Surgical methods of access - ENAP, apically displaced flap, modified technique according to Widman – Ramfjord Flashcards
Surgical methods of access
Excisional new attachment procedure(ENAP)
Definitive subgingival curettage procedure performed w/ knife
Surgical methods of access
Healing after Excisional new attachment procedure(ENAP)
- Immature collagen fibres appear within 21 days
- Formation of long thin, JE w/ no new CT
- After 2 weeks- normal colour contour, consistency, surface texture of gingiva
- Gingival margin well adapted to tooth
Surgical methods of access
Excisional new attachment procedure(ENAP) technique
- LA
- Internal bevel incision from FGM to below pocket=>
- Carried interproximally on facial and lingual sides
- Excised tissue removed w/curette and root planning performed
- CT attached to tooth surface preserved
- Approximation of wound edges
- Placement of sutures and periodontal dressing
Surgical methods of access
Apically repositioned flap
- Maintainence of adequate attached gingiva after surgery
- Mucogingival complex displaced in apical direcction
- Buccal surfaces in both jaws and lingual in upper jaw
Surgical methods of access
Apically repositioned flap procedure
- Bevel incision w/ scalloped outline
- Vertical releasing incisions extending out into alveolar mucosa
- Full thickness mucoperiosteal flap raised w/ periosteal elevator
- Pocket epithelium, granulation tissue removed w/ curettes
- Exposed root surfaces scaled and planned
- Alveolar bone crest recontoured to more apical level
- Buccal lingual flap repositioned to level of recontoured bone
- Periodontal dressing applied
- After healing-adequate zone of gingiva preserved and no residual pockets remain
Surgical methods of access
During apical repositoned flap, distance of reverse bevel incision from buccal/lingual gingival margin depends on
pocket depth and thickness and width of gingiva
Surgical methods of access
During apical repositoned flap, if the gingiva is thick and only narrow zone of keratinised tissue present
Incision made close to tooth
Surgical methods of access
During apical repositoned flap bevel incision given scalloped outline to
Ensure maximal interproximal coverage of alveolar bone
Surgical methods of access
During apical repositoned flap, a periodontal dressing is applied to
*Protect exposed bone
* Retain soft tissue at level of bone crest
Surgical methods of access
Advantages of apically positioned flap
- Minimum pocket depth postoperatively
- Post surgical bone loss minimal if optimal soft tissue coverage of alveolar bone obtained
- Post operative position on gingival margin may be controlled
Surgical methods of access
Disadvantages of apically positioned flap
- Removal of periodontal tissues by bone resection
- Subsequent exposure of root surface
Surgical methods of access
Modified windman flap procedure
- Initial incision(11 blade) parallel to long axis of tooth and 1mm from buccal gingival margin
- Scalloped incision extended as far as possible between teeth
- Buccal and palatal full thickeness flaps elevated w/ mucoperiosteal elevator
- Third incision in horizontal direction close to alveolar bone crest
- Pocket epithelium and granulation tissue removed w/ curettes
- Exposed roots scaled and planned
- Flaps trimmed and adjusted to alveolar bone
- Flaps sutured together
- Surgical dressing placed over area
- Sutures removed after a week
Surgical methods of access
Scalloped incision during modified wingman flap is extened as far as possible to
Allow maximum amounts of interdental papilla to be included in flap
Surgical methods of access
Advantages of Modified wingman flap
- Close adaptation of soft tissues to root surfaces
- Minimal trauma to bone and CT
- Less exposure of root surfaces
