decision making flap surgery IN PERIODONTOLOGY

PERIO

1. Decision making in periodontal flap surgery Dr. N D Jayakumar Principal and Head Dept.Of Periodontics Saveetha Dental College

2. The treatment of periodontal diseases encompasses a vast array of nonsurgical and surgical techniques aimed at the elimination of infection and inflammation to establish a healthy periodontium. Introduction ..

3. to create an oral environment that is conducive to maintaining the patient's dentition in a healthy comfortable f unctional and esthetic state and , when feasible, to regenerate and preserve the periodontal attachment. The major goals of periodontal surgery are

4. Considerations when evaluating the role of surgical therapy in the overall treatment plan

5. 1. Accessibility of instruments to root surface. 2. Elimination of inflammation. 3. Creation of an oral environment conducive to plaque control. a. Establish gingival sulcus for easy periodontal disease control (elimination of pocket). b. Correct abnormal gingiva and alveolar bone morphologic characteristics that interfere with plaque control. c. Perform root-sectioning procedures or treatments to improve morphology for easier oral hygiene maintenance. d. Create an easy to clean and proper embrasure space. 4. Regeneration of periodontal apparatus destroyed by periodontal disease. Objectives of periodontal surgery

6. 5. Resolution of gingiva -alveolar mucosa problems. 6. Preparation of periodontal environment suitable to restorative and prosthodontic treatment. Periodontal surgery serves as the therapy prior to prosthodontic treatment. 7. Esthetic improvement.

7. 1 . Curettage 2. Gingivectomy 3 . Flap surgery a. Flap curettage b. Osseous resection • osteoplasty • ostectomy c. Bone graft d. GTR (guided tissue regeneration) • GTR with bone grafts • GTR without bone grafts 4. Mucogingival surgery a. Attached gingiva augmentation • Free autogenous gingival grafts • Pedicle gingival grafts • Apically positioned flap surgery b. Root coverage • Pedicle gingival grafts • Semilunar coronally positioned flaps • Free autogenous gingival grafts • Subepithelial connective tissue grafts • GTR (guided tissue regeneration) c. Frenum operation 5. Combination of various periodontal surgical approaches Methods of Periodontal Surgery

8. Know your patient and his or her medical status Develop a thorough and complete treatment plan Know anatomy of surgical sites Provide profound anesthesia Follow aseptic surgical technique Practice atraumatic tissue management • sharp, smooth incisions • careful flap reflection and retraction • avoid flap tension Attain hemostasis Use atraumatic suturing techniques • smallest needle and suture that can be used in the area • place sutures in keratinized tissue when possible • take adequate bites of tissue • minimum number of sutures to achieve closure Obliterate dead space between flap and bone Promote stable wound healing Principles of periodontal surgery

9. Medical History and Physical Status Thorough comprehensive medical history Written questionnaire and dialogue between patient and doctor

10. Determine the etiology diagnosis prognosis patient desires and expectations Diagnosis and treatment plan

11. Attached gingiva Maxillary buccal and facial aspects Palate Greater palatine nerve and artery: Nasopalatine nerve and artery Mandible Anterior facial region Posterior facial region. Mandibular lingual area Posterior aspect Lingual nerve and artery Surgical anatomy

12. Anatomic spaces

13. Anesthesia

14. Sterilization Patient preparation Prophylactic antibiotics Aseptic surgical technique

15. What is the purpose of reflecting a flap? What type of periodontal surgery are you planning to do? What are the medical conditions you will have to consider? In this case what do you think is the cause of the periodontal disease? What is your diagnosis? Why do you say so…? According to what classification..? What is the prognosis? How do you grade prognosis? What are the anatomical features you will have to take in to consideration when you plan flap surgery?? What are the anatomic spaces associated with the orofacial region?? What is the nerve supply to the maxillary gingiva and which nerve will you anaesthetize?? How do you sterilize the instruments? What is chemical sterilization? How do you prepare patients for periodontal surgery?

16. Armamentarium Incision Flap design Flap reflection Debridement Defect management Flap positioning Hemostasis Suturing Periodontal dressing Decisions to be made during flap surgery

17. Surgical plan..

18. What is your surgical plan??

19. Surgical plan

20. Armamentarium ..

21. What are the various instruments required for periodontal surgery?? What are the various knives used in periodontal surgery??

22. Incision and excision -periodontal knives, BP blade Deflection and re-adaptation of mucosal flaps - periosteal elevators Removal of adherent fibrous and granulomatous tissue -soft tissue rongeurs and tissue scissors Scaling and root planing - scalers and curettes Removal of bone tissue -bone rongeurs , chisels, and files Root sectioning burs Suturing -sutures and needle holders, suture scissors Bone grafts and GTR membrane Armamentarium

23. Mouth mirrors • Graduated periodontal probe/explorer • Handles for disposable surgical blades (e.g. Bard- Parker handle) • Mucoperiosteal elevator and tissue retractor • Scalers and curettes • Cotton pliers • Tissue pliers • Tissue scissors • Needle holder • Suture scissors • Plastic instrument • Hemostat • Burs.

24. Additional equipment may include: • Syringe for local anesthesia • Syringe for irrigation • Aspirator tip • Physiologic saline • Drapings for the patient • Surgical gloves, surgical mask, surgeon’s hood.

25. It is important that the instruments are kept in good working condition. The maintenance routine should ensure that scalers , curettes, knives with fixed blades, etc., are sharp and the hinges of scissors, rongeurs , and needle holders are properly lubricated. Spare instruments (sterile) should always be available to replace instruments found to be defective or accidentally contaminated.

26. Incisions and flap design

27. What are the incisions used in periodontal flap surgery? What are the principles of incision making?? What are the principles in making vertical incisions? What factors do you consider in making the primary incision?? What is external bevel incision? Where is it used?? What is internal bevel incision? Where is it used ??what are the advantages?? What is the level at which you start your internal bevel incision?? What is the level at which you start your internal bevel incision for undisplaced flap??

28. What are the various flap designs?? What are the key points and how do you decide the type of flap?? What is envelope flap?? Are you elevating a full thickness or partial thickness flap??? Why?? What are the advantages and disadvantages of undisplaced flap??? What are the advantages of modified W idman flap??? When do you choose modified W idman flap?? When do you choose apically displaced flap?? What is papilla preservation flap? When do you choose papilla preservation flap?? What are the principles of flap design? Why base should be broader how much broader?? Why?? Who designed the modified Widman flap?? What are the 3 incisions you are going to make?? Why do you prefer sulcular incision flap??

29. Incisions

30. Incision must be made with a sharp blade. The incision must be firm and the stroke must be continuous and deep to the bone. Vital structures should not be damaged. Avoid acute angulations between the incisions. The incision should always be made at right angle to the epithelial surface The line of incision is planned in such a way that, after surgery, the line of closure rests on sound bone Incision

31. Incisions

32. Flap design..

33. Definition:- A flap is a segment of gingiva and adjoining alveolar mucosa raised from the underlying tissues by surgical means to provide visibility of and access to the bone and root surface. Periodontal flap

34. Areas with irregular bony contours, deep craters, and other defects usually require surgical approach. Pockets on teeth in which a complete removal of root irritants is not considered clinically possible may call for surgery. This occurs frequently in molar and pre molar areas. In cases of furcation invovement of grade II or III a surgical approach ensures the removal irritants; any necessary root resection or hemi section also requires surgical intervention. Intra bony pockets on distal areas of last molars frequently complicated for by mucogingival problems are usually unresponsive to non surgical methods. Persistent inflammation in areas with moderate to deep pockets even after repeated non surgical therapy may require a surgical approach. Indications of periodontal flap

35. Contraindications

36. Classification of flaps

37. Flap design is based on the principle of maintaining an optimal blood supply to the tissue. There are generally two basic flap designs: those with and those without vertical releasing incisions

38. Envelope flap Triangular flap Trapezoidal flap

39. Basic requirements of flap design

40. Blood supply to the flap Greater the ratio of flap length to flap base- greater the vascular compromise at the flap margins Recommended flap length (height)-to-base ratio should be no greater than 2:1

41. Full thickness and partial thickness flaps

42. Comparison of full thickness and partial thickness flaps

43. Modified Widman flap Undisplaced flap Apically positioned flap Conventional flap

44. 1965 Morris - unrepositioned mucoperiosteal flap Ramford & Nissle (1974) - modified Widman flap technique While the original widman flap technique included both apical displacement of the flaps and osseous recontouring (elimination of bony defects) to obtain proper pocket elimination, the modified widman flap technique is not intended to meet these objectives. Modified Widman flap

45. Advantages of Modified Widman Flap The possibility of obtaining a close adaptation of the soft tissues to the root surfaces. Minimum trauma to the alveolar bone and the soft connective tissues Less exposure of the root surfaces, which from an esthetic point of view is an advantage in the treatment of anterior segments of the dentition. Modified Widman flap

46. Advantages Completely eliminates the pocket Can be performed in cases with pocket formation and gingival enlargements Disadvantages Not preferred in anterior region Can result in inadequate width of attached gingiva Undisplaced flap

47. Advantages 1. Eliminates periodontal pocket 2. Preserves attached gingiva and increases its width 3. Establishes gingival morphology facilitating good hygiene 4. Ensures healthy root surface necessary for the biologic width on alveolar margin and lengthened clinical crown Apically positioned flap

48. 1. May cause esthetic problems due to root exposure 2. May cause attachment loss due to surgery 3. May cause hypersensitivity 4. May increase the risk of root caries 5. Unsuitable for treatment of deep periodontal pockets 6. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control Disadvantages

49. Primary incision (initial incision) The primary incision is an internal bevel incision 1-3 min from the gingival margin inclined toward the alveolar crest. The flap, is reflected to expose underlying bone and root. Important points include: • Preserve the gingival tissue as much as possible. • Prepare a thin and uniform flap, which can adapt to bone and tooth surface closely. • For a thick gingiva , thin the flap edge and create a better postoperative gingival morphology.

50. l. Band of attached gingiva 2. Method of periodontal surgery 3. Depth of periodontal pocket 4. Whether osteoplasty and ostectomy are necessary 5. Thickness of the gingiva and alveolar process 6. Esthetics The placement of the primary incision is determined by the following factors:

51. Secondary incision The secondary incision is a sulcular incision, which incises the cervical area from the bottom of the, pocket toward the alveolar crest. Its purpose is to facilitate the removal of the inflammatory granulation tissue surrounding the cervical area and the secondary flap of soft tissue walls of the periodontal pocket (after reflecting the primary flap). A no. 12 blade, a small Wedelstadt chisel, and an Ochsenbein chisel are recommended.

52. Third incision The third incision is an interdental incision along the alveolar crest and alveolar septum from the buccal to the lingual side. It separates cervical secondary flap from the alveolar crest and interdental bone after reflecting the buccal and lingual flaps. The secondary flap is easily removed as a single piece by the third incision. The Orban interdental knife is recommended for this incision.

53. 1. Narrow band of attached gingiva 2. Thin gingiva and alveolar process 3. Shallow periodontal pocket 4. Desire to lessen postoperative gingival recession for esthetic reasons in the maxillary anterior region 5. As a secondary incision of usual flap surgery 6. Bone graft or GTR: desire to preserve as much periodontal tissue (especially interdental papilla) as possible to completely cover grafted bone and membrane by flaps Indications for the Sulcular Incision

54. 1. Primary incision of flap surgery if there is a sufficient band of attached gingiva 2. Desire to correct bone morphology ( osteoplasty , osseous resection) 3. Thick gingiva (such as palatal gingiva ) 4. Deep periodontal pockets and bone defect 5. Desire to lengthen clinical crown Indications for the Internal Bevel Incision

55. Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Later, Cortellini et al. (1995,1999) described modifications of the flap design to be used in combination with regenerative procedures. Papilla preservation flap

56. Flap reflection

57. How do you reflect the flap?? How much do you reflect?? How do you know whether periosteum is fully separated?? What is sharp dissection ? Where do you use it??

58. Once the planned flap design has been established by the initial and thinning incision(s ), the following step is the atraumatic elevation of the flap a full-thickness flap is elevated using a sharp periosteal elevator directed beneath the periosteum , and always kept against the bone . Papillae are reflected first, followed by the marginal gingiva, working across the anterior/posterior extent of the incisions until the flap margin has been freed from the teeth or alveolar crest, or both This procedure should be accomplished using gentle force. If an abundance of force is required to gain release of the flap, the logical explanation is that the fibrous attachment to the underlying bone has not been completely severed . In such instances, it is better to retrace the incision(s) with the surgical blade rather than risk tearing the flap. Flap reflection

59. Once the flap margin has been completely released, the periosteal elevator is directed in both a horizontal and vertical plane until adequate access is achieved. The tissue is gently separated with a prying motion from the underlying bone following the morphologic contour of the bone The flap reflection should be adequate to expose the complete defect and stop when not more than 2 mm of healthy bone is visible

60. Lack of access to the surgical site is caused by inadequate flap reflection . This usually results in greater tissue trauma, decreased treatment efficiency , and heightened therapist frustration Periosteum left behind on bone surface Common errors in flap reflection..

61. Use of surgical retractors Passive without any tension Edge of the retractor kept on bone Continuous flap retraction for long periods also is not advised. Flap retraction

62. Debridement and defect management

63. Why do you debride the pocket?? What are the types of curettes used?? What are the principles of instrumentation?? Curettage with hand instruments compared to ultrasonic curettage?? Root planing - why is it done?? Compare root planing with hand instruments and ultrasonics ..

64. What are the defects you have seen?? What are ledges? What are hemisepta , craters?? What is ostectomy , osteoplasty ?? What are the steps in ostectomy , osteoplasty ?? What are the instruments used?? What is reverse architecture?? What is normal contour of bone?? Why should physiological contour of bone be achieved?? What are combination defects? What is furcations involvement?? Classification?? What are the treatment options for furcation involvement?? Why do you opt for bone grafts?? When do you decide on GTR?? What is new attachment??

65. R oots are planed, defects are degranulated , and flaps are closed either at or apical to their original position Debridement is complete when healthy bone is visible and when no more granulation tissue is left behind Debridement and defect management

66. Classification of osseous defects

67. Furcation involvement

68. Once the planned treatment has been completed, surgical flaps may be repositioned When no repositioning of flap is planned the flap is placed at the root-bone junction Flap positioning

69. Hemostasis

70. How do you ensure hemostasis during surgery? What is primary , secondary and tertiary hemorrhage?? How do we manage it??

71. Intraoperative bleeding Post operative bleeding Primary hemorrhage Secondary hemorrhage Tertiary hemorrhage Hemostasis

72. Intraoperative - oozing from capillaries and small arterioles within the flap, or from nutrient canals and marrow spaces in the bone. C ontrolled with pressure using moist gauze for 2 to 5 minutes . Small artery is source of bleeding- vessel ligation The use of a local anesthetic with vasoconstrictors is a common technique to temporarily control minor intraoperative bleeding. Hemostasis

73. Bleeding from bone -stopped by burnishing the bone in the area of the bleed with a molt elevator , or curette. If this is ineffective, bone wax can be compressed into the area of the bleed. Once bleeding is controlled, excess bone wax should be carefully removed to avoid possible delay of normal healing events.

74. Postoperative bleeding after the patient returns home may be an unfortunate event if local anesthetic infiltration is used to stop bleeding at the end of surgery. Direct pressure on the flaps for 5 minutes should be the first means to obtain hemostasis at the conclusion of a surgical procedure. If bleeding persists, the use of hemostatic agents other than local anesthetic with a vasoconstrictor is indicated. Under no circumstances should the patient be allowed to leave if significant bleeding is evident. Nausea from ingesting blood, hematoma formation under the flaps with delayed healing, and increased susceptibility to infection are likely sequelae of excessive postoperative bleeding.

75. Suturing

76. What are the principles of suturing?? What are the types of suture materials?? When do you use interdental ligation?? When do you use direct loop suture?? When do you use figure of eight?? When is a continuous sling suture used?? What are the indications for absorbable and non-absorbable sutures?? What are the types of suture needles used in periodontal surgery?? What are the indications for conventional cutting and reverse cutting needles?? What are suture knots?? what determines the type of knot you place??

77. A surgical suture is one that approximates the adjacent cut surfaces or compresses blood vessels to stop bleeding Suturing

78. Suturing is performed to..

79. IDEAL SUTURE MATERIAL ( Postlethwait (1971), Varma and colleagues (1974), and Ethicon (1985)

80. MATERIAL CHOICE Depends on the following: - Surgical procedure. - biocompatibility. - Clinical experience and preference. - Quality and thickness of tissue. - Rate of absorption versus time for tissue healing.

81. The purpose of knots is to join the two ends of the suture in a secure but gentle ways “Suture security is the ability of the knot and material to maintain tissue approximation during the healing process” (Thacker and colleagues, 1975). There are three types of knots that are useful to the periodontal surgeries. The square knot, Surgeon's knot Slip (or) granny knots. Knots

82. Loop Knot Ears Parts of a knot- T hackers and colleagues 1975

83. Desirable Needle Characteristics Made of high quality stainless steel. As slim as possible without compromising strength. Stable in the grasp of a needle holder. Able to carry suture material though tissue with minimal trauma. Sharp enough to penetrate tissue with minimal resistance. Rigid enough to resist bending yet ductile enough to resist breaking during surgery. Sterile & corrosion resistant. Needles

84. Types of cutting needles

85. PRINCIPLES OF SUTURING The needle holder should grasp the needle at approximately 3/4 th of the distance from the point The needle should enter the tissue perpendicular to the surface The needle should pass through the tissue following the curve of the needle The suture should be placed at an equal distance from the incision on both sides and at equal depths If one side is free, needle should pass from free to the fixed side

86. Needle should pass from thinner to the thicker side If one tissue plane is deeper then the needle should pass from the deeper to the superficial side The distance that the needle is passed into the tissue should be greater than the distance from tissue edge The tissue should not be closed under tension The tissue should be tied so that tissue is merely approximated not blanched The knot should not be placed on incision line Suture should be placed approximately 3-4 mm apart.

87. Suturing techniques..

88. Suturing techniques… Technique Indications Interrupted Closure of vertical releasing incisions and interproximal areas; replaced and coronally positioned flap closure Sling Allows separate facial or lingual flap positioning in a isolated area Continuous sling Allows separate facial or lingula flap in a whole sextant to be sutured separately. Double continuous sling Apically positioned flap closure

89. Technique Indications Vertical mattress Narrow interdental spaces Horizontal mattress Wider interdental spaces Suspensory Coronally advanced flaps, root coverage Anchoring In guided tissue regeneration when adjacent space is edentulous

90. Adequate flap adaptation, obliteration of dead space under the flap , control of postoperative swelling, and carefully explained postoperative instructions are key elements in achieving a stable wound. Wound management

91. Periodontal dressing

92. What is the purpose of giving a pack?? Is a pack always necessary?? What are the types of periodontal dressings??

93. Physical effect Therapeutic effect Periodontal dressings

94. Most periodontal dressings currently in use are eugenol -free and are either a two-paste chemical cure material containing zinc oxide, mineral oils, rosin and bacteriostatic , or fungicidal agents Coe-Pak —GC America, Inc., Alsip, IL; PerioCare —Pulpdent Corp, Watertown, MA), or a visible light-cured gel , composed of polyether urethane dimethacrylate resin and silanated silica - Barricaid , Dentsply International, Milford, DE Cyanoacrylate also has been used as a dressing, especially over free soft tissue autografts

95. Every surgical procedure must have an end-point in mind before the initiation of treatment With the current emphasis on evidence-based periodontal therapy, scientific knowledge, when available , should become the primary driving force in therapeutic and surgical decision making Clinical judgment, personal experience, and patient preferences are still valuable entities in this decision-making process, but they must be integrated with sound science to improve the predictability, quality, and efficiency of periodontal care. Conclusion

96. References.. …