Flap adaptation is then done with the help of moistened gauze and any excess blood is expressed. It is better to graft an infrabony defect than not grafting. 1. The operated area will be cleaner without dressing and will heal faster. Trismus is the inability to open the mouth. The internal bevel incision accomplishes three important objectives: (1) it removes the pocket lining; (2) it conserves the relatively uninvolved outer surface of the gingiva, which, if apically positioned, becomes attached gingiva; and (3) it produces a sharp, thin flap margin for adaptation to the bonetooth junction. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. 3. Several techniques can be used for the treatment of periodontal pockets. 3. The no. Periodontal pockets in areas where esthetics is critical. Refer to oral surgeon for biopsy ***** B. More is the thickness of the gingiva, farther is the incision placed to include more tissue which needs to be removed. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. The patient is recalled after one week for suture removal. Step 2: The initial, or internal bevel, incision is made. 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. Clinical crown lengthening in multiple teeth. Severe hypersensitivity. Patients at high risk for caries. A. The esthetic and functional demands of maxillofacial reconstruction have driven the evolution of an array of options. The starting point on the gingiva is determined by whether the flap is apically displaced or not displaced (Figure 57-7). It is also known as a partial-thickness flap. According to flap reflection or tissue content: During the initial phase of healing, inflammatory cells are attracted by platelet and complement derived mediators and aggregate around the blood clot. This will allow the clinician to retain the maximum amount of gingival tissue, including the papilla, which is essential for graft or membrane coverage. 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. While doing laterally displaced flap for root coverage, the vertical incision is made at an acute angle to the horizontal incision, in the direction toward which the flap will move, placing the base of the pedicle at the recipient site. The incision is then carried out till the line angle of the tooth blending it into the gingival crevice. 2011 Sep;25(1):4-15. See video of the surgery at: Modified flap operation. The root surfaces are checked and then scaled and planed, if needed (. Placing periodontal depressing is optional. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. Coronally displaced flap Connective tissue autograft Free gingival graft Laterally positioned flap Apically displaced flap 5. After the area to be operated is irrigated with an anti-microbial solution, local anesthesia is applied and the area is isolated after profound anesthesia has been achieved. Contents available in the book .. For the correction of bone morphology (osteoplasty, osseous resection). Contents available in the book .. If detected, they are removed. Access flap for guided tissue regeneration. In 1965, Morris4 revived a technique described early during the twentieth century in the periodontal literature; he called it the unrepositioned mucoperiosteal flap. Essentially, the same procedure was presented in 1974 by Ramfjord and Nissle,6 who called it the modified Widman flap (Figure 59-3). The buccal and palatal/lingual flaps are reflected with the help of a periosteal elevator. ), Only gold members can continue reading. 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. Then sharp periodontal curettes are used to remove the granulomatous tissue and tissue tags. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3 mm. Henry H. Takei, Fermin A. Carranza and Jonathan H. Do. Otherwise, the periodontal dressing may be placed. The interdental incision is then given to remove the wedge of tissue that contains the pocket wall. 7. Crown lengthening procedures to expose restoration margins. Triangular The first incision or the internal bevel incision is then made from the bleeding points directed at an apical level to the alveolar crest. These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. It is contraindicated in the areas where treatment for an osseous defect with the mucogingival problem is not required, in areas with thin periodontal tissue with probable osseous dehiscence or osseous fenestration and in areas where the alveolar bone is thin. It enhances the potential for effective periodontal maintenance and preservation of attachment levels. Locations of the internal bevel incisions for the different types of flaps. These techniques are described in detail in. Coronally displaced flap. 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. b. Because the pocket wall is not displaced apically, the initial incision should eliminate the pocket wall. 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. It is also known as the mucoperiosteal (mucosal tissue + periosteum) flap. Areas which do not have an esthetic concern. When the flap is returned and sutured in its original position. The secondary flap removed, can be used as an autogenous connective tissue graft. Suturing is then performed to stabilize the flaps in their position. A crescent-shaped incision is sometimes used during the crown lengthening procedure. In Figure 2, the frequency of the types of flap surgical techniques followed were analyzed. . Contraindications of periodontal flap surgery. The incision is made. The internal bevel incision may be a marginal incision (from the top of gingival margin) or para-marginal incision (at a distance from the gingival margin). Technique-The technique that weusehas been reported previously (Zucman and Maurer 1965). Palatal flaps cannot be displaced because of the absence of unattached gingiva. Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. 6. 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. This incision is always accompanied by a sulcular incision which results in the formation of a collar of gingival tissue which contains the periodontal pocket lining. It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. Contents available in the book . In non-esthetic areas with moderate to deep pockets and for crown lengthening, this incision is indicated. The incision is made not only around the facial and lingual radicular area but also interdentally, where it connects the facial and lingual segments to free the gingiva completely around the tooth (Figure 57-9; see Figure 57-5). This increase in the width of the attached gingiva is based on the apical shift of the mucogingival junction, which may include the apical displacement of the muscle attachments. Vertical incisions increase flap mobility, thus facilitating better access to the operative area. The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. Undisplaced flap Palatal Flap The surgical approach is different here because of the nature of the palatal tissue which is attached, keratinized tissue and has no elastic properties associated with other gingival tissues, hence no displacement and no partial thickness flaps. 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. The blade is pushed into the sulcus till resistance is felt from the crestal bone crest. The flaps are then apically positioned to just cover the alveolar crest. 4. Therefore, the two anatomic landmarksthe pocket depth and the location of the mucogingival junctionmust be considered to evaluate the amount of attached gingiva that will remain after the surgery has been completed. It reduces mouth opening, is commonly associated with pain and causes difficulty in mastication. Following is the description of step by step procedure followed while doing a modified Widman flap surgery. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. 2014 Apr;41:S98-107. 1. Eliminate or reduce pocket depth via resection of the pocket wall, 3. Step 2: The mucogingival junction is assessed to determine the amount of keratinized tissue. May cause attachment loss due to surgery. In the following discussion, we shall study in detail, the surgical techniques that are followed in various flap procedures. After the primary incision, tissue can now be retracted with the help of rat-tail pliers. The proper placement of the flap margin at the toothbone junction during closure is important to prevent either recurrence of the pocket or the exposure of bone. preservation flap ) papila interdental tidak terpotong karena tercakup ke salah satu flep (gambar 2C). For the management of the papilla, flaps can be conventional or papilla preservation flaps. The interdental incision is then made to severe the inter-dental fiber attachment. The interdental papilla is then freed from the underlying bone and is completely mobilized. Unsuitable for treatment of deep periodontal pockets. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. Tooth movement and implant esthetics. Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned flap . Contents available in the book . International library review - 2022-2023| , , & - Academic Accelerator The incision is made around the entire circumference of the tooth using blade No. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. The step-by-step technique for the undisplaced flap is as follows: Step 1: The periodontal probe is inserted into the gingival crevice & penetrates the junctional epithelium & connective tissue down to bone. Contents available in the book .. Step 6:Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. After the patient has been thoroughly evaluated and pre-pared with non-surgical periodontal therapy, quadrant or area to be operated is selected. a. Full-thickness flap. According to flap reflection or tissue content: C. According to flap placement after surgery: Diagram showing full-thickness and partial-thickness flap. What are the steps involved in the Apically Displaced flap technique? 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. 7. The first, second and third incisions are placed in the same way as in case of modified Widman flap and the wedge of the infected tissue is removed. Different Flap techniques for treatment of gingival recession (Lateral-coronal-double papilla-semilunar-tunnel-apical). The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). 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 (. In case, where osseous recontouring is done the flap margins may be re-scalloped and trimmed to adapt to the root bone junction. Frenectomy-frenal relocation-vestibuloplasty. A full-thickness flap is elevated with the help of a periosteal elevator whereas partial-thickness flap is elevated using sharp dissection with a Bard-Parker knife. The following steps outline the undisplaced flap technique. With the migration of these cells in the healing area, the process of re-establishment of the dentogingival unit progresses. A. Areas where post-operative maintenance can be most effectively done by doing this procedure. May cause esthetic problems due to root exposure. A new technique for arthroscopic meniscectomy using a traction suture, , 2015-02, ()KCI . Papilla Preservation Flaps :it incorporates the entire papilla in one of the flap by means of crevicular interdental incison to sever the connective tissue attachment & a horizontal incision at the base . This is especially important because, on the palatal aspect, osseous deformities such as heavy bone ledges and exostoses are commonly seen. The modified Widman flap procedure involves placement of three incisions: the initial internal bevel/ reverse bevel incision (first incision), the sulcular/crevicular incision (second incision) and the horizontal/interdental incision (third incision). Intrabony pockets on distal areas of last molars. This internal bevel incision is placed at a distance from the gingival margin, directed towards the alveolar crest. 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). With the conventional flap, the interdental papilla is split beneath the contact point of the two approximating teeth to allow for the reflection of the buccal and lingual flaps. ( intently, the undisplaced flap is perhaps the most commonly performed type ol periodontal surgery. The present systematic review analysed the clinical outcomes of resective surgery versus access flap procedures in subjects with periodontitis stages II-III (previously termed moderate to advanced periodontitis), in order to support the development of evidence-based guidelines for periodontal therapy. The undisplaced flap is therefore considered an internal bevel gingivectomy. Position of the knife to perform the internal bevel incision. Contents available in the book . The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. Flap for regenerative procedures. 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). Suturing is then done using a continuous sling suture. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. In these flaps, the entire papilla is incorporated into one of the flaps. 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 incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. Contents available in the book .. 1. 12D blade is usually used for this incision. During crown lengthening, the shape of the para-marginal incision depends on the desired crown length. 15c, 11 or 12d. Areas which do not have an esthetic concern. Step 3: Crevicular incision is made from the bottom of the . Contents available in the book .. C. According to flap placement after surgery: The undisplaced flap and gingivectomy are the two techniques that surgically removed the pocket wall. The flap is then elevated with the help of a small periosteal elevator. The flap was repositioned and sutured [Figure 6]. Contents available in the book .. This is mainly because of the reason that all the lateral blood supply to. Step 2:The gingiva is reflected with a periosteal elevator (Figure 59-3, D). The flap is placed at the toothbone junction by apically displacing the flap. 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 buccal and the lingual/palatal flaps are then elevated to expose the diseased root surfaces and the marginal bone. 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. Step 3: The second, or crevicular, incision is made from the bottom of the pocket to the bone to detach the connective tissue from the bone. To fulfill these purposes, several flap techniques are available and in current use. The modified Widman flap has been described for exposing the root surfaces for meticulous instrumentation and for the removal of the pocket lining.6 Again, it is not intended to eliminate or reduce pocket depth, except for the reduction that occurs during healing as a result of tissue shrinkage. The apically displaced flap is. 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%). 12D blade is usually used for this incision. - Charter's method - Bass method - Still man method - Both a and b correct . The factors that are associated with post-operative swelling include the type of the incision, its extension, tissue manipulation during the surgery and the duration of surgery. 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction. Conventional flap. One incision is now placed perpendicular to these parallel incisions at their distal end. 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. The information presented in this website has been collected from various leading journals, books and websites. It is an access flap for the debridement of the root surfaces. 30 Q . Undisplaced flaps are one of the most common periodontal surgeries for correcting anatomical factors that predispose patients to predisposing periodontal disease, and makes it possible to improve aesthetics by eliminating obstacle of wearing a denture. The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. that still persist between the bottom of the pocket and the crest of the bone. 5. Clin Appl Thromb Hemost. The para-marginal internal bevel incision accomplishes three important objectives. Hemorrhage occurring after 7-14 days is secondary to trauma or surgery. The most abundant cells during the initial healing phase are the neutrophils. The thicker the tissue is, the more apical the ending point of the incision (see Figure 59-4). The challenging nature of scaphoid fracture and nonunion surgery make it an obvious target. Sixth day: (10 am-6pm); "Perio-restorative surgery" Modified Widman flap and apically repositioned flap. Contents available in the book .. Step 3:A crevicular incision is made from the bottom of the pocket to the bone in such a way that it circumscribes the triangular wedge of tissue that contains the pocket lining. Apically displaced flap can be done with or without osseous resection. Contents available in the book .. The flaps may be thinned to allow for close adaptation of the gingiva around the entire circumference of the tooth and to each other interproximally. An intact papilla should be either excluded or included in the flap. Increase accessibility to root deposits for scaling and root planing, 2. As already stated, depending on the thickness of the gingiva, any of the following approaches can be used. The incision is usually started at the disto-palatal line angle of the last molar and continued forward using a scalloped, inverse-beveled, partial-thickness incision to create a thin partial-thickness flap. Fibrous enlargement is most common in areas of maxillary and mandibular . Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. 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 thickness of the gingiva. This flap procedure allows complete access to the root surfaces allowing their mechanical debridement and decontamination under direct vision. It is most commonly caused due to infection and sloughing of blood vessels. Local anesthesia is administered to achieve profound anes-thesia in the area to be operated. Tooth with extremely unfavorable clinical crown/root ratio.
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