Periodontal flaps Flashcards
which are the types of tissue attachment healing
- regeneration
- new attachment
- reattachment
- repair
what is regeneration
reproduction or reconstitution of a lost or injured part
- new alveolar bone, cementum and PDL are formed restoring new architecture and function of the attachment aparatus
what is an example of regeneration
bone replacement grafting
what is new attachment healing
the union of connective tissue with a root surface that has been deprived of its original attachment apparatus
- reunion of CT with a root surface which has been pathologically exposed
what is an example of healing through new attachment
a CT graft to cover an area of root recession
what is reattachment
the reunion of CT with a root surface on which viable periodontal ligament tissue is presentw
what is an example of reattachment healing
the reunion of CT with a root surface on which viable periodontal ligament tissue is present
what is an example of healing through reattachment
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 CT fibers
describe repair
the healing of a wound that does not fully restore the architecture or function of the part
what is an example of repair
healing of a long JE
what is the purpose of long JE
this is the body’s protective healing to prevent ankylosis and root resorption
what is the most commonly used flap
full thickness
what is a full thickness flap
all soft tissue including the periosteum is reflected exposing the underlying bone
what is another name for the full thickness flap
mucoperiosteal flap
what is a partial (split) thickness flap
epithelium and some CT is reflected leaving periosteum and some CT tissue overlying the bone
what are the principles of tissue attachment
- preparation of soft tissue wall
- preparation of root surfaces
- debridement of bony defects
- adaptation of soft tissue to root surface
- control of etiology pre and post surgery
when is preparation of soft tissue done
- not as a separate procedure
- done in conjunction with scaling
what are the root changes that hinder tissue attachment
- 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)
what is the therapeutic endpoint indicating success
a functional, comfortable, healthy dentition with stable probing attachment levels
how do you decide what procedure to use
- diagnosis
- know your end point- regneration, pocket elimination, pocket reduction
- know indications and contraindications
- maintenance
what is curettage
removal of the connective and epithelial attachment circumferentially with a curette
what is ENAP
removal of the connective and epithelial attachment circumferentially with a scalpel
define 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
define gingivoplasty
gingival deformities are reshaped and reduced to create a normal and functional form. the incision creates an external bevel
what are the indications for a gingivectomy
- elimination of suprabony pockets which cant 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
- elimination of gingival enlargements
- elimination of asymmetrical or unesthetic gingival topography
- exposure of unerupted teeth when adequate keratinized tissue is present
the 3 indications for gingivectomy with suprabony considerations are usually corrected by:
flap surgery for access
what is the most common indication for gingivectomy
elimination of gingival enlargements
what are the contraindications for gingivectomy
- 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 the keratinized tisue
- severely inflamed tissue (needs scaling and root planing)
- esthetics (anterior maxilla)
- anatomical preclusion (lack of keratinized tissue)
what are the advantages of gingivectomy
relatively simple and fast
what are the disadvantages of gingivecomy
- limited applicability ( suprabony defects)
- longer healing period (4-5 weeks)
- more post operative discomfort
- less effective than flap surgery ( no access to osseous defects)
describe the gingivectomy technique
- marking of the pocket depth
- resection of the gingiva with incision starting apical to the pocket base and externally beveled at a 45 degree angle
- 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
what are the 3 major steps to gingivectomy
- removal of tissue
- debridement of any granulation tissue and root debridement
- post surgical control of bleeding
how can hemostasis be achieved after surgery
pressure or external clotting aid
______ may be needed for tissue protection during post- op function
periodontal pack
what is open flap debridement
surgical debridement of the root surface and removal of granulation tissue from osseous defects following reflection of a mucoperiosteal flap
what are the modifications to open flap debridement
- modified widman
- curtain procedure (maxillary anteriors)
what are the open flap objectives
- 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
what are the open flap indications
- 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
what are the open flap contraindications
- 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
what is the open flap technique
- 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 incision are placed dependent on the extent of the defects and amount of pocket reduction planned
what are the 3 main steps in open flap technique
- root surface and osseous defect debridement
- flap closure with apically positioning
- suturing
what are the modifications for the open flap technique
- minimal osteoplasty to improve flap adaptation
- positioning of flaps in relation to the osseous crest for either pocket reduction or elimination
what is flap necrosis due to
compromised blood supply due to over thinning of flap or vascular compromise
what is the source of healing in flap necrosis
PDL, flap margin, and underlying bone
what is the modified widman flap
a modification of subgingival curettage with flap retention
what are the objectives of the modified widman flap
- minimal tissue recession by not reflecting past the alveolar crest
- conservation of alveolar bone- no osteoplasty or ostectomy
- new attachment- long JE is the result
what are the indications for the modified widman
- moderate disease
- infrabony defects
- patient with high caries rate or root sensitivity
-anterior esthetic areas
what are the contraindications for modified widman
severe disease and greater access needed
what are the advantages and disadvantages to the modifed widman
- advantages: access to root surfaces, esthetics, minimal recession, primary closure
- disadvantages: flat or concave post operative tissue contours
what is the modified widman technique?
- first incision: started -0.5-1mm apical to the gingival margin and aimed at the 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
what is the objective of the anterior curtain
to gain access to interproximal defects in the maxillary anterior region with minimal recession
what is the technique for the anterior curtain
- palatal flap
- incisions only in the facial interproximal areas, with no direct facial incisions
- debridement and then closure
what are the indications and contraindications for the anterior curtain
- indications: maxillary anterior region with interproximal or palatal osseous defects and no facial bone loss, esthetic concern
- contraindications: facial bone loss
goal of all surgery is to:
access to defects
what should be considered when deciding which procedure is to be done
- diagnosis
- goal of therapy
- limitations of each technique
- personalized therapy
success of all surgical procedures is dependent on:
the patient’s home care and maintenance
