Perio flap procedures

Question 1

forms of tissue attatchment healing

Answer 1

regen
new attatchment
reattatchment
repair

Question 2

regen

Answer 2

Reproduction or reconstitution of a lost or injured part. New alveolar bone ,cementum, and periodontal ligament are formed restoring new architecture and function of the attachment apparatus. (Example of a bone replacement grafting procedure.)

Question 3

new attatchment

Answer 3

The union of connective tissue with a root surface that has been deprived of its original attachment apparatus. i.e. Reunion of connective tissue with a root surface which has been pathologically exposed.(Example of a connective tissue graft to cover an area of root recession

Question 4

reattatch

Answer 4

The reunion of connective
tissue with a root surface on which viable periodontal ligament tissue is present. (Example is where biologic width (now termed supracrestal tissue attachment) existed before a flap was reflected and when the flap is replaced, reattachment occurs with the intact connective tissue fibers

Question 5

repair

Answer 5

Repair: The healing of a wound that does not fully restore the architecture or function of the part. (The primary example is healing by a long junctional epithelium. This is the body’s protective healing to prevent ankylosis and root resorption.

Question 6

Full thickness flap:

Answer 6

Full thickness flap: all soft tissue
including the periosteum is reflected
exposing the underlying bone. (Most
commonly used flap, and also called a mucoperiosteal flap.)

Question 7

Partial (split) thickness flap:

Answer 7

epithelium and some connective tissue is reflected, leaving periosteum and some connective tissue overlying the bone.

Question 8

Principles of Tissue Attachment:
 Preparation of?
 Preparation of root?
 Debridement of?
 Adaptation of soft tissue to?
 Control of?

Answer 8

 Preparation of soft tissue wall (not necessary as a separate procedure! It is accomplished in conjunction with scaling.)
 Preparation of root surface *
 Debridement of bony defects
 Adaptation of soft tissue to root surface **
 Control of etiology pre- and post-surgery***

Question 9

Root Changes Hindering Tissue Attachment

Answer 9

 Foreign body nature of exposed diseased root surfaces (presence of endotoxin)
 Endotoxin adsorbed on and into cementum
 Pathologic changes in root surface (hypo- and hypercalcification areas)
 Decreased organic material in exposed cementum (loss of fibers and alterations in the organic material related to endotoxin)

Question 10

Therapeutic End Point: Success

Answer 10

 A functional, comfortable, healthy
dentition with stable probing
atttachment levels

Question 11

ENAP:

Answer 11

ENAP: Removal of the connective
and epithelial attachment circumferentially with a scalpel

Question 12

Gingivectomy:

Answer 12

The excision of the soft tissue wall of the periodontal pocket. The incision forms an external bevel or surface
that is exposed to the oral cavity

Question 13

Gingivoplasty:

Answer 13

Gingival deformities are reshaped and reduced to create a normal and functional form. The incision creates an external bevel.

Question 14

Gingivectomy Indications
 pockets

Answer 14

 Elimination of suprabony pockets which can’t be adequately debrided without tissue removal.
 Elimination of suprabony pockets if the pocket wall is fibrous and firm and therefore will not shrink after non-surgical therapy.
 Access for restorative with suprabony pockets.

 These three indications are usually corrected by flap surgery for access.

Question 15

Gingivectomy Indications
 Elimination of?
 topogrpahy?
 Exposure of?

Answer 15

 Elimination of gingival enlargements (most common indication for gingivectomy).**
 Elimination of asymmetrical or unesthetic gingival topography (gingivectomy and/or gingivoplasty).
 Exposure of unerupted teeth when adequate keratinized tissue is present

Question 16

Gingivectomy Contraindications
 Access is needed to?
 Base of pocket? or?
 inflammation?
 Esthetics?
 Anatomical preclusion?

Answer 16

 Access is needed to infrabony defects.
 Base of pocket is apical to MG junction, or when keratinized tissue is inadequate so that a gingivectomy would remove all of the keratinized tissue.
 Severely inflamed tissue (needs scaling and root planing)
 Esthetics (anterior maxilla)
 Anatomical preclusion (lack of keratinized tissue)

Question 17

Gingivectomy Advantages and
Disadvantages
 Advantages

Answer 17

 Relatively simple and fast

Question 18

Gingivectomy Disadvantages
 Limited?
 healing period?
 post-op?
 Less effective than?

Answer 18

 Limited applicability (suprabony defects)
 Longer healing period (4-5 weeks)
 More post-operative discomfort
 Less effective than flap surgery (no access to osseous defects)

Question 19

Gingivectomy Technique
Marking of?
Resection of the gingiva with
incision starting?

Answer 19

Marking of the pocket depth.
Resection of the gingiva with incision starting apical to pocket base and externally beveled at a 45° angle

Question 20

Gingivectomy Technique
 Bone exposure?
 Complete removal of?
 Thick tissue will require?
 Can do via ?.

Answer 20

 Bone exposure is to be avoided.
 Complete removal of pocket if possible.
 Thick tissue will require a more apical start of the incision.
 Can do via internal bevel incision, but it is more difficult to accomplish.

Question 21

Gingivectomy Technique
 Removal of?
 Debridement of any? and?
 Post-surgical control of bleeding?

Answer 21

 Removal of tissue.
 Debridement of any granulation tissue and root debridement.
 Post-surgical control of bleeding.
Hemostasis by pressure or external clotting aid. Periodontal pack may be needed for tissue protection during post-op function

Question 22

Open Flap Debridement

Answer 22

 Surgical debridement of the root surface and removal of granulation tissue from osseous defects following reflection of a mucoperiosteal flap.

Question 23

open flap debride mods anterior

Answer 23

Modified Widman
 Curtain procedure (maxillary anteriors

Question 24

Open Flap Objectives
 Access to?
 Preserve?
 Reduction or elimination of ?
 Minimize?
 Improved for better patient home care?

Answer 24

 Access to root surface and osseous defects.
 Preserve osseous support.
 Reduction or elimination of periodontal pockets.
 Minimize post-surgical pain, root sensitivity, and esthetic compromise.
 Improved access for better patient home care

Question 25

Open Flap Indications
 dx state?
 Where what is possible?
 To preserve?
 As an? or as part of?
 post-operative discomfort?

Answer 25

 Advanced disease where access is needed to root surfaces and osseous defects.
 Where regeneration may be possible.
 To preserve tissue for esthetics.
 As an exploratory procedure or as part of the non-surgical phase of treatment for fibrous tissue.
 Less post-operative discomfort.

Question 26

Open Flap Contraindications
 Patient is unable to?
 Increased tissue recession may result in?
 Potential of?

Answer 26

 Patient is unable to tolerate a surgical procedure.
 Increased tissue recession may result in esthetic compromise.
 Potential of root caries and root sensitivity due to greater root exposure post- surgically

Question 27

open flap techniques
 Intrasulcular incisions?
 Papillas are thinned ?
 Mucoperiosteal flap?
 Vertical incision use?
 Palatal incisions are placed dependent on?
 Root surface and osseous defect?
 Flap closure postioning?
 Suturing?

Answer 27

 Intrasulcular incisions (step-back incisions not indicated since they are ineffective).
 Papillas are thinned to a uniform thickness.
 Mucoperiosteal flap is reflected.
 Vertical incisions can be used.
 Palatal incisions are placed dependent on the extent of the defects and amount of pocket reduction planned.
 Root surface and osseous defect debridement.
 Flap closure with apically positioning.
 Suturing

Question 28

open flap mods
 osteoplasty use?
 Positioning of flaps in relation to?

Answer 28

 Minimal osteoplasty to improve flap adaptation.
 Positioning of flaps in relation to the osseous crest for either pocket reduction or elimination

Question 29

Flap Necrosis

Answer 29

 Flap necrosis due to compromised
blood supply due to over-thinning
of flap or vascular compromise
 Source of healing is the PDL,
flap margin, and underlying bone

Question 30

flap necrosis pro

Answer 30

fills in with granulation tissue creating 0mm pockets

Question 31

Modified Widman Flap

Answer 31

 Modified Widman is a modification of subgingival curettage with flap reflection

Question 32

mod widman flap objectives:
 Minimal tissue recession by?
 Conservation of alveolar bone?
 New Attachment ?

Answer 32

 Minimal tissue recession by not reflecting past the alveolar crest.
 Conservation of alveolar bone - no osteoplasty or ostectomy
 New Attachment ???? (long J.E. actually is the result=repair)

Question 33

Modified Widman Indications:
 dx state?
 defect location?
 Patient with?
 what areas in arches?

Answer 33

 Moderate disease
 Infrabony defects
 Patient with high caries rate or root sensitivity
 Anterior esthetic areas

Question 34

modified Widman contraindications

Answer 34

 Severe disease and greater access needed.

Question 35

Modified Widman Advantages:
 Access to?
 looks?
 recession?
 closure?

Answer 35

 Access to root surfaces
 Esthetics??
 Minimal recession
 Primary closure???
Good access for home care
less potential for root caries/sensitivity

Question 36

modified widman disadvantages

Answer 36

Flat or concave post-operative tissue
contours

Question 37

Modified Widman Technique
 First incision
 Second incision
 Third incision

Answer 37

 First incision is started 0.5-1.0 mm apical to gingival margin and “aimed” at alveolar crest.
 Minimal removal of interproximal tissues for “primary closure”.
 Full thickness flap elevated to alveolar crest.
 Second incision is intrasulcular.
 Third incision made following the alveolar crest

Question 38

Anterior Curtain
 Objective is

Answer 38

Anterior Curtain
 Objective is to gain access to interproximal defects in the maxillary anterior region with minimal recession

Question 39

Anterior Curtain technique

Answer 39

 Palatal flap
 Incisions only in the facial interproximal areas, with no direct facial incisions
 Debridement and then closure

Question 40

Anterior Curtain
 Indications

Answer 40

 Maxillary anterior region with interproximal or palatal osseous defects and no facial bone loss.
 Esthetic concern

Question 41

Anterior Curtain
 Contraindication

Answer 41

 Facial bone loss.

Question 42

how to know which procedure to use?

Answer 42

• must match diagnosis to procedure
• know desired end point
• know indications and contra
• maintenance

Question 43

how can miod widman flaps be better adapted?

Answer 43

• flaps or bone may be trimmed to improve adaptation