periodontalsurgery-190403161834 (1).pptx

PERIO

1. PERIODONTAL SURGERY Periodontal flaps Ass. Prof. Enas Elgendy

2. Lecture outlines Definition Indication of flap surgery Classification of flaps Advantages of the periodontal flap Types of Incisions Flap techniques for pocket therapy: Modified Widman flap Un displaced flap (excisional procedure of the gingiva) Apically-displaced flap Distal molar surgery (Distal Wedge) Excisional new attachment procedure ENAP

3. Periodontal flap Incising the gingival tissues with the purpose of controlling or eliminating the periodontal diseases. Gingiva &/or oral mucosa is surgically elevated from underlying tissue for accessibility &visibility of bone & root.

4. Periodontal surgery may be Resective Procedures. It is the procedure that means to eliminate or reduce the pocket, by excising or amputating the tissue constricting the pocket wall. e.g ; Gingivectomy , Gingivoplasty , Apically positioned flap with or without osseous surgery. New attachment procedures. It is the reunion of connective tissue by formation of new cementum with inserting collagen fibers on root surface that has been deprived of its periodontal ligament e.g ; Closed curettage. Excisional new attachment procedure (ENAP). Open flap curettage. Modified widman flap procedure. Regeneration procedures. The use of regenerative materials, including bone grafts, barrier membranes, and wound-healing agents, are well documented. Intrabony defects, particularly vertical defects with multiple osseous walls, are often amenable to regeneration with these techniques. Papilla preservation flap Conventional flap with regenerative procedures

5. - Gingivectomy →resect soft tissue wall of pocket -Flap surgery →displace soft tissue wall of pocket

6. Indication o f Flap Surgery Gain access for root debridement Pocket elimination or reduction → patient can maintain root surface free of plaque Reshaping of soft &hard tissues Regeneration of alveolar bone, PL & cementum

7. Periodontal flaps can be classified based on the following: Bone exposure after flap reflection According to Position or Placement of the flap after surgery According to Design of Flap/management of the papilla Classification of flaps

8. A) According to bone exposure during reflection (thickness of the flap): Full thickness flaps Partial “split” thickness flap

9. Based on bone exposure after flap reflection Partial-thickness (mucosal) flaps (split-thickness flap) Full-thickness ( mucoperiosteal ) flaps The flap includes only the epithelium and a layer of the underlying connective tissue. The bone remains covered by a layer of connective tissue, including the periosteum . All soft tissue, including the periosteum , is reflected to expose the underlying bone. Sharp dissection is necessary to reflect a partial split thickness flap. Technique is relatively difficult A periosteal elevator is used to separate the mucoperiosteum from the bone. It is indicated: the flap is to be positioned apically, coronal or laterally. When periosteum is left on bone: Prevent marginal bone loss used for s uturing the flap to keep in position (apically displaced) It is indicated: osseous surgery is needed (including regenerative techniques).

10. Displaced flaps Undisplaced flaps (repositioned) When the flap is positioned reflection should extend to the level of alveolar mucosa When the flap is returned and sutured to its original position Coronally : coronally positioned flap usually for anterior teeth Laterally: laterally positioned flap (pedicle flap) in mucogingival surgery Apically: apically positioned flap. N.B. Palatal flaps cannot be displaced because of the absence of unattached gingiva . Based on According to position or placement of the flap after surgery

11. In order to displace the flap in any direction, reflection should extend to the level of alveolar mucosa. Moreover vertical incisions are performed at both ends of the flap. Palatal flaps cannot be displaced owing to the absence of alveolar mucosa.

12. The interdental papilla Facial papilla Lingual papilla Col region The interdental papilla occupies the space in the interdental embrasure apical to the contact point. There are three parts of interdental papilla:

13. The interdental papilla Interdental papilla ( IDP) acts as a biological barrier which protects the underlying periodontal structures, apart from playing an important role in esthetics. The loss of IDP as a result of periodontal disease or of periodontal therapy leads to esthetic (black triangle), phonetic, and food impaction problems. This is why, it is important in periodontal surgery to preserve the inter dental papilla .

14. Papilla preservation flap Split papilla flaps ( Conventional flaps) The entire interdental papilla is incorporated in either the facial or lingual flap. The interdental papilla is split beneath the contact point into facial papilla which is included in the facial flap and lingual papilla which is included in the lingual flap. Papilla preservation flaps When the interdental spaces are too wide When the flap is to be undisplaced . Conventional flaps When the interdental spaces are too narrow When the flap is to be displaced. According to Design of Flap/Based on Management of the papilla

15. Advantages o f the Periodontal Flap Existing gingiva is preserved. Marginal alveolar bone is exposed so as to identify the morphology of the bony defect (1 wall, 2 wall or 3 wall intra bony defect) and so to make proper treatment. Furcation areas are exposed and so the degree of involvement can be detected. Flap can be repositioned at its original level or shifted apically or coronally , thereby making it possible to adjust the gingival margin. Regenerative techniques cannot be performed without reflecting a flap such as placing grafts or treatment by guided tissue regeneration (GTR). Flap procedure preserves the oral epithelium and may make the use of surgical dressing not so important as compared to gingivectomy . Post operative period is usually more pleasant for the patient when compared to gingivectomy .

16. Incisions f or Conventional Flap Horizontal incision Internal (reverse) bevel incision Crevicular (second, intrasulcular / sulcular ) incision The third or interdental incision

17. Incisions f or Conventional Flap 2 . Vertical incision Oblique releasing incision Diagram of the vertical incision: the broken lines illustrate the incorrect incision where the flap base is smaller than the flap margin. If vertical incisions are renounced, tearing may occur at the end of the horizontal incision during flap mobilization (small picture). Facial vertical incisions should not be made in the center of an interdental papilla or over the radicular surface of a tooth . Incisions should be made at the line angles of a tooth either to include the papilla in the flap or to avoid it completely

18. Incision For Papilla preservation flap Crevicular with no Interdental incision Bard-Parker scalpel blades and handle

19. Increase accessibility to root deposits for scaling and root planing . Eliminate or reduce pocket depth via resection of the pocket wall. Gain access for osseous respective surgery. Expose the area to perform regenerative methods. When should one consider for surgical pocket therapy?

20. Flap Surgery for pocket therapy 1- Modified W idman flap. 2- The undisplaced ( unrepositioned ) flap 3-Apically displaced flap. 4- Distal Wedge procedure 5- Excisional new attachment procedure ENAP

21. Modified Widman flap Technique Primary incision : An inverse bevel incision directed at the alveolar crest is made 0.5-1mm from the gingival margin and parallel to the long axis of the tooth. It is important to produce enough scalloping of the interdental incision in order obtain primary closure interdentally. Sometimes a crevicular incision may be used when esthetics is of concern or minimal gingival width is present.

22. Modified Widman flap Flap elevation : Elevation of a full thickness flap is done using a periosteal elevator exposing 1-2 mm of alveolar bone. Vertical releasing incisions are not usually needed.

23. Modified Widman flap Second incision : This incision is made from the bottom of the pocket to the alveolar crest around the neck of each tooth.

24. Modified Widman flap Third incision : After the flap is reflected, a third incision is made in the interdental spaces using an interproximal knife and the gingival collar is removed.

25. Modified Widman flap Tissue tags and granulation tissue are removed using a curette. Root surfaces are checked and scaled and root planed. Residual periodontal fibers attached to the tooth surface should not be disturbed.

26. Modified Widman flap Suturing : flaps are then replaced at their original position and secured by tight interrupted sutures . Effort must be made to keep the facial and lingual interproximal tissues as close to each other as possible so that no interproximal bone remains exposed at the time of suturing.

27. Modified Widman flap

28. Modified Widman Flap (MWF)

29. Modified Widman flap INDICATIONS: Access and visualization of the root surface. Effective with pocket depths of 5-7 mm When regeneration is the goal and not total pocket irradiation . CONTRAINDICATIONS: Lack of or very thin and narrow attached gingiva can render the technique difficult, because a narrow band of attached gingiva does not permit the initial scalloped incision (internal gingivectomy ).

30. Modified Widman flap Advantages Adaptation of healthy connective tissues to the root surfaces. Better esthetics when compared to apically positioned flap. Less potential for root hypersensitivity as compared to apically positioned flap. Preservation of interdental tissues allows for proper coverage of intrabony defects as well are grafts placed in bony defects. Disadvantages May lead to residual probing depth in the presence of infra bony pockets. New attachment is unpredictable. Healing is usually by a long junctional epithelium . It does not attempt to reduce the pocket depth (except for reduction that occurs during healing as a result of tissue shrinkage), but it does eliminate the pocket lining.

31. Post operative care Patients should follow these instructions: Avoid eating or drinking for 1 hour. Not to rinse vigorously with hot water. Avoid eating hard, sharp or sticky food Patient may take an analgesic if there is pain when the anaesthetic wears off. Chlorhexidine gluconate 0.2% may be used twice daily for plaque control on the operated side with the dressing until proper mechanical plaque control is resumed. If there is bleeding, patient is told to exert pressure on the dressing for 15 minutes using a piece of gauze. Patient should use the tooth brush on unoperated side.

32. Post-operative antibiotics should not be routinely prescribed. Antibiotics may be prescribed for a diabetic patients or medically compromised patients or in case of regenerative techniques. Dressing is usually removed after 1 week. All debris must be completely removed and the wound washed with warm saline. If wound is not sufficiently epithelialized or if it is tender, a new dressing is applied for a further week. Patient is instructed to start gentle tooth brushing with a soft tooth brush. Patient’s oral hygiene must be followed up until healing is complete followed by a 3-6 month follow up. These post-operative instructions are applicable for all periodontal surgical techniques. Post operative care

33. Modified Widman flap If a modified Widman flap is performed in an area with a deep intrabony lesion, bone repair may occur within the defect at its most apical portion. Crestal bone resorption is also seen as a response to the flap procedure and crestal bone exposure. Amount of bone fill depends on: the anatomy of osseous defect ( e.g , three wall intrabony defect often provides a better prognosis for bone repair than two or one-walled defects and the amount of crestal bone resorption .

34. Healing of modified Widman flap Healing of MWF will begin by organization of the blood clot between the tooth and flap into granulation tissue. This granulation tissue is slowly replaced by connective tissue over the next 2-5 weeks . Epithelium proliferates over the connective tissue wound almost to its pre-operative position. If the root is free of irritants, the long junctional epithelium can adhere to it. A mature long junctional epithelial attachment may take several weeks to form . Give reason Why it is not allowed to measure probing pocket depth before 3 months After MWF?

35. The modified Widman flap results in healing by a long junctional epithelium with some bone fill with or without a true connective tissue attachment.

36. Repair and Regeneration

37. Healing of modified Widman flap :

38. Apically positioned flap This technique is indicated for: Pocket eradication. Preserving or increasing the zone of attached gingiva. It is also considered one of the mucgogingival techniques. This flap could be a full thickness ( mucoperiosteal ) or split thickness (mucosal) flap depending on the purpose.

39. Apically positioned flap Healing: The inner surface of the flap in contact with the bone undergoes inflammation, organization and healing. The thin blood clot is replaced by granulation tissue in about a week. This matures into collagenous connective tissue in 2-5 weeks. The inner surface of the flap unites with the bone to produce a mucoperiosteum which will increase the attached gingival zone. Epithelium will begin to proliferate 2 days after surgery from the flap margin over the connective tissue wound. The epithelium will migrate apically at a rate of 0.5 mm per day to form a new junctional epithelium. A mature epithelial attachment takes about 4 weeks to form. Some resorption of the alveolar bone margin will occur as a result of raising the flap which is about 0.5 mm. Connective tissue attachment will reform between the marginal tissue and root cementum from the bone margin to the base of the junctional epithelium. This will prevent further apical migration of the junctional epithelium.

40. Advantages It may give more stable results since pockets are totally eliminated and the dentogingival junction is normal as compared to the long junctional epithelium which results after the MWF. Limitation It cannot be done on the palatal aspect and it leads to increased clinical crown lengthening.

41. Undisplaced ( unrepositioned ) flap The undisplaced flap is 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 consider internal bevel gingivectomy . 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 .

42. The pockets are measured with the periodontal probe , and a bleeding marks were made. 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 The second or crevicular incision The flap is reflected with a periosteal elevator (blunt dissection). Usually there is no need for vertical incisions because the flap is not displaced apically. The interdental incision is made with an interdental knife. The triangular wedge of tissue created by the three incisions is removed with a curette. The area is debrided

43. Distal Wedge Excision Indication Pocket elimination in edentulous areas. Treatment of distal pockets on the maxillary or mandibular arches . Crown lengthening: to re-contour periodontal tissue that form on the abutment tooth adjacent to edentulous area, maxillary tuberosity Better if sufficient attached gingiva distal to tooth is present (simpler & no risk of recurrence). Pocket depth of about 6-7 m (Better) &if distal furcation is slightly involved, Limitation Free movable gingiva(recurrence) Lingual nerve

44. Distal Wedge Excision Techniques: Half moon shaped inverse bevel incision from mid buccal to mid palatal aspect.- Corresponding intrasulcular incision. Parallel incisions 10 mm distal to tooth. Distal perpendicular incisions Undermined incisions for flap creation( hatched area) Contouring gingivectomy to eliminate redundant tissue .

45. Distal Wedge Excision Suturing and gingivectomy of redundant distal gingival tissues Flap reflection – Root planning Wedge removal

46. Excisional new attachment procedure ENAP It is subgingival curettage performed with a knife to remove the gingival epithelium.   -Gain new attachment Decrease probing depth -Access root surface -Maintenance of esthetics

47. Excisional new attachment procedure ENAP Technique : After adequate anesthesia ENAP consists of an internal bevel incision performed with a surgical knife (Bard-Parker blade no. 11 or 15. Carry the incision interproximally on both the facial and the lingual side, attempting to retain as much interproximal tissue as possible. The intention is to cut the inner portion of the soft tissue wall of the pocket, all around the tooth. Remove the excised tissue with a curette, and carefully perform root planing on all exposed cementum to achieve a smooth, hard consistency. Preserve all connective tissue fibers that remain attached to the root surface. Approximate the wound edges; if they do not meet passively, recontour the bone until good adaptation of the wound edges is achieved. Place sutures and a periodontal dressing.