flap surgery.pptx

this presentation covers all the aspects and techniques of flap surgery with relevant diagrams and is made from from authentic text books and articles.

1. DEPARTMENT OF PERIODONTOLOGY AND IMPLANTOLOGY PERIODONTAL FLAP SURGERY Shreya Rastogi

2. CONTENTS Introduction Objectives of periodontal flap Indications of periodontal flap Classification of periodontal flap Principles of flap design Flap retraction Incisions Elevation of the periodontal flap Flap design Instruments used in periodontal surgery Techniques for access & pocket depth reduction/Elimination Flap procedures : Original widman flap Neumann flap Modified flap operation

3. Apically repositioned flap Modified widman flap operation Undisplaced flap Palatal flap Flaps for reconstrutive surgery Papilla preservation flap conventional flap operation Healing after flap surgery Conclusion

4. INTRODUCTION A periodontal flap is a section of gingiva &/or mucosa surgically separated from the underlying tissues to provide visibility of and access to the bone and root surface. (Glickman) A flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement.

5. OBJECTIVES OF PERIODONTAL FLAP : Increase accessibility to root deposits for scaling & root planing Eliminate or reduce pocket depth by resection of the pocket wall Gain access for osseous resective surgery if it is necessary Expose the area to perform regenerative methods

6. INDICATIONS : - Flap procedures are indicated in cases of periodontitis with active ( inflammed ) pocket over 5mm deep, which do not respond to initial therapy. Grade 2 and 3 furcation involvement

7. CLASSIFICATION OF FLAPS Periodontal flaps can be classified as follows – a) Based on bone exposure after flap reflection - mucoperiosteal or full thickness flap - partial thickness or mucosal flap b) Based on placement of flap after surgery - displaced flap - non displaced flap c) Based on management of papilla - conventional flap - papilla preservation flap

8. 1) Full thickness or mucoperiosteal flap- All the soft tissue, including the periosteum, is reflected to expose the bone. Indication- need to view the alveolar bone 2) Partial thickness or mucosal flap- It includes only the epithelium and a layer of underlying connective tissue. The bone remains covered by a layer of connective tissue, including the periosteum. Also known as split thickness flap. Indication- when flap is to be positioned apically, laterally or coronally; or when the operator does not want to expose the bone. A) Based on bone exposure after flap reflection

9. Fig : A) internal bevel incision to reflect full thickness flap . B) internal bevel incision to reflect a partial thickness flap.

10. 1) Non – displaced flap The flap is returned and sutured in its original position. 2) Displaced flap The flap is placed apically, coronally, or laterally to its original position. 1) Conventional flap In this the interdental papilla is split beneath the contact point of the two approximating teeth to allow reflection of buccal and lingual flaps. B) Based on flap placement after surgery C) Based on management of papilla

11. The incision is usually scalloped to maintain gingival morphology and retain as much papilla as possible. Indications- 1) When the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla. 2) When the flap is to be displaced. Examples- modified Widman flap, the undisplaced flap, the apically displaced flap, & the flap for reconstructive procedures. 2) Papilla preservation flap In this the entire papilla is incorporated into one of the flaps by means of crevicular interdental incisions to sever

12. the connective tissue attachment and a horizontal incision at the base of the papilla, leaving it connected to one of the flaps. Indications- When there are open interdental spaces When esthetics is of concern When bone regeneration techniques are attempted.

13. PRINCIPLES OF FLAP DESIGN According to Hupp (1993) , the following principles should be followed for flap design Prevention of flap necrosis : The apex of the flap should never be wider than the base The flap sides should either run parallel to each other or preferably converge moving from the base of the flap to the apex of the flap. Length of the flap should be no more than twice the width of the base The base of the flaps should not be excessively twisted or stretched Whenever possible, an axial blood supply should be included in the base of the flap Prevention of flap tearing : Vertical releasing incision should be placed one full tooth anterior to the sites of any anticipated bone removal Vertical incision should be started at the line angle of the tooth or in adjacent interdental papilla & carried obliquely apically into the unattached gingiva

14. FLAP RETRACTION - Retraction should be passive without any tension. - It is important that edge of retractor should be kept on bone. - Irrigation of surgical field is necessary

15. INCISIONS There are basically two types of periodontal flap incisions- Horizontal incisions Vertical incisions Internal bevel incision Crevicular incision Interdental incision 1) Oblique releasing incision

16. HORIZONTAL INCISIONS Horizontal incisions are directed along the margin of the gingiva in a mesial or a distal direction. Types of horizontal incisions recommended are- It is the incision from which the flap is reflected to expose the underlying bone and root. 1) Internal bevel incision

17. Objectives of internal bevel incision are - It removes the pocket lining Conserves the relatively uninvolved outer surface of the gingiva, which when apically positioned, becomes attached gingiva. Produces a sharp, thin flap margin for adaptation to the bone tooth junction. This incision is also termed as the first incision because it is the initial incision in the reflection of a periodontal flap. Also termed as reverse bevel incision because its bevel is in reverse direction from that of the gingivectomy incision.

18. Blade used for making this incision - #15C or #15 surgical blade. Fig: Position of the knife in performing internal bevel incision . The internal bevel incision starts from a designated area on the gingiva and is directed to an area at or near the crest of the bone.

19. It is made from the base of the pocket to the crest of the bone. The incision together with the initial reverse bevel incision forms a V- shaped wedge ending at or near the crest of bone. This wedge of tissue contains most of the inflamed & granulomatous areas that constitute the lateral wall of the pocket as well as the junctional epithelium & the connective tissue fibers that still persist between the bottom of the pocket & the crest of the bone. 2) Crevicular incision

20. Fig : Position of knife in performing crevicular incision.

21. A periosteal elevator is inserted into the initial internal bevel incision, & the flap is separated from the bone . The most apical end of the internal bevel incision is exposed and visible. With this access, the surgeon is able to make the interdental incision. This incision is made to separate the collar of the gingiva that is left around the tooth. Knife used for this incision- Orban knife. 3) Interdental incision

22. The incision is made not only around the facial & the lingual radicular area but also interdentally, connecting the facial and the lingual segments to the free the gingiva completely around the tooth. Fig : Three incisions necessary for flap surgery. A) internal bevel incision B) crevicular incision C) interdental incision.

23. VERTICAL INCISIONS Vertical or oblique releasing incisions can be used on one or both ends of the horizontal incision, depending on the purpose & design of the flap. Vertical incisions at both the ends are necessary if the flap is to be apically displaced. Vertical incision must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced.

24. Vertical incisions are avoided in the lingual or palatal areas. Facial vertical incisions should not be made in the centre of an interdental papilla or over the radicular surface of a tooth. Fig : The incision should be made at the line angles.

25. Incisions should be made at the line angles of a tooth either to include the papilla in the flap or to avoid it completely. Vertical incisions should also be designed to avoid short flaps with long, apically directed incisions because this could jeopardize the blood supply of the flap.

26. ELEVATION OF THE FLAP S.no Type of flap Reflection accomplished by Instrument used 1) Full thickness flap or mucoperiosteal flap Blunt dissection Periosteal elevator which separates the mucoperiosteum from the bone. 2) Partial thickness flap or mucosal flap Sharp dissection Surgical scalpel (#15)

27. Fig : Elevation of flap with periosteal elevator to obtain full thickness flap. Fig: Elevation of flap with BP knife to obtain a split thickness flap.

28. FLAP DESIGN Envelope flap: only if linear incisions are given without vertical releasing incisions. Pedicle flap : if two vertical releasing incisions are included. The major blood supply is from its base .  

29. Envelope flap Pedicle flap

30. INSTRUMENTS USED IN PERIODONTAL SURGERY GENERAL CONSIDERATIONS Surgical procedures used in periodontal therapy often involve the following measures (instruments): • Incision and excision (periodontal knives) • 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) • Application of wound dressing (plastic instruments )

31. THE INSTRUMENT TRAY • 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 (ad modum Ewald ) • Tissue scissors • Needle holder • Suture scissors • Plastic instrument • Hemostat • Burs. 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.

32. Set of instruments used for periodontal surgery and included in a standard tray

33. SURGICAL INSTRUMENTS Knives Gingivectomy knives From left to right: Kirkland 15/16 Orban 1/2 Waerhaug 1/2. The shape of the blades are from left to right: No. 11, No. 12, No. 12D, No. 15, and No. 15C.

34. A universal 360º handle for disposable blades, which allows the mounting of the blade in any angulated position of choice. Double-ended sickle scalers and curettes useful for root debridement in conjunction with periodontal surgery. From left to right: Curette SG 215/16C Syntette , Sickle 215-216 Syntette , mini-curette SG 215/16MC .

35. A set of burs useful in periodontal surgery. The rotating fine-grained diamond stones may be used for debridement of infrabony defects. The round burs are used for bone recontouring . Examples of instruments used for bone recontouring . From left to right: Bone chisels Ochsenbein no.1 and 2 (Kirkland 13K/13KL) Bone chisel Ochsenbein no. 3 Schluger curved file no. 9/10

36. TECHNIQUES FOR ACESS & POCKET DEPTH REDUCTION / ELIMINATION The three different categories of flap techniques used in periodontal flap surgery are The modified widman flap The undisplaced flap Apically displaced flap The modified widman flap facilitates by exposing the root surface for meticulous instrumentation & for removal of pocket lining . It is not intended to eliminate or reduce the pocket depth , except for the reduction that occurs in healing by tissue shrinkage . The un-displaced flap improves accessibility for instrumentation , but also removes the pocket wall thereby reducing or eliminating the pocket . The apically displaced flap provides accessibility & eliminate the pocket, but it does the latter by apically positioning for soft tissue wall of the pocket . Therefore it preserves or increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tisssue . This increases the width of attached gingiva based on the apical shift of the MGJ .

37. Locations of the internal bevel incisions for the different types of flaps .

38. FLAP PROCEDURES THE ORIGINAL WIDMAN FLAP In 1918 Leonard Widman published one of the first detailed descriptions of the use of a flap procedure for pocket elimination. In his article “The operative treatment of pyorrhea alveolaris ” Widman described a mucoperiosteal flap design aimed at removing the pocket epithelium and the inflamed connective tissue, thereby facilitating optimal cleaning of the root surfaces.

39. Scaling, root planing , and osseous recontouring are performed in the surgical area. The palatal flap is replaced and a secondary, scalloped, reverse bevel incision is made to adjust the length of the flap to the height of the remaining alveolar bone. The shortened and thinned flap is replaced over the alveolar bone and in close contact with the root surfaces

40. Among a number of suggested advantages of the apically repositioned flap procedure, the following have been emphasized: • Minimum pocket depth post-operatively • If optimal soft tissue coverage of the alveolar bone is obtained, the post-surgical bone loss is minimal • The post-operative position of the gingival margin may be controlled and the entire muco -gingival complex may be maintained. The sacrifice of periodontal tissues by bone resection and the subsequent exposure of root surfaces (which may cause esthetic and root sensitivity problems) were regarded as the main disadvantages of this technique .

41. THE MODIFIED WIDMAN FLAP In 1965 , Morris revived a technique described early in the 20 th century in the periodontal literature , - “ unrepostioned mucoperiosteal flap ” . Same procedure was presented in 1974 by Ramfjord & Nissle who called it the “ modified Widman flap ” . It is also recognized as the open flap curettage technique . 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

42. Initial incision is placed 0.5–1 mm from the gingival margin (a) and parallel to the long axis of the tooth (b). Following careful elevation of the flaps, a second intracrevicular incision (a) is made to the alveolar bone crest (b) to separate the tissue collar from the root surface.

43. A third incision is made perpendicular to the root surface (a) and as close as possible to the bone crest (b), thereby separating the tissue collar from the alveolar bone. ( a) Following proper debridement and currettage of angular bone defects, the flaps are carefully adjusted to cover the alveolar bone and sutured. (b)Complete coverage of the interdental bone as well as close adaptation of the flaps to the tooth surfaces should be accomplished.

44. The main advantages of the modified Widman flap technique in comparison to other procedures previously described are, according to Ramfjord and Nissle (1974): • The possibility of obtaining a close adaptation of the soft tissues to the root surfaces • The minimum of trauma to which the alveolar bone and the soft connective tissues are exposed • 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.

45. THE UNDISPLACED FLAP The undisplaced flap is perhaps the 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 may be considered an internal bevel gingivectomy . The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall. To perform this technique without creating a mucogingival problem it should be determined that enough attached gingiva will remain after removal of the pocket wall. The location of different areas where the internal bevel incision is made in an undisplaced flap. The incision is made at the level of the pocket to discard the tissue coronal to it if there is sufficient remaining attached gingiva.

46. Step 1: 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. Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva . The incision is usually carried to a point apical to the alveolar crest, depending on the thickness of the tissue. The thicker the tissue, the more apical is the ending point of the incision . In addition, thinning of the flap should be done with the initial incision because at this time, it is easier to accomplish than later with a loose reflected flap that is difficult to manage. 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. Step 4 : The flap is reflected with a periosteal elevator (blunt dissection) from the internal bevel incision. Usually there is no need for vertical incisions because the flap is not displaced apically. Step 5 : The interdental incision is made with an interdental knife, separating the connective tissue from the bone.

47. Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette. Step 7 : The area is debrided, removing all tissue tags and granulation tissue using sharp curettes. Step 8 : After the necessary scaling and root planing , the flap edge should rest on the root-bone junction. If this is not the case, due to improper location of the initial incision or to the unexpected need for osseous surgery, the edge of the flap is rescalloped and trimmed to allow the flap edge to end at the root-bone junction. Step 9: A continuous sling suture is used to secure the facial and the lingual or palatal flaps. This type of suture, using the tooth as an anchor, is advantageous to position and hold the flap edges at the root-bone junction. The area is covered with a periodontal pack.

48. The Palatal Flap The surgical approach to the palatal area differs from that for other areas because of the character of the palatal tissue and the anatomy of the area. The palatal tissue is all attached, keratinized tissue and has none of the elastic properties associated with other gingival tissues. Therefore the palatal tissue cannot be apically displaced, nor can a partial (split) thickness flap be accomplished. The initial incision for the palatal flap should be such that when the flap is sutured, it is precisely adapted at the root-bone junction. Therefore the location of the initial incision is important for the final placement of the flap. Oschenbein and Bohannan (1963,1964) described a palatal approach for osseous surgery

49. The initial incision for a flap varies with the anatomic situation. The initial incision may be the usual internal bevel incision, followed by crevicular and interdental incisions. If the tissue is thick, a horizontal gingivectomy incision may be made, followed by an internal bevel incision that starts at the edge of this incision and ends on the lateral surface of the underlying bone. The placement of the internal bevel incision must be done in such a way that the flap fits around the tooth without exposing the bone .

50. The angle of the internal bevel incision in the palate and the different ways to thin the flap. A, The usual angle and direction of the incision. B, The thinning of the flap after it has been slightly reflected with a second internal incision. C, The beveling and thinning of the flap with the initial incision if the position and contour of the tooth allow. D, The problem encountered in thinning the flap once it has been reflected. The flap is too loose and free for proper positioning and incision.

51. The purpose of the palatal flap should be considered before the incision is made. If the intent of the surgery is debridement, the internal bevel incision is planned so that the flap adapts at the root-bone junction when sutured. If osseous resection is necessary, the incision should be planned to compensate for the lowered level of the bone when the flap is closed. Probing and sounding of the osseous level and the depth of the intrabony pocket should be used to determine the position of the incision. A, A distal view of incisions made to eliminate a pocket distal to the maxillary second molar. B, Two parallel incisions and the removal of the intervening tissue. C, Thinning of the flap and contouring of the bone. D, Approximation of the buccal and palatal flaps.

52. Indications- Areas that require osseous surgery Pocket reduction Reduction in enlarged bulbous tissue

53. FLAPS FOR RECONSTRUCTIVE SURGERY Two flap designs are available for regenerative surgery: the papilla preservation flap and the conventional flap with only crevicular incisions. The flap design of choice is the papilla preservation flap, which retains the entire papilla covering the lesion. However, to use this flap, there must be adequate interdental space to allow the intact papilla to be reflected with the facial or lingual/palatal flap. When the interdental space is very narrow, making it impossible to perform a papilla preservation flap, a conventional flap with only crevicular incisions is made.

54. THE PAPILLA PRESERVATION FLAP In order to preserve the interdental soft tissues for maximum soft tissue coverage following surgical intervention involving treatment of proximal osseous defects, Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Later, Cortellini et al. (1995b, 1999) described modifications of the flap design to be used in combination with regenerative procedures. For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions

55. Intracrevicular incisions are made at the facial and proximal aspects of the teeth.

56. An intracrevicular incision is made along the lingual/palatal aspect of the teeth with a semilunar incision made across each interdental area. A curette or a papilla elevator is used to carefully free the interdental papilla from the underlying hard tissue. ( c,d ) The detached interdental tissue is pushed through the embrasure with a blunt instrument to be included in the facial flap .

57. The flap is replaced and sutures are placed on the palatal aspect of the interdental areas .

58. Cortellini et al in 1995, proposed a modification in the PPF and named it as Modified Papilla preservation flap Papillary preservation flap and its modified flap design, both required a wide interdental space as a pre-requisite to bring about appreciable functional and esthetic value

59. To apply esthetic value to teeth having narrow interproximal zone, Cortellini et al in 1999 proposed the Simplified Papilla preservation flap technique Both the modifications of PPF, require utilization of horizontal and/or vertical internal mattress sutures which relieve the tension in the flap, permit coronal positioning of the flap and aid in passive closure of the interdental tissues.

60. CONVENTIONAL FLAP FOR REGENERATIVE SURGERY The technique for employing a conventional flap for regenerative surgery is as follows: Step 1 : Using a #12 blade, incise the tissue at the bottom of the pocket and to the crest of the bone, splitting the papilla below the contact point. Every effort should be made to retain as much tissue as possible to subsequently protect the area. Step 2 : Reflect the flap maintaining it as thick as possible, not attempting to thin it as is done for resective surgery. The maintenance of a thick flap is necessary to prevent exposure of the graft or the membrane due to necrosis of the flap margins

61. HEALING AFTER FLAP SURGERY 1) Immediately after suturing ( up to 24 hours) A connection between the flap and the tooth or bone surface is established which contains fibrin reticulum with many PMN leukocytes, erythrocytes, debris of injured cells, & capillaries at the edge of the wound. 2) 1-3 days after flap surgery. The space between the flap & the tooth or bone is thinner & epithetlial cells migrate over the border of the flap, usually contacting the tooth at this time.

62. 3) One week after surgery. An epithelial attachment to the root has been established by means of hemidesmosomes & a basal lamina. Blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, & the PDL. 4) Two weeks after surgery. Collagen fibers begin to appear parallel to the tooth surface. Union of the flap to the tooth is still weak because of presence of immature collagen collagen fibers. 5) One month after surgery. A fully epithelialized gingival crevice with a well defined epithelial attachment is present. There is beginning of functional arrangement of supra crestal fibers.

63. CONCLUSION Periodontal surgery requires an organized, step by step, gentle approach to each procedure that results in minimal tissue trauma and expedites completion of surgery in the least time.