FLAP PERIODONTAL. Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. Areas where post-operative maintenance can be most effectively done by doing this procedure. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. Periodontal flaps can be classified as follows. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. The granulation tissue, as well as tissue tags, are then removed. Contents available in the book . Step 2:The gingiva is reflected with a periosteal elevator (Figure 59-3, D). The researchers reported similar results for each of the three methods tested. The flap is then elevated with the help of a small periosteal elevator. With the migration of these cells in the healing area, the process of re-establishment of the dentogingival unit progresses. 34. This flap procedure may be regarded as internal bevel gingivectomy because the first incision or the internal bevel incision given during this procedure is placed at the level of pocket depth (Figure 62.1), thus including all the soft tissue containing and supporting periodontal pocket. According to management of papilla: Flaps in which the interdental papilla is split beneath the contact of two approximating teeth, allowing the reflection of buccal and lingual flaps, are described as the conventional flaps. Once bone sounding has been done, a gingivectomy incision without bevel is given using a periodontal knife to remove the tissue above the alveolar crest. The choice of which procedure to use depends on two important anatomic landmarks: the pocket depth and the location of the mucogingival junction. Journal of periodontology. Periodontal flaps can be classified on the basis of the following: For bone exposure after reflection, the flaps are classified as either full-thickness (mucoperiosteal) or partial-thickness (mucosal) flaps (Figure 57-1). The thickness of the gingiva. The reasons for placing vertical incisions at line angles of the teeth are. The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. This will allow the clinician to retain the maximum amount of gingival tissue, including the papilla, which is essential for graft or membrane coverage. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The vertical incisions are extended far enough apically so that they are at least 3 mm apical to the margin of the interproximal bony defect and 5 mm from the gingival margin. in adults. Under no circumstances, the incision should be made in the middle of the papilla. However, there are important variations in the way these incisions are performed for the different types of flaps (Figures 59-1 and 59-2). Give local anaesthetic for 2 weeks and recall C. Recall for follow up after 6 weeks D. 13- Which is the technique that will anesthetize both hard and soft tissues of the lower posterior teeth region in one injection A. Gow gates***** B. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. Contents available in the book .. The techniques that are used to achieve reconstructive and regenerative objectives are the papilla preservation flap8 and the conventional flap, which involve only crevicular or pocket incisions. 15 or 15C surgical blade is used most often to make this incision. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). Sixth day: (10 am-6pm); "Perio-restorative surgery" The bleeding is frequently associated with pain. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. Contents available in the book .. Contents available in the book . After the gingivectomy incision, primary and the secondary incisions are placed in the same way as described in the partial-thickness flap procedure. May cause hypersensitivity. Contents available in the book .. 2. The base of the flap should be wider than the flap margin so that the blood supply to the flap is not jeopardized. Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. The primary incision or the internal bevel incision is then made with the help of No. 3. Incisions can be divided into two types: the horizontal and vertical incisions 7. The flap is sutured with interrupted or continuous sling sutures. Vertical incisions increase flap mobility, thus facilitating better access to the operative area. Tooth with marked mobility and severe attachment loss. It was described by Kirkland in 1931 31. Conflicting data surround the advisability of uncovering the bone when this is not actually needed. This is termed. Normal interincisal opening is approximately 35-45mm, with mild . During crown lengthening, the shape of the para-marginal incision depends on the desired crown length. According to flap reflection or tissue content: Care should be taken to insert the blade in such a way that the papilla is left with a thickness similar to that of the remaining facial flap. The vertical incision should always be placed at the line angles of the teeth and never (except rare instances, such as a double papilla flap) over the height of contour of the root. (adsbygoogle = window.adsbygoogle || []).push({}); The external bevel incision is typically used in gingivectomy procedures. After the removal of the secondary flap, scaling and root planing is done and the flap is adapted to its position. For the undisplaced flap, the internal bevel incision is initiated at or near a point just coronal to where the bottom of the pocket is projected on the outer surface of the gingiva (see Figure 59-1). Journal of clinical periodontology. The meniscus comma sign has been described for displaced flap tears of the meniscus. The pockets are then measured and bleeding points are produced with the help of a periodontal probe on the outer surface of the gingiva, indicating the bottom of the pocket. B. Laterally displaced flap. The pockets are measured with the periodontal probe, and a bleeding point is produced on the outer surface of the gingiva to mark the pocket bottom. 1. The following steps outline the modified Widman flap technique. It is most commonly caused due to infection and sloughing of blood vessels. Maintaining primary closure after guided bone regeneration procedures: Introduction of a new flap design and preliminary results. Contents available in the book .. Kirkland flap method was the most commonly followed (60.47%), then it was modified widman flap (29.65%), undisplaced flap (6.39%) and distal wedge which was the lowest (3.48%). A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces 1. The granulation tissue is highly vascularized, so it bleeds profusely. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. The undisplaced flap is therefore considered an internal bevel gingivectomy. Contents available in the book .. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. Pockets around the teeth in which a complete removal of root irritants is not clinically possible without gaining complete access to the root surfaces. News & Perspective Drugs & Diseases CME & Education This is a commonly used incision during periodontal flap surgeries. the.undisplaced flap and the gingivectomy. After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. In the upcoming chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of lost periodontal structures. The area is re-inspected for any remaining granulation tissue, tissue tags or deposits on the root surfaces. A study made before and 18 years after the use of apically displaced flaps failed to show a permanent relocation of the mucogingival junction.1. The root surfaces are checked and then scaled and planed, if needed (. The flap procedures on the palatal aspect require a different approach as compared to other areas because the palatal tissue is composed of a dense collagenous fiber network and there is no movable mucosa on the palatal aspect. These incisions are made in a horizontal direction and may be coronally or apically directed. Apically displaced flap, and Contents available in the book .. The flaps are then apically positioned to just cover the alveolar crest. 12D blade is usually used for this incision. Unsuitable for treatment of deep periodontal pockets. Methods Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting , were included for this prospective cohort . Because the alveolar bone is partially exposed, there is minimum post-operative pain and swelling. Different Flap techniques for treatment of gingival recession (Lateral-coronal-double papilla-semilunar-tunnel-apical). Signs and symptoms may include continuous flow, oozing or expectoration of blood or copious pink saliva. The reduction of bacterial load and inflammation minimizes further loss of tooth-supporting structures and thus aid in the better prognosis of teeth, provided, the patient stays on a strict maintenance schedule. The partial-thickness flap is indicated when the flap is to be positioned apically or when the operator does not want to expose bone. For this reason, the internal bevel incision should be made as close to the tooth as possible (i.e., 0.5mm to 1.0mm) (see, For the undisplaced flap, the internal bevel incision is initiated at or near a point just coronal to where the bottom of the pocket is projected on the outer surface of the gingiva (see, The techniques that are used to achieve reconstructive and regenerative objectives are the, The initial incision is an internal bevel incision to the alveolar crest starting 0.5mm to 1mm away from the gingival margin (, The gingiva is reflected with a periosteal elevator (. This drawback of conventional flap techniques led to the development of this flap technique which intended to spare the papilla instead of splitting it. a. Preservation of good blood supply to the flap is another important consideration. Apically displaced flap. This is essentially an excisional procedure of the gingiva. . The bleeding is frequently associated with pain. Intrabony pockets on distal areas of last molars. The use of continuous suturing in suture materials tearing through the flap edges and both plastic surgery (1) and periodontal surgery subsequent retraction of the flaps to less desirable has many advantages. Hence, this suturing is mainly indicated in posterior areas where esthetics. The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. The continuous sling suture has an advantage that it uses tooth as an anchor and thus, facilitates to hold the flap edges at the root-bone junction. The starting point on the gingiva is determined by whether the flap is apically displaced or not displaced (Figure 57-7). Mitral facies or malar flush There is a tapping apex beat which is undisplaced. It is discarded after the crevicular (second) and interdental (third) incisions are performed (Figure 57-5). Contents available in the book .. Several techniques can be used for the treatment of periodontal pockets. This is also known as. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. Two types of horizontal incisions have been recommended: the internal bevel incision. At last periodontal dressing may be applied to cover the operated area. To perform this technique without creating a mucogingival problem, the clinician should determine that enough attached gingiva will remain after removal of the pocket wall. The buccal and palatal/lingual flaps are reflected with the help of a periosteal elevator. The square, Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. Step 2:The initial or internal bevel incision is made (Figure 59-4) after scalloping the bleeding marks on the gingiva (Figure 59-5). Contents available in the book . Click this link to watch video of the surgery: Modified Widman Flap surgery. For flap placement after surgery, flaps are classified as either (1) nondisplaced flaps, when the flap is returned and sutured in its original position, or (2) displaced flaps, which are placed apically, coronally, or laterally to their original position. Reconstruction of Distal Phalangeal Soft Tissue Defects with Reverse Homodigital Artery Island Flap, , 2014-11, () . Contents available in the book . Clinical crown lengthening in multiple teeth. Enter the email address you signed up with and we'll email you a reset link. An intact papilla should be either excluded or included in the flap. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective . techniques revealed that 67.52% undergone kirkland flap, 20.51% undergone modified widman flap, 5.21% had papilla preservation flap, 2.25% had undisplaced flap, 1.55% had apically displaced flap and very less undergone distal wedge procedure which depicts that most commonly used flap technique was kirkland flap among other techniques. 2014 Apr;41:S98-107. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. Inferior alveolar nerve block C. PSA 14- A patient comes with . The cell surface components or adhesive molecules of bacteria that interact with a variety of host componentsand responsible for recognizing and binding to specific host cell receptors A. Cadherins B. Adhesins C. Cohesins D. Fimbriae Answer: B 2. Areas which do not have an esthetic concern. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. The following outline of this technique: The modified Widman flap. The internal bevel incision starts from a designated area on the gingiva, and it is then directed to an area at or near the crest of the bone (. Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned flap with or without resective osseous surgery, and orthodontic forced eruption with or without fibrotomy have been proposed for clinical crown lengthening. Areas which do not have an esthetic concern. - Charter's method - Bass method - Still man method - Both a and b correct . This is also known as Ledge-and-wedge technique. b. A detailed description of the historical aspect of various flap surgeries has been given in the previous chapter. After this, the second incision or the sulcular incision is made from the bottom of the pocket to the crest of the alveolar bone. With this incision, the gingiva containing pocket lining is separated from the tooth surface. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. Apically displaced flaps have the important advantage of preserving the outer portion of the pocket wall and transforming it into attached gingiva. The triangular wedge technique is used in cases where the adequate zone of attached gingiva is present and in cases of short or small tuberosity. The flap was repositioned and sutured and . This flap procedure utilizes two incisions referred to as primary and secondary incisions which contain tissue which has to be removed. Contents available in the book .. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. It is an access flap for the debridement of the root surfaces. The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. It conserves the relatively uninvolved outer surface of the gingiva. May increase the risk of root caries. Flap design for a sulcular incision flap. C. According to flap placement after surgery: Eliminate or reduce pocket depth via resection of the pocket wall, 3. See Page 1 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction. Pocket depth was initially similar for all methods, but it was maintained at shallower levels with the Widman flap; the attachment level remained higher with the Widman flap. The interdental incision is then given to remove the wedge of tissue that contains the pocket wall. This suturing causes the apical positioning of the facial papilla, thus creating open gingival embrasures (black holes). Step 1:The initial incision is an internal bevel incision to the alveolar crest starting 0.5mm to 1mm away from the gingival margin (Figure 59-3, C). Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. Contents available in the book .. Contents available in the book .. Otherwise, the periodontal dressing may be placed. It differs from the modified Widman llap in that the soft tissue pocket wall is removed with the initial incision; thus it may be considered an internal bevel glngivectomy. In Figure 2, the frequency of the types of flap surgical techniques followed were analyzed. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. Placement of the vertical incisions is absolutely essential in cases where the flap has to be re-positioned coronally (coronally displaced flap) or apically (apically displaced flap) from its original position. Contents available in the book .. This incision has also been termed the first incision, because it is the initial incision for the reflection of a periodontal flap; it has also been called the reverse bevel incision, because its bevel is in reverse direction from that of the gingivectomy incision. Vertical relaxing incisions are usually not needed. The periodontal pockets on the distal aspects of last molars, both in maxillary and the mandibular arches present a unique situation for which specific surgical designs have been advocated. Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. This is a modification of the partial thickness palatal flap procedure in which gingivectomy is done prior to the placement of primary and the secondary incision. 5. This incision is indicated in the following situations. As already discussed in, History of surgical periodontal pocket therapy and osseous resective surgeries the original Widman flap was presented to the Scandinavian Dental Association in 1916 by Leonard Widman which was later published in 1918. This is mainly because of the reason that all the lateral blood supply to . The undisplaced flap and gingivectomy are the two techniques that surgically removed the pocket wall. The challenging nature of scaphoid fracture and nonunion surgery make it an obvious target. Increase accessibility to root deposits for scaling and root planing, 2. That portion of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granulomatous tissue. Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/ palatally. Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty. The first documented report of papilla preservation procedure was by. Historically, gingivectomy was the treatment of choice for these areas until 1966, when Robinson 32 addressed this problem and gave a separate surgical procedure for these areas which he termed distal wedge operation. The internal bevel incision in an undisplaced flap procedure is started at the same point where an external bevel incision is started in agingivectomyprocedure. Because the pocket wall is not displaced apically, the initial incision should eliminate the pocket wall. The secondary flap removed, can be used as an autogenous connective tissue graft.