FLAP SURGERY CONCEPTSRATIONALE OF POCKET ELIMINATION
INTRODUCTION
• The ultimate goal of periodontal therapy has been aimed to restore the health and function of the periodontium.
• To achieve this goal, many non surgical and surgical techniques have been proposed to treat a variety of periodontal conditions, most commonly – the periodontal pocket
PERIODONTAL POCKET
Periodontal pocket is defined as ‘ a pathologically deepened gingival sulcus’
The etiologic factor for pocket formation is plaque.
Vicious cycle continues without pocket therapy
POCKET THERAPY EFFECTSACTIVE POCKET:
Underlying bone is lost
• After Phase I therapy the inflammatory changes in the pocket wall subside, rendering the pocket inactive and reducing its depth
• The extent of this reduction depends on the depth before treatment and the degree to which the depth reduces, is the result of the edematous and inflammatory component of the pocket wall.
INACTIVE POCKET:
• Inactive pockets can sometimes heal with a long junctional epithelium
• Unstable condition, chances of recurrence
• Inactive pockets maintained by:
Frequent scaling and root planing
Transforming pocket into healthy sulcus
Bottom of healthy sulcuseither coronal to the bottom of the pocket- re
attachmentat the bottom of the pocket- no gain of attachment
TREATMENT OUTCOME
• PERIODONTAL REGENERATION is defined histologically as regeneration of the tooth’s supporting tissues, including alveolar bone, periodontal ligament, and cementum over a previously diseased root surface.
• NEW ATTACHMENT - embedding of new periodontal ligament fibers into new cementum and the attachment of the gingival epithelium to a tooth surface previously denuded by disease. (GPT 2001)
• RE ATTACHMENT – the attachment of the gingiva or the periodontal ligament to the areas of the tooth from which they have been removed in the course of treatment (or during preparation of teeth for restorations)
• EPITHELIAL ADAPTATION – the close apposition of the gingival epithelium (long junctional epithelium) to the tooth surface with no gain in height of gingival fiber attachment.
Possible results of pocket therapy. An active pocket can become inactive and heal by means of a long junctional epithelium. Surgical pocket therapy can result in a healthy sulcus, with or without gain of attachment. Improved gingival attachment promotes restoration of bone height, with re-formation of periodontal ligament fibers and layers of cementum.
TREATMENT MODALITIES FOR POCKET ELIMINATION
NEW ATTACHMENT TECHNIQUES
Eliminate pocket depth by reuniting the gingiva to the tooth at a position coronal to the bottom of the preexisting pocket.
Usually associated with filling in of bone and regeneration of periodontal ligament and cementum.
Offers the ideal result
Most common method.
Rationale: The wall of the pocket consists of soft tissue and may also include bone in the case of intrabony pockets.
It can be removed by the following:
• Retraction or shrinkage: Scaling and root-planing procedures resolve the inflammatory process gingiva shrinks pocket depth reduction.
• Surgical removal - gingivectomy technique /undisplaced flap.
• Apical displacement with an apically displaced flap.
REMOVAL OF THE POCKET WALL
accomplished by tooth extraction or by partial tooth extraction
(hemisection or root resection).
REMOVAL OF THE TOOTH SIDE OF THE POCKET
Gingival curettage
Excisional new attachment procedure (ENAP)
Flap for debridement (Modified Widman flap)
Gingivectomy
Apically positioned flap, often in conjunction with bone resection
Root resection or amputation
(FLORES AND MENGEL 1995)
Procedures to restore tissue attachment
Resective procedures
1 Characteristics of the pocket: depth, relation to bone, and configuration.
2 Accessibility to instrumentation, including presence of furcation involvements.
3 Existence of mucogingival problems.
4 Response to Phase I therapy.
5 Patient cooperation, including ability to perform effective oral hygiene. Smokers must
be willing to stop their habit.
Criteria for Method Selection
6 Age and general health of the patient.
7 Overall diagnosis of the case: various types of gingival
enlargement and types of periodontitis (e.g., chronic marginal
periodontitis, localized aggressive periodontitis, generalized
aggressive periodontitis).
8 Esthetic considerations.
9 Previous periodontal treatments.
NON SURGICAL THERAPY- SCALING AND ROOT PLANING
• Supra and subgingival debridement results in mechanical disruption of plaque biofilm
• GOLD STANDARD modality for periodontal treatment
Attributed to:
1) Exposure of cementum, root dentin and pocket epithelium for novel colonization
2) Species thriving in diseased pocket find new habitat less hospitable
3) Decrease in pocket depth as a result of resolution of inflammation, decreased edema, and a readaptation of apical junctional epithelium
• Healing following non surgical therapy is almost complete at 3 months, however limited healing continues for 9 or more months.
• Measurements are made at baseline and again at 3 months as a method of evaluation and effectiveness of therapy( LINDHE)
STUDY INITIAL PROBING DEPTH
RESULTS AFTER SRP
Cobb et al. (1996)Meta- analysis
1-3mm 4-6mm˃7mm
-0.34mm(attachment loss)+0.55mm ( gain)+1.29mm (gain)
Claffey et al. (2000)˂3.5mm4- 6.5 mm˃7mm
-0.5mm attachment loss0-1mm attachment gain1-2 mm attachment gain
Surgical pocket therapy
The effectiveness of periodontal therapy is predicated on success in completely eliminating calculus, plaque, and diseased cementum from the tooth surface.
LIMITATIONS OF NON SURGICAL THERAPY
The presence of irregularities on the root surface
As the pocket becomes deeper, the surface to be scaled increases, more irregularities appear on the root surface, and accessibility is impaired
The presence of furcations will also create insurmountable problems for scaling the root surface
• First surgical technique used in periodontal therapy were described as means of gaining access to diseased root surfaces
Access accomplished without excision of soft tissue pocket by
Open view operations
Diseased gingiva excised by gingivectomy procedures
Concept – not only soft and inflamed tissue but also infected and necrotic bone had to be eliminated
Required alveolar bone exposure- FLAP PROCEDURES
SURGICAL POCKET THERAPY
• Increase accessibility to root surfaces, making it possible to remove all irritants
• Reduce or eliminate pocket depth ,making it possible for the patient to maintain root surface free of plaque
• Reshape hard and soft tissues to attain harmonious topography.
Criteria for selection of surgical technique: based on clinical findings1) Soft tissue pocket wall
2) Tooth surface3) Underlying bone4) Attached gingiva
• Pocket elimination procedures not involving underlying osseous structures:
Gingival curettage
ENAP
Gingivectomy
CURETTAGE• Defined as ‘ removal of pocket epithelium and underlying connective
tissue’. (Genco ,1976)
• Subgingival curettage: Pocket epithelium and connective tissue are removed down to the crest of alveolar bone.
CONTRAINDICATIONSINDICATIONS
Can be done as a part of new attachment attempts in intrabony pockets
As a part of non-definitive therapy prior to other regenerative procedures
In medically compromised patients where other extensive flap surgeries are not indicated
As a part of maintenance therapy
Acute infections
Fibrous pockets
Pockets beyond MGJ
Furcation involvements
1989 World Workshop in Clinical Periodontics concluded that curettage had ‘no justifiable application during active therapy for chronic adult periodontitis’
Curettage is a procedure which provides historic interest in the evolution of periodontal therapy but has no current clinical relevance in the treatment of chronic periodontitis
• (AAP Academy Report 2002)
EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP)ENAP is the surgical procedure of which an internal bevel incision is made to remove the epithelial lining of the crevice and the junctional epithelium, allowing root preparation
Definitive subgingival curettage
Developed by the U.S Naval Dental Corps based on studies by Yukna (1976), Yukna and Fedi (1976)
Gain new attachmentDecrease probing depth
Access root surfaceMaintenance of esthetics
PROCEDURE
• Internal bevel incision from marginal gingiva to a point below the bottom of the pocket- to cut inner portion of soft tissue wall
• Remove excised tissue with a curette, root planing on exposed root preserving all CT fibers that are attached to root
• Approximate wound edges, bone recontouring if necessary
Author Studies Result
Yukna et al,1976 Excisional new attachment procedure was used to treat 75 suprabony pockets on 32 teeth in 9 patients
One-year postoperative -mean pocket reduction from 4.7 mm to 2.0 mm, of which 2.1 mm (77%) was new attachment and 0.6 mm was recession.
Yukna and Williams Jr,1980 Patients treated with the Excisional New Attachment Procedure were evaluated 5 years or more following the procedure
An overall mean net gain in clinical attachment of 1.5 mm was found at 5 years after treatment, and probeable depths approached 3.0 mm
LASER ASSISTED EXCISIONAL NEW ATTACHMENT PROCEDURE ( LANAP)
• Patterned after the Excisional New Attachment Procedure (ENAP), LANAP is designed to remove diseased and necrotic tissue selectively from within the periodontal sulcus
• The first pass with the laser (referred to as laser troughing) is accomplished by using the short duration pulse.
• Laser troughing affects sulcular debridement and de-epithelialization.
• Executed by moving the fiber continuously, beginning at the gingival crest and working back and forth systematically, stepping down to the base of the pocket.
• Following laser troughing, SRP is accomplished first by using a piezo-electric scaler
• Followed by small curettes and root files for removing root surface accretions. Aggressive root planing is minimized.
• A second pass, using the PerioLase with the 635- /sec “long pulse,” μfinishes debriding the pocket, completes removal of epithelial tissue, provides hemostasis, and creates a soft clot.
• The primary goal of LANAP is debridement to remove pocket epithelium and underlying infected tissue within the periodontal pocket completely and to remove calcified plaque and calculus adherent to the root surface
Clinical steps of LANAP, beginning with charting probe depths (A). The primary endpoint of LANAP is debridement of inflamed and infected connective tissue within the periodontal sulcus (B) Removal of calcified plaque and calculus adherent to the root surface (C). In addition, the bacteriocidal effects of the FR pulsed Nd:YAG laser plus intraoperative use of topical antibiotics are designed for the reduction of microbiotic pathogens (antisepsis) within the periodontal sulcus and surrounding tissues. A second pass with the 635 /sec “long pulse” laser finishes debriding the pocket (D). μGingival tissue is compressed against the root surface to close the pocket and aid with formation and stabilization of a fibrin clot (E). Oral hygiene is stressed and continued periodontal maintenance is scheduled. No probing is performed for at least six months.
GINGIVECTOMY
Pioneered by ROBISCEK(1884)
The excision of the soft tissue wall of a pathogenic periodontal pocket.( Grant et al,1979)
Pickerill (1912) - coined ‘gingivectomy’
Zentler (1918) - modified the Robicsek technique, proposed a scalloped incision
G o l d m a n ( 1 9 5 1 ) - described the current gingivectomy procedure
CONTRAINDICATIONS
Firm, fibrotic suprabony pockets ˃5mm, persisting after SRP
Gingival enlargements- pseudopockets
Suprabony abscesses
Presence of alveolar ledges, irregular margins
Infrabony pockets
Pockets extending beyond the MGJ
Anterior aesthetic areas
INDICATIONS
PROCEDURE
• Pocket marking
• Gingivectomy incision
• Knives- No. 12/15 blade, Blake knife, Kirkland, Orban,
• Goldman-Fox
• External bevel incision- at 45°, apical to base of pocket, continuous, scalloped
• Secondary incisions done with orbans knife.
• Tissue removal- Curette/scaler
• Root scaling and planing
• Periodontal dressing
Pocket marking
Gingivectomy incision
Tissue removal- curette /scaler Residual pocket
depth is assessed
LIMITATIONS
• Open wound, healing by secondary intention
• Zone of attached gingiva may be reduced/ eliminated
• Alveolar defects not revealed, if present
• Exposure of root -root sensitivity
FLAP SURGERY
• Periodontal flap is defined as ‘ the section of gingiva and/or mucosa surgically elevated from the underlying tissues to provide visibility and access to the bone and root surfaces’
GLICKMAN
RATIONALE
To enable visual instrumentation of root
surfaces
To re-establish the healthy, clinical status of periodontium
with long term maintenance
To restore the periodontal apparatus when attachment
loss has occurred
OBJECTIVES• Pocket elimination or reduction
• Preservation of adequate zone of attached gingiva
• To permit access to underlying bone for treatment of osseous defects
INDICATIONS
SPECIAL INDICATIONS
HISTORICAL BACKGROUNDNeumann (1911) 1st introduced mucoperiosteal flap- ‘Neumann flap’
Cieszynski (1911) Reverse bevel incision
Leonard Widman (1918) Modified the Neumann flap
Kirkland (1931) Modified flap procedure
Nabers (1954) Introduced ‘repositioning of attached gingiva’
Ariaudo and Tyrrell (1962) Modified Nabers procedure
Friedman (1962) Apically positioned flap
Morris (1965) ‘Unrepositioned mucoperiosteal flap’
Ramfjord and Nissle (1974) ‘Modified Widman flap’
CLASSIFICATION ( Carranza)
•Mucoperiosteal flapFULL
THICKNESS FLAP
•Split thickness; mucosalPARTIAL
THICKNESS FLAP
Based on flap placement after surgery
UNDISPLACED (NON-DISPLACED; UNREPOSITIONED)
• Eg: Modified Widman, undisplaced flap
DISPLACED (REPOSITIONED)
• Eg : Coronally positioned
• Laterally positioned
• Apically positioned
BASED ON THE MANAGEMENT OF PAPILLA
CONVENTIONAL FLAPS: modified widman flap, undisplaced flap, apically displaced flap, flap for reconstructive procedures
• Papilla is split at center under contact point and included in both buccal and palatal/lingual flaps
PAPILLA PRESERVATION FLAP
• Papilla is included in one of the flaps by semicircular incision
Classification ( Ramjford,1979)• According to the main purpose of the procedure
Pocket elimination flap
Reattachment flap surgery
Mucogingival repair.
• Widman flap, •The undisplaced (unrepositioned) flap•The apically displaced flap.
COMPARISON BETWEEN FULL THICKNESS AND PARTIAL THICKNESS
Full thickness Partial thickness
Healing Primary intention Secondary intention
Bone defect treatment possible difficult
Blood supply to flaps sufficient decrease
Elimination/ reduction of periodontal pocket
possible possible
Bleeding less much
Postoperative discomfort less much
Possibility of flap penetration
less much
Fixation of flaps Firm fixation with periosteal sutures
FLAP INCISIONS
HORIZONTAL INCISIONS
VERTICAL INCISIONS
HORIZONTAL INCISIONS
Directed along the margin of the gingiva in a mesial or a distal direction.
Two types of horizontal incisions have been recommended:
A) The internal bevel incision- starts at a distance from the gingival margin and is aimed at the bone crest.
B) The crevicular incision- starts at the bottom of the pocket and is directed to the bone margin.
C) The interdental incision - performed after the flap is elevated
INTERNAL BEVEL INCISION• First incision/ Reverse bevel incision
• Basic incision
Placement of internal bevel incision- depends
on the objective of treatment
• Removal of pocket lining : close to the gingival margin (0.5-1mm) - Modified Widman flap
• Removal of pocket lining and preservation of the keratinized gingiva : close to gingival margin- Apically displaced flap
• Removal of pocket lining and minimizing dead space formation : apical to bottom of pocket -Undisplaced flap
• PRIMARY INCISION DEPENDS ON:
Width of attached gingiva
Type of surgery
Esthetics
Osseous reconstruction ,If required
Depth of pockets
Clinical crown lengthening, if required
CREVICULAR INCISION
• Second incision
• Starts from base of pocket and is directed to alveolar crest
• Along with the first incision it produces a V shaped wedge of tissue
INTERDENTAL INCISION• Third incision
• Directed horizontally from the internal bevel incision to remove the wedge shaped tissue
VERTICAL INCISIONS• Given when flaps have to be displaced
• Directed perpendicularly to gingival margins at the line angles of teeth
• THEY SHOULD NOT BE PLACED :
Pronounced concavities
Prominent bony ledges
Exostoses
Should not cross root prominences
Should not split interdental papilla
• Best to include papilla with the flap to enhance blood supply and facilitate suturing
CORRECT INCISION
INCORRECT INCISION
THINNING I NCISIONS
• Internal/ undermining incisions extending from gingival margin towards base of flap to decrease bulk of connective tissue on the underside of flap
• Indicated in Palatal flaps, Distal wedge, Internal bevel gingivectomy, Bulky papillae
PERIOSTEAL RE LEASING INCISIONS
Incisions at base of flap severing underlying periosteum
INDICATED
to release flap tension allowing for coronal/ lateral placement,
to provide primary closure over barrier membranes in GTR and GBR procedures
FLAP TECHNIQUES FOR POCKET ELIMINATION
WIDMAN FLAP (Leonard Widman,1918)
Full thickness mucoperiosteal flap aimed at removing:
Pocket epithelium and the inflamed connective tissue
ADVANTAGES
Facilitates optimal cleaning of root surfaces
Less discomfort for the patient, healing occurs by primary intention
Re establish a proper contour of the alveolar bone in sites with angular bony defects
Two releasing incisions, scalloped reverse bevel incision connecting two
releasing incisionsCollar of inflamed gingival tissue is
removed after flap elevation
Bone recontouring suturing
NEUMANN FLAP,1920• Intracrevicular incision through the base of the gingival pocket
• Entire gingiva (and part of the alveolar mucosa) was elevated in a mucoperiosteal flap
• Sectional releasing incisions
• Flap elevation, the inside of the flap curetted to remove the pocket epithelium and the granulation tissue
• The root surfaces were subsequently carefully “cleaned”
• Any irregularities of the alveolar bone corrected to give the bone crest a horizontal outline
• Flaps trimmed to allow both an optimal adaptation to the teeth and a proper coverage of the alveolar bone on both the buccal/lingual (palatal) and the interproximal sites
• Flap replaced at crest of alveolar bone
KIRKLAND FLAP,1931• Modified flap operation- to be used in the treatment of “ Periodontal pus
pockets”.
• Incisions made intracrevicularly through the bottom of the pocket
• Retraction of the gingiva- debridement
• Elimination of the pocket epithelium and granulation tissue from the inner surface of the flaps
Intracrevicular incision Gingiva is retracted to expose the diseased root surface
Exposed root surfaces are subjected to mechanical debridement
Suturing
DIFFERENCE FROM NEUMANN AND ORIGINAL WIDMAN FLAP
Did not include-Extensive sacrifice of non inflamed tissues
Apical displacemnt of gingival margin
AdvantagesUseful in anterior regions for esthetic reasons
Potential for bone regeneration in intrabony defects
UNDISPLACED FLAP• Pocket elimination procedure using internal bevel incision. Also called as
INTERNAL BEVEL GINGIVECTOMY
• Pocket wall is eliminated with first incision
• Elimination of ‘dead space’ as the flap margin is place over bone crest postoperatively
• However, sufficient attached gingiva is a pre-requisite
• Usually used for pocket elimination of palatal pockets
The incision is made at the level of the pocket to discard the tissue coronal to the pocket if there is sufficient remaining attached gingiva.
APICALLY REPOSITIONED FLAP
Nabers(1954) – one vertical incision- ‘repositioning of attached gingiva’
Ariaudo and Tyrrell (1957) – two
vertical incisions
Friedman (1962) – coined the term
‘apically repositioned flap’
Apical displacement of entire mucogingival unit to eliminate the pockets while retaining the attached gingiva. To maintain keratinized gingiva
Surgical access for osseous surgery, treatment of infrabony pockets and root planing.
OBJECTIVES
USED FOR
The apically displaced flap technique can be used for(1) pocket eradication and/or
(2) widening the zone of attached gingiva. (3)crown lengthening procedures for cosmetic enhancement and
restorative treatment
Indicated in
• Mandibular buccal and lingual surfaces
• Maxillary buccal surfaces
It can be raised as
• Full thickness flap
• Partial thickness flap
Advantages
Reduction of probing depth,
Preserving or increasing the presurgical zone of gingiva,
Facilitation of healing, accessibility to bone, roots, furcations, subgingival caries, and other anatomical aberrations,
Controlling the tissue placement,
Usefulness in conjunction with other treatment modalities.
Disadvantages
Sacrifice of crestal alveolar process and supporting bone
Extensive exposure of root surfaces.
Vertical releasing incision, the reverse bevel incision is made through the gingiva and
periosteum to separate the inflamed tissue adjacent to the tooth
Mucoperiosteal flap is raised and the tissue collar remaining around the teeth, including the pocket epithelium and the
inflamed connective tissue is removed with a curette
Osseous surgery is performed with a rotating bur
Recapture the physiologic contour of the bone
Repositioned in an apical direction to level of the recontoured bone crest and retained by sutures
FRIEDMAN AND LEVIN CLASSIFICATION ,1962
Class I: More than adequate keratinized gingiva width
Labial or buccal incision 1-3mm from crest of gingiva.
Flap apically positioned to cover 1-2mm of cementum
Class II: Adequate keratinized gingiva
Crestal incision used.
Flap apically positioned to the crest of the bone
Class III- Insufficient gingival keratinized width
Sulcular incision
Flap is positioned 1-2mm below crest of bone to increase width of keratinized gingiva.
MODIFIED WIDMAN FLAP• Ramfjord and Nissle in 1974 coined the term modified Widman flap
• Procedure was employed by Morris in 1965 and was termed the unrepositioned mucoperiosteal flap.
• Morris in 1965 has described this flap as “the simple mucoperiosteal flap, combined with the inverted beveled incision and osseous resection.”
• Conservative flap design of which includes a reverse bevel incision from the marginal gingiva to the alveolar crest, the intrasulcular incision to the bottom of the pocket, and the horizontal incision from the alveolar crest to the bottom of the pocket.
• It is used whenever reattachment with minimal gingival recession is desired.
It is preferred in the case of
• Moderately deep pockets
• Moderate furcation involvement, and
Patient with a high caries rate and root sensitivity problem.
Initial incision is placed:0.5-1mm from the gingival margin
Parallel to long axis of tooth
Elevation of the flaps,Intracrevicular incision is made to alveolar bone
crestTo separate the collar tissue from root surface
Third incision is made:Perpendicular to root surface and
As close to possible to the bone crest thereby separating the tissue collar from alveolar
bone
Flaps are carefully adjusted to cover the alveolar bone and sutured
Complete coverage of the interdental bone as well as close adaptation of the flaps to the tooth surfaces should
be accomplished
Advantages:
• Possibility of obtaining close adaptation of soft tissues to root surfaces
• Less exposure of root surfaces – esthetic advantage in the anterior segments ( Ramfjord and Nissle,1974)
• SRP at base of deep pockets can be done with direct vision
• Complete removal of pocket epithelium
• Primary intention healing
• Esthetically superior to gingivectomy/ APF
Original Widman flap Modified Widman flap
Pocket elimination procedure Pocket reduction procedure
Apical displacement of flap No apical displacement
Osseous recontouring can be done
Not designed for osseous contouring
• Ramfjord and Nissle performed an extensive longitudinal study comparing the Widman procedure, as modified by them, with the curettage technique and the pocket elimination methods that include bone contouring when needed.
• The patients were assigned randomly to one of the techniques, and results were analyzed yearly up to 7 years after therapy.
• Similar results with the three methods tested.
• Pocket depth was initially similar for all methods but was maintained at shallower levels with the Widman flap;
• The attachment level remained higher with the Widman flap.
Laser-assisted modified Widman flap (LAMWF).• Pocket lining was removed with the help of a diode laser
• The laser setting used for this procedure was 4 W in continuous mode.
• Crevicular incision was given with a bard parker # 15 blade directed toward the alveolar crest. Full thickness mucoperiosteal flap was raised buccally and lingually. The granulation tissue was removed from the defects by manual debridement
• Reduction in probing depth was from 11 mm to 6 mm
• Radiographs revealed increased bone fill
PAPILLA PRESERVATION FLAP( Takei et al,1985)• To preserve the interdental soft tissues for maximum soft tissue coverage
involving treatment of proximal osseous defects
• Cortellini et al. (1995, 1999) – modifications of the flap design to be used in combination with regenerative procedures.
• For aesthetic reasons, it is often utilized in the surgical treatment of anterior tooth regions
Sulcular incision Semilunar incision- dip 5mm apically from line angles
Papilla elevated in facial flap
suturing
Modified papilla preservation (Cortellini et al, 1995)
• Access to the interdental defect consists of a horizontal incision buccal keratinized gingiva at the base of the papilla
• Connected with mesio-distal buccal intrasulcular incisions for elevation of full-thickness buccal flap
• Residual interdental tissues are dissected from neighboring teeth and the underlying bone and elevated towards the palatal aspect
• Elevation of full thickness palatal flap, including the interdental papilla, interdental defect exposure
• Debridement of the defect
• Buccal flap is mobilized with vertical and periosteal incisions, when needed
Simplified papilla preservation( Cortellini et al,1999)
• To overcome technical problems encountered with the MPPT
Difficult application in narrow interdental spaces and in posterior areas
Suturing technique not appropriate for use with non supportive barriers
Modified papilla preservation is used in wide interdental spaces (>2mm ) especially in anterior dentition.
Sulcular incisions and buccal flap elevation
Palatal flap reflection
Oblique incision in papilla begins at the gingival margin line angle, blade parallel to the long axis of
the tooth and reaches the midpoint of the distal surfaceof adjacent tooth below the contact point
PALATAL FLAPS• Palatal flaps historically involved reflecting full thickness flap to remove
necrotic and granulomatous tissue.
Advantages of palatal approach-EstheticsEasier access for osseous surgeryLess resorption because of thicker boneWider palatal embrasure spaceA natural cleansing area.
Oschenbein and Bohannan(1963,1964) described a palatal approach for osseous surgery
Indications-
• Areas that require osseous surgery
• Pocket reduction
• Reduction in enlarged bulbous tissue
Contraindications-
• Broad shallow palate- damage to palatal vessels
Palatal pocket elimination procedures• Full thickness
• Partial thickness
• Modified partial thickness
• Beveled flap
• Undisplaced flap
PARTIAL THICKNESS PALATAL FLAP
• Developed by Staffileno et al (1969)
Objectives: To facilitate treatment of palatal osseous defects
To overcome problems of extensive gingival recession
AdvantagesMinimal trauma
Rapid healingEase of palatal tissue manipulation
Establishment of favorable gingival contours
MODIFIED PARTIAL THICKNESS PALATAL FLAP
• Oshenbein(1958) ,Oshenbein and Bohannan(1963) described the technique
• Popularized by Prichard( 1965)
• Also known as LEDGE AND WEDGE TECHNIQUE
• Stage I : Gingivectomy
But no bevel
tissue ledge is created
• Stage II : Partial thickness flap
• Primary partial thickness thinning incision
• Secondary incision - inner flap removal
BEVELED FLAP- MODIFICATION OF THE APF
Primary incision is made intracrevicularly
Scaling, root planing and osseous recontouring
Shortened and thinned flap replaced over the alveolar bone
Secondary, scalloped reverse bevel incision is made to adjust to the height of the remaining alveolar bone
DISTAL MOLAR SURGERY• Treatment of periodontal pockets on the distal surface of distal molars is
complicated by the presence of bulbous tissues over the tuberosity (maxillary) or by a prominent retromolar pad (mandibular)
Factors to be considered for distal-molar surgery
• Pocket depth
• Amount of keratinized gingiva
• Accessibility
• Available distance from distal aspect of tooth to the end of tuberosity/ retromolar pad
• Anatomic considerations : Lingual nerve, Internal oblique ridge, Muscle attachments
DISTAL WEDGE PROCEDURE ( ROBINSON,1966)
INDICATIONS
• When only limited amounts of keratinized gingiva is present
• Presence of distal angular bony defect
Facilitates access to osseous defectPreserves sufficient amounts of gingiva and mucosa to
achieve soft tissue coverage
Buccal and lingual vertical incisions through the retromolar
pad to form a triangle behind mandibular molar
Triangular shaped wedge of tissue is dissected from the
underlying bone and removed
Flaps are reduced in thickness by undermining incisions
Suturing
FOR MANDIBULAR MOLARSIncisions are governed by location of keratinized gingiva
Incisions :
• Triangular wedge
• Square, parallel or H design
• Linear or pedicle
FOR MAXILLARY MOLARS
Simpler compared to mandibular as more fibrous and attached tissue is generally present
Incisions may be
• Triangular wedge
• Linear wedge
ADVANTAGES OF DISTAL WEDGE • Maintenance of attached tissue
• Access for treatment of both the distal furcations and underlying osseous irregularities
• Closure by a mature thin tissue which is especially important in retromolar area
• Greater access and opening when done in conjunction with other flap procedures
OSSEOUS SURGERY• Principles outline by Schluger(1949) and Goldman( 1950)
• “Gingival contour is dependent on the underlying bony contour and the elimination of the soft tissue pockets has to be combined with osseous recontouring”.
• To maintain
Shallow pockets
Optimal gingival contour after surgery
OSTEOPLASTY- FRIEDMAN (1955)
• Reshaping of alveolar bone to achieve a more physiological form without removal of tooth supporting bone
Indications
• Buccal/ lingual bony
• ledges
• Intrabony defect-buccal/lingual,
• tilted molars
• Interproximal defects
• Furcation involvement
OSTECTOMY
Removal of tooth supporting bone to reshape the deformities.
INDICATIONS :
• Elimination of interdental craters
• Correction of one walled defects
• Other angular defects not amenable to regeneration
• Horizontal alveolar bone loss with irregular marginal contours
Healing after flap surgery
• Immediately after suturing (up to 24 hours)- a connection between the flap and the tooth or bone surface is established by a blood clot,
• 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, usually contacting the tooth at this time.
• One week after surgery- an epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina.
The blood clot is replaced by granulation tissue
• Two weeks after surgery- collagen fibers begin to appear parallel to the tooth surface.
• One month after surgery- a fully epithelialized gingival crevice with a well-defined epithelial attachment is present.
Beginning functional arrangement of the supracrestal fibers
• 1 to 3 days- Full-thickness flaps, result in a superficial bone necrosis.
• 4 to 6 days- Osteoclastic resorption follows .Loss of bone of about 1 mm and the bone loss is greater if the bone is thin.
• If Osseous remodeling does not include excessive thinning of the radicular bone. Bone repair reaches its peak at 3 to 4 weeks.
LONG TERM STUDIES COMPARING SURGICAL AND NON- SURGICAL
THERAPIES
MICHIGAN STUDIES
Ramfjord et al. (1968)32 patients with moderate-severe periodontitis
all patients 1st received nonsurgical therapy and then divided into
Group 1: subgingival curettage
Group II: pocket elimination (gingivectomy, APF with osseous resection)
Short term observations (1-3 yrs)
• Group 1: slight gain in CAL
• Group II : loss of attachment following pocket elimination procedures
Long term evaluation (4-7 yrs)
• No significant differences between the 2 groups
• Surgical technique – reduction in PD was greater and better sustained
Knowles et al. (1979)78 patients evaluated over 1-8 yrsEffect of subgingival curettage, Modified Widman flap and pocket
elimination procedureResults:All techniques reduced PD with subgingival curettage being the
least effectiveModerate pockets (4-6 mm)- similar CA gainAdvanced pockets (7-10mm)- Modified Widman produced greatest
gain in CA, followed by curettage and pocket elimination
GOTHENBURG STUDIES
Lindhe et al. (1982)15 patients, split mouth study
SRP alone vs. SRP + Modified Widman Results at 2 yrs demonstrated that surgical therapy results in
greater probing depth reduction than nonsurgical therapy
CRITICAL PROBING DEPTHRoot planing : 2.9 mmFlap : 4.2 mm
MINNESOTA STUDY
Pihlstrom et al. (1985)SRP alone vs. flap in 6 ½ yr follow up No significant difference in probing depth reduction and
gingival inflammationAlthough attachment gain seemed to be greater with flap
procedures for deeper pockets.
AARHUS STUDY
Isidor and Korning (1986) Root planing and Modified Widman flap to apically positioned
flap during 5 year of follow up obtained similar results for both the treatment.
WASHINGTON STUDY
Oslen et al (1985) compared apically positioned flap without osseous
recontoring to a.p.f. with osseous recontouring in a 5 year follow up study.
osseous recontouring was more effective in reducing pockets and controlling the inflammation than flap surgery
TUCSON STUDIES
Becker et al. (1988)
Root planing, Modified Widman flap, apically positioned flap with osseous surgery
1 yr observation period – minimal differences in probing depth reductions and attachment gain between the 3 procedures
NEBRASKA STUDIES
Kaldahl et al. (1988)
82 patients, split mouth design study for 2 yrs
SRP vs. Modified Widman flap vs. Modified Widman flap with osseous resection
All resulted in decrease in PD
Greatest with flap with osseous resection, followed by Modified Widman flap and SRP
INTERPRETATION OF LONGITUDINAL STUDIES
Non-surgical therapy is the “corner stone of periodontal therapy” in all types of pocket depths.
Surgical techniques have produced greater pocket depth reduction
No difference on long term evaluation
Thus, SRP will always be performed first for any patient with periodontitis
Modified widman flap, osseous surgery and scaling
• Clinical probing depth and clinical attachment levels evaluated.
• Modified widman flap gave better results for gain in clinical attachment ,while all three modalities significantly reduced probing depth.
( Becker et al,2001)
Modified widman flap vs root planing ( Lindhe et al,1982)
• Effect of root planing alone and with a modified widman flap
• Assessment of resultant level of attachment and in relation to initial pocket depth
• SRP- loss of attachment in pocket shallower than 2.9mm
• Gain of attachment in deeper pockets
Modified widman flap- loss of attachment in pockets shallower than 4.2mm
Gain of attachment in deeper pockets
Loss of attachment implies true loss of connective tissue
Gain- could be false
Failures of flap surgery
• Pre therapeutic causes
• Therapeutic causes
• Post therapeutic causes
PRE THERAPEUTIC CAUSES
1) Incorrect patient selection
2) Improper diagnosis
Systemic condition
Type of periodontitis
Involvement of hopeless tooth
Oral hygiene assessment
3) Inappropriate dental restorations
4)Morphology of tooth surfaces
Failure to eliminate aberrations like enamel pearls and grooves which act as a “guide plane” for a bacterial penetration of deeper periodontal tissues
5)Habits
mouth breathing
bruxism
thumb sucking
Smoking
6)Occlusal trauma
THERAPEUTIC CAUSES
Improper selection of surgical technique :
• width of attached gingiva
• height of remaining bone
• pocket depth
• mobility
• co-operation of the patient
• patients systemic back ground
• decreased width of attached gingiva- internal bevel incision will further decrease the width of attached gingiva leading to mucogingival problems
• Surgical technique which does not allow proper adaptation of interdental tissue will lead to food and plaque accumulation in the interproximal area and therapy leads to recurrence of periodontal disease
• Improper asepsis of the surgical field and patient, improper sterilization of the instruments
Improper flap design:
• A properly designed flap will anatomically fall into its correct position on its bony base following surgery
• If a mucoperiosteal flap is not designed correctly it may
Rise too high coronally- redundant tissue with subsequent repocketing
Fall far short of the osseous margin- resorption or sequestra formation
Inadequately cover the bone graft- minimizing the opportunity for ideal healing
• Inadequate thinning of the full thickness flap (palatal flap), results in an excessively thick bulky gingival margin -gingivoplasty
• It may also encourage the overzealous tightening of the sutures, thereby endangering the blood supply and enhancing the possibility of sloughing of flap and post operative pain
Incomplete debridement
Improper suturing
• Improper incision: the rationale of any periodontal flap surgery is to gain access to underlying root and bone surfaces.
• If incisions are not made upto the bone/root surface and a mucosal flap is elevated which hinders in gaining proper access to the underlying root surfaces, It can cause increased amount of bone resorption.
• Therefore while giving incision the blade should hit the bone in order to elevate a full thickness flap.
• REFLECTION OF THE FLAP: elevation of the periodontal flap should be such that only around 1 mm of marginal bone is exposed.
Over reflection - bone resorption,
Under reflection - limited access to the underlying root/bone surface.
• DEBRIDEMENT OF THE ROOT SURFACES AND THE BONE: complete debridement with removal of plaque and calculus from the root surface
• SUTURING of the separated flaps should be done to closely adapt the flap to the tooth margins.
Failure to properly place the sutures gaping of the wound and hence recurrence of the disease
POST THERAPEUTIC CAUSES
Unsupervised healing :
• Post-operative care
Inadequate restorations post surgically :
• failure to replace missing teeth
• correct overhanging restorations
• correct carious lesions
FAILURES ASSOCIATED WITH PALATAL FLAPS
The flap may be too short. This results in delayed healing & increased patient discomfort.
Poor marginal flap adaptation caused by incomplete thinning of the tissue.
Damage to the palatal artery- Incision beyond the vertical height of the alveolus, bringing the scalpel blade close to the palatal artery
Extension beveling or thinning of tissue on a low, broad palate.
Tissue placement to high onto the teeth results in poor flap adaptation & recurrent pocket formation.
Selection of technique???
• Suprabony, fibrous pocket with sufficient attached gingiva- Gingivectomy
• Infrabony pocket, osseous deformities, furcation involvement, muco-gingival problems- Flap surgery
• Location
Amount of attached gingiva
Need for osseous recontouring
TREATMENT FOR GINGIVAL POCKETS• Pocket wall can be
Edematous & soft
Fibrotic
• Edematous pockets shrink after elimination of local factors. Therefore scaling & root planing and curettage is the preferred treatment.
• Fibrotic pockets do not subside predictably after S.R.P. Hence preferred method is gingivectomy
TREATMENT FOR PERIODONTAL POCKETS
Therapy for pockets with horizontal bone loss
• N.S.T
• Surgical therapy if required
Therapy for pockets with vertical bone loss
• N.S.T
• Surgical therapy to eliminate the bone defect by resection or regeneration
Anterior areas• Scaling and root planing is the technique of choice
• PAPILLA PRESERVATION FLAP- improved accessibility for root surfaces
regenerative surgery of osseous defects
• Results in less recession and reduced soft tissue crater formation interproximally
• SULCULAR INCISION FLAP- teeth too close interproximally
• MODIFIED WIDMAN FLAP- esthetics not the primary consideration
• APICALLY DISPLACED FLAP with bone recontouring
Posterior areas• Osseous surgery required for enhanced accessibility or the need of
definitive pocket elimination
• Accessibility- undisplaced flap/ apically displaced flap
• Osseous defects amenable to reconstruction- papilla preservation flap
sulcular flap
modified widman flap
• Osseous defects with no possibility of reconstruction- flap with osseous recontouring
Excisional surgeries
Resective surgery
Regenerative procedures
• Tissue attachment procedures , although not capable of generating predictable new attachment, are effective in controlling the progression of chronic periodontitis.
• The patient and the dentist have an option between flap debridement procedures and other debridement approaches to control disease progression.
• Choice must be made upon a multitude of factors including clinical expertise, systemic and local etiologic factors, time and economic factors.
Among the tissue attachment procedures, FLAP DEBRIDEMENT SURGERY remains an important part of
periodontal therapy.
Thank you
Top Related