Periodontal Flaps Flashcards by sophie rosen

Regeneration:

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.)

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New Attachment:

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)

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Reattachment:

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.)

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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.)

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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.)

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 Partial (split) thickness flap:

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

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Principles of Tissue
Attachment
(5)

 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***

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Root Changes Hindering
Tissue Attachment
(3)

 Foreign body nature of exposed diseased
root surfaces (presence of endotoxin)
 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)

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Foreign body nature of exposed diseased
root surfaces (presence of endotoxin)

 Endotoxin adsorbed on and into
cementum

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Therapeutic End Point: Success

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

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Therapeutic End Point: Success
 A functional, comfortable, healthy
dentition with stable probing
atttachment levels.
Which procedure to use?
(4)

 Diagnosis
 Know your end point (regeneration,
pocket elimination, pocket reduction)
 Know indications and contraindications
 Maintenance**

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Curettage:

Removal of the
connective and epithelial
attachment circumferentially
with a curette

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ENAP:

Removal
of the connective
and epithelial
attachment
circumferentially
with a scalpel

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 Gingivectomy:

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.

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 Gingivoplasty:

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

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Gingivectomy Indications
 These three indications are usually
corrected by flap surgery for access
(3)

 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.

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Gingivectomy Indications
(3)

 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.

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Gingivectomy Contraindications
 Access is needed to
 Base of pocket is
 Severely

 Anatomical

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

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Gingivectomy Advantages and
Disadvantages
 Advantages
(1)
 Disadvantages
(4)

 Relatively simple and fast.

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

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Gingivectomy Technique
(2)

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

Resection of the gingiva with incision
starting apical to pocket base and
externally beveled at a 45° angle.
 — is to be avoided.
 Complete removal of — if possible.
 Thick tissue will require a more —
start of the incision.
 Can do via — bevel incision, but it is
more difficult to accomplish

Bone exposure
pocket
apical
internal

Gingivectomy Technique
(3)

 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

Open Flap Debridement

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

Open Flap Debridement
Modifications:
(2)

 Modified Widman
 Curtain procedure (maxillary anteriors)

Open Flap Objectives  Access to (2)  Preserve ---  Reduction or elimination of ---  Minimize (3)  Improved ...

root surface and osseous defects. osseous support. periodontal pockets. post-surgical pain, root sensitivity, and esthetic compromise. access for better patient home care

Open Flap Indications (5)

 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.

Open Flap Contraindications (3)

 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

Open Flap Technique (5)

 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.

Open Flap Technique  Root surface and osseous defect ---.  Flap closure with --- positioning.  Suturing

debridement apically

Open Flap Technique Modifications: (2)

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

Flap Necrosis  Flap necrosis due to

compromised blood supply due to over-thinning of flap or vascular compromise

Flap necrosis  Source of healing is the

PDL, flap margin, and underlying bone

Modified Widman Flap  Modified Widman is a modification of

subgingival curettage with flap reflection

SKIPPED Modified Widman Flap Objectives (3)

 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)

SKIPPED Modified Widman  Indications (4)

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

SKIPPED Modified Widman Contraindications (1)

 Severe disease and greater access needed.

SKIPPED Modified Widman  Advantages (4)

 Access to root surfaces  Esthetics??  Minimal recession  Primary closure???

SKIPPED Modified Widman  Disadvantages (1)

 Flat or concave post-operative tissue contours

SKIPPED Modified Widman Technique  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.

SKIPPED Modified Widman Technique  Second incision is.

intrasulcular

SKIPPED Modified Widman Technique  Third incision

made following the alveolar crest.

Anterior Curtain  Objective is to

gain access to interproximal defects in the maxillary anterior region with minimal recession

Anterior Curtain Technique (3)

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

Anterior Curtain  Indications (2)

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

Anterior Curtain  Contraindication (1)

 Facial bone loss.

Comparison of Techniques  Which procedure should be done?  --  -- of therapy  -- of each technique  -- therapy  Goal of all surgery is ---

Diagnosis Goal Limitations Personalized access to defects

Success of all surgical procedures is dependent on

the patient’s home care and maintenance