Periodontal Flaps - Review Flashcards by Abagayle Moody

Reproduction or reconstitution of a lost of injured part:

Regeneration

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List the three components of periodontal regeneration:

Alveolar bone
PDL
Cementum

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In periodontal regeneration, new alveolar bone, PDL, and cementum are formed restoring:

new architecture and function of the attachment apparatus

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Give an example of periodontal regeneration:

bone replacement grafting

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Bone graft material placed to maintain space and allow new bone, cementum and PDL cells to come in and create new materials:

What is this an example of?

Bone replacement grafting

Periodontal regeneration

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The union of connective tissue with a root surface that has been deprived of its original attachment apparatus. Provides a reunion of CT with a root surface which has ben pathologically exposed:

New attachment

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The union of connective tissue with a root surface that has been deprived of its ORIGINAL attachment apparatus.

What does this provide:

It provides a reunion of CT with a root surface that has been pathologically exposed.

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Tissue grafting (connective tissue graft covering area of root recession) is an example of:

NEW attachment

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The reunion of connective tissue with a root surface on which viable PDL tissue is present:

Reattachment

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Biologic width/supracrestal tissue - existed before a flap was reflected and when the flap is replaced, reattachment occurs with the intact CT fibers. This is an example of:

Reattachment

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The healing of a wound that does NOT fully restore the architecture or function of the part:

Repair

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The healing by a long junctional epithelium that is the body’s protective healing to prevent ankylosis and root resorption. This is an example of:

Repair

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ALL soft tissue including the periosteum is reflected exposing the underlying bone:

Full thickness flap

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What is the most commonly used flap?

full thickness flap

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Another name for full thickness flap:

mucoperiosteal flap

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A flap in which epithelium and some connective tissue is reflected, leaving periosteum and some connective tissue overlying the bone:

Parital thickness flap

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What type of flap is less commonly used?

partial thickness flap

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Another name for partial thickness flap:

split thickness flap

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List the 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 include:

Foreign body nature of exposed diseased root surfaces (presence of endotoxin)
Pathologic changes in root surface (hypo & hyper calcification areas)
Decreased organic material in exposed cementum (loss of fibers and alterations in the organs c material related to endotoxin)

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What is the therapeutic endpoint (success) of periodontal flap surgeries?

A functional, comfortable, healthy dentition with stable probing attachment levels

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How do you know which surgical periodontal procedure to use?

diagnosis
Know your endpoint (regeneration, pocket elimination, pocket reduction)
know indications and contraindications
maintenance

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Removal of connective tissue and epithelial attachment with a curette:

Currettage

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Removal of connective tissue and epithelial attachment circumferentially with a scalpel:

ENAP

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Two ways to surgically involve the gingiva. Normal epithelium has finger-like projections (rete ridges). The connective tissue grows down and the epithelium grows upwards:

Gingivectomy vs. Gingivoplasty

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

gingivectomy

REMOVES diseased gum tissue:

gingivectomy

What is the function of a gingivectomy?

Eliminates gingival enlargement and eliminates supra bony pockets

T/F: A gingivectomy is responsible for removing infra bony pockets:

false- supra bony packets

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

gingivoplasty

What is the function of a gingivoplasty?

Reshapes otherwise healthy gum tissue

Reshapes otherwise healthy gum tissue:

gingivoplasty

What is the most common INDICATION for a GINGIVECTOMY:

Elimination of gingival enlargements

List the indications for gingivectomies:

1. elimination of gingival enlargements (most common) 2. elimination of asymmetric of anesthetic gingival topography 3. Exposure of unerupted teeth when adequate keratinized tissue is present.

- elimination of gingival enlargements (most common) - elimination of asymmetric of anesthetic gingival topography - Exposure of unerupted teeth when adequate keratinized tissue is present

Indications for gingivectomy

List the CONTRAINDICATIONS for a GINGIVECTOMY:

1. Access is needed to INFRAbony defects 2. Base of pocket is apical to MG junction 3. When keratinized tissue is inadequate (in this case the gingivectomy would remove ALL the keratinized tissue) 4. Severely inflamed tissue (needs SRP) 5. Esthetics (anterior maxilla) 6. Anatomical preclusion (lack of keratinized tissue)

T/F: A gingivectomy is a great option for anterior maxilla gingival overgrowth

false- contraindicated in this region

List the ADVANTAGES of a gingivectomy:

Simple & Fast

List the DISADVANTAGES of a gingivectomy:

1. limited applicability (Suprabony defects only) 2. longer healing period (4-5 weeks) 3. less effective than flap surgery (no access to osseous defects)

Three indications for gingivectomy that are usually corrected via flap surgery for access:

1. elimination of SUPRABONY pockets that cannot be adequately derided without tissue removal 2. Elimination of SUPRABONY pockets if the pocket wall is fibrous and firm and therefore will NOT shrink after non-surgical therapy 3. Access for restorative with SUPRABONY pockets

Describe the gingivectomy technique:

1. marking of pocket depth 2. resection of the gingiva with incision starting APICAL to the pocket base and externally beveled at 45 degree angle 3. removal of pocket (tissue) 4. debridement of granulation tissue 5. post-surgical control of bleeding

T/F: With a gingivectomy, bone exposure is to be avoided

true

T/F: With a gingivetomy partial removal of pocket is ideal if possible.

false- complete removal of pocket

T/F: With gingivetomy, thick tissue will require a more coronal start of the incision

false- more apical start

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

open flap debridement

What type of incision is used in an open flap debridement?

Intrasulcular bevel incision

List the modifications of an open flap debridement:

1. modified Widman 2. anterior curtain

What is the key to success of all surgical perio procedures?

patients home care and maintenance

The anterior curtain OFD modification is use on:

maxillary anteriors

Open flap objectives include: (5)

1. ACCESS to root surface and osseous defects 2. PRESERVATION of osseous support 3. REDUCTION or ELMINIATION of periodontal pockets 4. MINIMIZE post-surgical pain, root sensitivity, and esthetic compromise 5. IMPROVED ACCESS for better patient home care

Open flap indications: (5)

1. Advanced disease where access is needed to root surfaces and osseous defects 2. Where regeneration may be possible 3. To preserve tissue for esthetics 4.As an exploratory procedure or as part of a non-surgical phase of treatment for fibrous tissue 5. Less post-op discomfort

Open flap contraindications:

1. patient is unable to tolerate a surgical procedure 2. increased tissue recession may result in esthetic compromise 3. potential or root caries and root sensitivity due to greater root exposure post-surgically

Describe Open flap technique: (5)

1. Intrasulcular incisions 2. Papilla's thinned to uniform thickness 3. Mucoperiosteal flap is selected 4. Vertical incisions can be used 5. Palatal incisions are placed based on the extent of defects and amount of pocket reduction planned

What type of incision is NOT indicated in open flap technique? Why?

Step-back incision due to them being ineffective

What type of flap is used in an open flap technique?

mucoperiosteal flap

The modified Widman flap (modification to open flap technique) results in :

minimal tissue recession

Modification of the subgingival curettage with flap reflection. Allows for access to the root surface and does not reflect past the alveolar crest:

modified Widman flap

In a modified Widman flap, the tissue is not reflected past:

alveolar crest

The modified Widman flap conserves ____ due to no osteplasty or osteotomy:

alveolar bone

Indications for modified Widman flap:

1. moderate disease 2. INFRAbony defects 3. high caries rate 4. root sensitivity 5. anterior esthetic areas

Contraindications for modified Widman flap:

severe disease and greater access needed

List the advantages to the modified Widman flap:

1. great access to root surface 2. possible esthetic improvement 3. minimal recession occurs 4. primary closure

List the disadvantages of the modified Widman flap:

flat or concave post-op tissue contour

Conservative approach and will not increase the width of keratinized tissue:

modified Widman flap

- first incision is started 0.5-1.0mm apical to the gingival margin and "aimed" at alveolar crest - second incision is intrasulcular to create wedge - third incision is made horizontal following alveolar breast to remove wedge

Three steps to modified Widman (incisions)

Modification to open flap debridement that aims to gain access to interproxoimal defects in the maxillary anterior region with minimal recession:

anterior curtain flap

Indications for anterior curtain flap:

1. maxillary anterior region with interproximal or palatal osseous defects and no facial bone loss 2. esthetic concerns

What is the only contraindication to anterior curtain flap?

facial bone bone loss

In this type of flap modification, the incisions are ONLY made int he facial interproximal (no direct facial incisions)

anterior curtain flap

Describe the anterior curtain flap technique:

1. palatal flap 2. incisions only in the facial interproximal areas (with no direct facial incisions) 3. debridement 4. closure/suture

- 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-op discomfort - If you think root fractures and need to confirm

These are indications for open flap debridement

- Patient is unable to tolerate a surgical procedure - patient has already had surgery and did not see improvement - increased tissue recession may result in ethnic compromise - potential root caries and potential sensitivity due to greater root exposure post surgically

contraindications to open flap debridement

1. Intrasulcular incision placed and papillary are thinned to a uniform thickness 2. mucoperiosteal flap is relfeced 3. root surface and osseous defect debridement 4. flap closure with apical positioning 5. sutures

Open flap technique

With an open flap procedure, a ____ incision may be used to reduce tension

vertical

With an open flap procedure, ____ incisions may be used dependent on the extent of the defects and amount of pocket reduction planned.

palatal

Why would we modify the open flap procedure to include minimal osteoplasty?

to improve flap adaptation

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

flap necrosis

List the reason for flap necrosis:

compromised blood supply due to over-thinning of flap

In minimal osteoblasts, bony projections (i.e. exostoses) should be removed ____ to ___ to allow the fall to approach the tooth in a better manner and allow for adequate flap adaptation

prior; flap suturing

In minimal osteoblasts, flap should be positioned in relation to the ____ for either pocket reduction or elimination

osseous crest

Situation in which the flap was too thin and was not approximated to crystal bone and shrunk back up due to lack of blood supply.

flap necrosis

What is the source of healing?

PDL

Goal of periodontal surgery:

all flaps headless of technique give function to provide ACCESS

List three places of access provided by periodontal surgery:

1. access to debride the root surface and osseous defect 2. access to place bone replacement graft 3. access for osseous correction