Periodontal Flaps

Question 1

Regeneration:

Answer 1

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 2

New Attachment:

Answer 2

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 3

Reattachment:

Answer 3

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 4

Repair:

Answer 4

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 5

Full thickness flap:

Answer 5

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

Question 6

 Partial (split) thickness flap:

Answer 6

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

Question 7

Principles of Tissue
Attachment
(5)

Answer 7

 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 8

Root Changes Hindering
Tissue Attachment
(3)

Answer 8

 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)

Question 9

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

Answer 9

 Endotoxin adsorbed on and into
cementum

Question 10

Therapeutic End Point: Success

Answer 10

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

Question 11

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

Answer 11

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

Question 12

Curettage:

Answer 12

Removal of the
connective and epithelial
attachment circumferentially
with a curette

Question 13

ENAP:

Answer 13

Removal
of the connective
and epithelial
attachment
circumferentially
with a scalpel

Question 14

 Gingivectomy:

Answer 14

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 15

 Gingivoplasty:

Answer 15

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

Question 16

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

Answer 16

 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.

Question 17

Gingivectomy Indications
(3)

Answer 17

 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 18

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

Answer 18

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)

Question 19

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

Answer 19

 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)

Question 20

Gingivectomy Technique
(2)

Answer 20

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

Question 21

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

Answer 21

Bone exposure
pocket
apical
internal

Question 22

Gingivectomy Technique
(3)

Answer 22

 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 23

Open Flap Debridement

Answer 23

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

Question 24

Open Flap Debridement
Modifications:
(2)

Answer 24

 Modified Widman
 Curtain procedure (maxillary anteriors)

Question 25

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

Answer 25

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

Question 26

Open Flap Indications
(5)

Answer 26

 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 27

Open Flap Contraindications
(3)

Answer 27

 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 28

Open Flap Technique
(5)

Answer 28

 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.

Question 29

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

Answer 29

debridement
apically

Question 30

Open Flap Technique
Modifications:
(2)

Answer 30

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

Question 31

Flap Necrosis
 Flap necrosis due to

Answer 31

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

Question 32

Flap necrosis
 Source of healing is the

Answer 32

PDL,
flap margin, and underlying bone

Question 33

Modified Widman Flap
 Modified Widman is a modification of

Answer 33

subgingival curettage with flap reflection

Question 34

SKIPPED
Modified Widman Flap
Objectives
(3)

Answer 34

 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)

Question 35

SKIPPED
Modified Widman
 Indications
(4)

Answer 35

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

Question 36

SKIPPED
Modified Widman
Contraindications
(1)

Answer 36

 Severe disease and greater access
needed.

Question 37

SKIPPED
Modified Widman
 Advantages
(4)

Answer 37

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

Question 38

SKIPPED
Modified Widman
 Disadvantages
(1)

Answer 38

 Flat or concave post-operative tissue
contours

Question 39

SKIPPED
Modified Widman Technique
 First incision

Answer 39

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.

Question 40

SKIPPED
Modified Widman Technique
 Second incision is.

Answer 40

intrasulcular

Question 41

SKIPPED
Modified Widman Technique
 Third incision

Answer 41

made following the alveolar
crest.

Question 42

Anterior Curtain
 Objective is to

Answer 42

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

Question 43

Anterior Curtain
Technique
(3)

Answer 43

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

Question 44

Anterior Curtain
 Indications
(2)

Answer 44

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

Question 45

Anterior Curtain
 Contraindication
(1)

Answer 45

 Facial bone loss.

Question 46

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

Answer 46

Diagnosis
Goal
Limitations
Personalized
access to defects

Question 47

Success of all surgical procedures is
dependent on

Answer 47

the patient’s home care
and maintenance