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Periodontal Flap

Periodontal Flap

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Periodontal Flap

  1. 1. Dept of periodontics Periodontal flaps Presented by, SHIJI MARGARET D.SAPNA D.SARANYA S.SHIFAYA NASRIN CRRI
  2. 2. Definition “A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility and access to the bone and root surface.
  3. 3. INDICATIONS: •Irregular bony contours •Deep craters •Pockets on teeth in which a complete removal of root irritants is not clinically possible •Grade II or III furcation involvement •Root resection / hemisection •Intrabony pockets on distal areas of last molars •Persistent inflammation in areas with moderate to deep pockets.
  4. 4. CONTRAINDICATIONS • Uncontrolled medical conditions such as ‐unstable angina ‐uncontrolled diabetes ‐uncontrolled hypertension ‐myocardial infarction / stroke within 6 months •Poor plaque control •High caries rate •Unrealistic patient expectations or desires
  5. 5. Classification of flaps Bone exposure after flap reflection •Full thickness (mucoperiosteal) •Partial thickness (mucosal) Placement of the flap after surgery •Non displaced flaps •Displaced flaps Management of the papilla •Conventional flaps •Papilla preservation flaps
  6. 6. BASED ON BONE EXPOSURE AFTER REFLECTION  FULL THICKNESS FLAP Periosteum is reflected to expose the underlying bone. Indicated in resective osseous surgery.
  7. 7. PARTIAL THICKNESS FLAP •Split thickness flap. •Periosteum covers the bone. •Indicated when the flap has to be positioned apically. •When the operator does not desire to expose the bone
  8. 8. BASED ON FLAP PLACEMENT AFTER SURGERY •Non displaced flaps:  When the flap is returned and sutured in its original position. •Displaced flaps:  When the flap is placed apically, coronally or laterally to their original position
  9. 9. DESIGN OF THE FLAP •Split the papilla (conventional flap) •Preserve it (papilla preservation flap)
  10. 10. MODIFIED WIDMAN FLAP Presented by Ramfjord and Nissle in 1974
  11. 11. THE ORIGINAL ‘WIDMAN’ FLAP  The flap was elevated to expose 2-3 mm of the alveolar bone.  The soft tissue collar incorporating the pocket epithelium and connective tissue was removed, the exposed root surface scaled and the bone recontoured to re-establish a 'physiologic' alveolar form.  The flap margins were placed at the level of the bony crest to achieve optimal pocket reduction.
  12. 12. THE TERM MODIFIED WIDMAN FLAP Exposure of the interproximal bone and elimination of infrabony defects by osseous recontouring is not carried out (No surgical pocket elimination and apical displacement of the flap) Incase of esthetic considerations,intracrevicular incisions starting at the free gingival margins are used to minimize postsurgical gingival shrinkage. Vertical releasing incisions are usually not used
  13. 13. INDICATIONS:  Effective with pocket depths of 5-7 mm CONTRAINDICATIONS:  Lack of or very thin and narrow attached gingiva can render the technique difficult, because a narrow band of attached gingiva does not permit the initial scalloped incision (internal gingivectomy).
  14. 14. ADVANTAGES: Root cleaning done with direct vision. Healing by primary intention. Minimal crestal bone resorption. Lack of post operative discomfort.
  15. 15. PROCEDURE: 1) Internal bevel incision should be made to the alveolar crest starting 0.5 to 1 mm away from the gingival margin. 1- Modified widman flap 2- Undisplaced flap
  16. 16. INTERNAL BEVEL INCISION IN FACIAL AND PALATAL ASPECTS
  17. 17. 2) Flap is elevated 3)Crevicular incision is made from the bottom of the pocket to bone
  18. 18. 4)Interdental incision sectioning the base of the papilla 5)Tissue tags and granulation tissue are removed.
  19. 19. 6) Scaling and root planing of exposed root surfaces
  20. 20. 7)Suturing done and covered with tetracycline oinment and with a periodontal surgical pack
  21. 21. Post operative results
  22. 22. THE UNDISPLACED FLAP  Most commonly performed type of periodontal surgery.  It differs from the modified Widman flap in that the soft tissue pocket wall is removed with the initial incision; thus it considered an internal bevel gingivectomy.
  23. 23. PROCEDURE 1) The pockets are measured with periodontal probe and a bleeding point is produced on the outer surface of gingiva to mark the pocket bottom PRE OPERATIVE VIEWS
  24. 24. 2) Internal bevel incision in the facial and palatal aspects
  25. 25. 3)Crevicular incision is made and Flap is elevated
  26. 26. 4)Interdental incision is made 5)Triangular wedge of tissues is removed with curette 6)All tissue tags and granulation tissue are removed
  27. 27. 7)After the scaling and root planing the flap edge should rest on the root bone junction. 8)Flaps have been placed in their original site and Sutured.
  28. 28. Post operative results
  29. 29. It can be used for both pocket eradication as well as widening the zone of attached gingiva. It can be a full thickness (mucoperiosteal) or a split thickness (mucosal) flap.
  30. 30. DISADVANTAGES: May cause esthetic problems due to root exposure. May cause attachment loss due to surgery. May cause hypersensitivity. May increase the risk of root caries. Unsuitable for treatment of deep periodontal pockets. Possibility of exposure of furcations and roots, which complicates post operative supragingival plaque control.
  31. 31. CONTRAINDICATIONS: Periodontal pockets in severe periodontal disease. Periodontal pockets in areas where esthetics is critical. Deep intrabony defects. Patient at high risk for caries. Severe hypersensitivity. Tooth with marked mobility and severe attachment loss. Tooth with extremely unfavorable clinical crown / Root ratio.
  32. 32. PROCEDURE for apically displaced flap 1. An internal bevel incision is made, it should be no more than 1mm from the crest of the gingiva and directed to the crest of gingiva. 2. Crevicular incisions are made, followed by initial elevation of the flap; then interdental incision and the wedge of tissue containing pocket wall is removed
  33. 33. 3. Vertical incisions are made extending beyond the mucogingival junction. Full thickness flap elevated by blunt dissection with periosteal elevator Split –thickness flap elevated using sharp dissection with a bard- parker knife
  34. 34. 4.After debridement of the areas 5.Sutures in place
  35. 35. PRE TREATMENT-POST TREATMENT
  36. 36. CROWN LENGTHENING BY APICALLY DISPLACED FLAP PRE-TREATMENT BEFORE OSSEOUS RESECTION FLAP APICALLY POSITIONED AND SUTURED POST-TREATMENT
  37. 37. CROWN LENGTHENING BY APICALLY DISPLACED FLAP PRE-TREATMENT Before debridement After debridement Incision Sutures in place
  38. 38. Pre treatment Post treatment
  39. 39. FLAPS FOR REGENERATIVE SURGERY Two flap designs are available for regenerative surgery: 1. The papilla preservation flap& 2. The conventional flap with only crevicular incisions.
  40. 40. Entire papilla is incorporated into one of the flaps. INDICATIONS: •Where esthetics is of concern. •Where bone regeneration techniques are attempted
  41. 41. CONVENTIONAL FLAP FOR REGENERATIVE SURGERY In the conventional flap operation, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla, thereby splitting the papilla into a facial half and a lingual or palatal half. INDICATIONS:  When the interdental areas are too narrow to permit the preservation of flap.  When there is a need for displacing flaps. The interdental papilla is split beneath the contact point of the two approximating teeth to allow for reflection of buccal and lingual flaps
  42. 42. DISTAL MOLAR SURGERY
  43. 43. Treatment of periodontal pockets on the distal surface of terminal molars is often complicated by the presence of bulbous fibrous tissue over the maxillary tuberosity or prominent retromolar pads in the mandible. Operations for this purpose were described by Robinsonand Braden
  44. 44. Impaction Of A Third Molar Distal To A Second Molar Little Or No Bone Distal To The Second Molar. Often Leads To A Vertical Osseous Defect Distal To The Second Molar.
  45. 45. Typical incision design for a surgical procedure distal to the maxillary second molar.
  46. 46. Incision designs for surgical procedures distal to the mandibular second molar. •The incision should follow the areas of greatest attached gingiva and underlying bone.
  47. 47. Distal wedge Triangular Square , parallel or H-design Linear or pedicle The size, shape ,thickness and access of the tuberosity or retromolar area determine treatment procedures
  48. 48. TRIANGULAR DISTAL WEDGE: Triangular wedge incisions are placed creating the apex of the triangle close to the hamular notch and the base of the triangle next to the distal surface of the terminal tooth.
  49. 49. Triangular incision -Using no.12 0r no.15 scalpel blade Triangular wedge of tissue removal-using scalers ,hoes , or knives Walls of the wedge are thinned using scalpel blade- for proper adaptation to underlying bone
  50. 50. LINEAR DISTAL WEDGE: two parallel incisions over the crest of the tuberosity that extend from the proximal surface of the terminal molar to the hamular notch area. The distance between the two linear incisions is determined by the thickness of the tissues
  51. 51. Two parallel inverse bevel thinning incision –using n0.15 blade Periosteal elevators are used to raise the flap Kirkland or orban knives –to remove the wedge of tissue
  52. 52. DISTAL POCKET ERADICATION PROCEDURE WITH THE INCISION DISTAL TO THE MOLAR SCALLOPED INCISION AROUND THE REMAINING TEETH
  53. 53. FLAP REFLECTED AND THINNED AROUND THE DISTAL INCISION FLAP IN POSITION BEFORE SUTURING. IT SHOULD BE CLOSELY APPROXIMATED
  54. 54. FLAP SUTURED BOTH DISTALLY AND OVER THE REMAINING SURGICAL AREA
  55. 55. PERIODONTAL PACKS Periodontal dressing or periodontal packs is a productive materials applied over the wound created by periodontal surgical procedure minimise postoperative infection aand haemorrahage Facilitates healing Protects against pai
  56. 56. Zinc –oxide eugenol packs Zno eugenol packs packs based on reaction of zno & eugenol include – wondr pak The addition of accelerators such as Zinc acetate gives the dressing a betterworking time. It is supplied as a liquid and a powder that are mixed prior to use. Eugenol may produce allergic reaction (reddening of area and burning pain )
  57. 57. Non eugenol packs Reaction between metallic oxide and fatty acid is basis for coe-Pak Supplied in two tubes One tube contains oxides of various metals (Mainly zinc oxide) and lorothidol (a fungicide) and second tube contains non ionized carboxylic acids and chlorothymol (bacteriostatic agents)
  58. 58. Retenton of packs Mechanically by interlocking in interdental spaces and joining the facial and lingual portion of the pack
  59. 59. Antibacterial properties Improved healing and patient comfort – incorporating antibiotics Bacitracin, oxytetracycline , neomycin nitrofurazone(hypersensitivity)
  60. 60. Preparation and application of periodontal dressing Equal length of the two paste placed on a paper pad Mixed with a wooden tongue depressor for 2-3 minutes until paste loses its tackiness
  61. 61. Paste is placed in a paper cup of water at room temperature With lubricated fingers rolled into cylinders and placed on the surgical wound
  62. 62. Strip of pack is hooked around last molar and pressed into place anteriorly Lingual pack is joined to facial strip at the distal surface of last molar and fitted into place anteriorly Gentle pressure on the facil and lingual surfaces join the pack interproximally
  63. 63. Continous pack cover the edentulous space
  64. 64. Instructions for patients after surgery 1. The pack should remain in place until it is removed in the office at the next appointment 2. For the first three hours after the operation avoid hot foods to permit the pack to harden 3. Do not smoke 4. Do not brush over the pack
  65. 65. Removal of periodontal pack After 1 week Inserting a surgical hoe along the margin and exert gentle lateral pressure Pieces of pack- removed with scalers Entire area rinsed with peroxide to remove superficial debris
  66. 66. Findings at pack removal Epithelialized but bleed readily when touched Pockets should not be probed
  67. 67. HEALING AFTER FLAP SURGERY Immediately after suturing (0 to 24 hours),established by a blood clot, which consists of a fibrin reticulum with many polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of the wound. One to 3 days after flap surgery,the space between the flap and the tooth or bone is thinner, and epithelial cells migrate over the border of the flap One week after surgery‐The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, and the periodontal ligament.
  68. 68. Two weeks after surgery,collagen fibers begin to appear parallel to the tooth surface. Union of the flap to the tooth is still weak, owing to the presence of immature collagen fibers, although the clinical aspect may be almost normal. •One month after surgery,a fully epithelialized gingival crevice with a well‐defined epithelial attachment is present. There is a beginning functional arrangement of the supracrestal fibers.

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