Periodontal flaps- Review Flashcards
Reproduction or reconstitution of a loss or injured part:
Regeneration
List the three components of periodontal regeneration:
- alveolar bone
- PDL
- cementum
In periodontal regeneration, new alveolar bone, cementum, and PDL ligament are formed, restoring:
new architecture and function of the attachment apparatus
Give an example of periodontal regeneration:
Bone replacement grafting
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
The union of connective tissue with the root surface that has been deprived of its original attachment apparatus. Provides a reunion of CT with the root surface that has been pathologically exposed:
New attachment
The new attachment is defined as the union of connective tissue with the root surface that has been deprived of its ORIGINAL attachment apparatus.
What does this provide?
Provides a reunion of CT with a root surface that has been pathologically exposed
Tissue grafting (connective tissue graft covering area of root recession) is an example of:
New attachment
The reunion of connective tissue with the root surface on which viable PDL tissue is present:
Reattachment
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
The healing of a wound that does NOT fully restore the architecture or function of the part:
Repair
The healing by a long junctional epithelium, that is the body’s protective healing to precent ankylosis and root resorption. This is an example of:
Repair
ALL soft tissue including the periosteum is reflected exposing the underlying bone:
Full thickness flap
Most commonly used flap:
Full thickenss flap
A full thickness flap is also called:
Mucoperiosteal flap
A flap in which epithlium and some connective tissue is reflected, LEAVING PERIOSTEUM and some connective tissue overlying the bone:
Partial thickness flap
What type of flap is less commonly used?
Partial thickness flap
Another name for partial thickness flap:
Split thickness flap
List the principles of tissue attachments: (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
Root changes hindering tissue attachment include:
- 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)
What is the therapeutic endpoint (success) of periodontal flap surgeries?
A functional, comfortable, healthy dentition with stable probing attachment levels
How do you know what surgical periodontal procedure to use?
- diagnosis
- know your endpoint (regeneration, pocket elimination, pocket reduction)
- know indications and contraindications
- maintenance
removal of connective and epithelial attachment with a currette:
Currettage
Removal of connective tissue and epithelial attachment circumferentially with a scalpel:
ENAP
Two ways to surgically involve the gingiva. Normal epithelium has finger-like projections (rete ridges). The connective tissue grows down and 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 suprabony pockets
T/F: A gingivectomy is responsible for removing infrabony pockets
False- suprabony pockets
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 a gingivectomy:
- elimination of gingival enlargements (most common)
- elimination of asymmetrical or unesthetic gingival topography
- exposure of unerrupted teeth when adequate keratinized tissue is present
-elimination of gingival enlargements (most common)
-elimination of asymmetrical or unesthetic gingival topography
-exposure of unerrupted teeth when adequate keratinized tissue is present
Indications for gingivectomy
List the contraindications for a gingivectomy:
- Access is needed to INFRAbony defects
- Base of pocket is apical to MG junction
- When keratinized tissue is inadequate (in this case a gingivectomy would removal ALL keratinized tissue)
- Severely inflamed tissue (needs SRP)
- Esthetics (anterior maxilla)
- 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 gingivectomy:
Simple & fast
List the disadvantages of gingivectomy:
- limited applicability (suprabony defects only)
- longer healing period (4-5 weeks)
- less effective than flap surgery (no access to osseous defects)
Three indications for gingivectomy that are usually corrected via flap surgery for access:
- elimination of SUPRAbony pockets which cannot 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
Describe the gingivectomy technique:
- marking of pocket depth
- resection of the gingiva with incision starting APICAL to the pocket base and externally beveled at a 45 degree angle
- removal of pocket (tissue)
- debridement of granulation tissue
- post-surgical control of bleeding
T/F: With a gingivectomy bone exposure is to be avoided
True
T/F: With a gingivectomy, partial removal of pocket is ideal if possible
False- complete removal of pocket
T/F: With a gingivectomy thick tissue will require a more coronal start of the incision
False- apical
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 incison
List the modifications of an open flap debridement:
- Modified widman
- Anterior curtain
What is the key to success of all surgical periodontal procedures?
Patient’s home care and maintenance
The anterior curtain OFD modification is used on:
maxillary anteriors
Open flap objectives include: (5)
- ACCESS to root surface and osseous defects
- PRESERVATION of osseous support
- REDUCTION or elimination of periodontal pockets
- MINIMIZE post-surgical pain, root sensitivity and esthetic compromise
- IMPROVED ACCESS for better patient home care
Open flap indications:
- advanced disease where access is needed to roto 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
Open flap contraindications: (3)
- patient is unable to tolerate a surgical procedure
- increased tissue recession may result to esthetic compromise
- potential of root caries and root sensitivity due to greater root exposure post-surgically
Describe open flap technique: (5)
- Intrasulcular incison
- Papillas thinned to uniform thickness
- mucoperiosteal flap is reflected
- vertical incisions can be used
- palatal incisions placed dependent on extent of defects and amount of pocket reduction planned
What type of incison is NOT indicated in open flap technique, why?
Step back incisons are not indicated due to them being ineffective
What type of flap is used in an open flap technique?
Mucoperiosteal
The modified widman (modification to open flap technique) results in:
minimal tissue recession
Modification of the subgingval currettage with flap reflection, allowing 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 osteoplasty or ostectomy
alveolar bone
Indications for modified widman flap: (5)
- moderate disease
- INFRAbony defects
- high caries rate
- root sensitivity
- anterior esthetic areas
Contraindications for modified widman flap:
severe disease and greater access needed
List the advantages to the modified widman flap:
- great access to root surface
- possible esthetic improvement
- minimal recession occurs
- primary closure
List the disadvantages to the modified widman flap:
Flat or concave post-op tissue contour
A conservative approach and will not increase the width of keratinized tissue:
Modified widman flap
- First incison is started 0.5-1mm apical to the gingival margin and “aimed” at alveolar crest
-Second incison is intrasulcular to create wedge
-Third incison made horizontally following the alveolar crest to remove wedge
3 steps of modified widman (incisions)
Modification to open flap debridement that aims to gain access to interproximal defects in the maxillary anterior region with minimal recession:
Anterior curtain flap
Indication for aterior curtain flap:
- maxillary anterior region with interproximal or palatal osseous defects and no facial bone loss
- esthetic concerns
What is the only contraindication to anterior curtain flap?
Facial bone loss
In this type of flap modification, incisons are only made in the facial interproximal (no direct facial incisors):
Anterior curtain
Describe the anterior curtain flap technique:
- palatal flap
- incisions only in the facial interproximal areas (with no direct facial incisions)
- debridement
- 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 is fractured and need to confirm
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 tissue compromise
-Potential root caries and potential root sensitivity due to greater root exposure
Contraindications to open flap debridement
- Intrasulcular incison placed and papillas are thinned to a uniform thickness
- mucoperiosteal flap is reflected
- root surface and osseous defect debridement
- flap closure with apcial positioning
- 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 compromised:
Flap necrosis
List the reasons of flap necrosis:
-compromised blood supply due to over-thinning of flap
In minimal osteoplasty, bony projections (i.e. exostoses) should be removed _______ to ______ to allow the flap to approach the tooth in better manner and allow for better flap adaptation
prior; flap suturing
In minimal osteoplasty, flaps 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 crestal bone and shrunk back up due to a lack of blood supply
Flap necrosis
What is the source of healing?
PDL
What is the goal of periodontal surgery?
All flaps regardless of technique should function to provide ACCESS
list three places of access provided by periodontal surgery:
- access to debride the root surface and osseous defect
- access to place bone replacement graft
- access for osseous correction
