains exposed No bone exposed
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Apically Repositioned Flap
In the 1950s & 1960s removal of soft & hard tissueperiodontal pockets were described. This decade was
also important because of maintaining an adequate zone
of attached gingiva after surgery was emphasized.
The first technique for the preservation of the gingiva
following surgery denoted as Repositioned of attached
gingiva by Nabersin 1954 and modified by Ariaudo &
Tyrrell in 1957.
In 1962 Friedman proposed the term apically
repositioned flap for the Naberstechnique.
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According to Friedman the entire complex of the softtissues (gingiva & alveolar mucosa) rather than the
gingiva alone was displaced in apical direction & the
whole muco-gingival complex was maintained &
repositioned apically.
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The incisional and excisional technique used means that
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The incisional and excisional technique used means that
it is not always possible to obtain proper soft tissue
coverage of the denuded interproximal alveolar bone.
A periodontal dressing should therefore be applied to
protect the exposed bone and to retain the soft tissue at
the level of the bone crest.
After healing, an adequate zone of gingiva is
preserved and no residual pockets should remain.
Indications :
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Indications:
Pocket eradication and/or widening the zone of attached
gingiva.
Areas of thin periodontium or prominent roots where
dehiscence or fenestrations may be present.
Contraindications:
Labial anterior areas where tooth exposure is
unaesthetic.
Patient who are prone for root caries.
Advantages :Mi i k t d th t ti l
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Minimum pocket depth post-operatively.
If optimal soft tissue coverage of the alveolar bone isobtained, the post-surgical bone loss is minimal.
The post-operative position of the gingival margin may
be controlled and the entire muco-gingival complex maybe maintained.
Disadvantage :
The sacrifice of periodontal tissues by bone resection
and the subsequent exposure of root surfaces (may
cause esthetic root caries and root sensitivity problems).
Palatal Flap Su rgery
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p g y
Because of the anatom ic character ist ics of the palate, palatal flaps require
different designs.
Desirable to remove deep pdl pockets entirely and establish shallow
physiological sulcus for the following reasons:
1. Palatal tissue - masticatory mucosa and immobile; it has no elasticfibers and loose connective tissues. Therefore, it is impossible to
displace a palatal flap apically.
2. Thick, keratinized tissue; therefore, accurate close adaptation to the
tooth surface and bone margin is difficult, and postoperative gingivalmorphology may be unfavorable. Periodontal pockets tend to recur
postoperatively.
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3. Reduction of the periodontal pocket in a thickgingival wall in the palatal aspect is uncommon
because of the minimal gingival shrinkage achieved
by initial therapy such as brushing or scaling.
4. Inaccessibility of cleaning instruments may cause
inadequate self-care.
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Considerations for determining the position of the primary
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Considerations for determining the position of the primary
incision in palatal flap surgery are:
l. Thickness of palatal tissue
2. Depth of periodontal pocket
3. Degree of osseous defect
4. Necessity of osteoplasty and required clinical crown length
5. Surgical methods (or techniques) applied
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Advantages :
1. Flap thickness may be adjusted.
2. Palatal flap may be adapted to the proper position.
3. Better postoperative gingival morphology is possible with a thin flap design.
4. Treatments may be combined (osseous resection and wedge procedure).
5. Rapid healing.
6. Easy management of palatal tissue.
7. Minimal damage to palatal tissue.
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Contraindicated :
when a broad, shallow palate does not permit a
partial-thickness flap to be raised without
possible damage to the palatal artery.
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