Periodontal Flap Surgery

Purpose To gain access to deeper periodontal structures with direct vision. Relocation of the frenulum Maintenance of the attached tissue Pocket elimination and regeneration

Indications Pockets > 5mm persisting after phase I therapy Bony pockets and interdental craters Bony lesions in the furcations Need for surgical crown lengthening When to open up a flap? complicated morphology like: Deep and narrow pocket Difficult to achieve the correct angle

Contraindications Shallow, supraalveolar pockets subgingival scaling/rootplaning Esthetically sensitive areas Fibrous thickened gingiva gingivectomy  more favorable morphology

Comparison of open vs. closed

Instruments

Instruments Small elevators for mobilization of the mucoperiosteal flap

Instruments

Principles of Flap Design Local flap outlined by a surgical incision carries its own blood supply allows surgical access to underlying tissues can be replaced in the original position can be maintained with sutures and is expected to heal Used in oral surgical, periodontic, and endodontic procedures to gain access.

Principles of Flap Design Complications Flap necrosis Flap Dehiscence Flap Tearing Injury to Local Structures

Principles of Flap Design A. Flap necrosis Principles of Flap Design Base > Free margin to preserve an adequate blood supply unless a major artery is present in the base Width of Base > Length of Flap*2 less critical in oral cavity, but length < width a long, straight incision with adequate flap reflection heals more rapidly than a short, torn incision. An axial blood supply in the base Hold the flap with a retractor resting on intact bone to prevent tension.

Principles of Flap Design B. Flap Dehiscence Principles of Flap Design The incisions must be made over intact bone If the pathologic condition has eroded the buccocortical plate, the incision must be at least 6 or 8 mm away from it. The incision is 6 to 8 mm away from the bony defect created by surgery. Gently handle the flap's edges Do not place the flap under tension Do not cross bony prominences, ex: canine eminence

Principles of Flap Design B. Flap Dehiscence Principles of Flap Design

Principles of Flap Design C. Flap Tearing Principles of Flap Design Envelope flaps an incision around the necks of several teeth. extends 2 teeth anterior and 1 tooth posterior. If not provide sufficient access… Vertical (oblique) releasing incisions: extends 1 tooth anterior and 1 tooth posterior. started at the line angle of a tooth. carried obliquely apically into the unattached gingiva. If cross the papilla  localized periodontal problems

Principles of Flap Design D. Injury to Local Structures Principles of Flap Design Mandible: lingual n. & mental n.

Principles of Flap Design D. Injury to Local Structures Principles of Flap Design Maxilla: greater palatine a. & nasopalatine n./a.

Basic Incisions Can be sulcular, crestal, or inverse bevel

Basic Incisions Full thickness a: sulcular b: crestal (mucoperiosteal) a: sulcular b: crestal Depending on the amount of attached tissue present

Split/partial thickness Basic Incisions Split/partial thickness (mucosal) In areas of thin bony plates and for mucogingival procedures

Basic Incisions 2. inversebeveled Modified flap (mucoperiosteal) 2. inversebeveled incision to the crest of bone. 1. gingivectomy Incision for pocket reduction Requires adequate attached keratinized gingiva On the palate, enlarged tissue, or with limited access

Comparison of full- vs. partial-

Types of Mucoperiosteal Flaps Envelope/sulcular incision Envelope with one releasing incision (three-corner flap) Envelope with two releasing incisions (four-corner flap) Full-thickness mucoperiosteal flap

Types of Mucoperiosteal Flaps 1. Envelope/Sulcular flap 2 teeth anterior 1 tooth posterior

Types of Mucoperiosteal Flaps 2. Three-corner flap 1 tooth anterior 1 tooth posterior Greater access in an apical direction, especially in the posterior aspect of the mouth

Types of Mucoperiosteal Flaps 3. Four-corner flap 1 tooth anterior 1 tooth posterior rarely indicated

Common Periodontal Flap

1 Inverse bevel incision 0.5~2mm, extending to the alveolar crest. Thins gingival tissue and permits compete closure of the interdental osseous defects postoperatively.

1 Flap reflection. Full thickness mucoperiosteal flap is reflected to permits visualization.

1 Crevicular incision between the hard tooth and the diseased pocket epi., to the depth of the junctional epi.

1 Horizontal incision carried along the alveolar crest

1 Root planing with direct vision

1 Complete coverage of interdental defects

2 Sulcularly, crestally, or full-thickness flap labially positioned inverse beveled incision to bone Flap completed, reflected off bone Flap is apically positioned and sutured

2 A: The internal bevelled, scalloped incision is used for pocket elimination through apical repositioning of the flap. B: The flap positioned apically for pocket elimination.

Crestal incision with blade, partial-thickness flap parallel to long axis of tooth Flap raised by sharp dissection, periosteum retained over bone Flap is apically positioned at or below alveolar crest

No alveolar mucosa is present on the palate to permit apical positioning. Pocket elimination by palatal flap that just covers the contours of the bone to eliminate osseous defects. Requires skill and experience.

Osteoplasty Osseous grooving, peprmits better adaption of flaps to facilitate plaque removal alter healing

Osteoplasty

Osteoplasty

Suturing for Flap Surgery

Simple Loop Modification of Interrupted

Figure 8 Modification of Interrupted

Vertical mattress suture

Horizontal mattress suture

Single Interrupted Sling

Reference Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD, JD, FACS and Myron R Tucker, DDS Peterson's principles of oral and maxillofacial surgery, Michael Miloro,G. E. Ghali,Peter Larsen,Peter Waite An atlas of minor oral surgery: principles and practice, David A. McGowan Manual of minor oral surgery for the general dentist, Karl R. Koerner Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA, DDS, MSD Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition, EDWARD S. COHEN, DMD