Flap surgery

flap surgery

1. 57 Good morning

2. FLAP SURGERY PRESENTER: SHASHWATI PAUL II YR PG DEPT. OF PERIODONTOLOGY

3. CONTENTS INTRODUCTION DEFINITION HISTORY RATIONALE CLASSIFICATION OF FLAPS FACTORS AFFECTING FLAP DESIGN INCISIONS PROPERTIES OF IDEAL FLAP PRE-OPERATIVE CHECK LIST INDICATIONS CONTRAINDICATIONS FLAP DESIGNS CLOSURE OF FLAPS HEALING AFTER FLAP SURGERY COMPLICATIONS CONCLUSION REFERENCES

4. INTRODUCTION The surgical phase of periodontal therapy has the following objectives Improvement of prognosis of teeth Improvement of esthetics It consists of techniques for pocket therapy and for the correction of osseous and mucogingival defects.

5. DEFINITION Is a loosened section of tissue separated from the surrounding tissues except at its base Glossary of Periodontal Terms, 4 th Edition Is a section of the gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility of and access to the bone and the root surface Carranza’s Clinical Periodontology, 10 th Edition

6. HISTORY n . Robicsek 1884 Neuman 1911 Widman 1916 Kronfeld 1935 Nabers 1954 Apically repositioned flap 1962 Modified Widman 1974 Papillary preservation 1985

7. RATIONALE Means of gaining access to diseased root surfaces For pocket elimination / reduction To eliminate the infected and necrotic alveolar bone To maintain the mucogingival complex Possibility of regeneration of periodontal tissues

8. CLASSIFICATION OF FLAPS

9. I ) Purpose of Surgery: ( Ramfjord 1979) Pocket elimination Re-attachment flap surgery Mucogingival repair

10. II) Bone exposure after flap reflection: (Carranza) Full thickness ( mucoperiosteal flap) Partial thickness (mucosal flap)

11. MUCOPERIOSTEAL V/S MUCOSAL FLAPS Full Thickness Flap Partial Thickness Flap Healing Primary Intention Secondary Intention Bone defect treatment Possible Difficult Blood supply to flap Sufficient Decreased Pocket elimination/ reduction Possible Possible Bleeding Less More Post operative swelling Less Severe Post operative pain and discomfort Less More (Periodontal Surgery: A Clinical Atlas by Sato)

12. III) Flap placement after surgery: (Carranza) Non displaced flap Displaced flap Coronally displaced flap Apically displaced flap Laterally/ Horizontally displaced flap

13. IV) Management of papilla: (Carranza) Conventional flap Papilla preservation flap

14. FACTORS AFFECTING FLAP DESIGN Necessary access to the underlying bone and root surfaces Final posision of the flap Preservation of good blood supply to the flap

15. TWO BASIC FLAP DESIGNS ARE: Conventional flap Papilla preservation flap

16. INCISIONS HORIZONTAL INCISIONS Internal bevel incision/ first incision Crevicular incision/ second incision Interdental incision/ third incision VERTICAL INCISION

17. Horizontal Incisions: along the margin of the gingiva Coronally directed or Apically directed Externel bevel * Internal bevel * Sulcular / intra crevicular * Interdental incision

18. Internal bevel Incision : first/ primary/ reverse bevel incision From a designated area on the gingiva to an area at or near the crest of bone #11 0r #15 surgical scalpel

19. Objectives Removes the pocket lining Preserves the uninvolved outer surface of gingiva Produces a sharp, thin margin for adaptation at bone-tooth junction Indications: -Presence of moderate/deep periodontal pocket -Desire to correct bone morphology Pre-requisite: Sufficient Keratinized tissue

20. Crevicular Incision : second/ sulcular incision from base of pocket to crest of bone V-shaped wedge : inflammed and granulomatous areas of lateral pocket wall JE and connective tissue fibres

21. Indications: Periodontal pocket elimination/ reduction As a secondary incision for flap surgery to lessen post operative gingival recession in anterior maxillary regions Decisive Criteria: Narrow band of keratinized tissue Thin gingival biotype

22. Internal Bevel Incision Crevicular Incision

23. The Interdental Incision : separates the collar of gingiva around the tooth Orban’s interdental knife

24. Vertical Incisions: Must extend beyond the mucogingival line reaching the alveolar mucosa when displacement of flap is desired At line angles of the tooth – to include/exclude the papilla from flap Never over height of contour or root Avoid short ( mesio -distal) flaps

25. Incisions Description Indication External Bevel Coronally Directed Gingivectomy , crown lengthening, Gingivoplasty Internal Bevel Apically directed, placed at the crest of the gingival margin or stepped back from the margin 0.5 to 2.0 mm Excisional new attachment procedure, modified Widman flap, flap and curettage, crown lengthening Sulcular Apically directed, placed in the gingival crevice and directed toward the alveolar crest When preservation of gingiva. is critical, as in esthetic areas or areas of minimal keratinized tissue, guided tissue regeneration (GTR) procedures

26. Incisions Description Indication Releasing Perpendicular to the gingival margin at line angles of teeth To increase access, to allow apical or coronal positioning of flap Thinning Internal or undermining incision extending from gingival margin toward the base of the flap to decrease the bulk of connective tissue on the underside of the flap Palatal flaps, distal wedge procedures, internal bevel gingivectomy , bulky papillae Periosteal Incision at the base of the flap severing the underlying periosteum To release flap tension allowing coronal advancement of the flap

27. PROPERTIES OF IDEAL FLAP Ideal Flap/ Section of a soft tissue: Is outlined by a surgical incision Carries its own blood supply Allows surgical access to underlying tissues Can be placed in the original position Can be maintained with sutures in a particular desired position And is expected to heal

28. Sharp incisions heal rapidly Flap extension- 2 teeth anterior and 1 tooth posterior to area of surgery Incisions- over intact bone/ 6-8mm away from diseased bone. ( Peterson )

29. PRE OPERATIVE CHECKLIST Review case history and Phase I therapy Informed Consent Cessation of medication: Anti coagulants 48hours prior to procedure To quit or stop smoking for minimum of 3-4 weeks after the procedure. Daily dose of particular medication/ meal taken Patient records Emergency equipment/ medication Tests: Hb %, Clotting time 6-10mins, Bleeding time 1-6mins Appropriate infection control

30. INDICATIONS OF FLAP SURGERY To gain access for root debridement Bone regeneration in infrabony defects Pockets on teeth in which a complete removal of root irritants is not possible by non surgical therapy Areas with irregular bone contours or defects which need to be corrected Infrabony pockets distal to first molars In grade II and grade III furcations Persistent inflammation in moderate to deep pockets

31. CONTRAINDICATIONS OF FLAP SURGERY Lack of patient motivation or compliance Acute oral infections which may spread Systemic conditions / Medically compromised patients. Eg . Uncontrolled diabetes mellitus

32. FLAP DESIGNS

33. THE NEUMANN FLAP: 1911 Intracrevicular incision full thickness flap reflected Sectional releasing incisions made Inside of flap curetted Root surfaces “cleaned” Irregular alveolar bone corrected Flaps trimmed Replacing flap at crest of alveolar bone ( Periodontal Surgery: Resection to Regeneration, Richard Young, 2003)

34. THE ORIGINAL WIDMAN FLAP: 1918 Gingival incision follows outline of gingival margin 2 vertical release incisions Physiologic contour of alveolar bone re-established

35. Aimed at: Elimination of pocket epithelium Accessibility to root surfaces Bone Recontouring Sufficient ATTACHED GINGIVA is a pre-requisite. Advantages: Soft tissue margin at alveolar bone crest- no pockets remained Less discomfort- faster healing Recontour bone Disadvantage: Exposure of root surfaces vertical incisions

36. Sutured to original position Intracrevicular incision Expose diseased roots THE MODIFIED FLAP OPERATION: KIRKLAND 1931 Roots debrided - defects corrected

37. The Modified Flap Operation: Kirkland 1931 Did not include extensive sacrifice of non inflammed tissue No apical displacement of gingival margin Indicated in anterior aesthetic areas Potential for bone regeneration in intrabony defects

38. THE MODIFIED WIDMAN FLAP: Ramfjord and Nissle 1974 *1 st incision: 0.5-1mm away from gingival margin. *Accentuated initial incision : 1-2mm from mid palatal surface of tooth * Bone architecture not corrected *No inter proximal bone exposure *Interrupted inter proximal sutures

39. Indications: 1 .Moderate-deep periodontal pockets 2 .In sufficient attached gingiva 3 .Patients with sensitivity 4 .Reattachment with minimal gingival recession is desired

40. ADVANTAGES: Access and visualization of root surfaces Good adaptation of healthy connective tissue to root surfaces Better aesthetics Less potential root hypersensitivity Preservation of gingival width DISADVANTAGES : Residual probing depths in presence of infra bony pockets

41. The Original Widman Flap The Modified Widman Flap

42. THE UNDISPLACED FLAP: ‘Internal bevel gingivectomy ’- surgically removes the pocket wall Sufficient keratinized tissue a pre-requisite, to avoid mucogingival problem

43. The Undisplaced Flap: Pockets measured- Bleeding points produced Internal bevel incision- thinning of flap done Crevicular incision- full thickness flap reflected Interdental incision- triangular tissue wedge removed Edge of flap re-scalloped/ trimmed to rest on ‘root-bone’ junction Continuous sling suture

44. THE PALATAL FLAP: Initial incision varies with anatomic situation- internal bevel incision Thick tissue- horizontal gingivectomy incision Scalloping narrower apically than line angle areas Blade angled towards lateral surface of palatal bone while thinning flap Thin, knife-like gingival margin and sharp, thin gingival papilla

45. The Palatal Flap: * Thickness of palatal tissue * Purpose of palatal flap

46. THE APICALLY REPOSITIONED FLAP: FRIEDMAN 1962 Indications: Pocket reduction Increasing the zone of attached gingiva Disadvantages: Unaesthetic results- root exposure Hypersensitivity Incision is unrelated to pocket depth Not necessary to accentuate scallop interdentally

47. The Apically Displaced Flap: Classification of primary incision and displaced flap positions ( Periodontal Surgery: A Clinical Atlas by Sato)

48. THE BEVELED FLAP :FRIEDMAN Modification of apically repositioned flap For treatment of periodontal pockets on the palatal aspect of teeth. First, a conventional mucoperiosteal flap Debridement and osseous recontouring performed. The palatal flap prepared with a secondary scalloped and beveled incision Secured with interproximal sutures.

49. PAPILLA PRESERVATION FLAP: TAKEI ET AL, 1985 In Conventional flap: incise from bottom of pocket to crest of bone- splitting papilla below contact point In reconstructive surgery Maximum amount of gingiva and papilla are retained to cover the materials placed in the pocket Intra crevicular incision Semilunar incision across interdental area Wide osseous defect lingually / palatally - semilunar incision on facial aspect

50. Preserved papilla can be incorporated into the facial or lingual/palatal flap. The lingual or palatal incision should be semilunar incision across the interdental papilla. This incision dips apically from the line angle of the tooth so that the papillary incision is at least 5 mm from the crest of the papilla.

51. 4. An orban knife is introduced into this incision to sever half to two-thirds the base of the interdental papilla. 5. The papilla is then dissected from the lingual or palatal aspect and elevated intact with the facial flap. 6. The flap is elevated without thinning the tissue.

52. Palatal semilunar incision Crevicular incision Papilla reflected sutures

53. 5mm

54. SIMPLIFIED PAPILLA PRESERVATION TECHNIQUE Cortellini et al. in 1999 For narrow interdental spaces (< 2mm). An oblique incision across the defect-associated papilla, starting from the buccal line angle of the involved tooth to reach the mid- interdental part of the papilla at the adjacent tooth below the contact point. The papilla is cut into two equal parts

55. Oblique incision Intrasulcular incisions Horizontal inc at base sutures

56. DISTAL WEDGE PROCEDURE: ROBINSON (1966) AND BRADEN (1969 ) Treatment of periodontal pockets on the distal surface of terminal molars is complicated by the presence of bulbous fibrous tissue over the maxillary tuberosity or prominent retromolar pads in the mandible. Deep vertical defects may often present in conjunction with redundant fibrous tissue. These osseous lesions may result from incomplete repair after the extraction of impacted third molars

57. Location of incision: 1)Amount of attached gingiva 2)Available distance from distal aspect of molar to end of retromolar pad/ tuberosity 3) Pocket depth Simple gingivectomy incision can be used for soft tissue pocket and adja c ent fibrous tissue.

58. MODIFIED DISTAL WEDGE PROCEDURE In case of a deep periodontal pocket combined with angular bone defect at distal aspect of a maxillary molar. Two parallel reverse bevel incisions. Rectangular wedge tissue is removed. Root debridement, recontouring bone, flaps trimmed and sutured.

59. CLOSURE OF FLAPS OBJECTIVES Supporting and strengthening the wounds until healing increases their tensile strength. Minimizing the risk of infection and control of bleeding . Continuous Sling Suture Interrupted suture Mattress Sutures Periosteal Sutures Anchor sutures

60. HEALING AFTER FLAP SURGERY

61. COMPLICATIONS Periodontal surgery can produce profuse bleeding,especially during initial incisions and flap reflection. Excessive haemorrhaging after initial incisions and flap reflection may be caused by venules,arterioles and vessels. Anatomic variation- inadvertent laceration Root exposure post flap surgery- hypersensitivity Liver clot/ currant jelly clot – repeated delayed organisation of blood coagulum. Sensitivity to percussion Prolnged exposure or dryness of bone

62. Correction of Soft Tissue Pockets Closed Procedures. Modified Widman flap Apically positioned (repositioned) flap a . Full thickness b. Partial thickness ( supraperiosteal ) Distal wedge procedure Open Procedures. Gingivectomy Surgery for Correction of Osseous Deformities and Osseous Enhancement Procedures Closed Procedures. 1. Full- or partial-thickness flap a. Undisplaced flap b . Modified flap c. Modified Widman flap 2. Modified Distal wedge procedure 3. Conventional flap/ papilla preservation flaps

63. Correction of Mucogingival Problems Preservation of Existing Attached Gingiva. 1 . Apically positioned (repositioned) flap a . Full thickness b . Partial thickness 2. C onventional flap Increasing Dimension of Exisiting Attached Gingiva. Laterally positioned flap ( pedicle) a . Full thickness b . Partial thickness 2. Papillary flaps a . Double papillae b . Rotated papillae 3. Free soft tissue autografts a . Partial thickness b . Full thickness 4. Connective tissue autograft 5. Subepithelial connective tissue graft

64. Procedures Commonly Used for Root Coverage Pedicle Flaps (Full or Partial Thickness ). Laterally positioned flaps Double-papillae flaps 3 Coronally positioned flaps 4. Semilunar flap Free Soft Tissue Autografts .

65. CONCLUSION Proper understanding and knowledge of different incisions and flaps results in better treatment results with greater patient satisfaction.

66. REFERENCES CARRANZA 10 TH EDITION LINDHE 4 TH EDITION PERIODONTAL SURGERY BY SATO COHEN