16: 199-203 . The flaps are then apically positioned to just cover the alveolar crest. The granulation tissue and the pocket lining may be then separated from the inner surface of the reflected flap with the help of surgical scissors and a scalpel. These techniques are described in detail in. Contents available in the book .. As the flap is to be placed in an apical position, vertical incisions are made extending beyond the mucogingival junction. With the migration of these cells in the healing area, the process of re-establishment of the dentogingival unit progresses. All three flap techniques that were just discussed involve the use of the basic incisions described in Chapter 57: the internal bevel incision, the crevicular incision, and the interdental incision. 3) The insertion of the guide-wire presents Flap design for a sulcular incision flap. Its final position is not determined by the placement of the first incision. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. Fugazzotto PA. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see, Increase accessibility to root deposits for scaling and root planing, Eliminate or reduce pocket depth via resection of the pocket wall, Gain access for osseous resective surgery, if necessary, Expose the area for the performance of regenerative methods, Technique for Access and Pocket Depth Reduction or Elimination, All three flap techniques that were just discussed involve the use of the basic incisions described in. The local anesthetic agent is delivered to achieve profound anesthesia. Contents available in the book .. This flap procedure causes the greatest probing depth reduction. The incision is then carried out till the line angle of the tooth blending it into the gingival crevice. 1. The area is then irrigated with normal saline and flaps are adapted back in position. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. Enter the email address you signed up with and we'll email you a reset link. in 1985 28 introduced a detailed description of the surgical approach reported earlier by Genon and named the technique as Papilla Preservation Flap. The undisplaced flap is therefore considered an internal bevel gingivectomy. After this, the second incision or the sulcular incision is made from the bottom of the pocket to the crest of the alveolar bone. It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. One of the most common complication after periodontal flap surgery is post-operative bleeding. This wedge of tissue contains 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. At last periodontal dressing may be applied to cover the operated area. Contents available in the book .. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective. Contents available in the book .. The basic clinical steps followed during this flap procedure are as follows. Because the pocket wall is not displaced apically, the initial incision should eliminate the pocket wall. Contents available in the book .. In areas with a narrow width of attached gingiva. The incision is made . The triangular wedge of the tissue made by the above three incisions is then removed with the help of curettes. 2014 Apr;41:S98-107. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. We describe the technique of diagnosis and treatment of a large displaced lateral meniscus flap tear, presenting as a meniscus comma sign. Contents available in the book .. Following is the description of step by step procedure followed while doing a modified Widman flap surgery. Care should be taken to insert the blade in such a way that the papilla is left with a thickness similar to that of the remaining facial flap. Step 3:A crevicular incision is made from the bottom of the pocket to the bone in such a way that it circumscribes the triangular wedge of tissue that contains the pocket lining. Endodontic Topics. Step 3: Crevicular incision is made from the bottom of the . This will allow better coverage of the bone at both the radicular and interdental areas. The square, Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. After the area to be operated is irrigated with an anti-microbial solution, local anesthesia is applied and the area is isolated after profound anesthesia has been achieved. 2. The flap technique best suited for grafting purposes is the papilla preservation flap because it provides complete coverage of the interdental area after suturing. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. This drawback of conventional flap techniques led to the development of this flap technique which intended to spare the papilla instead of splitting it. Myocardial infarction / stroke within 6 months. Furthermore, the access to the bone defects facilitates the execution of various regenerative procedures. Burkhardt R, Lang NP. Once the interdental papilla is mobile, a blunt instrument is used to carefully push the interdental papilla through the embrasure. Click this link to watch video of the surgery: Areas where greater probing depth reduction is required. The operated area will be cleaner without dressing and will heal faster. Scalloping required for the different types of flaps (see, The apically displaced flap technique is selected for cases that present a minimal amount of keratinized, attached gingiva. After this, partial elevation of the flap is done with the help of a small periosteal elevator. 4. Triangular 12D blade is usually used for this incision. 6. 7. Areas where post-operative maintenance can be most effectively done by doing this procedure. Periodontal pockets in areas where esthetics is critical. Contents available in the book .. 4. Periodontal flaps can be classified on the basis of the following: For bone exposure after reflection, the flaps are classified as either full-thickness (mucoperiosteal) or partial-thickness (mucosal) flaps (Figure 57-1). After suturing, the flap is adapted around the neck of the teeth with the help of moistened gauze. Trombelli L, Farina R. Flap designs for periodontal healing. This procedure cannot be done on the palatal aspect as it has attached gingiva which cannot be displaced apically. It produces a sharp, thin flap margin for adaptation to the bone-tooth junction. After removing the wedge of the tissue the margins of the flap are undermined with the help of scalpel blades, In this technique, two incisions are made with the help of no. Contents available in the book . Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. For this reason, the internal bevel incision should be made as close to the tooth as possible (i.e., 0.5mm to 1.0mm) (see Figure 59-1). Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. With this access, the surgeon is able to make the third incision, which is also known as the interdental incision, to separate the collar of gingiva that is left around the tooth. Coronally displaced flap. The initial or internal bevel incision is made (. Areas where greater probing depth reduction is required. Practically, it is very difficult to put this incision because firstly, it is very difficult to keep the cutting edge of the blade at the gingival margin and secondly, the blade easily slips down into the pocket because of its close proximity to the tooth surface. Contents available in the book .. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva.It can cover teeth in various degrees, and can lead to aesthetic disfigurement. Methods Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting , were included for this prospective cohort . The intrasulcular incision is given using No. Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults; These landmarks establish the presence and width of the attached gingiva, which is the basis for the decision. The first documented report of papilla preservation procedure was by. Sixth day: (10 am-6pm); "Perio-restorative surgery" Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. Contents available in the book .. The periodontal pockets on the distal aspects of last molars, both in maxillary and the mandibular arches present a unique situation for which specific surgical designs have been advocated. After removing the wedge of the tissue the margins of the flap are undermined with the help of scalpel blades . News & Perspective Drugs & Diseases CME & Education Eliminate or reduce pocket depth via resection of the pocket wall, 3. Contents available in the book . Contents available in the book .. Palatal flaps cannot be displaced because of the absence of unattached gingiva. Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/ palatally. As soon the granulation tissue is removed, the clear bone margins and root surfaces are visible. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. The blood clot provides a framework for the proliferation and migration of cells from surrounding tissues including gingiva, periodontal ligament (PDL), cementum, and alveolar bone 38. Periodontal maintenance (Supportive periodontal therapy), Orthodontic-periodontal interrelationship, Piezosurgery in periodontics and oral implantology. For the conventional flap procedure, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla or its vicinity, thereby splitting the papilla into a facial half and a lingual or palatal half (Figures 57-3 and 57-4). Step 7:Continuous, independent sling sutures are placed in both the facial and palatal areas (Figure 59-3, I and J) and covered with a periodontal surgical pack. This procedure was aimed to provide maximum protection to osseous and transplant recipient sites. It was described by Kirkland in 1931 31. To perform this technique without creating a mucogingival problem, the clinician should determine that enough attached gingiva will remain after removal of the pocket wall. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. The crevicular incision is then placed from the bottom of the pocket till the alveolar crest. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see Chapter 57). 2. Within the first few days, monocytes and macrophages start populating the area, Post-operative complications after periodontal flap surgery, Hemorrhage occurring after 7-14 days is secondary to trauma or surgery. There is no need to determine where the bottom of the pocket is in relation to the incision for the apically displaced flap as one would for the undisplaced flap. 1972 Mar;43(3):141-4. So, this procedure cannot be employed when modified Widman flap, excisional new attachment procedure and regenerative procedures such as osseous grafting are done because these procedures require primary closure. The vertical incision must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced. This is a modification of the partial thickness palatal flap procedure in which gingivectomy is done prior to the placement of primary and the secondary incision. It is contraindicated in the areas where treatment for an osseous defect with the mucogingival problem is not required, in areas with thin periodontal tissue with probable osseous dehiscence or osseous fenestration and in areas where the alveolar bone is thin. Which of the following mucogingival surgical techniques is indicated in areas of narrow gingival recession adjacent to a wide band of attached gingiva that can be used as a donor site? free gingival autograft double papilla flap modified Widman flap laterally displaced (positioned . The internal bevel incision starts from a designated area on the gingiva, and it is then directed to an area at or near the crest of the bone (. This complete exposure of and access to the underlying bone is indicated when resective osseous surgery is contemplated. 2. 12 or no. 2. a. Non-displaced flap. In the present discussion, we discussed various flap procedures that are used to achieve these goals. The flap is then elevated with the help of a small periosteal elevator. As discussed in, Periodontal treatment of medically compromised patients, antibiotic prophylaxis is must in patients with medical conditions such as rheumatic heart disease. The incisions given are the same as in case of modified Widman flap procedure. If a full-thickness flap has been elevated, the sutures are placed along the mesial and the distal vertical incision lines to. After the primary incision, tissue can now be retracted with the help of rat-tail pliers. Conventional flap. Clin Appl Thromb Hemost. The conventional flap is used (1) when the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla, and (2) when the flap is to be displaced. May increase the risk of root caries. The following steps outline the undisplaced flap technique: Step 1: The pockets are measured with the periodontal probe. - Undisplaced flap - Apicaliy displaced flap - All of the above - Modified Widman flap. In the following discussion, we shall study in detail, the surgical techniques that are followed in various flap procedures. While doing laterally displaced flap for root coverage, the vertical incision is made at an acute angle to the horizontal incision, in the direction toward which the flap will move, placing the base of the pedicle at the recipient site. Inferior alveolar nerve block C. PSA 14- A patient comes with . These techniques are described in detail in Chapter 59. The first, second and third incisions are placed in the same way as in case of modified Widman flap and the wedge of the infected tissue is removed. Apically-displaced Flap Several techniques can be used for the treatment of periodontal pockets. techniques revealed that 67.52% undergone kirkland flap, 20.51% undergone modified widman flap, 5.21% had papilla preservation flap, 2.25% had undisplaced flap, 1.55% had apically displaced flap and very less undergone distal wedge procedure which depicts that most commonly used flap technique was kirkland flap among other techniques. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Minor osteoplasty may be carried out if osseous irregulari-ties are observed. Chlorhexidine rinse 0.2% bid was prescribed for 2 weeks, along with analgesics and the patient was given appropriate . The undisplaced flap and gingivectomy are the two techniques that surgically removed the pocket wall. The flap procedures on the palatal aspect require a different approach as compared to other areas because the palatal tissue is composed of a dense collagenous fiber network and there is no movable mucosa on the palatal aspect. During the initial phase of healing, inflammatory cells are attracted by platelet and complement derived mediators and aggregate around the blood clot. Flaps in which the interdental papilla is split beneath the contact of two approximating teeth, allowing the reflection of buccal and lingual flaps, are described as the conventional flaps. Unrealistic patient expectations or desires. Contents available in the book . The blade is pushed into the sulcus till resistance is felt from the crestal bone crest. The partial-thickness flap includes only the epithelium and a layer of the underlying connective tissue. The primary incision or the internal bevel incision is then made with the help of No. It is the incision from which the flap is reflected to expose the underlying bone and root. Ramfjord SP, Nissle RR. According to flap reflection or tissue content: C. According to flap placement after surgery: Diagram showing full-thickness and partial-thickness flap. It is an access flap for the debridement of the root surfaces. 1 and 2), the secondary inner flap is removed. Chlorhexidine rinse 0.2% bid . The choice of which procedure to use depends on two important anatomic landmarks: the pocket depth and the location of the mucogingival junction. In areas with deep periodontal pockets and bone defects. Contents available in the book .. If the tissue is too thick, the flap margin should be thinned with the initial incision. If the dressing has to be placed, a dry foil is first placed over the flap before covering it with the dressing so that the displacement of the pack under the flap is prevented. This is termed. (Courtesy Dr. Silvia Oreamuno, San Jose, Costa Rica. A technique using a mixture of bone dust and blood is called as a. bone blend technique b. bone swaging technique Short anatomic crowns in the anterior region. The bleeding is frequently associated with pain. Contents available in the book . Apically displaced flap can be done with or without osseous resection. Contents available in the book .. These incisions are made in a horizontal direction and may be coronally or apically directed. The gingival margin is removed, and the flap is reflected to gain access for root therapy. In addition, thinning of the flap should be performed with the initial incision, because it is easier to accomplish at this time than it is later with a loose, reflected flap that is difficult to manage.