periodontal flap surgery

periodontal flap surgery

1. 28-07-2023 1

2. Periodontal Flap Surgeries Guided by: Dr. Monica Mahajani Dr. Chandrahas Goud Dr. Anup Shelke Dr. Subodh Gaikwad Dr. Anup Gore Dr. Kuldeep Patil Dr. Amrita Das Presented by: Dr. Chavan Sneha S. (2nd Year PG) 28-07-2023 2

3. Periodontal flap is defined as ‘ the section of gingiva and/or mucosa surgically elevated from the underlying tissues to provide visibility and access to the bone and root surfaces’ - Glickman 28-07-2023 3

4. OBJECTIVES OF PERIODONTAL FLAP Access for root instrumentation 2. Gingival resection 3. Osseous resection 4. Periodontal regeneration 28-07-2023 4

5. Indications For Periodontal Surgery Access to root and osseous defects Resective surgery Regenerative surgery Preprosthetic surgery Crown lengthening Gingival augmentation Ridge augmentation Tori reduction Tuberosity reduction Vestibuloplasty Gingival enlargement Periodontal plastic surgery Esthetic anterior crown lengthening Soft tissue grafting for root coverage or to obtain on physiologic gingival dimension Papilla reconstruction Biopsy Implant surgery Treatment of periodontal abscess Exploratory surgery Ref:Kerala Dental Journal Vol. 34 | No. 1 Supplement | March 2011 28-07-2023 5

6. Contraindications For Periodontal Surgery Uncontrolled medical conditions like – uncontrolled asthma, uncontrolled hypertension, uncontrolled diabetes Poor plaque control High caries rate Unrealistic patient expectations or desires Ref:Kerala Dental Journal Vol. 34 | No. 1 Supplement | March 2011 28-07-2023 6

7. Categories of periodontal surgery Ref:Periodontal Flap Designs for Access and Osseous Surgery, S. Nares (ed.), Advances in Periodontal Surgery ; Antonio Moretti and Karin Schey 28-07-2023 7

8. Classification 28-07-2023 8

9. 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. The incision is usually scalloped to maintain gingival morphology and to retain as much papilla as possible. 28-07-2023 9

10. The papilla preservation flap incorporates the entire papilla in one of the flaps by means of crevicular interdental incisions to sever the connective tissue attachment as well as a horizontal incision at the base of the papilla to leave it connected to one of the flaps. 28-07-2023 10

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12. Full-thickness flap: All of the soft tissue, including the periosteum, is reflected to expose the underlying bone. This complete exposure of and access to the underlying bone is indicated when resective osseous surgery is contemplated. 28-07-2023 12

13. Partial-thickness flap- It includes only the epithelium and a layer of the underlying connective tissue. The bone remains covered by a layer of connective tissue that includes the periosteum. The partial-thickness flap is indicated when the flap is to be positioned apically or when the operator does not want to expose bone. 28-07-2023 13

14. When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when the periosteum is left on the bone. (Ref: Carranza FA, Jr, Carraro JJ: Effect of removal of periosteum on post- operative result of mucogingival surgery. J Periodontol 34:223, 1963) 28-07-2023 14

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16. Incisions: Periodontal surgery involves the use of horizontal (mesial-distal) and vertical (occlusal-apical) incisions. 28-07-2023 16

17. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. Two types of horizontal incisions have been recommended: The internal bevel incision , which starts at a distance from the gingival margin and which is aimed at the bone crest, and The crevicular incision , which starts at the bottom of the pocket and which is directed to the bone margin. In addition, the interdental incision is performed after the flap is elevated to remove the interdental tissue. 28-07-2023 17

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19. HISTORICAL BACKGROUND Neumann (1911) 1 st introduced mucoperiosteal flap- ‘Neumann flap’ Leonard Widman (1918) Modified the Neumann flap Kirkland (1931) Modified flap procedure Nabers (1954) Introduced ‘repositioning of attached gingiva’ Ariaudo & Tyrrell (1962) Modified Nabers procedure Friedman (1962) Apically positioned flap Morris (1965) ‘ Unrepositioned mucoperiosteal flap’ Ramfjord & Nissel (1974) ‘Modified Widman flap’ 28-07-2023 19

20. FLAP TECHNIQUES FOR POCKET ELIMINATION 28-07-2023 20

21. Five different flap techniques are used: the modified Widman flap, (2) the undisplaced flap, (3) the apically displaced flap, (4) the papilla preservation flap, (5) and the distal terminal molar flap. 28-07-2023 21

22. The original widman flap (Leonard Widman, 1918) 28-07-2023 22

23. In his article “The operative treatment of pyorrhea alveolaris”, Widman described a mucoperiosteal flap design that aimed to remove the pocket epithelium and the inflamed connective tissue, thereby facilitating optimal cleaning of the root surfaces. 28-07-2023 23

24. The original widman flap (Leonard Widman, 1918) Full thickness mucoperiosteal flap A imed at removing: Pocket epithelium and the inflamed connective tissue 28-07-2023 24

25. Two releasing incisions demarcate the area scheduled for surgical therapy. A scalloped reverse bevel incision is made in the gingival margin to connect the two releasing incision 28-07-2023 25

26. A mucoperiosteal flap is elevated to expose at least 2–3mm of the marginal alveolar bone. The collar of inflamed tissue around the neck of the teeth is removed with curettes and the exposed root surfaces are carefully instrumented. 28-07-2023 26

27. Bone recontouring is recommended in order to achieve an ideal anatomic form of the underlying alveolar bone. 28-07-2023 27

28. Following careful debridement of the teeth in the surgical area, the buccal and lingual flaps are laid back over the alveolar bone and secured in this position with interproximal sutures. 28-07-2023 28

29. Advantages: Less discomfort for the patient, healing occurs by primary intention Re-establish a proper contour of the alveolar bone in sites with angular bony defects Possible increase of attached gingiva 28-07-2023 29

30. Drawbacks: Post operative recession Associated sensitivity Esthetics compromise, especially in maxillary anterior region 28-07-2023 30

31. Neumann Flap (Robert Neumann 1920) 28-07-2023 31

32. An intracrevicular incision is made through the base of the gingival pockets and the entire gingiva (and part of the alveolar mucosa) is elevated in a mucoperiosteal flap. Sectional (vertical) releasing incisions are made to demarcate the area of surgery. Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol . 1982 Jul;53(7):456-9. 28-07-2023 32

33. Following flap elevation, the inside of the flap is curetted to remove the pocket epithelium and the granulation tissue. The root surfaces are subsequently carefully debrided. Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol . 1982 Jul;53(7):456-9. 28-07-2023 33

34. Any irregularities of the alveolar bone crest are corrected. Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol . 1982 Jul;53(7):456-9. 28-07-2023 34

35. The flaps are then trimmed to allow both an optimal adaptation to the teeth and a proper coverage of the alveolar bone on both the buccal/lingual (palatal) and the interproximal sites. Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol . 1982 Jul;53(7):456-9. 28-07-2023 35

36. replacing the flap at the crest of the alveolar bone. Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol . 1982 Jul;53(7):456-9. 28-07-2023 36

37. Advantages: Less discomfort for the patient, since healing occurred by primary intention. Possible to re‐establish a proper contour of the alveolar bone in sites with angular bony defects. 28-07-2023 37

38. Drawbacks: Post operative recession Associated sensitivity Esthetics compromise, especially in maxillary anterior region 28-07-2023 38

39. Modified flap operation (Kirkland flap, 1931) 28-07-2023 39

40. Modified flap operation (Kirkland flap, 1931)  Modified flap operation- to be used in the treatment of “ Periodontal pus pockets”. He demonstrated the basic gingival mucoperiosteal flap design of Neumann in 1920 for the original flap, but instead of trimming the flap for surgical pocket elimination, he attempted to eliminate the crevicular epithelial lining and the inflamed connective tissue by curettage of the flap. 28-07-2023 40

41. Pocket (sulcular/ crevicular) incisions are made on both the labial and the lingual aspects of the interdental area. The incisions are extended in a mesial and a distal direction. 28-07-2023 41

42. The gingiva is retracted (mucoperiosteal flap reflection) labially and lingually to expose the diseased root surfaces which are carefully debrided. 28-07-2023 42

43. Angular bony defects are curetted but no bone is removed. 28-07-2023 43

44. Following the elimination of the pocket epithelium and granulation tissue from the inner surface of the flaps, these are replaced at their original position and secured with interproximal sutures. 28-07-2023 44

45. DIFFERENCE FROM NEUMANN AND ORIGINAL WIDMAN FLAP: Did not include extensive sacrifice of non-inflamed tissues and (2) apical displacement of the gingival margin. 28-07-2023 45

46. Advantages: Useful in the anterior regions of the dentition for esthetic reasons, since the root surfaces were not markedly exposed. Potential for bone regeneration in intrabony defects. Possible pocket depth reductions due to tissue shrinkage/ wound contraction during post surgical healing. 28-07-2023 46

47. Apically Repositioned F lap 28-07-2023 47

48. Historical Aspect- Nabers in 1954, introduced “apically repositioned flap”. The procedure was named as “repositioning of the attached gingiva”. In 1957, Nabers modified the procedure by adding inverse bevel incision instead of trimming of gingival margins. It was done to achieve thin and knife edge gingival margins. He called this incision the “repositioning incision”. 28-07-2023 48

49. Nabers (1954) – one vertical incision- ‘repositioning of attached gingiva’ Ariaudo and Tyrrell (1957) – two vertical incisions Friedman (1962) – coined the term ‘apically repositioned flap’ 28-07-2023 49

50. OBJECTIVES Apical displacement of entire mucogingival unit to eliminate the pockets while retaining the attached gingiva. To maintain keratinized gingiva Surgical access for osseous surgery, treatment of infrabony pockets and root planing. 28-07-2023 50

51. A reverse bevel incision is made using a scalpel with a Bard– Parker® blade (No. 12B or No. 15). How far from the buccal/lingual gingival margin the incision should be made is dependent on the pocket depth as well as the thickness and the width of the gingiva. 28-07-2023 51

52. If preoperatively the gingiva is thin and only a narrow zone of keratinized tissue is present, the incision should be made close to the tooth. The beveling incision should be given a scalloped outline, to ensure maximal interproximal coverage of the alveolar bone when the flap subsequently is repositioned. 28-07-2023 52

53. Vertical releasing incisions extending out into the alveolar mucosa (i.e. past the mucogingival junction) are made at each of the end points of the reverse incision, thereby making apical repositioning of the flap possible. 28-07-2023 53

54. A full‐thickness mucoperiosteal flap including buccal/lingual gingiva and alveolar mucosa is raised by means of a mucoperiosteal elevator. The flap has to be elevated beyond the mucogingival line in order to be able later to reposition the soft tissue apically. 28-07-2023 54

55. The marginal collar of tissue, including pocket epithelium and granulation tissue, is removed with curettes and the exposed root surfaces are carefully scaled and planed. The alveolar bone crest is recontoured with the objective of recapturing the normal form of the alveolar crest, but at a more apical level. The osseous surgery is performed using burs and/ or bone chisels 28-07-2023 55

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57. Following careful adjustment, the buccal/lingual flap is repositioned to the level of the newly recontoured alveolar bone crest and secured in this position. 28-07-2023 57

58. A periodontal dressing should therefore be applied to protect the exposed bone and to retain the soft tissue at the level of the bone crest. After healing, an “adequate” zone of gingiva is preserved and no residual pockets should remain. 28-07-2023 58

59. USED FOR pocket eradication (2) widening the zone of attached gingiva. (3)crown lengthening procedures for cosmetic enhancement and restorative treatment 28-07-2023 59

60. Indicated in • Mandibular buccal and lingual surfaces • Maxillary buccal surfaces It can be raised as • Full thickness flap • Partial thickness flap 28-07-2023 60

61. Advantages: • 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 mucogingival complex may be maintained 28-07-2023 61

62. CONTRAINDICATIONS: Periodontal pockets in severe periodontal disease. Periodontal pockets in areas where esthetics is critical. Deep intrabony defects. Patient at high risk for caries. Severe hypersensitivity. Tooth with marked mobility and severe attachment loss. Tooth with extremely unfavorable clinical crown/root ratio. 28-07-2023 62

63. Disadvantages: Sacrifice of crestal alveolar process and supporting bone Extensive exposure of root surfaces. 28-07-2023 63

64. Beveled flap (modification of Apically repositioned flap) 28-07-2023 64

65. A conventional mucoperiosteal flap is first elevated by giving an intracrevicular incision. 28-07-2023 65

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67. Tooth surfaces are debrided and osseous recontouring is performed. 28-07-2023 67

68. The palatal flap is subsequently replaced and the gingival margin is adjusted to the alveolar bone crest by a secondary scalloped and beveled incision. 28-07-2023 68

69. The flap is secured in this position with interdental sutures. 28-07-2023 69

70. Modified Widman flap ( R amfjord & Nissle , 1974) 28-07-2023 70

71. Ramfjord and Nissle (1974) described the modified Widman flap technique that is also recognized as the open flap curettage technique. Modified Widman flap ( ramfjord & Nissle , 1974) 28-07-2023 71

72. The initial incision, which may be performed with a Bard–Parker® knife (No. 11), should be parallel to the long axis of the tooth and placed approximately 0.5 to 1mm from the buccal gingival margin in order to properly separate the pocket epithelium from the flap. 28-07-2023 72

73. The flap elevation should be limited and allow only a few millimeters (2 to 3mm) of the alveolar bone crest to become exposed. 28-07-2023 73

74. To facilitate the gentle separation of the collar of pocket epithelium and granulation tissue from the root surfaces, an intracrevicular incision is made around the teeth to the alveolar crest. 28-07-2023 74

75. A third incision (interdental) made in a horizontal direction and in a position close to the surface of the alveolar bone crest separates the soft tissue collar of the root surfaces from the bone. 28-07-2023 75

76. The pocket epithelium and the granulation tissues are removed by means of curettes. Following the curettage, the flaps are trimmed and adjusted to the alveolar bone to obtain complete coverage of the interproximal bone. 28-07-2023 76

77. The flaps are sutured together with individual interdental sutures. Surgical dressing may be placed over the area to ensure close adaptation of the flaps to the alveolar bone and root surfaces. The dressing, as well as the sutures, is removed after 1 week. 28-07-2023 77

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79. Advantages : 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 28-07-2023 79

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85. Papilla preservation flap (Takei et al, 1985) 28-07-2023 85

86. Probably the first report of a Papilla Preservation procedure was by Kromer in 1956 which was designed to retain osseous implants. App in 1973, reported a similar technique and termed it as Intact Papilla Flap, which retained the interdental gingival in the buccal flap. Evian et al preserved the interdental gingiva in the facial flap, which exposed osseous margins on the labial and the interproximal zone, while the palatal tissues were reflected separately. 28-07-2023 86

87. Genon and Bender in 1984 also reported a similar technique indicated for esthetic purposes. Takei et al in 1985 introduced a detailed description of the surgical approach reported earlier by Genon and named the technique as Papilla Preservation Flap, which ensured optimal interproximal coverage and facilitated placement and retention of bone grafts which prevented exfoliation of the graft material. 28-07-2023 87

88. Later, Cortellini et al. (1995b, 1999) and Cortellini and Tonetti (2007) described modifications to the flap design to allow minimally invasive surgical techniques 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. 28-07-2023 88

89. Intracrevicular incisions are made at the facial & proximal aspects of teeth. This method uses sulcular incisions around each tooth with no incision being made through the interdental papilla facially, 28-07-2023 89

90. The papilla preservation flap technique is initiated by an intrasulcular incision at the facial and proximal aspects of the teeth without making incisions through the interdental papillae . 28-07-2023 90

91. but the lingual/ palatal flap involves a sulcular incisison along each tooth with a semilunar incision made across each interdental papilla that dips apically from the line angles of the tooth so that the papillary incision line is at least 5 mm from the gingival margin allowing the interdental tissues to be dissected from the lingual or palatal aspect so that it can be elevated intact with the facial flap 28-07-2023 91

92. 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 papilla elevator is used to carefully free the interdental papilla from the underlying hard tissue. 28-07-2023 92

93. The detached interdental tissue is pushed through the embrasure with a blunt instrument to be included in facial flap. 28-07-2023 93

94. The flap is replaced & sutures are placed on the palatal aspect of the interdental areas. 28-07-2023 94

95. Distal molar surgery 28-07-2023 95

96. INDICATIONS: • When only limited amounts of keratinized gingiva is present • Presence of distal angular bony defect Facilitates access to osseous defect Preserves sufficient amounts of gingiva and mucosa to achieve soft tissue coverage Distal wedge procedure (Robinson 1966) 28-07-2023 96

97. Buccal and lingual vertical incisions are made through the retromolar pad to form a triangle behind a mandibular molar. The triangular-shaped wedge of tissue is dissected from the underlying bone and removed. 28-07-2023 97

98. The walls of the buccal and lingual flaps are reduced in thickness by undermining incisions (broken lines). The flaps, which have been trimmed and shortened to avoid overlapping wound margins, are sutured. 28-07-2023 98

99. Modified distal wedge procedure A deep periodontal pocket combined with an angular bone delect at the distal aspect of a maxillary molar. 28-07-2023 99

100. Two parallel bevel incisions, one broocal and one palatal are made from the distil surface of the molar to the posterior part of the tuberosity. 28-07-2023 100

101. where they are connected with a bucco lingual incision. The buccal and palatal incisions are extended in a mesial direction along the buccal and palatal surfaces of the molar to facilitate flap elevation. 28-07-2023 101

102. Buccal and palatal flaps are elevated Rectangular wedge is released from the tooth and underlying bone by sharp dissection and then removed 28-07-2023 102

103. Modified distal wedge procedure. Following bone recontouring and root debridement, the flaps are trimmed and shortened to avoid overlapping wound margins and sutured 28-07-2023 103

104. Immediately after suturing (≤24 hours), a connection between the flap and the tooth or bone surface is established by a blood clot, which consists of a fibrin reticulum with many polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of the wound. Bacteria and an exudate or transudate also result from tissue injury. Healing after flap surgery 28-07-2023 104

105. One to 3 days after flap surgery, the space between the flap and the tooth or bone is thinner. Epithelial cells migrate over the border of the flap, and they usually contact the tooth at this time. When the flap is closely adapted to the alveolar process, the inflammatory response is minimal. 28-07-2023 105

106. One week after surgery, an epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, and the periodontal ligament. 28-07-2023 106

107. 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 the presence of immature collagen fibers, although the clinical aspect may be almost normal. 28-07-2023 107

108. One month after surgery, a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. A functional arrangement of the supracrestal fibers is beginning. 28-07-2023 108

109. Undisplaced flap 28-07-2023 109

110. Undisplaced flap • Pocket elimination procedure using internal bevel incision. Also called as INTERNAL BEVEL GINGIVECTOMY • Pocket wall is eliminated with first incision • Elimination of ‘dead space’ as the flap margin is place over bone crest postoperatively • However, sufficient attached gingiva is a pre-requisite • Usually used for pocket elimination of palatal pockets 28-07-2023 110

111. The location of two 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 the pocket if remaining attached gingiva is sufficient. 28-07-2023 111

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113. Original Widman flap Modified Widman flap Pocket elimination procedure Pocket reduction procedure Apical displacement of flap No apical displacement Osseous recontouring can be done Not designed for osseous contouring 28-07-2023 113

114. Modified Papilla preservation flap ( cortellini et al, 1995) 28-07-2023 114

115. The first modification of PPF was reported by Checchi et al in 1988, where a horizontal incision over the interproximal area, in the opposite side of the bone defect was deemed ideal as it allowed protection of the regenerated area from the oral environment. 28-07-2023 115

116. Cortellini et al in 1995, proposed a modification in the PPF and named it as Modified Papilla preservation flap. The rationale for developing this technique was to achieve and maintain primary closure of the flap in the interdental space over the membrane. And for complete coverage of the membrane. 28-07-2023 116

117. Buccal and interproximal primary incision is continued intrasulcularly in the interproximal space and extended to the palatal aspect. A buccal horizontal incision is performed in the interproximal supracrestal connective tissue, coronal to the bone crest, to dissect the papilla. 28-07-2023 117

118. Primary intrasulcular incision (buccal and interproximal) involving two teeth neighboring the defect is made. A horizontal incision is traced in the buccal gingiva of the interdental space at the base of the papilla. This horizontal incision is then connected with the primary incision in the most apical portion of the buccal gingival of the neighboring teeth and a full thickness buccal flap was elevated to the level of the buccal alveolar crest. 28-07-2023 118

119. The papilla is then elevated towards palatal aspect. Following extension of the palatal incision, a full thickness palatal flap including the interdental papilla was elevated to fully expose the defect. The tissue thickness of papilla is reduced to permit coronal advancement of the flap. Vertical releasing incision divergent in corono -apical direction extending in to the alveolar mucosa can be placed in the interproximal spaces neighboring the defect if coronal advancement of the flap is desired. 28-07-2023 119

120. The Simplified Papilla preservation flap (SPPF) 28-07-2023 120

121. To apply esthetic value to teeth having narrow interproximal zone, Cortellini et al in 1999 proposed the Simplified Papilla preservation flap technique. 28-07-2023 121

122. An oblique incision is made across the defect associated papilla from the gingival margin at the buccal line angle of the involved tooth to reach the mid interproximal portion of the papilla under the contact point of the adjacent tooth. The oblique incision continues intrasulcularly in the buccal aspect of the teeth neighbouring the defect and extended to partially dissect the papillae of the adjacent interdental spaces allowing the elevation of a buccal flap with 2-3 mm exposure of alveolar bone. 28-07-2023 122

123. A buccolingual horizontal incision at the base of papilla close to the interproximal crest is made. Intrasulcular incisions are continued in the palatal aspects of the two teeth neighbouring the defect and extended into the interdental papilla of adjacent interdental spaces, following which a full thickness palatal flap including the interdental papilla is elevated. 28-07-2023 123

124. 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 28-07-2023 124

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