The most abundant cells during the initial healing phase are the neutrophils. Flap surgery is today's leading method for treating and repairing periodontal pockets. Triangular Pocket reduction surgery is an attempt to alleviate this destructive cycle and reduce the depth of the bacteria-harboring pockets. 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. Contents available in the book ……. 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. The internal bevel incisions are typically used in periodontal flap surgeries. Today's highly sophisticated and meticulous techniques allow the periodontal surgeon to reconstitute, regenerate, and reconstruct lost and destroyed tissues. Definition “A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility and access to the bone and root surface. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. Displaced flap: An internal surgical opening is used to access the affected gum tissues to create and raise a “flap” of gum tissue, similar to opening the flap of an envelope, aimed at the conservation of all healthy tissue. 7. 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. May increase the risk of root caries. The area is then irrigated with normal saline and flaps are adapted back in position. Contents available in the book …….. This incision is not indicated unless the margin of the gingiva is quite thick. The incision is started from the greatest scallop of the gingiva around the tooth, which is usually present little distal to the mid-axis of the tooth in case of maxillary incisors and canines. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. In areas with thin gingiva and alveolar process. The main objective of periodontal flap surgical procedures is to allow access for the cleaning of the roots of teeth and the removal of the periodontal pocket lining, as well as to treat the irregularities of the alveolar bone, so that when gingiva is repositioned around the teeth, it will allow for the reduction of pockets, infections, and inflammation. Minor osseous recontouring may be done and the flap is then adapted into the interdental areas. The internal bevel incision may be a marginal incision (from the top of gingival margin) or para-marginal incision (at a distance from the gingival margin). Contents available in the book ……. Modified flap operation, After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. If the disease can't be controlled by non-surgical treatments like cleaning and scaling, then periodontal Periodontal flaps can be classified as follows. Some clinicians prefer curettes (Molt 2 curette) or chisels (Ochsenbein No. If the disease can't be controlled by non-surgical treatments like cleaning and scaling, then periodontal flap surgery may be your best treatment option. Contents available in the book ……. Following is the description of marginal and para-marginal internal bevel incisions. Clinical crown lengthening in multiple teeth. This is a commonly used incision during periodontal flap surgeries. It is an access flap for the debridement of the root surfaces. In 1973, App 25 reported a similar technique and termed it as ‘Intact Papilla Flap’ which retained the interdental gingiva in the buccal flap. This incision is indicated in the following situations. The presence of thin gingiva which does not allow placement of adequate initial internal bevel incision. The incision is usually started at the disto-palatal line angle of the last molar and continued forward using a scalloped, inverse-beveled, partial-thickness incision to create a thin partial-thickness flap. Areas where post-operative maintenance can be most effectively done by doing this procedure. Severe hypersensitivity. 15c, 11 or 12d. In this technique, two incisions are made with the help of no. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. Contents available in the book …….. Modified Widman flap, Left untreated, they can cause a host of problems … (1985) 26 modified this procedure to preserve anterior esthetics after flap surgery. The flaps are then apically positioned to just cover the alveolar crest. To overcome the problem of recession, papilla preservation flap design is used in these areas. In the upcoming chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of lost periodontal structures. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. May cause hypersensitivity. Contents available in the book ……….. And even if you're prone to gum disease, proper professional treatment and regular care at home can help keep your teeth healthy for as long as possible. It is indicated where complete access to the bone is required, for example, in the case of osseous resective surgeries. The flap is then elevated with the help of a small periosteal elevator. After it is removed there is minimum bleeding from the flaps as well as the exposed bone. In the following discussion, we shall study in detail, the surgical techniques that are followed in various flap procedures. And even if you're prone to gum disease, proper professional treatment and regular care at home can help keep your teeth healthy for as long as possible. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective. In this flap, only epithelium and the underlying connective tissue are reflected, leaving the periosteum intact. 6. The Goals of Flap Surgery . The vertical incision should always be placed at the line angles of the teeth and never (except rare instances, such as a double papilla flap) over the height of contour of the root. Contents available in the book …….. The deposits on the root surfaces are removed and root planing is done. Root planing is done followed by osseous surgery if needed. The base of the flap should be wider than the flap margin so that the blood supply to the flap is not jeopardized. 4. The crevicular incision is then placed from the bottom of the pocket till the alveolar crest. The triangular wedge of the tissue made by the above three incisions is then removed with the help of curettes. Contents available in the book …….. 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. Periodontal pockets in areas where esthetics is critical. 11 or 15c blade. Contents available in the book …….. Regeneration of lost bone and periodontal ligament. The secondary incision is given from the depth of the periodontal pocket till the alveolar crest. This approach was described by Staffileno (1969) 23. The triangular wedge technique is used in cases where the adequate zone of attached gingiva is present and in cases of short or small tuberosity. Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. Contents available in the book …….. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. 5. Otherwise, the periodontal dressing may be placed. The flaps are then replaced to their original position and sutured using interrupted or continuous sling sutures. This is a commonly used incision during periodontal flap surgeries. Endodontic Topics. Normal interincisal opening is approximately 35-45 mm, with mild ……. The granulation tissue is highly vascularized, so it bleeds profusely. Periodontitis is a disease that attacks the supporting tissues of the tooth. Periodontal flap surgery describes the state of-the-art techniques and most commonly used approach to the surgical treatment and plastic surgical repair of periodontal pockets. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. Contents available in the book ……….. Trismus is the inability to open the mouth. Contents available in the book …….. For regenerative procedures, such as bone grafting and guided tissue regeneration. Contents available in the book …….. Flap is returned and Sutured in its original position • Currently,It is the most commonly performed type of periodontal surgery. A small periosteal elevator or Molt 2/4 curette can be used for this purpose. Journal of clinical periodontology. Flap surgery is especially helpful for people who have tartar deposits in deep pockets. In areas with deep periodontal pockets and bone defects. The factors that are associated with post-operative swelling include the type of the incision, its extension, tissue manipulation during the surgery and the duration of surgery. The objectives of periodontal flap surgery are to: Current surgical flap techniques are based on a sound understanding of wound healing and are therefore designed to enhance and maximize the body's healing potential. A. b. Papilla preservation flap. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort. 1. Papillae are then sutured with interrupted or horizontal mattress sutures. 3. The full-thickness mucoperiosteal flap procedure is the same as that described for the buccal and lingual aspects. In this flap procedure, no ostectomy is performed; however, minor osetoplasty may be done to modify the undesired bony architecture. Contents available in the book ……. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort. These bacteria cause inflammation of the tissues, resulting in sensitivity, bleeding, and pain. 1. It conserves the relatively uninvolved outer surface of the gingiva. The area is re-inspected for any remaining granulation tissue, tissue tags or deposits on the root surfaces. Periodontal Associates has been serving the Harrisburg and Hershey areas for more than 30 years, providing state of the art periodontal and dental implant … It is caused by trauma or spasm to the muscles of mastication. Contents available in the book …….. Contents available in the book ……. Contents available in the book ……. These are indicated in cases where interdental spaces are too narrow and when the flap needs to be displaced. This is also known as “Ledge-and-wedge technique”. The bleeding is frequently associated with pain. Reasons for the pocket reduction surgery Flap for regenerative procedures. Crown lengthening procedures to expose restoration margins. A vertical incision may be given unilaterally (at one end of the flap) or bilaterally (on both ends of the flap). Left untreated, they can cause a host of problems including gum disease, loss of the tooth-supporting bone structure, and possibly even systemic (whole-… Periodontal pockets in areas where esthetics is critical. Flap surgery isn't a cure for periodontal disease — but it helps create an environment that makes it easier to maintain your periodontal health. The operated area will be cleaner without dressing and will heal faster. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. 3. According to flap reflection or tissue content: If a full-thickness flap has been elevated, the sutures are placed along the mesial and the distal vertical incision lines to. As described in “History of surgical periodontal pocket therapy and osseous resective surgeries” the palatal approach for ……. 2. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. 1 and 2), the secondary inner flap is removed. A full-thickness flap is then elevated to expose 1-2 mm of the marginal bone. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. If detected, they are removed. The Goals of Flap Surgery . The average retail price of gum flap disinfection ranges from $4,000-$6,000 but can run higher for patients with extensive damage. Periodontal maintenance (Supportive periodontal therapy), Orthodontic-periodontal interrelationship, Piezosurgery in periodontics and oral implantology. 3. The secondary. The periodontal dressing is not required if the flap has been adapted adequately to cover the interdental area. Contents available in the book …….. Tooth with extremely unfavorable clinical crown/root ratio. Suturing is then done using a continuous sling suture. The narrow width of attached gingiva which may further reduce post-operatively. Hence, this suturing is mainly indicated in posterior areas where esthetics. Placement of the vertical incisions is absolutely essential in cases where the flap has to be re-positioned coronally (coronally displaced flap) or apically (apically displaced flap) from its original position. Contents available in the book …….. During this whole procedure, the placement of the primary incision is very important because if improperly given it may become short, leaving exposed bone or may become longer requiring further trimming which is difficult. The initial or the first incision is the internal bevel incision given not more than 1 mm from the crest of the gingiva and directed to the crest of the bone. This flap procedure utilizes two incisions referred to as primary and secondary incisions which contain tissue which has to be removed. Contents available in the book ……. Takei et al. Once bone sounding has been done, a gingivectomy incision without bevel is given using a periodontal knife to remove the tissue above the alveolar crest. Flap surgery isn't a cure for periodontal disease — but it helps create an environment that makes it easier to maintain your periodontal health. The primary objective of the flap surgeries is to gain access to the root surfaces and bone defects so that the deposits on the root surfaces can be eliminated and the granulation tissue can be removed. Contents available in the book ……….. Tooth with marked mobility and severe attachment loss. The first step ……. After healing, the resultant architecture of the area should enhance the ease and effectiveness of self-performed oral hygiene measures by the patient. (1995, 1999) 29, 30 described ……. Swelling is another common complication after flap surgery. Contents available in the book ……. The triangular wedge of the tissue, hence formed is removed. 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. Flap surgery isn't a cure for periodontal disease — but it helps create an environment that makes it easier to maintain your periodontal health. This incision is always accompanied by a sulcular incision which results in the formation of a collar of gingival tissue which contains the periodontal pocket lining. A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces 1. 6. The primary incision is placed with the help of 15c blade, but in case of limited access, blade 12 d can be used. This is especially important because, on the palatal aspect, osseous deformities such as heavy bone ledges and exostoses are commonly seen. The Goals of Flap Surgery . The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. The modified Widman flap procedure involves placement of three incisions: the initial internal bevel/ reverse bevel incision (first incision), the sulcular/crevicular incision (second incision) and the horizontal/interdental incision (third incision). Fundamental principles in periodontal plastic surgery and mucosal augmentation–a narrative review. Sulcular incision is now made around the tooth to facilitate flap elevation. The vertical incision must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. When the flap is placed apically, coronally or laterally to its original position. Contents available in the book ……….. Contents available in the book …….. Interrupted or continuous sling sutures are then placed to secure the flaps in their place. Unrealistic patient expectations or desires. It can be used in combination with other procedures such as osseous resection, regenerative procedures, hemisection procedure and procedures involving wedge excision. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3 mm. The main causes for the bleeding include intrinsic trauma to the operated site, even after repeated instructions patients tend to play with the area of surgery with their tongue and dislodge the blood clot, tongue may also cause suction of blood by creating small negative pressures that cause secondary bleeding, presence of foreign bodies, infection, salivary enzymes may lyse the blood clot before it gets organized and slippage of suture. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. 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. Treatment is based on an understanding of the disease process, the interaction between the bacterial biofilm or plaque collections at the gum line and the immune (resistance) system in a person susceptible to (likely to get) this disease. The bleeding may range from a minor leakage or oozing, to extensive or frank bleeding at the surgical site. b. Split-thickness flap. This procedure cannot be done on the palatal aspect as it has attached gingiva which cannot be displaced apically. As described in, Image showing primay and secondary incisions used in ledge and wedge technique. Treatment is therefore aimed at controlling the basic cause — the bacterial biofilm — over a lifetime. At last periodontal dressing may be applied to cover the operated area. The procedure involves lifting the gums off of the teeth to remove tartar buildup. The soft tissue is then retracted with tissue forceps and the scoring incision is given to separate the periosteum from the bone. The reduction of bacterial load and inflammation minimizes further loss of tooth-supporting structures and thus aid in the better prognosis of teeth, provided, the patient stays on a strict maintenance schedule. In the present discussion, we shall study in detail, the current concepts and advances in various periodontal flap surgeries. The first incision or the internal bevel incision is then made from the bleeding points directed at an apical level to the alveolar crest. In the present discussion, we discussed various flap procedures that are used to achieve these goals. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. Areas with sufficient band of attached gingiva. 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. 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